Dealing with Diabetes. Jennifer Larsen, MD. Medical Director, Nebraska Diabetes Care 2000 Sept.; 23 Prevalence of Diabetes & Impaired. Fasting Glucose …
Dealing with Diabetes
Jennifer Larsen, MD Medical Director, Nebraska Medical Center Diabetes Center Chief, Diabetes and Endocrinology University of Nebraska Medical Center
Dealing with Diabetes
What is diabetes? Are there disparities in diabetes risk, diabetes outcomes, or both among racial or ethnic groups? If so, why? What are we doing about it?
From 1990-1998, Diabetes increased
In all age groups In all races In all educational levels In all levels of smoking status At all weight levels In 35/43 states 54/1 kg measured wt increase
Diabetes Care 2000 Sept; 239: 1278-83
1
Prevalence of Diabetes from 1990-98 by Selected States
46 55 21
Nebraska
64 66 3
Missouri
47 61 28 Iowa
52 91 75
Oklahoma Diabetes Care 2000 Sept; 239: 1278-83
Diagnosis of diabetes
Fasting Blood Sugar mg/dl Normal 110 After meal Blood Sugar mg/dl 140 140-199
Impaired fasting 110-125 glucose or glucose tolerance Diabetes 126
200
Changes in Diabetes Prevalence from 1990-1998 by Age
100 Difference, 1990-98 699
Change from 1990-98
80 60
398 40 20 0 18-29 30-39 40-49 50-59 60-69 / 70 91 309 171 101
Age Groups
Diabetes Care 2000 Sept; 239: 1278-83
2
Body Mass Index BMI And
Relative Risk Of Type 2 Diabetes
70 60 50 Adjusted Relative Risk 40 30 20 10 0 22 22 229 23 239 24 249 25 269 27 289 29 309 31 329 33 349 35
BMI kg/m2
In women 35-55 years of age in 1976; data adjusted for age Adapted from Colditz et al Am J Epidemiol 1990;132:501-513
Prevalence of Diabetes Impaired Fasting Glucose USA, 1988-1994
40
Percent of Population
35 30 25 20 15 10 5 0 20-39 40-49 50-59 Age yr Undiagnosed Diabetes 60-74 75
Diagnosed Diabetes
Harris MI et al Diabetes Care 1998; 21:518-24
Impaired Fasting Glucose
US Adults 20 years with Diabetes or Impaired Fasting Glucose
30
Impaired fasting glucose Undiagnosed diabetes Diagnosed diabetes
20
82 53
10
93
48 25 68
Non-Hispanic White
45 36 89
28 69
0
All Races
7
African American
Mexican American
3
Diabetes mellitus: 2 diseases
5-10 Type 1 or autoimmune diabetes
90-95 Type 2 or Insulin resistant diabetes
Type 1 diabetes
juvenile onset, insulin deficient or insulin dependent
Usually occurs age 25 More common in N Europeans Associated with risk of other autoimmune diseases thyroid disease, arthritis Requires insulin for treatment to avoid diabetic ketoacidosis
Pancreas Islet
cells
ANTIBODY
INSULIN
Type 2 diabetes
adult onset, insulin resistant
Glucose Pancreas Islet cells INSULIN INSULIN INSULIN INSULIN
Usually occurs age 40 More common in AfricanAmericans, Latinos, and Native Americans, AsianAmericans Often runs in families Usually associated with obesity, high blood pressure, and heart disease Best treatment: weight loss, exercise
4
Prevalence Of Type 2 Diabetes US, 4574Y: Effect Of Ethnicity
Non-Hispanic White African American Hispanic Cuban Mexican Puerto Rican Asian/Pacific Islander Japanese Americans Native American Inuit Alaska Sioux Dakotas Pima Arizona 0 20 40 60 80 100 120
Diabetes Prevalence
NHANES II 1976-1980 HHANES 1982-1984 Estimated prevalence based on a cohort of second-generation men born between 1910 and 1939 residing in King County, Washington All ages, age-adjusted prevalence in 1987 Flegal et al Diabetes Care 1991;14suppl 3:628-638; Fujimoto et al Diabetes 1987;36:721-729; Gohdes Chapter 34 In: Diabetes in America 2nd ed 1995:683-702
Insulin resistance
Obesity Aging
High blood pressure
Change in lipids or fats in blood
Diabetes mellitus
Increased clotting: More clot proteins Less ability to break up clots More
inflammation in the blood vessel wall
Atherosclerosis
Diabetes complications
Eyes: retinopathy
Bleedingblindness
