Epidemiology of Diabetes CLASSIFICATION DIAGNOSIS/SCREENING PREVENTION/DELAY OF DM

2. TODAYS MISSION • Epidemiology of Diabetes • CLASSIFICATION • DIAGNOSIS/SCREENING • PREVENTION/DELAY OF DM

3. Epidemiology of Diabetes

4. Definition Diabetes – The term diabetes mellitus describes a metabolic disorder of multiple aetiology which is characterized by hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both.

5. DiabetesPrimary Goal for 2010 • Through prevention programs, reduce the disease incidence, its complications and its economic impact, in addition, to improve quality of life for all those persons that had diabetes or that are at risk to develop the disease. Reference: U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.

6. Epidemiology • The worldwide prevalence of DM has risen dramatically over the past two decades, from an estimated 30 million cases in 1985 to 285 million in 2010. International Diabetes Federation projects that 438 million individuals will have diabetes by the year 2030 . • Prevalence of both type 1 and type 2 DM is increasing worldwide, the prevalence of type 2 DM is rising much more rapidly, presumably because of increasing obesity, reduced activity levels as countries become more industrialized, and the aging of the population.

7. The magnitude of the healthcare problem of type 2 diabetes results not just from the disease itself but also from its association with obesity and cardiovascular risk factors, particularly dyslipidaemia and hypertension.  Type 2 diabetes has now been recognized as one manifestation of the “metabolic syndrome”, a condition characterized by insulin resistance and associated with a range of cardiovascular risk factors.

8. Various cardiovascular risk factors, including • hypertension and dyslipidaemia become • progressively worse with progression from normal • glucose tolerance to IGT/IFG to diabetes.

9. While there is good evidence for a strong genetic contribution to both obesity and diabetes, the increase in these conditions in both developed and developing countries appears to be due to a changing balance between energy intake and energy expenditure through physical activity. Physical activity levels have probably diminished by half.

10. The tendency for the increased prevalence of type 2 diabetes to be concentrated in lower socioeconomic groups in developed countries and higher socioeconomic groups in developing countries probably reflects the adoption of a “healthier” lifestyle by better educated people in developed countries, while it is generally the affluent in developing countries who enjoy a high calorie intake and low level of physical activity.

11. Approximately 1.6 million individuals (>20 years) were newly diagnosed with diabetes in 2010. DM increases with aging. • In 2010, the prevalence of DM in the United Sates was estimated to be 0.2% in individuals aged <20 years and 11.3% in individuals aged >20 years. • In individuals aged >65 years, the prevalence of DM was 26.9%. • The prevalence is similar in men and women throughout most age ranges (11.8% and 10.8%, respectively, in individuals aged >20 years).

12. In Asia, the prevalence of diabetes is increasing rapidly and the diabetes phenotype appears to be different from that in the United States and Europe—onset at a lower BMI and younger age, greater visceral adiposity, and reduced insulin secretory capacity.

13. Diabetes is a major cause of mortality, but several studies indicate that diabetes is likely underreported as a cause of death. In the United States, diabetes was listed as the seventh leading cause of death in 2007; a recent estimate suggested that diabetes was the fifth leading cause of death worldwide and was responsible for almost 4 million deaths in 2010 .

14. Global Prevalence of Diabetes

15. 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.

16. 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.

17. 79.4 42.3 Indonesia 30.3 Japan China 21.3 8.9 India USA Diabetes in the World Year2030 millions Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

19. 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.

20. Prevalence of Diabetes by Sex and Year, Puerto Rico BRFSS* 1997, 2001 - 2003 * BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1997-2003. Atlanta, GA: United States, Department of Health and Human Services.

21. Prevalence of Total Diabetes (diagnosed and undiagnosed diabetes) in the U.S. Adult Population, age ≥ 20, 1988-1994 to 2005-2006 Non-Hispanic Whites Non-Hispanic Blacks Mexican- Americans Overall Cowie et al., 2008;

23. Problem Statement • Iceberg Disease • Increased prevalence in newly industrialized and developing countries. • Disease acquired in the most productive period of their life.

