Diabetes, Global scenario, Indian Scenario, Types, Prevention and Control

1. DIABETES MELLITUS

3. Introduction
Diabetes is a chronic disease that occurs either when the pancreas does not
produce enough insulin or when the body cannot effectively use the insulin
it produces.
Insulin is a hormone that regulates blood sugar.
Hyperglycaemia, or raised blood sugar, is a common effect of uncontrolled
diabetes and over time leads to serious damage to many of the body's
systems, especially the nerves and blood vessels.

4. Health impact
Over time, diabetes can damage the heart, blood vessels, eyes, kidneys, and
nerves.
Adults with diabetes have a two- to three-fold increased risk of heart
attacks and strokes.
Combined with reduced blood flow, neuropathy (nerve damage) in the feet
increases the chance of foot ulcers, infection and eventual need for limb
amputation.
Diabetic retinopathy is an important cause of blindness, and occurs as a
result of long-term accumulated damage to the small blood vessels in the
retina. Diabetes is the cause of 2.6% of global blindness.
Diabetes is among the leading causes of kidney failure.

5. Types of diabetes
Type of diabetes Brief description
Type 1 diabetes β-cell destruction (mostly immune-mediated) and absolute insulin
deficiency; onset most common in childhood and early adulthood
Type 2 diabetes Most common type, various degrees of β-cell dysfunction and insulin
resistance; commonly associated with overweight and obesity
Hybrid forms of diabetes
Slowly evolving,
immune-
mediated
diabetes of adults
Similar to slowly evolving type 1 in adults but more often has features
of the metabolic syndrome, a single GAD autoantibody and retains
greater β-cell function
Ketosis-prone
type 2 diabetes
Presents with ketosis and insulin deficiency but later does not require
insulin; common episodes of ketosis, not immune-mediated
WHO CLASSIFICATION OF DIABETES MELLITUS 2019

6. Types of diabetes
Other specific types Brief description
Monogenic diabetes
- Monogenic defects of
β-cell function
- Monogenic defects in
insulin action
Caused by specific gene mutations, has several clinical manifestations
requiring different treatment, some occurring in the neonatal period,
others by early adulthood
Caused by specific gene mutations; has features of severe insulin
resistance without obesity; develops when β-cells do not compensate for
insulin resistance
Diseases of the exocrine
pancreas
Various conditions that affect the pancreas can result in hyperglycaemia
(trauma, tumor, inflammation, etc.)
Endocrine disorders
Occurs in diseases with excess secretion of hormones that are insulin
antagonists
Drug- or chemical-
induced
Some medicines and chemicals impair insulin secretion or action, some
can destroy β-cells
Infection-related
diabetes
Some viruses have been associated with direct β-cell destruction
Uncommon specific
forms of immune-
mediated diabetes
Associated with rare immune-mediated diseases
Other genetic syndromes

7. TYPES OF DIABETES
Hyperglycaemia first detected during pregnancy
Diabetes mellitus in
pregnancy
Type 1 or type 2 diabetes first diagnosed during pregnancy
Gestational diabetes
mellitus
Hyperglycaemia below diagnostic thresholds for diabetes in
pregnancy
Diagnostic criteria for diabetes: fasting plasma glucose ≥ 7.0 mmol/L or 2-hour post-load
plasma glucose ≥ 11.1 mmol/L or Hba1c ≥ 48 mmol/mol
Diagnostic criteria for gestational diabetes: fasting plasma glucose 5.1–6.9 mmol/L or 1-
hour post-load plasma glucose ≥ 10.0 mmol/L or 2-hour post-load plasma glucose 8.5–
11.0 mmol/L

8. Problem statement
The number of people with diabetes rose from 108 million in 1980 to 422
million in 2014.
The global prevalence of diabetes* among adults over 18 years of age rose
from 4.7% in 1980 to 8.5% in 2014.
Between 2000 and 2016, there was a 5% increase in premature mortality
from diabetes.
Diabetes prevalence has been rising more rapidly in low- and middle-
income countries than in high-income countries.
Diabetes is a major cause of blindness, kidney failure, heart attacks, stroke
and lower limb amputation.
In 2016, an estimated 1.6 million deaths were directly caused by diabetes.
Another 2.2 million deaths were attributable to high blood glucose in 2012.
Almost half of all deaths attributable to high blood glucose occur before the
age of 70 years. WHO estimates that diabetes was the seventh leading cause
of death in 2016.
WHO GLOBAL REPORT ON DIABETES

