Open Journal Systems

ORIGINAL CONTRIBUTIONS

Received: March 13^rd 2015

Accepted: May 15^th 2015

Evolution of the type 2 diabetes mellitus epidemia in insured population at the IMSS

María Eugenia Velasco-Contreras^a

^aDivisión de Medicina Familiar, Coordinación de Atención Integral de la Salud en Primer Nivel de Atención, Unidad de Atención Primaria de la Salud, Dirección de Prestaciones Médicas, Instituto Mexicano del Seguro Social, Ciudad de México, México

Communication with: Maria Eugenia Velasco-Contreras

Telephone: 5726 1700, extensión: 15919

Email: maria.velasco@imss.gob.mx

Background: The global increase in type 2 diabetes mellitus (DM2) is requiering higher demands in health institutions; It is a global emergency because of overspending that threaten social security, and kidney complications and cardiovascular damage, which affects millions enfermos.1 The aim of this work is to characterize the epidemic of DM2 with metabolic syndrome and define the institutional response containment-control universal educational interventions healthy lifestyles to prevent premature death and disability from ischemic heart disease (IHD), cerebrovascular disease (CVD), end stage renal disease ( IRT), blindness and amputations.

Methods: A review of the years 1990-2013: Epidemiological Bulletin; consultation services: Family Medicine, Specialties, Emergency, Hospitalization, and prevention studies estimate of expenditure and institutional savings.

Results: 48 % increase incidence, prevalence increased from 7 to 10.6 %, and mortality from 35.6 to 77.2 per 100 000 inhabitants. Hypertension, and deaths, and EVC CI, increased 58, 197, 142.5 % respectively. Consultations in 2013 were 9113 082. The estimate of expenditure for prediabetes screening and medical care to prevent complications saves near of 60 % of current expenditure.

Conclusions: control the epidemic by training patients, families and staff health healthy lifestyle is the treatment to revert to normal BMI, glucose, triglycerides, HDL cholesterol, LDL cholesterol, blood pressure and addictions to snuff/alcohol, to decelerate complications of the metabolic syndrome.

Keywords: Epidemics; Type 2 diabetes mellitus; Health promotion

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Type 2 diabetes mellitus (DM2) is a chronic disease that starts with impaired fasting glucose (IFG) with values ​​of 100-125 mg/dL, and/or glucose intolerance (GI), with postprandial glycemia at 2 hours ≥ 140 mg/dL; these values ​​are known as prediabetes; they do not cause symptoms and are only identified by measuring capillary blood glucose as a rapid screening test.³ When diabetic glycemia levels move to fasting blood glucose ≥ 126 mg/dL or postprandial 2 at hrs ≥ 200 mg/dL, it is necessary to classify it by degree of deterioration of glucose regulation mechanisms, clinically manifested based on the number and function of beta cells.

Stage 1: Insulin resistance (IR), offset by increased basal insulin and normoglycemia. Stage 2: Elevated fasting 100-125 mg/dL, elevation indicates cell loss with decreased rapid postprandial insulin secretion with GI or postprandial diabetic state. Stage 3: Unstable transitional period of early decompensation, glucose rises relatively quickly and passes to Stage 4 diabetic state with fasting glycemia ≥ 130 mg/dL and postprandial glycemia ≥ 200 mg/dL, showing increased cell loss. Stage 5: Severe decompensation with profound reduction in beta cells, acute weight loss, and easy progression to ketosis, similar to (insulin-dependent) diabetes mellitus type 1. 

The movement from Stages 1-4 may be progression or regression. People with DM2 with comprehensive treatment (healthy eating, daily exercise, avoiding smoking) can recover and move from Stage 4 to Stage 1 or 2.^4,5

Relationship between DM2 and metabolic syndrome (MS)

The grouping of components of metabolic syndrome is not accidental and occurs only in people resistant to insulin.⁶ MS The central disorder is generated by hyperinsulinemia-IR that answers the question: Why DM2 does not require insulin at the beginning? Factors associated with the development of DM2, according to studies in US national and ethnic populations, have risk in African-Americans, Latinos, and Native Americans 2, 2.5, and 5 times higher than in white people.⁷ Those with MS (hyperinsulinemia and IR) have 14 times the risk of DM2, regardless of their cultural and ethnic factors; the strongest predictors were fasting hyperinsulinemia and low postprandial insulin secretion, hypertension, dyslipidemia, IFG or GI, and cardio- and cerebrovascular morbidity and mortality.⁸ IR is manifested by the inability to eliminate energy/calories as CO₂ + H₂O in breathing and sweating; rather, to obtain energy, glucose from food is converted into 2 triglyceride molecules, which accumulate in adipose tissue, blood, the liver, and the pancreas. Furthermore, it has been shown that systemic hypertension (SH) is an indicator of the start of MS, since fasting hyperinsulinemia predicts SH, stroke, and heart disease independent of other known cardiovascular factors.⁹

