Diabetes

Beas BhattacharyaGreat Western Hospital

What is Diabetes?

History“Diabetes”Mid 16th century: Greek, diabainein - 'go through‘ Latin 'siphon', meaning “to pass through”

= Increased Urination

Indian physician(Susruta & Charaka)-5th cent AD

Polyuria with “sweet tasting urine”

Was thought to be a kidney disease

Basic problem

“a serious disease in which the body cannot properly control the amount of sugar in your blood because it does not have enough insulin”

Webster Dictionary

In a nutshell

Diabetes mellitus (DM) is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both.

Diagnosis –blood test

HBA1C>6.5%

Fasting plasma glucose is ≥7.0 mmol/L

2-hour post glucose load is ≥11.1 mmol/L.

Broadly two type

Lacking or not making insulin(Type 1)

Resistance to the working of Insulin (Type 2)

Insulin Discovery

The breakthrough: Toronto 1921 – Banting & Best

© 2004, John Walsh, P.A., C.D.E.

Before Insulin

Before insulin was discovered in 1921, everyone with type 1 diabetes died within weeks to years of its onset

JL on 12/15/22 and 2 mos later

3 million by 2010

WHO estimation(Adults)

285 million in 2010336 million in 2011

552 million by 2030.

Diabetes in UK

• Over 2.5 million people diagnosed1

• Approx 4.9% of UK adult population1

• T2D accounts for 85-95% of all cases1,2

The total number of people with diabetes in the UK could increase to >5.5 million by 20303

1. IDF Diabetes Atlas. The Global Burden [last accessed http://www.idf.org/diabetesatlas/5e/diabetes April 2012]2. World Diabetes Foundation. Diabetes Facts [Last accessed http://www.worlddiabetesfoundation.org/composite-35.htm April 2012]

3. Diabetes UK, One million people in the UK are unaware they have T2D [last accessed http://www.diabetes.org.uk/About_us/News_Landing_Page/One-million-people-in-UK-unaware-they-have-Type-2-diabetes/ April 2012]

2.5 mil2010

5.5 mil2030

Prevalence of diabetes in the UK

1940 1950 1960 1970 1980 1990 2000 20100

500,000

1,000,000

1,500,000

2,000,000

2,500,000

3,000,000

Diabetes in Swindon

Population Swindon – 209,200 (2011 Census)

Approx Diabetic Population Swindon – 14,000

6% of population has diabetes(Estimated 7.3%in 2020, 8.3% 2030)

Europe :5-6%Asia :11-12%

Why is that a problem?

Diabetes & it’s complications

Quality of lifeMorbidityMortalityCost

COMPLICATIONS OF DIABETES

Small vessel(Microvascular)• Eye disease(Retinopathy)• Kidney disease(Nephropathy)• Nerve/Foot affection(Neuropathy/Diabetic Foot

disease)

Big vessel (Macrovascular)• Cardiac events,Heart attacks• Peripheral vascular disease• Cerebrovascular disease

Diabetes has serious implications

Blindness

Leading causeof blindnessin working ageadults1

Kidney failure

Leading cause of end-stage kidney disease2

Heart Disease

Stroke

2 to 4 fold increase in cardiovascular mortality and stroke3

Amputations

Leading cause of non-traumatic lower extremity amputations5

8/10 diabetic patients die from cardiovascular events4

1 Fong DS et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 2Molitch ME et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 3 Kannel WB et al. Am Heart J 1990; 120:672–676. 4Gray RP & Yudkin JS. In Textbook of Diabetes 1997 Chapter 57.

5Mayfield JA et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.

Eye DiseaseRetinopathy

DIABETIC EYE DISEASE

Present in most diabetic people after 20 years >20% of patients develop sight threatening

retinopathy – improving with better careAbout 90% type 1 diabetes developed diabetic

retinopathy within 25 years of diagnosis. 12 % of new cases of blindness between the ages

of 45-74.

