Brazilian Primary Care of T2D with Reactive-Homeostatic and Lifestyle Changing- Allostatic Approaches: A Cost-Effectiveness Data

Abstract

The Brazilian Health System is committed to offer free of charge medications for Diabetes, with the expenditure with prescription drug being the increasingly large component of overall health care costs of the Ministry of Health. The program for Hypertension and Diabetes (HiperDia) provides distribution of more than 15 medications for those two diseases. However, besides this onerous pharmaceutical care, Brazil is facing a greater burden of T2D. The lack of discontinuing the soaring T2D might be due to the lack of knowledge of underlying epigenetics of insulin resistance and, consequently the principles for its treatment. The homeostasis model adopted by physicians in restoring the “low level” of plasma glucose probably has been inappropriate because if one signal is suppressed by a drug, the brain compensates by driving all the others harder. By adding more drugs to a complex system increases the frequency of iatrogenesis and costs. Alternatively, the allostasis model can explain insulin resistance without postulating any true defect because blood glucose fluctuates according to match the ever-shifting prediction of what might be needed. Insulin resistance would be caused by prolonged exposure to high glucose level that reduces its receptor number and sensitivity. Additionally, insulin and other hormones that regulate fuel supply are modulated rigorously from the brain by standard signals for vigilance such as cortisol. Cortisol related signals are elevated during states of hypervigilance and of hyposatisfaction. For people of lower socioeconomic status potential sources of satisfaction are less available, but food is abundant and cheap. Elevated cortisol raises appetite for carbohydrate and fat and shifts the distribution of fat deposits toward the viscera and reduces insulin sensitivity. The allostasis model suggests that the brain overrides local negative feedback (metabolic satiety signals) and people eat. Obesity contributes to T2D as well as to metabolic syndrome and atherosclerosis creating a profoundly lethal cascade, and all follow the familiar epidemiological pattern of disrupted communities. The guiding principle for rational treatment of T2D, would be to reduce the need for vigilance and to restore small satisfactions. Among population-based strategies, diet and physical exercise are the pillars of T2D treatment. In our community-based dynamic cohort, the lifestyle change protocol with dietary counseling and supervised walking-jogging exercises, reduced T2D by four exercise protocols such as high intensity (75%), Academy (71.3%), Mixed (78.6%) and Hydro-gymnastic (34.3%). Besides effective, this allostatic model experience showed to be also a money-saving alternative to be implemented by the government.