Tracking the Accelerating Epidemic: Its Causes and Outcomes

1
AusDiab 2005The Australian Diabetes, Obesity
and Lifestyle Study

• Tracking the Accelerating Epidemic Its Causes
  and Outcomes

2
Baseline data from AusDiab 2000

• The AusDiab survey carried out in 19992000
  provides benchmark Australian prevalence data
• 2000 findings, Australians ? 25 years old
• 7.4 had diabetes (doubled since 1981)
• 16.3 had pre-diabetes (IFG/IGT)
• 59.6 were mildly overweight or obese
• 28.8 had hypertension
• 51.2 had total cholesterol 5.5 mmol/L, and
  20.5 had elevated triglycerides ( 2.0 mmol/L)
• 2.5 had proteinuria, 6.4 had haematuria and
  1.1 had elevated serum creatinine

IFG - impaired fasting glucose IGT - impaired
glucose tolerance.
3
Aims of the five-year follow-up

• Describe the natural history of
• Type 2 diabetes
• Pre-diabetes (IFG/IGT)
• Associated cardiovascular disease, risk factors
  and complications
• Identify risk factors associated with worsening
  glucose tolerance status and diabetic
  complications
• Measure the progression of renal disease in
  diabetic and non-diabetic populations

IFG - impaired fasting glucose IGT - impaired
glucose tolerance.
4
Definitions for prevalence and incidence

• 19992000 dataPrevalence the proportion of
  people within a population who have a certain
  disease or condition at a particular time
• 200405 dataIncidence number of new cases of
  a disease or condition arising in a population
  over a period of time

5
Diabetes and pre-diabetes
6
Diabetes mellitus

• Is a metabolic disorder with multiple causes
  characterised by chronically elevated blood
  glucose levels
• Predisposes individuals to
• Cardiovascular disease Visual loss
• Amputations Renal
  failure
• Has many risk factors including obesity,
  hypertension and dyslipidaemia

7
Classification values for the oral glucose
tolerance test
Plasma glucose (mmol/L)
Glucose tolerance
World Health Organization. Department of
noncommunicable disease surveillance, 1999
8
Diabetes in AustraliaThe last 20 years
1000
e) AusDiab
d) Aust Bureau Statistics
800
c) Aust Bureau Statistics
600
Thousands
b) Nat Heart Foundation
400
a) Busselton
200
0
80
82
84
86
88
90
92
94
96
98
00
Year
9
Age- and gender-specific prevalence () of
diabetes
Percentage
Age group (years)
10
Age-specific prevalence () of IFG
Percentage
Age group (years)
IFG - impaired fasting glucose
11
Age-specific prevalence () of IGT
Percentage
Age group (years)
IGT - impaired glucose tolerance
12
Weighted prevalence () of associated conditions
stratified by glucose tolerance status

• Glucose tolerance status

Associated condition Diabetes IFG IGT Normal
Hypertension 69.3 43.5 50.1 21.1 Obesity (BMI ?
30 kg/m²) 44.4 30.1 31.5 15.9 LDL (? 3.5
mmol/L) 45.9 59.6 53.0 44.1 HDL (? 1.0
mmol/L) 23.1 16.8 11.6 10.6 Triglycerides (? 2.0
mmol/L) 42.9 31.4 31.1 16.0
On treatment, or systolic pressure ? 140 mmHg,
or diastolic pressure ? 90 mmHg
IGT - impaired glucose tolerance IFG - impaired
fasting glucose.
13
Incidence of diabetes according to gender
Incidence ( per year)
14
Incidence of diabetes according to baseline age
Incidence ( per year)

