WORLD HEALTH DAY 2016

• DR M A PARANDE ASSOCIATE PROFESSOR DEPT OF COMMUNITY MEDICINE BJGMC, PUNE

Diabetes

• Diabetes and its types• Aim of WHD, Theme, slogan• Problem- halt the rise• Epidemiology of diabetes• Clinical features and complications• Diagnosis• Prevention and Control

• Yoga and diabetes – Akurte Madam

100% Growth in Diabetes Patients in India in the Last 15 YearsDiabetics in India up 100% to 63m in 13 years

Let us build a healthier India by defeating diabetes : PM

GLOBAL HEALTH EMERGENCY OF 21ST CENTURY

WHO warns against diabetes epidemic

DIABETES

• First described in the Egyptian script(1500BCE)• Diabetes(ancient Greek, first used 230BCE) :- a

passer through; siphon(owing to the excess of urine passage in the patients)

• Milletus: ( latin) : sweetened with honey• Madhumeha:( Honey urine): since it attracted

ants.

DEFINITION

Diabetes is a heterogeneous group of diseases,

characterized by a state of chronic

hyperglycemia, resulting from a diversity of

etiologies, environmental & genetic, often acting

jointly.

Destruction of Pancreatic Islets & decreased insulin

Insulin secretary defect/ Insulin

Resistance

Cells unable to utilize glucose

Excessive glucose in blood while cells are

starving

Symptoms of DM like polyurea,

polydypsia and weight loss

Complications due to DM like

retinopathy, neuropathy &

infections

In diabetes, the cells' inability to utilize glucose gives rise to the ironic situation of "starvation in the midst of plenty". The abundant, unutilized glucose is wastefully excreted in the urine.

CLASSIFICATION (W.H.O)

1. Diabetes Mellitusa) Insulin Dependent Diabetes Mellitus (Type 1)b) Non-Insulin Dependent Diabetes Mellitus (Type 2) c) Malnutrition Related Diabetes Mellitus . d )Other types (Secondary to Pancreatic, Hormonal, drug induced, genetic & other abnormalities.)2. Impaired Glucose Tolerance.3. Gestational Diabetes Mellitus.

Type 1 diabetes• Autoimmune reaction against beta cells of pancreas.• Body can no longer produce the insulin. • Can affect people of any age, but onset usually

occurs in children or young adults.• Need insulin every day in order to control the

levels of glucose in their blood.• Without insulin, a person with type 1 diabetes

will die.

Type 2 Diabetes

• Common• Gradual onset• Silent• > 30 yrs. • Mild• Other diseases

INDIAN DIABETES

• LADA- Latent Autoimmune Diabetes of Adults

• Type 1.5

• Early start at 25 yrs, initial well controlled with

oral hypoglycaemic and then shifted to insulin

Gestational diabetes

• Blood sugar elevation during pregnancy • usually resolves once the baby is born• However, 25%-50% of women with gestational

diabetes will eventually develop type 2 diabetes later in life

• Patients with gestational diabetes are usually asked to undergo an oral glucose tolerance test about six weeks after giving birth

Theme - Diabetes• Goal of World Health Day 2016:

• Scale up prevention • strengthen care and • enhance surveillance

Slogan- Halt the rise: Beat diabetes

Diabetes: A public health problem

Halt the rise

52% 48%

Halt the rise

64% 36%

DEATHS 7th leading cause of death

Type-1 diabetes- children(global)Annual increase in cases- 3%

First time cases in children exceeded half a million

Top 10 countries- expenditure on diabetes

India is nowhere in top 10

Impaired Glucose Tolerance(IGT)

• 318 million(6.7% adults) have IGT(2015)• 2040- Projected adults with IGT= 7.8% of

adults.• 69.2% of them live in middle & low income

countries.• IGT – Increased risk of developing type 2 DM

increased risk of CVS disorder in future.

Top 10 countries- IGT(2015 & 2040)India at top

SEAR and India8.5% adults have diabetes

52.1% undiagnosed with diabetes.

Highest prevalence in Mauritius

India 2nd highest in prevalence in Diabetes.

