Dm 2


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  • The total number of deaths due to diabetes was estimated at 1,017,209 in 2007. The number of women dying from diabetes-related deaths far exceeded those of men in the older age groups.
  • Dm 2

    3. 4. 2007
    4. 5. 2025
    5. 6. Causes of the rise
    7. 9. <ul><li>Huge losses in the form of foregone economic growth </li></ul><ul><li>(relatively a greater problem in poorer countries) </li></ul><ul><li>2005 – 2015, WHO predicts net losses in national income from diabetes & cardiovascular disease of some - </li></ul><ul><ul><li>ID557 billion in China </li></ul></ul><ul><ul><li>ID303 billion in the Russian Federation </li></ul></ul><ul><ul><li>ID336 billion in India </li></ul></ul>Disease Burden on the World Economy
    8. 10. PROBLEM STATEMENT- INDIA <ul><li>India leads the world, about 20% of the total diabetic population, “diabetes capital of the world”. </li></ul><ul><li>“ Asian Indian Phenotype ” - unique clinical & biochemical abnormalities in Indians: </li></ul>
    9. 11. <ul><li>Madras Diabetes Research Foundation & MV Diabetes Specialities Centre, Chennai. </li></ul><ul><li>National prevalence (20-79 yrs) in </li></ul><ul><ul><li>2007 was 6.2% </li></ul></ul><ul><ul><li>Predicted- 7.6% in 2025 </li></ul></ul><ul><li>Diabetes type 1 incidence (0-14 yrs) </li></ul><ul><li>2007 is 4.2 per 100,000 children per year </li></ul><ul><li>IGT: national prevalence (20-79 yrs) </li></ul><ul><ul><li>2007 is 5.4% </li></ul></ul><ul><ul><li>2025 might go upto 6.1% </li></ul></ul>
    10. 12. Number of people with diabetes (20-79 yrs)
    11. 13. <ul><li>Mortality rates: </li></ul><ul><ul><li>The age adjusted mortality rates : </li></ul></ul><ul><ul><ul><li>1.5 – 2.5 times higher than in the general population </li></ul></ul></ul><ul><ul><li>Deaths attributable to diabetes as percentage of all deaths 2007: </li></ul></ul><ul><ul><ul><li>Males 9.7% </li></ul></ul></ul><ul><ul><ul><li>Females 15.5% </li></ul></ul></ul><ul><li>Mean health expenditure 2007 - USD 47 </li></ul>
    12. 14. <ul><ul><li>Diabetes related complications are </li></ul></ul><ul><ul><ul><li>coronary artery disease, peripheral vascular disease, </li></ul></ul></ul><ul><ul><ul><li>neuropathy, retinopathy, nephropathy. </li></ul></ul></ul><ul><li>People with diabetes are likely to develop </li></ul>
    13. 15. Prevalence in CHENNAI <ul><li>1989 to 2004, the prevalence increased significantly by 72.3% ( P <0.001) </li></ul><ul><li>IDDM incidence 10.5% per 100,000 children (10-12yrs) </li></ul>
    14. 16. WHO Classification of Diabetes Mellitus <ul><li>Type 1 : Insulin Dependent Diabetes Mellitus (IDDM) </li></ul><ul><li>Type 2 : Non- Insulin Dependent Diabetes Mellitus (NIDDM) </li></ul><ul><li>Malnutrition-related Diabetes Mellitus </li></ul><ul><li>Other Types: </li></ul><ul><ul><li>Pancreatic </li></ul></ul><ul><ul><li>Hormonal Imbalance </li></ul></ul><ul><ul><li>Liver related </li></ul></ul><ul><ul><li>Drug induced </li></ul></ul><ul><li>Impaired Glucose Tolerance </li></ul><ul><li>Gestational Diabetes mellitus </li></ul>
    15. 17. Type 1 IDDM <ul><li>Caused by complete deficiency of Insulin </li></ul><ul><li>resulting from Beta cell destruction </li></ul><ul><li>Onset : Abrupt and usually >30yrs of age </li></ul><ul><li>Idiopathic : 10 % of all IDDM </li></ul><ul><li>Auto Immunity: </li></ul><ul><ul><li>IDDM is 90% immune mediated </li></ul></ul><ul><ul><li>Islet cell antibodies, Insulitis </li></ul></ul><ul><ul><li>Associated with other autoimmune diseases such as Hashimoto’s thyroiditis, Addison’s disease & pernicious anaemia </li></ul></ul>
    16. 18. <ul><li>Genetic susceptibility: </li></ul><ul><ul><li>18 regions of the genome linked with type 1 diabetes risk, IDDM1 to IDDM18 </li></ul></ul><ul><ul><li>IDDM1, which contains the HLA (Human Leukocyte Antigens) genes that encode immune response proteins. </li></ul></ul><ul><li>Environmental Factors: </li></ul><ul><ul><li>Viral infections – congenital Rubella, Mumps, Measles and coxsackie B virus </li></ul></ul><ul><ul><li>Exposure to cow’s milk - Albumin from cow’s milk may react with islet cells of pancreas, leading to their destruction </li></ul></ul><ul><li>OGTT : </li></ul><ul><ul><li>Increased fasting blood glucose (>120mg/dl) </li></ul></ul><ul><ul><li>Post prandial blood glucose (>200mg/dl) </li></ul></ul>
    17. 19. Type 2 NIDDM <ul><li>High blood glucose due to insulin resistance </li></ul><ul><li>and relative insulin deficiency </li></ul><ul><li>Little tendency towards ketoacidosis </li></ul><ul><li>Increasingly diagnosed in children in parallel </li></ul><ul><li>to rising obesity rates </li></ul>INSULIN RESISTANCE
    18. 20. METABOLIC SYNDROME: Defined as a clustering of atherosclerotic cardiovascular disease risk factors and a systemic proinflammatory state.
