Risk of Type 2 Diabetes and It’s Complications Along The Continuum of Fasting Plasma Glucose...
-
Upload
jesse-douglas -
Category
Documents
-
view
215 -
download
0
Transcript of Risk of Type 2 Diabetes and It’s Complications Along The Continuum of Fasting Plasma Glucose...
Risk of Type 2 Diabetes and It’s Risk of Type 2 Diabetes and It’s Complications Along The Continuum Complications Along The Continuum
of Fasting Plasma Glucoseof Fasting Plasma Glucose
Gregory A. Nichols, PhDGregory A. Nichols, PhD
Collaborative Diabetes Education Conference Collaborative Diabetes Education Conference for Health Professionalsfor Health Professionals
January 30, 2010January 30, 2010
DisclosuresDisclosures Employed by Kaiser Permanente Center for Health Employed by Kaiser Permanente Center for Health
Research, Portland, OregonResearch, Portland, Oregon
Government Research Funding:Government Research Funding:– National Institute of Diabetes and Digestive and Kidney Disorders National Institute of Diabetes and Digestive and Kidney Disorders
(NIDDK)(NIDDK)
– Agency for Healthcare Research and Quality (AHRQ)Agency for Healthcare Research and Quality (AHRQ)
Industry Funding:Industry Funding:– GlaxoSmithKlineGlaxoSmithKline
– Novo NordiskNovo Nordisk
– Novartis PharmaceuticalsNovartis Pharmaceuticals
– Tethys BioscienceTethys Bioscience
– Takeda Pharmaceuticals North AmericaTakeda Pharmaceuticals North America
OverviewOverview
Part I - Diabetes and “Pre-diabetes”Part I - Diabetes and “Pre-diabetes”
Part II - Fasting Glucose as a Diabetes Part II - Fasting Glucose as a Diabetes Risk FactorRisk Factor
Part III – Nondiabetic Fasting Glucose Part III – Nondiabetic Fasting Glucose as a Risk Factor for Complications of as a Risk Factor for Complications of DiabetesDiabetes
Part I Part I Diabetes and “Pre-diabetes”Diabetes and “Pre-diabetes”
A brief history of the definition of a A brief history of the definition of a diabetes diagnosisdiabetes diagnosis
Defining other forms of dysglycemiaDefining other forms of dysglycemia
Diagnosing DiabetesDiagnosing Diabetes
Oral Glucose Tolerance Test (OGTT)Oral Glucose Tolerance Test (OGTT) 2-hour post-load 2-hour post-load >> 200mg/dl 200mg/dl
Fasting Plasma Glucose (FPG)Fasting Plasma Glucose (FPG) Prior to 1997, Prior to 1997, >> 140 mg/dl 140 mg/dl
Now, Now, >> 126 mg/dl 126 mg/dl
HbA1c HbA1c >> 6.5% (as of 2010) 6.5% (as of 2010)
These tests measure different things and often These tests measure different things and often identify different peopleidentify different people
Other Forms of DysglycemiaOther Forms of Dysglycemia(“Pre-Diabetes”)(“Pre-Diabetes”)
Impaired Glucose Tolerance (IGT)Impaired Glucose Tolerance (IGT)OGTT 2-hour post-load 140 - 199 mg/dlOGTT 2-hour post-load 140 - 199 mg/dl
Impaired Fasting Glucose (IFG)Impaired Fasting Glucose (IFG)From 1997-2003, 110 - 125 mg/dlFrom 1997-2003, 110 - 125 mg/dl
Since 2003, 100 - 125 mg/dlSince 2003, 100 - 125 mg/dl
HbA1c 5.7 – 6.4%HbA1c 5.7 – 6.4%
Summary of Part ISummary of Part I
Diabetes is a “category” on the continuum of Diabetes is a “category” on the continuum of glucose and is based on the point at which glucose and is based on the point at which riskrisk of diabetic retinopathy becomes elevatedof diabetic retinopathy becomes elevated
IFG and IGT are categories on the continuum IFG and IGT are categories on the continuum of glucose that were designed to represent of glucose that were designed to represent increased increased riskrisk of developing diabetes of developing diabetes
