Common Chronic Disease- DM/HD/IHD. Dr W.B.Chan Clinical Director Qualigenics Diabetes Centre

Common Chronic Disease- DM/HD/IHD Dr W.B.Chan Clinical Director Qualigenics Diabetes Centre

Pattern of Mortality in Hong Kong

Cardiovascular Mortality

Cerebrovascular Mortality

Proportion Due to Cardiovascular Diseases 29 28.5 28 27.5 27 26.5 26 25.5 25 24.5 24 Percentage of Cardiovascular death 1981 1991 1998 1999 2000

What is coronary heart disease?

Symptom of CHD Chest pain Exertion related Radiate to arm and jaw Sweating Shortness of breath Nausea Syncope

What is stroke

Haemorrhagic Stroke

Ischaemic Stroke

Clinical Features of Stroke Hemiplegia Dysphasia Facial asymmetry Diplopia Coma or death Swallowing difficulty Incontinence Numbness Dribling of saliva Ref : 7 Central Health Education Unit (Hong Kong)

What is blood pressure? Blood pressure refers to the pressure exerted by circulating blood on the inner walls of the arteries that carry blood from the heart. the systolic pressure as the heart contracts and the diastolic pressure as it relaxes between beats.

Electronic Sphygomanometer

Classification of HT(JNC 7) SBP/DBP Category <120/80 Normal 120-139/80 139/80-8989 Prehypertension >140/90 Hypertension 140-159/90 159/90-9999 Stage 1 >160/100 Stage 2

Prevalence of hypertension*: North America and Europe Prevalence (%) 80 70 60 50 40 30 20 10 0 Men Women Total United States Canada Europe Italy Sweden England Spain Finland Germany * BP 140/90 mmhg or treatment with antihypertensive medication Wolf-Maier K, et al. JAMA 2003;289:2363-2369

Prevalence of HT in Hong Kong 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% Male Female 10.00% 0.00% 15-24 25-34 35-44 45-54 55-64 >65 Overall prevalence: 27.2% Male 30.1% Female 24.9%

Change of Blood Pressure with Age

Hazard Ratio of Stroke in Relation to SBP

Hazard Ratio of IHD in Relation to SBP

Composite Endpoint in Relation to SBP

Relative Contribution of DBP and SBP to Cardiovascular Risk

Elderly with Isolated Systolic Hypertension

Multiple antihypertensive agents are needed to achieve target BP Number of antihypertensive agents Trial Target BP (mmhg) 1 2 3 4 UKPDS DBP <85 ABCD DBP <75 MDRD MAP <92 HOT DBP <80 AASK MAP <92 IDNT SBP <135/DBP <85 ALLHAT SBP <140/DBP <90 DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure Bakris GL, et al. Am J Kidney Dis 2000;36:646-661; Lewis EJ, et al. N Engl J Med 2001;345:851-860; Cushman WC, et al. J Clin Hypertens 2002;4:393-404

WHO Criteria for diabetes (DM) Fasting Plasma Glucose 2 hour glucose (mmol/l( mmol/l) 5.5 normal 5.6-6.9 6.9 IFG/IGT 7.0 DM <7.8 7.8-11.1 >11.1 IFG/IGT DM IFG=impaired fasting glycemia IGT=impaired glucose tolerance

Age-adjusted prevalence of type 2 DM in the 35-64 age group 12.0% 10.0% 8.0% 10.2% 9.5% 6.0% 4.0% Women Men 2.0% 0.0% Prevalence Lam TH, et al. Diabet Med 2000;17:798-806

Mortality rate is twice as great in patients with diabetes Mortality rate (deaths per 1000 patient-years) 35 30 25 20 15 10 5 0 Ratio 2.5 Ratio 2.2 Ratio 2.1 Control Diabetes Whitehall study Paris Prospective study Helsinki Policemen study Balkau B et al. Lancet 1997; 350: 1680.

