Provide information on the diabetes epidemic in the people with diabetes in Latin America and the Caribbean the primary prevention of diabetes and its …
Diabetes in the Americas
Alberto Barcelo, MD, MSc Pan American Health Organization, Washington DC
Never have doctors known so much about how to prevent and control this disease, yet the epidemic keeps on raging
Christine Gorman Time Nov 30, 2003
Objectives:
Provide information on the diabetes epidemic in the Americas Present data on the increased risk for CVD among people with diabetes in Latin America and the Caribbean Multi country data, SABE, CAMDI Rationale for the primary prevention of diabetes and its implication for health policy
The Prevalence of Type 2 Diabetes is reaching epidemic proportion
Diabetes in the World: WHO Projections
Millions
350 300 250 200 150 100 50 0 1985 1995 2005 2015 2025
Estimated prevalence of diabetes in the Americas, 2000-2025
PREVALENCE 31 40 41- 50 51- 60 61- 82 83-122
2000: 35 million
2025: 64 Million
Reference: King H, Aubert RE, Herman WH Global Burden of Diabetes, 1995-2025 Diabetes Care 1998;21:1414-1431
Prevalence of Diabetes Among Adults in the US, BRFSS, 19931994
4
46
6
Mohkdad, JAMA 2001
Prevalence of Diabetes Among Adults in the US, BRFSS, 1999
4
Mohkdad, JAMA 2001
46
6
Prevalence of Diabetes Among Adults in the
US, BRFSS, 2000
4
46
6
Mohkdad, JAMA 2001
Age-Adjusted Prevalence of Diabetes in the Americas, 1976-91
25 20 15 10 5 0
Ba rb ad o Ms ex Tr ic o in id ad US /T A ob ag Ja o m ai ca C Su uba ri na m Bo e l C ivia ol om bi a Br az A rg i en l U rb tin an a Pe Pa ru ra gu ay C hi le
Pan American Health Organization, 2001
Adjusted to the World Population
Diagnosed Diabetes Mellitus in Puerto Rico
101 109
51 35 4
1976
1980
1986
1995
2000
Sources: Haddock et al, 1991; Ríos et al, 2001
Glucose Intolerance in a Health Area of Havana, Cuba 1971 and 1998
236 84
33 51 1971 1998 Pre-Diabetes Diabetes 92
144
Source: Diaz-Diaz et al, 2000
Between a half and a third of those suffering diabetes are not aware of their condition
Diagnosed and Undiagnosed Prevalence of Diabetes by Age in the US NHANES III
Men Women
25
Prevalence
20 15 10 5 0
20-39 40-49 50-59 60-74 75 20-39 40-49 50-59 60-74 75 Age Groups
Undiagnosed Diagnosed
Harris et al, Diabetes Care, 1998
Obesity in Children
The percent of children 0-5 with over nutrition in LAC has increased over the years
12 105 10 8 6 6 4 2 0 Dominica St Kitts 97 71 1990 1999
Weight-for-height Z-score more than 20
Source: CFNI,
2001
People with Diabetes Present an increased Risk for CVD and Premature Mortality
Diabetes-Related Mortality
Mortality among people with diabetes 25 times higher
UNDERLYING ANY CAUSE
Latin America the Caribbean
40,000
300,000
Diabetes Related Mortality
Percent
Rate X100,000
13
8
12
2
Dominica
Underlying Any Cause
Costa Rica
Source: PAHO, CPC, 2000 Dominica; Rodríguez 1988, Revista Costarricense de Ciencia Medicas Costa Rica
Mortality Trend in Chile Heart Diseases
Diabetes
Stroke
Diabetes Complications Lifetime Risk Long-term Complications Neuropathy Nephropathy Heart Diseases End Stage Renal Disease Blindness Stroke 44 38 25 15 12 12
CDC Cost-Effectiveness Group, 2002
Awareness, treatment and control of hypertension among people with diabetes in the US and Latin America
100 80 60 40 20 0
US Whites Controlled US Blacks Uncontrolled Chile Untreated Bolivia Unknown
Legend: Hypertension under treatment, SBP140 and DBP90, Hypertension under treatment, SBP139 and DBP89, Diagnosed not treated hypertension, Newly diagnosed hypertension Source:23, unpublished data Chile and Bolivia
The SABE Project Salud Bienestar y Envejecimiento
Cluster sampling design of
elderly 60 years 10,891 participants from Bridgetown, Sao Paulo, Santiago de Chile, Havana, Mexico City and Montevideo Self-reported prevalence of major NCDs
