COS  

The Philippine Cardiovascular Outcome Study The Philippine Cardiovascular Outcome Study Diabetes Mellitus (PhilCOS-DM):Diabetes Mellitus (PhilCOS-DM):

An 8-year Follow-up of the An 8-year Follow-up of the 1998 Food and Nutrition Research Institute 5th National Nutrition Survey (FNRI-NNS) 1998 Food and Nutrition Research Institute 5th National Nutrition Survey (FNRI-NNS)

in the National Capital Region, Region 3 and Region 4.in the National Capital Region, Region 3 and Region 4.    

Rody G. Sy, MDRody G. Sy, MD Maria Luz Joanna B. Soria, MD Maria Luz Joanna B. Soria, MD

Bernard S. Vega. Bernard S. Vega. MDMDJennifer S. Flores, MDJennifer S. Flores, MD

Felicidad Velandria, RNDFelicidad Velandria, RNDFelix Eduardo Punzalan, MDFelix Eduardo Punzalan, MD

Tommy Ty-Willing, MDTommy Ty-Willing, MD

Cardiovascular Institute CARDINAL SANTOS MEDICAL CENTERCardiovascular Institute CARDINAL SANTOS MEDICAL CENTERCardiovascular Section University of the Philippines-Philippines General HospitalCardiovascular Section University of the Philippines-Philippines General Hospital

IntroductionIntroduction

IntroductionIntroduction

Diabetes Mellitus is a risk factor for: AtherosclerosisCoronary heart diseaseHeart Failure

Incidence of Fatal or Nonfatal MI During a 7-Year Follow-Incidence of Fatal or Nonfatal MI During a 7-Year Follow-up in Relation to History of MI in Nondiabetic vs Diabetic up in Relation to History of MI in Nondiabetic vs Diabetic

Subjects: Subjects: East-West StudyEast-West Study

0

10

20

30

40

50

Inci

dence

Duri

ng

Follo

w-u

p (

%)

(n=69)

Nondiabetics with prior MI

Nondiabetics with no prior MI

Diabetics with prior MI

Diabetics with no prior MI

18.8

Haffner SM et al. N Engl J Med 1998;339:229-234.

(n=1304) (n=169) (n=890)3.0 0.5 7.8 3.2

3.5

45.0

20.2

Events per100 person-yr:

P<0.001

p<0.001

21.935.864%

21.935.864%

6.915.5120%

6.915.5120%

20.9.25.823%

20.9.25.823%

1.32.269%

1.32.269%

5.511.6111%

5.511.6111%

World2000 = 159 million2025 = 280 millionIncrease of 76%

ASIA102.2189.485%

ASIA102.2189.485%

Global Projections for the Diabetes Global Projections for the Diabetes Epidemic: 2000–2025Epidemic: 2000–2025

Zimmet P et al..Numbers are in Millions

Diabetes in Asia is a Growing Diabetes in Asia is a Growing EpidemicEpidemic

0 10000 20000 30000 40000 50000 60000 70000 80000

Australia

China

Indonesia

Japan

Korea

Malaysia

Philippines

Singapore

Taiwan

Thailand

India

2025

2003

Number of People with Diabetes (000)

Source: http://www.eatlas.idf.org/prevalence/index (accessed 10/7/2005)

20% Prevalence growth

IntroductionIntroduction1983 & 1998 prevalence of DM 4%

2003 NNHeS prevalence of DM 4.6%

In 2006, we attempted the first longitudinal study in the Philippines on some cardiovascular and diabetic outcomes.

PhilCOS-DMPhilCOS-DM

ObjectivesObjectivesA descriptive cohort study to determine:

8-year incidence rate of diabetes mellitus and impaired fasting glucose (IFG)

based on fasting blood glucose (FBG)

prevalence rate of diabetes mellitus, IFG and impaired glucose tolerance (IGT)

based on interview, FBG and 2-hours post glucose (2H PG) load, of the NCR, Region 3, and Region 4.

