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POST-IDFHIGHLIGHTS
Diabetes: Epidemie of the 21st century!..
M.Chana( Morocco )
Diabetes is the exploding pandémie on the 21st century.-Prevalence: 2003:194000 2007:240000 (6% of adult population) 2025: 350 million -Overall there are 7 million more people with diabetes each year
-For every person directly affected by diabetes;2 or 3 persons are indirectly affected by diabetes
-There is insufficient recognition of the devastating human,social and economic impact of diabetes.
-A sillent killer ,killing one person every 10 secondes ,diabetes is currently responsible for more deaths than HIV/Aids Death under-estimated: (1-3million);( 2,5% in Africa to 8,5% in North America -one amputation every 30 secondes.
M.Sillink .Forum : United Nations Resolution on Diabetes.
-Global health expenditures to treat and prevent diabetes and its complications: ID 286.1 billion of goods and services will be consumed by diabetes in 2007,and at least ID 381,1 billion in 2025.
“To do nothing is no longer an option”. IDF declares that is time for governments to act.
-The actual Resolution will encourage national governments to tackle the challenge of diabetes by a range of prevention,treatment and care strategies and will recognize the free “special needs” groups: -diabetes in children -diabetes in pregnancy , - the ederly ,indigenous people and migrant population from developping countries
Ph.Bennett:Global burden-International comparisons J.B Brown:The economics of Diabetes. M.Hirst.Forum:UN Resolution on Diabetes.
IDF has declared 2007 as the year of the child.
-Increasing prevalence of diabetes in children (3% a year – rise of diabetes in children ) -Urge immediate action to prevent unnecessary death and disability.
-Type 1 Diabetes -70,000 children develop type 1 diabetes annually - 440,000 children will live with type 1 diabetes in 2007 -Type 2 Diabetes -Type 2 in adolescents,and even children,is an emerging problem,and has added a new dimension to the epidemic of type 2 diabetes ( 2-3% ) It has potentially serious outcomes, especially in some ethnic communities -The increasing incidence has followed a similar increase in the prevalence of obesity ,and parallels a change from a traditional to a more Western diet
G.Soltesz:”Global epidemiology of type 1 and type 2 diabetes” J.Shaw.Symposium”Type 2 diabetes in childhood/adolescence:Epidemiology”
-Although type 1 diabetes remains the main form of the disease in children worldwide, it is likely that type 2 diabetes will be the predominant form within 10 years in many ethnic groups. It has already been reported in children in a number of countries, -Japan: type 2 diabetes is already more common than type 1 and accounts for 80% of childhood diabetes
-United States: 8.0 % of children in grades 5-12 had pre-diabetes 0,4% had type diabetes(20-30% type 2 diabetes)
-Austria : annual incidence of 0,25/100000 in children aged < 15 years 1,5% of all new cases of diabetes in the age group.
-In New Zealand Maori adolescents ; 36% of new cases of diabetes were type2,rising to 55% in a study including people up to the age of 30.
-In Taiwan: prevalence of undiagnosed diabetes : 9.0 -15.3 per 100000 boys and girls aged 6-18 ( more than four times the incidence of type 1 diabetes) low and high birthweight were risk factors for type 2 diabetes risk factors which elevated cholesterol and blood pressure.
Clinical characteristics of type 2 Diabetes in the young
Number Not epidemic but in increasing
Ethnicity Minority Non-minority
Common present
Age at diagnosis 12- 14 years
Sex F > M
BMI 29 – 38 kgs / m²
Acanthosis nigricans common ( 56 – 92 % )
Family 85 - 100%
Ketosis 5 – 35 %
S.Arsalanian. Symposium ”Type 2 diabetes in childhood/adolescence: Pathogenesis of type 2 diabetes in youth:an evolving chameleon”
With the increasing rates of obesity in the general population as well as in youth with type 2 diabetes,the distinction between “pure” type 2 diabetes and obese type 1 diabetes may not be possible on the basis of clinical features.