    19. 21. Monogenic Forms of Diabetes <ul><li>Rare forms, accounting for about 1 – 5 % of all cases </li></ul><ul><li>Mostly the gene mutation is inherited; in others its spontaneous. </li></ul><ul><li>They are Neonatal DM and MODY </li></ul><ul><li>Neonatal DM : </li></ul><ul><ul><li>first 6 months of life, do not produce enough insulin, </li></ul></ul><ul><ul><li>one in 100,000 to 500,000 live births </li></ul></ul><ul><ul><li>Permanent neonatal diabetes mellitus (PNDM) </li></ul></ul><ul><ul><li>Transient neonatal diabetes mellitus (TNDM). </li></ul></ul><ul><ul><li>Intrauterine growth retardation </li></ul></ul>
    20. 22. Maturity Onset Diabetes of Young <ul><li>Onset prior to age 25, </li></ul><ul><li>a family history of diabetes in multiple </li></ul><ul><li>successive generations </li></ul><ul><li>Impaired β-cell function & insulin resistance </li></ul><ul><li>and late β-cell failure </li></ul><ul><li>Mutations in 10-12 different genes </li></ul><ul><li>People with MODY </li></ul><ul><ul><li>are generally not overweight </li></ul></ul><ul><ul><li>do not have other risk factors for type 2 diabetes, </li></ul></ul><ul><ul><li>may have only mild or no symptoms </li></ul></ul><ul><ul><li>(discovered on routine tests) </li></ul></ul>
    21. 23. IMPAIRED GLUCOSE TOLERANCE <ul><li>Is an intermediate state of dysglycemia </li></ul><ul><li>Has an intermediately raised glucose level after 2 hours, but less than would qualify for type 2 diabetes mellitus. </li></ul><ul><li>The fasting glucose may be either normal or mildly elevated. </li></ul>Venous blood Capillary blood Fasting <120 <120 2hrs after glucose load 120-180 140-200
    22. 24. <ul><li>Due to a severe malnutrition. </li></ul><ul><li>On Starvation, there is nothing that the insulin can act upon. </li></ul><ul><li>The body slowly reduces its production due to Negative Feedback control. </li></ul><ul><li>A fasting glucose that is higher than the upper limit of normal, but not high enough to be classified as diabetes mellitus. </li></ul><ul><li>a pre-diabetic state, associated with insulin resistance & increased risk of cardiovascular pathology, although of lesser risk than IGT </li></ul><ul><li>There is a 50% risk over 10 years of progressing to overt diabetes </li></ul>Malnutrition related Diabetes Mellitus Impaired Fasting Glucose
    23. 25. Effect of Diabetes on the Pregnant Woman Effect of Diabetes on the Foetus Gestational Diabetes Mellitus <ul><li>A condition in which women without previously diagnosed diabetes exhibit high blood glucose levels during pregnancy, affecting 3-10% of pregnancies </li></ul><ul><li>The hormones produced during pregnancy increase a woman's resistance to insulin, resulting in impaired glucose tolerance </li></ul>
    24. 26. TYPE 3 DIABETES <ul><li>A new diabetic condition referred to as type 3 diabetes , which simply means that one has both type 1 and type 2 diabetes. </li></ul><ul><li>Type 1 to Type 3: </li></ul><ul><li>Type 2 to Type 3: </li></ul>Need more insulin
    25. 27. NATURAL HISTORY Epidemiological Determinants <ul><li>AGENT </li></ul><ul><li>HOST FACTORS </li></ul><ul><li>ENVIRONMENTAL RISK FACTORS </li></ul>
    26. 28. AGENT <ul><li>PANCREATIC DISORDERS </li></ul><ul><ul><li>Infections, Tumors , Obstructions, Removal </li></ul></ul><ul><li>DEFECTS IN FORMATION OF INSULIN </li></ul><ul><li>BETA CELL DESTRUCTION </li></ul><ul><li>DECREASED INSULIN SENSITIVITY </li></ul><ul><ul><li>Decreased adipocyte & monocyte insulin receptors </li></ul></ul><ul><li>AUTOIMMUNITY </li></ul><ul><li>GENETIC DEFECTS </li></ul><ul><ul><li>Mutation in insulin gene </li></ul></ul><ul><ul><li>Mutations in insulin receptor gene : </li></ul></ul><ul><ul><li>Donohue syndrome, Rabson-Mendenhall syndrome, Type A insulin resistance </li></ul></ul>
