Diabetes,MetabolicSyndromeAndCVD

IAS-OSLACourse(LipidMetabolismandCardiovascularRisk)24-27February2017Muscat– Oman

DrNoorALBusaidiDirectorofNationalDiabetesandEndocrineCentrePresidentofOmanDiabetesAssociation

Agenda4Diabetes and Risk Factors

4 Natural History of Diabetes

4Diabetes and CVD

4Definition of Metabolic Syndrome

4Pathophysiology of CVD in Diabetes and Metabolic syndrome

4Management Concept

Diabetesstatisticalfigureshavealwaysbeenalarming,reflectinghealththreatsacrosstheglobe

4 415 million people have diabetes; by 2040 this will rise to 642 million

4 One in eleven adult have diabetes

4 One in two with diabetes is undiagnosed

4 In MENA region, four out of ten adult with diabetes are undiagnosed

4 One in seven birth is affected by gestational diabetes

4 129.4 million live births to women affected by diabetes during pregnancy in 2015

4 12 % of the global health expenditure is spend on diabetes

Latest IDF Statistics

EstimatednumberofpeoplewithDiabetesworldwideandperregionin2015and2040(20-79)years

Today, the prevalence of diabetes in the Middle-East, and specifically inthe gulf region, reflects a substantial and alarming increase

Source:IDF Atlas

Diabetes Prevalence in GCC Countries

0

5

10

15

20

25

2000 2010 2011 2012 2013 2014

Kuwait

Qatar

Saudi Arabia

UAE

Bahrain

Oman7

23.13

Similarly,therestoftheMiddle-Eastcountriesareexperiencinganoticeableincreaseintheprevalenceofdiabetes

Diabetes Prevalence in ME Countries

0

5

10

15

20

25

2000 2010 2011 2012 2013 2014

Yemen

Iraq

Jordan

Egypt

Lebanon

Palestine

Turkey

Syria

Source:IDF Atlas

16.56

9.3

Additionally,theprevalenceofinsufficientphysicalactivitiesinadultsage15+reflectsalarmingfigures

Source: WHO,EMROPublication2014

Over75%

Ashkan Afshin et al. BMJ Open 2015;5:e006385

Economicimprovement,inthelastfourdecadesintheME,combinedwithalargefoodchoicesresultedindrasticdietarychanges(1/2)

National level intakes of protective dietary factors in the Middle East and North Africa, by country (2010)

Ashkan Afshin et al. BMJ Open 2015;5:e006385

National level harmful dietary factors in the Middle East and North Africa, by country (2010)

Economicimprovement,inthelastfourdecadesintheME,combinedwithalargefoodchoicesresultedindrasticdietarychanges(2/2)

Men Women Total

Current Daily Tobacco Smoking (%)

Bahrain 30.2 7.4 18.8Egypt 37.2 .6 18.9Iraq 26.6 2.9 14.8Jordan 47.6 4.9 26.3Kuwait 31.2 2.8 17Lebanon 44.6 30.7 37.6Oman 6.4 .3 3.4Palestine 36.2 2.2 19.3Qatar 29.1 .6 14.7Saudi Arabia 8.5 3.4 6Syria 38.9 - -UAE 13.1 1.2 7.2Yemen 29.3 8 18.6

Source:www.thelancet.comVol.383Jan25,2014

Furthermore, smoking is considerably high, especially among men,presenting an additional risk factor for NCD

Smoking in Middle East Countries

Smoking among women in the Middle East is gaining popularityespecially among young girls, presenting a growing health threat

Smoking in Middle Eastern Countries

PrevalenceofWater-PipesmokingamongyoungfemalesofArabiccountries

Dar-Odeh andAbu-Hammad HarmReductionJournal2011,8:24http://www.harmreductionjournal.com/content/8/1/24

A recently published survey by King Abdul-Aziz University in Saudi shows that smoking among secondary school girls reached 65%, while intermediate stands at 45%

Smoking Among Young Girls

2008-2009EstimatedExcess Pt’s Load

201320122011BothFemalesMales(15,241)(15,083)(16,059)39,97624,861

(62.2%)15,115 (37.8%)

