2. Diabetes mellitus (DM) is a Heterogeneous chronic Metabolic disorder
Hyperglycaemia results from a defect in insulin action and / or deficiency of
insulin secretion.
3. In type I diabetes mellitus, the body simply does not make insulin (5% of
diabetics).
In type II diabetes, either the body does not make enough insulin or the cells
begin to resist it (95% of diabetics).
4. DM : Leading cause of death and morbidity
Morbidity implies the effects due to the disease, which reduce or mar the
quality of life of the affected person. It causes blindness, heart attack,
stroke, kidney failure and amputation.
This ailment is affecting younger people also. In the past decade, the
incidence among people in the 30‘s has jumped by 70%. It is up by 10% among
under the 30's.
This implies that these younger people will be struggling with amputations,
blindness and heart disease at the prime of their life.
5. Diagnosis of Diabetes is for life
Entails certain lifestyle and social restraints
Mounting therapeutic obligations
Problems of employment and insurance
Extreme care to be exercised in pronouncing such a diagnosis
Delay in diagnosis raises the risk of issue damage and long term complications
6. Prevalence
India had 19.4 million diabetics in 1995
India will have 57.2 million patients in 2025
India tops the list of diabetes in 1995 and 2025 also
The world wide prevalence of diabetes will be 300 million in 2025 of which 72
million will be in developed countries and 228 million in developing countries
That is: 75% of diabetics will be in developing countries
7. Ten top countries – Number of adults with DM in Millions
S.NO COUNTRY 1995 COUNTRY 2025
1 India 19.4 India 57.2
2 China 16 China 37.6
3 US 13.9 US 21.9
4 Russian Federation 8.9 Pakistan 14.5
5 Japan 6.3 Indonesia 12.4
6 Brazil 4.9 Russian Federation 12.2
7 Indonesia 4.5 Mexico 11.7
8 Pakistan 4.3 Brazil 11.6
9 Mexico 3.8 Egypt
10 Ukraine 3.6 Japan 8.5
11 All other countries 49.7 103.6
Total 135.3 300
WHO Tech report 1985
8. The Rising Prevalence of Diabetes In Developing Countries
140
120
100
Millions
80
60
40
20
0
20-44 Yrs 46-64 Yrs 65 Yrs
1995 2025
9. The rising prevalence of Diabetes world wide
300 300
250
200
177
1985
150 135 1995
2000
100 2025
50 30
0
1985 1995 2000 2025
4 million deaths per year related to DM. (9% of the global total.)
10. Factors for Rising of Diabetic Epidemic
o Genetic Predisposition
o Environmental factors
Sedentary life style
Change in food habits
Stress of Urban living
o Increase in population
o Increasing aging population (Longevity)
o High Ethnic susceptibility
11. Effects of Urbanization
Consumption of excess calories
Reduction in complex carbohydrates with increased consumption single sugars
and fat
Availability of energy saving methods of transport and labour hence severely
reduced physical activity.
Increased levels of stress.
12.
Factors Responsible
Unchangeable Modifiable Preventable
Male Gender Dyslipidaemia life style
F.H. of Diabetes mellitus Hypertension Obesity
Ageing Diabetes Smoking
Viral infections Alcohol
Stress
Sedentary
Food habits
13. Indications for testing for diabetes in asymptomatic, undiagnosed
individuals.
Testing for diabetes should be considered in all individuals at age 45
years, and above and, if normal, it should be repeated at 2 year
intervals.
14. Testing should be considered at a younger age or be carried out more
frequently in individuals who:
o Are obese ( BMI over > 27)
o Those with a family history of DM (especially first degree)
o Those with diabetes developing during pregnancy (GDM)
o Mother of a big baby at birth (above 3.5 kg)
o Mother prone for diabetes
o Low birth weight child (IUGR)–child can develop diabetes in future
o Have a HDL cholesterol < 35mg/dl and /or a triglyceride level >200mg/dl.
o On previous testing , had IFG or IGT
o Are members of high risk ethnic population (South Asians)
o Poly cystic Ovarian Disease in Females
15. Prevalence of complications at diagnosis
50% of patients had complications at diagnosis
o 37% had retinopathy
o 18 % had microalbuminuria
o 10% had peripheral neuropathy.
