epidemiology of diabetes mellitus
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Epidemiology of Diabetes mellitus
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 valuesList the preventive measures in accordance with the levels of preventionEnumerate the components of self-management in
PLAN
Definition and Classification of DiabetesBurden of diabetes mellitus (Type 2)Epidemiological determinantsClinical featuresPrevention and controlSummary
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
Classification
Type 1 diabetesLack of insulinAutoimmuneUsually childrenType 2 diabetesInsulin resistanceLifestyle factorsUsually adultsGestational diabetesInsulin resistanceDuring pregnancyRisks to mother and childImpaired Glucose tolerance (IGT)Malnutrition Related Diabetes (MRDM)Other TypesHormonalDrug InducedGenetic
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 82.5http://en.wikipedia.org/wiki/File:Diabetes_world_map_-_2000.svg
Worldwide Prevalence of Diabetes 2000-2030
Diabetes Prevalence 2013
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
http://www.diabetesatlas.org/across-the-globe.html
Proportion of Diabetes related deaths in people under 60 out of all dying due to diabetes
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/
Estimated number of diabetic subjects in India.
Epidemiology of type 2 diabetes: Indian scenario Indian J Med Res 125, March 2007, pp 217-230
Projected increase in diabetes - India
Because of “Asian Indian Phenotype”
unique clinical and biochemicalabnormalities in Indians
increased insulin resistance, greater abdominal adiposity
higher waist circumference despite lower BMI,
lower adiponectin and higher highsensitive C-reactive protein levels.
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
India vs world prevalence of diabetes
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
Secular trends in the prevalence of impaired glucose tolerance (IGT) and diabetes at Chennai
Age wise prevalence of diabetes Chennai urban rural epidemiology study (CURES) vs National Urban Diabetes Survey (NUDS) [ref 39]
Haat09i1p1.pdf
Global Prevalence of DiabetesDIABETES CARE, VOLUME 27, NUMBER 5, MAY 2004
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.
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
Risk factors Lead to
four key metabolic/physiological changes: raised blood pressure, overweight/obesity, hyperglycemia and hyperlipidemia.
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%)
Epidemiological Determinants
1. Insulin deficiency; complete or partial Pancreatic disordersInsulin synthesis abnormality Destructions of beta cells Autoimmune reaction2. Insulin Resistance
Risk factorsNon- Modifiable Risk factors
Age GenderGenetic factorsEthnicity Family History
Modifiable Risk factors
Physical inactivityDiet High saturated fat intake, salt intake Low vegetables and fruits intake Low Dietary Fibre intakeStress
Clinical features
Mostly AsymptomaticPolydipsia, Polyuria and Polyphagia
Blood sugar testing FastingPost-prandial – after a 75g glucose loadICMR-WHO guidelines for management of Type 2 DM, 2005
Table 1: Values for DiagnosisFasting 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 Type2 Diabetes Mellitus (T2DM). (May 2009)
Diagnostic values for Type 2 Diabetes Mellitus OGTTCategor
y0-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)
Complications of DM
MacrovascularCoronary heart diseaseMost common cause of death50 to 80% of all the deaths due to DiabetesMicrovascularRetinopathyNephropathyNeuropathyFoot ulcer Most common cause of disability 50% of non-traumatic amputationsComplications of DM
Primary Prevention
Healthy nutritional habits Promotion of physical activity Maintenance of ideal body weight Create awareness on lifestyle modificationEnabling Environment
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
Screening High Risk
Family History Symptoms of
Hyperglyceamia Complications of
diabetes – tiredness, burning feet, infections, balanitis
Tuberculosis Steroids Polycystic Ovarian
Disease Prematrue vascular
disease
Secondary Prevention Self Care in diabetes
Identification card Adherence to drugs and diet regimenPeriodic check ups Foot care No fasting and feasting
Follow up care
3 monthly6 monthlyAnnuallyFBG and PPBGClinical examination including BP and foot examinationReinforce life style modifications and compliance to drug treatmentHbA1cBlood urea and serum creatinineLipid profileUrine: protein/albumin; micro albuminuriaFundus examinationECG
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
Tertiary Prevention
Disability limitation and rehabilitation
Major cause of disabilityBlindnessRenal failure Gangrene of foot
Special clinics
Program for control of NCDs
National Program for control of CVD, Diabetes, Cancer, Stroke (NPCDCS)
Age-standardized prevalence of overweight in adults aged 20+ years
Age-standardized prevalence of obesity in adults aged 20+ years
Classification of Obesity
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
Targets for control f Diabetes
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