Back to Basics: Endocrinology Diabetes, Obesity and Thyroid

1. Back to Basics: EndocrinologyDiabetes, Obesity and Thyroid

2. Diagnosis of Diabetes • What are the CDA criteria for the diagnosis of diabetes? • Who should be screened for type 2 diabetes • Which type of diabetes has a stronger genetic component type 1 or type 2? • Which type of diabetes only presents in the elderly population?

3. Screening for Type 2 Diabetes Every 3 years in individuals  40 years of age Earlier and/or more frequently in individuals with additional risk factors FPG 5.7-6.9 mmol/L plus risk factor(s) for diabetes/IGT 2hPG in a 75-g OGTT CDA 2003 Clinical Practice Guidelines. Can J Diabetes 2003;27:S11

4. Definitions of Impaired Fasting Glucose (IFG) and Impaired Glucose Tolerance (IGT) and Diabetes 8.5 Diabetes 7.5 6.9 IFG IFG + IGT Fasting Glucose (mmol/L) 6.5 6.1 5.6* 5.5 Normal Glucose IGT 4.5 3.5 3 4 6 8 10 12 14 7.8 11.1 2-h Post-load Glucose(mmol/L) * 1. ADA Diabetes Care 2006;29(Suppl 1):S47,2. CDA Can J Diabetes 2003;27(Suppl 2):S7, 3.WHO 1999 NDC/NCS.99.2 accessed Mar 2 2006 from www.who.int

5. The World Wide Epidemic:Prevalence of Diabetes 5% 8% 3% 14% 4%

6. The Worldwide Epidemic:Diabetes Trends Sources: www.who.int www.idf Zimmet P. et al Nature: 414, 13 Dec 2001

7. The Diabetes Epidemic in Canada Prevalence, Risk Factors, and Current Cost Implications

8. Prevalence (%) 1.30 to 2.90 1996 - 1997 1994 - 1995 3.00 to 3.40 3.50 to 3.90 4.00 to 4.40 5.00 to 5.40 5.50 to 5.90 4.60 3.90 No data 2.7 3.1 3.40 3.2 2.8 2.5 3.2 3.1 3.20 3.2 3.50 3.1 3.20 3.0 3.2 2.8 4.6 3.6 2000 - 2001 1998 - 1999 3.2 1.3 5.8 5.2 3.4 3.9 3.1 4.0 4.0 3.4 3.1 3.1 4.1 3.1 5.0 3.10 4.0 3.6 4.2 3.3 4.4 5.1 5.2 The Canadian Epidemic: Prevalence in Canada, 1994/95 to 2000/01, by Province Source: Statistics Canada: CANSIM II

9. Diabetes Risk Factors Modifiable Risk Factors Physical Activity Obesity Diet & Non-Modifiable Risk Factors Ethnicity Family History

11. Diabetes Risk Factors:Modifiable Source: Choi B, Shi F. Diabetologia 2001, 44:1221-1231.

12. Diabetes Risk Factors:Modifiable Source: Choi B, Shi F. Diabetologia 2001, 44:1221-1231.

13. Diabetes Risk Factors:Modifiable Source: Choi B, Shi F. Diabetologia 2001, 44:1221-1231.

14. Diabetes Risk Factors:Modifiable • Relative risk for developing type 2 is cumulative. • A physically inactive individual (less than 30 min/wk of exercise) • who consumes an unhealthy diet • and is modestly overweight (BMI 25-30) • would have a 30-fold increased (1.8*2*8) risk of developing type 2 DM compared to the general population, • which would translate to a lifetime risk of nearly 100% REF: Atlas of Diabetes 2nd Ed, Part 2, JS Sklyer, Editor

15. Run away from diabetes

16. The Epidemic: Non-Modifiable Risk Factors Ethnicity Age Family History / Genetics

17. The Epidemic: Ethnic Groups at High Risk for DM Aboriginal Latino South East Asian Asian African Descent

18. Diabetes Risk Factors:Non-ModifiableOther High-risk Groups in Canada • 77.1% of Canada’s immigrant population are coming from populations which from high risk ethnic groups • 7.3% Latinos • Central and South America, 7.3% • 57.0% Asian • 12.8% African Decent • Caribbean and Bermuda, 5.5% • Africa, 7.3% REF: Statistics Canada, 1996 Census

