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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Obesity has long been known as a driver and predictor of the increasing global prevalence of type 2 diabetes mellitus&#46; The World Health Organisation &#40;WHO&#41; has projected that more than 532 million people will developed diabetes by 2030&#46; In Spain the evidence on the incidence of type 2 diabetes is limited due to insufficient data&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> However&#44; it is recognized that both the incidence and the prevalence of type 2 diabetes are increasing and the age at diagnosis is decreasing&#46; A recent national survey found that the prevalence of type 2 diabetes in Spain is 13&#46;8&#37; &#40;95&#37; CI 12&#46;8&#8211;14&#46;7&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This prevalence can be subdivided into patients who have been diagnosed &#40;7&#46;8&#37;&#41; and those not yet diagnosed &#40;6&#37;&#41;&#46; A lower prevalence of 10&#46;3&#37; has been reported in Catalonia and the prevalence of undiagnosed type 2 diabetes was 6&#46;7&#37; in this area&#46; The national survey supported the association between diabetes and obesity&#46; Spain&#39;s obesity prevalence rate of 28&#46;2&#37; ranks among the highest in the OECD countries&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Diabetes is generally a disease with a high level of comorbidity and this has to be addressed in the treatment strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The high level of comorbidity with other chronic diseases is a challenge to the single-disease and fragmented focus in the health system and represents an increasing economic burden&#46; Comorbidity may not be adequately addressed in the current structure of health care systems&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Hospital-based systems such as DRGs are unable to capture the entire morbidity profile of patients and ignore the important impact of comorbidities&#46; These systems focus on episodic categorization and only capture hospitalized patients and fail to address the non-hospitalized population which represents the majority of any given population&#46; Complementary systems to hospital systems that address the entire medical experience for an individual over a period of time are needed to estimate the morbidity profile of a patient and the related economic burden&#46; According to the literature outpatient care profiling systems such as the ACG system may assist health-care systems to better identify undiagnosed type 2 diabetic individuals&#44; estimate cost of care and implement care coordination more effectively&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">It is a challenge to identify undiagnosed type 2 diabetic individuals for proactive treatment plans and monitoring&#46; Often&#44; the diagnosis of ischaemic heart disease&#44; renal disease and peripheral vascular disease is not obtained from standard registers&#46; The latter may&#44; among others&#44; be due to different focus from different specialties&#46; Thus&#44; a diabetic individual transferred to an orthopaedic surgical department for an amputation will not necessarily be equipped with a diagnosis of diabetes&#46; To address the diabetes epidemic a small number of countries have established a national diabetes register based on existing administrative records&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> One advantage of this approach is that the entire population is covered by uniform inclusion criteria&#46; Another is that the misclassification is believed to be small&#46; Other countries conduct epidemiological surveys and&#47;or combine data from different databases and national patient registers&#46; Both approaches will&#44; to some extent&#44; serve to improve the identification and registration of type 2 diabetes patients&#44; but the true burden of diabetes remains unknown&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">This issue of Rev Clin Esp features an article on the clinical and economic characteristics associated with type 2 diabetes&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The article by Sicr&#225;s-Mainar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> represents an effort to combine data from different databases in which the obesity-related expenses in diabetics are described and analyzed&#46; Sicr&#225;s-Mainar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> confirm that obesity per se is a major driving factor for the cost of co-morbidities that focus&#46; However&#44; the population described is biased by the fact that the obesity and diabetes groups are much older than the control group&#46; Also&#44; it seems surprising that only 3&#37; of these individuals suffer from diabetic neuropathy which is far from that reported in the literature&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Epidemiological data suggest that diabetics in the same age range have a much higher rate of complications&#44; including both obese and overweight individuals&#46; Overall&#44; it is a matter of concern that different populations turn out to have very variable levels of complications&#46; A high economic burden comes from the number of amputations performed in the diabetic community and this should be added on top of those expenditures reported by Sicr&#225;s-Mainar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">As Sicr&#225;s-Mainar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> note in their discussion section their study of clinical and economic characteristics associated with type 2 diabetes has strength and weaknesses&#46; It is a strength of the study that it applies recognized risk-adjustment&#47;casemix instruments such as resource utilisations bands based on Adjusted Clinical Groups and the Charlson index to adjust for casemix&#46; In contrast to most of the Spanish studies relating to cost of diabetes that only address healthcare cost&#44; another advantage is that the present study includes labour productivity losses&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Application of risk screening tools is a promising method&#44; even though some