Diabetes Update

Pam Allweiss, MD, MPH pca8@cdc.gov Centers for Disease Control and Prevention.
Division of Diabetes Translation
The findings and conclusions of this presentation are those of the presenter and do not necessarily represent views of the Centers for Disease Control and Prevention

An American Epidemic

Age-adjusted Percentage of U.S. Adults Who Were Obese or Who Had Diagnosed Diabetes
Obesity (BMI 30 kg/m2) 1994

2000

2009

No Data

<14.0%

14.0-17.9%

18.0-21.9%

22.0-25.9%

>26.0%

Diabetes 1994 2000 2009

No Data

<4.5%

4.5-5.9%

6.0-7.4%

7.5-8.9%

>9.0%

CDCs Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

26 million
with Diabetes

79 million
with Pre-Diabetes

Epidemic of Diabetes
Diabetes affects almost 26 million Americans (8.3%), one quarter of whom dont know they have it. Another 79 million Americans have pre-diabetes, which raises their risk of developing type 2 diabetes, heart disease, and stroke. About 1.9 million new cases of diabetes were diagnosed in people aged 20 or older in 2010.

www.yourdiabetesinfo.org

www.DiabetesAtWork.org

Number and Percentage of U.S. Population with Diagnosed Diabetes, 19582010

8 7 25

Percentage with Diabetes

Number with Diabetes

6 5 4 3 2

15

10

5 1 0 1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06 09 0

Year
CDCs Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

Number with Diabetes (Millions)

20

Percentage with Diabetes

Estimated lifetime risk of developing diabetes for individuals born in the United States in 2000
60 50
Total Non-Hispanic Black Non-Hispanic White Hispanic

Percent

40 30 20 10 0 Men Women

Narayan et al, JAMA, 2003

Source: 20052008 National Health and Nutrition Examination Survey.

The Diabetes Epidemic

Aging of America Diverse ethnic groups, various incidence and prevalence of diabetes Earlier diagnosis and reclassification Pre-diabetes: Borderline Diabetes or a touch of sugar = real condition that needs to be treated By 2050, 1 in every 3 adult Americans will have diabetes if current trends continue

Estimated Cost of Diabetes in U.S. (ADA 2007)

Total: $174 billion Indirect costs include increased absenteeism ($2.6 billion) and reduced productivity while at work ($20.0 billion) for the employed population Reduced productivity for those not in the labor force ($0.8 billion) Unemployment from disease-related disability ($7.9 billion) Lost productive capacity due to early mortality ($26.9 billion)

Diabetes 101: What is Diabetes

Not just a sugar problem Interaction of food, insulin, other hormones (glucagon) Physical activity/Obesity Pancreatic function Genetics Other commonly associated conditions: hypertension, lipid problems The complications, not just the diagnosis of diabetes, cause the problems Diabetes is common, serious BUT treatable

Diabetes means:
2 x the risk of high blood pressure 2 to 4 x the risk of heart disease 2 to 4 x the risk of stroke #1 cause of adult blindness #1 cause of kidney failure Causes more than 60% of non-traumatic lower-limb amputations each year

NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2010.

Complications
Eyes Kidneys Nerves Cardiovascular disease and stroke Randomly controlled studies show that these complications can be prevented or controlled with good blood sugar control but this might involve multiple shots etc More shots does not mean worse diabetes!

Symptoms
Frequent urination Excessive thirst Extreme hunger or constant eating Unexplained weight loss Presence of glucose in the urine Tiredness or fatigue Changes in vision Numbness or tingling in the extremities Slow-healing wounds or sores Abnormally high frequency of infection

Many people have no symptoms

Diagnosis (Diabetes Care 1-2010)

1) A1C 6.5%. (by lab using a method that is NGSP certified and standardized to the DCCT assay.* (caveats: anemia, pregnancy) 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 plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*
OR

4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose 200 mg/dl (11.1 mmol/l). *In the absence of unequivocal hyperglycemia, criteria 13 should be confirmed by repeat testing

Types of Diabetes
Type 1: traditionally age <20, no endogenous insulin, may be any age, about10-20% of people with diabetes, Rx = insulin Type 2: traditionally >40, multiple problems with insulin secretion and action, may be any age, about 80-90% of people with diabetes, Rx may include oral agents and/or insulin or newer agents (incretins, GLP1 ) Pre-diabetes Gestational Diabetes

Who Is At Risk?
Age 45 or older Overweight High blood pressure Pre-diabetes

Inactive
Ethnic or minority population Family history of diabetes Excess abdominal fat

High blood fats

Darkening of the skin Polycystic ovary syndrome History of Gestational Diabetes or large baby

Could You be at Risk for Diabetes?

Where do you start?
ADA Risk Test (paper or online) www.diabetes.org

Categories of increased risk for diabetes (Pre-diabetes) Impaired Fasting Glucose: FPG 100 mg/dl (5.6 mmol/l) to 125 mg/dl (6.9 mmol/l) Impaired Glucose Tolerance: 2-h PG in the 75-g OGTT : 140 mg/dl (7.8 mmol/l) - 199 mg/dl
(11.0 mmol/l)

A1C 5.76.4%
For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at higher ends of the range.

Why Control Diabetes? Do Any Interventions Work?

