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Type 2 diabetes,
the metabolic syndrome and
cardiovascular disease in Europe
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TIMETOACT Type 2 diabetes,the metabolic syndrome and cardiovascular disease in Europe
Diabetes mellitus is a chronic disease whichhas been described as a state of raised bloodglucose (hyperglycaemia) associated with
premature mortality.
Hyperglycaemia seriously damages many ofthe bodys systems, especially the blood
vessels and nerves.
Diabetes
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Diabetes arises when the beta cells in thepancreasfail to produce enough of the hormone
insulin - type 1 diabetes
Orwhen the body cannot effectively use the insulin
produced - type 2 diabetes..
90% of people with diabeteshave type 2 diabetes.
Type 1 and type 2 diabetes
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Pancreas
Kidneys
Stomach
The pancreas
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Insulin is a hormone that allows cells to extractglucose from the blood and use it for energy.
Insulin is produced by the beta cells of the
pancreas.
It regulates protein and lipid metabolism.
Insulin
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When a person has diabetes, either:
their pancreas does not produce the insulin theyneed - type 1 diabetes
or their body cannot use this insulin effectively type 2 diabetes.
This leads to an increase in the amount ofglucose in the blood. This high concentration of
glucose or high blood sugar is termedhyperglycaemia.
Insulin and diabetes
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Synthesised in glands, hormones are chemicalsignaling molecules which have a specificregulatory effect upon the activity of bodytissues.
Hormones are transported around the body inthe blood so that they can act on tissues at adistance from the gland in which they wereproduced.
Hormones can only act in those tissues wherethey have specific receptors in the cells.
Hormones
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Chronic elevation of blood glucose eventuallyleads to tissue damage.
The kidneys, eyes, peripheral nerves and vasculartree manifest the most significant diabetic
complications. The mechanism for this is complex and not yet
fully understood. It involves:
The direct toxic effects of high glucose levels
The impact of elevated blood pressure Abnormal lipid levels
Functional and structural abnormalities of smallblood vessels
Tissue damage
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Out-of-control diabetes, when severe, leads to the
body using stored fat for energy and a subsequentbuild-up of acids (ketone bodies) in the blood. This isknown as ketoacidosis and is associated with veryhigh glucose levels. It requires emergency treatmentand can lead to coma and even death.
Recurrent or persistent infections (includingtuberculosis).
Both hyperglycaemia and hypoglycaemia (abnormallylow blood glucose resulting from treatment) may
cause coma and, if untreated, may be fatal.
The short term effects of diabetes
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The long term effects of diabetes can be divided into macrovascular complications
microvascular complications.
Macrovascular complications affect the larger blood
vessels, such as those supplying blood to the heart, brainand legs. The most common macrovascular fatalcomplication is coronary artery disease. Strokes are also acommon cause of disability and death in people withdiabetes.
Microvascular complications affect the small bloodvessels, such as those supplying blood to the eyes andkidneys. The microvascular complications of diabetes areretinopathy, nephropathy and neuropathy.
The long term effects of diabetes
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Visual impairment:
diabetic retinopathy,cataract and
glaucoma
Kidney disease(diabetic nephropathy)
Sexualdysfunction
Sensory impairment(peripheral neuropathy)
Ulceration
Stroke(cerebrovascular disease)
Heart disease(cardiovascular disease)
Bacterial and fungalinfections of the skin
Severe hardening of
the arteries (atherosclerosis) Autonomic neuropathy(including slow emptying
of the stomach and diarrhea)
Necrobiosis lipidoica
Gangrene
The major diabetic complications
Poor blood supply to lower limbs(peripheral vascular disease)
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If someone has the typical symptoms of diabetes thediagnosis is clear:
- increased thirst- excess urine- weight loss- a clearly raised plasma glucose level
Ketones in the urine accompanied by high plasma glucoselevels is also a clear indication of diabetes.
However, diagnosis is less straightforward for those withminor degrees of hyperglycaemia, and in the person
without symptoms, two abnormal results on separateoccasions are needed.
Diagnosing diabetes
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VenousPlasma*Glucose
concentration, Mmol l-1
(mg dl-1
)Diabetes mellitus
Fastingor
2-h post glucose load
7.0 (126)
11.1 (200)
Impaired Glucose Tolerance (IGT)2-h post glucose load 7.8 -
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Overweight and
obesity
Physicalinactivity
High-fat and
low-fiber diet
Ethnicity
Familyhistory
Age
Low birthweight
Urbanisation
Risk factors for type 2 diabetes
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The close association of type 2 diabetes with
cardiovascular disease has led to the hypothesis thatthey both share a common antecedent. This concepthas been labeled The Metabolic Syndrome by theWorld Health Organization and others.
