Centro para el Manejo de Datos

1. Centro de Diabetes para Puerto Rico Centro de Diabetes para Puerto Rico Centro para el Manejo de Datos Centro para el Manejo de Datos Estado Libre Asociado de Puerto Rico Estado Libre Asociado de Puerto Rico

2. over the past few decades, diabetes has emerged as an important medical problem in developing regions of the world • In a more recent report on global diabetes estimates and projections for the years 2000–2030,Wild et al. showed that the worldwide prevalence of diabetes for all age groups would increase from 2.8% in 2000 to 4.4% in 2030, with a corresponding 114% increase in the numbers, from 171 million to 366 million. The greatest relative increases will occur in developing regions, namely India and the Middle Eastern Crescent

3. Important contributors include an increase in the urban population in developing countries and an increase in the proportion of people >65 years of age across the world

4. Diabetes mellitus (DM) is a common syndrome and caused by lack or decreased effectiveness of endogenous insulin • The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.

5. Classification of primary diabetes • Type 1 (insulin-dependent (IDDM), juvenile onset): • Only 5–10% of those with diabetes • May occur at any age but more common in patients <30y. • results from a cellular-mediated autoimmune destruction of the β-cells of the pancreas

6. Some patients, particularly children and adolescents, may present with ketoacidosis as the first manifestation of the disease. • These patients are also prone to other autoimmune disorders such as Hashimoto’s thyroiditis, vitiligo, autoimmune hepatitis and pernicious anemia.

7. Type 2 (non-insulin dependent (NIDDM), maturity onset): • 90–95% of those with diabetes • the cause is a combination of resistance to insulin action and an inadequate compensatory insulin secretory response • a degree of hyperglycemia sufficient to cause pathologic and functional changes in various target tissues, but without clinical symptoms, may be present for a long period of time before diabetes is detect

9. Islet Cell Dysfunction and Abnormal Glucose Homeostasis in Type 2 Diabetes

10. Most patients with this form of diabetes are obese, obesity itself causes some degree of insulin resistance • Insulin resistance may improve with weight reduction and/or pharmacological treatment of hyperglycemia but is seldom restored to normal

11. The risk of developing this form of diabetes increases with: • age, • obesity, • and lack of physical activity. • In women with prior GDM • Individuals with hypertension or dyslipidemia

13. Type 1 DM • Younger • More lean • Insulin-deficient • Low triglycerides • Older • Overweight • Insulin-resistant • High TG’s/Low HDL-C Type 2 DM

14. Gestational diabetes mellitus (GDM) • GDM is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. • GDM complicates 4% of all pregnancies in the U.S., resulting in 135,000 cases annually

15. Presentation of DM • Acute: Ketoacidosis • Sub-acute: Weight loss, polydipsia, polyuria, lethargy, irritability, infections (candidiasis, skin infection, recurrent infections slow to clear), genital itching, blurred vision, tingling in hands/feet.

16. With complications: Presentation with skin changes, peripheral neuropathy with risk of foot ulcers, amputations, nephropathy, eye disease • Asymptomatic: DM may be detected on routine screening during well man/woman checks .

17. Natural History of DM 2 Insulin secretion Postprandial glucose Microvascular complications Fasting glucose Years from diagnosis 0 10 5 15 -10 -5 Onset Diagnosis Insulin resistance Macrovascular complications Pre-diabetes Type 2 diabetes Adapted from Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26:771-789; Nathan DM. N Engl J Med. 2002;347:1342-1349

18. Impact of Diabetes Mellitus Diabetes The leading cause of new cases of end stage renal disease The leading cause of nontraumatic lower extremity amputations A 2- to 4-fold increase in cardio-vascular mortality The leading cause of new cases of blindness in working-aged adults www.hypertensiononline.org

19. Criteria for the Diagnosis of Diabetes

20. Global Prevalence of Diabetes

21. Estimated global prevalence of type 1 and type 2 diabetes

22. Global Prevalence Estimates, 2000 and 2030 4.4 % 2.8 % Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

23. 31.7 20.8 Indonesia 17.7 Japan China 8.4 6.8 India USA Diabetes in the World Year2000 millions Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

24. 79.4 42.3 Indonesia 30.3 Japan China 21.3 8.9 India USA Diabetes in the World Year2010 millions Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

25. Prevalence of Diabetes by Country * > 18 years only. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1999-2003. Atlanta, GA: United States, Department of Health and Human Services. ** Dunstan DW, Zimmet PZ, Welborn TA, Courten MP, Cameron AJ, Sicree RA, et al. The raising prevalence of diabetes and impaired glucose tolerance. Diabetes Care. 2002; 25(5): 829-834. *** Warsy AS, el-Hazmi MA. Diabetes mellitus, hypertension and obesity-common multifactorial disorders in Saudis. Eastern Mediterranean Health Journal. 1999; 5(6): 1236-42.

26. Prevalence of Diabetes in Adults United States, BRFSS* 1998 - 2003 * BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1998-2003. Atlanta, GA: United States, Department of Health and Human Services.

27. Global Incidence of IDDM

31. RISK FACTORS OF DM

32. GENETIC RISK • There is ample evidence that type 2 diabetes has a strong genetic component. • Type 2 diabetes clusters in families. • The lifetime risk of developing type 2 diabetes is about 40% in offspring of one parent with type 2 diabetes ; the risk approaches 70% if both parents have diabetes.

