Transcript pP - Great Western Hospital

Beas Bhattacharya
Great Western Hospital
What is Diabetes?
History
 “Diabetes”
 Mid 16th century:
Greek, diabainein - 'go through‘
Latin 'siphon', meaning “to pass through”
= Increased Urination
 Indian physician(Susruta & Charaka)-5th cent AD
Polyuria with “sweet tasting urine”
 Was thought to be a kidney disease
Basic problem
“a serious disease in which the body
cannot properly control the amount of
sugar in your blood because it does not
have enough insulin”
Webster Dictionary
In a nutshell
Diabetes mellitus (DM) is a group of
diseases characterized by high levels of
blood glucose resulting from defects in
insulin production, insulin action, or
both.
Diagnosis –blood test
 HBA1C>6.5%
 Fasting plasma glucose is ≥7.0 mmol/L
 2-hour post glucose load is ≥11.1 mmol/L.
Broadly two type
 Lacking or not making insulin(Type 1)
 Resistance to the working of Insulin (Type 2)
Insulin Discovery
The breakthrough: Toronto 1921 – Banting & Best
Before Insulin
JL on 12/15/22 and 2 mos later
Before insulin was discovered in 1921,
everyone with type 1 diabetes died
within weeks to years of its onset
© 2004, John W alsh, P.A., C.D.E.
WHO estimation
(Adults)
285 million in 2010
3 million by 2010
336 million in 2011
552 million by 2030.
Over 2.5 million people diagnosed1
•
• Approx 4.9% of UK adult population1
• T2D accounts for 85-95% of all cases1,2
The total number of people with diabetes in the UK
could increase to >5.5 million by 20303
2.5 mil
2010
3.
5.5 mil
2030
1. IDF Diabetes Atlas. The Global Burden [last accessed http://www.idf.org/diabetesatlas/5e/diabetes April 2012]
2. World Diabetes Foundation. Diabetes Facts [Last accessed http://www.worlddiabetesfoundation.org/composite-35.htm April 2012]
Diabetes UK, One million people in the UK are unaware they have T2D [last accessed http://www.diabetes.org.uk/About_us/News_Landing_Page/One-millionpeople-in-UK-unaware-they-have-Type-2-diabetes/ April 2012]
Prevalence of diabetes in the UK
3,000,000
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
1940
1950
1960
1970
1980
1990
2000
2010
 Population Swindon – 209,200 (2011 Census)
 Approx Diabetic Population Swindon – 14,000
 6% of population has diabetes
(Estimated 7.3%in 2020, 8.3% 2030)
Europe :5-6%
Asia :11-12%
Why is that a problem?
Diabetes & it’s complications
Quality of life
Morbidity
Mortality
Cost
COMPLICATIONS OF DIABETES
Small vessel(Microvascular)
• Eye disease(Retinopathy)
• Kidney disease(Nephropathy)
• Nerve/Foot affection(Neuropathy/Diabetic Foot disease)
Big vessel (Macrovascular)
• Cardiac events,Heart attacks
• Peripheral vascular disease
• Cerebrovascular disease
Diabetes has serious implications
Stroke
2 to 4 fold increase in
cardiovascular
mortality and stroke3
Blindness
Leading cause
of blindness
in working age
adults1
Heart Disease
8/10 diabetic patients
die from cardiovascular
events4
Kidney failure
Amputations
Leading cause of
end-stage kidney disease2
Leading cause of nontraumatic lower
extremity amputations5
1 Fong
DS et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 2Molitch ME et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98.
3 Kannel WB et al. Am Heart J 1990; 120:672–676. 4Gray RP & Yudkin JS. In Textbook of Diabetes 1997 Chapter 57.
5Mayfield JA et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
Eye Disease
Retinopathy
DIABETIC EYE DISEASE
 Present in most diabetic people after 20 years
 >20% of patients develop sight threatening retinopathy –
improving with better care
 About 90% type 1 diabetes developed diabetic retinopathy
within 25 years of diagnosis.
 12 % of new cases of blindness between the ages of 45-74.
Diabetes Foot Disease
Microvascular Damage Leads to
Neuropathy
Normal nerve
Damaged nerve
Damage to myelinated
and unmyelinated
nerve fibers
Occluded vasa nervorum


