Diabetes Update

Pam Allweiss, MD, MPH pca8@cdc.gov

Centers for Disease Control and Prevention. Division of Diabetes Translation

The findings and conclusions of this presentation are those of the presenter and

do not necessarily represent views of the Centers for Disease Control and Prevention

An American Epidemic

Age-adjusted Percentage of U.S. Adults Who Were Obese or Who

Had Diagnosed Diabetes

Obesity (BMI ≥30 kg/m2)

Diabetes

1994

1994

2000

2000

No Data <14.0% 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0%

No Data <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% >9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

2009

2009

26 million

with Diabetes

79 million with Pre-Diabetes

Epidemic of Diabetes

• Diabetes affects almost 26 million Americans (8.3%), one quarter of whom don’t know they have it.

• Another 79 million Americans have pre-diabetes, which raises their risk of developing type 2 diabetes, heart disease, and stroke.

• About 1.9 million new cases of diabetes were diagnosed in people aged 20 or older in 2010.

www.yourdiabetesinfo.org www.DiabetesAtWork.org

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Number with Diabetes

Number and Percentage of U.S. Population with Diagnosed Diabetes,

1958–2010

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics

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Total Non-Hispanic WhiteNon-Hispanic Black Hispanic

Narayan et al, JAMA, 2003

Estimated lifetime risk of developing diabetes for

individuals born in the United States in 2000

Source: 2005–2008 National Health and Nutrition Examination Survey.

The Diabetes Epidemic

• Aging of America

• Diverse ethnic groups, various incidence and prevalence of diabetes

• Earlier diagnosis and reclassification

• Pre-diabetes: “Borderline Diabetes” or a “touch of sugar” = real condition that needs to be treated

• By 2050, 1 in every 3 adult Americans will have diabetes if current trends continue

Estimated Cost of Diabetes in U.S. (ADA 2007)

• Total: $174 billion

• Indirect costs include increased absenteeism ($2.6 billion) and reduced productivity while at work ($20.0 billion) for the employed population

• Reduced productivity for those not in the labor force ($0.8 billion)

• Unemployment from disease-related disability ($7.9 billion)

• Lost productive capacity due to early mortality ($26.9 billion)

Diabetes 101: What is Diabetes

• Not just a “sugar” problem • Interaction of food, insulin, other hormones

(glucagon) • Physical activity/Obesity • Pancreatic function • Genetics • Other commonly associated conditions:

hypertension, lipid problems • The complications, not just the diagnosis of

diabetes, cause the problems • Diabetes is common, serious BUT treatable

Diabetes means:

• 2 x the risk of high blood pressure

• 2 to 4 x the risk of heart disease

• 2 to 4 x the risk of stroke

• #1 cause of adult blindness • #1 cause of kidney failure • Causes more than 60% of non-traumatic

lower-limb amputations each year NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2010.

Complications

• Eyes

• Kidneys

• Nerves

• Cardiovascular disease and stroke

• Randomly controlled studies show that these complications can be prevented or controlled with good blood sugar control but this might involve multiple shots etc

• More shots does not mean “worse diabetes”!

Symptoms

• Frequent urination

• Excessive thirst

• Extreme hunger or constant eating

• Unexplained weight loss

• Presence of glucose in the urine

• Tiredness or fatigue

• Changes in vision

• Numbness or tingling in the extremities

• Slow-healing wounds or sores

• Abnormally high frequency of infection

• Many people have no symptoms

Diagnosis (Diabetes Care 1-2010)

• 1) A1C ≥6.5%. (by lab using a method that is NGSP certified and standardized to the DCCT assay.* (caveats: anemia, pregnancy)

• OR

• 2) FPG ≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*

• OR

• 3) 2-h plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*

• OR

• 4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dl (11.1 mmol/l).

• *In the absence of unequivocal hyperglycemia, criteria 1–3 should be confirmed by repeat testing

Types of Diabetes

• Type 1: traditionally age <20, no endogenous insulin, may be any age, about10-20% of people with diabetes, Rx = insulin

• Type 2: traditionally >40, multiple problems with insulin secretion and action, may be any age, about 80-90% of people with diabetes, Rx may include oral agents and/or insulin or newer agents (incretins, GLP1 )

• Pre-diabetes

• Gestational Diabetes

Who Is At Risk? • Age 45 or older

• Overweight

• Inactive

• Ethnic or minority

population

• Family history of

diabetes

• Excess abdominal fat

• High blood pressure

• Pre-diabetes

• High blood fats

• Darkening of the skin

• Polycystic ovary

syndrome

• History of Gestational

Diabetes or large baby

Could You be at Risk for Diabetes?

Where do you start? • ADA Risk Test (paper or online)

www.diabetes.org

Categories of increased risk for diabetes (Pre-diabetes)

• Impaired Fasting Glucose: FPG 100 mg/dl (5.6 mmol/l) to 125 mg/dl (6.9 mmol/l)

• Impaired Glucose Tolerance: 2-h PG in the 75-g OGTT : 140 mg/dl (7.8 mmol/l) - 199 mg/dl (11.0 mmol/l)

• A1C 5.7–6.4% • For all three tests, risk is continuous, extending

below the lower limit of the range and becoming disproportionately greater at higher ends of the range.

Why Control Diabetes? Do Any Interventions Work?

• Bottom Line: Does better glucose control translate to better outcomes or better health in the individual?

• Yes!

• For every 1% drop in A1c the risk of microvascular complications (eye, kidney, and nerve damage) can be reduced by up to 40%.

