3 Dr. Sanjeev Phatak(2003)

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Epidemiology of Diabetes : 

Epidemiology of Diabetes Dr Sanjeev Phatak

The application of epidemiology : 

The application of epidemiology Study Natural history of the disease Study Prevalence & Incidence Study Morbidity and mortality Possible aetiology Preventive & curative measures Study Genetic basis of the disease

Slide 3: 

The study of epidemiology involves much more than number counting.

Slide 6: 

The fact that the mostly preventable disease diabetes has become so prevalent that it is “A public health humiliation.” The Lancet editorial, Volume 375, Issue 9733, Page 2193, 26 June 2010

DM Epidemiology: History : 

DM Epidemiology: History

Slide 8: 

Most famous physician of the medieval world “Diabetes mellitus was seldom seen in “cold” Europe, whereas it was frequently encountered in “warm” Africa.” “I, too, have not seen it in the West, nor did any of my teachers under whom I studied mention that they had seen diabetes. However, here in Egypt, in the course of approximately ten years, I have seen more than twenty people who suffer from this illness.” Maimonides – (1135-1204AD) The First Diabetes Epidemiologist?

DM Epidemiology: History : 

DM Epidemiology: History The first WHO Expert Committee on Diabetes Mellitus Convened in Geneva in 1964. The classification of diabetes based on scientific research was developed in 1979 WHO/IDF training course in epidemiology of diabetes held in Cambridge UK in 1980. This was the first of several courses that have boosted the numbers of diabetologists from many countries around the globe becoming “infected” and joining the epidemiology ranks

DM Epidemiology: History : 

Ron LaPorte and the Pittsburgh Group in the early 1980s, established the concept of diabetes registers. These registers form the basis of investigative studies on both the genetic and environmental risk factors for Type 1 diabetes. DM Epidemiology: History

DiabetesFacts & Figures : 

DiabetesFacts & Figures

Slide 12: 

Estimated global prevalence of type 1 and type 2 diabetes

Estimated Number of Diabetic Subjects in India. : 

Estimated Number of Diabetic Subjects in India. Mohan V, et al. 2007, 217-230.

Prevalence of Diabetes in Different Habitat in India : 

Prevalence of Diabetes in Different Habitat in India Ramachandran A. et al. 1992; 1348-1355.

Studies showing a rising trend in the prevalence of Type-2 diabetes in India. : 

Studies showing a rising trend in the prevalence of Type-2 diabetes in India.

Regional estimated for Diabetes (20-79 age group) for 2003 and 2025 : 

* AFR – Africa, EMME – Eastern Mediterranean and Middle East, EUR – Europe, NA – North America, SACA – South America and Central America, SEA – Southeast Asia, WP – Western Pacific. IDF – Southeast Asian Region. Regional estimated for Diabetes (20-79 age group) for 2003 and 2025

Prevalence rates of type-2 diabetes and IGT in India’s urban population : 

Prevalence rates of type-2 diabetes and IGT in India’s urban population

Prevalence rates of diabetes and IGT in India’s urban population : 

Prevalence rates of diabetes and IGT in India’s urban population

Temporal changes in prevalence of diabetes and IGT in urban southern India : 

Temporal changes in prevalence of diabetes and IGT in urban southern India

Urban Rural Difference : 

Rural: Urban divide in population is 70:30 Ongoing rural to urban shift in the population. Differences between those living in major cities and those living in smaller towns. Significant diversity amongst people living in rural, semi-urban and urban areas. Urban Rural Difference

Urban Rural Difference : 

Urban Rural Difference

Diabetes in India : 

Diabetes in India Previously, it was well known that diabetes in urban Indian areas was a serious issue, but it appears that the epidemic has now spread to the countryside. In a recent study by Dr V. Mohan it was found that prevalence of DM was around 12 per cent in urban areas, the prevalence in rural areas of Tamil Nadu was 8-10 per cent.“ A recent survey indicates that the prevalence of diabetes in rural areas of India could be between 8 and 10 per cent.

