marco songini prevalence of diabetic complications in relation to demographics in europe

Marco SonginiPrevalence of

diabetic complicationsin relation to demographics

in Europe State-of-the-art in reference to

published data

Part 2: microvascular diseases, neuropathy and costs of diabetes

Dr Marco Songini is the director of the Diabetes Unit at S. Michele Hospital in Cagliari (Sardinia-Italy).

He is also the vice-president of ASRIS (Association for the Study of Type 1 Diabetes in Sardinia)

DM-MED project is aimed to develop recommendations for public health policy in the Mediterranean countries with emphasis on the prediction, prevention and control of Types 1 and 2 diabetes and their complications. The emphasis of this meeting was on description of the health programs of the participating countries, on the epidemiology of diabetes and its complications in the Mediterranean region, and on the need for methodology of diabetes registries.

The present is one of the lectures of the DM-MED meeting.

Epidemiology of diabetes chronic complicationsMicrovascular diseases

Retinopathy in Diabetes in Europe

Type 1 diabetesType 2 diabetesAll

NE WE EE SE0

102030

405060708090

%

Diabet Med, 14 (S1); 1997


Frequency of retinopathy among Eurodiab PCS pts at baseline

Proliferative

Background

0 10 20 30 40 50 60 70

%1 23 45 67 89 10

11 1213 1415 161719 2021

2223

18


Retinopathy in Type 2 diabetes (UKPDS)

1.030.830.830.79

0.780.0170.0120.015

0 - 3 years0 - 6 years0 - 9 years0 - 12 years

RR p 0.5 1 2

Relative Risk& 99% CI

Favoursconventional

therapy(2)

Favours intensive therapy(1)


Retinopathy in Type 2 diabetes (UKPDS)

243 461 207 411 152 3000

20

40

60

% p

atie

nts

3 years 6 years 9 years

p=0.38p=0.019 p=0.004

Years from randomisation

- TC

- LTC


Nephropathy in Diabetes in Europe

Type 1 diabetes

Type 2 diabetes

All

NE WE EE SE0

5

10

15

20

%



Frequency of nephropathy (albuminuria) among Eurodiab PCS pts at baseline

0 10 20 30 40 50

%

macroalbuminuria

microalbuminuria

1 23 45 67 89 1011 1213 1415 1617 1819 2021 2223 2425 26


Risk of albuminuria among Eurodiab PCS pts

0102030405060

microalbuminuriaat baseline (351 pts)

normoalbuminuriaat baseline (1,134 pts)

Progressionto micro

Progressionto macro

Regression to normo

%

13%2 %

14 %

51 %

Epidemiology of diabetes chronic complications

Microvascular diseasesAlbuminuria among Eurodiab PCS pts

Risk factors at baseline for progression

HbA1c, AER and after adjusting for HbA1c & AER

fasting triglycerides, LDL and HDL cholesterol, BMI, WHR,

any retinopathy

From normoto microalbuminuria

HbA1c, AER

and after adjusting for HbA1c& AER

GT, WHR,peripheral neuropathy

From microto macroalbuminuria


Nephropathy in Type 2 diabetes (UKPDS)

Favoursconventionaltherapy(2)

Favoursintensive

therapy(1)

0.890.830.880.760.670.70

0.240.0430.130.000620.0000540.033

BaselineThree yearsSix yearsNine yearsTwelve yearsFifteen years

RR p 0.5 1 2

Relative Risk& 99% CI


Nephropathy in Type 2 diabetes (UKPDS)

Years from randomisation

% p

atie

nts

317 618 274 543 166 2990

10

20

30

40

2418

29

20

3329

3 years 6 years 9 years

p=0.008p=0.052 p=0.33-TC

-LTC

Epidemiology of diabetes chronic complicationsNeuropathy in Diabetes in Europe

Type 1 diabetes

Type 2 diabetes

All

NE WE EE SE0

10203040506070

%


Epidemiology of diabetes chronic complicationsFrequency of neuropathy

among Eurodiab PCS pts at baseline

0 10 20 30 40 50 60 70 80

%1 23 45 67 89

11 1213 1415 1617 1819 2021 2223 2425 26

10

Epidemiology of diabetes chronic complicationsIncidence of neuropathy

among Eurodiab PCS pts over the follow up

05

10152025303540

SymptomsAbsence of reflexesAbnormal VPT

Abnormal autonomic functionNeuropathy (2 or more abnormal of symptoms, reflexes, VPT, autonomic function)

%

The prevalence raised from 26% at baseline to 34% at the end of follow up

The Costs of Diabetes (1)

--

Direct costs (43-50% of total costs)Direct costs (43-50% of total costs)Personal costsPersonal costs - Hospital services- Hospital services

- Physician in-patient service- Physician in-patient service- Out-patient care (services and GPs, - Out-patient care (services and GPs,

nursing home, home care)nursing home, home care)- Travel (ambulances)- Travel (ambulances)- Supplies (oral hypoglycaemic drugs, - Supplies (oral hypoglycaemic drugs,

insulin, syringes, cotton swabs, glucose insulin, syringes, cotton swabs, glucose and urine test strips)and urine test strips)

Non-personalNon-personalcostscosts

- Research (biomedical and - Research (biomedical and social sciences)social sciences)

- Health education- Health education- Support services- Support services

Diabetes in Europe, Ed Rhys Williams, 1993

The Costs of Diabetes (2)