24. Undiagnosed or inadequately treated patients develop multiple chronic complications. • Lack of awareness about interventions for prevention and management of complications.

27. Eastern Mediterranean Health Journal, Vol. 15, No. 3, 2009 591 ٢٠٠٩ ، المجلة الصحية لشرق المتوسط، منظمة الصحة العالمية، المجلد الخامس عشر، العدد ٣ Prevalence of type 2 diabetes in the Islamic Republic of Iran: systematic review and meta-analysis A.A Haghdoost,1,2 M. Rezazadeh-Kermani,1 B. Sadghirad 3 and H.R. Baradaran4

28. Province Prevalence • Bushehr 12.62 (7.62–17.63) • Qazvin 13.09 (7.93–18.25) • Gilan 5.45 (1.78–9.13) • Isfahan 8.20 (5.23–11.17) • Kerman 13.16 (7.55–18.77) • Khorasan 9.09 (2.28–15.89) • Kordestan 3.35 (0–7.36) • Tehran 7.43 (4.04–10.81) • Yazd 14.01 (10.75–17.27)

29. Prevalence of diabetes in IRAN Year 2000 2030 Diabetic patients 2,103,000 6,421,000 • Prevalence of diabetes in Yazd Province Year2000 2030 Diabetic patients 145,000 442,722

30. Prevalence of Diabetes in People aged ≥30 years: The Results of Screening Program of Yazd Province, Iran, in 2012 • Cross-sectional study , 2012. • 14993 subjects were randomly selected and enquired by a pretested questionnaire. • Prevalence rate of known diabetes and impaired fasting glucose was 16.3% & 11.9% respectively. Journal of Research in Health Sciences2014.

31. Female gender, increasing age, high blood pressure, increased BMI and positive family history, are independent risk factor for diabetes.

32. Diagnosisand Type of Diabetes

33. Definition Diabetes – The term diabetes mellitus describes a metabolic disorder of multiple aetiology which is characterized by hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action or both.

34. Diagnosis • Fasting plasma glucose • HgbA1C • Oral glucose tolerance test (75 gram)

36. Specific Criteria • FPG  126 on two separate occasions • A1C ≥ 6.5% • Symptoms of hyperglycemia and a • casual plasma glucose  200 • 2hr plasma glucose  200 during • OGTT

37. Classification • Type 1 Diabetes • Type 2 Diabetes • Other Specific Types • Gestational Diabetes

38. Type 1 Diabetes • ß-cell destruction, leading to absolute insulin deficiency • Immune-mediated diabetes(common) • Idiopathic

39. Type 1 Diabetes Insulitis

40. Pathogenesis of Type 1 DM Environment ? Viral infe..?? Genetic HLA-DR3/DR4 Type 1 DM

41. Type 2 Diabetes May range from predominantly insulin resistance to predominantly an insulin secretory defect

42. Type 2 Diabetes • Loss of ß-cells • Amyloid deposits • Hyalinization

43. Pathogenesis of Type 2 DM Environment Low Birth Weight Obesity Genetic ß cell defect Genetic Secretory Defect Insulin resistance May require Insulin ß cell exhaustion

44. Other Specific Types A. Genetic defects in Beta Cell Function/ Insulin secretion B. Genetic defects in Insulin Action C. Diseases of the Exocrine Pancreas D. Endocrinopathies E. Drug or Chemical Induced F. Infections G. Uncommon Immune forms H. Genetic Syndromes with Diabetes

46. Diseases of the pancreas Acquired causes include Pancreatitis, Trauma, infection, panreatectomy, and pancreatic carcinoma. Fibrocalculous pancreatopathy Cystic fibrosis and Hemochromatosis

47. Secondary DM Secondary causes of Diabetes mellitus include : • Acromegaly • Cushing syndrome • Thyrotoxicosis • Pheochromocytoma • Chronic pancreatitis • Pancreatic Cancer

49. Diagnosis of Gestational Diabetes

50. Gestational diabetes mellitus (GDM) • (diabetes diagnosed during pregnancy • that is not clearly overt diabetes)