PPT (5 MB) - Institute for Oral Health

Rising Tide of Diabetes: 

A Global Epidemic 

Jane Kelly, M.D. 

jkelly@cdc.gov 

National Diabetes Education Program 

Centers for Disease Control and Prevention 

Institute of Oral Health conference 

November 26, 2007 

A joint initiative of CDC & NIH

Objectives 

• Describe the rising global burden of 

diabetes 

• Describe key findings of landmark 

studies in diabetes care and prevention 

• Identify the National Diabetes 

Education Program (NDEP) as a 

resource for free evidence-based, 

culturally-appropriate educational 

materials 


What is Diabetes? 

• Diabetes is a group of diseases 

characterized by high levels of blood glucose 

(blood sugar) 

Fasting glucose > 126 

75 gram OGTT 2 hour value > 200 

Or 

Random glucose > 200 with symptoms 

(excessive thirst/urination, dizziness, 

blurred vision, weight loss, fatigue) 

Diabetes can lead to serious health problems 

and premature death 

NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005. 


Why Does Diabetes Continue to 

Command Our Attention? 

Because EVERY 24 HOURS there are: 

• 4,100 new cases of diabetes, 

• 810 deaths due to diabetes, 

• 230 amputations, 

• 120 kidney failures, and 

• 55 new cases of blindness 

Source: NIDDK, National Diabetes Statistics fact sheet. HHS, NIH, 2005. 


Estimated Cost of Diabetes 

in the United States 

• Direct Medical 

Cost: $92 billion 

• Indirect Cost: 

$40 billion 

• Total Cost: 

$132 billion 

Source: Lewin Group, Inc., for the American Diabetes Association, 2002. 


Common Types of Diabetes 

Type 1 diabetes 

• 5% to 10% of diagnosed cases of 

diabetes 

Type 2 diabetes 

• 90% to 95% diagnosed cases of 

diabetes 



Common Types of Diabetes 

Gestational diabetes mellitus 

• 7% of all U.S. pregnancies, or about 

200,000 cases annually 

• Increased lifelong risk for mother and 

child for developing type 2 diabetes 





Type 2 Diabetes 

Prediabetes 

Obesity 

Sedentary 

Lifestyle 

Beta Cell Defect 

Insulin 

Resistance 

Gender 

A joint initiative of CDC & NIH 

Age 

Puberty 

Genetics 

Ethnicity

Risk Factors for Diabetes 

Older age 

Overweight (BMI ≥ 25)* 

Hypertension* 

Abnormal lipid levels* 

Family history of diabetes 

Race/ethnicity 

History of gestational 

diabetes 

History of vascular 

disease 

Signs of insulin 

resistance 

PCOS 

Inactive lifestyle* 

Previous IGT or IFG* 

*Modifiable risk factors 

American Diabetes Association. Diabetes Care 2007; 30;(Suppl.1):S4-41. 


Does obesity really matter? 

Let’s look at some maps 


Obesity Trends* Among U.S. Adults 

BRFSS, 1991, 1996, 2003 

(*BMI ≥30, or about 30 lbs overweight for 5’4” person) 

1991 

1996 

2003 

No Data


Diabetes and Obesity: 

Prevalence (%) 

7.5 

7.0 

6.5 

6.0 

5.5 

5.0 

4.5 

4.0 

The Continuing Epidemic 

Diabetes 

Mean body weight 

1990 1992 1994 1996 1998 2000 

Year 

Mokdad et al. Diabetes Care. 2000;23:1278. 

Mokdad et al. JAMA. 1999;282:1519. 

Mokdad et al. JAMA. 2001;286:1195. 

kg 

78 

77 

76 

75 

74 

73 

72 

• Prevalence of obesity, 

increased by 61% since 

1991 

• More than 60% of US 

adults are overweight 

• BMI and weight gain 

major risk factors for 

diabetes 


Worldwide Diabetes Prevalence 

Estimated Prevalence (millions) 

80 

70 

60 

50 

40 

30 

20 

10 

1995 

2000 

2025 (projected) 

0 

Africa Americas Eastern 

Mediterranean 

Europe 

Southeast 

Asia 

A joint initiative of CDC & NIH 

Western 

Pacific

Causes 

• Population aging and growth 

• Urbanization and industrialization 

• Increasing obesity 

• Unhealthy diets and sedentary 

lifestyle 

• Genetic component likely 


Burden of Diabetes 

• Dietary changes world wide: 

