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DIABETES

INTRODUCTION
Heterogeneous group of diseases, characterised by
hyperglycemia, resulting from a diversity of environmental
and genetic, acting jointly

Underlying cause defective production or action of insulin

Long term disease with variable clinical manifestation and


progression
IDDM
Most severe
Its onset is typically abrupt
seen in indlviduals less than 30 years of age
Lethal unless promptly diagnosed and treated.
immune mediated in over 90 per cent of cases and
idiopathic in less than 10 per cent case
Associated with ketosis if untreated
Mostly in children 10- 14 years occasionally in adults
Contd...

catabolic disorder where circulating insulin is virtually


absent
plasma glucagon elevated, and
pancreatic B cells fail to respond to isulinogenic stimuli.
Exogenous insuline is therefore needed
NIDDM
More common
Gradual onset
Middle aged and elderly
Mild
Slow to devlop ketosis
Impaired glucose tolerance (lGT) describes a state
intermediate- at risk group between diabetes mellitus and
normality. It can only be defined by the oral glucose
tolerance test
INSULIN RESISTANCE METABOLIC SYNDROME

In obese patients with type 2 diabetes, the association of


Hyperglycaemia,
hyperinsulinaemia,
dyslipidaemia, hypertension,
which leads to coronary artery disease,stroke, may result
from a genetic defect producing insulin resistance, with the
latter being exaggerated by obesity.
INSULIN RESISTANCE METABOLIC SYNDROME
insulin resistance predisposes hyperglycaemia, which results
in hyperinsulinemia which contributes in high levels of
triglycerides and sodium retention by renal tubules. thus
hypertension.
High levels of insulin can stimulate proliferation to initiate
atherosclerosis
PROBLEM STATEMENT - WORLD
Iceberg disease
Number of cases of diabetes worlwide is estimated to be
150 million. This number is predicted to double by 2021
prevalence rate of about 5.4 % with the greatest number of
cases being expected in China and India
20 per cent of the current diabetic population resides in the
South-East Asia Region
The number of diabetic persons in the countries of this
region is likely to triple by the year 2025
Contd..
The percentage of diabetic cases residing in urban areas is
projected to increase from 54% in 1995 to 73 % by the
year 2025
prevalence of type 1 diabetes in Asia is relatively low,
accounting for about 9.7 per cent of all diabetes mellitus
cases in the Region.
The insulin dependent diabetes registry at Chennai (lndia)
reported an incidence of 10.5 per 100,000 children in the
age group of 1O-I2 years
PROBLEM STATEMENT - INDIA

prevalence of disease in adults was found to be 2.4 % in


urban dwellers.
High frequencies in glucose tolerance, indicate the potential
for further rise in of diabetes mellitus in the coming decades
Epidemiological determinants
Agent

Underlying cause- insulin deficiency. This may be due to


(a) pancreatic disorders- inflammatory, neoplastic and other disorders
such as cystic fibrosis
(b) defects in the formation of insulin synthesis of abnormal,
biologically less active insulin molecule;
(c) destruction of beta cells, eg viral infections and chemical agents
(d) decreased insulin sensitivity, due to decreased markers of adipocyte
and monocyte insulin receptors.
(e)genetic defects, e.g., mutation of insulin gene;
(f) Auto immunity
HOST FACTORS
1. Age
At any age
Prevalence increases with age
NIDDM- middle years of age
Malnutrition related DM- younger age
Prognosis bad if DM develops at young age
2. Sex
UK- male female reatio- equal
South east asia male > femalle
3. Genetic factors
Type 2 strong genetic component
Type 1- 50%
Type 1 DR3 & DR 4
TYPE 2 not HLA associated
HOST FACTORS contd...
5. Immune mechanism
Cell mediated & humoral against islet cells
6. Obesity
Central adiposity- risk factor for type 2, decreases receptor for
insulin
WC, WHR determinants of type 2 DM
Central obesity- determinant of insulin resistance
No role in type 1
7. Maternal diabetes
Offsprings of diabetic mother-
high risk of type 2 DM
Large at birth tend to develop obesity
Environmental risk factors
1. Sedentary life style
Risk for type 2 DM
2. Diet
High saturated fat intake type 2 DM risk
3. Dietary fibre
High intake- decreased risk of type 2 DM4.
4. Malnutrition
Partial failure of beta cells
5. Alcohol
Damage pancreas and obesity TYPE 2 DM
6. Viral infection
Rubella, mumps, human coxsachie virus B4- beta cell destruction
7. Chemical agents
Alloxan, streptozocin, rodenticide, foods containing cyanide-
cassava- toxic effect on beta cells
Environmental risk factors contd..
8. Stress
Surgery, trauma- may bring out the disease
9. Malnutrition
Partial faliure of beta cells
10. Other factors
Associated with occupation
Marital status
Religion
Economic status
Education
Urbanization
Changes in life style
Now more common in low social class whereas 50 years ago was
common in high social class
Environmental risk factors contd..
SCREENING FOR DIABETES

