-Dr N.D Moulick Prof & Head, Dept. of Medicine,

LTMMC & LTMGH

Rationale for Screening Disorder is an important public health problem.

An early asymptomatic stage exists.

There is a suitable screening list

An accepted treatment is available.

Early treatment during the asymptomatic stage improves the outcome.

Public Health Problem DM – Major cause of early illness and death worldwide.

Global prevalence continues to rise 6.4% in adults.

Ranges 3.8 – 10.2% by region.

Major cause for hospitalization.

Complications affect many organs.

Asymptomatic Relatively long period exists.

High risk patients – IGT from DM

Screening Test Several Available – F, PP, random, glycated Hb

Optimal test - debatable

Accepted treatment Sulphonylureas

Biguanides

Alpha-glucosidase inhibitors

Thiazolidine diones

Gliptins

“INSULINS”

Interventions Diabetes Control and Complications Treatment DCCT.

United Kingdom Prospective Diabetes Study UKPDs

Type 2

Prediabetes intervention care prevents or delay onset.

Screening test FPG & HbA1c specificity and sensitivity depends on the

population tested.

F > 126 mg% (7.0 mmol/L)

PP > 200 mg% (11.1 mmol/L)

Specificity > 95%

Sensitivity 50%

Especially if patients 65yr

Screening test HbA1c > 6.5%

Specificity - 79%

Sensitivity – 44%

Correlates well with retinopathy.

Blood Glucose Expert committee on Diagnosis & Clarification of

Diabetes Mellitus defined three Categories

Normal FPG < 100 mg%

Increased Risk also called prediabetes.

Impaired fasting FPG -> 100-125

Blood Glucose DM – Repeat on subsequent days

F > 126 mg%

Plasma Glucose > 200 mg%

Presence of symptoms

In fact, many persons with Type II diabetes already show the presence of the long term complications associated with diabetes at the time of diagnosis.

It is now widely accepted that if diabetes is detected early and adequate steps are taken, it may be possible to significantly delay the onset and progression of these complications.

Thus, this is all the more reason to try and diagnose the onset of diabetes at the earliest.

Although diabetes does have its typical signs and symptoms, many people do not exhibit these "typical" signs and symptoms even though they have diabetes.

All those who complain of symptoms or show signs commonly associated with diabetes must have a test for diabetes.

If feasible, all persons over the age of 30 years should undergo an annual test to rule out the presence of diabetes.

Persons at high risk MUST undergo testing when they present for medical attention for whatever reason, and if negative, must have a regular annual check, thereafter.

A negative test for diabetes does NOT mean that the person will never get diabetes. It only means that the person does not have diabetes at the time of testing.

Persons at HIGH RISK for diabetes:

All persons manifesting any of the following signs and symptoms: polyuria, polydipsia ,weight loss in spite of adequate food

intake, Polyphagia , undue tiredness and fatigue, tingling or numbness in the extremities, burning feet, generalised pruritus, pruritus vulvae, balanitis, Delayed wound healing, impotency, premature cataracts, visual disturbances.

Persons at HIGH RISK for diabetes: All persons with a family history of diabetes.

All obese patients, especially those with central obesity, waist-hip (W-H) ratio, approx. >0.95 in men and >0.85 in women, and/or a Body Mass Index (BMI) >25.

All adult patients with tuberculosis, including atypical presentations, recurrent infections, non-healing ulcers.

Patients with atherosclerosis and its complications, especially those with premature acrovascular disease.

Persons at HIGH RISK for diabetes: All patients with high blood pressure and lipid

abnormalities.

All women with a bad obstetric history, recurrent fetal wastage, and those who give birth to large weight babies.

Persons who were large weight babies; very low birth weight babies may also be predisposed to diabetes.

Persons who show an acute rise in the blood glucose levels at time of physical (myocardial infarction, cerebrovascular accidents, acute infections, trauma, etc.) or mental stress.

Persons taking drugs which are known to increase blood glucose levels like steroids, thiazide diuretics, oral contraceptives, beta-blockers, phenytoin sodium, etc.

All persons over the age of 30 years should undergo an annual test for the presence of diabetes

The diagnosis of diabetes MUST be based on blood glucose estimations.

Urine glucose testing must NOT be used to diagnose diabetes. True blood glucose should be estimated using enzymatic methods like

the Glucose Oxidase method. It should be clear whether the blood glucose estimation has been

carried out on capillary blood, whole venous blood, or on venous plasma. A fasting venous whole blood glucose of more than 110 mg% (venous plasma glucose > 126 mg%) OR a random venous whole blood glucose level of more than 180 mg%, (venous plasma glucose > 200 mg%), confirmed on repeat testing, in a patient with characteristic sign and symptoms of diabetes, is diagnostic.

Doing a Glucose Tolerance Test in a known diabetic is NOT necessary. In all other persons, a Glucose Tolerance Test must be carried out in

order to exclude diabetes.

HIGH RISK Patients Women who had GDM during a previous pregnancy. Women with a first degree relative who is a diabetic. Women who gave birth to large weight babies in a previous

pregnancy. Women whose newborn, in a previous pregnancy, showed any

complication known to be associated as arising from maternal GDM.

