Preventing Complications of Endocrine Disorders: Strategies and Solutions

1. Prevention of complications of endocrine disorders R.Fielding Department of Community Medicine, HKU.

2. Learning objectives • Estimate the extent of morbidity and use of resources from complications of endocrine disorders due to overweight and inactivity • outline the main barriers to prevention of endocrine complications • explain key contributions to these barriers • suggest cost-effective solutions

3. Common endocrine complications • type 2 (NIDDM) diabetes, • hypertension, • dyslipidaemia, and • cardiovascular diseases including AMI, AP, PVD & stroke. • Why are these now considered complications of endocrine disorders?

4. Because they reflect disorders or more accurately complications arising from a syndrome of over nutrition and inactivity, which produces disturbances in the regulation of energy metabolism. • These “diseases” are, therefore, more accurately described as complications, but doctors seldom take this perspective, preferring to look at each “disease” as a separate thing: endocrinologists care for NIDDM, cardiologists for AMI, etc.

7. Prevalence of DM in HK • 58% of men, 49% of women BMI >23.5 • 38% men 34% women BMI >25 • 5% men, 7% women BMI >30 • Prevalence of DM in • males • 2% (CI 0-3.7%) at 25-34 to 22% (14.4-29.1%) at age 65-74 • females • 1.4% (0-4.6%) at 25-34 to 29% (21.4-37.3%) in age 65-74. • Over 70% were unaware they had DM (Janus et al, 1997)

8. Complications prevalence in Chinese • in NIDDM, HK Chinese • 22% (95% non-proliferative retinopathy) • 4% clinical nephropathy • 13% clinical neuropathy (Wang & Lam, 1998) • Nephropathy OR raised in Chinese( McGill, et al 1996) • Mainland diabetic patients (Xu et al, 1997) • 50% hypertensive 45% neuropathy • 37% retinopathy (4.5% blind) • 25% IHD 23% proteinuria • 12% stroke 1% amputation

9. Risk factors for complications • Chinese, Malays and Indians NIDDM vs.Cauca. • Those with NIDDM had • higher mean body mass indices, waist-hip ratios and abdominal diameters • more hypertension, higher triglycerides, lower LDL (Hughes et al, 1998) • Retinopathy in NIDDM Asian Indian, Chinese, and Creole Mauritians - vs Caucasians seen with • increasing duration of diabetes, • higher fasting plasma glucose, systolic blood pressure, and urinary albumin concentration, • decreasing body mass index (Dowse et al, 1998)

10. Total physical activity independent predictor of 2-h post-load glucose concentration after controlling for BMI, waist-hip ratio, age, and family history of NIDDM. (Pereira, et al, 1995) • Visceral fat accumulation is associated with dyslipidemia, hypertension, insulin resistance, and albuminuria in (HK) Chinese patients with NIDDM (Anderson, et al, 1997) • Therefore, inactivity, BMI, longer DM raise risk for complications.

11. Cause or effect? • “Although obesity, especially abdominal obesity, is the commonest cause of complications such as type 2 diabetes, hypertension, dyslipidaemia, and cardiovascular diseases, doctors most often use drugs to treat the complications rather than the underlying condition. “ • So, these symptoms of unhealthy lifestyle are treated as causes when they are in fact, effects.

12. Etiology of complications: Barriers to prevention • Biological : • genetic - unalterable, “brittle” DM • Lifestyle: • obesity, diet, inactivity, smoking • Attitudinal: • DM “common” and accepted; emphasis on genetics minimization of efforts to prevent; aversion to activity in HK; Chinese cultural belief that fat=good; overeating common and gluttony norm.

13. Service: • inadequate screening for DM • lack of continuity of care • failure to screen for complications • Psychological • poor compliance with diet, activity and medication leads to poor insulin control. • Poor DPR • little understanding of consequences of poor control • “helplessness” - can’t do anything aboutdisease -only doctors can “cure”.

14. Key contributions to barriers • Incomplete / inadequate detection and follow-up • Lack of organized shared care between specialist and GP • Discontinuity of care • Poor medical record keeping • Little attention paid to effective patient education • Little attention given to importance of DPR

15. Screening for type 2 DM? • Benefits of early detection and treatment of undiagnosed diabetes have not been proved • Effectiveness of diabetes screening in reducing cardiovascular disease depends on disease prevalence, background cardiovascular risk, and risk reduction in those screened and treated • Disadvantages of screening are important and should be quantified

16. Screening? • Universal screening is unmerited, but targeted screening in specific subgroups may be justified • Clinical management of people with established diabetes should be optimised before a screening programme is considered. • (Wareham & Griffin, BMJ, 2001, 322, 986.)

17. Conclusions • How important are these complications? • DM currently most common important known endocrine disorder in HK affecting about 10% of population. • Prevalence of complications 20-30%. 2-3% of HK popn. will have complications if present rates persist = 7 million/100x0.3 = 21,000 with avoidable complications. • Barriers are mostly to do with poor service organization, failure of adherence and screening.

18. Further reading • American Diabetic Association • Poems • UK Study reducing risk of complications • Fitness protocol • Screening guidelines