Epidemiology of Diabetes Mellitus

Diabetes mellitus is a group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. Diabetes is a major public health problem that is approaching epidemic proportions globally. As of 2013, 382 million people have diabetes worldwide= 8.3% of the adult population. In 2014, the IDF estimated that diabetes resulted in 4.9 million deaths..

The major long-term complications relate to damage to blood vessels. Diabetes doubles the risk of CVD and about 75% of deaths in diabetics are due to coronary artery disease. More than one-half of diabetic patients suffer retinopathy, nephropathy, and neuropathy. More 1/4 th of all renal failure patients results from DM.

Essential features of the (ADA) recommendations for diabetes (in non-pregnant adults) and the previous WHO recommendations Previous WHO recommendationsProvisional ADA recommendations Based on clinical stages General: Based on clinical stages Same -FPG >7.8 mmol/l (>140 mg) or -2 h PG > 11.1 mmol/l (>200 mg) an OGTT Diabetes: -Symptoms of diabetes plus ‘casual’ PG >11.1 mmol/l or - FPG >7.0 mmol/l (>126 mg) or -2 h PG >11.1 mmol/l (>200 mg) an OGTT with 75 gm or -- A1c >6.5% -Any of the above need to be confirmed on a subsequent day for the diagnosis to be made.

Essential features of the (ADA) recommendations for diabetes (in non-pregnant adults) and the previous WHO recommendations (cont.) Previous WHO recommendationsProvisional ADA recommendations SameImpaired glucose tolerance (IGT): 2 h PG >7.8 mmol/l (140) but <11.1 mmol/l (<200 mg) Impaired fasting glucose (IFG): FPG >6.1 mmol/l (>110 mg) and <7.0 mmol/l (<126 mg) Impaired fasting glucose (IFG): FPG >5.6 mmol/l (>100 mg) and <7.0 mmol/l (<126 mg) Diabetes: A1C >6.5% Dx of “pre-diabetes”: A1C range of 5.7–6.4% Diabetes: A1C >6% Dx of “pre-diabetes”: A1C range of 5.6–5.9%

Types of Diabetes Mellitus A. Non-insulin dependent diabetes mellitus (NIDDM) B. Insulin dependent diabetes mellitus (IDDM) C. Gestational diabetes mellitus (GDM) D. Induced diabetes mellitus

Prevalence of NIDDM in certain countries CountryPrevalence (ADA criteria, >20 years old) United States9.6% Pima Indians50-70% Native Indians, Canada19% England7.1% Turkey7.2% China9.8% Poland15.7% India8.6% Oman14% Jordan12.7% United Arab Emirates18.3%

National data on prevalence of NIDDM Sareeh, Sikhra, South Mazar, & Sabha13.4% - Gefgefa6% -Housha & Ramon Sareeh12.7%16.1% - National15%

Factors associated with NIDDM VariableOdds Ratio (OR)p-value Gender (M vs. F)2.0 <.001 Age(>40 vs. <40 Y)12.7 <.001 Family History DM (Y vs. N)2.5 <.001 High cholesterol (Y vs. N)1.6 <.001 High triglycerides (Y vs. N)2.1 <.001 Hypertension (Y vs. N)1.6 <.01 Body mass index (obese vs. non-obese) NS (obese& overweight vs. non-obese)*1.9 <.01 Smoking NS Source: Ajlouni et.al.: Diabetes and impaired glucose tolerance in Jordan: prevalence and associated factors. J Internal Medicine, 1998, 244; * Further analysis of data.

Frequency distribution of certain CVD risk factors by diabetic status Among Jordanian adults. VariableNIDDMGeneral population High cholesterol 44.8% 30.2% High triglycerides 45% 26.2% Hypertension (130/85)74.9% 39% Obese & overweight88.9% 83.2% Smoking13.9% 15.5% Source: Ajlouni et.al.: Diabetes and impaired glucose tolerance in Jordan: prevalence and associated factors. J Internal Medicine, 1998, 244;

