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1. EPIDEMIOLOGY
OF
Sheral Samson
BScN
epidemiology of diabetes 1

2. s
By the end of presentation, the learners will be able to:
Briefly describe the disease “diabetes mellitus”
Develop an epidemiological triangle of diabetes to explain the interaction among all
the components of diabetes triad.
Explain the natural history of diabetes mellitus.
Discuss the levels of prevention and related modes of interventions applied for the
prevention of diabetes mellitus.
Give the global and national morbidity (prevalence & incidence) and mortality rate of
diabetes mellitus.
Survey the epidemiological study designs related to the diabetes mellitus.
List some recommendations for the improvement of diabetes in Pakistan.
OBJECTIVES:
epidemiology of diabetes 2

3. DIABETES MELLITUS
The name diabetes mellitus refers to these s/s:
Diabetes, from the Greek diabainein, meaning “to pass through,” describes the copious
urination
Mellitus, from the Latin meaning “sweetened with honey,” refers to sugar in the urine.
“Diabetes is a metabolic disorder, characterized by uncontrolled amount of glucose in the
blood due to insufficient insulin or insulin resistant”
epidemiology of diabetes 3

4. epidemiology of diabetes 4

5. RESULT FASTING
BLOOD
GLUCOSE
HbA1C GLUCOSE
TOLERANCE
TEST
RANDOM
GLUCOSE
TEST
POST
PRANDIAL
{AFTER
2HRS}
Normal 70-99 mg/dl Below
5.7%
70-140 mg/dl 70-140 mg/dl 70-140 mg/dl
Prediabetes
100-125
mg/dl
5.7%-6.4% 140-199 mg/dl 140-199mg/dl 140-199 mg/dl
Diabetes 126 mg/dl-
higher
6.5%-above 200 mg/dl-
Above
200 mg/dl-
above
200 mg/dl-
above
epidemiology of diabetes 5

6. Complications of
DM
Cardiovascular disease
Neuropathy
Nephropathy
Retinopathy
Foot damage
Skin conditions
Hearing impairment
Depression
epidemiology of diabetes 6

7. EPIDEMIOLOGICAL TRIADOF DIABETESMELLITUS
AGENT
refers to risk factor /cause
HOST ENVIRONMENT
refers to medium
epidemiology of diabetes 7

8. • Age
• Ethnicity
• Genetics-Autoantibodies
• Obesity
• High LDL diet
• Physical inactivity
• Placental hormones
• Stress, smoking
• Health condition; PCOs
ENVIRONMENT
• Sedentary behavior
• Unhealthy lifestyle
• Socio-economic status
• Culture
• Heredity
• pregnancy
Host
• Individual (genetically, nutritionally,
anatomically, psychologically
susceptible)
AGENT
EPI.
TRIAD OF DIABETES
epidemiology of diabetes 8

9. PRE-PATHOGENESIS PHASE PATHOGENESIS PHASE
STAGE OF SUSCEPTIBILITY
(at risk)
• Genes-
autoantibodies(T1DM)
• Obesity
• High LDL diet
• Physical inactivity
• Stress, smoking
• Health condition; PCOs
• Placental hormones
EARLY PATHOGENESIS LATE PATHOGENESIS
STAGE OF SUBCLINICAL DISEASE
PREDIABETES
(pathological changes)
• Last for months to years
• Autoantibodies develop and
damage the beta-cells (T1DM)
• Typically has no distinct sign or
symptom except sole sign of high
blood sugar
• Hypercholesterolemia, nicotine and
stress hormones cause insulin
resistance.
• Secretion of placental hormones
cause insulin resistance in pregnant
women(normally beta cells secrete
extra insulin to cover up the
secretion of placental hormones but
in some ladies it can’t do so)
STAGE OF CLINICAL
DISEASE
(clinical manifestations)
HYPERGLYCEMIA-
• Polyuria
• Polyphagia
• Polydipsia
• Dry mouth
• Weight loss
• Fatigue
• Blurred vision
• Slow healing cuts or
wounds
• Numbness or tingling
• Feet swelling
STAGE OF
TERMINATION
• Disease progress to
complications;
CVD
RETINOPATHY-
BLINDNESS
FOOT DAMAGE-
AMPUTATION
NEPHROPATHY-CKD
HEARING IMPAIREMENT
• NO RECOVERY
• COMPLICATIONS-
ORGAN FAILURE-
DEATH
PRIMARY
PREVENTION
SECONDARY
PREVENTION
TERTIARY
PREVENTION
HOST
AGENT
ENVIRONMENT
epidemiology of diabetes 9

