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Strategies for Prevention of Type 2 Diabetes

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Title: Strategies for Prevention of Type 2 Diabetes


1
Strategies for Prevention of Type 2 Diabetes
  • By
  • Abdullatif Husseini

2
Main topics
  • Definitions.
  • Magnitude of Type 2 diabetes.
  • Factors associated with Type 2 diabetes.
  • Levels of prevention.
  • Types of interventions.
  • Barriers and obstacles.
  • Components of prevention programs.
  • Central issues in Type 2 diabetes prevention.

3
Type 2 Diabetes definition
  • It is the most common form of diabetes,
    characterized by disorders of insulin resistance
    and insulin secretion, either of which may be the
    predominant feature. Both are usually present at
    the time that the diabetes is clinically
    manifest.
  • 2hr post glucose load venous plasma glucose
    concentration (gt 11.1 mmol/l).

4
Impaired glucose tolerance (IGT) definition
  • An intermediate category between normal glucose
    tolerance and unequivocal diabetes. It describes
    an abnormality of glucose regulation.
  • 2hr post glucose load venous plasma glucose
    concentration (7.8 - lt 11.1 mmol/l).

5
Prevention Strategies
  • Strategy A set of essential preventive measures
    believed sufficient to control a health problem.
  • The word prevention embodies the goals of
    medicine to promote health, to preserve health,
    to restore health when it is impaired, and to
    minimize suffering and distress.
  • source Last M, 1995 Dictionary of
    epidemiology.

6
Preventive strategies approaches in the design
  • A population-based strategy, involving altering
    the lifestyle and environmental determinants of
    Type 2 diabetes.
  • A high-risk strategy applying preventive measures
    on individuals identified as high-risk for Type 2
    diabetes.

7
Magnitude of the Problem
  • The number of people with diabetes will nearly
    double within the first quarter of this
    millennium.
  • World Health Report, 1997 Geneva WHO.

8
Developed Vs Developing
Region 2000 2025
Developed countries 6.2 54.8 million 7.6 72.2 million
Developing countries 3.5 99.6 million 4.9 227.7 million
King et al, Diabetes Care 1998 21 1414-31
9
Why is the prevalence of Type 2 diabetes
increasing?
  • Aging of the population.
  • Increased incidence due to urbanization
    especially in the developing countries.
  • More sedentary lifestyle.
  • Food consumption patterns, more foods with high
    fat content and more refined carbohydrates.

10
Factors associated with Type 2 diabetes
  • Modifiable
  • 1- Behavioral and lifestyle-related such as
    obesity and physical inactivity.
  • 2- Metabolic and intermediate risk categories
    such as IGT, IFG and GDM.
  • Non Modifiable
  • 1- Genetic factors.
  • 2- Demographic determinants such as age and
    ethnicity.

11
Why should we prevent diabetes?
  • To reduce human suffering.
  • To alleviate the economic burden.
  • To prevent morbidity and mortality from
    diabetes-related CVD.

12
Levels of prevention in Type 2 diabetes
  • Primary Includes activities aimed at preventing
    diabetes from occurring in susceptible
    populations or individuals.
  • Secondary Early diagnosis and effective control
    of diabetes in order to avoid or at least delay
    the progress of the disease.
  • Tertiary Includes measures taken to prevent
    complications and disabilities due to diabetes.

13
Why the primary prevention?
  • There is an urgent need to take the prevention
    of cardiovascular disease more seriously. The
    only sensible strategy is the population approach
    to primary prevention.
  • Beaglehole, the Lancet 2001 358 661-3

14
Metabolic syndrome prevention
  • The main components of the metabolic syndrome
    are glucose intolerance (diabetes or IGT),
    obesity, hypertension and dyslipidemia.
  • All of those components are risk factors for CVD
    and can be targeted in life style interventions
    to prevent Type 2 diabetes.

15
Primary prevention
  • Most of the results on prevention come from
    studies on high risk groups rather than
    populations.
  • Studies have shown that people with IGT has a 2-7
    fold higher risk of progression to Type 2
    diabetes than persons with normal glucose
    tolerance.
  • Among the factors that predicted progression were
    obesity, elevated fasting and 2-h blood glucose
    and fasting insulin concentrations.

16
Types of interventions
  • Behavioral interventions including changing diet
    and increasing physical activity.
  • And/or
  • Pharmacological interventions utilizing
    pharmaceutical agents to improve glucose
    tolerance and insulin sensitivity.

