[MUSIC] We are now now in the second case study of this modules about the screening of cardiovascular conditions. I will speak about the screenings of diabetes, I will use the same structure as for the first module as for the first case studies about hypertensions. And the things that I will speak about, burden of disease which is diabetes, benefits and harms of treatments, evidence and issue with the screenings of diabetes. And you will see there is much more issue with the screenings of diabetes than the screenings for hypertensions. And I will finish with, should we screen or should we not screen for diabetes, with recommendations for screenings of diabetes. About the burden of disease, diabetes mellitus, which is the common names for diabetes, but I will during this presentation speak smoothly or use attempts of diabetes, is a state of chronically elevated blood glucose. There is two major type of diabetes, Type 1 diabetes occurring early in life, which is called juveniles diabetes and which is caused by a lack of insulins. The other cause of diabetes is Type 2 diabetes, the other type of diabetes, which is much more frequent coming in elderly patients which are typically overweight. The whole talk will be mostly about this types, the Type 2 diabetes, and I will mostly speaks about the screenings of Type 2 diabetes. About the burden of disease, why do we care about diabetes? There is two types of complications due to diabetes, what we call macrovascular complications, and what we call microvascular complications. Microvascular complications is due to complications, the effects of diabetes on small vessels. And there is a familiar of complications due to microvascular complications, that is retinal damage in diabetes is the major cause of blindness in high income countries worldwide. There is also due to microvascular complications, neuropathy and nephropathy. And for the link with nephropathy, diabetes is the major cause of insufficience of chronic renal disease In high income countries. About macrovascular complications, in the sense that diabetes has some effects on big vessels, arteries, coronary heart disease, and so on. Diabetes is the major cause of macrovascular disease, and that is, for examples, it's the cause of coronary heart disease. And it's a major cause of death due to diabetes and coronary heart disease. What is a very striking about the recent trends of diabetes worldwide, is that due to the obesity epidemics, we have seen worldwide an increase in the prevalence of diabetes. This is observed worldwide in high income countries, in low income countries. Here on the slides, in USA we have beautiful data to show that. And you see on the slides how the prevalence of diabetes has increased between 1995, this is on the left of the screens. And on the right of the screens you see the prevalence of diabetes. And as you can see, that everywhere in USA you have these more darker colors of the pictures, showing that the prevalence has increased, and reaching up to 10% of the populations in some states of USA. It's not limited to USA as I've told you before, it's worldwide. We have that in developed countries in Europe, in Switzerland, and now increasingly so, also in low and middle income countries. So it's really a big issue worldwide for that things. Let's speak right now about the benefits and harms of treatments. When you treat diabetes you expect to have benefits on microvascular complications and macrovascular complications. In fact, with the treatment of diabetes, you have mostly benefits on microvascular complications. So you can prevent complications, for examples, due to nephropathy, due to neuropathy. You have some success and treatments has been shown to be successful to reduce those kinds of issue. The treatments is typically made by dietary and lifestyle modifications, or you have drug treatments for the diabetes. They either choose insulins or you use oral glucose lowering treatments, you could have both types of treatments. So it is successful to reduce microvascular complications, but what remains little bit surprising, is that we have difficulty to reduce the macrovascular complications. And it's a big issue, this is one of the major issue with screenings of diabetes and the treatments, that you have some difficulty to prevent macrovascular complications. And macrovascular complications, this is very important, because diabetes patients, they are a high risk of dying of those complications. So if you're not successful to reduce macrovascular complications, there is some frustrations and you're not really happy about that. And you will see that in the issue and the screenings, it is a major problems we've got with the screening and treatment of diabetes. So if we look at the evidence about the screenings, there is two trials I think, That had tried to show that whether if the screenings for diabetes is beneficial for the patients. And these two trials have been show no effects on the reductions of macrovascular complications. It was relatively deceitful to do that and it was a problems to see that. Other trials have tried to show if we screen for more early forms of, for what we call prediabetes, which is, for example, impaired fasting glucose, or impaired glucose tolerance. And if we screen for those conditions, and we treat earlier, there is some trial having shown that you can reduce or delay the occurrence of diabetes mellitus. So you see overall, we have a mixed picture, no real benefits of the screenings of diabetes itself, but some benefit to have early forms and trying to delay the occurrence of diabetes, all right. We've mentioned the issue of the treatments and we've seen that evidence is in between for the benefit of treatments. Other issue about the screenings for diabetes is, should we perform are targeted screenings? Targeted screenings is a very interesting strategy for the screenings of diabetes, because in generals when you make a targeted screenings you can increase the performance of screenings. For diabetes, high risk individuals are those who are overweight or obese, who have a family history of diabetes, or who are elderly. One questions which remains unresolved, is that at which age should we begins the screenings of diabetes? Should we begins at 40, at 50, at 60, it's unclear at which age we should begin for the screenings for diabetes. Another issue which is related to the screenings of diabetes, but not only, this is also questions for other screenings, is what is a frequency at which we should do screenings? Should we do that every year, every five years, every ten years? And this is a major issue with the screening of diabetes. We have no clear evidence about that. But as I mentions, this is not only for diabetes, we see that also for the screenings of hypertension as another issue. Finally, a major issue with the screenings of diabetes and its treatments, is it is not clear, what are the goals of the treatments? Should we aim to normalize the levels of blood pressure? This is what you call intense treatments of diabetes. While several studies have shown that if you have an intense treatments, you increase the risk of disease of the patients, which this is something we really don't want have the effect of screening treatments of diabetes. So, let's finish this talks about should we screen or should we not screens for diabetes. And recommendations are much more complex than for hypertensions. Here on the slides, you see the recommendation of the US Preventive Services Task Force. This task force is making very fantastic works about screening, this is why I mentioned those kind of recommendations. And as you can see, they would conclude with moderate certainty that measuring blood pressure to detect impaired fasting glucose, impaired glucose tolerance, or diabetes, has a moderate net benefit in adults at increased risk of diabetes. So with the recommend screenings for abnormal blood pressure, only among those who are at increased risk of diabetes. This is what we call a targeted screenings. If we look now at the Canadians recommendations, they have something similar in the sense that screenings should consider the risk of diabetes in the populations. And they have three types of recommendations, depending on the risk of the recommendations. And here on the slides, you can see that depending on your risk of diabetes, if you are low risk of diabetes, there is no recommendations for screenings. But if you are high risk, you have recommendations for screenings, and the frequency of screenings will be higher in those who are at the highest risk of diabetes. But again, these are relatively weak recommendations, because we have not so much strong quality evidence. This is low quality evidence. And with these recommendations we come at the end of this case study about the screenings of diabetes, I thank you for your interest. [MUSIC]
