younger ages. ³ This trickle-down effect places more prevent obesity and diabetes to all healthcare providers. women and fetuses at risk, resulting in a greater need Prevention holds the greatest promise in curbing the pro-for prenatal services. ¹¹ What is also emerging is that the jections of diabetes and the chronic inflammatory condi-risk of death associated with diabetes may be correlated tions that parallel its etiology. with abnormal birth weight (low birth weight defined as

< 6. 5 lbs. and high birth weight defined as ≥ 8. 5 lbs.) ³ Efforts to curb the epidemic of chronic conditions associ-Lower birth weight is associated with postnatal rapid ated with these disease trends can no longer rely primar-weight gain and central adiposity, MSyn, diabetes, and ily on treatment; rather, our efforts must be concentrated CVD in adulthood. ⁷ This population may represent a sub- on helping young people grow up with healthy lifestyles. set of at-risk diabetic individuals. ¹² Babies who are large This shift in healthcare priorities will provide interven-for gestational age because of consequences of maternal tions that liberate future generations from the harmful insulin resistance and glucose intolerance are at high lifestyles that became the inevitable by-product of the risk for future obesity. ⁷ Without intervention strategies detrimental environmental and societal influences of the targeting women of child-bearing age, particularly those 20th century. This shift in priorities requires cooperation in subgroups at greater risk for diabetes, an increase in of all healthcare providers and calibrated health promo-gestation-related complications can be expected that may tion messages. Given the association of obesity-related place future generations at greater risk for diabetes. conditions with periodontal disease, the dental profession must willingly play a role in such health-promotion and

As if the present day epidemic is not devastating enough, disease-intervention strategies. A key question is whether current predictions suggest that by 2030 there will be the dental profession is educationally prepared to expand 23 million individuals with diagnosed and 7 million with its responsibility for diabetes prevention and treatment. undiagnosed diabetes, with another estimated 70 million with impaired fasting or postprandial glucose. ³ Di- It is time for a new model of care which is grounded in rect costs of diabetes could be close to $175 billion/year, promotion of healthy lifestyle before risk factors develop, with an additional $75 billion/year in indirect costs. ¹³ In as well as risk elimination or modification for insulin-reference to a potential pandemic, Bloomgarden recently resistant or pre-diabetic individuals. Mobilizing dental wrote, “The economic and personal burden of diabetes professionals to embrace this challenge could positively will be almost overwhelming” and suggested the follow- impact diabetes trends. Yet, can this level of care happen ing measures to avert the pandemic: ¹³ in real world practice?

1. Continue to invest in research. Guidelines Meet Real World Practice
2. Abandon an acute-care model and adopt a chronic- The American Diabetes Association (ADA) recently pub-
care model. lished revised standards of medical care for diabetes (Jan-
3. Focus on early treatment and prevention. uary 2006). ² Throughout the guidelines there is a range
4. Find a way to limit obesity. of interventions to improve diabetes outcomes, including
screening of asymptomatic adults and children who may

Collectively, the previous statistics present a strong ar- be at risk, progressive strategies to prevent and delay gument for multiple levels of preventive care. This is a diabetes, and care of patients with diagnosed diabetes. ² departure from our current healthcare system which fo- Nowhere in the guidelines does the ADA specify that its cuses on treatment of diabetes and other chronic diseas- recommendations are the sole responsibility of the medi-es in an attempt to minimize related disability or loss of cal community. The guidelines state that the standards of function. Implementing preventive strategies before risk care are intended for clinicians, without specific refer-factors develop in children and adolescents by promot- ence to any one healthcare profession. ing lifestyle changes that emphasize exercise, proper diet, weight loss, and the importance of being tobacco-free In these revised standards, the ADA also made rather bold (primordial prevention) is key. Strategies aimed at reduc- statements that question the ability of the current health-ing risk factors in individuals who are already insulin care-delivery system to implement such standards of care resistant (secondary prevention) is also essential. These for diabetes. Several statements are included below. preventive strategies cannot be realized as a population- • “The implementation of the standards of care for diabased strategy without expanding the responsibility to betes has been suboptimal in most clinical settings.”