# Presentation: 572096

## Diabetes in the Americas

*Alberto Barcelo, MD, MSc*
*Pan American Health Organization,*
*Washington DC*

## Slide 2

## Never have doctors known so much 

**about how to prevent and control this **
**disease, yet the epidemic **
**keeps on raging.......**
- 	Christine Gorman
- 	Time
- 	Nov 30, 2003

## Objectives:

- Provide information on the diabetes epidemic in the Americas
- Present data on the increased risk for CVD among people with diabetes in Latin America and the Caribbean
- 			Multi country data, SABE, CAMDI
- Rationale for the primary prevention of diabetes and its implication for health policy

## The Prevalence of Type 2 Diabetes is reaching epidemic proportion

## Diabetes in the World: WHO Projections

**Millions**

**Estimated prevalence of diabetes in the Americas, 2000-2025***

**2000: 35 million**

- * Reference: King H, Aubert RE, Herman WH. Global Burden of Diabetes, 1995-2025. *Diabetes Care* 1998;21:1414-1431

**2025: 64 Million**

-              Prevalence of Diabetes Among Adults           in the US, BRFSS, 1993–1994

- Mohkdad, JAMA 2001

##  Prevalence of Diabetes Among Adults           in the US, BRFSS, 1999

-  Prevalence of Diabetes Among Adults           in the US, BRFSS, 1999

- Mohkdad, JAMA 2001

##  Prevalence of Diabetes Among Adults           in the US, BRFSS, 2000

-  Prevalence of Diabetes Among Adults           in the US, BRFSS, 2000

- Mohkdad, JAMA 2001

## Age-Adjusted* Prevalence of Diabetes in the Americas, 1976-91

- 	*Adjusted to the World Population

- Pan American Health Organization, 2001

## Diagnosed Diabetes Mellitus in Puerto Rico

- Sources: Haddock et al., 1991; Ríos et al., 2001

## Glucose Intolerance in a Health Area of Havana, Cuba 1971 and 1998

- Source: Diaz-Diaz et al., 2000

**8.4%**

**23.6%**

## Between a half and a third of those suffering diabetes are not aware of their condition

## Diagnosed and Undiagnosed Prevalence of Diabetes by Age in the US (NHANES III)

**Diagnosed and Undiagnosed Prevalence of Diabetes by Age in the US (NHANES III)**

***Harris et al., Diabetes Care, 1998***

## Obesity in Children

**The percent of children (0-5) with over nutrition* in LAC has increased over the years**

- *Weight-for-height Z-score more than 2.0
- Source: CFNI, 2001

## People with Diabetes Present an increased Risk for CVD and Premature Mortality

##        Diabetes-Related Mortality

- 			**UNDERLYING****	****ANY CAUSE**
**Latin America ****	****	****40,000****	****300,000 **
**& the Caribbean**

- Mortality among people with diabetes 2.5 times higher

##        Diabetes Related Mortality

**Percent**

**Rate X100,000**

**Source: PAHO, CPC, 2000 (Dominica); Rodríguez 1988, Revista Costarricense de Ciencia Medicas (Costa Rica)**

## Mortality Trend in Chile

**Mortality Trend in Chile**

**Heart Diseases**

**Stroke**

**Diabetes**

## Diabetes Complications(Lifetime Risk)

- CDC Cost-Effectiveness Group, 2002

| Long-term Complications | % |
| --- | --- |
| Neuropathy | 44 |
| Nephropathy | 38 |
| Heart Diseases | 25 |
| End Stage Renal Disease | 15 |
| Blindness | 12 |
| Stroke | 12 |

## Awareness, treatment and control of hypertension among people with diabetes in the U.S. and Latin America

**Awareness, treatment and control of hypertension among people with diabetes in the U.S. and Latin America**

- Legend: * Hypertension under treatment, SBP<140 and DBP<90, **Hypertension under treatment, SBP>139 and DBP<89, ***Diagnosed not treated hypertension, ****Newly diagnosed hypertension.
- Source:23, unpublished data (Chile and Bolivia)

## The SABE Project (Salud Bienestar y Envejecimiento)

**Cluster sampling design of elderly **
**	****(60+ years)**
**10,891 participants from Bridgetown, Sao Paulo, Santiago de Chile, Havana, Mexico City and Montevideo**
**Self-reported prevalence of major NCD’s**

