EPIDEMIOLOGY OF DIABETES

KURSUS POS BASIK PENGURUSAN DIABETES 31 julai 2009

Is NCD (CVD, DM) an important health problem ?

Disease Burdens : Global & Local

How serious is the problem ?

Global Death in 2005

35 million or 60% of all deaths are caused by chronic diseases.

17 million deaths approximately 30% are due to infectious diseases, maternal and perinatal conditions, and nutritional deficiencies combined.
An additional 5 million deaths 9% of the total resulted from violence and injuries.

RISK FACTORS & DISEASES

END POINT Non-modifiable risk factors: Age Sex Ethnicity Genes Modifiable risk factors: Diet - unhealthy Physical inactivity Tobacco use

Intermediate Risk Factors

stroke

Heart Disease

Alcohol Stress
Socioeconomic, cultural & environmental determinants: Globalization Urbanization Population ageing

Obesity/Overweight Raised blood pressure Raised blood glucose Abnormal blood lipids

Diabetes Cancers Lung Disease

DIABETES
Diabetes: badan tidak dpt menggunakan karbohidrat (gula & kanji) dgn sempurna dlm pemakanan disebabkan oleh kekurangan/ tindakan insulin yg tidak berkesan. Glukos (gula) akan terkumpul dlm darah & mengalir melalui ginjal & keluar dlm air kencing.

2 jenis diabetes: I. Bergantung kpd insulin ( IDDM ) II. Tidak Bergantung kpd insulin ( NIDDM )

Values for diagnosis of diabetes mellitus and other categories of hyperglycaemia

Plasma venous glucose mmol/L (mg/dl)

Diabetes mellitus: 7.0 ( 126 ) Fasting and/or 11.1(200) 2-hour post glucose load/casual Impaired Glucose Tolerence (IGT): <7.0 ( 126) Fasting concentration ( if measured ) and/or 7.8-11.0 ( 140-199) 2 - hour post glucose load Impaired fasting glycaemia(IFG): 5.6-6.9 (100-125) Fasting and/or < 7.8 (140) 2 hours ( if measured)

Diagnostic values for Type 2 DM/glucose intolerance -OGTT

OGTT plasma glucose values (mmol/L) Category 0- Hour 2-Hour

normal
IFG IGT DM

< 5.6
5.6 - 6.9

< 7.8
7.8 - 11.0

>7

> 11.1

Diabetes Mellitus
(sweet flowing river of honey) is a global health problem.
(King, H., 1993).

This rising trend is due to many factors population growth, aging,urbanization, increasing prevalence of obesity/overweight,unhealty diet & physical inactivity

Annual incidence of type 2 diabetes and prevalence of obesity among Japanese school children

MyNCDS-1 Overall NCD Risk Factors Prevalence and Burden 2006

MALAYSIA NCD SURVEILLANCE - 1 2005/2006
Inadequate Vegetable & Fruit

8.7 million
72.8 %

Lifestyle RF

Physical Inactivity

60.1 %
Current Smoker

7.2 million 3.0 million

25.5 %

10.5 millions (90 %)

at least 1 RF

Alcohol Consumption

1.5 million 12.2 % 2.0 million 5.8 million

25.7 % 16.3 % Intermediate RF

Obesity

Central Obesity

48.6 %
Raised Blood Pressure

3.1 million 1.3 million 11.0 % 6.4 million 0 10 20 30

8 millions (70 %)
at least 1 RF 53.5 %

Raised Blood Glucose

Hypercholesterolemia

40

50

60

70 80 PREVALENCE %

Value in the bar represent estimated population for adults aged 25 64 years

Common risk factors Intermediate risk factors

Projected NCD Risk Factors Burden 2015 / 2020 (million)

Adults aged 25 64 years

NCD Risk Factors

Unhealthy Diet Physical Inactivity Current Smoker Alcohol Consumption Obesity Central Obesity Raised Blood Pressure Raised Blood Glucose Hypercholesterolemia At least 1 risk factor

Estimated Population 2005 8.7 7.2 3.1 1.5 1.9 5.8 3.1 1.3

Estimated Population 2015 10.8 8.9 3.8 1.8 2.4 7.2 3.8 1.6

Estimated Population 2020 11.8 9.7 4.1 2.0 2.7 7.9 4.2 1.8

6.4
11.6

7.9
14.4

8.7
15.7

Prevalence of NCD Risk Factors in Malaysia (1996-2006)

NHMS II (1996) Age group Smoking Physically Inactive Unhealthy Diet Overweight (BMI 25 & <30 kg/m2) Obesity (BMI 30 kg/m2) Hypercholesterolaemia 18 years MANS (2003) 18 years MyNCDS-1 (2005) 25-64 years NHMS III (2006) 18 years

24.8%
88.4% N.A. 16.6% 4.4% N.A.

