Epidemiology of diabetes mellitus

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

9. 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

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

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

12. 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/

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

14. 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.

15. 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

16. India vs world prevalence of diabetes

17. 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

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

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

20. Global Prevalence of Diabetes DIABETES CARE, VOLUME 27, NUMBER 5, MAY 2004

21. Diabetes in India - 2015 Total adult population (1000s) (20-79 years) 798,988 Number of deaths in adults due to diabetes 1,027,911 Prevalence of diabetes in adults (20-79 years) (%) 8.7 Cost per person with diabetes (USD) 94.9 Total cases of adults (20-79 years) with diabetes (1000s) 69,188.6 Number of cases of diabetes in adults that are undiagnosed (1000s) 36,061.1

22. 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 .

23. 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

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

25. 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%)

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

27. 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

28. 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

29. Diagnostic criteria Fasting blood glucose 2 hr PP ( 75g glucose ) NORMAL <110mg/ dL <140mg/ dL IMPAIRED GLUCOSE TOLERANCE 110-126mg/ dL 140-200mg/ dL DIABETIC >126mg/ dL > 200mg/ dL

30. 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)

31. 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)

32. 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

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

34. 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

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

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

37. 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

38. 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

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

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

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

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

43. Classification of Obesity

44. 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

45. Targets for control f Diabetes