Non-communicable diseases (NCDs) II CVDs & DM

Cardiovascular Disease 2

Introduction The worldwide burden of cardiovascular disease is substantial. In most industrialized countries, cardiovascular disease are the leading cause of disability and death. Developing countries, with previous low rate are now seeing increased rates as economic develop, infectious disease are controlled and life expectancy improves.

The world’s number one killer: 17.9 million people die each year from CVDs, an estimated 31% of all deaths worldwide. >75% of CVD deaths occur in low-income and middle-income countries. 85% of all CVD deaths (Four out of five CVD deaths ) are due to heart attacks and strokes.

Definition Cardiovascular disease refers to the class of diseases that involve the heart and blood vessels (arteries and veins). While the term technically refers to any disease that affects the cardiovascular system, it is usually used to refer to those related to atherosclerosis (arterial disease). 5

CVD are present in many forms and have different categories and include:- Hypertension (high blood pressure) Coronary heart disease (heart attack) Cerebrovascular disease (stroke) Peripheral vascular disease Heart failure Rheumatic heart disease Congenital heart disease Cardiomyopathies

Risk factors for cardiovascular disease Non-modifiable Risk Factors Age Gender, men under the age 64 are much more likely to die of coronary heart disease than women. Genetic factors/Family history of cardiovascular disease. Race (or ethnicity), Studies show that blacks are twice as likely to develop high blood pressure as Caucasians. Environment, your chances can increase because of areas with a lot of air pollution, stress , occupation, poverty and unemployment

Modifiable Risk Factors cigarette smoking high cholesterol high blood Pressure lack of exercise diabetes obesity alcohol psychosocial factors

Risk factors for CVD in Palestine CVD is estimated to cause 40% of all mortalities in Palestine. A study done to identify the most common coronary heart disease risk factors among adult population in Gaza Strip. This study showed that the most common identified CHD risk factors were :

physical inactivity 53%, hypertension and obesity 43% for each, family history 38%, diabetes mellitus 34%, high LDL 34%, elevated cholesterol level 33%, smoking 29%, low HDL 27%, and elevated triglycerides level 14%

The result of previous study seems to be that most of the identified CHD risk factors could be preventable. These results may highlight the need to community-based interventions along with health education programs.

Q: What can I do to avoid a heart attack or a stroke? The good news, according to WHO, is that 80% of premature heart attacks and strokes are preventable. Eat a healthy diet: This should include plenty of fruit and vegetables, whole grains, lean meat, fish. Restricted salt, sugar and fat intake. No Alcohol. Take regular physical activity: At least 30 minutes of regular physical activity every day helps to maintain cardiovascular fitness.

Avoid tobacco use: Tobacco in every form is very harmful to health - cigarettes, cigars, pipes, or chewable tobacco. Exposure to second-hand tobacco smoke is also dangerous. The risk of heart attack and stroke starts to drop immediately after a person stops using tobacco products. Check and control your overall CV risk:  Know your blood pressure Know your blood lipids Know your blood sugar

Diabetes Mellitus

Definition of DM Diabetes is a chronic disease characterized by elevated levels of blood glucose that occurs when the pancreas does not produce enough insulin, or alternatively, when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar

Glucose Tolerance Categories FPG 2-hr PG on OGTT mg/dL mg/dL 126 Diabetes Mellitus 200 Diabetes Mellitus 100 and <126 Prediabetes 140 and <200 Prediabetes Glucose Tolerance <100 Normal <140 Normal Slide 6 Glucose Tolerance Categories Normal and abnormal glucose levels are defined here FPG <110 mg/dL and a 2-hour plasma glucose (PG) <140 mg/dL following glucose challenge are normal FPG between 110 and 126 mg/dL is now defined as a category of impaired glucose, while the 2-hour plasma glucose challenge levels between 140 and 199 mg/dL are defined as impaired glucose tolerance 3 principal criteria have been cited by the ADA to signify the presence of diabetes mellitus, and results from each must be confirmed by repeat testing on a subsequent day Symptoms of diabetes and a casual plasma glucose 200 mg/dL FPG 126 mg/dL 2-hour plasma glucose 200 mg/dL during an OGTT Casual plasma glucose is measured without regard to the time of the last meal Measurement of FPG requires no caloric intake for 8 hours. This test is recommended for routine clinical use Once diagnosis is confirmed, A1C, which provides a measure of average blood glucose level over the preceding 2 to 3 months, is used to help monitor glycemic control The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2002;25:S5 The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2002;25(suppl):S5

