Changing trends in epidemiology of type 1 diabetes mellitus throughout the world: How far have we...
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Transcript of Changing trends in epidemiology of type 1 diabetes mellitus throughout the world: How far have we...
Changing trends in epidemiology of type 1 diabetes mellitus throughout
the world: How far have we come and where do we go from here
Ingrid Libman, M.D., Ph.D.
Ronald LaPorte, Ph.D.
University of Pittsburgh
Objectives
* Counting diabetes: Historical background
* Diabetes Registries: What have we learned?
* Challenges ahead: Where do we go from here?
Objectives
* Counting diabetes: Historical background
* Diabetes Registries: What have we learned?
* Challenges ahead: Where do we go from here?
Need to count disease, specifically diabetes,
started a long time ago……..
Counting diabetes: Why is it important?
Reducing the incidence of disease (primary prevention)
Reducing the prevalence of disease (secondary prevention)
PreventionPrevention
ControlControlOngoing operations or programs aimed at reducing the incidence and/or prevalence of
diseaseLast, Dictionary of Epidemiology
Counting diabetes…
Galen, disciple of HippocratesSecond century AD
…“diarrhea of the urine”….. “the thirsty disease”…
…“rare”….…“only seen two cases”…..
Aretaeus the CappadocianDisciple of Hippocrates
Second century AD
….“Diabetes is a wonderful affection, not very frequent among men, being a melting
down of the flesh and limbs into urine”……
…”the patient is short-lived if the constitution of the disease be completely established”…
Maimonides1135-1204 AD
…”diabetes seldom seen in cold Europeand frequently encountered in warm Africa”…
…” have not seen in the West”……” here, in Egypt, in the course of 10 years,
I have seen more than twenty peoplewho suffer this illness”….
Historical background
End of 1970’s
* Types of diabetes loosely divided into “juvenile onset” and “maturity onset”
* Enormous variation in cut-off values for the fasting glucose level and after OGTT
* Size of glucose load varied between 50 g and 100 gr or body weight related
Historical background
* Chemical diabetes: no symptoms of diabetes, normal fasting glucose, but demonstrable abnormality of oral glucose tolerance test
* Studies done* small number of children * different doses of glucose administered * different criteria for defining abnormal glucose tolerance (USPHS, Fajans and Conn, University Diabetes Group Program, etc)
Book summarizing contributions, clinical and population-based on the subject of
diabetes epidemiology and highlighted the many gaps in our diabetes epidemiology
knowledge at that time
Kelly West, 1978 "Epidemiology of Diabetes
and its Vascular Complications"
It took many centuries….
“A survey of twenty diabetologists revealed that they employ diagnostic criteria differing quite substantially.
In some populations, including the general population of the United States, these disparities would result in very major differences in the rates of "diabetes." Under certain
common circumstances, some diabetologists would classify as normal more than half of the one- and two-hour values
considered to be abnormal by other well-qualified diabetologists”
Substantial differences in the diagnostic criteria used by diabetes experts
KW WestDiabetes 1975
Historical background
1979 & 1980
* IDDM and NIDDM defined
* 75 gr oral glucose tolerance test (OGTT) became the gold standard with fasting and 2 hour values defined
* Category of IGT added (metabolic stage intermediate between normal glucose homeostasis and diabetes)
Diabetes in childhood = IDDM
the epidemiologist’s “dream”
Easy to diagnose Abrupt onset Requiring medical attention Requiring medication (insulin)
By the 1980’s …..
