In the name of Allah Diabetes Mellitus Risk Factors

Alipasha Meysamie, MD, MPH

Professor in Community and Preventive Medicine

[email protected]

Diabetes Mellitus Risk Factors and Prevention

1

In the name of AllahDiabetes Mellitus Risk Factors

and Prevention

Alipasha Meysamie; MD, MPH

Professor in Community and Preventive

Medicine

Global Causes of Mortality

Year 2012 2000Population (thousands) 7,075,456 6,123,850

GHE 2012 cause categoryDeaths

(000s)%

Deaths

(000s)%

All Causes 55,859 100.0% 52,806 100.0%

I.Communicable, maternal,

perinatal and nutritional conditions12,822 23.0% 16,310 30.9%

II. Noncommunicable diseases 37,892 67.8% 31,470 59.6%

III. Injuries 5,144 9.2% 5,026 9.5%

Global Causes of Mortality 2012Rank Cause Deaths (000s) % Deaths

Deaths per 100,000 population

0 All Causes 55859 100.0 789.51 Ischaemic heart disease 7356 13.2 104.02 Stroke 6671 11.9 94.33 Chronic obstructive pulmonary disease 3104 5.6 43.94 Lower respiratory infections 3052 5.5 43.15 Trachea, bronchus, lung cancers 1600 2.9 22.66 HIV/AIDS 1534 2.8 21.77 Diarrhoeal diseases 1498 2.7 21.28 Diabetes mellitus 1497 2.7 21.29 Road injury 1255 2.3 17.7

10 Hypertensive heart disease 1141 2.0 16.111 Preterm birth complications 1135 2.0 16.012 Cirrhosis of the liver 1021 1.8 14.413 Tuberculosis 935 1.7 13.214 Kidney diseases 864 1.6 12.215 Self-harm 804 1.4 11.416 Birth asphyxia and birth trauma 744 1.3 10.517 Liver cancer 740 1.3 10.518 Stomach cancer 733 1.3 10.419 Colon and rectum cancers 724 1.3 10.220 Alzheimer's disease and other dementias 701 1.3 9.9

IR Iran Causes of Mortality

Year 2012 2000Population (thousands) 76,424 65,911

GHE 2012 cause categoryDeaths

(000s)%

Deaths

(000s)%

All Causes 395.5 100.0% 337.0 100.0%


perinatal and nutritional conditions38.2 9.7% 46.7 13.9%

II. Noncommunicable diseases 302.0 76.4% 235.0 69.7%

III. Injuries 55.2 14.0% 55.3 16.4%

IR Iran Burden of Disease

(DALY)

Year 2012 2000Population (thousands) 76,424 65,911

GHE 2012 cause categoryDALYs

(000s)%

DALYs

(000s)%

All Causes 21243.8 100.0% 20388.8 100.0%


perinatal and nutritional conditions 3372.9 15.9% 4546.0 22.3%

II. Noncommunicable diseases 14417.8 67.9% 12166.0 59.7%

III. Injuries 3453.1 16.3% 3676.8 18.0%



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2

Global Causes of Mortality

Death (000s) 2012 2000All Causes 55,859 100.0% 52,806 100.0%Communicable, maternal,

perinatal and nutritional conditions12,822 23.0% 16,310 30.9%

Noncommunicable diseases 37,892 67.8% 31,470 59.6%Malignant neoplasms 8,206 14.7% 6,413 12.1%Other neoplasms 193 0.3% 144 0.3%Diabetes mellitus 1,497 2.7% 1,046 2.0%Endocrine, blood, immune

disorders411 0.7% 283 0.5%

Mental and behavioral disorders 257 0.5% 200 0.4%Neurological conditions 1,420 2.5% 806 1.5%Sense organ diseases 1 0.0% 2 0.0%Cardiovascular diseases 17,519 31.4% 14,881 28.2%Respiratory diseases 4,042 7.2% 3,938 7.5%Digestive diseases 2,264 4.1% 2,035 3.9%Genitourinary diseases 1,196 2.1% 900 1.7%Skin diseases 111 0.2% 95 0.2%Musculoskeletal diseases 217 0.4% 138 0.3%Congenital anomalies 556 1.0% 588 1.1%Oral conditions 2 0.0% 1 0.0%

