01 overview of diabetes cpg

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EPIDEMIOLOGY OF DIABETES EPIDEMIOLOGY OF DIABETES UNIT KAWALAN PENYAKIT TIDAK BERJANGKIT UNIT KAWALAN PENYAKIT TIDAK BERJANGKIT (NCD)(NCD)JABATAN KESIHATAN NEGERI SABAHJABATAN KESIHATAN NEGERI SABAH2Diabetes: The DiseaseIt is a common chronic disorderThere is chronic hyperglycaemia together with other metabolic abnormalitiesIt is due to insulin resistance and/or deficiency as well as increased hepatic glucose outputIt is a risk factor for CVDCurrently there is no known cure but the disease can be controlled enabling the person to lead a healthy and productive lifeThe aim of management is directed at reducing complications (micro and macrovascular)2 types 1) IDDM 2) NIDDM3Prevalence of Diabetes in Malaysia (1986-2006)NHMS I (1986) NHMS II (1996) NHMS III (2006)NHMS III (2006)Age group 35 years 30 years 18 years 30 yearsPrevalence6.3% 8.3% 11.6% 14.9%Known diabetes 4.5% 6.5% 7.0% 9.5%Newly diagnosed 1.8% 1.8% 4.5% 5.4%Impaired Glucose Tolerance * / Impaired Fasting Glucose **4.8% * 4.3% * 4.2% ** 4.7% **In 2006, there is an estimated 1.5 million Malaysians age 18 years and above living with diabetes.4Type 2 diabetes increases CVD risk*p < 0.1; p < 0.05; p < 0.01; p < 0.001Adapted from Kannel WB et al. Am Heart J 1990; 120: 6726.Coronary mortality 4 5 1 2 3 6Angina pectorisStrokeMen with diabetesWomen with diabetesAge-adjusted risk ratio(1 = risk for individuals without diabetes) Any CVD event Intermittent claudication Cardiac failure Sudden deathN/A*CHD MI 5EVERY 1% reduction in HBA1cREDUCED RISK*1%Deaths from diabetesHeart attacksMicrovascular complicationsPeripheral vascular disordersUKPDS 35. BMJ 2000; 321: 405-12.Better Control EqualsReduced Risk of Complications- 3 7 %- 4 3 %*p 7 > 11.10 10 20 30 40 50 60 70 80PREVALENCE %Overall NCD RiskOverall NCD Risk Factors Prevalence and BurdenPrevalence and Burden 2006 2006Value in the bar represent estimated population for adults aged 25 64 yearsCommon risk factorsIntermediate risk factorsInadequate Vegetable & Fruit 8.7 million72.8 % Physical Inactivity 7.2 million 60.1 %Current Smoker3.0 million25.5 %Alcohol Consumption1.5 million 12.2 %Obesity2.0 million16.3 %Central Obesity 5.8 million48.6 %Raised Blood Pressure3.1 million25.7 %Raised Blood Glucose1.3 million 11.0 %Hypercholesterolemia6.4 million 53.5 %MALAYSIA NCD SURVEILLANCE - 12005/2006MALAYSIA NCD SURVEILLANCE - 12005/2006 MyNCDS-1 MyNCDS-1Lifestyle RF10.5 millions 10.5 millions(90 %)at least 1 RFIntermediate RF8 millions 8 millions(70 %)at least 1 RF Projected NCD Risk Factors Burden 2015 / 2020 (million)Adults aged 25 64 years15.7 14.4 11.6At least 1 risk factor8.7 7.9 6.4Hypercholesterolemia1.8 1.6 1.3Raised Blood Glucose4.2 3.8 3.1Raised Blood Pressure7.9 7.2 5.8Central Obesity2.7 2.4 1.9Obesity2.0 1.8 1.5Alcohol Consumption4.1 3.8 3.1Current Smoker9.7 8.9 7.2Physical Inactivity11.8 10.8 8.7Unhealthy DietEstimatedEstimated PopulationPopulation 2020 2020EstimatedEstimated PopulationPopulation 2015 2015EstimatedEstimated Population Population 2005 2005NCD Risk Factors NCD Risk Factors17Prevalence of NCD Risk Factors in Malaysia (1996-2006)NHMS II (1996) MANS (2003) MyNCDS-1 (2005)NHMS III (2006)Age group 18 years 18 years 25-64 years 18 yearsSmoking 24.8% N.A. 25.5% 