Part II - Part II - Fasting Glucose as a Fasting Glucose as a Diabetes Risk FactorDiabetes Risk Factor
Impaired Fasting Glucose (IFG) and Risk of Impaired Fasting Glucose (IFG) and Risk of DiabetesDiabetes
Normal Plasma Glucose and Risk of DiabetesNormal Plasma Glucose and Risk of Diabetes
Glucose, other Risk Factors, and Risk of Glucose, other Risk Factors, and Risk of DiabetesDiabetes
Risk of Progression Risk of Progression From IFG to DiabetesFrom IFG to Diabetes
PopulationYears of
F/UIsolated
IFGIFG &
IGT
Hoorn Study (1998) Dutch 5.8-6.5 33.0% 64.5%
Paris Prospective Study (2001) French 2.5 2.7% 14.9%
Vaccaro et al. (1999) Italian 11.5 9.1% 44.4%
Shaw et al. (1999) Mauritius 5.0 21.6% --
Gabir et al. (2000)Pima
Indians 5.0 -- 41.2%
Gimeno et al. (1998)Brazilian-Japanese 7.0 -- 72.7%
Baltimore Longitudinal Study on Aging (2003) U.S. 10.0 -- 25.0%
Sample SelectionSample Selection
28,335 KPNW non-diabetic members with at 28,335 KPNW non-diabetic members with at least two FPG tests 100-125 mg/dl between least two FPG tests 100-125 mg/dl between 1994 and 20031994 and 2003
5,452 with a prior test < 100 mg/dl5,452 with a prior test < 100 mg/dl
4,526 had first abnormal value 100-1094,526 had first abnormal value 100-109
926 had first abnormal value 110-125926 had first abnormal value 110-125
Follow-up through 12/31/05 Follow-up through 12/31/05
Study SampleStudy Sample
Added IFG (100-109 mg/dl)
Original IFG (110-125
mg/dl) p value
Number (%) of Subjects 4,526 (83.0%) 926 (17.0%) --
Age at IFG Incidence 59.7 (11.1) 57.9 (11.6) <0.0001
Percent Female 48.1% 53.9% 0.001
Systolic Blood Pressure 134 (13) 136 (13) 0.017
Diastolic Blood Pressure 79 (7) 80 (7) 0.033
Body Mass Index 31.0 (6.3) 33.2 (7.2) <0.0001
HDL Cholesterol 51 (15) 48 (14) <0.0001
Triglycerides 190 (215) 212 (138) 0.004
LDL Cholesterol 126 (30) 121 (31) <0.0001
Nichols et al., Diabetes Care 2007;30:228-233
Nichols et al., Diabetes Care 2007;30:228-233.
Proportion of Subjects Progressing to Diabetes, Proportion of Subjects Progressing to Diabetes, Months Until Progression, Months Until Progression,
and Rate of Progression, by IFG Stageand Rate of Progression, by IFG Stage
Did Not Did Not Progress to Progress to
Original IFGOriginal IFGProgressed to Progressed to Original IFGOriginal IFG TotalTotal
Initial IFG Initial IFG Stage was Stage was
Added IFGAdded IFGInitial IFG Stage Initial IFG Stage was Original IFGwas Original IFG TotalTotal
Total, All Total, All SubjectsSubjects
nn
(%)(%)
3,7533,753
(82.9%)(82.9%)
773773
(17.1%)(17.1%)4,5264,526
773773
(45.5%)(45.5%)
926926
(54.5%)(54.5%)1,6991,699 5,4525,452
Progressed to Progressed to DiabetesDiabetes
201 201
(5.4%)(5.4%)
164164
(21.2%)(21.2%)
365365
(8.1%)(8.1%)
164164
(21.2%)(21.2%)
249249
(26.8%)(26.8%)
413413
(24.3%)(24.3%)
614614
(11.3%)(11.3%)
Mean (SD) Months Mean (SD) Months from 1from 1stst FPG FPG Measure to Measure to Progression to Progression to DiabetesDiabetes
31.131.1
(23.2)(23.2)
54.154.1
(27.6)(27.6)
41.441.4
(25.8)(25.8)
29.529.5
(25.9)(25.9)
28.728.7
(26.5)(26.5)
29.029.0
(26.2)(26.2)
36.336.3
(27.9)(27.9)
Diabetes Incidence Diabetes Incidence per Yearper Year
0.910.91 3.243.24 1.341.34 5.165.16 5.875.87 5.565.56 1.951.95
Added IFG (100-109 mg/dL) Original IFG (110-125 mg/dL)
Nichols et al., Diabetes Care 2007;30:228-233.