Hepatic steatosis. The accumulation of triglycerides as liver fat does not occur in all patients with obesity, only 70%. But IR is always presented with hepatic steatosis, regardless of whether or not weight is normal.¹⁰ Another common cause of hepatic steatosis is the consumption of fructose (sugar 200 times sweeter than glucose, which has been used to sweeten foods for the last 30 years) that also generates MS and elevated uric acid.^11-15 The Health Profile study of IMSS workers showed a strong association between obesity and consumption of unhealthy foods, fasting, and lack of daily consumption of fruits and vegetables; tobacco addiction was strongly associated with obese women and raised the risk of acute myocardial infarction (AMI) in diabetic patients 50 fold, while excessive alcohol consumption was associated with obese men, and raised AMI 38 fold in patients with hypertension.¹⁶

It is difficult to define the epidemiology of DM2 due to the existence of thousands of subclinical cases, undiagnosed in an estimated 30 to 50% of actual cases, in very susceptible populations, with prediabetes and diabetes, clinical course and silent development of late complications, which only begin to show symptoms when a patient's life is compromised or they cause permanent disability.¹⁷ In addition, the millions of known patients are treated with a variety of therapeutic regimens: insulin, medications, diet, exercise, or a combination of the above, almost invariably reporting poor metabolic control.¹⁸ Epidemiology as a discipline has provided the elements of classification for diabetes mellitus: genetic, clinical, therapeutic, immunological, molecular biology, magnitude, frequency, significance, and prognostic projected to 2030;¹⁹ in addition, predictive factors explaining the global DM2 epidemic are: increased life expectancy, ethnicities with susceptibility to DM2 (indigenous American populations), the obesity epidemic due to the nutritional transition, comfort, sedentary lifestyle, urbanization, industrialization, and, finally, new criteria for diabetes as of 1997.²⁰ In Mexico and at IMSS, the real magnitude of the incidence and prevalence of this disease is limited by methodological issues common to all institutions worldwide. Its significance according to the World Health Organization,¹ (WHO) is that DM2 is the leading cause of adult blindness, non-trauma amputations, and chronic kidney failure; in people over 55 years, the frequency is very high, with one in three having DM2, so they have higher rates of hospitalization, longer stays, and attend outpatient and emergency services more. WHO also ranks it as a rising pandemic, estimated at 347 million worldwide, with 1.5 million deaths from chronic hyperglycemia. Over 80% of deaths occur in low- and middle-income countries, and it will be the seventh leading cause of death in 2030.²¹ The Encuesta Nacional de Salud reported that only 50% of Mexicans with DM2 recognize their status, i.e. 6.4 million, representing only 9.1% of those over age 20, but it states that the true prevalence is 18%. Also, the most common chronic complications were reported as: vision loss 47.6% (3 million); burning, pain, or loss of sensation in the feet 38% (2.4 million); retinopathy 13.9% (889,000); heart attack 2.8% (182,000); amputations 2% (128,000); and dialysis 1.4% (89,000).

Costs of care for patients with diabetes mellitus type 2

To estimate the direct costs of medical care for patients with DM2 in IMSS, the clinical records were reviewed for 497 patients admitted to secondary and tertiary care units during the period 2002-2004. The costs were quantified using the disease cost approach (DCA) from the provider's perspective, microcosting technique, and bottom-up methodology. Average annual costs were estimated for diagnosis, complications, and total disease. The total annual cost of patients with DM2 was US $452,064,988, corresponding to 3.1% of operating expenses. The average annual cost per patient was US $3,193.75; US $2,740.34 corresponded to the patient without complications and US $3,550.¹⁷ for the patient with complications. Bed days in hospital and in the intensive care unit were the most expensive services. As for the high costs of medical care to patients with DM2, the findings indicate that complications from DM2 represent an economic burden that health institutions should consider in their budgets, in order to provide quality prevention services in time to regain health. The use of this microcosting methodology allows an approach to real usage and disease management data.^22,23

