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Diabetes Mellitus
 Introduction

• Diabetes is a chronic, metabolic disease characterized by elevated

levels of blood glucose which leads over time to serious damage to the
heart, blood vessels, eyes, kidneys and nerves.
• It is a group of metabolic disorders characterized and identified by the
presence of hyperglycemia resulting from defects in insulin secretion,
insulin action/utilization or both.
• Diabetes is a major cause of blindness, kidney failure, heart attacks,
stroke and lower limb amputation.
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Diagnostic Criteria

Diagnostic criteria for diabetes:

• Fasting plasma glucose ≥126mg/dL or 2-hour post-load plasma
glucose ≥ 200 mg/dL or HbAlc ≥ 6.5 %.

Diagnostic criteria for gestational diabetes:

• Fasting plasma glucose ≥ 92 -124 mg/dL or 1-hour post-load plasma
glucose ≥ 180 mg/dL or 2-hour post-load plasma glucose ≥ 154 - 198
mg/dL.

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Classification (WHO, 2019)
Types of Diabetes Brief Description

Type 1 Diabetes β- cell destruction (mostly immune

mediated) and absolute insulin
deficiency; onset most common in
childhood and early adulthood.

Type 2 Diabetes Most common type, various degrees of

β- cell dysfunction and insulin
resistance; commonly associated with
overweight and obesity.

Hybrid form of diabetes New types of diabetes

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Contd...

Slowly evolving, immune-mediated Similar to slowly evolving type 1 in

diabetes of adult. (LADA: Latent adult but more often has features of the
Autoimmune diabetes in Adults) metabolic syndrome.

Ketosis- prone 2 diabetes Presents with ketosis and insulin

deficiency but later does not require
insulin; common episodes of ketosis, not
immune- mediated

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Contd...
Other specific types
• Monogenic diabetes
- Monogenic defects of B-cell function
- Monogenic defects in insulin action
• Diseases of the exocrine pancreas
• Endocrine disorders
• Drug- or chemical- induced
• Infection-related diabetes
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Contd...

• Uncommon specific forms of immune-mediated diabetes

• Other genetic syndromes sometimes associated with diabetes
• Unclassified diabetes
• Hyperglycaemia first detected
1. Diabetes mellitus in pregnancy
2. Gestational diabetes mellitus

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Epidemiology of DM
World

• Non-communicable diseases (NCDs) kill 41 million people each year,

equivalent to 74% of all deaths globally .

• Each year, 17 million adult people die from a NCD before age 70; All
NCD deaths, 77% are in low- and middle-income countries.

• Diabetes is the fourth disease of global burden of non-communicable

disease. 2.0 million deaths caused by diabetes globally. (WHO, 2023)
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Contd...
• Between 2000 and 2019, there was a 3% increase in diabetes mortality
rates by age.
• About 537 million people worldwide have diabetes including more
than 1.2 million children and adolescents who have type 1 diabetes.
• About 240 million people are living with undiagnosed diabetes.
• More than 1 in 10 adults aged 20-79 years have diabetes. 3 in 4 adults
with diabetes live in low- and middle-income countries.
(IDF, 2021)

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Contd...
In the past 3 decades the prevalence of type 2 diabetes has risen
dramatically in countries of all income levels due to the rising burden of
changes in diet and physical activity, maternal obesity, childhood
obesity and other unknown factors.

Over 90% of individuals with diabetes around the world have Type 2
diabetes. The majority living in low-and middle-income countries.

Both the number of cases and the prevalence of diabetes have been
steadily increasing over the past few decades. (WHO, 2023)
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Contd...
• Diabetes is the eighth leading cause of death in the United States.
More than 37 million US adults have diabetes, and 1 in 5 of them
don’t know they have it.
• Diabetes is the no. 1 cause of kidney failure, lower-limb amputations,
and adult blindness. In the last 20 years, the number of adults
diagnosed with diabetes has more than doubled.
(CDC, 2023)

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Contd...
• Diabetic retinopathy is responsible for 2.1% of global blindness.
• Asia accounts for 60% of the world's diabetic population.
• According to the International Diabetes Federation (IDF), an estimated
82 million adults aged 20–79 years were living with DM in the South
East Asia Region in 2017.

