type 2 diab.metabolic syndrome

8/14/2019 Type 2 Diab.metabolic Syndrome

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Type 2 diabetes,

the metabolic syndrome and

cardiovascular disease in Europe


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TIMETOACT Type 2 diabetes,the metabolic syndrome and cardiovascular disease in Europe

Diabetes mellitus is a chronic disease whichhas been described as a state of raised bloodglucose (hyperglycaemia) associated with

premature mortality.

Hyperglycaemia seriously damages many ofthe bodys systems, especially the blood

vessels and nerves.

Diabetes


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TIMETOACT Type 2 diabetes,the metabolic syndrome and cardiovascular disease in Europe

Diabetes arises when the beta cells in thepancreasfail to produce enough of the hormone

insulin - type 1 diabetes

Orwhen the body cannot effectively use the insulin

produced - type 2 diabetes..

90% of people with diabeteshave type 2 diabetes.

Type 1 and type 2 diabetes


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Type 2 diabetes,the metabolic syndrome and cardiovascular disease in Europe

Pancreas

Kidneys

Stomach

The pancreas


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Insulin is a hormone that allows cells to extractglucose from the blood and use it for energy.

Insulin is produced by the beta cells of the

pancreas.

It regulates protein and lipid metabolism.

Insulin


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When a person has diabetes, either:

their pancreas does not produce the insulin theyneed - type 1 diabetes

or their body cannot use this insulin effectively type 2 diabetes.

This leads to an increase in the amount ofglucose in the blood. This high concentration of

glucose or high blood sugar is termedhyperglycaemia.

Insulin and diabetes


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Synthesised in glands, hormones are chemicalsignaling molecules which have a specificregulatory effect upon the activity of bodytissues.

Hormones are transported around the body inthe blood so that they can act on tissues at adistance from the gland in which they wereproduced.

Hormones can only act in those tissues wherethey have specific receptors in the cells.

Hormones


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Chronic elevation of blood glucose eventuallyleads to tissue damage.

The kidneys, eyes, peripheral nerves and vasculartree manifest the most significant diabetic

complications. The mechanism for this is complex and not yet

fully understood. It involves:

The direct toxic effects of high glucose levels

The impact of elevated blood pressure Abnormal lipid levels

Functional and structural abnormalities of smallblood vessels

Tissue damage


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Out-of-control diabetes, when severe, leads to the

body using stored fat for energy and a subsequentbuild-up of acids (ketone bodies) in the blood. This isknown as ketoacidosis and is associated with veryhigh glucose levels. It requires emergency treatmentand can lead to coma and even death.

Recurrent or persistent infections (includingtuberculosis).

Both hyperglycaemia and hypoglycaemia (abnormallylow blood glucose resulting from treatment) may

cause coma and, if untreated, may be fatal.

The short term effects of diabetes


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The long term effects of diabetes can be divided into macrovascular complications

microvascular complications.

Macrovascular complications affect the larger blood

vessels, such as those supplying blood to the heart, brainand legs. The most common macrovascular fatalcomplication is coronary artery disease. Strokes are also acommon cause of disability and death in people withdiabetes.

Microvascular complications affect the small bloodvessels, such as those supplying blood to the eyes andkidneys. The microvascular complications of diabetes areretinopathy, nephropathy and neuropathy.

The long term effects of diabetes


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Visual impairment:

diabetic retinopathy,cataract and

glaucoma

Kidney disease(diabetic nephropathy)

Sexualdysfunction

Sensory impairment(peripheral neuropathy)

Ulceration

Stroke(cerebrovascular disease)

Heart disease(cardiovascular disease)

Bacterial and fungalinfections of the skin

Severe hardening of

the arteries (atherosclerosis) Autonomic neuropathy(including slow emptying

of the stomach and diarrhea)

Necrobiosis lipidoica

Gangrene

The major diabetic complications

Poor blood supply to lower limbs(peripheral vascular disease)


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If someone has the typical symptoms of diabetes thediagnosis is clear:

- increased thirst- excess urine- weight loss- a clearly raised plasma glucose level

Ketones in the urine accompanied by high plasma glucoselevels is also a clear indication of diabetes.

However, diagnosis is less straightforward for those withminor degrees of hyperglycaemia, and in the person

without symptoms, two abnormal results on separateoccasions are needed.

