Diabetes Prevention

PUBH 501: Topics in Community and

Preventive Medicine: Medicine in Society II
Fall 2015
Page 22 onwards

Prevention of Diabetes and Ethical issues:

Objectives
Describe the most common risk factors for
diabetes
Discuss strategies for prevention of diabetes
Identify ethical considerations that bear on the
prevention, progression and complications
associated with diabetes
Analyze the role of professional competencies
in overcoming challenges to diabetes
prevention
Ethics and clinical trials of medications for
diabetes

What is Diabetes Mellitus?

A disease in which the body does not produce or
properly use insulin
The disease is characterized by high levels of
blood glucose as a result of defects in insulin
production, insulin action, or both
Insulin is a hormone that is needed to convert
sugar, starches and other food into energy
needed for daily life
Diabetes is associated with serious complications
and premature death
Patients with diabetes can take steps to control
the disease and lower the risk of complications
and premature deaths

Types of diabetes: Type 1

Referred to as insulin-dependent diabetes mellitus
(IDDM) or juvenile-onset diabetes
Develops when the body's immune system destroys
pancreatic beta cells
Common in children and young adults
5% to 10% of all diagnosed cases of diabetes
Patients with type 1 diabetes must have insulin
delivered by injection or a pump
Poor management often associated hyperglycemia,
hypoglycemia, ketoacidosis and celiac disease
Risk factors include autoimmune, genetic, and
environmental factors
There is no known way to prevent Type 1 diabetes

Types of diabetes: Type 2

Referred to as Non-insulin-dependent diabetes
mellitus (NIDDM) or adult-onset diabetes
90% to 95% of all diagnosed cases of diabetes
Develops as insulin resistance, a disorder in which
the cells do not utilize insulin efficiently
The pancreas gradually loses its ability to produce
insulin, as demand for insulin rises
Conditions associated with type 2 diabetes include
hyperglycemia and hypoglycemia

Types of diabetes: Type 2

Risk factors include older age, obesity, family
history of diabetes, history of gestational diabetes,
impaired glucose metabolism, physical inactivity,
and race/ethnicity
African Americans, Hispanic/Latino Americans,
American Indians, Asian Americans and Native
Hawaiians or Other Pacific Islanders are at high
risk for type 2 diabetes
Increasingly being diagnosed in children and
adolescents

Types of diabetes: Gestational diabetes

Diagnosed glucose intolerance during pregnancy
Frequently diagnosed in obese pregnant women
with family history of diabetes
Often diagnosed in pregnant African Americans,
Hispanic/Latino Americans, and American Indians
Requires treatment to normalize maternal blood
glucose levels to avoid complications in infants
5% to 10% of women will develop type 2, diabetes
soon after pregnancy
40% to 60% of women will develop type 2, diabetes
within 5-10 years post-delivery

Types of diabetes: Other specific types

Diabetes resulting from:
specific genetic conditions (maturity-onset diabetes
of youth)
surgery
drugs
malnutrition
infections
pancreatic disorders, and other illnesses
Account for 1% to 5% of all diagnosed diabetes

Pre-Diabetes
Blood glucose levels are higher than normal but not
high enough for a diagnosis of type 2 diabetes.
Pre-diabetes is sometimes called "impaired fasting
glucose (IFG) or "impaired glucose tolerance (IGT)
IFG is a condition in which the fasting blood glucose
level is elevated (100 to 125 milligrams per deciliter
or mg/dL) after an overnight fast
IGT is a condition in which the blood glucose level is
elevated (140 to 199 mg/dL) after a 2-hour oral
glucose tolerance test

Pre-Diabetes
In 20032006, 25.9% of U.S. adults aged 20 years
or older had IFG (35.4% of adults aged 60 years
or older)
Approximately 57 million American adults aged 20
years or older with IFG had pre-diabetes in 2007
IFG prevalence among U.S. adults aged 20 years
or older in 20032006 was 21.1% for non-Hispanic
blacks, 25.1% for non-Hispanic whites, and 26.1%
for Mexican Americans after adjusting for age and
sex

Prevalence of diabetes in the US, 2007

All Ages:
Total: 23.6 million people or 7.8% of population
have diabetes (Diagnosed: 17.9 million people,
Undiagnosed: 5.7 million people)
Prevalence of diagnosed diabetes in people
younger than 20 years of age, US, 2007:
About 186,300 people younger than 20 years have
diabetes (type 1 or type 2). This represents 0.2% of
all people in this age group

Prevalence of diabetes in the US, 2007

Age 20 years or older: 23.5 million or 10.7% of all
people in this age group have diabetes
Age 60 years or older: 12.2 million or 23.1% of all
people in this age group have diabetes
Men: 12.0 million or 11.2% of all men aged 20 years
or older have diabetes
Women: 11.5 million or 10.2% of all women aged 20
years or older have diabetes
Non-Hispanic whites: 14.9 million, or 9.8% of all
non-Hispanic whites aged 20 years or older have
diabetes
Non-Hispanic blacks: 3.7 million, or 14.7% of all
non-Hispanic blacks aged 20 years or older have
diabetes

Prevalence of Diabetes by Race/Ethnicity

Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview
Survey. U.S. Bureau of the Census, census of the population and population estimates. Data computed by the Division of Diabetes Translation, National
Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention.