9. Problem statement
• An estimated 463 million adults aged 20 –79 years are currently living with
diabetes. This represents 9.3% of the world’s population in this age group. The
total number is predicted to rise to 578 million (10.2%) by 2030 and to 700 million
(10.9%) by 2045.
• The estimated number of adults aged 20–79 years with impaired glucose tolerance
is 374 million (7.5% of the world population in this age group). This is predicted to
rise to 454 million (8.0%) by 2030 and 548 million (8.6%) by 2045.
• An estimated 1.1 million children and adolescents (aged under 20 years) have type
1 diabetes. It is currently not possible to estimate the number of children and
adolescents with type 2 diabetes.
• The number of deaths resulting from diabetes and its complications in 2019 is
estimated to be 4.2 million.
• An estimated 15.8% (20.4 million) of live births are affected by hyperglycaemia in
pregnancy in 2019.
• Annual global health expenditure on diabetes is
• estimated to be USD 760 billion. It is projected that expenditure will reach USD 825
billion by 2030 and USD 845 billion by 2045. INTERNATIONAL DIABETES FEDERATION ATLAS 2019

10. Problem statement
WHO GLOBAL REPORT ON DIABETES
WHO Region
Prevalence (%) Number (millions)
1980 2014 1980 2014
African Region 3.1% 7.1% 4 25
Region of the Americas 5% 8.3% 18 62
Eastern Mediterranean
Region
5.9% 13.7% 6 43
European Region 5.3% 7.3% 33 64
South-East Asia Region 4.1% 8.6% 17 96
Western Pacific Region 4.4% 8.4% 29 131
Total 4.7% 8.5% 108 422

11. Problem statement
Diabetes prevalence in 2019 and projections to 2030 and 2045 (65–99 years) - INTERNATIONAL
DIABETES FEDERATION ATLAS 2019

12. Problem statement
Global diabetes estimates and projections – INTERNATIONAL DIABETES FEDERATION ATLAS 2019

13. Problem statement – India
According to the World Health Organization (WHO):
There are estimated 72.96 million cases of diabetes in adult population of India.
The prevalence in urban areas ranges between 10.9%-14.2% and prevalence in
rural India is at 3.0-7.8% ,among population aged 20 years and above with a
much higher prevalence among individuals aged over 50 years.
According to National Diabetes and Diabetic Retinopathy Survey report (2015-19):
Prevalence of diabetes in India has been recorded at 11.8% in the last four years,
prevalence of known diabetes cases was 8% and new diabetes cases at 3.8%.
The prevalence of diabetes among males was 12%, whereas among females it
was 11.7%.
Highest prevalence of diabetes (13.2%) was observed in the 70-79 years’ age
group.

14. Risk factors for diabetes
1. If he/she is overweight (BMI is more than 23kg/m2)
2. If he/she is physically inactive, that is, he or she exercises less than 3 times
a week
3. If he/she has high blood pressure
4. If he/she has impaired fasting glucose or impaired glucose tolerance
5. If his/her triglyceride and/or cholesterol levels are higher than normal
6. If his/her parents/siblings or grandparents have or had diabetes
7. If she delivered a baby whose birth weight was 4 kgs or more
8. If she has had diabetes or even mild elevation of blood sugars during
pregnancy

15. When to suspect diabetes
1. Symptoms of uncontrolled hyperglycemia: excess thirst, excess
urination, excess hunger with loss of weight
2. Frequent infections
3. Non-healing wounds
4. Unexplained lassitude
5. Fatigue
6. Impotence in men

16. Criteria for diagnosis of T2DM using venous blood samples
Fasting Glucose (mg/dl) 2-hour Post-Glucose Load
(mg/dl)
Diabetes Mellitus >=126 or >=200
Impaired Glucose Tolerance < 126 and >140 to <200
Impaired Fasting Glucose >=110 to <126
*WHO Definition 1999 Capillary blood glucose value is also sufficient. Where capillary
blood glucose measured by glucometer is used in the fed state (i.e., post food/post
glucose/post meal), the >200 mg/dl cut off may be revised to >220 mg/dl.

