Non-Communicable Diseases with Special Reference to Type 2 Diabetes Mellitus

1. Non-Communicable Diseaseswith Special Reference to Type 2 Diabetes Mellitus Prof. (emeritus) Dr. med. Frank P. Schelp

2. Figure 1: Stages of Health, Nutritional, and Demographic Change Demographic Transition Epidemiologic Transition Nutrition Transition High fertility/mortality High prevalence infectious disease High prevalence undernutrition Reduced mortality, changing age structure Receding pestilence, poor environmental conditions Receding famine Focus on family planning, infectious disease control Focus on famine alleviation/prevention Diet-related Non-communicable diseases predominate Reduced fertility, aging Chronic diseases predominate Focus on healthy aging spatial redistribution Focus on medical intervention, policy initiatives, behavioral change Source: Popkin, Barry M. ( 2002)Public Health Nutrition 5:93-103.

3. Global deaths situation in perspective • From 58 million death in 2005 • 60% caused by chronic diseases • 30% by infectious diseases including • HIV/AIDS • Tuberculosis • Malaria • Maternal and prenatal conditions • Nutritional deficiencies • 9% caused by violence and injuries • 45% of chronic disease deaths occur prematurely (under the age of 70)

5. Chronic diseases* are …. ”diseases which have one or more of the following characteristics: they are permanent, leave residual disability, are caused by nonreversible pathological alteration, require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation or care”. *also called “non-communicable diseases” or “Lifestyle-related diseases” Aha

6. Chronic diseases according to WHO • Cardiovascular diseases • Cancers • Chronic respiratory disorders • Diabetes • Neuropsychatric and sense organ disorders • Musculoskeletal and oral disorders • Digestive diseases • Genito-urinary diseases • Congenital abnormalities and skin diseases

7. Main chronic diseases* • Cardio vascular diseases • Heart disease • Stroke • Diabetes • Cancer • Chronic respiratory diseases • *”Best Buys” WHO 2011

8. Common modifiable risk factors • Unhealthy diet • Physical inactivity • Tobacco use Non-modifiable risk factors • Age • Gender • Heredity

9. Intermediate risk factors • Raised blood pressure • Raised blood glucose • Abnormal blood lipids • Overweight/obesity

10. Cancer

11. Cancers in Tropical and Less-industrialised Countries • Cancers exotic for tropical countries mainly • Burkitt‘s Lymphoma • Cancers more prevalent in tropical countries and less prevalent in industrialised countries • Bile duct cancer (cholangiocarcinoma) • Cancers highly prevalent in highly- and less industrialised countries but with different characteristics • Bladder cancer • Cancers highly prevalent in industrialised- and less-industrialised countries • Lung cancer

12. ‘Metabolic syndrome’ Medical disorder - increase risk of developing • Cardiovascular disease • Diabetes mellitus type 2 • High blood pressure • Central obesity (also known as visceral, male-pattern or apple-shaped adiposity) • Overweight with fat deposits mainly around the waist • Decreased HDL cholesterol; • Elevated triglycerides

13. Definition according to American Heart Association/Updated NCEP (National Cholesterol Education Program) • Elevated waist circumference: • Men — Equal to or greater than 102 cm • Women — Equal to or greater than 88 cm • Elevated triglycerides: Equal to or greater than 150 mg/dL • Reduced HDL (“good”) cholesterol: • Men — Less than 40 mg/dL • Women — Less than 50 mg/dL • Elevated blood pressure: Equal to or greater than 130/85 mm Hg or use of medication for hypertension • Elevated fasting glucose: Equal to or greater than 100 mg/dL (5.6 mmol/L) or use of medication for hyperglycemia

14. Controversy • Different sets of conflicting and incomplete diagnostic criteria • Is the metabolic syndrome anything more than the sum of its constituent parts? • Generally, the individual disorders that comprise the metabolic syndrome are treated separately

15. Associated diseases to overnutrition • Diabetes type 2 • Hypercholesterolemia • High plasma triglycerides • Hypertension • Heart disease • Cancer • Gallstones • Arthritis • Gout • Fertility and pregnancy problems • Sleep apnea • Social- and emotional consequences

16. Diabetes mellitus • Diabetes is a chronic disease - increased concentration of glucose in the blood (hyperglycaemia). • Type 1 diabetes (previously known as insulin-dependent or childhood-onset diabetes) - lack of insulin production. • Type 2 diabetes (formerly called non-insulin-dependent or adult-onset diabetes) - ineffective use of insulin. • It often results from excess body weight and physical inactivity. • Gestational diabetes - hyperglycaemia recognized during pregnancy

18. Risk Factors of Diabetes Type 2 • Excessive carbohydrate intake (i.e. glycogenic index is high in connection with rice as major energy source) • Urban lifestyle • Obesity • Drugs (diuretics – thiazide type; steroids; steroids used in oral contraceptives – induce diabetes in susceptible individuals) • Genetic factors

