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7th DIETS/EFAD Conference / Diabetes pandemic garda_25112013_website_final


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7th DIETS/EFAD Conference …

7th DIETS/EFAD Conference
Diabetes pandemic garda_25112013_website_final

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  • 1. 7th DIETS/EFAD Conference Type 2 Diabetes: the pandemic waiting to happen Cathy Breen EFAD ESDN Diabetes Lead/Irish Nutrition and Dietetic Institute/ Endocrine Unit, St Columcille’s Hospital, Loughlinstown, Co Dublin, Ireland Garda, Italy. November 8th, 2013 ©, 2013
  • 2. Type 2 Diabetes: the pandemic waiting to happen?  Pandemic   Waiting to happen? Extensively epidemic (Steadmans Medical Dictionary, 28th Ed)  An infectious epidemic occurring worldwide or over a very wide area, crossing international boundaries, and usually affecting a large number of people (Wikipedia, 2013) IDF, 2012
  • 3. IDF, 2012
  • 4. Prevalence: Europe
  • 5. Diabetes Prevalence in 2000 vs. 2030 Over 430 million cases predicted by 2030
  • 6. Age-Adjusted Prevalence of Diagnosed Diabetes Among U.S. Adults Aged 18 Years or older 2000 1994 No Data <4.5% 4.5-5.9% 6.0-7.4% 2010 7.5-8.9% CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at >9.0%
  • 7. Why the explosion?
  • 8. Risk factors for Type 2 diabetes WHO, 2011
  • 9. Diabesity?   Type 2 diabetes ↔ Obesity ~80% of adults with T2 diabetes are overweight / obese (McLaughlin, 2007)
  • 10. Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or older Obesity (BMI ≥30 kg/m2) 1994 No Data <14.0% 2010 2000 14.0-17.9% 18.0-21.9% 22.0-25.9% >26.0% Diabetes 1994 No Data 2010 2000 <4.5% 4.5-5.9% 6.0-7.4% 7.5-8.9% CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at >9.0%
  • 11. Diabesity  Adipose tissue drives insulin resistance and hyperglycaemia Rosen & Spiegelman, 2006
  • 12. Type 2 diabetes: why worry?  Costs  Quality of life    Burden of diabetes Complications / co-morbidities Monetary  Overburdened health care systems IDF, 2012
  • 13. Diabetes and quality of life/health status AIHF, from AUSDiab Study 1999-2000 Solli, 2010
  • 14. Diabetes complications
  • 15. Monetary costs Kanavos, 2012
  • 16. Type 2 diabetes (dietary) management      Glycaemic control → carbohydrate quantity & quality Weight loss → calories Lipid management → saturated vs. unsaturated fat Blood pressure management → salt / alcohol Overall dietary quality → fruit & veg, fibre Low calorie, higher fibre diet, lower GL diet Individualising macronutrient composition Low fat diet + lipase inhibitors Meal replacement Very low calorie diets CALORIE RESTRICTION • Structured diabetes education + patient empowerment • Individualised, supportive approach • Intense review as part of a behavioural lifestyle intervention (MDT approach) Bariatric surgery
  • 17. Dietary approaches in Type 2 diabetes  Evidence for: Low fat diets, low carbohydrate diets, high protein diets Low glycaemic index/load diets Mediterranean diet Meal replacements Very low calorie diets  “The true application of research findings can usually be found in the author’s description of the participants’ usual diet before randomization. The red meats, salty snacks, and sweets participants typically ate were replaced with lower-fat protein sources, lower-fat dairy, whole grains— fewer empty-calorie foods in place of more nutrient-dense foods” (Perry, 2005)  What do our patients want? Food based recommendations that can be easily understood and translated into everyday life
  • 18. It works!  Structured dietetic-led diabetes education programmes  ROMEO (Italy): Dietitian-led T2DM groups significantly improved outcomes compared to a medically and pedagogically-led group (Trento, 2008)   X-PERT (UK): Improved HbA1c (-0.6 vs. -0.1%), weight (-0.5 vs. 1.1kg) + improved diabetes knowledge + fruit/veg intake (Deakin, 2006) Intense lifestyle interventions e.g. LookAhead  4 years:   Weight -6.2 v.s -0.88% (P <0.001) Significantly better HbA1c, fitness, BP, HDL, TAG Gregg, 2012
