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Diabetes Mellitus: Definition and Treatment

Learn about the definition of diabetes mellitus, its types, diagnosis, epidemiology, screening, and treatment options. Discover the importance of prevention strategies in managing this metabolic disorder.

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Diabetes Mellitus: Definition and Treatment

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  1. Diabetes mellitus(definition and treatment) z.Ghaemmaghami MD ShahidBeheshtiUnivercity of medical sciences Jan 10,2012

  2. Agenda • Definition of DM • Variant • Diagnosis • Epidemiology • Screening • Treatment • prevention

  3. What is the definition of diabetes mellitus?

  4. 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.)

  5. factors contributing to hyperglycemia include: 1- reduced insulin secretion 2-decreased glucose utilization 3- increased glucose production

  6. 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

  7. Agenda • Definition of DM • Variant • Diagnosis • Epidemiology • Screening • Treatment • prevention

  8. How many types of DM exist?

  9. 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

  10. 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

  11. Clinical Manifestations • Polyuria • Polydipsia • Polyphagia • Fatigue, tingling or numbness in hands, slow healing wounds and recurrent infections

  12. Agenda • Definition of DM • Variant • Diagnosis • Epidemiology • Screening • Treatment • prevention

  13. 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)

  14. Categories of increased risk for diabetes IFG = FPG 100–125 mg/dl IGT = 2-h plasma glucose after 75 g glucose 140 mg/dl to 199 mg/dl A1C =5.7–6.4%

  15. 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

  16. 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

  17. Insulin Resistance Insulin Resistance

  18. 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

  19. 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

  20. Type 2 versus type 1 diabetes • Insulin resistance - Patients with type 2 diabetes usually have clinical features associated with insulin resistance • acanthosisnigricans • hypertension • dyslipidemia • polycystic ovary syndrome which are not commonly seen in children with type 1 disease

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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)

  26. 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

  27. 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

  28. 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 > = 180 mg/dL (10.0 mmol/L) • 2 h > = 153 mg/dL (8.5 mmol/L)

  29. Agenda • Definition of DM • Diagnosis • Variant • Epidemiology • Screening • Treatment • prevention

  30. 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

  31. شيوع ديابت نوع 1 در كشورهاي مختلف 30 فنلاند سوئد 20 نروژ دانمارك، اسكاتلند، هلند، آمريكا، زلاند نو 10 كانادا انگلستان 5 كويت فرانسه بحرين

  32. 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

  33. Agenda • Definition of DM • Diagnosis • Variant • Epidemiology • Screening • Treatment • prevention

  34. 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

  35. 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/m2] and have one additional risk factor for diabetes

  36. Risk Factors for Type 2 Diabetes Mellitus • Family history of diabetes (i.e., parent or sibling with type 2 diabetes) • Obesity (BMI >=25 kg/m2) • Habitual physical inactivity • Race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) • Previously identified IFG or IGT

  37. Agenda • Definition of DM • Diagnosis • Variant • Epidemiology • Screening • Treatment • prevention

  38. Management • Nutritional • Exercise • Monitoring • Pharmacologic • Education

  39. 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 diabetesMonitoringcarbohydrat • intake,whether by carbohydrate counting, choices, or • experience-based estimation, remains a key strategy in • achieving glycemic control

  40. 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

  41. 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

  42. Dietary Management • Consistent, well-balanced small meals several times per day • Exchange system or counting carbohydrates

  43. 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

  44. 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)

  45. 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

  46. 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

  47. Prevention • Moderate reduction in weight • Regular exercise • Balanced diet

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