Diabetes A Major Health Problem for All Stuart R. Chipkin, MD,
FACE School of Public Health and Health Sciences University of
Massachusetts, Amherst
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Diabetes- Precursors and Complications I. Diabetes- Major cause
of morbidity and mortality in US and Russia II. Risk factor
analysis 1.Nutrition- Diet choices 2.Physical activity and
inactivity 3.Other Risk factors- blood pressure, tobacco,
cholesterol, III. Research/program description 1. Pre-diabetes:
Research study to compare physical activity, medication or
combination - Outcome: insulin sensitivity 2. Diabetes: Share
diabetes personnel with four primary care sites - Outcome:
laboratory data (a1c) and ER visits 3. Risk factors for
complications: Electronic Medical Record data collection, state
guidelines promotion, case manager utilization - Blood pressure,
cholesterol, foot examinations, eye examinations
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Classification of Diabetes Mellitus by Etiology Type 1 -cell
destructioncomplete lack of insulin Type 2 -cell dysfunction and
insulin resistance Gestational -cell dysfunction and insulin
resistance during pregnancy Other specific typesGenetic defects of
-cell function Exocrine pancreatic diseases Endocrinopathies Drug-
or chemical-induced Other rare forms 11
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Type 1 diabetes The main abnormality is absolute insulin
deficiency Type 2 diabetes Both insulin resistance and relative
insulin deficiency contribute Glucotoxicity and lipotoxicity Poor
metabolic control worsens insulin deficiency and insulin resistance
Defects in Diabetes
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Current estimates: Over 24 million people in U.S. (7%) Over age
60, rates exceed 20% Recent increases of 20% may be reaching a
plateau type 1 = 10% (2 million) type 2 = 90% (21 million)
Currently 6-7 million are still undiagnosed Prevalence of
pre-diabetes over 42 million Total treatment cost: $174 billion/yr
Diabetes in the U.S.
Retinopathy in Diabetes Patients- Northwest Russia (
Arkhangelsk ) Dedov I et al; Rev Diabet Stud. 2009 Summer; 6(2):
124129.
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Cataract Prevalence in Diabetes Patients- Northwest Russia
Dedov I et al; Rev Diabet Stud. 2009 Summer; 6(2): 124129.
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Diabetes Patients- Northwest Russia Dedov I et al; Rev Diabet
Stud. 2009 Summer; 6(2): 124129.
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Consequences of Diabetes Premature morbidity and mortality
Cardiovascular disease risk increased 2-4 times Exceeds cost of
treating all other complications combined Stroke risk increased 2.5
times Leading cause of new blindness in people 20-74 years old
Leading cause of non-traumatic amputation Reportedly higher rates
in Russia Leading cause of kidney failure
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Key Facts- World Health Organization Worldwide, more than 220
million people have diabetes. In 2005, an estimated 1.1 million
people died from diabetes. Almost half of diabetes deaths occur in
people under the age of 70 years; 55% of diabetes deaths are in
women. WHO projects that diabetes deaths will double between 2005
and 2030. Healthy diet, regular physical activity, maintaining a
normal body weight and avoiding tobacco use can prevent or delay
the onset of diabetes.
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Measures of Hyperglycemia Random plasma glucose (RPG) without
regard to time of last meal Fasting plasma glucose (FPG) before
breakfast Oral glucose tolerance test (OGTT) 2 hours after a 75-g
oral glucose drink Postprandial plasma glucose (PPG) 2 hours after
a meal Hemoglobin A 1c (A1C) reflects mean glucose over 23 months
Fructosamine/glycated serum protein reflects mean glucose over 12
weeks 5
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American Diabetes Association. Diabetes Care. 2010; (suppl 1)
*Requires confirmation by repeat testing Symptoms of diabetes plus
random plasma glucose 200 mg/dL (11.1 mM)* or Fasting Plasma
Glucose 126 mg/dL (7mM)* or 2-h PG during a 75-g OGTT 200 mg/dL
(11.1 mM)* or A1c > 6.5% Making the Diagnosis of Diabetes
Impaired Fasting Glucose and Impaired Glucose Tolerance
Different conditions intermediate Between Normal and Diabetes
Impaired Glucose Tolerance (IGT) 2-h PG on OGTT 140 but 200 mg/dL
Predicts increased risk of diabetes and cardiovascular disease
Impaired Fasting Glucose (IFG) FPG 100 but 126 mg/dL Predicts
increased risk of diabetes and micro- and macrovascular
complications 9
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Who Should Be Tested for Diabetes? Consider if One or More of
the Following Apply Symptoms suggesting diabetes: weight loss,
hunger, urinary frequency, blurred vision Age >45 (>30 if
patient has other risk factors) Prior IGT or IFG or family history
of diabetes Prior gestational diabetes or baby weighing >9 lb
(4.1kg) Women with polycystic ovarian syndrome (PCOS) Obesity (BMI
25 kg/m 2 ), especially adolescents African, Latino, Asian, or
Native American ancestry History of vascular disease or
hypertension American Diabetes Association. Diabetes Care.