Examination of tissues from patients with diabetes reveals capillary damage, including occlusion in the vasa nervorum
Reduced blood supply to the neural tissue results in impairments in nerve signaling that affect both sensory and motor
function
Dyck PJ, Giannini C. J Neuropathol Exp Neurol. 1996;55:1181-1193.
Sheetz MJ, King GL. JAMA. 2002;288:2579-2588.
Effects of Diabetic Peripheral Neuropathy
Images: 1,4Edward J Bastyr, III, MD;
2,3Rayaz A Malik, MBChB, PhD, MRCP.
The facts
 Foot in Diabetes-20% of total diabetes
expenditure
 6000-7000/year Amputations : 2009-2012
 5 yr Mortality: post amputation>40%
Hospital costs of amputation are £25 million
per year.
Even a modest 10% reduction will have
significant cost savings
Cardiovascular Disease D.O.H. 2013
Kidney Disease
Diabetic kidney disease
= the single most common cause of renal failure
Diagnosis in patients with ESRD (%)
30
24.0
20
20.7
15.6
11.8
10
7.8
7.3
6.9
6.0
0
Diabetes
Uncertain
aetiology*
Other
Glomerulo Pyelonephr Polycystic
-nephritis
itis
kidney
Primary Renal Diagnosis†
Renal
vascular
disease
Hypertension
*Includes presumed glomerulonephritis not biopsy proven.
† Figures shown are calculated excluding data not available. Data for primary renal diagnosis (PRD) missing in 10.8% of patients. In centres with >25% missing PRD data, percentages in the
other diagnostic categories not calculated. Centres with very high rates of uncertain diagnosis also excluded.
Adapted from: Nephron Clin Pract 2010;115(Suppl.1) The Renal Association. UK Renal Registry. Twelfth Annual Report 2009.
30
CV event risk greatest when diabetes and
CKD both present
No diabetes/no CKD
Diabetes/no CKD
No diabetes/CKD
Diabetes/CKD
CV event incidence
per 100 patient-years
60
50
40
30
20
10
0
CHF
AMI
CVA/TIA
PVD
ASVD*
Death
CHF=congestive heart failure; AMI=acute myocardial infarction; CVA/TIA=cerebrovascular accident/transient ischemic attack;
PVD=peripheral vascular disease; ASVD=atherosclerotic vascular disease.
*ASVD was defined as the first occurrence of AMI, CVD/TIA, or PVD.
Adapted from: Foley RN, et al. J Am Soc Nephrol 2005;16:489–95.
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England National Diabetes Audit
2009-10
Prevalance of
End Stage Renal Disease
( dialysis or transplantation in type 2 diabetes)
2003-4 = 0.26%
2009-10 = 0.56%
Kidney disease 'biggest threat' for diabetics
BBC News 2013
“An audit of 1.9 million people with Type 1
and Type 2 diabetes found more than
13,000 had a stroke in 2009-10,
a 57% rise from 2006-7.
And more than 7,000 had kidney failure, up
31% from 2006-7.”
What are the cause of mortality
in patients with diabetes Nephropathy ?
Stroke
Sudden
Death
Myocardial
Infarction
Heart
Failure
Is it all doom and gloom?
 Awareness
 Community based service advocated
 Early detection
 National bodies-Diabetes UK
 NSF 9 standards
 Focused, specialised services-E.g. Foot service
 New drugs, insulin pumps
 New evidences
What can we do?
We all have a role
As health professional, community, public
 -Raise awareness
 Change lifestyle
 Diabetes is a Pandemic evolving
 There won’t be many family unscathed or untouched
 Responsibility is not just on health care professionals
-it’s on all of us!
Who are at risk?
Overweight/BMI>25 WITH
 Family History-1st degree





