Diabetes Mellitus

Kh. Shafiur Rahaman
IMPH Student(2015-2016)
School of Public health
tehran univerSity of Medical
ScienceS

ePideMiology of non
coMMunicable diSeaSeS (ncdS)
Professor Dr. Kourosh Holakouie Naieni

unhealthy diet
 An unhealthy diet is one of the major risk factors for
a range of chronic diseases, including cardiovascular
diseases, cancer, diabetes and other conditions linked
to obesity.
 An unhealthy diet fails to provide your body with the
correct amounts and types of nutrients for maximum
health.
 High dietary intakes of saturated fat, trans-fats and
salt, and low intake of fruits, vegetables and fish are
linked to cardiovascular risk.
 Approximately 16 million (1.0 per cent) DALYs and 1.7
million (2.8 per cent) of deaths worldwide are
attributable to low fruit and vegetable consumption.

definition
 Diabetes mellitus is a chronic disease caused by
inherited and/or acquired deficiency in production of
insulin by the pancreas, or by the ineffectiveness of
the insulin produced. Such a deficiency results in
increased concentrations of glucose in the blood,
which in turn damage many of the body's systems, in
particular the blood vessels and nerves. (WHO)
 Diabetes is a chronic disease that occurs when the
body cannot produce enough insulin or cannot use
insulin effectively. Insulin is a hormone produced in
the pancreas that allows glucose from food to enter
the body’s cells where it is converted into energy
needed by muscles and tissues to function.
(International Diabetes Federation, 2013)

claSSification/tyPe
 Type 1 diabetes
Type 1 diabetes (previously known as insulin-dependent, juvenile or
childhood-onset) is characterized by deficient insulin production
and requires daily administration of insulin.
 Type 2 diabetes
 Type 2 diabetes (formerly called non-insulin-dependent or adult-
onset) results from the body’s ineffective use of insulin.
 Type 2 diabetes comprises the majority of people with diabetes
around the world, and is largely the result of excess body weight
and physical inactivity.
 Gestational diabetes
Gestational diabetes is hyperglycaemia with blood glucose values
above normal but below those diagnostic of diabetes, occurring
during pregnancy.
 Impaired glucose tolerance and impaired fasting glycaemia

deScriPtive ePideMiology
 Incidence of Diabetes
 The number of people with diabetes has risen from
108 million in 1980 to 422 million in 2014.
 The majority of the 382 million people with diabetes
are aged between 40 and 59
 80% of them live in low- and middle-income countries
 The number of people with diabetes will increase by
55% by 2035
 In the WHO South-East Asia Region, this number has
increased from 17 million in 1980 to 96 million in 2014
 There were 7.1 million cases of diabetes in
Bangladesh in 2015

nuMber of PeoPle with diabeteS by idf
region, 2013

toP 10 countrieS / territorieS of nuMber
of PeoPle with diabeteS (20-79 yearS), 2013

 Prevalence of Diabetes
 Some 382 million people worldwide, or 8.3% of adults,
are estimated to have diabetes.
 80% live in low- and middle-income countries
 Almost 9% of the adult population of the WHO
South-East Asia Region has diabetes, which is the
second highest prevalence after the Eastern
Mediterranean Region.
 In Bangladesh the prevalence of DM is 8% (Male
8.6%, female 7.4%)
deScriPtive ePideMiology

eStiMated Prevalence and nuMber of
PeoPle with diabeteS (adultS 18+ yearS)

toP 10 countrieS/territorieS for
Prevalence* (%) of diabeteS (20-79 yearS),
2013

high riSk grouPS for diabeteS
 Risk for type 2 diabetes increases with age,
particularly after age 45
 Being overweight or obese is another major risk
factor—particularly if the extra weight is around the
waist.
 People younger than 45 years of age can develop type
2 diabetes if they have a strong genetic
predisposition and are overweight.
 Family history of type 2 diabetes.
 People with physical inactivity
 People with High blood pressure
 Women with History of gestational diabetes.

trendS in Prevalence of diabeteS
The new estimates show an increasing trend towards
younger and younger people developing diabetes

trendS in age-Standardized Prevalence of
diabeteS in bangladeSh

Etiology:
Type 1
Diabetes is caused by a lack of insulin due to the destruction of
insulin-producing beta cells in the pancreas.
Genetic Susceptibility
Environmental factors especially certain viruses are thought to
play a role in the development of type 1 diabetes, and there is
epidemiological evidence that supports this theory
Epidemiological studies have shown a significant association
between the incidence of enterovirus infections and the
development of type 1 diabetes and/or autoimmunity (Yeung,
Rawlinson, Craig, 2011) especially in genetically susceptible individuals
(Hober, Sane, 2010).
analytical ePideMiology