21.5%Physically Inactive 88.4% 85.6%* 60.1% 43.7%Unhealthy Diet N.A. N.A. 72.8 N.A.Overweight(BMI 25 & 60%> 60% PoorlyPoorly control controlStudy on the adequacy of outpatient management of type II DM cases in MOH Hospitals and Health Centres in 20066mth & HbA1c < 6.5%Status of Control by HbA1c Controlled = 10.4%Uncontrolled = 46.4%Indeterminable = 43.2%6 mth & FBS < 5.6mmol/LStatus of Control by FBSControlled = 10.5%Uncontrolled = 81.9%Indeterminable = 7.6%1.3 million adults aged 25-64 yrs had High Blood GlucoseIndian>Malay>ChineseMyNCDS-1: The FactsSCREENING AND DIAGNOSISOBJECTIVE.-To detect pre-diabetes and diabetes in specific high risk population groups and to ensure timely and appropriate management.STRATEGY.- Screening for high risk group.- Selective screening according to criteria.WHO SHOULD BE SCREENED?1) Symptomatic any individual who has symptoms suggestive of DM. ( tiredness, lethargy, polyuria, polydipsia, polyphagia, weight loss, pruritus vulvae, balanitis ) must be screened.2) Asymptomatic consider in all adults who are overweight (BMI > 23) or waist circumference > 80cm for women & >90cm for men and have additional risk factors :- HDL cholesterol < 0.9mmol/Lor triglycerides(TG) > 1.7mmol/L.- Hx of CVD.- HPT. - First degree relative with DM- Physical inactivity.- Women with polycystic ovarian syndrome (PCOS).- Women with Hx of gestational diabetes (GDM) should be screened for DM annually.- Ethnicity (those of Indian ethnic background are at higher risks of developing DM Type 2)For asymptomatic, screening should begin at age > 30 years.PREGNANT WOMEN.Should be screened if they have any of the following risk factors :- BMI > 27- Previous big baby weighing 4kg or more.- Previous GDM.- Bad obstetrics Hx. - Glycosuria at the first prenatal visit.- Current obstetrics problems (essential HPT, PIH and polyhydrmnios)- Age above 25 years.HOW IS SCREENING DONE?-Screening can be done by measuring RBS (capillary blood) using glucometer and strips.- In pregnant women, do OGTT using 75 gm glucose at least once at 24 weeks gestation.- Screeningfor DM should be performed annually in those with risk factors and those > 30 years.- In children and adolescents at risk of developing DM, screening should be initiated at 10 years old or at onset of puberty if puberty occurs at a younger age. Screening is performed every 2 years.- ALL newly diagnosed DM Type 2 need to be reviewed by a medical doctor in which screening for other cardiovascular risk need to be done or planned. TREATMENT OF DIABETES1) Diet and physical activity. Exercise 30 minutes 3 times a week.2) Lose weight. Try to achieve normal BMI.3) Medication.- Metformin (Glucophage ) 500 mg tablet.) Dose is 500 mg 1 gram TDS.) Adverse effects includes anorexia, nausea and vomiting.) Contraindicated in patients with renal impairment, chronic liver disease and cardiac failure.- Glibenclamide ( Daonil ) 5 mg tablet.) Dose is 2.5 15 mg daily.) Adverse effects includes increase appetite and weight gain.) Contraindicated in DM Type 1.- Gliclazide ( Diamicron ) 80 mg tablet.) Dose is 40 320 mg daily.) Adverse effects includes GI disturbances and rashes.) Contraindicated in DM Type 1.45TREATMENT OF DIABETESMedicationcont- Acarbose ( Glucobay ) 50 mg tablet.) Dose 50 200 mg TDS) Use only in DM type 2.) Adverse effects includes flatulence and bowel sounds and diarrhoea.) Contraindicated in patients less than 18 years, pregnant women and breast feeding mothers.