Diabetes Foot Disease

Microvascular Damage Leads to Neuropathy

Examination of tissues from patients with diabetes reveals capillary damage, including occlusion in the vasa nervorum Reduced blood supply to the neural tissue results in impairments in nerve signaling that affect both sensory and motor

function

Dyck PJ, Giannini C. J Neuropathol Exp Neurol. 1996;55:1181-1193.Sheetz MJ, King GL. JAMA. 2002;288:2579-2588.

Normal nerve Damaged nerve

Occluded vasa nervorum

Damage to myelinated and unmyelinated

nerve fibers

Effects of Diabetic Peripheral Neuropathy

Images: 1,4Edward J Bastyr, III, MD; 2,3Rayaz A Malik, MBChB, PhD, MRCP.

The factsFoot in Diabetes-20% of total

diabetes expenditure 6000-7000/year Amputations : 2009-

2012

5 yr Mortality: post amputation>40%

Hospital costs of amputation are £25 million per year. Even a modest 10% reduction will have significant cost savings

Cardiovascular Disease D.O.H. 2013

Kidney Disease

Diabetic kidney disease= the single most common cause of renal failure

Dia

gn

osi

s in

pati

en

ts w

ith

ES

RD

(%

)

Diabetes Uncertain

aetiology*

Other Glomerulo-

nephritis

Pyelonephritis

Polycystic kidney

Renal vascular disease

Hypertension

0

30

20

10

24.0

20.7

15.6

11.8

7.8 7.3 6.96.0

Adapted from: Nephron Clin Pract 2010;115(Suppl.1) The Renal Association. UK Renal Registry. Twelfth Annual Report 2009.

*Includes presumed glomerulonephritis not biopsy proven.† Figures shown are calculated excluding data not available. Data for primary renal diagnosis (PRD) missing in 10.8% of patients. In centres with >25% missing PRD data, percentages in the other diagnostic categories not calculated. Centres with very high rates of uncertain diagnosis also excluded.

Primary Renal Diagnosis†

30

CV event risk greatest when diabetes and CKD both present

Adapted from: Foley RN, et al. J Am Soc Nephrol 2005;16:489–95.

CHF=congestive heart failure; AMI=acute myocardial infarction; CVA/TIA=cerebrovascular accident/transient ischemic attack;PVD=peripheral vascular disease; ASVD=atherosclerotic vascular disease. *ASVD was defined as the first occurrence of AMI, CVD/TIA, or PVD.

CHF AMI CVA/TIA PVD ASVD* Death

CV

eve

nt

incid

en

ce

per

100 p

ati

en

t-ye

ars

No diabetes/no CKDDiabetes/no CKDNo diabetes/CKDDiabetes/CKD

60

50

40

30

20

10

0

32

England National Diabetes Audit 2009-10

Prevalance of End Stage Renal Disease

( dialysis or transplantation in type 2 diabetes)2003-4 = 0.26% 2009-10 = 0.56%

Kidney disease 'biggest threat' for diabeticsBBC News 2013

“An audit of 1.9 million people with Type 1 and Type 2 diabetes found more than 13,000 had a stroke in 2009-10,

a 57% rise from 2006-7.

And more than 7,000 had kidney failure, up 31% from 2006-7.”

What are the cause of mortality in patients with diabetes Nephropathy ?

Stroke MyocardialInfarction

HeartFailure

SuddenDeath

Is it all doom and gloom?

Positives

AwarenessCommunity based service advocatedEarly detectionNational bodies-Diabetes UKNSF 9 standardsFocused, specialised services-E.g. Foot

serviceNew drugs, insulin pumpsNew evidences

What can we do?

We all have a roleAs health professional, community, public

-Raise awarenessChange lifestyle

Diabetes is a Pandemic evolving

There won’t be many family unscathed or untouched

Responsibility is not just on health care professionals

-it’s on all of us!

