Transcript K.A.P STUDY ON HT & DM INTRODUCTION In 2003, there were 189 million diabetic in the world.

K.A.P STUDY ON
HT & DM
INTRODUCTION
In 2003, there were 189 million diabetic in the
world. The global prevalence of Type-2 diabetes is
expected to double in the period 2000–2025 and
may reach a level of almost 324 million people.
The "Top 10" countries of the world in terms of the
number of people with diabetes: India, China,
Russian Federation, Brazil, Indonesia, Pakistan,
Mexico, Ukraine, Egypt, Japan. India tops the list
of 10 countries, followed by china. In fact in 1997,
the diabetic population in India was 11.6%, which
in 2000 was estimated to be 14.7% and to rise to
17.4% in 2005. Today, India has 25 million diabetic
patients, more than any other country, and the
number is expected to rise to 35 million by 2010
and to 57 million by 2025!).
The important risk factors for the high prevalence
of diabetes include: (a) High familial aggregation.
(b) Obesity, especially central obesity. (c) Insulin
resistance. (d) Lifestyle changes due to urbanization.
Moreover, diabetes occurs at a much younger age in
India than in the developed countries. Family History
of Diabetes, Age, Body Mass Index (BMI), waist to
hip ratio and sedentary life-style showed positive
association with diabetes in Indian population.
Diabetes is the single most important metabolic
disease, which can affect nearly every organ system
in the body. The reasons for this escalation are due
to changes in lifestyle, people living longer than
before (ageing) and low birth weight could lead to
diabetes during adulthood.
Lifestyle modifications, inclusive of dietary
modification, regular physical activity and weight
reduction are indicated for prevention of diabetes.
However, in developing nations urbanization is
occurring rapidly and is producing lifestyle changes
that adversely affect metabolism and are thereby
causing a large increase in the number of diabetic
patients. Long-term complications of diabetes will
also occur in a large proportion of diabetic patients in
the developing countries during the most productive
years of their lives, causing severe economic and
social burdens. Therefore, developing countries such
as India are expected to confront an enormous health
care burden due to a large number of the population
suffering from this chronic disorder and its sequelae.
Hypertension affects all ages, but primarily occurs in
adults. 690 million people have hypertension
worldwide (20% prevalence). It is one of the major
risk factor for stroke, Coronary Heart Diseases.
There are 5 million deaths/ year worldwide due to
strokes alone, with another 30 million are suffering
from its disabling effects.
Hypertension is extremely common in patients
with diabetes mellitus. Tight control of hypertension
in diabetes has shown to decrease the
complications like ischaemic heart disease and renal
failure thereby reducing the morbidity and mortality.
Management of hypertension in diabetes includes
weight reduction, dietary restriction of sodium,
adequate intake of potassium and calcium, regular
exercise, cessation of smoking and drug therapy.
CLASSIFICATION OF DIABETES
1. Type I diabetes
MELLITUS
A) Immune mediated b) idiopathic
2. Type 2 diabetes
3. Other specific types
a. Genetic defects of beta cell function
b. Genetic defects insulin action, lipoatropic diabetes
c. Disease of exocrine pancreas
d. Endocrinopathies, acromegaly Cushing’s syndrome,
hyperthyroidism
e. Drug or chemical induced glucocorticoids, thyroid
hormones, beta-blockers, thiazides
f. Infections congenital rubella, cytomegalovirus
g. Uncommon forms of immune mediated diabetes
h. Other genetic syndromes sometimes associated with
diabetes down’s syndrome,
k. F Syndrome., turners syndrome.
4. Gestational diabetes mellitus
Type 2 diabetes is characterized by four major
metabolic events: chronic hyperglycemia, insulin
resistance, reduced insulin response and
increased hepatic glucose output. It is not clear,
however, which of these events come first and
how they may lead to Type 2 diabetes. The
development of Type 2 diabetes can be divided
into four phases. Genetic susceptibility is a
prerequisite for the development of the disease.
However, specific genes causing Type 2 diabetes
are still unknown. The second stage appears to
be the development of insulin resistance.
Subsequently, impaired glucose tolerance (IGT)
develops and finally Type 2 diabetes (DM)
appears.
Those with the highest fasting insulin levels had
the highest risk of developing diabetes over the
period. Individuals with higher fasting insulin
levels have higher incidence both of diabetes
itself and of IGT. Therefore higher fasting or
post-load insulin levels precede both IGT and
Type 2 diabetes. Several factors influence the
development and severity of insulin resistance.