– Lose of interest in culturally 

distinct foods

Fast food restaurants target food 

trends within a country 

Red Bean Sunday

Lining up to eat at McDonalds in Moscow 


1990: Another rush to eat at McDonalds in Russia 


Countries With Largest 

Number of People With 

Diabetes 

• India 19 million 57 

million 

• China 16 million 38 

million 

• USA 14 million 22 

million 

• Pakistan 

15 million 

1995 2025 

4 million 


Diabetes Stats in the US 

• #1 cause of blindness 

• #1 cause of kidney failure 

• #1 cause of non-traumatic amputation 

• Major contributor to the #1 cause of death 

in the United States: heart disease and 

stroke 


Mortality in Patients With Diabetes 

Causes of Death 

50 

40 

Deaths (%) 

30 

20 

10 

0 

CHF/CAD 

Diabetes Cancer Stroke Infection Other 

Geiss LS et al. In: Diabetes in America. 2nd ed. 1995; ch 11. 


Diabetes 

touches 

everything 


This is what a person with normal 

vision sees 


This is what a person with 

diabetic retinopathy sees 



People with diabetes and 

severe periodontitis have: 

• 6x increased risk of poor glycemic control 

• 82% of had 1 or more macrovascular 

complication (CVD, CVA) (vs 21% w/o) 

• Death rate due to CVD= 2.3x higher 

• Death rate from nephropathy= 8.5x 


Diabetes is serious, common, costly 

yet controllable 

• Affects over 21 million people in the 

United States 

• Over 6 million have DM and do not 

know it. 

• Costs over $132 billion/year in health 

care expenditures 

• One of the six leading causes of death 

• Effective interventions promote multiple 

good outcomes 


Diabetes Control and Complications 

Trial (DCCT) 

Compared effects of two diabetes 

treatment regimens – standard therapy 

and intensive control – on the 

complications of diabetes 

DCCT. New England Journal of Medicine, 329(14), September 30, 1993. 


DCCT Findings 

Lowering blood glucose from average A1C 

of 7.9 to 7.0 reduced risk of: 

• Eye disease by 76% 

• Kidney disease by 50% 

• Nerve disease by 60% 

That’s the difference between an average 

blood glucose of 150 and 180 



DCCT Findings 

Glucose control is key to preventing 

or delaying complications of diabetes 

Any sustained lowering of blood 

glucose helps, even if the person has 

a history of poor control 



Epidemiology of Diabetes 

Interventions and Complications 

Study (EDIC) 

Observational study 

DCCT participants 

Looked at risk factors for long-term complications 

DCCT/EDIC N Engl J Med 2005: 353:2643-2653. 


EDIC Findings: Intensive Therapy 

and Diabetes Complications 

Participants continue to benefit from 

metabolic memory of intense glucose control 

Intensive therapy aimed at achieving 

near normoglycemia: 

•Reduces CVD events by more than half 

•Should be implemented as early as 

possible 



EDIC Findings: Cardiovascular Events 

0.12 

Cumulative Incidence of First of Any Event 

Cumulative Incidence 

0.10 

0.08 

0.06 

0.04 

0.02 

Risk reduction 42% 

95% CI: 9% to 63% 

P = 0.02 

Conventional 

Intensive 

0.00 

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 


Years from Study Entry 


EDIC Findings: Cardiovascular Events 

0.12 

Non-Fatal MI, Stroke, or CVD Death 

Cumulative Incidence 

0.10 

0.08 

0.06 

0.04 

0.02 

Risk reduction 57% 

95% CI: 12% to 79% 

P = 0.02 

Conventional 

Intensive 

0.00 

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 161 

6 17 18 19 20 21 


Years from Study Entry 


United Kingdom Prospective 

Diabetes Study (UKPDS) 

Clinical Trial 

Looked at intensive management of blood 

glucose levels and long term risk-factors for 

diabetes complications 

UKPDS. BMJ. 2000; 321:405-412. 


UKPDS 

Improved blood pressure 

control reduces risk of: 

• Retinopathy progression (34%) 

• Vision loss (47%) 

• Diabetes-related deaths (32%) 

• Microvascular disease (37%) 

• Heart failure (56%) 

• Stroke (44%) 

United Kingdom Prospective Diabetes Study 


ABCD 

& 

ACE inhibitor reduces 

risk of: 

HOPE 

• Heart attack 

• Stroke 

• CV death 

And slows kidney disease. 


CARE 

& 

4S 

Lipid therapy reduces 

risk of coronary events 

• Cholesterol and Recurrent 

Events Trial (CARE) 

Reduced risk by 24 % 

• Scandinavian Simvastatin 

Survival Study (4S) 

Reduced risk by 42 to 55% 


SEARCH 

For Diabetes in Youth Study 

• Observational study 

• Physician-diagnosed diabetes in youth 

ages 0-19 

• Data will help researchers better 

understand and treat diabetes in young 

people 

(SEARCH). Diabetes Care 2006 29(8): 1891-6. 


