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Diabetes Mellitus: Epidemiology & Prevention

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Public health concepts of Diabetes

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Diabetes Mellitus: Epidemiology & Prevention

  1. 1. 1
  2. 2. Diabetes: Dr. S. A. Rizwan, M.D., Assistant Professor, Dept. of Community Medicine, VMCHRI, Madurai
  3. 3. At the end of this lecture you should be able to  Describe the burden of diabetes at the global and regional level  Describe the epidemiological features of diabetes  Discuss the trends in diabetes prevalence over the years  List out the strategies needed for prevention of diabetes  Appraise the diabetes scenario in India 3
  4. 4. 4
  5. 5. 6 IDF Diabetes Atlas, 2015
  6. 6. Type 1 DM Type 2 DM Gestational Diabetes LADA (latent autoimmune diabetes in adults) MODY (maturity-onset diabetes of youth) Secondary DM 7 IDF Diabetes Atlas, 2015
  7. 7.  Type 2 diabetes and cardiovascular share a common antecedent.  The concept The Metabolic Syndrome  Clustering of central obesity with several other major cardiovascular disease risk factors 8
  8. 8. 9 American Diabetic Association
  9. 9. 10 Fasting Plasma Glucose Post Prandial Plasma Glucose 100 200 100 200 126110 140 Normal Impaired Fasting Glucose Impaired Glucose Tolerance Diabetes Mellitus OR
  10. 10. 11 FPG PPPG 100 200 100 200 126110 140
  11. 11. 12 FPG PPPG 100 200 100 200 126110 140
  12. 12. 13 FPG PPPG 100 200 100 200 126110 140
  13. 13. 14 FPG PPPG 100 200 100 200 126110 140
  14. 14. 16 IDF Diabetes Atlas, 2015
  15. 15. 17 IDF Diabetes Atlas, 2015
  16. 16. 18 IDF Diabetes Atlas, 2015
  17. 17. 19
  18. 18. The Lancet 2011 378, 31-40DOI: (10.1016/S0140-6736(11)60679-X) 20
  19. 19. 21 IDF Diabetes Atlas, 2015
  20. 20. 23 IDF Diabetes Atlas, 2015
  21. 21. Indian J Med Res 125, March 2007, pp 217-230 24
  22. 22. Indian J Med Res 125, March 2007, pp 217-230 25
  23. 23. 27
  24. 24. 28
  25. 25. 29
  26. 26. 30 Overweight and obesity Physical inactivity High-fat and low-fiber diet Ethnicity Family history Age Low birth weight Urbanisation
  27. 27. 31  Non Modifiable  Genetic factors  Age  Ethnicity  Modifiable  Obesity and physical inactivity  Metabolic factors: IGT, IFG and GDM
  28. 28. Host factors  Age  Sex  Genetic factors: HLA DR3 and DR4  Defective immune response  Central Obesity Environmental factors  Sedentary life style  High saturated fat intake  Malnutrition- failure of β cells  Excessive alcohol  Viral infections (Mumps, Rubella)  Chemical agents- Alloxan, streptozotocin, cyanide  Environmental stress 32
  29. 29. Dietary factors  Characteristics of fat intake  Dairy  Glycemic load  “Western diet”  Fast food intake  Soda intake  Alcohol intake 33
  30. 30. Indian J Med Res 125, March 2007, pp 217-230 34
  31. 31. 35 IDF Diabetes Atlas, 2015
  32. 32. Short term effects of diabetes 36  Ketoacidosis  Recurrent or persistent infections (including tuberculosis)  Both hyperglycaemia and hypoglycaemia may cause coma
  33. 33. Long term effects of diabetes 1. Microvascular 2. Macrovascular 37
  34. 34. Prevalence & timeline 38
  35. 35. Continuum of CVD risk 39
  36. 36.  Aging of the population  Urbanization especially in the developing countries  More sedentary lifestyle  Food consumption patterns  More foods with high fat content  More refined carbohydrates 41
  37. 37.  To reduce human suffering  Improve Quality of Life  Reduce the number of hospitalization  Reduce mortality from diabetes  Prevent sudden cardiac death 42
  38. 38. The human and economic costs of diabetes could be significantly reduced by investing in prevention, particularly early detection, in order to avoid the onset of diabetic complications At least 50% of all people with diabetes are unaware of their condition 43 IDF Diabetes Atlas, 2015