Institutional strengths for control: reverse metabolic syndrome to prevent DM2 and its long-term complications

Prevention of DM2 progression in people with prediabetes

DM2 has been shown to be potentially reversible by changing eating and physical exercise habits, more effectively than with only metformin.²⁴ Elevated glucose concentrations while fasting and after an oral glucose load, overweight, and a sedentary lifestyle are potentially reversible. Presumably these factors can be modified with a lifestyle intervention program, or the development of diabetes could be prevented or delayed with metformin. 3234 people were randomly assigned to treatment with placebo or metformin (850 mg twice a day) or a program to modify their eating habits to lose 7% of their body weight and do at least 150 minutes of physical activity per week. The average age was 51 years, the average BMI 34 kg/m², and 68% were women. Mean follow-up was 2.8 years. The incidence of DM2 was 11.0, 7.8, and 4.8 cases per 100 person-years in the placebo, metformin, and lifestyle change groups, respectively. The lifestyle intervention reduced the incidence by 58% (95% CI: 48-66%), and metformin by 31% (95% CI: 17-43%), compared to the placebo group. It is concluded that changes in eating and physical exercise habits are twice as effective as only treatment with metformin to prevent progression from prediabetes to diabetes.

Prevention of chronic complications in patients with DM2

In patients with DM2, intensive blood glucose control decreased the progression of microvascular and macrovascular disease (MMD) in a sample of 4075 patients (recruited to UKPDS) with 10.7 years of follow-up; median glycated hemoglobin (HbA1c) was 7.4% in the metformin group, compared to 8.0% in the conventional group. Risk of chronic complications was reduced by 32%, mortality by DM had a 42% reduction, and they were associated with fewer hypoglycemic attacks than patients treated with insulin and sulfonylureas.^25,26 Strict blood pressure control substantially reduced the presence of chronic vascular complications and increased the time without complications and of survival. Micro and macro complications decreased by 24%, mortality from DM decreased 32%, strokes 44%, and microvascular retinal abnormalities 37%. After nine years of follow-up, 47% had lower risk of deterioration of visual acuity.^27,28

Dyslipidemia in diabetes mellitus type 2

Cardiovascular disease is a significant cause of morbidity and mortality in patients with diabetes mellitus. DM2 is recognized as a risk equivalent to coronary heart disease. Its lipid profile or dyslipidemia shows increased triglycerides and LDL-C, and decreasing HDL-C is a key factor promoting atherosclerosis in these patients. These processes involved in atherogenesis are exacerbated by IR or MS. There is abundant evidence that aggressive statin therapy reduces cardiovascular complications in patients with DM2. The goal is to reach LDL levels < 100 mg/dL, and HDL < 70 mg/dL, which provides even greater benefits; this is a modifiable cardiovascular risk factor in patients. Lipid-lowering therapy provides a substantial reduction in cardiovascular risk in patients with DM2. A 37% reduction in cardiovascular events has been shown with statins in patients randomized to (atorvastatin 10 mg compared to placebo). Many patients today do not receive adequate treatment for the dyslipidemia commonly occurring with IR, known as the atherogenic lipid triad.²⁹

In conclusion, patients with MS, prediabetes, or DM2 in the first 4 stages can avoid diseases such as retinopathy, nephropathy, neuropathy, cardiovascular or cerebrovascular disease, peripheral vascular disease, and amputations by maintaining tight control of blood sugar, dyslipidemia, and hypertension,^25-29 by identifying (complete diagnosis) micro- and macrovascular risk factors of each particular patient, depending on the progress of the disease.

Institutional prevention and control of DM2

The Early DM2 Detection Program in the Preventive Medicine services of the UMF is called PREVEN-IMSS, as of 2002.³⁰

