Non-Communicable Diseaseswith Special Reference to Type 2

Diabetes Mellitus

Prof. (emeritus) Dr. med. Frank P. Schelp

Figure 1: Stages of Health, Nutritional, and Demographic Change

Focus on famine alleviation/prevention

Focus on family planning,infectious disease control

Chronic diseases predominate

Reduced fertility, aging

Focus on medical intervention, policy initiatives, behavioral change

Focus on healthy aging spatial redistribution

Demographic Transition Epidemiologic Transition Nutrition Transition

Receding pestilence, poorenvironmental conditions

Reduced mortality,changing age structure

High prevalence infectious disease

Diet-related Non-communicable

diseases predominate

Receding famine

High prevalence undernutrition

High fertility/mortality

Source: Popkin, Barry M. ( 2002) Public Health Nutrition 5:93-103.

Global deaths situation in perspective

• From 58 million death in 200560% caused by chronic diseases30% by infectious diseases including

HIV/AIDSTuberculosisMalariaMaternal and prenatal conditionsNutritional deficiencies

9% caused by violence and injuries• 45% of chronic disease deaths occur

prematurely (under the age of 70)

Double Burden of Communicable and non-comunicable diseases in Developing Countries

Boutayeb, A: Transaction Royal Soc Trop Med Hyg (2006) 100, 191-199

Non-communicable diseases (%)

Communicable diseases+MCH+Nutrition (%)

Injuries (%)

0 10 20 30 40 50 60 70 80

Percent

1990

2000

2020

Chronic diseases* are ….

”diseases which have one or more of the following characteristics: they are permanent, leave residual disability, are caused by nonreversible pathological alteration, require special training of the patient for rehabilitation, or may be expected to require a long period of supervision, observation or care”.

*also called “non-communicable diseases” or “Lifestyle-related diseases”

• Cardiovascular diseases• Cancers• Chronic respiratory disorders• Diabetes• Neuropsychatric and sense organ disorders• Musculoskeletal and oral disorders• Digestive diseases• Genito-urinary diseases• Congenital abnormalities and skin diseases

Main chronic diseases*

• Cardio vascular diseases– Heart disease– Stroke

• Diabetes

• Cancer

• Chronic respiratory diseases

• *”Best Buys” WHO 2011

Common modifiable risk factors

• Unhealthy diet

• Physical inactivity

• Tobacco use

Non-modifiable risk factors

• Age

• Gender

• Heredity

Intermediate risk factors

• Raised blood pressure

• Raised blood glucose

• Abnormal blood lipids

• Overweight/obesity

Cancer

Cancers in Tropical and Less-industrialised Countries

• Cancers exotic for tropical countries mainly– Burkitt‘s Lymphoma

• Cancers more prevalent in tropical countries and less prevalent in industrialised countries– Bile duct cancer (cholangiocarcinoma)

• Cancers highly prevalent in highly- and less industrialised countries but with different characteristics– Bladder cancer

• Cancers highly prevalent in industrialised- and less-industrialised countries– Lung cancer

‘Metabolic syndrome’

Medical disorder - increase risk of developingCardiovascular diseaseDiabetes mellitus type 2High blood pressure Central obesity (also known as visceral, male-pattern

or apple-shaped adiposity)Overweight with fat deposits mainly around the waist Decreased HDL cholesterol; Elevated triglycerides

Definition according to American Heart Association/Updated

NCEP (National Cholesterol Education Program)

• Elevated waist circumference: – Men — Equal to or greater than 102 cm – Women — Equal to or greater than 88 cm

• Elevated triglycerides: Equal to or greater than 150 mg/dL

• Reduced HDL (“good”) cholesterol: – Men — Less than 40 mg/dL – Women — Less than 50 mg/dL

• Elevated blood pressure: Equal to or greater than 130/85 mm Hg or use of medication for hypertension

• Elevated fasting glucose: Equal to or greater than 100 mg/dL (5.6 mmol/L) or use of medication for hyperglycemia

Controversy

• Different sets of conflicting and incomplete diagnostic criteria

• Is the metabolic syndrome anything more than the sum of its constituent parts?

