diabetes mellitus: epidemiology & prevention

Diabetes: epidemiology & preventionDr. S. A. Rizwan, M.D.,Assistant Professor,Dept. of Community Medicine,VMCHRI, Madurai

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Learning objectivesAt the end of this lecture you should be able to

Describe the burden of diabetes at the global and regional level

Describe the epidemiological features of diabetes Discuss the trends in diabetes prevalence over the years List out the strategies needed for prevention of diabetes Appraise the diabetes scenario in India

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Outline

Introduction

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What is diabetes?

IDF Diabetes Atlas, 2015

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Types of diabetesType 1 DMType 2 DMGestational DiabetesLADA (latent autoimmune diabetes in adults)MODY (maturity-onset diabetes of youth)Secondary DM


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DM as part of metabolic syndrome Type 2 diabetes and

cardiovascular share a common antecedent.

The concept The Metabolic Syndrome

Clustering of central obesity with several other major cardiovascular disease risk factors

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Diagnostic criteria for DM

American Diabetic Association

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Diagnostic criteria

Fasting Plasma Glucose

Post Prandial Plasma Glucose

100 200

100 200

126110

140

NormalImpaired Fasting Glucose

Impaired Glucose

ToleranceDiabetes Mellitus

OR

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Normal

FPG

PPPG

100 200

100 200

126110

140

12

IFG

FPG

PPPG

100 200

100 200

126110

140

13

IGT

FPG

PPPG

100 200

100 200

126110

140

14

DM

FPG

PPPG

100 200

100 200

126110

140

Global burden

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Number of diabetics globally


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Prevalence of diabetes globally


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Mortality due to diabetes


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Trends in diabetes burden

20The Lancet 2011 378, 31-40DOI: (10.1016/S0140-6736(11)60679-X)

Trends in diabetes burden

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Burden at a glance


Burden in India

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Top 10 countries with diabetics


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Trend of diabetics in India

Indian J Med Res 125, March 2007, pp 217-230

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Regional prevalence of DM


Epidemiological features

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Etiology of Type 1 DM

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Etiology of Type 2 DM

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Comparison between type 1 & 2 DM

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Risk factors for type 2 DM

Overweight and obesity

Physical inactivity

High-fat and low-fiber diet

Ethnicity

Family history

Age

Low birth weight

Urbanisation

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Risk factors for type 2 DM Non Modifiable

Genetic factors Age Ethnicity

Modifiable Obesity and physical inactivity

Metabolic factors: IGT, IFG and GDM

BECAUSE

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Host factors Age Sex Genetic factors: HLA DR3 and DR4

Defective immune response Central Obesity

Environmental factors Sedentary life style High saturated fat intake Malnutrition- failure of β cells Excessive alcohol Viral infections (Mumps, Rubella)

Chemical agents- Alloxan, streptozotocin, cyanide

Environmental stress


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Dietary factors Characteristics of fat intake Dairy Glycemic load “Western diet” Fast food intake Soda intake Alcohol intake


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Age distribution of DM in India


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Gender & residence


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Complications of DM

Short term effects of diabetes

Ketoacidosis Recurrent or persistent infections (including tuberculosis)

Both hyperglycaemia and hypoglycaemia may cause coma

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Complications of DM

Long term effects of diabetes1. Microvascular2. Macrovascular

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Complications of DM

Prevalence & timeline

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Complications of DM

Continuum of CVD risk

Prevention & control

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Why is the prevalence of DM increasing? Aging of the population Urbanization especially in the developing countries More sedentary lifestyle Food consumption patterns

More foods with high fat content More refined carbohydrates

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Why should we prevent diabetes? To reduce human suffering Improve Quality of Life Reduce the number of hospitalization Reduce mortality from diabetes Prevent sudden cardiac death

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Managing DiabetesThe human and economic costs of diabetes could be significantly reduced by investing in prevention, particularly early detection, in order to avoid the onset of diabetic complicationsAt least 50% of all people with diabetes are unaware of their condition


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Levels of prevention in Type 2 DM

Primary Includes activities aimed at preventing diabetes from occurring in

susceptible populations Secondary

Early diagnosis and effective control of diabetes in order to delay the progress of the disease

Tertiary Prevent complications and disabilities due to diabetes

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Primary prevention

“There is an urgent need to take the prevention of cardiovascular disease more seriously. The only sensible strategy is the population approach to primary prevention” - Beaglehole, the Lancet 2001; 358: 661-3

Why primary prevention?

