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The Diabetes Epidemic--Part I

The Impact of Oral Healthcare Providers

THE NEXT DDS

 

Worldwide, 220 million people have diabetes.1 Data indicate that global factors such as population growth, aging, urbanization, and increasing prevalence of obesity and physical inactivity will cause the number of cases of diabetes to double by the year 2030.2 In the US, most recent figures (2008) indicate that 24 million people or nearly 8% of the population have the disease.3 The Centers for Disease Control (CDC) predict that if the current trends continue, 1 in 3 Americans will develop diabetes in their lifetime, and will lose on average, 10-15 years of life.4 As the rate of diabetes increases, it is likely that dental practitioners will treat more individuals living with this chronic and debilitating disease.

 

TYPES OF DIABETES

Diabetes is a group of diseases characterized by high levels of blood glucose (hyperglycemia) resulting from defects in insulin production, insulin action or both. The type of diabetes an individual has is dependent upon the circumstances at the time of diagnosis. The diagnosis of diabetes traditionally has been based upon glucose criteria. In 2010, the American Diabetes Association included the A1C test, a reading that reflects average blood glucose over the preceding 2-3 months as one of the tests to diagnose diabetes. The three most common types of diagnosed diabetes are: Type 1, Type 2, and Gestational diabetes. In recent years, a new category for those at increased risk was developed. These individuals are referred to as having pre-diabetes.5  

 

Type 1

Previously called juvenile or insulin-dependent diabetes, type 1 diabetes develops when the body’s immune system destroys pancreatic beta cells, the cells of the body responsible for insulin production. The cause of type 1 is not well known. It is likely that there may be a genetic predisposition as well as related environmental factors. People with type 1 must take insulin to stay alive. Type 1 accounts for about 5%-10% of all cases of diabetes.5 Three quarters of Type 1 cases are diagnosed in children < 18 years of age; however it can occur at any time.6 About 15,000 youth are newly diagnosed with type 1 each year.7  

The onset of type 1 diabetes is often acute or mimics the flu. Symptoms of type 1 diabetes are often referred to as polyuria (frequent urination), polydipsia (unusual thirst), and polyphagia (extreme hunger). Other symptoms include unexplained weight loss, extreme fatigue, and irritability. Diagnosis usually occurs fairly soon after the on-set of symptoms. Children with type 1 may have other autoimmune diseases such as celiac disease and autoimmune thyroiditis.6  

 

Type 2

Once called adult-onset or non-insulin dependent diabetes, type 2 diabetes usually begins as insulin resistance, a disorder where cells do not use insulin properly. Over time, as the need for insulin increases, the pancreas gradually loses its ability to produce insulin. Diet, exercise, oral hypoglycemic drugs, and insulin all may be used in the treatment of type 2 diabetes. Currently, this type accounts for 90% to 95% of diabetes cases.6,7  

People with undiagnosed diabetes most often have type 2. The signs and symptoms of type 2 diabetes may be similar to those for type 1 but may also include frequent infections, blurred vision, cuts/bruises that are slow to heal, tingling/numbness in the hands or feet, or recurring skin, periodontal, or bladder infections. Many individuals with type 2 diabetes have no symptoms and may go undiagnosed for several years; often until other health complications appear.8  

The risk of developing type 2 diabetes increases with age, obesity, and lack of physical activity. Type 2 is associated with family history and may be more likely to occur in those with a history of gestational diabetes or impaired glucose tolerance, now called pre-diabetes. Type 2 is more likely to occur in adults age 40 and over, but with increasing rates of childhood obesity, there are approximately 3,700 cases of type 2 in children diagnosed annually. Type 2 diabetes onset may be delayed or even prevented by lifestyle changes.7  

 

Gestational Diabetes Mellitus (GDM)

Gestational diabetes has been defined as any degree of glucose intolerance with onset or first recognition during pregnancy. This type of diabetes affects about 7% of pregnancies resulting in 200,000 cases per year. Risk assessment for GDM generally occurs at the first prenatal visit. Individuals who are obese, have a history of previous GDM, or a strong family history of diabetes may be tested in the first trimester. Women of average risk are generally tested at 24 –28 weeks gestation. GDM usually resolves with delivery, however glycemic testing should be performed six weeks post partum to confirm.5 There has been a progressive increase (10%) in the number of women whose diabetes does not resolve after pregnancy. It is believed that they had undiagnosed type 2 diabetes prior to pregnancy not GDM.9  

Children born to mothers with GDM are at an increased risk of having a large birth weight. They are also at risk for becoming obese, glucose intolerant, and developing diabetes in late adolescence and young adulthood. Women with GDM are more likely to develop hypertension during pregnancy and/or need a cesarean delivery.10 They also have 40%-60% chance of developing diabetes in the next 5 - 10 years.7  