Injuries 5,144 9.2% 5,026 9.5%

IR Iran Causes of Mortality

Death (000s) 2012 2000All Causes 395.5 100.0% 337.0 100.0%Communicable, maternal,


Noncommunicable diseases 302.0 76.4% 235.0 69.7%Malignant neoplasms 53.6 13.5% 42.4 12.6%Other neoplasms 0.7 0.2% 0.5 0.2%Diabetes mellitus 8.8 2.2% 4.9 1.5%Endocrine, blood, immune

disorders7.5 1.9% 4.2 1.3%

Mental and behavioral disorders 5.2 1.3% 2.8 0.8%Neurological conditions 7.5 1.9% 4.0 1.2%Sense organ diseases 0.0 0.0% 0.0 0.0%Cardiovascular diseases 180.8 45.7% 145.1 43.1%Respiratory diseases 14.8 3.8% 12.1 3.6%Digestive diseases 8.3 2.1% 6.8 2.0%Genitourinary diseases 8.7 2.2% 5.2 1.6%Skin diseases 0.2 0.1% 0.2 0.1%Musculoskeletal diseases 0.5 0.1% 0.4 0.1%Congenital anomalies 5.5 1.4% 6.3 1.9%Oral conditions 0.0 0.0% 0.0 0.0%

Injuries 55.2 14.0% 55.3 16.4%

Global Burden of Disease

DALY(000s) 2012 2000All Causes 2,743,857 100.0% 2,872,910 100.0%Communicable, maternal,

perinatal and nutritional conditions 925,728 33.7% 1,243,422 43.3%

Noncommunicable diseases 1,512,578 55.1% 1,315,770 45.8%Malignant neoplasms 223,957 8.2% 186,938 6.5%Other neoplasms 5,232 0.2% 4,211 0.1%Diabetes mellitus 59,258 2.2% 44,060 1.5%Endocrine, blood, immune disorders 27,414 1.0% 21,964 0.8%Mental and behavioral disorders 199,893 7.3% 170,527 5.9%Neurological conditions 79,424 2.9% 60,353 2.1%Sense organ diseases 52,870 1.9% 45,453 1.6%Cardiovascular diseases 393,805 14.4% 352,854 12.3%Respiratory diseases 137,110 5.0% 132,356 4.6%Digestive diseases 78,048 2.8% 74,480 2.6%Genitourinary diseases 56,579 2.1% 47,868 1.7%Skin diseases 19,249 0.7% 17,096 0.6%Musculoskeletal diseases 111,483 4.1% 88,529 3.1%Congenital anomalies 52,532 1.9% 55,308 1.9%Oral conditions 15,723 0.6% 13,772 0.5%

Injuries 305,552 11.1% 313,718 10.9%

IR Iran Burden of Disease

DALY(000s) 2012 2000All Causes 21243.8 100.0% 20388.8 100.0%Communicable, maternal,


Noncommunicable diseases 14417.8 67.9% 12166.0 59.7%Malignant neoplasms 1601.0 7.5% 1426.4 7.0%Other neoplasms 26.6 0.1% 21.6 0.1%Diabetes mellitus 522.5 2.5% 335.9 1.6%Endocrine, blood, immune disorders 354.4 1.7% 293.2 1.4%Mental and behavioral disorders 2695.5 12.7% 2112.7 10.4%Neurological conditions 606.1 2.9% 472.7 2.3%Sense organ diseases 409.4 1.9% 334.4 1.6%Cardiovascular diseases 4246.6 20.0% 3858.4 18.9%Respiratory diseases 852.9 4.0% 763.6 3.7%Digestive diseases 267.9 1.3% 250.1 1.2%Genitourinary diseases 487.5 2.3% 353.9 1.7%Skin diseases 141.5 0.7% 119.6 0.6%Musculoskeletal diseases 1507.7 7.1% 1085.1 5.3%Congenital anomalies 541.9 2.6% 606.7 3.0%Oral conditions 156.2 0.7% 131.4 0.6%

Injuries 3453.1 16.3% 3676.8 18.0%

Ranking of 10 selected Risk Factors of cause of death

Attributable Death Risk Factors of Hyperglycemia

• Susceptible to change

– Diet

– Obesity

– Inactivity

– Insulin Resistance

– HTN

– Stress

– Alcohol

– Toxins

• Immutable to change

– Age

– Gender

– Family History

– Genetic Factors

– Personality



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3

Prevention of NCDs

• Risk Determination & Stratification

– Risk Factor Modification

• Screening

• Early Treatment

• Integrated Approaches

– Health Promotion & Disease Prevention Clinics

Epidemicity of CVD• MONICA

– Multinational MONItoring of trends and determinants in CArdiovascular disease

Prediabetic State

• Period before symptomatic diabetes.

