Prevention of complications of endocrine disorders R.Fielding Department of Community Medicine, HKU.
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Transcript of Prevention of complications of endocrine disorders R.Fielding Department of Community Medicine, HKU.
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Prevention of complications of endocrine disorders
R.Fielding
Department of Community Medicine, HKU.
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Learning objectives
• Estimate the extent of morbidity and use of resources from complications of endocrine disorders due to overweight and inactivity
• outline the main barriers to prevention of endocrine complications
• explain key contributions to these barriers
• suggest cost-effective solutions
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Common endocrine complications
– type 2 (NIDDM) diabetes, – hypertension, – dyslipidaemia, and – cardiovascular diseases including AMI, AP, PVD
& stroke.
• Why are these now considered complications of endocrine disorders?
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• Because they reflect disorders or more accurately complications arising from a syndrome of over nutrition and inactivity, which produces disturbances in the regulation of energy metabolism.
• These “diseases” are, therefore, more accurately described as complications, but doctors seldom take this perspective, preferring to look at each “disease” as a separate thing: endocrinologists care for NIDDM, cardiologists for AMI, etc.
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Prevalence of DM in HK• 58% of men, 49% of women BMI >23.5
• 38% men 34% women BMI >25
• 5% men, 7% women BMI >30
• Prevalence of DM in – males
• 2% (CI 0-3.7%) at 25-34 to 22% (14.4-29.1%) at age 65-74
– females • 1.4% (0-4.6%) at 25-34 to 29% (21.4-37.3%) in age 65-74.
• Over 70% were unaware they had DM (Janus et
al, 1997)
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Complications prevalence in Chinese
• in NIDDM, HK Chinese – 22% (95% non-proliferative retinopathy)– 4% clinical nephropathy– 13% clinical neuropathy (Wang & Lam, 1998)
• Nephropathy OR raised in Chinese( McGill, et al 1996)
• Mainland diabetic patients (Xu et al, 1997)
– 50% hypertensive 45% neuropathy– 37% retinopathy (4.5% blind)– 25% IHD 23% proteinuria– 12% stroke 1% amputation
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Risk factors for complications • Chinese, Malays and Indians NIDDM vs.Cauca.
– Those with NIDDM had • higher mean body mass indices, waist-hip ratios
and abdominal diameters• more hypertension, higher triglycerides, lower LDL
(Hughes et al, 1998)
• Retinopathy in NIDDM Asian Indian, Chinese, and Creole Mauritians - vs Caucasians seen with– increasing duration of diabetes, – higher fasting plasma glucose, systolic blood
pressure, and urinary albumin concentration, – decreasing body mass index (Dowse et al, 1998)
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• Total physical activity independent predictor of 2-h post-load glucose concentration after controlling for BMI, waist-hip ratio, age, and family history of NIDDM. (Pereira, et al, 1995)
• Visceral fat accumulation is associated with dyslipidemia, hypertension, insulin resistance, and albuminuria in (HK) Chinese patients with NIDDM (Anderson, et al, 1997)
• Therefore, inactivity, BMI, longer DM raise risk for complications.
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Cause or effect?• “Although obesity, especially abdominal
obesity, is the commonest cause of complications such as type 2 diabetes, hypertension, dyslipidaemia, and cardiovascular diseases, doctors most often use drugs to treat the complications rather than the underlying condition. “
• So, these symptoms of unhealthy lifestyle are treated as causes when they are in fact, effects.
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Etiology of complications: Barriers to prevention
• Biological : – genetic - unalterable, “brittle” DM
• Lifestyle:– obesity, diet, inactivity, smoking
• Attitudinal:– DM “common” and accepted; emphasis
on genetics minimization of efforts to prevent; aversion to activity in HK; Chinese cultural belief that fat=good; overeating common and gluttony norm.
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• Service:– inadequate screening for DM
– lack of continuity of care
– failure to screen for complications
• Psychological– poor compliance with diet, activity and medication
leads to poor insulin control.
– Poor DPR
– little understanding of consequences of poor control
– “helplessness” - can’t do anything about disease -only doctors can “cure”.
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Key contributions to barriers• Incomplete / inadequate detection and
follow-up• Lack of organized shared care
between specialist and GP• Discontinuity of care• Poor medical record keeping• Little attention paid to effective
patient education• Little attention given to importance of
DPR
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Screening for type 2 DM?
• Benefits of early detection and treatment of undiagnosed diabetes have not been proved
• Effectiveness of diabetes screening in reducing cardiovascular disease depends on disease prevalence, background cardiovascular risk, and risk reduction in those screened and treated
• Disadvantages of screening are important and should be quantified
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Screening?
• Universal screening is unmerited, but targeted screening in specific subgroups may be justified
• Clinical management of people with established diabetes should be optimised before a screening programme is considered.
»(Wareham & Griffin, BMJ, 2001, 322, 986.)
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Conclusions• How important are these complications?
– DM currently most common important known endocrine disorder in HK affecting about 10% of population.
– Prevalence of complications 20-30%. 2-3% of HK popn. will have complications if present rates persist = 7 million/100x0.3 = 21,000 with avoidable complications.
– Barriers are mostly to do with poor service organization, failure of adherence and screening.
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Further reading
• American Diabetic Association
• Poems
• UK Study reducing risk of complications
• Fitness protocol
• Screening guidelines