Pre-diabetes. Dr Neel Basudev. GPSI Lambeth DICT, Diabetes Lead Lambeth CCG

Transcription

1 Pre-diabetes Dr Neel Basudev GPSI Lambeth DICT, Diabetes Lead Lambeth CCG

2 The Prevention of Diabetes

3 Where has this come from? Pre-diabetes mellitus (PDM) Term introduced by Tommy G. Thompson (Health & Human Services) and ADA in 2002 Touch of sugar, borderline diabetes, sugars bit high, high risk Background Description Definition Intervention

4 The diabetes continuum Normal At risk Pre-DM DM Salvageable risk

5 It s obvious to who?

6 Type 2 diabetes is a progressive condition Plasma Glucose 7mmol/L Postmeal glucose Fasting glucose -Cell Function Insulin resistance Insulin secretion Years of Diabetes Adapted from International Diabetes Center (IDC). Minneapolis, Minnesota. 6-6

7 How can we detect it? Fasting plasma glucose Easy, requires fasting, variable Oral Glucose Tolerance Test Complicated, expensive, picks up IGT, variable HbA1c Easy, average glucose, less variable, standardised

8 Diagnostic Criteria (WHO) Fasting plasma glucose (mmol/l) Plasma glucose 2 hours post 75 g glucose (mmol/l) Random plasma glucose (mmol/l) Glycated haemoglobin Normal < 6.0 < 7.8 < 7.8 < 42 mmol / mol) (6.0%) Impaired fasting glucose (IFG) < Impaired glucose tolerance (IGT) Diabetes mellitus (if asymptomatic, two tests required) < At risk or prediabetes : mmol / mol ( %) > 7.0 > 11.1 > 11.1 > 48 mmol / mol (> 6.5%)

9 10 yr cumulative DM incidence per 1000 pyear PDM conversion rates NGT Pre-diabetes >60 Age group (years) Source: Forouhi et al, Diabetic Medicine 2007

10 The DECODE Study Prevalence of pre-diabetes by age and sex Men Women % Age group (years) Source: The DECODE study group Diabetes Care 2003

11 The Prevention Paradox A large change in the risk in high-risk individuals will have a large change in their risk, but a small effect in the population. A small change in the risk in the total population is having a small effect on the disease rate in high risk people, but a large effect in the population. G. Rose

12 NHS Health Check Diabetes Filter

13 The big obesity problem The Foresight Report.50 by 50

14 The evolution of obesity

15 Risk Factors for PDM Positive family history (parents and siblings mainly) Overweight/obesity (BMI > 30 or >27.5 in Asian groups) BME group (South Asian, African-Caribbean, black African and Chinese descent and those from lower socioeconomic groups) Age over 40, but younger in BME groups Sedentary lifestyle A history of gestational diabetes in women Features of the metabolic syndrome (hypertension of >140/90 and dyslipidaemia)

16 Is PDM a disease?

17 Rate/100 pyear What happens as HbA1c goes up? CVD incidence Total mortality <5% 5-5.4% % 6-6.4% % >=7% HbA 1c Source: Khaw et al. Ann Int Med 2004

18 PDM increases CVD risk

19 Interventions Weight loss Lifestyle Exercise Drug treatment

20 Diabetes Prevention Programme US study, 3 years, PDM 45% BME Intensive lifestyle, metformin, placebo Low fat and calorie 150min activity (74%) and 7% weight loss (50%) Behaviour changes, monthly visits Risk of diabetes was reduced by 58% (P<0.001) in the intervention group 31% metformin group 6.9 people treated for 3 years to prevent 1 case 38% at 10 year follow up

21 Diabetes Prevention Study Finnish study, 3years, PDM Reduce weight and fat, increase fibre and exercise (see below) Similar results- Risk of diabetes reduced by 58% NNT to prevent one case of diabetes= 6.4 (over years) Weight reduction > 5% Fat intake < 30 E% Saturated fat intake < 10 E% Fibre intake 15 g/1000 kcal Physical activity > 30 min/day N Engl J Med 2001; 344:

22 The more you do, the more you get!

23 Successful completion?

24 Weight Change DPS

25 A Legacy Effect DPS

26 A Legacy Effect Da Qing

27 The main evidence summarised

28 BMI and Diabetes

29 Drugs or diet to prevent diabetes? Gillies et al. BMJ 2007;334:299

30 What are we trying to achieve? Reduction Increase

31 What we don t know Practicality and Intensity Average CCG. 15% high risk= 16,000. DPS= 113,000 dietician sessions WTE Dieticians CVD risk reduction Disease label Prevent or delay diabetes Cost $24billion for DPP Uptake DPP. 2million targeted. 30,000 OGTT Ability to change behaviour

32 The National and Local Picture Wave one of a national Diabetes Prevention Programme NHSE are making a significant investment of 60 million over the next 3 years they will fund the actual intervention itself but not the case finding or triage/referral process Main referral pathway in will be via GP then Health checks No national incentive scheme planned at this stage for primary care We have 2,000 patients currently read coded as prediabetes in lambeth

33 I took your advice doc and got a running machine

34 Thanks for listening Questions?

35 One Last Thing DESMOND for SMI Having a diagnosis of schizophrenia confers a 2 decade drop in life expectancy 60% attributable to physical health Modified DESMOND- effect of medications and making it more manageable for those who would be unable to focus for the original 6 hour session 700 patients in Lambeth who are on both the mental health register and have type 2 diabetes Any guess how many have done DESMOND?