Cardiovascular Consequences of Diabetes: An Epidemiologic Overview

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Cardiovascular Consequencesof DiabetesAn
Epidemiologic Overview

• Darren K. McGuire, MD, MHSc
• Donald W. Reynolds Cardiovascular Clinical
  Research Center
• University of Texas Southwestern Medical Center
  at Dallas
• 5th Annual Diabetes Summit Linking Science to
  Medicine
• November 12, 2005

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Thanks to Our Sponsors
Pfizer Guidant Cordis Sankyo Takeda Novartis CV
Therapeutics The Medicines Company
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Obesity Trends Among U.S. Adults BRFSS1985
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1986
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1987
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1988
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1989
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1990
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1991
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1992
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1993
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1994
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1995
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1996
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1997
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1998
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS1999
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS2000
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS2001
JAMA 199928216, JAMA 200128610.
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Obesity Trends Among U.S. Adults BRFSS2002
http//www.cdc.gov/brfss/interactive
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Obesity Trends Among U.S. Adults BRFSS2003
http//www.cdc.gov/brfss/interactive
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Obesity Trends Among U.S. Adults BRFSS2004
http//www.cdc.gov/brfss/interactive
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Obesity and Physical Inactivity in Children A
Call to Arms

• US Children
• 15 are overweight
• Type 2 DM now exceeds type 1
• 2/3 have ?1 component of the Metabolic Syndrome
• 10 have Metabolic Syndrome
• 1/3 of US children born in 2000 likely to develop
  type 2 DM during lifetime

Pediatrics. August 2003 De Ferranti et al.
Circulation 2004 110 2494-2497 Narayan KMV et
al. JAMA 2003 290 1884-1890
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Metabolic Syndrome Beyond Hyperglycemia
of Population
Ford ES, et al. JAMA. 2002287356-359.
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Opportunities for improvement

• Identify the patients with DM
• Continue to expand therapeutic focus
• Apply the existing evidence for CVD risk
  modification

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Looking but not seeing.
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Opportunity 2 Redirect the Focus Patient
Beliefs about Diabetes Risks
ACC/ADA Diabetes knowledge survey n2008
http//www.diabetes.org/main/uedocuments/executive
summary.pdf
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Diabetes Mellitus A Cardiovascular Disease
United Kingdom Prospective Diabetes Study n3867
UKPDS Investigators. Lancet 1998 352 837
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Opportunity 3 Apply the Evidence
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Our Presidents Lead The Way!
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Physical Inactivity A Call to Arms
10,000 Steps Daily
30 minutes most days
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Portion Distortion
Hardee's "Monster Thickburger 2 1/3-pound slabs
of Angus beef 4 strips of bacon 3 slices of
cheese Mayonnaise Buttered sesame seed bun
1420 Calories 107 g Fat
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Preventing Diabetes Results from the Diabetes
Prevention Program
Placebo (n1082)
Metformin (n1073, plt0.001 vs. Placebo)
Lifestyle (n1079, plt0.001 vs. Metformin ,plt0.001
vs. Placebo)
Risk reduction 31 by metformin 58 by lifestyle
NEJM 346393-403, 2002
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Diabetes Prevention Program3-year Follow Up
The DPP Research Group. Diabetes Care 2005 28
888-894
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ADA Standards of Medical Care Primary
Cardiovascular Risk Modification

• Lifestyle counseling
• Smoking abstinence Exercise Weight Control
  Diet
• Aspirin for agegt40 OR another CRF
• Lipids
• For agegt40, statin regardless of baseline LDL
• TGslt150 and HDLgt40
• Blood pressure target of lt130/80
• ACEI, ARB, Thiazide, BBlocker, CCB
• ACEI
• independent of BP for agegt55 another CRF

Diabetes Care 2005 28 (supp) S4-S36
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Suboptimal CVD Risk Modification in DM Patients
NHANES 1999-2000
N370 with DM age 20
Saydah et al. JAMA 2004 291 335-342
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Conclusions

• Diabetes is common and increasing
• Tracking obesity
• Children emerging as special risk population
• Diabetes is under diagnosed
• Associated with CVD risk and disease even at the
  time of diagnosis
• Evolution of clinical thinking beyond glucose to
  control to include CVD issues
• Continued efforts to improve CVD outcomes
  necessary
• Application of existing evidence
• Continued investigation

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http//www.dvdres.com