  39. 39.  Primary  Includes activities aimed at preventing diabetes from occurring in susceptible populations  Secondary  Early diagnosis and effective control of diabetes in order to delay the progress of the disease  Tertiary  Prevent complications and disabilities due to diabetes 44
  40. 40.  “There is an urgent need to take the prevention of cardiovascular disease more seriously. The only sensible strategy is the population approach to primary prevention” - Beaglehole, the Lancet 2001; 358: 661-3 Why primary prevention? 45 M. V. Hospital for Diabetes & Diabetes Research Centre
  41. 41.  Behavioral interventions: including changing diet and increasing physical activity  Pharmacological interventions: utilizing pharmaceutical agents to improve glucose tolerance and insulin sensitivity Strategies 46
  42. 42.  Population strategy  Primordial prevention (prevention of emergence of risk factors)  Maintain body weight through adoption of healthy nutritional habits and physical exercise  High risk strategy  Sedentary life style, obesity  Avoid alcohol  Smoking  High blood pressure  Elevated cholesterol and triglyceride levels Approaches 47
  43. 43.  All of those components are risk factors for CVD and can be targeted in life style interventions to prevent Type 2 diabetes Metabolic syndrome prevention 48
  44. 44.  Diet and physical activity reduce the incidence of Type 2 diabetes.  Diet and exercise for 5 years in men with IGT reduced the incidence of Type 2 diabetes by 50% - Eriksson et al, Diabetologia 1991; 34: 891-8  Reductions in the incidence of diabetes in subjects with IGT who were randomized to diet, exercise, or combined diet-exercise treatment groups - Pan et al, Diabetes Care, 1997; 20: 537-44 Behavioral interventions 49
  45. 45.  The evidence for the ability of pharmacological interventions to prevent Type 2 diabetes awaits confirmation  Metformin Pharmacological interventions 50
  46. 46. Evidence from studies 51 Control Diet Exercise D&E Pan et al, Diabetes Care, 1997; 20: 537-44
  47. 47. Evidence from studies 52 Study Year Interventions Outcome DaQing (China) 1997 Diet, physical activity or both (control group: general) Reduction in diabetes incidence 31% in diet group, 46% in physical activity and 42% in diet and physical activity compared to control group Finnish Diabetes Prevention Study 2001 Diet and physical activity (control group: general advice) Reduction by 58% of the risk of diabetes compared to control group Diabetes Prevention Program (USA) 2002 Diet, physical activity, metformin and placebo 58% reduction in incidence of diabetes with lifestyle intervention, 31% with metformin STOP-NIDDM 2002 Acarbose or placebo 32% patients randomised to acarbose and 42% randomised to placebo developed diabetes
  48. 48.  The purpose of secondary prevention activities such as screening is to identify asymptomatic people with diabetes Why secondary prevention? 53
  49. 49.  Population screening  Selective screening  Opportunistic screening Approaches 54
  50. 50.  Urine examination  Test for glucose, 2 hours after a meal  Lack of sensitivity  Not appropriate for case finding  Blood sugar testing  “Standard oral glucose test”  2hr value after 75 g oral glucose  Measure fasting, random, post prandial Strategies 55
  51. 51. Indian Diabetes Risk Score 56 Interpretation: Total score < 30 - low risk 30-50 - medium risk > 60 - high risk Factors Score Age <35 0 35-49 20 >50 30 Abdominal obesity (WC) <80 cm (F), <90 (M) 0 80-89 cm (F), 90-99 (M) 10 >90 cm (M), >100 (M) 20 Physical activity Vigorous labour 0 Mild to moderate 20 No exercise 30 Family history None 0 One parent 10 Both parents 20 J Assoc Physicians India 2005; 53 : 759-63.
