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Diabetes Epidemic You



Revised 04/2011 DIABETES EPIDEMIC and YOU is not a cliché! It is a mandate for the awakening of the "silent" millions worldwide with "normal" fasting blood sugars and undiagnosed diabetes. If you have a "normal" fasting blood sugar, YOU may be one of the undiagnosed millions. YES, I do mean YOU.




Diabetes Epidemic You



Since Hippocrates' time, earliest diagnosis provided the greatest opportunity for treatment and cure. This book highlights the earliest identification of type 2 diabetes by utilizing the insulin assay with the oral glucose tolerance.


My cumulative experience of 14,384 oral glucose tolerances with insulin assays established the earliest diagnosis of prediabetes and diabetes when the blood sugars were normal. Prediabetes is type 2 diabetes. The tolerances were separated according to age groups, from 3Ð13 years to 81Ð90+ years. Each group was further divided into normal glucose tolerances, impaired glucose tolerances, and diabetes mellitus glucose tolerances. YOU, upon testing by oral glucose tolerance, will be in one of these categories.


DIABETES EPIDEMIC and YOU is not a cliché! It is a mandate for the awakening of the "silent" millions worldwide with "normal" fasting blood sugars and undiagnosed diabetes. If you have a "normal" fasting blood sugar, YOU may be one of the undiagnosed millions. YES, I do mean YOU.


My cumulative experience of 14,384 oral glucose tolerances with insulin assays established the earliest diagnosis of prediabetes and diabetes when the blood sugars were normal. Prediabetes is type 2 diabetes. The tolerances were separated according to age groups, from 3D13 years to 81D90+ years. Each group was further divided into normal glucose tolerances, impaired glucose tolerances, and diabetes mellitus glucose tolerances. YOU, upon testing by oral glucose tolerance, will be in one of these categories.


Aside from the impact on our economy and health care system, diabetes can have a devastating effect on those who suffer from it. Complications can include cardiovascular disease, nerve damage, kidney disease, eye problems, poor circulation and limb amputations.


Changes in human behaviour and lifestyle over the last century have resulted in a dramatic increase in the incidence of diabetes worldwide. The epidemic is chiefly of type 2 diabetes and also the associated conditions known as 'diabesity' and 'metabolic syndrome'. In conjunction with genetic susceptibility, particularly in certain ethnic groups, type 2 diabetes is brought on by environmental and behavioural factors such as a sedentary lifestyle, overly rich nutrition and obesity. The prevention of diabetes and control of its micro- and macrovascular complications will require an integrated, international approach if we are to see significant reduction in the huge premature morbidity and mortality it causes.


Tuberculosis (TB) remains a major cause of mortality in developing countries, and in these countries diabetes prevalence is increasing rapidly. Diabetes increases the risk of TB. Our aim was to assess the potential impact of diabetes as a risk factor for incident pulmonary tuberculosis, using India as an example.


We constructed an epidemiological model using data on tuberculosis incidence, diabetes prevalence, population structure, and relative risk of tuberculosis associated with diabetes. We evaluated the contribution made by diabetes to both tuberculosis incidence, and to the difference between tuberculosis incidence in urban and rural areas.


In India in 2000 there were an estimated 20.7 million adults with diabetes, and 900,000 incident adult cases of pulmonary tuberculosis. Our calculations suggest that diabetes accounts for 14.8% (uncertainty range 7.1% to 23.8%) of pulmonary tuberculosis and 20.2% (8.3% to 41.9%) of smear-positive (i.e. infectious) tuberculosis.


Diabetes makes a substantial contribution to the burden of incident tuberculosis in India, and the association is particularly strong for the infectious form of tuberculosis. The current diabetes epidemic may lead to a resurgence of tuberculosis in endemic regions, especially in urban areas. This potentially carries a risk of global spread with serious implications for tuberculosis control and the achievement of the United Nations Millennium Development Goals.


Tuberculosis remains a leading cause of death globally. In 2005 there were an estimated 8.8 million new cases of tuberculosis worldwide, with 1.9 million of those occurring in India[1]. Incidence of tuberculosis is greatest among those with conditions impairing immunity[2], such as human immunodeficiency virus (HIV) infection and diabetes. The consequences of mismanagement of tuberculosis in a patient with diabetes can be severe, but there are simple and immediate opportunities for improving treatment success and reducing mortality.


