Chapter 1

Chapter 1
Introduction to diabetes mellitus
Epidemiology of diabetes mellitus

Chapter 1

Objective

To understand what is meant by prevalence rate of diabetes mellitus and how it is estimated.
To explain why there are differences in prevalence rate of diabetes mellitus in different places and in
same place at different times.
To explain how to assess the risk factors of diabetes mellitus in a population.

Distance Learning Program

Certificate Course on Diabetology

Diabetes mellitus [DM]

Diabetes mellitus is defined as chronic/persistent hyperglycemia, due to deficiency of insulin secretion, or of
insulin action, or both. At recent time several other pathological processes are recognized in causing diabetes,
specially type2. Diabetes mellitus is classified on the basis of aetiology into four types.

1. Type1 diabetes mellitus (T1DM)

2. Type2 diabetes mellitus (T2DM)
3. Other specific types
4. Gestational diabetes mellitus (GDM)

Type1 diabetes mellitus (T1DM)

Type1 diabetes (also previously called 'insulin dependent diabetes/juvenile onset diabetes') occurs due to
destruction of the insulin producing beta cells of the islets of Langerhans of pancreas by auto-immune
mechanism. At the time of onset of diabetes, there is little or no insulin in the body. Some environmental factors
trigger the autoimmune reaction in genetically susceptible individuals. This type of diabetes can affect people of
any age, but usually occurs in children or young adults. The onset is often sudden and sypmtoms are florid.

Type2 diabetes mellitus (T2DM)

Type2 diabetes constitues major portion of diabetic population. This type of diabetes occurs due to insulin
resistance and relative insulin deficiency, usually develops with increasing age (previously called non-insulin
dependent diabetes/maturity onset diabetes). Enviornmental factors like obesity and physical inactivity are
known strong determinants in genetically susceptible individuals. This type of diabetes usually passes through
pre-diabetic stage (Impaired Fasting Glucose- IFG and Impaired Glucose Tolerance- IGT). At diagnosis a large
number of cases of T2DM remain asymptomatic and often present with diabetic specific complications.

Other specific types of diabetes

Some specific diseases, drugs or genetic conditions/syndromes are associated with development of chronic
hyperglycemia. These forms of diabetes are classified as specific types of diabetes mellitus.

Gestational diabetes mellitus (GDM)

GDM is glucose intolerance of any degree which starts or is recognized during pregnancy. Maintaining blood
glucose very tightly reduces the risk to the mother and the baby.

Diabetic complications

Uncontrolled diabetes mellitus sets in an abnormal state in metabolism in the body.

Epidemiology of DM
Diabetes mellitus, a chronic and debilitating disease, is associated with a range of complications.
Epidemiological evidences suggest that number of diabetics is increasing worldwide. In some parts of the world
it is alarmingly high. It is putting tremendous burden on medical, economic and social infrastructure. It is now
believed that low and middle-income countries will face the greatest burden of diabetes. It is to be noted that
nearly 50% diabetic cases remain undiagnosed.

This section of the chapter will help you to understand the meaning of prevalence rate of diabetes mellitus, why
there is differences of prevalence rate of diabetes in different places and in same place at different times. You
will also learn how to estimate it.
Definition of prevalence of diabetes mellitus

Prevalence of diabetes mellitus in a defined population at a certain time is the number of persons suffering from
diabetes mellitus per 100 persons at that given time.

(Present prevalence -Previous prevalence) x 100

Prevalence =
Previous prevalence
Number of affected persons x 100
Prevalence increased =
(changed)
Total number of population

Example: In a survey in 2009 among city dwellers of Dhaka, aged 20 to 79 years, documented a prevalence of
diabetes mellitus as 7.8%. This means 7.8 per 100 people aged 20-79 years of Dhaka city in the year 2009 were
suffering from diabetes mellitus. Here, the population defined was city dwellers of Dhaka aged 20-79 years and
the time defined was 2009. In another survey of 1985 the prevalence was 5.3%. So the prevalence of diabetes
changed (increased) among the Dhaka city dwellers by 47% in 24-year time.

Global trend
Diabetes mellitus is now one of the most common non-communicable diseases globally. It is epidemic in many
developing and industrializing countries. China and India hold the 1st and 2nd position respectively having 98.4
and 65.1 millions of total cases of diabetes in adult poputation (20 to 79 years) in 2013. According to prevalence
rate Tokelau and Micronesia hold the 1st and 2nd position respectively having 37.5% and 35.0% diabetics in
adult poputation in 2013.

In addition to diabetes, IGT also constitutes a major public health problem, both because of its association with
diabetes incidence and its own association with an increased risk of cardiovascular disease.

Type2 diabetes constitutes about 85 to 95% of all diabetes. This increasing trend of type2 diabetes is associated
with rapidly changing lifestyle such as increasing urbanization, dietary changes, reduced physical activity along
with population aging.

Type1 diabetes usually accounts for only a minority of the total burden of diabetes in a population. Now-a-days
it is also increasing. Higher incidence is seen in Finland, Sweden, Denmark, Norway and the UK.

Global estimate of DM and IGT

Almost half of the diabetics are between the ages of 40 and 59 years, with slight predominance of males.

Graph

Bangladesh trend
Magnitude of diabetes mellitus in Bangladesh is increasing. Such a comment requires appropriate data on this
issue. The next table has summarized findings of 10 screening studies carried out from 1966 to 2003 where any
blood glucose >7.8 mmo/L after 2 hours of a meal was considered as an abnormal glucose tolerance. In the mid
70's the rate was around 1.0 to 1.5%, which has increased to 15% recently.

Global estimate of DM and IGT

Global estimate of DM and IGT

Diabetes in the young

Type1 diabetes is rapidly increasing in children and adolescents in many countries; the overall annual increase
is estimated to be around 3%. Total number of type1 diabetics globally is nearly 500,000. Numbers of newly
diagnosed cases per year are 79,000 and 12,500 cases globally and for SEAR respectively (0 to 14 years). In
Bangladesh the incidence is 4.2 per 100,000 per year.

Type2 diabetes in children and adolescents is also increasing in all countries, and evidence suggests that in a
growing number of countries type2 diabetes is now also being diagnosed in childhood whether poor or rich.
More on this issue is discussed in appropriate section.
Morbidity and mortality
Diabetes is one of the major causes of premature illness and death in most countries. Cardiovascular diseases,
resulting from damage to large blood vessels, cause death of 50% or more of people with diabetes depending on
the population. At least one complication will be present in 50% of newly detected diabetes cases.

The SEA Region was estimated to have the second highest number of deaths due to diabetes of all the regions in
2013. An estimated 1.2 million adults was expected to die from diabetes-related causes accounting for 14.2% of
all deaths in the 20-79 years age group, where the global figure was 8.4%.

Perform activities in the Interactive Modules.

Further reading

Text Book of Diabetes, 4th edition, edited by Richard I G Holt, Clive S Cockram, Allan Flyvbjerg &
Barry J Goldstein, Wiley-Blackwell, 2010.
Diabetes Atlas, 6th edition, IDF (International Diabetes Federation), 2013.
Diabetes Atlas, 5th edition, IDF (International Diabetes Federation), 2011.
Diabetes Atlas, 4th edition, IDF (International Diabetes Federation), 2009.