Type - 1 Diabetes Mellitus:Indian and Global Scene Burden ...
Transcript of Type - 1 Diabetes Mellitus:Indian and Global Scene Burden ...
Type - 1 Diabetes Mellitus:Indian and Global
Scene – Burden & Challenges.
C.V.Krishnaswami – FRCP(E) DTM&H(EDIN) FAMS.
Head of Diabetes Department,Voluntary Health Services,
Chennai, Tamil Nadu, India.
In “who has seen the wind”
CHRISTINA ROSSETTI
But when the trees bows down their heads
the wind is passing by.
Neither you nor I ;
Who has seen the wind ?
Reflections on Medical education
Frank Davidoff, M.D.
WHO HAS SEEN A BLOOD SUGAR?
Incidence of IDDM in children aged under 15
WHO 94387
Diabetes Voice. Vol. 44. March. No: 1/99. P.33
EVIDENCE FOR INCREASING PREVELANCE OF
DIABETES MELLITUS IN CHILDHOOD
Prevalence of diabetes mellitus among the cohort of children in the
child health and education study….. At age 10 years was
1.3/1000(1970), previous British birth cohort Studies 0.6/1000(1946)
Sarah Steward-Brown et al.
B.M.J.,1983;286:1855-1857
Increasing incidence of J.I.D.D.M. in the west:
5% of Diabetic clinic population
P.Forsham - (1970)
10% of Diabetics - Drury - (1976)
20% of Diabetes - Rayfield & Seto - (1978)
INCIDENCE OF INSULIN DEPENDENT DIABETES IN
ENGLAND: A STUDY IN THE OXFORD REGION ,
1985-86
P.J.Bingley and Gale(B.M.J., 1989; 298,558-60)
The overall yearly Incidence of newly diagnosed Insulin-
dependent diabetes mellitus in people under 21 was 15.6
cases/100,000….case ascertain was greater than 95%
Conclusion: The incidence of insulin dependent diabetes in
England is considerably higher than reported from
large Scale studies’
CLINICAL REVIEWS
Rise in Incidence Of Type 1 Diabetes In Infants
International Diabetes Monitor Volume 14,Number 1,2002
Epidemiology of type 1 diabetes mellitus in Switzerland : steep rise
in incidence in under 5 years old children in the past decade.
Schoenle EJ, Lang-Muritano M,Gschwend S,Laimbacher J,Mullis
PE,Torresani T,Biason-Lauber A,Molinari L, Diabetologia
2001;44:286-9
Age-Specific
incidence of type 1
diabetes mellitus in
children aged 0-14
years and 0-4 years
in Switzerland
between 1991 and
1999.
The solid line shows the average rate of change, which was
significant in both age groups: 0-14 years, slope = 0.33 + or – 0.13
(p = 0.03); 0-4 years, slope = 0.88 +or- 0.13 (p = 0.0002)
International Diabetes Monitor Volume 14,Number 1,2002
Between 1991 and 1999 only the youngest age group
contributed to the overall increase in incidence of type 1
diabetes in children.
In this prospective study (1991 – 1999) the authors found that
the annual incidence of childhood diabetes had increased from
7.8/100,000 in 1991 to 10.6/100,000 in 1999, corresponding to an
annual average increase of 5.1%. The most striking finding was
the increased incidence in the 0-4 year age group, which had
risen from 2.4 to 10.5 per 100,000, corresponding to an average
yearly increase of 23.8% (Fig 1)
There was no variation in 5-9 year or 10-14 year age groups,
meaning that the 0-4 year age group alone was responsible for
the rise in the childhood type 1 diabetes in the 10 years of
follow-up.
The present paper refers to an incident of 10.6 / 100,000 in 1999,
representing an average annual increase of 5.1%, higher than the
EURODIAB average increase of 3.5% (2.5-4.4%). But what is more
important is that only the youngest age group (0-4 years)
contributed to this increase.
Whatever the speculative explanation for the rise in incidence in the
youngest Swiss children, the phenomenon represents a challenging
burden to the health care system.
Volume 14,Number 1,2002International Diabetes Monitor
Tahoku J.exp. Mod., 1983 141 Suppl., 161-170
The Significance of Certain Epidemiological Variants in the
genesis of Juvenal Insulin-Dependent Diabetes Mellitus the need
for A Global program of Co-operation.