India- 77.2million prediabetes

ComparisonREGION Prevalence No of people

suffering from diabetes(millions)

Undiagnosed diabetes

Mean diabetes related expenditure per person with DM

World 8.8% 415 46% 1622

SEAR 8.5% 78.3 51% 92.9

India 8.7% 69.2 52% 94.9

Maharashtra

• ICMR study- Highest prevalence- kerala- 19-20% Lowest- Kashmir-6.1%Maharashtra- Urban- 9.3% rural – 6-7% 9.2 million cases, 14% IGTPune – Urban -12- 19%(newly detected were young) Rural- 9.1%

EPIDEMIOLOGY

• AGENT FACTORS-• Pancreatic disorders• Defects in formation of insulin• Destruction of beta-cells• Decreased insulin sensitivity• Genetic defects• Autoimmunity

EPIDEMIOLOGY (contd)

• HOST FACTORS:• Age• Sex• Genetic Factors• Genetic Markers• Autoimmune Mechanisms• Obesity• Maternal diabetes - LBW

EPIDEMIOLOGY (contd)

• ENVIRONMENTAL FACTORS:• Diet• Sedentary lifestyle• Dietary fiber • malnutrition• Alcohol• Viral infections• Chemical agents• Stress

RISK FACTORS FOR TYPE 2 D.M.

• Family history• Obesity (BMI >25 kg/m2)• Habitual physical inactivity• Race/ethnicity• Previously identified IGT or IFT.• History of GDM or delivery of baby >4 kg • Hypertension (130/85)• HDL cholesterol level <40 mg/dL and/or a triglyceride level

>150 mg/dL .• Polycystic ovarian syndrome or acanthosis nigricans.• History of vascular disease

Syndrome X

Insulin Resistance

dyslipedimia

Obesity

Diabetes Mellitus

Hypertension

Accelerated CVS Disease

Treatment

Classification BMI (kg/m2)

Risk of co-morbidities

Waist circumference< 90 cm (men)< 80 cm (women)

≥ 90 cm (men)≥ 80 cm (women)

Waist Hip ratio<0.95(men) >0.95(men)<0.85(women) >0.85(women)

Underweight <18.5 Low (but risk of other clinical problems increased)

Average

Normal range 18.5-22.9 Average IncreasedOverweight ≥23

At risk 23.0-24.9 Increased ModerateObese I 25-29.9 Moderate SevereObese II ≥ 30.0 Severe Very severe

Clinical features• Increased urine output(polyuria)• Increased thirst and dehydration(polydipsia)• Weight loss despite of increased appetite• Fatigue, nausea and vomiting• Recurrent infections• Blurred vision

Complications

Investigations

• Fasting blood glucose Retina examination• Post prandial Kidney function test• BP ECG• HbA1C Foot examination

Diagnostic Criteria for Pre diabetes and Diabetes in Nonpregnant Adults

Normal High Risk for Diabetes Diabetes

FPG <110 mg/dL IFGFPG ≥110-125 mg/dL FPG ≥126 mg/dL

2-h PG <140 mg/dL IGT2-h PG ≥140-199 mg/dL

2-h PG ≥200 mg/dLRandom PG ≥200 mg/dL + symptoms*

A1C <5.5% 5.5 to 6.4%For screening of prediabetes†

≥6.5%Secondary‡

rule of “thirds” – about one third of prediabetic people will develop diabetes in the next five years, one third will remain prediabetic, while one third will revert to normal

Normal Complications

Death

Prediabetes - the harbinger of future diabetes

Diagnostic Criteria for Gestational Diabetes

Test Screen at 24-28 weeks gestation

FPG, mg/dL >92

1-h PG*, mg/dL ≥180

2-h PG*, mg/dL ≥153

3-h PG*, mg/dL ≥140

*Measured with an OGTT performed 2 hours after 75-g oral glucose load.

CMGS

PREVENTION AND CONTROL• Follow medical advice –treatment and

follow up

• Diet

• Exercise

• Lifestyle modifications

• Marriage counselling

Treatment- Oral hypoglycemic drugs

Insulin

Follow up- 3 mthly

The glycemic index - is a tool that allows you to see how the fruits, vegetables and other carbohydrates you eat affect your blood sugar levels.

Glycemic Index Reference Range• High Glycemic Index 70-100• Moderate Glycemic Index 50-70• Low Glycemic Index <50

Eat healthy

Be physically activeModern smoking continous sitting > 2hrs= 1 cigarette smoking

TV watching – 1hr= 2% wt gain/yr

Take the stairs rather than the elevator, park at the far end of the parking lot, walk while talking on the phone, or walk to your co-worker’s desk rather than emailing him or her.

Life style modifications

NPCDCS

• Diabetes, CV Diseases and stroke• Involvement of primary health care staff• CHC- Basic investigations• DH- and tertiary care hospital

• URBAN- Screening > 30 YRS, yearly basis, all pregnant mothers

Diabetes clinic in SGH-EVERY Wednesday -2-4pmH1N1 vaccine- all diabetics

Screening camp – daily from 1st April to 7th April

Poster competition and exhibition- 6th April

• Health care partner• Knowledge• Motivate- healthy life style• Lead by example• Be a change agent

THANK YOU

AKURTE MADAM