• Subsequently INSULIN RESISTANCE• Fasting Insulin 8–11 μIU/mL(57–79 pmol/L)

• HOMA-IR (Homeostasis model of insulin resistance)

• HOMA-B (Homeostasis model of B cell function)

• IFG

• IGTT

• Quicki (Quantitative insulin sensitivity check index )

• Metabolic Syndrome

Diabetes Mellitus



– 1.95 for ATPIII, and 1.85 for IDF.

• IFG ≥ 100 / ≥110

• IGTT ≥ 140

• Quicki (Quantitative insulin sensitivity check index )

1 / (log(fasting insulin µU/mL) + log(fasting glucose mg/dL))

Diabetes Mellitus



– 1.95 for ATPIII, and 1.85 for IDF.

1 / (log(fasting insulin µU/mL) + log(fasting glucose mg/dL))

Metabolic Syndrome• IDF (International Diabetes Federation) (2006)

– Central obesity (waist circumference# with ethnicity specific values,

≥ 94cm for Europid men and ≥ 80cm for Europid women) – In Iran (90 cm for both men and women)

• # If BMI is >30 kg/m², central obesity can be assumed

– AND any two of the following:

– Raised triglycerides : • > 150 mg/dL (1.7 mmol/L), or

• Specific treatment for this lipid abnormality.

– Reduced HDL cholesterol: • < 40 mg/dL (1.03 mmol/L) in males,

• < 50 mg/dL (1.29 mmol/L) in females, or

• specific treatment for this lipid abnormality

– Raised blood pressure : • Systolic BP > 130 or diastolic BP >85 mm Hg, or

• Treatment of previously diagnosed hypertension.

– Raised fasting plasma glucose :• (FPG)>100 mg/dL (5.6 mmol/L), or

• previously diagnosed type 2 diabetes.

• If FPG >5.6 mmol/L or 100 mg/dL, OGTT Glucose tolerance test strongly recommended.



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4

Metabolic Syndrome

• Adult Treatment Panel III (2006) – At least three of the following:

• Central obesity: waist circumference – ≥ 102 cm (male), ≥ 88 cm (female)

• Dyslipidaemia: – TG ≥ 150 mg/dl

• Dyslipidaemia: – HDL-C < 40 mg/dl (male), < 50 mg/dl (female)

