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Treatment of DM2 2016 KMA Waleed Aldahi , MD, FRCPC Fellow of JDC Harvard University Program Director of Endocrine and Diabetes Board , Kuwait Consultant Endocrine & Diabetes Coronary Heart Disease - Mortality Male CHD Mortality/1,000 60 50 40 With Diabetes* Female Without Diabetes Male 30 20 Female 10 0 0-3 4-7 8-11 12-15 Duration of Follow-up (yrs) * Diagnosed between 35 and 65 years of age Am J Med 90(2A): 56S-61S,1991 16-19 20-23 • 9.2% of the world diabetics • 1: 9 have Diabetes • Average prevalence 10.9% IDF Regions and global projections of the number of people with diabetes (20-79 years), 2013 and 2035 MENA The Global Burden IDF: Prevalence (%) estimates of diabetes (20-79 years), 2015 Diabetes in GCC Countries GCC: Gulf Cooperation Council Diabetes in Kuwait Type 2 Increasing prevalence; – 1970-1980 : – 1980-1990 : 7% (MOH) 12% – 1996-1998 : overall prevalence 15.7% IGT 7.0 % Abdella etal, Diabetes Res. & Clinical Pract.42 (1998) 187 - 196 In Kuwait …….. اذا ما عندك سكر انت غير كويتي You are not Kuwaiti If you don’t have diabetes الديوانية:المرجع Top 10 countries/territories for prevalence* (%) of IGT (20-79 years), 2013 and 2035 Why the Gulf Diabetes : family business • All are type 2 diabetic patients. • Five level study. Sex Males Females Total Total 33 41 74 Affected 20 16 36 % 60.6 39 48.6 • Intermarriage. 90’s • Gene mixture. • High diabetes prevalence 70’s 50’s Affected female Affected male 30’s Non-affected female Non-affected male <30 Mean Range AGE (years) . 23 15-31 SAUDI DIABETES GENOME Age group Survey weighted descriptive statistics by gender– age group in UAE Nutrition transition in the United Arab Emirates. European Journal of Clinical Nutrition (2011), 1–10 Characteristics of 3003 Kuwaiti adults aged 20 and above Abdella etal, Diabetes Res. & Clinical Pract.42 (1998) 187 - 196 Characteristics Non diabetic (%) Type 2 DM (%) IGT (%) Exercise Inactive Occasional 58.9 24.0 67.5* 20.1* 58.2 25.3 Family history No Yes 50.1 49.9* 43.5 56.5* 38.5 61.5* Hypertension Normal Ht 90.0 10.0 74.8 25.2 80.2 19.8 BMI Normal 25 G1 25-30 G2 >30 21.6 38.5* 39.5* 14.5 30.5* 55.0* 11.0 25.3* 63.7* low levels of daily exercise (daily activity ≤10 min) Badran and Laher (13) citing “STEPwise data from selected countries in The National Oceanic Atmospheric Administration (NOAA)’s National Weather Service’s Heat Index Chart Heat index in Arabian Gulf Countries (Available at: http://www.nws.noaa.gov/os/ heat/index.shtml). Per capita GDP and health expenditures in the highincome Middle Eastern countries relative to highincome OECD countries (2010) Source: World Development Indicators 2013 Diabetes Equation… For Officials simple math Diabetes = $$$$$$$$ Unwin, N et al. (2009) International Diabetes Federation World Atlas, Fourth Edition. International Diabetes Federation Unwin, N et al. (2009) International Diabetes Federation World obesity Risk of type 2 diabetes The relationship between BMI and the risk of developing type 2 diabetes 93.2 100 Women 54.0 Men 70 40.3 40 15.8 10 27.6 42.1 21.3 11.6 8.1 6.7 4.3 5 0 5.0 2.9 1.0 1.0 1.0 1.5 <22 <23 2323.9 2424.9 4.4 2.2 2526.9 2728.9 2930.9 3132.9 Body mass index (kg/m2) 33- 35+ 34.9 The prevalence of male and female obesity levels in selected European countries Yugoslavia Greece Romania Czech Rep. England Finland Germany Scotland Slovakia Portugal Spain Denmark Belgium Sweden France Italy Netherlands Norway Hungary Switzerland 30 20 10 0 10 % BMI ≥ 30 20 30 40 Overweight and obesity among our children Obesity among Kuwaitis 10-20 yrs KNSS WHO 2007 WHO/EMRO – Started 2001 17,364 subjects (M=8728 – F=8636) 30 25 20 Mean Percentage 15 of overweight 10 5 22.8 26.3 13.1 23.5 15.3 0 10-13 yrs 5-9 yrs Male 14-20 yrs Female 25.7 Prediction of Female Children’s BMI (kg/m2 ) using the Parents’ Questionnaire in Kuwait International Journal of Health Sciences, Vol. 3(1), March 2015 Prediction of Male Children’s BMI (kg/m2 ) using the Parents’ Questionnaire in Kuwait The bigger the Burger the bigger the problem Complex Disease Multiple, Complex Pathophysiological Abnormalities in T2DM pancreatic insulin secretion incretin effect _ gut carbohydrate delivery & absorption pancreatic glucagon secretion ? HYPERGLYCEMIA _ + hepatic glucose production renal glucose excretion peripheral glucose uptake Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011 Antihyperglycemic Agents • Metformin • Sulfonlyureas/glinides • Insulin Antihyperglycemic Agents • Metformin • Thiazolidinediones • Sulfonlyureas/glinides • GLP-1 agonists • DPP IV inhibitors • Alpha glucosidase inhibitors • SGL2 Inhibitors • Insulin Multiple, Complex Pathophysiological Abnormalities in T2DM GLP-1R agonists Insulin Glinides S U s incretin effect DPP-4 inhibitors Amylin mimetics _ pancreatic insulin secretion pancreatic glucagon secretion DA agonists AGIs gut carbohydrate delivery & absorption ? HYPERGLYCEMIA Metformin _ Bile acid sequestrants + hepatic glucose production SGL2 I s renal glucose excretion TZDs peripheral glucose uptake Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011 New Classes Presently in Development • • • • • • • • • • • • • • Long-acting GLP-1 receptor agonists Ranolazine Dual & Pan PPAR agonists 11 Hydroxysteroid Dehydrogenase (HSD)- 1 inhibitors Fructose 1,6-bisphosphatase inhibitors Glucokinase activators G protein-coupled Receptor (GPR)- 40 & -119 agonists Protein Tyrosine Phosphatase (PTB)- 1b inhibitors Camitine- Palmitoyltransferase (CPT)- 1 inhibitors Acetyl COA Carboxylase (ACC)- 1 & -2 inhibitors Glucagon receptor antagonists Salicylate derivatives Immunomodulatory drugs Sodium- Glucose Cotransporter (SGLT) {-1} & -2 inhibitors Care Providers Most People With Diabetes Are Not Reaching Their Goals People with Diabetes Meeting Goals (%) 100% 80% 60% 40% 60% (20% at >9%) 67% 65% 48% 37% 20% 0% A1C <7% Total Cholesterol <200 mg/dL Data from NHANES (National Health and Nutrition Examination Survey). Joy SV. Diabetes Educ. 2008;34(suppl 3):54S-59S. BP <140/90 mm Hg Annual Eye Exam Foot Exam Each Visit Achieving Control in Diabetes Can Be a Challenge: A Cycle of Frustration The health care provider is frustrated and may blame the patient The patient is given an overwhelming or vague goal: Cycle of Frustration “ Follow a meal and exercise plan, take medications, and check blood sugars” How Do We Break the Cycle? • Support patient with education and coaching The patient may feel like a failure if his or her disease is not controlled Seley JJ. Am J Nurs. 2007;107(suppl 6):4-5. • Need time, knowledge, good communication, and caring Personal barriers to diabetes care. Personal barriers to diabetes care Simmons D Diabetes Spectr 2001;14:10-12 Copyright © 2011 American Diabetes Association, Inc. The Chronic Care Model Wagner EH et al., Improvingchroniccare.org ال حياة لمن تنادي Specialist input leads to better outcomes in type 2 diabetes 17% In the Verona Diabetes Study, individuals attending a specialist diabetes center had a substantially improved chance of survival compared with those seen only by family physicians Verlato G, et al. Diabetes Care 1996; 19:211–213. Goals to improve diabetes care • Promote active self-management. • Enhance psychological care. • Enhance communications between people with diabetes and health care providers. • Promote communication and coordination between health care professionals. • Reduce barriers to effective therapy. Skovlund S E , Peyrot M Diabetes Spectr 2005;18:136-142 Translating Goals Into Action :Strategy • Raise awareness and advocacy • Educate and mobilize people with diabetes and those at risk • Train health care providers and enhance their competencies • Provide practical tools and systems • Drive policy and health care systems change • Develop psychosocial research in diabetes Skovlund S E , Peyrot M Diabetes Spectr 2005;18:136-142 Remember that all what we do will be carried by our patients Thanks