The metabolic syndrome reflects the clustering ofcentral obesity with several other major cardiovascular
disease risk factors.
Central obesity Dyslipidaemia
Hypertension
Impaired glucose regulation or diabetes
Insulin resistance
The metabolic syndrome
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A disturbing feature of diabetes has been theclustering of diabetes with other well-knowncardiovascular risk factors, in particular central(abdominal) obesity.
The occurrence of central obesity, hypertensionand disturbed blood lipids is dramaticallyincreased in people with diabetes.
People with IGT and IFG also have a substantial
increase in cardiovascular risk factors and, likepeople with diabetes, higher cardiovascular risk.
Metabolic syndrome:The link between type 2diabetes and cardiovascular disease?
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There is now broad agreement on the overall riskfactors which must be taken into account whendefining the metabolic syndrome. These havebeen called the deadly quartet.
Impairedglucose
regulation
HypertensionObesity
Dyslipidaemia
Metabolic syndrome:
Overall risk factors
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It is suggested that insulin resistance and central obesityare the key underlying defects in the aetiology of type 2diabetes.
A universal definition of metabolic syndrome is urgentlyneeded to identify individuals at high risk of developingdiabetes and cardiovascular disease.
Impairedglucose
regulationHypertension
Obesity
Dyslipidaemia
Insulinresistance
Metabolic syndrome:
Key underlying defects
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Risk Factor Defining Level
Abdominal obesityMen
Women
Waist circumference>102 cm (>40 in)
>88 cm (>35 in)
Triglycerides 150 mg/dL (1.7 mmol/L)
HDL cholesterolMenWomen
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Central Obesity
Waist circumference - ethnicity specific*- for Europids: Male 94 cm
Female 80 cm
plus any two of the following:
Raised Triglycerides 150mg/dL (1.7mmol/L)
or specific treatment for this lipid abnormality
Low HDL Cholesterol
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05
10
15
20
2530
35
40
45
20-29 30-39 40-49 50-59 60-69 >70
Age
Prevalence
(%)
Men
Women
(N=8814)
Ford. JAMA 2002
Metabolic syndrome:Prevalence in the US as defined by NCEP ATP III
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Men Women
Lima, Peru 21.6% 30%
Mexico City 55.6% 64%
Spain 27.3% 31.7%
Greece 24.5%
Hong Kong 7.4% of Chinese men andwomen
USA 39%
Germany 57% 46%
Metabolic syndrome:
Prevalence in adults as defined by IDF criteria
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Sedentary lifestyle/physical inactivity
High fat, energydense diet
Ethnicity
Family
history
Stopping smoking
Age
Risk factors for obesity
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Cancer
Gall-bladderdisease
Kidneyfailure
Stroke
Heartfailure
Athero-sclerosis
Type 2diabetes
Hyper-tension
Respiratorydisease
Obesity
The health consequences of obesity
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BMI = weight (kg)/height (m)
Individuals with a BMI
between 25 to 29.9 are considered overweight
of 30 and above are considered obese.
The risk of serious health consequences such as type 2diabetes, coronary heart disease, hypertension,dyslipidaemia, albuminuria and a wide range of otherconditions increases with BMI.
Obesity is most commonly assessed by a single
measure, the Body Mass Index (BMI), which uses amathematical formula based on a persons height andweight.
Measuring obesityBody Mass Index
M i b it t h
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BMI DOES NOT show the difference between excess fat and
muscle.
identify whether the fat is laid down in
particular sites. For example, abdominal fathas more serious health consequences than fatlocated elsewhere.
The relation between fatness and BMI differs with
age, race and gender.
.
Measuring obesity up to here
The limitations of the Body Mass Index
M i b it
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Classification BMI (kg/m2) Risk of co-morbidities
Underweight 30.0
Class I 30.0-34.9 Moderate
Class II 35.0-39.9 SevereClass III 40.0 Very severe
Measuring obesity
WHO classification of adult categories of BMI
M i b it
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Classification BMI
(kg/m2
)
Risk of co-morbidities
Waist circumference
< 90 cm (men)< 80 cm (women)
90 cm (men) 80 cm (women)
Underweight
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1.0 1.0 1.0 1.5
4.4
6.7
11.621.3
42.1
2.22.9
4.35.0
15.827.6
40.3
54.0
93.2
8.110
Women
Men
40
70
100
0
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The presence of abdominal obesity is more highlycorrelated with the metabolic risk factors than is anelevated BMI.
