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Le diabète de type 2 vu par l’épidémiologiste

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Disease Management and Health Outcomes

Abstract

Type 2 Diabetes as Seen by the Epidemiologist

The prevalence of type 2 diabetes mellitus varies from 1% in Africa to 4% in North America, giving, in 1997, a total of 120 million individuals with type 2 diabetes worldwide. It is interesting to note that in Eastern Asia — despite the particularly low prevalence of 1.1% in China — Hong Kong has by contrast a frequency of 5.6%, and Japan, where life expectancy is high, registers a prevalence of 4.9%. Even within Europe, figures vary considerably, with 2.4% in Northern Europe, 2.8% in Western Europe, 2.5% in Eastern Europe and 4.1% in Southern Europe. It has been estimated that type 2 diabetes mellitus affects a total of 21 million people throughout Europe, and worldwide figures could well reach 215 million by the year 2010.

In addition to the different methods of evaluation, these discrepancies can probably be explained by variations in life expectancy, environmental and lifestyle differences and finally by genetic influences.

Diabetes mellitus is a group of syndromes characterised by chronic hypergly-caemia resulting from decreased insulin secretion (insulin deficiency) and/or insulin activity (insulin resistance). Most patients can be classified as having either insulin-dependent diabetes mellitus (type 1, juvenile-onset diabetes), or non— insulin-dependent diabetes mellitus (type 2, maturity-onset diabetes), which mainly affects individuals aged more than 50 years. The former accounts for 10 to 20% of patients with diabetes, while the latter affects the remaining 80 to 90%.

When hyperglycaemia is manifest and constant, the diagnosis of diabetes is unquestionable. The situation is more complex for borderline levels. Recent standards adopted in the USA have lowered the threshold fasting plasma glucose level for the diagnosis of diabetes to 7.0 mmol/L or 1.26 g/L, on two separate occasions. The fact that this symptom is particularly subject to fluctuations adds to the difficulties encountered regarding the pathogenesis of this disease, where both hereditary and environmental factors interact. The role of heredity, based on polygenetic transmission, has been confirmed by the considerable progress made in the field of genetic analysis. Other markers, whose role would appear to be confirmed, include birth weight and age, but, here, intervention of any sort is clearly difficult. In addition to these considerations, environmental and behavioural risk factors have been demonstrated by studies in migrants. The role of obesity, and particularly prolonged duration of the condition, has long been recognised. There would appear to be a link between abdominal fat distribution and non— insulin-dependent diabetes mellitus associated with metabolic disorders involving insulin resistance.

The combination, to varying extents, of all these factors leads to glucose intolerance and finally to type 2 diabetes. Behavioural attitudes can have a strong influence on the progression of this disease, not only with regard to dietary aspects but also physical activity.

Type 2 diabetes mellitus remains asymptomatic over long periods, and is consequently often diagnosed late in its development, either incidentally or when an individual presents with a complication of the disease. The progression and prognosis of type 2 diabetes are often dominated by the associated micro- and macrovascular complications. The former include retinopathy (with a prevalence of 20 to 50%), nephropathy (20 to 42%) and neuropathy (10 to 45%). Large vessel disorders account for 75% of deaths among diabetic patients. These mainly involve vessels of the heart (with a prevalence of 5 to 44%), those of the lower limbs (1 to 14%) and, to a lesser extent, those of the brain.

Although cardiovascular disease is the most frequently observed complication of type 2 diabetes mellitus, leading to between 2 and 3 times more deaths in diabetic than in nondiabetic individuals, it is also of note that, regardless of cause, the death rate in patients with diabetes is at least twice that in nondiabetic individuals.

The complications of non-insulin-dependent diabetes mellitus, mainly micro-and macrovascular, are characteristic of the debilitating effects this disease can have on everyday life. The introduction of simple measures relating to hygiene and diet could prevent the development and aggravation of such complications.

