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    Ncd2014 diabetes prevention_110314_jaana_lindström Ncd2014 diabetes prevention_110314_jaana_lindström Presentation Transcript

    • PREVENTION OF TYPE 2 DIABETES Jaana Lindström PhD, Adjunct professor, Head of Unit Diabetes Prevention Unit Department of Chronic Diseases Prevention National Institute for Health and Welfare Helsinki, Finland 11.3.2014
    • 2 OUTLINE: • Epidemiology of type 2 diabetes • Prevention of type 2 diabetes: Clinical evidence ”Are we doing the right things?” • Real-world implementation: Effectiveness trials “Are we doing the things right?” Outline
    • 3 Diagnosing diabetes and ”pre-diabetes”: WHO 1999 criteria and ADA 2003 criteria* Plasma venous glucose concentration, mmol/l ADA 2010 Diabetes: +HbA1c >6.5% Pre-diabetes: +HbA1c 5.7-6.4% *Cut-off points based on manifestation of micro-vascular complications retinopathy and nephropathy
    • 4 Development of type 2 diabetes Prediabetes Diabetes Blood glucose Microvascular complications Macrovascular complications
    • 5 Clinical diagnosis of T2DM Without symptoms: - High fasting or 2h value - Diagnosis must be confirmed on separate day With symptoms: - One high value Peltonen et al. Suomen Lääkärilehti 3/2006 vsk 61:163- www.kaypahoito.fi Measuring only fasting value is not enough: f-gluc>7.0 2h-gluc>11.1
    • 6 Retinopathy Leading cause of adult blindness1 Nefropathy Leading cause of kidney disease2 Stroke 2 – 4x increased risk3 Neuropathy Leading cause for lower limb amputations5 Cardiovascular diseases 75% of diabetics die of CVD event4 1. Fong DS, et al. Diabetes Care 2003; 26 (Supplement 1):S99–S102. 2. Molitch ME, et al. Diabetes Care 2003; 26 (Supplement 1):S94–S98. 3. Kannel WB, et al. Am Heart J 1990; 120:672–676. 4. Gray RP & Yudkin JS. Chapter 57, Textbook of Diabetes, 1997; Edited by JC Pickup & G Williams. Blackwell Sciences Ltd. 5. Mayfield JA, et al. Diabetes Care 2003; 26 (Supplement 1):S78–S79. Micro- and macrovascular complications of diabetes Periferal vascular disease Leading cause for revascularisations and lower linb amputations Microvascular Macrovascular Dementia
    • 7 Epidemiology: Diabetes trends in Finland 0 100 000 200 000 300 000 400 000 500 000 600 000 1960 1970 1980 1990 2000 2010 2020 Total estimate Numberofdiabetics 0 5 10 15 Prevalenceinpopulationsurveys,% Population surveys Finrisk1987 Finrisk1992 Health2000 Finrisk2002 D2D2004 Drug register Puska et.al. Yleislääkärilehti 2008;2:11-3
    • 8 Cost of diabetes treatment in 2007 • Type 2 diabetes without complications 1 300 eur • Type 2 diabetes with complications 5 700 eur • In the long run, the costs related to loss of productivity due to diabetes (e.g. cost of early retirement) are 1,5x medical costs Source: Jarvala et al. Diabeteksen kustannukset Suomessa 1998-2007 - tutkimus, Dehko.
