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Diabetes: a risk factor for cancer · L’INSULINORESISTANCE AU CŒUR DU SYNDROME MÉTABOLIQUE (1)...
Transcript of Diabetes: a risk factor for cancer · L’INSULINORESISTANCE AU CŒUR DU SYNDROME MÉTABOLIQUE (1)...
Not for external distribution
Diabetes: a risk factor for cancer
Introduction
« Lorsque les gros maigrissent, les maigres meurent »
proverbe Chinois
Endostatique
Fluctuation Interne Fluctuation Externe
Fluctuation de ressources alimentaires
Equilibre Energétique
Systèmes de régulation de la prise alimentaire
Exostatique
2 systèmes destinés à assurer l’équilibre énergétique
Fluctuation de ressources alimentaires
Equilibre Energétique
Système endostatique de régulation de la prise alimentaire
Rôle : 1. Compenser les oscillations internes des ressources énergétiques 2. Obtenir et mobiliser les ressources nécessaires ! Faire face à nos besoins immédiats
Endostatique
Fluctuation Interne
Fluctuation de ressources alimentaires
Equilibre Energétique
Rôle :
1. Compenser la diminution des sources d’approvisionnement alimentaire
2. Constituer des réserves énergétiques
! Faire face à des restrictions futures
Système exostatique de régulation de la prise alimentaire
Fluctuation Externe
Exostatique
Systèmes de régulation et environnement pathogène
Dans un environnement d’abondance alimentaire et de moindre activité physique, ces systèmes de régulation deviennent inadaptés, ce qui peut expliquer l’explosion de l’obésité et des troubles associés du métabolisme glucido-lipidique.
Disponibilité variable des ressources alimentaires, au cours de l’évolution
- 200 000 ans Homo sapiens
- 7500 ans Domestication/Agriculture
- 4 Ma Australopithèque
Chasseur, Cueilleur Eleveur, Cultivateur
variables stables
Durée des différentes phases à l’échelle de l’évolution
Nécessité de stocks
énergétiques
Ressources alimentaires
Not for external distribution
Diabetes: a risk factor for cancer
Aujourd'hui Hier
Débordement pathologique des systèmes de régulation énergétique
Ressources supra-Stables
Facilite la survie Prédispose à la pathologie
Ressources variables
Je mange quand il y a de la nourriture
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14%
Not for external distribution
Diabetes: a risk factor for cancer
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19%
Not for external distribution
Diabetes: a risk factor for cancer
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% ≥20%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% ≥20%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% ≥20%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% ≥20%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Not for external distribution
Diabetes: a risk factor for cancer
Source: Behavioral Risk Factor Surveillance System, CDC.
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
Obesity Trends* Among U.S. Adults BRFSS, 2002
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 2006
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Not for external distribution
Diabetes: a risk factor for cancer
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 2008
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 2009
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Source: Behavioral Risk Factor Surveillance System, CDC.
Obesity Trends* Among U.S. Adults BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5� 4� person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
Pourquoi prendre en charge ?
Les complications sont multiples :
Respiratoire
Ostéoarticulaire
Cutanéo-muqueuse ect…
Not for external distribution
Diabetes: a risk factor for cancer
Not for external distribution
Diabetes: a risk factor for cancer
Athérosclérose Diabète de type 2 Intolérance au glucose Dyslipidémie Hypertension artérielle
Diminution de Obésité (tronculaire) l’activité fibrinolytique
PAI1
Microalbuminurie Hyperuricémie Syndrome des ovaires polykystiques
SYNDROME D ’ INSULINORESISTANCE
METABOLIQUE
L’INSULINORESISTANCE AU CŒUR DU SYNDROME MÉTABOLIQUE (1)
Stéatose hépatique Cancer sein et corps utérin
Syndrome des ovaires polykystiques
Not for external distribution
Diabetes: a risk factor for cancer
Diabetes et obésité: facteurs de risque de cancer
49
• Le diabète augmente le risque de cancer
• L’obésité : facteur de risque de diabète et de cancer
