1. K.A.P STUDY ON HT & DM

4. INTRODUCTION In 2003, there were 189 million diabetic in the world. The global prevalence of Type-2 diabetes is expected to double in the period 2000–2025 and may reach a level of almost 324 million people. The "Top 10" countries of the world in terms of the number of people with diabetes: India, China, Russian Federation, Brazil, Indonesia, Pakistan, Mexico, Ukraine, Egypt, Japan. India tops the list of 10 countries, followed by china. In fact in 1997, the diabetic population in India was 11.6%, which in 2000 was estimated to be 14.7% and to rise to 17.4% in 2005. Today, India has 25 million diabetic patients, more than any other country, and the number is expected to rise to 35 million by 2010 and to 57 million by 2025!).

5. The important risk factors for the high prevalence of diabetes include: (a) High familial aggregation. (b) Obesity, especially central obesity. (c) Insulin resistance. (d) Lifestyle changes due to urbanization. Moreover, diabetes occurs at a much younger age in India than in the developed countries. Family History of Diabetes, Age, Body Mass Index (BMI), waist to hip ratio and sedentary life-style showed positive association with diabetes in Indian population. Diabetes is the single most important metabolic disease, which can affect nearly every organ system in the body. The reasons for this escalation are due to changes in lifestyle, people living longer than before (ageing) and low birth weight could lead to diabetes during adulthood.

6. Lifestyle modifications, inclusive of dietary modification, regular physical activity and weight reduction are indicated for prevention of diabetes. However, in developing nations urbanization is occurring rapidly and is producing lifestyle changes that adversely affect metabolism and are thereby causing a large increase in the number of diabetic patients. Long-term complications of diabetes will also occur in a large proportion of diabetic patients in the developing countries during the most productive years of their lives, causing severe economic and social burdens. Therefore, developing countries such as India are expected to confront an enormous health care burden due to a large number of the population suffering from this chronic disorder and its sequelae.

9. Hypertension affects all ages, but primarily occurs in adults. 690 million people have hypertension worldwide (20% prevalence). It is one of the major risk factor for stroke, Coronary Heart Diseases. There are 5 million deaths/ year worldwide due to strokes alone, with another 30 million are suffering from its disabling effects. Hypertension is extremely common in patients with diabetes mellitus. Tight control of hypertension in diabetes has shown to decrease the complications like ischaemic heart disease and renal failure thereby reducing the morbidity and mortality. Management of hypertension in diabetes includes weight reduction, dietary restriction of sodium, adequate intake of potassium and calcium, regular exercise, cessation of smoking and drug therapy.

10. CLASSIFICATION OF DIABETES MELLITUS 1. Type I diabetes A) Immune mediated b) idiopathic 2. Type 2 diabetes 3. Other specific types a. Genetic defects of beta cell function b. Genetic defects insulin action, lipoatropic diabetes c. Disease of exocrine pancreas d. Endocrinopathies, acromegaly Cushing’s syndrome, hyperthyroidism e. Drug or chemical induced glucocorticoids, thyroid hormones, beta-blockers, thiazides f. Infections congenital rubella, cytomegalovirus g. Uncommon forms of immune mediated diabetes h. Other genetic syndromes sometimes associated with diabetes down’s syndrome, k. F Syndrome., turners syndrome. 4. Gestational diabetes mellitus

11. Type 2 diabetes is characterized by four major metabolic events: chronic hyperglycemia, insulin resistance, reduced insulin response and increased hepatic glucose output. It is not clear, however, which of these events come first and how they may lead to Type 2 diabetes. The development of Type 2 diabetes can be divided into four phases. Genetic susceptibility is a prerequisite for the development of the disease. However, specific genes causing Type 2 diabetes are still unknown. The second stage appears to be the development of insulin resistance. Subsequently, impaired glucose tolerance (IGT) develops and finally Type 2 diabetes (DM) appears.

12. Those with the highest fasting insulin levels had the highest risk of developing diabetes over the period. Individuals with higher fasting insulin levels have higher incidence both of diabetes itself and of IGT. Therefore higher fasting or post-load insulin levels precede both IGT and Type 2 diabetes. Several factors influence the development and severity of insulin resistance. Obesity, physical Inactivity and over nutrition worsen insulin resistance, while weight reduction, physical training and calorie restriction decrease insulin resistance. Several factors influence the development and severity of insulin resistance.

13. The WHO criterion for IGT is a venous plasma glucose level of 7.8-11.0 mmol/l two hours after a 75g oral glucose load. Obesity, besides being a risk factor for the development of insulin resistance, is also a risk factor for development of IGT. The general consensus from a number of studies is that the major factor determining conversion from IGT to Type 2 diabetes is failure of insulin secretion from the beta cells of the pancreas. The reason for the failure is uncertain but several possible mechanisms have been proposed. In summary, the pathogenesis of Type 2 diabetes involves the inheritance of diabetes susceptibility genes. The risk of developing the disease is first manifested by insulin resistance.

14. Thus Type 2 diabetes is characterized by the presence of hyperglycemia accompanied by insulin resistance and defects in insulin secretion. The other characteristic metabolic abnormality, increased hepatic glucose output, occurs as a result of insulin deficiency. Once Type 2 diabetes is established, individuals are at risk for the development of many or all of the complications of the disease. Diabetic complications account for almost all of the excess morbidity and mortality associated with Type 2 diabetes.

15. Importance of Tight Control: The landmark study on type2 diabetes is UKPDS4 and it has shown that tight control of hypertension had a great impact on cardiovascular risk reduction. Similar conclusions are also noted in other studies revealed a lower cardiovascular risk and lower decline in renal functions when the systolic pressure is kept below 130 mm Hg and diastolic pressure below 80 mm Hg.