Indirect costsIndirect costs - Income losses due to illness and - Income losses due to illness and disabilitydisability

- Present value of future earning lost - Present value of future earning lost by those who died prematurely as a by those who died prematurely as a result of diabetesresult of diabetes

- Psychological costs to diabetic - Psychological costs to diabetic patients and their families patients and their families (Intangible costs)(Intangible costs)

Diabetes in Europe, Ed Rhys Williams, 1993

$ bi

llion

1965 1970 1975 1980 1985 1990 1995

10

20

30

40

50

The Costs of DiabetesDirect Costs of Diabetes in the USA

* US$ 15,114 per diabetic /yearly(compare to US$ 548 for others /yearly)

* Taylor AK, Diabetes Care, 1987

The Costs of Diabetes in Europe

England and Wales: Total costs for diabetes England and Wales: Total costs for diabetes (Laing W et al, 1989)(Laing W et al, 1989)5% of total expenditure of the National Health Service5% of total expenditure of the National Health Service

England and WalesEngland and Wales: Direct costs for Type 1 diabetes : Direct costs for Type 1 diabetes (Gray et al,1995)(Gray et al,1995)£ 1,024 per pt /year£ 1,024 per pt /year

France: Total costs for diabetes France: Total costs for diabetes (Triomphe A et al, 1988)(Triomphe A et al, 1988)Type 1 diabetes FF 12,178 per pt /yearType 1 diabetes FF 12,178 per pt /year

Type 2 diabetes FF 6,908 per pt /yearType 2 diabetes FF 6,908 per pt /year

UK: Direct costs for type 2 diabetes UK: Direct costs for type 2 diabetes (Moore P, 2000)(Moore P, 2000)4.7 % of total expenditure of the National Health Service4.7 % of total expenditure of the National Health Service

Sweden: Total costs for diabetes Sweden: Total costs for diabetes (Olsson J et al, 1987)(Olsson J et al, 1987)$ 8,400 per pt /year$ 8,400 per pt /year

Finland: Direct costs for diabetes Finland: Direct costs for diabetes (Kangas T et al, 1989)(Kangas T et al, 1989)5.8% of total expenditure of the National Health Service5.8% of total expenditure of the National Health Service

01234567

Wor

ldAfri

caAsia

Nth Ameri

ca

Latin A

merica

Europe

Oceania

1995

2000

2010

Global estimates and projections of diabetes prevalences from 1995 to 2010

%


There is no sex difference for the risk of CHD in people with type 1 diabetes. Independently of age and HbA1c, the risk factors for CHD in men and women are different. In fact in men CHD is strongly associated with AER, smoking, WHR, whilst in women duration of the disease, systolic BP, AER, fasting triglycerides play a major role.

The incidence of neuropathy over approximately a 7 year period is 25%. Risk factors for incidence, independent of age and HbA1c were cholesterol, fasting triglycerides, presence of CVD at baseline and presence of retinopathy at baseline. Existence of previous CVD increased the risk of neuropathy 3 times.

Eurodiab-PCS: summary (1)Eurodiab-PCS: summary (1)

Eurodiab-PCS: summary (2)Eurodiab-PCS: summary (2)Regression from micro to normoalbuminuria was significantly related to HbA1c, AER, WHR and peripheral neuropathy. These results emphasise the importance of good glycaemic control to prevent nephropathy, and indicate that markers of insulin resistance, such as triglycerides and WHR, need to be strictly monitored.

There are not still data reporting the incidence of retinopathy among this cohort. At baseline retinopathy was present in about one third of the patients (mostly background).

Intensive therapy aimed to reduce fasting glycaemia to normal values (less than 108 mg/dl vs less than 270 mg/dl) is worthwhile as it reduces risk of complications, the greatest effect being on microvascular complications.A tight blood pressure control is worthwhile as it reduces risk of complications, particularly evident in heart failure and stroke after 3 years from randomisation.All these data indicate that the reduction in risk of complications of diabetes is not a dream but it is a realisable goal.

UKPDS: summaryUKPDS: summary

Conclusions (1)The prevalence of diabetes, either type 1 and type 2, is increasing worldwide. The interaction between some genetic components and some environmental factors is responsible for the etiopathogenesis of these diseases. However, the environmental factors for type 1 diabetes have still to be largely identified whilst, as far as type 2 diabetes, overweight, low levels of habitual physical activity and some aspects of westernized diet have been already recognised as to be important for developing the disease.

Independently of the type of diabetes, the incidence and prevalence of chronic complications are tightly related not only to glyco-metabolic control but also to other risk factors, such as blood lipids and blood pressure, which can be easily prevented by early monitoring and treatment.

Conclusions (2)It is of note that, independently of the different design and period of follow up of the studies so far reported, the risk for developing diabetes complications is also dependent from a genetic background, which varies among the different areas and populations investigated. Furthermore, the same complications could be related to different risk factors according to the population analysed.

49

Conclusions (3)These findings suggest that, across different countries, the prevalence of diabetic complications may be widely variable, and that the efforts for their prevention must be oriented and differentiated according to the data emerging form their own investigations and to their own risk factors involved.

The interpretation of these differences could be carried out only by setting out large and reliable epidemiological investigations where data will be collected uniformly among the different geographical areas.

marco songini prevalence of diabetic complications in relation to demographics in europe

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