Urine examination
Blood sugar testing
Urine examination
Urine test for glucose 2 hrs after meal
All with glycosuria are considered diabetic unless otherwise proved
by a standard oral glucose tolerance test
Studies confirm that glusoce is found in urine in only severe forms
of disease and not in milder forms and such cases are missed
Lack of sensitivity ( only 10-50%)
This means that many diabetic would have been missed if it is the
only test
ie it yields more false positives
Also glycosuria may be found in normal people too
This gives rise ti false positive
But specificity is 90% - so yeild of false positive nothigh
Finally- urine testing not an appropriate tool for case finding or
epidemiological surveys
BLOOD SUGAR TESTING
Because of inadequacies of urine examination standard oral glucose
test- remains cornerstone of diagnosis of diabetes
Mass screening programmes have used glucose measurements of
fasting, post-prandial or random blood sample
The measurement of glucose levels in random blood samples is
considered unsatisfactory for epidemiological use: at the most, it can
give only a crude estimate of the frequency of diabetes in a population
The fasting value alone is considered less reliable since true fasting
cannot be assured and spurious diagnosis of diabetes may more
readily occur
for epidemiological purposes, the 2-hour value after 75 g oral glucose
may be used either alone or with the fasting value
Automated biochemistry has now made it possible to screen
thousands of samples for glucose estimation.
TARGET POPULATION
Screening of the whole population for diabetes is not a rewarding
exercise
However, screening of "high-risk" groups is considered more
appropriate.
These groups are:
(i) those in the age group 40 and over
(ii) those with a family history of diabetes
(iii) the obese
(iv) women who have had a baby weighing more than 4.5 kg (or 3.5
kg in constitutionally small populations)
(v) women who show excess weight gain during pregnancy, and
(vi) patients with premature atherosclerosis.
PREVENTION AND CARE

Primary prevention
Population strategy
High risk strategy
Secondary prevention
Tertiary prevention
POPULATION STRATEGY

The scope for primary prevention of IDDM is limited on the basis of


current knowledge and is probably not appropriate
However, the development of prevention programmes for NIDDM
based on elimination of environmental risk factors is possible.
The preventive measurers comprise maintenance of normal body
weight through adoption of healthy nutritional habits and physical
exercise.
The nutritional habits include an adequate protein intake, a high intake
of dietary fibre and avoidance of sweet foods.
Elimination of other less well defined factors such as protein
deficiency and food toxins may be considered in some populations.
These measures should be fully integrated into other community-
based programmes for the prevention of non-communicable diseases
(e.g., coronary heart disease).
HIGH RISK STRATEGY
There is no special high-risk strategy for IDDM diabetes.
At present, there is no practical justification for genetic counselling as
a method of prevention
Since NIDDM appears to be linked with sedentary lifestyle, over-
nutrition and obesity, correction of these may reduce the risk of
diabetes and its complications.
Since alcohol can indirectly increase the risk of diabetes, it should be
avoided.
Subjects at risk should avoid diabetogenic drugs like oral
contraceptives.
It is wise to reduce factors that promote atherosclerosis, e.g., smoking,
high blood pressure, elevated cholesterol and high triglyceride levels.
These programmes may most effectively be directed at target
population groups.
SECONDARY PREVENTION

Glycosylated Hb
Self care
Home based blood glucose
SECONDARY PREVENTION
When diabetes is detected. it must be adequately treated.
Aims of treatment are :
to maintain blood glucose levels within the normal limits as is
practicable
To maintain ideal body weight.
Treatment is based on
(a) diet alone- small balanced meals more frequently,
(b) diet and anti diabetic drugs. or
(c) diet and insulin.
Good control of glucose protects against the development of
complications
SECONDARY PREVENTION

Proper management of the diabetic is most important to prevent


complications.
Routine checking of blood sugar, of urine for proteins and ketones, of
blood pressure, visual acuity &weight should be done periodically.
The feet should be examined for any defective blood circulation
(Doppler ultrasound probes are advised), loss of sensation and the
health of the skin.
Primary health care is of great importance diabetic patients since most
care is obtained at this level.
GLYCOSYLATED HEMOGLOBIN

There should be an estimation of glycated (glycosylated) haemoglobin


at half-yearly intervals.
This test provides a long-term index of glucose control.
This test is based on the following rationale: glucose in the blood is
complexed to a certain fraction of haemoglobin to an extent
proportional to the blood glucose concentration.
Percentage of such glycosylated haemoglobin reflects the mean blood
glucose levels during the red cell life-time (i.e. About heprevious2 -
3months)
SELF CARE
A crucial element in secondary prevention is self care.
That is, the diabetic should take a major responsibility for his own
care with medical guidance - eg
adherence to diet and drug regimens,
examination of urine
blood glucose monitoring;
self administration of insulin,
abstinence from alcohol
maintenance of optimum weight,
attending periodic check-ups
recognition of symptoms associated with glycosuria and
hypoglycemia
HOME BLOOD GLUCOSE MONITORING

Assessment of control has been greatly aided by the recent facility of


immediate, reasonably accurate, capillary blood glucose
measurements by one of the many meters now available or the direct
reading Haemoglukotest sirips
patient should carry an identification card showing his name, address,
telephone number (if any) and the details of treatment he is receiving.
In short, he must have a working knowledge of diabetes.
TERTIARY PREVETION
Diabetes is major cause of disability through its complications, eg
blindness, kidney failure, coronary thrombosis, gangrene of lower
extremities, etc.
The main objective at the tertiary level is to organise specialized
clinics (Diabetic clinics) and units for providing diagnostic and
management skills of a high order
There is a great need to establish such clinics in large towns & cities
The tertiary level should also be involved in basic, clinical and
epidemiological research.
It has also been recommended that local and national registries for
diabetics to be established
THANK YOU...