Incidence of diabetes
Approximately, 1.6 million new cases of diabetes
were diagnosed in 20 years or older in US in 2007

Incidence

Mortality
Diabetes (72,507 deaths) was the seventh leading
cause of death listed on U.S. death certificates in
2006
According to death certificate reports, diabetes
contributed to a total of 233,619 deaths in 2005
Underreporting of Diabetes. Studies have found that
only about 35% to 40% of decedents with diabetes
had it listed anywhere on the death certificate and
only about 10% to 15% had it listed as the
underlying cause of death
Overall, the risk for death among people with
diabetes is about twice that of people without
diabetes of similar age

Diabetes Mortality Trends

Cost of Diabetes in the US in 2007

Total (direct and indirect): $174 billion
Direct medical costs: $116 billion
After adjusting for population age and sex
differences, average medical expenditures
among people with diagnosed diabetes were 2.3
times higher than what expenditures would be in
the absence of diabetes.
Indirect costs: $58 billion (disability, work loss,
premature mortality)

Risk Factors
Family history and genetics
first degree relative increases ones
chances of developing type 2 diabetes by
40%
Family background of African American,
American Indian, Asian American, Pacific
Islander, or Hispanic American/Latino
History of gestational diabetes and birth to a
baby weighing 9 lbs or higher
Dyslipidemia (HDL-C < 35mg/dL or
Triglyceride > 250mg/dL)
Overweight and obesity
Poor diet
Physical Inactivity

Treatment: Medications

Treatment: Medications
Prescribed Insulin
If diet, exercise, and medication are not
sufficient in maintaining normal blood glucose
levels
Injection of insulin under the skin using a
syringe
Administering of insulin must be carefully
recorded and regulated
Administered one to four times a day

Source: 20042006 National Health Interview Survey

Complications of Diabetes in US
Heart disease (CHD) and stroke

CHD is the leading cause of diabetes-related deaths

CHD death rates is 2 to 4x higher among diabetics
Stroke is 2 to 4x higher among people with diabetes
About 65% of deaths among people with diabetes
are due to CHD and stroke

High blood pressure

In 20032004, 75% of adults with self-reported

diabetes had blood pressure greater than or equal to
130/80 millimeters of mercury (mm Hg), or used
prescription medications for hypertension

Complications of Diabetes in US

Blindness

The leading cause of new cases of blindness

among adults aged 20-74 years is diabetes
Diabetic retinopathy 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% of new cases in 2005.
In 2005, 46,739 people with diabetes began
treatment for end-stage kidney disease
In 2005, a total of 178,689 people with end-stage
kidney disease due to diabetes were living on
chronic dialysis or with a kidney transplant

Complications of Diabetes in US

Nervous system disease

About 60% to 70% of people with diabetes have mild

to severe forms of nervous system damage
The results of such damage include impaired
sensation or pain in the feet or hands, slowed
digestion of food in the stomach, carpal tunnel
syndrome, erectile dysfunction, or other nerve
problems
Almost 30% of people with diabetes aged 40 years
or older have impaired sensation in the feet
Severe forms of diabetic nerve disease are a major
contributing cause of lower-extremity amputations
Screen annually for distal polyneuropathy (pin-prick
sensation)

Complications of Diabetes in US

Amputations

More than 60% of non-traumatic lower-limb amputations

occur in people with diabetes
In 2004, about 71,000 non-traumatic lower-limb amputations
were performed in people with diabetes.

Dental disease

Periodontal (gum) disease is more common in people with

diabetes Among young adults, those with diabetes have
about twice the risk of those without diabetes
Persons with poorly controlled diabetes (A1c > 9%) were
nearly 3 times more likely to have severe periodontitis than
those without diabetes
Almost one-third of people with diabetes have severe
periodontal disease with loss of attachment of the gums to
the teeth measuring 5 millimeters or more

Complications of Diabetes in US

Complications of pregnancy
Poorly controlled diabetes before conception and
during the first trimester of pregnancy can cause
major birth defects in 5% to 10% of pregnancies
and spontaneous abortions in 15% to 20% of
pregnancies
Poorly controlled diabetes during the second and
third trimesters of pregnancy can result in
excessively large babies, posing a risk to the
mother and the child

Complications of Diabetes in US
Other complications
Uncontrolled diabetes often leads to biochemical
imbalances that can cause acute life-threatening
events, such as diabetic ketoacidosis and
hyperosmolar (nonketotic) coma
People with diabetes are more susceptible to
many other illnesses and, once they acquire
these illnesses, often have worse prognoses
For example, they are more likely to die with
pneumonia or influenza than people who do not
have diabetes

Diabetic Guidelines (2008): Screening

Testing should be considered in all adults who are
overweight (BMI > 25) and have at least 1 risk factor
from below:
Physical inactivity
First-degree relative with diabetes
Members of high-risk population (e.g. African
American, Latino, Native American, Asian, Pacific
Islander)
Women who delivered a baby weighing > 9lb or
were diagnosed with gestational diabetes (GDM)
Hypertension (>=140/90 or on therapy for
hypertension)
HDL <35 and or TG > 250

Prevention or Delay of diabetes

Progression to diabetes among persons with prediabetes can be delayed by losing weight and
increasing physical activity
In the Diabetes Prevention Program, a large
prevention study of people at high risk for diabetes
showed that lifestyle intervention reduced
developing diabetes by 58% over 3 years
The reduction was even greater, 71%, among
adults aged 60 years or older
Interventions to prevent or delay type 2 diabetes in
individuals with pre-diabetes can be feasible and
cost-effective
Research has found that lifestyle interventions are
more cost-effective than medications

Prevention or delay of diabetes

Diabetes Prevention Program, people treated with
the drug metformin reduced their risk of developing
diabetes by 31% over 3 years
treatment with metformin was most effective among
younger, heavier people (those 25-40 years of age
who were 50 to 80 pounds overweight) and less
effective among older people and people who were
not as overweight
STOP-NIDDM Trial, treatment of people with IGT
with the drug acarbose reduced the risk of
developing diabetes by 25% over 3 years
lifestyle changes and medication have also been
shown to increase the probability of reverting from
IGT to normal glucose tolerance