,Epidemiology of Insulin Resistance, Diabetes Mellitus, and Coronary Heart Disease Steven Haffner, MD,Adapted from World Health Organization. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications. Geneva: World Health Organization:1999:52.,Criteria for the Diagnosis of Diabetes Mellitus and Hyperglycemia Plasma Glucose Concentration,7.0 (126)6.1 (110) to 7.0 (11.1 (200) 7.8 (140) to 11.1 (20 years) by Year and Region,2000,2025,Hospitalization Costs for Chronic Complications of Diabetes in the US,American Diabetes Association. Economic Consequences of Diabetes Mellitus in the US in 1997. Alexandria, VA: American Diabetes Association, 1998:1-14.,Total costs 12 billion US $ CVD accounts for 64% of total costs,Others,Ophthalmic disease,Cardiovascular disease,Renal disease,Neurologic disease,Peripheral vascular disease,Annual CHD Deaths per 1000 Persons,Kannel WB, McGee DL. JAMA 1979;241:2035-2038.,Framingham Study: DM and CHD Mortality 20-Year Follow-up,17,8,17,4,Men,Women,DM Non-DM,Ischemic heart disease,% of Deaths,Geiss LS et al. In: Diabetes in America. 2nd ed. 1995; chap 11.,Mortality in People with Diabetes Causes of Death,Other heart disease,Diabetes,Cancer,Stroke,Infection,Other,Mortality per 1000 person-years*,*Age-adjusted Adapted from Gu K et al. Diabetes Care 1998;21:1138-1145.,Mortality Due to Heart Disease in Men and Women with or without Diabetes (US),29.9,19.2,Men,Women,Diabetes No Diabetes,All heart disease,Ischemic heart disease,Men,Women,11.5,6.3,23.0,7.1,11.0,3.6,Nondiabetes,Diabetes,*Defined in 1971-1975, followed up through 1982-1984. *Defined in 1982-1984, followed up through 1992-1993. Gu K et al. JAMA 1999;281:1291-1297.,Trends in Mortality Rates for Ischemic Heart Disease in NHANES Subjects with and without Diabetes*,17.0,6.8,-16.6%,+10.7%,Men, cohort 1* Men, cohort 2* Women, cohort 1* Women, cohort 2*,-43.8%,-20.4%,14.2,7.6,7.4,4.2,2.4,1.9,(P=0.46),(P=0.76),(P200 mg/dl, smoking, SBP 120 mmHg Stamler J et al. Diabetes Care 1993;16:434-444,All three,No diabetes,Diabetes,Two only,Putative Mechanism for Increased Atherosclerosis in Type 2 Diabetes,BLACK BOX,Dyslipidemia Hypertension Hyperinsulinemia/insulin resistance Hemostatic abnormalities Hyperglycemia AGE proteins Oxidative stress,AGE = advanced glycation end products Adapted from Bierman EL. Arterioscler Thromb 1992;12:647-656.,+ = moderately increased compared with nondiabetic population + = markedly increased compared with nondiabetic population = not different compared with nondiabetic population,Prevalence of Cardiovascular Risk Factors in Diabetic Subjects Relative to Nondiabetics,Type 1,Dyslipidemia Hypertriglyceridemia Low HDL Small, dense LDL Increased apo B Hypertension Hyperinsulinemia/insulin resistance Central obesity Family history of atherosclerosis Cigarette smoking,Adapted from Chait A, Bierman EL. In: Joslins Diabetes Mellitus. Philadelphia: Lea & Febiger, 1994:648-664.,Type 2,Risk Factor,+ + ,+ + + + + + + + ,Differences in HDL Cholesterol and LDL Size by Diabetic Status in Women and Men,Howard BV et al. Diabetes Care 1998; 21:1258-1265.,0 -2 -4 -6 -8,Differences between participants with and without diabetes,HDL Cholesterol,LDL Size,0 -2 -4 -6 -8,mg/dL,Women Men,Women Men,Strategies for Reduction of Diabetic Complications,Microvascular complications - Aggressive screening - Improved metabolic control Macrovascular complications - Improved glycemic control (positive but minor) - Prevention of type 2 diabetes - Aggressive treatment of established CVRF in diabetic and possibly prediabetic subjects - Diabetic agents that improve cardiovascular risk,Incidence Rates of MI and Microvascular Endpoints by Mean Systolic Blood Pressure: UKPDS,