Diagnosing diabetes


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VenousPlasma*Glucose

concentration, Mmol l-1

(mg dl-1

)Diabetes mellitus

Fastingor

2-h post glucose load

7.0 (126)

11.1 (200)

Impaired Glucose Tolerance (IGT)2-h post glucose load 7.8 -


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Overweight and

obesity

Physicalinactivity

High-fat and

low-fiber diet

Ethnicity

Familyhistory

Age

Low birthweight

Urbanisation

Risk factors for type 2 diabetes


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The close association of type 2 diabetes with

cardiovascular disease has led to the hypothesis thatthey both share a common antecedent. This concepthas been labeled The Metabolic Syndrome by theWorld Health Organization and others.

The metabolic syndrome reflects the clustering ofcentral obesity with several other major cardiovascular

disease risk factors.

Central obesity Dyslipidaemia

Hypertension

Impaired glucose regulation or diabetes

Insulin resistance

The metabolic syndrome


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A disturbing feature of diabetes has been theclustering of diabetes with other well-knowncardiovascular risk factors, in particular central(abdominal) obesity.

The occurrence of central obesity, hypertensionand disturbed blood lipids is dramaticallyincreased in people with diabetes.

People with IGT and IFG also have a substantial

increase in cardiovascular risk factors and, likepeople with diabetes, higher cardiovascular risk.

Metabolic syndrome:The link between type 2diabetes and cardiovascular disease?


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There is now broad agreement on the overall riskfactors which must be taken into account whendefining the metabolic syndrome. These havebeen called the deadly quartet.

Impairedglucose

regulation

HypertensionObesity

Dyslipidaemia

Metabolic syndrome:

Overall risk factors


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It is suggested that insulin resistance and central obesityare the key underlying defects in the aetiology of type 2diabetes.

A universal definition of metabolic syndrome is urgentlyneeded to identify individuals at high risk of developingdiabetes and cardiovascular disease.

Impairedglucose

regulationHypertension

Obesity

Dyslipidaemia

Insulinresistance

Metabolic syndrome:

Key underlying defects


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Risk Factor Defining Level

Abdominal obesityMen

Women

Waist circumference>102 cm (>40 in)

>88 cm (>35 in)

Triglycerides 150 mg/dL (1.7 mmol/L)

HDL cholesterolMenWomen


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Central Obesity

Waist circumference - ethnicity specific*- for Europids: Male 94 cm

Female 80 cm

plus any two of the following:

Raised Triglycerides 150mg/dL (1.7mmol/L)

or specific treatment for this lipid abnormality

Low HDL Cholesterol


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05

10

15

20

2530

35

40

45

20-29 30-39 40-49 50-59 60-69 >70

Age

Prevalence

(%)

Men

Women

(N=8814)

Ford. JAMA 2002

Metabolic syndrome:Prevalence in the US as defined by NCEP ATP III

b li d


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Men Women

Lima, Peru 21.6% 30%

Mexico City 55.6% 64%

Spain 27.3% 31.7%

Greece 24.5%

Hong Kong 7.4% of Chinese men andwomen

USA 39%

Germany 57% 46%

Metabolic syndrome:

Prevalence in adults as defined by IDF criteria


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Sedentary lifestyle/physical inactivity

High fat, energydense diet

Ethnicity

Family

history

Stopping smoking

Age

Risk factors for obesity


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Cancer

Gall-bladderdisease

Kidneyfailure

Stroke

Heartfailure

Athero-sclerosis

Type 2diabetes

Hyper-tension

Respiratorydisease

Obesity

The health consequences of obesity

M i b it


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BMI = weight (kg)/height (m)

Individuals with a BMI

between 25 to 29.9 are considered overweight

of 30 and above are considered obese.

The risk of serious health consequences such as type 2diabetes, coronary heart disease, hypertension,dyslipidaemia, albuminuria and a wide range of otherconditions increases with BMI.

Obesity is most commonly assessed by a single

measure, the Body Mass Index (BMI), which uses amathematical formula based on a persons height andweight.

Measuring obesityBody Mass Index

M i b it t h


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BMI DOES NOT show the difference between excess fat and

muscle.

identify whether the fat is laid down in

particular sites. For example, abdominal fathas more serious health consequences than fatlocated elsewhere.

The relation between fatness and BMI differs with

age, race and gender.

.