10. LEVEL RISK
FACTORS
DISEASE COMPLICATIONS MODEOF INTERVENTIONS
PRIMORDIAL
To keep body
healthy, prevent
body from
occurrence of risk
factors.
Absent Absent Absent INDIVIDUALAND MASS
EDUCATION
• Educate to maintain normal body
weight.
• Adoption of healthy nutritional
habits and physical exercise.
• Childhood obesity prevention
through education.
• Educate to maintain a nutritious
diet.
• Girls in reproductive age or even
in childhood maintain weight,
take appropriate nutrition, and
be physically active.
epidemiology of diabetes 10

11. LEVEL RISK
FACTORS
DISEASE COMPLICATIONS MODEOF INTERVENTIONS
PRIMARY
To prevent
the disease
from
occurrence by
overcoming
the risk
factors.
Present Absent Absent  HEALTH PROMOTION
• Avoid sedentary behavior.
• Be physically active.
• Eat healthy and balanced diet; low
saturated fats , a low added sugars
and high fiber diet.
 SPECIFIC PROTECTION
• Aerobic exercises results in weight
loss.
• Quit smoking.
• Immunomodulation to delay the
occurrence of T1DM.
epidemiology of diabetes 11

12. LEVEL RISK
FACTORS
DISEASE COMPLICATION MODEOF
INTERVENTIONS
SECONDARY
To prevent the
further progression
of disease and
prevention of
diabetic
complications.
Present Present Absent  EARLY DIAGNOSIS
• Classic signs of hyperglycemia; high
sugar level, increase thirst, increase
hunger, dehydration and so on.
• Fasting plasma glucose test
• Oral glucose tolerance test
• HbA1C
 TREATMENT
• Administer insulin
• Lifestyle changes.
• Adjusting diet and staying active
• Monitoring and maintaining glucose
levels
• Manage high blood pressure
• Treat dyslipidemia
• Smoking cessation
epidemiology of diabetes 12

13. LEVEL RISK
FACTORS
DISEASE COMPLICATION MODEOF INTERVENTIONS
SECONDARY Present Present Absent
• Medications; metformin
• Recognition of symptoms associated
with hypoglycemia.
• Attending periodic checkups.
• Routine checking of blood sugar, of
urine for proteins and ketones, of
blood pressure, visual acuity and
weight should be done .
• The foot should be examine for any
defective blood circulation , loss of
sensation and the health of the skin.
epidemiology of diabetes 13

14. LEVEL RISK
FACTOR
DISEASE COMPLICATION MODE OF INTERVENTIONS
TERTIARY
Prevent the
worsening of
complications and
rehab patient.
Present Present Present  COMPLICATIONS
LIMITATIONS:
• Screening of patients with diabetes
for diabetic retinopathy to prevent
progression to blindness through
prompt treatment
• Prevent recurrence or further
complications through appropriate
medication.
• Appropriate diabetic foot care to
avoid further damage or foot
complications or to preventing
from spreading further; wear
appropriate shoes, never go
barefoot, keep toenails trimmed.
• CVD patients take high HDL, low
LDL, high fiber diet, 30 minutes
brisk walk.
epidemiology of diabetes 14

15. LEVEL RISK
FACTOR
DISEASE COMPLICATION MODE OF INTERVENTIONS
TERTIARY Present Present Present
• People, especially older ones, with diabetic
complications such as autonomic neuropathy,
cardiovascular disease should avoid exercising
outdoors on very hot and humid days.
 REHABILITATION:
• Follow-up to ensure adherence to medication
regimen, monitor changes, and assist them in
maintaining independence in daily life.
• Participate in social gathering.
• Attain glycemic control.
• Patient education is important to help people
with diabetes enhance self care.
• Psychological support
• Exercises
• Other behavior modifications(physically active,
healthy diet, smoking cessation)
epidemiology of diabetes 15

