AEPI555D

1. Translational epidemiology

2. Venkat Narayan, K. M. et. al Diabetes Care. 2000; 23:1794-8
Translation research for chronic
disease: the case of diabetes

3. Translation research for chronic disease
Diabetes Care. 2000; 23:1794-8

4. Diabetes mellitus
• Diabetes is a “wonderful” affliction
• not very frequent among men
• being a melting down of the flesh and limbs into
urine.
– patients never stop making water
– disease is chronic
– long period to form
– death speedy
– Life is disgusting and painful; thirst unquenchable;
excessive drinking,
• Its cause is of a cold and humid nature as in
dropsy
Aretaeus the Cappadocian (c. AD 30-90)

5. Diabetes mellitus: a clinical
syndrome (signs and symptoms)

6. w3.ouhsc.edu/phar5442/Lectures/Diabetes.html
Diabetes mellitus: a clinical syndrome

7. ADA criteria for the diagnosis of
diabetes mellitus: Case definition
In the absence of unequivocal hyperglycemia,
these criteria should be confirmed by repeat testing on a different day.
The third measure (OGTT) is not recommended for routine clinical use.
1. Symptoms of diabetes plus casual plasma glucose concentration ≥ 200
mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time
since last meal. The classic symptoms of diabetes include polyuria, polydipsia,
and unexplained weight loss.
OR
2. FPG ≥ 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at
least 8 h.
OR
3. 2-h postload glucose ≥ 200 mg/dl (11.1 mmol/l) during an OGTT. The test
should be performed as described by WHO, using a glucose load containing
the equivalent of 75 g anhydrous glucose dissolved in water.

8. Banting, FG, Best CH. The internal secretion of the
pancreas. J Lab Clin Med, 1922; 7:467-468
Insulin

9. Insulin is secreted by the pancreatic islet
beta cell

10. Incidence of Diagnosed Diabetes per 1,000 Population Aged 18–79 Years, by Age, United
States, 1980–2010
From 1980 through 2010, the incidence of diagnosed diabetes increased in adults aged 18–44
years and adults aged 65–79 years. Among adults aged 45–64 years, incidence of diagnosed
diabetes showed little change during the 1980s, but increased beginning in the 1990s through
2010
Centers for Disease Control and Prevention

11. Crude and Age-Adjusted Incidence of Diagnosed Diabetes per 1,000 Population Aged 18–79
Years, United States, 1980–2010
From 1980 to 2010, the crude incidence of diagnosed diabetes increased 161% from 3.3 to
8.6 per 1,000 population. Similarly, the age–adjusted incidence increased 140% from 3.5 to
8.4 per 1,000 population, suggesting that the majority of the change was not due to the aging
of the population. However, from 1980 to 2010, incidence did not increase at a constant rate.
Both crude and age–adjusted incidence remained unchanged in the 1980s, and then
increased in the 1990s through 2010. From 2008 through 2010, both crude and age–adjusted
incidence has shown little change.
Centers for Disease Control and Prevention

12. Estimated prevalence of diagnosed and
undiagnosed diabetes in people aged 20 years
or older, by age group, United States, 2007
2.6
10.8
23.8
0
5
10
15
20
25
20-39 40-59 60+
Age Group
Percent
CDC. National Diabetes Fact Sheet, 2007.
Source: 2003–2006 National Health and Nutrition Examination Survey estimates
of total prevalence (both diagnosed and undiagnosed) were projected to year 2007.

13. Crude and Age-Adjusted Percentage of Civilian, Noninstitutionalized Population with Diagnosed
Diabetes, United States, 1980–2010
From 1980 through 2010, the crude prevalence of diagnosed diabetes increased by 176% (from
2.5% to 6.9%). During this period, increases in the crude and age-adjusted prevalence of
diagnosed diabetes were similar, indicating that most of the increase in prevalence was not
because of changes in the population age structure.
Centers for Disease Control and Prevention

14. 0
10
20
30
40
50
60
Men Women
Percent
Total Non-Hispanic White
Non-Hispanic Black Hispanic
Narayan et al, JAMA, 2003
Estimated lifetime risk of developing diabetes for
individuals born in the United States in 2000

15. Complications of diabetes mellitus
Diabetic ketoacidosis and hyperosmolar (nonketotic) coma
Heart disease and stroke
• Heart disease and stroke: 65 percent of deaths in diabetics.
– Heart disease death rates about 2 to 4 times higher
– Stroke risk 2 to 4 times higher
Blindness
• Diabetes is the leading cause of new cases of blindness among adults and causes
12,000 to 24,000 new cases of blindness each year.
Kidney disease
• Diabetes is the leading cause of kidney failure, accounting for 44 percent of new
cases in 2002.
Nervous system disease
• About 60 to 70 percent of diabetics have mild to severe forms of nerve damage.
– impaired sensation or pain in the feet or hands
– Amputation

16. Some characteristics of chronic diseases
• Person
– Multiple, non-specific risk factors
– Disability prominent
– Impact on quality of life important
– Primary, secondary and tertiary prevention
• Time
– Duration of disease
– Epidemic curve
– Long latency
– Fetal/childhood origin
– Time dependency of risk factors
• Place
– Asynchrony of epidemic in different populations
• Societal
– Expensive half-way technologies
• Medication
• Organ replacement therapy

17. Risk factors for Type 2 DM:
Multifactorial etiology
• Familial/Genetic predisposition
– Identical twin: High concordance (~100%)
– Sib: Moderate concordance (~30%)
• Fetal origins hypothesis
• Gender/gestational diabetes
• Race
• Obesity
• Sedentary lifestyle

18. Long latency

19. Risk factors for diabetes over the life course

20. advanced glycation end (AGE) products Hg A1c
Measuring glucose control

21. Effect of intensified glycemic control on the risk for any type
of macrovascular event in type 1 and type 2 DM: RCTs
Am Heart J. 2006;152:27-38.

22. EBM clinical practice guidelines:
American Diabetes Association.
Standards of medical care in diabetes.
Diabetes Care 2004; 27 (Suppl. 1): S15–34

23. Amundson GM, O'Connor PJ, Solberg LI, Asche SE, Woods RC, Parker ED, Crain AL. Diabetes care quality:
insurance, health plan, and physician group contributions. Am J Manag Care. 2009 Sep;15(9):585-92.

24. • Increase
• diagnosed diabetes
• who receive formal diabetes education
• glycosylated hemoglobin at least twice a year
• annual dilated eye examination
•annual foot examination
•annual dental examination
•self-blood-glucose-monitoring at least once /day
• Reduce
•diabetes death rate.
•lower extremity amputations
•Undetected microalbuminuria
Healthy People 2020: Objectives
Retained From Healthy People 2010

25. Healthy People 2020: New and modified
Objectives
• Reduce
•the annual number of new cases of
diabetes
•the diabetes death rate
•Among diabetics improve
•glycemic control
•blood pressure control
•lipid control
•Increase % engaged in diabetes prevention
behaviors among at-risk population

27. Copyright restrictions may apply.
Shojania, K. G. et al. JAMA 2006;296:427-440.
Community interventions:
Postintervention Differences in Serum HbA1c Values After Adjustment for Study Bias and
Baseline HbA1c Values