Obesity, physical Inactivity and over nutrition
worsen insulin resistance, while weight
reduction, physical training and calorie
restriction decrease insulin resistance. Several
factors influence the development and severity
of insulin resistance.
The WHO criterion for IGT is a venous plasma
glucose level of 7.8-11.0 mmol/l two hours after a
75g oral glucose load. Obesity, besides being a
risk factor for the development of insulin
resistance, is also a risk factor for development
of IGT. The general consensus from a number of
studies is that the major factor determining
conversion from IGT to Type 2 diabetes is failure
of insulin secretion from the beta cells of the
pancreas. The reason for the failure is uncertain
but several possible mechanisms have been
proposed. In summary, the pathogenesis of Type
2 diabetes involves the inheritance of diabetes
susceptibility genes. The risk of developing the
disease is first manifested by insulin resistance.
Thus Type 2 diabetes is characterized by the
presence of hyperglycemia accompanied by
insulin resistance and defects in insulin
secretion. The other characteristic metabolic
abnormality, increased hepatic glucose output,
occurs as a result of insulin deficiency. Once
Type 2 diabetes is established, individuals are
at risk for the development of many or all of the
complications of the disease. Diabetic
complications account for almost all of the
excess morbidity and mortality associated with
Type 2 diabetes.
Importance of Tight Control:
The landmark study on type2 diabetes
is UKPDS4 and it has shown that tight
control of hypertension had a great
impact on cardiovascular risk reduction.
Similar conclusions are also noted in
other studies revealed a lower
cardiovascular risk and lower decline in
renal functions when the systolic
pressure is kept below 130 mm Hg and
diastolic pressure below 80 mm Hg.
Management of Hypertension:
All the patients should have complete work-up
including detailed physical examination
documenting the cardiovascular status, the
peripheral circulation, fundus examination and
assessment of body mass index. Basal
investigation should include lipid profile, renal
profile, serum electrolytes, urinary protein
estimation and assessment of glycaemic status.
Non-pharmacological measures — All patients
who are smokers should be advised to stop it
and avoid even passive exposure to smoking.
Weight reduction should be considered as an
important measure in those who are overweight
and obese, by regular exercises and dietary
modification.
DIAGNOSIS OF TYPE 2 DM:
SUG
FPG
2HR PPG
NORMAL
<110
<140
IFG/IGT
110-125
140-199
D.M
>125
>200
DIAGNOSIS OF HYPERTENSION:
The Joint National Committee on
Prevention, Detection, Evaluation and
Treatment of High Blood Pressure (JNC
1997) in its recent report recommend that a
diabetic be labeled as hypertensive if
systolic blood pressure is above 130 mm
Hg and diastolic more than 85 mm Hg. On
the basis of benefits shown in
epidemiological studies, it is advisable to
keep systolic pressure below 130 mm Hg
and diastolic below 80 mm Hg.
CLASSIFICATION OF BLOOD PRESSURE
FOR ADULTS AGE 18 AND OLDERS:
Category
(mm of Hg)
OPTIMAL
NORMAL
HIGH – NORMAL
Stage – 1
Stage – 2
Stage – 3
Systolic
(mm of Hg )
< 120
< 130
130 – 139
HYPERTENSION
140 – 159
160 – 179
> 180
Diastolic
(mm of Hg)
< 80
<85
85 - 89
90 – 99
100 – 109
> 110
GENERAL OBJECTIVE
To study the knowledge, attitude,
and practice of prevention of
diabetes and hypertension among
patients attending Railway Health
Unit/ TondiarPet from January 2004
to March 2004.
SPECIFIC OBJECTIVE
1. To define the magnitude of the hypertension
and diabetes problem in Railway Population
with evidence based data
2. To measure the prevalence of HT and DM
among different age group, different category
of employees, socio economic status and other
influence of factors.
3. To find out other risk factors e.g. obesity,
excessive salt intake, alcohol intake,
psychological stress, illiteracy and poor socio
economic status.
4. To identify the type and prevalence of cardio
vascular complication among DM and HT
ERRORS and LIMITATIONS
Interviewer’s Bias
Respondent Bias
Influence of By standards and Spectators
TIME CONSTRAINT
As I have to complete my study within shorter period,
large sample size could not be obtained.
