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Non-Communicable Diseases
with Special Reference to Type 2
Diabetes Mellitus
Prof. (emeritus) Dr. med. Frank P. Schelp
Figure 1: Stages of Health, Nutritional, and Demographic Change
Demographic Transition
Epidemiologic Transition
Nutrition Transition
High
fertility/mortality
High prevalence
infectious disease
High prevalence
undernutrition
Reduced mortality,
changing age structure
Receding pestilence, poor
environmental conditions
Receding famine
Focus on family planning,
infectious disease control
Reduced fertility,
aging
Focus on healthy aging
spatial redistribution
Focus on famine
alleviation/prevention
Chronic diseases
predominate
Diet-related
Non-communicable
diseases predominate
Focus on medical intervention, policy
initiatives, behavioral change
Source: Popkin, Barry M. ( 2002) Public Health Nutrition 5:93-103.
Global deaths situation in
perspective
• From 58 million death in 2005
 60% caused by chronic diseases
 30% by infectious diseases including
 HIV/AIDS
 Tuberculosis
 Malaria
 Maternal and prenatal conditions
 Nutritional 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
Non-communicable diseases (%)
Communicable diseases+MCH+Nutrition (%)
1990
2000
2020
Injuries (%)
0
10
20
30 40 50 60
Percent
Boutayeb, A: Transaction Royal Soc Trop Med Hyg (2006) 100, 191-199
70 80
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 lessindustrialised countries
– Lung cancer
‘Metabolic syndrome’
Medical disorder - increase risk of developing
 Cardiovascular disease
 Diabetes mellitus type 2
 High 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
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•
•
•
•
•
•
•
•
•
•
•
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 insulindependent or childhood-onset diabetes) - lack of
insulin production.
• Type 2 diabetes (formerly called non-insulindependent 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 Lamphu
Province
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 2010
2009 N = appr. 7,600; 2010 N= appr. 700
80
70
Percent
60
50
2009
2010
40
30
20
10
0
2009
2010
Female
Male
BMI
Systolic
Diastolic
CBG
62.9
69.6
37.1
30.4
56
65
20.6
15.6
17.9
19.1
14.6
14.1
BMI: 23 and ove r;Syst.: 140 mmHg and ove r; Diast.: 90 mmHg and ove r; CBG : 126 mg/dl and ove r
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
30
25
Percent
20
15
10
5
0
2010
Father
Mother
CBG
VPG
HbA1c
10.8
28.7
8
6.6
17.6
T2DM patients with father or mother having DM; CBG and VPG: 126 mg/dl and over; HbA1c : 6.5% and over
Risk to develop T2DM having first degree relative with DM
Odds ratio (crude) with 95% CI
5
4
3
2
1
0
High
Low
OR
2009
2010
2.14
1.35
1.7
4.17
1.79
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 NonCommunicable Diseases (NCDs) which
took place 19-20 September 2011 in
New York.
“Best Buy” Interventions
Risk factor / disease
Tobacco use
Interv entions
Tax increase
Smoke free working and public places
Health information warning
Bans on tobacco adv ertising, promotion
and sponsorship
Harmful alcohol use
Tax increase
Restricted access to retailed alcohol
Bans on adv ertising
Unhealthy diet/physical inactiv ity
Reduced salt intake
Increase polyunsaturated fat
Public awareness on diet and physical
activ ity
CVD and diabetes
Counseling and drug therapy
Treatment of hart attacks with asperin
Cancer
Hepatitis B immunization (liv er cancer)
Screening and treatment (cerv ical
cancer)