A/Prof Ken Sikaris - Sonic Healthcare - Impact of the diabetes epidemic and changing guidelines on...

A/Prof Ken Sikaris 9th September 2014

Impact of the diabetes epidemic

and changing guidelines

on laboratory workload

A/Prof Ken SikarisDirector of Clinical Support Systems

Sonic Healthcare

BSc(Hons), MBBS, FRCPA, FAACB, FFSc, GAICD


Australia


Diabetes in Australia: 1980 - 2000

0

200

400

600

800

1000

’80 ’82 ’84 ’86 ’88 ’90 ’92 ’94 ’96 ’98 ’00

Th

ou

san

ds

Year

a)

Busselton

b) Nat Heart

Foundation

c) Aust Bureau

Statistics

d) Aust Bureau

Statistics

e) AusDiab


Ausdiab Diabetes Prevalence 1999-2012


Approx 1.5 million today, 3.5 million by 2033.

275 Australians develop type 2 diabetes every day

By 2023 type 2 diabetes is projected to become

the leading specific cause of disease burden for

men and the second leading cause for women.

Diabetes in Australia


ABS Survey 2011-2012

ALL MEN WOMEN

DIABETES Fasting Glucose 5.1% 6.3% 3.9%

HbA1c 5.4% 6.6% 4.2%

PREDIABETES Fasting Glucose 3.1% 4.1% 2.1%

HbA1c 5.4% 5.5% 5.3%

1 in 16 Australians are diabetic

4% reported to have diabetes85% Type 2

12% Type 1


ABS Survey 2011-2012


Diabetes Complications


CVD

(Exp

on

en

tia

l)


Cardiovascular Disease

Diabetes or pre-diabetes

In 65% of CVD


Improving CVD: Statins?


CVD mortality trends

Factors

Smoking

Antihypertensives

Statins

Survival after AMI

Angioplasty

Antithrombotics


Leading Causes of Death


CVD Hospitalisations


Improving Diabetes Outcomes


Australian Diabetes Costs

Total Costs

$6.6 billion (2003)

HbA1c $0.01 billion


Cost distribution in Type 2 diabetes


Preventable Health Costs


Diabetic Renal Disease


The Deadly QuartetKaplan Arch Int Med

1989;149:1514-1520


Which one of the

deadly quartet is

missing?


Top tests for diabetes, lipids, HT


BEACH: TYPE 2 DIABETES & GP’s

2000-02 2006-08

GP visits 2.6% 3.3%

Pathology Requests/Visit 63.6% 88.4%

Total Diab Tests 1,700,000 3,100,000

% of all GP pathology 4.9% 6.0%


http://www.medicareaustralia.gov.au/statistics/mbs_item.shtml


MBS Schedule 66608: Vitamin D


MBS Schedule 66551: HbA1c

About $16 million / annum* (50% coned)


MBS Schedule 2517: Diabetes PIP


MBS Schedule 10951: Diabetes Education


MBS Schedule 717: 45y/o Health Check


MBS Schedule 66536: HDLC


MBS Schedule 66560: Microalbumin


MBS Schedule 66542: OGTT


FPG vs 2hPG and diabetes.

6.1 7.0FPG (mmol/L)

IFG

7.8 11.1GLU-2h (mmol/L)

IGT

or

Diabetesnormal

and

5.5

(GDM 5.1)


Gestational Diabetes


MBS Schedule 66545: Glucose Challenge Test Pregnancy


MBS Schedule 66545: Oral Glucose Tolerance Test in Pregnancy


MBS Schedule 66554: HbA1c pregnancy


New GDM Criteria

• ADIPS 1999-2014

– Prevalence 8%

• IADPSG (HAPO)

– Projected Prevalence 14%

• Optimal Glucose sample (fluoride-ice/citrate)

–Potential Prevalence 20%

»Same as HAPO


ADA Working Party Report Diabetes Care 2009; 32: 1327-34

ADA recommends: HbA1c 6.5% for diagnosis of diabetes

Pre

va

len

ce

of

retin

op

ath

y


Stroke

(Exp

on

en

tia

l)


All causes of mortality

(Exp

on

en

tia

l)


ABS Survey 2011-12: Chronic Disease

Cancer Diabetes

Heart Disease


ABS Survey 2011-12: Chronic Disease

Cancer

Diabetes

Heart Disease


0.4

1.8

0.4

0.7

1.4

0.4

0.8

1.6

0.8

0.0

0.4

0.8

1.2

1.6

2.0

Normal Overweight Obese

Males

Females

All

Incidence of diabetes according to baseline body mass index

Baseline BMI status

Incid

en

ce (

% p

er

year)

Body mass index (BMI: weight/height2) was categorised into three groups: (i) normal: BMI < 25.0 kg/m2; (ii) overweight: 25.0─29.9 kg/m2; and (iii) obese: ≥ 30.0 kg/m2.


