The prevention of diabetes and its complications World Health - - PowerPoint PPT Presentation

The prevention of diabetes and its complications

World Health Organization

Overview

• Primary prevention

– Type 1 diabetes – Type 2 diabetes

• Risk factors for Type 2 diabetes
• Population based measures
• Targeting high risk groups
• Prevention of complications

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Prevention of Type 1 diabetes

• Possible to identify those at very high risk

through:

– Family history – Genetic background (HLA haplotypes) – Auto-antibodies to islet cells (insulin producing cells of the pancreas)

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Prevention of Type 1 diabetes

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• Interventions that have been tried in high

risk individuals include:

– Immuno-suppression – Antioxidant drugs e.g. nicotinamide – Insulin administration – Vaccination

• None of them shown to work

Prevention of Type 2 Diabetes

The Major Modifiable Risk Factors

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Overweight and obesity Abdominal/central obesity Physical inactivity Elevated fasting and 2 hr glucose levels -

usually precedes the development of diabetes by several years

Body mass index and incident diabetes

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Source: BMJ 2002; 324:1570 (Based on data from the Pima Indians)

• 2002 World Health Report estimated that

around 60% of Type 2 diabetes could be attributed to BMI > 21 kg/m2

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Trends in obesity from selected countries

Source: International Obesity Task Force

Approaches to population wide prevention of obesity and diabetes - lessons from smoking?

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World Health Organization

What led to this……?

10 20 30 40 50 60 70 1 9 4 8 1 9 5 2 1 9 5 6 1 9 6 6 1 9 7 1 9 7 4 1 9 7 8 1 9 8 2 1 9 8 6 1 9 9 1 9 9 4 1 9 9 8

Percentage

Men Women

Smoking in UK

Source of figures: General Household Surveys

Not properly known but likely to be…..

A combination of:

• Health education - schools, workplaces, mass

media etc

• Health protection - taxation, control of supply,

regulation/banning of advertising

• Targeted, cost-effective behaviour change

interventions - reminders to smokers, nicotine replacement

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And probably none would work in isolation

“what has been demonstrated…is that approaches that are firmly based on the principle of personal education and behaviour change are unlikely to succeed in an environment in which there are plentiful inducements to engage in opposing behaviours…It would therefore seem appropriate to devote resources to programmes which focus on reducing the exposure of the population to obesity promoting agents by addressing the environmental factors such as transportation, urban design, advertising and food pricing…”

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From WHO 1997 Global Obesity Report

High risk approaches to the prevention of Type 2 diabetes

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Study Study Population Population Number Number Age Age Initial BMI Initial BMI DaQing DaQing Chinese with IGT(WHO) 530 45 Chinese with IGT(WHO) 530 45 26 26 FDPS Finnish with IGT (WHO) 522 55 FDPS Finnish with IGT (WHO) 522 55 31 31 STOP STOP-

• NIDDM

NIDDM Europids Europids with IGT 429 54 31 with IGT 429 54 31 DPP Americans with IGT 3234 51 DPP Americans with IGT 3234 51 34 34 TRIPOD Hispanic TRIPOD Hispanic-

• American 23634 31

American 23634 31 with GDM in previous 4 yrs with GDM in previous 4 yrs

Prevention studies in high risk populations

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% reduction in the incidence of Type 2 diabetes

• 60
• 50
• 40
• 30
• 20
• 10

D D i i e e t t

E E x x e e r r c c i i s s e e

E E x x e e r r c c i i s s e e + + D D i i e e t t

A c a r b

• s

e

M M e e t t f f

• r

r m m i i n n

D i e t + E x e r c i s e

T r

• g

l i t a z

• n

e

D i e t + E x e r c i s e

Da Qing Stop NIDDM TRIPOD

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FDPS DPP

Slide from Prof D Nathan

Diabetes Prevention Programme

Eligible participants Eligible participants Randomized Randomized Standard lifestyle recommendations Standard lifestyle recommendations

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Intensive Metformin Intensive Metformin Placebo Placebo Lifestyle Lifestyle (n = 1079) (n = 1073) (n = 1079) (n = 1073) (n = 1082) (n = 1082)

DPP Lifestyle Intervention

An intensive program with the following specific goals:

• >

> 7% loss of body weight and maintenance of 7% loss of body weight and maintenance of weight loss weight loss – – Dietary fat goal Dietary fat goal --

• - <25% of calories from fat

<25% of calories from fat – – Calorie intake goal Calorie intake goal --

• - 1200

1200-

• 1800 kcal/day

1800 kcal/day

• >

> 150 minutes per week of physical activity 150 minutes per week of physical activity

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Mean Weight Change

• 8
• 6
• 4
• 2

1 2 3 4

Years from Randomization W e ig h t C h a n g e (k g )

Placebo Metformin Lifestyle

The DPP Research Group, NEJM 346:393-403, 2002

1 2 3 4 10 20 30 40 Placebo (n=1082) Metformin (n=1073, p<0.001 vs. Plac) Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )

Percent developing diabetes All participants All participants

Years from randomization Cumulative incidence (%)

Placebo (n=1082) Metformin (n=1073, p<0.001 vs. Placebo) Lifestyle (n=1079, p<0.001 vs. Metformin , p<0.001 vs. Placebo)

Incidence of Diabetes Incidence of Diabetes

Risk reduction Risk reduction 31% by metformin 31% by metformin 58% by lifestyle 58% by lifestyle

The DPP Research Group, NEJM 346:393-403, 2002

DPP - Lifestyle Intervention

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• 16 session core curriculum (over 24 weeks)
• Long-term maintenance program
• Supervised by a case manager
• Access to lifestyle support staff

– Dietitian – Behavior counselor – Exercise specialist

Diabetes related complications - macrovascular

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• Macrovascular - majority of deaths in

people with diabetes are from CVD, especially ischaemic heart disease.

• Risk factors for macrovascular disease are

similar to those in people without diabetes e.g.

– Dyslipidaemia, hypertension, smoking, plus ? hyperglycaemia

Diabetes related complications - microvascular

• Retinopathy
• Nephropathy
• Neuropathy (along with peripheral vascular

disease, major cause of diabetic foot disease)

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Prevention of complications in Type 2 Prevention of complications in Type 2 diabetes diabetes -

• Glucose Control, UKPDS

Glucose Control, UKPDS

The intensive glucose control policy maintained a lower HbA1c by mean 0.9 % over a median follow up of 10 years from diagnosis of type 2 diabetes with reduction in risk of: 12% for any diabetes related endpoint p=0.029 25% for microvascular endpoints p=0.0099 16% for myocardial infarction p=0.052 24% for cataract extraction p=0.046 21% for retinopathy at twelve years p=0.015 33% for albuminuria at twelve years p=0.000054

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Prevention of complications in Type 2 Prevention of complications in Type 2 diabetes diabetes -

• Blood Pressure Control, UKPDS

Blood Pressure Control, UKPDS

A tight blood pressure control policy which achieved blood pressure of 144 / 82 mmHg gave reduced risk of

24% for any diabetes-related endpoint p=0.0046 32% for diabetes-related deaths p=0.019 44% for stroke p=0.013 37% for microvascular disease p=0.0092 56% for heart failure p=0.0043

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People suffering events (%)

SIMVASTATIN: MAJOR VASCULAR EVENTS by YEAR in DIABETIC PATIENTS

Years of follow-up PLACEBO SIMVASTATIN Logrank p<0.00001 1 2 3 4 5 6 5 10 15 20 25 30

Data from over 5000 people with diabetes in the Heart Protection Study

Prevention of complications in established disease

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• Retinal - retinal screening and laser therapy

for proliferative retinopathy

• Renal - reduced progression to end stage

renal disease through blood pressure lowering

• Diabetic foot - identification, education and

responsive health care for people with at risk feet.

The complications of diabetes are not an inevitable outcome, and the risk can be reduced substantially by appropriate

• therapy. Diabetes therapy is no longer

mainly about glucose lowering per se, but about overall reduction in the risk factors for diabetic complications.

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In conclusion

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• The evidence base for the prevention of

Type 2 diabetes and for a substantial proportion of diabetes related complications is strong.

• We know what to do - we lack knowledge
• n how to translate it into practice; and

knowledge on the most cost effective interventions where resources are scarce