The Science Diabetes Control

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  • 1. The Science: Diabetes Control The National Diabetes Education Program Changing the Way Diabetes is Treated.
  • 2. What is Diabetes?
    • Diabetes is a group of diseases characterized by high levels of blood glucose (blood sugar)
    • Diabetes can lead to serious health problems and premature death
    • About 24 million Americans have diabetes
    NIDDK, National Diabetes Statistics 2007. www.diabetes.niddk.nih.gov/dm/pubs/statistics/
  • 3. Common Types of Diabetes
    • Type 1 diabetes
      • 5% to 10% of diagnosed cases of diabetes
    • Type 2 diabetes
      • 90% to 95% diagnosed cases of diabetes
    NIDDK, National Diabetes Statistics 2007. www.diabetes.niddk.nih.gov/dm/pubs/statistics/
  • 4. Common Types of Diabetes
    • Gestational Diabetes occurs during pregnancy
      • 5 to 10 % of women with gestational diabetes are found to have type 2 diabetes
      • Increased lifelong risk for mother and child for developing type 2 diabetes
      • 40-60 % women with gestational diabetes will develop diabetes in the next 5 to 10 years
    NIDDK, National Diabetes Statistics 2007. www.diabetes.niddk.nih.gov/dm/pubs/statistics/
  • 5. Risk Factors for Diabetes
    • Age 45 and older
    • Overweight (BMI ≥ 25)
    • Hypertension
    • Abnormal lipid levels
    • Family history of diabetes
    • Race/ethnicity
    • History of gestational diabetes
    • History of vascular disease
    • Signs of insulin resistance
      • (such as PCOS or acanthosis nigricans)
    • IGT or IFG on previous test
    • Inactive lifestyle
    American Diabetes Association. Diabetes Care 2008; 31;(Suppl.1):S12-54.
  • 6. Diabetes and Cardiovascular Disease
    • Cardiovascular disease is the leading cause of death for people with diabetes
    • In adults with diabetes:
      • 68% die of heart disease or stroke
      • the risk for stroke is two to four times higher
      • 75% have high blood pressure
      • smoking doubles the risk for heart disease
    NIDDK, National Diabetes Statistics 2007. www.diabetes.niddk.nih.gov/dm/pubs/statistics/
  • 7. Diabetes Complications
    • Diabetes is the leading cause of:
      • kidney failure
      • new cases of adult blindness
      • nontraumatic lower-limb amputations
    • In adults with diabetes:
      • the risk of periodontal (gum) disease is two to three times higher
      • 60 to 70 % have mild to severe nervous system damage
    NIDDK, National Diabetes Statistics 2007. www.diabetes.niddk.nih.gov/dm/pubs/statistics/
  • 8. Diabetes Control and Complications Trial (DCCT)
    • Compared effects of two diabetes treatment regimens – standard therapy and intensive control – on the complications of diabetes in people with type 1 diabetes
    DCCT. New England Journal of Medicine, 329(14), September 30, 1993.
  • 9. Glucose control is key to preventing or delaying complications of diabetes Any sustained lowering of blood glucose helps , even if the person has a history of poor control DCCT Findings DCCT. New England Journal of Medicine, 329(14), September 30, 1993.
  • 10. DCCT Findings
    • Lowering blood glucose reduced risk of:
    • Eye disease by 76%
    • Kidney disease by 50%
    • Nerve disease by 60%
    DCCT. New England Journal of Medicine, 329(14), September 30, 1993.
  • 11. United Kingdom Prospective Diabetes Study (UKPDS)
    • Clinical Trial
    • Looked at intensive management of blood glucose levels and long term risk-factors for diabetes complications in type 2 diabetes
    UKPDS. BMJ. 2000; 321:405-412.
  • 12. Mirrored the findings of DCCT in people with type 2 diabetes—better glucose control reduced development of microvascular complications Demonstrated the need for management of high blood pressure and cholesterol as well as blood glucose levels (the ABCs of diabetes) UKPDS Findings UKPDS. BMJ. 2000; 321:405-412.
  • 13. UKPDS Findings Stratton IM, et al. BMJ . 2000;321:405-412. P <.0001 P = .035 P = .021 P = .0001 Risk reduction with 1% decline in annual mean A1C 0% 15% 30% 45% Micro-vascular Disease 37% PVD 43% Stroke MI 14% 12% Heart Failure Cataract Extraction 16% 19%
  • 14. Epidemiology of Diabetes Interventions and Complications Study (EDIC)
    • Observational study
    • DCCT participants (type 1 diabetes)
    • Looked at risk factors for long-term complications
    DCCT/EDIC N Engl J Med 2005: 353:2643-2653.
  • 15.