33. Intriguingly, the risk in the offspring seems to be greater if the mother rather than the father has type 2 diabetes • a first-degree relative of a patient with type 2 diabetes has a threefold increased risk of developing the disease

34. ADULT OBESITY • Obesity and weight gain are major risk factors for type 2 diabetes, and they have been blamed for or implicated in the rising prevalence of diabetes worldwide. • A community-based survey in Saudi Arabia in 1995–2000 of people aged 30–70 years found that 36.9% were overweight and 35.5% were obese. • Men were more likely to be overweight and women were more likely to be obese

35. CHILDHOOD OBESITY • The sharp increase in the prevalence of overweight and obesity worldwide is not only limited to adults, but also extends to adolescents and children and even to preschool children. This increase in weight led to an increase in the incidence of type 2 diabetes in childhood, to a point that it is becoming more common than type 1 diabetes in a few countries, such as in Japan and Taiwan

36. Dietary risk factors • Studies utilizing a variety of epidemiological approaches have implicated a range of lifestyle-related environmental factors in the etiology of type 2 diabetes

37. CARBOHYDRATEAND DIETARY FIBER • refined carbohydrates, and sugars in particular, might be involved in the etiology of type 2 diabetes • Over 40 studies have examined the role of sugars in the etiology of type 2 diabetes, with about half suggesting a positive association and a comparable number suggesting no association

38. On the other hand, there is rather more support for the suggestion that foods rich in slowly digested or resistant starch or high in dietary fiber (nonstarch polysaccharide) might be protective In controlled experiments, diets high in soluble fiber-rich foods [20] or foods with a low glycemic index are associated with improved diurnal blood glucose profiles and long-term overall improvement in glycemic control, as evidenced by reduced levels of glycated hemoglobin

39. Some other studies provide indirect support for this hypothesis. Diabetes risk appears to be lower in Seventh-Day Adventists who are vegetarians than in those who are not strict vegetarians [22]. • The diet of vegetarians is characterized by a high intake of dietary fiber, but differs in other ways from that of nonvegetarians. In addition to not eating meat and animal products, vegetarians also have less saturated fat,more polyunsaturated fat and a diet which differs in micronutrient composition when compared with nonvegetarians.

40. DIETARY FATS • More than 60 years ago, Himsworth [23] suggested that high intakes of fat increased the risk of diabetes in populations and individuals. • In the San Luis Valley Diabetes Study, a high fat intake was associated with an increased risk of type 2 diabetes and impaired glucose tolerance (IGT) [25];

41. in a follow-up, 1 to 3 years later, fat consumption predicted progression to type 2 diabetes in those with IGT

42. On the other hand, no association was found between fat intake and risk of type 2 diabetes in a 12-year follow-up of women in Gothenburg, Sweden • The type of dietary fat may also be relevant. Saturated fatty acids were positively related to fasting and postprandial glucose levels in normoglycemic Dutch men, the effect being independent of energy intake and obesity.

43. In a recent Italian study, intake of butter (rich in palmitic and myristic acids) was positively associated with fasting glucose levels, and the use of olive oil (high in oleic acid) was inversely associated with fasting glucose Levels • The ratio of polyunsaturated to saturated fatty acids in serum phospholipids has been shown to be inversely associated with insulin secretion and positively associated with insulin action

44. PROTEIN • There are no firm epidemiological data concerning • the role of protein intake in the etiology of • type 2 diabetes, • though the fact that meat-eating • Seventh-Day Adventists have higher rates than • those who do not eat meat has been taken to • suggest a possible deleterious effect of animal • protein

45. The strong positive associations • between animal protein and saturated fatty acids • and vegetable protein and dietary fiber mean that • it is almost impossible to disentangle separate • effects in epidemiological studies. • High intakes of proteins, especially animal • protein, appear to be associated with an increased • risk of nephropathy in type 1 diabetes [44], so • restriction of protein may help to delay progression • of microalbuminuria to clinical nephropathy

46. OTHER DIETARY FACTORS • Several micronutrients, most notably chromium, • zinc, magnesium and vitamin E, have been implicated • in the pathogenesis of type 2 diabetes • and/or been shown to be associated with improved • glycemic control. • However, no epidemiological • studies have provided convincing support for the • role of any of these nutrients in the etiology of the • disease. There is, perhaps, rather more support for • the suggestion vitamin D deficiency may be important

47. Vitamin D deficiency impairs insulin release, • followed, if prolonged, by impairment of insulin • secretion and reduction of glucose tolerance which • progresses to irreversible diabetes.

48. smooking • The role of smoking • as a risk factor for type 2 diabetes has received • relatively little attention. Smoking induces insulin • resistance [51], and cigarette smokers have • been shown to be relatively glucose intolerant and • Dyslipidemic • Thus, smokers might be expected to be at • considerably increased risk of type 2 diabetes.

49. PHYSICAL INACTIVITY • In cross-sectional epidemiological • studies, type 2 diabetes rates have been shown • to be lower amongst physically active individuals • than amongst those not having regular physical • activity

50. The protective effect of physical • activity against type 2 diabetes has been confirmed • in several prospective studi