Study from ahmedabad : 

Study from ahmedabad Prevalance of 14.3% in males,12.6% in females in people above age 30 Prevalance more in middle class and higher middle class popullation(16-19%) AGENDA study,S.Phatak,U.Dhruv,2003

Recent study(ongoing) : 

Recent study(ongoing) Prevalance of Overweight(BMI>23)-23% in males,21% in females T2DM 18% in males,15.5% females HTN 31% in males,24% in females Heart Diseaese11% in males,6.5% in females Unpublished data,2010

Comparison of Prevalence of Diabetes in India - year 2003 and 2025. : 

Population (20-79) (Thousands) DM Prevalence (%) Diabetes Atlas, International Diabetes Federation. Comparison of Prevalence of Diabetes in India - year 2003 and 2025.

Comparison of Prevalence of IGT in India for the year 2003 and 2025. : 

Diabetes Atlas, International Diabetes Federation. IGT Prevalence (%) Population (20-79) (Thousands) Comparison of Prevalence of IGT in India for the year 2003 and 2025.

Prevalence of diabetes (20-79 age group) by region of the world : 

IDF – Southeast Asian Region. Prevalence of diabetes (20-79 age group) by region of the world

Number of people with diabetes (20 – 79 age group) by region : 

IDF – Southeast Asian Region. Number of people with diabetes (20 – 79 age group) by region

Vascular complications of Type-2 diabetes (n=3010) : 

Vascular complications of Type-2 diabetes (n=3010) Ramachandran A.2007,9-12.

Facts and Figures : 

WHO projects that in the next two decades, the largest increase of DM will be seen in the economically productive age group i.e. 20 – 45 year old individuals in developing countries SEA countries catching up with the prevalence of DM in the affluent societies Density of diabetes prevalence in India is far ahead than that in China. The prevalence of diabetes for all age-groups worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030 Facts and Figures

Which country is having highest number of Diabetics? : 

Which country is having highest number of Diabetics? A. INDIA B.CHINA C.USA

China has again overtaken India !! : 

China has again overtaken India !! China is now the country with the largest number of people with diabetes (The New England Journal of Medicine in March 2010) China has 92.4 million adults with the disease instead of estimated 40 million in 2009 by IDF. In China, 60.7% are undiagnosed, due to Poor public awareness Limited opportunities for diagnosis. India is no different !!

Slide 33: 

CAD and Diabetes In Indians Studies showing Prevalence of CAD in diabetica

Diabetes : Economic impact : 

Diabetes : Economic impact

Diabetes : Economic impact : 

Diabetes : Economic impact

"Diabetes Research and Clinical Practice" -IDF Magazine : 

"Diabetes Research and Clinical Practice" -IDF Magazine "The Socio-economics of diabetes from a Developing Country: A Population based Cost of Illness Study“ by MV Hospital for Diabetes and Diabetes Research Centre Chennai India to spend $32bn on diabetes care in 2010 60% of diabetics pay for the expenditure incurred for treatment and management of the disease from their personal savings.

India to spend $32bn on diabetes care in 2010 : 

Monthly income <Rs 10,000 60% of them borrow, mortgage or sell their property just to keep their blood sugar level under control. 27% finance their treatment while dipping into their savings. Monthly income between Rs 10,000 -30,000 72% pay from their savings 11.7% take loans to pay for their treatment. India to spend $32bn on diabetes care in 2010

India to spend $32bn on diabetes care in 2010 : 

India to spend $32bn on diabetes care in 2010 Higher income group 81% pay their medical bills from their personal savings. Health insurance coverage was in only 2%. Rs 5,000 as indirect cost annually in the form of lost man days while making rounds to hospitals for treatment. Extrapolating the figures, the study claims that the nation will spend a whopping $31.9 billion this year on diabetes care.