  52. 52.  Includes actions taken to prevent and delay the development of acute or chronic complications Why tertiary prevention? 57
  53. 53.  Strict metabolic control, education and effective treatment  Screening for complications in their early stages when intervention is more effective Approaches 58
  54. 54.  Screening for diabetic retinopathy is cost-effective where subsequent treatment, such as laser treatment, is available and affordable  Where there is no access to laser treatment, good metabolic control aimed at delaying the progress of diabetic eye disease is likely to be cost-effective Screening for eye problems 59
  55. 55. A number of interventions have been found to be effective in preventing foot problems  Education  Pressure-relieving interventions  Multidisciplinary clinics Managing foot problems 60
  56. 56.  Renal failure in diabetes can be detected very early by screening for ‘microalbuminuria’  However, effective treatment must be available in order to follow on from the detection of this early sign of renal failure Screening for renal problems 61
  57. 57.  The same basic improvements in diet and physical activity that prevent type 2 diabetes are likely to prevent CVD complications  Also, a wide range of drugs has now been proven to be effective in reducing the risk of CVD in people with diabetes, and in treating diabetes-associated CVD once it is present Macrovascular complications 62
  58. 58. Evidence from studies 63 Strategy Complication Reduction Lipid control  Coronary heart disease mortality  Major coronary heart disease event  Any atherosclerotic event  Cerebrovascular disease event ↓ 36%¹ ↓ 55%¹ ↓ 37%¹ ↓ 62%¹ Blood Pressure Control  Cardiovascular disease  Heart failure  Stroke  Diabetes-related deaths ↓ 51%² ↓ 56%³ ↓ 44%³ ↓ 32%³ Blood Glucose Control  Heart Attack ↓ 37%³ 1 The 4S Study, 2 Hypertension Optimal Treatment (HOT) Randomised Trial, 3 UKPDS
  59. 59.  Standardized data collection on disease magnitude, risk factors and mortality statistics.  Clear action plan with specific targets, and well defined evaluation.  Initiating community-based interventions for primary prevention.  Advocacy for influencing policies.  Advocacy for the rights of people with diabetes for quality care at all levels.  Establishing acceptable standards for health care for people with diabetes.  Establishing an effective referral system and defining the role of each level of health care.  Educating the population about this important global epidemic  Provision of appropriate training for health care providers  Coordination of prevention efforts 64
  60. 60.  Type 2 diabetes prevention must be integrated in a major program addressing the prevention of other lifestyle related disorders like CVD and some cancers  Primary prevention is of the essence especially in resource-constrained countries  Diabetes prevention is an inter-sectoral effort requiring cooperation and coordination  Diabetes prevention should be addressed within the context of health system reform ensuring the availability of acceptable health care standards  Culturally appropriate and economically feasible interventions should be adopted 65
  61. 61.  Type 2 diabetes is a major challenge to human health  Type 2 diabetes can be prevented  Primary prevention is a suitable and affordable choice  There is strong evidence that lifestyle interventions are effective in diabetes prevention  Barriers for prevention should be addressed 66
  62. 62. 67
  63. 63. Clinical services  Glycemic control  BP control  Lipid management  Annual eye examinations  Foot care  Kidney disease testing  Flu immunization  Preconception care  Diabetes education  Case Management  Targeted Screening Promotion of behaviors  Education and awareness for: • Physical activity • Reduced Tobacco • Healthy diet • Regular doctor visits • Self monitoring • Self mgt education 68 Population targeted policies • Health care access legislation • Drug and supply reimbursement policies • Population registry and feedback systems
  64. 64.  Taxation  Food and Menu labeling  Engage Private Industry  Crop subsidy policies  Incentives/promotion for community availability and affordability of foods  Incentives/promotion for community support for physical activity  Regulation of foods in public areas  School food and physical education policies 69
