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12 th Annual Diabetes Awareness Day
12th Annual Diabetes Awareness Day
What’s New in Type 2 Diabetes?
• Global increase in rate of diabetes • New glucose-‐lowering pills approved in Canada
• EpigeneAcs and gestaAonal diabetes • 2014 ADA Clinical PracAce Guidelines on lifestyle modificaAon therapy for diabetes Ø Diet and exercise
World Diabetes Day 2014
Diabetes: protect our future Focus on Healthy Living and Diabetes • Make healthy food the easy choice • Healthy eaAng: make the right choice • Healthy eaAng begins with breakfast
Almost half of all people with diabetes live in just 3 countries
China India USA
Diabetes is a huge and growing problem, and the costs to society are high and escalaAng
382 million people have diabetes in 2013
By 2035, this number will rise to 592 million
Do you know • 1 out of 12 people with diabetes globally
• 1 in 2 people with diabetes don’t know they have it
• Every 7 seconds 1 person dies from diabetes!
• 4.9 million deaths in 2014
Diabetes is a global disease! EsAmated global prevalence of diabetes
InternaAonal Diabetes FederaAon. IDF Diabetes Atlas. FiWh EdiAon. 2014
2000 2013 2035 151 million 387 million 592 million
Diabetes Prevalence Rates in Canada, 2008/09
Canada 6.8%, N=2,359,252
Age-‐ and sex-‐adjusted diabetes prevalence increased by 40% in the next 10 years, from 6.8% in a populaAon to 9.9% or 3.4 million in 2020!
Public Health Agency of Canada, Diabetes in Canada. Ottawa, 2011
Diabetes is more than a health issue and requires concerted policy
acIon across many sectors
Each Person with Type 2 Diabetes Presents a Unique Set of Challenges
Hyperglycemia Obesity
Dyslipidemia Hypertension
Nephropathy
The Importance of Health Behaviour Changes
Exercise
Diet
You are what you eat!
guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright © 2013 Canadian Diabetes Association
NutriIon Checklist
ü REFER for nutriAon counseling by a registered dieAAan ü FOLLOW EaAng Well with Canada’s Food Guide
ü INDIVIDUALIZE dietary advice based on preferences and treatment goals
ü CHOOSE low glycemic index carbohydrate food sources
ü KNOW alternaAve dietary paderns for type 2 diabetes
ü ENCOURAGE matching of insulin to carbohydrate in DM1
ü ENCOURAGE nutriAonally balanced, calorie-‐reduced diet in overweight or obese paAents
2013
ObjecAve • To assess the long-‐term effects of dietary intervenAons on glycemic
control, need for diabetes medicaAons, and remission of type 2 diabetes Design and methods • Overweight middle-‐aged men and women with newly diagnosed type 2
diabetes were randomized to a low-‐carbohydrate Mediterranean diet (LCMD; n = 108) or a low-‐fat diet (n = 107)
• AWer 4 years, parAcipants who were sAll free of diabetes medicaAons were further followed up unAl the primary end point (need of a diabeAc drug); remission of diabetes (parAal or complete); and changes in weight, glycemic control, and cardiovascular risk factors were also evaluated
Diabetes Care 2014; April 10 (online), doi:10.2337/dc13-‐2899/-‐/DC1
CumulaAve HR for AnAdiabeAc MedicaAons
Esposito K, et al. Diabetes Care 2014; April 10 (online)
Prevalence of Any Diabetes Remission
14.7% 10.5% 9.7%
7.6% 5.8% 5%
Esposito K, et al. Diabetes Care 2014; April 10 (online)
Changes in A1C and Body Weight
Esposito K, et al. Diabetes Care 2014; April 10 (online)
Key Messages on Diet and Diabetes
• NutriAonally balanced, calorie-‐reduced diet should be followed to achieve and maintain a lower, healthier body weight for most overweight or obese people with or who are at risk for diabetes