The program began in 1969 with the detection of capillary glucose levels using a colorimetric reactive tape; in 2006 the screening test was modified with glucose measurement to identify prediabetes and DM2.^31,32 We evaluated its efficiency and effectiveness in the UMF 31 in Mexico City, with 9682 detections from January to June 2013. 78 patients (0.8%) were identified with abnormal results (AR), while at least 3% of the total cases had been expected; detection of people with AR increased when measuring blood glucose in people aged ≥ 15 years with waist measurements of: ≥ 102 cm in men, and ≥ 88 cm in women. We identified 47% of total patients with AR without follow-up. Only 5% met Early DM2 Detection criteria with prediabetes blood glucose values.³³ We also analyzed the Censo Nominal de Diabetes Mellitus, which is generated from the registry of patients with AR, issued by the UMF Área de Informática médica y Archivo clínico (ARIMAC). By reviewing electronic medical records (EMR) for 35 morning and 35 evening clinics, it was identified that 20% of patients with AR do not have a diagnosis.⁵ We added variables to the census to find out the percentage of clinical-metabolic control by clinic, and the timeliness of issuing quarterly, semi-annual, and annual reports. We used as variables: the year of diagnosis to classify the evolution of DM at < 5 years, > 5 years, and > 10 years; height; BMI to classify patients as underweight, ideal weight, overweight, obese, and morbidly obese; and whether the patient smokes or consumes alcohol.

The result of the indicators recorded in a random clinic was: average age 60 years, mean time of evolution 10 years, 60.5% women, obesity 50%, morbid obesity 8%, hyperglycemia ≥ 130 mg/dL 65%, hypertension 45%, smoking 18%, excessive alcohol consumption 12%. 

The aim of our study was to characterize the behavior of the global DM2 epidemic in the population enrolled in IMSS; to analyze their evolution parallel to the obesity and MS epidemic (hypertension and mortality from cardio- and cerebrovascular diseases); and to demonstrate that organized educational interventions prevent serious shared terminal complications like: premature death from IHD and CVD, and disabling complications with long evolution and high cost, such as terminal kidney failure, blindness, and amputations.

We intend to apply to the enrolled population the knowledge generated by hundreds of studies that have shown that it is possible to prevent prediabetes and progression to diabetes, as well as DM2 and its progression to chronic micro- and macrovascular complications.

Methods

During the months of June to December 2014 we did a review of IMSS information sources, prioritizing information from the CVE portal, epidemiological bulletins, and the document Burden of disease in the enrolled population, published in 2012 by DPM. Relevant literature was also consulted on the evolution of the global DM2 epidemic, and reviews of its relationship with MS and related and associated chronic diseases such as obesity, primary hypertension, gout, dyslipidemia, and long-term vascular complications (like IHD, CVD, CKF); we also consulted the Institutional Standards for Early Detection Program Updating and the generation of the Censo Nominal de Diabetes Mellitus.

We made a conservative estimation of costs based on outpatient care data in primary and secondary care, and separately for patients hospitalized for any chronic complications. The estimated cost was published in the policy document Institutional Program for Diabetes Mellitus Care in the population enrolled at IMSS in 2000, and with the application of risk reduction indicators for complications with treatment for the strict control of blood glucose, hypertension, and dyslipidemia, published by the UK diabetes study group (UKPDS), with which we estimated the institutional savings that could be had if we applied the intervention in the enrolled population with DM2.

Results

The annual report of new cases of DM2 increased 48% in 23 years, with an annual average of 2.08%. The morbidity of 280.1 per 100,000 enrollees (E) came to 309.4. We noted an increase in cases from 2002 to 2003, with a 56% increase of cases recorded, which is related to the expansion of coverage of the registration system for new cases in the UMF system as a whole. Totaling new cases in the period gives us a figure of 2,849,172 (prevalent cases), which turns out to be similar to that obtained by the División de Información Estadística en Salud of the DPM from the nominal census of patients with diabetes attending outpatient Family Medicine (CEMF), which indirectly indicates high sensitivity of the recording system for new cases per week (Figure 1).

HT reports increased 58%, with an annual growth of 2.5%. This gives a total of 4,232,708, twice that of DM2 attending CEMF. The morbidity of 424.6 x 100,000 E came to 456.8, meaning an increase of 7% (Figure 2).

The report of new cases of ischemic heart disease has decreased by 25% in the period, and recorded annual morbidity by 44% (Figure 3).

Reports of new cases of cerebral vascular disease decreased by 22%, and the annual morbidity declined by 46% (Figure 4).

Consultations for diabetes mellitus increased by 208% (9% annually). Admission of 150/10,000 enrollees (E) dropped to 100/10,000 E.3 Hospital mortality increased from 23.9 to 30.4 (Figure 5).

Also, hospital mortality from diabetes mellitus is shown from 1990 to 2013 (Figure 6).