Kidneys: nephropathy
Elevated urine albumin/creatinine ratio test Kidney failure dialysis and transplantati 
on
Nerves: neuropathy
Numbness of the feet
Blood vessel disease: vascular events
Angina, heart attack Transient ischemic attack TIA, stroke Claudication pain in the legs with walking, gangrene, amputation
5
DCCT:
Risk of progression of diabetic complications by mean HbA1c
15 13 11
Diabetic retinopathy Diabetic nephropathy Neuropathy Microalbuminuria
Relative Risk
9 7 5 3 1
6
7
8
9
10
11
12
HbA1C
Skyler, based on DCCT data, Endocrinol Metab Clin North Am 25:243, 1996
Changes in diet and weight loss improves insulin resistance and vascular disease
Calories appropriate to needs Decreased saturated fat red meats Nothing magic about low carb diet
ADA diet AHA diet ACS diet
Exercise for Heart Health
Regular Moderate Incorporated Into your Lifestyle Improves insulin resistance and heart disease risk
6
Prevent complications
Glucose control fasting 120 and rest of day 150 mg/dl: A1C every 3 months and 6 or at least 7 BP control: goal
130/80 mm Hg, treatment should include ACE or ARB medication Stop smoking LDL bad cholesterol 100 mg/dl; check each year Aspirin a day, Flu shot each fall Foot care: Check for dryness, evidence of injury; every infection is an emergency; 50 amputations are preventable Dilated eye exam each year would prevent 90 blindness
Risk of Diabetes Complications Vary with Ethnic Group
Diabetic retinopathy
More common in African-Americans
Diabetic nephropathy
More common in African-Americans, Latinos, Native Americans
Diabetic vascular disease: heart failure and stroke
More common in African-Americans
Why are complications different between races or ethnic groups?
Gene polymorphisms Behaviors are different eg, smoking frequency, dietary salt intake, obesity Access to medical care or education are different Stress of life greater Options presented or the persons response to the options presented by their health provider are different
7
Diabetes Prevention Program: 1 Lifestyle Exercise and 7 weight loss vs 2 2 Metformin vs 3 Control over 28 y
Placebo
Control
Diabetes 28
Metformin Lifestyle Lifestyle
Diabetes 58
Diabetes Prevention Program Research Group et al, N Engl
J Med 2002; 346:393-403
Diabetes Prevention Program: Risk Reduction By Race-Ethnicity
African Caucasian American N1768 N645 0 Hispanic N508 American Indian N171 Asian N142
-20
Percent Reduction Vs Placebo
-40
-60
Lifestyle Metformin
-80
Includes Pacific Islanders N 20 Adapted from DPP Research Group N Engl J Med 2002;346:393-403
Preventing diabetes complications How are we doing in Nebraska?
BP every visit 100 BP 130/80 mm Hg 50140/90 A1C: Every 3-6 months 85 had 1/yr A1C 7 normal 6 53 8 Foot exam at least annually 71 recorded in last year Annual dilated eye exam 57 Annual urine albumin/creatinine ratio 10 Fasting lipids each year 65 had a total cholesterol only LDL bad cholesterol 100 mg/dl 43 had LDL130
HMO Nebraska 1998 data
8
Summary
What is diabetes? A disease where insulin is either not made antibody destruction or doesnt work type 2 Are there disparities in diabetes risk and outcomes among racial or ethnic groups? Yes If so, why? Multiple answers-genes, behaviors, cultural traditions, covert racism or distrust, access to care What are we doing about it? Educate patients and providers to prevent diabetes and its complications Racial differences are
not an excuse
Summary
Diabetes is common and risk depends in part on ethnic or racial heritage Diabetes frequency is increasing in part because of obesity; weight loss can prevent diabetes Diabetes complications can be prevented with specific medications or target goals Ethnic heritage does not mean you have to suffer the consequences of diabetes
9
Source:maine.gov