Etiology:
Type 2
Type 2 diabetes is characterized by insulin resistance and a progressive decline in
pancreatic β cell insulin production.
Genetic Susceptibility
Obesity is definitely a major risk factor for the development of type 2 diabetes (Li,
Zhao, Luan, et al, 2011), and the greater the degree of obesity, the higher the risk
(Nguyen, Nguyen, Lane, Wang, 2011)
Other factors that increase the risk of developing type 2 diabetes are the presence
of the metabolic syndrome (Eckel, 2008).
Type 2 diabetes is much more common in African-Americans than other ethnic
groups. There may be a genetic explanation for this, but socio-economic factors are
probably to blame (Link, McKinlay, 2009).
Physical inactivity
Positive family history
Increasing age

Risk factors for type 2 diabetes include:
Age (greater than age 45)
Overweight
Physical inactivity
Family background that is American Indian, African American,
Hispanic/Latino, Asian American, or Pacific Islander
Parent or sibling with diabetes
High blood pressure
Abnormal cholesterol levels
Having had a baby that weighed more than 9 pounds or having had
gestational diabetes
Pre-diabetes
History of polycystic ovary disease (PCOS)

Web of causation
Pre-diabetes(1)
Diabetes
Having had gestational diabetes(2)
Abnormal cholesterol
levels(2)
Parent or sibling with
diabetes(1,2)
High blood pressure(2)
Positive family history(2)
Physical inactivity(1)Being overweight(1)Being old(1)
History of polycystic ovary
disease(1,2)
Being obese(1)
Genetic Susceptibility(2)

Below is a list of possible complications that can be caused by badly
controlled diabetes:-
Eye complications - glaucoma, cataracts, diabetic retinopathy,
and some others.
Foot complications - neuropathy, ulcers, and sometimes gangrene
which may require that the foot be amputated
Skin complications - people with diabetes are more susceptible to
skin infections and skin disorders
Heart problems - such as ischemic heart disease, when the blood
supply to the heart muscle is diminished
Hypertension - common in people with diabetes, which can raise
the risk of kidney disease, eye problems, heart attack and stroke
Mental health - uncontrolled diabetes raises the risk of
suffering from depression, anxiety and some other mental
disorders
coMPlication of diabeteS

 Hearing loss - diabetes patients have a higher risk of developing
hearing problems
 Gum disease - there is a much higher prevalence of gum disease
among diabetes patients
 Gastroparesis - the muscles of the stomach stop working
properly
 Ketoacidosis - a combination of ketosis and acidosis;
accumulation of ketone bodies and acidity in the blood.
 Neuropathy - diabetic neuropathy is a type of nerve damage
which can lead to several different problems.
 HHNS (Hyperosmolar Hyperglycemic Nonketotic Syndrome) -
blood glucose levels shoot up too high, and there are no ketones
present in the blood or urine. It is an emergency condition.

 Nephropathy - uncontrolled blood pressure can lead to kidney
disease
 PAD (peripheral arterial disease) - symptoms may include pain
in the leg, tingling and sometimes problems walking properly
 Stroke - if blood pressure, cholesterol levels, and blood glucose
levels are not controlled, the risk of stroke increases
significantly
 Erectile dysfunction - male impotence.
 Infections - people with badly controlled diabetes are much
more susceptible to infections
 Healing of wounds - cuts and lesions take much longer to heal

Prevention & control
 Large, population-based studies in China, Finland and USA have
recently demonstrated the feasibility of preventing, or delaying,
the onset of diabetes in overweight subjects with mild glucose
intolerance (IGT).
 The studies suggest that even moderate reduction in weight and
only half an hour of walking each day reduced the incidence of
diabetes by more than one half.
 Public and professional awareness of the risk factors for, and
symptoms of diabetes are an important step towards its
prevention and control.
 Eat healthy diets
 Avoid tobacco smoking