• Generally, the individual disorders that comprise the metabolic syndrome are treated separately

Associated diseases to overnutrition

• Diabetes type 2• Hypercholesterolemia• High plasma triglycerides• Hypertension• Heart disease• Cancer • Gallstones• Arthritis• Gout• Fertility and pregnancy problems• Sleep apnea• Social- and emotional

consequences

Diabetes mellitus

• Diabetes is a chronic disease - increased concentration of glucose in the blood (hyperglycaemia).

• Type 1 diabetes (previously known as insulin-dependent or childhood-onset diabetes) - lack of insulin production.

• Type 2 diabetes (formerly called non-insulin-dependent or adult-onset diabetes) - ineffective use of insulin. – It often results from excess body weight and

physical inactivity. • Gestational diabetes - hyperglycaemia

recognized during pregnancy

Risk Factors of Diabetes Type 2

• Excessive carbohydrate intake (i.e. glycogenic index is high in connection with rice as major energy source)

• Urban lifestyle• Obesity• Drugs (diuretics – thiazide type; steroids;

steroids used in oral contraceptives – induce diabetes in susceptible individuals)

• Genetic factors

Diagnosis

• Fasting Plasma Glucose – Normal level less than 110 mg/dl – Pre-diabetes- between 110 and 125 mg/dl– Diabetes - greater than or equal to 126 mg/dl

• Casual Plasma Glucose/Random Plasma Glucose – Glucose value of greater than or equal to 200 mg/dl

• Glycated hemoglobin (HbA1c)– Levels over 6.4% indicative for type 2 DM

Glycated hemoglobin

• HbA1c is a test that measures the amount of glycated hemoglobin Glycated hemoglobin is a substance in red blood cells formed when blood sugar (glucose) attaches to hemoglobin.

• An HbA1c of 6.4% or less is normal

Oral Glucose Tolerance

• Blood glucose is measured before and after a person has taken a thick, sweet drink of glucose and other sugars.

• For someone with diabetes, the glucose value remains high (greater than or equal to 200 milligrams per deciliter of mg/dl ) two hours after consuming the drink.

• IGT Fasting <126 mg/dl after 2h 140 mg/dl• DM Fasting 126 mg/dl after 2h 200 mg/dl

Complications• Diabetic retinopathy - cause of blindness - damage to

the small blood vessels in the retina. After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment.

• Diabetic neuropathy - damage to the nerves - affects up to 50% of people with diabetes - common symptoms are tingling, pain, numbness, or weakness in the feet and hands.

• Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation.

• Leading causes of kidney failure. 10-20% of people with diabetes die of kidney failure.

• Diabetes increases the risk of heart disease and stroke. 50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke).

Complications• Diabetic retinopathy - cause of blindness - damage to

the small blood vessels in the retina. After 15 years of diabetes, approximately 2% of people become blind, and about 10% develop severe visual impairment.

• Diabetic neuropathy - damage to the nerves - affects up to 50% of people with diabetes - common symptoms are tingling, pain, numbness, or weakness in the feet and hands.

• Combined with reduced blood flow, neuropathy in the feet increases the chance of foot ulcers and eventual limb amputation.

• Leading causes of kidney failure. 10-20% of people with diabetes die of kidney failure.

• Diabetes increases the risk of heart disease and stroke. 50% of people with diabetes die of cardiovascular disease (primarily heart disease and stroke).

The foregoing information had been derived from the International Diabetic Federation (IDF) which also summarized the prevalence of diabetes mellitus worldwide on the following map:

Type 2 diabetes mellitus (T2DM) in Thailand

• Measured as DALY*– Rank 2 ♀; Rank 8 ♂

• Prevalence (2005 nation wide, age adjusted)– T2DM 6.7% (7.4%♀; 6%♂)– IFG** 12.5% (10.4% ♀; 14.7% ♂)