COS

MethodologyMethodologySelection of FNRI-NNS subjects: two-

staged stratified sampling design (1998)

1998 FNRI-NNSNCR, n= 470Reg3, n= 351Reg4, n= 495

TOTAL = 1316

2006 PhilCOSNCR, n= 345 (73%)Reg3, n= 309 (88%)Reg4, n= 431 (87%)

TOTAL = 1085 (82%)

8-years follow-up

COS

MethodologyMethodology

1998 FNRI (N=1316)

2006 revisited (N= 1085)

FBG (N=864)

2h post-glucose load (N=800)

Unretrieved =18%

Barangay Health Workers

Questionnaire

One Touch Ultratm

75 gram glucose load

Alive = 913

COS

COS

0

50

100

150

200

250

300

350

400

1 5 9 13 17 21 25 29 33 37 41

FBS (MG/DL)

CBG (MG/DL)

Validation of the “One touch Validation of the “One touch glucometer CBG vs FBS-glucometer CBG vs FBS-

CSMCCSMC

Criteria for DM, IFG, IGTCriteria for DM, IFG, IGTFasting Plasma Glucose (FBG) < 100 mg/dL

= normal

FBG = 100-125 mg/dL = impaired fasting glucose (IFG)

FBG >126 mg/dL = diabetes

2-h post glucose load (2HPG)<140 mg/dL

= normal

2-h PG = 140-199 mg/dL = impaired glucose tolerance (IGT)

2-h PG > 200 mg/dL = diabetes

COS

Data Processing & Data Processing & AnalysisAnalysis

Encoding – Microsoft Access

Analysis – SPSS V12

Data storage – MS Excel & SPSS V12

COS

RESULTSRESULTS

COS

COSDemographics of the 1998 FNRI-Demographics of the 1998 FNRI-

NNS NNS Variables Male

(n=633) Mean + SD

Female(n= 683)

Mean + SD

p valueM vs F

Total N

Total PopulationMean + SD

Age (y) 49.94 + 16.86 48.319 + 16.17 0.0753 1316 49 +17

FBG (mg/dL) 94.06 + 35.30 94.05 + 36 0.9946 1316 94 +36

T cholesterol (mg/dL) 167.09 + 42.31 174.90 + 43.58 0.0010 1316 171 +43

Triglyceride (mg/dL)130.70 + 73.93 114.74 + 58.36 0.0001 1316 122 +67

HDL-C (mg/dL) 32.04 + 13.39 34.02 + 14.64 0.01 1315 33 +14

LDL-C (mg/dL) 109.23 + 38.16 118.15 + 38.0 0.0001 1315 114 +38

Systolic BP (mmHg) 128.15 + 22.90121.95 + 24.37 0.0001

1315 125 +24

Diastolic BP (mmHg) 82.01 +13.09 78.42 + 13.02 0.0001 1315 80 +13

WEIGHT (kg) 58.43 +11.39 81.71 + 10.62 0.0001 1302 55 +11

HEIGHT(m) 162.34 + 6.43 150.46 + 5.51 0.0001 1302 156 +8

BMI (kg/m2) 22.11 + 3.71 22.81 + 4.40 0.0018 1302 22 +4

Waist (cm) 80.07 +10.75 75.37 + 10.32 0.0001 1315 78 +11

Hip (cm) 87.18 + 7.12 89.86 + 9.52 0.0001 1315 89 +9

COS Demographics of the 2006 Demographics of the 2006

PhilCOS PhilCOS Variables

Total 2006

Male(n=427)

Mean + SD

Female(n=498)

Mean + SD

Age (y) 55.55 +- 15.87 55.44 +- 15.93 55.64+-15.83

FBG (mg/dL) 105.75 +- 40.96 108.75 +- 44.83 103.24+-37.28

Systolic BP (mmHg) 124.14 +- 21.99 126.73 +- 21.24 121.96 +- 22.39

Diastolic BP (mmHg) 81.96 +- 11.46 83.25 +- 10.86 80.87 +-11.84

Waist (cm) 80.08 +- 11.61 81.33 +-11.03 79.02 +-11.99

Anti-hypertens use 177 (19%) 79 (19%) 98 (20%)

Self-reported diabetes 86 (9%) 31 (7%) 55 (11%)

Self-reported CAD/Angina 55.55 +- 15.87 23 (5%) 25 (5%)

Self-reported Stroke 105.75 +- 40.96 26 (6%) 25 (5%)

Prevalence of Diabetes Mellitus Prevalence of Diabetes Mellitus based on based on

FBG, 2H PGL, Diabetic FBG, 2H PGL, Diabetic Questionnaire, and CombinationQuestionnaire, and Combination

 

DMQ’NAIRE

FBG>125 mg/dL

2H PG>200

mg/dL

FBG OR DMQ OR

2H PG

TOTAL 9% 12% 10% 18%

MALE 7% 14% 9% 18%

FEMALE 11% 10% 10% 18%

COS

PhilCOS-DM accepted that the most accurate prevalence rate of Diabetes was the combination of the 3 measures: 18%.

