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Changing trends in epidemiology of type 1 diabetes mellitus throughout the world: How far have we co

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Title: Changing trends in epidemiology of type 1 diabetes mellitus throughout the world: How far have we co


1
Changing trends in epidemiology of type 1
diabetes mellitus throughout the world How far
have we come and where do we go from here
  • Ingrid Libman, M.D., Ph.D.
  • Ronald LaPorte, Ph.D.
  • University of Pittsburgh

2
Objectives
  • Counting diabetes Historical background
  • Diabetes Registries What have we learned?
  • Challenges ahead Where do we go from here?

3
Objectives
  • Counting diabetes Historical background
  • Diabetes Registries What have we learned?
  • Challenges ahead Where do we go from here?

4
Need to count disease, specifically diabetes,
started a long time ago..
5
Counting diabetes Why is it important?
Prevention
Reducing the incidence of disease (primary
prevention) Reducing the prevalence of disease
(secondary prevention)
Control
Ongoing operations or programs aimed at reducing
the incidence and/or prevalence of disease
Last, Dictionary of Epidemiology
6
Counting diabetes
diarrhea of the urine .. the thirsty
disease rare .only seen two cases..
Galen, disciple of Hippocrates Second century AD
7
.Diabetes is a wonderful affection, not very
frequent among men, being a melting down of the
flesh and limbs into urine
the patient is short-lived if the constitution
of the disease be completely established
Aretaeus the Cappadocian Disciple of
Hippocrates Second century AD
8
diabetes seldom seen in cold Europe and
frequently encountered in warm Africa have
not seen in the West here, in Egypt, in the
course of 10 years, I have seen more than twenty
people who suffer this illness.
Maimonides 1135-1204 AD
9
Historical background
End of 1970s
  • Types of diabetes loosely divided into
  • juvenile onset and maturity onset
  • Enormous variation in cut-off values for
  • the fasting glucose level and after OGTT
  • Size of glucose load varied between 50 g
  • and 100 gr or body weight related

10
Historical background
  • Chemical diabetes no symptoms of diabetes,
    normal fasting glucose, but demonstrable
    abnormality of oral glucose tolerance test
  • Studies done
  • small number of children
  • different doses of glucose administered
  • different criteria for defining abnormal
  • glucose tolerance (USPHS, Fajans and Conn,
  • University Diabetes Group Program, etc)

11
It took many centuries.
Book summarizing contributions, clinical and
population-based on the subject of diabetes
epidemiology and highlighted the many gaps in our
diabetes epidemiology knowledge at that time
Kelly West, 1978 "Epidemiology of Diabetes and
its Vascular Complications"
12
A survey of twenty diabetologists revealed that
they employ diagnostic criteria differing quite
substantially. In some populations, including
the general population of the United States,
these disparities would result in very major
differences in the rates of "diabetes." Under
certain common circumstances, some diabetologists
would classify as normal more than half of the
one- and two-hour values considered to be
abnormal by other well-qualified diabetologists
Substantial differences in the diagnostic
criteria used by diabetes experts
KW West Diabetes 1975
13
Historical background
1979 1980
  • IDDM and NIDDM defined
  • 75 gr oral glucose tolerance test (OGTT)
  • became the gold standard with fasting
  • and 2 hour values defined
  • Category of IGT added (metabolic stage
  • intermediate between normal glucose
  • homeostasis and diabetes)

14
Diabetes in childhood IDDM
  • Easy to diagnose
  • Abrupt onset
  • Requiring medical attention
  • Requiring medication (insulin)

the epidemiologists dream
15
By the 1980s ..
  • Few registries monitoring IDDM incidence
  • Limited information but geographical
    differences in incidence identified
  • However, lack of standardization
  • - different case definition
  • - different ages
  • - different degrees of ascertainment

16
1983
  • An international collaborative IDDM
  • registry group should be established
  • to develop standardized norms
  • Validation of the completeness of
  • case ascertainment should be required
  • Investigators should share their patient
  • intake forms
  • Plan for sharing of data between registries
  • should be established