criticism has been raised towards the different comorbidity indices&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;9</span></a> Among the recognized methods are the Charlson and Adjusted Clinical Groups indices&#46; A surprisingly low Charlson index was found by Sicr&#225;s-Mainar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and probably illustrates the difficulties in achieving accurate information from databases&#46; Sicr&#225;s-Mainar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> measure general comorbidities in three different ways&#58; mean number of diagnoses&#44; Charlson index and resource utilization bands&#46; Apparently&#44; the index condition &#40;DM2&#41; was included in all of the three measures of comorbidity&#46; However&#44; it could be argued that comorbidity measures should exclude the index condition&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Comorbidity is morbidity in addition to an index condition rather than a general morbidity measure such as the standard Charlson and Adjusted Clinical Groups casemix measures&#46; It could also be argued that the index condition should be excluded before the application of resource utilisation bands to describe DM2 patients&#8217; comorbidity burden&#46; This may be one reason why the Danish resource utilisation band measure of type 2 diabetes patients by additional morbidity burden seems to be lower &#40;2&#46;2 rather than 2&#46;9&#41;&#46; It can also be discussed whether the above-mentioned types of riskscreening tools based on retrospective information are appropriate for planning and compatible with the goal of personalized medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The Spanish literature on clinical and economic characteristics associated with type 2 diabetes is fragmented and outdated according to a recent review and the article by Sicr&#225;s-Mainar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46; In general&#44; the rather extreme disparity has been related to differences in patient sampling&#44; demographic factors&#44; diabetes prevalence&#44; variations in definitions and registration systems&#44; access to care&#44; and quality of healthcare systems&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Numerous reports on the co-existence of other medical disorders in obese and&#47;or diabetics exist and their contribution to mortality and morbidity holds a high level of prediction and stresses the cardiovascular momentum of diabetes&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Obesity is a strong predictor for developing diabetes which is also the case for cancer&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The handling of cancer adds to the economic burden from obesity&#46; It can be argued whether obesity is the primary factor driving the costs of type 2 diabetes patients&#44; but it is clear that obesity and type 2 diabetes are closely related&#46; The respective contribution to the economic burden of obesity from diabetes and cancer may be hard to disentangle&#44; but a common denominator is cardiovascular disease leading to increased morbidity and mortality&#46; In treating diabetes another mortality-related factor is hypoglycaemia&#46; A recent trial<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> shows that type 2 diabetes patients&#8217; risk of hypoglycaemia-related mortality was increased by 3&#46;4 times that for persons without the disease&#46; A loss of labour productivity should be added to the economic burden in work-active individuals&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">It should be stressed that not all obese individuals will develop diabetes&#46; However&#44; the data supplied by Sicr&#225;s-Mainar et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> imply that obesity is an independent factor in the expenses tied to the diabetic population&#46; Even though the message is somewhat blurred by confounding&#44; the data deserve credit&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Even a slight weight-loss can achieve profound improvement in metabolic regulation<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>&#44; and an increasing number of training programmes available as applications for smartphones could potentiate the effect of training programmes&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Strong evidence shows that physical inactivity increases the risk of major non-communicable diseases such as type 2 diabetes as well as the medical and non-medical costs&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a> The literature also indicates that lifestyle changes was more effective than pharmacological intervention&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Nevertheless&#44; we need more evidence on the effect of lifestyle changes&#44; anti-obesity drugs and bariatric surgery in the obese diabetic population&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Until more unambiguous evidence has been established about the best way to prevent or at least reduce type 2 diabetes&#44; we have to focus on finding solutions for vulnerable patients and consider diabetes in the obese individual as a further complication and economic burden of society&#46;</p></span>"
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Vol. 214. Núm. 3.
Páginas 140-142 (abril 2014)
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Vol. 214. Núm. 3.
Páginas 140-142 (abril 2014)
Editorial
Obesity and co-morbidities in type 2 diabetes: An opportunity to bend the Health Care Cost Curve
Obesidad y comorbilidades de la diabetes tipo 2: una oportunidad para controlar la curva de costes de la asistencia sanitaria
Visitas
1042
T. Kristensen
Autor para correspondencia
trkristensen@health.sdu.dk

Corresponding author.
Associate Professor of Health Economics, Research Unit of General Practice & Institute of Public Health, Centre of Health Economics Research, University of Southern Denmark, Odense, Denmark
K. Yderstræde
Senior Consultant, Department of Endocrinology, Odense University Hospital , Odense, Denmark
Associate Professor of Medicine, University of Southern Denmark, Odense, Denmark
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