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Epidemiology of Diabetes Mellitus

Presenter : Dr. Pramod Kumar SahModerator : Dr. Pradeep Deshmukh

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The diabetes capital of the world

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The fact that the mostly preventable disease diabetes has become so prevalent that is

“A Public Health Humiliation”

The Lancet editorial, volume 375, Issue 9733, Page 2193, 26 june 2010.

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FRAME WORK

1. Introduction

2. Burden of DiseaseWorld,South East region, India, Maharashtra,Wardha

3. Epidemiological determinants of Diabetes

4. Evolution of Diabetes

5. prevention and Control of Diabetes

6. National programme for prevention of Diabetes.

7. Programs Initiated by Diabetes Foundation of India

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INRTODUCTION:

India has a long history with diabetes mellitus and first described by Charaka and Sushruta (1500 BCE).

It has been especially rapid since the 1990s and is strongly related to lifestyle changes brought by economic transition, industrialization, and globalization.

Becoming epidemic of diabetes places a huge burden on individuals and families, represents a drain on health resources, and threatens to derail the productivity, growth, and development of the nation.

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DEFINITION

Diabetes is a heterogeneous group of

diseases, characterized by a state of chronic

hyperglycemia, resulting from a diversity of

etiologies, environmental and genetic, acting

jointly.

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CLINICAL CLASSIFICATION

Diabetes Mellitus (DM)

Insulin-dependent DM (IDDM, Type 1)

Non Insulin dependent DM (NIDDM, Type 2)

Malnutrition related DM (MRDM)

Impaired Glucose Tolerance (IGT)

Gestational DM (GDM)

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CLASSIFICATION OF DIABETES MELLITUS BASED ON THE AGE OF THE RECOGNIZED ONSET.

Infantile or child-hood diabetes: Recognised onset between age 0 and 14 years.

Young diabetes: Recognised onset between 15 and 24 years.

Adult diabetes: Recognised onset between 25 and 64 years.

Elderly diabetes: Recognised onset over 65 years of age. (WHO TRS)

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Table : WHO (1999) criteria for the Diagnosis of Diabetes Mellitus (ICMR guidelines also have the same diagnostic criteria for India)

S. NO Categories of Hyperglycemia Glucose Concentrations mmol/l (mg/dl) plasma

1. Diabetes Mellitus

Fasting ≥7.0 (≥126)

2-hour post glucose load (75g) ≥ 11.1 (≥200)

2. Impaired Glucose Tolerance (IGT)

Fasting <7.0 (<126)

2 hour post glucose load (75g) ≥ 7.8 (≥140) and <11.1 (<200)

3. Impaired Fasting Glycemia (IFG)

Fasting ≥and <7.0 (<126) 6.1 (≥110)

2 hour post glucose load (75g) <7.8 (<140)

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NATURAL HISTORY OF TYPE 2 DIABETES

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BURDEN OF DIABETES

Global burden of Diabetes

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THE GLOBAL BURDEN

366 million people have diabetes in 2011; by 2030 this

will have risen to 552 million

The number of people with type 2 diabetes is increasing

in every country

80% of people with diabetes live in low-and middle-

income countries

The greatest number of people with diabetes are between

40 to 59 years of age

183 million people (50%) with diabetes are undiagnosed

Diabetes caused 4.6 million deaths in 2011

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.

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Global Projections for the Diabetes Epidemic: 2000-2030 (in millions)

NA19.733.972%

LAC13.333.0248%

EU17.825.141%

A+NZ1.22.065%

SSA 7.118.6261%

World2000 = 171

million2030 = 366

millionIncrease 213%

China20.842.3204%

Wild, S et al.: Global prevalence of diabetes:Estimates for 2000 and projections for 2030 Diabetes Care 2004 In press

India31.779.4251%

MEC20.152.8263%

Estimated Number of People with Diabetes Worldwide, 2010 and 2030

IDF Diabetes Atlas, 4th ed. ©International Diabetes Federation, 2009.

Country/Territory2010

Millions Country/Territory2030

Millions

1 India 50.8 1 India 87.0

2 China 43.2 2 China 62.6

3 USA 26.8 3 USA 36.0

4 Russian Federation 9.6 4 Pakistan 13.8

5 Brazil 7.6 5 Brazil 12.7

6 Germany 7.5 6 Indonesia 12.0

7 Pakistan 7.1 7 Mexico 11.9

8 Japan 7.1 8 Bangladesh 10.4

9 Indonesia 7.0 9 Russian Federation 10.3

10 Mexico 6.8 10 Egypt 8.6

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The Rising Prevalence of Diabetes In Developing Countries

0

20

40

60

80

100

120

140

20-44 Yrs 46-64 Yrs 65 Yrs

mil

lio

ns

1995 2025

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PREVALENCE T2DM IN INDIA (ICMR)

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PREVALENCE OF T2DM IN DIFFERENT HABITATS(ICMR)