Primary prevention:
Lifestyle intervention is an effective way to prevent the
development of type 2 diabetes in high-risk individuals.
However, identifying people at high risk and individualized
intervention are resource demanding, suggesting a need for
prioritizing research into methods for population-based diabetes
prevention in low- and middle-income countries.
Furthermore, data for evidence of efficacy for primary
prevention have mainly come from people with impaired glucose
tolerance, and studies among people at earlier stages in the natural
history (for example those with isolated impaired fasting
glycaemia) are needed.
Reducing the prevalence of obesity and increasing population
levels of physical activity might slow or reverse the diabetes
epidemic

Secondary prevention: (early detection and treatment)
Approximately half of all individuals with type 2 diabetes remain
undiagnosed, even in the most developed countries.
Treatment of diabetes usually starts late in the natural history
of the disease, which suggests that intervention at an earlier stage
might reduce the complications in the long term.
The main aim of this prevention program to slow down the
worsening of this condition and prevent it from causing further
complication.
This prevention program can only be implemented if the diabetes
has been diagnosed at an early stage.
In this prevention program, patient needs to check his/her blood
glucose after every single meal.
Avoid high calorie intake, eat balanced diet.
Avoid smoking, alcohol. Being physically active.

Tertiary prevention:
Concerns with the real treatment of diabetes by health
professional.
Includes actions taken to prevent and delay the development of
acute or chronic complications.
Acute complications: such as hypoglycemia, severe hyperglycemia
and infections.
Chronic complications: such as atherosclerosis, retinopathy,
nephropathy, neuropathy and foot problems.
Have regular checkups, diet, medications.
Get HbA1C test on a regular basis.

 There is a major distinction between diagnostic
testing and screening.
 When an individual exhibits symptoms or signs of the
disease, diagnostic tests are performed, and such
tests do not represent screening.
 The purpose of screening is to identify asymptomatic
individuals who are likely to have diabetes.
 Separate diagnostic tests using standard criteria are
required after positive screening tests to establish a
definitive diagnosis.
Screening and diagnoSiS

 According to the American Diabetes Association, all
patients should be screened for diabetes at three-
year intervals beginning at age 45, especially people
who are overweight or obese.
 f multiple risk factors are present, screening should
be done at an earlier age and more frequently.
 The U.S. Preventive Services Task Force recommends
that adults with high blood pressure or high
cholesterol be screened for type 2 diabetes (insulin-
resistant diabetes) in an effort to
reduce cardiovascular disease.
Screening

Symptoms:
In incidences of prediabetes, there are no symptoms.
People may not be aware that they have type 1 or type
2 diabetes because they have no symptoms or because
the symptoms are so mild that they go unnoticed for
quite some time.
However, some individuals do experience warning
signs, so it's important to be familiar with them.
diagnoSiS

 Any one of the following tests can be used for diagnosis:
 An A1C test, also called the hemoglobin A1c, HbA1c, or
glycohemoglobin test
 A fasting plasma glucose (FPG) test
 An oral glucose tolerance test (OGTT)
 Another blood test, the random plasma glucose (RPG) test, is
sometimes used to diagnose diabetes during a regular health
checkup. If the RPG measures 200 milligrams per deciliter or
above, and the individual also shows symptoms of diabetes, then
a health care provider may diagnose diabetes.
DIAGNOSIS

 HbA1C (A1C or glycosylated hemoglobin test)
 The A1C can be used for the diagnosis of both
prediabetes and diabetes.
 The A1C test measures your average blood glucose
control for the past 2 to 3 months.
 This test is more convenient because no fasting is
required.
 An A1C of 5.7% to 6.4% means that you are at high
risk for the development of diabetes and you have
prediabetes.
 Diabetes is diagnosed when the A1C is 6.5% or higher.
DIAGNOSIS

 Fasting Plasma Glucose Test (FPG)
Just prior to having this test run, the patient must fast (nothing to
eat or drink except water) for eight hours.
DIAGNOSIS

 Oral Glucose Tolerance Test (OGTT)
 The health care provider draws the patient's blood before and
two hours after the patient drinks a large, premeasured
beverage containing glucose.
 Then, the doctor can compare the before-and-after glucose
levels contained in the person's plasma to see how well the body
processed the sugar. These levels are measured in mg/dL.
DIAGNOSIS

 The goal of diabetes management is to keep blood glucose levels
as close to normal as safely possible.
 Since diabetes may greatly increase risk for heart
disease and peripheral artery disease, measures to control blood
pressure and cholesterol levels are an essential part of diabetes
treatment as well.
 People with diabetes must take responsibility for their day-to-day
care.
 Dietary Management and Physical Activity
Modifying eating habits and increasing physical activity are typically
the first steps toward reducing blood sugar levels.
 Insulin Therapy
 Oral Medications
TREATMENT

cONGRESSES AND MEETINGS (NATIONAl & INTERNATIONAl)

