DIABETUL ZAHARAT TIP2

O chemare la actiune

Dr Mirela Culman
Institutul national de
Diabet,Nutritie si Boli metabolice
,,Nicolae Paulescu”
 Bolile cardiovasculare – cauză majoră de
deces
deces (%)

45
40
35
30
25
20
15
10
5
0
BCI altele diabet cancer AVC infectii altele
(CV)

Geiss LS et al. Diabetes in America.2nd ed.Bethesda, MD:NIH;1995

 Mortalitate cardiovasculară crescută la
pacienţii cu Sindrom metabolic
CHD deaths Cardiovascular deaths
10 10
Cumulative hazard (%)

Relative risk Relative risk

DMS
3.77 (1.74, 8.17) 3.55 (1.96, 6.43)
5 5

DMS

0 No DMS 0 No DMS

0 4 8 12 0 4 8 12
Years of follow-up

Lakka HM et al. JAMA 2002;288:2709-16

Conglomerat de factori de risc pentru boala
cardio vasculară

Statusul
protrombotic Microalbuminuria
proinflamator

Obezitatea abdominală
 Riscul de boală cardiovasculară se multiplică
în funcţie de factorii de risc asociaţi

HIPERTENSIUNE DISLIPIDEMIE
TAS 15o mmHg X 3,8 Colesterol 260 mg/dl
X 1,5 X 2,3
X 6,2
X 2,6 X4

DIABET X 1,8

Risc bazal 15/1000 (1,5%) în 8 ani

KannelWB.Importanceof hypertensionas amajor risk factorin cardiovascular disease ,in Hypertension:

Physiopathology and treatament. New York NY:MacGraw-Hill BookCo;1977:888-910
 Sindromul metabolic - Quartetul ucigaş
WHOa EGIRb NCEPc
Insulin resistance Insulin resistance FPG
&/or FPG (hyperinsulinaemia)
Plus 2 or more of: Plus 2 or more of: Plus 2 or more of:
Blood pressure Blood pressure Blood pressure
TG,  HDL-C TG,  HDL-Cd TG
Microalbuminuria  HDL-C
Central obesity Central obesity Central obesity

aWorld Health Organisation; bEuropean Group for the study

of Insulin resistance; cNational Cholesterol Education Program;
dand/or treatment for dyslipidaemia
Eschwege E. Diabetes Metab 2003;29:6S19-27
Prevalenţa sindromului metabolic în Europa

35 <40 years 40-55 years >55 years

30
Prevalence (%)

25
20
15
10
5
0
Men Women Men Women
Definiţie OMS Definiţie EGIR

Balkau B et al. Diabetes Metab 2002;28:364-76

Eschwege E. Diabetes Metab 2003;29:6S19-27
Prevalenţa sindromului metabolic în USA

50 White African-American
Mexican-American Other
40
Prevalence (%)

30

20

10

0
Men Women Men Women
National Cholesterol Education World Health Organisation
Program definition definition

Ford ES, Giles WH. Diabetes Care 2003;26:575-81

Eschwege E. Diabetes Metab 2003;29:6S19-27
Cel mai tipic exemplu de sindrom
metabolic

Diabetul tip 2

La fiecare 21 secunde apare un caz nou de diabet !

 Epidemie globală de diabet

333
diabetes world wide (millions)

350
Number of people with

300
250
194
 72%
200
150
100
50
0
2003 2025
Year

International Diabetes Federation

 Diabetul determină risc crescut pentru
evenimente cardiovasculare
Risc de 3 ori mai mare Risc de 2–5 ori mai mare de
De infarct de miocard moarte de cauză crdiovasculară

Fără diabet Cu diabet

80 RR 2.6

person-years (age adjusted)

120
Incidence (%)

60

CV deaths/100,000
RR 4.1

40 80 RR 4.8

20 40 RR 5.1

0
No Diabetes 0
diabetes 0 1 2 3
RR: relative risk Number of cardiovascular risk factors

1Haffner SM et al. NEJM 1998;339:229-34; 2Stamler J et al. Diabetes Care 1993;16:434-44

Pacientul cu DZ 2 are prognostic asemănător cu cel
nediabetic care a suferit un IM

100

80
% Surviving

No diabetes, no MI
60 Diabetes, no MI
No diabetes, with prior MI
Diabetes, with prior MI
40

0 2 4 6 8
Years of follow-up

Haffner SM et al. NEJM 1998;339:229-34

Toate atingerile de organ date de diabet
sunt de natură angiopată Micro/Macro

Liebl A. et al. Dtsch. Med. Wochenschr. 126,585,2001

AVC La fiecare 12 minute

Orbire La fiecare 90 minute

IM La fiecare 19 minute

Dializă La fiecare 90 minute

Amputaţie La fiecare 19 minute

În Statele Unite
În fiecare 24 de ore

Peste 65 orbesc
656 dezvoltă insuficenţă renală şi încep
dializa renală
Peste 500 mor datorită complicaţiilor
2200 persoane sunt diagnosticate cu
diabet
153 suferă o amputaţie de m inferior
Prevalenţa complicaţiilor dibetului