* Few registries monitoring IDDM incidence
* Limited information but geographical differences in incidence identified
* However, lack of standardization:- different case definition- different ages- different degrees of ascertainment
“Registries of Persons with IDDM”(International Workshop on
the Epidemiologyof IDDM)
1983 *An international collaborative IDDM registry group should be established to develop standardized norms
*Validation of the completeness of case ascertainment should be required
*Investigators should share their patient intake forms
*Plan for sharing of data between registries should be established
LaPorte R et al. Diabetes Care 1985
Diabetes in Childhood: IDDM Registries
Establishment of population-based registries around the world
Monitor the global pattern of the disease
Provide a basis for standardized studies of risk factors
Karvonen M et al. Diabetes Care 2000
Argelia, Argentina, Antigua, Australia, Austria, Bahamas, Barbados, Belgium, Brazil, Bulgaria, Chile, China, Colombia, Costa Rica, Croatia, Cuba, Czech Republic, Denmark, Dominica, Dominican Republic, Egypt, Estonia, Finland, France, Germany, Greece, Hong Kong, Hungary, Iceland, India, Ireland, Israel, Italy, Japan, Korea, Kuwait, Lithuania, Malta, Mauritius, Mexico, Netherlands, New Zealand, Norway, Paraguay, Peru, Poland, Portugal, Romania, Russia, Saint Kitts, Slovakia, Slovenia, Spain, Sudan, Sweden, Switzerland, Taiwan, Tanzania, Thailand, Tunisia, United Kingdom, Uruguay, USA, Venezuela
DIAMOND ProjectCountries participating
DIAMOND ProjectAlgeria: Dr. K. Bessaoud (Oran). Argentina: Dr. M. Molinero de Ropolo (Cordoba); Dr. M. de Sereday, M.L. Marti, Dr. M. Damiano, and Dr. M. Moser (Avellaneda); Dr. S. Lapertosa (Corrientes), Dr. A. Libman (Rosario), Dr. O. Ramos (Buenos Aires). Australia: Dr. C. Verge and Dr. N. Howard (New South Wales). Austria: Dr. E. Schober. Barbados: Dr. O. Jordan. Belgium: Dr. I. Weets, Dr. C. Vandevalle, Dr. I. De Leeuw, Dr. F. Gorus, Dr. M. Coeckelberghs, and Dr. M. Du Caju (Antwerp region). Brazil: Dr. L. J. Franco and Dr. S.R.G. Ferreira (3 centers, state of Sao Paulo). Bulgaria: Dr. R. Savova and Prof. V. Christov (West Bulgaria) and Dr. V. Iotova and Prof. Valentina Tzaneva (Varna). Canada: Dr. E. Toth (Alberta) and Dr. M.H. Tan (Prince Edward Island). Chile: Dr. E. Carrasco and Dr. G. Lopez (Santiago). China: Dr. Yang Ze (Henan, Dalian, Guilin, Jilin, Nanning, and Zunyi); Dr. Bo Yang (Tieling); Dr. Chen Shaohua and Dr. Fu Lihua (Jinan); Dr. Deng Longqi (Sichuan); Dr. Shen Shuixian (Shanghai); Dr. Teng Kui (Wulumuqi); Dr. Wang Chunjian, Dr. H. Jian, and Dr. J. Ju (Zhengzhou); Dr. Yan Chun and Dr. Y. Ze (Beijing); Dr. Deng Yibing and Dr. Li Cai (Changchun); Dr. Ying-Ting Zhang (Jilin province); Dr. Liu Yuqing and Dr. Long Xiurong (Shenyang); Dr. Zhaoshou Zhen (Huhehot); Dr. Zhiying Sun (Dalian); Prof. Wang Binyou (Harbin); and Dr. Gary Wing-Kin Wong (Hong Kong). Colombia: Dr. P. Aschner (Santafè de Bogotà, D.C.). Cuba: Dr. O. Mateo de Acosta, Dr. I. Hernández Cuesta, Dr. F. Collado Mesa, and