M. V. Hospital for Diabetes & Diabetes Research Centre

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Primary prevention

Behavioral interventions: including changing diet and increasing physical activity

Pharmacological interventions: utilizing pharmaceutical agents to improve glucose tolerance and insulin sensitivity

Strategies

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Primary prevention

Population strategy Primordial prevention (prevention of emergence of

risk factors) Maintain body weight through adoption of healthy

nutritional habits and physical exercise High risk strategy

Sedentary life style, obesity Avoid alcohol Smoking High blood pressure Elevated cholesterol and triglyceride levels

Approaches

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Primary prevention

All of those components are risk factors for CVD and can be targeted in life style interventions to prevent Type 2 diabetes

Metabolic syndrome prevention

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Primary prevention

Diet and physical activity reduce the incidence of Type 2 diabetes.

Diet and exercise for 5 years in men with IGT reduced the incidence of Type 2 diabetes by 50%- Eriksson et al, Diabetologia 1991; 34: 891-8

Reductions in the incidence of diabetes in subjects with IGT who were randomized to diet, exercise, or combined diet-exercise treatment groups- Pan et al, Diabetes Care, 1997; 20: 537-44

Behavioral interventions

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Primary prevention

The evidence for the ability of pharmacological interventions to prevent Type 2 diabetes awaits confirmation

Metformin Pharmacological interventions

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Primary preventionEvidence from studies

0

10

20

30

40

50

60

70

Control Diet Exercise D&E

Pan et al, Diabetes Care, 1997; 20: 537-44

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Primary preventionEvidence from studies

Study Year Interventions Outcome

DaQing (China)

1997

Diet, physical activity or both (control group: general)

Reduction in diabetes incidence 31% in diet group, 46% in physical activity and 42% in diet and physical activity compared to control group

Finnish Diabetes Prevention Study

2001

Diet and physical activity (control group: general advice)

Reduction by 58% of the risk of diabetes compared to control group

Diabetes Prevention Program (USA)

2002

Diet, physical activity, metformin and placebo

58% reduction in incidence of diabetes with lifestyle intervention, 31% with metformin

STOP-NIDDM

2002

Acarbose or placebo

32% patients randomised to acarbose and 42% randomised to placebo developed diabetes

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Secondary prevention

The purpose of secondary prevention activities such as screening is to identify asymptomatic people with diabetes

Why secondary prevention?

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Population screening Selective screening Opportunistic screening

Approaches

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Urine examination Test for glucose, 2 hours after a meal Lack of sensitivity Not appropriate for case finding

Blood sugar testing “Standard oral glucose test” 2hr value after 75 g oral glucose Measure fasting, random, post prandial

Strategies

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Secondary preventionIndian Diabetes Risk Score

Interpretation:

Total score

< 30 - low risk

30-50 - medium risk

> 60 - high risk

Factors ScoreAge

<35 035-49 20

>50 30Abdominal obesity (WC)

<80 cm (F), <90 (M) 080-89 cm (F), 90-99 (M) 10

>90 cm (M), >100 (M) 20Physical activity

Vigorous labour 0Mild to moderate 20

No exercise 30Family history

None 0One parent 10

Both parents 20J Assoc Physicians India 2005; 53 : 759-63.

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Tertiary prevention

Includes actions taken to prevent and delay the development of acute or chronic complications

Why tertiary prevention?

