practice: A multidisciplinary approach Richard Hobbs, MD Oxford, - PowerPoint PPT Presentation

Managing diabetes in daily cardiovascular practice: A multidisciplinary approach Richard Hobbs, MD Oxford, United Kingdom Cardio Diabetes Master Class February 22-23, 2019 - Barcelona, Spain

Managing diabetes in daily clinical practice: a multi-disciplinary approach Richard Hobbs Nuffield Professor and Head, Nuffield Department of Primary Care Health Sciences University of Oxford, United Kingdom Speaker or sponsorship disclosures in past 5 years: Amgen, Bayer, BMS, Boehringer Ingelheim, Medtronic, Merck, Novartis, Pfizer, Roche

Type 2 Diabetes Mellitus healthcare burden There are CV disease is the CV disease Over 29 million approximately leading cause of contributes up people in the 1.7 million morbidity and to 49% of total US currently new cases mortality in direct costs of have diabetes 1 of diabetes in the patients with T2D 2 treating T2D 3 US every year 1

Prevention or delaying onset of Diabetes becomes increasingly important Why ? How ?  CV risk is incompletely  Tackling Obesity/ sedentary explained by conventional lifestyle/ caloric intake risk factors  Legislation  Prognosis is worse with duration  CV risk factor and CV prevention medications

Trend in obesity prevalence among adults Health Survey for England 1993 to 2015 (3yr av) Adult (aged 16+) obesity: BMI ≥ 30kg/m 2

Trend in excess weight among adults Health Survey for England 1993 to 2015 (three-year average) Adult (aged 16+) overweight including obese: BMI ≥ 25kg/m 2

Trend in severe obesity among adults Health Survey for England 1993 to 2015 (three-year average) Adult (aged 16+) severe obesity: BMI ≥ 40kg/m 2

Prevalence of overweight and obesity by age: men Health Survey for England 2015 Adult (aged 16+) BMI thresholds: overweight: 25 to <30kg/m 2 ; Obese: ≥30kg/m 2

Change in prevalence of health risk categories Using both BMI and waist circumference: Health Survey for England 1993‐1994 2014‐2015 Adults aged 16+. Using combined waist circumference and BMI classification, as recommended by NICE

Food energy from non-milk extrinsic sugars Men and women aged 19-64 and 65+ years: National Diet and Nutrition Survey (2012/13 to 2013/14)

Estimated daily salt intake Men and women aged 19-64 and 65+ years; National Diet and Nutrition Survey (2008/09-2011/12) & Assessment of dietary sodium (2014)

Consumption of oily fish Men and women aged 19-64 and 65+ years; National Diet and Nutrition Survey (2012/13 to 2013/14)

Relative Risk of BMI for type 2 diabetes 84,941 nurses: 16 years follow-up 40 Relative risk of type 2 38.8 30 diabetes 20 20.1 10 7.6 1.0 0 15 20 25 30 35 40 Body mass index Hu FB. N Engl J Med. 2001; 345:790-7.

Obesity in children

BMI status of children by age National Child Measurement Programme 2016/17 Obese 9.6% Reception Obese 20.0% Year 6 This analysis uses the 2 nd , 85 th , 95 th and 99.6 th centiles of the British 1990 growth reference (UK90) for BMI to classify children as underweight, healthy weight, overweight , obese or severely obese.

Prevalence of overweight and obesity Children aged 2-10 and 11-15 years; Health Survey for England 2014-2016 Child overweight BMI between ≥ 85 th centile and <95 th centile, child obesity BMI ≥ 95 th centile of the UK90 growth reference

Food energy from non-milk extrinsic sugars Children aged 4-10 and 11-18 years: National Diet and Nutrition Survey (2012/13 to 2013/14 combined)

Estimated daily salt intake Children aged 4-6, 7-10 and 11-18 years: National Diet and Nutrition Survey (2008/09 to 2011/12) Data not available for NDNS Years 5 & 6 (2012/13 to 2013/14)

Consumption of oily fish Children aged 4-10 and 11-18 years: National Diet and Nutrition Survey (2012/13 to 2013/14)

BMI during adolescence and CV mortality Twig G et al, NEJM 2016;374:2430-40

Potential solutions to diabetes/CVD prevention?

