EDITORIAL
Diabetes in prisons: Improving its management
Type 2 diabetes is the chronic disease with the most important progression throughout recent years and it has become the great epidemic of the 21st century. We know that it currently affects 14%1 of adults in Spain, that its incidence increases with age, affecting 30% of adults over 60 years old and that its development depends of both genetic and environmental factors.
We therefore can expect a high percentage of individuals hosted in correctional facilities having type 2 diabetes and many developing the disease during their stay, due to an ageing correctional population and the prevalence of obesity among inmates, both factors leading to a higher risk of developing the disease1. On the other hand, this population has some specific features which lead to a higher probability of developing the disease such as potential reduced physical activity, a high prevalence of infectious diseases such as AIDS2 or the use of psychotropic drugs.3
The main goal when dealing with diabetes is preventing its long-term complications such as cardiovascular disease, the loss of eyesight and renal impairment. In order to do so, optimal longterm metabolic control must be achieved although the first step is early diagnosis and treatment. It is therefore of paramount importance to obtain a thorough clinical record and carry on appropriate physical and analytical examinations to inmates upon imprisonment assessing potential complications and cardiovascular risk among those who have already been diagnosed4, and making initial diagnosis in other cases.
After the identification of patients they must immediately begin appropriate medical treatment and optimal continued nutritional monitoring as to avoid the incidence of hypo and hyperglycemia.
The management of diabetes among inmates should follow the same standards as the rest of the general population, regarding therapeutic schemes and control parameters. It is also essential to establish an individualized treatment and control plan according to the age, comorbidity and features of each patient, according to the recommendations of current clinical guidelines.5
Control objectives must be the same as those of the general population with glycated hemoglobin levels under7%, although objectives must be tailored according to the individual features of each patient, especially according to age6 and reconsidering less strict objectives in old multi-pathological patients.
Lifestyle modification is the most important part of treatment in every case and therefore specific nutritional needs must be assessed avoiding weight gain and physical inactivity, encouraging aerobic and resistance exercise among these patients.7
Along with lifestyle modification, metformin has been consolidated as the first-line drug for all patients with type 2 diabetes after proving its cardiovascular benefit and lack of relevant side-effects. Nevertheless throughout recent years, new families with a different synergistic mechanism of action have arisen and allow for their association and safe adaptation to each particular case.
Incretin mimetics8 have proven effective for hyperglycemia without the corresponding risk of hypoglycemia. Both oral DPP4 inhibitors and injectable GLP-1 analogues have been thoroughly studied, the later achieving a greater weight loss and thus being indicated in patients with BMI over 30 with further advantage of weekly administration. They can be associated to other oral antidiabetic drugs (OADs) and to insulin.
More recently, SGLT2 inhibitors9 have proven effective in the control of type 2 diabetes through an increased excretion of glucose leading to lower blood glucose levels regardless of insulin. They have been studied alone and with other oral medications and insulin. They never cause hypoglycemia and they have scarce side-effects mostly limited to genitourinary infections. They also lead to significant weight loss and they have the advantage that blood pressure (BP) is reduced, along with cardiovascular risk and mortality.
Despite the availability of the best pharmacological treatments, diabetes education should not be dismissed, since it is the cornerstone of diabetes management and should also be implemented in prisons, with nursing staff developing a leading role for patients to self-test when indicated and for them to achieve an effective control of their disease.
We must not forget that diabetes needs a comprehensive intensive therapeutic approach10, with a thorough assessment and control of all cardiovascular risk factors since they are the main cause of mortality in these patients.
Monitoring programs should be implemented in prison for all inmates suffering the disease as to control all potential complications, both macro and microangiopathic. Regular control and treatment of hypertension and hyperlipidemia are needed along with the implementation of active programs for inmates to give up smoking.
It is highly recommended that clinical records be shared by the health system to achieve a comprehensive and complete management of the disease with structured intervention protocols including the derivation to specialized services when needed. The health of diabetic patients depends on this structured and multi-disciplinary approach.
Edelmiro Menéndez Torre MD
Endocrinology and Nutrition Head of Service
HUCA — Oviedo.
REFERENCES
1. Soriguer Escofet F, Goday A, Carmena R, Casamitjana R, Delgado E, Franch J, et al. Prevalence of diabetes mellitus and impaired glucose regulation in Spain: the Di@bet.es Study. Diabetologia. 2012 Jan; 55(1): 88-93.
2. Hadigan C, Kattakuzhy S. Diabetes mellitus type 2 and abnormal glucose metabolism in the setting of human immunodeficiency virus. Endocrinology and metabolism clinics of North America. 2014 Sep; 43(3): 685-96.
3. Galling B, Roldán A, Nielsen RE, Nielsen J, Gerhard T, Carbon M, et al. Type 2 Diabetes Mellitus in Youth Exposed to Antipsychotics: A Systematic Review and Meta-analysis. JAMA Psychiatry. American Medical Association; 2016 Mar; 73(3): 247-59.
4. American Diabetes Association. Diabetes management in correctional institutions. Vol. 31 Suppl 1, Diabetes care. American Diabetes Association; 2008. pp. S87-93.
5. Menéndez Torre E, Lafita Tejedor FJ, Artola Menendez S, Puig Domingo M, Mediavilla Bravo JJ. [Recommendations for the pharmacological treatment of hyperglycemia in type 2 diabetes. Working Group for Consensus and Clinical Guidelines of the Spanish Diabetes Society.]. Endocrinol Nutr. 2011; 58: 112-20.
6. Gómez Huelgas R, Diez-Espino J, Formiga F, Lafita Tejedor FJ, Rodriguez Manas L, Gonzalez- Sarmiento E, et al. [Treatment of type 2 diabetes in the elderly]. 2013. pp. 134.e1-134.e12.
7. Dempsey PC, Larsen RN, Sethi P, Sacre JW, Straznicky NE, Cohen ND, et al. Benefits for Type 2 Diabetes of Interrupting Prolonged Sitting With Brief Bouts of Light Walking or Simple Resistance Activities. Diabetes Care. 2016 May 24; 39(6): 964-72.
8. Puig Domingo M, Reviriego J. [Incretins as new therapeutic targets of type 2 diabetes]. Rev Clin Esp. 2007 Jul; 207(7): 352-64.
9. Lisenby KM, Meyer A, Slater NA. Is an SGLT2 inhibitor right for your patient with type 2 diabetes? J Fam Pract. 2016 Sep; 65(9): 587-93.
10. Gaede P, Lund-Andersen H, Parving H-H, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. Massachusetts Medical Society; 2008 Feb 7; 358(6): 580-91.
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