Estado Libre Asociado de Puerto Rico Estado Libre Asociado de Puerto Rico

Estado Libre Asociadode Puerto Rico

Estado Libre Asociadode Puerto Rico

over the past few decades, diabetes has emerged as an important medical problem in developing regions of the world

In a more recent report on global diabetes estimates and projections for the years 2000–2030,Wild et al. showed that the worldwide prevalence of diabetes for all age groups would increase from 2.8% in 2000 to 4.4% in 2030, with a corresponding 114% increase in the numbers, from 171 million to 366 million. The greatest relative increases will occur in developing regions, namely India and the Middle Eastern Crescent

Important contributors include an increase in the urban population in developing countries and an increase in the proportion of people >65 years of age across the world

Diabetes mellitus (DM) is a common syndrome and caused by lack or decreased effectiveness of endogenous insulin

The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.

Classification of primary diabetes

Type 1 (insulin-dependent (IDDM), juvenile onset):

Only 5–10% of those with diabetesMay occur at any age but more common in

patients <30y.results from a cellular-mediated autoimmune

destruction of the β-cells of the pancreas

Some patients, particularly children and adolescents, may present with ketoacidosis as the first manifestation of the disease.

These patients are also prone to other autoimmune disorders such as Hashimoto’s thyroiditis, vitiligo, autoimmune hepatitis and pernicious anemia.

Type 2 (non-insulin dependent (NIDDM), maturity onset):

90–95% of those with diabetesthe cause is a combination of resistance to

insulin action and an inadequate compensatory insulin secretory response

a degree of hyperglycemia sufficient to cause pathologic and functional changes in various target tissues, but without clinical symptoms, may be present for a long period of time before diabetes is detect

Islet Cell Dysfunction and Abnormal Glucose

Homeostasis in Type 2 Diabetes

Most patients with this form of diabetes are obese, obesity itself causes some degree of insulin resistance

Insulin resistance may improve with weight reduction and/or pharmacological treatment of hyperglycemia but is seldom restored to normal

The risk of developing this form of diabetes increases with:

age, obesity, and lack of physical activity.In women with prior GDMIndividuals with hypertension or dyslipidemia

OlderOverweightInsulin-resistantHigh TG’s/Low HDL-C

• YoungerYounger

• More leanMore lean

• Insulin-deficientInsulin-deficient

• Low triglyceridesLow triglycerides

Type 1 DM

Type 2 DM

Gestational diabetes mellitus (GDM)GDM is defined as any degree of glucose

intolerance with onset or first recognition during pregnancy.

GDM complicates 4% of all pregnancies in the U.S., resulting in 135,000 cases annually

Presentation of DMAcute: Ketoacidosis

Sub-acute: Weight loss, polydipsia, polyuria, lethargy, irritability, infections (candidiasis, skin infection, recurrent infections slow to clear), genital itching, blurred vision, tingling in hands/feet.

With complications: Presentation with skin changes, peripheral neuropathy with risk of foot ulcers, amputations, nephropathy, eye disease

Asymptomatic: DM may be detected on routine screening during well man/woman checks .

Adapted from Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26:771-789 ;Nathan DM. N Engl J Med. 2002;347:1342-1349

Natural History of DM 2

Type 2 diabetes

Years from diagnosis

0 5-10 -5 10 15

Pre-diabetes

Onset Diagnosis

Insulin secretion

Insulin resistance

Postprandial glucose

Macrovascular complications

Fasting glucose Microvascular complications

DiabetesDiabetes

The leading cause of

new cases of end

stage renal disease

A 2- to 4-fold

increase in cardio-

vascular mortality

The leading cause of

new cases of

blindness in working-

aged adults

The leading cause of

nontraumatic lower

extremity amputations

www.hypertensiononline.org

Criteria for the Diagnosis of Diabetes

Global Prevalence of Diabetes

Estimated global prevalence of type 1 and type 2 diabetes

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Global Prevalence Estimates, 2000 and 2030

0.0% 1.0% 2.0% 3.0% 4.0% 5.0%

2000

2030 4.4%

2.8%

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

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millions

India

31.731.7

China

20.820.8

USA

17.717.7

Indonesia

8.48.4

Japan

6.86.8

YearYear20002000

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

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millions

India

79.479.4

China

42.342.3

USA

30.330.3

Indonesia

21.321.3

Japan

8.98.9

YearYear20102010

Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.

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> *18 years only. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1999-2003. Atlanta, GA: United States, Department of Health and Human Services.