Dr. O. Diaz-Diaz. Denmark: Dr. B.S. Olsen, Dr. A.J. Svendsen, Dr. J. Kreutzfeldt, and Dr. E. Lund (4 counties). Dominica: Dr. E.S. Tull. Estonia: Dr. T. Podar. Finland: Prof. J. Tuomilehto and Dr. M. Karvonen. France: Dr. C. Levy-Marchal and Dr. P. Czernichow (4 regions). Germany: Dr. A. Neu (Baden-Wuerttemberg). Greece: Dr. C. Bartsocas, Dr. K. Kassiou, Dr. C. Dacou-Voutetaki, Dr. A.C. Kafourou, Dr. Al Al-Qadreh, and Dr. C. Karagianni (Attica region). Hungary: Dr. Gyula Soltesz (18 counties). Israel: Prof. Z. Laron, Dr. O. Gordon, Dr. Y. Albag, and Dr. I. Shamis. Italy: Dr. F. Purrello, Dr. M. Arpi, Dr. G. Fichera, Dr. M. Mancuso, and Dr. C. Lucenti (eastern Sicily); Prof. G. Chiumello (Lombardia region); Dr. G. Bruno and Prof. G. Pagano (Turin province); Dr. M. Songini, Dr. A. Casu, Dr. A. Marinaro, Dr. R. Ricciardi, Dr. M.A. Zedda, and Dr. A. Milia (Sardinia); Dr. M. Tenconi and Dr. G. Devoti (Pavia province); Prof. P. Pozzilli, Dr. N. Visalli, Dr. L. Sebastiani, Dr. G. Marietti, and Dr. R. Buzzetti (Lazio region); and Dr. V. Cherubini (Region Marche). Japan: Dr. A. Okuno, Dr. S. Harada, and Dr. N. Matsuura (Hokkaido); Dr. E. Miki, Dr. S. Miyamoto, and Dr. N. Sasaki (Chiba); and Dr. G. Mimura (Okinawa). Kuwait: Dr. A. Shaltout and Dr. Mariam Qabazrd. Latvia: Dr. G. Brigis. Lithuania: Dr. B. Urbonaite. Luxembourg: Dr. C. de Beaufort. Mauritius: Dr. H. Gareeboo. Mexico: Dr. O. Aude Rueda (Veracruz). The Netherlands: Dr. M. Reeser (5 regions). New Zealand: Dr. R. Elliott (Auckland) and Dr. R. Scott, Dr. J. Willis, and Dr. B. Darlow (Canterbury). Norway: Dr. G. Joner (8 counties). Pakistan: Dr. G. Rafique (Karachi). Paraguay: Dr. J. Jimenez, Dr. C.M. Palaeios, Dr. F. Canete, Dr. J. Vera, and Dr. R. Almiron. Peru: Dr. S. Seclén (Lima). Poland: Dr. D. Woznicka, Dr. P. Fichna (Wielkopolska) and Dr. Z. Szybinski (Cracow). Portugal: Dr. C. Menezes (Portalegre), Dr. E.A. Pina (Algarve region), Dr. M.M.A. Ruas and Dr. F.J.C. Rodrigues (Coimbra), and Dr. S. Abreu (Madeira Island). Romania: Dr. C. Ionescu-Tirgoviste (Bucharest region). Russia: Dr. E. Shubnikof (Novosibirsk). Slovakia: Dr. D. Michalkova. Slovenia: Prof. C. Krzisnik, Dr. N. Bratina-Ursic, Dr. T. Battelino, and Dr. P. Brcar-Strukelj. Spain: Dr. A. Goday, Dr. C. Castell, and Dr. C. Lloveras (Catalonia). Sudan: Dr. M. Magzoub (Gezira province). Sweden: Prof. G. Dahlquist. Tunisia: Dr. K. Nagati (Kairouan) and Dr. F.B. Khalifa (Gafsa, Beja, Monastir). U.K.: Dr. A. Burden and N. Raymond (Leicestershire); Dr. B.A. Millward and Dr. H. Zhao (Plymouth); Dr. C.C. Patterson, Dr. D. Carson, and Prof. D. Hadden (N. Ireland); Dr. P. Smail and Dr. B. McSporran (Aberdeen); and Dr. P. Bingley (Oxford region). U.S.: Dr. E.S. Tull (Virgin Islands), Dr. R.E. LaPorte and Dr. I. Libman (Allegheny County, PA), Dr. J. Roseman and Dr. S.M. Atiqur Rahman (Jefferson County, AL), Dr. T. Frazer de Llado (Puerto Rico), and Dr. R. Lipton (Chicago). Uruguay: Dr. A.M. Jorge (Montevideo). Venezuela: Dr. P. Gunczler and Dr. R. Lanes (Caracas, second center), Dr. H. King (WHO, Geneva, Switzerland).