    27. 29. HOST FACTORS <ul><li>AGE </li></ul><ul><li>SEX </li></ul><ul><li>GENETIC FACTORS </li></ul><ul><li>GENETIC MARKERS </li></ul><ul><li>IMMUNE MECHANISMS </li></ul><ul><li>OBESITY </li></ul><ul><li>MATERNAL DIABETES </li></ul>
    28. 30. AGE & SEX <ul><li>NIDDM – usually middle years of life </li></ul><ul><li>Malnutrition related DM - young people, worse prognosis </li></ul><ul><li>In south east Asia, an excess of male diabetics. </li></ul>
    29. 31. <ul><li>GENETIC FACTORS </li></ul><ul><li>GENETIC MARKERS </li></ul><ul><li>Inheritance factor for IDDM is small </li></ul><ul><li>NIDDM has a concordance in twin studies of 80-90%, suggesting a strong genetic component. </li></ul><ul><li>Family History: </li></ul><ul><ul><li>25 - 33% of type 2 diabetics have family members with diabetes. </li></ul></ul><ul><ul><li>A first-degree relative poses 40% risk of developing diabetes </li></ul></ul><ul><li>IDDM is associated with HLA B8 and B15 & more strongly with HLA-DR3 and DR4 </li></ul><ul><li>NIDDM is not HLA associated </li></ul><ul><li>Type-2 diabetics </li></ul><ul><li>mutation in a zinc transporter SLC30A8, which is involved in regulating insulin secretion. </li></ul>
    30. 32. <ul><li>IMMUNE MECHANISMS </li></ul><ul><li>HORMONAL IMBALANCES </li></ul><ul><li>Glucagonomas </li></ul><ul><li>Pheochromocytomas </li></ul><ul><li>Cushing syndrome </li></ul><ul><li>Acromegaly </li></ul>
    31. 33. ROLE OF OBESITY IN DM <ul><li>80 - 95% of the increases in type 2 diabetes are due to obesity. </li></ul><ul><li>Apple-shaped abdomen is associated with </li></ul><ul><ul><li>insulin resistance and diabetes, </li></ul></ul><ul><ul><li>heart disease, high blood pressure, stroke, </li></ul></ul><ul><ul><li>unhealthy cholesterol levels. </li></ul></ul><ul><li>Number of Insulin receptors are reduced in the adipose tissue </li></ul><ul><li>Waist circumferences </li></ul><ul><ul><li>> 35 inches in women </li></ul></ul><ul><ul><li>>40 inches in men </li></ul></ul><ul><ul><li>specifically associated with a greater risk </li></ul></ul><ul><li>Metabolic syndrome </li></ul><ul><li>No role in IDDM </li></ul>
    32. 34. Effect of weight loss on fasting blood glucose
    33. 35. ENVIRONMENTAL RISK FACTORS <ul><li>Sedentary lifestyle </li></ul><ul><li>Diet </li></ul><ul><li>Dietary fibre </li></ul><ul><li>Malnutrition </li></ul><ul><li>Alcohol </li></ul><ul><li>Viral infections </li></ul><ul><li>Chemical agents </li></ul><ul><li>Stress </li></ul><ul><li>Other factors </li></ul>
    34. 36. LIFESTYLE <ul><li>Lack of exercise alters the interaction between insulin & its receptors </li></ul>
    35. 37. DIETARY FACTORS <ul><li>DIETARY FIBRE </li></ul><ul><li>Rich in NSP, Reduces blood glucose </li></ul><ul><li>Min Daily intake of 20g of fibre </li></ul><ul><li>MALNUTRITION </li></ul><ul><li>PEM (Partial beta cell failure) </li></ul><ul><li>ALCOHOL </li></ul><ul><li>Damages Liver & Pancreas </li></ul><ul><li>Promotes Obesity </li></ul>. <ul><li>GnT-4a ENZYME </li></ul><ul><li>Mutations affecting the enzyme GnT-4a glycosyltransferase disrupts insulin production </li></ul>
    36. 38. Other Factors <ul><li>Smoking </li></ul><ul><li>According to a 2006 study, smokers are more than twice as likely to develop diabetes as people who have never smoked. </li></ul><ul><li>Passive smoking </li></ul>
    37. 39. SOCIAL FACTORS