Baseline age (years)
15
Incidence of diabetes accordingto baseline
glucose tolerance status
Incidence ( per year)
Baseline glucose tolerance
NGT - normal glucose tolerance IFG - impaired
fasting glucose IGT - impaired glucose
tolerance.
16
Incidence of IGT and IFG
Incidence ( per year)
IGT - impaired glucose tolerance IFG - impaired
fasting glucose.
17
Incidence of diabetes according to baseline body
mass index
Incidence ( per year)
Baseline BMI status
Body mass index (BMI weight/height2) was
categorised into three groups (i) normal BMI lt
25.0 kg/m2 (ii) overweight 25.0-29.9 kg/m2
and (iii) obese 30.0 kg/m2.
18
Incidence of diabetes according to baseline waist
circumference categories
Incidence ( per year)
Baseline waist circumference categories
Waist circumference (i) normal lt 94.0 cm for
males, lt 80.0 cm for females (ii) overweight
94.0-101.9 cm for males, 80.0-87.9 cm for
females (iii) obese 102.0 cm for males,
88.0 cm for females.
19
Incidence of diabetes accordingto baseline
physical activity
Incidence ( per year)
Baseline physical activities categories
20
Incidence of diabetes according to baseline
hypertension status
Incidence ( per year)
Baseline hypertension status
Hypertension (high blood pressure) was defined as
having a blood pressure 140/90 mmHg and/or
taking blood-pressure lowering medication.
21
Incidence of diabetes according to baseline
dyslipidaemia status
Incidence ( per year)
Dyslipidaemia status at baseline
Dyslipidaemia was defined as those with
triglycerides 2.0 mmol/L or high-density
lipoprotein cholesterol levels lt 1.0 mmol/L.
22
Incidence of diabetes according to baseline
metabolic syndrome status
Incidence ( per year)
Baseline metabolic syndrome status
Metabolic syndrome was defined according to the
definition by the International Diabetes
Federation.
23
Diabetes ? Key findings

• Every year 0.8 of Australian adults develop
  diabetes
• Every day in Australia approximately 275 adults
  develop diabetes
• Those with pre-diabetes were 1020 times more
  likely to develop diabetes than those with normal
  blood glucose levels
• Obesity, hypertension, dyslipidaemia, physical
  inactivity and the metabolic syndrome each
  increased the risk for developing diabetes

24
Obesity
25
Body mass index classification

• Body mass index (kg/m2)

Normal lt 25.0 Overweight 25.0
29.9 Obese 30.0
26
Classification of abdominal obesity by waist
circumference

• Waist circumference (cm)

Males Females
Normal lt 94.0 lt 80.0 Overweight 94.0
101.9 80.0 87.9 Obese 102.0 88.0
27
Age-specific prevalence () of obesityby BMI
waist circumference

• Age (years)

Classification 25-34 35-44 45-54 55-64 65-74 75 T
otal
BMI Males 17.0 17.5 20.5 25.5 20.5 11.6 19.1 Fe
males 12.2 19.4 26.0 31.9 29.7 14.9 21.8 Persons
14.7 18.4 23.2 28.7 25.5 13.5 20.5 Waist
Males 13.6 24.6 27.4 35.8 41.2 36.8 26.6 Female
s 17.1 25.6 37.6 46.7 52.2 43.0 33.9 Persons 15.3
25.1 32.4 41.2 47.3 40.5 30.3
BMI ? 30 kg/m² Waist circumference males ?
102 cm females ? 88 cm
28
Mean weight change over five years according to
baseline age
Mean change in weight (kg)
- 0.3
- 2.2
25 34
35 44
45 54
55 64
65 74
75
Total
Baseline age (years)
29
Mean body mass index change over five years
according to baseline age
1.0
1.0
Mean change in BMI (kg/m2)
- 0.2
25 34
35 44
45 54
55 64
65 74
75
Total
Baseline age (years)
30
Mean waist circumference change over five years
according to baseline age
3.0
3.0
2.0
Mean change in waist circumference (cm)
25 34
35 44
45 54
55 64
65 74
75
Total
Baseline age (years)
31
Mean weight change over five years according to
baseline body mass index status
Mean weight change (kg)
1.0
Baseline BMI status
32
Mean waist circumference change over five years
according to baseline BMI status
2.0
Mean waist circumference change (cm)
Baseline BMI status
33
Incidence of obesity according to baseline body
mass index status
Incidence ( per year)
2.0
Baseline BMI status
34
Proportion of individuals classified by body mass
index in 200405 according to baseline body mass
index status

