DEMA-CVN.

COM
GII THIU

CC TI BO CO TI HI NGH TIM MCH MIN TRUNG- TY NGUYN M RNG LN TH VI TI BUN MA THUT THNG 8 NM 2011

TIN I THO NG
PRE-DIABETES
PGS.TS TRN HU DNG Ph ch tch Hi Ni tit i tho ng Vit Nam

T L MC BNH T TRN TH GII TCYTTG CNH BO D BO N NM 2025

135 TRIU
1995 4,0%

300 TRIU
2025 5,4%

NGI T 20 TUI TR LN

Global Projections for the Diabetes Epidemic: 1995-2010

26.5 32.9 24% 14.2 17.5 23% 9.4 14.1 50% 15.6 22.5 44% 84.5 132.3 57%

1.0 1.3 33% World 2000 = 151 million 2010 = 221 million Increase 46%

T L MC BNH T TRN NGI LN CHU

Papua New Guinea highlands Rural Fiji, Melanesians China Thailand

Malaysia
Japan South Korea Urban Fiji, Melanesians Cook Islands Singapore Hong Kong Urban Kiribati Urban Samoans Urban Papua New Guinea Indigenous Australians Nauru 0 5 10 15 20 T L (%)
Zimmet P. 2002.

25

30

35

40

45

Nhng nc c s bnh nhn T nhiu nht, d kin vo nm 2030

Ai cp

Philippin
Nht bn Bangladesh

Brazil
Pakistan Indonesia Hoa k Trung quc

n
0 20 40 60 80 100

S lng bnh nhn T (triu ngi)

Adapted from Wild SH et al . Diabetes Care 2004; 27: 2569 70.

chn on T
T khi c 1 trong 4 tnh hung sau: Glucose mu lc i 126 mg/dl (7mmol/L). Glucose mu bt k 200 mg/dl (11,1 mol/L) + tiu nhiu, ung nhiu, st cn*. Glucose mu 2gi sau NPDNG 200mg/l (11,1mmol/L). Mi: HbA1C 6,5% * Cc tiu chun ny cn 2 ln xt nghim, tr T/C 2.

Risk factors for prediabetes and diabetes

Obesity Inactivity Age Family history Ethnic groups Gestational diabetes Polycystic ovary syndrome
High blood pressure High levels of LDL Low levels of HDL High levels of triglycerides High levels of ferritin Low levels of adiponectin
Diabetes Vasc Dis Res 2008;5:15-18 Diabetes Care 2007;30(Suppl 1):S4-S41

Other conditions:

Bo ph dng Qu To & Qu L
Qu To & Qu L

Trn vng bng

Di vng bng

Nam > 90 cm

N > 80 cm

Tiu chun vng bng dnh cho khu vc Nam

DIN BIN I THO NG

ng bnh thng

Tin T i tho ng

Tin i tho ng l g ?
L tnh trng tng glucose nh cha n mc

T. a s din bin n T. Trn lm sng khng c triu chng g. T l cao trn nhng ngi c nguy c. Bt u c bin chng, nht l tim mch: Tin T thc cht l mt bnh. C th phng nga.

Tin T: Prediabetes
Nm 1980 theo WHO: Tin T = Gim dung np

glucose IGT. Nm 1977 theo ADA: Tin T = Ri lon glucose lc i IFG. Nm 2003, ADA gim mc chn on IFG t 110mg/dL xung 100mg/dL. chng minh: IFG v IGT u c nguy c T v bnh tim mch.