Who are at risk?Overweight/BMI>25

WITH

Family History-1st degree relative

Ethnicity- e.g.South Asians

Gestational DiabetesPast Big babyCardiovascular diseaseHigh lipids

Symptoms

excessive hunger

headache

profuse sweatingExcessive thirst

DPMI Workforce Development – The Alfred Workforce Development Team June 2005

Cornerstones of treatment

Insulin/tablets

Physical activity

Diet

Lifestyle changes

Lifestyle modification• Diet• Exercise• Weight loss• Smoking

cessation

If a 1% reduction in HbA1c is achieved, you could expect

a reduction in risk of:

• 21% for any diabetes-related endpoint

• 37% for microvascular complications

• 14% for myocardial infarction

Stratton IM et al. BMJ 2000; 321: 405–412.

Dietary recommendations for diabetes

Eat starchy foods regularly

Eat more fruit and vegetables

Reduce animal or saturated fat

Cut down on sugarReduce salt

Exercise / activity

30 minutes moderate intensity most days preferably all

Helps to: Increased insulin sensitivityDecreased insulin requirementsWeight reductionLipid controlBlood pressure control

CHRONIC COMPLICATIONS OF DIABETES

1. Absolute prevention of complications-stop it!

2. Preventing the progression of complications to sight / life threatening disease- stop progress!

Evidence

Beneficial effects of good glycaemia control on complications

DCCT Kumamoto UKPDS

HBA1C 9→7% 9→7% 8→7%

Retinopathy 63% 69% ~20%

Nephropathy 54% 70% 25-30%

Neuropathy 60% --- ---

Glucose Control Study Summary

The intensive glucose control policy maintained a lower HbA1c by 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=0.02925% for microvascular endpoints p=0.0099

16% for myocardial infarction p=0.05224% for cataract extraction p=0.046

21% for retinopathy at twelve years p=0.01533% for albuminuria at twelve years p=0.000054

What can we do as community ?“Charity begins at home”- holds trueWe can’t change our genes but we can change

our habits.

If not for us, can we do it for the community, the future generation.

Maybe be set an example for others e.g. .as a proactive and responsible community

What can communities do?

Raise public awareness Create a sense of urgencyCommunicate the magnitude of the problemGet people involved in improving their healthRecognise those who are most at riskReduce risk to families, friends and wider communities

Open day regular discussion/public meets(like today!)

Break the barriers-GP-Hospital-”Community”

Council & Government bodies-cheaper exercise options (Town Garden

walks/Swindon Football ground cycle rides)-Healthy affordable food stalls at City centre etc

Measure Up: Tactics Roadshows ~20 UK towns/year

Simple 2-minute test to assess risk of diabetes

Advice about diabetes Advertising

Posters at strategic locations throughout the UK

Adverts in national newspapers and consumer magazines

Online targeting of at risk groups

Lobbying Extended poster campaign

and awareness day at UK Houses of Parliament

Campaigning at conferences of UK political parties

Diabetes UK. Measure Up – Are You At Risk of Diabetes. http://www.diabetes.org.uk/Measure_Up_-_are_you_at_risk_of_diabetes/.

NSF 9 standardsNSF

9 standards

NICE & NSF9 Key care process

Blood glucose level measurement

Blood pressure measurementCholesterol level

measurementRetinal ScreeningFoot and leg checkKidney function testing(Blood)Kidney function testing(urine)Weight checkSmoking status check

of NEWER DRUGS

ANTI-HYPERGLYCEMIC THERAPY

- Metformin

- Sulfonylureas

- Thiazolidinediones

- DPP-4 inhibitors

- GLP-1 receptor agonists

-Dapagliflozin

-

Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]

Treatment goals

Symptom freePrevent short term complicationsPrevent long term complicationsQuality of life = Lifestyle focus

Diabetes UK Careline

A support helpline for anyone with diabetes, their friends, family and carers.

How to contact Call: 0345 123 2399

Monday–Friday, 9am–5pm.