Predictors of Progression to DiabetesPredictors of Progression to Diabetes
Risk Ratio 95% CI p value Risk Ratio 95% CI p value
Progressed to Original IFG 3.11 2.43 – 3.98 <0.0001 -- -- --
Initially Added IFG -- -- -- 1.12 0.88 - 1.42 0.352
Initial FPG (per mg/dl) 1.08 1.04 - 1.13 0.0003 1.07 1.04 - 1.10 <0.0001
Age (per 10 Years) 0.92 0.86 - 0.99 0.020 0.92 0.87 – 0.98 0.015
Female Sex 1.47 1.11 - 1.93 0.007 1.33 1.02 - 1.72 0.032
Current Smoker 1.51 1.15 - 1.99 0.003 1.17 0.89 - 1.53 0.255
BMI (per kg/m2) 1.04 1.02 - 1.06 <0.0001 1.03 1.02 - 1.05 <0.0001
Systolic BP (per 5mmHg) 1.10 1.04 - 1.16 <0.0001 1.08 1.03 - 1.14 0.001
HDL-C (per 5mg/dl) 0.88 0.83 - 0.93 <0.0001 0.88 0.84 - 0.93 <0.0001
LDL-C (per 5mg/dl) 0.97 0.95 - 0.99 0.003 0.99 0.97 - 1.01 0.411
Triglycerides (per 50mg/dl) 1.01 1.00 - 1.02 0.026 1.03 1.01 - 1.04 0.0003
Progression from IFG 100-109 Progression from IFG 110-125
Adapted from Nichols et al., Diabetes Care 2007;30:228-233
SummarySummary Patients with IFG progress to diabetes at a rate of Patients with IFG progress to diabetes at a rate of
1.3-5.6% per year1.3-5.6% per year
Those who progress do so in 29-59 months, and Those who progress do so in 29-59 months, and more rapid progression prior to diabetes is a more rapid progression prior to diabetes is a warning signwarning sign
High BMI and low HDL-C are the strongest non-High BMI and low HDL-C are the strongest non-glucose predictors of progressionglucose predictors of progression
Each mg/dl of fasting glucose increases risk of Each mg/dl of fasting glucose increases risk of progression to diabetes by 7-8%progression to diabetes by 7-8%
Next QuestionNext Question
Does the apparently linear relationship Does the apparently linear relationship between fasting glucose and progression to between fasting glucose and progression to diabetes extend below 100 mg/dl? diabetes extend below 100 mg/dl?
