Sindrome metabolica/dia bete

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1 Sindrome metabolica/dia bete Giulio Marchesini Alma Mater Studiorum Università di Bologna

2 Grundy, Circulation 2005 Criteria for Metabolic Syndrome

3 Central role of obesity Factor analysis on changes in the parameters of MS Axis are Factors of MS Changes in BMI, WHR and Fasting insulin are central to the 3 independent factors in the entire cohort Ely Study: a prospective cohort established in 1990 Maison, Diabetes Care 2001

4 8-year incidence of metabolic syndrome Abdominal obesity predicts the metabolic syndrome San Antonio Heart Study: 628 non-hispanic whites and 1,340 Mexican Americans >30 <30 Body mass index (kg/m 2 ) >102 cm (men) >88 cm (women) <102 cm (men) <88 cm (women) Han; Obes Res 2002

5 Relative risk Abdominal obesity increases the risk of developing T2DM 24 Nurses Health Study; 43,581 women < >96.3 Waist circumference (cm) Carey, Am J Epidemiol 1997

6 mg/dl mg/dl Intra-abdominal adiposity and dyslipidaemia 310 Triglycerides 60 HDL-cholesterol Lean Low High Visceral fat (obese subjects) 30 Lean Low High Visceral fat (obese subjects) Pouliot, Diabetes 1992

7 Adjusted relative risk Abdominal obesity predicts the risk of CV events 1.4 Waist circ. (cm): 1.29 Tertile 1 Tertile 2 Tertile 3 Men < > Women < > CVD death MI All-cause deaths Adjusted for BMI, age, smoking, sex, CVD, disease, DM, HDL-C, total-c Dagenais, Am Heart J 2005

8 Come fare lo screening?

9 Quale test di screening? Peso BMI (peso/altezza 2 ) Circonferenza vita Rapporto vita/fianchi Circonferenza vita/altezza (Circonferenza collo) (circonferenza polso)

10 Screening x DM2 L OMS ha definito criteri che rendono un test di screening raccomandabile: Test semplice da eseguire, Test facile da interpretare, Test di elevata accuratezza diagnostica, Test con favorevole rapporto costo/beneficio. Holland. WHO European Centre for Health Policy: Screening in Europe, 2006

11 Elementi PRO screening Il DM2 presenta una lunga fase asintomatica (malattia diagnosticata solo se ricercata con screening). Sono disponibili test di screening non invasivi, semplici e poco costosi. La percentuale di DM2 non diagnosticato varia fra il 30 e il 50% dei casi di diabete tipo 2 e nella fase pre-clinica si sviluppano le complicanze. Un compenso glicemico ottimale fin dalle prime fasi della malattia e la correzione dei fattori di rischio CV associati riducono l incidenza e la progressione delle complicanze. Le complicanze acute e croniche del DM2 hanno un grave impatto sulla qualità di vita dell individuo, nonché sulla salute pubblica. Nel corso dello screening possono essere identificati soggetti con IGT e IFG nei quali interventi sullo stile di vita prevengono/ritardano lo sviluppo della malattia conclamata.

12 Elementi CONTRO screening La prevalenza della malattia non è elevata. Alla diagnosi di diabete può far seguito la comparsa di depressione. Dispendio di tempo ed energia da parte del paziente per eseguire test aggiuntivi necessari a confermare la diagnosi e per le visite di follow-up. Possibili effetti avversi del trattamento. Incremento dei costi, almeno iniziali, derivanti dal trattamento anticipato della malattia rispetto alla sua naturale evoluzione. Carenza di evidenze sulla maggior efficacia di interventi messi in atto nella fase pre-clinica della malattia rispetto a quelli instaurati dopo la diagnosi clinica.

13 Screening

14 The ADDITION-Cambridge study A primary care-based screening and intervention study for T2DM. Two phases: 1. a pragmatic parallel group, unbalanced, cluster-randomised trial of screening; 2. a cluster-randomised trial comparing the effects of intensive multifactorial therapy with routine care in individuals with screen-detected T2DM. Simmons, Lancet 2012 (Oct 3)

15 The ADDITION-Cambridge study Of high-risk individuals in screening practices, (94%) were invited for screening during , (73%) attended, and 466 (3%) were diagnosed with diabetes control individuals were followed up. During person-years of follow up (median duration 9.6 years [IQR ]), there were 1532 deaths in the screening practices and 377 in control practices (mortality hazard ratio [HR] 1.06, 95% CI ). Simmons, Lancet 2012 (Oct 3)

16 The ADDITION-Cambridge study In this large UK sample, screening for type 2 diabetes in patients at increased risk was not associated with a reduction in all-cause, cardiovascular, or diabetes-related mortality within 10 years. The benefits of screening might be smaller than expected. Simmons, Lancet 2012 (Oct 3)

17 The SWEETHEART registry 2,767 pts presenting with STEMI or NSTEMI Those without known DM had an OGTT at day 4 after admission. Female pts. have higher rates of known and newlydiagnosed DM (30.2 and 19.7% compared with 23.1 and 15.3 in males) 3-Year mortality rates with known DM not different between males and females (35.4% and 30.0). Mortality in newly-diagnosed DM much higher in females (30.5% vs. 21.8). Tschoepe, Diabetologia 2012

18 CAD as risk for DM 506 consecutive non-dm patients undergoing coronary angiography for suspected CAD (significant CAD, 293 cases) Follow up, 7.5 years (3795 patient-years) 107 incident cases of DM (21.1%, 2.8% per year) Patients with significant CAD had a 33% increased risk of incident DM at follow-up Conclusion: The presence of CAD indicates an increased risk of DM. Repeated screening and targeted programs are warranted to prevent diabetes Saely, Diabetologia 2012

19 Impatto delle Malattie croniche non trasmissibili (CNCD) sui Sistemi Sanitari Le CNCD avranno un effetto devastante sui Sistemi Sanitari, orientati oggi prevalentemente alla cura, non alla promozione della salute Il diabete potrebbe diventare la pandemia del 21* secolo Occorrono interventi sistematici sulla popolazione The lives of far too many people in the world are being blighted and cut short by chronic disease such as heart disease, stroke, cancer, chronic respiratory disease and diabetes LEE Jong-wook Director-General, World Health Organization