SEARCH Findings 

Determine prevalence and correlates of 

selected CVD risk factors among youth with 

diabetes 

21% of young people with diabetes had at least 

two CVD risk factors 

Prevalence of CVD risk factors was higher 

among youth aged 10-19 years and among 

young girls 



SEARCH Findings 

In young people with type 2 diabetes 

• 92% had at least two CVD risk factors 

In young people with type 1 diabetes 

• 14% had at least two CVD risk factors 



The Face of Diabetes is Getting 

Younger 


Stages in the natural history 

of Type 2 diabetes 

Normal 

IGT 

Type 2 DM 

Complications 

Disability 

Death 

Genetic 

predisposition 

Preclinical 

state 

Clinical 

disease 

Complications 

Disability 

Death 

Primary Secondary Tertiary 

prevention prevention prevention 


Estimated 54 million Americans 

ages 40-74 have pre-diabetes 

• Pre-diabetes is a condition where blood 

sugar levels are higher than normal, but 

not high enough for diabetes. 

• Impaired fasting glucose FBS of 100-125 

Or 

• Impaired glucose tolerance 

– 2 hour OGTT value of 140-199 

• People with pre-diabetes are at an 

increased risk for developing diabetes. 


Diabetes Prevention Program (DPP) 

Lifestyle Intervention 

Intensive Lifestyle Modification 

A comprehensive program with the 

following specific aims: 

• Reduction of fat and calorie intake 

• Physical activity at least 150 minutes / wk 

• > 7% loss of body weight 

• Reduced risk of diabetes 58% 

Worked in all ethnicities, all ages 


Diabetes Prevention Program 

Among people 60 and 

older, lifestyle changes 

reduced the development 

of diabetes by 71 percent. 


What’s all this got to 

do with me? 


What’s all this to do with me? 

• Number of people in your practice with diabetes 

has dramatically increased 

• Diabetes will continue to rise 

• Diabetes onset and complications at earlier age 

• Metabolic control of diabetes influences oral 

health outcomes 

• Oral health providers may be front line position 

for influencing patient behavior – diabetes 

management and primary prevention 


National Diabetes Education Program 

Changing the Way Diabetes Is Treated 


NDEP structure 

• Joint initiative of CDC and NIH 

• Partnership with over 200 organizations 

– Public and private organizations 

– Traditional (e.g., American Diabetes 

Association) and non-traditional 

(National Urban League) partners 

– Diabetes Prevention and Control 

Programs 

• Program goal: To reduce the morbidity and 

mortality associated with diabetes and its 

complications by changing the way 

diabetes is treated 


Two main campaigns 


NDEP products general public 

• Different ethnic background (African 

American, American Indian/Alaska 

Native, Hispanic/Latino, Asian 

American/Pacific Islander) 

• Different ages (children, older adults) 

• Many materials in English, Spanish and 

15 Asian and Pacific Islander languages 


Changing the Way Diabetes is Treated 

NDEP Kids Tip Sheets in Spanish 


High Risk Populations 


Changing the Way Diabetes is Treated 

“It’s Never Too Early to 

Prevent Diabetes” 


Supporting 

materials for 

primary 

prevention 


And there’s more… 

• Materials for 

• Health care professionals 

• Community-based organizations 

• Media outreach 

• Working with business and managed 

care 


NDEP Websites 


NDEP Workgroups 

• Health Care Provider • African American 

• Older Adults 

• American 

• Children and 

Indian/Alaska 

Adolescents 

Native 

• Business and • Hispanic/Latino 

Managed Care • Asian 

American/Pacific 

Pharmacy, Podiatry, Optometry 

Islander 

and Dentistry 

(PPOD) 


Pharmacy, Podiatry, Optometry 

and Dental (PPOD) Role in NDEP 

• Need and opportunity identified: 

– Many people with diabetes or at risk 

don’t access a primary care provider 

– Many seek services of a PPOD 

provider for diabetes-related 

concerns 

– PPOD providers are well-positioned 

to deliver NDEP messages 



PPOD provider may be the first to 

see a person experiencing a problem 

• Patients may consult a PPOD provider 

before the primary care provider 

• All providers need “cross-training” 

• Perfect opportunity to keep diabetes on 

the radar screen 

• All providers need to give consistent 

messages, recognize early danger signs, 

and promote the team approach 

• PPOD providers are well-positioned to 

advise and educate their patients about 

diabetes control and prevention 



Working Together To Manage 

Diabetes 

• Promote multidisciplinary diabetes care 

• Section on “What You As A Health Care 

Provider Can Do” 