Normal and diabetic blood sugar ranges For healthy individuals, normal blood sugar levels are : Between 4.0 to 5.4 mmol/L (72 to 99 mg/dL) when fasting  Up to 7.8 mmol/L (140 mg/dL) 2 hours after eating For people with diabetes, blood sugar level targets are: Before meals: 4 to 7 mmol/L (72 to 126 mg/dL) for people with type 1 or type 2 diabetes After meals: under 9 mmol/L (162 mg/dL) for people with type 1 diabetes and under 8.5 mmol/L (153 mg/dL) for people with type 2 diabetes

Conversion between mmol/l and mg/dl

Impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) refer to levels of blood glucose concentration above the normal range, but below those which are diagnostic for diabetes. (IGT) and (IFG) are intermediate conditions in the transition between normality and diabetes. Subjects with IGT and/or IFG are at substantially higher risk of developing diabetes and cardiovascular disease than those with normal glucose tolerance.

Etiologic Classification of Diabetes Mellitus b-cell destruction with lack of insulin Type 1 Insulin resistance with insulin deficiency Type 2 pancreas diseases, drug- or chemical induced Other specific types Insulin resistance with b-cell dysfunction Gestational Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997;20:1183-1197.

Complications of Diabetes Macrovascular Microvascular Brain Cerebrovascular disease Transient ischemic attack Cerebrovascular accident Cognitive impairment Eye Retinopathy Cataracts Glaucoma Heart Coronary artery disease Coronary syndrome Myocardial infarction Congestive heart failure Kidney Nephropathy Microalbuminuria Gross albuminuria Kidney failure Extremities Peripheral vascular disease Ulceration Gangrene Amputation Nerves Neuropathy Peripheral Autonomic

Key facts The number of people with diabetes has risen from 108 million in 1980 to 422 million in 2014. The global prevalence of diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014. Diabetes is a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation. In 2016, an estimated 1.6 million deaths were directly caused by diabetes. WHO estimates that diabetes was the seventh leading cause of death in 2016. Cont’d ….

Key facts People with diabetes can live long and healthy lives when their diabetes is detected and well-managed. Type 2 diabetes is much more common than type 1 diabetes. Early diagnosis and intervention is the starting point for living well with diabetes.

Prevalence of DM in Palestine Palestinian diabetes mellitus prevalence (for adults aged 25 or more) was: 9.7% in 2000, increasing to 15.3% by 2010. The forecasts were 20.6% for 2020 and 21.5% for 2030 (BMJ Open, 2013).

Diabetes prevalence forecasting between 2000 and 2030. Niveen M E Abu-Rmeileh et al. BMJ Open 2013;3:e003558 ©2013 by British Medical Journal Publishing Group

The World Diabetes Foundation (WDF) 2018: The prevalence of Diabetes in the Palestinian population in the West Bank, Gaza and E. Jerusalem is high in the range of 15.3% compared to a worldwide prevalence of 6%, however, information from numerous sources suggest the rate could be much higher (18-21%).   Of the total diabetic population in Palestine, 4.4% of persons are diagnosed with type 1 diabetes, 95.3% are diagnosed with type 2 diabetes.

Major risk factors Family history Obesity Age (older than 45) History of gestational diabetes High cholesterol Hypertension Diseases of the pancreas (infection, cancer) Sedentary lifestyle

Prevention Increased exercise Reduce calorie intake Weight reduction Decreases need for insulin Reduce calorie intake Improves insulin sensitivity Weight reduction Improves insulin action  Get plenty of fiber include fruits, vegetables, beans, whole grains and nuts improving blood sugar control and Promote weight loss

Triad of Treatment Diet Medication Exercise Lower calorie Fewer foods of “high glycemic index” Spread meals evenly Medication Oral hypoglycemics Insulins Exercise

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