**Dunstan DW, Zimmet PZ, Welborn TA, Courten MP, Cameron AJ, Sicree RA, et al. The raising prevalence of diabetes and impaired glucose tolerance. Diabetes Care. 2002; 25(5): 829-834.

***Warsy AS, el-Hazmi MA. Diabetes mellitus, hypertension and obesity-common multifactorial disorders in Saudis. Eastern Mediterranean Health Journal. 1999; 5(6): 1236-42.

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*BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 1998-2003. Atlanta, GA: United States, Department of Health and Human Services.

Global Incidence of IDDM

0 5 10 15 20 25 30 35

FIN

CAN

SWD

SCOT

NOR

US

UK

DEN

PLD

Cuba

JPN

MEX

PRC

GENETIC RISKThere is ample evidence that type 2

diabetes has a strong genetic component.Type 2 diabetes clusters in families.The lifetime risk of developing type 2

diabetes is about 40% in offspring of one parent with type 2 diabetes ; the risk approaches 70% if both parents have diabetes.

Intriguingly, the risk in the offspring seems to be greater if the mother rather than the father has type 2 diabetes

a first-degree relative of a patient with type 2 diabetes has a threefold increased risk of developing the disease

ADULT OBESITYObesity and weight gain are major risk

factors for type 2 diabetes, and they have been blamed for or implicated in the rising prevalence of diabetes worldwide.

A community-based survey in Saudi Arabia in 1995–2000 of people aged 30–70 years found that 36.9% were overweight and 35.5% were obese.

Men were more likely to be overweight and women were more likely to be obese

CHILDHOOD OBESITYThe sharp increase in the prevalence of

overweight and obesity worldwide is not only limited to adults, but also extends to adolescents and children and even to preschool children. This increase in weight led to an increase in the incidence of type 2 diabetes in childhood, to a point that it is becoming more common than type 1 diabetes in a few countries, such as in Japan and Taiwan

Dietary risk factorsStudies utilizing a

variety of epidemiological approaches have implicated a range of lifestyle-related environmental factors in the etiology of type 2 diabetes

CARBOHYDRATEAND DIETARY FIBERrefined carbohydrates, and sugars in

particular, might be involved in the etiology of type 2 diabetes

Over 40 studies have examined the role of sugars in the etiology of type 2 diabetes, with about half suggesting a positive association and a comparable number suggesting no association

On the other hand, there is rather more support for the suggestion that foods rich in slowly digested or resistant starch or high in dietary fiber (nonstarch polysaccharide) might be protective In controlled experiments, diets high in soluble fiber-rich foods [20] or foods with a low glycemic index are associated with improved diurnal blood glucose profiles and long-term overall improvement in glycemic control, as evidenced by reduced levels of glycated hemoglobin

Some other studies provide indirect support for this hypothesis. Diabetes risk appears to be lower in Seventh-Day Adventists who are vegetarians than in those who are not strict vegetarians [22].

The diet of vegetarians is characterized by a high intake of dietary fiber, but differs in other ways from that of nonvegetarians. In addition to not eating meat and animal products, vegetarians also have less saturated fat,more polyunsaturated fat and a diet which differs in micronutrient composition when compared with nonvegetarians.

DIETARY FATSMore than 60 years

ago, Himsworth [23] suggested that high intakes of fat increased the risk of diabetes in populations and individuals.

In the San Luis Valley Diabetes Study, a high fat intake was associated with an increased risk of type 2 diabetes and impaired glucose tolerance (IGT) [25];

in a follow-up, 1 to 3 years later, fat consumption predicted progression to type 2 diabetes in those with IGT

On the other hand, no association was found between fat intake and risk of type 2 diabetes in a 12-year follow-up of women in Gothenburg, Sweden

The type of dietary fat may also be relevant. Saturated fatty acids were positively related to fasting and postprandial glucose levels in normoglycemic Dutch men, the effect being independent of energy intake and obesity.

