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DR J. GIRI DIRECTOR REGIONAL DIABETIC CENTRE KG HOSPITAL COIMBATORE. DIABETES MELLITUS. AN ASIAN EPIDEMIC. DIABETES MELLITUS IS A HETEROGENOUS CHRONIC METABOLIC DISORDER. HYPERGLYCEMIA RESULTS FROM A DEFECT IN INSULIN ACTION AND / OR DEFICENCY OF INSULIN SECRETION .

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slide1

DR J. GIRI

DIRECTOR

REGIONAL DIABETIC CENTRE

KG HOSPITAL

COIMBATORE

slide2

DIABETES MELLITUS

AN

ASIAN EPIDEMIC

slide3

DIABETES MELLITUS IS A

HETEROGENOUS CHRONIC

METABOLIC DISORDER

HYPERGLYCEMIA RESULTS

FROM A DEFECT IN INSULIN

ACTION AND / OR DEFICENCY

OF INSULIN SECRETION.

slide4

In type I diabetes mellitus, the body

simply does not make insulin (5% of diabetics).

In type II diabetes, either the body does

not make enough insulin or the cells begin

to resist it (95% of diabetics).

slide5

DM : Leading cause of death and morbidity

Morbidity implies the effects due to the disease,

which reduce or mar the quality of life of the affected

person. It causes blindness, heart attack, stroke,

kidney failure and amputation.

This ailment is affecting younger people also. In the

past decade, the incidence among people in the 30\'s

has jumped by 70%. It is up by 10% among under the 30\'s.

This implies that these younger people will be

struggling with amputations, blindness and

heart disease at the prime of their life.

slide6

Diagnosis of Diabetes is for life.

  •     Entails certain lifestyle and social

restraints.

  •     Mounting therapeutic obligations
  •     Problems of employment and

Insurance.

  •     Extreme care to be exercised in

pronouncing such a diagnosis

  • Delay in diagnosis raises the risk of

tissue damage and longterm

complications

slide7

PREVALENCE

India had 19.4 million diabetics in 1995.

India will have 57.2 million patients in 2025.

India tops the list of diabetes in 1995 and 2025 also.

The world wide prevalence of diabetes

will be 300 million in 2025 of which

72 million will be in developed countries

and 228 million in developing countries,

i.e.

75% of diabetics will be in developing countries.

slide10

The rising prevalence of Diabetes world wide

4 million deaths per year related to DM.

(9% of the global total.)

slide11

Factors for Rising of Diabetic Epidemic

Genetic Predisposition

Environmental factors

Sedentary life style

Change in food habits

Stress of Urban living

Increase in population

Increasing aging population (Longevity)

High Ethnic susceptibility

slide12

Effects of Urbanisation

  •  Consumption of excess calories
  • Reduction in complex carbohydrates with
  • Increased consumption single sugars and fat.
  • Availability of energy saving methods of

transport and labour hence severely

  • Reduced physical activity.
  • Increased levels of stress.
slide13

Factors Responsible:

Unchangeable Modifiable Preventable

Male Gender Dyslipidaemia Obesity

F.H. of Diabetes mellitus Hypertension Smoking

Ageing Diabetes Alcohol

Viral infections Stress

Sedentary life style

Food habits

slide14

Natural History of Diabetes

Normal Impaired Fasting IGT Diabetes Diabetes +

Glucose Complication

Risk of Micro Vascular Diseases

Risk of Macro Vascular Diseases

slide15

OGTT – DIAGNOSTIC VALUES

TEST NORMAL IFT IGT DM

Fasting <110 110 – 125 <140 >140

(mgs%)

2 Hrs PG <140 - >140 >200

NORMAL

IFT

IGT

DM

slide16

Indications for testing for diabetes in asymptomatic,undiagnosed individuals.

Testing for diabetes should be considered in

all individuals at age 45yrs,and above and, if

normal, it should be repeated at 2 year

intervals.

Testing should be considered at a

younger age or be carried out more

frequently in individuals who:

slide17

Are obese ( BMI over  27).

  •  Those with a family history of DM

(especially first degree).

  • Those with diabetes developing during pregnancy (GDM).
  •    Mother of a big baby at birth (above 3.5 kg)

– mother prone for diabetes.

