Dorte Vistisen

Global healthcare expenditure on diabetes for 2010 and 2030

AIMS To estimate the global health expenditure on diabetes among people aged 20-79 years for the years 2010 and 2030. METHODS Country-by-country expenditures for 193 countries, expressed in United States Dollars (USD) and in International Dollars (ID), were estimated based on the countrys age-sex specific diabetes prevalence and population estimates, per capita health expenditures, and health expenditure ratios per person with and without diabetes. Diabetes prevalence was estimated from studies in 91 countries. Population estimates and health expenditures were from the United Nations and the World Health Organization. The health expenditure ratios were estimated based on utilization and cost data of a large health plan in the U.S. Diabetes expenditures for the year 2030 were projected by considering future changes in demographics and urbanization. RESULTS The global health expenditure on diabetes is expected to total at least USD 376 billion or ID 418 billion in 2010 and USD 490 billion or ID 561 billion in 2030. Globally, 12% of the health expenditures and USD 1330 (ID 1478) per person are anticipated to be spent on diabetes in 2010. The expenditure varies by region, age group, gender, and countrys income level. CONCLUSIONS Diabetes imposes an increasing economic burden on national health care systems worldwide. More prevention efforts are needed to reduce this burden. Meanwhile, the very low expenditures per capita in poor countries indicate that more resources are required to provide basic diabetes care in such settings.

Moving to an A1C-Based Diagnosis of Diabetes Has a Different Impact on Prevalence in Different Ethnic Groups

OBJECTIVE To compare screen-detected diabetes prevalence and the degree of diagnostic agreement by ethnicity with the current oral glucose tolerance test (OGTT)-based and newly proposed A1C-based diagnostic criteria. RESEARCH DESIGN AND METHODS Six studies (1999–2009) from Denmark, the U.K., Australia, Greenland, Kenya, and India were tested for the probability of an A1C ≥6.5% among diabetic case subjects based on an OGTT. The difference in probability between centers was analyzed by logistic regression adjusting for relevant confounders. RESULTS Diabetes prevalence was lower with the A1C-based diagnostic criteria in four of six studies. The probability of an A1C ≥6.5% among OGTT-diagnosed case subjects ranged widely (17.0–78.0%) by study center. Differences in diagnostic agreement between ethnic subgroups in the U.K. study were of the same magnitude as between-country comparisons. CONCLUSIONS A shift to an A1C-based diagnosis for diabetes will have substantially different consequences for diabetes prevalence across ethnic groups and populations.

There really is an epidemic of type 2 diabetes

The number of people with diabetes has increased throughout the world, and the rate of increase shows no signs of slowing. The Diabetes Atlas estimates that there were 194 million people with diabetes in 2003 and predicts an increase to 333 million by 2025 [1]. Figures from the World Health Organization (WHO) are similar [2]. These prediction models do not require an increase in the incidence of diabetes, but anticipate that the total number of individuals with diabetes will increase because of improved life expectancy, population growth and progressive urbanisation. Studies from many parts of the world have reported an increasing age-specific prevalence of diabetes. Recent data from the National Health and Nutrition Examination Survey (NHANES) studies in the USA show that the prevalence of diagnosed diabetes is relatively constant within each stratum of BMI, but imply that an increasing prevalence and incidence of diabetes would be expected as a consequence of increasing obesity [3]. In Denmark, three population-based surveys were carried out (in 1974, 1996 and 2000) in 60-year-old men and women living in the same geographical area in greater Copenhagen. These showed that prevalence increased from 7.8 through 12.3 to 14.0% in men, and from 5.6 through 6.8 to 13.6% in women [4, 5]. Although this might suggest an increasing incidence of diabetes, it could also be explained by other factors, including the longer survival of individuals with a diagnosis of diabetes. Thus, the central question is: to what extent can this increasing prevalence be explained by improved life expectancy and demographic factors, as against a simple increase in incidence or an imbalance between incidence and mortality? The last of these explanations was first put forward by Stovring et al. [6], using data from a Danish pharmacoepidemiological database, and has been developed further by Green et al. in this issue of the journal [7]. The term ‘diabetes epidemic’ has been used in recent years to describe the increasing burden of this disease. The term ‘epidemic’ was first coined in relation to infectious diseases and refers to a substantial increase in the number of new cases over a short, defined period of time [8]. More recently, the term has been extended to non-communicable diseases such as diabetes and to risk factors such as obesity; however, no specific, universally agreed definition has been adopted. Although the term has been used to describe an increasing prevalence, a true ‘epidemic’ would require an increasing incidence of diabetes. In consequence, loose terminology is partly responsible for the current dilemma. We will discuss potential explanations for the increasing prevalence of diabetes and will use different data sets to quantify the influence of each of these alternative explanations within a model system.

