Dysglycaemia and cardiovascular risk Asian experience

Chang-Yu Pan, China

Growing prevalences of diabetes and prediabetes in Asia

Western-Pacific region Prediabetes 2003 79 million (6%) 2025 120 million (7%) Diabetes 2003 43 million (3%) 2025 76 million (4%)

IDF Diabetes Atlas. www.eatlas.idf.org.

Growing prevalences of diabetes and prediabetes in China

Peoples Republic of China Prediabetes 2003 33 million (4%) 2025 54 million (5%) Diabetes 2003 23 million (3%) 2025 46 million (4%)

IDF Diabetes Atlas. www.eatlas.idf.org.

Prediabetes is common in China particularly IGT

Total prevalence of prediabetes: 11.7%

Isolated IFG 1.7%

15% 10%

Isolated IGT 8.8%

75%

IFG + IGT 1.2%

Shanghai community cross-sectional epidemiological survey Shanghai Diabetes Institute

Chinese IGT population is at high risk of type 2 diabetes

Chinese individuals with IGT progress to type 2 diabetes faster than American individuals with IGT
20 18 16 14 12 10 8 6 4 2 0 Incidence/100pys 17.2 13.3 11.1

Chinese BMI 22.4kg/m2

Chinese BMI 27.5kg/m2

American BMI 34.2kg/m2

2hPG levels of IGT controls in Da-Qing Study and DPP were similar (mean value 160mg/dL)

Prediabetes is associated with an increased risk of mortality

DECODA (n=6,817)
Multivariate hazard ratio 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 <6.1 6.16.9 7.0 FPG (mmol/L) <7.8 7.811.0 11.1 2hPG (mmol/L) All-cause mortality
p=0.001 p=0.006

CVD mortality
p<0.001 p<0.001

Nakagami T, et al. Diabetologia 2004;47:38594.

Postprandial hyperglycaemia is associated with an increased risk of mortality

DECODA (n=6,817)
Multivariate hazard ratio 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0 All-cause mortality
p=0.81 p=0.83

CVD mortality
p<0.001 p<0.001

<6.1

6.16.9 7.0 FPG (mmol/L)

<7.8

7.811.0 11.1 2hPG (mmol/L)

adjusted for 2hPG criteria

adjusted for FPG criteria

Nakagami T, et al. Diabetologia 2004;47:38594.

Postprandial hyperglycaemia is associated with an increased risk of CVD

Singapore National Health Survey 1992 (n=3,568)
3.5 3.0 Hazard ratio 2.5 2.0 1.5 1.0 0.5 0 <5.6 5.66.0 FPG level (mmol/L) >6.0
Tai ES, et al. Diabetes Care 2004;27:172834.

NGT

IGT

Individuals with IGT had a higher risk of ischaemic heart disease than those with NGT in each FPG category

China Heart Survey study design

52 hospitals in 7 cities in China

Enrolled patients admitted with CAD (n=3,513)

Data collected by case record form

Patients without known diabetes received OGTTs

Hu DY, et al. Eur Heart J 2006;27:25739.

China Heart Survey dysglycaemia is common in patients with CAD

OGTT cohort (n=2,263)
NGT
Prediabetes 27% 36% Newly diagnosed 33% 23%

Whole population (n=3,513)

diabetes (OGTT)
Newly diagnosed diabetes (FPG test) Previously known diabetes 3% 17% ~3/4 of patients have hyperglycaemia 24%

37% ~2/3 of patients have hyperglycaemia

Hu DY, Pan CY, Yu WM. Eur Heart J 2006;27:25739.

China Heart Survey OGTTs diagnose prediabetes and type 2 diabetes

Proportion of patients (%) 100 80 60 40 NGT IFG IGT Type 2 diabetes

20
0 FPG OGTT FPG OGTT Acute admission Elective admission
Hu DY, Pan CY, Yu WM. Eur Heart J 2006;27:25739.

Early diagnosis of prediabetes is essential

Early diagnosis and management of prediabetes can reduce the risk of both type 2 diabetes and cardiovascular disease Western Pacific Diabetes Declaration (WPDD) guidelines: The risk of complications is related to the duration of diabetes, as well as the degree of hyperglycaemia. However, due to delayed diagnosis, these complications may already be present at diagnosis
WPDD. www.wpdd.org/downloads/Diabetes_Book.pdf.

WHO Technical Report

Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia
Risk might best be assessed by the use of prediction scores which, in addition to plasma glucose, also include other risk factors The poor reproducibility of IFG and IGT suggests that absolute FPG or 2hPG measurement might be more informative than categorisation into IFG or IGT

IDF Congress 2006, Cape Town, South Africa

Screening high-risk populations in Europe FINDRISC

1. Age <45 years (0p); 4554 years (2p); 5564 years (3p); >64 years (4p) 2. Body mass index <25kg/m2 (0p); 2530kg/m2 (1p); >30kg/m2 (3p) 3. Waist circumference measured below the ribs (usually at the level of the navel) Men: <94cm (0p); 94102cm (3p); >102cm (4p) Women: <80cm (0p); 8088cm (3p); >88cm (4p) 4. Do you usually have daily at least 30 minutes of physical activity at work and/or during leisure time (including normal daily activity)? Yes (0p); No (2p) 5. How often do you eat vegetables, fruit or berries? Every day (0p); Not every day (1p) 6. Have you ever taken antihypertensive medication regularly? No (0p); Yes (2p) 7. Have you ever been found to have high blood glucose (e.g. in a health examination, during an illness, during pregnancy)? No (0p); Yes (5p) 8. Have any of the members of your immediate family or other relatives been diagnosed with diabetes (type 1 or type 2)? No (0p); Yes grandparent, aunt, uncle or first cousin (but not own parent, brother, sister or child) (3p); Yes parent, brother, sister or own child (5p) Tuomilehto J, et al. www.diabetes.fi.

Screening high-risk populations in China hospital poster

Recruit patients with >2 risk factors: 1. Family history of T2D 2. Hypertension 3. Obesity 4. History of gestational diabetes

5. Delivery of a baby >4kg

6. Dyslipidaemia 7. >40 years old Toll-free hotline provided

Results of 2002 screening campaign in China

City Total hospitals 10 Total patients 4,585 Diagnosis Healthy 2,854 62% 1,559 31% 2,631 51% 2,289 60% 9,333 50% IGT 592 13% 1,529 30% 452 9% 516 14% 3,089 17% T2D 1,139 25% 1,988 39% 2,083 40% 1,005 26% 6,215 33%

Guangzhou

Hangzhou
Beijing Shanghai Total

10
11 10 41

5,076
5,166 3,810 18,637

WHO Technical Report

Definition and Diagnosis of Diabetes Mellitus and Intermediate Hyperglycaemia
Recommendation 6

The OGTT should be retained as a diagnostic test for the following reasons:
FPG alone fails to diagnose approximately 30% of cases of previously undiagnosed diabetes OGTT is the only means of identifying people with IGT OGTT is frequently needed to confirm or exclude an abnormality of glucose tolerance in asymptomatic people
IDF Congress 2006, Cape Town, South Africa

Conclusions
The China Heart Survey confirms that CVD is associated with dysglycaemia in Chinese patients Early diagnosis and management of dysglycaemia, with either lifestyle modification or pharmacotherapy, is essential

Simple risk-prediction tools are available that can be used for routine screening to identify high-risk individuals