Etiopathology of Diabetes Dr Shahjada Selim Assistant Professor Department of Endocrinology Bangabandhu Sheikh Mujib Medical University, Dhaka Email: [email protected] , [email protected]
Etiopathology of Diabetes
Dr Shahjada Selim Assistant Professor
Department of EndocrinologyBangabandhu Sheikh Mujib Medical University, Dhaka
Email: [email protected], [email protected]
Diabetes: A global emergency
Diabetes around the world
Diabetes around the world
Diabetes around the world
South-East Asia
At a glance 2015 2040Adult population (20-79 years) 926 million 1.31 billionDiabetes (20-79 years)Regional prevalence 8.5% (6.8-10.8%‡) 10.7% (8.5-13.7%‡)Age-adjusted comparative prevalence 9.1% (7.3-11.6%‡) 9.9% (7.9-12.8%‡)Number of people with diabetes 78 million
(63-100 million‡)
140 million(112-180 million‡)Number of deaths due to diabetes 1.2 million -
Health expenditure due to diabetes (20-79 years)Total health expenditure, R=2*, USD 7.3 billion 12.9 billionImpaired glucose tolerance (20-79 years)Regional prevalence 4.6% (2.2-6.5%‡) 5.6% (2.7-7.4%‡)Age-adjusted comparative prevalence 4.7% (2.4-6.7%‡) 5.4% (2.5-7.2%‡)Number of people with impaired glucose tolerance 42.2 million
(20.7-60.2 million‡)
73.9 million(35.0-96.9 million‡)Type 1 diabetes (0-14 years)
Number of children with type 1 diabetes 81,400 -Number of newly diagnosed children each year 13,100 -
* See Glossar y‡ Uncertainty inter val IDF Diabetes Atlas · Seventh Edition
Mauritius has one of the highest adult diabetesprevalence rates in the world (22.3% age- adjusted comparative prevalence, 24.3% raw prevalence). The Maldives (9.2% age-adjusted,7.5% raw) has the second-highest prevalence rate in the region. India is home to the second largest number of adults living with diabetes worldwide, after China. People with diabetes in India, Bangladesh, and Sri Lanka make up 99.0% of the region’s total adult diabetes population.
Health expenditureA total of USD7.3 billion (R=2*) to USD12.4 billion (R=3*) (ID24.9 billion to ID42.4 billion) was spent on the 78 million people living with diabetes in2015, 12% of the health budget of the region. This accounts for 1% of the global health spending on diabetes. Compared to the other IDF regions, the South-East Asia Region had the lowest health expenditure per person with diabetes (USD93 to USD158, ID319 to ID542).
A further 42.2 million people have impairedglucose tolerance and are at increased risk of developing type 2 diabetes in the future. The number of people with diabetes in the region is predicted to be 140 million by 2040 – 10.7% ofthe adult population aged 20-79. This increase is largely a consequence of ongoing urbanisation and increasing life expectancy.
Data sourcesAll countries except Bhutan had primary data sources that were used to generate estimates for diabetes in adults in the region. A total of 13 data sources from six countries were used. Diabetes prevalence estimates for India, Nepal, Sri Lanka and Bhutan were based, in part, on data sources that were more than five years old and may be underestimates.
There are an estimated 81,400 children under theage of 15 living with type 1 diabetes in the South- East Asia Region. Approximately 13,100 children developed type 1 diabetes in the region during2015.
Estimates for type 1 diabetes in children werelargely based on data from India, the Maldives and Mauritius.
91
India is home to the second largest numberof children with type 1 diabetes in the world (70,200), after the USA, and accounts for the majority of the children with type 1 diabetes in the region. The incidence rate for type 1 diabetes in India was used to extrapolate figures for other similar countries, and therefore plays a pivotal role in the regional and global estimates.MortalityWith 1.2 million deaths in 2015, the region hadthe second highest number of deaths attributable to diabetes of any of the seven IDF regions, after the Western Pacific Region. More than half (53.2%) of these deaths occurred in people under60 years of age. India was the largest contributor to regional mortality, with one million deaths attributable to diabetes.
Chapter 4 – Diabetes by region
Map 4.6 Prevalence* (%) estimates of diabetes (20-79 years), 2015
Prdiabetes by age(20-79 years) and sex
< 77 - 88 - 8.58.5 - 99 - 10> 10
* comparative prevalence
93Figure 4.6 Mortality due to diabetes, South-East Asia Region, 2015
Percentage of all-cause mortality due to diabetes by age (20-79 years) and sex MaleFemale35
30
25
20
15
10
5
020-29 30-39 40-49 50-59 60-69 70-79
Death due to diabetes by age3% 8% 15% 27% 25% 22%
53% under the age of 60 1,188,465 total deaths due to diabetes(664,071 women, 524,394 men)
Chapter 4 – Diabetes by region
20-2
9 ye
ars
30-3
9 ye
ars
40-4
9 ye
ars 50-59 years 60-69 years 70-79 years
Pr di (2
20
15
10
5
0
evalence (%) estimates of
MaleFemale
20-29 30-39 40-49 50-59 60-69 70-79
Pathogenesis of Type 1 diabetes.Autoimmune Type 1 Diabetes• Beta cells destroyed via autoimmune mechanism.• Genetically predisposed people:triggering factor =
production of islet cell Ab.
• Islet cell Ab destroy Beta cells.• Insulin production decreases.
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 9
Pathogenesis of Type 1 diabetes.Autoimmune Type 1 Diabetes• Viruses + other environmental agents have been
shown to be triggering factors.• Viruses can damage beta cells by:
1.Direct invasion. 2.Triggering an auto immune
response.
