Prevention of complications of endocrine disorders

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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 gt23.5
• 38 men 34 women BMI gt25
• 5 men, 7 women BMI gt30
• 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 fatgood 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 - cant 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