• Les médiateurs possibles
• Conclusions
Pancréas (Huxley, Br J Cancer 2005); N=36
2.10
1.82
1.30
1.24
1.0
1.20
Endométre (Friberg, Diabetologia 2007); N=16
1.3 1.6 1.9 2.1 0.9 0.6
Colorectal (Larsson, J Natl Can Inst 2005); N=15
Vessie (Larsson, Diabetologia 2006): N=16
Sein (Larsson, Int J Can 2007): N=20
50
Diabetes et risque de cancer Meta-analyses 2005–2007
Risque augmenté
Summary OR:
OR, odds ratio
51
Diabetes et mortalité par cancer
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
No diabetes Prediabetes Undiagnosed diabetes
Known diabetes
Haz
ard
ratio
Men
Women
All
Adapté deZhou et al. Diabetologia 2010;53:1867–76
Incr
ease
d r
isk
Progression du diabéte
No diabetes Undiagnosed diabetes
Prediabetes Known diabetes
52
• Le diabète augmente le risque de cancer
• L’obésité : facteur de risque de diabète et de cancer
• Les médiateurs possibles
• Conclusions
53
Relative risk of developing type 2 diabetes by BMI category
0
20
40
60
80
100
<24 <25 <27 <29 <31 <33 <35 35+ BMI (kg/m2)
Rela
tive
risk
of de
velo
ping
typ
e 2
diab
etes
N=114,281 female registered nurses aged 30 to 55
Data for women only Colditz et al. Ann Intern Med 1995;122:481–6 BMI, body mass index
Not for external distribution
Diabetes: a risk factor for cancer
54
Prevalence of diabetes increases with increasing BMI
Prospective Studies Collaboration. Lancet 2009;373:1083–96
Males
Females
BMI (kg/m2)
15 25 35 50
0
10
20
Prev
alen
ce (
%)
55
BMI et risque de cancer chez l�homme
Renehan et al. Lancet 2008;371:569–78
Oesophageal adenocarcinoma
Thyroid
Colon
Renal
Liver
Malignant melanoma
Multiple myeloma
Rectum
Gallbladder
Leukaemia
Pancreas
Non-Hodgkin lymphoma
Prostate
Gastric
Lung
Oesophageal squamous
5
4
22
11
4
6
7
18
4
7
12
6
27
8
11
3
0.5 0.8 1.0 2.01.5
1.52 (1.33–1.74)
1.33 (1.04–1.70)
1.24 (1.20–1.28)
1.24 (1.15–1.34)
1.24 (0.95–1.62)
1.17 (1.05–1.30)
1.11 (1.05–1.18)
1.09 (1.06–1.12)
1.09 (0.99–1.21)
1.08 (1.02–1.14)
1.07 (0.93–1.23)
1.06 (1.03–1.09)
1.03 (1.00–1.07)
0.97 (0.88–1.06)
0.76 (0.70–0.83)
0.71 (0.60–0.85)
<0.0001
0.02
<0.0001
<0.0001
0.12
0.004
<0.0001
<0.0001
0.12
0.009
0.33
<0.0001
0.11
0.49
<0.0001
<0.0001
24%
77%
21%
37%
83%
44%
7%
3%
0%
0%
70%
0%
73%
35%
63%
49%
Cancer'site'and' type Number'of'studies
Risk ratio (per 5 kg/m 2 increase)
RR'(95% 'CI) P I 2
56
BMI et risque de cancer chez la femme
Endometrium
Gallbladder
Oesophageal adenocarcinoma
Renal
Leukaemia
Thyroid
Postmenopausal breast
Pancreas
Multiple myeloma
Colon
Non-Hodgkin lymphoma
Liver
Gastric
Ovarian
Rectum
Malignant melanoma
Premenopausal breast
Lung
Oesophageal squamous
19
2
3
12
7
3
31
11
6
19
7
1
5
13
14
5
20
6
2
0.5 0.8 1.0 2.01.5
1.59 (1.50–1.68)
1.59 (1.02–2.47)
1.51 (1.31–1.74)
1.34 (1.25–1.43)
1.17 (1.04–1.32)
1.14 (1.06–1.23)
1.12 (1.08–1.16)
1.12 (1.02–1.22)
1.11 (1.07–1.15)
1.09 (1.05–1.13)
1.07 (1.00–1.14)
1.07 (0.55–2.08)
1.04 (0.90–1.20)
1.03 (0.99–1.08)
1.02 (1.00–1.05)
0.96 (0.92–1.01)
0.92 (0.88–0.97)
0.80 (0.66–0.97)
0.57 (0.47–0.69)
<0.0001
0.04
<0.0001
<0.0001
0.01
0.001
<0.0001
0.01
<0.0001
<0.0001
0.05
0.56
0.30
0.26
0.05
0.001
0.03
<0.0001
77%
67%
0%
45%
80%
5%
64%
43%
0%
39%
47%
4%
55%
0%
0%
39%
84%
60%
Cancer'site'and' type Number'of'studies
Risk ratio (per 5 kg/m 2 increase)
RR'(95% 'CI) P I 2
Renehan et al. Lancet 2008;371:569–78
Women
Sjöström, 2009
(Sweden)
Adams, 2009
(Utah, USA)
McCawley, 2009
(Virginia, USA)
Men
Sjöström, 2009
(Sweden)
Adams, 2009
(Utah, USA)
Men'and'women
combined
Christou, 2008
(Canada)
•Prospective
intervention trial
•Retrospective
registry
•Retrospective
clinical data
respository
•Prospective
intervention trial
•Retrospective
registry
•Retrospective
hospital-based
10.9
12.5
9.9
10.9
12.5
5.05
79 (1410)
215 (5654)
53 (1482)
38 (590)
39 (942)
21 (1035)
130 (1447)
412 (7872)
203 (3495)
39 (590)
65 (1570)
487 (5746)
0.58 (0.44–0.77)
0.73 (0.62–0.86)
0.62 (0.46–0.83)
0.97 (0.62–1.52)
1.02 (0.69–1.51)
0.22 (0.14–0.34)
Age, smoking, weight change,
energy intake, and matching
Age and BMI
None
Age, smoking, weight change,
energy intake, and matching
Age and BMI
Age, sex, and BMI
0.2 0.5 1 1.5
First'author(country)
S tudysetting
Meanfollo w ;up(years)
Surgerycases(cohort)
C ontrolcases(cohort)
Risk' ratio(95%'C I)
Adjustments
Risk ratio
57
Chirurgie bariatrique et réduction du risque de cancer
Renehan. Lancet Oncol 2009;10:640–1
Quels pourraient etre les éléments explicatifs ?
