In The name of God

Diabetes epidemiology: Reflecting your clinic?

Question #1

• Approximately what percentage of your T2 diabetes patients are obese (>30 kg/m2)*?

1. <10%

2. 25%

3. 50%

4. 75%

5. >90%

*WHO Diabetes Fact Sheet No. 311. September 2006

Epidemiological transition” in newly industrialised nations

Cockram CS 2000. HKMJ; 6 (1): 43-52Mohan et al 2007. Indian J Med Res; 125: 217-230

Adapted from IDF Diabetes Atlas 4th ed., 2009

Aging population

Dietary changes Reduced physical activity

UrbanisationUnhealthy lifestyle choices

Urbanisation, Western dietary habits linked to obesity rates

• Emergence of obesity linked to lifestyle changes associated with urbanisation, modernisation

• Population adopts Western dietary habits, decreased physical activity etc.

Chiarelli and Marcovecchio 2008. EJE; 159: S67-S74Yach et al 2006. Nature Medicine; 12(1): 62-66

19702000

Methods:

• Conducted in 2007

• 5,287 Iranian citizens included

• Sample size aged 15–64 years

Results:

• Diabetes 8.7%8.7%

• Hypertension 26.6%26.6%

• Obesity 22.3%22.3%

• Central obesity 53.6%53.6%

FemaleFemale

Male

Prevalence of Diabetes and its risk factors in Iran

Esteghamati A, et al. Third national surveillance of risk factors of non-communicable diseases (SuRFNCD-2007) in Iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and dyslipidemia. BMC Public Health. 2009 May 29;9:167

2.5 million Iranian2.5 million Iranian

Obesity contributes to increase in prevalence of T2DM

• Obesity• 2-fold increase in the

odds of developing diabetes for 40-55 yr age group over a 30 year period

• Physical inactivity

• Increase in the number of individuals > 65 years

Fox CS et al. The Framingham Offspring Study. Circulation 2006;113:2914–8

Normal weight Overweight Obese

1970s 1980s 1990s0

5

10

15

20

8 y

ear

rate

(%

)

Diabetes epidemic: 54% increase in diabetes from 2010 to 2030

Adapted from IDF Diabetes Atlas 4th ed., 2009

World 2010 = 285 million2030 = 439 million

Increase 54%

North AmericaEurope

Middle East and North Africa

Africa

South and Central America

Western Pacific

Southeast Asia

Diabetes: from the globe to your clinic• Assume you are a physician in the

Asia/Western Pacific region, where the diabetes prevalence level is approximately 5-7%

• If you oversee a group of 200 patients, then:

• 14 will have diabetes (7%)

• 11 of these 14 remain undiagnosed (75%)

• Screen for high risk groups

• Only 2 of these people are undergoing optimal treatment

• Only 1 of these people have their diabetes properly controlled

IDF Diabetes Atlas 4th ed., 2009Asia-Pacific Type 2 Diabetes Policy Group. Practical Targets and

Treatments 4th Ed. 2005.

Poor glucose control is associated with increased risk of complications

Stroke

Retinopathy and blindness

Heart disease

Kidney disease

Neuropathy

Diabetic foot disease

Peripheral vascular disease

Erectile dysfunction

International Diabetes Federation. Diabetes Atlas, 2006

Prevalence of Retinopathy and NeuropathyRetinopathy and Neuropathy in Type 2 diabetic patients in Iran compared to other countries

Study Location

Prevalence of Retinopathy (%)

Qazvin 51.1

Isfahan 45.4

Germany 16.1

Australia 21.9

Egypt 32.1

Study location

Prevalence of Neuropathy (%)

Isfahan 75.1

Islamshahr 33.3

Diabetes Atlas, 3rd edition, International diabetes federation, 2006

France 28.8

Australia 13.1

Egypt 21.9

How well are diabetic risk factors controlled in Iran?

6.4% 1.1%

25.7% NA

HbA1c

Measured in the previous year

Patients at goal

Lipids

Delaveri A.,Archives of Iranian Med 2009;12:492-495

Question #3• What do you think is the greatest obstacle to

improving diabetes care in Iran?

1. Lack of infrastructure/healthcare training

2. Patient compliance towards diet and exercise

3. Physician attitude

4. Resistance of patients to medication

5. Difficulty managing diabetic complications

6. Other

Question #4

• Approximately what percentage of patients do you treat with insulin?

1. 5%

2. 10%

3. 15%

4. 20%

5. >20%

Antidiabetic treatment use: OHA’s favoured, insulin used infrequently

International Diabetes Federation. Diabetes Atlas. 2006: 273-287.

Suboptimal care results in diabetic complications

• Assume you are a physician overseeing a group of approximately 50 patients diagnosed with diabetes

• If your clinic is in Iran:• 38 patients will have suboptimal control of

HbA1c

• Approximately 4 patients (8%) will be treated with insulin; 28 patients will be treated with OADs only and 18 patients will be treated with diet only

• 6 patients (11.3%) will suffer from renal failure as a complication of their diabetes

IDF Diabetes Atlas 4th ed., 2009Novo Nordisk. Changing Diabetes Barometer. 2009

International Diabetes Federation. Diabetes Atlas. 2006: 273-287.

Local insulin usage: human insulin preferred vs. analogues in Iran

0

20

40

60

80

100

Iran

Analogue Insulins

Human Insulins

Insu

lin U

sag

e (

%) • Prevalence of Diabetes in

Iran in 2007 was 8.7%*

• In Iran, insulin is prescribed to less than 7.5% of diabetic patients

• Uncontrolled blood sugar = increased risk of complications

99%

1%

*Esteghamati A, et al. Third national surveillance of risk factors of non-communicable diseases (SuRFNCD-2007) in Iran: methods and results on prevalence of diabetes, hypertension, obesity, central obesity, and Dyslipidemia. BMC Public Health 2009, 9:167** National Pharmaceutics Statistics, Ministry of Health, 2009,Iran

**

Question #5

• Which of the following factors do you feel is most important to improving diabetes care in your region in the future?

1. Diabetes prevention via education programmes

2. Patient lifestyle changes (diet and exercise)

3. Treatment advances/new drugs

4. Improved training for clinicians

5. Political will/government investment in diabetes care

6. Other

Age atdiagnosis

First majorcomplications

*Average risk reduction

Better treatment extends and improves lives

First minorcomplications

Baseline (HbA1c = 7.0%)EarlierDiagnosis +EnhancedTreatment

69-71

71”Mr. Lee"

Age at diabetes diagnosis 52

65-6852

25-40%* 25-65%*

71 years

52 66-68

68 years

Baseline(HbA1c =9.1%)”Mr. Kim"

Age at diabetes diagnosis 52

60-62

UKPDS Risk Engine: modelled data based on newly diagnosed cohort at age 52

Taking action now can have a positive impact

Mr. Kim Mr. Lee

Age at diagnosis 52 52

DetectionBy coincidence after first minor symptoms occurred

Through GP monitoring before first minor symptoms occurred

TreatmentRandom visits to doctor and

limited monitoring

Quarterly consultations with well educated diabetes team

and consistent monitoring

HbA1c 9.1% 7.0

Life expectancy from diagnosis 16 19

Years free of complications from diagnosis

8 13

UKPDS Risk Engine: modelled data based on newly diagnosed cohort at age 52