Economic Burden of Diabetes on India : 

Economic Burden of Diabetes on India Impact on People and Families 23 Million years of life lost due to disability and reduced quality of life Steals time from education, paid work and leisure In India, the poor spend 25% of the income to stay alive battling hyperglycemia Treatment brunt is on the pocket of patient in India due to poor healthcare infrastructure

Economic Burden of Diabetes on India : 

Economic Burden of Diabetes on India Other Impacts Large amount of expenditure towards the treatment of complications (Heart disease and Stroke) Developing countries like India harbor 80% of world Diabetics, but expenditure is only 20% 20% diabetics in Developing country spending 80% of expenditure toward treatment

Economic Burden of Diabetes on India : 

The WHO predicts India and China will respectively lose US$236.6 billion and US$557.7 billion of national income to diabetes and CV disease between 2005 and 2015. Economic Burden of Diabetes on India

Economic Burden of Diabetes on India : 

The International Diabetes Federation (IDF) estimates that an equivalent of 23 million years of life are lost to the disability and to reduced quality of life caused by the preventable complications of diabetes. WHO estimates that diabetes, heart disease and stroke together will cost about $333.6 billion to the Indian economy. The human, social and economic impact of diabetes. Economic Burden of Diabetes on India

Prescription cost of a Diabetic Patient : 

Prescription cost of a Diabetic Patient

Other Hidden Cost : 

Other Hidden Cost Cost of Investigations Transport costs Man days lost of patients & attendants Cost of complications

Indian Diabetes Drug marketGrowing at 12% Annually : 

Indian Diabetes Drug marketGrowing at 12% Annually AIOCD Data

The Diabetes Care Devices in Emerging Markets to Grow due to Growing Number of Diabetics : 

The Diabetes Care Devices in Emerging Markets to Grow due to Growing Number of Diabetics

% of Diabetic Patient on Antidiabetics, Antihypertensive & Statin : 

% of Diabetic Patient on Antidiabetics, Antihypertensive & Statin

Rule of Halves in Diabetes : 

Rule of Halves in Diabetes 1Hart JT. Rule of halves: implications of increasing diagnosis and reducing dropout for future workload and prescribing costs in primary care. Br J Gen Pract 1992; 42: 116.2. Novo Nordisk. Changing Diabetes Barometer, First Report, 2007.

Type 2 DM - global epidemic - why ? : 

49 Type 2 DM - global epidemic - why ? Prevalence depends on: Age Residence(urban/rural) Obesity Physical activity Ethnicity

Slide 50: 

50 Prevalence of DM in 60 years old Men Decoda:Nakagami; Diabetologia 2003

Slide 51: 

51 Prevalence of DM in 60 years old Women Decoda:Nakagami; Diabetologia 2003

Type 2 DM - global epidemic - why ? : 

52 Type 2 DM - global epidemic - why ? Prevalence depends on: Age Residence (urban/rural) Obesity Physical activity Ethnicity

Age standardized prevalence of Type 2 DM(native and migrant Asian Indian populations) : 

53 Age standardized prevalence of Type 2 DM(native and migrant Asian Indian populations)

Urban-Rural ratio : 

54 Urban-Rural ratio

Type 2 DM - global epidemic - why ? : 

55 Type 2 DM - global epidemic - why ? Prevalence depends on: Age Residence(urban/rural) Obesity Physical activity Ethnicity

OBESITY : 

OBESITY Overweight and obesity are some of the biggest challenges facing modern medicine today Obesity contributes significantly to morbidity Mortality risk increases in direct proportion to excess weight Obesity is the world’s 2nd most important risk for premature mortality (after smoking). Even slight overweight increases morbidity & mortality by inducing risk factors for metabolic disorders.

Relationship Between BMI and Risk of Type 2 Diabetes : 

Relationship Between BMI and Risk of Type 2 Diabetes Chan J et al. Diabetes Care 1994;17:961. Colditz G et al. Ann Intern Med 1995;122:481.

Relationship Between Weight Gain in Adulthood and Risk of Type 2 Diabetes Mellitus : 

Relationship Between Weight Gain in Adulthood and Risk of Type 2 Diabetes Mellitus Willett et al. N Engl J Med 1999;341:427.