2004;27(suppl 1):S11-S14; AACE/ACE medical guidelines. Endocr
Pract. 2002;8(suppl 1):40-82
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Prerequisites for a Prevention Program Important health problem
posing a significant health burden on society Well-understood
natural history with identifiable parameters that measure
progression to disease Test to identify the pre-disease state that
is safe, acceptable and predictive Safe, effective and reliable
means of preventing or delaying disease Ability to find high-risk
individuals and the cost of the intervention should be
cost-effective and not burdensome Sherwin R et al; Diabetes Care
27:S48-S54, 2004
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Etiology of Type 2 Diabetes Impaired Insulin Secretion and
Insulin Resistance Type 2 diabetes Genes and environment Impaired
insulin secretion Insulin resistance Impaired glucose tolerance
Progressive hyperglycemia and high free fatty acids
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Adapted from Ramlo-Halsted BA, Edelman SV. Prim Care.
1999;26:771-789 Natural History of Type 2 Diabetes Macrovascular
complications Microvascular complications Insulin resistance
Impaired glucose tolerance Undiagnoseddiabetes Known diabetes
Insulin secretion Postprandial glucose Fasting glucose 17
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Prevention of Type 2 Diabetes Insulin resistance may be an
important early stage of intervention Evidence exists for
interventions to increase insulin sensitivity
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Clustering of Factors Reflecting Insulin Resistance in Russia
Sidorenkov et al. BMC Public Health 2010, 10:23
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Diabetes Prevention Case study 45 year old woman comes to see
you because her older brother was recently diagnosed with diabetes.
She is overweight, tries to avoid sugar, and says that she
exercises when she cleans her house. She has been told of high
blood pressure and high cholesterol. She was told to exercise and
decrease her salt. Her father had diabetes and had a leg
amputation.
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Diabetes prevention Case study Physical examination notes a
blood pressure of 150/88, pulse of 76 and BMI of 29 kg/m 2. Fasting
laboratory test shows: - Glucose of 122 mg/dl (6.8 mM) -
Electrolytes and kidney function normal - Liver tests (ALT/AST are
twice normal) - Triglyceride= 280 (3.2 mmol/L) - HDL= 29 (0.75
mmol/L) - LDL= 150 mg/dl (3.9 mmol/L)
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Diabetes Prevention Which of these would you do next? Tell her
to keep exercising and watching her diet. Tell her to cut out all
sugar in her diet. Find out more about why she doesnt exercise
more. Find out how she defines a healthy diet. Discuss barriers to
physical activity. Start medication. Are there other resources for
her? Family Work Community
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Diabetes Prevention- Finnish Study Incidence of diabetes
Control group:59 (23%) 6% per year Intervention group:27 (11%) 3%
per year Overall risk reduction of 58% Diabetes did not develop in
any of the subjects who reached at least four of five goals
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Tuomilehto et al; NEJM 344: 1343-50, 2001
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Diabetes Prevention Program Crude incidence (cases per 100
person-years) -Placebo11.0 -Metformin 7.8 -Lifestyle 4.8 -Estimated
cumulative incidence of diabetes -Placebo28.9% -Metformin21.7%
-Lifestyle14.4% Compared with placebo, diabetes risk was 58% lower
in lifestyle group 31% lower in metformin group
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N Engl J Med; 346: 393-403, 2002
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Diabetes Prevention Program Number needed to treat (three
years) Lifestyle 6.9 Metformin13.9 Advantage of lifestyle was
greater in Older subjects Lower BMI
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What about metformin PLUS lifestyle? Ramachandran A et al;
Diabetologia 49: 289-297, 2006 Green= Control Relative Risk
Reduction: - Turquoise= Lifestyle (p=0.018) - Red= Metformin
(0.029) - Blue= Metformin + Lifestyle (0.022) Progress to DM Cntrl=
55% LSM=39.3% MET=40.5% LSM+MET= 39.5%
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India Diabetes Prevention Program While metformin and lifestyle
both prevented or delayed onset of diabetes, there was no additive
effect. Compared with U.S. DPP, India DPP: Used smaller dose of
metformin Had baseline diets close to recommended Subjects did not
lose weight
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Impact of Energy Deficit on Insulin Sensitivity Black SE et al:
J Appl Physiol, 99:2285-2293, 2005
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Research Question Energy Metabolism Laboratory Examine the
impact of three strategies on insulin sensitivity in people with
pre- diabetes (either IFG alone or IFG with IGT) Metformin alone
Structured, supervised exercise program (3x per week for 12 weeks)
Metformin + exercise Outcome measures Insulin sensitivity (
euglycemic hyperinsulinemic clamp ) Weight, BMI, waist
circumference, blood pressure Fasting glucose, lipid profile, body
composition
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Impact of metformin, lifestyle or both Pre-diabetes subjects
Malin S et al IPE, Miami, FLA 2010;
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Diabetes Case study 51 year old man presents with increasing
fatigue and muscle weakness. He does manual work and has noticed a
change in his endurance. While he thought he was just getting
older, a fellow employee saw him going to urinate several times in
one shift and checked his blood sugar using a meter; the glucose
was 360 mg/dl (20 mM). He has not been to the doctor in many years.
