diabetes – a 21 st century epidemic
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Diabetes – A 21 st Century Epidemic. Diagnosis and what is it A common disease An expensive disease A serious disease A treatable disease A preventable disease. FPG. 2-Hour PG on OGTT. Diabetes Mellitus. Diabetes Mellitus. 126 mg/dL. 7.0 mmol/L. 200 mg/dL. 11.1 . mmol/L. - PowerPoint PPT PresentationTRANSCRIPT
Diabetes – A 21st Century Epidemic
Diagnosis and what is itA common disease
An expensive diseaseA serious disease
A treatable disease A preventable disease
Diagnosis and what is itGlucose Tolerance Categories
Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197.
FPG
126 mg/dL
100 mg/dL
7.0 mmol/L
5.7 mmol/L
Impaired FastingGlucose
Normal
2-Hour PG on OGTT
200 mg/dL
140 mg/dL
11.1 mmol/L
7.8 mmol/L
Diabetes Mellitus
Impaired GlucoseTolerance
Normal
Diabetes Mellitus
What is it ?Diabetes is a Vascular DiseaseBackground Retinopathy
100 125 150 175 200 Fasting Plasma Glucose
%
Aff
ecte
d
Natural History of Type 2 Diabetes
Adapted from: International Diabetes Center (Minneapolis, Minnesota).
Insulin resistance
RelativeFunctio
n (%)
Glucose
(mg/dL)
Years of Diabetes-15 -10 -5 0 5 10 15 20 25
-15 -10 -5 0 5 10 15 20 25
Fasting glucose
Post-meal glucose
ß-cell
IGT Diabetes
755025
0
100125
350
250
100
300
200150
Etiologic Classification of Diabetes Mellitus
Type 1 -cell destruction with lack ofinsulin
Type 2 Insulin resistance with insulindeficiency
Other specific types Genetic defects in -cell function, exocrine pancreas diseases, endo- crinopathies, drug- or chemical- induced, and other rare forms
Gestational Insulin resistance with -celldysfunction
Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197.
• 23.6 million (10.7% ≥ 20 y.o) at a cost of $174 billion in 2007– 57 million with prediabetes
• 6th disease specific cause of death.• Leading cause of:
– Kidney failure.– Adult blindness.– Nontraumatic limb amputation.– Cardiovascular disease.
ADA. Diabetes Care 31:596-615, 2008
Diabetes in the U.S.
Diabetes is a Common Disease : Estimated Prevalence of Diabetes in the US:Adult Men and Women
Harris, et al. Diabetes Care. 1998;21:518-524, with permission.
0
10
20
30
75+60-7450-5940-4920-39Age (y)
1.6 1.7
6.8 6.1
12.9 12.4
20.217.8
21.1
17.5
MenWomen
Perc
ent o
f Pop
ulat
ion
Estimated Prevalence of Diabetes in the US: Breakdown by Ethnicity
Data from Harris, et al. Diabetes Care. 1998;21:518-524.
4.8
2.5
8.2
3.6
9.3
4.5
0
2
4
6
8
10
HispanicAmerican
AfricanAmerican
Non-HispanicWhite
Diagnosed
Undiagnosed
Perc
ent o
f Pop
ulat
ion
Diabetes – An expensive disease
Direct and indirect costs of diabetes estimated to be $174 Billion annually in the USA in 2007
Costs to most health systems is 2-3 fold greater annually for patients
with diabetes
1997 Per Capita Health Care Costs:Persons With and Without Diabetes
Data from American Diabetes Association. Diabetes Care. 1998;21:296-309.
Ann
ual C
osts
($10
00s)
0
5
10
15
20
25
OutpatientDrugs
OfficeVisits
EROutpatientServices
Inpatient
23.5
12.2
2.51.5 0.7 0.4 0.7 0.4 0.7 0.2
Diabetes
No diabetes
Diabetes – A serious but treatable disease
Microvascular complicationsBlindness, renal failure and nerve dysfunction
Macrovascular complicationsAtherosclerosis –MI, Stroke and amputationsHypertension - Stroke, CHF, CAD
Conduit Artery Resistance Precapillary Capillaries Arterioles Arterioles
The Arterial Tree in Diabetes
Atherosclerosis Hypertension Retinopathy Neuropathy Nephropathy
Framingham Heart Study 30-Year Follow-Up:CVD Events in Patients With Diabetes (Ages 35-64)
109
20
11
9 63819
3*
30
0
2
4
6
8
10
Age-adjusted annual rate/1,000
Men Women
Total CVD
CHD Cardiac failure
Intermittent claudication
Stroke
Riskratio
P<0.001 for all values except *P<0.05.
Wilson PWF, Kannel WB. In: Hyperglycemia, Diabetes and Vascular Disease.Ruderman N et al, eds. Oxford; 1992.
Kannel WB. Am Heart J. 1985;110:1100-1107.Abbott RD et al. JAMA. 1988;260:3456-3460.
Women, Diabetes, and CHD
• Diabetic women are at high risk for CHD• Diabetes eliminates relative cardioprotective
effect of being premenopausal– risk of recurrent MI in diabetic women is
three times that of nondiabetic women• Age-adjusted mean time to recurrent MI or
fatal CHD event is 5.1 yr for diabetic women vs 8.1 yr for nondiabetic women
National Diabetes Data Group. Diabetes in America. 2nd ed. NIH;1995.