## Slide 24

## THE CENTRAL AMERICA DIABETES INITIATIVE:

**THE CENTRAL AMERICA DIABETES INITIATIVE:**
**COSTA RICA, EL SALVADOR, HONDURAS, GUATEMALA & NICARAGUA**

## Multinational survey on diabetes, hypertension and other CVD risk factors

**Multinational survey on diabetes, hypertension and other CVD risk factors**

- Diagnosis of diabetes
**Fasting plasma glucose (**_**> **_**126 mg/dl) and 2-h post glucose load (**_**>**_** 200 mg/dl)**

**8,000 Participants from Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama.**

## Glucose tolerance in Guatemala, 2003

## Slide 28

## Slide 29

## Today

**Today**

## ?

-           (or slow down) the
-           the diabetes

- Epidemic

**?**

## Rationale for Primary Prevention

**Scientific**
**Economic**

## Stages in the natural history 

**Genetic **
**predisposition**

**Preclinical **
**state**

- Normal

- IGT

**Disability**
**Death**

**Clinical **
**disease**

- Type 2 DM

**Disability**
**Death**

**Complications**

**Complications**

*** ******Primary                   Secondary       Tertiary***
***prevention                prevention        prevention***

**Stages in the natural history **
**of Type 2 diabetes**

**Notes:**
A simpler model for NIDDM development is this two step one proposed by Bennett and colleagues. Underlying it is the complex model shown previously, but this will be used to focus on several design issues of relevance.
After onset, diabetes induces several changes in the network of intermediate traits that are of interest to us.

## What is the 

- Evidence

- Yes

- No

**What is the**** **

## Major Studies 

**Da Qing IGT and Diabetes Study, China**
**Diabetes Prevention Study, Finland**
**Diabetes Prevention Program, USA**
**STOP NIDDM, Europe, Canada**
**Troglitazone in the Prevention of Diabetes (TRIPOD), USA**

## Benefits

**Study                       Reduction in risk (%)**
**	****	****	****	****	****Lifestyle****	****Drug**
**Da Qing****	****	****  ****	****  31-46**
**DPS****	****	****	****   ****	****    58**
**DPP****	****	****	****   ****	****    58****	****	****  31**
**Stop NIDDM****	****	****   ****	****	****  25**
**TRIPOD****	****	**** ****	****	****	****  55**

## What are the current policy recommendations? 

**American Diabetes Association**
**	****Prediabetes:**
**	****	****Opportunistic screening for IGT or IFG:**
**	****	****>= 45 yrs**
**	****	****Emphasis on those with BMI >25 **
**	****	****Consider others if are overweight with  ****	****	****risk factors**
**	****	**
**	**

- ADA Position Statement Diabetes Care 2004;27:S47

## What are the current policy recommendations? 

**   ****IDF IGT/IFG Consensus Statement. Report of an Expert Consensus Workshop**
**	**
**    ****IGT or IFG should receive lifestyle advice**
**    ****If lifestyle fails, consider drugs**
**    ****Target those at highest risk for DM and CVD****	**

- Unwin N et al. Diabetic Medicine 2002;19:708

## What are the current policy recommendations? 

**Finnish National Policy**
**	****Prediction models for future risk**
**	****Use fewer screening tests**
**    ****Tailor to the individuals’ level of risk**

- Lindstrom J Diabetes Care 2003;26:725

## Diabetes and Hypertension Screening in Mexico

## The Primary Prevention of DM in the Americas (lifetime horizon)

- Population at risk (45-64 years): 125,600,974

-  Type 2 DM New Cases per Year: 1,117,773

-  Potentially Preventable: 550,813

-  Needed to Include in Prevention Program : 3,760,676

## DM Type 2 Primary Prevention: Future Savings

**Gain QALY’s: **5,444,194** **
**YPLL Saved: **$57,941,304,589
- Saving in Direct (Medical care) : $37,534,686,912
- Total Savings: $95,475,991,501

## Conclusion

**Although there is limited data on the prevalence of diabetes and major CVD in LAC, the available information indicates that the prevalence of DM is increasing.**
**There is evidence that type 2 DM and some of its complications can be prevented. **

## Conclusion

**In view of the burden that diabetes represents to people and society there is a need to commence primary prevention strategies as well as improve diabetes management.**