Bottom Line: Does better glucose control translate to better outcomes or better health in the individual? Yes! For every 1% drop in A1c the risk of microvascular complications (eye, kidney, and nerve damage) can be reduced by up to 40%.
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.p

Control the ABCS

A1c: Glucose control Blood Pressure control Cholesterol (lipid) control Smoking cessation

Causes of Hyperglycemia in Type 2 Diabetes

Receptor + postreceptor defect

Peripheral Tissues (Muscle)

Insulin resistance

Glucose

Liver
Increased glucose production

Pancreas
P.231997 PPS

Impaired insulin secretion

Source: 20072009 National Health Interview Survey.

Physiologic Serum Insulin Secretion Profile

75

Breakfast
50

Lunch

Dinner

Plasma Insulin (U/mL)

25

0 4:00

8:00

12:00

16:00

20:00

24:00

28:00

32:00

Time
Polonsky KS et al, N Engl J Med 1996.

So what are some resources and how can we use them?

Where is the community partner?

 CDC and NIH program formed after evidence showed that better glucose control translated into fewer complications Public and private partnerships to improve diabetes treatment and outcomes Increased public awareness of the seriousness of diabetes, its risk factors, and strategies for preventing diabetic complications NDEP translates the latest science and spreads the word that diabetes is serious, common, and costly, yet controllable and, for type 2, preventable Focus group tested by diverse audiences, multiple languages NO COPYRGHT : Add your logo! Over 200 public/private partnerships
www.yourdiabetesinfo.org www.ndep.nih.gov

National Diabetes Education Program

NDEP Campaign Materials: Control &

Prevention

Different types of materials

Print Downloads Podcasts Videos Promotion resources Behavior change resources PP Presentations such as: Diabetes: the numbers, and Science of control

Materials for Consumers

Content
Healthy eating/ how to eat out/tasty recipes Take care of your feet/Be smart about your heart Team care Tips to stay healthy Know your numbers

4 Steps to control your diabetes brochure

Also available in these languages: Bengali, Cambodian, Chinese, Gujarati, Haitian Creole (and CD), Hindi, Hmong, Japanese, Korean, Laotian, Samoan, Spanish, Tagalog, Thai, Tongan, Urdu, Vietnamese

Materials for Professionals and Lay Workers

The Road to Health/El Camino Hacia La Buena Salud CHW Primary prevention toolkit

The Road to Health (RTH) Toolkit/ El camino hacia la buena salud Toolkit : A Toolkit on Primary Prevention of Type 2 Diabetes for Community Health Workers (CHWs)/Promotores

The Road to Health Toolkit was developed based on the findings from the Diabetes Prevention Program (DPP) study and focus groups with African American and Hispanic/Latino Community Health Workers. Focus groups with CHWs from urban and rural African American and Hispanic/Latino communities: Diabetes testing, management, and prevention strategies Barriers, opportunities, perceptions Focus on primary prevention Tools needed Training video

NDEP Websites

www.diabetesatwork.org Content
General Diabetes Education : Nutrition, Weight Control, and Physical Activity Lunch and Learn topics Lesson Plans (English and Spanish) Fact Sheets (English and Spanish) Guide to choosing a health plan, developed with AAHP Supervisors guide NO COPYRIGHT!

Fotonovela: Do it for them! But for you too. (Hazlo por ellos! Pero por ti tambin.)
This fotonovela is a bilingual (Spn/Eng) fotonovela featuring dramatic stories of Latinas talking to Latinas about preventing or delaying type 2 diabetes and being healthy for their children and themselves. The stories use three womens challenges in maintaining a healthy lifestyle to convey an important message: Increasing physical activity, making healthy food choices and losing weight (if you are overweight) decreases or delays your risk of developing type 2 diabetes.

Tasty Recipes for People with Diabetes and Their Families (Ricas recetas para personas con diabetes y sus familiares)
A bilingual booklet, Tasty Recipes is filled with recipes specifically designed for Latin Americans. Recipes are accompanied by their nutritional facts table. The booklet also includes diabetes health information and resources. This effective, yet practical, educational promotional tool is a terrific addition to any kitchen.

Words of Wisdom
Cant transform everything at once Use the web sites to print out forms and recipes Dont re-invent the wheel Learn from others

The Diabetes Prevention Program (DPP): The New Frontier: Lifestyle Modifications or Medication
Goal: To prevent or delay the development of type 2 diabetes in persons with impaired glucose tolerance (IGT) High-risk individuals with IGT and elevated FPG (N=3234) randomized to Placebo Intensive lifestyle intervention; at least monthly contact with case managers Metformin titrated to 850 mg bid Reduction at 2.8 years 58% in the intensive lifestyle intervention group 31% in the metformin group
The Diabetes Prevention Program Research Group. Diabetes Care. 1999;22:623. NIDDK. http://www.niddk.nih.gov/welcome/releases/8_8_01.htm.

National Diabetes Prevention Program

Goal: Systematically scale the translated model of the Diabetes Prevention Program (DPP) for high risk persons in collaboration with community-based organizations that have necessary infrastructure, health payers, health care professionals, public health, academia, and others to reduce the incidence of type 2 diabetes in the United States.

National Diabetes Prevention Program

Training = CDC contracted with Emory University to establish the Diabetes Training and Technical Assistance Center (DTTAC) and developed Master Trainer curriculum and unified Lifestyle Coach curriculum www.dttac.org. Recognition Program = CDC and partners developed the standards for program recognition

For more information: http://www.cdc.gov/diabetes/prevention/

www.cdc.gov/diabetes/prevention

How do I get NDEP materials?

All NDEP materials are copyright-free. Download from
www.yourdiabetesinfo.org

Visit all of the NDEP Web sites:

www.ndep.nih.gov
www.betterdiabetescare.nih.gov

www.cdc.gov/diabetes/ndep www.diabetesatwork.org