Diabetes Mellitus

Type 2 diabetes mellitus is a metabolic disorder characterized by elevated serum glucose levels due to insulin resistance in tissues such as muscle and fat, combined with a relative insulin deficiency and increased hepatic glucose production. Comorbid conditions are health issues that occur more frequently in diabetic patients compared to age-matched non-diabetic individuals. Many of these health issues complicate glycemic control and contribute to diabetic target organ damage; therefore, optimal management of these conditions helps prevent or delay such complications. Current quality indicators focus on three common comorbidities: hypertension, dyslipidemia, and obesity. These comorbidities independently increase the risk of cardiovascular disease, which remains the leading cause of mortality among diabetic patients (1).

It is estimated that approximately 80% of adult diabetic patients also have hypertension, at least twice the prevalence found in the general population. The coexistence of diabetes and hypertension significantly increases cardiovascular risk and contributes to microvascular complications such as diabetic retinopathy and nephropathy (2,3). Strict blood pressure control is crucial in diabetic patients, with the hypertension threshold set at 140/90 mmHg, like the general population (4).

Annual lipid profile monitoring, particularly LDL cholesterol, is also recommended, as intensive LDL lowering therapy significantly reduces the risk of myocardial infarction, stroke, and mortality in diabetes (4). Treatment typically includes lifestyle modification and statin therapy. The Israeli guidelines from the 2014 Society for the Study, Prevention, and Treatment of Atherosclerosis emphasize maintaining target LDL levels. For diabetic patients at high cardiovascular risk (without additional risk factors beyond diabetes), LDL cholesterol should be maintained at or below 100 mg/dL. For those at very high risk (with at least one additional risk factor), LDL targets are 70 mg/dL or lower (5). These guidelines adopt 100 mg/dL as the upper LDL target for all diabetic patients.

Obesity is a significant risk factor for the development of type 2 diabetes and complicates glycemic control. It also worsens other comorbidities and increases cardiovascular risk (4). In overweight diabetic patients, even modest and sustained weight loss improves glycemic control, blood pressure, and lipid profiles, reducing the need for pharmacologic therapy. Diabetes management guidelines recommend regular monitoring and maintenance of healthy body weight through proper nutrition, physical activity, behavioral therapy, and, if necessary, pharmacologic treatment or bariatric surgery. Bariatric (metabolic) surgery has proven effective in inducing weight loss, improving diabetes control, and reducing cardiovascular risk factors. Surgery is recommended for diabetic patients with a BMI ≥40 kg/m² or with a BMI between 35 and 40 kg/m² and uncontrolled diabetes.