• BMI in 200405

BMI status at baseline
Body mass index (BMI weight/height2) was
categorised into three groups (i) normal BMI lt
25.0 kg/m2 (ii) overweight 25.0-29.9 kg/m2
and (iii) obese 30.0 kg/m2.
35
Proportion of individuals classified by waist
circumference in 200405 according to baseline
waist circumference categories
Waist circumference categories at baseline
Waist circumference categories in 200405
Waist circumference (i) normal lt 94.0 cm for
males, lt 80.0 cm for females (ii) overweight
94.0-101.9 cm for males, 80.0-87.9 cm for
females (iii) obese 102.0 cm for males,
88.0 cm for females.
36
Obesity ? Key findings

• People aged lt 65 years showed an average weight
  increase of 1.8 kg over five years
• People aged 65 years showed a loss in weight of
  0.8 kg over the same period
• Waist circumference ? average gain over five
  years was 2.1 cm greater in females than males
• Younger people gained more weight and had a
  greater increase in waist circumference than did
  older people
• Twice as many overweight people became obese as
  reverted to normal

37
Hypertension
38
Role of hypertension

• High blood pressure is a risk factor for
  cardiovascular and renal disease
• For individuals with diabetes, high blood
  pressure is a risk factor for microvascular
  complications as well as cardiovascular disease
• The baseline study found that 28.8 of adults
  25 years of age were classified as
  hypertensive (BP 140/90 mmHg or taking BP
  lowering medication)

39
Classification of blood pressure
Systolic blood Diastolic
blood Blood-pressure
pressure (mmHg) pressure (mmHg)
lowering medication
Normal lt 140 and lt 90 and No
Hypertension 140 or 90 or Yes
Guidelines Subcommittee. J Hypertens 1999 17
151?83.
40
Prevalence () of adequate blood pressure
control among people on anti-hypertensive therapy

• Age (years)

2534 3544 4554 5564 6574 75 Total
Males 55.8 45.3 37.4 28.7 20.1 34.3 Females 75.5
75.9 59.2 47.6 43.2 33.7 46.4 Persons 75.5 66.4 52
.6 42.6 37.3 29.3 41.4
Systolic pressure ? 140 mmHg, and a diastolic
pressure ? 90 mmHg, and on anti-hypertensive
medication
41
Proportion of individuals classified with
hypertension in 2004?05 according to baseline
hypertension
Hypertension status in 200405
Hypertension status at baseline
42
Incidence of hypertension according to baseline
age
Incidence ( per year)

Baseline age (years)
43
Incidence of hypertension according to baseline
glucose tolerance status
Incidence ( per year)
Baseline glucose tolerance status
NGT - normal glucose tolerance IFG - impaired
fasting glucose IGT - impaired glucose
tolerance DM diabetes mellitus
44
Incidence of hypertension according to baseline
body mass index status
Incidence ( per year)
Baseline BMI status
BMI Body mass index where (i) normal was a BMI
of lt 25.0 kg/m2 (ii) overweight was a BMI of
25.0-29.9 kg/m2 and (iii) obese was a BMI of
30.0 kg/m2.
45
Incidence of hypertension according to baseline
smoking status
Incidence ( per year)
Baseline smoking status
46
Hypertension ? Key findings

• 3.0 of adults develop hypertension every year
• The risk increases with age from 1.0 per year at
  25?34 years of age to 8.4 per year at 65?74
  years of age
• Those at greatest risk are people
• With diabetes and pre-diabetes (females higher
  risk than males)
• Who are overweight or obese (females higher risk
  than males)
• Who smoke (males higher risk than females)

47
Metabolic syndrome
48
Significance of the metabolic syndrome

• The metabolic syndrome is characterised by
  central or abdominal obesity, and a clustering
  of cardiovascular risk factors, such as
• Abnormal glucose tolerance
• Raised triglycerides
• Decreased HDL-cholesterol
• Hypertension
• Hyperinsulinaemia (with underlying insulin
  resistance)
• The metabolic syndrome confers a higher risk of
  diabetes and cardiovascular disease