Email: careline@diabetes.org.uk

Website-http://www.diabetes.org.uk/

Diabetes UK Phone AppsLog and track a range

of levels: blood glucose, insulin, carbohydrates, calories, weight and ketones

View your data in day and week graphs to spot trends

See your daily average blood glucose level, total carbohydrates and total calories

Other websiteshttp://www.nhs.uk/

Conditions/diabetes-type2/Pages/living-with.aspx

DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) programme

Thank you!

Questions ?

www.plymouthdiabetes.org.uk/

Pathophysiology-biochemical and vascular factors

Background

Foot in Diabetes-20% of total diabetes expenditure Annual cost Diabetic Foot ulcer £600 million+ Annual cost of diabetes related amputation £119

million6000+ Amputations : 2009/20105% of diabetics develop a foot ulcer each yearRoughly 100,000 people with foot ulcers (per year)0.5% of these will go onto have an amputation

South west has a high amputation and admission rate

Abdominal obesity and increased risk of cardiovascular events

Dagenais GR et al, 2005

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k

1 1 1

1.17 1.16 1.14

1.29 1.27

1.35

0.8

1

1.2

1.4

CVD death MI All-cause deaths

Tertile 1

Tertile 2Tertile 3

Men Women<95

95–103>103

<87

87–98>98

Waistcircumference (cm):

The HOPE study

Adjusted for BMI, age, smoking, sex, CVD disease, DM, HDL-cholesterol, total-C; CVD: cardiovascular disease; MI: myocardial infarction; BMI: body mass index; DM: diabetes mellitus; HDL: high-density lipoprotein cholesterol

Chronic kidney disease and cardiovascular (CV) risk

Adapted from: Go AS, et al. N Engl J Med 2004;351:1296-1305.

As eGFR decreases, risk of CV events increases

* Adults (1,120,295 ) within large US integrated healthcare system, with serum creatinine measured: 9.6% had been diagnosed with diabetes.

Age-standardised rates of CV events according to eGFR*

0

5

10

15

20

25

30

35

40

2.11

45 - 59 30 - 44 15 - 29 <15

Estimated GFR (ml/min/1.73m2)

73,108 34,690 18,580 8,809 3,824No. of events

Ag

e-s

tan

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ised

rate

s of

CV

eve

nts

(per

100 p

ers

on

-yrs

)

≥60

3.65

11.29

21.8

36.6

66

Impact of Intensive Therapy for Diabetes: Summary of Major Clinical Trials

Study Microvasc CVD Mortality

UKPDS DCCT / EDIC*

ACCORD ADVANCE

VADT

Long Term Follow-up

Initial Trial

* in T1DM

Kendall DM, Bergenstal RM. © International Diabetes Center 2009

UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:854.

Holman RR et al. N Engl J Med. 2008;359:1577. DCCT Research Group. N Engl J Med 1993;329;977.

Nathan DM et al. N Engl J Med. 2005;353:2643. Gerstein HC et al. N Engl J Med. 2008;358:2545.

Patel A et al. N Engl J Med 2008;358:2560. Duckworth W et al. N Engl J Med 2009;360:129. (erratum:

Moritz T. N Engl J Med 2009;361:1024)

Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (1)

•Physical inactivity

• First-degree relative with diabetes

• High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)

• Women who delivered a baby weighing >9 lb or were diagnosed with GDM

• Hypertension (≥140/90 mmHg or on therapy for hypertension)

• HDL cholesterol level<35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)

• Women with polycystic ovarian syndrome (PCOS)

• A1C ≥5.7%, IGT, or IFG on previous testing

• Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)

• History of CVD

*At-risk BMI may be lower in some ethnic groups.

1. Testing should be considered in all adults who are overweight(BMI ≥25 kg/m2*) and who have one or more additional risk factors:

ADA. Testing in Asymptomatic Patients. Diabetes Care 2012;35(suppl 1):S14. Table 4.