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A/Prof Ken Sikaris delivered the presentation at 2014 National Pathology Forum. The National Pathology Forum 2014 featured case studies on innovative testing methods in the fields of genetics, biobanking and PoCT. The highly interactive nature of the National Pathology Forum allowed delegates to network with each other and converse with the speakers asking questions as part of debates, industry roundtables, short workshops and panel discussions. For more information about the event, please visit: http://bit.ly/pathology14
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A/Prof Ken Sikaris 9th September 2014
Impact of the diabetes epidemic
and changing guidelines
on laboratory workload
A/Prof Ken SikarisDirector of Clinical Support Systems
Sonic Healthcare
BSc(Hons), MBBS, FRCPA, FAACB, FFSc, GAICD
A/Prof Ken Sikaris 9th September 2014
Australia
A/Prof Ken Sikaris 9th September 2014
Diabetes in Australia: 1980 - 2000
0
200
400
600
800
1000
’80 ’82 ’84 ’86 ’88 ’90 ’92 ’94 ’96 ’98 ’00
Th
ou
san
ds
Year
a)
Busselton
b) Nat Heart
Foundation
c) Aust Bureau
Statistics
d) Aust Bureau
Statistics
e) AusDiab
A/Prof Ken Sikaris 9th September 2014
Ausdiab Diabetes Prevalence 1999-2012
A/Prof Ken Sikaris 9th September 2014
Approx 1.5 million today, 3.5 million by 2033.
275 Australians develop type 2 diabetes every day
By 2023 type 2 diabetes is projected to become
the leading specific cause of disease burden for
men and the second leading cause for women.
Diabetes in Australia
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
ABS Survey 2011-2012
ALL MEN WOMEN
DIABETES Fasting Glucose 5.1% 6.3% 3.9%
HbA1c 5.4% 6.6% 4.2%
PREDIABETES Fasting Glucose 3.1% 4.1% 2.1%
HbA1c 5.4% 5.5% 5.3%
1 in 16 Australians are diabetic
4% reported to have diabetes85% Type 2
12% Type 1
A/Prof Ken Sikaris 9th September 2014
ABS Survey 2011-2012
A/Prof Ken Sikaris 9th September 2014
Diabetes Complications
A/Prof Ken Sikaris 9th September 2014
CVD
(Exp
on
en
tia
l)
A/Prof Ken Sikaris 9th September 2014
Cardiovascular Disease
Diabetes or pre-diabetes
In 65% of CVD
A/Prof Ken Sikaris 9th September 2014
Improving CVD: Statins?
A/Prof Ken Sikaris 9th September 2014
CVD mortality trends
Factors
Smoking
Antihypertensives
Statins
Survival after AMI
Angioplasty
Antithrombotics
A/Prof Ken Sikaris 9th September 2014
Leading Causes of Death
A/Prof Ken Sikaris 9th September 2014
CVD Hospitalisations
A/Prof Ken Sikaris 9th September 2014
CVD Hospitalisations
A/Prof Ken Sikaris 9th September 2014
Improving Diabetes Outcomes
A/Prof Ken Sikaris 9th September 2014
Australian Diabetes Costs
Total Costs
$6.6 billion (2003)
HbA1c $0.01 billion
A/Prof Ken Sikaris 9th September 2014
Cost distribution in Type 2 diabetes
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
Preventable Health Costs
A/Prof Ken Sikaris 9th September 2014
Diabetic Renal Disease
A/Prof Ken Sikaris 9th September 2014
The Deadly QuartetKaplan Arch Int Med
1989;149:1514-1520
A/Prof Ken Sikaris 9th September 2014
Which one of the
deadly quartet is
missing?
A/Prof Ken Sikaris 9th September 2014
Top tests for diabetes, lipids, HT
A/Prof Ken Sikaris 9th September 2014
BEACH: TYPE 2 DIABETES & GP’s
2000-02 2006-08
GP visits 2.6% 3.3%
Pathology Requests/Visit 63.6% 88.4%
Total Diab Tests 1,700,000 3,100,000
% of all GP pathology 4.9% 6.0%
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 66608: Vitamin D
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 66608: Vitamin D
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 66551: HbA1c
About $16 million / annum* (50% coned)
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 2517: Diabetes PIP
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 10951: Diabetes Education
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 717: 45y/o Health Check
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 66536: HDLC
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 66560: Microalbumin
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 66542: OGTT
A/Prof Ken Sikaris 9th September 2014
FPG vs 2hPG and diabetes.
