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Pierre DROUIN lecture

Pierre DROUIN lecture. Pierre DROUIN (1939-2002). Born in Nancy (Lorraine) Professor of Diabetes in 1975 in Nancy President of ALFEDIAM 1993-1995 President of MGSD 1998-2000. Epidemiology of type 2 diabetes in Mediterranean countries: critical analysis of past forecasts; new trends.

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Pierre DROUIN lecture

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  1. Pierre DROUIN lecture

  2. Pierre DROUIN (1939-2002) • Born in Nancy (Lorraine) • Professor of Diabetes in 1975 in Nancy • President of ALFEDIAM 1993-1995 • President of MGSD 1998-2000

  3. Epidemiology of type 2 diabetes in Mediterranean countries: critical analysis of past forecasts; new trends Dominique Simon INSERM U-780, 94800 Villejuif et Service de Diabétologie de la Pitié, Paris

  4. Plan of the lecture • Methodological issues on epidemiological features of Type 2 diabetes (T2D) • Available data on T2D incidence/prevalence and their recent evolution in Mediterranean countries • Causes of the new trends of T2D prevalence/Prevention

  5. Methodological issues on epidemiological features of T2D

  6. Methodological issues : how to assess epidemiological features of T2 D ? • Definition of diabetes and T2 D • Incidence: nb new T2D cases over a period of time/nb subjects without T2D at baseline • Prevalence: nb cases T2D/total nb inhabitants

  7. Definition of diabetes • Casual plasma glucose  200 mg/dl (11,1 mM) • Fasting plasma glucose  126 mg/dl (7,0 mM) [until 1999,  140 mg/dl (7,8 mM)] • 2-hr plasma glucose after 75-g oral glucose load (OGTT)  200 mg/dl (11,1 mM) Confirmed by a second abnormal measurement

  8. Definition of T2D • Not type 1 diabetes (immunological or insulinsecretion criteria??) neither secondary diabetes (pancreatitis, Cushing’s syndrome, haemochromatosis) nor MODY type diabetes • All the non insulin-treated diabetic patients and use of an algorithm for insulin-treated patients : - diabetes diagnosis before 30 yrs (35 yrs? 40 yrs?) - insulin treatment within 1 (2?) year(s) following D. diagnosis • ENTRED study in France: 92% T2D, 6% T1D, 2%??

  9. Incidence of T2D • Need to have blood glucose (BG) measured at baseline to select non diabetic subjects • Need to follow-up these subjects and to interview for antidiabetic drug treatment and, if no antidiabetic treatment, to perform new BG measurements • Which BG measurement : fasting, casual, OGTT data on very few populations: Pima Indians, PPS, DESIR study, Asturias study…

  10. Prevalence of T2D • Cross-sectional study on all the subjects of the studied population to look for known diabetes and to measure BG using an OGTT then another BG measurement for confirmation, theoretically ! • In practice, usually, for epidemiological purposes: - only one BG test abnormal to define diabetes - often only fasting BG measured or 2-steps procedure (casual BG measured to screen for OGTT) - selection of age group at-risk for D. ≥ 30 (40?) yrs

  11. Prevalence of T2D - Pitfalls • Representativeness of the studied sample? - need to have recent census data - need to have a high response rate ( > 60%? 70?...) from the randomized subjects • Which BG measurement? • Which age group selected ?

  12. Prevalence of T2D- 2 examples • Vietnamese study (Hanoi) in 1990: 4912 subjects ≥ 15 yrs were examined (95.0% of the eligible population); screening used capillary BG before dinner then OGTT if CBG ≥ 105 mg/dl (93.9% of positive screenees) • Caldia study (New Caledonia) in 1993: 9390 subjects aged 30-59 yrs were examined (78.3% of the eligible population); screening used fasting CBG then OGTT if CBG ≥ 110 mg/dl (92.8% of positive screenees) and OGGT in 517 negative screenees Quoc PS et al. Am J Epidemiol 1994; 139: 713-22 Papoz L et al. Am J Epidemiol 1996; 143: 1018-24

  13. « Surrogate markers » of T2D prevalence • Health Insurance System database recording nominal information on all antidiabetic drugs reimbursed to the patients accurate data on the prevalence of pharmacologically treated D. but ignores only-diet treated D. patients and undiagnosed D. patients • National database of antidiabetic drugs sales: need to define the prescribed daily dose for each drug • Interview on antidiabetic drug use: need for a representative sample of population; only known D.