C.V.KRISHNASWAMI and P.CHANDRA*
Voluntary Health Services Hospital and Government Stanley Hospital, Department
of pediatrics,Government Stanley Hospital Chennai Tamilnadu
MAGNITUDE OF YOUNG DIABETES IN INDIA URBAN
POPULATION
ABSTRACT:
As there is paucity of reports in India on the prevalence of diabetes in the
young, aged <20 years, a population based survey was undertaken to assess the
same. Urban population was selected for the survey. The prevalence of diabetes
among these aged 0-20 years was assumed as 0.2%. The sample size of the total
population required to estimate it with 95% CI and + 25% precision was
calculated y random cluster sampling method. The required sample size of all the
ages was 155000 which was obtained from 30 randomly selected corporation
divisions of the city. Ten trained social workers recorded required information of
the selected families on the prescribed forms by daily house visits. This study was
conducted during 1998 – 1999. Among 156258 individuals of all ages surveyed, there
were 60310 persons aged 0-20 years. The age standardized prevalence of known
diabetes was 0.02% in those aged < 20 years. This survey indicates that diabetes of
any category is not a public health problem in those aged <20 years in Chennai
city, India.
_
_
Key words: Diabetes mellitus, Type-1 diabetes, Prevalence, Type 2 diabetes, Young population
"The essence of the practice of medicine is that it is an intensely
personal matter...the treatment of a disease may be entirely
impersonal ; the care of a patient must be entirely personal .The
significance of the intimate personal relationship between physician
and patient cannot be too strongly emphasized for in an
extraordinary large number of cases both diagnosis and treatment
are directly dependent on it...One of the essential qualities of the
clinician is interest in humanity , for the secret of the care of the
patient is in caring for the patient".
--Francis W.Peabody,1927
Chapter 1
HUMANISTIC QUALITIES IN MEDICENE
JOHN A BENSON Jr
By learning you will teach;
By teaching you will learn.Latin Proverb
The High Risk Foot in diabetes Mellitus.
Robert G.Frykberg.
Churchill Living stone 1991.
SERVICES OFFERED BY THE
VHS DIABETES DEPARTMENT
• In the NGO sector catering to the public of Chennai, TamilNadu (India) for over 35 years
The Services Include :
Regular Out-Patient services for all persons with Diabetes
SPECIAL COMPREHENSIVE FREE MEDICARE FOR ALL PERSONS with JIDDM(Type 1 DM with onset below 15 years) includes supply of Insulin HMBG monitoring / training with equipment and regular follow up with all investigations like FLOURESCEINE ANGIOGRAPHY for eyes, renal package, foot care etc., treatment of co-morbid conditions, educational and social support, job placements and rehabilitation, plus pregnancy care and delivery.
VHS DIABETES DEPARTMENT
Diabetes & pregnancy for all with GDM screening
Diabetes Foot care service
Diabetes Renal care service
Diabetes Retinopathy surveillance and prevention of
blindness program for type IDDM
Diabetes nutrition department – clinical services, diploma
training and research programmes
Diabetes specialists nurse educators service and training
certificate programme
REHABLITATION SERVICES
Diabetes Research and academics activities (Shri Prakash
CME Programme for doctor).
Public Education programme (Shri Prakash Endowment
Public Lectures).
VHS DIABETES DEPARTMENT
RESEARCH ACTIVITIES 2001-2002
Prevalence of diabetes-survey in chennai city-
collaborative work,along-with the national institute of epidemiology,chennai.
Natural History of diabetic Nephropathy in type 2 diabetes
Magnitude of young onset diabetes in south India-Are we doing enough?
Preliminary Experience in alternate Modalities of wound healing in Diabetes.
Incidence of gestational diabetes in pregnant women,chennai.
VHS DIABETES DEPARTMENT
RESEARCH ACTIVITIES 2001-2002
Study of children of people with Type 1 Diabetes
Psychological impact of Type 1 Diabetes on children of
different age group?