UKPDS
16. Chronic complications of Diabetes
o Mortality is increased by 200%
o Heart disease and stroke rate is 200% to 400%.
o Blindness 10 times more common in diabetes.
o Gangrene and amputation of lower limbs about 20 time
o Second leading cause of fatal renal disease.
o Other chronic complication (neuropathy, infections and sexual
dysfunctions)
o As a result of diabetes, hospitalisation expense increase by 2 to 3 folds
(WHO expert committee on Diabetes mellitus)
17. Cost of diabetic care
Estimated annual cost of diabetes care would be Rs.9,000 crores and the
average expenditure per patient per year would be a minimum of Rs 5,000/-
For an average Indian family with an adult with Diabetes, as much as 25% of
the family income may be devoted to diabetes care.
WHO
18. ECONOMIC BURDEN
$ 948
Photocoagulation
Disability benefit for $14,296
blindness (yearly)
Acute cardiovascular disease $ 15,952
hospitalization $ 31,225
Lower extremity ulcer /infection/amputation
Renal replacement treatment of ESRD (yearly) $ 46,207
Multiple insulin injection (yearly) $ 3324
Max SU + Metformin (yearly) $3041
Insulin + Maximum OHA (yearly) $2757
Evaluation for proteinuria $1080
Preventive Vascular foot evaluation(yearly) $124
measures / Evaluation for neuropathy $106
comprehensive
Yearly Ophthalmic
treatment
Exam $100
Treatment of complications
19. Annual Direct Cost: (Background variable adjusted)
for routine treatment, not requiring hospitalization in different settings.
Total patients 611 - - - - - - - - Rs 5959
Type I (35) 6432
Type 2(576) 5928
OHA alone (395) 4722
Insulin alone/OHA (217) 8195
SEX Male(335) 5580
Female(276) 6417
Rayappa PH et al., Int. J. Diab. Dev. Countries. : July to September 1999
HYPERGLYCAEMIA – ECONOMIC BURDEN
20. PLACE GOVERNMENT (172) Rs 2855
Private (439) 7176
Duration Less than 5 years (216) 5522
5 to 14 years (277) 6240
15 plus years (118) 6063
Stay Urban 5756
Rural 6266
Rayappa PH et al., Int. J. Diab. Dev. Countries. : July to September 1999
HYPERGLYCAEMIA – ECONOMIC BURDEN
21. Complications None (185) 5606
I (168) 5616
II (134) 5954
III plus (124) 6747
Rayappa PH et al., Int. J. Diab. Dev. Countries. : July to September 1999.
HYPERGLYCAEMIA – ECONOMIC BURDEN
22. New Indian Express on 18/02/2000
MAN USES SPEEDING TRAIN TO AMPUTATE HIS GANGRENOUS FOOT
This is the tragic story of the 45-year-old man with diabetes who developed gangrene
of his foot last September. The foot would not heal and the resulting pain and lack of
mobility meant that he had to give up his work as a plumber. The alternative
employment he took up - selling fruits at the side of the road – was not a success
because of the foot's offensive smell. No one would buy his fruits.
Attendance of the doctors for dressing and other treatment were costing him Rs 75/-
each time and he was told that the amputation he needed would cost Rs 15,000.
As a consequence of this advice, he decided to use the local train to amputate his
foot. He survived, but how long remains to be seen.
This is an effort to make sense of cost effectiveness information on
diabetes programmes and its importance for physicians and policy planners.
23. EXPECTED ECONOMIC BURDEN
DUE TO DM RELATED COMPLICATIONS
IN THE YEAR 2025
Diabetic Retinopathy Rs. 1,425 crores/ year
Assumption: 5% of DM will undergo laser therapy. Rs. 5,000 for laser treatment
Renal Disease Rs. 28,500 crores/year
Assumption: 5% of the DM patients will need dialysis. Rs.1,00,000/ for dialysis
Coronary Artery Disease Rs. 28,500 crores/
year
Assumption: 5% of DM patients will need bypass surgery. Rs. 1,00,000/ for bypass
Foot Complications Rs. 5,700
crores/year
24. The economic burden of diabetes
India is the ‘ Diabetes Capital of the world’
A dubious distinction
Can we afford it?
