Public health concepts of Diabetes

1. 1

2. Diabetes:
Dr. S. A. Rizwan, M.D.,
Assistant Professor,
Dept. of Community Medicine,
VMCHRI, Madurai

3. At the end of this lecture you should be able to
 Describe the burden of diabetes at the global and regional level
 Describe the epidemiological features of diabetes
 Discuss the trends in diabetes prevalence over the years
 List out the strategies needed for prevention of diabetes
 Appraise the diabetes scenario in India
3

4. 4

6. 6
IDF Diabetes Atlas, 2015

7. Type 1 DM
Type 2 DM
Gestational Diabetes
LADA (latent autoimmune
diabetes in adults)
MODY (maturity-onset
diabetes of youth)
Secondary DM
7
IDF Diabetes Atlas, 2015

8.  Type 2 diabetes and cardiovascular
share a common antecedent.
 The concept The Metabolic
Syndrome
 Clustering of central obesity with
several other major cardiovascular
disease risk factors
8

9. 9
American Diabetic Association

10. 10
Fasting
Plasma
Glucose
Post
Prandial
Plasma
Glucose
100 200
100 200
126110
140
Normal
Impaired
Fasting
Glucose
Impaired
Glucose
Tolerance
Diabetes
Mellitus
OR

11. 11
FPG
PPPG
100 200
100 200
126110
140

12. 12
FPG
PPPG
100 200
100 200
126110
140

13. 13
FPG
PPPG
100 200
100 200
126110
140

14. 14
FPG
PPPG
100 200
100 200
126110
140

16. 16
IDF Diabetes Atlas, 2015

17. 17
IDF Diabetes Atlas, 2015

18. 18
IDF Diabetes Atlas, 2015

19. 19

20. The Lancet 2011 378, 31-40DOI: (10.1016/S0140-6736(11)60679-X)
20

21. 21
IDF Diabetes Atlas, 2015

23. 23
IDF Diabetes Atlas, 2015

24. Indian J Med Res 125, March 2007, pp 217-230
24

25. Indian J Med Res 125, March 2007, pp 217-230
25

27. 27

28. 28

29. 29

30. 30
Overweight
and obesity
Physical
inactivity
High-fat and
low-fiber diet
Ethnicity
Family
history
Age
Low birth
weight
Urbanisation

31. 31
 Non Modifiable
 Genetic factors
 Age
 Ethnicity
 Modifiable
 Obesity and physical
inactivity
 Metabolic factors: IGT, IFG
and GDM

32. Host factors
 Age
 Sex
 Genetic factors: HLA DR3 and
DR4
 Defective immune response
 Central Obesity
Environmental factors
 Sedentary life style
 High saturated fat intake
 Malnutrition- failure of β cells
 Excessive alcohol
 Viral infections (Mumps, Rubella)
 Chemical agents- Alloxan,
streptozotocin, cyanide
 Environmental stress
32

33. Dietary factors
 Characteristics of fat intake
 Dairy
 Glycemic load
 “Western diet”
 Fast food intake
 Soda intake
 Alcohol intake
33

34. Indian J Med Res 125, March 2007, pp 217-230
34

35. 35
IDF Diabetes Atlas, 2015

36. Short term effects
of diabetes
36
 Ketoacidosis
 Recurrent or persistent infections (including
tuberculosis)
 Both hyperglycaemia and hypoglycaemia may
cause coma

37. Long term effects
of diabetes
1. Microvascular
2. Macrovascular
37

38. Prevalence &
timeline
38

39. Continuum of CVD
risk
39

41.  Aging of the population
 Urbanization especially in the developing countries
 More sedentary lifestyle
 Food consumption patterns
 More foods with high fat content
 More refined carbohydrates
41

42.  To reduce human suffering
 Improve Quality of Life
 Reduce the number of hospitalization
 Reduce mortality from diabetes
 Prevent sudden cardiac death
42

43. The human and economic costs of diabetes could be significantly
reduced by investing in prevention, particularly early detection, in
order to avoid the onset of diabetic complications
At least 50% of all people with diabetes are unaware of their
condition
43
IDF Diabetes Atlas, 2015