No. Screened

75,59737.8%33.5%36.1%31%36%22%BMI>30141,03968.4%62.5%70.6%68%76%54%Abnormal WC45,35819.8%20.1%26.5%13%13%15%Pre-HTN**41,07016.1%18.2%20.3%20%19%22%HTN**75,59732%33.5%46.2%35%35%35%Pre-DM**22,1158.5%9.8%13%8%7%10%DM**109,89748.8%48.7%56.8%48%49%47%High Choles.51,22518.6%22.7%38.9%29%26%33%eGFR < 90-6013,7653.1%6.1%7.4%9%8%11%eGFR < 60-3011,2830.5%0.5%0.8%1%1%1%eGFR < 30

** Primary diagnosis & Target Omani Pop. 40+ yrs excluding Diagnosed DM & HTN cases ~225,662NCD Screening Program Results (2008-2009, 2011 & 2012)

Moreover, a national NCD screening, conducted in Oman, showed a highprevalence of Pre-Diabetes age 40 and above

*(#)Sourcenumberisavailableintheappendix

The high prevalence of diabetes complications adds another dimension ofchallenges on human health (1/2)

Country Retinopathy Nephropathy Neuropathy

KSA 30-31%*(1,2) 40%*(1) 38-94%*(1,2)

UAE 19-58%*(2,3) 34-40.8%*(2,3) 35-81.3%*(2,3)

Oman 14.4-16.6%*(1,2) 31-42.5%*(2,11) 9%*(11)

Qatar 12.5-23.5%*(2,13) 12.4%*(13) 9.5%*(13)

Kuwait 30.7%*(14) 12.4%*(14) 32.1%*(14)

Bahrain 20-20.4%*(19) 37%*(2)

Egypt 16-41%*(2,13) 42-46.3%*(1,4) 22-60%*(1,4)

Jordan 45%*(1) 33%*(1) 19%*(10)

Iraq 12.9%*(20) 13%*(16)

Lebanon 16.6%*(17) 19.45%*(13) 16.96%*(13)

Yemen 55%*(1)

Micro Vascular Complications

The high prevalence of diabetes complications adds another dimension ofchallenges on human health (2/2)

Macro Vascular Complications

Country CVD CHD PVD Hypertension Dyslipidemia

KSA 1.8%*(9) 37-41%*(1) 33-41.9%*(8,11) 62.4%*(8)

UAE 8%*(3) 10.5-43%*(2,3) 12%*(2) 54%*(3) 53.3%*(3)

Oman 5%*(11) 20%*(11) 2%*(11) 40-66%*(6,11)

Qatar 34%*(12)

Kuwait 30.3%*(14) 1%*(14) 29%*(12) 72.8%*(14)

Bahrain 12.1%*(2) 37%*(12)

Egypt 41.5%*(15) 9.70% 42.1%*(12)

Jordan 5.4%*(16) 71.7%*(15) 68%*(15)

Iraq 4.6%*(16) 7.8%*(16) 31%*(16)

Lebanon 4.1%*(18) 27.81*(17) 18.3%*(18) 66%*(17) 48%*(17)

Yemen 5.8%*(2) 17.8-25.4%*(2) 9.1%*(2) 53.4%*(19)*(#)Sourcenumberisavailableintheappendix

Agenda4Diabetes and Risk Factors

4Natural History of Diabetes

4Diabetes and CVD

4Definition of Metabolic Syndrome

4Pathophysiology of CVD in Diabetes and Metabolic syndrome

4Management Concept

ThechangesleadingtoMacrovascularcomplicationsoccurwaybeforethediagnosisofdiabetes(1/2)

ThechangesleadingtoMacrovascularcomplicationsoccurwaybeforethediagnosisofdiabetes(2/2)

Ischemicheartdiseaseistheleadingcauseofdiabetesrelateddeath

Thepathophysiologyofthelinkbetweendiabetesandcardiovasculardisease(CVD)iscomplexandmultifactorial

DiabetesandCVD

Ø #dysregulationofvasculartonecausedbyatomicneuropathy

Ø #DecreasedbioavailabilityofNO,apotentvasodilator

Ø #Increasedsecretionofthevasoconstrictorendothelin-1

Ø Enhancedactivationofplateletsandclottingfactorsintheblood

Ø PlateletaggregationØ Levelsofplateletcoagulation

productsØ CoagulationactivationmarkersØ Clottingfactors(fibrinogen,

factorVII,VIII,XI,XII,kallikrein)

Ø #Metabolismofexcesssubstrates(glucoseandfattyacids)

Ø #pro-inflammatorycytokinescanenhancetheproductionofROS.