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Contd...

IDF, 2021
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Health Expenditure

• The global health expenditure of diabetes was USD $966 billion – a

316% increase over the last 15 years.

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Contd...
Nepal
• NCDs accounted for 39 % of the total country’s disease burden, and
71.1% of all deaths were due to NCDs.
• Out of all deaths, 22% were attributed to CVDs, 7% to cancers, 5 %
to respiratory diseases and 1.7% to diabetes.
• 4, 36,000 people in Nepal have diabetes and this is likely to rise to 13,
28,000 by 2030.
• And, more than 95% of people diagnosed with diabetes have type
2. and 1 in 16 adults has diabetes. Proportion of undiagnosed diabetes
is 43.5%
(International Diabetes Federation Fact sheet, 2021)
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Contd...
• Prevalence of diabetes in Nepal among adults increased from 3.6% in
2013 and 5.8% in 2019.

• 73.5% diabetic people are unaware of their raised blood sugar status.

• More diabetic women are unaware of their raised blood glucose status
than men.
(National Burden of Disease, 2019)

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Contd...
• The prevalence of DM is seen to have increased with age.
• Participants in the age group of 60 years and above had about five
times higher odds of having DM.
• Urban residents were more likely to have DM compared with those
residing in rural areas. Nepal Diabetes Association 2022, found higher
prevalence (14.6%) of DM in urban area in comparison to rural area
(2.5%).
(NDA, 2022)
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Contd...

Increasing urbanization leading to change in dietary pattern, sedentary

lifestyle, reduction in physical activity might have contributed to the
higher burden of DM.

STEPS survey 2019 suggests inadequate intake of fruits and vegetables

and lower participation in physical activity among urban population
compared with their rural counterparts.

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Contd...

• Of all people with hypertension, 29.1% had diabetes (known or newly

diagnosed) and 43.0% had glucose intolerance of some form.

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Epidemiological Determinants
1. Agent
The underlying cause of diabetes is insulin deficiency which is absolute
in type 1 diabetes and partial in type 2 diabetes. This may be due to a
wide variety of mechanisms.
• Pancreatic disorders - inflammatory, neoplastic and other disorders
such as cystic fibrosis
• Defects in the formation of insulin, e.g., synthesis of an abnormal,
biologically less active insulin molecule

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Contd...
• Destruction of beta cells, e.g., viral infections and chemical agents
• Decreased insulin sensitivity, due to decreased numbers of adipocyte
and monocyte insulin receptors.
• Genetic defects, e.g., mutation of insulin gene
• Autoimmunity.

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2. Host Factors
1. Age: Although diabetes may occur at any age, surveys indicate that
prevalence rises with age.

2. Sex: In the UK the overall male-female ratio is about equal. In

south-east Asia, an excess of male diabetics has been observed.

3. Genetic factors: In identical twins development of type 2 diabetes

was approximately 90%. And type 1 diabetes was only about 50%.

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Contd...

4. Immune mechanisms:

There is some evidence of both cell mediated and of humoral

activity against islet cells.
Some people appear to have defective immunological mechanisms,
and under the influence of some environmental "trigger", attack
their own insulin producing cells.

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Contd...

5. Obesity:

Central obesity is also an important determinant of insulin resistance,

the underlying abnormality in most cases of type 2 diabetes.
Obesity reduces the number of insulin receptors on target cells.
Voluntary weight loss improves insulin sensitivity.
Obesity appears to play no role in type 1 diabetes pathogenesis.

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Contd...

6. Maternal diabetes:

Maternal diabetes associated with intrauterine growth retardation and

low birth weight.
Those born to mothers after they have developed diabetes have a three-
fold higher risk of developing diabetes than those born before.

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3. Environmental Risk Factors
• Sedentary lifestyle
• Diet
• Dietary fiber
• Malnutrition
• Alcohol
• Viral infections
• Chemical
• Stress

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Screening for Diabetes

1. Urine Examination

Glucose is found in urine in the most severe cases of diabetes, it is often

absent in milder forms of the disease and such cases are likely to be
missed by urine test. This· is known as lack of "sensitivity".