Our objective was to estimate the population-level impact of diabetes on the incidence of pulmonary tuberculosis in India. We chose India as an illustrative example because of its large population size, the availability of relatively good data on both diabetes and tuberculosis, and because the latter indicate that both these conditions are major public health problems there. We also aimed to evaluate the contribution made by diabetes to the higher tuberculosis incidence in urban compared with rural populations.


Data were extracted from the sources below, as summarised in Table 1. Analyses were limited to the adult population aged 25 years and over, as estimates of diabetes prevalence and the relative risks of incident tuberculosis associated with diabetes were available for this age group only.


Numbers of diabetes cases in India were estimated by multiplying age-specific diabetes prevalence estimates from PODIS by the age- and sex-specific United Nations population estimates for India in 2000[12].


We obtained age-specific relative risks for the association between diabetes and incident tuberculosis (for total pulmonary tuberculosis and smear-positive tuberculosis separately) from a study of 814,713 Korean civil servants[17]. As separate age-specific relative risks were not reported for men and women, we applied the same estimates to both sexes.


This is the only large-scale prospective study quantifying the diabetes-associated risk of incident tuberculosis (reactivation was excluded by baseline chest x-ray) within a single population. The only study we found at the time of undertaking the analyses which had been undertaken in India had a small sample size and was cross-sectional in design, so was less precise and could not account for temporal associations and does not provide age specific relative risk estimates,[18] Recently a case control study of risk factors for TB has been published from India in which known diabetes was ascertained by questionnaire[19], but this only provides a single, all ages, estimate of relative risk.


Estimates of diabetes prevalence, tuberculosis incidence and the relative risk of tuberculosis incidence associated with diabetes were applied to age- and sex-specific estimates of the Indian population to calculate the Attributable Fraction (Population)[20] (see below). We calculated crude estimates of the AF(P) using data for tuberculosis incidence and diabetes prevalence for the overall population, as well as estimates stratified by age and sex. The published 95% confidence intervals for the relative risks were used to derive upper and lower bounds for the AF(P) estimates.


We estimated the proportion of tuberculosis attributable to diabetes among those with diabetes using the Attributable Fraction (Exposed)[20] (see below) for smear-positive and total pulmonary tuberculosis. Age-adjusted relative risks and 95% confidence intervals were calculated using Mantel-Haenszel methods.


The proportion by which the incidence rate of the outcome of interest (here, incident tuberculosis) in the entire population would theoretically be reduced if the exposure of interest (here, diabetes) were eliminated.


The proportion by which the incidence rate of the outcome of interest (here, incident tuberculosis) in the exposed population would theoretically be reduced if the exposure of interest (here, diabetes) were eliminated.


We aimed to estimate the contribution made by diabetes to the higher tuberculosis incidence observed in urban as compared with rural populations. We approached this by calculating the theoretical urban and rural tuberculosis incidences which would be expected from the distribution of diabetes prevalence and the diabetes-associated relative risk for developing tuberculosis. This initially required partitioning tuberculosis incidence across the populations with and without diabetes. We defined the equation:


where TBT is the total tuberculosis incidence rate, TBND is tuberculosis incidence in the sub-population without diabetes, RR is the relative risk of incident tuberculosis for diabetes, and PDIA is the prevalence of diabetes. This equation was used to estimate tuberculosis incidence in the populations with and without diabetes by solving mathematically for TBND. Tuberculosis incidence in the population with diabetes is TBND RR. Theoretical urban and rural tuberculosis incidences were then calculated using the equation above with the urban and rural diabetes prevalences reported by PODIS[3]. For comparison, urban and rural tuberculosis incidences were also calculated using recent measurements of the annual risk of tuberculosis infection[21] and Styblo's equation[22], which has been shown to be applicable within India[23].


The prevalence of diabetes among people with tuberculosis was estimated by calculating the number of tuberculosis cases in the populations with and without diabetes, and hence the percentage of cases with diabetes. Numbers of tuberculosis cases were calculated by multiplying age-specific estimates of tuberculosis incidence and of diabetic and non-diabetic population size. Age-specific tuberculosis incidences in the populations with and without diabetes were estimated using the same methods described under Urban/rural distribution. 041b061a72


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