Transcript Diabetes

Diabetes
Dr.Isazadehfar
Assistant Professor of Community
and Preventive Medicine
What is diabetes?
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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.
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The term diabetes mellitus describes a metabolic
disorder of multiple aetiology characterized by chronic
hyperglycaemia with disturbances of carbohydrate, fat
and protein metabolism
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The effects of diabetes mellitus include long–term
damage, dysfunction and failure of various organs
Carbohydrate Digestion
Diabetes
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Diabetes mellitus may present with characteristic
symptoms such as thirst, polyuria, blurring of vision, and
weight loss.
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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.
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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.
Diabetes Long-term Effects
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Retinopathy with potential blindness
Nephropathy→ renal failure
Neuropathy → foot ulcers
amputation
Charcot joints
autonomic dysfunction
Cardiovascular disease
Peripheral vascular disease
Cerebrovascular disease
Types of Diabetes
Type 1 Diabetes Mellitus
 Type 2 Diabetes Mellitus
 Gestational Diabetes
 Other types:
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 MODY
(maturity-onset diabetes of
youth)
 Secondary Diabetes Mellitus
Type 1 diabetes
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Insulin-dependent diabetes mellitus (IDDM) or
juvenile-onset diabetes.
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Account for 5% to 10% of all cases of diabetes
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develops when the body’s immune system destroys
pancreatic beta cells
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usually strikes children and young adults, although
disease onset can occur at any age
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Risk factors may include: autoimmune, genetic,
and environmental factors
Type I Diabetes
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Low or absent endogenous insulin
Dependent on exogenous insulin for life
Onset generally < 30 years
Onset sudden
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Symptoms: 3 P’s: polyuria, polydypsia, polyphagia
Type I Diabetes Cell
Type 2 diabetes
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non-insulin-dependent diabetes mellitus (NIDDM) or adultonset diabetes
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account for about 90% to 95% of all cases of diabetes
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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.
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is associated with older age, obesity, family history of diabetes,
history of gestational diabetes, impaired glucose metabolism,
physical inactivity, and race/ethnicity
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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
Type II Diabetes
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Insulin levels may be normal, elevated or depressed
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Characterized by insulin resistance
diminished tissue sensitivity to insulin
impaired beta cell function (delayed or inadequate
insulin release)
Often occurs >40 years
Type II Diabetes
Type II Diabetes
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Risk factors: family history, sedentary
lifestyle, obesity and aging
Controlled by weight loss, oral hypoglycemic
agents and or insulin
Gestational diabetes
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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
‫‪GDM‬‬
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‫انجام آزمایش قند خون در اولین ویزیت حاملگی‬
‫تکرار تست در هفته ‪ 24-28‬اگر تست اول منفی بود‬
‫انجام تست در هفته ‪ 24-28‬برای 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
‫‪ GDM‬پایین‪ ،‬نداشتن سابقه عدم تحمل گلوکز و سابقه دیابت‬
‫در بستگان درجه اول‪ ،‬نداشتن سابقه زایمان مشکل دار‬
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‫برای خانم ها با خطر باال یا متوسط‪:‬‬
‫ انجام تست تحمل گلوکز خوراکی(‪ )OGTT‬یا‬‫ تست تحمل گلوکز ‪ GCT‬و در صورتی که قند خون‬‫بیش از ‪140 mg/dl‬شد ← پیگیری با تست تحمل‬
‫گلوکز خوراکی‬
‫‪GDM‬‬
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‫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
‫‪ 105‬و گلوکز ‪ 2‬ساعت بعد از غذا کمتر از ‪mg/dl‬‬
‫‪130‬‬
Other types of DM
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Other specific types of diabetes result from
specific genetic conditions (such as maturityonset diabetes of youth), surgery, drugs,
malnutrition, infections, and other illnesses
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Such types of diabetes may account for 1% to
5% of all diagnosed cases of diabetes
Secondary DM
Secondary causes of Diabetes mellitus
include:
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Acromegaly
Cushing syndrome
Thyrotoxicosis
Pheochromocytoma
Chronic pancreatitis
Cancer
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Drug induced hyperglycaemia:
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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
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Phenothiazine → Inhibit insulin secretion
Protease Inhibitors → Inhibit the conversion of
proinsulin to insulin
Thiazide Diuretics → Inhibit insulin secretion due to
hypokalaemia
What goes wrong in diabetes?
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Multitude of mechanisms
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Insulin
Regulation
 Secretion
 Uptake or breakdown
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Beta cells
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damage
Action of Insulin on the Cell Metabolism
Action of Insulin on Carbohydrate, Protein
and Fat Metabolism
 Carbohydrate
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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
Action of Insulin on Carbohydrate, Protein
and Fat Metabolism
 Protein
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Stimulates protein synthesis
Inhibits protein breakdown;
diminishes gluconeogenesis
Action of Insulin on Carbohydrate, Protein
and Fat Metabolism
 Fat
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Stimulates lipogenesis - the transport of
triglycerides to adipose tissue
Inhibits lipolysis – prevents excessive
production of ketones or ketoacidosis
Screening for Diabetes
Fasting Blood
Glucose
Significance
Action
<110
Normal
Retest in 3 years
>110 & <126
IGT
1. Additional Testing
2. Check risk factors
3. MNT
>126
Diabetes likely
1. Confirm by 2nd FBG
2. Treat DM
Management of DM
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The major components of the treatment of diabetes are:
A
• Diet and Exercise
B
• Oral hypoglycaemic
therapy
C
• Insulin Therapy
A. Diet
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Diet is a basic part of management in every case.