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 10
Pathogenesis of Type 1 diabetes.Autoimmune Type 1 Diabetes• Implicated viruses:
mumps, intrauterine rubella, coxsackie B virus, echo virus, gytomegalo virus and herpes virus.
• Chemical substances that reduce diabetes:alloxan, streptozotosin and dietary nitroamides.
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 11
Pathogenesis of Type 1 diabetes.Idiopathic Type 1 Diabetes• No known aetiology.• Permanent insulinopaenia.• This form is strongly inherited.• Not HLA associated.
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 12
Clinical features of Type 1 diabetes. • Presents acutely. Symptoms due to hyperglycaemia
(thirst, polyuria, tiredness,weight loss).
• Ketone production - abdominal pain, nausea and vomiting.
• Other symptoms: blurred vision, repeated infections.
• No chronic complications at diagnosis, may only be apparent 5-10 years post diagnosis.
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 13
Incidence of Type 1 diabetes.• Incidence peaks at 11-13 years.• Seasonal variation: lowest rates in spring and
summer.• Geographical variation: Japan has a very low
incidence.• 10% of Type 1 diabetics are over 65 years of age.
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 14
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 15
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 16
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 17
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 18
Pathophysiology of type 2 diabetes
Cernea S & Raz I. Diabetes Care 2011;34(suppl 2):S264–S271
CNS, central nervous system; GI, gastrointestinal; T2DM, type 2 diabetes mellitus
Adipocyte
CNS
Incretin deficiency
GI tract
Altered fat metabolism
INSULIN RESISTANCE INADEQUATE INSULIN SECRETION
↑ HEPATIC GLUCOSE
PRODUCTION
↑ BLOOD GLUCOSE
Hyperglucagonaemia↑ hepatic sensitivity
to glucagon
cellsα cells
SkeletalMuscle Pancreas
Muscle
Kidney
Enhanced glucose reabsorption
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 20
Type 2 diabetes
• Patients frequently undiagnosed for many years.• May present with hyperglycemia symptoms.• Coma is rare in type 2 diabetes.• May progress to an absolute state of insulin
deficiency.
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 21
Pathogenesis of Type 2 diabetes.• Cause: insulin secretory failure on the background of
insulin resistance.• Impaired insulin secretion due to beta cell malfunction
can be associated with:1. Incorrect secretion pattern.2. Ratio of proinsulin to insulin.3. Amyloid deposits.4. Slow destruction of beta cells
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 22
Mechanisms for insulin resistance.1. Receptor numbers are decreased. (Often seen in
obese and aged patients.)2. Receptor structure is abnormal.3. Insulin resistance at post receptor events.
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 23
Clinical features of Type 2 diabetes.• Diagnosis due to presence of complications.(At least 30% patients have complications at diagnosis).• Symptoms are mild, gradual onset : classic diabetic
symptoms may be present.• Type 2 diabetics are usually: usually occurs in young
or elderly, in fat (“apple obesity”).
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 24
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 25
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 26
Insulin Secretion in Insulin Secretion in Non-DiabeticsNon-Diabeticsand Type 2 Diabeticsand Type 2 Diabetics
Clock Time (Hours)06:00
NormalType 2 DM
10:00 14:00 18:00 22:00 02:00 06:00
800
700
600
500
400
300
200
100Insu
lin S
ecre
tion
(pm
ol/m
in)
O'MEARA et al. Am. J. Medicine, 1990;89May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada
Selim 27
Glucose Contributions to HbAGlucose Contributions to HbA1c1c
+Postprandial Glucose,
Influenced by: Preprandial glucose Glucose load from meal Insulin secretion Insulin sensitivity in
peripheral tissues and liver
Fasting Glucose,Influenced by: Hepatic glucose
production Hepatic sensitivity to
insulin
HbA1c =
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 28
Postprandial glucose• Most of the day may be postprandial• HbA1c = FPG + PPG• Postprandial from the time glucose starts to rise
until it comes down again• Time period up to 2.5 h after a meal – normal
individuals 1.5 h• Testing of PPG recommended 2h after the start of a
meal
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 29
Hyperglycemic "Peaks"
Fasting/Preprandial glucose elevations
Acute toxicity Chronic toxicity
Tissue lesion
Complications
Overall Glycemic Control (HbA1c)
Possible Pathogenesis of Diabetic Possible Pathogenesis of Diabetic ComplicationsComplications
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 30
Which glucose variable?• Fasting plasma glucose (FPG), postprandial plasma
glucose (PPG) and HbA1c all have pros and cons• Where feasible, HbA1c should be the standard
measurement by which to gauge risk and treatment efficacy
• FPG and PPG are useful • to adjust daily treatment• to monitor for hypoglycaemia• for confirmation as haemoglobin metabolism problems may
mask true HbA1c levels• if there is a lack of resources for HbA1c measurement
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 31
Link Between Obesity and Type 2 Diabetes:Nurses’ Health Study
Colditz GA, et al. Ann Intern Med. 1995;122:481-486.
020406080
100120
<22 22-22.9
23-23.8
24-24.9
25-26.9
27-28.9
29-30.9
31-32.9
33-34.9
>35
BMI (kg/m2)
Age-A
djuste
d Rela
tive R
isk
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 32
EVERY 1% reduction in HBA1C
REDUCED RISK*
1%
Deaths from diabetes
Heart attacks
Microvascular complications
Peripheral vascular disorders
UKPDS 35. BMJ 2000; 321: 405-12
Lessons from UKPDS:Better control means fewer complications
-37%
-43%
*p<0.0001
-14%
-21%
May 2, 2023 Etiopathogenesis of diabetes by Dr Shahjada Selim 33