DIABETUL ZAHARAT TIP2 O chemare la actiune

Dr Mirela Culman Institutul national de Diabet,Nutritie si Boli metabolice ,,Nicolae Paulescu

Bolile cardiovasculare cauz major de deces

deces (%)
45 40 35 30 25 20 15 10 5 0 BCI altele (CV) diabet cancer AVC infectii altele

Geiss LS et al. Diabetes in America.2nd ed.Bethesda, MD:NIH;1995

Mortalitate cardiovascular crescut la pacienii cu Sindrom metabolic

CHD deaths
10 10

Cardiovascular deaths

Cumulative hazard (%)

Relative risk 3.77 (1.74, 8.17) 5

DMS 5

Relative risk 3.55 (1.96, 6.43)

DMS

0
0 4

No DMS
8 12

0
0 4

No DMS
8 12

Years of follow-up
Lakka HM et al. JAMA 2002;288:2709-16

Conglomerat de factori de risc pentru boala cardio vascular

Statusul protrombotic proinflamator

Microalbuminuria

Obezitatea abdominal

Riscul de boal cardiovascular se multiplic n funcie de factorii de risc asociai

HIPERTENSIUNE TAS 15o mmHg X 1,5 X 2,6

X 3,8 X 6,2

DISLIPIDEMIE Colesterol 260 mg/dl X 2,3 X4

DIABET

X 1,8

Risc bazal 15/1000 (1,5%) n 8 ani

KannelWB.Importanceof hypertensionas amajor risk factorin cardiovascular disease ,in Hypertension: Physiopathology and treatament. New York NY:MacGraw-Hill BookCo;1977:888-910

Sindromul metabolic - Quartetul uciga

WHOa
Insulin resistance &/or FPG Plus 2 or more of: Blood pressure TG, HDL-C Microalbuminuria Central obesity Central obesity

EGIRb
Insulin resistance (hyperinsulinaemia) Plus 2 or more of: Blood pressure TG, HDL-Cd

NCEPc
FPG Plus 2 or more of: Blood pressure TG HDL-C Central obesity

aWorld Health Organisation; bEuropean Group for the study of Insulin resistance; cNational Cholesterol Education Program; dand/or treatment for dyslipidaemia Eschwege E. Diabetes Metab 2003;29:6S19-27

Prevalena sindromului metabolic n Europa

35

<40 years

40-55 years

>55 years

Prevalence (%)

30 25 20 15 10 5 0 Men Women Men Women

Definiie OMS Definiie EGIR

Balkau B et al. Diabetes Metab 2002;28:364-76 Eschwege E. Diabetes Metab 2003;29:6S19-27

Prevalena sindromului metabolic n USA

50 White Mexican-American African-American Other

Prevalence (%)

40 30 20 10 0

Men

Women

Men

Women

National Cholesterol Education Program definition

World Health Organisation definition

Ford ES, Giles WH. Diabetes Care 2003;26:575-81 Eschwege E. Diabetes Metab 2003;29:6S19-27

Cel mai tipic exemplu de sindrom metabolic Diabetul tip 2

La fiecare 21 secunde apare un caz nou de diabet !

Epidemie global de diabet

Number of people with diabetes world wide (millions)

350 300 250 200 150 100 50 0 194

333

72%

2003

2025

Year
International Diabetes Federation

Diabetul determin risc crescut pentru evenimente cardiovasculare

Risc de 3 ori mai mare De infarct de miocard
Fr diabet
80

Risc de 25 ori mai mare de moarte de cauz crdiovascular

Cu diabet
RR 2.6

CV deaths/100,000 person-years (age adjusted)

Incidence (%)

60 40 20 0

120
RR 4.1

80 40 0
RR 5.1

RR 4.8

No Diabetes diabetes

RR: relative risk

1Haffner

0 1 2 3 Number of cardiovascular risk factors

SM et al. NEJM 1998;339:229-34; 2Stamler J et al. Diabetes Care 1993;16:434-44

Pacientul cu DZ 2 are prognostic asemntor cu cel nediabetic care a suferit un IM

100

% Surviving

80 No diabetes, no MI

60

Diabetes, no MI
No diabetes, with prior MI Diabetes, with prior MI

40 0 2 4 Years of follow-up
Haffner SM et al. NEJM 1998;339:229-34

Toate atingerile de organ date de diabet sunt de natur angiopat Micro/Macro

Liebl A. et al. Dtsch. Med. Wochenschr. 126,585,2001

AVC Orbire IM Dializ Amputaie

La fiecare 12 minute La fiecare 90 minute

La fiecare 19 minute
La fiecare 90 minute La fiecare 19 minute

n Statele Unite n fiecare 24 de ore

Peste 65 orbesc 656 dezvolt insuficen renal i ncep dializa renal Peste 500 mor datorit complicaiilor 2200 persoane sunt diagnosticate cu diabet 153 sufer o amputaie de m inferior

