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Similar to alignment and integration of topics:Diabetes
alignment and integration of topics:Diabetes
- 1. 1 Learning objectives Atthe 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
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- 4. 4 What is diabetes? IDF DiabetesAtlas, 2015
- 5. 5 DM as partof metabolic syndrome 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
- 6. 6 Diagnostic criteria forDM American Diabetic Association
- 7. 7 Diagnostic criteria Fasting Plasma Glucose Post Prandial Plasma Glucose 100 200 100200 126 110 140 Normal Impaired Fasting Glucose Impaired Glucose Tolerance Diabetes Mellitus OR
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- 13. 13 Number of diabeticsglobally IDF Diabetes Atlas, 2015
- 14. 14 Prevalence of diabetesglobally IDF Diabetes Atlas, 2015
- 15. 15 Mortality due todiabetes IDF Diabetes Atlas, 2015
- 16. 16 Trends in diabetesburden
- 17. 17 The Lancet 2011378, 31-40DOI: (10.1016/S0140-6736(11)60679-X) Trends in diabetes burden
- 18. 18 Burden at aglance IDF Diabetes Atlas, 2015
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- 20. 20 Top 10 countrieswith diabetics IDF Diabetes Atlas, 2015
- 21. 21 Trend of diabeticsin India Indian J Med Res 125, March 2007, pp 217-230
- 22. 22 Regional prevalence ofDM Indian J Med Res 125, March 2007, pp 217-230
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- 27. 27 Risk factors fortype 2 DM Overweight and obesity Physical inactivity High-fat and low-fiber diet Ethnicity Family history Age Low birth weight Urbanisation
- 28. 28 Risk factors fortype 2 DM Non Modifiable Genetic factors Age Ethnicity Modifiable Obesity and physical inactivity Metabolic factors: IGT, IFG and GDM BECAUSE
- 29. 29 Risk factors fortype 2 DM 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
- 30. 30 Risk factors fortype 2 DM Dietary factors Characteristics of fat intake Dairy Glycemic load Fast food intake Soda intake Alcohol intake
- 31. 31 Age distribution ofDM in India Indian J Med Res 125, March 2007, pp 217-230
- 32. 32 Gender & residence IDFDiabetes Atlas, 2015
- 33. 33 Complications of DM Ketoacidosis Recurrent or persistent infections (including tuberculosis) Both hyperglycaemia and hypoglycaemia may cause coma Short term effects of diabetes
- 34. 34 Complications of DM Long termeffects of diabetes 1. Microvascular 2. Macrovascular
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- 38. 38 Why is theprevalence of DM increasing? 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
- 39. 39 Why should weprevent diabetes? To reduce human suffering Improve Quality of Life Reduce the number of hospitalization Reduce mortality from diabetes Prevent sudden cardiac death
- 40. 40 Managing Diabetes The humanand 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 IDF Diabetes Atlas, 2015
- 41. 41 Levels of preventionin Type 2 DM 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
- 42. 42 Primary prevention “There isan 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? M. V. Hospital for Diabetes & Diabetes Research Centre
- 43. 43 Primary prevention Behavioral interventions:including changing diet and increasing physical activity Pharmacological interventions: utilizing pharmaceutical agents to improve glucose tolerance and insulin sensitivity Strategies
- 44. 44 Primary prevention 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
- 45. 45 Primary prevention All ofthose components are risk factors for CVD and can be targeted in life style interventions to prevent Type 2 diabetes Metabolic syndrome prevention
- 46. 46 Primary prevention Diet andphysical 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
- 47. 47 Primary prevention The evidencefor the ability of pharmacological interventions to prevent Type 2 diabetes awaits confirmation Metformin Pharmacological interventions
- 48. 48 Primary prevention 0 10 20 30 40 50 60 70 Control Diet ExerciseD&E Evidence from studies Pan et al, Diabetes Care, 1997; 20: 537-44
- 49. 49 Secondary prevention The purposeof secondary prevention activities such as screening is to identify asymptomatic people with diabetes Why secondary prevention?
- 50. 50 Secondary prevention Population screening Selective screening Opportunistic screening Approaches
- 51. 51 Secondary prevention 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
- 52. 52 Secondary prevention Indian Diabetes Risk Score Interpretation: Totalscore < 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.