N.A.
85.6%* N.A. 27.4% 12.7% N.A.

25.5%
60.1% 72.8 30.9% 16.3% 53.5%

21.5%
43.7% N.A. 29.1% 14.0% 20.6%

In 2006, there is an estimated 2.8 million Malaysians age 18 years and above are current smokers, 5.5 million physically inactive, 3.6 million overweight and 1.7 15 million Malaysians obese.

DIABETES : A FORECAST
The number of people with diabetes is expected to increase alarmingly in the coming decades : 1985 = estimated 30 million people with diabetes worldwide 2000 = figure had risen to 150 million 2025 = expected to rise to 380 million

The prevalence of diabetes in adults is projected to rise in both developed and developing countries but by 2025 the largest increase in diabetes prevalence will take place in developing countries

5 countries with the largest number of people with diabetes in 2007

India = 40.9 million China = 39.8 million United States = 19.2 million Russia = 9.6 million Germany = 7.4 million

5 countries with the highest diabetes prevalence in adult population in 2007

Nauru = 30.7% United Arab Emirates = 19.5% Saudi Arabia = 16.7% Bahrain = 15.2% Kuwait = 14.4%

Prevalence rates are significantly rising among comparatively young and productive populations in the developing world

 3.8 million deaths are attributable to diabetes. Greater number die from cardiovascular disease made worse by diabetes related lipid disorder & hpt

Selected Non-Communicable Diseases at Ministry of Health Facilities, 2000 & 2005

Types of Disease 1. Hypertensive Disease 2. Ischaemic Heart Disease 3. Other Heart Disease 4. Cerebro-Vascular Disease 5. Diabetes Mellitus 6. Injury 7. Suicide and Para suicide
Source: MOH

No of Discharges 2000 32,886 33,623 17,598 13,868 27,179 157,823 1,837 40,244 2005 38,445 39,594 25,362 16,896 39,762 145,127 2,482 52,593

No. of Death 2000 155 2,556 2,406 2,936 323 2,689 151 2,832 2005 180 2,948 2,299 3,209 402 2,661 156 3,800

8. Cancer

10 PRINCIPAL CAUSES OF DEATH IN GOVERNMENT HOSPITAL 2005 (SABAH)

SEBAB DISEASE OF CIRCULATORY SYSTEM CERTAIN INFECTIOUS & PARASITIC DISEASE DISEASE OF RESPIRATORY SYSTEM NEOPLASMS CERTAIN CONDITION ORIGINATING IN THE PERINATAL PERIOD DISEASE OF DIGESTIVE SYSTEM DISEASE OF GENITOURINARY SYSTEM INJURY POISONING AND CERTAIN OTHER CONSEQUENCES OF EXTERNAL CAUSES DISEASE OF NERVOUS SYSTEM CONGENITAL MALFORMATIONS,DEFORMATION AND CHROMOSOMAL ABNORMALITIES BIL KEMATIAN ( PERATUS) 810 ( 20.67 % ) 666 (17.00% ) 489 ( 12.48% ) 489 ( 12.48% ) 312 ( 7.96% ) 181 ( 4.62% ) 174 ( 4.44% ) 169 ( 3.98 %) 118 ( 3.01 % ) 108 ( 2.76 % )

35
SUMBER:HEALTH FACTS JABATAN KESIHATAN NEGERI SABAH 2005

Projection of Risk Factor Burden-1

Disease Burden Prev Rate 1996 NHMS2 2002 2006 2010 2020

HPT DM

29.9% 8.3%

2,190,504 608,000

2,631,500 730,490

2,850,000 790,400

2,987,900 829,400

3,557,400 987,500

Note: Based on NHMS2 1996. Prevalance rate remain constant. Disease Burden= Pi x [p0 + (pi x Td)]

Projection of Risk Factor Burden -2

Disease Burden HPT
NHMS2

1996

2002

2006 4,383,450 (45.9%) 983,650 (10.3%)

2010 5,226,300 (52.3%) 1,109,200 (11.1%)

2020 8,126,100 (68.3%) 1,558,600 (13.1%)

2,190,504 3,476,435 (29.9%) (39.5%) 608,000 (8.3%) 836,200 (9.5%)

DM

Note: Based on NHMS2 1996. Prevalence rate increase proportionately.