Résumé

Au niveau mondial, la prévalence du diabète de type 2, non insulino-dépendant, varie de 1% en Afrique à 4% en Amérique du Nord, représentant au total, en 1997, près de 120 millions de diabétiques de type 2. En Asie, si la Chine a des taux de prévalence particulièrement bas à 1,1%, Hong Kong a par contre une fréquence de diabète de type 2 de 5,6% et le Japon, pays à espérance de vie élevée, un taux de 4,9%. En Europe, les prévalences du diabète non insulino-dépendant varient beaucoup avec 2,4% en Europe du Nord, 2,8% en Europe de l’Ouest, 2,5% en Europe de l’Est et 4,1% en Europe du Sud. On peut estimer à un peu plus de 21 millions le nombre de diabétiques de type 2 en Europe. Ce chiffre pourrait atteindre au niveau mondial 215 millions en 2010.

Les différences de prévalence peuvent s’expliquer par les variations d’espérance de vie, d’environnement, de mode de vie et enfin, de patrimoine génétique.

Le diabète recouvre en réalité deux maladies: le diabète insulino-dépendant souvent du sujet jeune (type 1), 10 à 20% des diabétiques, et le diabète non insulino-dépendant (type 2), 80 à 90% des diabétiques, qui touche le plus souvent les individus à partir de la cinquantaine.

Le diagnostic de diabète ne pose pas de problème lorsque l’hyperglycémie est franche et constante. Il est plus difficile pour les valeurs frontières. Des critères américains récents ont abaissé le seuil de la glycémie à jeun à partir duquel le sujet peut être considéré comme diabétique (7,0 mmol/L ou 1,26 g/L en deux occasions). La variabilité de la glycémie qui définit le diabète s’ajoute aux difficultés pathogéniques de cette maladie où s’intriquent facteurs génétiques et environnement. Le rôle de l’hérédité a été confirmé par les avancées importantes de l’analyse génétique et repose sur un mode de transmission polygénique.

D’autres marqueurs déterminés a priori interviennent, comme le poids de naissance et l’âge, sur lesquels il est “difficile” d’agir. A côté de ces éléments, il existe des facteurs de risque liés à l’environnement et au comportement, bien mis en évidence par les études des migrants. Le rôle de l’obésité et son ancienneté, est reconnu depuis longtemps, plus précisément le lien entre répartition abdominale des graisses et diabète non insulino-dépendant, comme associé à des anomalies métaboliques en rapport avec une insulinorésistance, pouvant s’inscrire dans le cadre du syndrome X.

Tous ces facteurs se combinent à divers degrés pour aboutir à une intolérance au glucose puis au diabète non insulino-dépendant. Les attitudes comporte-mentales, aussi bien sur le plan alimentaire que sur celui de l’activité physique, peuvent avoir une grande influence sur cette évolution.

Longtemps asymptomatique, le diabète de type 2 est souvent découvert tard dans son évolution, parfois en présence de complications. L’évolution et le pro-nostic du diabète de type 2 sont dominés par les complications micro et macro-vasculaires qui lui sont associées. Ce sont essentiellement, pour les atteintes microvasculaires, la rétinopathie (avec une prévalence de 20 à 50%), la néphropathie (20 à 42%), la neuropathie (10 à 45%). L’atteinte des gros vaisseaux est responsable de 75% des décès des diabétiques. Elle concerne surtout les vaisseaux du cœur, (prévalence de 5 à 44%) et ceux des membres inférieurs (1 à 14%), puis à un moindre degré, ceux du cerveau.

Les maladies cardiovasculaires représentent les complications les plus fréquentes du diabète de type 2, entraînant 2 à 3 fois plus de décès que chez les non diabétiques. Il faut également noter que les taux de décès toutes causes con-fondues, sont multipliés au moins par 2 chez les diabétiques par rapport aux non diabétiques.

La gravité de cette maladie provient de ses complications, essentiellement micro et macrovasculaires, alors que de simples mesures de prévention hygiéno-diététiques pourraient être prises très tôt pour éviter son développement et son aggravation.

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Authors and Affiliations

  1. INSERM Unité 21, Villejuif et Faculté de Médecine Paris XI, 16 ave Paul Vaillant-Couturier, 94807, Villejuif Cedex, France

    E. Eschwège & B. Balkau

  2. Service de Diabétologie, Hôpital Henri-Mondor, Créteil, France

    D. Simon

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Eschwège, E., Simon, D. & Balkau, B. Le diabète de type 2 vu par l’épidémiologiste. Dis-Manage-Health-Outcomes 4 (Suppl 1), 1–12 (1998). https://doi.org/10.2165/00115677-199804001-00001

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