Sample SelectionSample Selection 46,578 KPNW members with FPG < 100 46,578 KPNW members with FPG < 100
mg/dl between 1997 and 2000mg/dl between 1997 and 2000
No diabetes or previous FPG No diabetes or previous FPG >> 100 mg/dl 100 mg/dl
Categories of baseline FPG:Categories of baseline FPG:< 85 mg/dl< 85 mg/dl85-89 mg/dl85-89 mg/dl90-94 mg/dl90-94 mg/dl95-99 mg/dl95-99 mg/dl
Followed through 4/30/07 for development of Followed through 4/30/07 for development of diabetes (mean of 81 months)diabetes (mean of 81 months)
Study SampleStudy Sample
< 85 mg/dL85-89 mg/dL
90-94 mg/dL
95-99 mg/dL
n (%)
8,705 (18.7%)
10,983 (23.6%)
13,704 (29.4%)
13,186 (28.3%)
Age* 55.4 (11.0) 56.6 (10.7) 57.8 (11.0) 59.1 (11.1)
% Male* 28.7% 35.5% 42.9% 49.4%
BMI* 28.0 (5.8) 28.6 (5.8) 29.2 (5.9) 29.9 (6.0)
Systolic BP* 128 (19) 130 (18) 131 (19) 134 (19)
Diastolic BP * 79 (10) 79 (10) 80 (10) 81 (10)
HDL-Cholesterol* 57 (17) 56 (17) 54 (16) 52 (16)
LDL-Cholesterol* 123 (34) 126 (34) 129 (35) 130 (34)
Triglycerides* 142 (122) 147 (115) 156 (106) 164 (114)
Adapted from Nichols et al., Am J Med 2008;121:519-524
Cumulative Diabetes Incidence by Cumulative Diabetes Incidence by Category of Normal Fasting GlucoseCategory of Normal Fasting Glucose
0
2
4
6
8
10
12
0 6 12 17 21 24 28 32 35 38 41 45 48 51 55 58 62 66 70 74 77 81 85 89 92 98 102 108
Months of Follow-up
Cu
mu
lati
ve
In
cid
en
ce
(%
)
95-99 mg/dL
9.9/1,000 person-years
95% CI, 9.3 - 10.690-94 mg/dL
5.6/1,000 person-years95% CI, 5.1 - 6.1
85-89 mg/dL
3.6/1,000 person-years95% CI, 3.2 - 4.1
< 85 mg/dL
3.1/1,000 person-years95% CI, 2.6 - 3.5
log-rank p<0.0001
Nichols et al., Am J Med 2008;121:519-524
Hazard Ratios of Diabetes Incidence Hazard Ratios of Diabetes Incidence Adjusted for Risk FactorsAdjusted for Risk Factors
2.33(1.95 - 2.79)
1.49(1.23 - 1.79)
1.08(0.87 - 1.33)1.00
(referent)
0.00
1.00
2.00
3.00
< 85 mg/dL 85-89 mg/dL 90-94 mg/dL 95-99 mg/dL
Baseline Fasting Plasma Glucose Category
Ha
za
rd R
ati
o
Nichols et al., Am J Med 2008;121:519-524.
Cox Regression of Diabetes Cox Regression of Diabetes Incidence (Continuous FPG)Incidence (Continuous FPG)
Hazard Ratio 95% CI p value
Fasting Plasma Glucose (per mg/dL) 1.06 1.05 - 1.07 <0.0001
Age (per year) 1.01 1.00 - 1.02 <0.001
Male Sex 1.01 0.90 - 1.13 0.837
BMI (per kg/m2) 1.08 1.07 - 1.09 <0.0001
Systolic BP (per 5 mmHg) 1.02 1.01 - 1.03 0.008
HDL-Cholesterol (per 5 mg/dL) 0.90 0.88 - 0.92 <0.0001
LDL-Cholesterol (per 10 mg/dL) 0.97 0.96 - 0.99 0.0001
Triglycerides (per 50 mg/dL) 1.09 1.07 - 1.10 <0.0001
Current Smoker 1.37 1.22 - 1.54 <0.0001
Diagnosed Cardiovascular Disease 1.65 1.40 - 1.93 <0.0001
Diagnosed Hypertension 1.51 1.35 - 1.68 <0.0001Nichols et al., Am J Med 2008;121:519-524
Characteristics of Patients Who Characteristics of Patients Who Developed DiabetesDeveloped Diabetes
< 85 mg/dL 85-89 mg/dL 90-94 mg/dL 95-99 mg/dL
Age 56.6 (9.7) 57.4 (9.5) 58.7 (10.4) 59.1 (10.5)
% Male 42.9% 45.5% 46.5% 49.8%
BMI 32.7 (6.7) 33.5 (7.2) 33.4 (7.3) 33.0 (6.8)
Systolic BP 134 (18) 137 (18) 136 (20) 136 (19)%
Diastolic BP 82 (10) 82 (11) 82 (11) 82 (10)
HDL-Cholesterol 49 (15) 46 (15) 47 (14) 47 (14)
LDL-Cholesterol 123 (37) 124 (36) 127 (37) 125 (34)
Triglycerides 239 (364) 213 (257) 212 (149) 209 (131)
Current Smoker 27.4% 25.8% 25.0% 22.0%
Cardiovascular Disease 9.7% 8.3% 11.9% 11.7%