• http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.p

Control the ABCS

• A1c: Glucose control

• Blood Pressure control

• Cholesterol (lipid) control

• Smoking cessation

Glucose

Liver

Peripheral Tissues (Muscle)

Pancreas

Receptor + postreceptor defect

Increased glucose production

Impaired insulin secretion

Insulin resistance

P.23

Causes of Hyperglycemia in Type 2 Diabetes

©1997 PPS

C

Source: 2007–2009 National Health Interview Survey.

Physiologic Serum Insulin Secretion Profile

Polonsky KS et al, N Engl J Med 1996.

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Breakfast Lunch Dinner

So what are some resources and how can we use them?

Where is the community partner?

National Diabetes Education Program

• CDC and NIH program formed after evidence showed that better glucose control translated into fewer complications

• Public and private partnerships to improve diabetes treatment and outcomes

• Increased public awareness of the seriousness of diabetes, its risk factors, and strategies for preventing diabetic complications

• NDEP translates the latest science and spreads the word that diabetes is serious, common, and costly, yet controllable and, for type 2, preventable

• Focus group tested by diverse audiences, multiple languages

• NO COPYRGHT : Add your logo!

• Over 200 public/private partnerships

www.yourdiabetesinfo.org www.ndep.nih.gov

NDEP Campaign Materials: Control & Prevention

Different types of materials • Print

• Downloads

• Podcasts

• Videos

• Promotion resources

• Behavior change resources

• PP Presentations such as: Diabetes: the numbers, and Science of control

Materials for Consumers

Content

• Healthy eating/ how to eat out/tasty recipes

• Take care of your feet/Be smart about your heart

• Team care

• Tips to stay healthy

• Know your numbers

4 Steps to control your diabetes brochure

• Also available in these languages:

• Bengali, Cambodian, Chinese, Gujarati, Haitian Creole (and CD), Hindi, Hmong, Japanese, Korean, Laotian, Samoan, Spanish, Tagalog, Thai, Tongan, Urdu, Vietnamese

Materials for Professionals and Lay Workers

The Road to Health/El Camino

Hacia La Buena Salud CHW Primary

prevention toolkit

The Road to Health (RTH) Toolkit/ El camino hacia la buena salud Toolkit : A Toolkit on Primary Prevention of Type 2 Diabetes for Community Health

Workers (CHWs)/Promotores

• The Road to Health Toolkit was developed based on the findings from the Diabetes Prevention Program (DPP) study and focus groups with African American and Hispanic/Latino Community Health Workers.

• Focus groups with CHWs from urban and rural African American and Hispanic/Latino communities: – Diabetes testing, management, and prevention

strategies – Barriers, opportunities, perceptions – Focus on primary prevention – Tools needed – Training video

NDEP Websites

www.diabetesatwork.org Content

• General Diabetes Education :

• Nutrition, Weight Control, and Physical Activity

• Lunch and Learn topics

• Lesson Plans (English and Spanish)

• Fact Sheets (English and Spanish)

• Guide to choosing a health plan, developed with AAHP

• Supervisor’s guide

• NO COPYRIGHT!

Fotonovela: Do it for them! But for you too. (¡Hazlo por ellos! Pero por ti también.)

This fotonovela is a bilingual (Spn/Eng) fotonovela featuring dramatic stories of Latinas talking to Latinas about preventing or delaying type 2 diabetes and being healthy for their children and themselves. The stories use three women’s challenges in maintaining a healthy lifestyle to convey an important message: • Increasing physical activity, • making healthy food choices and • losing weight (if you are overweight)

decreases or delays your risk of developing type 2 diabetes.

Tasty Recipes for People with Diabetes and Their Families (Ricas recetas para personas con diabetes y sus familiares)

• A bilingual booklet, Tasty Recipes is filled with recipes specifically designed for Latin Americans.

• Recipes are accompanied by their nutritional facts table. The booklet also includes diabetes health information and resources.

• This effective, yet practical, educational promotional tool is a terrific addition to any kitchen.

Words of Wisdom

• Can’t transform everything at once

• Use the web sites to print out forms and “recipes”

• Don’t re-invent the wheel

• Learn from others

The Diabetes Prevention Program (DPP): The New Frontier: Lifestyle Modifications or Medication

• Goal: To prevent or delay the development of type 2 diabetes in persons with impaired glucose tolerance (IGT)

• High-risk individuals with IGT and elevated FPG (N=3234) randomized to

– Placebo

– Intensive lifestyle intervention; at least monthly contact with case

managers

– Metformin titrated to 850 mg bid

• Reduction at 2.8 years

– 58% in the intensive lifestyle intervention group

– 31% in the metformin group

The Diabetes Prevention Program Research Group. Diabetes Care. 1999;22:623.

NIDDK. http://www.niddk.nih.gov/welcome/releases/8_8_01.htm.

National Diabetes Prevention Program

Goal:

Systematically scale the translated model of the Diabetes Prevention Program (DPP) for high risk persons in collaboration with community-based organizations that have necessary infrastructure, health payers, health care professionals, public health, academia, and others to reduce the incidence of type 2 diabetes in the United States.

National Diabetes Prevention Program

• Training = CDC contracted with Emory University to establish the Diabetes Training and Technical Assistance Center (DTTAC) and developed Master Trainer curriculum and unified Lifestyle Coach curriculum – www.dttac.org.

• Recognition Program = CDC and partners developed the standards for program recognition

• For more information: http://www.cdc.gov/diabetes/prevention/

www.cdc.gov/diabetes/prevention

How do I get NDEP materials?

All NDEP materials are copyright-free. Download from

www.yourdiabetesinfo.org

Visit all of the NDEP Web sites:

www.ndep.nih.gov

www.betterdiabetescare.nih.gov

www.cdc.gov/diabetes/ndep

www.diabetesatwork.org