MODULE-1

CCD batch-33
 Objective
PA M1 L1

Through this module activity, you will be able to:

• Define and classify diabetes mellitus.
• Understand what is meant by prevalence rate of diabetes
mellitus and how it is estimated.
• Explain why there are differences in prevalence rate of
diabetes mellitus indifferent places and in same place at
different times.
 Definition of diabetes mellitus
PA M1 L2

• Diabetes mellitus is defined as chronic/persistent

hyperglycemia, due to deficiency of insulin secretion, or of
insulin action, or both.
• Several pathological processes are involved in causing
diabetes. These processes are regulated by genetic and/or
environmental factors.
 Three parts of definition

Biochemical hallmark Physiological changes Pathological process

Diabetes mellitus is 1. Deficiency of insulin 1. Several pathological

defined as secretion, processes are involved
chronic/persistent 2. Deficiency of insulin in causing diabetes.
hyperglycemia. action, or 2. The processes are
3. Both. regulated by genetic
and/or environmental
factors.
 Classification of diabetes mellitus
PA M1 L3

• Diabetes mellitus is classified into four types/classes on the

basis of aetiology.

DM: Classification
1. Type 1 diabetes mellitus (T1DM)
2. Type 2 diabetes mellitus (T2DM)
3. Gestational diabetes mellitus (GDM)
4. Other specific types or secondary diabetes mellitus (20DM)
 Four classes of DM: on the basis of aetiology
1. Type 1 DM
Destruction of beta cells by autoimmune
process leading to insulin secretion to
nil.
3. GDM
Women identified to have glucose
intolerance during pregnancy and is
usually due to defect of insulin action.
2. Type 2 DM
Defect in insulin secretion and/or action
produced by genetic and/or
environmental factors.
4. Other specific types or
Secondary DM
Defect in insulin secretion and/or
action in individual with known
disease, drugs or genetic
condition/syndrome.
 Type 1 diabetes mellitus
PA M1 L4

• Type 1 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 symptoms are
florid.

Pathophysiology of T1DM
Auto-immune destruction
of the insulin producing
beta cells of the islets of
Langerhans.
There is little or no insulin
in the body at the time of
onset of diabetes.
T1DM: Important features
Factors of T1DM Some other features of
T1DM
Environmental factors • Usually occurs in
trigger the autoimmune children or young
reaction in genetically adults.
susceptible individuals. • The onset is often
sudden and symptoms
are florid.
 Type 2 diabetes mellitus
PAM1L5

• Type 2 diabetes constitutes 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’).
• Environmental 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.

Pathohysiology of T2DM
Diabetes occurs due to
insulin resistance and
relative insulin deficiency,
usually develops with
increasing age.
T2DM: Important features
Factors of T2DM
Environmental factors like •
obesity and physical
inactivity are known strong
determinants in genetically
susceptible individuals.
• At diagnosis a large
Some other features of
T2DM
This type of diabetes
usually passes through
pre-diabetic stage
(Impaired Fasting
Glucose-IFG and
Impaired Glucose
Tolerance-IGT).
number of cases of
T2DM remain
asymptomatic and
often present with
diabetic specific
complications.
 Other specific types of diabetes mellitus
PAM1L6

• Some specific diseases, drugs or genetic

conditions/syndromes are associated with development of
chronic hyperglycemia. These forms of diabetes are classified
as other specific types of diabetes mellitus.
• Occurs in persons with known disease, drugs or genetic
condition/syndrome associated with secretion and/or action
defect of insulin. Causes include:
– Endocrinopathies
– Drugs and toxins
– Pancreatic disease, etc
• Features of primary condition and features related to diabetes
are present in this type of diabetes.
 20DM: Important features

Pathphysiology of 20DM Factors of 20DM Some other features of

20DM
Occurs in persons with Known factors like This type of diabetes has
known disease, drugs or • Endocrinopathies • Features primary
genetic • Drugs & toxins condition and
condition/syndrome, • Pancreatic disease, etc. • Features related to
associated with secretion diabetes.
and/or action defect
of insulin.
 Gestational diabetes mellitus (GDM)
PAM1L7

• 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.
• When the pregnancy is over and glucose intolerance returns
to normal then this GDM becomes her past medical history;
otherwise she will be named according to the degree of
glucose intolerance i.e. IFG, IGT or DM.
 GDM: Important features

Pathophysiology of GDM Factors of GDM Some other features of

GDM
GDM is glucose Known factors are Pregnancy outcome is
intolerance of any degree • Age, Obesity, Family bad
which starts or is history of DM and Bad • For Mother and
recognized during obs. history. • For Baby.
pregnancy. So hormones
released by placenta have
pathophysiologic link.
 Diabetic complications
PA M1 L8