Measuring obesity up to here

The limitations of the Body Mass Index

M i b it


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Classification BMI (kg/m2) Risk of co-morbidities

Underweight 30.0

Class I 30.0-34.9 Moderate

Class II 35.0-39.9 SevereClass III 40.0 Very severe

Measuring obesity

WHO classification of adult categories of BMI

M i b it


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Classification BMI

(kg/m2

)

Risk of co-morbidities

Waist circumference

< 90 cm (men)< 80 cm (women)

90 cm (men) 80 cm (women)

Underweight


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5

1.0 1.0 1.0 1.5

4.4

6.7

11.621.3

42.1

2.22.9

4.35.0

15.827.6

40.3

54.0

93.2

8.110

Women

Men

40

70

100

0


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The presence of abdominal obesity is more highlycorrelated with the metabolic risk factors than is anelevated BMI.

The new IDF consensus definition of the metabolicsyndrome stipulates the following as a pre-requisite for

a diagnosis of metabolic syndrome:

80 cm for European women

94 cm for European men

Waist circumference is calculated by comfortablymeasuring the waist halfway between the bottom of the ribcage and the top of the pelvis.

Waist circumferenceand the metabolic syndrome

Country/ethnic specific


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Country/Ethnic group Waist circumference

Europids MaleFemale

94 cm 80 cm

South AsiansMaleFemale

90 cm 80 cm

ChineseMale

Female

90 cm

80 cm

JapaneseMaleFemale

90 cm 80 cm

Ethnic South and CentralAmericans

Use South Asian recommendations untilmore specific data are available

Sub-Saharan Africans Use European data until more specificdata are available

Eastern Mediterranean andMiddle East (Arab) populations

Country/ethnic specificvalues for waist circumference


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Insulin resistance

Insulin resistance: A state in which agiven level of insulin produces a lessthan expected biological effect.


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Insulin resistance is an underlying feature of boththe metabolic syndrome and type 2 diabetes.

It is associated with abnormalities in both glucoseand lipid metabolism.

These abnormalities are associated with anincreased risk of cardiovascular disease and areoften present before the onset of type 2 diabetes.

Insulin resistance

Insulin resistance: the link between


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Obesity and type 2 diabetes are causallylinked.

The means by which excess body fat

causes type 2 diabetes is not clearlydefined, but it appears that excess fatincreases insulin resistance, raising bloodglucose levels and the likelihood of

developing diabetes.

Insulin resistance: the link betweenobesity and type 2 diabetes?


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Weight gain leads to insulin resistance throughseveral mechanisms:

Fat accumulation induces insulin resistancethrough changes in its hormonal and othersecretions. Protective hormones decline as fat

cells expand, particularly in the abdomen. Physical inactivity, both a cause and consequence

of weight gain, also contributes to insulinresistance.

Insulin resistance places a greater demand on the

pancreatic capacity to produce insulin, which alsodeclines with age, leading to the development ofclinical diabetes.

Weight gain and insulin resistance


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Impaired fasting glucose (IFG) andimpaired glucose tolerance (IGT) are notclinical entities in their own right but rather riskcategories for future diabetes and/or

cardiovascular disease.

The terms refer to different measurements ofabnormal glucose regulation: IFG in the fasting

state and IGT in the post prandial state.

Impaired glucose regulation


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IGT: Blood levels that are higher than normalin response to an oral glucose load but belowthe level of someone with diabetes.

IFG: raised fasting levels of glucose.



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IGT and IFG are considered risk categoriesfor developing type 2 diabetes.

Both IFG and IGT represent a riskof 25% to 50% of developing type 2diabetes in the next 10 years but it is notinevitable.

IFG and IGT are particularly amenable to

treatment through lifestyle interventions.



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Hypertension (high blood pressure):damages the smaller vessels in the circulatorysystem. Over time they become scarred,hardened, narrowed and less elastic. High bloodpressure can also both predispose to and

accelerate the development of atherosclerosis.

Systolic blood pressure: 130mm Hg of mercury

or

Diastolic blood pressure: 85mm Hg of mercury

Component of theMetabolic Syndrome(according to the IDFconsensus definition)

Hypertension

li id i


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Dyslipidaemia: Abnormal levels of lipids(fats) in the blood.

Dyslipidaemia

Dyslipidaemia and cardiovascular


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Dyslipidaemia is a major risk factor for cardiovascular

disease - for patients with metabolic syndrome as wellas those with type 2 diabetes

The dyslipidaemia observed in these high risk patientsis complex, and is characterised by:

Normal or only slightly elevated LDL cholesterol

Hypertriglyceridemia ( TG)

Low high-density lipoprotein cholesterol ( HDL)

Small, dense LDL particles All these elements can be measured in the blood.