Ø #Mitochondrialdysfunction

Ø AtherosclerosisØ DyslipidemiaØ OxidationofLDLØ Glycation ofLDLØ EndothelialDysfuction

Macrovascular

Oxidativestress

Microvascular

Hypercoagulability

Hyperglycemia-inducedmitochondrialROSproductionactivateseachofthefourmajorpathwaysofhyperglycemicdamage…

…oxidativestressisacruciallyimportantconceptinthepathophysiologyofthecardiovascularcomplicationsindiabetes

Diabetes:complication

Macrovascular Microvascular

Stroke

HeartDisease&Hypertension

FootProblems

PeripheralVascularDisease

DiabeticEyeDiseaseRetinopathy&Cataracts

RentalDisease

Neuropathy

FootProblems

Addthereferencehere

Agenda4Diabetes and Risk Factors

4 Natural History of Diabetes

4Diabetes and CVD

4Definition of Metabolic Syndrome

4Pathophysiology of CVD in Diabetes and Metabolic syndrome

4Management Concept

MetabolicSyndromeassociatedwithcardiovascularriskfactorcluster

InsulinResistance

Atherosclerosis

EndothelialDysfunction

DifferentDefinitionofMetabolicSyndrome

BMCPublicHealth(2015)15:1313

AHA-NHBIandJISdefinitionswerebetterindicatorsbecausetheywereabletocapturemoreindividualswithMetS andfoundtobebestpredictorofCVD

PrevalenceofMetS bysexandagegroupsbasedonhavingMetSusingdifferentdefinitions

BMCPublicHealth(2015)15:1313

DefinitionsofMetabolicSyndromeconsistofthreeoutoffivecriteriabasedonAHA-NHBIandJIS

Waist CircumferenceMen

Women>40 in (102 CM)> 35 in (88 CM)

Blood PressureSystolic

Diastolic≥ 130 mm Hg≥ 85 mm Hg

Triglycerides ≥ 150 mg/dL

High – Density Lipoprotein (HDL) CholesterolMen

Women> 40 mg/dL> 50 mg/dL

Fasting Glucose ≥ 100 mg/dL

Agenda4Diabetes and Risk Factors

4 Natural History of Diabetes

4Diabetes and CVD

4Definition of Metabolic Syndrome

4Pathophysiology of CVD in Diabetes and Metabolic syndrome

4Management Concept

PathophysiologyofCVDinDiabetesandMetabolicSyndrome

Ø ObesityinfluencethesubsetsofTcells

Ø ImbalanceinCD4/TH-2Ø IncreaseCD8/TH-1cellsØ ImbalanceinTH-1/TH-2Ø MastcellaccumulationØ Neutrophilsinfiltration

Ø Obesitycausevascularstructureandfunctionchangeswithinadiposetissue

Ø -capillaryrarefactionandlocalizedhypoxia

Ø Decreaseadiposetissuecapillarization

Ø ExcessofcaloricintakeØ ExpansionofadiposetissueØ AdiposehyperplasiaØ AdiposehypertrophyØ InfiltratebymacrophageØ Differentmacrophagephenotype

Ø Allpro-inflammatorycytokinesareupregulatedinobesity

Ø OverexpressingvascularendothelialgrowthfactorA(VEGF-A)inadipocytes

Ø IncreaseCRPandIL-6,TNFinadiposetissue

InsulinResistance

T2DM

Cardiovasculardisease

Agenda4Diabetes and Risk Factors

4 Natural History of Diabetes

4Diabetes and CVD

4Definition of Metabolic Syndrome

4Pathophysiology of CVD in Diabetes and Metabolic syndrome

4Management Concept

Healthforallandatalllevel

4 AllocatebudgetforpreventionofDiabetesandmetabolicsyndrome

4 Communitybasedprimarypreventionprograms

4 Create educationalprogramforpatientsandfamilies

4 massmediacampaign

4 Trainingofhealthcareprofessional

4 Applyevidencebasedpracticeforearlyinterventiontargetinghighriskgroup

4 Createguidelineandstranderdforbestpractice.

4 Establisharesearchenvironmenttoobtainaclearpictureaboutthehealthsystem,diseasepatterns,epidemiologicalstudies,geneticepidemiologyofdiabetes,basicscientificstudies,andclinicaltrials…

4 Qualitymanagementintervention

PreventionandEducation EarlyIntervention Research/QualityManagement

Anintegratedsystemisneededtocombatthisepidemiccomplexdisease

ThankYou

Oman