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Epidemiology of DiabetesCLASSIFICATION DIAGNOSIS/SCREENING PREVENTION/DELAY OF DM

TODAYS MISSIONTODAYS MISSION

Epidemiology of Diabetes

Definition

Diabetes – The term diabetes mellitus describes a metabolic disorder of multiple aetiology which is characterized by hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both.

DiabetesPrimary Goal for 2010

• Through prevention programs, reduce the disease incidence, its complications and its economic impact, in addition, to improve quality of life for all those persons that had diabetes or that are at risk to develop the disease.

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Reference: U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.

Epidemiology• The worldwide prevalence of DM has risen dramatically over

the past two decades, from an estimated 30 million cases in 1985 to 285 million in 2010. International Diabetes Federation projects that 438 million individuals will have diabetes by the year 2030 .

• Prevalence of both type 1 and type 2 DM is increasing worldwide, the prevalence of type 2 DM is rising much more rapidly, presumably because of increasing obesity, reduced activity levels as countries become more industrialized, and the aging of the population.

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The magnitude of the healthcare problem of type 2 diabetes results not just from the disease itself but also from its association with obesity and cardiovascular risk factors, particularly dyslipidaemia and hypertension.

Type 2 diabetes has now been recognized as one manifestation of the “metabolic syndrome”, a condition characterized by insulin resistance and associated with a range of cardiovascular risk factors.

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Various cardiovascular risk factors, including

hypertension and dyslipidaemia become

progressively worse with progression from normal

glucose tolerance to IGT/IFG to diabetes.

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While there is good evidence for a strong genetic contribution to both obesity and diabetes, the increase in these conditions in both developed and developing countries appears to be due to a changing balance between energy intake and energy expenditure through physical activity.

Physical activity levels have probably diminished by half.

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The tendency for the increased prevalence of type 2 diabetes to be concentrated in lower socioeconomic groups in developed countries and higher socioeconomic groups in developing countries probably reflects the adoption of a “healthier” lifestyle by better educated people in developed countries, while it is generally the affluent in developing countries who enjoy a high calorie intake and low level of physical activity.

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• Approximately 1.6 million individuals (>20 years) were newly diagnosed with diabetes in 2010. DM increases with aging.

• In 2010, the prevalence of DM in the United Sates was estimated to be 0.2% in individuals aged <20 years and 11.3% in individuals aged >20 years.

• In individuals aged >65 years, the prevalence of DM was 26.9%.

• The prevalence is similar in men and women throughout most age ranges (11.8% and 10.8%, respectively, in individuals aged >20 years).

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• In Asia, the prevalence of diabetes is increasing rapidly and the diabetes phenotype appears to be different from that in the United States and Europe—onset at a lower BMI and younger age, greater visceral adiposity, and reduced insulin secretory capacity.

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• Diabetes is a major cause of mortality, but several studies indicate that diabetes is likely underreported as a cause of death. In the United States, diabetes was listed as the seventh leading cause of death in 2007; a recent estimate suggested that diabetes was the fifth leading cause of death worldwide and was responsible for almost 4 million deaths in 2010 .

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Global Prevalence of Diabetes

Global Prevalence Estimates, 2000 and 2030

0.0% 1.0% 2.0% 3.0% 4.0% 5.0%

2000

2030 4.4 %

2.8 %

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

Diabetes in the World

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millions

India

31.731.7

China

20.820.8

USA

17.717.7

Indonesia

8.48.4

Japan

6.86.8

YearYear20002000

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

Diabetes in the World

17

millions

India

79.479.4

China

42.342.3

USA

30.330.3

Indonesia

21.321.3

Japan

8.98.9

YearYear20302030

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

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Prevalence of Diabetes in Adults United States, BRFSS* 1998 - 2003

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* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1998-2003. Atlanta, GA: United States, Department of Health and Human Services.

Prevalence of Diabetes by Sex and Year, Puerto Rico BRFSS* 1997, 2001 - 2003

20* BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Centers for Disease Control and Prevention. Behavioral

Risk Factor Surveillance System 1997-2003. Atlanta, GA: United States, Department of Health and Human Services.

0

2

4

6

8

10

12

14

16

18

20

1988-94

2005-06

1988-94

2005-06

1988-94

2005-06

1988-94

2005-06

Undiagnosed

Diagnosed

0

2

4

6

8

10

12

14

16

18

20

1988-94

2005-06

1988-94

2005-06

1988-94

2005-06

1988-94

2005-06

Undiagnosed

Diagnosed

Overall Non-HispanicWhites

Non-HispanicBlacks

Mexican-Americans

Cowie et al., 2008;

Prevalence of Total Diabetes (diagnosed and undiagnosed diabetes) in the U.S. Adult Population, age ≥ 20,

1988-1994 to 2005-2006

Problem Statement

Iceberg Disease

Increased prevalence in newly industrialized and developing countries.

Disease acquired in the most productive period of their life.

Iceberg Disease

Increased prevalence in newly industrialized and developing countries.