He smokes 1 pack of cigarettes per day and drinks 1 liter of vodka
every 2 days. He plays soccer on weekends but only in nice weather.
He lives alone. His mother had diabetes- so did her siblings.
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Diabetes- case study Physical examination: Pulse= 96 BP=160/98
BMI=36 kg/m 2 Fundi: small microaneurysms Neck: no goiter, no
bruits Lungs: clear. Heart: normal heart sounds (tachycardia)
Abdomen: soft, bowel sounds present. No liver/spleen enlargement
Ext: no swelling. Pulses in feet present. Skin is dry and cracked.
Neuro: No Achilles reflexes but patellar 2/2
Diabetes- new onset What are next steps Education- who does
this? Diet Physical activity Self blood glucose monitoring
Medications How can you implement your plan? Family Work
Community
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Number of people with diabetes9,624,900 Percent with impaired
glucose tolerance (20-79 years) 16.7 New cases of type 1 diabetes
(children
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Survey of Diabetes Awareness Russia Longitudinal Monitoring
Survey (RLMS- www.cpc.unc.edu/rlms): www.cpc.unc.edu/rlms 38 sites
across Russian Federation (St. Petersburg, Moscow and 36 districts
based on SES, urban/rural status status Major findings: Over half
the individuals who reported having diabetes did not receive any
formal medical treatment or dietary advice. Half those who were
diabetes aware in this survey were receiving no medical treatment,
not even advice about weight loss or diet. Limiting factor for
medication changed during the study from availability to
affordability Perlman F and McKee Martin Diab Res and Clin Pract
80:305-313, 2008.
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Percent of Patients with Diabetes Reaching A1C Goal < 7% in
2010
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Diabetes- Risk Factors for Complications Case study 67 year old
man comes to see you after being seen in hospital for infected foot
ulcer. He has had diabetes for 18 years. Also has poorly controlled
hypertension and high cholesterol. He is on a diuretic for HTN and
a low dose statin for cholesterol. He was told he should take
insulin for his diabetes. He went to a diabetes education program
10 years ago. He does not monitor his blood sugars at home. He
tries to follow a diet. He does not exercise. He used to smoke more
but has decreased. He did not smoke while in the hospital. His
father died from kidney failure due to diabetes. His older brother
had a stroke. He lives with his wife; he has two children who are
married and live nearby.
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Diabetes- Risk Factors for Complications Physical examination
notes a blood pressure of 140/90, pulse of 72 and BMI of 31 kg/m 2.
He has background retinopathy, clear lungs, systolic heart murmur
and benign abdomen. His feet are dry and pulses are poor. He does
not feel a monofilament on his toes. There is a healing ulcer on
the right foot- 3 cm in diameter over the lateral malleolus.
Laboratory test: - a1c= 11% - Triglyceride= 160 mg/dl (1.81 mmol/L)
- HDL= 30 mg/dl (0.77 mmol/L) - LDL= 118 mg/dl (3.1 mmol/L) -
creatinine= 1.9 () - urine albumin:creat ratio= 80
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Diabetes- Risk Factors for Complications What other questions
do you have for him? How do you prioritize his problems? How will
you address his problems? Immediate vs. Long-term Other
professionals to involve Community resources
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Percent of Patients with Diabetes Reaching LDL Goal < 100
mg/dl (