      • Participants continue to benefit years later from period of intense glucose control
      • Years after intensive therapy:
        • Lasting benefits for eye, nerve, and kidney disease
        • Reduces CVD events by more than half
    EDIC Findings: Intensive Therapy and Diabetes Complications DCCT/EDIC N Engl J Med 2005: 353:2643-2653.
  • 16. Cumulative Incidence Years from Study Entry EDIC Findings: Cardiovascular Events Cumulative Incidence of First of Any Event 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Risk reduction 42% 95% CI: 9% to 63% P = 0.02 0.12 0.10 0.08 0.06 0.04 0.02 0.00 Conventional Intensive DCCT/EDIC N Engl J Med 2005: 353:2643-2653.
  • 17. Conventional Intensive Non-Fatal MI, Stroke, or CVD Death EDIC Findings: Cardiovascular Events 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Years from Study Entry 0.00 0.02 0.04 0.06 0.08 0.10 0.12 Cumulative Incidence Risk reduction 57% 95% CI: 12% to 79% P = 0.02 DCCT/EDIC N Engl J Med 2005: 353:2643-2653.
  • 18. UKPDS 10 yr Follow-Up Study- insulin/sulfonylurea group
    • Differences in A1C between intensive & standard glycemic control treatment groups were lost after one year
    • Relative risk reductions at 10 yr in intensive insulin/sulfonylurea group:
      • 9% for any diabetes end point (P=0.04)
      • 24% microvascular disease (P=0.001)
      • 15% myocardial infarction (P=0.01)
      • 13% death from any cause (P=0.007)
    N Engl J Med 2008; 359
  • 19. UKPDS 10 yr Follow-Up Study- metformin group
    • Differences in A1C between intensive & standard glycemic control treatment groups were lost after one year
    • Relative risk reductions at 10 yr in intensive
    • metformin group:
      • 21% for any diabetes end point (P=0.01)
      • 33% myocardial infarction (P=0.005)
      • 21% death from any cause (P=0.002)
    N Engl J Med 2008; 359
  • 20. UKPDS 10 yr Follow-Up Study- Blood Pressure findings
    • Between group differences lost within 2 yrs
    • Significant relative risk reductions in tight control group were not maintained
    • Benefits of BP control do not extend beyond intensive therapy period & ongoing treatment is essential
    N Engl J Med 2008; 359
  • 21. Recent Clinical Trial Findings:
    • Intensive glucose control in type 2 diabetes:
    • lowers risk of new or worsening microvascular complications (ADVANCE)
    • was associated with increased mortality in patients with longstanding DM and known CVD (ACCORD)
    • increases risk of severe hypoglycemia (ADVANCE, ACCORD and VADT)
    ACCORD: N Engl J Med 2008; 358(24):2545-59 ADVANCE: N Engl J Med 2008; 358 (24): 2560-72 VADT: J Diabetes Complications 2003; 17 (6): 314-22
  • 22. Key points of recent findings:
    • Intensive glucose control in newly diagnosed type 1 or type 2 diabetes has benefits during intensive therapy AND a legacy effect for later micro- and macrovascular benefits
    • Optimal glucose management should start as early as possible & continue as long as possible
    • While the A1C goal for the general population is <7%, treatment must be individualized.
    N Engl J Med 2008; 359
  • 23. SEARCH For Diabetes in Youth Study
    • Observational study
    • Physician-diagnosed diabetes in youth ages 0-19
    • Data will help researchers better understand and treat diabetes in young people
    (SEARCH) . Diabetes Care 2006 29(8): 1891-6.
  • 24. SEARCH Findings
    • Determine prevalence and correlates of selected CVD risk factors among youth with diabetes
    • 21% of young people with diabetes had at least two CVD risk factors
    • Prevalence of CVD risk factors was higher among youth aged 10-19 years and among girls
    (SEARCH) . Diabetes Care 2006 29(8): 1891-6.
  • 25. SEARCH Findings
    • In young people with type 2 diabetes:
      • 92% had at least two CVD risk factors
    • In young people with type 1 diabetes:
      • 14% had at least two CVD risk factors
    (SEARCH) . Diabetes Care 2006 29(8): 1891-6.
  • 26. National Diabetes Education Program Materials
  • 27. Diabetes Control: Patient Materials
  • 28. Diabetes Control: Health Care Professionals
  • 29. NDEP Websites
  • 30. Other NDEP Campaign Tools at www.YourDiabetesInfo.org
    • TV, radio, and print PSAs
    • Sample feature articles
    • Sample press releases and media advisories
    • Fact sheets
    • Web buttons/blurbs
    • NDEP logos and banners
  • 31.
      • For more information about NDEP and to order or download free materials:
    • Call 1-888-693-NDEP
    • or
    • Visit www.YourDiabetesInfo.org
    The U.S. Department of Health and Human Services’ National Diabetes Education Program is jointly sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention with the support of more than 200 partner organizations.