Prevention of Type 2

Diabetes

Edited by

Dr Manfred Ganz, M.D.

Specialist Internal Medicine, Diabetologist (DDG)

Associate Professor of Medicine

Campus Biomedico, University of Rome, Italy

Innodata047085734X.jpg

Prevention of Type 2

Diabetes

Prevention of Type 2

Diabetes

Edited by

Dr Manfred Ganz, M.D.

Specialist Internal Medicine, Diabetologist (DDG)

Associate Professor of Medicine

Campus Biomedico, University of Rome, Italy

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ISBN 0470 85733 1

Typeset in 10.5/13pt Times by Thomson Press (India) Limited, New DelhiPrinted and bound in Great Britain by Antony Rowe Ltd., Chippenham, WiltshireThis book is printed on acid-free paper responsibly manufactured from sustainable forestryin which at least two trees are planted for each one used for paper production.

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For my loving family: my wife Helmi

with Nicholas, Fabian, Simon, Angela,

our foster child Christina, my parents

Rosa-Maria and Josef for their lifelong support

Contents

Foreword xiii

Preface xv

List of Contributors xvii

SECTION 1 THE DIABETES EPIDEMIC:DESCRIPTION OF THE PROBLEM 1

1 The Diabetes Epidemic; Genes and Environment Clashing 3Paul Zimmet, Adrian Cameron and Jonathan Shaw

Introduction 3

An Epidemiological Perspective 3

The Hidden Epidemic Impaired Glucose Tolerance and Impaired

Fasting Glycaemia 6

Glucose Intolerance and the Metabolic Syndrome 6

Globalization its Impact on Human Health 8

Type 2 Diabetes in Children and Adolescents 9

Prevention the Reality and the Challenge 10

References 10

2 Type 2 Diabetes Mellitus: Primary and Secondary PreventionThe Vision of the International Diabetes Federation 15Pierre Lefebvre

Introduction 15

Primary Prevention of Type 2 Diabetes Mellitus 16

Prevention of Complications of Type 2 Diabetes Mellitus 17

The Global Issue 18

References 19

3 Type 2 Diabetes Mellitus in Children and Adolescents 21Thomas Reinehr and Martin Wabitsch

Introduction 21

Pathophysiology of Type 2 Diabetes Mellitus in Children and Adolescents 22

Epidemiology of Type 2 Diabetes Mellitus in Children and Adolescents 23

Clinical Presentation of Type 2 Diabetes Mellitus in Children and Adolescents 25

Clinical Features of Caucasian Children with Type 2 Diabetes Mellitus 25

Differential Diagnosis of Type 2 Diabetes Mellitus in Children and Adolescents 27

Diagnostic criteria of Type 2 Diabetes Mellitus in Children and Adolescents 29

Complications of Type 2 Diabetes Mellitus in Children and Adolescents 31

Screening for Type 2 Diabetes Mellitus in Children and Adolescents 33

Treatment of Type 2 Diabetes Mellitus in Children and Adolescents 34

Pharmacological Treatment of Type 2 Diabetes Mellitus

in Children and Adolescents 35

Monitoring and Treatment of Complications of Type 2 Diabetes Mellitus

in Children and Adolescents 37

Prevention of Type 2 Diabetes Mellitus in Children and Adolescents 37

Conclusions 38

References 38

SECTION 2 SCREENING FOR TYPE 2 DIABETES 41

4 Screening for Undiagnosed Diabetes:

Whom, Where, When and How 43Tim Kenealy, Bruce Arroll and Peter Muller

Undiagnosed Diabetes and Its Harms 43

The Rate of Undiagnosed Diabetes in New Zealand 43

Should We Screen for Diabetes? 45

Theory of Screening 48

Screening Theories are Difficult to Apply to Diabetes: Implications of the

Diagnostic Criteria for Screening Decisions 55

Current Recommendations, New Zealand and International 56

Current Practice in New Zealand 56

Studies of Practical Screening in New Zealand 57

Systematic Opportunistic Screening in General Practice 58

Who to Test: Which Groups are at Relatively High Risk? 59

How to Test: Specific Screening Tests and cut-off Values? 62

Screening Intervals 71

Difficulty Applying Recommendations to Individual Patients 71

Screening Algorithms for Asymptomatic People 72

Summary 72

References 73

5 Genetic Screening and Prevention of Type 2 Diabetes 81Paolo Pozzilli

Introduction 81

Lessons from Type 1 Diabetes for Genetic Screening 83

Methods for Early Prediction of Type 1 Diabetes and Prevention Strategies 84

Type 2 Diabetes: Where do We Stand as regards Genetic Screening 85

Genes that are Identified with a Predisposition to Type 2 Diabetes: the New Scene 86

