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Estado Libre Asociado de Puerto Rico Estado Libre Asociado de 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 diabetes May 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 diabetes the 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 GDM Individuals with hypertension or dyslipidemia Type 1 DM Type 2 DM • Younger • More lean • Insulin-deficient • Low triglycerides Older Overweight Insulin-resistant High TG’s/Low HDL-C 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 DM Acute: 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 . Natural History of DM 2 Years from diagnosis -10 -5 Onset 0 5 10 15 Diagnosis Insulin resistance Insulin secretion Postprandial glucose Fasting glucose Microvascular complications Macrovascular complications Pre-diabetes Type 2 diabetes Adapted from Ramlo-Halsted BA, Edelman SV. Prim Care. 1999;26:771-789; Nathan DM. N Engl J Med. 2002;347:1342-1349 Impact of Diabetes Mellitus Diabetes The leading The leading cause of cause of nontraumatic new cases of end lower stage renal extremity disease amputations www.hypertensiononline.org A 2- to 4fold increase in cardiovascular mortality The leading cause of new cases of blindness in workingaged adults Criteria for the Diagnosis of Diabetes Global Prevalence of Diabetes Estimated global prevalence of type 1 and type 2 diabetes Global Prevalence Estimates, 2000 and 2030 4.4 % 2030 2000 0.0% 2.8 % 1.0% 2.0% 3.0% 4.0% 5.0% Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053. ¡Viva la Vida con Salud! Diabetes in the World 31.7 India Year 2000 20.8 China 17.7 USA 8.4 Indonesia 6.8 millions Japan Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053. ¡Viva la Vida con Salud! Diabetes in the World 79.4 India Year 2010 42.3 China 30.3 USA 21.3 Indonesia 8.9 millions Japan Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053. ¡Viva la Vida con Salud! Prevalence of Diabetes by Country Prevalence (%) 11.0 7.4 7.1 7.0 5.0 Puerto Rico Australia (2003)* (2002)** United States (2003)* Arabia (1999)*** Alaska (2003)* * > 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. ¡Viva la Vida con Salud! Prevalence of Diabetes in Adults United States, BRFSS* 1998 - 2003 Prevalence (Mean %) 8.0 7.1 7.0 6.0 5.0 4.0 5.4 5.6 6.1 6.5 6.7 3.0 2.0 1.0 0.0 1998 1999 2000 2001 2002 2003 * 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. ¡Viva la Vida con Salud! Global Incidence of IDDM PRC MEX JPN Cuba PLD DEN UK US NOR SCOT SWD CAN FIN 0 5 10 15 20 25 30 35 GENETIC RISK There 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 OBESITY Obesity 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 OBESITY The 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 factors Studies utilizing a variety of epidemiological approaches have implicated a range of lifestyle-related environmental factors in the etiology of type 2 diabetes CARBOHYDRATE AND DIETARY FIBER refined 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 FATS More 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 PROTEIN There are no firm epidemiological data concerning the role of protein intake in the etiology of type 2 diabetes, though the fact that meat-eating Seventh-Day Adventists have higher rates than those who do not eat meat has been taken to suggest a possible deleterious effect of animal protein The strong positive associations between animal protein and saturated fatty acids and vegetable protein and dietary fiber mean that it is almost impossible to disentangle separate effects in epidemiological studies. High intakes of proteins, especially animal protein, appear to be associated with an increased risk of nephropathy in type 1 diabetes [44], so restriction of protein may help to delay progression of microalbuminuria to clinical nephropathy OTHER DIETARY FACTORS Several micronutrients, most notably chromium, zinc, magnesium and vitamin E, have been implicated in the pathogenesis of type 2 diabetes and/or been shown to be associated with improved glycemic control. However, no epidemiological studies have provided convincing support for the role of any of these nutrients in the etiology of the disease. There is, perhaps, rather more support for the suggestion vitamin D deficiency may be important Vitamin D deficiency impairs insulin release, followed, if prolonged, by impairment of insulin secretion and reduction of glucose tolerance which progresses to irreversible diabetes. smooking The role of smoking as a risk factor for type 2 diabetes has received relatively little attention. Smoking induces insulin resistance [51], and cigarette smokers have been shown to be relatively glucose intolerant and Dyslipidemic Thus, smokers might be expected to be at considerably increased risk of type 2 diabetes. PHYSICAL INACTIVITY In cross-sectional epidemiological studies, type 2 diabetes rates have been shown to be lower amongst physically active individuals than amongst those not having regular physical activity The protective effect of physical activity against type 2 diabetes has been confirmed in several prospective studi Prevalence of Factors Associated with Diabetes, Puerto Rico BRFSS* 2003 63.6% 45.2% 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. ¡Viva la Vida con Salud! Stages in the Evolution of Major Diabetes Surveillance Indic Primary Prevention Physical activity• IFG / IGT• Diet/nutrition• Body composition• Normal Preventive Care Practices Foot exam• HbA1c testing• Dilated eye examination• Diabetes education• Prediabetes Diabetes The future: inued evolution of all domains. New generation quality of care Community or system level County and state level Health service measures for PP Complications Death Indicators of Burden: Risk Factors for Complications DM prevalence and incidence Uncontrolled blood pressure• Acute complications Inadequate glycemic control• Amputation ESRD Hyperlipidemia• CVD Smoking• Death Sedentary behavior• et al J Public Health Management Practice, 2003 (suppl). S44-51 Treatment In 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. NutritionalManagement of D M Diets 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 items Low 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 diabetes Total daily energy intake should be distributed as follows: (i) Carbohydrate >50% mainly as complex higher fibre carbohydrate moderate sucrose intake (ii) Fat 30–35% Mainly monounsaturated fat (iii) Protein 10–15% (decreasing with age) Fruit and vegetables (recommend five portions per day)