Disease acquired in the most productive period of their life.

Undiagnosed or inadequately treated patients develop multiple chronic complications.

Lack of awareness about interventions for prevention and management of complications.

Undiagnosed or inadequately treated patients develop multiple chronic complications.

Lack of awareness about interventions for prevention and management of complications.

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Eastern Mediterranean Health Journal, Vol. 15, No. 3, 2009 591

العدد ٢٠٠٩ عشر، الخامس المجلد العالمية، الصحة منظمة المتوسط، لشرق الصحية المجلة ،٣

Prevalence of type 2 diabetes in the

Islamic Republic of Iran: systematic

review and meta-analysisA.A Haghdoost,1,2 M. Rezazadeh-Kermani,1 B. Sadghirad 3 and H.R. Baradaran4

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Province Prevalence • Bushehr 12.62 (7.62–17.63)• Qazvin 13.09 (7.93–18.25)• Gilan 5.45 (1.78–9.13)• Isfahan 8.20 (5.23–11.17)• Kerman 13.16 (7.55–18.77)• Khorasan 9.09 (2.28–15.89)• Kordestan 3.35 (0–7.36)• Tehran 7.43 (4.04–10.81)• Yazd 14.01 (10.75–17.27)28

• Prevalence of diabetes in IRAN Year 2000 2030Diabetic patients 2,103,000 6,421,000

• Prevalence of diabetes in Yazd ProvinceYear 2000 2030Diabetic patients 145,000 442,722

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Prevalence of Diabetes in People aged ≥30 years: The Results of

Screening Program of Yazd Province, Iran, in 2012

Cross-sectional study , 2012.14993 subjects were randomly selected and

enquired by a pretested questionnaire. • Prevalence rate of known diabetes and

impaired fasting glucose was 16.3% & 11.9% respectively.

Journal of Research in Health Sciences 2014.

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• Female gender, increasing age, high blood pressure, increased BMI and positive family history, are independent risk factor for diabetes.

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DiagnosisDiagnosisand Type of Diabetesand Type of Diabetes

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Definition

Diabetes – The term diabetes mellitus describes a metabolic disorder of multiple aetiology which is characterized by hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both.

Diagnosis

Fasting plasma glucose

HgbA1C

Oral glucose tolerance test (75 gram)

Specific Criteria

FPG 126 on two separate occasions

A1C ≥ 6.5%

Symptoms of hyperglycemia and a casual plasma glucose 200

2hr plasma glucose 200 during OGTT

Classification

Type 1 Diabetes Type 2 Diabetes Other Specific Types Gestational Diabetes

Type 1 Diabetes 

ß-cell destruction, leading to absolute insulin deficiency

 Immune-mediated diabetes(common)

Idiopathic

Type 1 Diabetes

Insulitis

Pathogenesis of Type 1 DM

Genetic HLA-DR3/DR4

Environment ? Viral infe..??

Type 1 DM

May range from predominantly insulin

resistance to predominantly an insulin

secretory defect

Type 2 Diabetes

Type 2 Diabetes

Loss of ß-cells Amyloid deposits

Hyalinization

Pathogenesis of Type 2 DM

ß cell defect Genetic

Secretory Defect Insulin resistance

May require Insulinß cell exhaustion

Other Specific Types

A. Genetic defects in Beta Cell Function/ Insulin secretionB. Genetic defects in Insulin ActionC. Diseases of the Exocrine PancreasD. EndocrinopathiesE. Drug or Chemical InducedF. InfectionsG. Uncommon Immune formsH. Genetic Syndromes with Diabetes

Diseases of the pancreas

Acquired causes include Pancreatitis, Trauma, infection, panreatectomy, and pancreatic

carcinoma.

Fibrocalculous pancreatopathy

Cystic fibrosis and Hemochromatosis

Secondary DMSecondary DMSecondary causes of Diabetes mellitus include :

Acromegaly

Cushing syndrome

Thyrotoxicosis

Pheochromocytoma

Chronic pancreatitis

Pancreatic Cancer

Secondary causes of Diabetes mellitus include :

Acromegaly

Cushing syndrome

Thyrotoxicosis

Pheochromocytoma

Chronic pancreatitis

Pancreatic Cancer

Diagnosis of Gestational Diabetes

Diagnosis of Gestational Diabetes

Gestational diabetes mellitus (GDM)

(diabetes diagnosed during pregnancy

that is not clearly overt diabetes)

Screening for and diagnosis of GDM

Screening for and diagnosis of GDM

75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks of gestation in women not previously diagnosed

with overt diabetes.

OGTT : Morning after an overnight fast of at least 8 h.

75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks of gestation in women not previously diagnosed

with overt diabetes.

OGTT : Morning after an overnight fast of at least 8 h.

Screen women with GDM for persistent

diabetes at 6–12 weeks post partum , using

the OGTT and non pregnancy diagnostic

criteria.

Women with a history of GDM should

have lifelong screening for the development

of diabetes or pre diabetes at least every 3

years.