  65. 65. It is the corner stone of DM management It covers:  Self care  Changing behavior to prevent and control of complications  Encourage interaction with health care providers Education of diabetic patients 70
  66. 66.  Nature of disease, types  Clinical presentation, diagnosis, complications  Types of treatment, side effects  Exercise, self monitoring , avoidance and recognition of hypoglycemia, and hyperglycemia  Foot care  Pregnancy and OC  Avoidance of smoking  CV RFs  Need for follow up  Self management skills and attitudes Contents of Educational Program 71
  67. 67.  Patients should be educated to practice self-care  This allows the patient to assume responsibility and control of his/her own diabetes management  Self-care should include:  Blood glucose monitoring  Body weight monitoring  Foot-care  Personal hygiene  Healthy lifestyle/diet or physical activity  Identify targets for control  Stopping smoking Diabetic Self-Care 72
  68. 68.  Individual counseling  Group teaching  Educational materials: posters, pamphlets, books  Special educational programs are needed for special groups as children and pregnant women Types of education methods 73
  69. 69.  Basic understanding of DM and its managements  Training in educational methods  Training of dietetics and nurses Education of Health Professionals 74
  70. 70.  Prevention or modification of dietary habits and other life-style characteristics that link with DM Education of the community 75
  71. 71.  Economic problems: unavailability of needed resources  Socio-cultural problems  Lack of data, knowledge and skills 76
  72. 72. Obesity is not considered negatively Fad Food Culture has caught up Changing diet is very difficult No value given to physical exercise No time for physical exercise at work Fatalism 77
  73. 73. Dietary counselling Patient education Physical activity Medication compliance Aggressive follow-up Sudden death assessment 78
  74. 74.  India’s response to the growing burden of non-communicable diseases National programme for prevention and control of diabetes, cardiovascular disease and stroke 79 c.
  75. 75. Objectives 80 AWARENESS SCREENING CASE MANAGEMENT IN PHC PRE–DIABETES & LIFE STYLE MODIFICATIONS
  76. 76. Plan of action 81 Guidelines Trainings Detection camps in Sub centres & Main Centres Detection / Screening Camps at institutions Regular, fixed day weekly NCD clinic at PHC Preparation of Patient Treatment Cards BCC Activities
  77. 77. Key interventions 82 Key Area Activities Health Promotion  Public awareness through multi-media  Counseling for healthy lifestyle (Balanced diet, regular exercise, avoid alcohol and tobacco) Early Diagnosis  Screening of persons above 30 years and all pregnant women for diabetes and hypertension at all levels; facilities up to Sub-centre level Case Management  Facilities for diagnosis and treatment (NCD Clinic) at CHC level & above  CCU at District Hospital and above  Treatment of cancer at District Hospital & above Capacity Building  Infrastructure Development & Equipment  Training of human resources at all levels Management & Monitoring  NCD Cell at National, State & District level  Surveillance, monitoring & evaluation  Regular review meetings
  78. 78. Activities at different health care facilities 83 Tertiary centres Comprehensive care, research, training, telemedicine District Hospital Diagnosis & management of difficult cases, CCU, dialysis, training CHC Early detection & appropriate treatment, health promotion
  79. 79. a) Screening for undiagnosed cases b) Foot care c) Lipid lowering agents d) Metformin 85
  80. 80. a) FPG >126 b) PPPG >100 & <140 c) PPPG >140 & <200 d) FPG <110 86
  81. 81. a) USA b) China c) Russia d) Canada 87
  82. 82. a) 8.8% b) 6.5% c) 12.0% d) 3.0% 88
  83. 83. a) 70 million b) 50 million c) 100 million d) 40 million 89
  84. 84. a) Retinopathy b) Stroke c) Coronary heart disease d) Peripheral vascular disease 90
  85. 85. a) Primordial b) Primary c) Secondary d) Tertiary 91
  86. 86. a) Separate centre will be set up for stroke, DM b) Will be implemented in 10 districts in 5 states c) CHC has facilities for diagnosis and treatment of CVD, diabetes d) Sub-centre will provide facilities for diagnosis and treatment 92
  87. 87. This presentation is available on Email your queries to sarizwan1986@outlook.com

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