Registries of Persons with IDDM (International
Workshop on the Epidemiology of IDDM)
LaPorte R et al. Diabetes Care 1985
17
Diabetes in Childhood IDDM Registries
  • Establishment of population-based registries
    around the world
  • Monitor the global pattern of the disease
  • Provide a basis for standardized studies of risk
    factors


Karvonen M et al. Diabetes Care 2000
18
DIAMOND ProjectCountries participating
Argelia, Argentina, Antigua, Australia, Austria,
Bahamas, Barbados, Belgium, Brazil, Bulgaria,
Chile, China, Colombia, Costa Rica, Croatia,
Cuba, Czech Republic, Denmark, Dominica,
Dominican Republic, Egypt, Estonia, Finland,
France, Germany, Greece, Hong Kong, Hungary,
Iceland, India, Ireland, Israel, Italy, Japan,
Korea, Kuwait, Lithuania, Malta, Mauritius,
Mexico, Netherlands, New Zealand, Norway,
Paraguay, Peru, Poland, Portugal, Romania,
Russia, Saint Kitts, Slovakia, Slovenia, Spain,
Sudan, Sweden, Switzerland, Taiwan, Tanzania,
Thailand, Tunisia, United Kingdom, Uruguay, USA,
Venezuela
19
DIAMOND Project
Algeria Dr. K. Bessaoud (Oran). Argentina Dr.
M. Molinero de Ropolo (Cordoba) Dr. M. de
Sereday, M.L. Marti, Dr. M. Damiano, and Dr. M.
Moser (Avellaneda) Dr. S. Lapertosa
(Corrientes), Dr. A. Libman (Rosario), Dr. O.
Ramos (Buenos Aires). Australia Dr. C. Verge and
Dr. N. Howard (New South Wales). Austria Dr. E.
Schober. Barbados Dr. O. Jordan. Belgium Dr. I.
Weets, Dr. C. Vandevalle, Dr. I. De Leeuw, Dr. F.
Gorus, Dr. M. Coeckelberghs, and Dr. M. Du Caju
(Antwerp region). Brazil Dr. L. J. Franco and
Dr. S.R.G. Ferreira (3 centers, state of Sao
Paulo). Bulgaria Dr. R. Savova and Prof. V.
Christov (West Bulgaria) and Dr. V. Iotova and
Prof. Valentina Tzaneva (Varna). Canada Dr. E.
Toth (Alberta) and Dr. M.H. Tan (Prince Edward
Island). Chile Dr. E. Carrasco and Dr. G. Lopez
(Santiago). China Dr. Yang Ze (Henan, Dalian,
Guilin, Jilin, Nanning, and Zunyi) Dr. Bo Yang
(Tieling) Dr. Chen Shaohua and Dr. Fu Lihua
(Jinan) Dr. Deng Longqi (Sichuan) Dr. Shen
Shuixian (Shanghai) Dr. Teng Kui (Wulumuqi) Dr.
Wang Chunjian, Dr. H. Jian, and Dr. J. Ju
(Zhengzhou) Dr. Yan Chun and Dr. Y. Ze
(Beijing) Dr. Deng Yibing and Dr. Li Cai
(Changchun) Dr. Ying-Ting Zhang (Jilin
province) Dr. Liu Yuqing and Dr. Long Xiurong
(Shenyang) Dr. Zhaoshou Zhen (Huhehot) Dr.
Zhiying Sun (Dalian) Prof. Wang Binyou (Harbin)
and Dr. Gary Wing-Kin Wong (Hong Kong). Colombia
Dr. P. Aschner (Santafè de Bogotà, D.C.). Cuba
Dr. O. Mateo de Acosta, Dr. I. Hernández Cuesta,
Dr. F. Collado Mesa, and Dr. O. Diaz-Diaz.
Denmark Dr. B.S. Olsen, Dr. A.J. Svendsen, Dr.
J. Kreutzfeldt, and Dr. E. Lund (4 counties).
Dominica Dr. E.S. Tull. Estonia Dr. T. Podar.
Finland Prof. J. Tuomilehto and Dr. M. Karvonen.
France Dr. C. Levy-Marchal and Dr. P. Czernichow
(4 regions). Germany Dr. A. Neu
(Baden-Wuerttemberg). Greece Dr. C. Bartsocas,
Dr. K. Kassiou, Dr. C. Dacou-Voutetaki, Dr. A.C.