The figure of DM in Malaysia

1960 = 0.65% 1982 = 2.1% 1986 ( NHMS 1) = 6.3% 1996 (NHMS 2) = 8.3%

Status of Diabetes Mellitus in Malaysia in the past 20 years

1986 NHMS I
Remarks

1996 NHMS II
old & above

2006 NHMS III

old & above 11.6% 7.0% 4.5% 4.2%**

2006 NHMS III

years old 2.4% 0.4% 2.0% 3.1% #

2006 NHMS III

35 years
old & above

30 years 18 years 18 29

30 years
old & above

Prevalence Known diabetes Newly diagnosed Impaired Glucose Tolerance (IGT) / Fasting Glucose (IFG)

6.3% 4.5% 1.8% 4.8% *

8.3%
6.5% 1.8% 4.3% *

14.9%
9.5% 5.4% 4.7%

**based on IGT; # based on IFG

 Rise in the prevalence of diabetes, the prevalence of diabetic complications is also expected to increase correspondingly - DM is the largest cause of kidney failure in developed countries - 10%-20% of people with DM will die of renal failure - 2.5 million people worldwide are affected by diabetic retinopathy - Cardiovascular disease is the major cause of death in DM - People with Type 11 diabetes are over twice as likely to have heart attack or stroke who do not have diabetes

Prevalence of Diabetes by States

NHMS 3 (2006)
Prevalence of All Diabetic by States
18 16 14 12 10 8 6 4 2 0

14.86 15.23 15.33

11.55%

Prevalence

10.04

11.07 11.1

11.74 12.01

12.1

12.6 12.61

13.45 13.61 11.55

7.94 4.93

Jo ho Te r re ng ga nu K el an ta n Se la ng or W Pa P ha K ua ng la Lu m pu r

States

Burdens

M el ak N a .S em bi la n N at io na l

Sa ba W h P La bu an Sa ra w ak

Pe ra k

Pe rl is

ed ah K

Pe na ng

Prevalence of All Diabetic by Age Group (aged 18 yrs)

30 25
Prevalence (%)
24.4 20.8 15.0
Overall Prevalence 11.55%

26.2

24.5

22.8

21.6 13.8

20 15 10 5 0
2.0 2.0 10.3

3.1

4.9

6.4

Age Group

Burdens

1.2 million (~80%)

National Prevalence of All Diabetes Prevalence of Diabetes by Residence by Residence (aged 18 yrs)
(BURDENs ) (997,000 )

12.5 12 11.5 11 10.5 10 9.5

Prevalence (%)

12.1

National Prevalence 11.55%

(468,000 )

10.5

Urban Residence
Sig Diff

Rural

Prevalence of Diabetes by Gender

( BURDENs ) (674,000 ) 11.9 (795,000 )
National Prevalence 11.55%

12.0

Prevalence (%)

11.8 11.6 11.4 11.2 11.0 Male

11.3

Fem ale

Diff-Not sig.

Prevalence of Diabetes by Race , Aged 18 yrs

( BURDENs )
Prevalence (%)

25.0 20.0 15.0 10.0 5.0 0.0

(221,000 )

19.9
(823,000 ) (314,000 )

11.9

11.4

(78,000 )

6.0

National Prevalence 11.55%

(28,000 )

4.5

Indian

Malay

Chinese

Other Bumi

Others

Race
Sig Diff

Prevalence of Diabetes among Malaysian Adults (Age >30 years), a comparison NHMS II & III

16 14 12 10 8 6 4 2 0

14.9
9.5

Prevalence (%)

6.5 1.8
Known Diabetics

8.3
5.4

Newly Diabetics
NHMS II NHMS III

All Diabetics

National Prevalence Diabetes by Job Description in Malaysia

Job Category
Prevalence
%

Burdens 000 40 88 122 61

Senior Officials Managers

Professionals Technical & Associates Clerical Workers

&

15.9
10.0 12.1 8.7

Service Workers & Shops

Skilled Agricultural & Fishery Crafts & Related Trade Workers Machine Operators & Assemblers Elementary Occupations