17
Behavioral interventions
  • Several studies has shown that diet and physical
    activity reduced the incidence of Type 2
    diabetes.
  • Example The Swedish Malmo study showed that diet
    and exercise for 5 years in men with IGT reduced
    the incidence of Type 2 diabetes by 50.
  • Eriksson et al, Diabetologia 1991 34
    891-8

18
Examples
  • The DaQing Chinese study showed that over 6 years
    there were significant and similar reductions in
    the incidence of diabetes in subjects with IGT
    who were randomized to diet, exercise, or
    combined diet-exercise treatment groups.
  • Pan et al, Diabetes Care, 1997 20 537-44

19
Cumulative incidence of diabetes at 6 years
Data from Pan et al, Diabetes Care, 1997 20
537-44
20
Examples- Cont
  • The Finnish Diabetes Prevention Study showed that
    Type 2 diabetes can be prevented by changes in
    the lifestyles of high-risk subjects
    (middle-aged, overweight subjects with IGT). The
    risk of diabetes was reduced by 58 in the
    intervention group. The cumulative incidence was
    11 in the intervention group compared to 23 in
    the control group.
  • Tuomilehto et al. NEJM, 2001 344 1343-50

21
Pharmacological interventions
  • Several studies examined the effects of various
    therapeutics in the prevention of diabetes.
  • The evidence for the ability of pharmacological
    interventions to prevent Type 2 diabetes awaits
    confirmation.

22
Examples
  • The Diabetes Prevention Program (DPP) funded by
    the NIH-USA to perform a major IGT intervention
    to examine the potential for prevention of Type 2
    diabetes. It includes both lifestyle and
    pharmacological interventions.
  • Diabetes Prevention Program, Diabetes Care
    1999 22 623-4

23
Population-based prevention
  • Solid data on the ability of community wide
    programs encouraging healthy diet and exercise to
    reduce the incidence of Type 2 diabetes are not
    yet available.
  • However, some studies has shown the ability of
    such programs in reducing the risk factors for
    diabetes among other non-communicable diseases.

24
Secondary prevention
  • The purpose of secondary prevention activities
    such as screening is to identify asymptomatic
    people with diabetes.
  • Is there an effective intervention that may
    retard the progression of disease or the severity
    of its complications?

25
Screening approaches
  • Population screening
  • Selective screening
  • Opportunistic screening

26
Tertiary prevention
  • Includes actions taken to prevent and delay the
    development of acute or chronic complications.
  • Acute complications such as hypoglycemia, severe
    hyperglycemia and infections.
  • Chronic complications such as atherosclerosis,
    retinopathy, nephropathy, neuropathy and foot
    problems.

27
Effective interventions
  • Strict metabolic control, education and effective
    treatment.
  • Screening for complications in their early stages
    when intervention is more effective.

28
Obstacles and barriers for prevention
  • Economic problems unavailability of needed
    resources.
  • Socio-cultural problems.
  • Lack of data, knowledge and skills.

29
Examples of socio-cultural barriers
  • Obesity is not considered negatively.
  • No value given to physical exercise.
  • Changing diet is very difficult.
  • No time is granted to do physical exercise at
    work.
  • Fatalism.

30
Major components of effective prevention programs
  • Standardized data collection on disease
    magnitude, risk factors and mortality statistics.
  • Clear action plan with specific targets, and well
    defined evaluation.
  • Initiating community-based interventions for
    primary prevention.
  • Advocacy for influencing policies.

31
Major components of effective prevention
programs- Cont
  • Advocacy for the rights of people with diabetes
    for quality care at all levels.
  • Establishing acceptable standards for health care
    for people with diabetes.
  • Establishing an effective referral system and
    defining the role of each level of health care.

32
Major components of effective prevention
programs- Cont
  • Educating the population about this important
    global epidemic.
  • Provision of appropriate training for health care
    providers.
  • Coordination of prevention efforts.

33
Central issues in Type 2 diabetes prevention
  • Type 2 diabetes prevention must be integrated in
    a major program addressing the prevention of
    other lifestyle related disorders like CVD and
    some cancers.
  • Primary prevention is of the essence especially
    in resource-constrained countries.
  • Diabetes prevention is an inter-sectoral effort
    requiring cooperation and coordination.

34
Central issues in Type 2 diabetes prevention- Cont
  • Diabetes prevention should be addressed within
    the context of health system reform ensuring the
    availability of acceptable health care standards.
  • Culturally appropriate and economically feasible
    interventions should be adopted. Imposing
    unacceptable or unaffordable interventions will
    have a negative impact.

35
What do we know about Type 2 diabetes prevention?
  • Type 2 diabetes is a major challenge to human
    health.
  • Type 2 diabetes can be prevented.
  • Primary prevention is a suitable and affordable
    choice.
  • There is strong evidence that lifestyle
    interventions are effective in diabetes
    prevention.
  • Barriers for prevention should be addressed.
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