Mortality in Type 1 Diabetes
Study of Type 1 Diabetes and autonomic neuropathy
Study of progressive of nephropathy in Type 1
Diabetes:Retrospective/Prospective
The following projects are the basic research
projects in progress during the year
DNA Repair Mechanism in peripheral lymphocyte in
Diabetes
Telemere dynamic in health & disease
Molecular markers in Type 1 diabetes *classification of
IDDM patients
Gene mapping of children of Type 1 Diabetes :a
collaborative study
Long term follow up of the complication profile in Type 1
Diabetes
I thank the following team mates for their co-operation and selfless
service:
Dr.P.V.Asha Bai Dr.A.Srivatsa Mrs.Mala Chettri
Dr.A.Ganesan Dr.Prema Krishnaswami Dr.Meenakshi Dhamija
Dr.M.Chellamariappan Dr.T.A.Vidya Mrs.Sundari.N
Dr.G.Vijay Kumar Mr.M.Bhaskar Rao Mrs. Parvathi.R
Dr.N.S.Raji Ms. Yogambal Dr.V.Vijayalakshmi
Mrs.Ramalakshmi Mrs.Subhashini Mrs.Lalitha Subramaniam
Peter H. Forsham
The Cost of Insulin-dependent Diabetes Mellitus (IDDM) in
England and Wales
A. Graya,b, P.Fenna,c and A. McGuirea,d
Oxford Center for Health Economics Researcha, Center for
Socio-Legal Studies, Wolfson College, Oxfordb, School of
Management and Finance, University of Nottingham, and
Department of Economics, City University, London, UKd
This study estimates the direct health and social care costs of
insulin-dependent diabetes mellitus (IDDM) in England and Wales in
1992 to be 96 million, or 1021 per person in a population with IDDN
estimated at 94,000 individuals. These costs include insulin maintenance,
hospitalization, GP and out-patient consultants, renal replacement
therapy, and payments to informal carers. Expenditure is concentrated on
younger age groups, with one-third of the total expended on those aged
0-24.
Around one-half of the total costs can be directly attributed to
IDDM, with the remainder associated with the range of complications of
the disease. The single largest area of service expenditure is renal
replacement therapy. The cost estimates are most sensitive to incidence
rates of IDDM, number on dialysis and average duration of dialysis. A
further 113 million pounds may be lost each year due to premature
deaths result in lost productive contributions to the economy. The direct
and indirect costs of IDDM are therefore significant. The cost of illness
framework presented here should the economic evaluation of new and
existing treatment regimens, which may improve value for money by
reducing costs and/or increasing the quality or quantity of life for the
people with IDDM.
Key words: Insulin-dependent diabetes mellitus Cost of illness Health economics
The Cost of Insulin-dependent Diabetes Mellitus (IDDM) in
England and Wales
Table 1. IDDM in England and Wales: baseline estimated population and prevalence
19
100
100
59
55
33
18
5
0
0
1.84
0.65
2.72
2.36
a2.59
2.45
2.38
1.00
0.05
0.00
93 581
4 344
17 791
19 177
18 297
16 726
12 615
5 048
182
0
499 359
3 323
12 630
35 572
33229
51 105
71 971
104 832
131 755
60 471
9.8
0.5
2
4
4.7
7.5
13.6
20.8
35.6
31.3
50 955
6 646
6 315
8 143
7 070
6 814
5 292
5 040
3 701
1 932
All
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70-79
> 80
IDDM as % of
total population
with diabetes
IDDM
prevale
nce per
1000
IDDM
population
Total
population
with
Diabetes
Diabetes
Prevalence
per 1000
Population of
England and
Wales
Age group
The question to be asked is what is the situation in India with regard
to Incidence of IDDM, the cost of treating the same and the burden
to the individual, State/Nation? If one takes a look around all the
hospitals and their Renal Units (Government and Private) the
number of cases of IDDM Renal Failure is very low indeed: So is the
number of IDDM related PDR/visual loss when one surveys all the
Ophthalmic institutions (Government and Private).
Based on the experience of working with children & young people
(with IDDM) & trying to give them lifetime comprehensive free
Medicare plus rehabilitation programs for the past 37years, I am
convinced of the urgent need for proper and detailed documentation
plus continuous follow–up of these cases throughout the country and
create a meaningful and statistically viable data base for future
research. At the Voluntary Health Service Diabetes Department, we
have started this process with online electronic medical records of all
our patients with Diabetes under the age of 40years.
We have over 400 persons with complete data of the natural history
of their diabetes & it’s progression over the past 3 ½ decades.