The new IDF consensus definition of the metabolicsyndrome stipulates the following as a pre-requisite for
a diagnosis of metabolic syndrome:
80 cm for European women
94 cm for European men
Waist circumference is calculated by comfortablymeasuring the waist halfway between the bottom of the ribcage and the top of the pelvis.
Waist circumferenceand the metabolic syndrome
Country/ethnic specific
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Country/Ethnic group Waist circumference
Europids MaleFemale
94 cm 80 cm
South AsiansMaleFemale
90 cm 80 cm
ChineseMale
Female
90 cm
80 cm
JapaneseMaleFemale
90 cm 80 cm
Ethnic South and CentralAmericans
Use South Asian recommendations untilmore specific data are available
Sub-Saharan Africans Use European data until more specificdata are available
Eastern Mediterranean andMiddle East (Arab) populations
Country/ethnic specificvalues for waist circumference
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Insulin resistance
Insulin resistance: A state in which agiven level of insulin produces a lessthan expected biological effect.
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Insulin resistance is an underlying feature of boththe metabolic syndrome and type 2 diabetes.
It is associated with abnormalities in both glucoseand lipid metabolism.
These abnormalities are associated with anincreased risk of cardiovascular disease and areoften present before the onset of type 2 diabetes.
Insulin resistance
Insulin resistance: the link between
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Obesity and type 2 diabetes are causallylinked.
The means by which excess body fat
causes type 2 diabetes is not clearlydefined, but it appears that excess fatincreases insulin resistance, raising bloodglucose levels and the likelihood of
developing diabetes.
Insulin resistance: the link betweenobesity and type 2 diabetes?
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Weight gain leads to insulin resistance throughseveral mechanisms:
Fat accumulation induces insulin resistancethrough changes in its hormonal and othersecretions. Protective hormones decline as fat
cells expand, particularly in the abdomen. Physical inactivity, both a cause and consequence
of weight gain, also contributes to insulinresistance.
Insulin resistance places a greater demand on the
pancreatic capacity to produce insulin, which alsodeclines with age, leading to the development ofclinical diabetes.
Weight gain and insulin resistance
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Impaired fasting glucose (IFG) andimpaired glucose tolerance (IGT) are notclinical entities in their own right but rather riskcategories for future diabetes and/or
cardiovascular disease.
The terms refer to different measurements ofabnormal glucose regulation: IFG in the fasting
state and IGT in the post prandial state.
Impaired glucose regulation
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IGT: Blood levels that are higher than normalin response to an oral glucose load but belowthe level of someone with diabetes.
IFG: raised fasting levels of glucose.
Impaired glucose regulation
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IGT and IFG are considered risk categoriesfor developing type 2 diabetes.
Both IFG and IGT represent a riskof 25% to 50% of developing type 2diabetes in the next 10 years but it is notinevitable.
IFG and IGT are particularly amenable to
treatment through lifestyle interventions.
Impaired glucose regulation
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Hypertension (high blood pressure):damages the smaller vessels in the circulatorysystem. Over time they become scarred,hardened, narrowed and less elastic. High bloodpressure can also both predispose to and
accelerate the development of atherosclerosis.
Systolic blood pressure: 130mm Hg of mercury
or
Diastolic blood pressure: 85mm Hg of mercury
Component of theMetabolic Syndrome(according to the IDFconsensus definition)
Hypertension
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Dyslipidaemia: Abnormal levels of lipids(fats) in the blood.
Dyslipidaemia
Dyslipidaemia and cardiovascular
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Dyslipidaemia is a major risk factor for cardiovascular
disease - for patients with metabolic syndrome as wellas those with type 2 diabetes
The dyslipidaemia observed in these high risk patientsis complex, and is characterised by:
Normal or only slightly elevated LDL cholesterol
Hypertriglyceridemia ( TG)
Low high-density lipoprotein cholesterol ( HDL)
Small, dense LDL particles All these elements can be measured in the blood.
