diabetes mellitus: epidemiology & prevention
TRANSCRIPT
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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Types of diabetesType 1 DMType 2 DMGestational DiabetesLADA (latent autoimmune diabetes in adults)MODY (maturity-onset diabetes of youth)Secondary DM
IDF Diabetes Atlas, 2015
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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
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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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
Risk factors for type 2 DM
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Dietary factors Characteristics of fat intake Dairy Glycemic load “Western diet” Fast food intake Soda intake Alcohol intake
Risk factors for type 2 DM
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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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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
IDF Diabetes Atlas, 2015
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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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Secondary prevention
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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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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Health education in DM
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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Health education in DM
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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Health education in DM
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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Health education in DM
Basic understanding of DM and its managements
Training in educational methods Training of dietetics and nurses
Education of Health Professionals
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Health education in DM
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
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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 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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