The second aspect would be genetic & molecular studies in these
young people and their families.
The third aspect would be setting up appropriate infrastructure to
analyze the influence of all the environmental factors involved in the
causation of Type-1 diabetes Mellitus in our country. This should
include both causative factors & probable protective ones also.
Finally if it is indeed true that the incidence of Type-1 diabetes in
children in India is very low as compared with the figures reported
from the Western World, we should make an integrated all out
scientific effort to pin point the reasons for this. The results of such
effort would be more than worthwhile for not only our children but
would benefit the children of the entire world, particularly those in
the developed world – Such an effort if successful, would be a
tremendous export product.
‘I don’t feel like a diabetic any more’: the impact of stopping insulin in patients
with maturity onset diabetes of the young following genetic testing
Maggie Shepherd and Andrew T Hattersley
Abstract – Hepatocyte nuclear factor-1 (HNF-1) maturity onset
diabetes of the young (MODY) is the commonest cause of monogenic
diabetes but is frequently misdiagnosed as type 1 diabetes. The
availability of genetic testing in MODY has improved diagnosis.
Sulphonylurea sensitivity in HNF-1 patients means that those on
insulin from diagnosis can transfer to sulphonylureas and may
improve glycaemic control. To gain insight into the implications for
patients of stopping insulin, in-depth interviews were conducted with
eight HNF-1 patients transferred to sulphonylureas after a median of
20 years on insulin. Thematic content analysis highlighted four key
themes:
‘I don’t feel like a diabetic any more’: the impact of stopping insulin in patients
with maturity onset diabetes of the young following genetic testing
Glucokinase
(MODY 2)
HNF-1 (MODY
3)
HNF-4 (MODY
1)
HNF-1
(MODY 5)
IPF-1
(MODY 4)
NEUROD1
(MODY 6)
Chromosomal
location
7p 12q 20q 17q 13q 2q
Frequency in a
large UK series
(%)
15 65 5 1 <1 0
Penetrance of
mutations at age
40(%)
Diabetes: 45
Impaired
fasting
glycaemic: 95
>90 >80 >80 >80 70 (2 families)
Onset of
Hyperglycemia
Early
childhood
(from birth)
Adolescence
Early adulthood
Similar to HNF-
1
Similar to HNF-
1
Early childhood 4th decade
Severity of
Hyperglycemia
Mild with
minor
deterioration
with age
Progressive May
be severe
Progressive
May be severe
Progressive May
be severe
Limited data Progressive
Micro vascular
complications
Rare Frequent Frequent Retinopathy
observed
Not Known Not Known
Pathophysiology Beta-cell
dysfunction
Beta-cell
dysfunction
Beta-cell
dysfunction
Beta-cell
dysfunction
Beta-cell
dysfunction
Beta-cell
dysfunction
Abnormality of
glucose sensing?
Yes No No No No No
Other phenotypic
features
Reduced birth
weight
Low renal
threshold and
sensitivity to
Sulphonylurea
Low plasma
triglycerides
Predominant
renal
phenotype;
cysts, renal
failure
Pancreatic
agencies in
homozygotes
Not known
The Natural History of Insulin-Dependent Diabetes Mellitus
ASTROLOGY-THE EVIDENCE OF SCIENCE-
PERCY SEYMOUR
I have sought…………for long years I have laboured;but I have not
found her ……where I lie down worn out the other men will stand,young
and fresh.by steps that I have cut they will climb;but the stairs that I have
built they will mount…..At the clumsy work they will laugh ……….they
will cruse me.BUT THEY MOUNT AND ON MY WORK;THEY
WILL CLIMB AND BY STAIR! THEY WILL FIND HER, AND
THROUGH ME…………
I believe that is all we can really expect from the scientific quest,but that
does not make it any less exciting-IT IS THE EXCITING OF THIS
ONGOING QUEST THAT SUSTAINS US.
By
FRANK DAVIDOFF
He who - is conceited: avoid him
He who knows not and knows not that he
- knows and knows that he knows
- knows not is a fool; instruct him.
He who knows and knows not that he knows
- is asleep ;awaken him
He who knows not and knows that he.
- knows not is a wise man-follow him
ARAB PROVERB
( From: Who has seen the Blood Sugar’?)