49
Classification of the metabolic syndrome

• Threshold

Component
Alberti KG et al. Lancet 2005 366 1059?62.
50
Incidence of the metabolic syndrome according to
gender
3.0
Incidence ( per year)
51
Incidence of the metabolic syndrome according to
baseline age
Incidence ( per year)
Baseline age (years)
52
Incidence of the metabolic syndrome according to
baseline waist circumference categories
Incidence ( per year)
Baseline waist circumference categories
Waist circumference (i) normal lt 94.0 cm for
males, lt 80.0 cm for females (ii) overweight
94.0-101.9 cm for males, 80.0-87.9 cm females
(iii) obese 102.0 cm for males, 88.0 cm for
females.
53
Incidence of the metabolic syndrome according to
baseline physical activity
Incidence ( per year)
Baseline physical activity status
54
Incidence of the metabolic syndrome according to
baseline glucose tolerance status
Incidence ( per year)
Baseline glucose tolerance status
NGT - normal glucose tolerance IFG - impaired
fasting glucose IGT - impaired glucose
tolerance DM diabetes mellitus
55
Metabolic syndrome ? Key findings

• The risk of developing the metabolic syndrome
• Was six times greater in people who were obese
  than those who were normal weight
• Was two times greater in people with diabetes
  than those with normal glucose tolerance
• Was greater in physically inactive people
• Increased with increasing age
• Was greater for males than females

56
Chronic kidney disease
57
Significance of chronic kidney disease

• Individuals with chronic kidney disease are at
  increased risk of end-stage renal failure, and
  premature cardiovascular disease1,2
• The incidence of end-stage kidney disease is 95
  cases/million population per annum3
• Diabetes is a leading cause responsible for 30
  of all new cases3

1. Anavekar NS et al. N Engl J Med 2004 351
1285?95. 2. Go AS et al. N Engl J Med 2004 351
1296?305. 3. McDonald SP et al. The 28th report
of the Australia and New Zealand Dialysis and
Transplant Registry 2006.
58
Definitions

• Estimated impaired glomerular filtration rate,
  eGFR, defined as lt 60 mL/min/1.73 m2
• Abnormal albuminuria defined as spot urine
  albumincreatinine 2.5 mg/mmol for males and
  3.5 mg/mmol for females

59
Incidence of impaired glomerular filtration rate
according to gender
Incidence ( per year)
60
Incidence of impaired glomerular filtration rate
according to baseline age
Incidence ( per year)
Baseline age (years)
61
Incidence of impaired glomerular filtration rate
according to baseline glucose tolerance status
Incidence ( per year)
Baseline glucose tolerance status
NGT - normal glucose tolerance IFG - impaired
fasting glucose IGT - impaired glucose
tolerance DM - diabetes mellitus.
62
Incidence of impaired glomerular filtration rate
according to baseline hypertension status
Incidence ( per year)
Baseline hypertension status
Hypertension (high blood pressure) was defined as
having a blood pressure 140/90 mmHg and/or
taking blood-pressure lowering medication.
63
Incidence of albuminuria according to gender
1.0
Incidence ( per year)
64
Incidence of albuminuria according to baseline
age
Incidence ( per year)
Baseline age (years)
65
Incidence of albuminuria according to baseline
glucose tolerance status
Incidence ( per year)
Baseline glucose tolerance status
NGT - normal glucose tolerance IFG - impaired
fasting glucose IGT - impaired glucose
tolerance DM diabetes mellitus
66
Incidence of albuminuria according to baseline
hypertension status
Incidence ( per year)
Baseline hypertension status
Hypertension (high blood pressure) was defined as
having a blood pressure 140/90 mmHg and/or
taking blood-pressure lowering medication.
67
Chronic kidney disease ? Key findings

• Approximately 1 of adults developed chronic
  kidney disease each year
• Approximately 1 of adults developed albuminuria
  each year
• People with hypertension have three times the
  risk of developing impaired GFR and albuminuria
• People with diabetes have five times the risk of
  developing albuminuria, and twice the risk of
  developing reduced kidney function