GLP-1 Response to Oral Glucose Is Reduced in Prediabetes, Screen-Detected Type 2 Diabetes, and Obesity and Influenced by Sex: The ADDITION-PRO Study

The role of glucose-stimulated release of GLP-1 in the development of obesity and type 2 diabetes is unclear. We assessed GLP-1 response to oral glucose in a large study population of lean and obese men and women with normal and impaired glucose regulation. Circulating concentrations of glucose, insulin, and GLP-1 during an oral glucose tolerance test (OGTT) were analyzed in individuals with normal glucose tolerance (NGT) (n = 774), prediabetes (n = 525), or screen-detected type 2 diabetes (n = 163) who attended the Danish ADDITION-PRO study (n = 1,462). Compared with individuals with NGT, women with prediabetes or type 2 diabetes had 25% lower GLP-1 response to an OGTT, and both men and women with prediabetes or type 2 diabetes had 16–21% lower 120-min GLP-1 concentrations independent of age and obesity. Obese and overweight individuals had up to 20% reduced GLP-1 response to oral glucose compared with normal weight individuals independent of glucose tolerance status. Higher GLP-1 responses were associated with better insulin sensitivity and β-cell function, older age, and lesser degree of obesity. Our findings indicate that a reduction in GLP-1 response to oral glucose occurs prior to the development of type 2 diabetes and obesity, which can have consequences for early prevention strategies for diabetes.

Determinants of Aortic Stiffness: 16-Year Follow-Up of the Whitehall II Study

Background Aortic stiffness is a strong predictor of cardiovascular disease endpoints. Cross-sectional studies have shown associations of various cardiovascular risk factors with aortic pulse wave velocity, a measure of aortic stiffness, but the long-term impact of these factors on aortic stiffness is unknown. Methods In 3,769 men and women from the Whitehall II cohort, a wide range of traditional and novel cardiovascular risk factors were determined at baseline (1991–1993) and aortic pulse wave velocity was measured at follow-up (2007–2009). The prospective associations between each baseline risk factor and aortic pulse wave velocity at follow-up were assessed through sex stratified linear regression analysis adjusted for relevant confounders. Missing data on baseline determinants were imputed using the Multivariate Imputation by Chained Equations. Results Among men, the strongest predictors were waist circumference, waist-hip ratio, heart rate and interleukin 1 receptor antagonist, and among women, adiponectin, triglycerides, pulse pressure and waist-hip ratio. The impact of 10 centimeter increase in waist circumference on aortic pulse wave velocity was twice as large for men compared with women (men: 0.40 m/s (95%-CI: 0.24;0.56); women: 0.17 m/s (95%-CI: −0.01;0.35)), whereas the opposite was true for the impact of a two-fold increase in adiponectin (men: −0.30 m/s (95%-CI: −0.51;−0.10); women: 0.61 m/s (95%-CI: −0.86;−0.35)). Conclusion In this large prospective study, central obesity was a strong predictor of aortic stiffness. Additionally, heart rate in men and adiponectin in women predicted aortic pulse wave velocity suggesting that strategies to prevent aortic stiffening should be focused differently by sex.

Trajectories of cardiometabolic risk factors before diagnosis of three subtypes of type 2 diabetes: a post-hoc analysis of the longitudinal Whitehall II cohort study

BACKGROUND Most clinicians acknowledge that type 2 diabetes is multifactorial and has heterogeneous characteristics, but neither prevention nor treatment is systematically stratified. To address the heterogeneity of the disease, we examined whether patients diagnosed on the basis of fasting glucose concentrations, those diagnosed on the basis of 2 h concentrations, and those diagnosed on the basis of both criteria differed in terms of pathogenesis or cardiovascular risks. METHODS Retrospectively, we analysed trajectories of cardiometabolic risk factors and 10 year cardiovascular risks in the prospective Whitehall II study cohort by use of multilevel longitudinal modelling. Participants were diagnosed by 75 g oral glucose-tolerance tests. We classified those diagnosed with type 2 diabetes into three subgroups: diagnosed on the basis of fasting glucose concentrations, diagnosed on the basis of 2 h glucose concentrations, and diagnosed on the basis of both concentrations. We also developed a classification tree for identification of individuals who are likely to have high fasting and 2 h glucose concentrations, but for whom only fasting concentrations are available. RESULTS Median follow-up was 14·2 years with 15,826 person-examinations (1991-2009). Of 10,308 individuals, 6843 were included and 6569 remained diabetes free. 274 cases of type 2 diabetes were identified: 55 had high fasting glucose concentrations only, 148 had high 2 h concentrations only, and 71 had high fasting and 2 h concentrations. At diagnosis, participants with high fasting and 2 h glucose concentrations had higher mean body-mass indices (30·9 kg/m(2) [SD 5·7]) than did those with high fasting concentrations (28·4 kg/m(2) [4·4]; p=0·0009) or 2 h concentrations (27·9 kg/m(2) [4·9]; <0·0001). Mean glycated haemoglobin A1c concentrations were also higher in the fasting and 2 h subgroup (7·4% [1·6]) than in the fasting (5·9% [0·5]; <0·0001) or 2 h (5·9% [0·6]; <0·0001) sugroups. Additionally, the fasting and 2 h subgroup had a higher proportion of individuals with moderate or high risk of cardiovascular disease than did the fasting subgroup (p=0·02). A classic pattern of β-cell decompensation before diagnosis was noted only in the fasting and 2 h subgroup. Additionally, glucose concentrations and insulin resistance accelerated more substantially before diagnosis in the fasting and 2 h subgroup than in the fasting subgroup or the 2 h subgroup. INTERPRETATION Patients with type 2 diabetes diagnosed on the basis of increased fasting glucose concentrations or 2 h glucose concentrations, or both, have distinct cardiometabolic risk development before diagnosis. FUNDING UK Medical Research Council, UK Economic and Social Research Council, British Heart Foundation, UK Health and Safety Executive, UK Department of Health, US National Heart Lung and Blood Institute, US National Institute on Aging, US Agency for Health Care Policy Research, and John D and Catherine T MacArthur Foundation.

