Diabetes Mellitus Introduction to Diabetes Epidemiology

STAR-initiative
Knut Borch-Johnsen

Diabetes Mellitus
Definition
A metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both Associated with a risk of developing late diabetic complications including Microvascular (retinopathy, nephropathy) Macrovascular (atherosclerosis) Neuropathy
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Increasing mortality from diabetes mellitus

J. Olefsky, JAMA 2001:285:628-632

Diabetes Epidemiology
Type 1 diabetes Type 2 diabetes Other specific types

Impaired glucose regulation (IFG & IGT) Insulin Resistance & Metabolic Syndrome
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Type 1 diabetes epidemiology

Very big variation in incidence and prevalence Variation in growth-rate Disease process relatively well described Genetic markers known Weak risk factors

Incidence of type 1 diabetes Age 0-14 years

40 35 30 25 20 15 10 5 0 Incidence (per 100.000)/year
IDF Diabetes Atlas 2003
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China Japan India USA New Zealand UK Denmark Canada Sweden Finland

Type 1 diabetes Increase in incidence/year

9 8 7 6 5 4 3 2 1 0 1
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Sweden Denmark UK New Zealand Canada Finland Japan China USA

Type 1 diabetes epidemiology

Very big variation in incidence and prevalence Variation in growth-rate Disease process relatively well described Genetic markers known Weak risk factors

2 minutes

Diabetes Epidemiology
Type 1 diabetes Type 2 diabetes Other specific types

Impaired glucose regulation Insulin Resistance & Metabolic Syndrome

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Type 2 diabetes epidemiology

Some variation in incidence and prevalence Variation in growth-rate Disease process partly understood Some and often weak genetic markers known Strong risk factors
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Prevalence of DM and IGT age 35-64 years

50 45 40 35 30 25 20 15 10 5 0 Diabetes IGT
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Poland Denmark Brazil USA (white) Alaska (inuit) US rural hisp. US urban hisp Nauru Pima(US)

Diabetes in Denmark 1974-96

20 15 10 5 0 Males DM Males IGT Females DM Females IGT

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1974 1996 1996 1974

Drivsholm et al.Diabetic Medicine 201

Diabetes and Gestational Diabetes Trends Among Adults in the U.S., BRFSS 1990, 1995 and 2001
1990 1995

2001

No Data

<4%

4%-6%

6%-8%

8%-10%

>10%
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Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and other obesity-related health risk factors, 2001. JAMA 2003 Jan 1;289(1).

World wide epidemic

India: 2000:32 mill 2020: 81 mill

Zimmet, Nature 2001

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DIABETES
60 50
Diabetic patients in Millions

Top Three Countries in the world

40
57 million

30 20
19 million

10 0
U.S. CHINA INDIA U.S. CHINA INDIA

1995

2025
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King et al, Diabetes Care, 1998

Type 2 DM - global epidemic why ?

Prevalence depends on:
Age Residence(urban/rural) Obesity Physical activity Ethnicity

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Type 2 DM - global epidemic why ?

Prevalence depends on:
Age Residence (urban/rural) Obesity Physical activity Ethnicity

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Age standardized prevalence of Type 2 DM

(native and migrant Asian Indian populations)

Rural southern India Tamil Nadu (urban) Madras Dar-es-Salaam (Tanzania) Durban (South Africa) Mauritius Fiji

2% 5% 7% 8% 12% 14% 17% (x 2.5) (x 3.5) (x 4) (x 6) (x 7) (x 8,5)

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Urban-Rural ratio
Fiji Kiribati Vest-Samoa Papua NyGuinea 4 3 (8 / 2) (12 / 4)

1.8 (15 / 8) 2.8 (35 / 13)

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2 minutes

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Type 2 DM - global epidemic why ?

Prevalence depends on:
Age Residence(urban/rural) Obesity Physical activity Ethnicity

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Non-pharmacological, observational
Obesity
RR risk of DM in females (ref. BMI < 22)
22-23 24-25 > 31 3.0 5.0 40

(Colditz & al, Ann Int Med, 1995, 122; 481-6)

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Obesity (BMI>30) in USA 1960-2000 (males)

40 35 30 25 20 15 10 5 0 20-39y 40-59y 60-74y
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1960-62 1971-74 1976-80 1988-94 1999-2000

Flegal & al, JAMA 2002, 288, 1723-7

Obesity children in USA 1960-2000 BMI >95-centile (boys)

16 14 12 10 8 6 4 2 0 2-5y 6-11y 12-19y Ogden & al, JAMA 2002, 288, 1728-32
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1963-65 1966-70 1971-74 1976-80 1988-94 1999-2000

Obesity* Trends Among U.S. Adults

BRFSS, 1991, 1995 and 2000
(*BMI u 30, or ~ 30 lbs overweight for 54 person)

1991

1995

2000

No Data

<10%

10%-14%

15-19%

20%
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Source: Mokdad A H, et al. JAMA 1999;282:16, 2001;286:10.

Obesity Trends* Among U.S. Adults BRFSS, 2001

Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10.

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Diabetes and Gestational Diabetes Trends Among Adults in the U.S., BRFSS 1990, 1995 and 2001
1990 1995

2001

No Data

<4%

4%-6%

6%-8%

8%-10%

>10%
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Mokdad AH, Ford ES, Bowman BA, et al. Prevalence of obesity, diabetes, and other obesity-related health risk factors, 2001. JAMA 2003 Jan 1;289(1).

Type 2 DM - global epidemic why ?

Prevalence depends on:
Age Residence (urban/rural) Obesity Physical activity Ethnicity

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Non-pharmacological, observational
Exercise
Vigorous exercise > 1/week, 25% risk reduction
(Manson & al, Lancet 1991, 338; 774-8., JAMA, 1992, 268,63-7)

Looking TV 2-10 hours per week: RR 1.66 of having DM compared with 0-1 hour per week
( HU et al; Arch Intern Med 2001;161: 1542-1548)

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Modal Travel in Urban Areas:

Europe and North America Percent of Trips by Mode
Country Netherlands Germany England Italy Canada USA Bicycle 30 12 8 5 1 1 Walking 18 22 12 28 10 9 Public Transport 5 16 14 16 14 3 Car 45 49 62 42 74 84

Transportation Quarterly 1997; 51:31 Transportation Quarterly

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Distribution of Hours of TV Per Day:

NHES Youth Aged 12-17 in 1967-70 and NLSY Youth Aged 12-17 in 1990
35 30 25 Percent 20 Distribution 15 10 5 0

NHES 1967-70 NLSY 1990

0-1 0-1

1-2 1-2

2-3 2-3

3-4 3-4

4-5

5+

TV Hours (Youth Report) TV Hours (Youth Report)

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Prevalence of Obesity by Hours of TV per Day:

NHES Youth Aged 12-17 in 1967-70 and NLSY Youth Aged 10-15 in 1990
Prevalence (%) 40 35 30 25 20 15 10 5 0 TV Hours Per Day (Youth Report)
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NHES 1967-70 NLSY 1990

Type 2 DM - global epidemic why ?

Prevalence depends on:
Age Residence(urban/rural) Obesity Physical activity Ethnicity

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Prevalence of DM in 60 years old Men

80
Prevalence of DM (%)

60
Europe

40 20 0 15 20 25 BMI (kg/m )
2

Malta India China Japan

30

35
35

Decoda:Nakagami; Diabetologia 2003

Prevalence of DM in 60 years old Women

80
Prevalence of DM (%)

60 40 20 0 15 20 25
BMI (kg/m )
36 2

Europe Malta India China Japan

30

35

Decoda:Nakagami; Diabetologia 2003

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