Prevalence of Obesity in India : 

Prevalence of Obesity in India

Prevalence of Overweight in India : 

Prevalence of Overweight in India

Mean BMI in India : 

Mean BMI in India

Prevalence of Overweight and Obesity in different income groups of Delhi (Nutrition Foundation of India Study) : 

Prevalence of Overweight and Obesity in different income groups of Delhi (Nutrition Foundation of India Study) Prevalence (%) Slums Middle-Class Total Overweight (BMI > 25) Males ND ND 19.6 Females ND ND 44.5 Obesity (BMI > 30) Males 1 32.3 ND Females 4 50 ND Abdominal obesity Males ND 49.7 ND Females ND 34.9 ND ND: Not determined http://nutritionfoundationofindia.res.in/

Study from ahmedabad : 

Study from ahmedabad 5564 school children ,age 12-18 Boys 14.3% overweight,2.9% obese Girls 9.2% overweight,1.5% obese Prevalance more in Higher socioeconomic classes,junk food eaters,afternoon sleepers RKGoyal,U Dhruv,B saboo,S phatak,V Shah,N shah,2005

The Five City Study : 

The Five City Study Total No. of subjects : 3257 Age group: 25-64 yrs CITIES: Moradabad (n=902), Trivandrum (n=760), Calcutta (n=410), Nagpur (n=405), Bombay (n=780) Subjects were classified into as 5 social classes, based on socioeconomic status Int J Cardiol 1999;69:139-147

Type 2 DM - global epidemic - why ? : 

65 Type 2 DM - global epidemic - why ? Prevalence depends on: Age Residence (urban/rural) Obesity Physical activity Ethnicity

Non-pharmacological, observational : 

66 Non-pharmacological, observational Exercise Vigorous exercise > 1/week, 25% risk reduction (Manson & al, Lancet 1991, 338; 774-8., JAMA, 1992, 268,63-7) Looking TV 2-10 hours per week: RR 1.66 of having DM compared with 0-1 hour per week ( HU et al; Arch Intern Med 2001;161: 1542-1548)

Slide 67: 

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Slide 68: 

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Slide 69: 

69

Type 2 DM - global epidemic - why ? : 

70 Type 2 DM - global epidemic - why ? Prevalence depends on: Age Residence(urban/rural) Obesity Physical activity Ethnicity

Do any drugs Increase incidence of DM? : 

Do any drugs Increase incidence of DM?

Statin & Diabetes : 

Statin & Diabetes Meta analysis of 13 statin trials with 91 140 participants Statin therapy was associated with a 9% increased risk for development of diabetes Risk was highest in trials with older participants Treatment of 255 (95% CI 150—852) patients with statins for 4 years resulted in one extra case of diabetes. Attar N, Preiss D, Murray HM, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet 2010; 375: 735-742.

Statin & Diabetes : 

Statin & Diabetes With statin Risk of diabetes is low & far outweighs the benefit i.e. reduction in coronary events. Clinical practice in patients with moderate or high cardiovascular risk or existing cardiovascular disease should not change. Attar N, Preiss D, Murray HM, et al. Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. Lancet 2010; 375: 735-742.

Suggested approach : 

Suggested approach Treatment Role of Government NGO Diabetes bodies Pharmaceutical companies Affordability Role of Health insurance agencies Knowledge dissemination in public & Health care personals

Slide 75: 

“Medicine might be winning the battle of Glucose control, but it is losing the war against diabetes” The Lancet editorial, Volume 375, Issue 9733, Page 2193, 26 June 2010

Suggested approach : 

Suggested approach Complications: Early Diagnosis Heart disease Stroke Diabetes Foot care & screening Urine Microalbuminuria/ Urine ACR S. creatinine Neuropathy screening Eye Screening

Suggested approach : 

Suggested approach Complications: Treatment Heart disease Stroke Diabetes Foot care Nephropathy Neuropathy Retinopathy

Slide 78: 

Life was much simpler when apple and blackberry were only fruits

Thank You : 

Thank You

Slide 80: 

“0.1 per cent of the $ 2.9 million allocated to the health sector was passed on to non-communicable diseases like diabetes. Most of the aid is directed to HIV/AIDS.” Dr. Nigel Unwin, medical officer, diabetes unit, WHO

Prescription cost of a Diabetic Patient : 

Prescription cost of a Diabetic Patient

Other Hidden Cost : 

Other Hidden Cost Cost of Investigations Transport costs Man days lost of patients & attendants Cost of complications

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