Screen women with GDM for persistent

diabetes at 6–12 weeks post partum , using

the OGTT and non pregnancy diagnostic

criteria.

Women with a history of GDM should

have lifelong screening for the development

of diabetes or pre diabetes at least every 3

years.

ScreeningScreeningWho should you screen?

Adults who are overweight (BMI>25) or obese(BMI >30) and have 1 or more additional risk factors

Routine testing for others not meeting criteria should begin at age 45

If normal repeat every 3 years or more frequently if risk status changes

Who should you screen?

Adults who are overweight (BMI>25) or obese(BMI >30) and have 1 or more additional risk factors

Routine testing for others not meeting criteria should begin at age 45

If normal repeat every 3 years or more frequently if risk status changes

Risk FactorsRisk Factorso Physical inactivityo 1st degree relative with diabeteso High risk ethnic groups(African-American, Latino-Asian- Amer , Pacific Islanders)o Women who delivered a baby >9lbs +GDMo Hypertensiono HDL<35 or TG >250o Women with PCOSo IGT or IFG on previous testingo Hx CVDo Severe obesity or acanthosis nigricans

o Physical inactivityo 1st degree relative with diabeteso High risk ethnic groups(African-American, Latino-Asian- Amer , Pacific Islanders)o Women who delivered a baby >9lbs +GDMo Hypertensiono HDL<35 or TG >250o Women with PCOSo IGT or IFG on previous testingo Hx CVDo Severe obesity or acanthosis nigricans

Screening for type 1 diabetesScreening for type 1 diabetes

Consider referring relatives of those

with type 1 diabetes for antibody testing for

risk assessment in the setting of a clinical

research study. (E)

Consider referring relatives of those

with type 1 diabetes for antibody testing for

risk assessment in the setting of a clinical

research study. (E)

People with type 1 diabetes present with acute symptoms of diabetes and markedly elevated blood glucose levels, and some cases are diagnosed with life threatening ketoacidosis.

Measurement of islet autoantibodies in relatives of those with type 1 diabetes identifies individuals who are at risk for developing type 1 diabetes.

People with type 1 diabetes present with acute symptoms of diabetes and markedly elevated blood glucose levels, and some cases are diagnosed with life threatening ketoacidosis.

Measurement of islet autoantibodies in relatives of those with type 1 diabetes identifies individuals who are at risk for developing type 1 diabetes.

Such testing ,coupled with education about

symptoms of diabetes and follow-up in an

observational clinical study, may allow earlier

identification of onset of type 1 diabetes

and lessen presentation with ketoacidosis

at time of diagnosis.

Such testing ,coupled with education about

symptoms of diabetes and follow-up in an

observational clinical study, may allow earlier

identification of onset of type 1 diabetes

and lessen presentation with ketoacidosis

at time of diagnosis.

Children-Type II ScreeningChildren-Type II Screening

Overweight(BMI>85% for age and sex, weight for height>85%, or weight > 120% of ideal for height)

Plus any 2 +

Initiate at age 10 or onset of puberty, q3yrs.

Overweight(BMI>85% for age and sex, weight for height>85%, or weight > 120% of ideal for height)

Plus any 2 +

Initiate at age 10 or onset of puberty, q3yrs.

Fam Hx DMII 1st or 2nd deg relative. Nat Amer , Latino, Asian/Amer , Pacific Islander.

Signs of Insulin Resistance (HTN, Acanthosis Nigricans ,Dyslipidemia or PCOS or small-for-gestational age

birth weight). Maternal Hx of DM or GDM.

Initial EvaluationInitial Evaluation

Hx of complications: Microvascular: Retinopathy, Nephropathy, Neuropathy. Macrovascular: CHD , PAD , Cerebro- vascular disease.

Hx of complications: Microvascular: Retinopathy, Nephropathy, Neuropathy. Macrovascular: CHD , PAD , Cerebro- vascular disease.

PREVENTION/DELAY OF T2DM

PREVENTION/DELAY OF T2DM

PREDIABETESPREDIABETES Those patients with impaired fasting glucose (100-125) or impaired glucose tolerance

(2hr between 140-199)

Both are risk factors for future DM and cardiovascular disease.

Diet and Exercise…..how much? Follow up counseling important for success Metformin may be considered

Those patients with impaired fasting glucose (100-125) or impaired glucose tolerance

(2hr between 140-199)

Both are risk factors for future DM and cardiovascular disease.

Diet and Exercise…..how much? Follow up counseling important for success Metformin may be considered

THANKS

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Prevalence of diabetes in the WHO South-East Asia Region

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• Between 1996 and 2004. In those > 40 years the prevalence was 24% and it increased by 0.4% with each year after 20 years of age. The risk of type 2 diabetes was1.7% greater in women than men

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Genetic defects of Insulin secretion

Maturity Onset Diabetes of the Young (MODY)

Six Genetic Ioci on different chromosomes have been identified to date.

Glucokinase related MODY(MODY 2) is common….but in India….HNF-4 alfa.

Usually Non ketotic / Non obese

Often in successive generations