16. HEALTHINDICATORS RELATEDTO DIABETES MELLITUS
MORBIDITYRATE
Morbidity rate can be measure by:
• Incidence rate
• Prevalence
YEAR PREVALENCE INCIDENCE
2009 285million -
2014 422million 137million
2017 451million 29million
2019 463million(9.3%) 12million
2021 537million (10.5%) 74million
• IDF estimated that prevalence of diabetes will be projected to 643million and 783million(12.2%) by the years
2030 and 2045, respectively.
INTERNATIONAL DIABETES FEDERATION
epidemiology of diabetes 16

17. GLOBAL RANKINGWITH DIABETIES
2019 2021
RANK# COUNTRY PREVALANCE RANK# COUNTRY PREVALANCE
1. China 116 million 1. China 141 million
2. India 77 million 2. India 74 million
3. America 31 million 3. Pakistan 33 million
4. Pakistan 19 million 4. America 32 million
INTERNATIONAL DIABETES FEDERATION
epidemiology of diabetes 17

18. YEAR PREVALANCE INCIDENT RATE
2015 7 million -
2016 26.3% -
2017 7.5 million (6.9%)…18TH RANK -
2019 19 million……………..4TH RANK 11.5 million
2021 33 million…………....3RD RANK 14 million
PAKISTANPREVALANCE ANDINCIDENCE
INTERNATIONAL DIABETES FEDERATION
epidemiology of diabetes 18

19. MORTALITY RATE
2019 2020 2021
GLOBALLY 4.2 million or 11.3% - 6.7 million or 12.2%
PAKISTAN
RANK # 35 WORLDWIDE
IN 2020
- 63852 deaths or 4.37% or
52.4/100000
-
LIFE EXPECTANCY
2020
GLOBALLY T1DM;70.96 &T2DM;75.19
PAKISTAN 67.27
INTERNATIONAL DIABETES FEDERATION
epidemiology of diabetes 19

20. HEALTHEXPENDITURE
2017 2019 2021
GLOBALLY USD 850 billion USD 917 billion USD 966 billion
PAKISTAN - - PKR 145.97 billion
INTERNATIONAL DIABETES FEDERATION
epidemiology of diabetes 20

21. STUDY DESIGNS # 01
Outcomes of Gestational Diabetes Mellitus in Pakistani Mothers:
An Experience of a TertiaryCare Hospital
Samina Naseem Khattak, Abid Hussain Shah, Ayesha Imran, Muhammad Irfan
Khattak, Khurram Mansoor & Asma Naveed Memon
Vol. 11 no. 4 (2021)
epidemiology of diabetes 21

22. ABSTRACT:
Objective: To assess the incidence and outcome of gestational diabetes mellitus (GDM) during pregnancy among sample
of Pakistani population.
Study Design and Setting: This was an analytic case-control prospective study carried out at two centers (CMH Kharian
and PNS Shifa Hospital Karachi) from 1st Jan till 30th July 2021.
Methodology Previously healthy mothers were divided into three groups according to their risk of elevated glucose levels
gestational diabetes mellitus (GDM) during pregnancy. Associations between GDM eminence (exposure variable) and
pregnancy-related, fetal, and neonatal outcomes were reviewed (i.e., mode of delivery, preterm baby, pregnancy-induced
hypertension, and fetal macrosomia, stillbirth, premature delivery etc. One way ANOVA was employed to compare the
significant differences in different dependent variables amongst three groups. P Values of <0.05 were considered substantial.
Results: A total of 120 patients were divided into 3 groups Group 1 (uncontrolled sugar group) who could not achieve
adequate sugar control, Group II (adequate sugar control group) and Group III as control group (Non-Diabetic). The mean
age in our population was 24 (+ 4.15) years most of study population 70% of mothers were under 25 years of age. The
majority (95%) of deliveries in the control group (Euglycemic) were uneventful, but poor fetal outcomes were noted in
groups 1 2 (documented to have elevated blood sugars,) especially in the group with Uncontrolled Sugar. GDM was
positively associated with preterm birth, stillbirth and macrosomia.
Conclusion: GDM is a prevalent disease in Pakistan and needs and has association with poor pregnancy outcomes. Urgent
attention requires at individual and state level to reduce morbidity and mortality.
epidemiology of diabetes 22