Diabetes and Life Expectancy Male Female Diabetic Nondiabetic Nondiabetic Diabetic Mortality(every 1000 person-year) 5.88 13.69 5.33 13.15 Life Expectancy 77.5 64.7 82.9 70.7 Health Adjusted Life Expectancy 70.2 58.3 73.5 62.8

Risk of MI is increased in type 2 diabetes * Risk of fatal or nonfatal MI (%) 60 40 20 0 No prior MI Prior MI Nondiabetic subjects * Type 2 diabetic subjects n = 1304 n = 69 n = 890 n = 169 7-year incidence in a Finnish-based cohort *p < 0.001 versus no prior MI p < 0.001 vs no diabetes Adapted from Haffner SM. New Engl J Med 1998; 339: 229 34.

Diabetes is associated with major CVDs in Asia Pacific Fatal CHD Fatal cerebrovascular disease Other fatal CVD All fatal CVD Fatal CHD and nonfatal MI Fatal cerebrovascular disease and nonfatal stroke 0 0.5 1 1.5 2 2.5 3 3.5 Hazard ratio associated with having diabetes (95% CI) Adapted from Asia Pacific Cohort Studies Collaboration. Diabetes Care 2003; 26: 360 6.

Diabetes increases the risk of mortality in Asia Pacific 3 Data from 24 Asia Pacific cohort studies (n = 161,214) Crude annual death rate (%) 2 1 1.1% 2.4% CVD accounted for 46% of the known causes of death in those with diabetes 0 Without diabetes With diabetes Asia Pacific Cohort Studies Collaboration. Diabetes Care 2003; 26: 360 6.

Incidence of diabetes in end-stage renal failure: Australia Type 1 1980 2000 Type 2 (insulin requiring) Type 2 (non insulin) Total new patients 500 1800 Number of diabetic patients 400 300 200 100 1500 1200 900 600 300 Number of new patients 0 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 Year of entry 0 Australian and New Zealand Dialysis and Transplant Registry.

Hong Kong Renal Registry (95-99) 99) 99 98 97 Diabetes Non-DM 96 95 0 1000 2000 3000 4000 5000 Overall 58% increase DM 100% increase Non-DM 48% increase No of cases of Renal replacement therapy Lui SF et al HK J Nephrology 2000

Visual Impairment Due to Diabetes

Retinopathy

UKPDS: increased risk of diabetes-related complications corresponding with a 1% increase in HbA 1c 1% increase in HbA 1c 0.9% decrease in HbA 1c 21% 14% 12% 37% 25% Increase in any diabetesrelated endpoint * Increase in risk of MI* Increase in risk of stroke** Increase in risk of microvascular complications* Decrease in risk of microvascular complications *p < 0.0001; **p = 0.035; p = 0.0099 Adapted from UKPDS Group. UKPDS 35. BMJ 2000; 321: 405 12; UKPDS Group. UKPDS 33. Lancet 1998; 352: 837 53.

Decline in β-cell function is associated with loss of glycaemic control 9 Conventional HbA 1c (%) 8 7 Intensive 6 0 4.5 6.2% = normal range of HbA 1c 0 3 6 9 12 15 Years from randomisation Adapted from UKPDS Group. UKPDS 33. Lancet 1998; 352: 837 53.

The UKPDS demonstrated progressive decline of β-cell function over time 100 β-cell function (% β) 80 60 40 20 Mean β-cell function at diagnosis Start of treatment p < 0.0001 0 10 9 8 7 6 5 4 3 2 1 0 1 2 3 4 5 6 Time (years) HOMA model, diet-treated n = 376 Adapted from Holman RR. Diabetes Res Clin Pract 1998; 40 (Suppl): S21 5.

Incidence of Diabetic Endpoint with Regard to Glycaemic Control

Relative Risk of Death with Regard to Glycaemic Control

Relative Risk of Complications with Regard to Glycaemic Control

Medical Nutrition therapy (MNT) Diabetic Control Exercise Medications

Goals of medical nutrition therapy Address individual nutritional needs Attain and maintain optimal metabolic outcomes Blood glucose Lipid profiles Blood pressure Prevent and treat chronic complications Obesity, Hypertension, Cardiovascular disease, Renal impairment Improve overall health

