Diagnosis classification and prevention of diabetes · Slides current until 2008 Diagnosis and types Curriculum Module II-1 Slide 35 of 48 References 1. American Diabetes Association

Slides current until 2008

Diagnosis, classification and prevention of diabetes

Section 1 | 1 of 4

Curriculum Module II–1 | Diagnosis, classification and presentation of diabetes


Diagnosis and typesCurriculum Module II-1

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Polyurea



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Definition of diabetes

Characterized by hyperglycaemia

• Defects in insulin production

• Autoimmune or otherdestruction of beta cells

• Insulin insensitivity

• Impaired action of insulin on target tissues



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Definition of diabetes

Chronic hyperglycaemia associatedwith long-term damage to:

• Eyes

• Kidneys

• Nerves

• Heart and blood vessels



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The diabetes epidemic

• 230 million affected in 2006

• 350 million within 20 years

• Most rapid in Indian and Asian subcontinents

IDF Diabetes Atlas



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Classification

• Type 1 diabetes

– autoimmune

– LADA

– idiopathic

• Type 2 diabetes



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Other specific types

• MODY

• Defects in insulin action

• Diseases of the pancreas

• Endocrine disorders

• Drug- or chemical-induced

• Infections

Classification



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• Uncommon forms of immune-mediated diabetes

• Other genetic syndromes

• Gestational diabetes

Classification



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Insulin

GluconeogenesisGlycogenolysisGlycogen synthesis

Glucose uptakeGlycogen synthesis

Blood glucose

Insulin and glucose disposal

Free fatty acid release



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Glucose uptakeGlycogenolysisGluconeogenesis (amino acids)Ketone production (fatty acids)

Glucose uptakeProtein degradation → amino acids

Blood glucose

Insulin deficiency in type 1 diabetes

Triglyceride degradation → fatty acids



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Glucose uptake

Glycolysis

Gluconeogenesis (amino acids)

Glucose uptakeProtein degradation → amino acids

Blood glucose

Insulin insensitivity inttype 2 diabetes



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Beta-cell mass

Pathogenesis of type 1 diabetes

Time (months - years)

Trigger

Genetic

Pre-diabetes ‘Honeymoon’

Chronic phase

Clinical diabetes

Immunological abnormalities



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Idiopathic type 1 diabetes

Non-autoimmune type 1 diabetes

• No autoimmune markers

• Permanent insulinopenia

• Ketoacidosis

• People of African and Asian origin



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• Age of onset peaks

–preschool

–puberty

• Autumn/winter peaks

Epidemiology of type 1 diabetes



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Type 2 diabetes

• 90%-95% of people withdiabetes

• Insulin insensitivity andrelative insulin deficiency

• Obesity or overweight

• Complications often presentat diagnosis



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Pathogenesis of type 2 diabetes

• Multiple genes involved

• Hyperinsulinaemia

• Poor fetal nutrition → ↓ beta-cell formation

• Low birth weight/weight change

• “Thrifty gene”



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Age (years)

Endogenous insulin

Insulin requirements

Beta-cell loss

The natural history of type 2 diabetes

↑ Insulin requirements with age

Primary failure



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Epidemiology of type 2 diabetes

• Dramatic increase

• Aging population

• Disturbing trends parallel obesity epidemic

• Especially in adolescents and minority groups

• Increasing in young people



Slide 22 of 48ACTIVITY

• What are the most common risk factors for type 2 diabetes for people in your country?

• Are any of these risk factors modifiable?



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Risk factors for type 2 diabetes