10.7
9.7 6.4 11.7 9.0

225
87 48 81 50 423 201

Housewives Unemployed
Unclassified

14.2 16.1
6.7

1 3

41

People With Known Diabetes

Prevalence of Known Diabetes by Age

20.0 18.0 16.0

18.3

19.0

18.8

18.4 15.2

Prevalence (%)

14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0

0.2 0.3 0.6 1.2 2.5 7.0 5.5 8.7

13.3

7.8

-1 9

-2 4

-2 9

-3 4

-3 9

-4 4

-4 9

-5 4

-5 9

-6 4

-6 9

-7 4

-7 9 75

N at io

18

20

25

30

35

40

45

50

55

60

65

70

80

-8 1

na l

Prevalence of Known Diabetes by States

Prevalence (%)
12.0 10.0 8.0 6.0 4.0 2.0 0.0 11.4 7.0 2.4 8.8 8.9 9.3 7.6 8.0 8.1 8.3 6.8 7.0 5.7 6.6 4.1 4.8

State

People With Newly Diagnosed Diabetes

Prevalence (%)
0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0

Prevalence of Newly Diagnosed Diabetes by Age

Age group

N at io na l 18 -1 9 20 -2 4 25 -2 9 30 -3 4 35 -3 9 40 -4 4 45 -4 9 50 -5 4 55 -5 9 60 -6 4 65 -6 9 70 -7 4 75 -7 9 80 -8 1

Prevalence of Newly Diagnosed Diabetes by States

Prevalence of Newly Diabetic by States
7 6 5 4 3 2 1 0
5.95 5.97 6.04 5.43 5.49 4.9 5.02 6.55 4.54

Prevalence

2.53

3.17

4.28 3.75 3.89 4.03 4.07

States

Impaired Fasting Glucose (IFG)

Prevalence of Impaired Fasting Glucose (IFG) by States

Prevalence of the Impaired Fasting Glucose (IFG) by States
7 6 5 4 3 2 1 0
6.05 6.14 3.36 3.39
4.77 5.02 4.35 4.48 4.48 4.64 3.81 3.98

Prevalence

4.24

2.64 2.72 2.92

States

Diabetes in the Young (18 - <30)

Overall prevalence of known & newly diagnosed diabetes: 2.4 % Newly diagnosed diabetes: 2.0 % Known diabetes: 0.4% Impaired fasting glucose: 3.1%

Diabetes Prevalence
6

4.93

3.8

3.9

NHMS II 3 2.4 2 2 2.53 2.72 NHMS III

1.8

0 All Diabetics Known Diabetics Newly Diabetics IGT

SABAH

Glycaemic Control Status (HbA1c)

Among Diabetic in Government Facilities, 2002 - 2004
60000 50000 40000 30000 20000 10000 0
17122 (64%) 11032 48833 (65%) 33035 (68%) 38180 58603

> 60% Poorly control

2002

2003

2004 Abnormal HbA1c

Source: Disease Control Division, MOH

Total HbA1c

Study on the adequacy of outpatient management of type II DM cases in MOH Hospitals and Health Centres in 2006 Status of Control by HbA1c Controlled = 10.4% Uncontrolled = 46.4% Indeterminable = 43.2%
Status of Control by FBS Controlled = 10.5% Uncontrolled = 81.9% Indeterminable = 7.6%
6 mth & FBS < 5.6mmol/L 6mth & HbA1c < 6.5%

MyNCDS-1: The Facts

1.3 million adults aged 25-64 yrs had High Blood Glucose Indian>Malay>Chinese

Move a little more, eat a little less

Trend of Diabetes Prevalence in Malaysia (1986 2006)

1986 NHMS I
Remarks

1996 2006 NHMS NHMS III II 30

years old & above

2006 NHMS III 18 29

years old 2.4% 0.4% 2.0% 3.1% #

2006 NHMS III 30 years

old & above

35 years
old & above

18 years
old & above 11.6% 7.0% 4.5% 4.2%**

National Prevalence Known diabetes

6.3% 4.5%

8.3%
6.5%

14.9%
9.5% 5.4% 4.7%

Newly diagnosed
Impaired Glucose Tolerance (IGT) / Fasting Glucose (IFG)

1.8%
4.8% *

1.8%
4.3% *

Based on IGT; # Based on IFG