  • Low birth weight child (IUGR) – child can develop

diabetes in future.

  • Have a HDL cholesterol  35mg/dl and /or a

triglyceride level 200mg/dl.

  •  On previous testing , had IFG or IGT.
  • Are members of high risk ethnic population (South Asians)
  • Poly cystic Ovarian Disease in Females
slide18

PREVALENCE OF COMPLICATIONS

  • AT DIAGNOSIS
  • 50% OF PATIENTS HAD COMPLICATIONS AT DIAGNOSIS
  • ü      37% HAD RETINOPATHY
  • ü      18 % HAD MICROALBUMINURIA
  • ü      10% HAD PERIPHERAL
  • NEUROPATHY.
  • UKPDS
slide19

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%

slide20

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.)
slide21

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

slide22

Treatment of complications

ECONOMIC BURDEN

$ 948

Photocoagulation

Disability benefit for blindness (yearly)

$14,296

$ 15,952

Acute cardiovascular disease hospitalization

$ 31,225

Lower extremity ulcer /infection/amputation

Renal replacement treatment of ESRD (yearly)

$ 46,207

$ 3324

Multiple insulin injection (yearly)

Max SU + Metformin (yearly)

$3041

Insulin + Maximum OHA (yearly)

$2757

$1080

Evaluation for proteinuria

Preventive measures / comprehensive treatment

Vascular foot evaluation(yearly)

$124

Evaluation for neuropathy

$106

YearlyOphthal

Exam

$100

slide23

Type I (35)

6432

Type 2(576)

5928

OHA alone (395)

4722

Insulin alone/OHA (217)

8195

SEX

Male(335)

5580

Female(276)

6417

HYPERGLYCAEMIA – ECONOMIC BURDEN

Annual Direct Cost: (Background variable adjusted)

for routine treatment, not requiring hospitalisation in different settings.

Total patients 611 - - - - - - - - Rs 5959

Rayappa PH et al., Int. J. Diab. Dev. Countries. : July to September 1999

slide24

Type I (35)

6432

Type 2(576)

5928

OHA alone (395)

4722

Insulin alone/OHA (217)

8195

SEX

Male(335)

5580

Female(276)

6417

HYPERGLYCAEMIA – ECONOMIC BURDEN

Annual Direct Cost: (Background variable adjusted)

for routine treatment, not requiring hospitalisation in different settings.

Total patients 611 - - - - - - - - Rs 5959

Rayappa PH et al., Int. J. Diab. Dev. Countries. : July to September 1999

slide25

PLACE

GOVERNMENT (172)

Rs 2855

Private (439)

7176

Duration

Less than 5 years (216)

5522

5 to 14 years (277)

6240

15 plus years (118)

6063

Stay

Urban

5756

Rural

6266

HYPERGLYCAEMIA – ECONOMIC BURDEN

Rayappa PH et al., Int. J. Diab. Dev. Countries. : July to September 1999

slide26

Complications

None (185)

5606

I (168)

5616

II (134)

5954

III plus (124)

6747

HYPERGLYCAEMIA – ECONOMIC BURDEN

Rayappa PH et al., Int. J. Diab. Dev. Countries. : July to September 1999.

slide27

DIABETES AND DEPRESSION

Depression occurs at least 100% more frequently in patients with DM than in general population.

Patients with depressive disorder have more than twice the risk of developing DM Type 2 compared to patients without Depression.

slide28

New Indian Express on 18/02/2000

MAN USES SPEEDING TRAIN TO

AMPUTATE HIS GANGRENOUS FOOT

This is the tragic story of the 45-year-old man with

diabetes who developed gangrene of his foot last

September. The foot would not heal and the

resulting pain and lack of mobility meant that

he had to give up his work as a plumber. The alternative

employment he took up - selling fruits at the side

of the road – was not a success because of the foot\'s

offensive smell. No one would buy hisfruits.

slide29

Attendance of the doctors for dressing and

other treatment were costing him Rs 75/- each

time and he was told that the amputation he

needed would cost Rs 15,000.

As a consequence of this advice, he decided

to use the local train to amputate his foot.

He survived, but how long remains to be seen.

