Diabetes 101 Joint Task Force on Diabetes Prevention and Awareness - PowerPoint PPT Presentation

Diabetes 101 Joint Task Force on Diabetes Prevention and Awareness March 8 th , 2012 Thomas L. O’Connell, MD UNC Department of Medicine, Division of Endocrinology thomas_oconnell@med.unc.edu

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

Common Types of Diabetes • Type 1 diabetes in adults • 5% of diagnosed cases of diabetes • Type 2 diabetes in adults • 90% to 95% of diagnosed cases of diabetes National Diabetes Fact Sheet, CDC, 2011. http://www.cdc.gov/diabetes/pubs/factsheet11.htm

Etiologic Classification of Diabetes Mellitus Type 1 (<10%) β -cell destruction with lack of insulin Type 2 (>90%) Insulin resistance + insulin deficiency Other specific types Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197.

Natural History of Type 2 Diabetes *Postprandial glucose 350 300 Glucose 250 Fasting glucose (mg/dL) 200 150 100 Insulin resistance 250 % 200 Relative 150 100 to Normal At risk for b -cell dysfunction 50 Insulin level diabetes 0 25 30 -10 -5 0 5 10 15 20 Years * Post Prandial = 1-2 h ppg Bergenstal RM et al. Management of Type 2 Diabetes in Endocrinology. 4th Edition; Philadelphia, 2001

Common Types of Diabetes • Gestational Diabetes (GDM) • diagnosed during pregnancy • 5% to 10% of women with GDM are found to have diabetes, usually type 2, immediately following pregnancy • 35% to 60% of women with GDM will develop diabetes in the next 10 to 20 years • affects at least 7% of pregnancies National Diabetes Fact Sheet, CDC, 2011. http://www.cdc.gov/diabetes/pubs/factsheet11.htm

Diagnostic Criteria for Diabetes A1C  6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.* OR FPG  126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.* OR 2-h plasma glucose  200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.* OR In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose  200 mg/dl (11.1 mmol/l) * In the absence of unequivocal hyperglycemia, should be confirmed by repeat testing. ADA. Diabetes Care 35 (suppl. 1): s11-63, 2012

Screening • Testing should be considered in all adults who are overweight (BMI ≥25 kg/m 2 *) and have additional risk factors: – physical inactivity – first-degree relative with diabetes – members of a high-risk ethnic population (e.g., African American, Latino, Native American, Asian American, Pacific Islander) – women who delivered a baby weighing >9 lb or were diagnosed with GDM – hypertension (≥140/90 mmHg or on therapy for hypertension) – HDL cholesterol level <35 mg/dl and/or a triglyceride level >250 mg/dl – women with polycystic ovary syndrome – A1C ≥5.7%, IGT, or IFG on previous testing – other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) – history of CVD • In the absence of the above criteria, testing diabetes should begin at age 45 years • If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status. *At-risk BMI may be lower in some ethnic groups. ADA. Diabetes Care 35 (suppl. 1): s11-63, 2012

U.S. Diabetes Prevalence All Ages, 2010 • 25.8 million people have diabetes • Diagnosed: 18.8 million people • Undiagnosed: 7.0 million people National Diabetes Fact Sheet, CDC, 2011. http://www.cdc.gov/diabetes/pubs/factsheet11.htm

Estimated percentage of people aged 20 years or older with diagnosed and undiagnosed diabetes, by age group, United States, 2005-2008 Source: 2005 – 2008 National Health and Nutrition Examination Survey

Diabetes Incidence A total of 1.9 million new cases of diabetes were diagnosed in 2010 in the United States among people aged 20 years and older. National Diabetes Fact Sheet, CDC, 2011. http://www.cdc.gov/diabetes/pubs/factsheet11.htm

Diabetes Impact 25 million with diabetes, perhaps 70 million with “ prediabetes ” Daily Annually Cost $476,712,329 $174,000,000,000 New cases 4,658 1,700,000 Deaths 641 234,000 Amputations 195 71,000 ESRD 129 47,000 Blindness 66 24,000 Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008.