• Intended as a “cross-training” document, 

not a comprehensive guide to sub-specialty 

care 

• Educate PPOD providers so they can 

educate patients in turn 

• Sections specific to each discipline: 

– Key issues in each PPOD discipline 

– Referral recommendations 

– Patient education for self-management 


Working Together Key Messages 

• Recommend routine exams for 

complication prevention: oral health, 

comprehensive foot, dilated eye 

• Reinforce self-exams 

• Recognize danger signs 

• Pharmacist role in diabetes care team: 

medications management, 

individualized plans, use of glucose 

meter and other supplies 

• Importance of metabolic control (ABCs) 



Sample Key Messages 

• Reinforce the need for an annual 

comprehensive foot exam by a trained 

health care provider, and refer if no exam 

in past year. 

• Ask date of last dilated eye exam and 

refer to an optometrist or ophthalmologist 

if over 1 year since last exam 

• Ask the date of last dental/oral health 

exam 

• Remind the patient of the importance of 

taking medicines as prescribed 



Working Together revision 

• Updated statistics including information 

on pre-diabetes 

• More on primary prevention 

• More clinical vignettes 

• More clinical photos 

• More references 

• Key messages bullet point boxes 

• How to use accompanying medications 

supplement and patient education poster 


Sample vignettes – team care 

• A dentist notes that his patient smokes. 

In addition to telling the patient that 

smoking can cause oral cancer, he 

describes the impact tobacco use can 

have on increasing diabetes 

complications. 

• He asks the patient to consider 

quitting as an important step in 

controlling diabetes and gives him the 

1-800-QUITNOW number. 


Caveat! 

• Quick “crash course” on each 

specialty and its relation to diabetes 

• Each section is written for the 

OTHER providers to read. 

• Your own section may seem 

“simplistic”. 

• Goal: Consistent messages across 

the disciplines 

• Goal: encourage collaboration, Team 

approach 



Working Together Medication 

Supplement 

• Quick reference guide to meds 

commonly used by people who have 

diabetes 

• Example: Timing of insulin may help 

the dentist schedule a procedure at 

an appropriate time 

• Example: interaction of multiple 

meds given by multiple providers 


Spanish PPOD poster 

• Action steps that 

people with diabetes 

can take to “team up” 

with their PPOD 

provider 

• “I will” affirmations 


Translations 

I will control my diabetes with the support of 

the health care providers team! 


I will talk to my pharmacist 


I will visit my doctor or foot care provider 


I will visit my eye care provider 


I will visit my dental provider 

• I will visit my dentist at least once a 

year and I will tell him that I have 

diabetes. 

• I will ask how I should brush my teeth 

and how to use dental floss. 

• I will ask my dentist to tell me the 

early stages of mouth A and joint initiative gum of CDC & NIH

Revised English poster 

Adds: 

• I will ask about 

the link between 

blood glucose and 

gum disease 

• Tobacco 

message and 

Quitline # 


Pre-Diabetes 

• At least 54 million U.S. adults age 

20 and older have pre-diabetes— 

which raises their risk for type 2 

diabetes and cardiovascular 

disease 



NDEP Primary Prevention 

GAME PLAN tool kit 

Patient Materials 

Health Care Provider Toolkit 


High-Risk Audience Materials 


Role of PPOD professionals in 

primary prevention 


PPOD primary prevention 

brochures include 

• Statistics on rising prevalence of 

diabetes and prediabetes 

• Findings of the Diabetes Prevention 

Program (DPP) 

• Risk factors for type 2 diabetes 

• Ask – Advise – Assist approach 


Hypothetical scenarios 


• Includes the 

challenge: It is 

estimated that of 

persons born in 

2002, 1 in 3 will 

develop diabetes 

in his or her 

lifetime … unless 

something 

changes 

• Where to go for 

further information 


What can I do? 

• Share NDEP printed materials with patients 

• Put up NDEP posters in your office 

• Share NDEP PPOD and other health care 

professional tools with colleagues 

• Use NDEP community interventions kits to 

support community 

• Show music videos (Movimiento and Every 

Day Is a New Beginning) to motivate people 

to ask for information 

• Support employee wellness with 

www.diabetesatwork.org 

• Work with your state Diabetes Prevention 

and Control Program 


For more information about NDEP, or 

to order or download free materials: 

Call 1-800-438-5383 

or 

Visit www.ndep.nih.gov 

The U.S. Department of Health and Human Services’ National 

Diabetes Education Program is jointly sponsored by the National 

Institutes of Health and the Centers for Disease Control and 

Prevention with the support of more than 200 partner organizations.

PPT (5 MB) - Institute for Oral Health

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