Cardiovasc Diabetol 2007;6:32 N Engl J Med 2002;346:393-403 Diabetes Care 2005; 28(4):971-972

Sinh l bnh Tin i tho ng v i tho ng tp 2

Khng insulin

Nng insulin

Tin T. Hi chng chuyn ha -15 -10 -5

Gim tit incretin

0
Xut hin T

10
T r

15

20

25
Nm

30

Bnh l vi mch Bnh l mch mu ln

Ngun;Diabetologia 2008;51:853-861

CC TH TIN T
Ri lon glucose lc i (RLG)(IFG):
100mg/dl (5,6mmol/L) G0 < 126mg/dl (7mmol/L)

Gim dung np glucose (GDNG)(IGT): Nghim php

ung 75g glucose, o ng sau 2gi (G2):

140mg/dl (7,8mmol/L) G2 < 200mg/dl (11,1mmol/L)

CHN ON TIN T TRC Y

Tin T (RLG,GDNG)

Bnh thng

GLUCOSE MU I

NGHIM PHP

The main problem with screening for prediabetes is that both screening tests are needed to detect all prediabetic patients, but both are not fully utilized.
FPG test is the one used most often because: It is more convenient to the provider and patient It is less time consuming for the patient

It is cheaper to run
It has an increased patient compliance The OGTT is the only way to detect people with isolated IGT, so if this test is not used, a large subset of people who are at great risk for developing diabetes and cardiovascular disease are being missed.

If only a FPG is performed, 31% of the cases of prediabetes could be missed!!!

ADA: 2010
HBA1C t 5,7% -6,4% c nguy c nh IFG
hoc IGT: Prediabetes

CHN ON TIN T HIN NAY

T
6,5%

Tin T (RLG,GDNG)

< 6,5% 5,7%

< 5,7%

Bnh thng

GLUCOSE MU I

NGHIM PHP

HbA1C

Pre-Diabetes or Increased risk of Diabetes

A serious diagnosis, with legitimate therapies, including medications Impaired Fasting Glucose (IFG) : Fasting glucose 100-125 mg/dl Impaired Glucose Tolerance (IGT): 2-hr post-challenge 140-199 mg/dl New: HgbA1C between 5.7 6.4%

Prediabetes: IFG, IGT, Increased A1C

- Categories of increased risk* - Impaired fasting glucose FPG 100-125 mg/dl (5.6-6.9 mmol/l) - Impaired glucose tolerance 2-h PG on the 75-g OGTT 140-199 mg/dl (7.8-11.0 mmol/l) - A1C 5.7-6.4%
*For all 3 tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately greater at higher ends of the range.

ADA. I. Classification and Diagnosis. Diabetes Care 2010;33(suppl 1):S13. Table 3.

ADA Diagnostic Criteria: Normal, Diabetes, and Pre-diabetes

Clinical Practice Recommendations 2010

Parameter
1 Fasting Plasma Glucose (mg/dl)
2 2-h plasma glucose on OGTT (mg/dl)

Normal
<100
<140

Diabetes PreMethod diabetes

126
200

100125
140199

No caloric intake for at least 8 h

WHO method: 75 g glucose load

3 Random plasma glucose (mg/dl)

4 A1C %

<140

200

with classic symptoms of hyperglycemia or crisis

NGSP certified method standardized to the DCCT assay

<5.7

6.5

5.7 6.4

In the absence of unequivocal hyperglycemia, criteria 1, 2, and 4 should be confirmed by repeat testing.

Nguy c bin chng tim mch tin T gp i so vi ngi bnh thng

30.00 25.00

%bnh tim mch

20.00 15.00 10.00 5.00

12.00

6.00
0.00 Bnh thng Tin T

*MI=myocardial infarction. Adapted from: Hu F, et al. Diabetes Care. 2002;25:1129-1134.

CDC Data (center for desease control)

http://www.cdc.gov/diabetes/pubs/factsheets/prediabetes.htm accessed June 2010

Among adults with pre-diabetes in 2000, the prevalence of cardiovascular (heart) disease risk factors was high:
94.9% had dyslipidemia (high blood cholesterol); 56.5% had hypertension (high blood pressure); 13.9% had microalbuminuria

Insulin Resistance: Associated Conditions

San Antonio Heart Study: % of prediabetes converting to type 2 DM over 8 years

35 30 25 20
31.8

15 10 5 0
Neither Low insulin secretion
Low Low

11.0

TG HDL

6.2
1.0

Insulinresistant
High High

Both

HOMA IR Low D I30-0min/D G30-0min High

High Low
Diabetes Care 2004;27:2470-2477

Diabetes Care 2002;25:1177-1184

Overlap of MS with Insulin Resistance, Prediabetes and type 2 Diabetes

Insulin Resistance

Metabolic Syndrome (MS)

prediabetes (75% MS) Type 2 Diabetes (86% MS)

