the science diabetes control

Diabetes: Control

Revised November 2008

The National Diabetes Education Program

wwwYourDiabetesInfo.org ∙ 1-888-693-NDEP

A joint program of NIH and CDC

The Science: Diabetes Control

The National Diabetes Education Program Changing the Way Diabetes is Treated.

Diabetes: Control





What is Diabetes?Diabetes is a group of diseases characterized by high levels of blood glucose (blood sugar)

Diabetes can lead to serious health problems and premature death

About 24 million Americans have diabetes

NIDDK, National Diabetes Statistics 2007. www.diabetes.niddk.nih.gov/dm/pubs/statistics/

Diabetes: Control





Common Types of Diabetes

Type 1 diabetes• 5% to 10% of diagnosed cases of

diabetes

Type 2 diabetes• 90% to 95% diagnosed cases of

diabetes


Diabetes: Control





Common Types of Diabetes• Gestational Diabetes occurs during

pregnancy• 5 to 10 % of women with gestational diabetes are

found to have type 2 diabetes• Increased lifelong risk for mother and child for

developing type 2 diabetes• 40-60 % women with gestational diabetes will

develop diabetes in the next 5 to 10 years


Diabetes: Control





Risk Factors for Diabetes

• Age 45 and older• Overweight (BMI ≥ 25)• Hypertension• Abnormal lipid levels• Family history of diabetes• Race/ethnicity• History of gestational diabetes

• History of vascular disease• Signs of insulin resistance

(such as PCOS or acanthosis nigricans)

• IGT or IFG on previous test• Inactive lifestyle

American Diabetes Association. Diabetes Care 2008; 31;(Suppl.1):S12-54.

Diabetes: Control





Diabetes and Cardiovascular Disease

• Cardiovascular disease is the leading cause of death for people with diabetes

• In adults with diabetes:– 68% die of heart disease or stroke– the risk for stroke is two to four times higher – 75% have high blood pressure– smoking doubles the risk for heart disease

NIDDK, National Diabetes Statistics 2007.

www.diabetes.niddk.nih.gov/dm/pubs/statistics/

Diabetes: Control





Diabetes Complications•Diabetes is the leading cause of:

– kidney failure– new cases of adult blindness – nontraumatic lower-limb amputations

•In adults with diabetes:– the risk of periodontal (gum) disease is two to

three times higher– 60 to 70 % have mild to severe nervous

system damageNIDDK, National Diabetes Statistics 2007. www.diabetes.niddk.nih.gov/dm/pubs/statistics/

Diabetes: Control





Diabetes Control and Complications Trial (DCCT)

Compared effects of two diabetes treatment regimens – standard therapy and intensive control – on the complications of diabetes in people with type 1 diabetes

DCCT. New England Journal of Medicine, 329(14), September 30, 1993.

Diabetes: Control





Glucose control is key to preventing or delaying complications of diabetes

Any sustained lowering of blood glucose helps, even if the person has a history of poor control

DCCT Findings


Diabetes: Control





DCCT Findings

Lowering blood glucose reduced risk of:

• Eye disease by 76%

• Kidney disease by 50%

• Nerve disease by 60%


Diabetes: Control





United Kingdom Prospective Diabetes Study (UKPDS)

Clinical Trial

Looked at intensive management of blood glucose levels and long term risk-factors for diabetes complications in type 2 diabetes

UKPDS. BMJ. 2000; 321:405-412.

Diabetes: Control





Mirrored the findings of DCCT in people with type 2 diabetes—better glucose control reduced development of microvascular complications

Demonstrated the need for management of high blood pressure and cholesterol as well as blood glucose levels (the ABCs of diabetes)

UKPDS Findings

UKPDS. BMJ. 2000; 321:405-412.

Diabetes: Control





UKPDS Findings

Stratton IM, et al. BMJ. 2000;321:405-412.

P <.0001 P = .035 P = .021 P = .0001

Risk reduction with 1% decline in annual mean A1C

Micro-vascular Disease

37%

PVD

43%

StrokeMI

14% 12%

Heart Failure

Cataract Extraction

16%19%

0%

15%

30%

45%

Diabetes: Control





Epidemiology of Diabetes Interventions and Complications

Study (EDIC)

Observational study

DCCT participants (type 1 diabetes)

Looked at risk factors for long-term complications

DCCT/EDIC N Engl J Med 2005: 353:2643-2653.

