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 The Philippine Cardiovascular Outcome Study
Diabetes Mellitus (PhilCOS-DM)An 8-year
Follow-up of the 1998 Food and Nutrition
Research Institute 5th National Nutrition Survey
(FNRI-NNS) in the National Capital Region,
Region 3 and Region 4.  Rody G. Sy, MD Maria
Luz Joanna B. Soria, MD Bernard S. Vega.
MDJennifer S. Flores, MDFelicidad Velandria,
RNDFelix Eduardo Punzalan, MDTommy Ty-Willing,
MDCardiovascular Institute CARDINAL SANTOS
MEDICAL CENTERCardiovascular Section University
of the Philippines-Philippines General Hospital
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Introduction
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Introduction

• Diabetes Mellitus is a risk factor for
• Atherosclerosis
• Coronary heart disease
• Heart Failure

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Incidence of Fatal or Nonfatal MI During a 7-Year
Follow-up in Relation to History of MI in
Nondiabetic vs Diabetic Subjects East-West Study
45.0
Nondiabetics with prior MI Nondiabetics with no
prior MI Diabetics with prior MI Diabetics with
no prior MI
plt0.001
Incidence During Follow-up ()
20.2
18.8
Plt0.001
3.5
(n69)
(n1304)
(n169)
(n890)
Events per100 person-yr
3.0
0.5
7.8
3.2
Haffner SM et al. N Engl J Med 1998339229-234.
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Global Projections for the Diabetes Epidemic
20002025
20.9. 25.8 23
21.935.8 64
ASIA 102.2 189.4 85
5.5 11.6 111
6.9 15.5 120
1.3 2.2 69
World 2000 159 million 2025 280
million Increase of 76
Numbers are in Millions
Zimmet P et al..
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Diabetes in Asia is a Growing Epidemic
20 Prevalence growth
Number of People with Diabetes (000)
Source http//www.eatlas.idf.org/prevalence/index
(accessed 10/7/2005)
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Introduction

• 1983 1998 prevalence
• of DM 4
• 2003 NNHeS prevalence
• of DM 4.6

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PhilCOS-DM

• In 2006, we attempted the first longitudinal
  study in the Philippines on some cardiovascular
  and diabetic outcomes.

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Objectives

• A descriptive cohort study to determine
• 8-year incidence rate of diabetes mellitus and
  impaired fasting glucose (IFG)
• based on fasting blood glucose (FBG)
• prevalence rate of diabetes mellitus, IFG and
  impaired glucose tolerance (IGT)
• based on interview, FBG and 2-hours post glucose
  (2H PG) load, of the NCR, Region 3, and Region 4.

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Methodology

• Selection of FNRI-NNS subjects two-staged
  stratified sampling design (1998)

8-years follow-up
2006 PhilCOS NCR, n 345 (73) Reg3, n 309
(88) Reg4, n 431 (87) TOTAL 1085 (82)
1998 FNRI-NNS NCR, n 470 Reg3, n 351 Reg4, n
495 TOTAL 1316
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Methodology
1998 FNRI (N1316)
Unretrieved 18
2006 revisited (N 1085)
Alive 913
FBG (N864)
Barangay Health Workers Questionnaire One Touch
Ultratm 75 gram glucose load
2h post-glucose load (N800)
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Validation of the One touch glucometer CBG vs
FBS-CSMC
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Criteria for DM, IFG, IGT
Fasting Plasma Glucose (FBG) lt 100 mg/dL normal
FBG 100-125 mg/dL impaired fasting glucose (IFG)
FBG gt126 mg/dL diabetes
2-h post glucose load (2HPG) lt140 mg/dL normal
2-h PG 140-199 mg/dL impaired glucose tolerance (IGT)
2-h PG gt 200 mg/dL diabetes
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Data Processing Analysis

