EPIDEMIOLOGY AND PREVENTION OF DIABETES MELLITUS DIABETES Is

EPIDEMIOLOGY AND PREVENTION OF DIABETES MELLITUS

DIABETES Is defined as a group of metabolic disorders characterised by a state of chronic hyperglycemia resulting from a diversity of etiologies, environment and genetics acting jointly.

Classification • Type 1 DM(10%) Type 1 a: Immune mediated Type 1 b: Idiopathic • Type 2 DM(80%)

• Other specific types (10%) -Genetic defect of β-cell function due to mutations in various enzymes -Genetic defect in insulin action -Disease of exocrine pancreas -Endocrinopathies -Drug or chemical induced -Infections -Uncommon forms of immune mediated DM -Other genetic syndromes • Gestational DM

Etiological classification • • Genetic diabetes Pancreatic diabetes Endocrine diabetes Iatrogenic diabetes

Differences between Type 1 and Type 2 Features Frequency Age @ onset Type of onset TYPE I 10 -20% <35 yrs Abrupt & Severe Weight Normal Family History <20% TYPE II 80 -90% >40 yrs Gradual& Insidious Obese/Non. Obese About 60%

Differences between Type 1 and Type 2 Pathogenesis Autoimmune Insulin destruction of B- Resistance Cells Blood Insulin Decreased Insulin Normal/Increased Management Insulin & Diet Oral drugs+Diet+Exer cise+Insulin

Problem Statement • DIABETES is an ICE BERG disease • IN WORLD • Current number of cases worldwide: 150 million • Predicted by 2025 - 300 million

Estimated Prevalence Of DM by WHO E Med SE Asia Eur

IN INDIA

Determinants For Increase In Diabetes In Developing Countries • Population Growth • Age Structure • Urbanization – 20% of the current global diabetic population resides in SE Asia

The population in India has an increased susceptibility to DM. This is demonstrated by multiple surveys of migrant Indians residing in Fiji, SA and Singapore

Epidemiology and Natural History • AGENT FACTORS • HOST FACTORS • ENVIRONMENTAL FACTORS

AGENT FACTORS • Cause – Insulin Deficiency – In IDDM –Absolute Deficiency – In NIDDM- Partial Deficiency • Mechanisms – Pancreatic Disorders – Defects In Insulin Formation – Destruction Of Beta Cells – Decreased Insulin Sensitivity – Genetic Defects

HOST FACTORS • Age – Prevalence Increases with Age – NIDDM – Seen In Middle Years – Prognosis is Worse in Young Diabetics

Age Specific Incidence Rates of Type I & Type II DM per 100, 000 persons –years

• Sex – In SE Asia – Increased Prevalence In Males • Genetic Factors • Genetic Markers – Only IDDM is HLA associated • Immune Mechanisms • Obesity – Increased Insulin Resistance – Implicated in NIDDM • Maternal Diabetes

ENVIRONMENTAL RISK FACTORS • Sedentary Life Style • Dietary Fibers – Intake of Whole Grain, Cereals & Veg (rich in NSP)has Potential Protective Effect • Malnutrition • Alcohol

• • Viral Infection Chemical Agent Stress Other Social Factors – Economic Status – Education – Urbanization – Lifestyles l. NOW DIABETES IS MORE COMMON IN LOWER SOCIAL CLASS WHEREAS PREVIOUSLY THE GRADIENT WAS REVERSE

Genetic Susceptibility Concordance in Identical Twins 50% Susceptibility Gene-Chromosome 6 Pathogenesis Of Type I DM Environmental Factors Viral Infections Chemicals Geographical & Seasonal Variations Auto Immune Factors Islet Cell Antibodies Insulitis Type I DM

Genetic Factors Concordance in Identical Twins-80% Both Parents Diabetic-50% Constitutional Factors 1. Obesity 2. HTN 3. Low Physical Activity Decreased Insulin Secretion Insulin Resistance Receptor & Post receptor Defects Pathogenesis Of Type II DM HYPERGLYCEMIA Type II DM

CLINICAL FEATURES Polyuria and thirst Weakness or fatigue Polyuria with weight loss Recurrent blurred vision Vulvovaginitis or pruritus Peripheral neuropathy Nocturnal enuropathy Often asymptomatic TYPE 1 ++ ++ ++ - TYPE 2 + + ++ ++

COMPLICATIONS OF DIABETES

• Acute Metabolic Complications – Diabetic Ketoacidosis – Hyperosmolar non-ketotic coma – Hypoglycaemia

• Late Systemic Complications – Atherosclerosis – Diabetic microangiopathy – Diabetic nephropathy – Diabetic neuropathy – Diabetic retinopathy – Infections

Diagnostic Tests • Urine test a. Glucosuria: Benedict’s quantitative test Dipstick method b. Ketonuria: Rothera’s test Strip test • Single blood glucose estimation: O-toludine Somogyi-Nelson Glucose oxidase

