Diabetes

1. Diabetes Dr.Isazadehfar Assistant Professor of Community and Preventive Medicine

2. What is diabetes? • Diabetes mellitus (DM) is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both. • The term diabetes mellitus describes a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism • The effects of diabetes mellitus include long–term damage, dysfunction and failure of various organs

3. Carbohydrate Digestion

4. Diabetes • Diabetes mellitus may present with characteristic symptoms such as thirst, polyuria, blurring of vision, and weight loss. • In its most severe forms, ketoacidosis or a non–ketotic hyperosmolar state may develop and lead to stupor, coma and, in absence of effective treatment, death. • Often symptoms are not severe, or may be absent, and consequently hyperglycaemia sufficient to cause pathological and functional changes may be present for a long time before the diagnosis is made.

5. Diabetes Long-term Effects • Retinopathy with potential blindness • Nephropathy→renal failure • Neuropathy→ foot ulcers amputation Charcot joints autonomic dysfunction • Cardiovascular disease • Peripheral vascular disease • Cerebrovascular disease

6. Types of Diabetes • Type 1 Diabetes Mellitus • Type 2 Diabetes Mellitus • Gestational Diabetes • Other types: • MODY (maturity-onset diabetes of youth) • Secondary Diabetes Mellitus

7. Type 1 diabetes • Insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes. • Account for 5% to 10% of all cases of diabetes • develops when the body’s immune system destroys pancreatic beta cells • usually strikes children and young adults, although disease onset can occur at any age • Risk factors may include: autoimmune, genetic, and environmental factors

8. Type I Diabetes • Low or absent endogenous insulin • Dependent on exogenous insulin for life • Onset generally < 30 years • Onset sudden • Symptoms: 3 P’s: polyuria, polydypsia, polyphagia

9. Type I Diabetes Cell

10. Type 2 diabetes • non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes • account for about 90% to 95% of all cases of diabetes • It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. As the need for insulin rises, the pancreas gradually loses its ability to produce insulin. • is associated with older age, obesity, family history of diabetes, history of gestational diabetes, impaired glucose metabolism, physical inactivity, and race/ethnicity • African Americans, Hispanic/Latino Americans, American Indians, and some Asian Americans and Native Hawaiians or Other Pacific Islanders are at particularly high risk for type 2 diabetes • diagnosed in children and adolescents

11. Type II Diabetes • Insulin levels may be normal, elevated or depressed • Characterized by insulin resistance • diminished tissue sensitivity to insulin • impaired beta cell function (delayed or inadequate insulin release) • Often occurs >40 years

12. Type II Diabetes

13. Type II Diabetes • Risk factors: family history, sedentary lifestyle, obesity and aging • Controlled by weight loss, oral hypoglycemic agents and or insulin

14. Gestational diabetes • A form of glucose intolerance that is diagnosed in some women during pregnancy • More frequently among African Americans, Hispanic/Latino Americans, and American Indians. It is also more common among obese women and women with a family history of diabetes • During pregnancy, gestational diabetes requires treatment to normalize maternal blood glucose levels to avoid complications in the infant • After pregnancy, 5% to 10% of women with gestational diabetes are found to have type 2 diabetes • Women who have had gestational diabetes have a 20% to 50% chance of developing diabetes in the next 5-10 years

15. GDM • انجام آزمایش قند خون در اولین ویزیت حاملگی • تکرار تست در هفته 28-24 اگر تست اول منفی بود • انجام تست در هفته 28-24 برای تمام خانم ها با خطر متوسط • عدم توصیه تست برای خانم ها با خطر کم: سن زیر 25 سال، وزن طبیعی قبل از حاملگی، قومیت های خاص با GDM پایین، نداشتن سابقه عدم تحمل گلوکز و سابقه دیابت در بستگان درجه اول، نداشتن سابقه زایمان مشکل دار

16. برای خانم ها با خطر بالا یا متوسط: - انجام تست تحمل گلوکز خوراکی(OGTT) یا - تست تحمل گلوکز GCT و در صورتی که قند خون بیش از mg/dl 140شد ← پیگیری با تست تحمل گلوکز خوراکی

17. GDM • درمان اولیه: تعدیل رژیم غذایی و کنترل قند خون • در صورت وجود هیپرگلیسمی: تجویز انسولین • هدف از درمان: حفظ قند خون ناشتا کمتر از mg/dl 105 و گلوکز 2 ساعت بعد از غذا کمتر از mg/dl 130

18. Other types of DM • Other specific types of diabetes result from specific genetic conditions (such as maturity-onset diabetes of youth), surgery, drugs, malnutrition, infections, and other illnesses • Such types of diabetes may account for 1% to 5% of all diagnosed cases of diabetes

19. Secondary DM Secondary causes of Diabetes mellitus include: • Acromegaly • Cushing syndrome • Thyrotoxicosis • Pheochromocytoma • Chronic pancreatitis • Cancer

20. Drug induced hyperglycaemia: • Atypical Antipsychotics • Beta-blockers → Inhibit insulin secretion • Calcium Channel Blockers → Inhibits secretion of insulin • Corticosteroids→Cause peripheral insulin resistance and gluconeogensis • Fluoroquinolones - Inhibits insulin secretion • Niacin→ increased insulin resistance

21. Phenothiazine → Inhibit insulin secretion • Protease Inhibitors → Inhibit the conversion of proinsulin to insulin • Thiazide Diuretics → Inhibit insulin secretion due to hypokalaemia