 

Pre-Diabetes

Pre-diabetes is the name given to the condition where individuals have glucose levels that do not meet the criteria for diabetes but are higher than those considered normal. This includes those who have an impaired fasting plasma glucose level between 100 mg/dl and 125 mg/dl or impaired glucose tolerance of 140 mg/dl to 199 mg/dl. An A1C in the range of 5.7% to 6.4% may also be considered a risk factor.5 It is estimated that 57 million people age 20 and over and 7% of adolescents aged 12-19 years have prediabetes.7 People with pre-diabetes are at higher risk for developing type 2 diabetes, although lifestyle changes can prevent or delay the onset.7,11 Screening for pre-diabetes is recommended for adults of any age who are overweight and/or obese and have one or more additional risk factors for diabetes. General screening for those without risk factors should begin at age 45.6  

(Continued from page 1 )


IMPACT OF DIABETES

Diabetes is the seventh leading cause of death in the US. It is generally thought to be underreported as the main cause of death and more likely to be recorded as a contributing cause. Overall, the risk of death for people with diabetes is twice that of those without. Both type 1 and type 2 diabetes can lead to serious complications such as those considered microvascular; retinopathy (eye disease), nephropathy (kidney disease), neuropathy (nervous system disease) and macrovascular (heart disease and stroke).7 These complications are a major factor in the temporary and permanent disability of a person with diabetes.12 The cost of these complications results in medical expenditures that are 2.3 times higher than in the absence of diabetes.7  

 

Health Issues

Microvascular Complications

Diabetic retinopathy refers to any abnormality of the small blood vessels of the retina such as weakening of blood vessel walls or leakage from blood vessels. It is the most frequent cause of new cases of blindness among adults aged 20 - 74 years.7 Nearly all individuals with type 1 diabetes and more than 60% of those with type 2 develop retinopathy within 20 years of diagnosis. Up to 21% of those with type 2 have retinopathy at the initial diagnosis.13 People with diabetes are 40% more likely to suffer from glaucoma and 60% more likely to develop cataracts.14 After 15 years of having diabetes, approximately 2% become blind and 10% develop a severe visual impairment.1  

Diabetic nephropathy is a progressive disease involving damage to the blood vessels of the kidneys that act as filters to remove wastes, chemicals, and excess water from the blood. When blood vessels are damaged they allow protein to leak into the urine (called proteinuria). Diabetic nephropathy accounts for about 40% of new cases of end stage renal disease (ESRD). While about 30-40% of patients develop nephropathy, those with type 1 are more likely to progress to ESRD.15 About 10-20% of people with diabetes succumb to kidney failure.1  

Diabetic neuropathy is a form of nervous system damage often evidenced by a loss of protective sensation often afflicting the feet. About 60% of people with diabetes have mild to severe forms of nervous system damage. This can include impaired feeling in the feet or hands, slowed digestion, carpal tunnel syndrome or erectile dysfunction. Severe forms of this can lead to lower extremity amputation.7 The risk of foot ulcer and/or amputation is increased in people who have had diabetes for more than 10 years, are male, have poor glucose control, or have other complications; cardiovascular, retinal, or renal.16  

 

Macrovascular Complications

Heart disease and stroke are leading causes of diabetes-related death. In 2004, heart disease was noted on 68% of diabetes related deaths and stroke in 16% of cases. In adults with diabetes the risk for coronary heart disease (CDH) and stroke is 2 to 4 times higher than for adults without diabetes.7 People with diabetes are at risk of developing CHD up to fifteen years earlier than other people.17 In more than 20% of cases in people aged 50-75 years, CHD may be asymptomatic.18 Diabetes has also been shown to significantly affect mortality within thirty days after a coronary event.19  

Risk factors for CHD and stroke (collectively, cardiovascular disease, CVD) are hypertension and high cholesterol. Seventy-five percent of people with diabetes have hypertension defined as blood pressure ≥130/80 or use prescription medication to control blood pressure. In those with type 1 diabetes, hypertension may result from nephropathy.7 Individuals with type 2 often have lipid abnormalities as evidenced by high cholesterol, particularly a high LDL and low HDL, and high triglycerides.6  

 

Other Complications

People with diabetes may be more susceptible to other illnesses, and once they acquire them, may have a worse prognosis. When they get pneumonia or influenza, they have an increased risk of dying.7 Emerging evidence indicates that both depression and dementia may be more likely in people with diabetes.20,21 People susceptible to depression seem to be those with low levels of education, physical impairment or CVD.20 People with type 2 diabetes seem to have an increased risk of both Alzheimer’s disease and Vascular dementia.21 There are two possible ways this may happen. One theory is that neurons in the brain are affected by blood vessel damage to the brain, and blood vessel damage is a common complication of diabetes. Another pathway may relate to insulin. High insulin levels sometimes occur in people with type 2 as the pancreas pumps out higher levels of insulin in an effort to get a response in insulin resistant cells. When there is too much insulin, the body becomes overloaded with enzymes trying to break it down so that ameyloid protein accumulates in the brain leading to plaque formation.22  