Cardiovascular Disease

Curr Opin Endocrinol Diabetes Obes 2008;15:123-127

J Am Coll Cardiol 2006; 47: 1093-1100

Adiponectin in prediabetes compared to diabetes and control

Prediabet es
Subjects
Fasting glucose (mg/dL) Controls Type 2DM

28

28

32

112.821.3 132.405.2 97.171.93 8 7

Insulin (uU/mL)
IRI Adiponectin (ug/mL)

17.673.76 14.141.9 30.127.68

88.5819.0 174.4930. 61.928.2 3 12 9.520.49* 6.150.49 6.570.457 ,**
Med Sci Monit 2006;12(1):17-20

IRI Insulin resistance index. Data are means SE Yaturu S et al (LA-US) *P0.05 (prediabetes vs controls); **P0.05 (diabetes vs. controls)

Adiponectin in prediabetes with CAD compared to subjects without CAD

CAD No CAD

p Value
0.13 0.46

Subjects
Age BMI

34
6910

55
6511

29.125.02 28.275.29

HDL
LDL-C Adiponectin (ug/mL)
CAD Coronary Artery Disease

3911
10819.03 5.020.82

419.8
10835 9.941.02

0.27
0.10 <0.01

Yaturu S et al (LA-US)

Med Sci Monit 2006;12(1):17-20

Dch t hc T:Prediabetes
16% Dn chng b Tin T
AusDiab Study (Dunstan et al, 2002)

Tin T c nguy c
Bin chng tim mch. Microalbuminuria v thng tn thn kinh (thp hn T nhng cao hn ngi bnh thng) Nguy c ung th v, i trng, gan, ty. T.

T L HIN MC TIN T HOA K TUI 45 -74 Tt c chng tc Ngi da trng khng phi gc Ty ban nha 22,6% (11,9 triu ngi) 22,2% (8,9 triu ngi)

Ngi da en khng phi 18,9% (1 triu ngi) gc Ty ban nha Ngi gc Mexico 27,3% (0,7 triu ngi)

 c hin nay c 4 ngi trn 25 tui c 1 ngi b tng glucose mu (T hoc tin T)

The Epidemic of Diabetes and Pre-diabetes

What lies beneath

Diabetes: 26 million (11.3%) and increasing. By 2015, 37 million (15%) Americans will have

diabetes Pre-diabetes: 57 million: About 1/4 (22.6%) of overweight adults aged 4574 (CDC data)
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf http://www.cdc.gov/diabetes/pubs/factsheets/prediabetes.htm

Pre-Diabetes in the Young and the Old

The diabetogenic process begins
early low birth weight and poor nutrition

Diabetes epidemic due to:

-lack of exercise and overweight in young persons, and -aging of the population

Correlation with central obesity,

insulin resistance, glucose intolerance, high blood pressure , and dyslipidemia metabolic

syndrome

Ti 15 x, phng thnh ph Quy Nhn: 1.525 ngi t 30 tui tr ln:

4.8%

8.6%

Bnh t hng Tin T T

86.6%

DIN BIN TIN T

BNH THNG

T TIM TNG

IGT (GDNGlucose)

SAU 10 NM

GDN GLUCOSE IGT

Does pre diabetes predict diabetes? to diabetes in 11 year follow up Progression of IGT/IFG
Presentation Stephen Twigg. Pre diabetes Symposium ADS & ADEA Annual Scientific Meeting Sydney 2004

Impaired glucose Tolerance 11 year follow up

Impaired Fasting Glucose 11 year follow up

IGT 30% Diabetes 46%

Normal 38%

Diabetes

46%

48%

Normal 24%

IFG 7%

IGT 17%

ADA and WHO Glucose Tolerance Categories

Fasting Plasma Glucose 2-hr Plasma Glucose on OGTT

Diabetes Mellitus
Impaired Fasting Glucose (IFG) Normal

126 mg/dL

200 mg/dL

Diabetes Mellitus
Impaired Glucose Tolerance (IGT) Normal

100 mg/dL

PreDiabetes

140 mg/dL

* Diagnosis of DM can also be made based on unequivocal symptoms and a random glucose >200 mg/dL. Any abnormality should be repeated and confirmed on a separate day.