Dyslipidaemia and cardiovasculardisease
Dyslipidaemia key terms:
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Triglyceride: The major form of fat made in the liver.
Most of the fat we eat is composed of triglycerides. The
rest is cholesterol.
Raised levels of triglycerides ( TG) are a
characteristic of diabetic dyslipidaemia.
Cholesterol: A fat of the body. It is absorbed from
animal fat we eat and is also produced by the liver.
Cholesterol circulates in the blood in the form of
particles called lipoproteins.
y p y
Triglyceride and cholesterol
Dyslipidaemia key terms:
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High density lipoprotein (HDL):protectsagainstcardiovascular disease. Therefore lowlevels of HDL-C ( HDL-C) increase cardiovascular
disease.
Low density lipoprotein (LDL): LDL-Ccholesterolpromotes cardiovascular disease.
y p y
Lipoproteins
Dyslipidaemia key terms
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Small LDL particles are different from the largerLDL particles and may be more atherogenic.Therefore the cholesterol blood level in a patientwith diabetes may be misleading.
The combination of normal or only slightlyelevated levels of LDL cholesterol, low HDL( HDL) and the presence of small dense LDLparticles are characteristic of diabeticdyslipidaemia.
y p y
LDL particles
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Diabetic dyslipidaemia and insulin resistance:
HDL and TG and insulin resistance arefrequently correlated (with or without type 2diabetes).
Diabetic dyslipidaemia and coronary arterydisease:
HDL, TG and LDL indicate a significant
increase in the risk of coronary artery disease.
Diabetic dyslipidaemia
Atherogenic dyslipidemic profile
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LDL small and denseparticles
()LDL cholesterol
HDL cholesterol
Apolipoprotein B
Non-HDL cholesterol
Fasting VLDL
Triglycerides
t e oge c dys p de c p o ein the metabolic syndrome
C di l di
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Cardiovascular disease (CVD): Cardiovasculardiseases are defined as diseases and injuries ofthe circulatory system: the heart, the bloodvessels of the heart, and the system of bloodvessels throughout the body, and to (and in) the
brain.
Stroke: Stroke is the result of a blood flowproblem within, or leading to, the brain and isconsidered a form of cardiovascular disease.
Cardiovascular disease
Cardiovascular disease and type 2
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The processes by which diabetes can lead tocardiovascular damage do not develop independently.Each may accelerate or worsen the others.
Atherosclerosis and hypertension are the two mainprocesses which lead to cardiovascular disease.
Microangiopathy and autonomic neuropathy areother damaging effects which are specific to diabetes.
In many people with diabetes these different factorsco-exist, resulting in progressive damage to the heart
and blood vessels.
ypdiabetes
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Hypertension, atherosclerosis
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Today the most widespread forms of cardiovascular disease
are those which start with damage to the blood vessels hypertension and atherosclerosis.
Hypertension
is at least twice as common in people with diabetes as in
the general population. is also more frequent in people with impaired glucose
tolerance.
Atherosclerosis
Not only are people with diabetes at increased riskof developing atherosclerosis, but the process also tends
to be accelerated, more severeand more widespread.
yp ,and type 2 diabetes
The cardiovascular disease triad
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The major clinical manifestations of cardiovasculardisease can be divided into three groups.
Brain andcerebralcirculation -cerebrovasculardisease
Heart andcoronary
circulation -coronary heart
disease
Lower limbs -peripheral
vascular disease
The cardiovascular disease triad
The clinical consequences of
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People with type 2 diabetes have the same risk of
heart attack as people without diabetes who havealready had a heart attack.
Women with diabetes are subject to sudden death300% more often and men with diabetes 50% moreoften than their counterparts without diabetes of thesame age.
Strokes occur twice as often in people with diabetesand hypertension as in those with hypertension alone.
A person with diabetes has a two to three-fold greater
risk of heart failure compared to a person withoutdiabetes.
qdiabetes and cardiovascular disease
Heart attacks in people with and without
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5
0
10
15
20
25
30
35
40
50
Incidence(%)
No prior heart attackPrior heart attack
People withoutdiabetes
People with diabetes
p pdiabetes over a period of seven years
Cardiovascular risk factors
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Advancing age
Diabetes and other high blood glucose conditions Dyslipidaemia Genetic background High alcohol consumption Hypertension
Insulin resistance Left ventricular hypertrophy Male gender Menopause Obesity
Sedentary lifestyle Smoking
Bold text: modifiable risk factor
Cardiovascular risk factors
What is a risk factor?
