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

3. Epidemiology of Diabetes

4. 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. Diabetes Primary 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. 5 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. 6

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. 7

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

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. 9

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. 10

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. 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). 11

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. 12

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. 13

14. 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. Diabetes in the World 16 millions India 31.7 China 20.8 USA 17.7 Indonesia8.4 Japan 6.8 Year 2000 Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

17. Diabetes in the World 17 millions India 79.4 China 42.3 USA 30.3 Indonesia21.3 Japan 8.9 Year 2030 Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

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19. Prevalence of Diabetes in Adults United States, BRFSS * 1998 - 2003 19 * 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 20 * 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. Overall Non-Hispanic Whites Non-Hispanic Blacks Mexican- Americans Cowie et al., 2008; Prevalence of Total Diabetes (diagnosed and undiagnosed diabetes) in the U.S. Adult Population, age ≥ 20, 1988-1994 to 2005-2006

23. Problem Statement Iceberg Disease Increased prevalence in newly industrialized and developing countries. Disease acquired in the most productive period of their life. 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. Undiagnosed or inadequately treated patients develop multiple chronic complications. Lack of awareness about interventions for prevention and management of complications.

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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. Baradaran 4 27

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) 28

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

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 Sciences 2014. 30

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

32. Diagnosis and Type of Diabetes 32

33. 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. 34 Diagnosis Fasting plasma glucose HgbA 1 C Oral glucose tolerance test (75 gram)

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36. 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. 37 Classification  Type 1 Diabetes  Type 2 Diabetes  Other Specific Types  Gestational Diabetes

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

39. 39 Type 1 Diabetes Insulitis

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

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

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

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

44. 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

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

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

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49. 49 Diagnosis of Gestational Diabetes

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

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52. 52 Screening for and diagnosis of GDM Screening for and diagnosis of GDM 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks of gestation in women not previously diagnosed with overt diabetes. OGTT : Morning after an overnight fast of at least 8 h. 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks of gestation in women not previously diagnosed with overt diabetes. OGTT : Morning after an overnight fast of at least 8 h.

53. 53 Screen women with GDM for persistent diabetes at 6–12 weeks post partum, using the OGTT and non pregnancy diagnostic criteria. Women with a history of GDM should have lifelong screening for the development of diabetes or pre diabetes at least every 3 years. Screen women with GDM for persistent diabetes at 6–12 weeks post partum, using the OGTT and non pregnancy diagnostic criteria. Women with a history of GDM should have lifelong screening for the development of diabetes or pre diabetes at least every 3 years.

54. 54 Screening Who should you screen? Adults who are overweight (BMI>25) or obese(BMI >30) and have 1 or more additional risk factors Routine testing for others not meeting criteria should begin at age 45 If normal repeat every 3 years or more frequently if risk status changes Who should you screen? Adults who are overweight (BMI>25) or obese(BMI >30) and have 1 or more additional risk factors Routine testing for others not meeting criteria should begin at age 45 If normal repeat every 3 years or more frequently if risk status changes

55. 55 Risk Factors o Physical inactivity o 1st degree relative with diabetes o High risk ethnic groups(African-American, Latino-Asian- Amer, Pacific Islanders) o Women who delivered a baby >9lbs +GDM o Hypertension o HDL 250 o Women with PCOS o IGT or IFG on previous testing o Hx CVD o Severe obesity or acanthosis nigricans o Physical inactivity o 1st degree relative with diabetes o High risk ethnic groups(African-American, Latino-Asian- Amer, Pacific Islanders) o Women who delivered a baby >9lbs +GDM o Hypertension o HDL 250 o Women with PCOS o IGT or IFG on previous testing o Hx CVD o Severe obesity or acanthosis nigricans

56. 56 Screening for type 1 diabetes Consider referring relatives of those with type 1 diabetes for antibody testing for risk assessment in the setting of a clinical research study. (E) Consider referring relatives of those with type 1 diabetes for antibody testing for risk assessment in the setting of a clinical research study. (E)

57. 57 People with type 1 diabetes present with acute symptoms of diabetes and markedly elevated blood glucose levels, and some cases are diagnosed with life threatening ketoacidosis. Measurement of islet autoantibodies in relatives of those with type 1 diabetes identifies individuals who are at risk for developing type 1 diabetes. People with type 1 diabetes present with acute symptoms of diabetes and markedly elevated blood glucose levels, and some cases are diagnosed with life threatening ketoacidosis. Measurement of islet autoantibodies in relatives of those with type 1 diabetes identifies individuals who are at risk for developing type 1 diabetes.

58. 58 Such testing,coupled with education about symptoms of diabetes and follow-up in an observational clinical study, may allow earlier identification of onset of type 1 diabetes and lessen presentation with ketoacidosis at time of diagnosis.

59. 59 Children-Type II Screening  Overweight(BMI>85% for age and sex, weight for height>85%, or weight > 120% of ideal for height)  Plus any 2 +  Initiate at age 10 or onset of puberty, q3yrs.  Overweight(BMI>85% for age and sex, weight for height>85%, or weight > 120% of ideal for height)  Plus any 2 +  Initiate at age 10 or onset of puberty, q3yrs.  Fam Hx DMII 1st or 2nd deg relative.  Nat Amer, Latino, Asian/Amer, Pacific Islander.  Signs of Insulin Resistance (HTN, Acanthosis Nigricans,Dyslipidemia or PCOS or small-for-gestational age birth weight).  Maternal Hx of DM or GDM.

60. 60 Initial Evaluation  Hx of complications: Microvascular: Retinopathy, Nephropathy, Neuropathy. Macrovascular: CHD, PAD, Cerebro- vascular disease.  Hx of complications: Microvascular: Retinopathy, Nephropathy, Neuropathy. Macrovascular: CHD, PAD, Cerebro- vascular disease.

61. 61 PREVENTION/DELAY OF T2DM

62. 62 PREDIABETES  Those patients with impaired fasting glucose (100-125) or impaired glucose tolerance (2hr between 140-199)  Both are risk factors for future DM and cardiovascular disease.  Diet and Exercise…..how much?  Follow up counseling important for success  Metformin may be considered  Those patients with impaired fasting glucose (100-125) or impaired glucose tolerance (2hr between 140-199)  Both are risk factors for future DM and cardiovascular disease.  Diet and Exercise…..how much?  Follow up counseling important for success  Metformin may be considered

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64. THANKS 64

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68. Prevalence of diabetes in the WHO South-East Asia Region 68

69. Between 1996 and 2004. In those > 40 years the prevalence was 24% and it increased by 0.4% with each year after 20 years of age. The risk of type 2 diabetes was1.7% greater in women than men 69

70. 70 Genetic defects of Insulin secretion Maturity Onset Diabetes of the Young (MODY) Six Genetic Ioci on different chromosomes have been identified to date. Glucokinase related MODY(MODY 2) is common….but in India….HNF-4 alfa. Usually Non ketotic / Non obese Often in successive generations

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