1. COS
  The Philippine Cardiovascular Outcome Study Diabetes Mellitus (PhilCOS-DM): An 8-year Follow-up of the Food and Nutrition Research Institute 5th National Nutrition Survey (FNRI-NNS) in the National Capital Region, Region 3 and Region 4.     Rody G. Sy, MD Maria Luz Joanna B. Soria, MD Bernard S. Vega. MD Jennifer S. Flores, MD Felicidad Velandria, RND Felix Eduardo Punzalan, MD Tommy Ty-Willing, MD Cardiovascular Institute CARDINAL SANTOS MEDICAL CENTER Cardiovascular Section University of the Philippines-Philippines General Hospital

2. Introduction

3. Introduction Diabetes Mellitus is a risk factor for: Atherosclerosis
Coronary heart disease
Heart Failure

4. Incidence During Follow-up (%)
Incidence of Fatal or Nonfatal MI During a 7-Year Follow-up in Relation to History of MI in Nondiabetic vs Diabetic Subjects: East-West Study
45.0
Nondiabetics with prior MI
Nondiabetics with no prior MI
Diabetics with prior MI
Diabetics with no prior MI
p<0.001
Incidence During Follow-up (%)
20.2
18.8
P<0.001
Incidence of Fatal or Nonfatal MI During a 7-Year Follow-up in Relation to History of MI in Nondiabetic vs Diabetic Subjects: East-West Study
In the East-West Study, diabetics with prior myocardial infarction had a higher incidence of myocardial infarction than diabetics without prior myocardial infarction, but more importantly, diabetics without prior myocardial infarction had a 20.2% incidence of myocardial infarction at 7-year follow-up, compared with an 18.8% incidence in nondiabetics with prior myocardial infarction. These results were important in establishing diabetes as a CHD risk equivalent. Although this study was criticized because it was conducted in a relatively high-risk population for CHD, namely Finland in the early 1980s, a subsequently published analysis of the Organization to Assess Strategies for Ischemic Syndromes (OASIS) Registry, which included prospective data from 6 countries (Australia, Brazil, Canada, Hungary, Poland, and the United States), also found that diabetic patients without prior cardiovascular disease had the same event rates as nondiabetic patients with prior cardiovascular disease.
References:
Haffner SM, Lehto S, Ronnemaa T, Pyorala K, Laakso M. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med 1998;339:
Malmberg K, Yusuf S, Gerstein HC, Brown J, Zhao F, Hunt D, Piegas L, Calvin J, Keltai M, Budaj A. Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) Registry. Circulation 2000;102:
3.5
(n=69)
(n=1304)
(n=169)
(n=890)
Events per 100 person-yr:
3.0
0.5
7.8
3.2
Haffner SM et al. N Engl J Med 1998;339:

5. Global Projections for the Diabetes Epidemic: 2000–2025
20.9.
25.8
23%
64%
ASIA
102.2
189.4
85%
5.5
11.6
111%
6.9
15.5
120%
1.3
2.2
69%
World
2000 = 159 million
2025 = 280 million
Increase of 76%
Numbers are in Millions
Zimmet P et al..

6. Diabetes in Asia is a Growing Epidemic
20% Prevalence growth
Number of People with Diabetes (000)
Source: (accessed 10/7/2005)

7. Introduction 1983 & 1998 prevalence of DM 4% 2003 NNHeS prevalence

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

9. Objectives COS A 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.

10. COS
Methodology
Selection of FNRI-NNS subjects: two-staged stratified sampling design (1998)
8-years follow-up
1998 FNRI-NNS
NCR, n= 470
Reg3, n= 351
Reg4, n= 495
TOTAL = 1316
2006 PhilCOS
NCR, n= 345 (73%)
Reg3, n= 309 (88%)
Reg4, n= 431 (87%)
TOTAL = 1085 (82%)

11. 2h post-glucose load (N=800)
Methodology
1998 FNRI (N=1316)
Unretrieved =18%
2006 revisited (N= 1085)
Alive = 913
FBG (N=864)
Barangay Health Workers
Questionnaire
One Touch Ultratm
75 gram glucose load
2h post-glucose load (N=800)

12. Validation of the “One touch glucometer CBG vs FBS-CSMC
COS
Validation of the “One touch glucometer CBG vs FBS-CSMC

13. Criteria for DM, IFG, IGT COS Fasting Plasma Glucose (FBG)
< 100 mg/dL =
normal
FBG = mg/dL
impaired fasting glucose (IFG)
FBG >126 mg/dL
diabetes
2-h post glucose load (2HPG)
<140 mg/dL
2-h PG = mg/dL
impaired glucose tolerance (IGT)
2-h PG > 200 mg/dL

14. Data Processing & Analysis
COS
Data Processing & Analysis
Encoding – Microsoft Access
Analysis – SPSS V12
Data storage – MS Excel & SPSS V12

