diabetes melitus & sindroma metabolik pit

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METABOLIC SYNDROME & DIABETES MELLITUSthe problems and short course management

MIF TAHU RACHMAN

PADJADJARAN UNIVERSITYRSHS BANDUNG


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• IDEAL BODY WEIGHT ? BMI ? WAIST CIRCUMFERENCE ?

• METS : OVERWEIGHT

• DIABETES MELLITUS

• MANAGEMENT : DIET, EXERCISE, MEDICINE

(A B C D H H COST & EFFECTIVENESS)

BEHAVIOUR MODIFICATION #BeMo

Learning objectives


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Common definitions

Abbreviation Definition

NGT Normal Glucose Tolerance (Gula Darah Normal)

FPG Fasting Plasma Glucose (Gula Darah Plasma Puasa)

PPG Post-Prandial Plasma Glucose (Gula Darah Plasma Post Prandial)

IGT Impaired Glucose Tolerance (Toleransi Glukosa Terganggu)

IFG Impaired Fasting Glucose (Gula Darah Puasa Terganggu)

HbA1c

Average amount of glucose in the bloodstream over a 2-3 months

period


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Classification of diabetes• Type 1 diabetes

• Beta cell destruction, usually leading to absolute insulin deficiency

• Type 2 diabetes

• Progressive insulin secretory defect on the background of beta celldysfunction and insulin resistance

• Gestational diabetes mellitus

• Diabetes diagnosed in the second or third trimester of pregnancy thatis not clearly overt diabetes

• Other specific diabetes types

• Drug or chemical induced, e.g steroids, treatment of HIV/AIDS or afterorgan transplantation

• Genetic defects in beta cell function or in insulin action

• Diseases of the exocrine pancreas (e.g. cystic fibrosis)

ADA - Standards of Medical Care in Diabetes – 2016. Diabetes Care, Vol. 39, Supplement 1, January 2016.


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Differences between type 1and type 2 diabetesFeatures Type 1 Diabetes Type 2 Diabetes

Onset Sudden Gradual

Age at onsetAny age

(mostly young)Mostly in adults

Body habitus Thin or normal Often obese

Ketoacidosis Common Rare

Autoantibodies Usually present Absent

Endogenous insulin Low or absent Normal, decreased or increased

Prevalence Less prevalent in AsiaMore prevalent.90-95% of all people withdiabetes in Asia


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Are you ready ???


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Why are we seeing such an increasein the number of people with Type 2diabetes worldwide?

Unhealthy lifestyle Aging population Urbanisation

Dietary changes Sedentary lifestyleIDF Diabetes Atlas 2014Cockram 2000. HKMJ ; 6 (1): 43-52Mohan 2007. Indian J Med Res; 125: 217-230


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High blood glucose is the 3rd biggest riskfactor contributor to cardio-vasculardeaths globally

WHO 2011. Global Atlas on CVD prevention and Control

Attributable deaths due to selected risk factors (000’)


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Diabetes is developing fast in Indonesia

RISKESDAS Survey 2007

Laporan RISKESDAS 2013

2007 2013

1.5% 2.1%

4.2% 4.8%

10.2% 29.9%

Diagnosed diabetes

Undiagnosed diabetes

Impaired glucose tolerance


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2007 2013

1.5% 2.1%

4.2% 4.8%

10.2% 29.9%

Diagnosed diabetes




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2007 2013

1.5% 2.1%

4.2% 4.8%

10.2% 29.9%

Diagnosed diabetes





Approximately 10 million peoplewith diabetes in Indonesia


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0

20

40

60

80

100

Target HbA1c 7% Target HbA1c 6.5%

Over

target

81.01%

67.85%

…and diabetes control is suboptimal

Soewondo P, Soegondo S, Suastika K, Pranoto A, Soeatmadji DW, Tjokroprawiro A. The DiabCare Asia 2008 study-Outcomes on control and complications of type 2 diabetic patients in Indonesia Med J Indones 2010 19; 4: 235-244.