Hypertension 41.1% 49.6% 43.7% 43.6%
Months to Diabetes 59.0 (28.3) 54.6 (28.3) 54.4 (28.3) 53.8 (29.9)
Mean FPG at Diagnosis 150 (63) 145 (52) 141 (53) 142 (51)
Adapted from Nichols et al., Am J Med 2008;121:519-524
Characteristics of Patients who Did and Characteristics of Patients who Did and Did Not Develop DiabetesDid Not Develop Diabetes
Developed Diabetes No Diabetes p value
Age 58.5 (10.3) 57.4 (10.9) <0.0001
% Male 47.6% 40.1% <0.0001
BMI 33.2 (7.0) 28.8 (5.8) <0.0001
Systolic BP 136 (19) 131 (19) <0.0001
Diastolic BP 82 (10) 80 (10) <0.0001
HDL-Cholesterol 47 (14) 54 (16) <0.0001
LDL-Cholesterol 125 (36) 128 (34) 0.005
Triglycerides 213 (191) 151 (109) <0.0001
Current Smoker 23.9% 20.2% <0.001
Cardiovascular Disease 11.1% 6.0% <0.0001
Hypertension 44.2% 25.8% <0.0001
Nichols et al., Am J Med 2008;121:519-524
SummarySummary
Elevated risk of diabetes is associated with Elevated risk of diabetes is associated with higher values of “normal” fasting glucose, higher values of “normal” fasting glucose, perhaps to as low as 87 mg/dlperhaps to as low as 87 mg/dl
The 6% increase in risk per mg/dl was similar The 6% increase in risk per mg/dl was similar to the 7% found among patients with IFGto the 7% found among patients with IFG
The same risk factors consistently predict The same risk factors consistently predict diabetes regardless of FPGdiabetes regardless of FPG
Diabetes Risk and Diabetes Risk and The Metabolic SyndromeThe Metabolic Syndrome
Fasting Glucose Fasting Glucose >> 100 mg/dl 100 mg/dl
BP BP >> 130/85 mmHg 130/85 mmHg
Triglycerides Triglycerides >> 150 mg/dl 150 mg/dl
HDL-C < 40/50 mg/dlHDL-C < 40/50 mg/dl
Waist circumference Waist circumference >> 102/88 cm 102/88 cm
Age/sex Adjusted Incidence of Diabetes, by Presence of Individual Metabolic Syndrome Components
8.8(8.2 - 9.4)
21.9(21.2 - 22.7)
8.4(7.9 - 8.9)
26.2(25.3 - 27.1)
11.5(11.0 - 12.0)
27.6(26.5 - 28.7)
13.1(12.6 - 13.6)
29.1(27.8 - 30.4)
7.1(6.7 - 7.4)
47.0(45.4 - 48.7)
0.0
10.0
20.0
30.0
40.0
50.0
Inci
den
ce p
er 1
,000
per
son
-yea
rs (9
5% C
I)
Age/sex Adjusted Incidence of Diabetes by Number of Metabolic Syndrome Components
1.0
10.0
100.0
-1 0 1 2 3 4 5Number of Risk Factors
Inci
denc
e per
1,
000
pers
on-y
ears
(9
5% C
I)
Low HDL High TG Hypertension Obesity IFG
Summary of Part IISummary of Part II
Risk of diabetes associated with fasting Risk of diabetes associated with fasting glucose is continuousglucose is continuous
Other metabolic risk factors that are Other metabolic risk factors that are commonly associated with elevated glucose commonly associated with elevated glucose play important but largely supplementary play important but largely supplementary rolesroles
Part III – Nondiabetic Fasting Part III – Nondiabetic Fasting Glucose as a Risk Factor for Glucose as a Risk Factor for Complications of DiabetesComplications of Diabetes
Cardiovascular DiseaseCardiovascular Disease
Microvascular Diseases: Microvascular Diseases:
Nephropathy Nephropathy
Retinopathy Retinopathy
NeuropathyNeuropathy
Heart FailureHeart Failure
Medical CostsMedical Costs
Glucose and CVD EventsGlucose and CVD Events
Fasting glucose is (probably) associated with Fasting glucose is (probably) associated with CVDCVD