• Encoding Microsoft Access
• Analysis SPSS V12
• Data storage MS Excel SPSS V12

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RESULTS
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Demographics of the 1998 FNRI-NNS
Variables Male (n633) Mean SD Female (n 683) Mean SD p value M vs F Total N Total Population Mean SD
Age (y) 49.94 16.86 48.319 16.17 0.0753 1316 49 17
FBG (mg/dL) 94.06 35.30 94.05 36 0.9946 1316 94 36
T cholesterol (mg/dL) 167.09 42.31 174.90 43.58 0.0010 1316 171 43
Triglyceride (mg/dL) 130.70 73.93 114.74 58.36 0.0001 1316 122 67
HDL-C (mg/dL) 32.04 13.39 34.02 14.64 0.01 1315 33 14
LDL-C (mg/dL) 109.23 38.16 118.15 38.0 0.0001 1315 114 38
Systolic BP (mmHg) 128.15 22.90 121.95 24.37 0.0001 1315 125 24
Diastolic BP (mmHg) 82.01 13.09 78.42 13.02 0.0001 1315 80 13
WEIGHT (kg) 58.43 11.39 81.71 10.62 0.0001 1302 55 11
HEIGHT(m) 162.34 6.43 150.46 5.51 0.0001 1302 156 8
BMI (kg/m2) 22.11 3.71 22.81 4.40 0.0018 1302 22 4
Waist (cm) 80.07 10.75 75.37 10.32 0.0001 1315 78 11
Hip (cm) 87.18 7.12 89.86 9.52 0.0001 1315 89 9
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Demographics of the 2006 PhilCOS
Variables Total 2006 Male (n427) Mean SD Female (n498) Mean SD
Age (y) 55.55 - 15.87 55.44 - 15.93 55.64-15.83
FBG (mg/dL) 105.75 - 40.96 108.75 - 44.83 103.24-37.28
Systolic BP (mmHg) 124.14 - 21.99 126.73 - 21.24 121.96 - 22.39
Diastolic BP (mmHg) 81.96 - 11.46 83.25 - 10.86 80.87 -11.84
Waist (cm) 80.08 - 11.61 81.33 -11.03 79.02 -11.99
Anti-hypertens use 177 (19) 79 (19) 98 (20)
Self-reported diabetes 86 (9) 31 (7) 55 (11)
Self-reported CAD/Angina 55.55 - 15.87 23 (5) 25 (5)
Self-reported Stroke 105.75 - 40.96 26 (6) 25 (5)
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Prevalence of Diabetes Mellitus based on FBG, 2H
PGL, Diabetic Questionnaire, and Combination
  DM QNAIRE FBG gt125 mg/dL 2H PG gt200 mg/dL FBG OR DMQ OR 2H PG
TOTAL 9 12 10 18
MALE 7 14 9 18
FEMALE 11 10 10 18
PhilCOS-DM accepted that the most accurate
prevalence rate of Diabetes was the combination
of the 3 measures 18.
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Prevalence of IFG and IGT based on FBG and 2H-PG
load
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The 8-years Incidence of DM using FBG
FBSgt125 mg/dL
NCR 12
REGION 3 12
REGION 4 12
TOTAL (n 864) 12
MALE 14
FEMALE 10
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Spectrum of Glucose Homeostasis From 1998 IFG
to DM, IFG and normal in 2006 PhilCOS-DM
1998 IFG definition N25 (110-125 mg/dL) A. DM (FBG gt 126) n 12 ? 48
1998 IFG definition N25 (110-125 mg/dL) B. IFG (110-125) n 4 ? 16
1998 IFG definition N25 (110-125 mg/dL) C. Normal (lt110) n 9 ? 36
Among IFGs 48 became diabetics in 8 years.
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Spectrum of Glucose Homeostasis From 1998
Normoglucose to DM, IFG and Normal in 2006
PhilCOS-DM
1998 Normal definition of FBG N804 A. DM (FBG gt 126) n 74 ? 9
1998 Normal definition of FBG N804 B. IFG (110-125) n 81 ? 10
1998 Normal definition of FBG N804 C. Normal (lt110) n 649 ? 81
The 8-years incidence rate of IFG is 10.
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Prevalence of DM using FBG, 2 hour PG, or
Combination (n800)
2H-PGLgt200 10
FBGgt126 9
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FBG 2HPG
2HPG alone
FBG alone
4

