Diabetes mellitus (definition and treatment) - PowerPoint Presentation

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Diabetes mellitus

(definition and treatment)

z.Ghaemmaghami

MD

Shahid

Beheshti

Univercity

of medical sciences

Jan 10,2012

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A

genda

Definition of

DM

Variant

Diagnosis

Epidemiology

Screening

Treatment

prevention

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What is the definition of diabetes mellitus?

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Diabetes mellitus (DM) is a group of metabolic disturbances,

characterized mainly by

hyperglycaemia

, and finally resulting in the

appearance of

various complications (macro- and

micro-

angiopathy

, etc

.)

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factors contributing to hyperglycemia include:

1- reduced insulin secretion

2-decreased glucose utilization

3- increased glucose production

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The metabolic

dysregulation

associated with DM causes secondary

pathophysiologic

changes in multiple organ systems :

1-leading cause of end-stage renal disease (ESRD)

2-nontraumatic lower extremity amputations

3-adult blindness

4-predisposes to cardiovascular diseases

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A

genda

Definition of DM

Variant

D

iagnosis

Epidemiology

Screening

Treatment

prevention

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How many types of DM exist?

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Etiologic Classification of Diabetes

Includes four clinical classes:

Type 1 diabetes (results from

B-cell

destruction, usually leading to absolute insulin deficiency

) This form of diabetes, which accounts for only 5–10% of those with diabetes

Type 2 diabetes (results from a progressive insulin

secretory

defect on the background of insulin resistance

) This form of diabetes, which accounts for 90–95% of those with diabetes

ADA;

DIABETES CARE, VOLUME

35

SUPPLEMENT 1, JANUARY

2012

;

s4-s10

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Other specific types of diabetes

genetic defects in B-cell function

genetic defects in insulin action

diseases of the exocrine pancreas (such as cystic fibrosis)

drug

chemical induced (such as in the treatment of AIDS or after organ transplantation)

Gestational diabetes mellitus (GDM) diagnosed during pregnancy

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Clinical Manifestations

Polyuria

Polydipsia

Polyphagia

Fatigue, tingling or numbness in hands, slow healing wounds and recurrent infections

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A

genda

Definition of DM

Variant

Diagnosis

Epidemiology

Screening

Treatment

prevention

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Criteria

for the diagnosis of diabetes

1. A1C > = 6.5%.

OR

2. FPG > = 126 mg/dl (7.0

mmol

/l). Fasting is defined as no caloric intake for at least 8 h

OR

3. 2-h plasma glucose > = 200 mg/dl (11.1

mmol

/l) during an OGTT

OR

4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose > = 200 mg/dl (11.1

mmol

/l)

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IFG =

FPG

100–125 mg/dl

IGT = 2-h plasma glucose

after 75 g glucose 140

mg/dl

to

199

mg/dl

Categories of increased risk for diabetes

ADA;

DIABETES CARE, VOLUME 35 SUPPLEMENT 1, JANUARY 2012

;

s4-s10

A1C =5.7–6.4%

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Glycosuria

is suggestive of diabetes, but not diagnostic.

For example: patients with renal

glucosuria

or

Fanconi

syndrome will present with

glycosuria

but will be

normoglycemic

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Type 2 DM

Type 2 diabetes is one of many different types of diabetes mellitus

The initial step is to diagnose diabetes, and the

differentiate type 2 diabetes from other causes of

diabetes based upon the clinical presentation of the

patient

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Insulin

Resistance

Insulin Resistance

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Type 2 versus type 1 diabetes

 Because long term management differs for patients with type 2 versus type 1 diabetes, it is important to distinguish between the two diseases

Differentiation : clinical presentation, history, and laboratory studies

In general, the following features may be helpful to distinguish between the two types of diabetes

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Type 2 versus type 1 diabetes

Body

habitus

: Patients with type 2 diabetes are generally overweight

Age : Patients with type 2 diabetes generally present after the onset of puberty at a mean age of 13.5 years

Age of presentation of type 1 disease is bimodal with a peak between four and six years of age and a second before the onset of or in early puberty, 10 to 14 years of age

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Type 2 versus type 1 diabetes

Insulin resistance - Patients with type 2 diabetes usually have clinical features associated with insulin resistance

acanthosis

nigricans

hypertension

dyslipidemia

polycystic ovary syndrome

which are not commonly seen in children with type 1 disease

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Type 2 versus type 1 diabetes

Family history - Patients with either type 1 or type 2 diabetes can have an affected close relative; however, it is more common with type 2 diabetes

Ketoacidosis

- Patients with type 1 diabetes are somewhat more likely to present with

ketoacidosis

, due to insufficient insulin production, but this presentation is uncommon in type 2 diabetes

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Type 1 DM

Type 1 diabetes is suggested by the presence of pancreatic (islet)

autoantibodies

These include

autoantibodies

to insulin (IAA), islet cell cytoplasm (ICA),

glutamic

acid

decarboxylase

(GAD), or tyrosine

phosphatase

(IA-2)

reduced insulin and c-peptide levels

the absence of pancreatic

autoantibodies

does not rule out the possibility of type 1 diabetes

In addition, up to 30 % of individuals with the classical appearance and presentation of type 2 diabetes have positive

autoantibodies

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On occasion it is difficult to classify diabetes in patients with mixed features

There are in both (

ketoacidosis

, autoantibody, ↓insulin and c-

petide

)

Finally, the

pathophysiologic

features of both types of diabetes may coexist in the same patient, particularly if the patient has obesity

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Other specific types of diabetes