Prevalena complicaiilor dibetului

Data from a UK primary care audit (10,709 diabetic patients)
30

25
25

% Patients

20 15 10 5 0 CHD CVD

18

17

10 2
Diabetic foot Retinopathy Nephropathy

CHD: coronary heart disease CVD: cerebrovascular disease

Morgan CL. Diabet Med 2000;17:146-51

Raportul dintre costul global i costul complicaiilor

Non - overweight patients

Mean cost/patient (1000)

Overweight patients
Mean cost/patient (1000)

10 8 6 4 2 0 Conventional Intensive (SU (diet) or insulin)

Cost of managing complications

10 8 6 4 2 0 Conventional Intensive (diet) (metformin)

Overall costs (standard practice)

UKPDS 41. BMJ 2000;329:1375-8; UKPDS 51. Diabetologia 2000;44:298-304

Costurile diabetului nainte i dup diagnostic

Costs before diagnosis
35
Total treatment cost (US $ x 1000)

Costs after diagnosis

35 30 25 20 15 10 5 0

30 25 20 15 10 5 0 8 7 6 5 4 3 2 1 Years before diagnosis

Type 2 diabetes Matched controls

2 3 4 5 6 7 8 Years after diagnosis

Brown JB et al. Diabetes Care 1999;22:1116-24; Nichols GA et al. Diabetes Care 2000;23:1654-9

Diabetul tip 2 reduce sperana de via

Years of life expectancy lost according to age at diagnosis of diabetes

Age at Marks & Krall diagnosis 1971 12 14 10 11 89 67 45

Goodkin 1975

Panzram & Zabel-Langhennig 1981 78 56 34 3

20 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 +

16 11 10 6 5

Panzram G. Diabetologia 1987;30:123-31

Diabetul tip 2 amplific efectele adverse ale sindromului metabolic

Fr diabet
30
30

Diabet tip2
RR 2.2 p<0.001

Prevalence (%)

Prevalence (%)

20 RR 1.7 p=0.04 10 RR 1.2 p=0.62 RR 1.3 p=0.59

20

RR 2.3 p=0.007 RR 1.8 p=0.013

10

CHD

MI

Stroke

CHD

MI

Stroke

Dysmetabolic syndrome present

RR: relative risk

Dysmetabolic syndrome absent

Isomaa B et al. Diabetes Care 2001;24:683-9

Componentele sindromului metabolic amplific riscul cardiovascular la diabetici

Dyslipidaemia
50 40 30 20 10 0
2 .5 .2 2 <5 . 26 5. 6. 57 >7 .

Hypertension
Non-diabetic Diabetic

Obesity
30 20 10 0

CHD deaths/ 1000 patient-years

30 20 10 0
3 <1 6 52 1 63 1 5 >1 2

Serum cholesterol (mmol/L)

.2 .8 .8 4 6 6 <2 .2-2 >2 24

SBP (mmHg)

BMI (kg/m2)

Adlerberth AM et al. Diabetes Care 1998;21:539-45; Eschwege E. Diabetes Metab 2003;29:6S19-27

Complicaiile cronice ale diabetului apar mai frecvent la pacienii care asociaz sindrom metabolic
% patients with complications
60 50 40 30 20 10 0 38 28 20 53 44 36 + Dysmetabolic syndrome - Dysmetabolic syndrome 44 38 24 28

D SN

PV D

hy

R et

PVD: peripheral vascular disease CAD: coronary artery disease DSN: Distal sensory neuropathy

Costa LA et al. Diabet Med 2004;21:252-5

ic ro -

al b

um in ur ia

C A

in o

pa t

Riscul de complicaii cronice crete proporional cu severitatea sindromului metabolic

70

% with each risk factor

No. of risk factors:

None/one Three

Two Four

60 50 40 30 20 10 0 PVD CAD Stroke Retinopathy DSN

PVD: peripheral vascular disease CAD: coronary artery disease DSN: Distal sensory neuropathy

Costa LA et al. Diabet Med 2004;21:252-5

Managementul intensiv si multifacorial

Control glicemic bun

Tratament

Complicaii microvasculare i macrovasculare

Sindromul metaboloic
Rezistena la insulin, obezitate, hiperinsulinemia, hipertensiune, dislipidemia, ateroscleroz, status procoagulant, proinflamator