  14. Available data on T2D incidence/prevalence and its recent evolution in Mediterranean countries

  15. Incidence of Type 2 Diabetes in Europe and Spain Spain: 10-19 cases per 1.000 persons-year (7) Eur J Clin Invest 2008

  16. Paris Prospective Study - recruitment in the 70s - 5042 men - 42-52 yrs - WHO 1980 criteria - follow-up : 3 yrs Annual incidence : 4.2‰ Charles MA et al. Diabetes 1991; 40: 796-9 DESIR Study - recruitment in the 90s - 1863 men and 1954 women - 30-64 yrs - ADA criteria (FPG) - follow-up : 9 yrs Annual incidence :6.5‰ Balkau B et al. 2008; 31: 2056-61 Type 2 diabetes Incidence in France

  17. PREVALENCE OF DM IN ARAB COUNTRIES Somalia Djibouty Comors 26.4% Bahrain -Zurba FI / 1996 (>20) 24.0% Saudi -Nozha / 2004 (>30) 16.2% Jordan -Kamel Ajlouni / 2004 16.1% UAE / 2000 (30-64) 16.1% Oman -J. A. Al-Lawati / 2000 (30-64) 15% Qatar-Mahmoud Zirie 14.8% Kuwait -N.Abdella / 1996 14.0% Libya -Kadiki OA / 2001 13.1% Lebanon -Ibrahim S. Salti / 1997 12.0% Palastine -Abdul-Rahim,H / 2001 (30-65) 9.4% Syria -Al Bache N / 1999 8.2% Algeria - R. MALEK / 2001 6.6% Morocco -Tazi / 2003 6.6% Yemen -Abdallah A Gunaid / 2002 (20–85) 6.3% Egypt -Arab, M / 1997 (>20) 5.0% Iraq / 1979 4.0% Tunisia -Papoz L / 1988 3.4% Sudan - El-Bagir / 1996 2.6% Mauritania - M Ducorps / 1996 (30-64) 30% 20% 10% 0

  18. PREVALENCE STUDIES OF DIABETES IN SPAIN

  19. Highest rates High-intermediate rates Intermediate-low rates Lowest rates PREVALENCE OF MAJOR CV RFs BY GEOGRAPHICAL AREA IN SPAIN (90´s) *Spanish pop >20 years, INE 2000 Gabriel R. Rev Esp Cardiol 2008;61:1030-40

  20. Tasas más altas Tasas intermedio-altas Tasas intermedio-bajas Tasas más bajas PREVALENCEOF DIABETES MORTALITY FOR DIABETES Atlas municipal de mortalidad en España. 1989-1998. CNE. ISCIII Proyecto ERICE Rev Esp Cardiol 2008;61:1030-40

  21. Diabetes Mellitus in Syria 2006 (>25 year) Aleppo study of prevalence of DM and C.V .Risk Factors, Diabetes Research Unit ,Aleppo University 2006, (SUMETTED DATA)

  22. INCREASE OF PREVALENCE OF DM ON ONE DECADE Prevalence of DM in Syria in 1996(1,2)& 2006(3) (>25 year) 1.ALBACHE N.:Diabetes Research & Clinical Practice;2000,50,1 2.ZEHOR F., OWESS.S.(MINISTRY OF HEALTH) 3.ALBACHE,N ,R Al-Ali, S. Rastam, F. M. Fouad, F.Mzayek, W. Maziak : Epidemiology of Type 2 Diabetes in Aleppo, Syria ( submetted dada) c

  23. Malek R . Méd Mal Métab 2008; 2: 288-302

  24. Diabetes in Malta (≥ 15 yrs) Schranz AG Diabetes Care 1999; 22: 650

  25. Type 2 Diabetes Prevalence in Greece, Cyprus and Portugal 1-Diabetic Med 2005; 2-Diabetes Res Clin Pract 2008; 3-Diabetes Care 2006; 4-subm. EASD

  26. Type 2 Diabetes Prevalence in Italy and Turkey 1-BEN 2002; 2-Acta Diabetol 2009; 3- Nutr Metab Cardiov Dis 2008; 4-Diabetes Care 2002

  27. Data from the French Health Insurance System (CNAMTS) in 2005INSEE population : 62 500 000Général Insurance System population :55 500 000Général Insurance System population (minus SLM) :47 100 000Sample 1/600ème :75 000Anti-diabetic drugs(> 2 reimbursements during the year) :2 980

  28. Extrapolation of prevalenceto all the Health Insurance Systems(Metropolitan France )

  29. Evolution of treated-diabetes prevalence in France

  30. Prevalence of treated diabetes in France by age and gender in 2007

  31. Adjusted prevalence of treated diabetes by geographical area in 2007 in France

  32. Evolution of antidiabetic treatment in France

  33. Nb of diabetic patients free of charge for D. treatment (ALD 30) in France and cost for the Health Insurance System

  34. Cost of diabetes in France • Annual increase of 8.7% between 1998 and 2000 • According to complications : - no complication = 1 769 Euros/yr - microvascular complications = 2 048 Euros/yr - macrovascular complications = 5 126 Euros/yr - both types of complications = 6 407 Euros/yr

  35. Increasing incidence of type 2 diabetes in children and adolescents Until recently, most children presenting with diabetes had type 1 diabetes Type 2 diabetes is now increasingly reported Case reports in children from many countries, including US, Canada, Japan, Hong Kong, Australia, New Zealand, Libya and Bangladesh Accounts for up to 45% of recently recognized cases of diabetes among children and adolescents in the US Most cases of type 2 diabetes in children and adolescents are attributable to obesity Fagot-Campagna A, et al. BMJ 2001; 322:377–378.