Dyslipidaemia and cardiovasculardisease

Dyslipidaemia key terms:


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Triglyceride: The major form of fat made in the liver.

Most of the fat we eat is composed of triglycerides. The

rest is cholesterol.

Raised levels of triglycerides ( TG) are a

characteristic of diabetic dyslipidaemia.

Cholesterol: A fat of the body. It is absorbed from

animal fat we eat and is also produced by the liver.

Cholesterol circulates in the blood in the form of

particles called lipoproteins.

y p y

Triglyceride and cholesterol

Dyslipidaemia key terms:


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High density lipoprotein (HDL):protectsagainstcardiovascular disease. Therefore lowlevels of HDL-C ( HDL-C) increase cardiovascular

disease.

Low density lipoprotein (LDL): LDL-Ccholesterolpromotes cardiovascular disease.

y p y

Lipoproteins

Dyslipidaemia key terms


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Small LDL particles are different from the largerLDL particles and may be more atherogenic.Therefore the cholesterol blood level in a patientwith diabetes may be misleading.

The combination of normal or only slightlyelevated levels of LDL cholesterol, low HDL( HDL) and the presence of small dense LDLparticles are characteristic of diabeticdyslipidaemia.

y p y

LDL particles

Di b ti d li id i


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Diabetic dyslipidaemia and insulin resistance:

HDL and TG and insulin resistance arefrequently correlated (with or without type 2diabetes).

Diabetic dyslipidaemia and coronary arterydisease:

HDL, TG and LDL indicate a significant

increase in the risk of coronary artery disease.

Diabetic dyslipidaemia

Atherogenic dyslipidemic profile


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T


LDL small and denseparticles

()LDL cholesterol

HDL cholesterol

Apolipoprotein B

Non-HDL cholesterol

Fasting VLDL

Triglycerides

t e oge c dys p de c p o ein the metabolic syndrome

C di l di


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Cardiovascular disease (CVD): Cardiovasculardiseases are defined as diseases and injuries ofthe circulatory system: the heart, the bloodvessels of the heart, and the system of bloodvessels throughout the body, and to (and in) the

brain.

Stroke: Stroke is the result of a blood flowproblem within, or leading to, the brain and isconsidered a form of cardiovascular disease.

Cardiovascular disease

Cardiovascular disease and type 2


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The processes by which diabetes can lead tocardiovascular damage do not develop independently.Each may accelerate or worsen the others.

Atherosclerosis and hypertension are the two mainprocesses which lead to cardiovascular disease.

Microangiopathy and autonomic neuropathy areother damaging effects which are specific to diabetes.

In many people with diabetes these different factorsco-exist, resulting in progressive damage to the heart

and blood vessels.

ypdiabetes


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Hypertension, atherosclerosis


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T


Today the most widespread forms of cardiovascular disease

are those which start with damage to the blood vessels hypertension and atherosclerosis.

Hypertension

is at least twice as common in people with diabetes as in

the general population. is also more frequent in people with impaired glucose

tolerance.

Atherosclerosis

Not only are people with diabetes at increased riskof developing atherosclerosis, but the process also tends

to be accelerated, more severeand more widespread.

yp ,and type 2 diabetes

The cardiovascular disease triad


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The major clinical manifestations of cardiovasculardisease can be divided into three groups.

Brain andcerebralcirculation -cerebrovasculardisease

Heart andcoronary

circulation -coronary heart

disease

Lower limbs -peripheral

vascular disease

The cardiovascular disease triad

The clinical consequences of


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People with type 2 diabetes have the same risk of

heart attack as people without diabetes who havealready had a heart attack.

Women with diabetes are subject to sudden death300% more often and men with diabetes 50% moreoften than their counterparts without diabetes of thesame age.

Strokes occur twice as often in people with diabetesand hypertension as in those with hypertension alone.

A person with diabetes has a two to three-fold greater

risk of heart failure compared to a person withoutdiabetes.

qdiabetes and cardiovascular disease

Heart attacks in people with and without


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5

0

10

15

20

25

30

35

40

50

Incidence(%)

No prior heart attackPrior heart attack

People withoutdiabetes

People with diabetes

p pdiabetes over a period of seven years

Cardiovascular risk factors


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Advancing age

Diabetes and other high blood glucose conditions Dyslipidaemia Genetic background High alcohol consumption Hypertension

Insulin resistance Left ventricular hypertrophy Male gender Menopause Obesity

Sedentary lifestyle Smoking

Bold text: modifiable risk factor

Cardiovascular risk factors

What is a risk factor?


