Prevention of complications of endocrine disorders

R.Fielding

Department of Community Medicine, HKU.

Learning objectives

• Estimate the extent of morbidity and use of resources from complications of endocrine disorders due to overweight and inactivity

• outline the main barriers to prevention of endocrine complications

• explain key contributions to these barriers

• suggest cost-effective solutions

Common endocrine complications

– type 2 (NIDDM) diabetes, – hypertension, – dyslipidaemia, and – cardiovascular diseases including AMI, AP, PVD

& stroke.

• Why are these now considered complications of endocrine disorders?

• Because they reflect disorders or more accurately complications arising from a syndrome of over nutrition and inactivity, which produces disturbances in the regulation of energy metabolism.

• These “diseases” are, therefore, more accurately described as complications, but doctors seldom take this perspective, preferring to look at each “disease” as a separate thing: endocrinologists care for NIDDM, cardiologists for AMI, etc.

Prevalence of DM in HK• 58% of men, 49% of women BMI >23.5

• 38% men 34% women BMI >25

• 5% men, 7% women BMI >30

• Prevalence of DM in – males

• 2% (CI 0-3.7%) at 25-34 to 22% (14.4-29.1%) at age 65-74

– females • 1.4% (0-4.6%) at 25-34 to 29% (21.4-37.3%) in age 65-74.

• Over 70% were unaware they had DM (Janus et

al, 1997)

Complications prevalence in Chinese

• in NIDDM, HK Chinese – 22% (95% non-proliferative retinopathy)– 4% clinical nephropathy– 13% clinical neuropathy (Wang & Lam, 1998)

• Nephropathy OR raised in Chinese( McGill, et al 1996)

• Mainland diabetic patients (Xu et al, 1997)

– 50% hypertensive 45% neuropathy– 37% retinopathy (4.5% blind)– 25% IHD 23% proteinuria– 12% stroke 1% amputation

Risk factors for complications • Chinese, Malays and Indians NIDDM vs.Cauca.

– Those with NIDDM had • higher mean body mass indices, waist-hip ratios

and abdominal diameters• more hypertension, higher triglycerides, lower LDL

(Hughes et al, 1998)

• Retinopathy in NIDDM Asian Indian, Chinese, and Creole Mauritians - vs Caucasians seen with– increasing duration of diabetes, – higher fasting plasma glucose, systolic blood

pressure, and urinary albumin concentration, – decreasing body mass index (Dowse et al, 1998)

• Total physical activity independent predictor of 2-h post-load glucose concentration after controlling for BMI, waist-hip ratio, age, and family history of NIDDM. (Pereira, et al, 1995)

• Visceral fat accumulation is associated with dyslipidemia, hypertension, insulin resistance, and albuminuria in (HK) Chinese patients with NIDDM (Anderson, et al, 1997)

• Therefore, inactivity, BMI, longer DM raise risk for complications.

Cause or effect?• “Although obesity, especially abdominal

obesity, is the commonest cause of complications such as type 2 diabetes, hypertension, dyslipidaemia, and cardiovascular diseases, doctors most often use drugs to treat the complications rather than the underlying condition. “

• So, these symptoms of unhealthy lifestyle are treated as causes when they are in fact, effects.

Etiology of complications: Barriers to prevention

• Biological : – genetic - unalterable, “brittle” DM

• Lifestyle:– obesity, diet, inactivity, smoking

• Attitudinal:– DM “common” and accepted; emphasis

on genetics minimization of efforts to prevent; aversion to activity in HK; Chinese cultural belief that fat=good; overeating common and gluttony norm.

• Service:– inadequate screening for DM

– lack of continuity of care

– failure to screen for complications

• Psychological– poor compliance with diet, activity and medication

leads to poor insulin control.

– Poor DPR

– little understanding of consequences of poor control

– “helplessness” - can’t do anything about disease -only doctors can “cure”.

Key contributions to barriers• Incomplete / inadequate detection and

follow-up• Lack of organized shared care

between specialist and GP• Discontinuity of care• Poor medical record keeping• Little attention paid to effective

patient education• Little attention given to importance of

DPR

Screening for type 2 DM?

• Benefits of early detection and treatment of undiagnosed diabetes have not been proved

• Effectiveness of diabetes screening in reducing cardiovascular disease depends on disease prevalence, background cardiovascular risk, and risk reduction in those screened and treated

• Disadvantages of screening are important and should be quantified

Screening?

• Universal screening is unmerited, but targeted screening in specific subgroups may be justified

• Clinical management of people with established diabetes should be optimised before a screening programme is considered.

»(Wareham & Griffin, BMJ, 2001, 322, 986.)

Conclusions• How important are these complications?

– DM currently most common important known endocrine disorder in HK affecting about 10% of population.

– Prevalence of complications 20-30%. 2-3% of HK popn. will have complications if present rates persist = 7 million/100x0.3 = 21,000 with avoidable complications.

– Barriers are mostly to do with poor service organization, failure of adherence and screening.

Further reading

• American Diabetic Association

• Poems

• UK Study reducing risk of complications

• Fitness protocol

• Screening guidelines