Historical background
late 1990’s
* Type 1 and type 2 diabetes defined
* Lowered criteria for diagnosis of diabetes to fasting plasma glucose 126 mg/dl
* Category of IFG added (plasma glucose 110 mg/dl and < 126 mg/dl)
Objectives
* Counting diabetes: Historical background
* Diabetes Registries: What have we learned?
* Challenges ahead: Where do we go from here?
“One of the fundamental necessities of cancer surveillance is for users of cancer information to be assured that case definitions, data collection, is standardized. This enables compilation of case-specific information into useful and meaningful registers. It also enables meaningful comparison of data across different registries”
North American Association of Central Cancer Registries
IDDM Registries: Eligibility Criteria
diagnosis of “IDDM” by a physician
on insulin at time of discharge from the hospital
age at onset 0-14
resident of a defined area at diagnosis
diabetes not secondary to other conditions
IDDM Registries: Data to be collected
Name Sex Race Birth Date Date of first insulin injection Place of residence at diagnosis
Validation of the completeness of case ascertainment: Capture-recapture method
Hospitals
Physicians
Schools
Pharmacies
Incidence of T1DM in the Americas 0 – 14 years – DIAMOND Project
0 5 10 15 20 25
Peru
Paraguay
Mexico
Cuba
Chile
Venezuela
Colombia
Barbados
Argentina
Brasil
Uruguay
USA
Canada
/100,000
Karvonen M et al. Diabetes Care 2000
Important geographic differences
T1DM Incidence in Santiago, Chile 1986 - 2000
0 1 2 3 4 5
2000
1997
1994
1991
1988
1986
/100,000
Carrasco E et al. Diabetes et Metabolism 2003 p<0.001
25
30
35
40
45
50
55
1987 1988 1989 1990 1991 1992 1993 1994 1995 1996
Years
1-4 years
4-9 years
10-14years
Incidence of T1DM in FinlandChildren < 15 years, 1987-1996
Tuomilehto et al. Diabetologia 1999
100,000/year
Relative increase in incidence of T1DM Children 0 - 14 years
0
1
2
3
4
5
6
7
8
9
10 United Kingdom
Hungary
Hawaii
China
Slovakia
Norway
Finland
USA Allegheny
Sweden
Lithuania
Estonia
Yearly change: 2.5 % per year (2.3-2.7)
Adapted from Onkamo P et al, Diabetologia 1999
Increase in the incidence%/year
Important temporal changes
Allegheny County IDDM RegistryIncidence by race and period, 1965 - 1994,
0-19 years age group
0
5
10
15
20
1965-69
1970-74
1975-79
1980-84
1985-89
1990-94
Whites
Blacks
/100,000
Libman I et al. Diabetes Care 1998
Allegheny County IDDM RegistryIncidence by race and period, 1965-1994,
15-19 years age group
0
5
10
15
20
25
30
35
1965-69
1970-74
1975-79
1980-84
1985-89
1990-94
Whites
Blacks
/100,000
*
**
Libman I et al. Diabetes Care 1998
IDDM incidence by periodBlacks – 10 to 14 years
0
5
10
15
20
25
30
Chicago Philadelphia
1985-1989
1990-1994
/100,000
Lipton R et al.Diabetes/Metab Res Rev 2002Lipman T et al. Diabetes Care 2002
Objectives
* Counting diabetes: Historical background
* Diabetes Registries: What have we learned?
* Challenges ahead: Where do we go from here?
At present…
2000….
* Type 1 and type 2 diabetes defined
* Type 2 diabetes in children described
* Reports of “double”, “hybrid”, “atypical”
diabetes (mixed phenotype)
* Changes in the phenotype of typical T1DM
Diabetes in childhood IDDM
the epidemiologist’s “challenge”
Easy to diagnose Abrupt onset Requiring medical attention Requiring medication (insulin)
X
Diabetes in Childhood
Efforts such as DIAMOND and EURODIAB should continue