Author(s): Szybiski Z
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Abstract Diabetes mellitus is a growing health problem at all ages in all countries. The Saint Vincent Declaration signed by the representatives of all European countries--among them by Poland--indicated the main goals to reduce this burden. This may be achieved by elaboration and initiation of the nation-wide programme for early detection and control of diabetes on the population level. The Polish Task Force for Diabetes Management worked out and put into operation in 1998 the project commissioned by the Ministry of Health funded by the Polish State Committee for Research (PBZ-018-11). The urgent need for the implementation of this programme was a result of the increasing number of diabetic patients on the primary health care level, diabetic complications and hospitalisations. The programme was based on the assumption that primary and secondary prevention of NIDDM may eliminate or reduce its risk factors and therefore decrease its prevalence and morbidity and should integrate epidemiology, identification of risk factors, education, intervention models and economics of diabetes. This issue of the Polish Archives of Internal Medicine contains the main results of the programme and reflects an actual situation of diabetes in Poland creating a rational basis for intervention on the population level. Evaluation of the incidence rate of the diabetes type 1 in 10 selected areas (population basis 30\% of age group 0-29) revealed values from 8.4 to 14.7/100,000 in the age group 1-14 and from 4.4 to 11.2/100,000 in the age group 15-29. It accounts for the 2-3 fold increase in comparison with the results achieved in 1986 (Z. Szybinski). However an ascertainment of the register in the age group 15-29 dropped down during the last 10 years and additional sources of data must be involved in the survey. Prevalence of diabetes type 2 in 3 selected areas Krakow 10.77\% (M. Szurkowska), Lublin 15.6\% (J. Łopatynski) and Łódź 15.7\% (J. Drzewoski) based on the population random sample over 35 years of age, constitutes over 90\% of all patients with diabetes. When standardized to the Polish population the prevalence of diabetes type 2 accounts for 5.37\% and reflects a true endemic state. With comparison to a similar survey carried out in 1986 in Wrocław the prevalence 3.71\% of the diabetes type 2 increased 2-3 times. It allowed to calculate an actual number of patients with diabetes type 2--over 2 million and around 50\% of them represents "unknown" diabetes. Such high contribution of the unknown non-diagnosed diabetes has been confirmed in the survey carried out in Poznań on the non-randomized professional group of persons (B. Wierusz-Wysocka) in investigation on the first-degree relatives of patients with known diabetes in Warsaw (T. Kasperska-Czyzyk) and in Wroclaw (R. Wasikowa). This raises the question about the criteria of diagnosis for unknown diabetes. Comparative analysis carried out in Krakow revealed that fasting glycemia 7.0 mmol/L allowed to diagnose diabetes with 50\% with respect to the 2 hours oral glucose tolerance test (WHO 1985) and shouldn't be use as a tool for early diagnosis of diabetes type 2 (Z. Szybinski, M. Szurkowska) Identification of the risk factors in PMSDE for diabetes type 2 allowed to introduce the term "global risk factors", divided into two groups primary (obesity, age, pregnancy and genetic background) and secondary (hyperinsulinemia, hyperglycemia, dyslipidemia and hypertension). In the multifactor analysis obesity and hyperinsulinemia are the strongest predictors and modifiable risk factors of the development of diabetes type 2 and late complications. Especially hyperinsulinemia as an independent secondary risk factor for hypertension, dyslipidemia--in consequences late diabetic complications and perhaps carcinogenesis may play an important role as a predictor of diabetes type 2 and biochemical marker of effectiveness of non-pharmacological and pharmacological approach in the global concept of diabetes type 2 treatment (Z. Szybinski). Analysis of the late complications of diabetes were focussed on visual disability and lower extremity amputation due to diabetic foot development. Analysis of prevalence (PR) of visual disability due to diabetes in Krakow (J. Pantoflinski) and Olsztyn (E. Bandurska-Stankiewicz) revealed similar values, in the both areas around 6\% of general visual disability in population. Monitoring of the visual disability in diabetic patients seems to be a good indicator of the quality level of the diabetic care. Analysis of the lower extremity amputation carried out in Krakow district (A. Nazim) revealed that incidence rate of amputation in diabetics was 15 times higher than in non-diabetics and in 10.8\% of cases amputation was performed in unknown diabetes type 2. The preventive measures and non-pharmacological and pharmacological management approximately in diabetes should be solved with education based on the separate post of a diabetic educator within a diabetic team and on the primary health care level. The articles presenting elaborated educational model in diabetes are published in "Diabetologia Polska" (A. Czyzyk). Intervention model was tested in Krakow in the groups of obese patients with newly diagnosed "unknown" diabetes and was based on the 12 weeks supervised dietician education with standardized physical activity programme. In obese diabetic patients the weight loss less than 10\% of the initial body weight can markedly improve biochemical parameters like hyperglycemia dyslipidemia and hyperinsulinemia without pharmacological therapy and 45\% of patients has been transferred to the group of Impaired Glucose Tolerance (A. Gilis-Januszewska). Another model of intervention may be applied in menopausal women (J. Nadel, K. Cypryk) treated with hormonal replacement therapy as a complementary factor to education and if necessary to anti-diabetic drugs. Increase number of diabetic patients especially of the "unknown" type 2 has serious economic aspect by increasing a burden of patients, theirs families, society and health care system. Within PMSDE programme elaboration of the model for calculation the direct costs about of diabetes and burden in terms of years of life lost using DALY measure was performed (K. Kissimova-Skarbek). Average diabetes type 1 patients costs 7 times and type 2 over 3 times higher than average health care cost and 95\% of total time lost due to disability is caused by diabetes type 2. Therefor primary and secondary prevention of diabetes typ 2 have highest priority among strategic preventive targets. The Review Conference held in Warsaw at 24-25 February 2001 in the presence of WHO Experts formulated the recommendations focused on: 1. Elaboration of high risk strategy for early diagnosis of unknown diabetes type 2 based on the 2-hours OGTT (WHO 1985) 2. Continuation of the epidemiologic study in diabetes 3. Instituting the professional post for diabetes educator on the specialized and primary health care levels. 4. Further research are recommended for evaluation of the role of fasting glycemia and hyperinsulinemia as predictors and risk factors of diabetes type 2, for development of preventive models in diabetes type 2 and for development of the economical models to asses the costs of diabetes (Recommendations).
This article was published in Pol Arch Med Wewn
and referenced in Epidemiology: Open Access