V SEM THEORY DIABETES DR. KAN

1. Epidemiology of Diabetes
mellitus

2. Specific Learning Objectives
At the end of the class the student should be able to:
Enumerate the risk factors for Diabetes mellitus (DM)
Diagnose DM based on blood sugar values
List the preventive measures in accordance with the
levels of prevention
Enumerate the components of self-management in

3. PLAN
Definition and Classification of Diabetes
Burden of diabetes mellitus (Type 2)
Epidemiological determinants
Clinical features
Prevention and control
Summary

4. Definition
A metabolic disorder of multiple aetiology
characterized by chronic hyperglycaemia with
disturbances of carbohydrate, fat and protein
metabolism resulting from defects in insulin
secretion, insulin action or both

5. Classification
 Type 1 diabetes
Lack of insulin
Autoimmune
Usually children
Type 2 diabetes
Insulin resistance
Lifestyle factors
Usually adults
Gestational diabetes
Insulin resistance
During pregnancy
Risks to mother and child
Impaired Glucose tolerance (IGT)
Malnutrition Related Diabetes (MRDM)
Other Types
Hormonal
Drug Induced
Genetic

6. Prevalence of diabetes worldwide in 2000 (per 1000
inhabitants). World average was 28.23‰
no data
less than 7.5
7.5-15
15-22.5
22.5-30
30-37.5
37.5-45
45-52.5
52.5-60
60-67.5
67.5-75
75-82.5
more than 82.5
http://en.wikipedia.org/wiki/File:Diabetes_world_map_-_2000.svg

7. Worldwide Prevalence of Diabetes 2000-
2030

8. Diabetes Prevalence 2013

10. People with diabetes require at least two to three
times the health-care resources compared to people
who do not have
diabetes care may account for up to 15% of national
health care budgets
risk of tuberculosis is three times higher among
people with diabetes

12. http://www.diabetesatlas.org/across-the-globe.html

13. Proportion of Diabetes related deaths in people under
60 out of all dying due to diabetes

14. Age-standardized prevalence of diabetes in adults
aged 25+ years,
by WHO Region and World Bank income group, comparable estimates, 2008
Chapter 1 – Burden: mortality, morbidity and risk factors. http://www.who.int/diabetes/facts/en/

15. Estimated number of diabetic subjects in
India.
Epidemiology of type 2 diabetes: Indian scenario Indian J Med Res 125, March 2007, pp 217-230

16. Projected increase in diabetes - India
 Because of “Asian Indian Phenotype”
 unique clinical and biochemical
abnormalities in Indians
 increased insulin resistance, greater
abdominal adiposity
 higher waist circumference despite
lower BMI,
 lower adiponectin and higher high
sensitive C-reactive protein levels.

17. Recent population based studies showings the
prevalence of type 2 diabetes in different parts of India
Epidemiology of type 2 diabetes: Indian scenario Indian J Med Res 125, March 2007, pp 217-230

18. India vs world prevalence of diabetes

20. Indian Scenario
Prevalence – 8.6 %
66 million estimated cases
53% of these cases are undiagnosed
1/3rd of income spent on Diabetes in poorest
households
"Diabetes Capital of the World"
Source: Diabetes Atlas, International Diabetes Federation 6th edition

23. Secular trends in the prevalence of impaired glucose
tolerance (IGT) and diabetes at Chennai

24. Age wise prevalence of diabetes Chennai urban rural
epidemiology study (CURES) vs National Urban
Diabetes Survey (NUDS) [ref 39]
Haat09i1p1.pdf

25. Global Prevalence of DiabetesDIABETES CARE, VOLUME 27, NUMBER 5, MAY 2004

26. Why This Scenario?
 primary driver - rapid epidemiological transition
 associated with changes in dietary patterns
 decreased physical activity
 as evident from the higher prevalence of diabetes in the urban
population
 prevalence of microvascular complications retinopathy and
nephropathy are comparatively lower in Indians,
 prevalence of premature coronary artery disease is much higher
in Indians compared to other ethnic groups.

27. Risk factors
preventable risk factors underlie most NCDs.
Most NCDs are strongly associated and causally
linked with four particular behaviours:
tobacco use,
physical inactivity,
unhealthy diet
harmful use of alcohol

28. Risk factors Lead to
four key metabolic/physiological changes:
raised blood pressure,
overweight/obesity,
hyperglycemia and
hyperlipidemia.