S.Arsalanian. Symposium”Type 2 diabetes in childhood /adolescence:Pathogenesis of type 2 diabetes in youth:an evolving chameleon”
Diabetes in children increases the risk of life threatening diabetes complications at an early age.
Additional cardiovascular risk factors are often associated with type 2 diabetes in the young.
Follow-up data of indigenous Canadian children with type 2 diabetes showed that by age 18-33; who were diagnosed before age 17 years , -there was a 9% mortality rate ; -a 6,3% dialysis rate -a 38% pregnancy loss due to poor glycemic control.
F.Kaufman. Symposium”Type 2 diabetes in childhood/adolescence:Approach to therapy”
Type 2 diabetes in children requires meticulous management to control glycemia and to improve the long-term outcome of young patients
Successful treatment will require intensive efforts to alter lifestyle, which will need to focus on families as well as the individual.
Importance of family in management+++ Role of family in management(Bradshaw. J Pediatr End Metab 15,2002)
African American Family Study
Group 1 :direct family supervision Group 2 :no direct supervision p≤0,005 Group 1 ;ending HbA1c:7,1+/-0,8% Group 2 ;ending HbA1c:12,3+/-0,6%
F.Kaufman. Symposium”Type 2 diabetes in childhood/adolescence:Approach to therapy”
-Less than 10% of youth with type 2 diabetes can be managed with lifestyle alone.-Insulin is used with in youth with type 2 more often than it is used in adults.-More evidence is needed is about long-term safety and efficacy in relation to currently available oral hypoglycemic agents.TODAY trial is underway to determine ttt strategies that will help improve the outcome of type 2 diabetes in youth.
1- F.Kaufman. Symposium”Type 2 diabetes in childhood/adolescence:Approach to therapy” 2-Hannon, T. S. et al. Pediatrics 2005;116:473-480
Type 2 diabetes in children is likely to continue to rise until effective measures are available to prevent obesity in this age group.
Evaluation of WHO in childhood:
American continent(2006): 40% of overweight
13,2 % of obesity projected prevalence(2010) 46,4% of overweight
15,2% of obesity
Europe(2006): 31,8% of overweight 7,9% of obesity projected prevalence(2010): 38,2% of overweight
10% of obesity
« Predictors of Changes in Glucose Tolerance Status in Obese Youth. » Diabetes Care 28:902-909, 2005
A total of 102 obese children and adolescents were studied by performing an oral glucose tolerance test (OGTT) at baseline and after 2 years. At baseline: 71 subjects had normal glucose tolerance (NGT) 31 impaired glucose tolerance (IGT) -after 2 years:32,3% developed type 2 diabetes
S. Di Caprio : « The metabolic syndrome in adolescence »
Diabetes education has been recognized as an important element of diabetes management.
Until recently ,the discipline is coining the term to be self-managemnt education (DSME) to clearly define the purpose of education to be equipping individuals with the abilities to manage the technical as well as the psychosocial demands of diabetes on day to day to basis
DSME has expanded the scope of teaching from predominantly on disease management to include areas such as problem solving ,management on negative emotions,efficacy building,and dealing with health care system
Training the health care professionals++ : changed traditional professional training from didactic-lectures only model to interactive,practical workshops The aim is : to teach people to teach others,to help people to help themselves.
Proper education in diabetes management is therefore key to reduce complications and saving lives.
ECY Kan Symposium “Patient-centred care”: Self-management education:what are we doing?
Patient’s perspectives of diabetes care and education (whikblad 1991 )
Patients with good metabolic control:
Experience + feed back from the care team members
Lack of deeper communication
Education was rarely given
With acceptable metabolic control
Were prise by the care team members
They received information spontaneously
Often about technical aspects
With unsatisfactory metabolic control
Communication was based on Lies
Problem was unexplained
Drug prescriptions, laboratory reports and techniques dominated the contact.
R.Wredling.Symposium “Patient-centred care” : Establishing therapeutic relationships:trust and collaboration.