Prevalence of hypertension am ong th 
e elderly w ith and w ithout diabetes in seven countries
Prevalence of stroke among the elderly with and without diabetes in seven countries
Montevideo Mexico City Havana Santiago Sao Paulo Bridgetown Buenos Aires
0 10 20 30 40 50 60 70 80
Montevideo Mexico City Havana Santiago Sao Paulo Bridgetown Buenos Aires
0 2 4 6 8 10 12 14
With diabetes
Without diabetes
With diabetes
Without diabetes
Prevalence of heart diseases among the elderly with and without diabetes in seven countries
Montevideo Mexico City Havana Santiago Sao Paulo Bridgetown Buenos Aires
0 5 10 15 20 25 30 35 40 45
With diabetes
Without diabetes
THE CENTRAL AMERICA DIABETES INITIATIVE: COSTA RICA, EL SALVADOR, HONDURAS, GUATEMALA NICARAGUA
Multinational survey on diabetes, hypertension and other CVD risk factors
Diagnosis of diabetes Fasting plasma glucose 126 mg/dl and 2-h post glucose load 200 mg/dl 8,000 Participants from Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama
Glucose
tolerance in Guatemala, 2003
108
41
IGT New DM
43
Diag DM
Diagnosed and Undiagnosed Diabetes and Hypertension in Villa Nueva, Guatemala City, 2003
4
Percent
8 5 3 4 4 10
4
DM Males
DM Female Known
HTA Males
HTA Females
Newly Diag
CVD Risk Factors among people with and without DM, Guatemala 2003
Lack of Exercise High Cholesterol
9 23 49 55
Obesity
20 34
HTN
11 39
With DM
Without DM
Burden of Diabetes Burden of Diabetes
Today
TIME
How can we stop or slow down the the diabetes
?
Rationale for Primary Prevention
oScientific oEconomic
Stages in the natural history of Type 2 diabetes
Normal
Genetic predisposition
IGT
Preclinical state
Type 2 DM
Clinical disease
Complications
Disability Death
Complications
Disability Death
Primary prevention
Secondary prevention
Tertiary prevention
What is the
Major Studies
Da Qing IGT and Diabetes Study, China Diabetes Prevention Study, Finland Diabetes Prevention Program, USA STOP NIDDM, Europe, Canada Troglitazone in the Prevention of Diabetes TRIPOD, USA
Benefits
Study Da Qing DPS DPP Stop NIDDM TRIPOD Reduction in risk Lifestyle Drug 31-46 58 58 31 25 55
What are the current policy
recommendations?
American Diabetes Association Prediabetes: Opportunistic screening for IGT or IFG: 45 yrs Emphasis on those with BMI 25 Consider others if are overweight with risk factors
ADA Position Statement Diabetes Care 2004;27:S47
What are the current policy recommendations?
IDF IGT/IFG Consensus Statement Report of an Expert Consensus Workshop IGT or IFG should receive lifestyle advice If lifestyle fails, consider drugs Target those at highest risk for DM and CVD
Unwin N et al Diabetic Medicine 2002;19:708
What are the current policy recommendations?
Finnish National Policy Prediction models for future risk Use fewer screening tests Tailor to the individuals level of risk
Lindstrom J Diabetes Care 2003;26:725
Diabetes and Hypertension Screening in Mexico
The Primary Prevention of DM in the Americas lifetime horizon
Population at risk 45-64 years: 125,600,974 Type 2 DM New Cases per Year: 1,117,773 Potentially Preventable: 550,813 Needed to Include in Prevention Program : 3,760,676
DM Type 2 Primary Prevention: Future Savings
Gain QALYs: 5,444,194 YPLL Saved: 57,941,304,589 Saving in Direct Medical care : 37,534,686,912 Total Savings:
95,475,991,501
Conclusion
Although there is limited data on the prevalence of diabetes and major CVD in LAC, the available information indicates that the prevalence of DM is increasing There is evidence that type 2 DM and some of its complications can be prevented
Conclusion
In view of the burden that diabetes represents to people and society there is a need to commence primary prevention strategies as well as improve diabetes management