• Blood pressure– ≥ 130/85 mmhg

• Fasting plasma glucose – ≥ 100 mg/dl

Metabolic Syndrome Trend in IR Iran

2005 2007 2011 P value

Total N/A 35.9 (34.3-37.6) 32.9 (30.7-35.2) 0.011

Age

25-34 N/A 19.5 (16.4-22.3) 19.3 (16.5-22.1) 0.917

35-44 N/A 40.9 (37.6-44.3) 32.5 (28.6-36.3) <0.001

45-54 N/A 48.9 (45.56-52.4) 48.2 (43.4-53.1) 0.768

55-64 N/A 59.6 (56.2-63.1) 55.7 (51.8-59.7) 0.049

Gender

Male N/A 35.1 (32.7-37.6) 34.4 (30.8-37.9) 0.675

Female N/A 36.8 (34.5-39.1) 31.5 (29.4-33.7) <0.001

Residential area

Urban N/A 37.9 (35.9-40.1) 35.2 (32.6-37.8) 0.040

Rural N/A 30.1 (27.6-32.7) 26.4 (22.4-30.5) 0.085

Individual Components of IDF

Metabolic Syndrome

2005 2007 2011 P value

Central Obesity N/A 49.7 (47.9-51.5) 51.9 (48.9-54.8) 0.138

Raised

TriglyceridesN/A 35.7 (33.9-37.5) 36.9 (34.5-39.5) 0.305

Reduced

HDL-cholesterolN/A 55.8 (54.0-57.7) 54.7 (50.9-58.6) 0.559

Raised

Blood PressureN/A 41.2 (39.5-42.9) 38.9 (36.2-41.6) 0.098

Raised Fasting

Plasma GlucoseN/A 17.8 (16.5-19.1) 24.9 (22.0-27.9) <0.001

Hyperglycemia Risks

• Insulin resistance, hyperinsulinemia, and

elevated blood glucose

– 10% of PAF of first MI

• Diabetes

– CHD risk equivalent, Elevating it to the

Highest risk category

• Hyperglycemia without overt diabetes

mellitus

– With cardiovascular risk

Risk Factors Associated with

DM• Diabetics

– Greater burden of other atherogenic risk

factors

• Including

– Hypertension,

– Obesity,

– Increased total-to-HDL-cholesterol ratio,

– Hyper triglyceridemia, and

– Elevated plasma fibrinogen

Raised blood sugar

(Diabetes)

• 1.3 million deaths globally

• CVD accounts for 60% of mortality in

diabetes.

• Risk of cardiovascular events;

– Two to three times higher

• Risk disproportionately higher in women

• In some age groups,

– Twofold increase in the risk of stroke

• Poorer prognosis after cardiovascular

events



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5

World map showing

the prevalence of Raised Blood Glucose in Males

(ages 25+, age standardized)

World map showing

the prevalence of Raised Blood Glucose in Females


Unhealthy diet

• A modest reduction in salt intake • Reduces blood pressure in

• Both normal and raised blood pressure.

• Dietary salt • Increases blood pressure

• In most people with hypertension and