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Contd...
2. Blood sugar testing
Because of the inadequacies of urine examination, "standard oral
glucose test" remains the cornerstone of diagnosis of diabetes.
Mass screening programmes have used glucose measurements of
fasting, postprandial or random blood sample.
For epidemiological purposes, the 2-hour value after 75 g oral glucose
may be used either alone or with the fasting value.
Automated biochemistry has now made it possible to screen thousands
of samples for glucose estimation.
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Target population

Screening of "high-risk" groups is considered more appropriate.

These groups are:
• Those in the age group 40 and over
• Those with a family history of diabetes
• The obese
• Women who have had a baby weighing more than 4.5 kg.
• Women who show excess weight gain during pregnancy
• Patients with premature atherosclerosis
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1. Primordial Prevention
To keep the body healthy, prevent from body from occurrence of risk
factors.
• Individual and mass education
• Educate to maintain normal body weight.
• Adoption of healthy nutritional habits and physical exercise.
• Childhood obesity prevention through education.
• Educate to maintain a nutritious diet.
• Girls in reproductive age or even in childhood maintain weight, take
appropriate nutrition, and be physically active.
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2. Primary Prevention
To prevent the disease from occurrence by overcoming the risk factors.
It includes;
Population strategy and high-risk strategy

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A. Population Strategy

The scope for primary prevention of type 1 diabetes is limited.

However, the development of prevention programmes for type 2
diabetes based on elimination of environmental risk factors is possible.

The preventive measures comprise maintenance of normal body weight,

adoption of healthy nutritional habits and physical exercise.

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Contd...

The nutritional habits include an adequate protein intake, a high intake

of dietary fiber and avoidance of sweet foods.

Elimination of other less well defined factors such as protein deficiency

and food toxins may be considered in some populations.

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B. High-Risk Strategy

There is no special high-risk strategy for type 1 diabetes.

At present, there is no practical justification for genetic counselling as a
method of prevention.
Since NIDDM appears to be linked with sedentary lifestyle, over-
nutrition and obesity, correction of these may reduce the risk of diabetes
and its complications.
Since alcohol can indirectly increase the risk of diabetes, it should be
avoided.

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Contd...

Risk should avoid diabetogenic drugs like oral contraceptives.

It is wise to reduce factors that promote atherosclerosis, e.g., smoking,

high blood pressure, elevated cholesterol and high triglyceride levels.

These programmes may most effectively be directed at target population

groups.

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3. Secondary Prevention

When diabetes is detected, it must be adequately treated.

Early Detection and

Treatment

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Early Detection

• Routine checking of blood sugar, of urine for proteins and ketones, of

blood pressure, visual acuity and weight should be done periodically.

• The feet should be examined for any defective blood circulation, loss
of sensation and the health of the skin.

• Primary health care is of great importance to diabetic patients since

most care is obtained at this level.
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Contd...

Glycosylated haemoglobin: should be measured at half-yearly

intervals.

Home blood glucose monitoring:

Assessment of control has been greatly aided by the recent facility of
immediate, reasonably accurate, capillary blood glucose measurements
either by one of the many meters now available or the direct reading
Haemogluco test strips.

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Treatment

Treatment is based on
(a) Diet alone - small balanced meals more frequently
(b) Diet and oral anti diabetic drugs
(c) Diet and insulin.
Administer insulin, adjusting diet and staying active, monitoring and
maintaining glucose levels, manage high blood pressure, treat
dyslipidemia, smoking cessation.

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Contd...

Medications; metformin, recognition of symptoms associated with

hypoglycemia, attending periodic checkups, routine checking of blood
sugar, of urine for proteins and ketones, of blood pressure, visual acuity
and weight should be done.

The foot should be examine for any defective blood circulation, loss of
sensation and the health of the skin.
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4. Tertiary Prevention

Prevent the worsening of complications and rehab patient.

