1. Epidemiology of Diabetes Mellitus 1 Presenter : Dr. Pramod Kumar SahModerator : Dr. Pradeep Deshmukh

2. The diabetes capital of the world 2

3. 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. 3

4. F RAME WORK 1. Introduction 2. Burden of Disease World, 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 4

5. I NRTODUCTION : 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. 5

6. D EFINITION 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. 6

7. C LINICAL C LASSIFICATION 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) 7

8. C LASSIFICATION OF D IABETES M ELLITUS 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) 8

9. 9 Table : WHO (1999) criteria for the Diagnosis of Diabetes Mellitus (ICMR guidelines also have the same diagnostic criteria for India) S. NOCategories of HyperglycemiaGlucose 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)

10. N ATURAL H ISTORY OF T YPE 2 D IABETES 10

11. B URDEN OF DIABETES Global burden of Diabetes 11

12. T HE 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 12

13. G LOBAL P REVALENCE E STIMATES, 2000 AND 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.

14. Global Projections for the Diabetes Epidemic: 2000-2030 (in millions) NA 19.7 33.9 72% LAC 13.3 33.0 248% EU 17.8 25.1 41% A+N Z 1.2 2.0 65% SSA 7.1 18.6 261% World 2000 = 171 million 2030 = 366 million Increase 213% China 20.8 42.3 204% Wild, S et al.: Global prevalence of diabetes: Estimates for 2000 and projections for 2030 Diabetes Care 2004 In press India 31.7 79.4 251% MEC 20.1 52.8 263% 14

15. Estimated Number of People with Diabetes Worldwide, 2010 and 2030 IDF Diabetes Atlas, 4 th ed. ©International Diabetes Federation, 2009. Country/Territory 2010Millions Country/Territory 2030Millions 1India 50.8 1India 87.0 2China 43.2 2China 62.6 3USA 26.8 3USA 36.0 4Russian Federation 9.6 4Pakistan 13.8 5Brazil 7.6 5Brazil 12.7 6Germany 7.5 6Indonesia 12.0 7Pakistan 7.1 7Mexico 11.9 8Japan 7.1 8Bangladesh 10.4 9Indonesia 7.0 9Russian Federation 10.3 10Mexico 6.8 10Egypt 8.6 15

16. The rising prevalence of Diabetes world wide 4 million deaths per year related to DM. (9% of the global total.) 16

17. The Rising Prevalence of Diabetes In Developing Countries 17

18. P REVALENCE T2DM IN I NDIA (ICMR) 18

19. P REVALENCE OF T2DM IN DIFFERENT HABITATS (ICMR) 19 Prevalence

20. P REVALENCE OF T2DM IN DIFFERENT AGE - GROUP (ICMR) 20

21. D IFFERENCE OF DIABETIC RATE AMONG NON - DIABETIC AND DIABETIC (ICMR) 21

22.  Out of 7,42,736 population (>30 yr old & pregnant mothers) screened,  Diabetes is 19,779 (2.66%). (NPCDCS) Wardha

23. E STIMATED N UMBER OF DIABETES IN I NDIA 23

24. 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 24

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26. R ISK F ACTORS R ESPONSIBLE F OR DM 2: Non-Modifiable ModifiablePreventable  Genetic Factor Genetic Factor  Family History of Diabetes mellitusFamily History of Diabetes mellitus  Ageing  Viral infections  Dyslipidaemia Dyslipidaemia  Hypertension Hypertension  Low Birth weight Low Birth weight  Obesity Obesity  Smoking  Alcohol  Stress  Physical Inactivity Physical Inactivity  Food habits Food habits 26

27. G ENETIC 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 27

28. F AMILY H ISTORY  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%). 28

29. P LASMA L IPIDS AND L IPOPROTEINS L EVEL 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). 29

30. H YPERTENSION 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). 30

31. L OW /H IGH B IRTH W EIGHT (I NTRA - UTERINE E NVIRONMENT 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. 31

32. O BESITY 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. 32

33. P HYSICAL I NACTIVITY 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 ). 33

34. D IETARY H ABITS 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). 34

35. 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 35

36. Framingham Heart Study 30-Year Follow-Up: CVD Events in Patients With Diabetes (Ages 35-64) 20 6 38 19 3* 30 0 2 4 6 8 10 Age-adjusted annual rate/1,000 MenWomen Total CVD CHD Stroke Risk ratio 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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38. C ARDIOVASCULAR D ISEASE AND D IABETES 38

39. VASCULAR DISEASES IN TYPE 2 DM, ICMR MULTICENTRIC STUDY Vessel Disease Male Female Large vessel disease Coronary artery disease 8.1% 4.7% Cerebrovascular disease 1.7% 1.8% Pheripheral vascular disease 0.6% 0.2% Small vessel disease Retinopathy 16.3% 14.3% Nephropathy 15.4% 13.9% 39

40. 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.) 40

41. 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 41

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43. 5. P REVENTION AND C ONTROL OF D IABETES : Preventive Strategies for Diabetes 1. Primordial Prevention 2. Primary prevention (a) Population Strategy - Mass Approach - Targeted Group approach (b) Targeted High Risk Individual Strategy 3. Secondary Prevention 4. Tertiary Prevention 43

44. Conceptual framework of risk factors and level of prevention and management of Diabetes mellitus: 44

45. T OOLS FOR IDENTIFYING RISK CATEGORY FOR T2DM 45

46. M ETHODS OF CREATING AWARENESS 46

47. 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

48. EVERY 1% reduction in HBA 1C 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<0.000 1 -14% -21% 48

49. National Health programme 49

50. 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 50

51. C ONT …. 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 51

52. 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: 52

53. ` 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. 53

54. R EFERENCES : 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. 54

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