• Uncontrolled diabetes mellitus sets in an abnormal state in

metabolism in the body. Therefore, all tissues/organs of the
body are in threat of developing complications of diabetes.
Long term complications are mediated by microvascular and
macrovascular changes.
• A diabetic is at risk of developing coronary artery disease,
stroke, blindness, renal failure, lower limb amputation etc.
many times more than a non-diabetic person.
• Children with uncontrolled diabetes may have problem in
growth. …..
• Pregnancy in women with diabetes threatens both expectant
mother and foetus.
• Acute metabolic derangement may lead to life threatening
diabetic comas, such as diabetic ketoacidosis (DKA),
hyperosmolar non-ketotic coma (HONK) etc.
 Diabetic complications

Uncontrolled DM is key to Long term complications Acute metabolic

complication derangement
Uncontrolled DM sets in Long term complications Acute metabolic
an abnormal state in are mediated by derangement may lead
metabolism and thereby • microvascular and to life threatening
all tissues/organs of the • macrovascular changes. diabetic comas such as
body are in threat of DKA, HONK etc.
developing complications
of diabetes.
 Treatment of diabetes
PA M1 L9

• Treatment of diabetes mellitus is to achieve some specific

goals. ‘Treating to target’ provides effective prevention of
diabetic complications.
• The primary goal is the control of high blood glucose.
• Other goals includes:
– Management of co-existing disease conditions
(hypertension, dyslipidemia),
– Modification of risk factors (obesity, physical inactivity) and
– Screening for early detection of chronic complications.
 Treat to target

Goals of DM treatment Target based treatment Diabetes Education (DE)

1. Control of high blood Treating to target Diabetes education to the
glucose provides effective patients and their
2. Management of co- prevention of diabetic families is essential for
existing disease complications. cost effective treatment
conditions
3. Modification of risk
factors and
4. Screening for early
detection of chronic
complications.
 Epidemiology of diabetes mellitus
PA M1 L10

• The prevalence rate of diabetes mellitus varies in different

places and in same place at different times. Epidemiological
studies called survey or surveillance are done to understand
this phenomenon of DM.
• 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. …..
• There are evidences that low and middle-income countries
will face the greatest burden of diabetes.
• Nearly 50% diabetic cases remain undiagnosed.
• The change in prevalence rate of DM is due to the change of
risk factors in the population.
• The risk factors of diabetes mellitus are assessed by
epidemiological tools called survey and surveillance study.
 Prevalence of DM

Definition of Prevalence Formula of Prevalence Formula of Prevalence

Increased
It is the number of Prevalence = (Number of Prevalence Increased =
persons suffering form affected persons x 100) / [(Present Prevalence -
DM per 100 persons in a Total number of Previous Prevalence) x
defined population at a population. 100] / Previous
certain time. Prevalence].
 Example of prevalence of DM

• In a survey in 2009 (time) 800 city dwellers of Dhaka, aged 20

to 79 years (population), tested for diabetes mellitus and 64
persons were suffering from diabetes mellitus. Therefore
prevalence of diabetes mellitus documented as 8.0%
[(Number of DM persons x 100) / Total number of persons
tested].
 Example of prevalence increased

• In 1985 another similar survey documented the prevalence of

diabetes mellitus was 5.3%. So the prevalence of diabetes
increased among the Dhaka city dwellers by 50.94%
[{(Present Prevalence - Previous Prevalence) x 100} / Previous
Prevalence] in 24-year time.
 Global trend
PA M1 L11

• Diabetes mellitus is now one of the most common non-

communicable diseases globally. It is epidemic in many
developing and industrialized countries. China and India hold
the 1st and 2nd positions respectively having 114 and 73
millions of total cases of diabetes in adult population (20 to 79
years) in 2017.
• 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. …..
• Type 2 diabetes constitutes about 90% of all diabetes. This
increasing trend of type 2 diabetes is associated with
changing lifestyle such as increasing urbanization, dietary
changes, reduced physical activity along with population
aging.
• Type 1 diabetes usually accounts for only a minority of total
burden in a population. Now-a-days it is also increasing. High
incidence is seen in Finland, Sweden, Denmark, Norway and
UK.
 Global estimate of DM & IGT

  2017 2045
Total world population (billions) 7.5 9.5
Adult population (20-79 years, 4.8 6.4
billions)
DM in adult population 
Prevalence (%) 8.8 9.9
Number of people with DM 425 629
(millions)
IGT in adult population 
Prevalence (%) 7.3 8.3
Number of people with IGT 352 532
(millions)
• Almost two thirds of the diabetics are between the ages of 20
and 64 years, with slight predominance of males.
• Prevalence of diabetes and IGT in 7 IDF regions are shown in
the figure: Africa (AFR), Europe (EUR), Middle East and North
Africa (MENA), North America and Caribbean (NAC), South
and Central America (SACA), South-East Asia (SEA) and
Western Pacific (WP).
 Prevalence of DM by age & Prevalence of DM in seven IDF
Sex (Time 2015) regions (Time 2015 & projected for
2040 )
 