Data from a UK primary care audit (10,709 diabetic patients)

30
25
25
% Patients

20 18
17
15
10
10

5 2
0
CHD CVD Diabetic foot Retinopathy Nephropathy

CHD: coronary heart disease

CVD: cerebrovascular disease
Morgan CL. Diabet Med 2000;17:146-51
Raportul dintre costul global şi costul complicaţiilor

Non - overweight patients Overweight patients

10 10

Mean cost/patient (£1000)

Mean cost/patient (£1000)

8 8

6 6

4 4

2 2

0 0
Conventional Intensive (SU Conventional Intensive
(diet) or insulin) (diet) (metformin)

Cost of managing complications Overall costs (standard practice)

UKPDS 41. BMJ 2000;329:1375-8; UKPDS 51. Diabetologia 2000;44:298-304

Costurile diabetului înainte şi după diagnostic

Costs before diagnosis Costs after diagnosis

35 35
Total treatment cost

30 30
(US $ x 1000)

25 25
20 20
15 15
10 10
5 5
0 0
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Years before diagnosis Years after diagnosis

Type 2 diabetes
Matched controls
Brown JB et al. Diabetes Care 1999;22:1116-24;
Nichols GA et al. Diabetes Care 2000;23:1654-9
 Diabetul tip 2 reduce speranţa de viaţă
Years of life expectancy lost according to age
at diagnosis of diabetes
Age at Marks & Krall Goodkin Panzram &
diagnosis 1971 1975 Zabel-Langhennig
1981

20 - 29 12 – 14 16 –
30 - 39 10 – 11 11 –
40 - 49 8–9 10 7–8
50 - 59 6–7 6 5–6
60 - 69 4–5 5 3–4
70 + – – 3

Panzram G. Diabetologia 1987;30:123-31

 Diabetul tip 2 amplifică efectele adverse ale
sindromului metabolic
Fără diabet Diabet tip2
RR 2.2
30 30
p<0.001

Prevalence (%)
Prevalence (%)

20 20
RR 2.3
RR 1.7
p=0.007
p=0.04 RR 1.8
10 RR 1.2 RR 1.3 10 p=0.013
p=0.62 p=0.59

0 0
CHD MI Stroke CHD MI Stroke
Dysmetabolic syndrome present Dysmetabolic syndrome absent
RR: relative risk Isomaa B et al. Diabetes Care 2001;24:683-9
 Componentele sindromului metabolic
amplifică riscul cardiovascular la diabetici
Dyslipidaemia Hypertension Obesity
Non-diabetic Diabetic
50 30 30
1000 patient-years

40
CHD deaths/

20 20
30
20
10 10
10
0 0 0
6 52 2 .2 .8 .8
2

2
.5

.2

3 5 4 6 6
.

<1 1 >1
<5

>7
6

6- <2 .2-2 >2

2-

5-

3
5.

6.

1 24
Serum cholesterol
SBP (mmHg) BMI (kg/m2)
(mmol/L)
Adlerberth AM et al. Diabetes Care 1998;21:539-45;
Eschwege E. Diabetes Metab 2003;29:6S19-27
 Complicaţiile cronice ale diabetului apar mai
frecvent la pacienţii care asociază sindrom
metabolic
+ Dysmetabolic syndrome
% patients with complications

60 53 - Dysmetabolic syndrome
50 44 44
38 36 38
40
28 28
30 24
20
20
10
0
D

SN
hy
D

ia
A
PV

ur
t

D
C

pa

in
o

um
in
et

b
al
R

-
ro
ic
M
PVD: peripheral vascular disease
CAD: coronary artery disease
DSN: Distal sensory neuropathy Costa LA et al. Diabet Med 2004;21:252-5
Riscul de complicaţii cronice creşte proporţional cu
severitatea sindromului metabolic

No. of risk None/one Two

70
factors: Three Four
% with each risk factor

60

50

40

30

20

10

0
PVD CAD Stroke Retinopathy DSN
PVD: peripheral vascular disease
CAD: coronary artery disease
DSN: Distal sensory neuropathy Costa LA et al. Diabet Med 2004;21:252-5
 Managementul
intensiv si multifacorial

Control glicemic bun

Complicaţii
Tratament microvasculare şi
macrovasculare

Sindromul metaboloic
Rezistenţa la insulină, obezitate,
hiperinsulinemia, hipertensiune,
dislipidemia, ateroscleroză, status
procoagulant, proinflamator