19. Diagnosis • Fasting Plasma Glucose • Normal level less than 110 mg/dl • Pre-diabetes- between 110 and 125 mg/dl • Diabetes - greater than or equal to 126 mg/dl • Casual Plasma Glucose/Random Plasma Glucose • Glucose value of greater than or equal to 200 mg/dl • Glycated hemoglobin (HbA1c) • Levels over 6.4% indicative for type 2 DM

20. Glycated hemoglobin • HbA1c is a test that measures the amount of glycated hemoglobin Glycated hemoglobin is a substance in red blood cells formed when blood sugar (glucose) attaches to hemoglobin. • An HbA1c of 6.4% or less is normal

21. Oral Glucose Tolerance • Blood glucose is measured before and after a person has taken a thick, sweet drink of glucose and other sugars. • For someone with diabetes, the glucose value remains high (greater than or equal to 200 milligrams per deciliter of mg/dl ) two hours after consuming the drink. • IGT Fasting <126 mg/dl after 2h 140 mg/dl • DM Fasting 126 mg/dl after 2h 200 mg/dl

22. Complications • Diabetic retinopathy - cause of blindness - damage to the small blood vessels in the retina. After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment. • Diabetic neuropathy - damage to the nerves - affects up to 50% of people with diabetes - common symptoms are tingling, pain, numbness, or weakness in the feet and hands. • Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation. • Leading causes of kidney failure. 10-20% of people with diabetes die of kidney failure. • Diabetes increases the risk of heart disease and stroke. 50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke).

23. Complications • Diabetic retinopathy - cause of blindness - damage to the small blood vessels in the retina. After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment. • Diabetic neuropathy - damage to the nerves - affects up to 50% of people with diabetes - common symptoms are tingling, pain, numbness, or weakness in the feet and hands. • Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation. • Leading causes of kidney failure. 10-20% of people with diabetes die of kidney failure. • Diabetes increases the risk of heart disease and stroke. 50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke).

24. The foregoing information had been derived from the International Diabetic Federation (IDF) which also summarized the prevalence of diabetes mellitus worldwide on the following map:

25. Type 2 diabetes mellitus (T2DM) in Thailand • Measured as DALY* • Rank 2 ♀; Rank 8 ♂ • Prevalence (2005 nation wide, age adjusted) • T2DM 6.7% (7.4%♀; 6%♂) • IFG** 12.5% (10.4% ♀; 14.7% ♂) • *Disability adjusted life years • **Impaired fasting glucose

26. Attempt to control T2DM • Active screening of ‘target’ group • Clear cut suggestions how to conduct screening Including hypertension and nutritional status (BMI) into the program • Principle that population should actively support the efforts by adopting behavior to reduce prevalence and control complications

27. Routine screening process • Motivation of population by village health volunteers (VHV) and staff of sub-district health station • Assemble population in community • Eligible: Adults 35 years and older • Fasting capillary blood glucose (CBG) by glucometer • Individuals with ≥126 mg/dl referred to community hospital • Result confirmed by measuring venous plasma glucose (VPG)

28. Nong Bua Lamphu Province Na Klang district

29. Province: 125 inhabitants/qkm 6 districts 59 sub-districts 636 villages Na Klang district: Total population 91,000 8 sub-districts 131 villages 13 PCUs Description of area of investigation

31. Screening test using VPG and HbA1c as ‘Golden standard’ Sensitivity = 25/63 = 39.7% Specificity = 563/582 = 96.7% Positive predictive value = 25/44 = 56.8%

34. ‘Thrifty gene’ hypothesis • To ensure survival during periods of famine, certain genes evolved to regulate efficient intake and utilization of fuel stores. Such genes were termed “thrifty genes” in 1962. • T2DM – insulin resistance and relative insulin deficiency – metabolism of glucose delayed – beneficial in starvation

35. ‘Barker’s fetal origins of adult disease’

36. Aftereffects of ‘Dutch Hunger Winter’ • Individuals prenatally exposed to famine during the ‘Dutch Hunger Winter’ from September 1944 to March 1945 • Six decades later, less DNA methylation of the imprinted insulin-like growth factor 2 (IGF2) gene compared with their unexposed, same-sex siblings • Effect: Higher rates of obesity, lipid changes and cardiovascular diseases.

37. Importance of gestational diabetes for public health

38. Conclusion • Epidemics of tomorrow do not resemble those that previously occurred • Chronic diseases arepreventable but cannot be cured. • Chronic diseases present far greater problems to medical science and services than infectious diseases • Risk of new influenza pandemic require constant vigilance • The “invisible” epidemics • Heart disease • Stroke • Diabetes • Cancer and others • will take the greatest toll in deaths and disability

40. In May 2009, The NCD Alliance launched a campaign for a United Nations High-Level Summit on Non-Communicable Diseases (NCDs) which took place 19-20 September 2011 in New York.