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A risk factor can be genetic or acquired.
It may be identified as a single measurement (egweight), disease (eg hypertension) or lifestylecharacteristic (eg smoking).
The condition must be associated with that disease in a
manner which is beyond chance alone. A causal link istherefore implied.
A risk factor will not necessarily always lead to thedevelopment of the disease.
The ultimate purpose of identifying a risk factor is tomodify it in order to prevent the disease.
What is a risk factor?
Prevalence of cardiovascular risk factors in people
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Risk Factor Prevalence
HypertensionPrevalence is at least double in people with type2 diabetes
High BloodCholesterol
Prevalence is similar in people with diabetes
High Triglycerideswith Low HDL
Prevalence is higher in people with diabetes
Left ventricularHypertrophy
Most commonly seen in people with long-standing high blood pressure, but is also seen inthe absence of elevated blood pressure in peoplewith diabetes
Obesity Prevalence is stronger in people with diabetes.Weight distribution is also usually different, withmore central obesity which is linked with atendency to develop coronary heart disease.
Smoking People with diabetes smoke less(presumably due to medical advice).
p pwith diabetes, compared to people without diabetes
Targets for common cardiovascular
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Risk Factors Targets
Dyslipidaemia Decrease LDL cholesterol levels(46 mg/dl or 1.2 mmol/l*)
Lower triglycerides(
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There are currently more than 230 million people with
diabetes worldwide. If nothing is done to slow theepidemic, the number will exceed 350 million by 2025.
In 2003, the five countries with the largest numbers ofpersons with diabetes were
India (35.5 million)
China (23.8 million)
the United States (16 million)
Russia (9.7 million)
Japan (6.7 million).
By 2025, the number of people with diabetes is expectedto more than double in Africa, the Eastern Mediterranean,the Middle East, and South-East Asia.
Diabetes - a growing threat
Diabetes a growing threat
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By 2025 the number of people with diabetes isexpected to rise by
20% in Europe 50% in North America 75% in the Western Pacific
85% in South and Central America. For developing countries, there will be a
projected increase of a 170% of cases;
For developed countries, there will be a projected
rise of42%.
Diabetes is the fourth main cause of death inmost developed countries.
Diabetes a growing threat
The prevalence estimates
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Diabetes Atlas second edition, IDF 2003
< 2%
2% - 5%
5% - 8%
8% - 11%
11% - 14%
14% - 17%
17% - 20%
>20
of diabetes worldwide 2003
The prevalence estimates
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Diabetes Atlas second edition, IDF 2003
< 2%
2% - 5%
5% - 8%
8% - 11%11% - 14%
14% - 17%
17% - 20%
>20
of diabetes worldwide 2025
Prevalence of diabetes
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10
7.5
5
2.5
0AFR EMME EUR
2003 2025
NA SACA SEA WP
Prevalence(%)
(2079 age group) by region
A growing threat
Di b t i th ld l d th
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Diabetes increased by one-third during the 1990s,
due to the prevalence of obesity and an ageingpopulation.
Diabetes is particularly common in ageingpopulations, and the incidence is increasing in
proportion to the number of people living longer. The incidence of type 2 diabetes in children and
adolescents has also risen dramatically in recentyears.
Young people with diabetes will develop diabetes-related micro-and macrovascular complications at arelatively young age.
Diabetes in the elderly and the young
A growing threat
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Overweight and obesity can affect as many as30% 35% of people under the age of 30 insome developed countries.
In Europe, the UK has demonstrated the most
rapid increase in obesity which could see morethan 40% of the population obese by 2025.
Worldwide the prevalence of obesity is rising toepidemic proportions at an alarming rate, with
over half the worlds population already affected.
The obesity epidemic
A growing threat
Di bete d obe it
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Type 2 diabetes,the metabolic syndrome and cardiovascular disease in Europe
International Obesity Task Force figures suggestthat up to 1.7 billion people are already at aheightened risk of weight related non-communicable disease such as type 2 diabetes.
These rising levels are likely to drive theprevalence of diabetes even higher than presentforecasts, which do not take into accountchanges in the obesity epidemic.
It is estimated that at least half of all diabetescases would be eliminated if weight gain inadults could be prevented.