  Africa (AFR), Europe (EUR), Middle East and North

Africa (MENA), North America and Caribbean (NAC),
South and Central America (SACA), South-East Asia
(SEA) and Western Pacific (WP)
 South-East Asia trend
PA M1 L12

• South-East Asian Region is one of the most populous regions

in the world. Bangladesh and India are situated in this region.
Nearly one-fifth of all diabetics live in this region.
• Number of people suffering from DM in SEA region is also
increasing.
• Prevalence of T2DM in adult population (20 to 79 years) was
8.2% in 2013 and 8.5% in 2015, and total number people with
DM were 72.1 millions and 78 millions respectively.
• Prevalence of IGT in adult population in 2015 was 4.6% and
total number people with IGT was 42.2 millions. …..
• Number of Type 1 DM children in 2015 was (0-14 years)
81,400.
• Approximately 1.2 millions people of age 20-79 years died
from diabetes in 2015.
• Diabetes accounts for 53.2 % of mortality among the people
under 60 years of age.
 Estimate of DM & IGT in South-East Asia Region

  2017 2045
Adult population (20-79 years, 962 1370
millions)
DM in adult population 
Prevalence (%) 8.5 11.1
Number of people with DM 82 151
(millions)
IGT in adult population 
Prevalence (%) 3.0 3.7
Number of people with IGT 29 50
(millions)
Prevalence of DM by age & Prevalence of DM by 7 member countries in
Sex in SEA (Time 2015) SEA region (Time 2015 )
  Bangladesh 7.4 [5.5 - 12.5]
Bhutan 7.9 [7.0 - 9.3]
India 8.7 [7.0 - 10.6]
Maldives 7.5 [6.1 - 9.9]
Mauritius 24.3 [21.1 - 28.0]
Nepal 3.3 [2.3 - 9.5]
Sri Lanka 8.5 [6.1 - 12.9]
 Bangladesh & India trend
PA M1 L13

• Magnitude of DM in Bangladesh and India are also increasing.

The table below summarizes the issue.
 India & Bangladesh 2017 2017 2045 2045
at a glance (India) (Bangladesh) (India) (Bangladesh)
Diabetes estimates (20-79 years)
Country prevalence, % 8.8 (6.7-10.9) 6.9 (5.6-9.5) 11.4 (8.8-14) 9.4 (7.8-12.8)
Age-adjusted        
comparative 10.4 (8-12.9) 8.4 (6.8-11.6) 10.4 (8.1-12.9) 8.4 (6.8-11.6)
prevalence, %
Number of people 72,946.4 6,926.3 134,298.2 13,659.3
with diabetes, in (55,473-90,198.1) (5,628.9-9,513.4) (103,390.8- (11,273.8-
1,000s 165,171.9) 18,563.8)
Number of people with 42,210.3 3,878.7 77,711.4 7,649.2
undiagnosed DM, in (32,099.4-52,193) (3,152.2-5,327.5) (59,826.9- (6,313.3-
1,000s 95,576.5) 10,395.7)
Proportion of 57.9 56 57.9 56
undiagnosed cases, %
 Diabetes in the young
PA M1 L14

• Rapidly increasing in children and adolescents in many

countries.
• The overall annual increase is estimated to be around 3%.
• Total number of type 1 diabetics globally is over 11,00,000.
• Numbers of newly diagnosed cases per year are 132,600 and
19,500 across the globe and SEAR respectively (<20 years). …..
• In Bangladesh the incidence is 17.1 per 1000 population.
• Type 2 diabetes in children and adolescents is also increasing
in all countries, and evidence suggests that in a growing
number of countries type 2 diabetes is now also being
diagnosed in childhood whether poor or rich. More on this
issue is discussed in appropriate section.
 Morbidity & Mortality
PA M1 L15

• 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 for people with diabetes depending on the population.
At least one complication will be present in 50% of newly
detected diabetes cases. Around 4 million deaths related to
diabetes were reported globally in 2017.
• The SEA Region was estimated to have the second highest
number of deaths due to diabetes of all the regions in 2017.
An estimated 1.1 million adults were expected to die from
diabetes-related causes accounting for 14.0% of all deaths in
the 20-79 years’ age group, where the global figure was
10.7%.
 Summary
P-A M1 L16

• There are 14 Lessons in Module 1. I understand the following points:

• DM is defined as chronic/persistent hyperglycemia due to deficiency of
insulin secretion, or of insulin action, or both
• There are 4 classes of DM based on aetiology - T1DM, T2DM, GDM and
Other specific types.
• Prevalence of DM in a defined population at a certain time is the number
of persons with DM per 100 persons.
• There are some risk factors of DM. Prevalence of risk factors in a
population changes with time, and also is different for other populations.
• Prevalence of DM in a population is a changing parameter.
• Survey or surveillance study are used to determine risk factors and
prevalence of DM in populations.
 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, 8th edition, IDF (International Diabetes
Federation), 2017.
Thank you