Part 2

Educational Objectives

Upon completion of this activity, participants will be able to

• Name 5 current challenges for glycemic control in individuals with type 2 diabetes

• List the key physiologic, biochemical, and molecular events involved in the renal regulation of glucose metabolism

• Understand the effects of inhibiting glucose reuptake by the kidney in individuals with type 2 diabetes

Magnitude of the Diabetes EpidemicMagnitude of the Diabetes Epidemic

28.3 M40.5 M43.0%

16.2 M32.7 M102%

53.2 M64.164.1 M20%

67.0 M 99.4 M 48%

10.4 M18.7 M80%

46.5 M

80.3 M

73%

M=million; AFR=Africa; EMME=Eastern Mediterranean and Middle East; EUR=Europe; NA=North America; SACA=South and Central America; SEA=South-East Asia; WP=Western Pacific.

International Diabetes Federation. Diabetes Atlas. 3rd ed. Available at: http://www.eatlas.idf.org/index.asp.

World

2007=246 M2025=380 M

54%

AFR

NA

SACA

EUR

SEA

WP24.5 M44.5 M82%

EMME

2007 2025

Global Projections for theGlobal Projections for theDiabetes Epidemic: 2007-2025Diabetes Epidemic: 2007-2025

Global Increase in Obesity

Overweight, BMI ≥25 kg/m2; obese, BMI >28 kg/m2 (Asian) or >30 kg/m2.

James WP. J Intern Med. 2008;263:336-352.

USAUSA

UKUK

AustraliaAustraliaFinlandFinland

SwedenSwedenNorwayNorwayBrazilBrazilCubaCuba

JapanJapan

19701970 19751975 19801980 19851985 19901990 19951995 20002000 20052005

Pre

vale

nce

of

Ob

esit

y (%

)P

reva

len

ce o

f O

bes

ity

(%)

3535

3030

2525

2020

1515

1010

55

00

20022002 20072007 20152015

Obese 356 million 523 million 704 million

Overweight 1.4 billion 1.5 billion 2.3 billion

Increasing Problem of Obesity Increasing Problem of Obesity and Diabetes: United Statesand Diabetes: United States

*BMI ≥30 kg/m2.

Centers for Disease Control and Prevention. National diabetes fact sheet. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008;Mokdad AH, et al. JAMA. 1999;282:1519-1522; Mokdad AH, et al. Diabetes Care. 2000;23:1278-1283; Ogden CL, et al. NCHS data brief no 1. Hyattsville, MD: National Center for Health Statistics, 2007.

Obesity*Obesity* DiabetesDiabetes

US Population

(%)6.5

7.8

0

5

10 20% increase

1998 2007

17.9

34.3

0

20

40 92% increase

1998 2006

4040

2020

00

Increasing Problem of Obesity Increasing Problem of Obesity and Diabetes: Mexicoand Diabetes: Mexico

ObesityObesity DiabetesDiabetes

Mexican Population

(%)

Aguilar-Salinas CA, et al. Am J Med. 2002;113:569-574; Aguilar-Salinas CA, et al. Diabetes Care. 2003;26:2021-2026; Sánchez-Castillo CP, et al. Public Health Nutr. 2005;8:53-60.

14.9

19.4

25.129.0

0

20

40

1993 2000

Men MenWomen Women

4040

2020

00

21% increase

7

8.2

0

5

10

17% increase

1993 2000

1.8

6.9

4.1

9.0

0

5

10

1991 1999-2000

Men MenWomen Women

1010

55

00

169% increase

2.5

5.5

0

3

6

Increasing Problem of Obesity Increasing Problem of Obesity and Diabetes: Chinaand Diabetes: China

Obesity*Obesity* DiabetesDiabetes

Chinese Population

(%)

*Asian-specific obesity cut-point: BMI ≥28 kg/m2.

Gu D, et al. Diabetologia. 2003;46:1190-1198; Wildman RP, et al. Obesity (Silver Spring). 2008;16:1448-1453.

1994 2000-2001

120% increase

Increasing Problem of WeightIncreasing Problem of WeightGain and Diabetes: IndiaGain and Diabetes: India

Rural Indian Population

(%)

*BMI ≥25 kg/m2.

Ramachandran A, et al. Diabetologia. 2004;47:860-865.

Overweight*Overweight* DiabetesDiabetes

2.2

6.4

0

4

8 191% increase

1989 2003

2.0

17.1

0

10

20 750% increase

1989 2003

2020

1010

00

HyperglycemiaHyperglycemia

• Biochemical marker by which the diagnosis of diabetes is made

– Assessed with HbA1c, daily SMBG, and eAG

• Major and treatable risk factor for microvascular disease (DCCT, UKPDS 33 and 35)

• Independent and treatable risk factor for macrovascular disease (DCCT-EDIC, UKPDS 35 and 80)

• Self-perpetuating cause of diabetes

– Glucotoxicity → insulin resistance and impaired insulin secretion

eAG=estimated average glucose.SMBG=self-monitoring of blood glucose.

HbAHbA1c1c Is Correlated With Is Correlated With

Average GlucoseAverage Glucose

AG=average glucose.

Nathan DM, et al. Diabetes Care. 2008;31:1473-1478.

450

400

350

300

250

200

150

100

50

03 5 7 9 11 13 15

AG

(m

g/d

L)

HbA1c (%)