CRCA Talk

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Section of Public Health
Past, present and future research in (type 2)
diabetes Josie MM Evans Lecturer in Epidemiology
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Research areas

• Cardiovascular risk (associated with oral
  hypoglycaemic agents)
• Metformin and cancer
• Older people with type 2 diabetes
• Self-monitoring

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CARDIOVASCULAR RISK
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Risks of mortality, cardiovascular mortality and
CV hospital admission

• In non-diabetic patients who have had an MI
  compared with people newly diagnosed with type 2
  diabetes
• Adjusted risk ratio 2.93 (95 CI 2.54 - 3.41)
• In patients newly treated with sulphonylureas
  compared with those newly treated with metformin
• Adjusted risk ratio 2.96 (95 CI 2.41 2.64)

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METFORMIN
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Hypothesis

• Upstream regulator of AMP-activated kinase (AMPK)
  is the protein kinase LKB1
• AMPK is the target enzyme of metformin
• LKB1 is known to be a tumour suppressor
• Is use of metformin associated with a reduced
  risk of cancer in patients with type 2 diabetes?

Hawley SA, Boudeau J, Reid JL, Mustard KJ, Udd L,
Makela TP, Alessi DR, Hardie DG. Complexes
between the LKB1 tumor suppressor, STRAD
alpha/beta and MO25 alpha/beta are upstream
kinases in the AMP-activated protein kinase
cascade. J Biol. 20032(4)28.
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Case-control study

• Cases
• Patients with type 2 diabetes and a hospital
• admission with ICD9/10 code for cancer at
• least one year after diagnosis of diabetes
• N 1,276
• Controls
• Patients with type 2 diabetes without cancer
• matched to case for sex, age (within 3 years),
• duration of diabetes (within 3 years)
• 2 controls per cases
• N 2,552

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Adjusted odds ratios (with 95 CI) for exposure
to metformin
1.2
1
0.8
Adjusted odds ratio
0.6
0.4
0.2
0
Year
Ever
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Weaknesses

• Crudely defined case series for cancer
• Used date of hospital admission as index date

• We are applying to CSO for funding for a cohort
• study using SMR6 (Scotlands cancer registration
• database) for clinical information on cancer
  cases

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OLDER PEOPLE
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Life expectancy and diabetes
80
Non Diabetics
75
70
Diabetics
65
Life expectancy (yrs)
60
55
50
45
40
10
20
30
40
50
60
70
Age at diagnosis
Roper et al, BMJ, 2001
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Pilot Study

• We found no difference found in mortality in men
  diagnosed over 65 compared with their non
  diabetic counterparts (adjusted RR 1.06 95 CI
  0.94, 1.19).
• Finding not replicated for women (adjusted RR
  1.29 95 CI 1.15, 1.45).

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Treatment for older people

• Do nothing?
• Macrovascular
• Control of cardiovascular risk factors lose
  weight, exercise, lipid reducing tablets
• Microvascular
• Tight glycaemic control, glucose monitoring

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Research Questions

• What is the incidence and prevalence of
  microvascular and macrovascular morbidity in
  patients who are diagnosed over 65 years,
  compared with younger patients?
• What are the main causes of death and the
  incidence of diabetes-related mortality in
  patients who are diagnosed over 65 years compared
  with younger patients?

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Further Research?

• Qualitative work to complement the quantitative
  analyses
• Patients views and experiences of a diagnosis of
  type 2 diabetes in later life

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SELF-MONITORING
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Self-monitoring in type 2 diabetes

• Effectiveness of monitoring
• Quality of life
• Peoples understandings of monitoring

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Proposed Study

• Survey of peoples self-monitoring behaviour in
  Tayside collection of data on psycho-social
  characteristics, education, quality of life
• Link with MEMO/DARTS data
• In-depth qualitative interviews