19. Type 2 Diabetes is NOT a Mild Disease Diabetic Retinopathy Leading cause of blindness in working-age adults1 Stroke 2- to 4-fold increase in cardiovascular mortality and stroke3 Cardiovascular Disease 8/10 diabetic patients die from CV events4 Diabetic Nephropathy Leading cause of end-stage renal disease2 Diabetic Neuropathy Leading cause of non-traumatic lower extremity amputations5 1. Fong DS et al. Diabetes Care 2003; 26(Suppl 1):S99-S102. 2. Molitch ME et al. Diabetes Care 2003; 26(Suppl 1):S94-S98. 3. Kannel WB et al. Am J Heart 1990; 120:672-6. 4. Gray RP and Yudkin JS. In: Textbook of Diabetes. 1997. 5. Mayfield JA, et al. Diabetes Care 2003; 26(Suppl 1):S78-S79.

20. Diabetes Complications: Macrovascular • DM is a major risk factor for cardiac disease • Acute MI occurs 15-20 years earlier in those with DM • Heart disease accounts for approximately 50% of all deaths among people with diabetes in industrialized countries REF: Diabetes in Ontario, An ICES Practice Atlas, 2002

21. Diabetes Complications:Macrovascular • Several large epidemiological studies have found a strong relationship between • glucose level and subsequent coronary events, even at ‘pre-diabetes’ levels (IGT and IFG) • glucose levels that are only modestly elevated place patients at risk. REF: Coutiho M. et al Diabetes Care 1999;22:233-240. & DECODE Study Group. Arch Intern Med 2001;161:397-404.

22. Diabetes Complications: Macrovascular Relationship between FPG and CHD Metaregression - 20 prospective studies n = 95,783 - follow-up 12.4 yrs FPG > 6 mmol/L: RR 1.38 (1.06-1.67) 2.5 Relative Risk 2 1.5 1 4 5 6 7 8 9 Fasting glucose (mmol/L) REF: Coutinho et al. Diabetes Care 1999;22:233-40.

23. Diabetes Complications: Microvascular– Amputation • Diabetes…. • Is the leading cause of non traumatic amputation • Increases the risk of amputation by 20 fold • those living in the north or in low income neighborhoods and those with poor access to physician services are at particular risk for amputation. REF: Diabetes in Ontario, An ICES Practice Atlas, 2002

24. Diabetes Complications: Microvascular– Retinopathy Diabetes • Is a leading cause of adult-onset blindness • Prevalence of diabetic retinopathy is ~ 70% in persons with type 1 and 40% with person with type 2 diabetes. REF: Diabetes in Ontario, An ICES Practice Atlas, 2002

25. Diabetes Complications: Microvascular - Nephropathy • Diabetes • Is the leading cause of ESRD • Increases the risk of developing ESRD by up to 13-fold Refs: Meltzer S, et al CMAJ 1998; 159 (8 suppl):S1-S29, & Parchman ML, et al Medical Care 2002; 40(2):137-144.

26. Prevention strategies • Primary Prevention • Prevent diabetes through reduction of modifiable risk factors in general population • Secondary Prevention • Screening those at high-risk for diabetes • Tertiary Prevention • Upon diagnosis of diabetes, prevention of complications morbidity, and mortality REF: Diabetes Blueprint

27. Primary Prevention Model • Goal • Reducing modifiable risk factors for diabetes • Target • General population & high-risk groups • Messages • Healthy lifestyle choices • Current Delivery Models of Primary Prevention • Population Health • Primary Care

28. Primary Prevention Model: Population Health – National CDS Health Canada NADA REF: Health Canada

29. Secondary Prevention • Goal • Early identification of those with dysglycemia • Target • High-risk individuals and groups • Messages • Diabetes awareness • Current delivery model of secondary prevention relies on primary care

30. Secondary Prevention: Is It Effective? • Yes…. • Patients diagnosed with IGT can be prevented from progressing to type 2 diabetes • 58% reduction with lifestyle changes (DPP, DPS) • 30% reduction with medication (DPP, Stop NIDDM)

31. Tertiary Prevention: Is it Effective? • Yes… • Strong evidence for tertiary prevention particularly for microvascular disease • DCCT, UKPDS • How to translate this evidence into practice?