25. “Walk more , Eat less”
Sir George Alberti,
President IDF
Why are so many people suffering from DM in India
Ethnic predisposition
Indians are centrally fat (fat around the waist) due to lack of exercise
Economic growth – prosperity - change in dietary habits and adopting of
western style fast food
26. Strategies for primary prevention of macrovascular complications
Life style modifications
Diet
Exercise
Optimisation of body weight
Cessation of smoking
Reduction of mental stress
Metabolic control of Diabetes
Optimum control of Blood pressure
Drug Therapy
Aspirin
Lipid lowering agents
27. Annual screening for complications of Diabetes
Target organs Procedure
Retina Visual Acuity
Opthalmoscopy
Renal Micro albumin estimation
Macro albumin estimation
Peripheral nerves Foot examination
10 gm monofilament for detection of loss
of protective sensations
Biothesiometry
Plantar pressure measurement
Cardiovascular ECG
Blood pressure: Supine, sitting and
standing
Estimation of serum lipids
Peripheral vessels Palpation of all peripheral pulsation and
foot examination
Ankle/ Brachial pressure measurement
(ABI)
28. Hyperglycemia - prevention
FINNISH STUDY
Selection: 522 middle aged (mean 55 years)
Obese (mean BMI 31 kg/m2)
All were IGT.
DURATION: 3.2 years.
CONTROL GROUP INTERVENTION GROUP
Brief diet Intensive individualized instruction
Exercise On weight reduction, food intake, and
physical activity
RESULT: 58%, relative reduction in the incidence of diabetes in the intervention
group compared with control subjects.
29. HYPERGLYCAEMIA - PREVENTION
Weight control is the single most important lifestyle factor for prevention of type 2
diabetes.
Subjects: 84, 941.
ALL ARE FEMALES.
Period: 16 years.
Results: 91 % of cases of type 2 diabetes can be
prevented by adhering to 5 lifestyle
criteria:
Weight loss
Regular exercise
Diet modification
Abstinence from smoking
Consumption of limited amounts of
alcohol
N Engl Med 2001: 345: 790-797.
30. Hyperglycemia - prevention
Diabetes Prevention Program (DPP)
Selection: 3234 individuals.
Mean age 51 years.
More obese, (mean BMI 34 kg/ m2)
All were IGT.
Duration: 2.8 years. Division: 3 groups.
Lifestyle group Intensive nutrition and exercise
Masked medication group Metformin + diet + Exercise
Placebo group Placebo + diet + exercise
Result: 31% relative reduction in the progression of diabetes in the Metformin group
compared with other subjects.
31. What are the new developments worldwide?
NOTHING NEW
2000 years ago, Hippocrates said
No exercise Obesity Various illnesses
RELEVANT EVEN TODAY
Primary Diabetes Mellitus is a lifestyle related disease.
We cannot rely on drugs to correct lifestyle.
32. Diabetic foot epidemiology
o Cellulites occurs 9 times more frequently in diabetics than non-diabetics
o Osteomyelitis of the foot 12 times more frequently in diabetics than non-
diabetics
o Foot ulcerations and infections are the most common reason for a diabetic
to be admitted to the hospital
33. Diabetic foot ulcer epidemiology
o 25 % of diabetics will develop a foot ulcer
o 40-80% of these ulcers will become infected
o 25 % of these will become deep
o 50 % of patients with cellulites will have another episode within 2 years
34. Epidemiology (of amputation)
o 25-50 % of diabetic foot infections lead to minor amputations
o 10-40 % require major amputations
o 10-30 % of patients with a diabetic foot ulcer will go on to amputation
35. Diabetic foot & issues
o $34,700/year (home care and social services) in amputee
o After amputation 30% lose other limb in 3 years
o After amputation 2/3rds die in five years
o Type II can be worse
o 15% of diabetic will develop a foot ulcer
41. Message for people with diabetic foot
• Multi-disciplinary approach needed
• Going to be an increasing problem
• High morbidity and cost
• Solution is probably in prevention
• Most feet can be spared…at least for a while
42. MESSAGE for people with diabetes
GOOD METABOLIC CONTROL
BLOOD PRESSURE CONTROL
CONTROL OF SERUM LIPIDS
EARLY DETECTION OF COMPLICATIONS
LIFE STYLE MODIFICATON
