Type 2 Diabetes: the pandemic waiting to happen

Transcription

1 7 th DIETS/EFAD Conference Type 2 Diabetes: the pandemic waiting to happen Cathy Breen EFAD ESDN Diabetes Lead/Irish Nutrition and Dietetic Institute/ Endocrine Unit, St Columcille s Hospital, Loughlinstown, Co Dublin, Ireland Garda, Italy. November 8 th, 2013, 2013

2 Type 2 Diabetes: the pandemic waiting to happen? Pandemic Extensively epidemic (Steadmans Medical Dictionary, 28 th Ed) An infectious epidemic occurring worldwide or over a very wide area, crossing international boundaries, and usually affecting a large number of people (Wikipedia, 2013) Waiting to happen? IDF, 2012

3 IDF, 2012

4 Prevalence: Europe IDF Diabetes Atlas, 5th ed. International Diabetes Federation, 2011

5 Diabetes Prevalence in 2000 vs Over 430 million cases predicted by 2030 Source: International Chair on Cardiometabolic Risk ( Adapted from Hossain P et al. N Engl J Med 2007; 356: 213-5

6 Age-Adjusted Prevalence of Diagnosed Diabetes Among U.S. Adults Aged 18 Years or older No Data <4.5% % % % >9.0% CDC s Division of Diabetes Translation. National Diabetes Surveillance System available at

7 Why the explosion? Shoba et al (2004). Adapted from: Ramlo-Halsted BA, Edelman SV. The natural history of type 2 diabetes. Implications for clinical practice. Prim Care 1999;26:773.

8 Risk factors for Type 2 diabetes WHO, 2011

9 Diabesity? Type 2 diabetes Obesity ~80% of adults with T2 diabetes are overweight / obese (McLaughlin, 2007)

10 Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or older 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

11 Diabesity Adipose tissue drives insulin resistance and hyperglycaemia Rosen & Spiegelman, 2006

12 Type 2 diabetes: why worry? Costs Quality of life Burden of diabetes Complications / co-morbidities Monetary Overburdened health care systems IDF, 2012

13 Diabetes and quality of life/health status AIHF, from AUSDiab Study Solli, 2010

14 Diabetes complications

15 Monetary costs Kanavos, 2012

16 Type 2 diabetes (dietary) management Glycaemic control carbohydrate quantity & quality Weight loss calories Lipid management saturated vs. unsaturated fat Blood pressure management salt / alcohol Overall dietary quality fruit & veg, fibre Low calorie, higher fibre diet, lower GL diet Individualising macronutrient composition Low fat diet + lipase inhibitors Meal replacement Very low calorie diets Bariatric surgery CALORIE RESTRICTION Structured diabetes education + patient empowerment Individualised, supportive approach Intense review as part of a behavioural lifestyle intervention (MDT approach)

17 Dietary approaches in Type 2 diabetes Evidence for: Low fat diets, low carbohydrate diets, high protein diets Low glycaemic index/load diets Mediterranean diet Meal replacements Very low calorie diets The true application of research findings can usually be found in the author s description of the participants usual diet before randomization. The red meats, salty snacks, and sweets participants typically ate were replaced with lower-fat protein sources, lower-fat dairy, whole grains fewer empty-calorie foods in place of more nutrient-dense foods (Perry, 2005) What do our patients want? Food based recommendations that can be easily understood and translated into everyday life

18 It works! Structured dietetic-led diabetes education programmes ROMEO (Italy): Dietitian-led T2DM groups significantly improved outcomes compared to a medically and pedagogically-led group (Trento, 2008) X-PERT (UK): Improved HbA1c (-0.6 vs. -0.1%), weight (-0.5 vs. 1.1kg) + improved diabetes knowledge + fruit/veg intake (Deakin, 2006) Intense lifestyle interventions e.g. LookAhead 4 years: Weight -6.2 v.s -0.88% (P <0.001) Significantly better HbA1c, fitness, BP, HDL, TAG Gregg, 2012

19 EASD/ADA Guidelines, 2012 But where is the emphasis really?

20 Benefits of modest weight loss in Type 2 diabetes 1kg weight loss associated with: CVD risk reduction (6% in women, 3% in men) Reduced blood pressure (1mmg Hg) Reduced cholesterol (1% TC, 0.7% LDL, TG 2%) Increase HDL-cholesterol (0.2%) Reduce blood glucose (0.3%) Anderson, 2001; Anderson, 2003

21 Key messages for clinical practice 1. Focus on calorie restriction, portion control + weight management 2. Think more algorithmically i.e. individualise approaches and change the approach if it s not working

22 Is it cost effective? Lifestyle interventions? Yes, probably, at least in the shorter term (Jacobs Van der Bruggen, 2009; DPP, 2012) Report commissioned by the Dutch Association of Dietitians in 2012 (ICAN Study): For every 1 spend on dietary counseling, society gets a net in return: 56 in terms of improved health, 3 net savings in total health care costs and 4 in terms of productivity gains. Need to gather more diverse data routinely Less medication usage, improved dietary quality, improved quality of life, less hospital admissions, less A&E visits, less hypoglycaemia, less work absenteeism, reduced rates of progression to complications

23 IMAGE Work package 4 Subgroup 3: Guideline Nutrition

24 Preventing Type 2 diabetes: the simple things work 1. Weight loss (5-10%) 2. Reduce fat intake (<30%) 3. Reduce saturated fat intake (<10%) 4. Increase fibre intake (>15g/1000kcals) 5. Increase activity (>4hrs/week) Tuomilehto et al, NEJM, 2001

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26 Dietitians as uniquely qualified leaders in Type 2 diabetes treatment and prevention Working in primary & secondary health care, public & private sector, industry, administrative, education & research settings Unique knowledge and skill set relating to food and clinical nutrition Uniquely qualified to match the approach to the client Advanced behaviour change skills Clinically effective Inherent value placed on best practice that underpins all approaches Code of professional practice Commitment to CPD/LLL Expertise in audit & research Unified public health message Unique insight & capacity to deliver high quality, evidence-based, patient-centred approaches to the management and prevention of Type 2 diabetes

27 Dietitians know best! We understand the complex challenges that our patients face when trying to manage their diabetes within an increasingly obesogenic environment and overburdened health care systems. Clinical public health

28 Health 2020 Health2020 makes the case for investment in health and aims to support action across government and society to improve the health and well-being of populations and strengthen public health. Tackling Europe s major disease burdens, including diabetes, is a priority area within the policy. This will require coordinated public health action and health care system interventions, which must be underpinned by supportive environments. Innovation and leadership for health are at the core of Health 2020, and it encourages all stakeholders to take on new responsibility and accountability for population health.

29 What we can do This provides an opportunity for dietitians, as specialists with a unique insight and professional expertise in the area, to take leadership roles in developing local and national public health policies that support the aims of Health2020 for a healthier society that will reduce the burden of type 2 diabetes. Local, national, international diabetes advocacy groups Local / national diabetes service planning / steering committees Global Diabetes Survey We can be a strong voice about what needs to change Health in all policies approach Environmental planning Food marketing Unhealthy food taxation vs. healthy food subsidies

30 We ve been here before. Matthews, 2011

31 Bubonic plague could not be stopped by wishing that the population were less degenerate There is no public outrage that governments legislate to protect through legislation in other contexts e.g. seatbelts, fire escapes, crash barriers. Yet startlingly few public health policies are in place to protect us from excess calorie consumption