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Tertiary prevention

Strict metabolic control, education and effective treatment

Screening for complications in their early stages when intervention is more effective

Approaches

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Tertiary prevention

Screening for diabetic retinopathy is cost-effective where subsequent treatment, such as laser treatment, is available and affordable

Where there is no access to laser treatment, good metabolic control aimed at delaying the progress of diabetic eye disease is likely to be cost-effective Screening for

eye problems

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Tertiary prevention

A number of interventions have been found to be effective in preventing foot problems

Education Pressure-relieving interventions Multidisciplinary clinics

Managing foot problems

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Tertiary prevention

Renal failure in diabetes can be detected very early by screening for ‘microalbuminuria’

However, effective treatment must be available in order to follow on from the detection of this early sign of renal failure

Screening for renal problems

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Tertiary prevention

The same basic improvements in diet and physical activity that prevent type 2 diabetes are likely to prevent CVD complications

Also, a wide range of drugs has now been proven to be effective in reducing the risk of CVD in people with diabetes, and in treating diabetes-associated CVD once it is present

Macrovascular complications

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Tertiary preventionEvidence from studies

Strategy Complication Reduction

Lipid control

· Coronary heart disease mortality

· Major coronary heart disease event

· Any atherosclerotic event· Cerebrovascular disease

event

↓36%¹↓55%¹

↓37%¹↓62%¹

Blood Pressure Control

· Cardiovascular disease· Heart failure· Stroke· Diabetes-related deaths

↓51%²↓56%³↓44%³↓32%³

Blood Glucose Control · Heart Attack ↓37%³

1 The 4S Study, 2 Hypertension Optimal Treatment (HOT) Randomised Trial, 3 UKPDS

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Major components of effective prevention programs Standardized data collection on disease magnitude, risk factors and mortality statistics. Clear action plan with specific targets, and well defined evaluation. Initiating community-based interventions for primary prevention. Advocacy for influencing policies. Advocacy for the rights of people with diabetes for quality care at all levels. Establishing acceptable standards for health care for people with diabetes. Establishing an effective referral system and defining the role of each level of health

care. Educating the population about this important global epidemic Provision of appropriate training for health care providers Coordination of prevention efforts

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Central issues in Type 2 diabetes prevention Type 2 diabetes prevention must be integrated in a major program

addressing the prevention of other lifestyle related disorders like CVD and some cancers

Primary prevention is of the essence especially in resource-constrained countries

Diabetes prevention is an inter-sectoral effort requiring cooperation and coordination

Diabetes prevention should be addressed within the context of health system reform ensuring the availability of acceptable health care standards

Culturally appropriate and economically feasible interventions should be adopted

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What do we know about Type 2 diabetes prevention? Type 2 diabetes is a major challenge to human health Type 2 diabetes can be prevented Primary prevention is a suitable and affordable choice There is strong evidence that lifestyle interventions are effective in diabetes prevention

Barriers for prevention should be addressed

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Diabetes Pyramid of Prevention

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Clinical services Glycemic control BP control Lipid management Annual eye examinations Foot care Kidney disease testing Flu immunization Preconception care Diabetes education Case Management Targeted Screening

Promotion of behaviors Education and awareness for:• Physical activity• Reduced Tobacco• Healthy diet• Regular doctor visits• Self monitoring• Self mgt education

Classic Levers in the Public HealthResponse to Diabetes

Population targeted policies• Health care access legislation• Drug and supply

reimbursement policies• Population registry and

feedback systems

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Policy Options to Influence Diabetes Risk Taxation Food and Menu labeling Engage Private Industry Crop subsidy policies Incentives/promotion for community availability and affordability of foods Incentives/promotion for community support for physical activity Regulation of foods in public areas School food and physical education policies

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Health education in DM

It is the corner stone of DM managementIt covers: Self care Changing behavior to prevent and control of complications

Encourage interaction with health care providers

Education of diabetic patients

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Nature of disease, types Clinical presentation, diagnosis, complications Types of treatment, side effects Exercise, self monitoring , avoidance and

recognition of hypoglycemia, and hyperglycemia

Foot care Pregnancy and OC Avoidance of smoking CV RFs Need for follow up Self management skills and attitudes