  36. Worldwide prevalence of diabetes in 2030 (projected) Number of persons < 5,000 5,000–74,000 75,000–349,000 350,000–1,499,000 1,500,000–4,999,000 > 5,000,000 No data available Total cases > 370 million adults World Health Organization, 2003 http://www.who.int/diabetes/facts/world_figures/en/ (accessed September 2004). Worldwide prevalence of diabetes in 2000

  37. Causes of the new trends of Type 2 diabetes prevalence/Prevention

  38. Risk factors for type 2 diabetes • Ageing (increase in life expectancy) • Overweight and obesity due to changes in lifestyle . nutritional habits . physical activity

  39. PREVALENCE OF DM IN ARAB COUNTRIES IN URBAN & RURAL AREAS

  40. Influence of genetic and environmental factors on type 2 diabetes prevalence Schulz LO et al. Diabetes Care 2006; 29: 1866-71

  41. Prevalence of obesity in men in different countries BMI > 30 kg/m2 (%)

  42. Obesity In Arab World 80% 75% 66.0% 70% 59.4% 57.0% 60% 51.4% 47% 50% 41% 37.9% 40% 31.2% 31.5% 27.7% 27% 27% 27% 30% 22% 15.7% 20% 10% 0% Qatar Sudan Algeria Djibouti Somalia Iraq/1979 Comoros Yemen /2000 Libya -Kadiki/1990 Saudi-Taha / 1998 Kuwait / Kofo Rotimi Oman -Firdosi/1995, Egypt -Herman/1997 Syria -Al Bache 2006 Jordan - Ajlouni /2004 Morocco - Tazi / 2003 UEA -el Mugamer /1995 Bahrain -Farouq/1996, Tunisia -Ghannem/1997 Lebanon -Ibrahim S/1997, Mauritania - M Ducorps / 1996 Palestinian -Abdul-Rahim / 2001

  43. Prevention of type 2 diabetes In subjects identified as at high risk for type 2 diabetes, prevention of type 2 diabetes can be implemented by : • changes in lifestyle (nutritional habits, physical exercise) • pharmacological intervention

  44. Incidence of type 2 diabetes in IGT subjects- The Da Qing Study - Incidence (per 100 subject-years) 20 2 < 25 kg/m 2 > 25 kg/m 15 10 5 0 Controls Diet Exercise Diet + exercise Pan et al., Diabetes Care 1997; 20: 537-44

  45. Prevention of Type 2 Diabetes by intervention on lifestyle 1. Pan et al., Diabetes Care 1997; 20: 537-44 2. Tuomilehto et al., NEJM 2001; 344: 1343-50 3. DPP Research Group. NEJM 2002; 346: 393-403

  46. Prevention of Type 2 Diabetes by pharmacological intervention 1. DPP Study Group. NEJM 2002; 346: 393-403 2. Chiasson et al., Lancet 2002; 359: 2072-7 3. Buchanan et al., Diabetes 2002; 51: 2796-803

  47. Conclusions (1) • To collect valid epidemiological data on T2D is difficult • A choice has to be done in the processing and designing of epidemiological studies on T2D : - either to conduct a specific study in order to assess accurately T2D prevalence - either to use routine statistics data, less precise to estimate T2D prevalence, but cheaper and providing additional data interesting for Public Health

  48. Conclusions (2) • T2D is becoming an « epidemic » disease in the Mediterranean countries • T2D can be prevented at least in the short-term in at-high risk subjects by : - changes in lifestyle -pharmacological intervention

  49. Thanks for their kind collaboration to : • Nizar ALBACHE (Syria) • Eveline BERNARD (Servier – France) • Davide CARVALHO (Portugal) • Taner DAMCI (Turkey) • Rafael GABRIEL (Spain) • Vasilios KARAMANOS (Greece) • Rachid MALEK (Algeria) • Philippe RICORDEAU (France) • Gojka ROGLIC (Croatia – WHO Geneva) • Charles SAVONA-VENTURA (Malta) • Antoine SCHRANZ (Malta) • Philippe TUPPIN (France) • Josanne VASSALO (Malta) • Alain WEILL (France)

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