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Early detection and monitoring


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13

Muscle and fat

Glucose Homeostasis

INPUT NUTRISI

Liver

Normoglycemia

Islet

Beta cellproducesinsulin

Alpha cellproducesglucagon

FASTING

NORMAL


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14

Normoglycemia

Alpha cellproducesglucagon

Beta cellproducesinsulin

Muscle and fat

Liver

Glucose Homeostasis

INPUT NUTRISI

Insulin resistance

(decreased glucose uptake)

Diminished

insulin Hyperglycemia

Excess glucose output

TYPE 2 DM


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Insulin Resistance: Associated Conditions


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Metabolic Syndrome – A MultifacetedSyndrome

High

blood glucose

High

bloodpressure

Abnormal

lipid levels

Obesity

Heart diseaseStroke

Kidney failure

Depression?

Cancer?

Urineprotein

Inflammatory markers


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Adapted from Type 2 Diabetes BASICS. International Diabetes Center 2000

Type 2 diabetes is a progressivedisease


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Classical diabetes symptoms

Polyuria

Unexplainedweight loss

Polydipsia

Blurred vision

• Excessive urination at night

• Visual disturbance

• Excessive Thirst

• Even if food intake is normal

http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/symptoms/con-20034795


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Other diabetes symptoms

Numbnessand/or tingling

Fatigue

Itchy skin

Impotence

• In hands, legs and feet

• Regardless of exercise

• Affects legs, feet, and hands

• Physical and physiological

Adapted from Konsensus PERKENI 2015. Pengelolaan dan pencegahan diabetes melitus tipe 2 di Indonesia.


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Cut-points: Diabetes, IGT and IFG

mg/dL

2-hour Plasma Glucose

F a s t i n g P l a s m a G l u c o s e

( F P G )

mg/dL

140 200

100

126

NGTNormal Glucose

Tolerance

Diabetes

IFGImpaired

Fasting Glucose IGTImpaired Glucose

Tolerance Diabetes



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Diagnosis of Type 2 DiabetesKONSENSUS: Pengelolaan Dan Pencegahan DM Type 2. 2015

Fasting* Plasma Glucose ≥ 126 mg/dl

or

2-hour post 75g OGTT ≥ 200 mg/dl

or

Classical symptoms of diabetes** & Random plasma glucose concentration ≥200 mg/dl

or

HbA1c ≥ 6.5% (standardised assay***)

*Classical symptom of diabetes (polyuria, polydipsia, weight loss), only need 1 abnormal

BG, otherwise need 2 x abnormal BG level on different days**Fasting is defined as no caloric intake for at least 8 hours***Standarised to National Glycohaemoglobin Standardization Program (NGSP)

Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia. 2015


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What is good glycaemic control?

• Overall aim to achieve glucose levels as close to normal as possible

• Minimise development and progression of microvascular andmacrovascular complications

FPG


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HbA1c correlation with blood glucoselevel

HbA1c eAG

% mg/dL mmol/l

6.0 126 7.0

6.5 140 7.8

7.0 154 8.6

7.5 169 9.4

8.0 183 10.2

8.5 197 11.0

9.0 212 11.8

9.5 226 12.6

10.0 240 13.4

David M. Nathan, Judith Kuenen, Rikke Borg, Hui Zheng, David Schoenfeld, and Robert J. Heine, for the A1c-Derived AverageGlucose (ADAG) Study Group. Diabetes Care 2008

The relationship between A1C and eAG is described by the formula 28.7 X A1C –46.7 = eAG


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Risk of complications increasesas Hb1Ac increases

Stratton IM et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000;321:405–12

0

20

40

60

80

5 6 7 8 9 10 11

Myocardial infarction

Microvascular disease

Adjusted for age, sex, and ethnic group.

I n c i d e n c e

p e r

1 .