Pre

vale

nce

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PREVALENCE OF T2DM IN DIFFERENT AGE-GROUP(ICMR)

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DIFFERENCE OF DIABETIC RATE AMONG NON-DIABETIC AND DIABETIC(ICMR)

Out of 7,42,736 population (>30 yr old & pregnant

mothers) screened,

Diabetes is 19,779 (2.66%). (NPCDCS)

Wardha

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ESTIMATED NUMBER OF DIABETES IN INDIA

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Factors for Rising of Diabetic Epidemic 

Environmental factors Sedentary life style Change in food habits Stress of Urban living

Increase in population

Increasing aging population (Longevity)

High Ethnic susceptibility

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RISK FACTORS RESPONSIBLE FOR DM 2:

Non-Modifiable Modifiable Preventable

Genetic Factor

Family History of Diabetes mellitus Ageing

Viral infections

Dyslipidaemia

Hypertension

Low Birth weight

ObesitySmokingAlcohol StressPhysical InactivityFood habits

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GENETIC FACTORS

Since 2007, genome-wide association studies has catalogued around 20 genes (like TCF7L2, HHEX, FTO, CDKAL1, SLC30A8 etc.) showing strong association (with modest odds ratio ranges between 1.2 to 1.5) with type2 diabetes (Sladek et al. 2007, WTCCC 2007, Scott et al. 2007, Zeggini et al. 2007).

Hypothesis Related to DM

A. Thrifty gene theory or Barker's hypothesis

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FAMILY HISTORY

Viswanathan et al. 1996 in their study found nearly 75% of the T2DM patients have first degree family history of diabetes.

The prevalence among offspring with one diabetic parent to be 36%, which increased to 54% when there, was a positive family history of diabetes on the non-diabetic parental side also.

When both parents had diabetes, the prevalence rate increased further (62%).

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PLASMA LIPIDS ANDLIPOPROTEINS LEVEL

It has been reported by various workers that T2DM patients have elevated levels of total cholesterol, LDL-Chol, VLDL-Chol, hypertriglyceridemia and reduced levels of HDLChol (Laasko et al., 1987; Demant, 2001; Petersen et al., 2002; Eschwege, 2003).

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HYPERTENSION

In San Antonio Heart Study, the odds of incident diabetes were 2.21 greater for individuals with pre-hypertension than for those with normal blood pressure (95% CI 1.63–2.98) after adjusting for age, sex, and ethnicity (Mullican et al. 2009).

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LOW/HIGH BIRTH WEIGHT(INTRA-UTERINE ENVIRONMENT

EXPOSURE)

Meta-analysis done by Whincup et al. 2008 found a combined OR of 0.75 (95% CI, 0.70-0.81) per kilogram (increase in weight) of T2DM, adjusted for age and sex, in the 28 populations. The inverse association between birth weight and T2DM risk appeared graded in all studies, particularly at birth weights of 3 kg or less.

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OBESITY

Meta-analysis done by Vazquez et al. 2007 demonstrated the pooled relative risks for incident diabetes of 1.87 (95% confidence interval (CI): 1.67-2.10), 1.87 (95% CI: 1.58-2.20), and 1.88 (95% CI: 1.61-2.19) per standard deviation of body mass index, waist circumference, and waist/hip ratio, respectively, demonstrating that these three obesity indicators are the important risk factor for diabetes.

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PHYSICAL INACTIVITY

The protective effect of physical activity in subjects with an excessive BMI and elevated glucose levels; physical activity and weight control are critical factors in diabetes prevention in subjects with both normal and impaired blood glucose regulation (Hu et al. 2004).

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DIETARY HABITS

Mohan et al. 2009 found an odds ratio (OR) of 5.3 (2.98-9.45), p-vale<.001 for Refined Grains and an OR of 0·31 (0·15, 0·62), p-vale<.001 for dietary fiber intake (inversely related).

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0 0.5 1 1.5 2 2.5 3 3.5 4

Odds ratio

Reference

2.5 times higher risk

SYNERGISTIC EFFECT OF HERITABILITY AND PHYSICAL ACTIVITY ON GLUCOSE INTOLERANCE

Mohan V et al, J Assoc Physicians India, 51:771-777, 2003

Family history negative + Physical active

Family history positive + Physical active

Family history negative + Sedentary

Family history Positive + Sedentary

2.0 times higher risk

3.0 times higher risk

Chennai Urban Population Study

Framingham Heart Study 30-Year Follow-Up:CVD Events in Patients With Diabetes (Ages 35-64)

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63819

3*30

0

2

4

6

8

10

Age-adjusted annual rate/1,000

Men Women

Total CVD

CHD Stroke

Riskratio

P<0.001 for all values except *P<0.05.