Coutinho et al. (1999): 20 studies, RR 1.33 (1.06-Coutinho et al. (1999): 20 studies, RR 1.33 (1.06-1.67) for 75 vs. 110 mg/dl1.67) for 75 vs. 110 mg/dl
Levitan et al. (2004): 34 studies, RR 1.27 (1.13-Levitan et al. (2004): 34 studies, RR 1.27 (1.13-1.43) comparing top and bottom categories, 1.43) comparing top and bottom categories, possible threshold effect at 100 mg/dlpossible threshold effect at 100 mg/dl
Danaei et al. (2006): 1 in 5 deaths from ischemic Danaei et al. (2006): 1 in 5 deaths from ischemic heart disease are attributable to higher-than-heart disease are attributable to higher-than-optimum blood glucose optimum blood glucose excludingexcluding deaths deaths attributable to diabetesattributable to diabetes
Glucose and Microvascular DiseaseGlucose and Microvascular Disease
No data on neuropathyNo data on neuropathy
Diabetes diagnosis based on increased Diabetes diagnosis based on increased prevalence of retinopathy, which is present prevalence of retinopathy, which is present for up to 7 years prior to diagnosisfor up to 7 years prior to diagnosis
Cox et al. (2005) - No relationship between Cox et al. (2005) - No relationship between IFG/IGT and CKD, but strong association IFG/IGT and CKD, but strong association with diabeteswith diabetes
IFG and Heart FailureIFG and Heart Failure
FPG test in 1997 or 1998 < 126mg/dlFPG test in 1997 or 1998 < 126mg/dl
Age 50 or older and no evidence of diabetes Age 50 or older and no evidence of diabetes or CHFor CHF
10,113 subjects with IFG (100-125mg/dl)10,113 subjects with IFG (100-125mg/dl)
10,113 subjects with glucose < 100mg/dl 10,113 subjects with glucose < 100mg/dl matched on sex and 5-year age groupmatched on sex and 5-year age group
Followed for ~6.5 yearsFollowed for ~6.5 years
IFG and Heart FailureIFG and Heart Failure
1.08(1.03-1.13)
1.12(1.00-1.25)
1.19(1.04-1.36)
0.25
1
1.75
Per 10mg/dl 100-109 mg/dl 110-125 mg/dl
Baseline Fasting Plasma Glucose
Haz
ard
Rat
io
1.00
Nichols et al., Journal of Diabetes and Its Complications 2009;23:224-228
IFG and Heart Failure (2)IFG and Heart Failure (2)
1.01(0.87-1.16)
1.08(0.97-1.22)1.01
(0.97-1.07)
0.25
1
1.75
Per 10mg/dl 100-109 mg/dl 110-125 mg/dl
Baseline Fasting Plasma Glucose
Haz
ard
Rat
io
1.00
Nichols et al., Journal of Diabetes and Its Complications 2009;23:224-228
Comorbidities and Risk of DiabetesComorbidities and Risk of Diabetes
IFG IFG (n=15,732)(n=15,732)
NPG NPG (n=40,962)(n=40,962)
Relative Risk Relative Risk of Diabetes*of Diabetes*
Cardiovascular DiseaseCardiovascular Disease 18.5%18.5% 11.6%11.6%1.69 1.69
(1.58-1.82)(1.58-1.82)
Chronic Kidney DiseaseChronic Kidney Disease 8.7%8.7% 6.7%6.7%1.45 1.45
(1.32-1.60)(1.32-1.60)
Heart FailureHeart Failure 3.4%3.4% 1.8%1.8%2.13 2.13
(1.88-2.41)(1.88-2.41)
History of DepressionHistory of Depression 20.5%20.5% 20.6%20.6%1.41 1.41
(1.32-1.50)(1.32-1.50)
*Controlling for fasting plasma glucose
Medical Care CostsMedical Care Costs
Diabetes is enormously expensiveDiabetes is enormously expensive
If a diabetes diagnosis is an arbitrary If a diabetes diagnosis is an arbitrary point on a continuum of glucose, then point on a continuum of glucose, then wouldn’t costs also be elevated at sub-wouldn’t costs also be elevated at sub-diabetic levels of hyperglycemia (relative diabetic levels of hyperglycemia (relative to those with normal glycemia)?to those with normal glycemia)?
