Chapter 1
1.1 Introduction and epidemiology
Diabetes mellitus is a metabolic disorder characterized by chronic hyperglycaemia. The chronic
hyperglycaemia leads to microvascular damage and dysfunction especially the retina, kidneys
and nerves and acute metabolic derangements can result in emergencies such as diabetes keto-
acidosis and hyperosmolar nonketotic state. In addition, patients with diabetes develop
atherosclerosis at an earlier age and more aggressively leading to higher risk of cardio-vascular
disease, cerebrovascular disease and peripheral vascular disease. Because of these acute and
chronic complications diabetes has become an important cause for mortality and morbidity at a
global level.
1.2 Pathogenesis of diabetes
The hyperglycaemia in diabetes is mainly considered to be due to deficiency of insulin hormone
or resistance of the target tissues to insulin action or both. The type 1 diabetes is considered to be
due to absolute insulin deficiency as a result of beta cell destruction. Type 2 diabetes which is the
more common form of diabetes is considered to be due to insulin resistance and inability of the
pancreas to overcome the resistance. In addition to type 1 and type 2 diabetes there are several
aetiological forms of diabetes which are discussed in detail elsewhere.
In addition to above broader description many other mechanisms have been postulated
especially as pathogenetic mechanisms of type 2 diabetes (Fig 1.1) and several other factors
have been identified as risk factors for insulin resistance and beta cell dysfunction in type 2
diabetes. Commonly identified risk factors for type 2 diabetes include obesity, sedentary lifestyle,
genetics, epigenetics, medications, inflammation, circadian rhythm disruptions and the
microbiome.
Figure 1. 1: Pathogenesis of Diabetes Mellitus and mechanism of action of common anti diabetic drugs –
the ominous octet.
3
1.3 Diabetes related complications
Diabetes has become a major cause of chronic kidney disease, permanent blindness, myocardial
infarction, stroke, and non-traumatic lower limb amputation. Individuals with diabetes have a two-
to fourfold increased rate of cardiovascular mortality compared with those without. Incidence of
lower extremity amputation has come down in many countries of the world driven mainly by
reduction of major lower extremity amputations possibly due to improved care of diabetes and
diabetic foot disease. Worldwide, it is estimated that 80% of end stage renal disease (ESRD) cases
are due to diabetes or hypertension. Between 2002 and 2015, steep increases (approximately 40–
700%) in the incidence of diabetes-associated ESRD were reported in many countries and regions
of the world. Retinopathy affects approximately one third of adults with diabetes and represents
the leading cause of blindness in these individuals. Population-based studies conducted from the
1990s onwards report a 50–67% lower incidence of diabetic retinopathy compared with earlier
studies.
Diabetes, especially the type 2 form is frequently associated with derangements in lipoprotein
metabolism as well as other factors such as obesity and hypertension which in combination
contribute to significantly increase atherosclerotic cardiovascular risk. Therefore, management of
diabetes requires a multi modal, multi-disciplinary approach aimed at reduction of cardiovascular
risk and enhanced overall patient wellbeing and not merely blood glucose control.
1.4 History of diabetes
History of diabetes dates back to 1500 B.C. when a disease characterized by the ‘too great
emptying of urine’ was mentioned in Egyptian manuscripts. Indian physicians called
it madhumeha (‘honey urine’) because it attracted ants. The ancient Indian physician, Sushruta,
and the surgeon Charaka (400–500 A.D.) were able to identify the two types, later to be named
Type I and Type II diabetes. First complete description of diabetes was done in the first century
A.D. by Aretaeus the Cappadocian, who coined the word diabetes (Greek, ‘siphon’) and
dramatically stated “… no essential part of the drink is absorbed by the body while great masses
of the flesh are liquefied into urine”. Avicenna (980–1037 A.D.), the great Persian physician, in The
Canon of Medicine not only referred to abnormal appetite and observed diabetic gangrene but
also suggested a mixture of seeds (lupin, fenugreek, zedoary) as a treatment. The
term mellitus (Latin, ‘sweet like honey’) was coined by the British Surgeon-General, John Rollo in
1798, to distinguish this diabetes from the other diabetes (insipidus) in which the urine was tasteless.
1.5 Global epidemiology
According to the World Health Organization (WHO) the number of people with diabetes
increased from 108 million in 1980 to 463 million in 2019 (5,6). Global prevalence of diabetes
among adults over 18 years of age increased from 4.7% in 1980 to 9.3% in 2019(5, 6). According to
IDF diabetes atlas 2019, globally 1 in 11 adults aged 20-79 (463 million people) have diabetes (6).
About 50% of them (232 million people) are undiagnosed. 1 in 5 people with diabetes (136 million
people) are above 65 years old. 10% of global health expenditure (USD 760 billion) is spent on
diabetes. Hyperglycaemia in pregnancy affects 1 in 6 live births (20 million). Over 1.1 million
4
children and adolescents below 20 years have type I diabetes. Overall, 79% of people with
diabetes live in low- and middle-income countries like Sri Lanka.
Global prevalence of Diabetes
Figure 1. 2 the Global prevalence of Diabetes
Sri Lankan prevalence
In 2008, the prevalence of diabetes among Sri Lankans over the age of 20 years was 10.3% (males
9.8%, females 10.9%) (7). Thirty-six per cent of them were previously undiagnosed. Diabetes
prevalence was higher in the urban population compared with rural. The prevalence of pre-
diabetes was 11.5%. Those with diabetes and pre- diabetes compared with normal glucose
tolerance were older, physically inactive, frequently lived in urban areas and had a family history
of diabetes. They had higher body mass index, waist circumference, waist–hip ratio,
systolic/diastolic blood pressure, low-density lipoprotein cholesterol and triglycerides. This study
also showed disparities of diabetes prevalence in different provinces. The projected diabetes
prevalence for the year 2030 was 13.9%. However, Colombo urban study published in 2019
showed an alarming trend with an increase of diabetes prevalence in urban adult population to
27.6% (8). Furthermore, cumulative prevalence of diabetes and prediabetes was 57.9%. While this
dramatic change reflects the effect of urbanization and associated change in lifestyle it also
reiterates the importance of an up to date evidence based local guideline on management of
diabetes. This is also supported by the unpublished data from the Sri Lanka Non-Communicable
Disease Survey conducted in 2018 – 2020 period.
5
Figure1.3 Province specific prevalence D 1
(SLDCS was not conducted in North and the East)
This guideline prepared by the Ceylon College of Physicians aims to provide a comprehensive
evidence-based guidance on the management of diabetes and its complications and
associated co-morbidities.