Changes in DM dietary recommendations over the years Distribution of Calories Year CHO (%) Protein (%) Fat (%) Before 1921 Starvation Diets 1921 20 10 70 1950 40 20 40 1971 45 20 35 1986 50 60 12 20 30 1994 A 10 20 A,B 2002 60 70 (CHO + MUFA) 15 20 A,B A: Based on nutrition assessment B: < 10% saturated fat

ADA and EASD Recommendations Energy Reduce if BMI> 25 Protein 10-20% of total kcal Carbohydrates and fat Saturated fat < 10% Polyunsaturated 10% CHO + MUFA 60-70% Fiber 20-35 g /day Depending on body weight

Guidelines for Nutrition Intervention An individualized meal plan Address age, current medication, personal food preferences, lifestyles and willingness to change Meal spacing ( 3-63 6 meals a day) Spreading the nutrient loads, esp. CHO Minimize postprandial glucose response and maximize the use of endogenous insulin Moderate wt loss of 5-10% 5 in obese type 2 DM patients Improvement in glycemic control, BP and lipids

Asian Obesity Guideline: lower BMI Proposed classification of weight by BMI in adult Asians (Asia- Pacific Obesity Guideline 2000) Asian guidelines BMI > 23 overweight BMI > 25 obese Classification BMI (kg/m 2 ) Risk of co-morbidities Normal range 18.5 22.9 Average Overweight 23 Pre-obese 23 24.9 Increased Obese class I 25.0 29.9 Moderate Obese class II 30.0 34.9 Severe Obese class III 35.0 Very severe

Weight control principles Energy Intake > Energy expenditure Gain weight Energy Intake < Energy expenditure Lose weight Energy Intake = Energy expenditure Maintain weight

To lose 1-22 pound adipose tissue per week = promote negative energy balance = need to cut down 3500-7500 kcal /week (500-1000 kcal per day) through diet and exercise

食物中的隱藏脂肪 卡路里 脂肪佔卡路里比例 燒賣 45 60% (1 粒 ) 鰻魚 339 65% (100 克 )

食物中的隱藏脂肪 卡路里脂肪佔卡路里比例 貢丸 95 72% (2 粒 ) 山竹牛肉 98 75% (1 粒 )

食炒粉炒麵 = 飲油? 資料來源 : 東方日報 2004 年 8 月 18

甜品不油膩? 食物 油份 ( 克 ) 食物 油份 ( 克 ) 4 粒芝麻湯丸 15 > 1 包細薯條 12

甜品不油膩? 食物 油份 ( 克 ) 食物 油份 ( 克 ) 1 件甘筍蛋糕 29 > 1 條油炸鬼 13

Effect of Seeing Dietitian

Effect of Self Monitoring

Effect of DM educator

Short Term Effect of Exercise in Type 2 Diabetes Exercise at fasting state tend not to affect plasma glucose Exercise post-meal tend to lower plasma glucose

Long Term Effect of Exercise in Type 2 Diabetes Type 2 diabetes has predominant insulin resistance especially in Caucasian population Exercise reduce insulin resistance through mechanism similar to mechanism in normal subjects and weight loss A reduction in glucose 12 hour after exercise

Long Term Effect of Exercise in Type 2 Diabetes However, FBS and glucose tolerance no longer improve 72 hour after exercise, therefore recommended exercise at least every 2-32 3 days Meta-analysis analysis showed an average improvement of HbA1c by 0.7% in different exercise program

Long Term Effect of Exercise in Type 2 Diabetes Main limitation is the improvement in HbA1c is not sustained Likely due to non-compliance Compliance drop to as low as 20% 1 year after enrollment in an education program Diabetes with maintenance of exercise has lower cardiovascular mortality