• In about one third with normotension.

• Aggravates age related rise in blood pressure.

• High dietary intakes of saturated fat, trans-fat, cholesterol and salt, and low intake of fruits, vegetables and fish increase the risk of CVD.

Unhealthy diet

• 16 million (1.0%) DALYs and 1.7 million (2.8%) of deaths worldwide – Attributable to low fruit and vegetable

consumption

• A healthy diet to – A healthy body weight,

– A desirable lipid profile and

– A desirable blood pressure

• WHO recommends population salt intake – Less than 5 grams/person/day

– Current global levels of 9–12 grams/day

World map showing

the prevalence of Obesity, BMI≥30 kg/m2 in Males

( ages 20+, age standardized)

World map showing

the prevalence of Obesity, BMI≥30 kg/m2 in Females

( ages 20+, age standardized)



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6

World map showing Fruits and Vegetable Intake

(Grams per Person per Day) Diabetes Mellitus Trend in IR Iran

2005 2007 2011 P value

Total 7.9 (7.6-8.1) 9.2 (8.3-10.1) 10.6 (9.1-12.2) 0.005

Age

25-34 3.1 (2.8-3.4) 2.9 (1.7-4.1) 3.3 (1.9-4.6) 0.725

35-44 6.9 (6.4-7.3) 7.9 (6.1-9.8) 9.2 (6.5-11.9) 0.084

45-54 13.1 (12.5-13.7) 15.3 (12.7-17.8) 19.1 (15.3-22.8) 0.002

55-64 17.9 (17.2-18.6) 23.6 (20.6-26.7) 25.3 (22.7-27.9) <0.001

Gender

Male 7.0 (6.7 -7.4) 8.4 (7.1-9.6) 9.3 (6.9-11.7) 0.112

Female 8.7 (8.4-9.1) 10.0(8.7-11.4) 11.9 (10.3-13.6) 0.002

Residential area

Urban 8.7 (8.4-8.9) 9.9 (8.7-11.0) 11.9 (10.1-13.8) 0.003

Rural 5.6 (5.3-5.9) 7.2 (5.8-8.6) 6.9 (5.1-8.8) 0.421

Impaired Fasting Glucose Trend in IR Iran2005 2007 2011 P value

Total 15.3 (14.9-15.6) 9.7 (8.6-10.7) 14.4 (12.3-16.6) 0.985

Age

25-34 11.5 (10.9-12.2) 6.1 (4.4-7.8) 9.44 (7.2-11.7) 0.386

35-44 16.2 (15.6-16.9) 10.1 (8.0-12.1) 14.4 (11.4-17.4) 0.687

45-54 18.7 (18.0-19.4) 13.7 (11.3-16.1) 20.2 (16.4-24.0) 0.173

55-64 20.4 (19.6-21.1) 14.3 (11.8-16.9) 21.9 (18.7-25.2) 0.077

Gender

Male 15.9 (15.4 -16.4) 10.4 (8.8-11.9) 15.3 (12.6-17.9) 0.836

Female 14.7 (14.2-15.2) 8.94 (7.5-10.4) 13.6 (11.3-15.8) 0.830

Residential area

Urban 15.9 (15.5-16.3) 10.4 (9.1-11.8) 15.3 (12.9-17.8) 0.826

Rural 13.6 (13.1-14.1) 7.5 (6.0-8.9) 11.7 (8.9-14.8) 0.649

Physical inactivity

• Regular physical activity

– Reduces the risk of heart attacks and strokes.

