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1
Marco Songini Prevalence of diabetic
complications in relation to demographics in
Europe State-of-the-art in reference to
published data Part 2 microvascular diseases,
neuropathy and costs of diabetes
2
Dr Marco Songini is the director of the Diabetes
Unit at S. Michele Hospital in Cagliari
(Sardinia-Italy). He is also the
vice-president of ASRIS (Association for the
Study of Type 1 Diabetes in Sardinia)
3
DM-MED project is aimed to develop
recommendations for public health policy in the
Mediterranean countries with emphasis on the
prediction, prevention and control of Types 1 and
2 diabetes and their complications. The emphasis
of this meeting was on description of the health
programs of the participating countries, on the
epidemiology of diabetes and its complications in
the Mediterranean region, and on the need for
methodology of diabetes registries. The present
is one of the lectures of the DM-MED meeting.
4
Epidemiology of diabetes chronic complications
Microvascular diseases Retinopathy in Diabetes in
Europe
90
80
70
60

50
40
30
20
10
0
NE
WE
EE
SE
Diabet Med, 14 (S1) 1997
5
Epidemiology of diabetes chronic complications
Microvascular diseases Frequency of retinopathy
among Eurodiab PCS pts at baseline
1
2
3
4
5
6
Background
7
8
9
10
11
12
Proliferative
13
14
15
16
17
18
19
20
21
22
23
6
Epidemiology of diabetes chronic complications
Microvascular diseases Retinopathy in Type 2
diabetes (UKPDS)
Relative Risk
99 CI
RR
p
0.5
2
1
1.03
0.78
0 - 3 years
0.83
0.017
0 - 6 years
0.83
0.012
0 - 9 years
0.015
0.79
0 - 12 years
Favours
Favours intensive therapy(1)
conventional therapy(2)
7
Epidemiology of diabetes chronic complications
Microvascular diseases Retinopathy in Type 2
diabetes (UKPDS)


p0.004
p0.019
60
p0.38
40
patients
- TC
20
- LTC
0
243
461
207
411
152
300
3 years
6 years
9 years
Years from randomisation
8
Epidemiology of diabetes chronic complications
Microvascular diseases Nephropathy in Diabetes in
Europe
20
15

10
5
0
NE
WE
EE
SE
Diabet Med, 14 (S1) 1997
9
Epidemiology of diabetes chronic complications
Microvascular diseases Frequency of nephropathy
(albuminuria) among Eurodiab PCS pts at baseline

1

2
3
4
5
6
microalbuminuria
7
8
9
10
11
12
13
14
15
16
macroalbuminuria
17
18
19
20
21
22
23
24
25
26
0
10
20
30
40
50
10
Epidemiology of diabetes chronic complications
Microvascular diseases Risk of albuminuria among
Eurodiab PCS pts
60
51
50
normoalbuminuria at baseline (1,134 pts)
40

30
14
13
20
microalbuminuria at baseline (351 pts)
10
2
0
Progression to micro
Progression to macro
Regression to normo
11
Epidemiology of diabetes chronic complications
Microvascular diseases Albuminuria among Eurodiab
PCS pts
Risk factors at baseline for progression
From normo to microalbuminuria
From micro to macroalbuminuria
HbA1c, AER and after adjusting
for HbA1c AER fasting triglycerides, LDL
and HDL cholesterol, BMI, WHR, any
retinopathy
HbA1c, AER and after adjusting
for HbA1c AER ?GT, WHR, peripheral neuropathy
12
Epidemiology of diabetes chronic complications
Microvascular diseases Nephropathy in Type 2
diabetes (UKPDS)
Relative Risk
99 CI
RR
p
0.5
1
2
0.89
0.24
Baseline
0.83
0.043
Three years
0.88
0.13
Six years
0.76
0.00062
Nine years
0.67
0.000054
Twelve years
0.70
0.033
Fifteen years
Favours
Favours
conventional therapy(2)
intensive therapy(1)
13
Epidemiology of diabetes chronic complications
Microvascular diseases Nephropathy in Type 2
diabetes (UKPDS)


-TC
-LTC
Years from randomisation
14
Epidemiology of diabetes chronic complications
Neuropathy in Diabetes in Europe
70
60
50

40
30
20
10
0
NE
WE
EE
SE
Diabet Med, 14 (S1) 1997
15
Frequency of neuropathy among Eurodiab PCS pts
at baseline
Epidemiology of diabetes chronic complications

1
2

3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
10
20
30
40
50
60
70
80
0
16
Epidemiology of diabetes chronic complications
Incidence of neuropathy among Eurodiab PCS pts
over the follow up
Symptoms
Absence of reflexes
40
Abnormal VPT
35
Abnormal autonomic function
30
25