relative
Ethnicity- e.g.South Asians
Gestational Diabetes
Past Big baby
Cardiovascular disease
High lipids
Symptoms
Excessive thirst
profuse sweating
headache
excessive hunger
Cornerstones of treatment
Physical activity
Diet
DPMI Workforce Development
– The Alfred Workforce
Development Team June 2005
Insulin/tablets
Lifestyle changes
Lifestyle modification
•
•
•
•
Diet
Exercise
Weight loss
Smoking
cessation
If a 1% reduction in HbA1c is
achieved, you could expect a
reduction in risk of:
• 21% for any diabetes-related
endpoint
• 37% for microvascular
complications
• 14% for myocardial infarction
Stratton IM et al. BMJ 2000; 321: 405–412.
Dietary recommendations for
diabetes
 Eat starchy foods




regularly
Eat more fruit and
vegetables
Reduce animal or
saturated fat
Cut down on sugar
Reduce salt
Exercise / activity
 30 minutes moderate intensity most days preferably all
 Helps to:
 Increased insulin sensitivity
 Decreased insulin requirements
 Weight reduction
 Lipid control
 Blood pressure control
CHRONIC COMPLICATIONS OF DIABETES
1. Absolute prevention of complicationsstop it!
2. Preventing the progression of complications to sight /
life threatening disease- stop progress!
Evidence
Beneficial effects of good glycaemia control on complications
DCCT
Kumamoto
UKPDS
HBA1C
9→7%
9→7%
8→7%
Retinopathy
63%
69%
~20%
Nephropathy
54%
70%
25-30%
Neuropathy
60%
---
---
Glucose Control Study Summary
The intensive glucose control policy maintained a lower
HbA1c by 0.9 % over a median follow up of 10 years from
diagnosis of type 2 diabetes with reduction in risk of:
12%
25%
for any diabetes related endpoint
for microvascular endpoints
p=0.029
p=0.0099
16%
24%
for myocardial infarction
for cataract extraction
p=0.052
p=0.046
21%
33%
for retinopathy at twelve years
for albuminuria at twelve years
p=0.015
p=0.000054
What can we do as community ?
 “Charity begins at home”- holds true
We can’t change our genes but we can change our habits.
 If not for us, can we do it for the community, the future
generation.
 Maybe be set an example for others e.g. .as a proactive
and responsible community
What can communities do?
Raise public awareness
Create a sense of urgency
Communicate the magnitude of the problem
Get people involved in improving their health
Recognise those who are most at risk
Reduce risk to families, friends and wider communities
 Open day regular discussion/public meets(like
today!)
 Break the barriers-GP-Hospital-”Community”
 Council & Government bodies
-cheaper exercise options (Town Garden walks/Swindon
Football ground cycle rides)
-Healthy affordable food stalls at City centre etc
Measure Up: Tactics
 Roadshows ~20 UK towns/year
 Simple 2-minute test to assess
risk of diabetes
 Advice about diabetes
 Advertising
 Posters at strategic locations
throughout the UK
 Adverts in national
newspapers and consumer
magazines
 Online targeting of at risk
groups
 Lobbying
 Extended poster campaign and
awareness day at UK Houses of
Parliament
 Campaigning at conferences of
UK political parties
Diabetes UK. Measure Up – Are You At Risk of Diabetes.
http://www.diabetes.org.uk/Measure_Up_-_are_you_at_risk_of_diabetes/.
NICE & NSF
9 Key care process
NSF
9 standards
 Blood glucose level








measurement
Blood pressure measurement
Cholesterol level measurement
Retinal Screening
Foot and leg check
Kidney function testing(Blood)
Kidney function testing(urine)
Weight check
Smoking status check
of
NEWER DRUGS
ANTI-HYPERGLYCEMIC THERAPY
- Metformin
-
- Sulfonylureas
- Thiazolidinediones
- DPP-4 inhibitors
- GLP-1 receptor agonists
-Dapagliflozin
Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of prin
Treatment goals
 Symptom free
 Prevent short term complications
 Prevent long term complications
 Quality of life = Lifestyle focus
Diabetes UK Careline
 A support helpline for
anyone with diabetes, their
friends, family and carers.
 How to contact
Call: 0345 123 2399
Monday–Friday,
9am–5pm.
Email:
[email protected]
Websitehttp://www.diabetes.org.uk/
Diabetes UK Phone Apps
 Log and track a range of
levels: blood glucose,
insulin, carbohydrates,
calories, weight and
ketones
 View your data in day and
week graphs to spot trends
 See your daily average
blood glucose level, total
carbohydrates and total
calories
Other websites
 http://www.nhs.uk/Con
ditions/diabetestype2/Pages/livingwith.aspx
 DESMOND (Diabetes
Education and Self
Management for
Ongoing and Newly
Diagnosed) programme
Thank
you!
Questions ?
Pathophysiology-biochemical and vascular factors
www.plymouthdiabetes.org.uk/
Background
 Foot in Diabetes-20% of total diabetes expenditure
Annual cost Diabetic Foot ulcer £600 million+
 Annual cost of diabetes related amputation £119
million
6000+ Amputations : 2009/2010
5% of diabetics develop a foot ulcer each year
Roughly 100,000 people with foot ulcers (per year)
0.5% of these will go onto have an amputation