• Physical activity is

– A key determinant of energy expenditure and thus fundamental to energy balance and weight control.

• Insufficient physical activity

– Less than 5 times 30 minutes of moderate activity per week, or

– Less than 3 times 20 minutes of vigorous activity per week, or

– Equivalent.

Physical inactivity

• 150 minutes of moderate physical

activity each week (or equivalent)

– Reduce

• The risk of diabetes by 27%

• Insufficiently physically activity

– HICs; 41% of men and 48% of women

– LICs; 18% of men and 21% of women

World map showing

the prevalence of Insufficient Physical Activity , in

Males

(age 15+, age standardized)



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7

World map showing

the prevalence of Insufficient Physical Activity , in

Females

(age 15+, age standardized)

Obesity

• Obesity

• Strongly related to • Hypertension

• Type 2 diabetes and

• Dyslipidaemia.

• Imbalance between increased energy intake (diet) and energy expenditure (physical activity)

• A growing health problem worldwide.

Obesity

• 35.8 million (2.3%) of global DALYs

– caused by overweight or obesity

• 34% of adults over the age of 20

overweight

– 33.6% of men and 35% of women

World map showing

the prevalence of Overweight, BMI ≥ 25 kg/m2 in

Males


World map showing

the prevalence of Overweight, BMI ≥ 25 kg/m2 in

Females


BMI Trend in IR Iran

2005 2007 2011 P value

Total 26.3 (26.2-26.3) 26.5 (26.3-26.7) 26.6 (26.3-26.8) 0.042

Age

25-34 25.3 (25.2-25.4) 25.1 (24.8-25.4) 25.3 (24.9-25.7) 0.795

35-44 26.8 (26.7-26.9) 27.1 (26.8-27.4) 27.1 (26.7-27.6) 0.273

45-54 27.3 (27.2-27.4) 27.9 (27.5-28.2) 27.6 (27.3-28.0) 0.172

55-64 26.8 (26.7-26.9) 27.6 (27.2-27.9) 27.7 (27.4-27.9) <0.001

Sex

Male 25.3 (25.2-25.3) 25.4 (25.2-25.7) 25.9 (25.6-26.3) 0.001

Female 27.3 (27.2-274) 27.6 (27.3-27.8) 27.2 (26.9-27.4) 0.168

Residential area

Urban 26.6 (26.6-26.7) 26.9 (26.6-27.1) 26.9 (26.6-27.1) 0.187

Rural 25.3 (25.2-25.3) 25.5 (25.2-25.7) 25.7 (25.3-25.9) 0.029



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8

General Obesity Trend in IR Iran

2005 2007 2011 P value

Total 20.5 (20.1-20.9) 22.9 (21.4-24.4) 21.8 (20.4-23.3) 0.278

Age

25-34 14.6 (13.9-15.3) 14.5 (12.1-17.0) 14.4 (12.2-16.7) 0.869

35-44 23.4 (22.7-24.2) 26.5 (23.6-29.4) 24.6 (21.3-27.8) 0.740

45-54 26.7 (25.9-27.4) 31.1 (27.9-34.2) 28.9 (25.7-32.2) 0.386

55-64 23.8 (23.1-24.6) 29.5 (26.4-32.7) 29.1 (26.7-31.4) 0.001

Sex

Male 12.9 (12.5-13.4) 15.4 (13.7-17.2) 16.3 (14.6-18.0) 0.015

Female 29.9 (29.4-30.5) 33.9 (31.6-36.2) 31.1 (29.5-32.8) 0.305

Residential area

Urban 24.6 (24.2-25.1) 27.7 (25.8-29.7) 27.9 (26.4-29.5) 0.469

Rural 17.2 (16.7-17.7) 19.6 (17.3-21.9) 20.9 (18.9-22.9) 0.286

Obesity

• Central Obesity

– Android Obesity

• General obesity

– Gynoid Obesity• Developing

– 20-40% Adults

– 10-20% Youth and Children

• Age

• Gender

• Genetics• Low Socioeconomic Status

Obesity

• Body Mass index

– Quetelet`s index

h

WBMI

2

Obesity

– Ponderal index

– Broca`s index

3

)(

w

cmh

100)( cmh

Obesity

– Lorentz index

– Corpulence index

2.1idealw

w

mf

cmhcmh

4/3

150)(100)(

Obesity

• Skin Fold Thickness– Harpenden Skin Fold Caliper

– Boys < 40 mm

– Girls <50 mm

• Waist Circumference– IDF; M >= 94 ;F>= 80

– ATPIII; M>=102 ; F>= 88– Iranian; M & F >= 90

• Waist to Hip Ratio– Male < 1

– Female < 0.8

• Body Composition Analyzer



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9

Third national SuRFNCD-2007 in Iran

Third national SuRFNCD-2007 in Iran Obesity Complications• HTN

• Diabetes Mellitus

• Gall Stone

• CHD

• Varicose Veins

• Herniation

• Degenerative Joint Disease

• Psychosocial Stress

• Hazards of Interventions

• Sudden Death

• Decreased Life Expectancy

Obesity Prevention and Control• From Childhood

– Diet• No Low Volume High Calorie

• Low Fat, Low Sugar

• High Fiber

• Less than 1000 Cal per Day

• Intake<Expenditure

– Physical Activity• Intensity, Frequency

– Orlistat

– Surgery

– Education

Raised blood pressure

(Hypertension)• Major risk factor for strokes and heart

attacks as well as heart failure, renal impairment, peripheral vascular disease and blindness.

• Continuous relationship between blood pressure and cardiovascular risk (risk of developing heart attacks and strokes).

• Early detection of hypertension and treatment to reduce cardiovascular risk in people with hypertension • Vital for prevention of strokes and heart attacks.



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10

Raised blood pressure

(Hypertension)

• 7.5 million deaths, about 12.8% of the total of all annual deaths

• 57 million DALYS or 3.7% of total DALYS

• In some age groups,

• CVD risk doubles • For each incremental increase of 20/10 mmHg

• Starting as low as 115/75 mmHg.

