DIABETES MELLITUS TODAY

DIANA W. GUTHRIE RN, PhD 2006

DEFINITION & THE PROBLEM

CRITERIA FOR DIAGNOSIS DEFINITION PATHOPHYSIOLOGY PREVALENCE OBESITY METABOLIC SYNDROME

Glucose Tolerance Categories

FPG mg/dL
126 100 and <126
Diabetes Mellitus

2-hr PG on OGTT mg/dL

200 140 and <200 Diabetes Mellitus

Prediabetes Glucose
Normal

Prediabetes Tolerance
Normal

<100

<140

The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2002;25(suppl):S5

Etiologic Classification of Diabetes Mellitus

Type 1 Type 2 b-cell destruction with lack of insulin Insulin resistance with insulin deficiency

Other specific Types

Genetic defects in b-cell exocrine pancreas diseases, drug- or chemicalinduced, and other rare forms
Insulin resistance with b-cell dysfunction

Gestational

Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197.

Diabetes Trends* Among Adults in the U.S.,

(Includes Gestational Diabetes) BRFSS, 1990,1995 and 2001
1990 1995

2001

Source: Mokdad et al., Diabetes Care 2000;23:1278-83; J Am Med Assoc 2001;286:10.

Prevalence of Diabetes in Adults

United States, BRFSS: 2000

<4% >6%

46%

Obesity Trends* Among U.S. Adults BRFSS, 1991-2002

(*BMI 30, or ~ 30 lbs overweight for 5 4 woman)

1991

1995

2002

No Data

<10%

10%14%

15%19%

20%24%

25%

DNPA DNPA Graphics: Graphics:

Diabetes Trends* Among Adults in the U.S.,

(Includes Gestational Diabetes) BRFSS 2001

Source: Mokdad et al., J Am Med Assoc 2001;286:10.

Obesity Trends* Among U.S. Adults BRFSS, 2002

(*BMI 30, or 30 lbs overweight 5 4 woman) (*BMI 30, or~ ~ 30 lbs overweight for 54 for person)

No Data

<10%

10%14%

15%19%

20%24%

25%

Source: Behavioral Risk Factor Surveillance System, CDC

GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2025 (millions)

World 2003 = 194 million 2025 = 333 million Increase 72%

 20.8 million Americans have diabetes

Diabetes Today: An Epidemic

1.5 million new cases in 2005 more than 3500 each day

Complications of diabetes are a major cause of mortality and morbidity (2002 statistics)
90% of patients with diabetes are treated by primary care physicians
ADA National Diabetes Fact Sheet. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2005.pdf. Accessed April 11, 2005; ADA Diabetes Statistics. Available at http://www.diabetes.org/utils/printthispage.jsp?PageID=STATISTICS_233181. December 29, 2005.

Total Cost of Diabetes in the US, 2002

Total Cost $132 billion
Nursing home & hospice $14.4 billion

Outpatient care/ home health & medications $37.1 billion

Mortality $21.5 billion

Disability $18.3 billion

Inpatient care $40.3 billion

Health Care Expenditures $91.8 billion

American Diabetes Association. Diabetes Care. 2003;26(3):917-932.

Indirect Costs $39.8 billion

The Problem

Modern Life Has Both Conveniences and Costs

Illustration taken from: Lambert C, Bing C. The Way We Eat Now. Harvard Magazine. May-June, 2004;50.

METABOLIC SYNDROME
Obesity- high waist to hip ratio Hyperlipidemia Hyperinsulinemia Hypertension Hyperglycemia Acanthosis Nigricans PCOS

ACANTHOSIS NIGRICANS

ACANTHOSIS NIGRICANS

ACANTHOSIS NIGRICANS

Waist/Hip Ratio An Index of Abdominal Versus Peripheral Obesity

High WHR ( 0.95 in men) ( 0.80 in women)

Low WHR ( 0.95 in men) ( 0.80 in women)

American Diabetes Association

Visceral Fat Distribution

Normal vs Type 2 Diabetes

Normal

Type 2 Diabetes

Courtesy of Wilfred Y. Fujimoto, MD.

And America Continues to Enjoy Strong Economic Growth..

Course of Type 2 Diabetes

Obesity 350 300 Postmeal Glucose Fasting Glucose 250 200 150 100 50 250 200 150 100 50 0 -10 -5 0 5 10 15 20 25 30 b-cell Failure IFG* Diabetes Uncontrolled Hyperglycemia

Glucose (mg/dL)

Relative Function (%)

Insulin Resistance

Years of Diabetes *IFG=impaired fasting glucose. Burger HG, Loriaux DL, Marshall JC, Melmed S, Odell WD, Potts JT, Jr., Rubenstein AH. 2001. Diabetes Mellitus, Carbohydrate Metabolism, and Lipid Disorders. Chap. in Endocrinology. 4th ed. Edited by Leslie J. DeGroot and J. Larry Jameson. Vol. 1. Philadelphia: W.B. Saunders Co. Originally published in Type 2 Diabetes BASICS. (Minneapolis, International Diabetes Center, 2000).