Kafourou, Dr. Al Al-Qadreh, and Dr. C. Karagianni
(Attica region). Hungary Dr. Gyula Soltesz (18
counties). Israel Prof. Z. Laron, Dr. O. Gordon,
Dr. Y. Albag, and Dr. I. Shamis. Italy Dr. F.
Purrello, Dr. M. Arpi, Dr. G. Fichera, Dr. M.
Mancuso, and Dr. C. Lucenti (eastern Sicily)
Prof. G. Chiumello (Lombardia region) Dr. G.
Bruno and Prof. G. Pagano (Turin province) Dr.
M. Songini, Dr. A. Casu, Dr. A. Marinaro, Dr. R.
Ricciardi, Dr. M.A. Zedda, and Dr. A. Milia
(Sardinia) Dr. M. Tenconi and Dr. G. Devoti
(Pavia province) Prof. P. Pozzilli, Dr. N.
Visalli, Dr. L. Sebastiani, Dr. G. Marietti, and
Dr. R. Buzzetti (Lazio region) and Dr. V.
Cherubini (Region Marche). Japan Dr. A. Okuno,
Dr. S. Harada, and Dr. N. Matsuura (Hokkaido)
Dr. E. Miki, Dr. S. Miyamoto, and Dr. N. Sasaki
(Chiba) and Dr. G. Mimura (Okinawa). Kuwait Dr.
A. Shaltout and Dr. Mariam Qabazrd. Latvia Dr.
G. Brigis. Lithuania Dr. B. Urbonaite.
Luxembourg Dr. C. de Beaufort. Mauritius Dr. H.
Gareeboo. Mexico Dr. O. Aude Rueda (Veracruz).
The Netherlands Dr. M. Reeser (5 regions). New
Zealand Dr. R. Elliott (Auckland) and Dr. R.
Scott, Dr. J. Willis, and Dr. B. Darlow
(Canterbury). Norway Dr. G. Joner (8 counties).
Pakistan Dr. G. Rafique (Karachi). Paraguay Dr.
J. Jimenez, Dr. C.M. Palaeios, Dr. F. Canete, Dr.
J. Vera, and Dr. R. Almiron. Peru Dr. S. Seclén
(Lima). Poland Dr. D. Woznicka, Dr. P. Fichna
(Wielkopolska) and Dr. Z. Szybinski (Cracow).
Portugal Dr. C. Menezes (Portalegre), Dr. E.A.
Pina (Algarve region), Dr. M.M.A. Ruas and Dr.
F.J.C. Rodrigues (Coimbra), and Dr. S. Abreu
(Madeira Island). Romania Dr. C.
Ionescu-Tirgoviste (Bucharest region). Russia
Dr. E. Shubnikof (Novosibirsk). Slovakia Dr. D.
Michalkova. Slovenia Prof. C. Krzisnik, Dr. N.
Bratina-Ursic, Dr. T. Battelino, and Dr. P.
Brcar-Strukelj. Spain Dr. A. Goday, Dr. C.
Castell, and Dr. C. Lloveras (Catalonia). Sudan
Dr. M. Magzoub (Gezira province). Sweden Prof.
G. Dahlquist. Tunisia Dr. K. Nagati (Kairouan)
and Dr. F.B. Khalifa (Gafsa, Beja, Monastir).
U.K. Dr. A. Burden and N. Raymond
(Leicestershire) Dr. B.A. Millward and Dr. H.
Zhao (Plymouth) Dr. C.C. Patterson, Dr. D.
Carson, and Prof. D. Hadden (N. Ireland) Dr. P.
Smail and Dr. B. McSporran (Aberdeen) and Dr. P.
Bingley (Oxford region). U.S. Dr. E.S. Tull
(Virgin Islands), Dr. R.E. LaPorte and Dr. I.
Libman (Allegheny County, PA), Dr. J. Roseman and
Dr. S.M. Atiqur Rahman (Jefferson County, AL),
Dr. T. Frazer de Llado (Puerto Rico), and Dr. R.
Lipton (Chicago). Uruguay Dr. A.M. Jorge
(Montevideo). Venezuela Dr. P. Gunczler and Dr.
R. Lanes (Caracas, second center), Dr. H. King
(WHO, Geneva, Switzerland).
20
Historical background
late 1990s
  • Type 1 and type 2 diabetes defined
  • Lowered criteria for diagnosis of
  • diabetes to fasting plasma glucose ? 126 mg/dl
  • Category of IFG added (plasma glucose
  • ? 110 mg/dl and lt 126 mg/dl)