Diabetic Complications Microvascular Macrovascular Retinopathy Stroke Heart Nephropathy Disease Neuropathy Peripheral Vascular Disease Harris MI. Clin Invest Med 1995;18:231-239 Nelson RG et al. Adv Nephrol Necker Hosp 1995;24:145-156 World Health Organization, 2002;Fact Sheet N° 138

Diabetes Complications • Diabetes is the leading cause of: – kidney failure • 48,374 people with diabetes began treatment for end stage kidney disease in 2008 – new cases of adult blindness • 4.2 million people with diabetes aged 40 and older had diabetic retinopathy in 2005-2008 – nontraumatic lower-limb amputations • Over 65,000 nontraumatic lower-limb amputations were performed in people with diabetes in 2006 National Diabetes Fact Sheet, CDC, 2011. http://www.cdc.gov/diabetes/pubs/factsheet11.htm

Diabetes Complications • The risk of periodontal disease is two to three times higher in adults with diabetes • About one-third of people with diabetes have severe periodontal disease • 60% to 70% of people with diabetes have mild to severe nervous system damage • Almost 30% of people with diabetes aged 40 years and older have impaired sensation in the feet • People with diabetes are twice as likely to have depression National Diabetes Fact Sheet, CDC, 2011. http://www.cdc.gov/diabetes/pubs/factsheet11.htm

Can we do anything about microvascular complications?

Comparing intensive to conventional treatment for type 1 diabetes, DCCT achieved separation of A 1 C and BS A1C separation, 9.0 vs 7.1 % Average BS separation, 231 vs 155 mg/dL

DCCT: Absolute Risk of Sustained Retinopathy Progression by HbA 1c and Years of Follow-up Mean HbA 1c = 11% 24 10% 9% 20 16 Rate per 12 100 person- years 8% 8 4 7% 0 0 1 2 3 4 5 6 7 8 9 Time during study (y) DCCT Research Group. Diabetes . 1995;44:968-983.

In the DCCT, compared to conventional therapy, intensive therapy reduced the cumulative incidence of 3-step worsening of retinal photos Primary prevention cohort Secondary intervention cohort

Summary of risk reduction -- DCCT • Retinopathy – 76% reduction of new onset – 54% reduction of progression • Nephropathy – 39% reduction of occurrence of microalbuminuria – 54% reduction of occurrence of albuminuria • Neuropathy – 60% reduction of occurrence

UKPDS Epidemiologic Data in Type 2 Diabetes Lowering HbA 1c and Rates of Diabetes Complications Every 1% reduction in mean HbA 1c * translates to: • 37% reduction of risk for microvascular complications • 21% reduction of risk for death related to diabetes • 14% reduction of fatal and nonfatal myocardial infarction and in all cause mortality • 43% reduction of risk of amputation or death from peripheral vascular disease * P <0.0001 Stratton IM, et al. BMJ . 2000;321:405-412.

Intensive Diabetes Therapy: Reduced Incidence of Complications DCCT Kumamoto UKPDS 9  7.2% 9  7% 8  7% HbA1c 63% 69% 17-21% Retinopathy Nephropathy 54% 70% 24-33% Neuropathy 60% Improved - Cardiovascular 41% (NS) - 16% (p=0.052) disease DCCT Research Group. N Engl J Med . 1993;329:977-986. Ohkubo Y, et al. Diabetes Res Clin Pract . 1995;28:103-117. UKPDS 33: Lancet 1998; 352, 837-853.

What about macrovascular disease?

Diabetes & 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 – 67% have high blood pressure – smoking doubles the risk for heart disease National Diabetes Fact Sheet, CDC, 2011. http://www.cdc.gov/diabetes/pubs/factsheet11.htm

Type 2 Diabetes and CHD: After 7 yr followup, the presence of diabetes is as great a risk factor for MI, as is a history among nondiabetics of having a prior MI Nondiabetic Patients Diabetic Patients 50 45.0 P <0.001 P <0.001 40 7-Year Incidence of MI 30 20.2 18.8 20 10 3.5 0 No prior MI Prior MI No prior MI Prior MI n=1304 n=69 n=890 n=169 More recent studies suggest that this is perhaps only true for those with fairly long-standing diabetes – duration over ten years. The risk is about 2-3 times that of non-diabetic individuals without CAD. Haffner SM et al. N Engl J Med. 1998;339:229; Arch Intern Med. 2011;171:404