• 2HPG provides better information regarding future
  risk for CVD
• Elevated 2HPG also predicts the CVD risk in
  subjects with NORMAL FBG.
• Class 1, Level of Evidence A.
• ESC and EASD guidelines, 2007

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Prevalence of IFG, IGT or Combination (n800)
IGT (140-199 mg/dL) 26
IFG (100-125 mg/dL) 31
20
15
IFG alone
IFG IGT
IGT alone
11
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Prevalence of IFG, IGT or Combination
IGT 208
IFG 248
46
38
IFG alone
IFG IGT
IGT alone
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FBG predicted more pre-diabetics, but a further
38 can be predicted by 2H PG.
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Limitations of the Study

• Use of capillary blood sample
• Respondent migration and relocation
• Sampling limited to previously generated by the
  1998 FNRI-NNS
• ? more urban cohort
• ? healthier non-respondents
• ? Overestimate of morbidities comparing 2-points
  in time

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Conclusions

• Incidence rate of DM 12
• Incidence rate of IFG 10
• Prevalence rate of DM 18
• Prevalence rate of IFG 31
• Prevalence rate of IGT 26

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Awaiting The PhilCOS Extension Study
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PhilCOS

• Extension of the study
• Region 6 - Cebu
• Region 10 Mindanao
• Region 5 - Bicol

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Acknowledgement

• Sponsors
• Philippine Diabetes Association
• Philippine Lipid and Atherosclerosis Society
• Philippine Society of Hypertension
• Therapharma, Inc.
• Pfizer Phils., Inc.
• Johnson Johnson
• Research Assistants
• Maryjun Rangel and Armand Soriano
• Collaborators
• Philippines Diabetes Association key opinion
  leaders forum
• Special Mention
• Municipal Health Officers and Barangay Health
  workers

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The 2006 PhilCOS Prevalence of Stroke and Angina
within the Framingham CHD Risk Grouping.
FHS Risk grouping Events Events Events
FHS Risk grouping N Stroke N () Angina N ()
low 726 21 (3) 23 (3)
Med 242 16 (7) 16 (7)
high 117 12 (10) 8 (7)
All risks 1085 49 (5) 47 (4)
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The 2006 PhilCOS Prevalence of Stroke, CAD within
the Framingham CHD Risk Grouping.
Framingham CHD Risk Grouping Males (n420) Males (n420) Males (n420) Females (n493) Females (n493)
Framingham CHD Risk Grouping Stroke n24 CHD n22 Stroke n 25 CHD n 25
Low n666 6 (1) 5 (1) 15 (2) 18 (3)
Med n182 8 (4) 9 (5) 8 (4) 7 (4)
High n65 10(15) 8 (12) 2 (3) 0
Based on PhilCOS questionnaire
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CHD deaths vs non-CHD deaths according to sex and
the Framingham CHD Risk Grouping.
FHS Risk grouping Events Events Events
FHS Risk grouping Total subjects CHD N,() Non-CHD N,()
low 726 37 (5) 29 (4)
Med 242 32 (13) 24 (10)
high 117 26 (22) 24 (21)
All risks 1085 95 (9) 77 (7)
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CHD deaths vs non-CHD deaths according to sex and
the Framingham CHD Risk Grouping.
Framingham CHD Risk Grouping Males Males Males Females Females Females
Framingham CHD Risk Grouping CHD deaths n59 Non-CHD deaths n52 Total Males n110 CHD deaths n36 Non-CHD deaths n26 Total Females n62
Low (N66) 10 (15) 12 (18) 22 (33) 27 (41) 17 (26) 44 (67)
Med (N56) 24 (43) 18 (32) 42 (75) 8 (14) 6 (11) 14 (25)
High (N50) 25 (50) 21 (42) 46 (92) 1 (2) 3 (6) 4 (8)