32. Tertiary Prevention • Goals • Glucose, blood pressure, and lipid control to reduce the development of complications • Complication screening for early identification and management

34. Why are Obesity and Type 2 DM Increasing in Frequency? • More sedentary lifestyles • Worldwide changes in urbanization and nutrition • Aging population due to demographic growth rates (baby boomers) and increased life expectancy www.who.int and www.idf.org accessed March 16, 2006

35. 1985 1990 1994 1996 < 10% 1998 < 10% - 14.9% > 15% No data Obesity by Province: BMI 30 Source: Katzmarzyk PT, CMAJ Apr. 16, 2002; 166 (8)

36. Obesity • The most common metabolic condition in industrialized nations • Statistics Canada: 48% of Canadians between ages 20-64 yr are overweight (BMI>25) • Associated with dyslipidemia, impaired glucose tolerance and insulin resistance • Risk factor for developing metabolic syndrome, type 2 Dm, cardiovascular disease • Huge economic costs

37. Obesity in Canada: 1978/79 to 2004 Quick Facts: % of obese children increased from 3% to 8% Among adults, the increase was even more dramatic: from 14% to 23%, a total of 5.5 million people About 30% of baby boomers (aged 45 to 64) are obese Data from Canadian Community Health Survey www.statcan.ca/Daily/English/050706/d050706a.htm

42. Canada’s Food guide to healthy eating • Promote a diet with 30% or less energy from fat, 15-20% energy from protein and 50-55% from complex carbohydrates • Despite a decrease from 40% of energy from fat in U.S. diet in 1965 to 34% in 1991, incidence of obesity increased

43. Why is it Important to Recognize the Metabolic Syndrome? A prevalent condition associated with: • Significantly increased CVD risks • Significantly increased risks for type 2 diabetes It is treatable and preventable

44. Clinical Features of the Metabolic Syndrome • Abdominal obesity • Hyperglycemia • Atherogenic dyslipidemia • Hypertension • Proinflammatory state • Prothrombotic state

45. IDF Classification of the Metabolic Syndrome Risk Factors Cut Points Central obesity • Europids, Mid-east • S. Asians, Chinese • Japanese Men Waist C. Women  94 cm (37 in)  80 cm (31.5 in)  90 cm (35 in)  80 cm (31.5 in)  85 cm (33 in)  90 cm (35 in) Plus any 2 of the following for diagnosis: Triglycerides  1.7 HDL cholesterol • Men  0.90 • Women  1.10 Blood pressure  130 Syst. or diast.  85 mm Hg or Rx Fasting glucose  5.6 mmol/L Inadequate evidence to recommend routine measurement of insulin resistance (e.g., plasma insulin), proinflammatory state, or prothrombotic state in the diagnosis of the metabolic syndrome

46. Metabolic Syndrome • A common condition associated with increased cardiovascular disease risks • Treatment is aimed at lifestyle modification to achieve desirable body weight and reduce abdominal obesity • Multiple medical therapy may be required to achieve metabolic targets (lipids, glucose and BP) • Lifestyle modification benefits everyone!

47. Therapeutic strategies for the management of type 2 diabetes.

48. Targets for Metabolic Control: Glucose Control (2003 CDA Guidelines)

49. Risk categories and target lipid levels III-9

50. Achieve Target A1C within 6–12 Months Clinical assessment and initiation of nutrition and physical activity A1C ≥9% A1C <9% BMI <25 BMI ≥25 2 agents: Metformin TZD Secretagogue Insulin Acarbose Insulin Metformin TZD Secretagogue Insulin Acarbose Metformin (first-line) TZD Secretagogue Insulin Acarbose Timely adjustments/additions should be made to attain target A1C within 6–12 months. • Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Can J Diabetes 2003;27(Suppl 2):S1–152.