Public health population primary prevention strategies

Use of taxation to change lifestyle behaviours

Pooled estimates of effects of lifestyle interventions on primary prevention of T2DM -50% BMJ 2007

What are effective public health tobacco control policies? Cornerstone of tobacco control strategy: Do what is known to work and do it efficiently  Reduce affordability of tobacco (tax and illicit)  Mass media and social marketing campaigns  Enforcement to restrict youth access  Smokefree places  Smoking cessation support – Programme administration and management – Monitoring and surveillance Best Practices for Comprehensive Tobacco Control Programs — 2014.Atlanta: U.S. Department of Health and Human Services, Centers for Disease

Patient-level lifestyle intervention strategies

Lifestyle vs Metformin vs placebo in primary prevention of T2DM Diabetes Prevention Program - 31% Parallel - 58% DPP : N Engl J Med 2002; 346: 393-403 .

Pragmatic trials in weight behaviour

Pragmatic trials in weight behaviour

Management priorities to reduce CV risk of Diabetes  Prevent diabetes – Public health strategies – Population strategies in those at risk (obese and overweight) in community and primary care  Identify and treat diabetes early – Primary care case finding • patients presenting with any CV risk factor – Elevated BP, lipids, smokers, overweight

Management priorities to reduce CV risk of Diabetes  Prevent diabetes  Identify and treat diabetes early  In established diabetes, use guideline recommended strategies – Multifaceted risk reduction – Achieve targets – Consider lower targets

EUROASPIRE IV: Proportions at LDL-C targets in patients on lipid lowering at interview . 2012-13, EUROASPIRE V J Prev Cardiolog 23, 636-648.

EUROASPIRE IV: Action taken regarding statin use % Discontinued % Changed to % Returned to % Initiated A B high C low D Gender Men 68.3% (233/341) 10.7% (380/3548) 13.0% (306/2358) 31.4% (480/1531) Women 61.2% (79/129) 12.6% (134/1067) 11.5% (89/775) 38.7% (163/421) Age <60 years 66.4% (85/128) 9.8% (143/1456) 14.5% (126/866) 30.6% (220/718) ≥60 years 66.4% (227/342) 11.7% (371/3159) 11.9% (269/2267) 34.3% (423/1234) A No statin at discharge: % statin at interview. B Statin at discharge: % no statin at interview. C No or low/moderate intensity statin at discharge: % high intensity LDL-C lowering at interview. D High intensity LDL-C lowering at discharge: % low/moderate intensity statin or no statin at interview.

Persistence with lipid-lowering drugs at one-year Various methods to define discontinuation have been used 90 % Persistence with LLD at One-Year 80 70 60 50 40 30 20 10 0 Caspard Ellis Catalan Perreault Abraha Yang Larsen Sturken- Mantel- boom Teeuwisse USA CA ITA NL UK DK CAVE: Various methods to define discontinuation have been used. Caspard. Clin Ther. 2005; Perreault. Eur J Clin Pharmacol . 2005; Ellis. J Gen Intern Med . 2004; Abraha. Eur J Clin Pharmacol . 2003; Yang. Br J Clin Pharmacol . 2003; Larsen. Br J Clin Pharmacol . 2002; Catalan. Value Health. 2000; Mantel-Teeuwisse AK, et al. Heart. 2004.

Persistence with lipid lowering drugs USA Italy NL 100 90 % Fully Adherent: >80% PDC 80 70 60 50 40 30 20 10 0 0 3 6 9 12 18 24 Months After Starting Treatment US data: Benner et al. JAMA. 2002;288:255-261. Other data from general practice databases in NL and Italy data on file Pfizer Inc, NY, USA.

Management priorities to reduce CV risk of Diabetes  Prevent diabetes  Identify and treat diabetes early  Use guideline recommended strategies – Multifaceted risk reduction – Achieve targets – Consider lower targets  Critical role of primary care teams in CV risk management

Management priorities to reduce CV risk of Diabetes  Prevent diabetes  Identify and treat diabetes early  Use guideline recommended strategies – Multifaceted risk reduction – Achieve targets – Consider lower targets  Critical role of primary care teams in all of the above – Case finding of diabetes in all those with CV risk factors – Brief interventions for lifestyle factors and referral for support – Treat to CV risk factor targets, especially in those with diabetes  Explicit clinical pathways defined, training on targets, time for consultations (audit & feedback on performance)

Conclusions  Prevention of diabetes strategies are needed • Reducing obesity • Early diagnosis of diabetes (role of screening?)  Maximise traditional CV risk reduction • Consider novel diabetes drugs in those with established CVD  Important role for primary care teams – explicit roles and clinical pathways