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A risk factor can be genetic or acquired.

It may be identified as a single measurement (egweight), disease (eg hypertension) or lifestylecharacteristic (eg smoking).

The condition must be associated with that disease in a

manner which is beyond chance alone. A causal link istherefore implied.

A risk factor will not necessarily always lead to thedevelopment of the disease.

The ultimate purpose of identifying a risk factor is tomodify it in order to prevent the disease.

What is a risk factor?

Prevalence of cardiovascular risk factors in people


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Risk Factor Prevalence

HypertensionPrevalence is at least double in people with type2 diabetes

High BloodCholesterol

Prevalence is similar in people with diabetes

High Triglycerideswith Low HDL

Prevalence is higher in people with diabetes

Left ventricularHypertrophy

Most commonly seen in people with long-standing high blood pressure, but is also seen inthe absence of elevated blood pressure in peoplewith diabetes

Obesity Prevalence is stronger in people with diabetes.Weight distribution is also usually different, withmore central obesity which is linked with atendency to develop coronary heart disease.

Smoking People with diabetes smoke less(presumably due to medical advice).

p pwith diabetes, compared to people without diabetes

Targets for common cardiovascular


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Risk Factors Targets

Dyslipidaemia Decrease LDL cholesterol levels(46 mg/dl or 1.2 mmol/l*)

Lower triglycerides(


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There are currently more than 230 million people with

diabetes worldwide. If nothing is done to slow theepidemic, the number will exceed 350 million by 2025.

In 2003, the five countries with the largest numbers ofpersons with diabetes were

India (35.5 million)

China (23.8 million)

the United States (16 million)

Russia (9.7 million)

Japan (6.7 million).

By 2025, the number of people with diabetes is expectedto more than double in Africa, the Eastern Mediterranean,the Middle East, and South-East Asia.

Diabetes - a growing threat

Diabetes a growing threat


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By 2025 the number of people with diabetes isexpected to rise by

20% in Europe 50% in North America 75% in the Western Pacific

85% in South and Central America. For developing countries, there will be a

projected increase of a 170% of cases;

For developed countries, there will be a projected

rise of42%.

Diabetes is the fourth main cause of death inmost developed countries.

Diabetes a growing threat

The prevalence estimates


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Diabetes Atlas second edition, IDF 2003

< 2%

2% - 5%

5% - 8%

8% - 11%

11% - 14%

14% - 17%

17% - 20%

>20

of diabetes worldwide 2003

The prevalence estimates


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Diabetes Atlas second edition, IDF 2003

< 2%

2% - 5%

5% - 8%

8% - 11%11% - 14%

14% - 17%

17% - 20%

>20

of diabetes worldwide 2025

Prevalence of diabetes


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10

7.5

5

2.5

0AFR EMME EUR

2003 2025

NA SACA SEA WP

Prevalence(%)

(2079 age group) by region

A growing threat

Di b t i th ld l d th


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Diabetes increased by one-third during the 1990s,

due to the prevalence of obesity and an ageingpopulation.

Diabetes is particularly common in ageingpopulations, and the incidence is increasing in

proportion to the number of people living longer. The incidence of type 2 diabetes in children and

adolescents has also risen dramatically in recentyears.

Young people with diabetes will develop diabetes-related micro-and macrovascular complications at arelatively young age.

Diabetes in the elderly and the young

A growing threat

Th b it id i


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Overweight and obesity can affect as many as30% 35% of people under the age of 30 insome developed countries.

In Europe, the UK has demonstrated the most

rapid increase in obesity which could see morethan 40% of the population obese by 2025.

Worldwide the prevalence of obesity is rising toepidemic proportions at an alarming rate, with

over half the worlds population already affected.

The obesity epidemic

A growing threat

Di bete d obe it


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International Obesity Task Force figures suggestthat up to 1.7 billion people are already at aheightened risk of weight related non-communicable disease such as type 2 diabetes.

These rising levels are likely to drive theprevalence of diabetes even higher than presentforecasts, which do not take into accountchanges in the obesity epidemic.

It is estimated that at least half of all diabetescases would be eliminated if weight gain inadults could be prevented.