44.  Primary
 Includes activities aimed at preventing diabetes from occurring in
susceptible populations
 Secondary
 Early diagnosis and effective control of diabetes in order to delay the
progress of the disease
 Tertiary
 Prevent complications and disabilities due to diabetes
44

45.  “There is an urgent need to take the prevention of
cardiovascular disease more seriously. The only
sensible strategy is the population approach to primary
prevention” - Beaglehole, the Lancet 2001; 358: 661-3
Why primary
prevention?
45
M. V. Hospital for Diabetes & Diabetes Research Centre

46.  Behavioral interventions: including changing diet and
increasing physical activity
 Pharmacological interventions: utilizing
pharmaceutical agents to improve glucose tolerance
and insulin sensitivity
Strategies
46

47.  Population strategy
 Primordial prevention (prevention of emergence of risk
factors)
 Maintain body weight through adoption of healthy
nutritional habits and physical exercise
 High risk strategy
 Sedentary life style, obesity
 Avoid alcohol
 Smoking
 High blood pressure
 Elevated cholesterol and triglyceride levels
Approaches
47

48.  All of those components are risk factors for
CVD and can be targeted in life style
interventions to prevent Type 2 diabetes
Metabolic
syndrome
prevention
48

49.  Diet and physical activity reduce the incidence of Type
2 diabetes.
 Diet and exercise for 5 years in men with IGT reduced
the incidence of Type 2 diabetes by 50%
- Eriksson et al, Diabetologia 1991; 34: 891-8
 Reductions in the incidence of diabetes in subjects
with IGT who were randomized to diet, exercise, or
combined diet-exercise treatment groups
- Pan et al, Diabetes Care, 1997; 20: 537-44
Behavioral
interventions
49

50.  The evidence for the ability of
pharmacological interventions to prevent
Type 2 diabetes awaits confirmation
 Metformin Pharmacological
interventions
50

51. Evidence from
studies
51
Control Diet Exercise D&E
Pan et al, Diabetes Care, 1997; 20: 537-44

52. Evidence from
studies
52
Study Year Interventions Outcome
DaQing
(China)
1997 Diet, physical
activity or both
(control group:
general)
Reduction in diabetes
incidence 31% in diet group,
46% in physical activity and
42% in diet and physical
activity compared to control
group
Finnish
Diabetes
Prevention
Study
2001 Diet and physical
activity (control
group: general
advice)
Reduction by 58% of the risk
of diabetes compared to
control group
Diabetes
Prevention
Program
(USA)
2002 Diet, physical
activity,
metformin and
placebo
58% reduction in incidence
of diabetes with lifestyle
intervention, 31% with
metformin
STOP-NIDDM 2002 Acarbose or
placebo
32% patients randomised to
acarbose and 42%
randomised to placebo
developed diabetes

53.  The purpose of secondary prevention
activities such as screening is to identify
asymptomatic people with diabetes
Why secondary
prevention?
53

54.  Population screening
 Selective screening
 Opportunistic screening
Approaches
54

55.  Urine examination
 Test for glucose, 2 hours after a meal
 Lack of sensitivity
 Not appropriate for case finding
 Blood sugar testing
 “Standard oral glucose test”
 2hr value after 75 g oral glucose
 Measure fasting, random, post prandial
Strategies
55

56. Indian Diabetes
Risk Score
56
Interpretation:
Total score
< 30 - low risk
30-50 - medium risk
> 60 - high risk
Factors Score
Age
<35 0
35-49 20
>50 30
Abdominal obesity (WC)
<80 cm (F), <90 (M) 0
80-89 cm (F), 90-99 (M) 10
>90 cm (M), >100 (M) 20
Physical activity
Vigorous labour 0
Mild to moderate 20
No exercise 30
Family history
None 0
One parent 10
Both parents 20
J Assoc Physicians India 2005; 53 : 759-63.