Obesity in adults


Overweight children in Australia:


Obesity in Babies ! Lack of Exercise?

Kim

et a

l, O

be

sity 2

00

6;1

5:1

107

.


Changes in Dietary Composition


JAMA Intern Med. 2014;174(4):516-524. Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults Quanhe Yang, Zefeng Zhang, Edward W. Gregg, W. Dana Flanders, Robert Merritt, Frank B. Hu.

Prof Robert Lustig Auckland NZ Feb 2014


Insulin Resistance and Dyslipidemia

TGVLDL

(lipoprotein or hepatic lipase)

SDLDL

(CETP)

CE

HDL

TG

(hepaticlipase)

Kidney

Apo A-1(CETP)

LDL

TGCE

Liver

FFAFructose


How small is sdLDL?


Modified LDL is atherogenic


LDL gradient gel electrophoresis ‘Lipoprint’

http://www.4qc.com/products/lipoprint/Low-Risk-Lipo-Profile-large.html

http://www.4qc.com/products/lipoprint/Low-Risk-Lipo-Profile-large.html


Small Dense LDLAustin MA, King MC, Vranizan KM, Krauss RM, “Atherogenic lipoprotein

phenotype. A proposed genetic marker for coronary heart disease.”

Circulation 1990;82:495-506.

0.5 1.0 1.5 2.0 2.5 3.0

(mmol/L)


Triglycerides

<0.5

0.5 to <1.0

1.0 to <1.5

1.5 to <2.0

2.0 to <2.5

2.5 to <3.0

3

Triglycerides (mmol/L)

0

500

1000

1500

2000

2500

3000

3500

Thou

sand

s of

Peo

ple

Men

Women

35% > 1.5 mmol/L

22% > 1.5 mmol/L


Interpretation of blood fats• 30 years ago

– High cholesterol, Triglycerides unimportant

• 20 years ago– Bad cholesterol (LDLC), Good cholesterol (HDLC)

• 10 years ago– Modified LDL atherogenic

• Oxidised, Glycated, Apo(a)/Lp(a), Small Dense LDL)

• Today

– Triglycerides are important!– Move away from LDLC: Non HDLC = LDLC + VLDLC


Perspectives of Ken Sikaris.


TIME® Magazine June 23rd 2014


Professor Richard Johnson


Obesity versus Metabolic Dysfunction

240 million USA Adults

30% Obese

72 million

70% Normal

168 million

40% ‘Sick’

67 million

80% ‘Sick’

57 million

124 million USA Adults



Prof Robert Lustig 2014 Conclusions;



Movies

May 7th 201410th Jan 2014 Jul-Sep 2014

May 7th 2004

http://www.google.com.au/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&docid=mSCyKkbUwhyuwM&tbnid=qdOLLV8GJJFYaM:&ved=0CAUQjRw&url=http://filmpulse.net/sundance-2014-health-doc-fed-gets-new-poster/&ei=Vn0MU-GmI8TKkwXLuYCwBw&bvm=bv.61725948,d.dGI&psig=AFQjCNGNzaLTzmWGywauwPRm2yoUZeUHpA&ust=1393413821938400





‘That Sugar Film’ – Damon Gameau, January 2015


Conclusions

• Pandemic in Obesity & Type 2 diabetes

– Increasing proportion of health costs

– Increasing proportion of Pathology

• Pathology has witnessed pandemic

– Diagnosed

– Monitored

– Prevented?

• Assist in focussing community on prevention


Acknowledgements

• Inspiration

– Ms Louisa Sikaris

A/Prof Ken Sikaris - Sonic Healthcare - Impact of the diabetes epidemic and changing guidelines on...

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