15. COS
RESULTS

16. Demographics of the 1998 FNRI-NNS
COS
Demographics of the 1998 FNRI-NNS
Variables
Male
(n=633)
Mean + SD
Female
(n= 683)
p value
M vs F
Total N
Total Population
Age (y)
0.0753
1316
49 +17
FBG (mg/dL)
0.9946
94 +36
T cholesterol (mg/dL)
0.0010
Triglyceride (mg/dL)
0.0001
HDL-C (mg/dL)
0.01
1315
33 +14
LDL-C (mg/dL)
Systolic BP (mmHg)
Diastolic BP (mmHg)
80 +13
WEIGHT (kg)
1302
55 +11
HEIGHT(m)
156 +8
BMI (kg/m2)
0.0018
22 +4
Waist (cm)
78 +11
Hip (cm)
89 +9

17. Demographics of the 2006 PhilCOS
Variables
Total 2006
Male
(n=427)
Mean + SD
Female
(n=498)
Age (y)
FBG (mg/dL)
Systolic BP (mmHg)
Diastolic BP (mmHg)
Waist (cm)
Anti-hypertens use
177 (19%)
79 (19%)
98 (20%)
Self-reported diabetes
86 (9%)
31 (7%)
55 (11%)
Self-reported CAD/Angina
23 (5%)
25 (5%)
Self-reported Stroke
26 (6%)

18. COS
Prevalence of Diabetes Mellitus based on FBG, 2H PGL, Diabetic Questionnaire, and Combination DM
Q’NAIRE
FBG
>125
mg/dL
2H PG
>200
FBG OR
DMQ OR
TOTAL 9%
12%
10%
18%
MALE 7%
14%
FEMALE
11%
PhilCOS-DM accepted that the most accurate
prevalence rate of Diabetes was the combination
of the 3 measures: 18%.

19. Prevalence of IFG and IGT based on FBG and 2H-PG load
COS
Prevalence of IFG and IGT based on FBG and 2H-PG load -

20. The 8-years Incidence of DM using FBG
COS
The 8-years Incidence of DM using FBG
FBS>125 mg/dL
NCR
12%
REGION 3
REGION 4
TOTAL (n = 864)
MALE
14%
FEMALE
10%

21. Among IFGs 48% became diabetics in 8 years.
COS
Spectrum of Glucose Homeostasis: From 1998 IFG to DM, IFG and normal in 2006 PhilCOS-DM
1998 IFG definition
N=25
( mg/dL)
A. DM (FBG > 126) :
n = 12 →
48%
B. IFG ( )
n = 4
16%
C. Normal (<110)
n = 9
36%
Among IFGs 48% became diabetics in 8 years.

22. The 8-years incidence rate of
COS
Spectrum of Glucose Homeostasis: From 1998 Normoglucose to DM, IFG and Normal in 2006 PhilCOS-DM
1998 Normal definition of FBG
N=804
A. DM (FBG > 126) :
n = 74 → 9%
B. IFG ( )
n = 81
10%
C. Normal (<110)
n = 649
81%
The 8-years incidence rate of
IFG is 10%.

23. Prevalence of DM using FBG, 2 hour PG, or Combination (n=800)
COS
Prevalence of DM using FBG, 2 hour PG, or Combination (n=800)
FBG>126 = 9%
2H-PGL>200 = 10% 5% 6%
FBG alone
FBG & 2HPG
2HPG alone 4%
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

24. Prevalence of IFG, IGT or Combination (n=800)
COS
Prevalence of IFG, IGT or Combination (n=800)
IFG ( mg/dL) = 31%
IGT ( mg/dL) = 26%
20%
15%
IFG alone
IFG & IGT
IGT alone
11%

25. Prevalence of IFG, IGT or Combination
COS
Prevalence of IFG, IGT or Combination
IFG = 248
IGT = 208
46%
38%
IFG alone
IFG & IGT
IGT alone
16%
FBG predicted more pre-diabetics, but a further 38% can be predicted by 2H PG.

26. Limitations of the Study
COS
Limitations of the Study
Use of capillary blood sample
Respondent migration and relocation
Sampling limited to previously generated by the 1998 FNRI-NNS
? “more urban” cohort
? “healthier” non-respondents
? Overestimate of morbidities comparing 2-points in time

27. Conclusions Incidence rate of DM = 12% Incidence rate of IFG = 10%
COS
Conclusions
Incidence rate of DM = 12%
Incidence rate of IFG = 10%
Prevalence rate of DM = 18%
Prevalence rate of IFG = 31%
Prevalence rate of IGT = 26%

28. COS
Awaiting…
The PhilCOS
Extension Study

29. PhilCOS Extension of the study: Region 6 - Cebu Region 10 – Mindanao
Region 5 - Bicol

30. Acknowledgement COS Sponsors : Research Assistants : Collaborators :
Philippine Diabetes Association
Philippine Lipid and Atherosclerosis Society
Philippine Society of Hypertension
Therapharma, Inc.
Pfizer Phils., Inc.
Johnson & Johnson
Research Assistants :
Maryjun Rangel and Armand Soriano
Collaborators :
Philippines Diabetes Association key opinion leaders’ forum
Special Mention :
Municipal Health Officers and Barangay Health workers

31. PhilCOS DM