METHODOLOGY
STUDY DESIGN
CROSS-SECTIONAL STUDY, DESCRIPTIVE STUDY
EXCLUSION CRITERIA
Juvenile Diabetes, Gestational diabetes and diabetes due to
other causes were not taken to account
STUDY PLACE
Railway Health Unit, Tondiarpet Marshaling Yard, Chennai
Division, Southern Railway
STUDY SAMPLE
175 Patients attending Railway Health unit for regular check up
DATA COLLECTION AND INTERVIEW PERIOD
The interview was conducted from 1st January 2004 to 31st
March 2004 using the Questionnaire.
PRELIMINARY PREPARATION
The topic of the study was discussed with the Chief Medical Director/
S.Rly. The objectives were identified and included in this K.A.P study.
QUESTIONNAIRE DEVELOPMENT
The interviewer constructed the
questionnaire for the study.
MATERIALS/TOOLS
•Glucometer
•Tape to measure waist /hip ratio
•Sphygmomanometer
•Weighing machine
•Height measurement stand
•Urine sugar testing reagent strips
MONITORING DIABETES MELLITUS
AND HYPERTENSION
1.
2.
3.
4.
5.
6.
7.
POOR ROLE FOR URINE SUGAR
INITIAL DIAGNOSIS REPEAT AFTER 3 WEEKS
Hba1C, LIPID PROFILE, RENAL PARAMETERS
CARDIAC STATUS ECG, XRAY CHEST
MONITOR NEPHROPATHY URINE MICRO ALB
MONITOR NEUROPATHY
MONITOR RETINOPATHY ONCE A YEAR
HYPERTENSION
20
Series1
19
18
18
17
16
14
12
10
8
8
6
4
4
2
2
0
100-110
111-120
121-130
131-140
SYSTOLE - mm of Hg
141-150
>150
HT & DM
12
11
9
4
4
1
100-110
111-120
121-130
131-140
SYSTOLE - mm of Hg
141-150
>150
ht & dm
19
12
7
2
1
0
70-80
81-90
91-100
101-110
111-120
DIASTOLE - mm of Hg
>120
URINE SUGAR
35
33
30
30
25
22
20
15
13
9
10
5
0
1+
2+
3+
4+
Nil
Series1
HYPERTENSION
20
19
18
18
17
16
14
12
10
8
8
6
4
4
2
2
0
100-110
111-120
121-130
131-140
SYSTOLE-mm of Hg
141-150
>150
10
0
12 -1 2
1
0
14 14
1 0
16 - 16
1 0
18 - 18
1 0
20 - 20
1 0
25 - 25
1 0
30 - 30
1 0
35 - 35
1 0
-4
00
>
40
0
No of patients
RANDOM BLOOD SUGAR-Total patients-107
25
15
10
20
20
10
11
7
13
15
12
8
5
mgm/dl
7
4
0
HYPERTENSION
30
28
26
25
20
15
10
10
5
3
1
0
0
70-80
81-90
91-100
101-110
DIASTOLE-mm of Hg
111-120
>120
TOTAL CASES FOR STUDY - 175
80
70
68
66
60
50
41
40
30
20
10
0
HT
DM
HT& DM
TOTAL PATIENTS - 175
90
80
70
No of patients
60
50
40
30
20
10
0
30 - 40 years
Series1
8
41 - 50 years
51 - 60 years
73
78
AGE
> 60 years
16
TOTAL CASES FOR STUDY - 175
120
100
80
60
40
20
SEX
0
MALE
Series1
114
FEMALE
61
CATEGORY
CLAS S - 4
100
90
80
70
60
50
CLAS S - 3
DEP ENTANTS
40
30
RTD. EM P LOYEE
20
10
CLAS S - 1
CLAS S - 2
0
Series1
CLASS-1
CLASS-2
CLASS-3
CLASS-4
RTD.EMPLOYEE
DEPENTANTS
1
1
34
91
15
33
Patern of treatment
100
89
90
80
70
60
50
40
30
20
9
8
10
1
0
Insulin+Tablet
Tablet
Diet
Native treatment
HYPERTENSION & DIABETES
140
120
No of patients
100
80
60
40
20
0
Employee
Series1
127
Rtd.Employee
15
Category of patients
Dependents
33
TOTAL CASES - 175
120
105
100
80
60
41
40
17
20
9
3
0
< 5 years
> 5 to < 10 years
> 10 to < 15 years
> 15 to < 20 years
TREATMENT PERIOD
> 20 years