-The majority of diabetes patients with high level of emotional related problems were not recognized as such ,and consequently not recorded in their medical charts.-Only 20-30% of the emotional problems were recorded of patients with high score on diabetes –related emotional distress.
-Psychological co-morbidity are more present among persons with diabetes -30 % have one or other psychiatric diagnose -depression 2-4 times more common -Anxiety range between 27-40 %
-Identifying people with diabetes suffering from psychological support should be a full scale challenge for the health care provider in the future.
Why do so many of our patients manage their diabetes so poorly? - Emotional distress: Pb to complete self care task Lack of knowledge and practical skills Dissatisfaction with information Health care providers unsupportive
R.Wredling.Symposium “Patient-centred care” : Establishing therapeutic relationships:trust and collaboration.
The communication between patients and health care professionals is a factor of great importance for the perceived adequacy of both health care and medical care.
ECY Kan Symposium “Patient-centred care”:Self-management education:what are we doing?
Can we prevent type 1 diabetes?
INTERVENTION TRIALS
Primary prevention: Subjects(usually newborns)at high genetic risks without evidence of auto-immunity
TRIGR (Trial to Reduce Insulin Dependant Diabetes in the Genetically at Risk)
Aims: I-Determine in subjects with risk associated HLA genotype and first degree relative with type 1 diabetes if weaning to casein hydrolysate reduces the frequency of:
1-a:diabetes predictive auto-antibodies by 6 year 1-b-clinical diabetes by age 10 year.
II-Determine relation ships between cow milk anti-bodies
(a measure of exposure) and diabetes associated auto- antibodies.
D.Becker. Symposium”Prevention of type 1 diabetes:different approaches”:Eliminating/reducing environment contributors
Secondary prevention: Subjects with circulating antibodies
-DPT-1:whether insulin could prevent or delay onset of overt diabetes in relatives of patients with diabetes.Two separate trials: 1-studied parenteral insulin in relatives with >50% projected 5-year risk of diabetes. 2- studied oral insulin in relatives with 26-50% projected 5- year risk.
Overall,the insulin treatments had no effect,but in a subset of participants in the oral insulin group (those with high levels of insulin antibodies),a delay and perhaps a reduction in the incidence of type 1 diabetes was observed
J.Skyler. Symposium”Prevention of type 1 diabetes: Different approaches”:Insulin-related preventive approaches
Tertiary prevention: Subjects with clinical diabetes
- Hokt3γ1(Ala-Ala),a humanized ,modified anti-CD3 monoclonal antibody 21 patients within 6 weeks of type 1 diabetes diagnosis;patients in the treatment group had improved C-peptide responses,with effects lasting more than 1 year after a single course of treatment and whitout chronic immunosuppression
-”Insulin needs after CD3-antibody therapy in new-onset type 1 diabetes”. N Engl J Med 2005;352:2598-608. 80 patients with newly diagnosed type 1 diabetes were randomly assigned to receive either an anti-CD3 monoclonal anti-body (ChAglyCD3) or placeboResults : residual β-cell function was maintained for at least 18 months and that the effect was strongest in those with the greatest residual β-cell function at study entry.
G.Einsenbarth.Symposium”Prevention of type 1 diabetes:different approaches”: Targetting immune cells.
While it is often spoken that these efforts failed,in reality ,many important successes occurred and equally important ,vital lessons were learned.
1- It is now possible: to prevent the disorder in multiple animals models. to predict the development of type 1A diabetes in man
Prediction is based upon identification of genetic risk factors,expression of specific anti-islet auto-antibodies,and finally metabolic abnormalities.
2-Studies have set the standard for future trials and emphasized the requirement for international collaboration to facilitate well-designed trials.
TrialNet is a network of 18 clinical centres working in cooperation with screening sites throughout the United States,Canada,Finland,the United Kingdom,Italy,Germany,Australia and New Zealand.
M.Atkinson.Symposium”Auto-immunity of type 1 diabetes”:Can we prevent type 1 diabetes?
