PREVENTION OF TYPE 2 DIABETES AT NATIONAL LEVEL

Transcription

1 PREVENTION OF TYPE 2 DIABETES AT NATIONAL LEVEL Jaana Lindström PhD, Adjunct professor, Head of Unit Diabetes Prevention Unit Department of Chronic Diseases Prevention National Institute for Health and Welfare Helsinki, Finland

2 Outline OUTLINE: Epidemiology Prevention of type 2 diabetes: clinical evidence Identification of high-risk individuals National diabetes prevention programme in Finland 2

3 WHO 1999 criteria and ADA 2003 criteria Plasma venous glucose concentration, mmol/l ADA 2010 Diabetes: +HbA1c >6.5% Pre-diabetes: +HbA1c % 3

4 Type 2 diabetes* in Finland Women Men Total *data based on drug reimbursement and hospital registers Source: Sund et al: FinnDM II 4

5 Finrisk 1987 Finrisk 1992 Health 2000 Finrisk 2002 D2D 2004 Number of diabetics Prevalence in population surveys, % Epidemiology: Diabetes trends in Finland Drug register Population surveys Total estimate 0 Puska et.al. Yleislääkärilehti 2008;2:11-3 5

6 Disturbances in glucose metabolism in Finns aged y. FIN-D2D survey 2004 (n=2896) Men Women Diagnosed type 2 diabetes 7.4% 4.3% } 15.7% Screen-detected type 2 diabetes 8.3% 6.9% Impaired glucose tolerance 14.7% 15.9% Impaired fasting glucose 9.3% 4.8% Total*: 41.8% 33.2% } 11.2% Peltonen et. Al. Suom Lääkäril 2006;61:

7 Cost of diabetes treatment in 2007 Type 2 diabetes without complications eur Type 2 diabetes with complications eur In the long run, the costs related to loss of productivity due to diabetes (e.g. cost of early retirement) are 1,5x medical costs Source: Jarvala et al. Diabeteksen kustannukset Suomessa tutkimus, Dehko. 7

8 Outline Epidemiology Prevention of type 2 diabetes: clinical evidence Identification of high-risk individuals National diabetes prevention programme in Finland 8

9 Risk factors for type 2 diabetes Paulweber et al. Horm Metab Res 2010;42(Suppl 1): S3-S36 9

10 Body mass index and type 2 diabetes risk RR < x x >= RR < x x >=35.0 MEN Chan et al. Diabetes Care 1994; 17:961-9 WOMEN Colditz et al. Ann Intern Med 1995; 122:

11 Body mass index and prevalence of diabetes Prevalence, % Prevalence, % D2D-health survey Agegroup year Diagnosed diabetes Men Women < Body mass index Screen-detected diabetes Men Women < Body mass index Saaristo et al. BMC Public Health 2008;8:

12 BMI among year old men and women in Finland MEN WOMEN Pohjois-Karjala Pohjois-Savo 28 Turku/Loimaa Helsinki/Vantaa 27 Oulun lääni Lapin lääni 26 Pohjois-Karjala Pohjois-Savo Turku/Loimaa Helsinki/Vantaa Oulun lääni Lapin lääni Year : 70% of men were overweight BMI % 2007: BMI % BMI >30 19% BMI >30 21% 12

13 Obesity trends in adults

14 The Finnish Diabetes Prevention Study (DPS) The main aim: to determine whether lifestyle intervention of overweight, middle-aged men and women with impaired glucose tolerance (IGT) will prevent or delay the development of type 2 diabetes Individually randomized, controlled, multicenter trial 522 participants randomly allocated into intensive diet and physical activity intervention or control (standard) treatment Annual clinical and laboratory examination N Engl J Med 2001; 344:

15 DPS intervention goals: Weight reduction > 5% Fat intake < 30 % of total energy Saturated fat intake < 10 E% Fiber intake > 15 g/1000 kcal Aerobic and muscle strengthening exercise >30 min/day Lindström et al. Diabetes Care 2003; 26:

16 DPS lifestyle intervention: INTERVENTION GROUP: 7 dietary counselling sessions during the first year, and every 3 months thereafter Individually tailored diet based on 3-day food diaries Free-of-charge gym, individually designed exercise programme CONTROL GROUP: General advice about healthy diet and exercise habits No individualized counselling Lindström et al. Diabetes Care 2003; 26:

17 Cumulative incidence of diabetes DPS: Diabetes incidence was 58% lower among the intervention group compared with the control group after mean follow-up of 3,2 years HR Weight reduction > 5% Moderate fat <30 E% Low saturated fat <10 E% High fibre >15g/1000kcal Physical activity >30 min / day N Engl J Med 2001; 344:

18 DPS: Diabetes incidence was 43% lower among the intervention group compared with the control group after median follow-up of 7 years HR Intervention ceased Weight reduction > 5% Moderate fat <30 E% Low saturated fat <10 E% High fibre >15g/1000kcal Physical activity >30 min / day Lancet 2006; 368:

19 Incidence per 100 person years The DPS: The more goals achieved, the lower the risk! HR Number of goals achieved Weight reduction > 5% Moderate fat <30 E% Low saturated fat <10 E% High fibre >15g/1000kcal Physical activity >30 min /day Goals at year 3; incidence during 7 years follow-up 19

20 Prevention of type 2 diabetes by lifestyle intervention the evidence Study Intervention N Drop-out rate FU time Risk reduction Ref The Da-Qing Study China Diet Exercise Diet+exercise Control % 6 years 31% 46% 42% Pan et al Diabetes Care 20: The DPS Finland Diet+physical activity Control % 3,2 years 58% Tuomilehto et al new Engl J Med The DPP USA Diet+physical activity Metformin Placebo % 2,8 years 58% 31% DPP research group New Engl J Med 346: IDDP India Lifestyle Metformin Lifestyle+metformin Control % 30 months 28,5% 26,4% 28,2% Ramachandran et al Diabetologia 49: Japanese trial on IGT males Japan Diet+exercise Control % 4 years 67,4% Kosaka et al Diabetes Res Clin Pract 67: The SLIM Study The Netherlands Diet+physical activity Control % 3 years 58% Roumen et al Diabetic Medicine 25: EDIPS Newcastle UK Diet+physical activity Control % 3,1 years 55% Penn et al BMC Public Health 9 PREDIMED-Reus Spain Diet Control % 4 years 52% Salas-Salvado et al Diabetes Care 20

21 Meta-analysis of effect of lifestyle interventions on risk of developing type 2 diabetes NNT to prevent one case of diabetes = 6.4 (over years) Gillies et al BMJ 334:299-21

22 Outline Epidemiology Prevention of type 2 diabetes: clinical evidence Identification of high-risk individuals National diabetes prevention programme in Finland 22

23 The Finnish Diabetes Risc Score - FINDRISC AIM: To develop a simple, cheap and reliable way to identify people at high risk of type 2 diabetes in the general population which does not require: blood drawing other measurements by trained personnel medical equipment Lindström et al. Diabetes Care 2003;26:

24 FINDRISC: Risk model development: FINRISK-87 SURVEY Excluded if: - age < 35 yrs. - DM medication - missing variables 10 years follow-up (drug register) 182 T2D cases identified 4435 subjects with baseline data Validation cohort: FINRISK-92 SURVEY Excluded if - age < 35 yrs. - DM medication - missing variables 4586 subjects with baseline data 5 years follow-up (drug register) 67 T2D cases identified Lindström et al. Diabetes Care 2003;26:

25 Type 2 Diabetes Risk Score - FINDRISC: Age BMI Waist Physical activity Nutrition (f+v) Hypertension Hyperglycaemia Family history Lindström et al. Diabetes Care 2003;26:

26 DPS: Diabetes in the intervention vs. control group by baseline FINDRISC Incidence rate per 100 person-years % NNT= 3.6 NNT= 8.3 All FINDRISC Control Intervention Diabetes Care 2008; 31:

27 FINDRISC is used also outside of Finland FINDRISC modified FINDRISC 27

28 Outline Epidemiology Prevention of type 2 diabetes: clinical evidence Identification of high-risk individuals National diabetes prevention programme in Finland 28

29 NATIONAL DIABETES PROGRAMME: DEHKO Coordinator: The Finnish Diabetes Association Researchers Experts Clinicians Other professionals People with diabetes 1) Prevention of type 2 diabetes 2) Improving the quality of diabetes care 3) Support for self-care 29

30 Development Programme for the Prevention and Care of Diabetes in Finland: DEHKO Programme for the Prevention of Type 2 Diabetes in Finland Three strategies: Population strategy High risk strategy Early diagnosis and treatment strategy 30

31 Development Programme for the Prevention and Care of Diabetes in Finland: DEHKO Programme for the Prevention of type 2 Diabetes in Finland Pilot project FIN-D2D

32 FIN-D2D: Participating hospital districts Total population of Finland: ~5,2 million 20 hospital districts; 348 municpalities 5 hospital districts chose to participate in FIN-D2D: ~110 health centres in municipalities ~110 municipal occupational health care providers ~100 private occupational health care providers Target population ~1,5 million 32

33 FIN-D2D: Main aims Clarify the feasibility of a diabetes prevention programme based on the experiences from the Finnish Diabetes Prevention Study DPS within primary health care in Finland Make screening, diagnosis and interventions part of every-day work of primary health care Create new models and practices for prevention of diabetes and obesity Increase awareness of the risks of obesity and diabetes 33