• Overall prevalence of raised blood pressure in adults aged 25 and over; 40%

World map showing

the prevalence of Raised Blood Pressure, SBP≥ 135 and /or DBP ≥85

in Males


World map showing

the prevalence of Raised Blood Pressure, SBP≥ 135 and /or DBP ≥85

in Females


Hypertension Trend in IR Iran

2005 2007 2011 P value

Total 25.7 (25.3-26.0) 25.0 (23.7-26.2) 24.1 (22.2-26.0) <0.001

Age

25-34 12.8 (12.3-13.3) 10.9 (9.0-12.8) 10.3 (8.7-11.9) 0.001

35-44 22.4 (21.8-23.0) 22.9 (20.4-25.4) 20.1 (17.1-23.1) 0.096

45-54 38.8 (38.0-39.5) 38.4 (35.4-41.4) 40.9 (37.3-44.6) 0.220

55-64 55.6 (54.9-56.4) 56.0 (52.8-59.1) 52.6 (49.4-55.9) 0.023

Gender

Male 25.6 (25.1-26.0) 23.1 (21.4-24.9) 22.6 (20.0-25.2) <0.001

Female 25.7 (25.3-26.2) 26.8 (25.0-28.6) 25.6 (23.6-27.6) 0.134

Residential area

Urban 26.0 (25.6-26.4) 26.5 (25.0-28.1) 24.9 (22.8-27.1) 0.009

Rural 24.7 (24.2-25.3) 20.5 (18.5-22.5) 21.7 (19.0-24.4) <0.001

Pre-hypertension Trend in IR Iran

2005 2007 2011 P value

Total 45.5 (45.1-45.9) 40.4 (38.8-42.0) 40.4 (38.4-42.5) <0.001

Age

25-34 47.4 (46.6-48.1) 41.3 (38.3-44.3) 43.0 (40.3-45.7) <0.001

35-44 49.0 (48.2-49.7) 43.3 (40.4-46.3) 44.4 (40.7-48.1) <0.001

45-54 43.9 (43.1-44.6) 40.5 (37.5-43.5) 35.2 (32.0-38.4) <0.001

55-64 33.9 (33.2-34.6) 30.2 (27.3-33.1) 31.2 (28.6-33.8) 0.003

Gender

Male 51.3 (50.7-51.8) 46.8 (44.5-49.1) 46.9 (43.7-50.1) <0.001

Female 39.7 (39.1-40.3) 33.9 (31.7-36.1) 33.9 (31.8-36.0) <0.001

Residential area

Urban 45.9 (45.4-46.4) 40.9 (38.9-42.8) 40.9 (38.5-43.2) <0.001

Rural 44.5 (43.8-45.2) 38.9 (36.1-41.6) 39.2 (36.6-41.8) <0.001

Alcohol

• 14% of alcohol-attributable deaths

• Due to CVD and diabetes mellitus.

• Direct causal relationship

• Between levels and patterns of alcohol

consumption.

• High levels of alcohol consumption and

heavy episodic (binge) drinking



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11

Alcohol

• Hazardous and harmful drinking

– 2.5 million (3.8%) deaths worldwide in 2004.

• More than 50% of deaths due to CVDs,

liver cirrhosis and cancer.

• 4.5% of the global burden of disease –

DALYs

World map showing

the Adult per Capita consumption of pure alcohol

(Liters), in Males and Females

Family history

• Significant independent risk factor for DM,

– Particularly among younger individuals

• Significant family history

– Development of atherosclerotic CVD or death

from CVD in a first degree relative (ie, parent

or sibling) prior to age 55 (males) or 65

(females)

• 40 to 60% increased Risk

Reliability of self-reported

family history• Specificity

– Disease-free was high (90 to 95 percent),

• Sensitivity

– 6% mood disorder, up to 95% some types of

cancer

• Predictive value of an affirmative

statement

– Above 75% for

• Family histories of Hypertension, Diabetes, and

Hypercholesterolemia.

Reliability of self-reported

family history• Predictive value of an affirmative

statement

– For cardiac death

• only 66% for fathers and 47% for mothers.

• Predictive value of a negative statement

– Above 90% for family history of cardiac death

or for diabetes,

– Below 60% for family history of hypertension

or hypercholesterolemia.

Risk Factors of CHD

• Psychosocial Factors

– Depression, anger, stress

– Personality type; A; D

• Hormonal Risk Factors

– Estrogen Increased Risk

– Progesterone Protective

– OCP



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12

Prevention of Diabetes Mellitus• Primary Prevention

– Population Based Interventions

• Health Promotion and Disease Prevention Clinics

– High Risk Group Approach• Risk Stratification, Risk Factor Modification

• Secondary Prevention

Prevention and control od

Diabetes Mellitus• Integration with CVD Prevention

• Media campaigns,

• Partnership with the food industry,

• Involvement of local health-care and

community organizations,

• Agricultural reforms and

• Providing health care for those at high

cardiovascular risk

Prevention and control of

NCDs• Decrease in the consumption of

– Butter

– Other animal fats

– Milk

– Beef

– Potatoes

• Increased consumption of– Vegetable fat

– Poultry

– Fruit

• Decrease consumption of– Saturated fatty acids

• Increase – Polyunsaturated fatty acids

Prevention and control of

NCDs• Population wide strategies for

– Tobacco and

– Alcohol control

– And salt reduction

• Very cost effective.

• Drug Therapy

• Metformin

Multiple Risk Factor Intervention

Trial (MRFIT)

• Dramatic Decrease in CVD Mortality (MRFIT)

• Specific Interventions

– Lowering Dietary Risk

• Total fat <20-30%

• Saturated Fat <10%

• Cholesterol <100mg per 1000 Kcal Daily• Increase Fiber Intake

• No Alcohol

• Salt <5g Daily


Trial (MRFIT)

• Cigarette Smoking

– Quit With NRT, Bupropion, +Consultation

– Quit Lines, Face to Face, Web Based

– Decrease Blood Pressure

• Only 2 to 3 mmhg of Mean Population BP– Low salt diet

– No Alcohol

– Physical activity

– Weight Control

– Physical activity

• From Childhood



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Trial (MRFIT)• High Risk Groups