23. STUDY DESIGNS # 01
Prospective Study Of Cigarette Smoking, Alcohol Use, And The Risk Of Diabetes In Men
Eric B. Rimm, June Chan, Meir J. Stampfer, Graham A. Colditz and Walter C. Willett
BMJ: British Medical Journal
Vol. 310, No. 6979 (Mar. 4, 1995), pp. 555-559 (5 pages)
Published By: BMJ
epidemiology of diabetes 23

24. ABSTRACT
Objective—To examine the association between smoking, alcohol consumption, and the incidence of non-
insulin dependent diabetes mellitus in men of middle years and older.
Study Design and setting: Cohort questionnaire study of men followed up for six years from 1986. The
health professionals' follow up study being conducted across the United States.
Subjects—41 810 male health professionals aged 40-75 years and free of diabetes, cardiovascular disease,
and cancer in 1986 and followed up for six years.
Main outcome measure—Incidence of non-insulin dependent diabetes mellitus diagnosed in the six years.
Results—During 230 769 person years of follow up 509 men were newly diagnosed with diabetes. After
controlling for known risk factors men who smoked 25 or more cigarettes daily had a relative risk of
diabetes of 1.94 (95% confidence interval 1.25 to 3.03) compared with non-smokers. Men who consumed
higher amounts of alcohol had a reduced risk of diabetes (P for trend <0.001). Compared with abstainers
men who drank 30.0-49.9 g of alcohol daily had a relative risk of diabetes of 0.61 (95% confidence interval
0.44 to 0.91).
Conclusions—Cigarette smoking may be an independent, modifiable risk factor for non-insulin dependent
diabetes mellitus. Moderate alcohol consumption among healthy people may be associated with increased
insulin sensitivity and a reduced risk of diabetes.
epidemiology of diabetes 24

25. • Give mass education about all levels of preventive measures especially Lifestyle
modification (healthy diet , physical activity, normal BMI & exercise).
• Excess resources to those who cannot afford the treatment.
• Diabetes programs must offer accessible information, and must be delivered in a
format that is understand.
• Promoting primary prevention and awareness all over Pakistan using screening
methods such as RISK ASSSESMENT OF PAKISTAN INDIVIDUALS FOR
DIABETES (RAPID)
• Implementing a nationwide diabetes care programs including registrations,
treatment, and referral protocols…Diabetic Registry of Pakistan(DROP)
RECOMMENDATIONSFOR THE IMPROVEMENT OF DIABETES IN
PAKISTAN
epidemiology of diabetes 25

26. References
• International Diabetes Federation(IDF) Atlas 10th edition (2021)
https://diabetesatlas.org/#:~:text=Diabetes%20around%20the%20world%20in%202021%3A,%2D%20an
d%20middle%2Dincome%20countries.
• Prevalence of diabetes in Pakistan(15 may). MMI
https://mmi.edu.pk/blog/prevalence-of-diabetes-in-pakistan/
• Stephen.R.daneils (2011).”The Natural History of Diabetes”. The Journals of Pediatrics.
https://www.jpeds.com/article/S0022-3476(10)01017-6/fulltext
• William Herman. Et al (2015). “Early Detection and Treatment of Type 2 Diabetes Reduce
Cardiovascular Morbidity and Mortality: A Simulation of the Results of the Anglo-Danish-Dutch Study
of Intensive Treatment in People With Screen-Detected Diabetes in Primary Care ”.American Diabetes
Association.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4512138/
• Alberti KG, Zimmet PZ. Definition, diagnosis and classification of diabetes mellitus and its
complications. Part 1: diagnosis and classification of diabetes mellitus. Provisional report of a WHO
consultation. Diabetic medicine. 1998 Jul;15(7):539-53.
• Katherine Zeratsky.(2020). “Does alcohol and tobacco use increase the risk of diabetes?”. Mayo Clinic.
https://www.mayoclinic.org/diseases-conditions/type-2-diabetes/expert-answers/diabetes/faq-
20058540#:~:text=Tobacco%20use%20can%20increase%20blood,Katherine%20Zeratsky%2C%20R.D.%2C
%20L.D. epidemiology of diabetes 26

27. epidemiology of diabetes 27