16. Management of Hypertension: All the patients should have complete work-up including detailed physical examination documenting the cardiovascular status, the peripheral circulation, fundus examination and assessment of body mass index. Basal investigation should include lipid profile, renal profile, serum electrolytes, urinary protein estimation and assessment of glycaemic status. Non-pharmacological measures — All patients who are smokers should be advised to stop it and avoid even passive exposure to smoking. Weight reduction should be considered as an important measure in those who are overweight and obese, by regular exercises and dietary modification.

17. DIAGNOSIS OF TYPE 2 DM: SUG NORMAL IFG/IGT D.M FPG 125 2HR PPG 200

18. DIAGNOSIS OF HYPERTENSION: The Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 1997) in its recent report recommend that a diabetic be labeled as hypertensive if systolic blood pressure is above 130 mm Hg and diastolic more than 85 mm Hg. On the basis of benefits shown in epidemiological studies, it is advisable to keep systolic pressure below 130 mm Hg and diastolic below 80 mm Hg.

19. CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS AGE 18 AND OLDERS: Category Systolic Diastolic (mm of Hg) (mm of Hg ) (mm of Hg) OPTIMAL < 120 < 80 NORMAL < 130 <85 HIGH – NORMAL 130 – 139 85 - 89 HYPERTENSION Stage – 1 140 – 159 90 – 99 Stage – 2 160 – 179 100 – 109 Stage – 3 > 180 > 110

20. GENERAL OBJECTIVE To study the knowledge, attitude, and practice of prevention of diabetes and hypertension among patients attending Railway Health Unit/ TondiarPet from January 2004 to March 2004.

21. SPECIFIC OBJECTIVE 1.To define the magnitude of the hypertension and diabetes problem in Railway Population with evidence based data 2.To measure the prevalence of HT and DM among different age group, different category of employees, socio economic status and other influence of factors. 3.To find out other risk factors e.g. obesity, excessive salt intake, alcohol intake, psychological stress, illiteracy and poor socio economic status. 4.To identify the type and prevalence of cardio vascular complication among DM and HT

22. ERRORS and LIMITATIONS Interviewer’s Bias Respondent Bias Influence of By standards and Spectators

23. TIME CONSTRAINT As I have to complete my study within shorter period, large sample size could not be obtained. METHODOLOGY STUDY DESIGN CROSS-SECTIONAL STUDY, DESCRIPTIVE STUDY EXCLUSION CRITERIA Juvenile Diabetes, Gestational diabetes and diabetes due to other causes were not taken to account STUDY PLACE Railway Health Unit, Tondiarpet Marshaling Yard, Chennai Division, Southern Railway STUDY SAMPLE 175 Patients attending Railway Health unit for regular check up DATA COLLECTION AND INTERVIEW PERIOD The interview was conducted from 1st January 2004 to 31st March 2004 using the Questionnaire. PRELIMINARY PREPARATION The topic of the study was discussed with the Chief Medical Director/ S.Rly. The objectives were identified and included in this K.A.P study.

24. QUESTIONNAIRE DEVELOPMENT The interviewer constructed the questionnaire for the study. MATERIALS/TOOLS Glucometer Tape to measure waist /hip ratio Sphygmomanometer Weighing machine Height measurement stand Urine sugar testing reagent strips

25. MONITORING DIABETES MELLITUS AND HYPERTENSION 1.POOR ROLE FOR URINE SUGAR 2.INITIAL DIAGNOSIS REPEAT AFTER 3 WEEKS 3.Hba1C, LIPID PROFILE, RENAL PARAMETERS 4.CARDIAC STATUS ECG, XRAY CHEST 5.MONITOR NEPHROPATHY URINE MICRO ALB 6.MONITOR NEUROPATHY 7.MONITOR RETINOPATHY ONCE A YEAR

26. HYPERTENSION 2 4 19 17 8 18 0 2 4 6 8 10 12 14 16 18 20 100-110 111-120 121-130131-140141-150>150 SYSTOLE - mm of Hg Series1

27. HT & DM 1 4 11 9 4 12 100-110111-120 121-130 131-140 141-150>150 SYSTOLE - mm of Hg

28. 12 19 7 2 1 0 70-8081-9091-100101-110111-120>120 DIASTOLE - mm of Hg ht & dm

29. URINE SUGAR 22 9 13 30 33 0 5 10 15 20 25 30 35 1+2+3+4+Nil

30. HYPERTENSION 2 4 19 17 8 18 0 2 4 6 8 10 12 14 16 18 20 100-110111-120 121-130131-140 141-150>150 SYSTOLE-mm of Hg Series1

32. HYPERTENSION 26 28 10 3 0 1 0 5 15 20 25 30 70-8081-9091-100101-110111-120>120 DIASTOLE-mm of Hg

33. TOTAL CASES FOR STUDY - 175 68 66 41 0 10 20 30 40 50 60 70 80 HT DM HT& DM

34. TOTAL PATIENTS - 175 0 10 20 30 40 50 60 70 80 90 AGE No of patients Series1 8737816 30 - 40 years 41 - 50 years 51 - 60 years> 60 years

35. TOTAL CASES FOR STUDY - 175 0 20 40 60 80 100 120 SEX Series1 11461 MALEFEMALE

37. Patern of treatment 9 89 8 1 0 10 20 30 40 50 60 70 80 90 100 Insulin+Tablet TabletDiet Native treatment

38. HYPERTENSION & DIABETES 0 20 40 60 80 100 120 140 Category of patients No of patients Series1 1271533 EmployeeRtd.EmployeeDependents

39. TOTAL CASES - 175 105 41 17 9 3 0 20 40 60 80 100 120 < 5 years > 5 to < 10 years > 10 to < 15 years > 15 to < 20 years > 20 years TREATMENT PERIOD