Geo Data Institute, University of Southampton

Prevention of Diabetes and the Care ofPeople with Diabetes

M G Sayyad, KEM Hospital and Research Centre, Pune, India.

A L Searle, School of Mathematics, University of Southampton, UK.

A K Shahani, School of Mathematics and GeoData Institue, University of Southampton, UK.

J A Shirodkar, KEM Hospital and Research Centre, Pune, India.

C S Yajnik, KEM Hospital and Research Centre, Pune, India.

Prevention of Diabetes and the Care ofPeople with Diabetes

Outline of Presentation

• Diabetes

• History of diabetes

• Western and Indian Ayurvedic classifications

• Data Analysis and Modelling for control of diabetes

• Concluding remarks

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Diabetes

Problems with body’s carbohydrates metabolism

Excess glucose in blood

Many serious consequences. e.g. Kidney failure, blindness

Damage to body’s systems specially blood vessels and nerves

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A History of Diabetes

5000 BC Ancient Indian scriptures (Rig and Athrava vedas) mention health and diseases including 20 types of “obstinate urinary disorders” (Prameha).Pra = Abundance Meha = UrinePrameha= Passing of excessive urine

About 1000 BC Ayurvedic texts of Indian physicians Charak and Sushruta discuss classification, causes,prevention, and treatment of Prameha.

2nd Century AD The word Diabetes is used to describe passing of excessive urine

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A History of Diabetes

• Discovery that damaged pancreas, and in particular damage to a cluster of cells called Islets of Langerhans causes diabetes.• Mellitus is added to the word diabetes to distinguish the condition of excess glucose in urine from other urinary disorders.

19th Century

1922 Insulin is discovered. Injection of manufactured Insulin becomes a major advance for controlling diabetes.

Diabetes

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• Diabetes is a major, and a growing, health problem

• In year 2000, 3.2 million deaths due to diabetes.

• About 194 million people worldwide have diabetes.

• India had about 31.7 million people with diabetes in 2000. There could be about 80 million people with diabetes by 2030. • World’s diabetic population is estimated to double from 110 million in 1994 to 220 million by 2010.

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Classification of Diabetes

• Type 1 Diabetes Mellitus (Insulin dependent, IDDM)

•Type 2 Diabetes Mellitus (Non insulin dependent, NIDDM)

•Gestational Diabetes Mellitus(GDM)

•Pancreatic Diabetes Mellitus (FCPD, PDDM)

•Malnutrition Related Diabetes Mellitus (MRDM)

•Other

Classification of Diabetes

Type 1 Diabetes (IDDM)

• Usually in children and young adults• Severe symptoms, Sudden onset• Life long insulin

treatment• 5% to 10% of all diabetic cases

• Usually in adults• Mild symptoms, chronic

course• Various complications• Treated with diet,

exercise, tablets and insulin

• 90% to 95% of all diabetic cases

Type 2 Diabetes (NIDDM)

Ayurvedic Classification of Prameha

Prameha

Apathyanimittaja (Inherited)

defect in genetic

substance in mother or father

Sahaja (Acquired)

Over-eating

Lack of exercise

Note correspondencewith the “modern” Classification of Type 1and Type 2 diabetes

krisha

Lean body

Sthula

Obese body

VatajaUncurable Prameha

PittajaMaintainable Prameha

KaphajaCurable Prameha

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Causes of Type 2 Diabetes

• Wisdom of Sushruta: Oversleeping, lack of exercise, overeating, especially sweet and fatty things, are the primary causes of prameha.

• Modern knowledge: Obesity, smoking, and lack of exercise are risk factors for developing diabetes

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Diagnosis of Diabetes

• Commonest symptom is ‘no symptom’• Rapid weight change • General weakness • Recurrent infections• Excess urine• Excess thirst • Excess hunger• Delivering large weight babies

Level of glucose in blood has to be measured for detecting Diabetes

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Diagnosis of Prameha

• In the absence of measurement of blood glucose levels, signs and symptoms for diagnosing Prameha include:

• Colour, taste, smell, and other characteristics of urine

• Family history of Prameha

• Coating on teeth

• Secretion from eyes/nose,

• burning/cracked palms and soles

• thirst

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Obesity

• Obesity is a major risk factor for diabetes and Prameha

• Body Mass Index (BMI) = Weight / Height2 is used to define obesity.