Deaths from diabetes mellitus increased 257%, i.e. 11.1% per year, 5 times more than new cases; while mortality doubled, going from 35.6 x 100,000 E to 77.2 (Figure 7).

Deaths from ischemic heart disease increased 197.6%, or 8.5% per year, representing an increase 4 times higher than that for DM2; mortality increased from 22.7 x 100,000 E to 32.1 (Figure 8).

CVD deaths increased 142.5%, 3 times more than those from DM2, and mortality went from 19.9 x 100,000 E to 28.1 (Figure 9).

In 2013 the incidence of new cases of diabetes was 8% higher in women overall and 25% for hypertension.

Regarding presentation by age group, the incidence of new cases of IHD increased 11 times starting at age 25 for men; 39 times after age 45, and 35 times after age 65, when compared to those under 25. Age 45 to 64 was high-risk for men to present IHD events.

CVD increased by 9 times after age 25 for men, 38 times after age 45, and 52 times after age 65. In women it increased 10 times after age 25, 33 times after age 45, and 52 times after age 65.

Results of the estimation of institutional savings in operation in 2016 from Strengthening Chronic Disease Care (Fortalecimiento de la Atención de Enfermedades crónicas)

The conservative estimate of the cost from consultations for the population with DM2 does not include drugs or laboratory tests, only the estimated cost of the consultation by doctors for the care of health problems (Table I).

More than 80% of the spending is on hospital care; outpatient represents only 20% of the cost of the various renal, cardiovascular, and ocular complications, amputations, and disability. We estimate the savings from preventing DM2 in Table II.

Discussion

Epidemiology’s contribution as a discipline to define disease behavior in populations and individuals has shown DM2 as a chronic disease that affects society, families, and individuals, exposing them to impoverishment and great suffering.^18,19 The increase shows it as a global emergency of high mortality and disability. Mexico and the IMSS EP have several factors that have been identified to explain the increase in prevalence, such as: a large population with low socioeconomic level, urbanization with increased consumption of unhealthy foods and junk foods, soft drinks sweetened with high fructose, low educational level affecting the selection of nutrition, an increasingly elderly population, and an indigenous population with a minimal European component.¹⁷ The ENSANUT 2012 estimated a DM2 prevalence of 18%, one of the highest internationally according to WHO.²¹ Review of institutional information sources revealed the 48% increase of new cases in the reporting period, and the deaths increased by 257%, i.e. 5 times the incidence of new cases. This is explained by the increase of acute events with death such as MMD, CVE, and infectious respiratory and urinary complications, among the most frequent.³⁴ To all this we must add that hyperinsulinemia-IR-hyperglycemia has been associated with cancer,³⁵ so there should be no doubt that the disease results in extensive damage to the health of the EP and should be treated in detail, with solid criteria for its recognition as part of MS, and including the care of people with HT, in whom it is possible to overlook prediabetes or even diabetes, whose treatment is similar; and in whom one may also overlook hypertension-dyslipidemia: triglycerides-LDL cholesterol and low HDL-C.

Currently there is no doubt that the focus on lifestyle regarding food and physical activity is the cornerstone for treatment of any type of diabetes,³⁶ with the difference that in type 1 diabetes and in Stage 5 of DM2, insulin must be applied with the same characteristics as in healthy populations, i.e., a dose that acts as continuous baseline production insulin, and the necessary dose of rapid postprandial secretion insulin. In this regard we note that there is no doubt that non-physiological doses of insulin (hyperinsulinemia) generate insulin resistance through receptor saturation, which has led to the development of very slow-release insulins to avoid both hypoglycemia and IR.¹⁴ At IMSS, public health problems, like DM2 currently, have always seen cutting-edge development of care provided in developed countries, as is the case of universal vaccination programs, programs for the prevention and control of cancer in women, and now the chronic disease prevention and control programs that have their origin in the early detection of diabetes and hypertension in preventive medicine services since 1969. These programs are implemented by nurses and auxiliary public health specialists.³⁰ At present the only thing missing is to enable them to provide training to the EP in changing unhealthy lifestyles.³⁷ Standards are currently being developed that will be disseminated throughout this year in classes and workshops at all UMF in order to strengthen DM2 prevention interventions at IMSS.