29. attributable deaths
leading NCD risk factor globally
raised blood pressure 13% of global deaths are
attributed),
tobacco use (9%),
raised blood glucose (6%),
physical inactivity (6%),
and overweight and obesity (5%)

30. Epidemiological Determinants
1. Insulin deficiency; complete or partial
Pancreatic disorders
Insulin synthesis abnormality
Destructions of beta cells
Autoimmune reaction
2. Insulin Resistance

31. Risk factors
Non- Modifiable Risk
factors
Age
Gender
Genetic factors
Ethnicity
Family History
Modifiable Risk
factors
Physical inactivity
Diet
High saturated fat intake,
salt intake
Low vegetables and fruits
intake
Low Dietary Fibre intake
Stress

32. Clinical features
Mostly Asymptomatic
Polydipsia, Polyuria and Polyphagia
Blood sugar testing
Fasting
Post-prandial – after a 75g glucose load
ICMR-WHO guidelines for management of Type 2 DM, 2005

33. Table 1: Values for Diagnosis
Fasting Random
Venous
Plasma
Glucose
= 7.0
mmol/L
( 126 mg/dl)
>= 11.1
mmol/L
> 200 mg/dl
Clinical Practice Guidelines (CPG) on Management of Type
2 Diabetes Mellitus (T2DM). (May 2009)

34. Diagnostic values for Type 2 Diabetes
Mellitus OGTT
Category 0-hour 2-hour
Normal < 6.1* (110 mg/dl) < 7.8 (140 mg dl)
IFG 6.1* – 6.9
(110 – 125mg dl)
-
IGT - 7.8 – 11.0 (140 –
199 mg dl)
DM >= 7.0 (126mg/dl) >=11.1 (200 mg dl)

35. Complications of DM
 Macrovascular
Coronary heart disease
Most common cause of death
50 to 80% of all the deaths due to Diabetes
Microvascular
Retinopathy
Nephropathy
Neuropathy
Foot ulcer Most common cause of disability
50% of non-traumatic amputations
Complications of DM

36. Primary Prevention
Healthy nutritional habits
Promotion of physical activity
Maintenance of ideal body weight
Create awareness on lifestyle modification
Enabling Environment

37. Screening- Target population
Asymptomatic (ICMR)
Age >= 30 yrs
Overweight BMI >23
Central Obesity: Waist
Hip Ratio men > 0.9
Women > ).85
Family History
Sedentary Lifestyle
Previous History IFG IGT
Gestational Diabetes
Large Baby >3.5 kg
Hypertension >140/90
Dyslipedemia

38. Screening High Risk
Family History
Symptoms of
Hyperglyceamia
Complications of
diabetes – tiredness,
burning feet, infections,
balanitis
Tuberculosis
Steroids
Polycystic Ovarian
Disease
Prematrue vascular
disease

39. Secondary Prevention
Self Care in diabetes
Identification card
Adherence to drugs and diet regimen
Periodic check ups
Foot care
No fasting and feasting

40. Follow up care
 3 monthly
6 monthly
Annually
FBG and PPBG
Clinical examination including BP and foot examination
Reinforce life style modifications and compliance to drug treatment
HbA1c
Blood urea and serum creatinine
Lipid profile
Urine: protein/albumin; micro albuminuria
Fundus examination
ECG

41.  Maintain ideal blood glucose level
a. Nonpharmacological treatment
Dietary modification
Promotion of physical activity
Avoid Tobacco and Alcohol
Stress Management
b. Drugs
Oral hypoglycemic agents
Insulin

42. Tertiary Prevention

Disability limitation and rehabilitation
Major cause of disability
Blindness
Renal failure
Gangrene of foot
Special clinics

43. Program for control of NCDs
National Program for control of CVD, Diabetes,
Cancer, Stroke (NPCDCS)

44. Age-standardized prevalence of overweight in
adults aged 20+ years

45. Age-standardized prevalence of obesity in
adults aged 20+ years

46. Classification of Obesity

48. In 2008, 35% of adults aged 20 years and older were
overweight (BMI ≥ 25 kg/m2) (34% men and 35% of
women).
Worldwide prevalence of obesity has nearly doubled
between 1980 and 2008.
In 2008, 10% of men and 14% of women in the world
were obese (BMI ≥30 kg/m2), compared with 5% for men
and 8% for women in 1980
An estimated 205 million men and 297 million women
over the age of 20 were obese in 2008 – a total of more
than half a billion adults worldwide

49. Targets for control f Diabetes