21
Objectives
  • Counting diabetes Historical background
  • Diabetes Registries What have we learned?
  • Challenges ahead Where do we go from here?

22
One of the fundamental necessities of cancer
surveillance is for users of cancer information
to be assured that case definitions, data
collection, is standardized. This enables
compilation of case-specific information into
useful and meaningful registers. It also enables
meaningful comparison of data across different
registries
North American Association of Central Cancer
Registries
23
IDDM Registries Eligibility Criteria
  • diagnosis of IDDM by a physician
  • on insulin at time of discharge from the hospital
  • age at onset 0-14
  • resident of a defined area at diagnosis
  • diabetes not secondary to other conditions

24
IDDM Registries Data to be collected
  • Name
  • Sex
  • Race
  • Birth Date
  • Date of first insulin injection
  • Place of residence at diagnosis

25
Same definition and same data would allow
comparisons
26
Validation of the completeness of case
ascertainment Capture-recapture method
Physicians
Schools
Hospitals
Pharmacies
27
Incidence of T1DM in the Americas 0 14 years
DIAMOND Project
/100,000
Karvonen M et al. Diabetes Care 2000
28
Important geographic differences
Depending on where you live, different magnitude
of the problem
29
T1DM Incidence in Santiago, Chile 1986 - 2000
/100,000
plt0.001
Carrasco E et al. Diabetes et Metabolism 2003
30
Incidence of T1DM in Finland Children lt 15 years,
1987-1996
100,000/year
Tuomilehto et al. Diabetologia 1999
31
Relative increase in incidence of T1DM Children
0 - 14 years
Yearly change 2.5 per year (2.3-2.7)
Increase in the incidence /year
Adapted from Onkamo P et al, Diabetologia 1999
32
Important temporal changes
Clues to etiology?
33
Allegheny County IDDM RegistryIncidence by race
and period, 1965 - 1994, 0-19 years age group
/100,000
Libman I et al. Diabetes Care 1998
34
Allegheny County IDDM RegistryIncidence by race
and period, 1965-1994, 15-19 years age group
/100,000



Libman I et al. Diabetes Care 1998
35
IDDM incidence by periodBlacks 10 to 14 years
/100,000
Lipton R et al.Diabetes/Metab Res Rev 2002 Lipman
T et al. Diabetes Care 2002
36
Generate hypothesis
37
Objectives
  • Counting diabetes Historical background
  • Diabetes Registries What have we learned?
  • Challenges ahead Where do we go from here?

38
At present
2000.
  • Type 1 and type 2 diabetes defined
  • Type 2 diabetes in children described
  • Reports of double, hybrid, atypical
  • diabetes (mixed phenotype)
  • Changes in the phenotype of typical T1DM

39
Diabetes in childhood ? IDDM
  • Easy to diagnose
  • Abrupt onset
  • Requiring medical attention
  • Requiring medication (insulin)

X
the epidemiologists challenge
40
Diabetes in Childhood
Efforts such as DIAMOND and EURODIAB should
continue
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