K.A.P STUDY ON HT

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K.A.P STUDY ON HT DM
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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 20002025 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!).
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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.
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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.
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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.
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CLASSIFICATION OF DIABETES MELLITUS

• 1. Type I diabetes
• A) Immune mediated b) idiopathic
• 2. Type 2 diabetes
• 3. Other specific typesa. Genetic
  defects of beta cell function b. Genetic
  defects insulin action, lipoatropic diabetesc.
  Disease of exocrine pancreas d.
  Endocrinopathies, acromegaly Cushings syndrome,
  hyperthyroidisme. Drug or chemical induced
  glucocorticoids, thyroid hormones, beta-blockers,
  thiazidesf. Infections congenital rubella,
  cytomegalovirusg. Uncommon forms of immune
  mediated diabetesh. Other genetic syndromes
  sometimes associated with diabetes downs
  syndrome,
• k. F Syndrome., turners syndrome.4.
  Gestational diabetes mellitus

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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.
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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.
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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.
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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.  
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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.
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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.
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DIAGNOSIS OF TYPE 2 DM

• SUG NORMAL IFG/IGT
  D.M
• FPG lt110 110-125
  gt125
• 2HR PPG lt140 140-199
  gt200

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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.

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CLASSIFICATION OF BLOOD PRESSURE FOR ADULTS
AGE 18 AND OLDERS

• Category
  Systolic Diastolic
• (mm of Hg) (mm of
  Hg ) (mm of Hg)
•   OPTIMAL lt 120
  lt 80
• NORMAL lt 130
  lt85
• HIGH NORMAL 130 139
  85 - 89
• HYPERTENSION
• Stage 1 140 159
  90 99
• Stage 2 160
  179 100 109
• Stage 3 gt 180
  gt 110

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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.

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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

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ERRORS and LIMITATIONS

• Interviewers Bias
• Respondent Bias
• Influence of By standards and Spectators

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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.
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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

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MONITORING DIABETES MELLITUS AND HYPERTENSION

• 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
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HYPERTENSION
Series1
20
19
18
17
18
16
14
12
10
8
8
6
4
4
2
2
0
100-110
121-130
131-140
141-150
gt150
111-120
SYSTOLE - mm of Hg
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HT DM
12
11
9
4
4
1
121-130
100-110
111-120
131-140
141-150
gt150
SYSTOLE - mm of Hg
28
ht dm
19
12
7
2
1
0
70-80
81-90
91-100
101-110
111-120
gt120
DIASTOLE - mm of Hg
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URINE SUGAR
35
33
30
30
25
22
20
15
13
9
10
5
0
1
2
3
4
Nil
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HYPERTENSION
Series1
20
19
18
18
17
16
14
12
10
8
8
6
4
4
2
2
0
121-130
131-140
141-150
gt150
100-110
111-120
SYSTOLE-mm of Hg
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HYPERTENSION
30
28
26
25
20
15
10
10
5
3
1
0
0
70-80
81-90
91-100
101-110
111-120
gt120
DIASTOLE-mm of Hg
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TOTAL CASES FOR STUDY - 175
80
68
70
66
60
50
41
40
30
20
10
0
DM
HT
HT DM
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TOTAL PATIENTS - 175
90
80
70
60
50
No of patients
40
30
20
10
0
30 - 40 years
51 - 60 years
gt 60 years
41 - 50 years
8
73
78
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Series1
AGE
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TOTAL CASES FOR STUDY - 175
120
100
80
60
40
20
SEX
0
MALE
FEMALE
114
61
Series1
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Patern of treatment
100
89
90
80
70
60
50
40
30
20
9
8
10
1
0
InsulinTablet
Tablet
Diet
Native treatment
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HYPERTENSION DIABETES
140
120
100
80
No of patients
60
40
20
0
Employee
Rtd.Employee
Dependents
127
15
33
Series1
Category of patients
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TOTAL CASES - 175
120
105
100
80
60
41
40
17
20
9
3
0
lt 5 years
gt 10 to lt 15 years
gt 5 to lt 10 years
gt 20 years
gt 15 to lt 20 years
TREATMENT PERIOD