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DR J. GIRI DIRECTOR REGIONAL DIABETIC CENTRE KG HOSPITAL COIMBATORE

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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DR J. GIRI DIRECTOR REGIONAL DIABETIC CENTRE KG HOSPITAL COIMBATORE

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  1. DR J. GIRI DIRECTOR REGIONAL DIABETIC CENTRE KG HOSPITAL COIMBATORE

  2. DIABETES MELLITUS AN ASIAN EPIDEMIC

  3. DIABETES MELLITUS IS A HETEROGENOUS CHRONIC METABOLIC DISORDER HYPERGLYCEMIA RESULTS FROM A DEFECT IN INSULIN ACTION AND / OR DEFICENCY OF INSULIN SECRETION.

  4. 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).

  5. 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.

  6. 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

  7. 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.

  8. Ten top countries – Number of adults with DM in Millions WHO Tech report 1985

  9. The Rising Prevalence of Diabetes In Developing Countries

  10. The rising prevalence of Diabetes world wide 4 million deaths per year related to DM. (9% of the global total.)

  11. 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

  12. 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.

  13. 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

  14. Natural History of Diabetes Normal Impaired Fasting IGT Diabetes Diabetes + Glucose Complication Risk of Micro Vascular Diseases Risk of Macro Vascular Diseases

  15. 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

  16. 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:

  17. 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

  18. 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

  19. 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%

  20. 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.)

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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.

  27. 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.

  28. 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.

  29. 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.

  30. 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.

  31. THE ECONOMIC BURDEN OF DIABETES India is the ‘ Diabetes Capital of the world’ A dubious distinction Can we afford it?

  32. 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

  33. 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

  34. 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)

  35. 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.

  36. 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.

  37. 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.

  38. 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.

  39. CARRY HOME MESSAGE GOOD METABOLIC CONTROL BLOOD PRESSURE CONTROL CONTROL OF SERUM LIPIDS EARLY DETECTION OF COMPLICATIONS  LIFE STYLE MODIFICATON

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