17. Modified diagnostic criteria for diabetes
Fasting is defined as no caloric
intake for at least 8 hours.
The 2-hour postprandial
glucose test should be
performed using a glucose
load containing the equivalent
of 75g anhydrous glucose
dissolved in water.
The American Diabetes
Association (ADA)2
recommends diagnosing
‘prediabetes’ with HbA1c
values between 39 and 47
mmol/mol (5.7–6.4%) and
impaired fasting glucose when
the fasting plasma glucose is
between 5.6 and 6.9mmol/L
(100–125mg/dL).INTERNATIONAL DIABETES FEDERATION ATLAS 2019

18. Impaired glucose tolerance and impaired fasting glucose
 Impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) are
conditions of raised blood glucose levels above the normal range and
below the recommended diabetes diagnostic threshold.
 The terms ‘prediabetes’, ‘non-diabetic hyperglycaemia’, ‘intermediate
hyperglycaemia’ are in use as alternatives.
Glycosylated Haemoglobin (HbA1C)
 A fraction of hemoglobin in the RBCs is found to be in a glycosylated form i.e. has
glucose attached to it.
 The HbA1c level is proportional to average blood glucose concentration over the
previous two to three months and therefore is an excellent indicator of how well
the patient has managed his/her diabetes over the last four weeks to three
months.
 American Diabetes Association (ADA) recommends an HbA1c goal of less than 7%
for people with diabetes in general

19. Initial assessment of diabetic patients
History (Ask for) Physical Examination (Look for)
Duration since onset of symptoms Body Mass Index
Precipitating factors such as recent infections,
stress, change in dietary habits or physical
activity levels
Waist circumference, Waist-hip ratio
Acanthosis nigricans * Acanthosis nigricans *
Hypertension, pre-existing cardiovascular
Diseases
Blood pressure
Drug history Peripheral pulses
Diet
Feet: calluses, ulcers, prominent veins, edema,
injuries
Physical Activity: type, frequency Fundus examination
Family History Cardiovascular system
-Diabetes and complications -Age at onset -
Cardiovascular disease, if any
Peripheral nervous system Thyroid*Acanthosis nigricans is a brown to black, poorly defined, velvety hyperpigmentation of the skin,
usually present in the posterior and lateral folds of neck, axilla, groin, umbilicus, and other areas.
This occur due to insulin spill over (from excessive production due to obesity or insulin resistance)
into the skin which results in its abnormal growth, and the stimulation of colour producing cells.

20. Initial management
Pharmacotherapy for the management of hyperglycemia and any other
co-morbid conditions e.g. high blood pressure, dyslipidemia etc.;
Therapeutic lifestyle management, and
Diabetes patient Education and counselling

21. Principles of management
The basic principles in the management of type-2 diabetes are:
Modify Lifestyle: diet and physical activity.
Reduce Insulin resistance through reduction in weight, specifically
reduction of fat mass.
Pharmacological treatment (if inadequate control): Metformin/
Sulfonylureas.
Treatment for high blood pressure: ACE Inhibitors, Calcium channel
blockers such as amlodipine and diuretics such as hydrochlorothiazide (For
details refer the ppt on hypertension).

22. Ideal targets of control in the management of diabetes
Fasting Blood Glucose 115 mg/dl
Post Meal Blood Glucose <160 mg/dl
HbA1C <7%
Total Cholesterol <180 mg/dl
LDL-cholesterol <100 mg/dl
HDL cholesterol <45 mg/dl
Blood pressure <130/80 mg/dl
Serum TG <150mg/dl
Source: ICMR 2005 guidelines
Note: The targets for diabetic population are lower than the non-diabetes

23. Non-pharmacological management of diabetes
*Source: ICMR 2005 GUIDELINES
Lifestyle Goals in Diabetes:
To improve health through optimum nutrition
To provide energy for reasonable body weight , normal growth and development
To maintain glycemic control
To achieve optimum blood lipid levels
To individualise the diet according to complications and co-morbidities
Achieve optimal physical activity
Advise other behavioural changes for: smoking, other tobacco products and
alcohol
Advocate stress management

24. Non-pharmacological management of diabetes
Medical Nutrition Therapy (MNT) for diabetes mellitus requires application of
nutritional and behavioural sciences along with physical activity. We need a
four-pronged approach:
i. Nutritional assessment which includes metabolic, nutritional and life style
parameters.
ii. Setting goals – practical, achievable and acceptable to the patient -
individualised
iii. Nutritional Intervention, including nutrition education – individualized
meal plans according to family eating patterns
iv. Evaluation – to assess if the goals have been achieved and to make*Source: ICMR 2005 GUIDELINES