Diseases of the exocrine system

Cystic fibrosis,

hereditary

hemochromatosis

,

chronic pancreatitis

Endocrine abnormalities in glucose regulation

Cushing's syndrome

growth-hormone excess

glucagon-secreting tumors

catecholamine excess in

pheochromocytoma

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Drugs that can impair glucose tolerance or cause overt diabetes mellitus

Glucocorticoids

Oral contraceptives

Tacrolimus

and cyclosporine

Nicotinic acid (niacin)

HIV protease inhibitors

Thiazide

diuretics (primarily at doses above 25 mg/day of hydrochlorothiazide or its equivalent)

Atypical antipsychotics (

clozapine

, and some conventional antipsychotics)

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Gestational Diabetes Mellitus (GDM)

Glucose intolerance may develop during pregnancy

Insulin resistance is related to the metabolic changes of late pregnancy, and the increased insulin requirements may lead to IGT

GDM occurs in ~4% of pregnancies ; most women revert to normal glucose tolerance post-partum but have a substantial risk (30–60%) of developing DM later in life

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Screening for and diagnosis of GDM

Perform

a 75-g OGTT, with plasma glucose

measurement fasting and at 1 and 2 h, at

24–28 weeks’ gestation in women not

previously diagnosed with overt diabetes.

The OGTT should be performed in the

morning after an overnight fast of at least

8 h

.

ADA;

DIABETES CARE, VOLUME 35 SUPPLEMENT 1, JANUARY 2012

;

s4-s61

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The diagnosis of GDM is made when any of

the following plasma glucose values are

Fasting

> =

92 mg/

dL

(5.1

mmol

/L)

1 h

> = 1

80 mg/dL (10.0 mmol/L)

2 h

> =

153 mg/dL (8.5 mmol/L)

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A

genda

Definition of DM

Diagnosis

Variant

Epidemiology

Screening

Treatment

prevention

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Epidemiology

Although the prevalence of both type 1 and type 2 DM is increasing worldwide, the prevalence of type 2 DM is rising much more rapidly because of increasing obesity and reduced activity levels as countries become more industrialized

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شيوع ديابت نوع 1 در كشورهاي مختلف

30

20

10

5

فنلاند

سوئد

نروژ

دانمارك، اسكاتلند، هلند، آمريكا، زلاند نو

كانادا

انگلستان

كويت

فرانسه

بحرين

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The worldwide prevalence of DM has risen dramatically over the past two decades

7% of the population

DM increases with aging

In individuals >60 years, the prevalence of DM was 20.9%

The prevalence is similar in men and women throughout most age ranges

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A

genda

Definition of DM

Diagnosis

Variant

Epidemiology

Screening

Treatment

prevention

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Screening

Widespread use of the FPG as a screening test for type 2 DM is recommended because:

1) a large number of individuals who meet the current criteria for DM are asymptomatic and unaware that they have the disorder

2) epidemiologic studies suggest that type 2 DM may be present for up to a decade before diagnosis

3) as many as 50% of individuals with type 2 DM have one or more diabetes-specific complications at the time of their diagnosis

4) treatment of type 2 DM may favorably alter the natural history of DM

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The ADA recommends:

screening all individuals >45 years every 3 years

screening individuals at an earlier age if they are overweight [body mass index (BMI) > 25 km/m

2

] and have one additional risk factor for diabetes

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Risk Factors for Type 2 Diabetes Mellitus

Family history of diabetes (i.e., parent or sibling with type 2 diabetes)

Obesity (BMI >=25 kg/m

2

)

Habitual physical inactivity

Race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)

Previously identified IFG or IGT

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A

genda

Definition of DM

Diagnosis

Variant

Epidemiology

Screening

Treatment

prevention

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Management

Nutritional

Exercise

Monitoring

Pharmacologic

Education

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Macronutrients in diabetes management

The mix of carbohydrate, protein,

and fat

may be adjusted

to

meet the

metabolic goals

and individual

preferences

of the person with

diabetes

Monitoring

carbohydrat

intake,whether

by

carbohydrate counting, choices,

or

experience-based

estimation, remains

a key

strategy

in

achieving

glycemic

control

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Nutrition…

Saturated fat intake should be ,7%

of total calories

Reducing intake of trans fat lowers

LDL cholesterol

and increases HDL

cholesterol

intake

of trans

fat should

be minimized

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If

adults with diabetes

use alcohol

, they should limit intake to

a moderate

Routine

supplementation with antioxidants,

such

as vitamins E and C

and carotene

, is not advised because of

lack of

evidence of efficacy and concern

related to

long-term

safety

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Dietary Management

Consistent, well-balanced small meals several times per day

Exchange system or counting carbohydrates

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Exercise and Diabetes

Exercise increases uptake of glucose by muscles and improves utilization, alters lipid levels, increases HDL and decreases TG and TC

If on insulin, eat 15g snack before beginning

Check BS before, during and after exercising if the exercise is prolonged

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Exercise and Diabetes

Avoid trauma to the feet

Avoid pounding activities that could cause vitreous hemorrhage

Caution if CAD

Baseline stress test may be indicated (especially in those older than 30 and with 2 or more risk factors for CAD)

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Glucose monitoring

Patients on insulin should check sugars 2-4 times per day

Not on insulin, two or three times per week (according to text)

Should check before meals and 2 hours after meals

Parameters from physician very important

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HGB A1C

Measures blood levels over 2-3 months (per text)

High levels of glucose will attach to hemoglobin

Helps to ensure that the patient’s

glucometer

is accurate

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Prevention

Moderate reduction in weight

Regular exercise

Balanced diet

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Thank you for your attention