• A diet with lower glycemic load and less SSB is associated with lower risk for type 2 diabetes
• In adults with diabetes, the macronutrient distribuAon as a percentage of total energy can range from 45-‐60% carbohydrate, 15-‐20% protein, and 20-‐35% fat to allow for individualizaAon of nutriAon therapy based on preference and treatment goals [Grade D, consensus]
• Mediterranean and DASH dietary paderns are associated with improvement in glycemic control and lipid profile, as well as cardiovascular disease risk
2013
CDA CPG Expert Comm. Can J Diabetes 2013;37(Suppl 1):S45-‐S55
An insulin-‐independent Pathway to Lower Blood Sugar: Kidney SGLT2
1. Bailey CJ. Cur Diab Rep. 2009;9(5):360-‐367 2. Srinivasan BT, et al. Postgrad Med J. 2008;84(996):524-‐531. 3. Washburn WN. J Med Chem. 2009;52(7):1785-‐1794 4. Rajesh R, et al. Int J Pharma Sci Res. 2010;1(2):139-‐147 5. Marsenic O. Am J Kidney Dis. 2009;53(5):875-‐883
Insulin-‐dependent mechanism Insulin-‐independent pathway
Kidney
Insulin-‐independent renal SGLT2
Liver Muscle Adipose Assue
Insulin Replacement • Insulin
Insulin Release • Sulfonylureas • GLP-‐1 analogs • DPP-4 inhibitors • MegliAnides
Insulin AcIon • TZDs • Mepormin
Pancreas
Kidney SGLT2 InhibiAon: A Novel Approach to Type 2 Diabetes
1. Bailey CJ. Curr Diab Rep. 2009;9(5):360-‐367 2. Silverman M, et al. In: Windhager EE, ed. Handbook of Physiology. 1992;2017-‐2038 3. Rahmoune H, et al. Diabetes. 2005;54(12):3427-‐3434
Type 2 diabetes with SGLT2 inhibiIon
Excess glucose
Glomerulus
Renal proximal tubule
Glucose excreAon enabled through SGLT2 inhibiAon
Excess glucose excreAon
Reduced glucose levels out to the bloodstream
PaIents with type 2 diabetes
Urinary excreAon
Glucose
Excess glucose
Glomerulus
Renal proximal tubule
Glucose reabsorbAon
Renal SGLT2 InhibiAon: Untreated Type 2 PaAents
Adapted from: 1. Chao EC & Henry RR. Nat Rev Drug Discov. 2010;9(7):551-‐559 2. DeFronzo RA, et al. Diabetes Obes Metab. 2012;14(1):5-‐14 3. Washburn WN. J Med Chem. 2009;52(7):1785-‐1794
Urinary excreIon
Glucose returns to the bloodstream
Excess glucose
Glomerulus
Renal proximal tubule
Glucose reabsorpIon
RTG ~ 13.8 mmol/L In paIents with T2DM
and chronic hyperglycemia, the SGLT system is maladapted,
causing reabsorpIon of excess glucose
RTG = Renal Threshold of Glucose
Renal SGLT2 InhibiAon and Insulin-‐Independent Glucose Control in PaAents Treated with SGLT2i
Renal proximal tubule
Excess glucose
Glomerulus
SGLT2 inhibiIon enables more glucose to be excreted
Excess glucose excreIon in urine
Glucose reabsorpIon
RTG ~ 5 mmol/L
Reduced blood glucose reabsorbed into the
bloodstream
RTG = Renal Threshold of Glucose
1. Chao EC & Henry RR. Nat Rev Drug Discov. 2010;9(7):551-‐559 2. DeFronzo RA, et al. Diabetes Obes Metab. 2012;14(1):5-‐14
3. Washburn WN. J Med Chem. 2009;52(7):1785-‐1794
Gut Flora and Human Obesity
Ley RE, et al. Nature 444:1022-‐23
Fermicutes dominate over bacteroidetes in obese gut
FighAng Obesity with Bacteria
Walker AM & Parkhill J Science 2013;341:1069-‐1670
GestaAonal Diabetes
• Affects ~15% of pregnant women worldwide • In India alone about 4 million women have GDM
• Women with GDM are more likely to give birth to macrosomic or large-‐for-‐gestaAonal-‐age infants
• Infants of women with GDM have a higher prevalence of overweight and obesity, and higher risk of developing type 2 diabetes later in life
“Superior Doctors Prevent the Disease. Mediocre Doctors Treat the Disease Before Evident.
Inferior Doctors Treat the Full Blown Disease.”
Huang Dee, 2600 B.C. In Nai Ching, 1st Chinese Medical Text
Thank you!
12th Annual Diabetes Awareness Day