    • United Kingdom Prospective Diabetes Study (UKPDS) Extrapolation of the time of deterioration of pancreatic beta cell dysfunction Adapted from UKPDS 16. Diabetes 1995 0 20 40 60 80 100 Years from diagnosis of diabetes Betacellfunction(%) –10 –8 –6 –4 –2 0 2 4 6–12 Clinical Diagnosis 
    • 13/03/2014 10 Development of type 2 diabetes ASYMPTOMATIC DIABETES SYMPTOMATIC DIABETES IMPAIRED GLUCOSE TOLERANCE GENES ENVIRONMENT Insulin resistance >10YEARS Normal 10 years IGT DM Beta cell defect
    • 11 OUTLINE: • Epidemiology of type 2 diabetes • Prevention of type 2 diabetes: clinical evidence • Real-world implementation: Effectiveness trials Outline
    • Type 2 diabetes risk factors Risk markers • Age • Family history • Ethnicity • Metabolic syndrome • Low birth weight • Gestational diabetes • Delivery of macrosomic baby • Previous CVD • Polycystic ovary syndrome PCOS • Non-alcoholic fatty liver disease NAFLD Modifiable risk factors • Overweight / obesity • Abdominal obesity • Low physical activity • Smoking • Unhealthy diet Possible modifiable risk factors • Sleep deprivation • Distress and depression • Environmental pollutants • Intestinal bacterial flora
    • 13/03/2014 Esityksen nimi / Tekijä 13 The Finnish Diabetes Prevention Study (DPS) 1993-2012 Tuomilehto et al. N Engl J Med 2001; 344:1343-1350 • The main aim: to determine whether lifestyle intervention of men and women with impaired glucose tolerance (IGT) will prevent or delay the development of type 2 diabetes • Multicenter trial in 5 clinics in different parts of Finland • 522 volunteer participants randomly allocated into intensive diet and physical activity intervention or control (standard) treatment • Annual clinical and laboratory examination • An efficacy trial – does prevention work in ”optimal setting”
    • 13/03/2014 Esityksen nimi / Tekijä 14 • Weight reduction > 5% • Fat intake <30% of total energy • Saturated fat intake <10% of total energy • Dietary fibre > 15 g/1000 kcal • Aerobic and muscle strengthening physical activity > 30 min/day DPS: Lifestyle goals Lindström et al. Diabetes Care 2003; 26:3230-3236 Diet and physical activity in line with the general recommendations – no ”special diet”
    • 13/03/2014 Esityksen nimi / Tekijä 15 7 face-to-face counselling sessions during the 1st year, every three months thereafter Increase all physical activity Dietary counselling based on food diaries:  Regular meal pattern  Whole grains instead of refined grains  Daily abundant consumption of fruit and vegetables  Vegetable oils and margarines in moderation  Substitute energy-dense foods containing saturated fat, sugar, or alcohol with lower-energy items  ‘The plate model' to estimate portion sizes National Nutritional Council 1999 DPS: Lifestyle counselling was practical, continuing, interactive, and individualised Lindström et al. Diabetes Care 2003; 26:3230-3236
    • 13/03/2014 Esityksen nimi / Tekijä 16 ESIMERKKI: KTL DPS/2001 Nimi: Maija Malli PUH: 09-123456 PVM: 21.9.2001 viikonpäivä: perjantai oliko päivä tavallinen___ vai poikkeava, miten? Söin illalla ravintolassa AIKA PAIKKA RUOAT JA JUOMAT (LAATU JA VALMISTUSTAPA) SYÖTY MÄÄRÄ GRAMMOINA 7.10 KOTI KAURAPUUROA (VETEEN KEITETTY) 230 YKKÖSMAITOA 150 VOITA (PUURON SILMÄKSI) 10 KAHVIA (SUODATIN) 170 SOKERIA (TAVALLISTA PALASOKERIA) 2 PALAA KUOHUKERMAA 15 KORVAPUUSTI (TAIKINASSA KULUTUSMAITOA 50 JA SUNNUNTAI-LEIVONTAMARGARIINIA) 12.30 KOTI JAUHELIHAPIHVEJÄ (SAARIOINEN, MIKROSSA) 85 RUSKEAA KASTIKETTA (VOIHIN TEHTY) 100 PERUNOITA (KEITETTY KUORINEEN) 210 PORKKANARAASTETTA 60 ÖLJYKASTIKETTA (VIINIETIKKAA JA RYPSI- 15 ÖLJYÄ 1:3) KAURALEIPÄÄ (FAZERIN KAURAPUIKULA) 1 VIIPALE FLORAA (60% RASVAA, LAKTOOSITON) 6 VANILJAKERMAJÄÄTELÖÄ 125 KINUSKIKASTIKETTA (VALIO) 30 KAHVIA 110 KUOHUKERMAA 10 SOKERIA 1 PALA 15.00 NAAPU- OMENOITA (KOTIMAISIA, PIENIÄ) 2 KPL 2 X 70 RISSA JNE. My goals: 1_________________ 2_________________ 3_________________ Weight chart 90 92 94 96 98 100 102 104 106 108 110 0 3 6 9 12 15 18 21 24 27 30 33 36 Month kg DPS: Tools for information, self- monitoring and goal-setting Food Diary
    • Esityksen nimi / Tekijä 17 DPS: Diabetes incidence was 58% lower among the intervention group compared with the control group after mean follow-up of 3,2 years HR • Weight reduction > 5% • Moderate fat <30 E% • Low saturated fat <10 E% • High fibre >15g/1000kcal • Physical activity >30 min / day Tuomilehto et al. N Engl J Med 2001; 344:1343-1350 Cumulativeincidenceofdiabetes
    • 18 Log-rank test: p<0.001 Incidence rates: Intervention: 4.5 (95% CI 3.8-5.5), Control: 7.2 (95% CI 6.1-8.5) Hazard ratio=0.61 (95% CI 0.48-0.79), p<0.001 Adjusted hazard ratio=0.59 (95% CI 0.46-0.76), p<0.0010.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Estimateofprobabilityofremainingfreeofdiabetes 251 209 158 120 63 6Control 261 238 193 158 83 10Intervention Number at risk 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Follow-up time, years Intervention (106 events) Control (140 events) Adjusted HR: Adjusted for sex, age, 2h glucose and BMI at baseline. Diabetes incidence was 39% lower among the intervention group compared with the control group over 13 years* *median follow-up of 9 years Lindström et al. Diabetologia. 2012 Oct 24. Intervention Diabetes postponed by 5 years!