Treatment cannot be effective unless adequate
attention is given to ensuring appropriate
nutrition.
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Dietary treatment should aim at:
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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
A. Diet (cont.)
The following principles are recommended as dietary guidelines for
people with diabetes:
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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.
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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.
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Carbohydrates provide 50-60% of total caloric content of the diet.
Carbohydrates should be complex and high in fibre.
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Excessive salt intake is to be avoided. It should be particularly restricted in
people with hypertension and those with nephropathy.
Exercise
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Physical activity promotes weight reduction and
improves insulin sensitivity, thus lowering blood
glucose levels.
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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.
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People should, however, be educated about the
potential risk of hypoglycaemia and how to avoid it.
Management of Diabetes Mellitus
 Nutrition
 Blood
glucose
 Medications
 Physical activity/exercise
 Behavior modification
Medical Nutrition Therapy
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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
Nutritional Management for Type I
Diabetes
 Consistency
and timing of meals
 Timing of insulin
 Monitor blood glucose regularly
Nutritional Management for Type II
Diabetes
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Weight loss
Smaller meals and snacks
Physical activity
Monitor blood glucose and
medications
Diabetes Control and
Complications Trial
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Conventional therapy:
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1 - 2 insulin injections,
self monitoring B.G
routine contact with MD and case manager 4X/year.
Intensive therapy:
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3 or more insulin injections, with adjustments in dose according to
B.G monitoring,
planned dietary intake and anticipated exercise.
Diabetes Control and
Complications Trial
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Results:
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76%
60%
54%
39%
reduction
reduction
reduction
reduction
in
in
in
in
retinopathy
neuropathy
albuminuria
microalbuminuria
Implication: Improved blood
glucose control also applies to
person with type II diabetes.
Nutrition Recommendations
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Carbohydrate
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60-70% calories from carbohydrates
and monounsaturated fats
Protein
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10-20% total calories
Nutrition Recommendations
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Fat
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<10% calories from saturated fat
10% calories from PUFA
<300 mg cholesterol
Fiber
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20-35 grams/day
B. Oral Anti-Diabetic Agents
There are currently four classes of oral antidiabetic agents:
i. Biguanides
ii. Insulin Secretagogues – Sulphonylureas
iii. Insulin Secretagogues – Non-sulphonylureas
iv. α-glucosidase inhibitors
v. Thiazolidinedione (TZDs)
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B.2 Combination Oral Agents
Combination oral agents is indicated in:
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Newly diagnosed symptomatic patients with
HbA1c >10
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Patients who are not reaching targets after 3
months on monotherapy
Different Diabetes Complications
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Macro vascular
Micro vascular
Neuropathy
Infections
Macro vascular Complications
Macro-vascular Complications
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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
Macro-vascular Complications
The major cardiovascular risk factors in the nondiabetic 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.
Hypertension in Type 1 and 2 Diabetes
Type 1
Type 2
Develop after several
years of DM
Ultimately affects
~30% of patients
Mostly present at
diagnosis
Affects at least 60%
of patients
Goals of Treatment of
Hypertension
Lower target for diabetic patients than nondiabetic patients:
130/85 vs. 140/90
Dyslipidaemia in DM
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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
Micro vascular Complications
Eye Complications
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Cataracts
Non enzymatic glycation of lens protein and
subsequent cross linking
Sorbitol accumulation could also lead to
osmotic swelling of the lens but evidence of
involvement in cataract formation is less strong
Eye Complications
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Retinopathy (stages):
- Background
- Pre-proliferative
- Proliferative
- Advanced diabetic eye disease
- Maculopathy
Glaucoma
Background Retinopathy
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Micro aneurisms
Scattered exudates
Hemorrhages (flame
shaped, Dot and Blot)
Cotton wool spots (<5)
Venous dilatations
Background retinopathy
Proliferative Retinopathy
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New vessels (on disc,
elsewhere)
Fibrous proliferation
(on disc, elsewhere)
Hemorrhages
(preretinal, vitreous)
Panretinal photo-coagulation
Diabetic Nephropathy (DN)
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Diabetes has become the most common cause of
end stage renal failure in the US and Europe
About 20 – 30% of patients with diabetes
develop evidence of nephropathy
The prevalence of DN is higher in Black
Americans than in Whites (Figures for South
Africa is not available)
Stages of DN
Stage I
 glomerular filtration and kidney
hypertrophy
Stage II
u-albumin excretion < 30mg/24h
Stage III
Microalbuminuria (30 – 300 mg/24h)
Stages of DN (cont)
Stage IV
Overt nephropathy (> 300mg/24h, positive u
dipstick)
Stage V
ESRD characterized by  blood urea and
creatinine levels, hyperkalaemia and fluid
overload
Diabetic Neuropathy
Sensorimotor neuropathy (acute/chronic)
Autonomic neuropathy
Mononeuropathy
Proximal motor neuropathy
Specific Infections
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Community acquired
pneumonia
Acute bacterial cystitis
Acute pyelonephritis
Emphysematous
pyelonephritis
Perinephric abscess
Fungal cystitis
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Necrotizing fasciitis
Invasive otitis externa
Rhinocerebral
mucormycosis
Emphysematous
cholecystitis
Self-Care
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Patients should be educated to practice self-care. This
allows the patient to assume responsibility and control
of his / her own diabetes management. Self-care should
include:
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Blood glucose monitoring
Body weight monitoring
Foot-care
Personal hygiene
Healthy lifestyle/diet or physical activity
Identify targets for control
Stopping smoking