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 World Health Organization

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) World Health Organization

Prevention of Type 1 diabetes • 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 World Health Organization

Prevention of Type 2 Diabetes The Major Modifiable Risk Factors � Overweight and obesity � Abdominal/central obesity � Physical inactivity � Elevated fasting and 2 hr glucose levels - usually precedes the development of diabetes by several years World Health Organization

Body mass index and incident diabetes Source: BMJ 2002; 324:1570 World Health Organization (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/m 2 World Health Organization

Source: International Obesity Task Force Trends in obesity from selected countries World Health Organization

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

What led to this……? Smoking in UK Percentage 70 60 50 Men 40 Women 30 20 10 0 8 2 6 6 0 4 8 2 6 0 4 8 4 5 5 6 7 7 7 8 8 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 1 1 1 1 1 1 1 1 1 1 1 1 World Health Organization 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 And probably none would work in isolation World Health Organization

“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…” From WHO 1997 Global Obesity Report World Health Organization

High risk approaches to the prevention of Type 2 diabetes World Health Organization

Prevention studies in high risk populations Study Population Number Age Initial BMI Study Population Number Age 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 31 FDPS Finnish with IGT (WHO) 522 55 31 STOP- -NIDDM NIDDM Europids Europids with IGT 429 54 31 with IGT 429 54 31 STOP DPP Americans with IGT 3234 51 34 DPP Americans with IGT 3234 51 34 TRIPOD Hispanic TRIPOD Hispanic- -American 23634 31 American 23634 31 with GDM in previous 4 yrs with GDM in previous 4 yrs World Health Organization

% reduction in the incidence of Type 2 diabetes Stop Da Qing NIDDM TRIPOD 0 A M D M E E D E E T c e e x x i i D D x r x a t -10 e e t e r r r e o f f e e i i b c c t g o o t i -20 r r i o e e + r l r + s s s c c m m i E e e t t e E i i + + t -30 i i x x D D n n a e s s i i e z e e -40 r e e r o t t c n c i -50 e i s s e -60 e FDPS DPP World Health Organization Slide from Prof D Nathan

Diabetes Prevention Programme Eligible participants Eligible participants Randomized Randomized Standard lifestyle recommendations Standard lifestyle recommendations Intensive Metformin Placebo Intensive Metformin Placebo Lifestyle Lifestyle (n = 1079) (n = 1073) (n = 1082) (n = 1079) (n = 1073) (n = 1082) World Health Organization

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 • > World Health Organization

Mean Weight Change 0 W e ig h t C h a n g e (k g ) Placebo Metformin -2 Lifestyle -4 -6 -8 0 1 2 3 4 Years from Randomization The DPP Research Group, NEJM 346 :393-403, 2002

Incidence of Diabetes Incidence of Diabetes Percent developing diabetes All participants All participants Placebo (n=1082) Metformin (n=1073, p<0.001 vs. Placebo ) Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac ) Lifestyle (n=1079, p<0.001 vs. Metformin , Metformin (n=1073, p<0.001 vs. Plac) 40 Placebo (n=1082) p<0.001 vs. Placebo ) Cumulative incidence (%) Risk reduction Risk reduction 30 31% by metformin 31% by metformin 58% by lifestyle 58% by lifestyle 20 10 0 0 1 2 3 4 Years from randomization The DPP Research Group, NEJM 346 :393-403, 2002

DPP - Lifestyle Intervention • 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 World Health Organization

Diabetes related complications - macrovascular • 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 World Health Organization

Diabetes related complications - microvascular • Retinopathy • Nephropathy • Neuropathy (along with peripheral vascular disease, major cause of diabetic foot disease) World Health Organization

Prevention of complications in Type 2 Prevention of complications in Type 2 diabetes - - Glucose Control, UKPDS Glucose Control, UKPDS diabetes The intensive glucose control policy maintained a lower HbA 1c 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 World Health Organization

Prevention of complications in Type 2 Prevention of complications in Type 2 diabetes - - Blood Pressure Control, UKPDS Blood Pressure Control, UKPDS diabetes 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 World Health Organization

SIMVASTATIN: MAJOR VASCULAR EVENTS by YEAR in DIABETIC PATIENTS 30 25 Logrank p<0.00001 People suffering events (%) PLACEBO 20 15 SIMVASTATIN 10 5 0 0 1 2 3 4 5 6 Years of follow-up Data from over 5000 people with diabetes in the Heart Protection Study

Prevention of complications in established disease • 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. World Health Organization

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. World Health Organization

In conclusion • 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 on how to translate it into practice; and knowledge on the most cost effective interventions where resources are scarce World Health Organization