0 0 0

p a t i e n t - y e

a r s

12697 154 183 212 240 269

Mean HbA1c (%)

Mean mg/dl


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Optimising blood glucose control

Good control is≤ 7.0% HbA1c

Source: UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM et al. BMJ. 2000;321(7258):405-412.

Deaths relatedto diabetes

Microvascularcomplications

Myocardialinfarction

-14%

-37%

-21%

HbA1c-1%


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Practical monitoring scheme

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. PenatalaksanaanDiabetes Melitus Terpadu. 2009


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Practical monitoring scheme

cont…

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. PenatalaksanaanDiabetes Melitus Terpadu. 2009


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Initiating diabetes treatment


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The ominous octet

DeFronzo R A Diabetes 2009;58:773-795

Copyright © 2011 American Diabetes Association, Inc.


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The ominous octet, depicting the mechanism and site of action of antidiabetes medications based upon the

pathophysiologic disturbances present in T2DM

Copyright © 2013 American Diabetes Association, Inc. Adapted from DeFronzo R A et al. Diabetes Care 2013;36:S127-S138


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The ominous octet, depicting the mechanism and site of action of antidiabetes medications based upon the

pathophysiologic disturbances present in T2DM

Adapted from DeFronzo R A et al. Diabetes Care 2013;36:S127-S138Copyright © 2013 American Diabetes Association, Inc.

SGLT2


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Factors to consider when choosing anantihyperglycaemic agent

Effectiveness in lowering glucose

Other effects (e.g. reduced cardiovascularoutcomes with metformin, empagliflozin)

Safety profile

Tolerability

Cost

Effect on body weight

Nathan DM et al. Management of Hyperglycemia in type 2 Diabetes, a consensus algorithm for the initiation and adjustment of therapy, a consensus statement from ADA/EASD. Diabetes Care 2006;29(8):1963-72.


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American Diabetes Association. Approaches to glycemic treatment. Sec. 7. In Standards of Medical Care in Diabetes 2015.Diabetes Care 2015;38(Suppl. 1):S41–S48

ADA/EASD treatment algorithm


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Danish treatment guidelines for type2 diabetesHbA1c target value is individual

HbA1c


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RisikoKardiovaskular

(-)

RisikoKardiovaskular

(+)

IMT (kg/m2) 18,5 - < 23

Glukosa darah

Puasa (mg/dL) < 100

2 jam PP (mg/dL) < 140 A1C (%) < 7,0 < 7,0

Tekanan darah

Sistolik (mmHg) ≤ 130 ≤ 130

Diastolik (mmHg) ≤ 80 ≤ 80

Profil Lipid

Total kolesterol (mg/dL)Trigliserid (mg/dL)

HDL kolesterol (mg/dL)

LDL kolesterol (mg/dL) < 100 < 70

Target Pengendalian DM2


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• Metformin

• Sulfonylureas (SUs) and glinides

• α-glucosidase inhibitors (AGIs)

• Dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors)

• Glucagon-like peptide-1 (GLP-1) agonists

• Thiazolidinediones (TZDs)

Antihyperglycaemic agents that arecurrently available in Indonesia


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MetforminUse of metformin based on eGFR

eGFR level (ml/min per 1.73 m) Action

≥60 No renal contraindication to metformin.Monitor renal function annually.


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Diabetes and the elderly

• Always start with the lowest doseof any AHA

• Increase gradually

• Hypoglycaemia may increase therisk of falls and heart attack inelderly

• Use shorter-acting AHA to reducethe risk of hypoglycaemia

Remember the possibility of

• Forgetfulness• Poor motivation

• Depression

• Cognitive deficits

• Polypharmacy

• Reduced manual dexterity• These factors affect the ability to

maintain self-care and achievemaximum benefits from AHAs


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Behaviour Modification : #BeMO

Eat : intelligently

Pray : deeply

Love : your Body

Move : regularly


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WE DO NOT DREAM….WE SIMPLY WORKING HARD

KEEP AN OPEN MIND AND HEART

AND WE CAN BEAT THE DIABETES


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diabetes melitus & sindroma metabolik pit

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