Diabetes and obesity
Overweight and obesityh l hild (5 17 Y )
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35
30
25
20
15
10
5
0Americas Europe Near/Middle
EastAsia andPacific
Sub-SaharanAfrica
Worldwide
Overweight
Obese
Prevalence(%)
among school age children (517 Years)
The prevalence of male and female obesityl l i l t d E t i
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30 1020 0 10 20 30 40
% BMI 30
Yugoslavia
GreeceRomania
Czech Rep.
England
Finland
Germany
Scotland
Slovakia
PortugalSpain
Denmark
Belgium
Sweden
France
Italy
Netherlands
Norway
Hungary
Switzerland
levels in selected European countries
A growing threat
Th li ti f di b t
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Diabetes is the leading cause of blindness andvisual impairment in adults in developedcountries.
Diabetes is the most common cause ofamputation which is not the result of an
accident.
People with diabetes are 15 to 40 times morelikely to require a lower-limb amputationcompared to the general population.
Many people with diabetes develop severekidney disease, which may be fatal if leftuntreated.
The complications of diabetes
A growing threatDiabetes and cardiovascular disease
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70%80% of people with diabetes die ofcardiovascular disease.
For each risk factor present, the risk ofcardiovascular death is about three times greater
in people with diabetes as compared to peoplewithout the condition.
Cardiovascular disease is the number one causeof death in industrialized countries. It is also set
to overtake infectious diseases as the mostcommon cause of death in many parts of the lessdeveloped world.
Diabetes and cardiovascular disease
Changes in coronary heartdi t lit t i th USA
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TIMETOACT Type 2 diabetes,
the metabolic syndrome and cardiovascular disease in Europe
0
-10
-20
-30
-40
10
20
30
Co
ronaryheartd
iseasemortality(%)
People without diabetes People with diabetes
Men Women
disease mortality rates in the USA
The cost of diabetes
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The annual direct healthcare costs of diabetes
worldwide, for people in the 20 79 age bracket,is estimated to be at least 153 billioninternational dollars.
It is estimated that diabetes accounts for
between 5% and 10% of total healthcarespending in most countries and up to 25%in some.
If predictions of diabetes prevalence are fulfilled,total direct healthcare expenditure on diabetesworldwide will be between 213 billion and 396billion international dollars in 2025.
e cost o d abetes
The cost of diabetesDi bete d dio l di e e
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TIMETOACT Type 2 diabetes,
the metabolic syndrome and cardiovascular disease in Europe
Cardiovascular disease is the most importantsingle contributor to diabetes costs.
In the industrialised world, CVD accounts for 57%of total medical care costs for people with
diabetes. The trend of escalating diabetes prevalence, with
its impact on CVD, will no doubt lead to animmense financial burden in many countries,
unless action is taken to prevent diabetes and itscomplications.
Diabetes and cardiovascular disease
The cost of diabetesEstimates of the cost of diabetes care by region
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the metabolic syndrome and cardiovascular disease in Europe
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000 R=2
R=3
AFR EMME EUR NA SACA SEA WP
(inmillioninte
rnational
dollars
)
Estimates of the cost of diabetes care by region
The cost of diabetesThe CODE-2 Study
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A collaborative study of the direct costs of diabetes ineight European countries, the CODE-2 studydemonstrated that type 2 diabetes is a serious andcostly condition.
The study estimated that:
The total direct medical costs for the 10 million peoplewith type 2 diabetes in these countries were 29 billionEuros in 1998.
Type 2 diabetes accounted for between 3% and 6% oftotal healthcare expenditure in the different countries.
It also showed that diabetes-related complications arethe main reason for the high costs.
The CODE-2 Study
Total annual direct medical costs for patientswith type 2 diabetes (CODE-2 1998)
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Germany12.4 billion Euros
Sweden
0.7 billion Euros
Netherlands0.4 billion Euros
Italy5.8 billion Euros
UK
2.6 billion Euros
Spain2.0 billion Euros
Belgium1.1 billion Euros
France4.0 billion Euros
Total for these 8 countries = 29 billion Euros
with type 2 diabetes (CODE 2 1998)
Direct healthcare costs relevant todiabetes the example of Code 2
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General healthcare cost per patient (US$)
Additional cost due to presence of diabetes (US$)
500
1,000
1,500
2,000
2,500
3,000
3,500
0
U
S$
Belgium
France
Germany
Italy
Netherlands
Spain
Sweden UK
diabetes the example of Code-2
The cost of diabetesImplications for health systems
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Direct health care costs of diabetes are high andrising
Direct health care costs of the metabolicsyndrome dominate health care budgets
Preventing or delaying the onset oftype 2 diabetes results in considerablecost reduction
Improving metabolic control can also reduce
health care resource use
Implications for health systems
Proportion of hospital bed days usedfor the treatment of diabetic complications
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for the treatment of diabetic complications
Managing Diabetes and DiabeticComplications
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The human and economic costs of diabetes could
be significantly reduced by investing inprevention, particularly early detection, inorder to avoid the onset of diabetic complications.
