Sindrome

metabolica/Dia

bete

Giulio Marchesini

“Alma Mater Studiorum” Università

di Bologna

Criteria for Metabolic Syndrome

Grundy, Circulation 2005

Maison, Diabetes Care 2001

Ely Study: a prospective

cohort established in 1990

Central role of obesity

Factor analysis on changes

in the parameters of MS

• Axis are Factors of MS

• Changes in BMI, WHR and

Fasting insulin are

central to the 3

independent factors in

the entire cohort

Abdominal obesity predicts the

metabolic syndrome

>30 <30

<102 cm (men)

<88 cm (women)

>102 cm (men)

>88 cm (women)

Body mass index (kg/m2)

8-y

ear

incid

ence o

f

meta

bolic s

yndro

me

Han; Obes Res 2002

33

20

20

10

0

10

20

30

40

San Antonio Heart

Study:

628 non-Hispanic

whites and 1,340

Mexican

Americans

Abdominal obesity increases the

risk of developing T2DM

<71 71–75.9 76–81 81.1–86 86.1–91 91.1–96.3 >96.3

24

20

16

12

8

4

0

Rela

tive r

isk

Waist circumference (cm)

Nurses’ Health Study; 43,581 women

Carey, Am J Epidemiol 1997

Intra-abdominal adiposity and

dyslipidaemia

Pouliot, Diabetes 1992

310

248

186

124

62

0

60

45

30 m

g/dL

mg/dL

Triglycerides

Lean

HDL-cholesterol

Visceral fat

(obese subjects)

Low High Lean Visceral fat

(obese subjects)

Low High

Abdominal obesity predicts the

risk of CV events Adju

sted r

ela

tive r

isk

1 1 1

1.17 1.16 1.14

1.29 1.27

1.35

0.8

1

1.2

1.4

CVD death MI All-cause deaths

Tertile 1

Tertile 2 Tertile 3

Men Women <95

95–103 >103

<87

87–98 >98

Waist

circ. (cm):

Adjusted for BMI, age, smoking, sex, CVD, disease, DM, HDL-C, total-C

Dagenais, Am Heart J 2005

Come fare lo screening ?

Quale test di screening ?

• Peso

• BMI (peso/altezza2)

• Circonferenza vita

• Rapporto vita/fianchi

• Circonferenza vita/altezza

• (Circonferenza collo)

• (circonferenza polso)

Screening x DM2

L’OMS ha definito criteri che

rendono un test di screening

raccomandabile:

•Test semplice da eseguire,

•Test facile da interpretare,

•Test di elevata accuratezza

diagnostica,

•Test con favorevole rapporto

costo/beneficio.

Holland. WHO European Centre for Health

Policy: Screening in Europe, 2006

Elementi PRO screening

• Il DM2 presenta una lunga fase asintomatica (malattia diagnosticata

solo se ricercata con screening).

• Sono disponibili test di screening non invasivi, semplici e poco

costosi.

• La percentuale di DM2 non diagnosticato varia fra il 30 e il 50% dei

casi di diabete tipo 2 e nella fase pre-clinica si sviluppano le

complicanze.

• Un compenso glicemico ottimale fin dalle prime fasi della malattia

e la correzione dei fattori di rischio CV associati riducono

l’incidenza e la progressione delle complicanze.

• Le complicanze acute e croniche del DM2 hanno un grave impatto

sulla qualità di vita dell’individuo, nonché sulla salute pubblica.

• Nel corso dello screening possono essere identificati soggetti con

IGT e IFG nei quali interventi sullo stile di vita

prevengono/ritardano lo sviluppo della malattia conclamata.

Elementi CONTRO screening

• La prevalenza della malattia non è elevata.

• Alla diagnosi di diabete può far seguito la comparsa di

depressione.

• Dispendio di tempo ed energia da parte del paziente per

eseguire test aggiuntivi necessari a confermare la diagnosi

e per le visite di follow-up.

• Possibili effetti avversi del trattamento.

• Incremento dei costi, almeno iniziali, derivanti dal

trattamento anticipato della malattia rispetto alla sua

naturale evoluzione.

• Carenza di evidenze sulla maggior efficacia di interventi

messi in atto nella fase pre-clinica della malattia rispetto

a quelli instaurati dopo la diagnosi clinica.

Screening

The ADDITION-Cambridge study A primary care-based

screening and

intervention study for

T2DM.

Two phases:

1. a pragmatic parallel

group, unbalanced,

cluster-randomised

trial of screening;

2. a cluster-randomised

trial comparing the

effects of intensive

multifactorial therapy

with routine care in

individuals with

screen-detected

T2DM.

Simmons, Lancet 2012 (Oct 3)

The ADDITION-Cambridge study

Simmons, Lancet 2012 (Oct 3)

Of 16 047 high-risk individuals in screening practices, 15 089 (94%) were

invited for screening during 2001–06, 11 737 (73%) attended, and 466 (3%)

were diagnosed with diabetes. 4137 control individuals were followed up.

During 184 057 person-years of follow up (median duration 9.6 years [IQR

8.9–9.9]), there were 1532 deaths in the screening practices and 377 in

control practices (mortality hazard ratio [HR] 1.06, 95% CI 0.90–1.25).

The ADDITION-Cambridge study

Simmons, Lancet 2012 (Oct 3)

In this large UK sample, screening for type 2 diabetes in patients at increased risk

was not associated with a reduction in all-cause, cardiovascular, or diabetes-related

mortality within 10 years. The benefits of screening might be smaller than expected.

The SWEETHEART registry

• 2,767 pts presenting with STEMI or NSTEMI

• Those without known DM had an OGTT at day 4 after

admission.

• Female pts. have higher rates of known and newly-

diagnosed DM (30.2 and 19.7% compared with 23.1 and

15.3 in males)

• 3-Year mortality rates with known DM not different

between males and females (35.4% and 30.0).

• Mortality in newly-diagnosed DM much higher in

females (30.5% vs. 21.8).

Tschoepe, Diabetologia 2012

CAD as risk for DM

• 506 consecutive non-DM patients undergoing coronary

angiography for suspected CAD (significant CAD, 293

cases)

• Follow up, 7.5 years (3795 patient-years)

• 107 incident cases of DM (21.1%, 2.8% per year)

• Patients with significant CAD had a 33% increased risk

of incident DM at follow-up

Conclusion: The presence of CAD indicates an increased

risk of DM. Repeated screening and targeted programs

are warranted to prevent diabetes

Saely, Diabetologia 2012

Impatto delle Malattie croniche non

trasmissibili (CNCD) sui Sistemi Sanitari

Le CNCD avranno un effetto devastante sui Sistemi Sanitari,

orientati oggi prevalentemente alla cura, non alla

promozione della salute

Il diabete potrebbe diventare la pandemia del 21* secolo

Occorrono interventi sistematici sulla popolazione

“ The lives of far too many people in the

world are being blighted and cut short by

chronic disease such as heart disease ,

stroke, cancer, chronic respiratory disease

and diabetes”

LEE Jong-wook

Director-General,

World Health Organization