 

Disability

People with diabetes are at a greater risk of temporary incapacity and permanent disability. Disability from diabetes may prevent people from working or limit their employment opportunities.22 It has been shown to interfere with activities of daily living such as walking, climbing stairs, doing housework, and preparing meals. Older women (≥60 years) with diabetes had a 58% likelihood of falling compared to women without diabetes.12  

 

Economic Implications

The population with diabetes tends to be older and sicker resulting in high health care costs. In the year 2007, the total estimated costs for diabetes was $174 billion including $116 billion in direct medical costs and $58 billion in reduced national productivity. About $1 for every $10 spent on health care is attributed to diabetes, and $1 in every $5 is spent on caring for someone with diabetes. People with diabetes incur approximately $11,744 in health care expenditures per year compared to $5,095 for people without diabetes. About 50% of health care expenditures in people with diabetes are for hospital inpatient care followed by diabetes medication and supplies (12%), prescriptions for diabetic complications (11%) and physician office visits (9%).23  

 

Disparities Across Population Groups

Diabetes becomes more prevalent after the age of 20 affecting 10.7% of that population group. It is the most prevalent in people over 60 years of age with about 23% being affected. In the last few years, a trend shows that people are being diagnosed at earlier ages with more than half of new cases of diabetes occurring in adults between the ages of 40 and 59 years. Type 2 diabetes, while still infrequent, has also become more common among youth aged 10-19 years. Men have a slightly higher incidence than women, 11.2% versus 10.2%.

Minority groups seem to have a higher risk of developing type 2 diabetes. African American, Hispanic, American Indian, and Alaskan Native adults are twice as likely to have diabetes as Caucasians.4 Minority populations have been shown to develop diabetes earlier.7 Minority women are 2 to 4 times more likely to  have diabetes than white women. These groups are more likely to have diabetes complications that can lower quality of life.24  

(Continued from page 2 )


RISK FACTORS

People who are at risk for type 2 diabetes often have a genetic predisposition. Yet in most cases an environmental trigger like being overweight or obese is also necessary.25,26 Not all individuals with a family history will develop diabetes nor will every overweight or obese person. From a family history perspective, the risk for developing type 2 diabetes is 1 in 7 if you have a parent diagnosed before the age of 50 and 1 in 13 if the parent was diagnosed after age 50. If both parents have type 2, the risk increases to 1 in 2.25  

Overweight/obese is the strongest environmental risk factor for type 2. Overweight individuals are twice as likely to develop type 2 as those of a normal weight. For those who are obese, the risk ranges from 3 to 6 times more likely depending on body mass index (BMI).26  

The increase in type 2 diabetes has been attributed to the growing numbers of overweight and obese individuals. The metabolic and endocrine function of adipose tissue is influenced by obesity resulting in a greater production of agents that increase insulin resistance and systemic inflammation.28 A 2010 report found that 68% of US adults are overweight or obese. For men the rate is 72.3% versus 64.1% for women. However, women were more likely to be obese than men, 35.5% versus 32.2%. The overall prevalence of obesity is 33.8%.29 Results from the Framingham Heart Study indicate that overweight and obesity in adulthood are associated with large decreases in life expectancy and increases in early mortality.30 Obesity affects children and adolescents. Current statistics indicate that 10.4% of children ages 2-5 are obese as is 19.6% of 6-11 year olds, and 18.1% of 12-19 year olds.30 Studies have found that obese children and adolescents are more likely to become obese as adults.32  

Emerging data suggests that the role of overweight/obesity is influenced by the location of weight on the body.33,34,35 A large waist circumference (greater than 35 inches for women and more than 40 inches for men) means more abdominal or visceral fat, which has been shown to increase the risk of both CVD and diabetes. Waist circumference is increasing in youth at a pace faster than BMI.34 Visceral fat increases the likelihood of having fat around internal organs. A recent study found that those who had the highest amount of fat in the liver were more likely to be insulin resistant.36 Fat concentrated in the gluteofemoral areas of the body tends to be more passive than abdominal fat and may exert protective properties.35  

Another emerging risk factor for type 2 is smoking. A systematic review and meta-analysis of 25 published papers found that heavy smoking (more than 20 cigarettes per day) increased the risk of developing type 2 diabetes. The reason for this relationship has not been conclusively determined although some factors have been identified. While older studies showed that smokers tended to have lower BMIs than non smokers, a more recent investigation showed that today, smokers tend to have higher BMIs. Additionally, smokers with a normal BMI have been found to have greater abdominal fat. It is also possible that nicotine may exert a biological influence on the beta cells of the pancreas as smoking has also been shown to be a risk factor for pancreatitis and pancreatic cancer.37  

 

Conclusion

Diabetes is a disease the affects more than 200 million people around the world. There are two distinct kinds of diabetes, type I and type II, each with its own symptoms and challenges. There are a multitude of systemic and oral health implications diabetes can have on dental patients both young and old, which may require special accommodations to be made during treatment. For more information about this topic, continue on to part II of this article by visiting This Link.