- 53. 53 Tertiary prevention Includes actionstaken to prevent and delay the development of acute or chronic complications Why tertiary prevention?
- 54. 54 Tertiary prevention Strict metaboliccontrol, education and effective treatment Screening for complications in their early stages when intervention is more effective Approaches
- 55. 55 Tertiary prevention Screening fordiabetic 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
- 56. 56 Tertiary prevention A number ofinterventions have been found to be effective in preventing foot problems Education Pressure-relieving interventions Multidisciplinary clinics Managing foot problems
- 57. 57 Tertiary prevention Renal failurein 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
- 58. 58 Tertiary prevention The samebasic 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
- 59. 59 Tertiary prevention Evidence from studies Strategy Complication Reductio n Lipidcontrol · 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
- 60. 60 Major components ofeffective prevention programs 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
- 61. 61 Central issues inType 2 diabetes prevention 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
- 62. 62 What do weknow about Type 2 diabetes prevention? 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
- 63. 63 Diabetes Pyramid ofPrevention
- 64. 64 Classic Levers inthe Public Health Response to Diabetes 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 Population targeted policies • Health care access legislation • Drug and supply reimbursement policies • Population registry and feedback systems
- 65. 65 Policy Options toInfluence Diabetes Risk 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
- 66. 66 Health education in DM Itis 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
- 67. 67 Health education in DM 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
- 68. 68 Health education in DM 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
- 69. 69 Health education in DM 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
- 70. 70 Health education in DM Basic understanding of DM and its managements Training in educational methods Training of dietetics and nurses Education of Health Professionals
- 71. 71 Health education in DM Prevention or modification of dietary habits and other life-style characteristics that link with DM Education of the community
- 72. 72 Obstacles and barriersfor prevention Economic problems: unavailability of needed resources Socio-cultural problems Lack of data, knowledge and skills
- 73. 73 Socio-cultural barriers Obesity isnot 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
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- 75. 75 NP-NCD India’s responseto the growing burden of non- communicable diseases National programme for prevention and control of Non Communicable diseases c. NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF NON COMMUNICABLE DISEASES
- 76. 76 NP-NCD AWARENESS SCREENING CASE MANAGEMENT IN PHC PRE–DIABETES& LIFE STYLE MODIFICATIONS Objectives
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- 78. 78 NPCDS 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 Plan of action
- 79. 79 NPCDS 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 Key interventions
- 80. 80 NPCDS Tertiary centres Comprehensive care,research, training, telemedicine District Hospital Diagnosis & management of difficult cases, CCU, dialysis, training CHC Early detection & appropriate treatment, health promotion Activities at different health care facilities
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- 82. 82 Which of thefollowing is primary prevention of DM? a) Screening for undiagnosed cases b) Foot care c) Lipid lowering agents d) Metformin
- 83. 83 Which of thefollowing is impaired glucose tolerance? a) FPG >126 b) PPPG >100 & <140 c) PPPG >140 & <200 d) FPG <110
- 84. 84 Which country isnot in the top 10 countries for no. of diabetics? a) USA b) China c) Russia d) Canada
- 85. 85 What was theglobal prevalence of diabetes in 2015? a) 8.8% b) 6.5% c) 12.0% d) 3.0%
- 86. 86 What was theno. of diabetics in India in 2015? a) 70 million b) 50 million c) 100 million d) 40 million
- 87. 87 Which of thefollowing is NOT a macrovascular squeal of DM? a) Retinopathy b) Stroke c) Coronary heart disease d) Peripheral vascular disease
- 88. 88 Which prevention strategyis most sustainable for DM in India? a) Primordial b) Primary c) Secondary d) Tertiary
- 89. 89 True about NPCDCSis 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
- 90. Thank you This presentationis available on Email your queries to sarizwan1986@outlook.com
Editor's Notes
- #27 Modified from the IDF publication: ‘Diabetes and Obesity’, p.12; and ‘Time to Act’, p.53
- #28 Modified from the IDF publication: ‘Diabetes and Obesity’, p.12; and ‘Time to Act’, p.53
- #29 Modified from the IDF publication: ‘Diabetes and Obesity’, p.12; and ‘Time to Act’, p.53
- #30 Modified from the IDF publication: ‘Diabetes and Obesity’, p.12; and ‘Time to Act’, p.53