Incremental Cost of Diabetes Incremental Cost of Diabetes Before and After DiagnosisBefore and After Diagnosis
Costs for Non-Diabetes Control
Group
Incremental Costs for Diabetes
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
Co
st o
f Car
e (U
S$1
998)
Year -5 Year -4 Year -3 Year -2 Year -1 Year +1 Year +2 Year +3
Year Before or After Recognition
Nichols et al. Diabetes Care 2000;23:1654-1658
Costs of Impaired Fasting GlucoseCosts of Impaired Fasting Glucose
$1,497 $1,569 $1,747
$1,923 $1,991$2,045
$937$1,057
$1,174
$-
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
< 100mg/dL (n=28,335) 100-109mg/dL (n=18,738) 110-125mg/dL (n=12,878)
PharmacyOutpatientInpatient
$4,357$4,617
$4,966
Nichols and Brown, Diabetes Care 2005;28:2223-2229
Costs of Impaired Fasting Glucose (2)Costs of Impaired Fasting Glucose (2)
$1,157$1,547 $1,746
$1,790
$1,979$2,039
$852
$1,054
$1,175
$-
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
Stayed Below 100mg/dL(n=23,621)
100-109mg/dL (n=18,738) 110-125mg/dL (n=12,878)
PharmacyOutpatientInpatient
$3,799
$4,580
$4,960
Nichols and Brown, Diabetes Care 2005;28:2223-2229
Incremental Costs of Incremental Costs of Normal Fasting GlucoseNormal Fasting Glucose
$1,148$1,716
$2,164$2,599
$1,794
$1,940
$2,103
$2,613
$843
$803
$1,040
$1,356
$-
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
Stayed Below100mg/dL (n=23,621)
Progressed to 100-109mg/dl (n=1,741)
Progressed to 110-125mg/dl (n=462)
Progressed toDiabetes (n=485)
PharmacyOutpatientInpatient
$3,755
$3,900
$4,488
$6,796
Nichols and Brown, ADA 65th Scientific Sessions;2005:Abstract #117-OR
SummarySummary
The risk of developing diabetes is strongly The risk of developing diabetes is strongly associated with level of fasting glucoseassociated with level of fasting glucose
That risk is That risk is continuouscontinuous, or at least extends , or at least extends well below the point at which glucose is well below the point at which glucose is considered abnormalconsidered abnormal
Summary (2)Summary (2)
Other metabolic risk factors that are Other metabolic risk factors that are commonly associated with elevated glucose commonly associated with elevated glucose play important but largely supplementary play important but largely supplementary rolesroles
Non-diabetic levels of glucose increase the Non-diabetic levels of glucose increase the risk of “diabetic” complications as well as risk of “diabetic” complications as well as costs of medical carecosts of medical care
ConclusionConclusion
The relationships between glucose, other The relationships between glucose, other metabolic disturbances, diabetes, and it’s metabolic disturbances, diabetes, and it’s complications are complex and confoundedcomplications are complex and confounded
Categorizing glucose helps us understand Categorizing glucose helps us understand these interrelationships, but limits our ability these interrelationships, but limits our ability to predict riskto predict risk