AMARYL : the only drug to provide dual action Action on insulin resistance Action on insulin secretion HbA1 C reduction Amaryl Conventional Sulfonylureas ++ +++ 0/+ ++++ 1% to 2% 1% to 2% Glinides 0 ++ Biguanides ++++ 0 Glitazones +++ 0 0.9 to 1.7% 1% to 2% 0.5% to 1.3% α-glucosidase inhibitors 0 0 0.5% to 1% Data from Henry. Endocrinol Metab Clin. 1997;26:553-573 - Gitlin, et al. Ann Intern Med. 1998;129:36-38 - Neuschwander-Tetri, et al. Ann Intern Med. 1998;129:38-41 Medical Management of Type 2 Diabetes. 4th ed. Alexandria, Va: American Diabetes Association; 1998:1-139 - Fonseca, et al. J Clin Endocrinol Metab. 1998;83:3169-3176 Data from Bell & Hadden. Endocrinol Metab Clin. 1997;26:523-537 - De Fronzo, et al. N Engl J Med. 1995;333:541-549 - Bailey & Turner. N Engl J Med. 1996;334:574-579 Medical Management of Type 2 Diabetes. 4th ed. Alexandria, Va: American Diabetes Association; 1998:1-139 - Goldberg, et al. Diabetes Care 21:1897-1903

Mortality in Relation to Blood Pressure Control

Complications in Relation to Blood Pressure Control

Systolic Blood Pressure in Relation to Complications

Diastolic Blood Pressure in Relation to Cardiovascular Event (HOT Study) Incidence per 1000 patient-year follow up 25 20 15 10 5 0 Major Cardiovascular Endpoint Cardiovascular Mortality 90 mmhg 85 mmhg 80 mmhg

Salient Points Establish the importance of blood pressure control in diabetes Establish the target of 130/80 in diabetic patients Establish the need for polypharmacy in controlling blood pressure

CARDS Study 2838 diabetes patients aged 40 75 years LDL-cholesterol concentration of 4.14 mmol/l or lower, a fasting triglyceride amount of 6.78 mmol/l or less, at least one of the following: retinopathy, albuminuria, current smoking, or hypertension randomised to placebo (n=1410) or atorvastatin 10 mg daily (n=1428)

CARDS Study

Impact of Atorvastatin on Cardiovascular Event

National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) (ATPIII) Risk Category LDL-C Goal LDL-C C Level for Initiating TLC* Consider Drug Therapy CHD / CHD risk equivalents (10 yr. CHD risk >20%) Multiple (2+) risk factors (10 yr. CHD risk <20%) 0-11 Risk factor <2.6 mmol/l <3.4 mmol/l <4.1 mmol/l >2.6 2.6 mmol/l > 3.4 mmol/l > 4.1 mmol/l > 3.4 mmol/l (2.6-3.4 mmol/l: : drug optional) 10-yr risk 10%-20%: > 3.4 mmol/l 10-yr risk <10%: > 4.1 mmol/l > 5.2 mmol/l (4.1-5.2 mmol/l: drug optional) *TLC: Therapeutic Lifestyle Changes

Salient Points Type 2 diabetes is IHD risk equivalent LDL lowering with statin to 2.6mmol/l or lower is a must LDL-C C down to 1.8 is preferred in high risk DM patients Statins are mostly safe with long term use

Intensive Therapy v.s. Traditional Therapy

Intensive Therapy v.s. Traditional Therapy

Steno-2 2 study: effect of aggressive versus conventional treatment on complications of type 2 diabetes 60 No. at risk Primary composite endpoint (%) Conventional therapy Intensive therapy 50 40 30 20 10 0 0 Conventional therapy Intensive therapy 12 24 36 48 60 72 84 96 Months of follow-up 80 72 70 63 59 50 44 42 13 80 78 74 71 66 63 61 59 19 p = 0.007 Gaede P et al. N Engl J Med 2003; 348: 383 93.

Characteristics of Chronic Diseases Common Asymptomatic especially at early stage of disease Not curable, therefore need life long treatment Patient need to play active role in the treatment of disease Benefit of treatment not readily seen during early stage Treatment per se may induce symptom Complication once develop, mostly not reversible

Barrier to Successful Treatment Late presentation of disease Lack of understanding of the diseases Unwillingness to comply to life long treatment Patients play passive instead of active role Unwilling to accept treatment induced symptom Lack of awareness of doctor in detection and strict control Lack of infra-structure for education Financial/resources barrier

Key to Success Screening for early detection Public education to improve awareness Policy to improve incentive of accepting treatment Continues medical education Develop infra-structure for patient education Structure care emphasizing on target reaching Use of disease modifying drug, simple treatment regime and drugs with less side effect Appropriate resources allocation