Diabetes and obesity

Overweight and obesityh l hild (5 17 Y )


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35

30

25

20

15

10

5

0Americas Europe Near/Middle

EastAsia andPacific

Sub-SaharanAfrica

Worldwide

Overweight

Obese

Prevalence(%)

among school age children (517 Years)

The prevalence of male and female obesityl l i l t d E t i


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30 1020 0 10 20 30 40

% BMI 30

Yugoslavia

GreeceRomania

Czech Rep.

England

Finland

Germany

Scotland

Slovakia

PortugalSpain

Denmark

Belgium

Sweden

France

Italy

Netherlands

Norway

Hungary

Switzerland

levels in selected European countries

A growing threat

Th li ti f di b t


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TIMETOACT Type 2 diabetes,

the metabolic syndrome and cardiovascular disease in Europe

Diabetes is the leading cause of blindness andvisual impairment in adults in developedcountries.

Diabetes is the most common cause ofamputation which is not the result of an

accident.

People with diabetes are 15 to 40 times morelikely to require a lower-limb amputationcompared to the general population.

Many people with diabetes develop severekidney disease, which may be fatal if leftuntreated.

The complications of diabetes

A growing threatDiabetes and cardiovascular disease


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70%80% of people with diabetes die ofcardiovascular disease.

For each risk factor present, the risk ofcardiovascular death is about three times greater

in people with diabetes as compared to peoplewithout the condition.

Cardiovascular disease is the number one causeof death in industrialized countries. It is also set

to overtake infectious diseases as the mostcommon cause of death in many parts of the lessdeveloped world.

Diabetes and cardiovascular disease

Changes in coronary heartdi t lit t i th USA


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0

-10

-20

-30

-40

10

20

30

Co

ronaryheartd

iseasemortality(%)

People without diabetes People with diabetes

Men Women

disease mortality rates in the USA

The cost of diabetes


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The annual direct healthcare costs of diabetes

worldwide, for people in the 20 79 age bracket,is estimated to be at least 153 billioninternational dollars.

It is estimated that diabetes accounts for

between 5% and 10% of total healthcarespending in most countries and up to 25%in some.

If predictions of diabetes prevalence are fulfilled,total direct healthcare expenditure on diabetesworldwide will be between 213 billion and 396billion international dollars in 2025.

e cost o d abetes

The cost of diabetesDi bete d dio l di e e


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Cardiovascular disease is the most importantsingle contributor to diabetes costs.

In the industrialised world, CVD accounts for 57%of total medical care costs for people with

diabetes. The trend of escalating diabetes prevalence, with

its impact on CVD, will no doubt lead to animmense financial burden in many countries,

unless action is taken to prevent diabetes and itscomplications.

Diabetes and cardiovascular disease

The cost of diabetesEstimates of the cost of diabetes care by region


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0

20,000

40,000

60,000

80,000

100,000

120,000

140,000 R=2

R=3

AFR EMME EUR NA SACA SEA WP

(inmillioninte

rnational

dollars

)

Estimates of the cost of diabetes care by region

The cost of diabetesThe CODE-2 Study


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A collaborative study of the direct costs of diabetes ineight European countries, the CODE-2 studydemonstrated that type 2 diabetes is a serious andcostly condition.

The study estimated that:

The total direct medical costs for the 10 million peoplewith type 2 diabetes in these countries were 29 billionEuros in 1998.

Type 2 diabetes accounted for between 3% and 6% oftotal healthcare expenditure in the different countries.

It also showed that diabetes-related complications arethe main reason for the high costs.

The CODE-2 Study

Total annual direct medical costs for patientswith type 2 diabetes (CODE-2 1998)


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Germany12.4 billion Euros

Sweden

0.7 billion Euros

Netherlands0.4 billion Euros

Italy5.8 billion Euros

UK

2.6 billion Euros

Spain2.0 billion Euros

Belgium1.1 billion Euros

France4.0 billion Euros

Total for these 8 countries = 29 billion Euros

with type 2 diabetes (CODE 2 1998)

Direct healthcare costs relevant todiabetes the example of Code 2


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General healthcare cost per patient (US$)

Additional cost due to presence of diabetes (US$)

500

1,000

1,500

2,000

2,500

3,000

3,500

0

U

S$

Belgium

France

Germany

Italy

Netherlands

Spain

Sweden UK

diabetes the example of Code-2

The cost of diabetesImplications for health systems


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Direct health care costs of diabetes are high andrising

Direct health care costs of the metabolicsyndrome dominate health care budgets

Preventing or delaying the onset oftype 2 diabetes results in considerablecost reduction

Improving metabolic control can also reduce

health care resource use

Implications for health systems

Proportion of hospital bed days usedfor the treatment of diabetic complications


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for the treatment of diabetic complications

Managing Diabetes and DiabeticComplications


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The human and economic costs of diabetes could

be significantly reduced by investing inprevention, particularly early detection, inorder to avoid the onset of diabetic complications.