    • 13/03/2014 Esityksen nimi / Tekijä 19 Log-rank test: p=0.031 Incidence rates: Intervention: 4.9 (95% CI 3.8-6.3), Control: 7.0 (95% CI 5.5-8.9) Hazard ratio=0.69 (95% CI 0.49-0.97), p=0.031 Adjusted hazard ratio=0.67 (95% CI 0.48-0.94), p=0.0190.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Estimateofprobabilityofremainingfreeofdiabetes 185 138 103 32Control 221 172 138 57Intervention Number at risk 0 1 2 3 4 5 6 7 8 9 Follow-up time, years Intervention (62 events) Control (68 events) Adjusted HR: Adjusted for sex, age, 2h glucose and BMI at baseline. DPS: Diabetes incidence was 33% lower among the former intervention group compared with the former control group Lindström et al. Diabetologia. 2012 Oct 24. Intervention
    • 13/03/2014 Esityksen nimi / Tekijä 20 Changes in body weight in the DPS study -6 -5 -4 -3 -2 -1 0 1 2 Changeinbodyweight,% 0 1 2 3 4 5 6 7 8 9 10 Follow-up time, years Control Intervention Lindström et al. Diabetologia. 2012 Oct 24. Intervention
    • 13/03/2014 Esityksen nimi / Tekijä 21 The DPS: The more goals achieved, the lower the risk! HR Goals at year 3; incidence during 13 years time-span Adjusted for baseline age, bmi, 2h-glucose and sex 0 0,1 0,2 0,3 0,4 0,5 0,6 0,7 0,8 0,9 1 0 1 2 3 4 5 Number of goals achieved Hazardratio • Weight reduction > 5% • Moderate fat <30 E% • Low saturated fat <10 E% • High fibre >15g/1000kcal • Physical activity >30 min /day Lindström et al. Diabetologia. 2012 Oct 24.
    • 13/03/2014 Esityksen nimi / Tekijä 22 DPS: Diabetes incidence by weight change at year 1 HR=0.59 HR=0.76 HR=0.38 HR=1.59 reference p=0.000 Adjusted for age, sex, and baseline BMI 20/02/2014 22
    • 20/02/2014 23 DPS: Diet and physical activity by 1-year weight change (%) categories Total fat intake 28 30 32 34 36 38 40 0 0,5 1 1,5 2 2,5 3 Year E% Saturated fat intake 10 12 14 16 18 20 0 0,5 1 1,5 2 2,5 3 Year E% Total fibre intake 10 12 14 16 18 0 0,5 1 1,5 2 2,5 3 Year g/1000kcal Change in physical activity -2 -1 0 1 2 3 4 0 0,5 1 1,5 2 2,5 3 Year hours/week
    • 25 OUTLINE: • Epidemiology of type 2 diabetes • Prevention of type 2 diabetes: clinical evidence • Real-world implementation: Effectiveness trials Outline
    • 13/03/2014 Esityksen nimi / Tekijä 26 National diabetes programme DEHKO 2000-2010 → implementation project FIN-D2D 2003-2010 • Total population of Finland: ~5,2 million • 20 hospital districts; 348 municipalities • 5 hospital districts chose to participate in FIN-D2D: • ~110 health centres in municipalities • ~110 municipal occupational health care providers • ~100 private occupational health care providers • Target population ~1,5 million
    • 13/03/2014 Esityksen nimi / Tekijä 27 • Assess the feasibility of a diabetes prevention programme based on the DPS within primary health care in Finland • Increase awareness of the risks of obesity and diabetes • Make screening, diagnosis and interventions part of every-day work of primary health care • Create new models and practices for prevention of diabetes and obesity FIN-D2D: Main aims
    • 13/03/2014 Esityksen nimi / Tekijä 28 28 Screening individuals at high risk for T2DM (opportunistic or targeted screening) Referring screen positive individuals to OGTT in order to detect undiagnosed T2DM Starting lifestyle interventions in high risk individuals FIN-D2D High risk strategy in practice