Underweight: BMI <18.5 Normal weight: BMI in range 18.5–24.9

Overweight: BMI in range 25.0–29.9 Obese: BMI >30.0

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Obesity

• Indians have more body fat for a given BMI “Normal” BMI range for Indians = 20-23 kg/m2 BMI of obese Indians >23 kg/m2

•Dr Yajnik and his colleagues have demonstrated that central obesity, measured by Waist to Hip Ratio (WHR), is a good measure of risk of diabetes.

WHR = Waist circumference / Hip circumferenceObese Men: WHR > 0.95

Obese Women: WHR > 0.85

Obesity

• Obesity is a major and a growing health problem in many countries.

• Obesity in England has increased by about 400% in the past 25 years.

• At present about 2/3 of the population in England are overweight or obese.

• Diet and life style changes are major challenges for many obese people.

• Effectiveness of Ayurveda for controlling obesity?

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Control of Diabetes

Diabetes Control

Diet

ExerciseMedication

Education Regular monitoring

A Model for Preventing

and Treating Type 2 Diabetes Normal Glucose

Tolerance

Normal GlucoseTolerance

Type 2 Diabetes

Diabetic complications

Death

Risk factors Risk factors

Risk factors

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Wellcome Diabetes Study

Geo Data Institute, University of Southampton

Wellcome Diabetes Study

Geo Data Institute, University of Southampton

Wellcome Diabetes Study

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Wellcome Diabetes Study

Model Results for Effects of Treatments

Modelling Nephropathy

Transition Probabilities and Transition Times

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• Analysis of the Wellcome Diabetes Study provided estimates of the probabilities of transitions between the various states of the “Nephropathy” model

• Transition times were assumed to be Weibull variates.

• Analysis of the Wellcome Diabetes Study provided estimates the parameters of the various Weibull distributions.

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Selected Interventions

• Control of blood glucose

• Control of high blood pressure

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Risk Groups for Nephropathy

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Model Results for Effects of Treatments

Intervention Option

No Intervention Hypertension Glucose

OvertProteinuria n%

683 (644, 724)13.6 (12.8, 14.48)

143 (109,179) 2.9 (2.1, 3.5)

165 (156,173)3.3 (3.12, 3.46)

Chronic Renal Failure Patients n%

609 (558, 660)12.8 (11.8, 13.2)

20 (8,31)0.4 ( 0.2, 0.6)

26 (23,36)0.5 (0.4,0.7)

End Stage Renal Failure Patients n%

451 (409,494)9 (8.2, 9.9)

13 (11,24)0.26 (0.2, 0.5)

17 (7,27)0.34 ( 0.1, 0.5)

Kidney Transplants n%

21 (10, 31)0.5 (0.2,0.6)

1 (0,3)0.02 (0,0.06)

1 (0,3) 0.02 (0,0.06)

Deaths n%

1428 (1371, 1486)28.5 (27.4 ,29.7)

1185 (1131,1239)22 (21.1, 22.9)

1141 (1103, 1246)22.8 (22.3, 23.3)

Costs (Millions of Rupees) 44.6 ( 34.7, 54.6) 489.3 (486.7, 491.9) 395.3 (392.7, 398.0)

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High Blood Pressure Treatment: Deaths over time

Death

0

200

400

600

800

1000

1200

14003 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

Time (yrs)

No

of P

aien

ts

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Concluding Remarks

• Diabetes is a major threat to the health of many nations

• Control of blood glucose, blood pressure, and obesity will control diabetes.

• Side effects of the western drugs?

• Combination of the Eastern wisdom of Ayurveda and western Science is likely to be a powerful combination for controlling diabetes.