20
Neuropathy (2 or more abnormal of symptoms,
reflexes, VPT, autonomic function)
15
10
5
0
The prevalence raised from 26 at baseline to 34
at the end of follow up
17
The Costs of Diabetes (1)
-
Direct costs (43-50 of total costs)
Personal costs
- Hospital services - Physician in-patient
service - Out-patient care (services and GPs,
nursing home, home care) - Travel (ambulances) -
Supplies (oral hypoglycaemic drugs, insulin,
syringes, cotton swabs, glucose and urine test
strips)
Non-personal costs
- Research (biomedical and social sciences) -
Health education - Support services
Diabetes in Europe, Ed Rhys Williams, 1993
18
The Costs of Diabetes (2)
Indirect costs
- Income losses due to illness and disability -
Present value of future earning lost by those who
died prematurely as a result of diabetes -
Psychological costs to diabetic patients and
their families (Intangible costs)
Diabetes in Europe, Ed Rhys Williams, 1993
19
The Costs of Diabetes
Direct Costs of Diabetes in the USA
50
US 15,114 per diabetic /yearly (compare to US
548 for others /yearly)
40
30
billion
20
10
1965
1970
1975
1980
1985
1990
1995
Taylor AK, Diabetes Care, 1987
20
The Costs of Diabetes in Europe
21
Global estimates and projections of diabetes
prevalences from 1995 to 2010
7
1995
6
5
2000
4

3
2010
2
1
0
Asia
World
Africa
Europe
Oceania
Nth America
Latin America
Diabet Med, 14 (S1) 1997
22
Eurodiab-PCS summary (1)
There is no sex difference for the risk of CHD in
people with type 1 diabetes. Independently of age
and HbA1c, the risk factors for CHD in men and
women are different. In fact in men CHD is
strongly associated with AER, smoking, WHR,
whilst in women duration of the disease, systolic
BP, AER, fasting triglycerides play a major
role.
The incidence of neuropathy over approximately a
7 year period is 25. Risk factors for incidence,
independent of age and HbA1c were cholesterol,
fasting triglycerides, presence of CVD at
baseline and presence of retinopathy at baseline.
Existence of previous CVD increased the risk of
neuropathy 3 times.
23
Eurodiab-PCS summary (2)
Regression from micro to normoalbuminuria was
significantly related to HbA1c, AER, WHR and
peripheral neuropathy. These results emphasise
the importance of good glycaemic control to
prevent nephropathy, and indicate that markers of
insulin resistance, such as triglycerides and
WHR, need to be strictly monitored.
There are not still data reporting the incidence
of retinopathy among this cohort. At baseline
retinopathy was present in about one third of the
patients (mostly background).
24
UKPDS summary
Intensive therapy aimed to reduce fasting
glycaemia to normal values (less than 108 mg/dl
vs less than 270 mg/dl) is worthwhile as it
reduces risk of complications, the greatest
effect being on microvascular complications. A
tight blood pressure control is worthwhile as it
reduces risk of complications, particularly
evident in heart failure and stroke after 3 years
from randomisation. All these data indicate that
the reduction in risk of complications of
diabetes is not a dream but it is a realisable
goal.
25
Conclusions (1)
The prevalence of diabetes, either type 1 and
type 2, is increasing worldwide. The interaction
between some genetic components and some
environmental factors is responsible for the
etiopathogenesis of these diseases. However, the
environmental factors for type 1 diabetes have
still to be largely identified whilst, as far as
type 2 diabetes, overweight, low levels of
habitual physical activity and some aspects of
westernized diet have been already recognised as
to be important for developing the disease.
Independently of the type of diabetes, the
incidence and prevalence of chronic complications
are tightly related not only to glyco-metabolic
control but also to other risk factors, such as
blood lipids and blood pressure, which can be
easily prevented by early monitoring and
treatment.
26
Conclusions (2)
It is of note that, independently of the
different design and period of follow up of the
studies so far reported, the risk for developing
diabetes complications is also dependent from a
genetic background, which varies among the
different areas and populations investigated.
Furthermore, the same complications could be
related to different risk factors according to
the population analysed.
49
27
Conclusions (3)
These findings suggest that, across different
countries, the prevalence of diabetic
complications may be widely variable, and that
the efforts for their prevention must be oriented
and differentiated according to the data emerging
form their own investigations and to their own
risk factors involved. The interpretation of
these differences could be carried out only by
setting out large and reliable epidemiological
investigations where data will be collected
uniformly among the different geographical areas.