    • 29 AIM: To develop a simple, cheap and reliable way to identify people at high risk of type 2 diabetes in the general population which does not require: • blood drawing • other measurements by trained personnel • medical equipment How to identify high-risk individuals? The Finnish Diabetes Risk Score FINDRISC Lindström et al. Diabetes Care 2003;26:725-31
    • 13/03/2014 Esityksen nimi / Tekijä 30 Identification of high-risk individuals: The FINDRISC: • Age • BMI • Waist • Physical activity • Nutrition (f+v) • Hypertension • Hyperglycaemia • Family history www.diabetes.fi Lindström et al. Diabetes Care 2003
    • 13/03/2014 Esityksen nimi / Tekijä 31 FIN-D2D: Interventions Identification of high-risk subjects: -Opportunistic screening - Health check- ups - Pharmacies - Media - Campaigns 1. Visit (nurse) - Questionnaires (PA, diet, stage of change) - Blood tests 2. Visit (physician – if needed) Group intervention Individual intervention Self-initiated lifestyle changes Other Intervention forms Yearly follow-ups Primary health care or other players: Weight control groups Quit smoking-groups Exercise groups Self-activity groups Regular healthcare visits
    • 13/03/2014 Esityksen nimi / Tekijä 32 FIN-D2D: Positive experiences • Models of lifestyle intervention proven feasible in primary health care • 20 000 people with moderate or high diabetes risk identified and participated in interventions • Screening and risk assessment became part of daily practice: – The FINDRISC – OGTT testing increased x3 – Waist circumference measurement • Treatment paths built and health promotion units were established in all participating hospital districts • Collaboration – Hospital districts, municipalities, health care centres, occupational health care, NGOs, pharmacies, research organizations – Multi-professional team work • Nationwide recognition and increased awareness of obesity and diabetes problem
    • 33 n= 10 149 (women 67 %) Follow-up information n= 5 523 (54,4 %) Follow-up within 9-18 months n= 3 880 Saaristo et al. Diabetes Care 2010 1-year follow-up n=2 798 - No baseline OGTT n= 638 - Diabetes at baseline n= 444 Intervention offered FIN-D2D: High-risk cohort results -32% no intervention/self-help -35% individual only - 9% group only - 7% individual+group - 18% mode not known 20/02/2014 33
    • 13/03/2014 Esityksen nimi / Tekijä 34 FIN-D2D: Lifestyle intervention results • Majority of the participants chose individual lifestyle counselling instead of group counselling – No strong tradition for group activities (neither among caregivers nor clients) – Would require changes in models of care, e.g. invitations based on patient register search and evening classes • Mean number of intervention visits was 2,9 • Mean 1-year weight reduction was 1,2 kg • 17% lost more than 5%
    • 13/03/2014 Esityksen nimi / Tekijä 35 FIN-D2D: 1-year weight change by number of intervention visits Suomen Lääkärilehti 26-31, 2010 Increased >2,5% No change Reduced 2,4-4,9% Reduced <5% Weight change 0 2 3 4-1Number of visits
    • 13/03/2014 Esityksen nimi / Tekijä 36 FIN-D2D: 1-year diabetes incidence* and relative risk by weight change 0 1 2 3 4 5 6 7 8 >5% reduction 2,5-4,9% reduction No change >2,5% increase Saaristo et al. Diabetes Care 2010 Diabetesincidence(%) -69 % -29 % +10 % Ref RR *Age-adjusted
    • 13/03/2014 Esityksen nimi / Tekijä 37 FIN-D2D results projected to whole Finland: what if… DM-risk 260 000 DM 140 000No DM risk 260 000 670 000 BMI >30 kg/m2 (18-64 yrs.) Weight increase/no change DM 19 000 / year Weight reduction > 2.5% DM 6 000 /year DM 7,4 %/year DM 2,3 %/year Sane et al. Unpublished (50 % no dg.)