68
Mortality
69
Mortality rates

• AusDiab 2005 examined the 5-year all-cause
  mortality rates for males and females, for
  different age groups and for different levels of
  glucose tolerance
• The relative mortality risk was calculated for
  independent risk factors
• Over a median time of 5.2 years there were 355
  deaths (208 males, 147 females). This represents
  a mortality rate of 6.1 per 1,000 person years

70
Total mortality according to baseline glucose
tolerance status
Mortality rate (per 1000 py)
Baseline glucose tolerance
NGT - normal glucose tolerance IFG - impaired
fasting glucose IGT - impaired glucose
tolerance NDM - newly diagnosed diabetes KDM -
previously diagnosed diabetes.
71
Relative risk of mortality for people with
pre-diabetes and diabetes compared with people
with NGT
All-cause mortality hazard ratio
Baseline glucose tolerance status
After accounting for other risk factors. Bars
represent 95 confidence intervals
NGT - normal glucose tolerance IFG - impaired
fasting glucose IGT - impaired glucose
tolerance NDM - newly diagnosed diabetes KDM -
previously diagnosed diabetes.
72
Relative risk of mortality associated with
various risk factors
4
3
Allcause mortality hazard ratio
2
1
CVD
KDM
Smoking
Albuminuria
Hypertension
Impaired GFR
0
Baseline risk factors
After accounting for other risk factors. Bars
represent 95 confidence intervals
73
Baseline glucose tolerance status among those
dying of cardiovascular disease
21
33
13
13
20
NGT - normal glucose tolerance KDM
previously diagnosed diabetes NDM newly
diagnosed diabetes IFG - impaired fasting
glucose IGT - impaired glucose tolerance.
74
Prevalence () of smoking status among Australian
residents
Percentage
Smoking status
75
Trends in the age-standardised prevalence() of
hypertension 1980 2000
Percentage
Year
Age standardised to the 1991 Australian
population
ABS. Population by age and sex. Canberra ABS,
1999
76
Mortality ? Key findings

• Over five years
• People with previously known diabetes were twice
  as likely to die as were those with normal
  glucose tolerance
• People with previously known diabetes had a
  similar risk of mortality to smokers and people
  with previous cardiovascular disease
• Pre-diabetes was associated with a 45?55
  increase in mortality risk
• Over two-thirds of all cardiovascular disease
  deaths occurred in people with diabetes or
  pre-diabetes

77
Survey methods and response rates
78
Sampling frame for the AusDiab follow-up 2004 05
Individuals participating in the baseline
surveyn 11,247

• Individuals ineligible for invitation n 459
• Requested no further contact 128
• Deceased 310
• Excluded 21

Total individuals eligible for invitation to
AusDiab 200405 n 10,788
Excluded included participants who had
moved into a nursing facility classified for high
care, or were ineligible due to chronic or
terminal illness
79
Response rates to the AusDiab survey 2004 5
Eligible participants10,788
Cancelled1,990
Attendance at external pathology laboratory137
Health conditions telephone questionnaire
only2,261
On-site attendance6,400
Participated in AusDiab survey 200405 8,798
80
Response rates by state or territory
State Number On-site Pathology Self-reported Overa
ll eligible testing laboratory medical responder
s attendance conditions only n n
() n () n () n ()
VIC 1,429 821 (57.5) 52 (3.6) 337 (23.6) 1,210
(84.7) WA 1,526 990 (64.9) 28 (1.8) 210
(13.8) 1,228 (80.5) NSW 1,458 871 (59.7) 14
(1.0) 323 (22.1) 1,209 (82.9) TAS 1,700 1,102
(64.8) 2 (0.1) 296 (17.4) 1,400
(82.4) SA 1,700 945 (55.6) 29 (1.7) 467
(27.5) 1,441 (84.8) NT 1,202 702 (58.4) 5
(0.4) 189 (15.7) 895 (74.5) QLD 1,748 954 (54.6)
7 (0.4) 433 (24.8) 1,394 (79.7) ACT 25 15
(60.0) 0 (0) 6 (24.0) 21 (84.0) Total 10,788 6,40
0 (59.3) 137 (1.3) 2,261 (21.0) 8,798 (81.6)
External pathology laboratory facilities were
either not available or were limited in TAS, SA,
NT and QLD
81
Sponsors
The AusDiab study gratefully acknowledges the
generous support given by National Health and
Medical Research Council (NHMRC) Australian
Government Department of Health and Aging

