Download Presentation

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