Wilson PWF, Kannel WB. In: Hyperglycemia, Diabetes and Vascular Disease. Ruderman N et al, eds. Oxford; 1992. 36

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CARDIOVASCULAR DISEASE AND DIABETES

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VASCULAR DISEASES IN TYPE 2 DM, ICMR MULTICENTRIC STUDY

Vessel Disease Male Female Large vessel diseaseCoronary artery disease 8.1% 4.7%Cerebrovascular disease 1.7% 1.8%Pheripheral vascular disease 0.6% 0.2%

Small vessel diseaseRetinopathy 16.3% 14.3%Nephropathy 15.4% 13.9% 

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Chronic complications of Diabetes.       Mortality is increased by 200%

     Heart disease and stroke rate is 200% to 400%.

     Blindness 10 times more common in diabetes.

     Gangrene and amputation of lower limbs about 20 times

more common than in non-diabetics.

     Second leading cause of fatal renal disease.

 Other chronic complication (neuropathy, infections and

sexual dysfunctions)

     As a result of diabetes, hospitalisation expense increase

by 2 to 3 folds 

(WHO expert committee on Diabetes mellitus.)

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COST OF DIABETIC CARE

Estimated annual cost of diabetes care would be Rs.9,000 crores and the average expenditure per patient per year would be a minimum of Rs 5,000/-.

For an average Indian family with an adult with Diabetes, as much as 25% of the family income may be devoted to diabetes care.

WHO

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Prevention and Control Diabetes Mellitus

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Conceptual framework of risk factors and level of prevention and management of Diabetes mellitus:

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TOOLS FOR IDENTIFYING RISK CATEGORY FOR T2DM

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METHODS OF CREATING AWARENESS

Evidence on Prevention of diabetes(Population Strategy)

North Karelia Project (Finland): A comprehensive public health programme to prevent CVD and diabetes by policy & environmental intervention in an effective, community focused manner

Interventions: Raised awareness among

-Local consumers -Schools -Social & Health services

Policy modification -Banned tobacco advertisements -Low fat and vegetable products -Change in farmer’s payment scheme -Incentives for communities achieving low cholesterol level

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EVERY 1% reduction in HBA1C

REDUCED RISK*

1%

Deaths from diabetes

Heart attacks

Microvascular complications

Peripheral vascular disorders

UKPDS 35. BMJ 2000; 321: 405-12

Lessons from UKPDS:Better control means fewer complications

-37%

-43%

*p<0.0001

-14%

-21%

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National Health programme

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National program for Prevention and control of Cancer, Diabetes, Cardiovascular diseases and Stroke (NPCDCS):

Launched during Eleventh five year plan (2007-2012).

NPCDCS is implemented in a phased manner with a pilot being done in Preparatory Phase 2006-2007

The programme is being implemented in 20000 subcentres & 700 community health centres in 100 districts spread over 21 States during 2010-2012

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CONT….

Is envisaged providing preventive, promotive, curative and supportive services at various government health facilities.

has the objective of risk reduction for prevention of non-communicable chronic diseases (Diabetes, CVD and Stroke) and early diagnosis and appropriate management of Diabetes, Cardiovascular diseases and Stroke.

The expected outcomes for the pilot phase are awareness generated on HEALTHY LIFE STYLES; Health promotion at School, Community & work places; Decrease in the incidence of Non –Communicable Diseases particularly, Diabetes, Cardiovascular Diseases and Stroke

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1. “MARG” (The Path): Focuses on primary prevention with the aim of

creating awareness about diabetes, obesity, lipid disorders and heart disease in children and adolescents in North India.

In order to enable children of age 9-18 years to disseminate messages regarding healthy living to peers and family, they are teaching children optimal dietary and lifestyle practices for prevention of lifestyle diseases.

Programs Initiated by Diabetes Foundation of India:

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2. ‘CHETNA’ (Childrens’ Health Education Through Nutrition and Health Awareness”)

Is a program which aims to impart health education on the prevention of obesity, diabetes, and heart disease in school children.

3.‘TEACHER’ (Trends in childhood nutrition and lifestyle factors in India) :

Aim is to obtain an in-depth understanding of nutrition and lifestyle behaviours that affect health and well being of urban Indians, particularly children.

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REFERENCES:

2008-2013 Action Plan for the Global Strategy for the Prevention and Control of No communicable Diseases. Geneva:WHO;2008

National programme for prevention and control of cancer, diabetes, cvd and stroke (npcdcs) –Operational Guidelines, DGHS-MOHFW

  National programme for prevention and control of cancer, diabetes, cvd and stroke

(npcdcs)- Manual for Medical Officer  NCD REPORT –WHO,Chapter 1 – Burden: mortality, morbidity and risk factors  Health System Development :Primary Health care-Current Health Challenges and

the way forward  Kishore J .National Health Programmes of India. New Delhi :Century Publications,

2011   WHO TRS 310 .

The North Karelia Project: 30 years successfully preventing chronic diseases. Diabetes voice. 2008;53: 26-9.

 

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