57%

31%

10% 12%

64%

26%

10%

54%

32%

10%14%

68%

23%

9%

60%

30%

10% 10%

61%

28%

10%

TOTAL MALE FEMALE

TOTAL 57% 31% 10% 12% 64% 26% 10%

MALE 54% 32% 10% 14% 68% 23% 9%

FEMALE 60% 30% 10% 10% 61% 28% 10%

FBG<100 mg/dl (Normal)

FBG 100-125 mg/dl (IFG)

FBG 110-125 mg/dl (previous

IFG cut-off)

FBG>125 mg/dl (DM)

2H PG <140 mg/dl (Normal)

2H PG 140-199 mg/dl (IGT)

2H PG >200 mg/dl (DM)

-

Prevalence of IFG and IGT Prevalence of IFG and IGT based on FBG and 2H-PG loadbased on FBG and 2H-PG loadCOS

COSThe 8-years Incidence of DM using The 8-years Incidence of DM using

FBG FBG

FBS>125 mg/dL

NCR 12%

REGION 3 12%

REGION 4 12%

TOTAL (n = 864) 12%

MALE 14%

FEMALE 10%

Spectrum of Glucose Homeostasis: Spectrum of Glucose Homeostasis: From 1998 IFG to From 1998 IFG to

DM, IFG and normal in DM, IFG and normal in 2006 PhilCOS-2006 PhilCOS-DMDM

1998 IFG definition

N=25(110-125 mg/dL)

A. DM (FBG > 126) :n = 12

→48%

B. IFG (110-125) : n = 4 →16%

C. Normal (<110) : n = 9 →36%

COS

Among IFGs 48% became diabetics in 8 years.

1998 Normal

definition of FBG

N=804

A. DM (FBG > 126) : n = 74 →9%B. IFG (110-125) : n = 81 →10%

C. Normal (<110) :n = 649

→81%

Spectrum of Glucose Homeostasis: Spectrum of Glucose Homeostasis: From 1998 Normoglucose to From 1998 Normoglucose to

DM, IFG and Normal in DM, IFG and Normal in 2006 PhilCOS-2006 PhilCOS-DMDM

COS

The 8-years incidence rate of

IFG is 10%.

Prevalence of DM using FBG, 2 hour Prevalence of DM using FBG, 2 hour PG, or Combination (n=800)PG, or Combination (n=800)

5% 6%

2H-PGL2H-PGL>>200 = 10%200 = 10%FBGFBG>>126 = 9%126 = 9%

4%

FBG alone FBG & 2HPG 2HPG alone

COS

•2HPG provides better information regarding future risk for CVD…•Elevated 2HPG also predicts the CVD risk in subjects with NORMAL FBG.•Class 1, Level of Evidence A.

ESC and EASD guidelines, 2007

Prevalence of IFG, IGT or Prevalence of IFG, IGT or Combination (n=800)Combination (n=800)

IGT (140-199 mg/dL) = 26% IFG (100-125 mg/dL) = 31%

20% 15%11%

IFG alone IFG & IGT IGT alone

COS

Prevalence of IFG, IGT or Prevalence of IFG, IGT or Combination Combination

IGT = 208 IFG = 248

46% 38%16%

IFG alone IFG & IGT IGT alone

COS

FBG predicted more pre-diabetics, but a further 38% can be predicted by 2H

PG.

Limitations of the Limitations of the StudyStudy

Use of capillary blood sampleRespondent migration and relocationSampling limited to previously generated by the 1998 FNRI-NNS? “more urban” cohort? “healthier” non-respondents? Overestimate of morbidities comparing 2-points in time

COS

ConclusionsConclusionsIncidence rate of DM = Incidence rate of DM = 12%12%Incidence rate of IFG = Incidence rate of IFG = 10%10%

Prevalence rate of DM = Prevalence rate of DM = 18%18% Prevalence rate of IFG = Prevalence rate of IFG = 31%31%Prevalence rate of IGT = Prevalence rate of IGT = 26%26%

COS

Awaiting…Awaiting…The PhilCOSThe PhilCOS

Extension StudyExtension Study

COS

PhilCOSPhilCOSExtension of the study:

Region 6 - CebuRegion 10 – MindanaoRegion 5 - Bicol

COS

AcknowledgementAcknowledgementCOS

Sponsors : Sponsors : Philippine Diabetes AssociationPhilippine Lipid and Atherosclerosis SocietyPhilippine Society of HypertensionTherapharma, Inc.Pfizer Phils., Inc.Johnson & Johnson

Research Assistants :Research Assistants :Maryjun Rangel and Armand Soriano

Collaborators :Collaborators :Philippines Diabetes Association key opinion

leaders’ forum

Special Mention :Special Mention :Municipal Health Officers and Barangay Health Municipal Health Officers and Barangay Health

workersworkers

PhilCOSDM