Comparisons of Metabolic Syndrome Definitions in Four Populations of the Asia-Pacific Region

BACKGROUND To compare the prevalence of metabolic syndrome (MetS) by four MetS definitions in four Asia-Pacific populations, and to compare the prevalence of individual metabolic components. METHODS Population-based cross-sectional studies from Australia, Japan, Korea, and Samoa were used to assess the World Health Organization (WHO), European Group for the Study of Insulin Resistance (EGIR), modified National Cholesterol Education Program Adult Treatment Panel III (modATPIII), and International Diabetes Federation (IDF) MetS definitions. Age-adjusted MetS prevalences were compared within and between countries and kappa statistics were used to determine the agreement between IDF and the other three definitions. RESULTS Japanese people had the lowest prevalence of MetS regardless of definition, and Samoans generally the highest prevalence. Age-adjusted prevalences for the four definitions ranged from 16% to 42% in Australia, 3% to 11% in Japan, 7% to 29% in Korea and 17% to 60% in Samoa. With the exceptions of Korean and Japanese males, the highest prevalence of MetS was obtained with the IDF definition. The best overall agreement with IDF MetS definition was for modATPIII, and the worst for EGIR. There were marked differences in the prevalence of MetS between the sexes, with no systematic pattern, and between the prevalences of individual metabolic components. CONCLUSIONS Differences in the prevalence of MetS and its components, using the various definitions, both within and between populations, indicate that caution is required when comparing studies from different countries. Determining the clinical significance of these differences will require prospective outcome studies.

Sleep duration and sleep quality are associated differently with alterations of glucose homeostasis.

Diabet. Med. 29, e354–e360 (2012)

Comparing risk profiles of individuals diagnosed with diabetes by OGTT and HbA1c The Danish Inter99 study.

Diabet. Med. 27, 906–910 (2010)

Progression to Impaired Glucose Regulation and Diabetes in the Population-Based Inter99 Study

OBJECTIVE The purpose of this study was to estimate the progression rates to impaired glucose regulation (impaired fasting glucose or impaired glucose tolerance) and diabetes in the Danish population–based Inter99 study and in a high-risk subpopulation, separately. RESEARCH DESIGN AND METHODS From a population-based primary prevention study, the Inter99 study, 4,615 individuals without diabetes at baseline and with relevant follow-up data were divided into a low- and a high-risk group based on a risk estimate of ischemic heart disease or the presence of risk factors (smoking, hypertension, hypercholesterolemia, obesity, or impaired glucose tolerance). High-risk individuals (57.1%) were examined with an oral glucose tolerance test at 1 and 3 years, and all of the participants were reexamined at the 5-year follow-up. Person-years at risk were calculated. Progression rates to impaired glucose regulation and diabetes were estimated directly from baseline to the 5-year follow-up for all the participants and from baseline through the 1- and 3- to 5-year follow-up examinations for the high-risk individuals, separately. RESULTS In the combined low- and high-risk group, 2.1 individuals per 100 person-years progressed from normal glucose tolerance (NGT) to impaired glucose regulation or diabetes. Among high-risk individuals, 5.8 per 100 person-years with NGT progressed to impaired glucose regulation or diabetes, and 4.9 per 100 person-years progressed from impaired glucose regulation to diabetes. CONCLUSIONS Progression rates to impaired glucose regulation using the current World Health Organization classification criteria were calculated for the first time in a large European population-based study. The progression rates to diabetes show the same pattern as seen in the few similar European studies.