57.  Includes actions taken to prevent and delay
the development of acute or chronic
complications
Why tertiary
prevention?
57

58.  Strict metabolic control, education and
effective treatment
 Screening for complications in their early
stages when intervention is more effective
Approaches
58

59.  Screening for diabetic retinopathy is cost-effective
where subsequent treatment, such as laser treatment,
is available and affordable
 Where there is no access to laser treatment, good
metabolic control aimed at delaying the progress of
diabetic eye disease is likely to be cost-effective
Screening for
eye problems
59

60. A number of interventions have been found to
be effective in preventing foot problems
 Education
 Pressure-relieving interventions
 Multidisciplinary clinics Managing foot
problems
60

61.  Renal failure in diabetes can be detected very
early by screening for ‘microalbuminuria’
 However, effective treatment must be
available in order to follow on from the
detection of this early sign of renal failure
Screening for
renal problems
61

62.  The same basic improvements in diet and
physical activity that prevent type 2 diabetes
are likely to prevent CVD complications
 Also, a wide range of drugs has now been
proven to be effective in reducing the risk of
CVD in people with diabetes, and in treating
diabetes-associated CVD once it is present
Macrovascular
complications
62

63. Evidence from
studies
63
Strategy Complication Reduction
Lipid control
 Coronary heart disease mortality
 Major coronary heart disease
event
 Any atherosclerotic event
 Cerebrovascular disease event
↓ 36%¹
↓ 55%¹
↓ 37%¹
↓ 62%¹
Blood Pressure Control
 Cardiovascular disease
 Heart failure
 Stroke
 Diabetes-related deaths
↓ 51%²
↓ 56%³
↓ 44%³
↓ 32%³
Blood Glucose Control  Heart Attack ↓ 37%³
1 The 4S Study, 2 Hypertension Optimal Treatment (HOT) Randomised Trial, 3 UKPDS

64.  Standardized data collection on disease magnitude, risk factors and mortality statistics.
 Clear action plan with specific targets, and well defined evaluation.
 Initiating community-based interventions for primary prevention.
 Advocacy for influencing policies.
 Advocacy for the rights of people with diabetes for quality care at all levels.
 Establishing acceptable standards for health care for people with diabetes.
 Establishing an effective referral system and defining the role of each level of health
care.
 Educating the population about this important global epidemic
 Provision of appropriate training for health care providers
 Coordination of prevention efforts
64

65.  Type 2 diabetes prevention must be integrated in a major program
addressing the prevention of other lifestyle related disorders like CVD and
some cancers
 Primary prevention is of the essence especially in resource-constrained
countries
 Diabetes prevention is an inter-sectoral effort requiring cooperation and
coordination
 Diabetes prevention should be addressed within the context of health
system reform ensuring the availability of acceptable health care standards
 Culturally appropriate and economically feasible interventions should be
adopted
65

66.  Type 2 diabetes is a major challenge to human health
 Type 2 diabetes can be prevented
 Primary prevention is a suitable and affordable choice
 There is strong evidence that lifestyle interventions are effective in
diabetes prevention
 Barriers for prevention should be addressed
66

67. 67

68. Clinical services
 Glycemic control
 BP control
 Lipid management
 Annual eye examinations
 Foot care
 Kidney disease testing
 Flu immunization
 Preconception care
 Diabetes education
 Case Management
 Targeted Screening
Promotion of behaviors
 Education and awareness for:
• Physical activity
• Reduced Tobacco
• Healthy diet
• Regular doctor visits
• Self monitoring
• Self mgt education
68
Population targeted policies
• Health care access legislation
• Drug and supply reimbursement
policies
• Population registry and feedback
systems

69.  Taxation
 Food and Menu labeling
 Engage Private Industry
 Crop subsidy policies
 Incentives/promotion for community availability and affordability of foods
 Incentives/promotion for community support for physical activity
 Regulation of foods in public areas
 School food and physical education policies
69

70. It is the corner stone of DM management
It covers:
 Self care
 Changing behavior to prevent and control of
complications
 Encourage interaction with health care
providers
Education of
diabetic patients
70