Diabetes: Control





Participants continue to benefit years later from period of intense glucose control

Years after intensive therapy:• Lasting benefits for eye, nerve, and kidney disease

• Reduces CVD events by more than half

EDIC Findings: Intensive Therapy and Diabetes Complications


Diabetes: Control





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Years from Study EntryYears from Study Entry

EDIC Findings: Cardiovascular EventsCumulative Incidence of First of Any EventCumulative Incidence of First of Any Event

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Risk reduction 42% Risk reduction 42% 95% CI: 9% to 63%95% CI: 9% to 63%P = 0.02P = 0.02

0.120.12

0.100.10

0.080.08

0.060.06

0.040.04

0.020.02

0.000.00

ConventionalConventional

IntensiveIntensive


Diabetes: Control





ConventionalConventional

IntensiveIntensive

Non-Fatal MI, Stroke, or CVD DeathNon-Fatal MI, Stroke, or CVD Death

EDIC Findings: Cardiovascular Events

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 210 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Years from Study EntryYears from Study Entry

0.000.00

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0.080.08

0.100.10

0.120.12

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Risk reduction 57% Risk reduction 57% 95% CI: 12% to 79%95% CI: 12% to 79%P = 0.02P = 0.02


Diabetes: Control





UKPDS 10 yr Follow-Up Study- insulin/sulfonylurea group

Differences in A1C between intensive & standard glycemic control treatment groups were lost after one year

Relative risk reductions at 10 yr in intensive insulin/sulfonylurea group: 9% for any diabetes end point (P=0.04) 24% microvascular disease (P=0.001) 15% myocardial infarction (P=0.01) 13% death from any cause (P=0.007)

N Engl J Med 2008; 359

Diabetes: Control





UKPDS 10 yr Follow-Up Study- metformin group

Differences in A1C between intensive & standard glycemic control treatment groups were lost after one year

Relative risk reductions at 10 yr in intensive

metformin group: 21% for any diabetes end point (P=0.01) 33% myocardial infarction (P=0.005) 21% death from any cause (P=0.002)


Diabetes: Control





UKPDS 10 yr Follow-Up Study- Blood Pressure findings

Between group differences lost within 2 yrs

Significant relative risk reductions in tight control group were not maintained

Benefits of BP control do not extend beyond intensive therapy period & ongoing treatment is essential


Diabetes: Control





Recent Clinical Trial Findings:Intensive glucose control in type 2 diabetes:• lowers risk of new or worsening

microvascular complications (ADVANCE)• was associated with increased mortality in

patients with longstanding DM and known CVD (ACCORD)

• increases risk of severe hypoglycemia (ADVANCE, ACCORD and VADT)

ACCORD: N Engl J Med 2008; 358(24):2545-59ADVANCE: N Engl J Med 2008; 358 (24): 2560-72VADT: J Diabetes Complications 2003; 17 (6): 314-22

Diabetes: Control





Key points of recent findings: • Intensive glucose control in newly diagnosed

type 1 or type 2 diabetes has benefits during intensive therapy AND a legacy effect for later micro- and macrovascular benefits

• Optimal glucose management should start as early as possible & continue as long as possible

• While the A1C goal for the general population is <7%, treatment must be individualized.


Diabetes: Control





SEARCH For Diabetes in Youth Study

Observational study

Physician-diagnosed diabetes in youth ages 0-19

Data will help researchers better understand and treat diabetes in young people

(SEARCH). Diabetes Care 2006 29(8): 1891-6.

Diabetes: Control





SEARCH FindingsDetermine prevalence and correlates of selected CVD risk factors among youth with diabetes

21% of young people with diabetes had at least two CVD risk factors

Prevalence of CVD risk factors was higher among youth aged 10-19 years and among girls


Diabetes: Control





SEARCH Findings

In young people with type 2 diabetes:

• 92% had at least two CVD risk factors

In young people with type 1 diabetes:

• 14% had at least two CVD risk factors


Diabetes: Control





National Diabetes Education Program Materials

Diabetes: Control





Diabetes Control: Patient Materials

Diabetes: Control





Diabetes Control: Health Care Professionals

Diabetes: Control





NDEP Websites

Diabetes: Control





Other NDEP Campaign Tools at www.YourDiabetesInfo.org• TV, radio, and print PSAs

• Sample feature articles

• Sample press releases and media advisories

• Fact sheets

• Web buttons/blurbs

• NDEP logos and banners

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For more information about NDEP and to order or download free

materials:

Call 1-888-693-NDEPor

Visit www.YourDiabetesInfo.orgThe U.S. Department of Health and Human Services’ National

Diabetes Education Program is jointly sponsored by the National Institutes of Health and the Centers for Disease Control and

Prevention with the support of more than 200 partner organizations.

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