ASSOcIATIONS & NGO (NATIONAl & INTERNATIONAl)

AssociAtions & nGo (nAtionAl & internAtionAl)

Websites & JournAls (nAtionAl & internAtionAl)

burDen of DiseAse (nAtionAl & internAtionAl)
 Diabetes caused 1.5 million deaths in 2012.
 Higher-than-optimal blood glucose was responsible for an
additional 2.2 million deaths as a result of increased risks of
cardiovascular and other diseases, for a total of 3.7 million
deaths related to blood glucose levels in 2012.
 Many of these deaths (43%) occur under the age of 70.
 In 2014, 422 million people in the world had diabetes – a
prevalence of 8.5% among the adult population.
 The prevalence of diabetes has been steadily increasing for the
past 3 decades and is growing most rapidly in low- and middle-
income countries.
 Associated risk factors such as being overweight or obese are
increasing.
 Diabetes is an important cause of blindness, kidney failure,
lower limb amputation and other long-term consequences that
impact significantly on quality of life.

burDen of DiseAse (nAtionAl & internAtionAl)
PERCENTAGE OFALLDEATHS ATTRIBUTABLE TO HIGH BLOOD
GLUCOSE FORADULTS AGED 20–69 YEARS, BYWHO REGION
AND SEX, FORYEARS 2000 AND 2012

Burden of disease (national & international)
The financial cost
In addition to placing a large financial burden on individuals and their
families due to the cost of insulin and other essential medicines,
diabetes also has a substantial economic impact on countries and
national health systems.
This is because of an increased use of health services, loss of
productivity and the long term support needed to overcome diabetes
related complications, such as kidney failure, blindness or cardiac
problems
The majority of countries spend between 5% and 20% of their total
health expenditure on diabetes. The majority of countries spend
between 5% and 20% of their total health expenditure on diabetes.

The financial cost

Proportion (%) of people who died from diabetes before the age of 60

Top ten countries/territories for diabetes-related health
expenditure, 2015 and 2040

BANGLADESH at a glance

BANGLADESH at a glance
Top 10 diseases/causes of admission in medical college hospitals in
2011 and 2012

HealtH programs (national & international)

national& international guidelines

future researcH
What is the future for diabetes treatment?
The future of treating Type 1 diabetes
Islet Cell Transplants
Artificial pancreas
The future of treating Type 1 diabetes
Developing new drugs
Curb your blood sugar

cHallenges & oBstacles
Psychological Challenges for Children Living with Diabetes

conclusions and recommendations
 Establish national mechanisms such as high-level multisectoral
commissions to ensure political commitment, resource allocation,
effective leadership and advocacy for an integrated NCD
response, with specific attention to diabetes.
 Build the capacity of ministries of health to exercise a strategic
leadership role, engaging stakeholders across sectors and
society.
 Set national targets and indicators to foster accountability.
 Ensure that national policies and plans addressing diabetes are
fully costed and then funded and implemented.
 Prioritize actions to prevent people becoming overweight and
obese, beginning before birth and in early childhood.
 Strengthen the health system response to NCDs, including
diabetes, particularly at primary care level.
 Strengthen national capacity to collect, analyze and use
representative data on the burden and trends of diabetes and
its key risk factors.

references
1. https://ceufast.com/course/diabetes-epidemiology-etiology-and-
diagnosis
2. https://www.health.ny.gov/diseases/conditions/diabetes/who_is_at_
risk.htm
3. http://www.mayoclinic.org/diseasesconditions/diabetes/basics/cause
s/con-20033091
4. http://www.diabetes.org/?referrer=http://www.niddk.nih.gov
health-information/health-topics/Diabetes/causes
diabetes/Pages/index.aspx

interview or videos
 Diabetes - made simple
 Dolores Reisner – A Patient Story
 Laura's Diabetes Story
 Living with Type 2 Diabetes - Roxanne's Story - The
Nebraska Medical Center
 Prevent. Treat. Beat Diabetes - World Health Day
2016
 WHO- Diabetes - a patient’s view
 WHO_ Halt the rise, take the steps needed to beat
diabetes! World Health Day 2016

Diabetes Mellitus

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