– Obesity

– Family History

– Hypertensive

– Hyperlipidemia

– Smokers

– Pre Diabetes State

– OCP

Summary of Epidemiology

of Diabetes Mellitus• Developing

– 45 to 65 ys

• Developed• Over 65 ys

• Higher in Urban Area

• Higher in Asia

– Ethnicity, Life Style

• Gender

– EU; M=F

– Asia; M>F

– IR Iran; F>M

Diabetes Mellitus• Genetic Factors

– IDDM

• HLA DR3و HLA DR4 و HLA BB وHLA B15

• Highest Risk in DR3 and DR4 Both

• Auto Immunity

• Obesity

– Length and Severity

• Insulin Resistance

– Not all Obese

• Physical Inactivity

• Diet

– Malnutrition

– Alcohol

Diabetes Mellitus

• Viral Infections

– Rubella, Mumps, Coxsackievirus

• Chemical Hazards– Alloxan

– Streptozotocin

– Cassava

– Rodenticides

• Stress

• Low Socioeconomic Status

Diabetes Mellitus Screening • U/A

– BS >180 mg.dl

– 2h pp Urine Sugar

• Low Sensitivity; 10-15%

• High Specificity; 90%

• FBS– >=126

– >=100

• PPBS, 2hGTT, 75 g Glucose– >=200

– >=140• Random BS

Diabetes Mellitus Screening in

IR Iran • All >=30 + One of the Followings

– BMI >=30

– 1st Degree FHx

– 2 Symptoms of 4

– BP >=140/90

• Pregnant Women + One of the Followings

– 2 Repeated Spontaneous Abortion

– Stillbirth

– Child >=4 kg

– Hx of GDM

– 28 to 34 Gestational Week



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14

Diabetes Mellitus Prevention

• Primary

– Decrease Weight

• Healthy Diet

– High Protein

– High Fiber

– No Sugar

– No Toxin

– No Alcohol

• Physical Activity

• No OCP

– Integrated in CVD Prevention


• Secondary

– BS Control

– Low Weight

• Diet

– Higher Frequency; Lower Volume

– Diet + OHA

– Diet + Insulin + OHA

• Regular FBS, Visual Acuity, Foot Check,

Renal Check

• HBA1c


• Tertiary

– Complications Treatment

• Visual

• Renal

• CHD

• Foot Gangrane

World map showing

the prevalence of Current Daily Tobacco smoking in

Males

(age standardized adjusted estimates)

World map showing

the prevalence of Current Daily Tobacco smoking in

Females

(age standardized adjusted estimates)

Tobacco Smoking Trend in IR IranCurrent

Smokers2000 2005 2007 2011

Male25.6%

(24.4%-26.9%)

21.5%

(21.1%-21.9%)

24.9%

(23.1%-26.7%)

21.3%

(19.8%-23.0%)

Female1.2%

(1.0%-1.5%)

2.9%

(2.8%-3.1%)

1.9%

(1.3%-2.7%)

1.0%

(0.8%-1.4%)

Urban13.2%

(12.4%-14.1%)

11.7%

(11.5%-12.0%)

13.6%

(12.5%-14.8%)

11.2%

(10.3%-12.2%)

Rural14.4%

(13.5%-15.4%)

13.8%

(13.4%-14.2%)

13.1%

(11.2%-15.2%)

11.3%

(9.7%-13.2%)

15-243.1%

(2.6%-3.6%)

3.2%

(3.0%-3.5%)

6.0%

(4.7%-7.7%)

3.4%

(2.5%-4.6%)

25-3416.3%

(14.9%-17.7%)

12.3%

(11.8%-12.8%)

12.7%

(10.7%-15.0%)

10.8%

(9.4%-12.4%)

35-4420.7%

(19.1%-22.3%)

18.7%

(18.1%-19.3%)

20.9%

(18.4%-23.6%)

18.4%

(16.1%-21.0%)

45-5417.6%

(15.5%-19.9%)

18.8%

(18.3%-19.5%)

19.2%

(16.7%-21.9%)

16.1%

(13.7%-19.0%)

55-6415.0%

(12.6%-17.7%)

16.0%

(15.5%-16.6%)

13.9%

(11.7%-16.4%)

13.8%

(12.1%-15.7%)

Total13.5%

(12.9%-14.2%)

12.3%

(12.1%-12.5%)

13.5%

(12.5%-14.5%)

11.3%

(10.5%-12.1%)

Documents

In the name of Allah Diabetes Mellitus Risk Factors