At least 50% of all people with
diabetes are unaware of theircondition.
In some countries this figure may riseto 80%.
Complications
Managing diabetesBlood glucose and lipids
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There is conclusive evidence that good control ofblood glucose levels can substantially reduce therisk of developing complications and slow theprogression in all types of diabetes.
The management of high blood pressureand raised blood lipids (fats) is equallyimportant.
In all societies, better control of these parameters
would contribute to a substantial improvement inquality of life.
Blood glucose and lipids
Recent Trials Relevant to thePrimary Prevention of Type 2 Diabetes
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Diabetes and Obesity, Time to Act, p.33, IDF 2004
Study Year Interventions Outcome
DaQing
(China)
1997 Diet, physical
activity or both(control group:general)
Reduction in diabetes incidence
31% in diet group, 46% inphysical activity and 42% in dietand physical activity compared tocontrol group
FinnishDiabetes
PreventionStudy
2001 Diet and physicalactivity (control
group: generaladvice)
Reduction by 58% of the risk ofdiabetes compared to control
group
DiabetesPreventionProgram(USA)
2002 Diet, physicalactivity,metformin andplacebo
58% reduction in incidence ofdiabetes with lifestyleintervention, 31% with metformin
STOP-NIDDM
2002 Acarbose orplacebo
32% patients randomised toacarbose and 42% randomised toplacebo developed diabetes
Primary Prevention of Type 2 Diabetes
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Managing obesity
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Lifestyle interventions, including diet and moderate
physical activity (for example, walking 25 minutes perday, 6 times per week) can reduce the risk of diabetesby as much as 4060%.
Weight loss drugs have a role in individuals in whomlifestyle changes are either insufficientto produce the required weight control or areimpossible to achieve because of physical incapacity.
Weight management is the best strategy to preventthe development of type 2 diabetes.
Screening for undiagnosed diabetes
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Half or more of type 2 diabetes is undiagnosed.
Opportunistic screening during a healthcare visitfor other reasons can identify undiagnoseddiabetes, particularly in individuals at high risk.
Up to half of those afflicted already have signs ofcomplications at diagnosis.
Strong scientific evidence relating good metaboliccontrol to the prevention or delay of these
complications is now available.
Microvascular complications
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Eye Problems
Kidney Problems
Foot Problems
Eye problems
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All of these complications are common, and, ifleft untreated, lead to deterioration of vision andultimately, blindness.
They are all treatable if detected early and mostare potentially preventable.
The eye complications associated with diabetes (eitherspecific to diabetes or more common in people withdiabetes) are retinopathy, macular oedema, glaucomaand cataract.
Screening for eye problems
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Screening for diabetic retinopathy is cost-effective where subsequent treatment, such aslaser treatment, is available and affordable.
Where there is no access to laser treatment,
good metabolic control aimed at delaying theprogress of diabetic eye disease is likely to becost-effective.
Managing eye problems
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Diabetic eye disease can be prevented or delayed by
careful management of the underlying diabetes.
If detected early, well before symptoms begin, itsprogress can be further delayed by photocoagulation.
Laser treatment for diabetic retinopathy and macular
oedema is highly effective.
Laser screening is also particularly cost effective foryounger patients, in whom the number of years of sightsaved will be large.
Cataract can be dealt with cheaply and effectively bysurgical removal.
Foot problems
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The combination of nerve damage and insufficientblood supply in the legs and feet of people withdiabetes often leads to painful ulcers, infection andgangrene. This can ultimately result in amputation and
even death.
Foot problems
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Foot ulceration affects some 15% of all people with
diabetes some time during their lives.
In developed countries, amputation of lower extremities isat least 10 times more common in persons with diabetesthan in persons without diabetes.
