Editorial

Steven V. Edelman, MD, and Derek LeRoith, MD, PhD

The prevalence and incidence of type 2 diabetes mellitus (DM) are increasing dramatically in most areas of the United States, as well as in developed and developing countries around the globe. Although major efforts are under way to discover ways to prevent type 2 DM, the ability to screen and identify individuals at risk in large populations is quite poor. At the other end of the spectrum, we have a growing number of individuals with type 2 DM who are living longer and are approaching the need for insulin therapy, as oral medications are not able to achieve and maintain glycemic control over the long-term.

These “baby boomer” type 2 diabetics have special requirements in terms of the need for more aggressive insulin therapies, including the basal bolus or prandial regimen. This regimen is typically used in patients with type 1 DM; however, it is now being adapted for type 2 DM patients as well. Compared with that used in type 1 DM patients, the approach to instituting a physiologic regimen in patients with type 2 DM can be simpler and applied in a stepwise approach.

As the insulin regimen becomes more physiologic and as the goal for glycemic control continues to be lowered by our national and international DM organizations, the need for techniques to prevent hypoglycemia also becomes important. Although hypoglycemia occurs more frequently in patients with type 1 DM, it is an important issue that should be addressed in patients with insulin-requiring type 2 DM. Understanding the differences in clinical and physiologic responses is critical.

We have a great deal of work to do in this country in terms of prevention, early identification, and aggressive therapy of type 2 DM. This issue of Insulin addresses many of these important topics in treating patients with insulin-requiring type 2 DM. We hope the articles presented here will assist you in your endeavors in the community, health care institution, clinic, or private practice.

Physicians' Corner: Insulin and Type 2 Diabetes Mellitus Treatment Today: Are We at a Tipping Point?
Charles F. Shaefer, Jr., MD, FACP, FCCP

Awareness is growing among the primary care community regarding the possible impact of the increasing epidemic of type 2 diabetes mellitus (DM) in our patient population. Also, primary care has an urgent interest in developing strategies to best treat this disease. This bodes well, since it is now almost universally accepted that 90% of all type 2 DM patients will be cared for within the primary care community.

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Prevalence of Undetected High Risk for Type 2 Diabetes Mellitus in Primary Care: A South Florida Primary Care Practice - Based Research Network Study
John G. Ryan, DrPH, Fulton Velez, MD, Katherine Chung-Bridges, MD, MPH, John Lewis, PhD, Robert Schwartz, MD, Terri Jennings, PhD

Fewer than 1 in 5 patients at high risk reported having been informed of their elevated risk. This low rate of patient education may delay preventive measures and may contribute to the disproportionate effect of DM on ethnic groups in whom this disease is more common.

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Management of Type 2 Diabetes Mellitus with Basal-Prandial Insulin Therapy: A Case-Based Review
Stephen N. Davis, MD, FRCP

This article provides a case-based review outlining a novel strategy for advancing therapy with a modified basal and prandial insulin regimen to achieve recommended glycemic targets in type 2 DM as quickly as possible. Evidence-based treatment strategies are also discussed.

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Insulin Therapy and Hypoglycemia in Type 2 Diabetes Mellitus
Philip E. Cryer, MD

Pending the prevention and cure of DM, people with this disease need safe and effective therapies. Ultimately, that will require glucose-regulated insulin replacement or secretion. In the meantime, insight into the mechanisms of hypoglycemia-associated autonomic failure may lead to interventions that will further improve the lives of people affected by DM by reducing the frequency of hypoglycemia without compromising glycemic control.

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Factors Associated with Glycemic Control in Patients with Type 2 Diabetes Mellitus in Rural Areas of the United States
Haney Wahba, MD, FAAFP, Yue-Fang Chang, PhD

There is concern regarding the quality of diabetic care and the level of compliance with clinical guidelines in rural and underserved areas with limited resources and limited educational programs that are isolated from large medical centers.

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Patient Consensus
Steven V. Edelman, MD,University of California at San Diego, San Diego, California, Kathryn Britton, CPC, MAPP Theano Coaching Service, Chapel Hill, North Carolina

This article is about giving individuals with diabetes mellitus (DM) a voice to tell caregivers what they want from them. It is about increasing the understanding that caregivers have for patients with DM to create a stronger and more effective health care relationship.

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Corrections
Stephan A. Schreiber

The following abstracts were presented at the Insulin Congress (The Evolving Science and Practice of Insulin Therapy) held November 10-12, 2006, in Washington, DC, but did not appear in Volume 2, Supplement A of Insulin.

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Response to Previous Case Study
Derek LeRoith, MD, PhD

A 26-year-old black woman with type 2 diabetes mellitus (DM) presents to your office after being told by her primary care physician that her DM was poorly controlled. The patient has a history of peptic ulcer disease for which she takes omeprazole 40 mg daily. There is a remote history of nonspecific gastric surgery. She also has dyslipidemia, which is treated with atorvastatin 10 mg/d, and asthma, which is controlled with an albuterol metered dose inhaler. The patient has smoked 1 pack of cigarettes daily for 8 years and drinks ~6 beers a day on weekends. The patient weighed 180 pounds and was 5 feet 4 inches tall.

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