As a result of the operational review of Early DM2 Detection processes and the nominal census for monitoring indicators of metabolic clinical control, we believe that this strategy is essential for central and delegation-level advisory groups that, while reviewing and assessing the situation, should keep their attention on DM2 in the UMFs; the census should be adjusted to the variables proposed by the UMF 31 study group, in order to obtain indicators by UMF, by delegation, and nationally; these indicators are: time of evolution, classification of BMI as the most important item to modify the metabolic situation, DM, HT, achieving a fasting blood glucose < 130 mg/dL, and BP < 140/90 mm Hg with annual measurement each patient at HbA1c < 7%, all as a ressult of the lifestyle intervention.²

As for the conservative estimate of institutional costs,³⁷ by totaling the costs of outpatient care in family medicine and consultation with specialties, the annual cost exceeds 5,000 million pesos, an amount that includes only the cost of consultation for any kind of health care demand, without medicine and without laboratory and imaging studies. An always conservative estimate was made of the cost of care of patients with chronic complications, including nephropathy, cardiovascular complications, retinopathy and other eye problems, amputations, and disability; this was taken from data estimated by the institutional diabetes study group (1995-2001), and exceeds 20,000 million pesos. The probability of this cost being underestimated is very high, and further studies are needed with help from researchers in the field of health economics. Even with this problem, we consider it important to do the exercise of applying to that cost the percentage of risk decrease for chronic long-term complications in people newly diagnosed with less than 10 years of evolution and age under 60, to prevent those with this disease from believing that whatever they do will not change their grim prognosis. It is important for this population to know that it is possible to reverse the high levels of blood glucose, lipids, and blood pressure by changing their eating and lifestyle habits for healthy habits. Thus, when abnormal blood glucose levels are identified at younger ages, micro- and macrovascular complications can be avoided 20 years in advance by making these changes, as long as people at high risk for DM2 are trained to prevent disease onset and progression. In the estimation of institutional savings in operation in 2016 with Strengthening Chronic Disease Care in Family Medicine Units,² we use  evidence of indicators of decreased complications reached with control of blood sugar, lipids, and blood pressure as a result of lifestyle modification, exceeding 14,000 million annual savings by applying disease prevention through the detection and monitoring of prediabetes cases, and of those identified in stages before Stage 5 with severe pancreatic damage.

We are encouraged that there is a high probability that the results may be better by making lifestyle intervention widely available, regarding eating habits: preparing 5 meals, all with vegetables/fruits, and making a good effort to not consume soft drinks, junk food, and more than 2 tortillas or 2 pieces of bread. Getting at least 20 minutes of physical exercise a day with various physical activities that should be increased during the day, and do one’s best to avoid smoking and excessive alcohol, as these are clearly associated with terminal complications of MS, DM2, and HT.¹⁶

Conclusions

Subjects with prediabetes fasting blood glucose levels of 126 mg/dL to 160 mg/dL are considered to have Stage 3-4 diabetes, and their chance of chronic complications is less than that of patients with morning values exceeding 180 mg/dL. Having severe hyperglycemia for several hours a day has a harmful effect on the pancreas, killing the beta cells (apoptosis) and increasing acute manifestations of IHD or CVD. To the extent that we can convince patients that the main generator of hyperglycemia for several hours a day is the consumption of sweets, sugars, and refined flours, this becomes the most important information for them to implement in their daily life, helping conserve their pancreatic cell mass and preventing premature death and complications from cardio-cerebrovascular diseases, nephropathy, or varying degrees of kidney failure.²¹ Their presence is directly proportional to the years of hyperglycemia, the magnitude of postprandial elevation, and other factors that increase arterial damage such as hypertension and smoking (heart attack, stroke), severe capillary damage (renal, neural, and retinal failure, chronic pain, and diabetic foot).

The biggest expense for the institution is hospitalization and disability of people in the productive stage of life from chronic complications. Thus it is concluded that public health strategies aimed at preventing risk factors with nonpharmacological intervention strategies such as empowering people to change their eating habits and do physical activity daily, quitting smoking, and detecting intermediate GI and IFG status early, can reduce the heavy burden of DM2 for this social security institution.³⁴

In July 2014, the Director General of IMSS and the head of the Dirección de Prestaciones Médicas,² ordered adoption of the proposal for a research group to strengthen the care of chronic diseases in family medicine units, which, as we reviewed here, is where the chronic disease epidemic is manifested in its greatest significance and emergency. In March 2015 a pilot test began in 5 UMF to adjust the regulatory documents to implement the model of care for diabetes mellitus in UMFs system-wide in 2016.

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