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Diabetes Mellitus What's new and what hasn't changed

Diabetes Mellitus What's new and what hasn't changed. Martin C. Young MD Pediatric Endocrinologist Pediatric Specialized Care Rapides Medical Center, Alexandria LA. Defining Diabetes Mellitus (DM). Chronic hyperglycemia Acute complications Chronic complications macrovascular

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Diabetes Mellitus What's new and what hasn't changed

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  1. Diabetes MellitusWhat's new and what hasn't changed Martin C. Young MD Pediatric Endocrinologist Pediatric Specialized Care Rapides Medical Center, Alexandria LA

  2. Defining Diabetes Mellitus (DM) • Chronic hyperglycemia • Acute complications • Chronic complications • macrovascular • microvascular • other

  3. Types of DM • Type 1 • Type 2 • Other

  4. Type 1 & Type 2 DM • Type 1 (IDDM) • childhood infection of pancreas resulting in autoimmune destruction and loss of insulin • insulin dependent • Type 2 (NIDDM) • insulin resistance leading to pancreatic exhaustion • insulin requiring (often)

  5. DM is Common 1 • Prevalence • world: 150 million • USA: 20 million (6% population) • 1/3 all cases undiagnosed • High risk groups • AfroAmerican x2 • Hispanic x2 • American Native x5

  6. DM is Common 2 • 10% of people aged >20 yrs • 20% of people aged >60 yrs • USA 1997-2004 increase across ages 18-80 approx 40%

  7. DM is Expensive • US costs per annum >$ 100 billion

  8. Diagnosing DM • Your patient has DM until otherwise proven!

  9. http://www.diabetes.org

  10. OGTT 1

  11. Prediabetes • Impaired fasting glucose (IFG) • FBG 100-125 mg/dl • Impaired glucose tolerance (IGT) • BG 140-199 mg/dl at 2 hours on OGTT IFG & IGT are not benign

  12. OGTT 2

  13. Risk for Death by Fasting and 2-hour Blood Glucose Level 2.5 2.0 1.5 1.0 0.5 0.0 Hazard ratio ³11.1 7.8–11.0 2-hour plasma glucose(mmol/l) <7.8 <6.1 6.1–6.9 ³7.0 Fasting plasma glucose (mmol/l) Adjusted for age, center, sex DECODE Study Group. Lancet 1999;354:617–621

  14. Values to Remember • Fasting blood glucose >100 mg/dl • think "pre-diabetes" (IFG) • Random blood glucose > 140 mg/dl • think "prediabetes" (IGT) • Blood glucose > 200 mg/dl at any time • think "diabetes"

  15. How DM Presents 1 • Classic symptoms • polydipsia & polyuria • weight loss • Accidentally • urinalysis • random blood glucose • Suspiciously • recurrent candidiasis

  16. How DM Presents 2 • Screening • asymptomatic • high risk groups

  17. Screening for DM 1 • Aged >45 yrs • Aged <45 yrs, fat plus other risk factor • 1st degree relative with diabetes • physically inactive • high risk ethnic group • hypertension • dyslipidemia

  18. Screening for DM 2 • PCOS • IFG or IGT on OGTT previously • Acanthosis nigricans • Vascular disease

  19. Screening for DM 3 • Fasting blood glucose • OGTT (2 hr)

  20. Suspicious of DM? • Random blood glucose • Fasting blood glucose • OGTT • HbA1c (glycated hemoglobin) • Fructosamine (glycated albumin) • GlycoMark (1,5-Anhydroglucitol)

  21. Healthy (n=539) 24.6±7.2 µg/mL Diabetes (n=808) 7.3±7.1 µg/mL 20 30 0 10 40 50 Serum 1,5AG (µg/mL) Histogram of Serum 1,5AG Concentrations

  22. Associated syndromes Comorbidities "You're never alone with diabetes" Diabetes & Friends

  23. Syndromes Associated with Type 2 DM • Metabolic syndrome (MS) • Polycystic ovarian syndrome (PCOS) • Obstructive sleep apnea syndrome (OSAS)

  24. Metabolic Syndrome (MS) • Obesity • Hypertension • Dyslipidemia • Acanthosis nigricans • Abnormal glucose homeostasis A prothrombotic, proinflammatory, atherogenic, endothelial dysfunctional condition.

  25. Acanthosis Nigricans 1

  26. Acanthosis Nigricans 2

  27. Overlap of Type 2 DM and MS

  28. Polycystic Ovarian Syndrome • (Polycystic ovaries) • Hyperandrogenemia or hirsuitism • Menstrual disturbance

  29. MS, DM, PCOS Overlap The "fullcatastrophe"

  30. OSAS • Obstructive apnea during sleep due to airway occlusion from obesity • Recurrent hypoxemia • pulmonary hypertension • RV strain failure • Recurrent arousal from sleep • daytime fatigue, etc • Hypertension • Atrial fibrillation

  31. Why PCOS, MS & OSAS are Related to Type 2 DM • Insulin resistance • causes PCOS and Type 2 DM • can result from OSAS • Hyperinsulinism • hypertension • dyslipidemia • acanthosis nigricans • ovarian production of androgens

  32. Non-alcoholic Fatty Liver Disease 1 • NAFLD (non-alcoholic steatohepatitis, NASH) • Fatty infiltration of liver assocaited with obesity, MS and Type 2 DM • May progress to cirrhosis

  33. Non-alcoholic Fatty Liver Disease 2

  34. Type 2 DM • 90 % of all diabetes mellitus • 99% all adult diabetes • Approaching 30-50% of all childhood diabetes • Formally very rare in children • Profoundly underdiagnosed – "silent" • A disease of genes interacting with the "Western Way" of overeating and underexercising

  35. Type 2 DM Pathophysiology • Key concept I: insulin resistance • genetic • obesity • inactivity • OSAS • Key concept II: glycemic load • high glycemic index (GI) foods

  36. Insulin Resistance

  37. Bad Genes & Bad Choices

  38. Progression of Type 2 DM

  39. Pancreatic Failure • Insufficient insulin to prevent chronic hyperglycemia • Usually sufficient insulin to prevent ketoacidosis

  40. Look for Comorbidities! • Complications of DM • eye disease • vascular disease • neuropathy • nephropathy • dermatopathy • Associated syndromes • MS • PCOS • OSAS • NAFLD/NASH

  41. Eye Disease • Retinopathy • Cataracts

  42. Vascular Disease • Peripheral arterial disease • Ischemic heart disease • Cerebral vascular disease

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