25. Non-pharmacological management of diabetes
Dietary Recommendations:
a) Energy:
i. Ideal Body Weight (IBW) = (Height in cm – 100) * 0.9.
ii. Approximately, 25 kcals/kg ideal body weight/day can be given to a
moderately active patient with diabetes.
b) Energy or Calorie Distribution:
i. Carbohydrates: 55-60 % of energy from carbohydrates is an ideal
recommendation
ii. Fibre recommendation for general population is 40 g/day (2000
Kcals)
iii. Proteins should provide 12-15 % of the total energy intake for people
with diabetes
iv. Fats should provide 20-30 % of total energy intake for people with
diabetes.
*Source: ICMR 2005 GUIDELINES

26. Non-pharmacological management of diabetes
c) Fat quality
i. Saturated fats (SFA) ≤10% energy and 7% in those with raised blood lipid levels
ii. Polyunsaturated fats (PUFA) 10 % energy, n6: 3-7% energy, n3: >1% energy, n6/n3
ratio 5-10
iii.Monounsaturated Fatty Acids (MUFA) 10-15% energy + any calories left from the
carbohydrate portion
iv. Trans fats < 1% energy – preferably totally avoided
d) Salt:
i. Added (iodized) salt should be less than 5 g/day
ii. For persons with hypertension and diabetes, the intake should be reduced to less
than 3 g/ day
e) Alcohol:
i. best to avoid, however if used, should be taken in moderation
ii. it should not be counted as part of the meal plan.
iii.alcohol does provide calories (7 kcal/ g), which are considered as “empty calories”
iv. In the fasting state, alcohol may produce hypoglycaemia *Source: ICMR 2005 GUIDELINES

27. Non-pharmacological management of diabetes
f) Sweeteners:
i. Nutritive Sweeteners: These include fructose, honey, corn syrup,
molasses, fruit juice or fruit juice concentrates dextrose, maltose,
mannitol, sorbitol and xylitol. All these are best avoided.
ii.Non-nutritive Sweeteners: Aspartame, acesulfame K, stevia, sucralose
and saccharin are currently approved for use. However, they should be
used in moderation and are best avoided in pregnancy.
*Source: ICMR 2005 GUIDELINES

28. Non-pharmacological management of diabetes
Physical Benefits of exercise:
Improves insulin sensitivity, reduces the risk of heart disease, high blood
pressure, bone diseases, and unhealthy weight gain
Keeps one flexible and agile
Helps relieve stress, anxiety and prevents depression
Increases strength and stamina
Promotes sound sleep
Increases metabolic rate and digestion
Delays the process of aging
Activity and Exercise:
Recommendation is about 150 minutes of aerobic activity or its equivalent
/week along with some resistance training at least twice a week and flexibility
exercises.
Extra quick acting carbohydrate snack before the exercise and during the
exercise, if the exercise period extends the daily-recommended routine.
*Source: ICMR 2005 GUIDELINES

29. Healthy diet and physical activity
WHO recommendations on physical activity are provided for different age
groups
It is recommended that children and youth aged 5–17 years should do at
least 60 minutes of moderate- to vigorous-intensity physical activity daily.
It is recommended that adults aged 18–64 years should do at least 150
minutes of moderate - intensity aerobic physical activity (for example brisk
walking, jogging, gardening) spread throughout the week, or at least 75
minutes of vigorous-intensity aerobic physical activity throughout the week,
or an equivalent combination of moderate- and vigorous-intensity activity.
For older adults the same amount of physical activity is recommended, but
should also include balance and muscle strengthening activity tailored to
their ability and circumstances.

30. Pharmacological management of diabetes
1) Oral anti-hyperglycaemic agents (OHA)
2) Insulin therapy
3) Non-insulin injectable therapy

31. Anti – hyperglycaemic drugs
BIGUANIDES SULPHONYLUREAS DPP - 4 INHIBITORS
Dipeptidyl peptidase-4
inhibitors (Gliptins)
Metformin
Metformin SR
Glibenclamide
Glipizide
Glipizide modified
release
Gliclazide
Gliclazide modified
release
Glimepiride
Sitagliptin
Vildagliptin
Saxagliptin
Linagliptin
Teneligliptin
Gemigliptin
ALPHA GLUCOSIDASE
INHIBITORS
SGLT 2 INHIBITORS
Sodium-glucose
cotransporter-2
inhibitor
NON-SULPHONYLUREA
SECRETAGOGUES (Glinides)
Acarbose
Voglibose
Miglitol
Canagliflozin
Dapagliflozin
Empagliflozin
Repaglinide
Nateglinide