59
• Le diabète augmente le risque de cancer
• L’obésité : facteur de risque de diabète et de cancer
• Les médiateurs possibles
• Conclusions
Not for external distribution
Diabetes: a risk factor for cancer
Les candidats médiateurs
• L’inflammation chronique • L’hyperglycémie • L’hyperinsulinémie • Les traitements utilisés • Autres...
L’inflammation chronique
62
L’inflammation joue un role dans le risque de developer un diabete de type 2
0.00.20.40.60.81.01.21.41.61.82.0
1 2 3 4 5
RR (
95%
CI)
Quintile of IL-18 concentration based on control distribution
Hivert et al. Diabetologia 2009;52:2101–8
• Increased risk of developing type 2 diabetes with increasing levels of inflammatory markers
RR, relative risk; CI, confidence interval; IL, interleukin
63
Les cytokines inflammatoires jouent un role dans la progression du cancer
• Ces memes voies inflammatoires sont trés activées dans le diabète de type 2
Condition Tumour Causes
Oesophagite Cancer Oesophage Acidité gastrique, alcool tabac
Pancreatite Cancer Pancreatique Alcool Tabac
MICI Cancer Colorectal MICI
Cholecystite chronique Cancer vésicule Lithiase
Adapté de Hong et al. World J Gastroenterol 2010;16:2080–93; Yu et al. Nat Rev Cancer 2009;9:798–809; Mantovani et al Nature 2008; 454:436–44
Hyperglycémie
65
La valeur de la glycémie est trés etroitement corrélée avec le risque de certains cancers
Korean Cancer Prevention Study (n=1,298,385) Jee et al. JAMA 2005;293:194–202
Relative risks (95% confidence intervals)
Cancer site Fasting plasma glucose (mmol/L)
<5.0 5.0-6.0 6.1-6.9 7.0-7.7 >7.8 p
Pancreas (men) 1 1.08 (0.95–1.24)
1.34 (1.09–1.64)
1.37 (0.94–2.00)
2.09 (1.70–2.58) 0.03
Pancreas (women) 1 1.27
(1.03–1.57) 1.30
(0.96–2.02) 1.99
(1.13–3.49) 1.67
(1.09–2.56) 0.04
Kidney (men) 1 1.08 (0.93–1.25)
1.07 (0.84–1.38)
1.24 (0.78–1.96)
1.26 (0.94–1.71) 0.02
Liver (men) 1 1.01 (0.95–1.06)
1.16 (1.07–1.27)
1.45 (1.24–1.70)
1.72 (1.56–1.89) 0.01
Not for external distribution
Diabetes: a risk factor for cancer
66
Interpretation
• Par quels mécanismes ? De nombreuses hypothéses ?
• La glycémie comme facteur ?
66 67
Effet du glucose sur la prolifération cellulaire
0
20
40
60
80
100
120
140
160
2.75 5.5 11 22
Prol
ifera
tion
(%
) re
lative
to
5.5
mM
gl
ucos
e
Glucose concentration (mM)
HT29
SW480
MDA MB468
MCF-7
PC3
T24
Masur et al. Br J Cancer 2011;104:345–52
Cell line
Est ce l’hyperinsulinisme ?
69
Les 10-15 ans d’hyperinsulinisme avant le diabète ?