34 FIN-D2D partners: Finnish Diabetes Association National Public Health Institute The 5 hospital districts Funding: Municipalities in hospital districts Ministry of Social Affairs and Health Finland s Slot Machine Association Finnish Diabetes Association National Public Health Institute External research grants 34

35 FIN-D2D: High-risk strategy Screening, diagnosis and interventions: The Finnish Diabetes Risk Score FINDRISC CHD Gestational diabetes IFG/IGT Score < 7 Score 7-14 No preventive measures Written information Score 15 2h OGTT Diabetes Normoglycemia IFG IGT Treatment of hyperglycemia and risk factors INTERVENTIONS FOLLOW-UP 35

36 FIN-D2D Project: Interventions Primary health care or other players: Weight control groups Quit smoking-groups Exercise groups Self-activity groups Group intervention Identification of high-risk subject 1. Visit (nurse) 2. Visit (doctor) Individual intervention Yearly follow-ups Self-initiated lifestyle changes Other Intervention forms Regular healthcare visits 36

37 FIN-D2D: Positive experiences Nationwide recognition and icreased awareness of obesity and diabetes problem Models of lifestyle intervention are possible to implement in primary health care people with moderate or high diabetes risk identified and participated interventions within primary health care Screening and risk assessment part of daily practice: The FINDRISC OGTT testing increased x3 Waist circumference measurement Treatment paths built Collaboration Hospital districts, municipalities, health care centers, occupational health care, NGOs, pharmacies, research organizations Multi-professional team work International influence (DE-PLAN, IMAGE etc) 37

38 Visits and FINDRISC completers years visits/month ~10% of the population have done the FINDRISC Käynnit Visits sivulla Riskitestin FINDRISC täyttö Joulukuu

39 Transition from disease-based prevention to health promotion in wider scope Health promotion units were establised in all participating hospital districts Prevention was recognized important (however not in all levels ) Health in All Policies 39

40 FIN-D2D: Challenges Primary care information technology: several different systems; difficulties to monitor people Preventive work in health care as projects (requires coordination, now often competion of already scarce resources) How to get physicians involved in primary preventive work? Questionnaires to assess person s need and motivation for lifestyle change are too complicated How to get men involved in the interventions? How to get different socioeconomic groups activated? What to do with high-risk persons who do not participate in these sorts of programmes? How many are they? 40

41 FIN-D2D: High-risk individuals >10,000 high risk persons included in interventions in primary and occupational health care by the end of year Additional 9,900 persons with risk score 7-14 have received written information. More than 20,000 have contacted primary or occupational health care system due to programme. 41

42 D2D high-risk cohort n= (women 67 %) Intervention No follow-up n= (45,6 %) Follow-up information n= (54,4 %) Follow-up within 9-18 months n= No baseline OGTT n= diabetes n= year follow-up n=2 798 Suom Lääkäril /

43 D2D: Lifestyle intervention results Majority of the D2D high-risk participants chose individual lifestyle counselling instead of group counselling No strong tradition for group activities (neither among caregivers nor clients) Would require changes in models of care, e.g. invitations based on patient register search Mean number of intervention visits was 2,9 Mean 1-year weight reduction was 1,2 kg (in the DPS 4,5 kg) 17% lost more than 5% 43

44 D2D: 1-year weight change by number of intervention visits Weight change Increased >2,5% No change Reduced 2,4-4,9% Reduced <5% Number of visits Suomen Lääkärilehti 26-31,

45 Diabeteksen ilmaantuvuus (%) D2D: 1-year diabetes incidence* and relative risk by weight change 8 7 Ref +10 % RR % % 1 0 >5% lasku 2,5-4,9% lasku Ei muutosta >2,5% nousu *Age-adjusted Diabetes Care 2010; 33:

46 Population level evaluation FINRISK 2002 Northern Karelia Kainuu Turku-Loimaa Helsinki-Vantaa Northern Savo Northern Ostrobothnia FINRISK 2007 Northern Karelia Kainuu Turku-Loimaa Helsinki-Vantaa Northern Savo Northern Ostrobothnia N=2039 N=919 N=2255 N=1295 South Ostrobothnia Northern Ostrobothnia Northern Savo Central Finland Kainuu Northern Karelia FIN-D2D 2004 South Ostrobothnia Central Finland Pirkanmaa N=2896 FIN-D2D 2007 South Ostrobothnia Central Finland Pirkanmaa N=2868 Pirkanmaa Turku, Loimaa Helsinki, Vantaa Year Salopuro T ym. unpublished 46

47 D2D: Findings on the national level Half of all diabetes cases in the age group are unidentified Obesity trend in Finland seems to leveling off 47

48 Future challenges The diabetes epidemic prevails How to continue the work started by DEHKO? Who is in charge? Children and adolescents? The work has only started 48

49 European evidence-based guideline for the prevention of type 2 diabetes Toolkit for the prevention of type 2 diabetes Quality and outcome indicators for prevention of type 2 diabetes 49