  • 19. EASD/ADA Guidelines But where is the emphasis really?
  • 20. Benefits of modest weight loss in Type 2 diabetes 1Anderson, 2001; 2Anderson, 2003
  • 21. Key messages for clinical practice 1. 2. Focus on calorie restriction, portion control + weight management Think more ‘algorithmically’ i.e. individualise approaches and change the approach if it’s not working
  • 22. Is it cost effective?    Lifestyle interventions? Yes, probably, at least in the shorter term (Jacobs Van der Bruggen, 2009; DPP, 2012) Report commissioned by the Dutch Association of Dietitians in 2012 (ICAN Study):  For every €1 spend on dietary counseling, society gets a net €14 63 in return: €56 in terms of improved health, €3 net savings in total health care costs and €4 in terms of productivity gains. Need to gather more diverse data routinely  Less medication usage, improved dietary quality, improved quality of life, less hospital admissions, less A&E visits, less hypoglycaemia, less work absenteeism, reduced rates of progression to complications
  • 23. IMAGE Work package 4 – Subgroup 3: Guideline Nutrition
  • 24. Preventing Type 2 diabetes: the simple things work 1. 2. 3. 4. 5. Weight loss (5-10%) Reduce fat intake (<30%) Reduce saturated fat intake (<10%) Increase fibre intake (>15g/1000kcals) Increase activity (>4hrs/week) Tuomilehto et al, NEJM, 2001
  • 25. Dietitians as uniquely qualified leaders in Type 2 diabetes treatment and prevention          Working in primary & secondary health care, public & private sector, industry, administrative, education & research settings Unique knowledge and skill set relating to food and clinical nutrition  Uniquely qualified to match the approach to the client Advanced behaviour change skills Clinically effective Inherent value placed on best practice that underpins all approaches Code of professional practice Commitment to CPD/LLL Expertise in audit & research Unified public health message Unique insight & capacity to deliver high quality, evidence-based, patient-centred approaches to the management and prevention of Type 2 diabetes
  • 26. Dietitians know best!   We understand the complex challenges that our patients face when trying to manage their diabetes within an increasingly obesogenic environment and overburdened health care systems. Clinical ↔ public health
  • 27. Health 2020     Health2020 makes the case for investment in health and aims to support action across government and society to improve the health and well-being of populations and strengthen public health. Tackling Europe’s major disease burdens, including diabetes, is a priority area within the policy. This will require coordinated public health action and health care system interventions, which must be underpinned by supportive environments. Innovation and leadership for health are at the core of Health 2020, and it encourages all stakeholders to take on new responsibility and accountability for population health.
  • 28. What we can do  This provides an opportunity for dietitians, as specialists with a unique insight and professional expertise in the area, to take leadership roles in developing local and national public health policies that support the aims of Health2020 for a healthier society that will reduce the burden of type 2 diabetes.  Local, national, international diabetes advocacy groups  Local / national diabetes service planning / steering committees  Global Diabetes Survey  We can be a strong voice about what needs to change…  Health in all policies approach  Environmental planning  Food marketing  Unhealthy food taxation vs. healthy food subsidies
  • 29. We’ve been here before….  Plague Matthews, 2011 Thanks to Illona Kickbush, OECD
  • 30. “There is no public outrage that governments legislate to protect through legislation in other contexts e.g. seatbelts, fire escapes, crash barriers. Yet startlingly few public health policies are in place to protect us from excess calorie consumption ” “Bubonic plague could not be stopped by wishing that the population were less degenerate”