 

References:

  1. Diabetes: Fact sheet No. 312. November, 2009. World Health Organization. Available at: http://www.who.int/mediacentre/factsheets/fs312/en/index.html Accessed 04-13-10.
  2. Wild S et al. Global prevalence of diabetes. Diabetes Care 2004; 27(5):1047-1053.
  3. Centers for Disease Control and Prevention: Press Release: Estimates of Diagnosed Diabetes Now Available for all US Counties. June 24, 2008; Available at: http://www.cdc.gov/media/pressrel/2008/r080624.htm Accessed 04-13-10.
  4. Diabetes Successes and Opportunities for Population-based Prevention and Control: At a Glance 2010: Centers for Disease Control and Prevention. Available at http://www.cdc.gov/chronicdisease/resources/publications/AAG/ ddt.htm. Accessed 04-13-10
  5. American Diabetes Association position statement: Diagnosis and classification of diabetes mellitus. Diabetes Care 2010; 33(Suppl 1): S62-S69.
  6. 6American Diabetes Association position statement: Standards of Medical Care 2010. Diabetes Care 2010; 33(Suppl 1): S11-S61.
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  8. Diabetes Basics: Symptoms: American Diabetes Association. Available at: http://www.diabetes.org/diabetes-basics/symptoms Accessed 04-13-10
  9. Lawrence JM et al. Trends in the prevalence of preexisting diabetes and gestational diabetes mellitus among a racially/ethnically diverse population of pregnant women, 1999-2005. Diabetes Care 2008; 31:899-904.
  10. American Diabetes Association position statement: Gestational Diabetes Mellitus. Diabetes Care 2004; 27 (Suppl 1): S88-S90.
  11. Knowler WC et al. Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 2002; 346:393-403.
  12. Gregg EW et al. Cognitive and physical disabilities and aging-related complications of diabetes. Clinical Diabetes 2003; 21:113-118.
  13. American Diabetes Association Technical Review. Retinopathy in diabetes. Diabetes Care 2004; 27:S84-S87.
  14. American Diabetes Association: Eye Complications. Available at: http://www. diabetes.org/living-with-diabetes/complications/eye-complications.html Accessed: 04-14-10.
  15. American Diabetes Association Technical Review. Nephropathy in diabetes. Diabetes Care 2004; 27:S79-S93.
  16. American Diabetes Association Technical Review. Preventive foot care in people with diabetes. Diabetes Care 2003; 26:S78-S79.
  17. Booth G et al. Relation between age and cardiovascular disease in men and women with diabetes compared with non diabetic people: a population-based retrospective cohort study. Lancet 2006; 368(9529):29-36.
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  19. Donahoe SM et al. Diabetes and mortality following acute coronary syndromes. JAMA 2007; 298(7):765-775.
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  22. American Diabetes Association: Hot Topics: Alzheimer’s Disease and Diabetes. Available at: http://www.diabetes.org/assets/pdfs/hot-topics/hot-topicswinter- spring-2007.pdf Accessed: 04-19-10.
  23. American Diabetes Association Review: Economic costs of diabetes in the US in 2007. Diabetes Care 2008; 31:596-615.
  24. Misra R, Lager J. Ethnic and gender differences in psychosocial factors, glycemic control, and quality of life among adult type 2 diabetic patients. J Diabetes Complications. 2009; 23:54-64.
  25. American Diabetes Association: Genetics of Diabetes. Available at: http://www. diabetes.org/diabetes-basics/genetics-of-diabetes.html Accessed: 04-13-10.
  26. A Nation at Risk: Obesity in the United States: A Statistical Sourcebook; American Heart Association, 2005.
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  29. Flegal KM. Prevalence and trends in obesity among US adults: 1999-2008. JAMA 2010, 303:235-241.
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  35. Manolopoulos KN et al. Gluteofemoral body fat as a determinant of metabolic health. Int J of Obesity 2010: doi:10.1028/ijo.2009.286.
  36. Fabbrini E et al. Intrahepatic fat not visceral fat, is linked with metabolic complications of obesity. Proc Natl Acad Sci USA 2009;106:15430-15435.
  37. Willi C et al. Active smoking and the risk of type 2 diabetes: A systematic review and meta-analysis. JAMA 2007; 298:2654-2664.
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