How can We Track the Prediabetes Period using Genetic Markers? 87

Genetic Screening for MODY and Potential Preventive Strategy 88

Conclusion 90

Acknowledgements 91

References 91

viii CONTENTS

6 Screening Parameters and Techniques:

Limitations and Opportunities 93Knut Borch-Johnsen and Charlotte Glumer

The Epidemiology of Type 2 Diabetes 94

What is Screening and How do We Evaluate a Screening Test? 95

Screening Strategies 96

Who Should be Screened Targeted Screening Strategies Based on

Phenotypical Characteristics? 99

Limitations, Perspectives and Recommendation 99

References 101

7 Screening for Diabetes Mellitus the World Health

Organization Perspective 105Gojka Roglic, Rhys Williams and Stephen Colagiuri

Introduction 105

Formulating Policies on Screening for Type 2 Diabetes 109

Widening the Evidence Base 112

Implementing Policies on Screening for Type 2 Diabetes 117

Conclusions and Recommendations 117

References 120

SECTION 3 PREVENTION OF TYPE 2 DIABETES 125

8 Findings from Preventive Type 2 Diabetes Trials 127Markolf Hanefeld

The Common Soil Hypothesis a Rationale for Preventive Measures in

Subjects with IGT 128

Lifestyle Trials with Prevention of Diabetes as Primary Objective 130

Pharmacological Trials with Prevention of Diabetes as Primary Objective 132

Coronary Heart Disease Prevention Trials with Prevention of Diabetes

as the Secondary Objective 138

Studies for Primary Prevention of Diabetes in Progress 140

Is Impaired Glucose Tolerance (IGT) a Disease? 142

Who Should be Treated (and How)? 145

Do We Treat Type 2 Diabetes too Late? 146

References 147

9 A Paradigm Shift is Needed in the Primary Prevention

of Type 2 Diabetes 153Jaakko Tuomilehto

Primary Prevention of Type 2 Diabetes the Current Paradigm 153

Re-Defining the Paradigm of Primary Prevention of Type 2 Diabetes 155

New Paradigm A Population Approach for Prevention of Type 2 Diabetes 155

New Paradigm Who is at High Risk? 156

New Paradigm True Primary Prevention: Targeting People Before

Their Blood Glucose Values are Abnormal 158

CONTENTS ix

New Paradigm Prevention of Complications of Type 2 Diabetes

by Preventing Type 2 Diabetes Itself 159

New Paradigm How could Money for Diabetes Care be Allocated

in a More Efficient Way? 161

Comment 162

References 165

10 The Behaviour Change Process 169Frank J. Snoek and Richard R. Rubin

Introduction 169

Readiness to Change 170

Goal Setting 172

Supporting Behaviour Change 172

Changes and Maintenance 173

Implications 175

References 176

SECTION 4 PREVENTION OF COMPLICATIONSOF TYPE 2 DIABETES 179

11 Preventive Disease Management Risk Stratification

as a New Tool in the Hands of General Practitioners 181Thomas Konrad

Chronic Diseases, Health-Care Systems, Internet and Economic Burden:

From Intervention to Prevention 181

Basics of Preventive Medicine: Risk Stratification, Genetic

Testing and Information 183

Principles of Assessment of Risk Factors in Clinical Practice for

Cardiovascular Diseases and Diabetes Mellitus Type 2: Consequences

for the Individual Life 185

Preventive Disease Management for Diabetes Mellitus Type 2 and

Cardiovascular Diseases: Phenotyping the Early Detection of

Insulin Resistance and Endothelial Dysfunction 189

Integrative Preventive Care: Community-Based Strategy to

Avoid Chronic Diseases 193

Summary 197

References 198

12 Prevention of Obesity and Lipid Disorders 203Hermann Liebermeister

Reasons for Prevention 203

Problems in Prevention 212

Community-Based Prevention Studies 216

Promoting Physical Activity 218

Workside Interventions in Adults 220

x CONTENTS

Specific Weight Gain Prevention Trials in Adults 220

Prevention of Diabetes and Obesity 222

Prevention of Lipid Disorders 227

Perspectives of Obesity and Dyslipidaemia Prevention 230

Acknowledgement 234

References 235

13 Renal Dysfunction and Hypertension, Focus on

Type 2 Diabetes 245Carl Erik Mogensen

Introduction 245

Historical Aspects 246

Evaluation of Diabetic Renal Disease and Classification 246

Diagnostic Procedures 249

Prevention 251

Treatment Strategy 252

Treatment in Overt Diabetic Renal Disease 255

Recent Treatment Guidelines for Patients with Diabetes Mellitus

with Focus on Hypertension 257

The Dual- or Triple- Jeopardy Concept 257

Goals for Blood Pressure 258

Old and Very New Guidelines 258

Screening for Microalbuminuria 259

Prevention and Intervention Related to Type 2 Diabetes 261

Summary 263

References 263

14 Diabetic Retinopathy in the 21st Century:

Screening and Visual Outcomes 271Ayad Al-Bermani and Roy Taylor

Introduction 271

Epidemiology 272

Good Glycaemic Control 272

Good Blood Pressure Control 272

Other Risk Factors 273

Screening 273

Effect of Screening Upon Rates of Blindness 277

Treatment of Diabetic Retinopathy 278

Panretinal Photocoagulation 278

Treatment of Macular Oedema 280

Vitrectomy 280

Summary 282

References 282

15 Prevention and Treatment of Diabetic Neuropathy 285Anders A. F. Sima

Introduction 285

Clinical Presentation and Classification of DPN 286

CONTENTS xi

Pathogenetic Mechanisms 288

Tested Therapies 292

Future Therapeutic Opportunities 296

Concluding Thoughts 300

References 301

16 The Cardiologists View: Prevention of Macrovascular

Complications 313Michael Faust, Sabine Wiedenmann and Reinhard Griebenow

Prevalence of Cardiovascular Complications in Patients with Diabetes Mellitus 313

Occurrence of Diabetes in Patients with Cardiovascular Disease 315

Prognosis and Course of Coronary Heart Disease in Diabetic Patients 315

Explanatory Models for the Particular Fatal Course of Coronary Heart

Disease in Diabetic Patients (Risk Factors) 316

Cardiovascular Complications Preventive and Therapeutic Options 317

Interventional Revascularization 319

Procedure in Critical Ischaemia 320

References 320

17 Milestones and New Perspectives in Prevention of Type 2

Diabetes and its Complications 325Carl Erik Mogensen

Classification of Diabetes 325

Insulin Treatment with Focus on Euglycemia in Type 2 Diabetic Patients 327

Sulphonylurea (SU) Preparations 329

Metformin 330

Glitazones 330

The Metabolic Syndrome 331

Home Monitoring of Blood Glucose 331

Glycated Haemoglobin 332

Diabetes Nurses, Diabetes School and Dietary Help 332

Laser Treatment of Retinopathy, including Maculopathy, in Type 2 Diabetes 333

Diabetic Foot Care and Related Neuropathy 333

High Blood Pressure: Blood Pressure Lowering and Microalbuminuria 333

Lipid-Lowering Agents; Focus on Type 2 Diabetes 335

The Diet of Diabetic Patients 336

Multi-Factorial Intervention with Treatment Goals 336

Neuropathy 336

Conclusion 337

References 338

Index 343

xii CONTENTS

Foreword

This book is centred on the prevention of the most common form of the condition,

Type 2 diabetes. It covers screening and primary prevention, as well as the

secondary prevention of the devastating complications of diabetes. Its perspective

is worldwide with contributions from experts drawn from across Europe, North

America and AsiaPacific.

I sincerely hope that this timely publication will attract not only the interest of

the physicians and scientists who form its primary audience, but also the attention

of health policy and decision makers working at national, regional and inter-

national levels, so that it can play a part towards advocating change, encouraging

action and promoting increased awareness of a condition that can be treated but

not as yet cured.

As stated elsewhere in this book, it is through the promotion of diabetes

prevention that the International Diabetes Federation (IDF) strives to ensure that

the millions who are living with diabetes today will not face a future decline in the

quality of their care as a result of the many more millions who are predicted to

develop the condition. At the same time, IDF is working to increase global access

to and bring about improvements in the quality of available care.

IDF has redefined its mission in order to reflect more closely the activity in

which it is involved and in particular to reflect the growing concern with the

prevention of diabetes that is influencing the activities of diabetes representative

organizations throughout the IDF membership network.

In line with our vision of living in a world without diabetes, the new mission of

the IDF is to promote diabetes care, prevention and a cure worldwide.

My deep hope is that through this book diabetes prevention receives a boost in

attention and activities among all the partners involved globally.

Although IDF does not support research directly, through awareness and

education it encourages the efforts of those who are working towards a better

understanding of the causes of the various forms of diabetes and ultimately

towards a cure.

As we often say at IDF, the time has come to act. . . NOW!

Pierre Lefebvre

President International Diabetes Federation