Diabetes: An Introduction. UT Health Science Center

Transcription

1 Diabetes: An Introduction UT Health Science Center

2

3 DIABETES MELLITUS A metabolic disorder with multiple causes characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both

4 Carbohydrates are converted to Glucose

5 GLUCOSE INSULIN

6

7 DIABETES Type 1 diabetes No Insulin Type 2 diabetes Insulin Resistance Gestational Other Types Maturity-Onset Diabetes of Youth Due to medication, Infection, Surgery Pancreatic disease

8 TYPE I Previously named insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes Develops, we believe, as a result of autoimmune attack of and resulting destruction of pancreatic beta cells Usually develops in children and young adults 5% - 10% of all diagnosed cases of diabetes in adults Risk factors include autoimmune diseases, genetic diseases, or environmental factors There is no known way to prevent type 1 diabetes

9 TYPE II Previously called non insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes 90%-95% of all cases of diabetes in adults Usually begins as insulin resistance, a disorder in which the cells do not use insulin properly As the need for insulin rises, the pancreas gradually loses its ability to meet the demand Associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity

10 PREDIABETES Blood glucose levels higher than normal, but not high enough to be classified as diabetes Confers an increased risk of developing type 2 diabetes Prediabetics have either have impaired fasting glucose (IFG) or impaired glucose tolerance (IGT), or both IFG and IGT Impaired Fasting Glucose (IFG) Fasting blood sugar level is 100 to 125 milligrams per deciliter (mg/dl) after an overnight fast. Impaired Glucose Tolerance (IGT) Blood sugar level is 140 to 199 mg/dl after a 2-hour oral glucose tolerance test

11 GLUCOSE TOLERANCE CATEGORIES Fasting Plasma Glucose Must have two measures to make a diagnosis* 2-Hour Plasma Glucose on OGTT Diabetes Mellitus 126 mg/dl 7.0 mmol/l Impaired Impaired Fasting Glucose 110 mg/dl Fasting Glucose 6.1 mmol/l 100 mg/dl 5.6 mmol/l Normal 200 mg/dl 140 mg/dl Diabetes Mellitus Impaired Glucose Tolerance Normal 11.1 mmol/l 7.8 mmol/l Pre-Diabetes * One can also make the diagnosis of diabetes based on unequivocal symptoms and a random glucose > 200 mg/dl Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. Supplement 1, January 2004.

12 STATISTICS Total: 23.6 million children/adults - 7.8% of population -- have diabetes. Diagnosed: 17.9 million people Undiagnosed: 5.7 million people Pre-diabetes: 57 million people New Cases: 1.6 million new cases diagnosed ages 20 years in 2007 Under 20 years of age: 186,300 (0.22%) in this age have diabetes Children and adolescents: 1/400 to 1/600 have type 1 diabetes 2 million adolescents (1/6 overweight) age have pre-diabetes Age 20 years: 23.5 million (10.7%) in this age group have diabetes Age 60 years: 12.2 million (23.1%) in this age group have diabetes Men: 12.0 million, or 11.2% of all men aged 20 years have diabetes Women: 11.5 million (10.2%) of all women 20 years have diabetes Non-Hispanic whites: 6.6% Asian Americans: 7.5% Non-Hispanic blacks: 11.8% Hispanics: 10.4% National Diabetes Fact Sheet, 2007 jointly produced by the CDC, NIH, ADA, and other organizations

13 Age-adjusted Percentage of U.S. Adults Who Had Diagnosed Diabetes 1994 Missing data <4.5% % % % 9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

28 Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes 1994 Obesity (BMI 30 kg/m 2 ) Diabetes Missing Data <14.0% % % % 26.0% Missing data <4.5% % % % 9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

43 Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes Obesity (BMI 30 kg/m 2 ) No Data <14.0% % % % >26.0% Diabetes No Data <4.5% % % % >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

44 Costs Continue to Increase (U.S.) $240 $200 $160 $120 $80 $40 $92 $109 $138 $40 $47 $54 $132 $156 $ $0 Direct Indirect Total Diabetes Care 26: , 2003

45 COST OF DIABETES Total costs of diagnosed diabetes in 2007: $174 billion Direct medical costs : $116 billion for Indirect costs: $58 billion (disability, work loss, premature mortality) Factoring in the additional costs of undiagnosed diabetes, prediabetes, and gestational diabetes brings the total cost of diabetes in the United States in 2007 to $218 billion $18 billion for the 6.3 million people with undiagnosed diabetes $25 billion for the 57 million American adults with pre-diabetes $623 million for the 180,000 pregnancies with gestational diabetes After adjusting for population age and sex differences, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes National Diabetes Fact Sheet, 2007 jointly produced by the CDC, NIH, ADA, and other organizations

46 DIABETIC NEUROPATHY About 60-70% of people with diabetes have mild to severe forms of nervous system damage, including: Impaired sensation or pain in the feet or hands Slowed digestion of food in the stomach Carpal tunnel syndrome Other nerve problems More than 60% of nontraumatic lower-limb amputations in the United States occur among people with diabetes.