 South west has a high amputation and admission rate
Abdominal obesity and increased risk of
cardiovascular events
The HOPE study
Adjusted relative risk
Waist
circumference (cm):
1.4
Tertile 1
Men
<95
Women
<87
Tertile 2
Tertile 3
95–103
>103
87–98
>98
1.29
1
0.8
1.27
1.17
1.2
1
1.16
1
CVD death
1.35
1.14
1
MI
All-cause deaths
Adjusted for BMI, age, smoking, sex, CVD disease, DM, HDL-cholesterol, total-C;
CVD: cardiovascular disease; MI: myocardial infarction; BMI: body mass index; DM:
diabetes mellitus; HDL: high-density lipoprotein cholesterol
Dagenais GR et al, 2005
Chronic kidney disease and cardiovascular (CV) risk
Age-standardised rates of CV events
(per 100 person-yrs)
As eGFR decreases, risk of CV events increases
40
Age-standardised rates of CV events
according to eGFR*
36.6
35
30
25
* Adults (1,120,295 ) within
large US integrated
healthcare system, with
serum creatinine
measured: 9.6% had been
diagnosed with diabetes.
21.8
20
15
11.29
10
5
2.11
3.65
0
≥60
45 - 59
30 - 44
15 - 29
<15
Estimated GFR (ml/min/1.73m2)
No. of events
73,108
34,690
18,580
8,809
3,824
Adapted from: Go AS, et al. N Engl J Med 2004;351:1296-1305.
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Impact of Intensive Therapy for Diabetes:
Summary of Major Clinical Trials
Study
Microvasc
UKPDS
 
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
DCCT /
EDIC*
 


 
ACCORD

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
ADVANCE
VADT
CVD
Mortality







Kendall DM, Bergenstal RM. © International Diabetes Center 2009
UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:854.
Holman RR et al. N Engl J Med. 2008;359:1577. DCCT Research Group. N Engl J Med 1993;329;977.
Nathan DM et al. N Engl J Med. 2005;353:2643. Gerstein HC et al. N Engl J Med. 2008;358:2545.
Patel A et al. N Engl J Med 2008;358:2560. Duckworth W et al. N Engl J Med 2009;360:129. (erratum:
Moritz T. N Engl J Med 2009;361:1024)
Initial Trial
Long Term Follow-up
* in T1DM
Criteria for Testing for Diabetes in Asymptomatic
Adult Individuals (1)
1. Testing should be considered in all adults who are overweight
(BMI ≥25 kg/m2*) and who have one or more additional risk factors:
• Physical inactivity
• First-degree relative with diabetes
• High-risk race/ethnicity (e.g.,
African American, Latino, Native
American, Asian American, Pacific
Islander)
• Women who delivered a baby
weighing >9 lb or were diagnosed
with GDM
• Hypertension (≥140/90 mmHg or
on therapy for hypertension)
• HDL cholesterol level
<35 mg/dL (0.90 mmol/L) and/or a
triglyceride level >250 mg/dL (2.82
mmol/L)
• Women with polycystic ovarian
syndrome (PCOS)
• A1C ≥5.7%, IGT, or IFG on previous
testing
• Other clinical conditions associated
with insulin resistance (e.g., severe
obesity, acanthosis nigricans)
• History of CVD
*At-risk BMI may be lower in some ethnic groups.
ADA. Testing in Asymptomatic Patients. Diabetes Care 2012;35(suppl 1):S14. Table 4.