• Oral glucose tolerance test – Fasting value- <110 mg/dl (Normal) – Fasting value- 110 -126/dl (Impaired) – Post prandial- >200 mg/dl (DM) • Other test: -Glycosylated hemoglobin -Extended GTT -Intravenous GTT -Cortisone primed GTT -Insulin assay -C-peptide assay

Glycosylated Hemoglobin Test • This is an estimation of glycosylated haemoglobin at half yearly intervals. • It provides a long term index of glucose control. • It reflects the mean blood glucose levels during RBC lifetime. • Principle: – Glucose in the blood is complexed with a certain fraction of Hb to an extent proportional to the blood glucose concentration.

PREVENTION AND CONTROL • LEVELS OF PREVENTION: – Primordial prevention – Primary Prevention – Secondary Prevention – Tertiary Prevention

PRIMORDIAL PREVENTION • This is prevention of the emergence or development of risk factors in countries or population groups in which they have not yet appeared. • We direct efforts to discourage children from adopting harmful lifestyles like SMOKING, JUNK FOOD EATING.

PRIMARY PREVENTION • Population Strategy: for IDDM the scope of prevention is not developed as it is limited on the basis of current knowledge – for NIDDM its based on elimination of environmental risk factors i. e • Adoption of healthy nutrition habits • Maintenance of normal weight • Physical exercise

• High Risk Strategy: • For IDDM –no special high risk strategy. • For NIDDM – Target Population • • • Age Group 40 + Family History Obese Women Who Had Baby Weighing >4. 5 kgs Patients With Premature Atherosclerosis

– Strategy • Correction Of Obesity , Over nutrition & Sedentary Lifestyle • Avoidance Of Alcohol • Avoidance Of Smoking & factors causing HTN • Avoidance Of Diabetogenic Drugs e. g. . Oral Contraceptives

SECONDARY PREVENTION Aims: To maintain blood glucose levels as close within normal limits as is practicable. To maintain ideal body weight

New Patient Of Diabetes Type II Diet & Insulin Diet & Exercise CONTROLLED Uncontrolled Mild, Uncomplicated, Well Severe, Complications, Nourished Underweight Obese PP Hyperglycemia BG+TZD+SU CONTROLLED Uncontrolled Insulin CONTROLLED Insulin+BG

Self Care In Diabetes Mellitus • IN TYPE I DM – Insulin administration. – Self monitoring of blood glucose – Testing for urine glucose n ketones with Hemoglukotest strips. – Adjusting insulin dosage and food intake – Exercise – Should carry sugar or chocolate to prevent hypoglycemic shock

Microcellular foot wears for diabetics.

– – Foot care. Skin care. Periodic check ups. Carrying of identification card with phone no. address and details of treatment receiving. • IN TYPE II DM – Above mentioned programs. – Nutrition programme. – Weight control.

• All these mean EDUCATION of patient and their families

DIET COMPOSITION FOR DIABETICS NUTRIENT 1 - saturated fat 2 -Polyunsaturated fat 3 -monounsaturated fat 4 -total fat 5 -carbohydrate content 6 -fiber 7 -protein 8 -cholesterol % ENERGY INTAKE <7% Upto 10% Upto 20% 25%-35% 50%-60% 20 -30 gm/day 1 gm/kg body wt <200 mg/day

CURRENT MEDICAL NUTRITION THERAPY • Aim for a healthy weight. • Choose a variety of grains daily especially cereals. • Choose a variety of fruits and vegetables daily. • Choose a diet low in cholesterol & saturated fat. • Moderate intake of sugars

• Choose & prepare food with less salt. • Cut down on alcohol.

PLATE MODEL FOR MEAL PLANNING The plate is divided into 3 sections. the smallest section(20% of total area) is for meat, fish, eggs or cheese. The remainder is divided equally between staple food and veg. or fruits.

Staple Food – Rice Fish, meat or cheese Veg. & Fruits Plate Model For Meal Planning

Tertiary Prevention • AIM: – To organize specialized clinics (DIABETIC CLINICS) capable of providing diagnostic & management skills to prevent complications like blindness, kidney failure, gangrene etc. – To establish local registers for diabetics.

NATIONAL DIABETES CONTROL PROGRAM • Started on a pilot basis during 7 th five year plan in Tamilnadu, Karnataka, Jammu&Kashmir. • OBJECTIVES– – Identification of high risk sub. at an early age. Impart health education. Early diagnosis & management of cases. Arrest of acute metabolic & chronic cardiovascular & renal complications.

WHO Slogan “A Full Life Despite Diabetes ” • In 2006 – “ Diabetic Care For Everyone”

CONCLUSION `“No oils , no fats, no food fads” should be the diabetic mantra in India