• Age > 40 years

• First-degree relative with diabetes

• Member of high risk population

• History of impaired glucose tolerance, impaired fasting glucose

• Vascular disease

• History of gestational diabetes

• History of delivery of macrosomicbaby

CDA 2003



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• Hypertension

• Dyslipidaemia

• Abdominal obesity

• Overweight

• Polycystic ovary disease

• Acanthosis nigricans

• Schizophrenia

Risk factors for type 2 diabetes



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• Polydipsia

• Polyuria

• Nocturia

• Visual disturbance

• Fatigue

• Weight loss

• Infections

Signs and symptoms



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Diagnosing diabetes

≥11.1mmol/L7.8 to 11mmol/L**2hr PG <7.8mmol/L

≥7.0mmol/L[5.6] 6.1 to 6.9mmol/L*FPG <6.1mmol/L

DiabetesImpaired fasting glucose*

Impaired glucose tolerance**

Normal

CDA 2003, ADA 2004, WHO 2002



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Diagnosis of Diabetes

• Symptoms + gluc >11.0 mmol/l

• 2X FG > 6.9 mmol/l

• 2X 2hr GTT > 11.0 mmol/l



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Impaired glucose toleranceImpaired fasting glucose

• Intermediate states

• Increased risk of developing diabetes

• Prevention strategies to prevent or delay progression

• Increased risk of cardiovascular disease



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Prevention of type 1 diabetes

Insulin

• Diabetes Prevention Trial

• Diabetes Prediction and Prevention Project



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Lifestyle modification

• Da Qing Study

• Finnish Diabetes Prevention Study



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Lifestyle vs medication

• Diabetes Prevention Program

• STOP-NIDDM



Slide 32 of 48ACTIVITY

Type 2 diabetes can be delayed in people with IGT

Lifestyle modification is most effective

What do you think could be done at community level to prevent or delay diabetes?



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Summary

Type 1 diabetes

• Results from progressive beta-cell destruction

• People with type 1 diabetes need insulin therapy to live



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Type 2 diabetes

• Often characterized by insulin insensitivity and relative ratherthan absolute insulin deficiency

• A progressive condition

• Most people with type 2 diabetes will need insulin within 5 to 10 years of diagnosis

Summary



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References

1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2004; 27(suppl 1): S5-S10.

2. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diab 2003; 27(suppl 2).

3. Chiasson JL, Josse RG, Gomis R, et al. Acarbose for prevention of type 2 diabetes mellitus: The STOP-NIDDM randomized trial. Lancet 2002; 346: 393-403.

4. Delahanty LM and Halford BN. The role of Diet Behaviours in Achieving improved glycaemiccontrol in intensively treated patients in the Diabetes Control and Complications Trial. Diabetes Care 1993; 16(11): 1453-58.

5. Diabetes Control and Complications Trial Research Group. Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin dependent diabetes mellitus: Diabetes Control and Complications Trial. The Journal of Paediatrics 1994; 125(2): 177-88.

6. Diabetes Control and Complications Trial/epidemiology of diabetes interventions and complications research group intensive diabetes therapy and carotid intima-media thickness in type 1 diabetes mellitus. New Engl J Med 2003; 348: 2294-303.

7. Diabetes Control and Complications Trial: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-86.



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References

8. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 2002; 297: 356-59.

9. Diabetes Atlas 2006. Brussels: International Diabetes Federation, 2006.

10. Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated withthe metabolic syndrome. Diabetes Care 2001; 24(4): 683-9.

11. Pan X, Li G, Hu Y, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: The Da Qing IGT and Diabetes Study. Diabetes Care 1997; 20(4): 537-44.

12. Report of a WHO Consultation. Laboratory Diagnosis and monitoring of Diabetes Mellitus. World Health Organisation 2002. http://whqlibdoc.who.int/hq/2002/9241590483.pdf cited April 30, 2005.

13. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Eng J Med 2001; 344: 1343-50.

14. The Diabetes Prevention Program Research Group. The diabetes prevention Program (DPP). Diabetes Care 2002; 23(12): 2165-71.

15. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulpfonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet 1998; 352: 837-53.



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References

16. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes UKPDS 38. BMJ1998; 317: 703-13.

17. IDF Clinical Guidelines Task Force. Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation, 2005.

18. Harris SB, Ekoe JM, Zdanowicz Y, Webster-Bogaert S. Glycemic Control and morbidity in the Canadian primary care setting (results of the diabetes in Canada evaluation study). Diab Research and Clin Pract 2005; 70: 90-7.

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Diagnosis classification and prevention of diabetes · Slides current until 2008 Diagnosis and types Curriculum Module II-1 Slide 35 of 48 References 1. American Diabetes Association