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Diabetes

Diabetes. Gojka Roglic, WHO. WHO Global Strategy for the Prevention and Control of Noncommunicable Diseases (2000). Priority noncommunicable diseases : Cardiovascular disease Cancer Respiratory disease Diabetes. Outline. Diagnosis and classification Burden

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Diabetes

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  1. Diabetes Gojka Roglic, WHO

  2. WHO Global Strategy for the Prevention and Control of Noncommunicable Diseases (2000) Priority noncommunicable diseases: • Cardiovascular disease • Cancer • Respiratory disease • Diabetes

  3. Outline • Diagnosis and classification • Burden • Primary and secondary prevention • Screening

  4. Clinical stages: normoglycaemia IGT/IFG diabetes • Type 1 • Autoimmune • Idiopathic • Type 2 • Predominantly insulin resistance • Predominantly insulin secretory defects • Other specific types • Gestational diabetes

  5. Definition of diabetes mellitus and other categories of hyperglycaemia (WHO 1999, 2006)

  6. Number of persons with diabetes in the world (IDF Atlas, 4th ed) 285 million in 2010 438 million in 2030

  7. World diabetes prevalence in 2010 (IDF Atlas, 4th ed)

  8. Top 10 countries in the number of persons with diabetes (millions) ( IDF Atlas, 2010)

  9. Top 10 countries in the number of persons with diabetes (millions) 92.4 ( IDF Atlas, 2010)

  10. Top 10 countries in diabetes prevalence in the world( IDF Atlas, 2010)

  11. Age distribution of persons with diabetesin Europe, 2010(IDF Atlas, 4th ed)

  12. Age distribution of persons with diabetesin South-East Asia, 2010(IDF Atlas, 4th ed)

  13. The rising global prevalence of diabetes (millions)

  14. RISING PREVALENCE OF DIABETES IN URBAN INDIA (Mohan, 2006) 1989 - 2005 Within a span of 14 years, the prevalence of diabetes increased by 72.3%

  15. Is there a diabetes epidemic? …….dare we say ……… pandemic…?

  16. Possible causes of increasing diabetes prevalence (from Colagiuri et al, Diabetologia 2005) • Ageing of the population • Younger age at onset • Decreasing mortality • Increasing incidence (risk)

  17. Prevalence of overweight and obesity in population aged over 15 years (WHO STEPS Surveys)

  18. ”The epidemic of childhood obesity”

  19. Body mass index and incident diabetes Source: BMJ 2002; 324:1570 (Based on data from the Pima Indians)

  20. Estimated projected urban and rural populations in the world, 1950-2030

  21. Relative risk of Type 2 diabetes by different levels of occupational physical activity (from Hu et al, Diabetologia 2003) * adjusted for age, sex, BMI, systolic BP, smoking, education, other physical activity (n= 6898 Men+7392 women, 35-64 years old)

  22. Possible causes of increasing diabetes prevalence (from Colagiuri et al, 2005) • Ageing of the population • Younger age at onset • Decreasing mortality • Increasing incidence (risk) Explain only 20-25% increase in prevalence

  23. Figure 1.1 The major diabetes complications

  24. What is the burden of diabetic complications ? • No global/country estimates…. • Very few population-based studies • Lack of standardized definitions

  25. Percentage of blindness caused by diabetes( Adapted from WHO, 2002)

  26. Number of deaths attributable to diabetes in the year 2010 (IDF Atlas, 4th ed) 3.9 million HIV/AIDS deaths in 2008: 2.0 million (WHO 2009)

  27. Excess deaths attributable to diabetes as percentage of all deaths 20-79 yrs in 2010(IDF Atlas)

  28. Diabetes is an obstacle to achieving the Millennium Development Goals…… • Diabetes is likely to be responsible for 15% of all new tuberculosis cases in India Stevenson et al, BMC Public Health 2007

  29. Diabetes is an obstacle to achieving the Millennium Development Goals…… • Diabetes is likely to be responsible for 15% of all new tuberculosis cases in India (AIDS accounts for 3-4%)

  30. Diabetes is an obstacle to achieving the Millennium Development Goals…… • Improved maternal health is unlikely without diabetes control

  31. Age distribution of women with diabetes in India, 2007 (IDF Atlas, 3rd ed)

  32. Prevalence of diabetes in pregnancy, Tamilnadu State 2005-2007 (Seshiah, J Assoc Physicians India 2008) URBAN SEMI-URBAN RURAL

  33. Preventing diabetes

  34. Population-based prevention of diabetes • Type 1 No data • Type 2 (lifestyle modification) • Singapore: modest results in 12 years (Bhalla, Singapore Med J 2006) • Finland: currently being evaluated after 10 years

  35. Prevention of diabetes in persons at high risk

  36. Prevention of Type 1 diabetes • Possible to identify those at very high risk through: • Family history • Genetic background (HLA haplotypes) • Auto-antibodies to insulin and pancreas  cells

  37. Prevention of Type 1 diabetes • Interventions that have been tried in high risk individuals include: • Antioxidant drugs e.g. nicotinamide • Insulin (oral, parenteral) • None of them shown to work

  38. Prevention of Type 2 Diabetes The Major Risk Factors/markers • Overweight and obesity • Abdominal/central obesity • Physical inactivity • Elevated fasting and 2 hr glucose levels - usually precedes the development of diabetes by several years

  39. Lifestyle & Prevention of DM in subjects with IGTClinical Trials: DM as the Primary Outcome

  40. Pharmacologic agents in Prevention of DM in subjects with IGT: Clinical Trials with: DM as the primary outcome

  41. Cardiovascular Disease Prevention Trials with Diabetes as Secondary Outcome

  42. Cumulative incidence of DM in Da Qing Follow-up Study (Li et al, Lancet 2008)

  43. Prevention of type 1 is currently not possible • Prevention of type 2 is currently far from 100% many persons will still develop diabetes

  44. Preventing complications of diabetes

  45. Type 1 diabetes DIABETES CONTROL AND COMPLICATIONS TRIAL (DCCT) The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus NEJM,1993

  46. People (%) 60 50 40 75% Risk Reduction 30 76% Risk Reduction 20 10 End of follow-up End of DCCT HbA1c (%) 10 9.1 9 8.2 7.9 8 7.2 7 6 Follow-up median DCCT median Persisting effects of blood glucose control over 4-years on retinopathy progression DCCT, 2000, N E J M 4-Year follow-up of the DCCT – 3-step progression Conventional (n=603) Intensive (n=605)

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