1. Complication limitations

2. Rehabilitations

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Complications Limitations

Screening of patients with diabetes for diabetic retinopathy to prevent

progression to blindness through prompt treatment
Prevent recurrence or further complications through appropriate
medication.
Appropriate diabetic foot care to avoid further damage or foot
complications or to preventing from spreading further; wear appropriate
shoes, never go bare foot, keep toenails trimmed.

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Contd...

Older ones, with diabetic complications such as autonomic neuropathy,

cardiovascular disease should avoid exercising outdoors on very hot and
humid days.

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Rehabilitation

Follow-up to ensure adherence to medication regimen, monitor changes,

and assist them in maintaining independence in daily life.
Participate in social gathering.
Patient education is important to help people with diabetes enhance self
care.
Psychological support, exercises, other behavior modifications
(physically active, healthy diet, smoking cessation)

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WHO Response

• WHO aims to stimulate and support the adoption of effective measures

for the surveillance, prevention and control of diabetes and its
complications, particularly in low- and middle-income countries.

• To this end, WHO: provides scientific guidelines for the prevention of

major non- communicable diseases including diabetes; develops
norms and standards for diabetes diagnosis and care; builds awareness
on the global epidemic of diabetes and conducts surveillance of
diabetes and its risk factors.
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Contd...
• In April 2021 WHO launched the Global Diabetes Compact, a global
initiative aiming for sustained improvements in diabetes prevention
and care, with a particular focus on supporting low- and middle-
income countries.
• In May 2021, the World Health Assembly agreed a Resolution on
strengthening prevention and control of diabetes.
• In May 2022 the World Health Assembly endorsed five global diabetes
coverage and treatment targets to be achieved by 2030.

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Contd...
• 80% of people with diabetes are diagnosed
• 80% of people with diagnosed diabetes have good control of
glycaemia.
• 80% of people with diagnosed diabetes have good control of blood
pressure.
• 60% of people over 40 years old with diabetes receive statins.
• 100% of people with type 1 diabetes have access to affordable insulin
treatment and blood glucose self-monitoring.

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Nepal Government Response

1. Multispectral Action Plan for the Prevention and Control of Non

Communicable Diseases (2014-2020).
• (Key strategy; Reducing exposure to risk factors through health
promotion and primary prevention, Early diagnosis and
management of people with NCDs, and Surveillance to monitor
trends in risk factors and diseases.)

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Contd...
• Action area 1: Advocacy, partnership and leadership.
• Action area 2: Health Promotion and Risk Minimization.
• Action area 3: Health system strengthening for early detection and
management of NCDs (CVDs, COPDs, Diabetes and Cancers) and
their risks and their risk factors.
• Action area 4: Surveillance, Monitoring and Evaluation and Research.

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Contd...

2. Package of Essential Non-communicable Diseases (PEN)

• To improve access of cost effective interventions to the poor even in
resource constrained settings and to do early detection and
management of CVD, diabetes, chronic respiratory diseases and
cancer to prevent life threatening complications.

Main target for diabetes is halt the rise in obesity and diabetes.
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Contd...
3. WHO-Norad Nepal Integrated NCD Care model (NINCM)

• The NORAD-WHO Project aims to improve the delivery of essential

NCD services through the use of Nepal Integrated NCD Care Model
(NINCM) and will build on the existing initiatives of Package of
Essential Non-communicable (PEN) and mental health interventions
to develop a comprehensive service delivery including early detection,
management, and long-term care for common NCDs.

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Contd...

• The NORAD-WHO project will be implemented in the six selected

districts through the MoHP with WHO providing continued technical
support.

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References

1. Park, K. (2002). Park’s Textbook of Preventive and Social Medicine,

23rd edition, M/S banarsidas Bhannot publishers.
2. https://www.hindawi.com/journals/jdr/2022/4701796/
3. www.who.org
4. https://www.cdc.gov/diabetes/basics/diabetes.html
5. https
://mohp.gov.np/program/package-of-essential-non-communicable-di
seases-(pen)/en
6. https://diabetesatlas.org/regional-factsheets/
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