This is an effort to make sense of

cost effectiveness information on

diabetes programmes and its importance

for physicians and policy planners.

slide30

EXPECTED ECONOMIC BURDEN

DUE TO DM RELATED COMPLICATIONS

IN THE YEAR 2025

Diabetic Retinopathy Rs. 1,425 crores/ year

Assumption: 5% of DM will undergo laser therapy. Rs. 5,000 for laser treatment.

Renal Disease Rs. 28,500 crores/year

Assumption: 5% of the DM patients will need dialysis. Rs.1,00,000/ for dialysis.

Coronary Artery Disease Rs. 28,500 crores/ year.

Assumption: 5% of DM patients will need bypass surgery. Rs. 1,00,000/ for bypass.

Foot Complications Rs. 5,700 crores/year.

Assumption: 2% of DM will need surgical intervention. Rs. 50,000/ for surgery.

slide31

THE ECONOMIC BURDEN OF DIABETES

India is the ‘ Diabetes Capital of the world’

A dubious distinction

Can we afford it?

slide32

Walk more , Eat less

        • Sir GeorgeAlberti,
  • President IDF
  • Why are so many people suffering from DM in India ?
  • Ethnic predisposition
  • Indians are centrally fat. (fat around the waist)
  • Due to lack of exercise
  • Economic growth – prosperity - change in
  • dietary habits and adopting of Western style fast food
slide33

Strategies for primary prevention of macrovascular complications

Life style modifications

Diet

Exercise

Optimisation of body weight

Cessation of smoking

Reduction of mental stress

Metabolic control of Diabetes

Optimum control of Blood pressure

Drug Therapy

Aspirin

Lipid lowering agents

slide34

Annual screening for complications of Diabetes

Target organs Procedure

 Retina Visual Acuity

Opthalmoscopy

 Renal Micro albumin estimation

Macro albumin estimation

Pheripheral nerves Foot examination

10 gm monofilament for detection of loss of protective sensations

Biothesiometry

Plantar pressure measurement

 Cardiovascular ECG

Blood pressure: Supine, sitting and standing

Estimation of serum lipids

 Pheripheral vessels Palpation of all pheripharal pulsation and foot examination

Ankle/ Brachial pressure measurement (ABI)

slide35

HYPERGLYCAEMIA - PREVENTION:

FINNISH STUDY

Selection: 522 middle aged (mean 55 years)

Obese (mean BMI 31 kg/m2)

All were IGT. 

DURATION: 3.2 years.

CONTROL GROUP INTERVENTION GROUP

Brief diet Intensive individualised instruction

Exercise On weight reduction, food intake, and physical activity

RESULT: 58%, relative reduction in the incidence of diabetes in the intervention group compared with control subjects.

slide36

HYPERGLYCAEMIA - PREVENTION 

Weight control is the single most important lifestyle factor for prevention of type 2 diabetes.

Subjects: 84, 941.

ALL ARE FEMALES.

Period: 16 years.

Results: 91 % of cases of type 2 diabetes can be prevented by adhering to 5 lifestyle criteria.

Weight loss

Regular exercise

Diet modification

Abstinence from smoking

Consumption of limited amounts of alcohol

N Engl Med 2001: 345: 790-797.

slide37

HYPERGLYCAEMIA - PREVENTION:

Diabetes Prevention Program (DPP)

Selection: 3234 individuals.

Mean age 51 years.

More obese, (mean BMI 34 kg/ m2)

All were IGT.

Duration: 2.8 years.. Division: 3 groups.

Lifestyle group Intensive nutrition and exercise

Masked medication group Metformin + diet + Exercise

Placebo group Placebo + diet + exercise

Result: 31% relative reduction in the progression of diabetes in the Metformin group compared with other subjects.

slide38

What are the new developments worldwide?

Nothing new.

2000 years ago, Hippocrates said –

no exercise obesity various illnesses.

Relevant even today

Primary Diabetes Mellitus is a

lifestyle related disease.

We cannot rely on drugs to correct lifestyle.

slide39

CARRY HOME MESSAGE

GOOD METABOLIC CONTROL

BLOOD PRESSURE CONTROL

CONTROL OF SERUM LIPIDS

EARLY DETECTION OF COMPLICATIONS

 LIFE STYLE MODIFICATON

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