• *Disability adjusted life years • **Impaired fasting glucose

Attempt to control T2DM

• Active screening of ‘target’ group• Clear cut suggestions how to conduct

screening Including hypertension and nutritional status (BMI) into the program

• Principle that population should actively support the efforts by adopting behavior to reduce prevalence and control complications

Routine screening process

• Motivation of population by village health volunteers (VHV) and staff of sub-district health station

• Assemble population in community• Eligible: Adults 35 years and older• Fasting capillary blood glucose (CBG) by

glucometer • Individuals with ≥126 mg/dl referred to

community hospital• Result confirmed by measuring venous plasma

glucose (VPG)

Nong Bua LamphuProvince

Na Klang district

Description of area of investigation

• Province:– 125 inhabitants/qkm– 6 districts– 59 sub-districts– 636 villages

• Na Klang district:– Total population 91,000

– 8 sub-districts

– 131 villages

– 13 PCUs

Screening for T2DM 2009 and 20102009 N = appr. 7,600; 2010 N= appr. 700

BMI: 23 and over;Syst.: 140 mmHg and over; Diast.: 90 mmHg and over; CBG : 126 mg/dl and over

Female Male BMI Systolic Diastolic CBG 0

10

20

30

40

50

60

70

80

Per

cent 2009

2010

2009 62.9 37.1 56 20.6 17.9 14.6

2010 69.6 30.4 65 15.6 19.1 14.1

Screening test using VPG and HbA1c as ‘Golden standard’

VPG HbA1c Positive Negative

Positive 25 19 44

Negative 38 563 601

63 582 645

Sensitivity = 25/63 = 39.7% Specificity = 563/582 = 96.7%

Positive predictive value = 25/44 = 56.8%

First degree relative with DM and indicators of T2DM

2010

T2DM patients with father or mother having DM; CBG and VPG: 126 mg/dl and over; HbA1c : 6.5% and over

Father Mother CBG VPG HbA1c0

5

10

15

20

25

30

Per

cent

2010 10.8 28.7 8 6.6 17.6

Risk to develop T2DM having first degree relative with DMOdds ratio (crude) with 95% CI

2009 20100

1

2

3

4

5

High 2.14 4.17

Low 1.35 1.79

OR 1.7 2.37

‘Thrifty gene’ hypothesis

• To ensure survival during periods of famine, certain genes evolved to regulate efficient intake and utilization of fuel stores. Such genes were termed “thrifty genes” in 1962.– T2DM – insulin resistance and relative insulin

deficiency – metabolism of glucose delayed – beneficial in starvation

‘Barker’s fetal origins of adult disease’

Aftereffects of ‘Dutch Hunger Winter’

• Individuals prenatally exposed to famine during the ‘Dutch Hunger Winter’ from September 1944 to March 1945

• Six decades later, less DNA methylation of the imprinted insulin-like growth factor 2 (IGF2) gene compared with their unexposed, same-sex siblings

• Effect: Higher rates of obesity, lipid changes and cardiovascular diseases.

Importance of gestational diabetes for public

health

Conclusion

• Epidemics of tomorrow do not resemble those that previously occurred

• Chronic diseases are preventable but cannot be cured.

• Chronic diseases present far greater problems to medical science and services than infectious diseases

• Risk of new influenza pandemic require constant vigilance

• The “invisible” epidemics– Heart disease– Stroke– Diabetes– Cancer and others

• will take the greatest toll in deaths and disability

• In May 2009, The NCD Alliance launched a campaign for a United Nations High-Level Summit on Non-Communicable Diseases (NCDs) which took place 19-20 September 2011 in New York.

“Best Buy” InterventionsRisk factor / disease Interventions

Tobacco use Tax increaseSmoke free working and public places

Health information warning

Bans on tobacco advertising, promotion and sponsorship

Harmful alcohol use Tax increase

Restricted access to retailed alcohol

Bans on advertising

Unhealthy diet/physical inactivity Reduced salt intake

Increase polyunsaturated fat

Public awareness on diet and physical activity

CVD and diabetes Counseling and drug therapy

Treatment of hart attacks with asperin

Cancer Hepatitis B immunization (liver cancer)

Screening and treatment (cervical cancer)