Who should get tested for prediabetes?(ADA)

Age 45 or older Overweight Family history of diabetes Other risk factors for diabetes or pre-diabetes: sedentary lifestyle, hypertension, low HDL cholesterol, high triglycerides, history of gestational diabetes or giving birth to a baby weighing more than 9 pounds, or belonging to an ethnic or minority group at high risk for diabetes

Acanthosis Nigricans: a Sign of Insulin Resistance

Velvety, lightbrown-to-black discoloration usually on the neck, axilla, groin, dorsum of hands May point to PCOS in females Insulin sensitivity decreases by 30% at puberty with compensatory increase in insulin secretion

How often should be testing done? (ADA)

Every 3 years if glucose tolerance is
normal Every 1-2 years if pre-diabetes is diagnosed

 LM GIM NGUY C TIN N T

Dng thuc u n Hn ch ru, bia

 Thay i li sng vi n ung hp l, th dc

u n lm gim t nht 50% din bin t gim dung np glucose (tin T) thnh T

PHNG NGA DIN BIN TIN T N T

Theo Hip hi T Hoa k trc y ch cn

n ung hp l v tp th dc (150 pht/tun). Quan im hin nay nn dng thuc. Cc thuc th nghim: Metformin, Acarbose, Rosiglitazone. Kt hp n ung hp l vi th dc v thuc ROSIGLITAZONE cho kt qu ti u.

Prevention of Type 2 Diabetes

Study Subjects Intervention Relative Risk Reduction

Behavior

DaQing Finnish DPS US DPP

US DPP STOP-NIDDM EDIT TRIPOD XENDOS DREAM ACT-NOW ORIGIN NAVIGATOR

IGT IGT IGT + IFG

IGT + IFG IGT IFG Prior GDM IGT IGT IGT IFG or IGT IGT+IFG

Diet or Exercise or Both Lifestyle Lifestyle

Metformin Acarbose Metformin or Acarbose or Both Troglitazone Orlistat Rosiglitazone or Ramipril or Both Pioglitazone Glargine or Fish oil or Both Nateglinide or Valsartan or Both

64%/53%/61% IGT IGT

31% 25% NS 35% 45% 61%/NS 81% ~2010 ~2009

NOT FDA APPROVED FOR PREVENTION

NOT FDA APPROVED FOR PREVENTION

Medication

Li et al., Lancet 2008;371:1783-1789. ADA Position Statement on the Prevention or Delay of Type 2 Diabetes. Diabetes Care. 2002;25:742-749. Torgerson JS, et al. Diabetes Care. 2004;27:155-161. DREAM Trial Investigators. Lancet. 2006;368:1096-1105. DREAM Trial Investigators. N Engl J Med. 2006;355:1551-1562. DeFronzo RA, et al. ADA 68th Scientific Sessions 2008. Origin Trial Investigators. Am Heart J 2008;155:26-32.

What is the Treatment for Pre-diabetes?(ADA)

Population IFG or IGT Treatment

Lifestyle modification ( 5-10% weight loss and moderate intensity physical activity ~ 30 min/day) Lifestyle modification and metformin*

IFG and IGT plus:

Family history of CVD BMI 35kg/m2 Family history of diabetes in first-degree relatives Elevated triglycerides Reduced HDL cholesterol Hypertension *Metformin 850mg twice per day
Curr Opin Endocrinol Diabetes Obes 2008;15:123-127 Diabetes Care 2007; 30(3):753-759

KT LUN

Tin T xut hin nhiu nm trc T. T l cao dn n T. Tin T gm IFG, IGT, HbA1C tng. Bin chng tim mch gp i ngi c glucose bnh thng. Phng bnh :
Thay i li sng. Thm Metformin nu km nguy c.