At least 50% of all people with

diabetes are unaware of theircondition.

In some countries this figure may riseto 80%.

Complications

Managing diabetesBlood glucose and lipids


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There is conclusive evidence that good control ofblood glucose levels can substantially reduce therisk of developing complications and slow theprogression in all types of diabetes.

The management of high blood pressureand raised blood lipids (fats) is equallyimportant.

In all societies, better control of these parameters

would contribute to a substantial improvement inquality of life.

Blood glucose and lipids

Recent Trials Relevant to thePrimary Prevention of Type 2 Diabetes


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Diabetes and Obesity, Time to Act, p.33, IDF 2004

Study Year Interventions Outcome

DaQing

(China)

1997 Diet, physical

activity or both(control group:general)

Reduction in diabetes incidence

31% in diet group, 46% inphysical activity and 42% in dietand physical activity compared tocontrol group

FinnishDiabetes

PreventionStudy

2001 Diet and physicalactivity (control

group: generaladvice)

Reduction by 58% of the risk ofdiabetes compared to control

group

DiabetesPreventionProgram(USA)

2002 Diet, physicalactivity,metformin andplacebo

58% reduction in incidence ofdiabetes with lifestyleintervention, 31% with metformin

STOP-NIDDM

2002 Acarbose orplacebo

32% patients randomised toacarbose and 42% randomised toplacebo developed diabetes

Primary Prevention of Type 2 Diabetes


82/100

Managing obesity


83/100



Lifestyle interventions, including diet and moderate

physical activity (for example, walking 25 minutes perday, 6 times per week) can reduce the risk of diabetesby as much as 4060%.

Weight loss drugs have a role in individuals in whomlifestyle changes are either insufficientto produce the required weight control or areimpossible to achieve because of physical incapacity.

Weight management is the best strategy to preventthe development of type 2 diabetes.

Screening for undiagnosed diabetes


84/100



Half or more of type 2 diabetes is undiagnosed.

Opportunistic screening during a healthcare visitfor other reasons can identify undiagnoseddiabetes, particularly in individuals at high risk.

Up to half of those afflicted already have signs ofcomplications at diagnosis.

Strong scientific evidence relating good metaboliccontrol to the prevention or delay of these

complications is now available.

Microvascular complications


85/100



Eye Problems

Kidney Problems

Foot Problems

Eye problems


86/100



All of these complications are common, and, ifleft untreated, lead to deterioration of vision andultimately, blindness.

They are all treatable if detected early and mostare potentially preventable.

The eye complications associated with diabetes (eitherspecific to diabetes or more common in people withdiabetes) are retinopathy, macular oedema, glaucomaand cataract.

Screening for eye problems


87/100



Screening for diabetic retinopathy is cost-effective where subsequent treatment, such aslaser treatment, is available and affordable.

Where there is no access to laser treatment,

good metabolic control aimed at delaying theprogress of diabetic eye disease is likely to becost-effective.

Managing eye problems


88/100



Diabetic eye disease can be prevented or delayed by

careful management of the underlying diabetes.

If detected early, well before symptoms begin, itsprogress can be further delayed by photocoagulation.

Laser treatment for diabetic retinopathy and macular

oedema is highly effective.

Laser screening is also particularly cost effective foryounger patients, in whom the number of years of sightsaved will be large.

Cataract can be dealt with cheaply and effectively bysurgical removal.

Foot problems


89/100



The combination of nerve damage and insufficientblood supply in the legs and feet of people withdiabetes often leads to painful ulcers, infection andgangrene. This can ultimately result in amputation and

even death.

Foot problems


90/100



Foot ulceration affects some 15% of all people with

diabetes some time during their lives.

In developed countries, amputation of lower extremities isat least 10 times more common in persons with diabetesthan in persons without diabetes.

In developed countries, hospitalisation for people withdiabetes-related foot ulcers is approximately 60% longerthan for people without foot ulcers.