In a recent Italian study, intake of butter (rich in palmitic and myristic acids) was positively associated with fasting glucose levels, and the use of olive oil (high in oleic acid) was inversely associated with fasting glucose Levels

The ratio of polyunsaturated to saturated fatty acids in serum phospholipids has been shown to be inversely associated with insulin secretion and positively associated with insulin action

PROTEINThere are no firm epidemiological data

concerningthe role of protein intake in the etiology oftype 2 diabetes,though the fact that meat-eatingSeventh-Day Adventists have higher rates

thanthose who do not eat meat has been taken tosuggest a possible deleterious effect of animalprotein

The strong positive associationsbetween animal protein and saturated fatty acidsand vegetable protein and dietary fiber mean thatit is almost impossible to disentangle separateeffects in epidemiological studies.High intakes of proteins, especially animalprotein, appear to be associated with an increasedrisk of nephropathy in type 1 diabetes [44], sorestriction of protein may help to delay progressionof microalbuminuria to clinical nephropathy

OTHER DIETARY FACTORSSeveral micronutrients, most notably chromium,zinc, magnesium and vitamin E, have been

implicatedin the pathogenesis of type 2 diabetesand/or been shown to be associated with improvedglycemic control.However, no epidemiologicalstudies have provided convincing support for therole of any of these nutrients in the etiology of thedisease. There is, perhaps, rather more support forthe suggestion vitamin D deficiency may be

important

Vitamin D deficiency impairs insulin release,followed, if prolonged, by impairment of

insulinsecretion and reduction of glucose tolerance

whichprogresses to irreversible diabetes.

smookingThe role of smokingas a risk factor for type 2 diabetes has receivedrelatively little attention. Smoking induces insulinresistance [51], and cigarette smokers havebeen shown to be relatively glucose intolerant andDyslipidemicThus, smokers might be expected to be atconsiderably increased risk of type 2 diabetes.

PHYSICAL INACTIVITYIn cross-sectional epidemiologicalstudies, type 2 diabetes rates have been

shownto be lower amongst physically active

individualsthan amongst those not having regular

physicalactivity

The protective effect of physicalactivity against type 2 diabetes has been

confirmedin several prospective studi

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Prevalence of Factors Associated with Diabetes, Puerto Rico BRFSS* 2003

45.2%

63.6%

27.3%

Physical Inactivity Overweight /Obesity

Hypertension

*BRFSS = “Behavioral Risk Factor Surveillance System” (>18 years). Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System 2003. Atlanta, GA: United States, Department of Health and Human Services.

Normal Prediabetes Diabetes Complications Death

Risk Factors for Complications

• Uncontrolled blood pressure

• Inadequate glycemic control

• Hyperlipidemia• Smoking• Sedentary behavior

Preventive Care Practices

• Foot exam• HbA1c testing• Dilated eye

examination• Diabetes education

Desai et al J Public Health Management Practice, 2003 (suppl). S44-51

Stages in the Evolution of Major Diabetes Surveillance Indicators

Primary Prevention

• Physical activity• IFG / IGT• Diet/nutrition• Body

composition

Indicators of Burden:DM prevalence and incidence

Acute complicationsAmputation

ESRDCVD

Death

The future:Continued evolution of all domains.

New generation quality of careCommunity or system level

County and state levelHealth service measures for PP

TreatmentIn some individuals with diabetes, adequate

glycemic control can be achieved with weight reduction, exercise, and/or oral glucoselowering agents.

Individuals with extensive -cell destruction and therefore no residual insulin secretion require insulin for survival.

NutritionalManagementof D MDiets rich in monounsaturated fat reduce

total and low-density lipoprotein cholesterol without adverse effects on high- density lipoprotein cholesterol or triglyceride levels

a range of carbohydrate (45–60%) and fat (25–35%) intakes is compatible with good diabetes control provided that low glycaemic index carbohydrates and foods high in monounsaturated fat are promoted.

monounsaturated fatty acids should provide between 10 and 20% total energy

Glycemic index of certain food itemsLow GI: Pasta, Basmati rice, wholegrain

products, porridge, oat-based cereal bars, lentils and pulses including baked beans, and kidney beans

High GI: Corn Flakes, Rice Krispies, sugared cereals, white bread, rice (other than Basmati), potatoes, fruit juice, bananas, honey sandwich

for those people with Type 1 diabetes, especially

in those with hypertension, intakes of protein should not exceed 10–20% total energy because of the increased risk of nephropathy

It is recommended that a diet rich in foods which naturally contain significant quantities of antioxidants, especially fruit and vegetables, is followed

The normal protein requirements are:

. 2 g/kg per day in early infancy. 1 g/kg per day for a 10-year-old. 0.8 g/kg in later adolescence towards

adulthood

Nutritional recommendations for childhood and adolescent Type 1 diabetesTotal daily energy intake should be

distributed as follows:(i) Carbohydrate >50%mainly as complex higher fibre carbohydratemoderate sucrose intake(ii) Fat 30–35%Mainly monounsaturated fat(iii) Protein 10–15% (decreasing with age)Fruit and vegetables (recommend five

portions per day)