IFG, impaired fasting glucose
Obesity IFG Diabetes Uncontrolled hyperglycaemia
250 200 150 100 50
Insulin resistance
Insulin level Beta-cell failure
Insu
lin
Sec
retio
n (%
)
Normal
Adapted from Bergenstal et al. In: Degroot & Jameson (eds). Endocrinology 2001;821–35
Years of diabetes –10 25 20 15 10 5 0 –5 30
350 300 250 200 150 100 50
Postprandial glucose
Fasting glucose
Glu
cose
leve
l (m
g/dL
)
Normal
70
L’hyper insulinémie est associée à un moins bon pronostique de certains cancers
Carly et al. Endocr Relat Cancer, in press; Ma et al. Lancet Oncol 2008;9:1039–47
Insulin, nM Year since prostate cancer diagnosis
0 0.001 0.01 0.1 1 10 0.00
0.05
0.10
0.15
0.20
0.25
0.30
Ab
sorb
ance
(5
62
nm
)
Pro
bab
ility
of
Pca
-sp
ecif
ic s
urv
ival
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0 3 6 9 12 15 18
Quartile 1 Quartile 2 & 3 Quartile 4
Par quels mécanismes l’hyperinsulinémie pourrait induire
des cancers ?
71
Not for external distribution
Diabetes: a risk factor for cancer
Mécanismes potentiels
• mutations induites: ?
• Induction de la survie cellulaire aprés mutation : possible
• Stimulation de la croissance du cancer : trés probable
72
“Insulin and insulin-like growth factors are well known as key regulators of energy metabolism and growth. There is now considerable evidence that these hormones and the signal transduction networks they regulate have important roles in neoplasia.”
73
Insuline et IGF1
Pollak. Nat Rev Cancer 2008;8:915–28 IGF, insulin-like growth factor
74
La présence de récepteurs à ces subtances est corrélé au pronostic après cancer du sein
Cum
ulat
ive
surv
ival
Cum
ulat
ive
surv
ival
0.5
0.6
0.7
0.8
0.9
1.0
0.5
0.6
0.7
0.8
0.9
1.0
0 3 6 9 12 15 Time (years)
Negative IR Positive IR
Negative P-IGF-1R/IR Positive P-IGF-1R/IR
Law et al. Cancer Res 2008;68:10238–46 P, phosphorylated; IR, insulin receptor
Est ce la glycémie ou l’insuline le facteur prépondérant ?
�Elevated insulin production, as reflected by elevated concentrations of plasma C-peptide, may predict the risk of developing colorectal cancer, independently of BMI,, or levels of IGF-1 and IGFBP-3.�
Ma et al. J Natl Cancer Inst 2004;96:546–53
Renehan et al. Endocr Relat Cancer 2006;13:273–8
1998 Hankinson 60/78
Year Study Cumulative cases/controls
2000 Toniolo 156/358
2005 Schemhammer 311/551
Rinaldi 449/810
2006 Rinaldi 721/1344
Schemhammer 850/1619
Cumulative risk ratio (95% CI)
p-value
2.13 (1.25,3.64) 0.006
Associations avec IGF-1: cancer du sein après age 50 ans years
76
C’est peut etre l’Igf1 le facteur prépondérant pour d’autres cancers
Increased risk
1.0 2.0 5.0 10.0 Cumulative risk ratio (log scale)
77
La metformine a t�elle un effet �anticancer�?
*Placebo controlled Jalving et al. Eu J Cancer 2010;46:2369–80
Reference Tumour type Design Setting Concomitant treatment
Primary outcome
NCT00659568 Solid tumours Phase 1b Advanced Temsirolimus MTD
NCT01087983 Solid tumours Phase 1 Advanced Lapatinib MTD
NCT00984490 Breast Phase I Neoadjuvant Proliferation apoptosis
NCT00930579 Breast Phase I Neoadjuvant AMPK mTOR
NCT00897884 Breast Phase II Neoadjuvant Proliferation
NCT00881725 Prostate Phase II Neoadjuvant pAKT Martin-Castillo et al. 1990 Breast, HER-2+ Phase II Neoadjuvant Unknown
NCT00909506 Breast Phase IIa Adjuvant Tamoxifen Weight loss
Muti et al.91 Breast Phase IIa Prevention Breast cancer Cazzaniga et al. 1992 Breast Phase IIa Neoadjuvant Proliferation
NCT01101438 Breast Phase III Adjuvant Standard Survival
MTD, maximum tolerated dose; AMPK, adenosine monophosphate kinase; mTOR, mammalian target of rapamycin; pAKT, phosphorylated AKT; HER, human epidermal growth factor receptor
Essai Prospectif de la metformine dans le cancer
Not for external distribution
Diabetes: a risk factor for cancer
78
• Cancer deaths
• People with diabetes
Augmentation de la
prévalence du diabéte et du
cancer. Néccissité de comprendre
mieux les liens qui les
unissent
2008 7.6 million
2010 285 million
2030 >11 million
2030 438 million
Prise en charge au CH de Chalons :
*consultations spécialisées médicales et diététiques *programme autorisé au sein de l’utep pour l’éducation
thérapeutique dans le diabète *Prise en charge des troubles du comportement alimentaire *Proposition de prise en charge chirurgicale en lien avec le
CHU actuellement en cours d’élaboration