In developed countries, hospitalisation for people withdiabetes-related foot ulcers is approximately 60% longerthan for people without foot ulcers.
The costs of diabetic foot problems are so high that a hostof interventions are likely to be cost effective depending on
the problem and the circumstances in which theseinterventions are carried out.
Managing foot problems
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A number of interventions have been found to beeffective in preventing the consequences of
diabetic foot problems:
Education Pressure-relieving interventions
Multidisciplinary clinics
The cost effectiveness of managingfoot problems
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Although sources of cost savings vary country bycountry, the strategies of education, pressure-relieving interventions and multidisciplinary clinicshave been judged to be cost-effective.
(Unfortunately data on cost-effectiveness comes
exclusively from developed countries.)
One study identifies patient education as the mostcost-effective intervention. Even if risk reduction isonly half of the 50%86% reported in the literature,
the economic benefits of implementing such anapproach will be substantial.
foot problems
Renal problems
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The renal problems associated with diabetes areamong the most costly in terms of their directhealthcare costs.
People who develop these complications can, if leftuntreated, proceed to renal failure, which in turn
leads to premature death if dialysis or kidneytransplantation are not available.
When they are available, long-term dialysis or themore desirable option of transplantation brings high
healthcare costs to the individual and family, or to thehealthcare sector or, more typically, to both.
Screening for renal problems
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Renal failure in diabetes can be detected very early byscreening for microalbuminuria (very small traces of
protein in the urine).
A number of studies suggest that when the facilities fortreatment are available, screening for microalbuminuria iscost-effective.
Treatment with ACE inhibitors (even in the absence ofhypertension) is deemed, at least in the USA, to be cost-saving. When these are not available much can be donewith other, less costly and more readily available anti-hypertensives (when hypertension is present). Improved
blood glucose is also an important part of the response. However, effective treatment must be available in order to
follow on from the detection of this early sign of renalfailure.
Managing renal problems
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Keeping blood pressure at near-normal level inpeople with diabetes who also have hypertensionis known to be effective in preventing or delayingrenal failure.
Maintaining a near-normal level of blood glucosealso plays an important part.
In addition, even in the absence of hypertension,the anti-hypertensive ACE-inhibitor drugs havebeen shown to provide protection for the kidneyin people who have microalbuminuria.
The prevention of microvascularcomplications
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Maintaining near-normal levels of blood glucose
and blood pressure significantly decreases therisk of microvascular complications in people withdiabetes.
The DCCT, UKPDS and Kumamoto Studies have
demonstrated this in regard tohyperglycaemia.
The UKPDS Study and HOT Trial have shownthe importance of the effective control of bloodpressure.
The control of dyslipidaemia is also of vitalimportance, as is, if necessary, weight reduction.
p
The prevention of macrovascularcomplications
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The same basic improvements in diet andphysical activity that prevent type 2 diabetes arelikely to prevent CVD complications.
Also, a wide range of drugs has now been proven
to be effective in reducing the risk of CVD inpeople with diabetes, and in treating diabetes-associated CVD once it is present.
p
Drug therapy
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Each of these drugs can decrease CVD risk by20% - 30% or more:
AspirinOne of the worlds least expensive drugs, aspirin has beenproven to be risk-beneficial in people with diabetes.
However, caution is needed if the risk of strokes resultingfrom bleeding is high.
Beta Blockers, Diuretics and ACE Inhibitors(angiotensin converting enzyme inhibitors): lower blood
pressure
Drug therapy
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Each of these drugs can decrease CVD risk by20% - 30% or more:
ACE InhibitorsAlso the drug of choice for preventing renal disease the second most expensive complication of diabetes.
Lipid Lowering Agents such as statinsStatins appear to be beneficial in almost all peoplewith diabetes and seem to be safe over the usualrange of dosages used.
Highest Percentage Reduction of the Risk of DiabeticComplications in People with Type 2 Diabetes shown inRecent Studies
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Strategy ComplicationReduction ofComplication
Lipid control Coronary heart disease mortality
Major coronary heart diseaseevent
Any atherosclerotic event
Cerebrovascular disease event
36%
55%
37%
62%
Blood PressureControl
Cardiovascular disease
Heart failure
Stroke
Diabetes-related deaths
51%
56%
44%
32%
Blood GlucoseControl
Heart Attack 37%
1 The 4S Study2 Hypertension Optimal Treatment (HOT) Randomised Trial3 UKPDS