71.  Nature of disease, types
 Clinical presentation, diagnosis, complications
 Types of treatment, side effects
 Exercise, self monitoring , avoidance and
recognition of hypoglycemia, and hyperglycemia
 Foot care
 Pregnancy and OC
 Avoidance of smoking
 CV RFs
 Need for follow up
 Self management skills and attitudes
Contents of
Educational
Program
71

72.  Patients should be educated to practice self-care
 This allows the patient to assume responsibility
and control of his/her own diabetes management
 Self-care should include:
 Blood glucose monitoring
 Body weight monitoring
 Foot-care
 Personal hygiene
 Healthy lifestyle/diet or physical activity
 Identify targets for control
 Stopping smoking
Diabetic Self-Care
72

73.  Individual counseling
 Group teaching
 Educational materials: posters, pamphlets,
books
 Special educational programs are needed for
special groups as children and pregnant
women
Types of education
methods
73

74.  Basic understanding of DM and its
managements
 Training in educational methods
 Training of dietetics and nurses
Education of
Health
Professionals
74

75.  Prevention or modification of dietary habits
and other life-style characteristics that link
with DM
Education of the
community
75

76.  Economic problems: unavailability of needed resources
 Socio-cultural problems
 Lack of data, knowledge and skills
76

77. Obesity is not
considered
negatively
Fad Food
Culture has
caught up
Changing diet
is very
difficult
No value given
to physical
exercise
No time for
physical
exercise at
work
Fatalism
77

78. Dietary
counselling
Patient
education
Physical
activity
Medication
compliance
Aggressive
follow-up
Sudden
death
assessment
78

79.  India’s response to the growing burden of
non-communicable diseases
National programme
for prevention and
control of diabetes,
cardiovascular
disease and stroke
79
c.

80. Objectives
80
AWARENESS SCREENING
CASE
MANAGEMENT
IN PHC
PRE–DIABETES
& LIFE STYLE
MODIFICATIONS

81. Plan of action
81
Guidelines
Trainings
Detection
camps in Sub
centres &
Main Centres
Detection /
Screening
Camps at
institutions
Regular, fixed
day weekly
NCD clinic at
PHC
Preparation of
Patient
Treatment
Cards
BCC
Activities

82. Key interventions
82
Key Area Activities
Health
Promotion
 Public awareness through multi-media
 Counseling for healthy lifestyle (Balanced diet,
regular exercise, avoid alcohol and tobacco)
Early
Diagnosis
 Screening of persons above 30 years and all
pregnant women for diabetes and hypertension at
all levels; facilities up to Sub-centre level
Case
Management
 Facilities for diagnosis and treatment (NCD Clinic)
at CHC level & above
 CCU at District Hospital and above
 Treatment of cancer at District Hospital & above
Capacity
Building
 Infrastructure Development & Equipment
 Training of human resources at all levels
Management
& Monitoring
 NCD Cell at National, State & District level
 Surveillance, monitoring & evaluation
 Regular review meetings

83. Activities at
different health
care facilities
83
Tertiary centres
Comprehensive care, research,
training, telemedicine
District Hospital
Diagnosis & management of difficult
cases, CCU, dialysis, training
CHC
Early detection & appropriate
treatment, health promotion

85. a) Screening for undiagnosed cases
b) Foot care
c) Lipid lowering agents
d) Metformin
85

86. a) FPG >126
b) PPPG >100 & <140
c) PPPG >140 & <200
d) FPG <110
86

87. a) USA
b) China
c) Russia
d) Canada
87

88. a) 8.8%
b) 6.5%
c) 12.0%
d) 3.0%
88

89. a) 70 million
b) 50 million
c) 100 million
d) 40 million
89

90. a) Retinopathy
b) Stroke
c) Coronary heart disease
d) Peripheral vascular disease
90

91. a) Primordial
b) Primary
c) Secondary
d) Tertiary
91

92. a) Separate centre will be set up for stroke, DM
b) Will be implemented in 10 districts in 5 states
c) CHC has facilities for diagnosis and treatment of CVD,
diabetes
d) Sub-centre will provide facilities for diagnosis and
treatment
92

93. This presentation is available on
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