47 DIABETIC NEPHROPATHY Over 40% of new cases of end-stage renal disease (ESRD) are attributed to diabetes. In 2001, 41,312 people with diabetes began treatment for end-stage renal disease. 19% Incidence of ESRD Resulting from Primary Diseases (1998) In 2001, it cost $22.8 billion in public and private funds to treat patients with kidney failure. Minorities experience higher than average rates of nephropathy and kidney disease 3% 12% 23% 43% Diabetes Hypertension Glomerulonephritis Cystic Kidney Other Causes

48 DIABETIC RETINOPATHY Diabetic retinopathy is the most common cause of new cases of blindness among adults years of age. Each year, between 12,000 to 24,000 people lose their sight because of diabetes. During the first two decades of disease, nearly all patients with type 1 diabetes and over 60% of patients with type 2 diabetes have retinopathy

49 THE GLYCEMIC TRIAD HbA1c Long term average glucose level FPG Basal glucose level PPG Peak Glucose Level 49

50 Intensive Diabetes Therapy: Reduced Incidence of Complications DCCT Kumamoto UKPDS HbA1c 9 7.2% 9 7% 8 7% Retinopathy 63% 69% 17-21% Nephropathy 54% 70% 24-33% Neuropathy 60% Improved - Cardiovascular disease 41% (NS) - 16% (NS) DCCT Research Group. N Engl J Med. 1993;329: Ohkubo Y, et al. Diabetes Res Clin Pract. 1995;28: UKPDS 33: Lancet 1998; 352, Slide modified from D. Kendall - International Diabetes Center, Minneapolis.

51 Risk of Progression of Complications: DCCT Study Diabetic retinopathy Nephropathy Neuropathy Microalbuminuria Relative Risk HbA1c, % Skyler JF. Endocrinol Metab Clin North Am. 1996;25:

52 63% of Patients With Diabetes are Not At ADA A1C Goal <7% Adults aged years with previously diagnosed diabetes who participated in the interview and examination components of the National Health Examination Survey (NHANES), % of Subjects n = % 7% 12.4% 7.8% 17.0% 25.8% 37.0% 37.2% >8% Only 7% of adults with diabetes in NHANES attained: A1C level <7% Blood pressure <130/80 mm Hg Total cholesterol <200 mg/dl Saydah SH et al. JAMA. 2004;291: A1C >10% >9% >8% 7-8% <7%

53 TREATMENT People with diabetes can lower the occurrence of these and other diabetes complications by controlling blood glucose, blood pressure, and blood lipids Many people with type 2 diabetes can control their blood glucose by following a healthy meal plan and exercise program, losing excess weight, and taking oral medication Some people with type 2 diabetes may also need insulin to control their blood glucose Type 1 diabetes must have insulin delivered to their system Among adults with diagnosed diabetes (type 1 or type 2), 14% take insulin only, 13% take both insulin and oral medication, 57% take oral medication only, and 16% do not take either insulin or oral medication Medications for each individual will often change during the course of the disease Many people also need to take medications to control their cholesterol and blood pressure

54 As Patients Get Closer to A1c Goal, the Need to Manage PPG Increases % 60 Contributio n % 70% 50% 50% 55% 45% 60% 40% 70% 30% FPG PPG 0 < >10.2 A1C Range (%) Monnier L, et al. Diabetes Care. 2003;26:

55 UKPDS: Metformin Is Associated With a Reduction in Cardiovascular Events Hemoglobin A 1c Glibenclamide Conventional Chlorpropamide Insulin Metformin Years Metformin Mean Change in Risk* P Value Sulfonylurea/ Insulin Mean Change in Risk* P Value Diabetes-related death 42% % 0.19 All-cause mortality 36% % 0.49 Any diabetesrelated endpoint 32% % 0.46 Myocardial infarction 39% % 0.11 Stroke 41% % 0.6 *Compared with conventional therapy based on diet/exercise in overweight patients UKPDS = United Kingdom Prospective Diabetes Study Reprinted in an adapted form from UKPDS Group. Lancet 1998;352: , with permission from Elsevier.

56 Patients Remain on Monotherapy >1 Year After First A1c >8.0% * Length of time that the patient s A1c remained above 8.0% before a switch/addition in therapy* months Months months Metformin Only (n=354) Sulfonylurea Only (n=2517) *May include up-titration. Length of time between first A1c >8.0% and switch/addition in therapy could include periods where patients had subsequent A1c test values below 8%. Based on nonrandomized retrospective database analysis. Data from Kaiser Permanente Northwest Patients had to be continuously enrolled for 12 months with A1c lab values. Brown et al. Diabetes. 2003;52(suppl 1):A61-A62. Abstract 264-OR.

57 Role of the Patient in Diabetes Management Commit to self-care Participate in the development of a treatment plan Make ongoing decisions regarding self-care Communicate frequently and honestly with the rest of the team

58 Efficacy of Monotherapy with Oral Diabetes Agents Drug Fasting Plasma Glucose Reduction (mg/dl) A1C Reduction (%) Thiazolidinedione Sulfonylurea Biguanide Meglitinide Alpha-glucosidase inhibitor DeFronzo Annals of Internal Medicine 1999;131: Nathan N Engl J Med 2002; 347:

59 PREVENTION Progression to diabetes for prediabetics is not inevitable People with prediabetes who lose weight and increase their physical activity can prevent or delay diabetes and return their blood glucose levels to normal DPP a large prevention study, showed that lifestyle intervention reduced developing diabetes by 58% during a 3-year period The reduction was even greater, 71%, among adults aged 60 years or older Research has found that lifestyle interventions are more costeffective than medications

60 PREVENTING DIABETIC COMPLICATIONS Maintain blood pressure <130/80 mm/hg Maintain preprandial plasma glucose mg/dl Maintain postprandial plasma glucose <180 mg/dl Maintain A1C <7.0%