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
No Data
<14.0%
2000
14.0-17.9%
18.0-21.9%
2009
22.0-25.9%
>26.0%
Diabetes
1994
No Data
<4.5%
2009
2000
4.5-5.9%
6.0-7.4%
7.5-8.9%
>9.0%
CDC’s 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 don’t 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,
1958–2010
25
7
Percentage with Diabetes
6
Number with Diabetes
20
5
15
4
10
3
2
5
1
0
0
1958 61
64
67
70
73
76
79
82
85
88
91
94
97
00
03
06
Year
CDC’s Division of Diabetes Translation. National Diabetes Surveillance System
available at http://www.cdc.gov/diabetes/statistics
09
Number with Diabetes (Millions)
Percentage with Diabetes
8
Estimated lifetime risk of developing diabetes for
individuals born in the United States in 2000
60
Percent
50
Total
Non-Hispanic Black
Non-Hispanic White
Hispanic
40
30
20
10
0
Men
Narayan et al, JAMA, 2003
Women
Source: 2005–2008 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 1–3 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
• High blood pressure
• Overweight
• Pre-diabetes
• Inactive
• High blood fats
• Ethnic or minority
population
• Darkening of the skin
• Family history of
diabetes
• Excess abdominal fat
• 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 5.7–6.4%
• 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
C
Peripheral Tissues
(Muscle)
Receptor +
postreceptor defect
Insulin
resistance
Glucose
Liver
Increased glucose
production
Pancreas
P.23©1997 PPS
Impaired insulin
secretion
Source: 2007–2009 National Health Interview Survey.
Physiologic Serum Insulin Secretion
Profile
75
Plasma Insulin
(U/mL)
Breakfast
Lunch
Dinner
50
25
0
4:00
8:00
12:00
16:00
Time
Polonsky KS et al, N Engl J Med 1996.
20:00
24:00
28:00
32:00
So what are some resources and
how can we use them?
Where is the community partner?
National Diabetes Education
Program
• 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
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
Supervisor’s guide
NO COPYRIGHT!
Fotonovela: Do it for them! But for you too.
(¡Hazlo por ellos! Pero por ti también.)
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 women’s 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
• Can’t transform everything at once
• Use the web sites to print out forms and
“recipes”
• Don’t 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