22. What goes wrong in diabetes? • Multitude of mechanisms • Insulin • Regulation • Secretion • Uptake or breakdown • Beta cells • damage

23. Action of Insulin on the Cell Metabolism

24. Action of Insulin on Carbohydrate, Protein and Fat Metabolism • Carbohydrate • Facilitates the transport of glucose into muscle and adipose cells • Facilitates the conversion of glucose to glycogen for storage in the liver and muscle. • Decreases the breakdown and release of glucose from glycogen by the liver

25. Action of Insulin on Carbohydrate, Protein and Fat Metabolism • Protein • Stimulates protein synthesis • Inhibits protein breakdown; diminishes gluconeogenesis

26. Action of Insulin on Carbohydrate, Protein and Fat Metabolism • Fat • Stimulates lipogenesis - the transport of triglycerides to adipose tissue • Inhibits lipolysis – prevents excessive production of ketones or ketoacidosis

28. Screening for Diabetes

30. Management of DM • The major components of the treatment of diabetes are:

31. A. Diet • Diet is a basic part of management in every case. Treatment cannot be effective unless adequate attention is given to ensuring appropriate nutrition. • Dietary treatment should aim at: • Ensuring weight control • Providing nutritional requirements • Allowing good glycaemic control with blood glucose levels as close to normal as possible • Correcting any associated blood lipid abnormalities

32. A. Diet (cont.) The following principles are recommended as dietary guidelines for people with diabetes: • Dietary fat should provide 20-30% of total intake of calories but saturated fat intake should not exceed 10% of total energy. Cholesterol consumption should be restricted and limited to 300 mg or less daily. • Protein intake can range between 10-20% total energy (0.8-1 g/kg of desirable body weight). Requirements increase for children and during pregnancy. Protein should be derived from both animal and vegetable sources. • Carbohydrates provide 50-60% of total caloric content of the diet. Carbohydrates should be complex and high in fibre. • Excessive salt intake is to be avoided. It should be particularly restricted in people with hypertension and those with nephropathy.

33. Exercise • Physical activity promotes weight reduction and improves insulin sensitivity, thus lowering blood glucose levels. • Together with dietary treatment, a programme of regular physical activity and exercise should be considered for each person. Such a programme must be tailored to the individual’s health status and fitness. • People should, however, be educated about the potential risk of hypoglycaemia and how to avoid it.

34. Management of Diabetes Mellitus • Nutrition • Blood glucose • Medications • Physical activity/exercise • Behavior modification

35. Medical Nutrition Therapy • Maintain short and long term body weight • Reach and maintain normal growth and development • Prevent or treat complications • Improve and maintain nutritional status • Provide optimal nutrition for pregnancy

36. Nutritional Management for Type I Diabetes • Consistency and timing of meals • Timing of insulin • Monitor blood glucose regularly

37. Nutritional Management for Type II Diabetes • Weight loss • Smaller meals and snacks • Physical activity • Monitor blood glucose and medications

38. Diabetes Control and Complications Trial • Conventional therapy: • 1 - 2 insulin injections, • self monitoring B.G • routine contact with MD and case manager 4X/year. • Intensive therapy: • 3 or more insulin injections, with adjustments in dose according to B.G monitoring, • planned dietary intake and anticipated exercise.

39. Diabetes Control and Complications Trial • Results: • 76% reduction in retinopathy • 60% reduction in neuropathy • 54% reduction in albuminuria • 39% reduction in microalbuminuria • Implication: Improved blood glucose control also applies to person with type II diabetes.

40. Nutrition Recommendations • Carbohydrate • 60-70% calories from carbohydrates and monounsaturated fats • Protein • 10-20% total calories

41. Nutrition Recommendations • Fat • <10% calories from saturated fat • 10% calories from PUFA • <300 mg cholesterol • Fiber • 20-35 grams/day

42. B. Oral Anti-Diabetic Agents • There are currently four classes of oral anti-diabetic agents: i. Biguanides ii. Insulin Secretagogues – Sulphonylureas iii. Insulin Secretagogues – Non-sulphonylureas iv. α-glucosidase inhibitors v. Thiazolidinedione (TZDs)

43. B.2 Combination Oral Agents Combination oral agents is indicated in: • Newly diagnosed symptomatic patients with HbA1c >10 • Patients who are not reaching targets after 3 months on monotherapy

44. Different Diabetes Complications • Macro vascular • Micro vascular • Neuropathy • Infections

45. Macro vascular Complications

46. Macro-vascular Complications • Ischemic heart disease • Cerebrovascular disease • Peripheral vascular disease Diabetic patients have a 2 to 6 times higher risk for development of these complications than the general population

47. Macro-vascular Complications The major cardiovascular risk factors in the non-diabetic population (smoking, hypertension and hyperlipidemia) also operate in diabetes, but the risks are enhanced in the presence of diabetes. Overall life expectancy in diabetic patients is 7 to 10 years shorter than non-diabetic people.

48. Type 1 Develop after several years of DM Ultimately affects ~30% of patients Type 2 Mostly present at diagnosis Affects at least 60% of patients Hypertension in Type 1 and 2 Diabetes

49. Goals of Treatment of Hypertension Lower target for diabetic patients than non-diabetic patients: 130/85 vs. 140/90

50. Dyslipidaemia in DM • Most common abnormality is  HDL and Triglyserides • A low HDL is the most constant predictor of CV disease in DM • Target lipid values: LDL <2.6 mmol/l, HDL >1.15 mmol/l, TG < 2.5 mmol/l