Women who gave birth to still born babies or infants with congenital abnormalities.

Women with a bad obstetric history, including recurrent fetal wastage, hypertension, eclampsia, hydramnios, etc.

Women with repeated or persistent urinary tract infection. Women manifesting glycosuria during pregnancy. Women over the age of 30 years.

The information for these risk factors can be obtained based on four simple questions and one anthropometric measurement namely waist circumference. The four questions are:

1. What is your age?

2. Do you have a family history of diabetes? If yes, does your father or mother or both have diabetes?

3. Do you exercise regularly?

4. How physically demanding is your work [occupation]?

Table 1 : Indian Diabetes Risk Score [IDRS] developed based on multiple logistic regression analysis derived from CURES :

Particulars Score

Age [years]

< 35 [reference] 0

35 - 49 20

≥ 50 30

Abdominal obesity

Waist <80 cm [female] , <90 [male] [reference] 0

Waist ≥ 80 – 89 cm [female], ≥ 90 – 99 cm [male] 10

Waist ≥90 cm [female], ≥ 100 cm [male] 20

Physical activity

Exercise [regular] + strenuous work [reference] 0

Exercise [regular] or strenuous work 20

No exercise and sedentary work 30

Family history

No family history [reference] 0

Either parent 10

Both parents 20

Minimum score 0

Maximum score 100

Mohan etal JAPI

An IDRS value >60 had the optimum sensitivity (72.5%) and specificity (60.1%) for determining undiagnosed diabetes

Positive predictive value was 17%

Negative predictive value was 95.1%

Accuracy was 61.3%

The 67-years of independence have seen many changes in the socio-economic landscape of India.

During the decades that followed the colonial rule, India's economy, in absolute terms, has expanded to Rs 57 lakh crore from mere Rs 2.7 lakh crore

Nation's foreign exchange reserves have crossed $300 billion

Developing India

India's food grain production has more than doubled over the decades that followed colonial rule to a record 264 million tonnes in the fiscal year 2014.

•India has the dubious distinction of having the largest number of people with diabetes.

•Recent studies have shown that for every person known to have diabetes, there are more than 2 people who have diabetes but are unaware of it.

Prevalence of diabetes in urban India since 2000 Region Year Age of

subjects (years)

Prevalence (%)

Diabetes IGT

IFG

National Ramachandran et al

2000 > 20 12.1 14.0 --

Reddy et al. 2003 20-69 8.4 -- 6.4

Sadikot et al 2004 >20 5.9 6.3 4.8

Northern India Ramachandran et al

2000 >20 11.6 8.6 --

Gupta et al 2003 >20 8.6 -- 5.3

Prabhakaran et al† 2005 20-59 15 37

Southern India Ramachandran et al

2000 >20 13.5 16.8 --

Mohan et al 2004 > 20 14.3 10.2 --

2004 >20 14.3 10.2 --

Menon et al 2005 18-80 19.5 4.1 7.0

2005 18-80 19.5 4.1 7.0

Rank

Country 2010 (Million

s)

Country 2030 (Millions)

1 India 50.8 India 87.0 2

2 China 43.2 China 62.6

3 US 26.8 US 36.0

4 Russian Federation 9.6 Pakistan 13.8

5 Brazil 7.6 Brazil 12.7

6 Germany 7.5 Indonesia 12.0

7 Pakistan 7.1 Mexico 11.9

8 Japan 7.1 Bangladesh 10.4

9 Indonesia 7.0 Russian Federation 10.3

10 Mexico 6.8 Egypt 8.6

*IDF Diabetes Atlas, 4th edition. International Diabetes Federation, 2009

Top 10 countries for estimated numbers of adults with diabetes, 2010 and 2030*

GDP growth rate[edit]

This chart shows the Indian real GDP yoy growth rate (quarterly data) [1]

Since the economic liberalisation of 1991, India's GDP has been growing at a higher rate.[23]

YearGrowth (real) (%)20005.6

20016.020024.320038.320046.220058.420069.220079.020087.420097.420107.120116.820126.520135.120146.92015(estimates)7.5

India has more diabetics than any other country in the world, according to the International Diabetes Foundation,[7] although more recent data suggest that China has even more.[5]

The disease affects more than 62 million Indians, which is more than 7.1% of India's Adult Population.[8]

An estimate shows that nearly 1 million Indians die due to Diabetes every year.[7]

The average age on onset is 42.5 years.[7]

The high incidence is attributed to a combination of genetic susceptibility plus adoption of a high-calorie, low-activity lifestyle by India's growing middle class.[9]

Additionally, a study by the American Diabetes Association reports that India will see the greatest increase in people diagnosed with diabetes by 2030.[1

Studies in India indicate that more than 50% of people with diabetes have poor glycaemic control (HbA1c > 8%),

uncontrolled hypertension and

dyslipidaemia,

large percentage have diabetic vascular complications.

Overall, diabetes care in India leaves much to be desired.

Increased awareness amongst health professionals to improve the standard of diabetes care is urgently needed,

development of novel therapeutic agents

THANK YOU