6.1 7.0FPG (mmol/L)
IFG
7.8 11.1GLU-2h (mmol/L)
IGT
or
Diabetesnormal
and
5.5
(GDM 5.1)
A/Prof Ken Sikaris 9th September 2014
Gestational Diabetes
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 66545: Glucose Challenge Test Pregnancy
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 66545: Oral Glucose Tolerance Test in Pregnancy
A/Prof Ken Sikaris 9th September 2014
MBS Schedule 66554: HbA1c pregnancy
A/Prof Ken Sikaris 9th September 2014
New GDM Criteria
• ADIPS 1999-2014
– Prevalence 8%
• IADPSG (HAPO)
– Projected Prevalence 14%
• Optimal Glucose sample (fluoride-ice/citrate)
–Potential Prevalence 20%
»Same as HAPO
A/Prof Ken Sikaris 9th September 2014
ADA Working Party Report Diabetes Care 2009; 32: 1327-34
ADA recommends: HbA1c 6.5% for diagnosis of diabetes
Pre
va
len
ce
of
retin
op
ath
y
A/Prof Ken Sikaris 9th September 2014
Stroke
(Exp
on
en
tia
l)
A/Prof Ken Sikaris 9th September 2014
All causes of mortality
(Exp
on
en
tia
l)
A/Prof Ken Sikaris 9th September 2014
ABS Survey 2011-12: Chronic Disease
Cancer Diabetes
Heart Disease
A/Prof Ken Sikaris 9th September 2014
ABS Survey 2011-12: Chronic Disease
Cancer
Diabetes
Heart Disease
A/Prof Ken Sikaris 9th September 2014
0.4
1.8
0.4
0.7
1.4
0.4
0.8
1.6
0.8
0.0
0.4
0.8
1.2
1.6
2.0
Normal Overweight Obese
Males
Females
All
Incidence of diabetes according to baseline body mass index
Baseline BMI status
Incid
en
ce (
% p
er
year)
Body mass index (BMI: weight/height2) was categorised into three groups: (i) normal: BMI < 25.0 kg/m2; (ii) overweight: 25.0─29.9 kg/m2; and (iii) obese: ≥ 30.0 kg/m2.
A/Prof Ken Sikaris 9th September 2014
Obesity in adults
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
Overweight children in Australia:
A/Prof Ken Sikaris 9th September 2014
Obesity in Babies ! Lack of Exercise?
Kim
et a
l, O
be
sity 2
00
6;1
5:1
107
.
A/Prof Ken Sikaris 9th September 2014
Changes in Dietary Composition
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
JAMA Intern Med. 2014;174(4):516-524. Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults Quanhe Yang, Zefeng Zhang, Edward W. Gregg, W. Dana Flanders, Robert Merritt, Frank B. Hu.
Prof Robert Lustig Auckland NZ Feb 2014
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
Insulin Resistance and Dyslipidemia
TGVLDL
(lipoprotein or hepatic lipase)
SDLDL
(CETP)
CE
HDL
TG
(hepaticlipase)
Kidney
Apo A-1(CETP)
LDL
TGCE
Liver
FFAFructose
A/Prof Ken Sikaris 9th September 2014
How small is sdLDL?
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
Modified LDL is atherogenic
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
LDL gradient gel electrophoresis ‘Lipoprint’
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
Small Dense LDLAustin MA, King MC, Vranizan KM, Krauss RM, “Atherogenic lipoprotein
phenotype. A proposed genetic marker for coronary heart disease.”
Circulation 1990;82:495-506.
0.5 1.0 1.5 2.0 2.5 3.0
(mmol/L)
A/Prof Ken Sikaris 9th September 2014
Triglycerides
<0.5
0.5 to <1.0
1.0 to <1.5
1.5 to <2.0
2.0 to <2.5
2.5 to <3.0
3
Triglycerides (mmol/L)
0
500
1000
1500
2000
2500
3000
3500
Thou
sand
s of
Peo
ple
Men
Women
35% > 1.5 mmol/L
22% > 1.5 mmol/L
A/Prof Ken Sikaris 9th September 2014
Interpretation of blood fats• 30 years ago
– High cholesterol, Triglycerides unimportant
• 20 years ago– Bad cholesterol (LDLC), Good cholesterol (HDLC)
• 10 years ago– Modified LDL atherogenic
• Oxidised, Glycated, Apo(a)/Lp(a), Small Dense LDL)
• Today
– Triglycerides are important!– Move away from LDLC: Non HDLC = LDLC + VLDLC
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
Perspectives of Ken Sikaris.
A/Prof Ken Sikaris 9th September 2014
TIME® Magazine June 23rd 2014
A/Prof Ken Sikaris 9th September 2014
Professor Richard Johnson
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
Obesity versus Metabolic Dysfunction
240 million USA Adults
30% Obese
72 million
70% Normal
168 million
40% ‘Sick’
67 million
80% ‘Sick’
57 million
124 million USA Adults
Prof Robert Lustig Auckland NZ Feb 2014
A/Prof Ken Sikaris 9th September 2014
Prof Robert Lustig 2014 Conclusions;
Prof Robert Lustig Auckland NZ Feb 2014
A/Prof Ken Sikaris 9th September 2014
A/Prof Ken Sikaris 9th September 2014
Movies
May 7th 201410th Jan 2014 Jul-Sep 2014
May 7th 2004
A/Prof Ken Sikaris 9th September 2014
‘That Sugar Film’ – Damon Gameau, January 2015
A/Prof Ken Sikaris 9th September 2014
Conclusions
• Pandemic in Obesity & Type 2 diabetes
– Increasing proportion of health costs
– Increasing proportion of Pathology
• Pathology has witnessed pandemic
– Diagnosed
– Monitored
– Prevented?
• Assist in focussing community on prevention
A/Prof Ken Sikaris 9th September 2014
Acknowledgements
• Inspiration
– Ms Louisa Sikaris