Contents of Educational Program

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Patients should be educated to practice self-care

This allows the patient to assume responsibility and control of his/her own diabetes management

Self-care should include: Blood glucose monitoring Body weight monitoring Foot-care Personal hygiene Healthy lifestyle/diet or physical activity Identify targets for control Stopping smoking

Diabetic Self-Care

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Individual counseling Group teaching Educational materials: posters, pamphlets, books

Special educational programs are needed for special groups as children and pregnant women

Types of education methods

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Basic understanding of DM and its managements

Training in educational methods Training of dietetics and nurses

Education of Health Professionals

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Prevention or modification of dietary habits and other life-style characteristics that link with DM

Education of the community

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Obstacles and barriers for prevention Economic problems: unavailability of needed resources Socio-cultural problems Lack of data, knowledge and skills

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Socio-cultural barriersObesity is

not considered negatively

Fad Food Culture has caught up

Changing diet is very

difficultNo value given to physical exercise

No time for physical

exercise at work

Fatalism

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Tackling socio-cultural barriersDietary

counselling

Patient education

Physical activity

Medication compliance

Aggressive follow-up

Sudden death

assessment

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NPCDS

India’s response to the growing burden of non-communicable diseases

National programme for prevention and control of diabetes, cardiovascular disease and stroke

c.

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NPCDSObjectives

AWARENESS SCREENING

CASE MANAGEMEN

T IN PHC

PRE–DIABETES & LIFE STYLE

MODIFICATIONS

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NPCDSPlan of action

GuidelinesTrainings

Detection camps in Sub centres & Main Centres

Detection / Screening Camps at institutions Regular, fixed day weekly NCD clinic at PHC Preparation of Patient Treatment Cards BCC Activities

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NPCDSKey interventions

Key Area Activities

Health Promotion

Public awareness through multi-media Counseling for healthy lifestyle (Balanced diet,

regular exercise, avoid alcohol and tobacco)

Early Diagnosis

Screening of persons above 30 years and all pregnant women for diabetes and hypertension at all levels; facilities up to Sub-centre level

Case Management

Facilities for diagnosis and treatment (NCD Clinic) at CHC level & above

CCU at District Hospital and above Treatment of cancer at District Hospital & above

Capacity Building

Infrastructure Development & Equipment Training of human resources at all levels

Management & Monitoring

NCD Cell at National, State & District level Surveillance, monitoring & evaluation Regular review meetings

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NPCDSActivities at different health care facilities

Tertiary centres Comprehensive care, research,

training, telemedicine

District HospitalDiagnosis & management of difficult cases, CCU, dialysis,

training

CHCEarly detection & appropriate treatment, health promotion

Review

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Which of the following is primary prevention of DM?a) Screening for undiagnosed casesb) Foot carec) Lipid lowering agentsd) Metformin

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Which of the following is impaired glucose tolerance?a) FPG >126b) PPPG >100 & <140c) PPPG >140 & <200d) FPG <110

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Which country is not in the top 10 countries for no. of diabetics?a) USAb) China c) Russiad) Canada

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What was the global prevalence of diabetes in 2015?a) 8.8%b) 6.5%c) 12.0%d) 3.0%

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What was the no. of diabetics in India in 2015?a) 70 millionb) 50 millionc) 100 milliond) 40 million

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Which of the following is NOT a macrovascular squeal of DM?a) Retinopathyb) Strokec) Coronary heart diseased) Peripheral vascular disease

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Which prevention strategy is most sustainable for DM in India?a) Primordial b) Primaryc) Secondaryd) Tertiary

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True about NPCDCS isa) Separate centre will be set up for stroke, DMb) Will be implemented in 10 districts in 5 statesc) CHC has facilities for diagnosis and treatment of

CVD, diabetesd) Sub-centre will provide facilities for diagnosis and

treatment

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diabetes mellitus: epidemiology & prevention

Health & Medicine