Atherosclerosis in Diabetes
• ~80% of all diabetic mortality– 75% from coronary atherosclerosis– 25% from cerebral or peripheral vascular
disease• >75% of all hospitalizations for diabetic
complications• >50% of patients with newly diagnosed
type 2 diabetes have CHD
4S: Major CHD Event Reduction in a Patients With Diabetes
Pyörälä K et al. Diabetes Care. 1997;20:614-620.
0.50
0.60
0.70
0.80
0.90
1.00
Proportionwithout
major CHD event
Yr since randomization
- P=0.002
- P=0.0001
Diabetic, simvastatinDiabetic, placeboNondiabetic, simvastatinNondiabetic, placebo
32%
55%
Conduit Artery Resistance Precapillary Capillaries Arterioles Arterioles
The Arterial Tree in Diabetes
Atherosclerosis Hypertension Retinopathy Neuropathy Nephropathy
blood pressure control reduced risk for
Any diabetes-related endpoint 24% p=0.0046diabetes-related deaths 32% p=0.019stroke 44% p=0.013microvascular disease 37% p=0.0092 heart failure 56% p=0.0043retinopathy progression 34% p=0.0038deterioration of vision 47% p=0.0036
UKPDS Blood Pressure Control
Diabetes and CHD
• HOPE Study– 9297 pts >55y.o. with DM or vascular disease +
1 CVD risk factor (~3578 DM )– Placebo or Ramipril 10 mg qd followed ~ 4 yrs– Significant reductions in cardiovascular events
(MI, stroke and CV death) – Changes seen in both DM and non-DM groups
MICRO-HOPE
• No clinical proteinuria, CHF or diminished EF and not on ACE.
• 3577 patients with DM and either known CHD or one additional risk factor.
• Ramapril 10 mg/d or placebo.• Study stopped at 4.5 yrs by DSMB
ACE Inhibition in DM
Hope Trial Ramipril Placebo (n=1808) (n=1769) P Combined 277 351 .0004 MI 185 229 .01 Stroke 76 108 .007 CV Death 112 172 .0001
Conduit Artery Resistance Precapillary Capillaries Arterioles Arterioles
The Arterial Tree in Diabetes
Atherosclerosis Hypertension Retinopathy Neuropathy Nephropathy
Glucose Control Study SummaryGlucose Control Study Summary
The intensive glucose control policy maintained a lower HbA1c
by mean 0.9 % over a median follow up of 10 years from diagnosis of type 2 diabetes with reduction in risk of:
12% for any diabetes related endpointp=0.029
25% for microvascular endpoints p=0.0099
16% for myocardial infarctionp=0.052
24% for cataract extractionp=0.046
21% for retinopathy at twelve yearsp=0.015
33% for albuminuria at twelve years p=0.000054
Quality of Life:
-0.3
-0.2
-0.1
0
0.1
0.2
0.3
0.4Placebo
Effect of Improved Glycemic Control
Quality-of-LifeAnalog Rating
MentalHealth
CognitiveFunction
GeneralPerceived
Health
SymptomDistress
Extended-releaseglipizide
Improved
Worsened
Testa & Simonson, JAMA, 1998;280;1490-1496.
P<.05P<.01
P<.01P<.001
Glucose Control and Costs of CareGlucose Control and Costs of Care
A 6 year comparison between patients who improved glucose control (decline in HgbA1C >1%) or not has shown that improved glycemic control reduced annual health care costs for affected individuals
Reductions due to fewer physican and emergency room visits
Cost saving of $600-1000 annually.
Diabetes a preventable diseaseDiabetes a preventable disease
Several trials of diabetes prevention have been conducted for type 1 diabetes using vaccine strategies.
None have yet been successful
For Type 2 diabetes, multiple trials successfullydemonstrated that both lifestyle changes and pharmacologic interventions can delay or
prevent diabetes among individuals at high risk
Prevention of DM 2
F/U DM Incidence RiskReduction
Study Control DietExercise
Da Qing 6 Yr 68% 44% 31%
DPS 4 Yr 23% 11% 58%
DPP 3 Yr 29% 14% 58%
Prevention of Diabetes with Lifestyle Modification
Effect of Metformin and Lifestyle Modification on New Onset Diabetes - Lifestyle changes work better as we age
0
10
20
30
40
50
60
70
80
25-44 44-59 >59
MetforminLifestyle
Subject Age
% D
eclin
e in
Dia
bete
s In
cide
nce
• 161 island archipelago, most live on main island, pop 1.3 m• “Galapagos of the East”• Lowest age-adjusted mortality (CHD, stroke, cancer) • Longest disability-free life expectancy of 47 Japanese prefectures (states)• Highest centenarian prevalence
Okinawa
Centenarians in the World (by prevalence)
Willcox DC et al AGE 2006
Diabetes – A model for intervention in chronic disease• As the population ages:
– Diabetes becomes more common – Diabetes itself is more preventable by a
healthy lifestyle– Complications of diabetes while common
can be prevented
Ushi Okushima 106 Years Young and Still Diggin’ Life
Thank you !
Domo Arigato!