Factors That May Drive the Progressive Decline of Beta-cell Function

Hyperglycemia (glucose toxicity)

Insulin Resistance

b-cell
*FFA=free fatty acids; TG=triglycerides.

Lipotoxicity (elevated FFA*, TG*)

Adapted from: Kahn SE. J Clin Endocrinol Metab. 2001;86(9):4047-4058. Adapted from: Ludwig DS. JAMA. 2002;287(18):2414-2423.

Progression to Type 2 Diabetes

Genetic Factors Insulin resistance Hyperinsulinemia
Compensated insulin resistance Normal glucose tolerance Acquired: Obesity Sedentary lifestyle Aging

-cell decompensation
Impaired glucose tolerance

Genetic Factors
Kruszynska Y, Olefsky JM. J Invest Med. 1996;44:413-428. Weyer C, et al. J Clin Invest. 1999;104:787-794.

-cell failure

Glucose and/or fat toxicity

Type 2 diabetes

The Importance of Targeting Insulin Resistance Over 90% of type 2 diabetics are Insulin Resistant
Complex Dyslipidemia TG, sdLDL HDL Endothelial Dysfunction
Systemic Inflammation

Disordered Fibrinolysis

Insulin Resistance

Atherosclerosis

Hypertension

Visceral Obesity

2 Diabetes Adapted from the Consensus Development Type Conference of the American Diabetes Association. Diabetes Care. 1998;21(2):310-314. Haffner SM, et al. Diabetes Care. 1999;22(4):562-568. Pradhan AD, et al. JAMA. 2001;286(3):327-334.

ETIOLOGY OF T1DM

DQ*

SHORT ARM # 6 CHROMOSOME

IMPORTANCE OF GLUCOSE CONTROL

DCCT KUMAMOTO UKPDS IN-PATIENT CONTROL

Complications of Diabetes
Macrovascular
Brain Cerebrovascular disease Transient ischemic attack Cerebrovascular accident Cognitive impairment Heart Coronary artery disease Coronary syndrome Myocardial infarction Congestive heart failure Extremities Peripheral vascular disease Ulceration Gangrene Amputation

Microvascular
Eye Retinopathy Cataracts Glaucoma

Kidney Nephropathy Microalbuminuria Gross albuminuria Kidney failure

Nerves Neuropathy Peripheral Autonomic

Good Glycemic Control (Lower HbA1c) Reduces Incidence of Complications

DCCT Kumamoto 9 7% 69% 70%

UKPDS
8 7% 17-21%

HbA1c
Retinopathy
Nephropathy Neuropathy Macrovascular disease
* not statistically significant

9 7% 63% 54%

24-33%
16%*

60%
41%*

Diabetes Control and Complications Trial (DCCT) Research Group. N Engl J Med. 1993;329:977-986. Ohkubo Y et al. Diabetes Res Clin Pract. 1995;28:103-117. UK Prospective Diabetes Study Group (UKPDS) 33: Lancet. 1998;352:837-853.

29

HbA1c as Predictor of Retinopathy

Glycemic Goals For Diabetes

ADA HbA1C% <7.0 IDF <6.5 AACE <6.5 Mine <6.5

FBS/Pre 80-120 prandial Mg/dl Plasma 2hr 185 postpran-

<100

<110

<120

<135

<140

<140

Summary
The evidence is overwhelming that good control does count Morbidity and mortality can be reduced There is nothing inevitable about the complications of diabetes

Summary (cont)
The cost of diabetes is in its complications Any expense paid up front in better management will pay off handsomely in the long run The tools for good diabetes care already exist No tool is more important than the services of a certified diabetes educator

Summary (cont)
Assessment tools include Self Monitoring of Blood Glucose and HbA1C Targets should be established for each of these for each patients within the national guidelines When targets are not reached the help of a specialist should be sought Christopher D. Saudek MD. Pres. ADA 2002

Summary
Insulin administration should mimic nature Natures way is basal insulin 24 hrs. a day And bolus insulin with every feeding Insulin lispro, asparte or glulisine can supply bolus Insulin glargine or detemir can supply the basal with one injection per day Control of blood sugar will prevent the complications of diabetes