The costs of diabetic foot problems are so high that a hostof interventions are likely to be cost effective depending on

the problem and the circumstances in which theseinterventions are carried out.

Managing foot problems


91/100



A number of interventions have been found to beeffective in preventing the consequences of

diabetic foot problems:

Education Pressure-relieving interventions

Multidisciplinary clinics

The cost effectiveness of managingfoot problems


92/100



Although sources of cost savings vary country bycountry, the strategies of education, pressure-relieving interventions and multidisciplinary clinicshave been judged to be cost-effective.

(Unfortunately data on cost-effectiveness comes

exclusively from developed countries.)

One study identifies patient education as the mostcost-effective intervention. Even if risk reduction isonly half of the 50%86% reported in the literature,

the economic benefits of implementing such anapproach will be substantial.

foot problems

Renal problems


93/100



The renal problems associated with diabetes areamong the most costly in terms of their directhealthcare costs.

People who develop these complications can, if leftuntreated, proceed to renal failure, which in turn

leads to premature death if dialysis or kidneytransplantation are not available.

When they are available, long-term dialysis or themore desirable option of transplantation brings high

healthcare costs to the individual and family, or to thehealthcare sector or, more typically, to both.

Screening for renal problems


94/100



Renal failure in diabetes can be detected very early byscreening for microalbuminuria (very small traces of

protein in the urine).

A number of studies suggest that when the facilities fortreatment are available, screening for microalbuminuria iscost-effective.

Treatment with ACE inhibitors (even in the absence ofhypertension) is deemed, at least in the USA, to be cost-saving. When these are not available much can be donewith other, less costly and more readily available anti-hypertensives (when hypertension is present). Improved

blood glucose is also an important part of the response. However, effective treatment must be available in order to

follow on from the detection of this early sign of renalfailure.

Managing renal problems


95/100



Keeping blood pressure at near-normal level inpeople with diabetes who also have hypertensionis known to be effective in preventing or delayingrenal failure.

Maintaining a near-normal level of blood glucosealso plays an important part.

In addition, even in the absence of hypertension,the anti-hypertensive ACE-inhibitor drugs havebeen shown to provide protection for the kidneyin people who have microalbuminuria.

The prevention of microvascularcomplications


96/100



Maintaining near-normal levels of blood glucose

and blood pressure significantly decreases therisk of microvascular complications in people withdiabetes.

The DCCT, UKPDS and Kumamoto Studies have

demonstrated this in regard tohyperglycaemia.

The UKPDS Study and HOT Trial have shownthe importance of the effective control of bloodpressure.

The control of dyslipidaemia is also of vitalimportance, as is, if necessary, weight reduction.

p

The prevention of macrovascularcomplications


97/100



The same basic improvements in diet andphysical activity that prevent type 2 diabetes arelikely to prevent CVD complications.

Also, a wide range of drugs has now been proven

to be effective in reducing the risk of CVD inpeople with diabetes, and in treating diabetes-associated CVD once it is present.

p

Drug therapy


98/100



Each of these drugs can decrease CVD risk by20% - 30% or more:

AspirinOne of the worlds least expensive drugs, aspirin has beenproven to be risk-beneficial in people with diabetes.

However, caution is needed if the risk of strokes resultingfrom bleeding is high.

Beta Blockers, Diuretics and ACE Inhibitors(angiotensin converting enzyme inhibitors): lower blood

pressure

Drug therapy


99/100



Each of these drugs can decrease CVD risk by20% - 30% or more:

ACE InhibitorsAlso the drug of choice for preventing renal disease the second most expensive complication of diabetes.

Lipid Lowering Agents such as statinsStatins appear to be beneficial in almost all peoplewith diabetes and seem to be safe over the usualrange of dosages used.

Highest Percentage Reduction of the Risk of DiabeticComplications in People with Type 2 Diabetes shown inRecent Studies


100/100

Strategy ComplicationReduction ofComplication

Lipid control Coronary heart disease mortality

Major coronary heart diseaseevent

Any atherosclerotic event

Cerebrovascular disease event

36%

55%

37%

62%

Blood PressureControl

Cardiovascular disease

Heart failure

Stroke

Diabetes-related deaths

51%

56%

44%

32%

Blood GlucoseControl

Heart Attack 37%

1 The 4S Study2 Hypertension Optimal Treatment (HOT) Randomised Trial3 UKPDS

type 2 diab.metabolic syndrome

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