DIABETES A growing problem
Countries still grappling with infectious diseases such as tuberculosis, HIV/AIDS and malaria now face a double burden of disease Major social and economic change has brought an escalating diabetes epidemic to low- and middleincome countries 3 out of 4 people with diabetes now live in LMCs Diabetes kills and disables, impoverishes families, imposes a huge economic Burden on governments and business, and overwhelms health systems
Diabetes is a huge and growing problem, and the costs to society are high and escalating 382 million people have diabetes By 2035, this number will rise to 592 million AFR: Africa MENA: Middle East- North Africa SEA: South East Asia SACA: South America-Central America WP: Western Pacific NAC: North America-Canada EUR: Europe
Almost half of all people with diabetes live in just three countries China India USA
The socially disadvantaged in any country are especially vulnerable to diabetes
Increasing development and wealth is correlated with decreasing early mortality due to diabetes
Pathophysiology of Diabetes When you eat, your body breaks food down into glucose. Glucose is a type of sugar that is your body s main source of energy.
Pathophysiology of Diabetes As blood glucose rises, the body sends a signal to the pancreas, which releases insulin
Pathophysiology of Diabetes Acting as a key, insulin binds to a place on the cell wall (an insulin receptor), unlocking the cell so glucose can pass into it There, most of the glucose is used for energy right away
Blood glucose regulation Blood glucose goes up and down throughout the day: As your blood glucose rises (after a meal), the pancreas releases insulin
Type 2 diabetes Your pancreas may not produce enough insulin (insulin deficiency) Your cells don t use insulin properly The insulin can t fully unlock the cells to allow glucose to enter (insulin resistance)
Diagnosing diabetes Fasting plasma glucose test (FPG) results diabetes Pre-diabetes normal 126 mg/dl or greater 100 mg/dl to 125 mg/dl less than 100 mg/dl
Types of diabetes Type 1 diabetes Type 2 diabetes Gestational diabetes Lack of insulin Autoimmune Usually children Insulin resistance Lifestyle factors Usually adults Insulin resistance During pregnancy Risks to mother and child
Risk factors for type 2 diabetes Type 2 is more common in people who: Are overweight Are 45 or older Are physically inactive Have a parent or sibling with type 2 diabetes Are African American, Native American, Hispanic American, or Pacific Islander Have abnormal cholesterol levels Have had gestational diabetes, or given birth to a baby greater than 9 lbs Have high blood pressure
Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or Older Obesity (BMI 30 kg/m 2 ) 1994 2000 2010 No Data <14.0% 14.0% 17.9% 18.0% 21.9% 22.0% 25.9% 26.0% Diabetes 1994 2000 2010 No Data <4.5% 4.5% 5.9% 6.0% 7.4% 7.5% 8.9% >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics
Major diabetes complications Cardiovascular disease Eyes Kidney Feet Co-morbidities Fatty liver Sleep apnea
Diabetes = CVD Risk 50 40 Nondiabetic Patients P<0.001 Diabetic Patients P<0.001 45.0 7-Year Incidence of MI 30 20 10 0 18.8 20.2 3.5 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. Haffner SM et al. N Engl J Med. 1998;339:229; Arch Intern Med. 2011;171:404
HbA1c: the blood test with a memory What is HbA1c? Hemoglobin is a protein that makes your red blood cells red-colored When hemoglobin picks up glucose from your bloodstream, the hemoglobin becomes glycosylated HbA1c in your bloodstream. Glycosylated hemoglobin is HbA1c. The HbA1c test measures the percentage of HbA1c in your blood a number that corresponds to your average blood glucose for the previous 3 months
ABC s A A1c, or hemoglobin A1c test ADA goal is 7% or less AACE goal is 6.5% or less B Blood pressure < 130/80 mmhg for non-pregnant adults C Cholesterol HDL (good) cholesterol >40 mg/dl (men); >50 mg/dl (women) LDL (bad) cholesterol <100 mg/dl Triglycerides <150 mg/dl
Hypertension Goals for people with diabetes and hypertension Blood Pressure Systolic Diastolic Goal <140 mmhg <80 mmhg Lower targets (<130 mmhg) may be appropriate for certain individuals (younger patients) if it can be achieved without undue treatment burden. American Diabetes Association. Diabetes Care. 2014:37, S14-80
Dyslipidemia Patient Without overt CVD With overt CVD Goal LDL cholesterol <100 mg/dl LDL cholesterol <70 mg/dl (option of using high dose of statin) Combination therapy has been shown not to provide additional cardiovascular benefit above statin therapy alone and is not generally recommended. American Diabetes Association. Diabetes Care. 2014:37, S14-80
Good News for Type 1 Diabetes
Good News for Type 2 Diabetes
Prediabetes An important risk factor for future diabetes and CV disease Risk for prediabetes is a continuum Important to identify early and begin intervention immediately Interventions can reduce the rate of progression from prediabetes to diabetes - Healthy diet - Physical activity - Weight loss American Diabetes Association. Diabetes Care. 2014:37 Suppl 1:S81-90.
Diabetes Prevention Program 40 Placebo Cumulative Incidence of Diabetes (%) 30 20 10 Metformin Lifestyle 0 0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Years Knowler WC, et al. NEJM. 2002;346:393-403
Prediabetes Long-term consequences include Hypertension 1 Cancer 2 Risk increased by 15% Stomach/colorectal, liver, pancreas, breast, endometrium Alzheimer s disease 3 1. American Diabetes Association. Diabetes Care. 2014:37 Suppl 1:S81-90. 2. Baker LD, et al. Arch Neurol. 2011;68:51-57. 3. Huang Y, et al. Diabetologia. 2014 Sep 11. [Epub ahead of print]
Prediabetes Centers for Disease Control, 2012 37% (86 million) U.S. adults aged 20 years or older have prediabetes 1 Percentage was similar by race 51% aged 65 years Only 11% were aware they had it 2 In adolescents aged 12 to 19 years, prevalence of prediabetes and diabetes increased from 9% to 23% 3 1.National Diabetes Statistics Report. Available at: cdc.gov/diabetes/pubs/statsreport14.htm. 2. CDC. MMWR Morb Mortal Wkly Rep. 2013;62:209-212. 3. May AL, et al. Pediatrics. 2012;129:1035 1041.
Determinants of Prediabetes/Type 2 Diabetes: Call to Action There is an association between social and environmental factors and development of obesity and type 2 diabetes Better understanding needed Variables that influence behaviors that lead to obesity, prediabetes, and diabetes How to modify these variables Perform research conducted on community-level interventions Identify individuals at risk Adapted from: Hill J. O. et al. Diabetes Care. 2013;36:2430-2439.
Modifiable Risk Factors of Diabetes/Prediabetes for CV Disease Non-modifiable Age Race/Ethnicity Gender Family history Modifiable Physical inactivity Overweight/Obesity Hypertension Smoking Abnormal lipid metabolism High plasma glucose levels American Diabetes Association. Diabetes Care. 2014:37:S14-80.
Prevalence of Prediabetes in Children/Adolescents in the U.S. Li C, et al. Diabetes Care. 2009;32:342-347.
Herman WH, et al for the Diabetes Prevention Program Research Group. Ann Intern Med. 2005:142:323-332.
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