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