-Insulin.) For DM Type 1 ) and also DM Type 2 that are not well controlled. 46EPIDEMIOLOGY OF EPIDEMIOLOGY OF HYPERTENSION HYPERTENSION UNIT KAWALAN PENYAKIT TIDAK BERJANGKIT UNIT KAWALAN PENYAKIT TIDAK BERJANGKIT (NCD)(NCD)JABATAN KESIHATAN NEGERI SABAHJABATAN KESIHATAN NEGERI SABAHDEFINITION AND CLASSIFICATION OF HYPERTENSION.-Hypertension is defined as persistent elevation of systolic BP of 140 mmHg or greater and/or diastolic BP of 90 mmHg or greater.-Classification of BP for adults age 18 and older.- The classification is based on the average of two or more readings taken at two or more visits to the doctor. When SBP and DBP fall into different categories, the higher category should be selected to classify the individuals BP. 48Category Systolic Diastolic(mmHg)(mmHg)Prevalence in MalaysiaOptimalPrehypertensionHypertensionStage 1Stage 2Stage 3< 120and< 80120 139 and/or80 89140 159 and/or90 - 99160 179 and/or100 - 109> 180and/or> 11032 %37 %20 %8 %4 %What is a Risk Factor ? A risk is condition that places an individual at risk developinga health-related problem. has causal association e.gSMOKING -------- LUNG CANCERA risk factor can be genetic or acquired.Itmay be identifiedas :a disease, (eg hypertension) a single measurement(eg.weight ) lifestylecharacteristic (eg. Unhealthy diet, Smoking).IntermediateRisk FactorsRISK FACTORS & DISEASES RISK FACTORS & DISEASESNon-modifiable risk factors:AgeSexEthnicityGenesModifiable risk factors Modifiable risk factors: :Diet - unhealthy Diet - unhealthyPhysical inactivity Physical inactivityTobacco use Tobacco useAlcohol AlcoholStress StressSocioeconomic, cultural & environmental determinants:GlobalizationUrbanizationObesity/Overweight Obesity/OverweightRaised blood pressure Raised blood pressureRaised blood glucose Raised blood glucoseAbnormal blood lipids Abnormal blood lipidsDiabetes CancersLung DiseaseED (Erectile Dysfunction)strokeHeart DiseaseEND POINTEND POINTProjection of Risk Factor Burden-1DiseaseDisease Burden BurdenPrevPrev Rate Rate1996 1996NHMS2 NHMS22002 2002 2006 2006 2010 2010 2020 2020HPTHPT29.9% 29.9% 2,190,504 2,190,504 2,631,500 2,631,500 2,850,000 2,850,000 2,987,900 2,987,900 3,557,400 3,557,400DM DM 8.3% 8.3% 608,000 608,000 730,490 730,490 790,400 790,400 829,400 829,400 987,500 987,50051Note: Based on NHMS2 1996. Prevalance rate remain constant.Disease Burden= Pix [p0 + (pix Td)]HypertensionHypertension is a major health problem due to : 1) its high prevalence. 2)lack of awareness amongst the general population.3)its poor control and 4)its impact on cardiovascular morbidity and mortality.Globally 264% of the adult population in year 2000 had hypertension 266% of men and 261% of women , 292% were projected to have this condition by 2025 290% of menand 295% of womenThe estimated total number of adults with hypertension in 2000 was 972 million (957987 million); 333 millionin economically developed countries 639 millionin economically developing countries. The number of adults with hypertension in 2025 was predicted to increase by about 60% to a total of 156 billion Source: Global burden of hypertension: analysis of worldwide data, Lancet 2005; 365: 2172354Preval