32. Insulin therapy
Indications:
 Person with diabetes with significant symptomatic hyperglycaemia, loss of
weight and polyuria, polydipsia, polyphagia
 Fasting plasma glucose > 270 mg/dl or HbA1c >9%
 Severe infections
 Presence of ketosis
Other situations:
 Patients not responding to optimal doses of OHA alone or in combination.
 Acute hyperglycaemia, diabetic ketoacidosis/hyperglycemic-hyperosmolar
state/lactic acidosis.
 Stressful situations such as acute myocardial infarction, stroke, acute infections,
tuberculosis, trauma and other conditions requiring hospitalisation
 Pregnancy and lactation
 Peri-operative state
 Intolerant/contraindications to OHA
 Hepatic and renal failure
 Renal transplantation

33. Insulin therapy
Types of insulin preparations:
i. Human insulin
a) Short acting – human soluble insulin (regular)
b) Intermediate acting – neutral protamine Hagedorn (NPH)
c) Premixed- mixtures of regular and NPH insulin in 25/75, 30/70,
50/50 proportion
ii. Insulin Analogues:
a) Rapid acting (e.g. Lispro, Aspart, Glulisine)
b) Long acting (Glargine, Degludec, Detemir)
c) Premixed Insulin analogue (Lispro/ lispro protamine, aspart/ aspart
protamine)
d) Co-formulations (Degludec + Aspart insulin)

34. Non-insulin injectable therapy (GLP - 1 receptor agonists)
GLP - 1 Receptor Agonists
1) Exenatide
2) Liraglutide
3) Lixisenatide
4) Dulaglutide

35. Complications of diabetes
Acute complications:
Hypoglycaemia
Hyperglycaemic emergencies (Diabetic Ketoacidosis- DKA or
Hyperosmolar Hyperglycaemic State - HHS)
Chronic Complications:
Serious organ damage involving eyes, heart, kidney, nerves and limbs,
which ultimately can lead to blindness, heart attack, kidney failure and
limb amputation respectively
Coronary Artery Disease
Diabetic Nephropathy
Diabetic Retinopathy:
Diabetic Neuropathy
Diabetic Foot

36. When to refer to higher facility (CHC/SDH/DH)
Uncontrolled infections
Co-morbid conditions, e.g., Hypertension, CAD, COPD, CKD etc.
Severe cellulitis
Unresponsive UTI or other deep seated infections including bad
diabetic foot needing intravenous antibiotics
Recurrent UTI not responding to oral antibiotics
Presence of ketones in urine

37. Foot care advice to the patients
DO DO NOT
✅ Inspect feet daily using mirror ❌ Walk barefoot
✅ Wash feet daily in lukewarm water, also
in between toes
❌ Do not Smoke/alcohol abuse
✅ Apply moisturizing lotion to feet after
drying
❌ Expose to extreme temperature
✅ Have your feet checked at each clinic visit ❌ Use hot fomentation
✅ Inspect footwear daily for defects/foreign
bodies
❌ Use chemicals agents (e.g. corn plaster),
corn caps or blades to treat corns or
calluses
✅ Change footwear regularly
❌ Wear new footwear for more than few
hours
✅ Buy footwear preferably in the evening ❌ Neglect any minor foot lesions

38. WHO Voluntary Global Targets for Prevention and Control of Non-Communicable
Diseases to be Attained by 2025

39. KEY MESSAGES
• Diabetes is a serious, long-term condition that occurs when the body cannot
produce any or enough insulin or cannot effectively use the insulin it produces. The
main categories of diabetes are type 1, type 2 and gestational diabetes mellitus.
• Type 1 diabetes is the major cause of diabetes in childhood but can occur at any
age. At present, it cannot be prevented. People with type 1 diabetes can live
healthy and fulfilling lives but only with the provision of an uninterrupted supply of
insulin, education, support and blood glucose testing equipment.
• Type 2 diabetes accounts for the vast majority (around 90%) of diabetes worldwide.
It can be effectively managed through education, support and adoption of healthy
lifestyles, combined with medication as required. Evidence exists that type 2
diabetes can be prevented and there is accumulating evidence that remission of

40. KEY MESSAGES
• ‘Prediabetes’ is a term increasingly used for people with impaired glucose
tolerance and/ or impaired fasting glucose. It signifies a risk of the future
development of type 2 diabetes and diabetes-related complications.
• Pregnant women with gestational diabetes mellitus can have babies that are
large for gestational age, increasing the risk of pregnancy and birth
complications both for the mother and baby.

41. Diabetes control programme in India
NATIONAL PROGRAMME FOR PREVENTION AND
CONTROL OF CANCER, DIABETES,
CARDIOVASCULAR DISEASES AND STROKE*
*For details, refer to PPT on hypertension

42. THANK YOU