    • 13/03/2014 Esityksen nimi / Tekijä 38 Gender and SES issues? • 33% of the participants were men – partly because women had more screening opportunities • Those with lower education as well as manual workers were slightly overrepresented, as compared to Finnish general population • Socioeconomic position did not have any impact on the effectiveness of lifestyle intervention Rautio et al. BMC Scand J Publ Health 2011
    • 20/02/2014 39 Screening and Prevention of Type 2 Diabetes in a Finnish Airline Company The project 2006-2011
    • Screening and Prevention of Type 2 Diabetes in a Finnish Airline Company: The FINNAIR project 2006-2011 • Type 2 diabetes (T2D) is an emerging health problem among active workforce • Shift work and sleep disturbances increase the risk of T2D • Of the 7500 Finnair employees, 70% work in shifts The aims • To test the feasibility of risk screening and preventive interventions in occupational health care setting • To assess the prevalence of glucose metabolism disorders among workers with varying working hours in an airline company 4020/02/2014
    • Screening and lifestyle intervention 41 •FINDRISC risk score •f-gluc •n=2312 Low risk (70%): brief counselling Moderate or high risk (30%): •brief counselling •invitation to further counselling Individual (x1) and group counselling (x5) in work place • 60% of those invited participated in lifestyle counselling  • Group counselling was discontinued after first year due to very low attendance  20/02/2014
    • Follow-up results • 1485 (64%) employees participated in the follow-up health check-up – Mean follow-up time 2,5 years – Men 54% – Shift workers 61% – Average age 42.6 • Both men and women gained weight during the follow-up: men 0.4 kg and women 1.4 kg
    • -2 -1 0 1 2 Change in weight (kg) Low diabetes risk Increased diabetes risk Body weight change during the follow-up period among men *** Men
    • 0 2 4 6 8 10 12 14 16 18 20 Weight loss >5%, % Low diabetes risk Increased diabetes risk without intervention Increased diabetes risk with intervention Weight loss >5% during the follow-up period among men Men
    • 13/03/2014 Esityksen nimi / Tekijä 45 • Type 2 diabetes is preventable by lifestyle intervention • Diet and physical activity recommended for the general population is sufficient • The effect of lifestyle intervention is carried over for several years • A moderate weight reduction of 2.5 to 5% can have a large impact at individual and at national level • Implementation in the primary health care is feasible – need for multi- professional team work, new models of care, and collaboration between stakeholders Conclusions
    • 46 Future challenges • The diabetes epidemic prevails – Obesity trend has levelled of in Finland but simultaneously some dietary habbits have worsened → T2DM? • How to continue the work started by DEHKO and D2D? – CHRODIS 2014-2017 • European collaboration (Joint Action) to identify and disseminate best practices on strenghtening health care for people with chronic diseases • Diabetes as a case study • Children and adolescents? – Horizon2020? • Prevention of diabetic complications? – ePREDICE trial
    • Early Prevention of Diabetes Complications in Europe 2013- 2018 Primary Objective: • To assess the effect of lifestyle intervention plus linagliptin, metformin or their combination compared to lifestyle intervention alone on microvascular parameters (retinal, renal and neurological) in adults with non diabetic hyperglycaemia (IGT, IFG) • 3000 participants in 12 countries will be recruited
    • Lifestyle intervention • Structured individual counselling sessions (2 + optional 1) to facilitate personal goal setting • Structured group sessions monthly during the first 6 months and thereafter every 3 months -> ~17 sessions in total during 3 years • Lifestyle platform for independent goal-setting and behaviour monitoring:
    • Lifestyle intervention goals in a nutshell 1) Increase in fruit and vegetable intake 2) Shift towards better carbohydrate and fiber intake 3) Shift towards healthier fats 4) Shift towards healthier protein sources 5) Increase in physical activity / decrease in sedentary time 6) Shift towards a healthier weight 7) Improve sleep 8) Decrease stress
    • Health-e-Living ePREDICE Web Platform Tool Health questionnaire Goal setting Plan making Diary Progress monitoring Automated feedback Messaging Information
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