Insulin-dependent diabetes mellitus (IDDM) an autoimmune disease resulting in the destruction of insulin producing cells. autoimmune diabetes, growth-onset diabetes, insulin- dependent diabetes mellitus, juvenile diabetes, juvenile-onset diabetes, ketoacidosis-prone diabetes, ketosis-prone diabetes, type I diabetes autoimmune diabetesgrowth-onset diabetesinsulin- dependent diabetes mellitusjuvenile diabetes juvenile-onset diabetesketoacidosis-prone diabetes ketosis-prone diabetestype I diabetes

IDDM= insulin dependent diabetes mellitus CA= Cancer CF= Cystic fibrosis MS=Multiple sclerosis JRA= Juvenile rheumatoid arthritis MD= Muscle dystrophy Incidence/100,000

Incidence/100,000

Incidence of Type 1 diabetes in Jordan (cases per 100,000 per year) among children age 0-4 years by year of diagnosis and gender. Year of diagnosisPopulationCasesMalesFemalesIncidence ,845, ,774, ,703, ,635, ,570, Source: Ajlouni et.al.: Incidence of insulin-dependent diabetes mellitus in Jordanian children aged 0-4 during Acta paediar suppl 427:

Gestational diabetes mellitus Gestational diabetes mellitus (GDM) is defined as “carbohydrate intolerance of variable severity with onset or first recognition during pregnancy

 Approximately, 135,000 cases of GDM, representing on average 3-8% of all pregnancies, are diagnosed annually in the US.  It is among the most common public health problem in pregnancy.  Higher incidence of GDM has been reported in ethnic groups that have a high prevalence of type 2 diabetes; figures approaching 20% have been reported in certain ethnic populations.  GDM complicates 2%-5% of pregnancies in North America health settings which is more than 10 times as common as pre-gestational diabetes.  Complications include: - maternal hypertension, - preeclampsia, - postpartum DM, - infant macrosomia, - hyperbilirubinemia, - congenital abnormalities, - stillbirth, - traumatic delivery, - infant perinatal death

Epidemiology of gestational diabetes mellitus and associated risk factors among attendants of antenatal services at Al Corniche maternity hospital, Abu Dhabi City, UAE. Study design At her first visit each singleton, non-diabetic pregnant, and at gestational age between weeks is included in the study if she satisfies one of the following criteria: 1. has a positive family history of diabetes mellitus 2. has a personal history of GDM. 3. has a body mass index more than 27. Women with abnormal FBS were treated as diabetic patients without being subjected to oral glucose tolerance test (OGTT). Only women with normal FBS were subjected to OGTT. OGTT was performed by measuring plasma glucose level at fasting and 2- hours post 75 gm of oral glucose loading.

WHO defined patient as having impaired GTT when FBS is <7.8 mmols/liter and a 2-hours plasma glucose level between 7.8mmols/liter and 11 mmols/liter. defined patient as diabetic when FBS >7.8mmols/liter or 2-hours plasma glucose >11.1mmols/liter. Pregnant with FBS >7.8 mmols/liter or 2-hours plasma glucose >11.1 mmols/liter are defined as having GDM. Results: GDM prevalence was 15.9%

Primary prevention and early detection of type 2 diabetes When looking for the opportunity to prevent type 2 diabetes, risk determinants can be viewed in terms of being either modifiable or non-modifiable. Modifiable risk factors Overweight & obesity Sedentary lifestyle Dietary factors Tobacco smoking Previously identified glucose intolerance (IFG & IGT)

Non-modifiable risk factors Age Sex Family history type 2 diabetes Genes/genetic markers Previous gestational diabetes Ethnicity

1. Primary Prevention: Life-style modifications in nutrition, physical activity and weight reduction help delay the development of Type II Diabetes in individuals at risk may be recommended for the general population. The incidence of diabetes is more likely increased in smokers. PIC-Norfolk, a UK cohort of 24,155 participants aged years, the authors assessed the association between achievement of five diabetes healthy behavior prevention goals (BMI 4 h/week) and risk of developing diabetes at follow-up (mean 4.6 years). None of the participants who met all five goals developed diabetes, whereas diabetes incidence was highest in those who did not meet any goals. Conclusion: If the entire population were able to meet one more goal, the total incidence of diabetes would be predicted to fall by 20%.

Primary prevention components of the program include:  extensive use of the mass media,  fiscal and legislative measures, and  widespread community, school, and workplace health education activities.