• Abbott Australasia
• Alphapharm
• AstraZeneca
• Aventis Pharma
• Bio-Rad Laboratories
• Bristol-Myers Squibb
• City Health Centre Diabetes Service, Canberra
• Department of Health and Community Services,
  Northern Territory
• Department of Health and Human Services, Tasmania
• Department of Health, NSW
• Department of Health, WA
• Department of Health, SA
• Department of Human Services, VIC
• Diabetes Australia
• Diabetes Australia Northern Territory
• Eli Lilly Australia

• Estate of the Late Edward Wilson
• GlaxoSmithKline
• Highpoint Shopping Centre
• Jack Brockhoff Foundation
• Janssen-Cilag
• Kidney Health Australia
• Marian EH Flack Trust
• Menzies Research Institute
• Merck Sharp Dohme
• Multiplex
• Novartis Pharmaceuticals
• Novo Nordisk Pharmaceuticals
• Pfizer Pty Ltd
• Pratt Foundation
• Queensland Health
• Roche Diangonostics Australia
• Royal Prince Alfred Hospital, Sydney
• Sanofi-Synthelabo

82
Contributors
Principal Investigators
Paul Z Zimmet AO International Diabetes
Institute Robert Atkins AM Department of
Epidemiology and Preventive Medicine, Monash
University Timothy Welborn AO Department of
Medicine, University of Western
Australia Jonathan Shaw International Diabetes
Institute
Stan Bennett Australian Institute of Health and
Welfare Damien Jolley Monash Institute of Health
Services Research, Monash University Terry Dwyer
AM Murdoch Childrens Research Institute Stephen
Colagiuri Department of Endocrinology, Prince of
Wales Hospital Pat Phillips Department of
Endocrinology, Queen Elizabeth Hospital Kerin
ODea Department of Medicine, University of
Melbourne
Associate Investigators
Liz Bingham Department of Health and Human
Services, Tasmania Steve Chadban Royal Prince
Alfred Hospital and University of Sydney Terry
Coyne School of Population Health, University of
Queensland John McNeil Department of
Epidemiology and Preventive Medicine, Monash
University Neville Owen School of Population
Health, University of Queensland Kevan
Polkinghorne Department of Nephrology, Monash
Medical Centre Robyn Tapp Department of
Epidemiology and Preventive Medicine, Monash
University Hugh Taylor Centre for Eye Research
Australia Andrew Tonkin Department of
Epidemiology and Preventive Medicine, Monash
University Tien Wong Centre for Eye Research
Australia
Collaborators
83
AusDiab report authors
2004/2005 report
1999/2000 report

• D Dunstan
• P Zimmet
• T Welborn
• R Sicree
• T Armstrong
• R Atkins
• A Cameron
• J Shaw
• S Chadban

• E Barr
• D Magliano
• P Zimmet
• K Polkinghorne
• R Atkins
• D Dunstan
• S Murray
• J Shaw

84
AusDiab Staff

• AusDiab Project Manager Shirley Murray
• Epidemiologists Elizabeth Barr, Adrian Cameron,
  David Dunstan, Dianna Magliano, Richard Sicree.
• IDI Field Staff Annaliese Bonney, Nicole Meinig,
  Theresa Whalen.
• IDI Support Staff Travis Clarke, Gay Filby, Sue
  Fournel, Hasan Jahangir, Larna Prout, Carol
  Robinson, Marc Seifman, Debbie Shaw, Lisa
  Southgate, Ray Spark, Kajen Vivekananthan,
  Jonathan Zimmerman.
• Other contributors Theresa Dolphin, Irene Tam,
  Gabriella Tikellis, Adam Meehan, Genevieve Healy,
  Sarah White.

85
AusDiab information

• For more information and publications visit
• Reports and newsletters available
• AusDiab Report 2001
• AusDiab Report 2006
• Newsletter September 2004
• Newsletter September 2006

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