understanding of diabetes

8/11/2019 Understanding of Diabetes

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An Understanding of Diabetes

DR JAMES EMMANUEL

Queen Elizabeth Hospital


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Overview

I. Definition/AetiologyII. Classification

Prediabetes Type 1 DM Type 2 DM Secondary diabetes

III. PathophysiologyIV. Clinical manifestations


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Definition of diabetes

Characterized by hyperglycaemia Defects in insulin production Autoimmune or other

destruction of beta cells Insulin insensitivity (resistance) Impaired action of insulin on

target tissues


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Definition of diabetes

Chronic hyperglycaemiaassociated with long-termdamage 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

Pre-diabetes

Type 1 diabetes Type 2 diabetes Gestational diabetes


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What is Pre-diabetes?

A condition that precedes T2DM People with pre-diabetes have blood

glucose levels higher than normal but nothigh enough to be diagnosed with diabetes

People with pre-diabetes can prevent ordelay the onset of type 2 diabetes throughlifestyle change and/or medication


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Pre-diabetes (IFG, IGT)

IFG (Impaired Fasting Glucose)IGT (Impaired Glucose Tolerance)

At risk of developing T2DM Cardiovascular disease Stroke Often asymptomatic


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IGT

Pre-diabetes


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Diabetes

Mellitus ImpairedFastingGlucose

Normal

7.0 mmol/l

5.6 mmol/l

FBGDiabetesMellitus

ImpairedGlucoseTolerance

Normal

11.1 mmol/l

7.8 mmol/l

2-HourPPBG

How Do You Diagnose Diabetes?

Diagnosing Diabetes

Diabetes

Reference: Type 2 Diabetes: Practical Targets and Treatments: Asian-Pacific Type 2 Diabetes Policy GroupSecond Edition (1999). IDF-WPR and WHO.


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Preclinicalstate

Normal IGT

Clinicaldisease

Type 2Diabetes

DisabilityDeath

Complications

Complications

Primaryprevention

Secondaryintervention

Tertiaryintervention

The continuum of glucose intolerance


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Insulin

GluconeogenesisGlycogenolysisGlycogen synthesis

Glucose uptakeGlycogensynthesis

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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Type 2 diabetes

Carbohydrate

Glucose (G)

Insulin (I)

I

I

Defective insulin

secretion

Excessive fattyacid release

Reduced glucoseuptake

Excess glucoseproduction

Resistance to the action of insulin


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Pathogenesis of type 1 diabetes

Immunological activation

Progressive beta-cell destruction

Insufficient beta-cell function

Dependent on exogenous insulin Risk of ketoacidosis


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Epidemiology of type 1 diabetes

Increasing in recent years

Geographic variation

Relative affluence

Lack of treatment

IDF Diabetes Atlas


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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-cellformation

Low birth weight/weight change


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Stage INormalglucosetolerance

Stage IIIGT

Stage III

AtherogenesisHyperinsulinaemiaIR

Diabetes genes

LipogenesisObesity

Waist hip ratio Hypertension

TGHDL

Type 2 diabetes mellitus

Macrovascularcomplications

Microvascularcomplications

Type 2 diabetes mellitus:the tip of the iceberg

Insulin secretory deficiency

Postprandialplasma glucoseGlucoseproductionGlucose transport


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Clinical manifestations How do diabetics present?

Asymptomatic Signs and symptoms

Polydipsia Polyuria Nocturia Visual disturbance

Fatigue Weight loss Infections

Complications


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MEDICATION

AGENT EXAMPLES ACTION

SULFONYLUREA Glipizide, Glimepiride, Promote insulinsecretion.

BIGUANIDES Metformin Increases insulinsensitivity andreduces glucoseproduction in the

liver. GLUCOSIDASEINHIBITOR

Acarbose Reduce GIabsorption ofglucose.

THIAZOLIDINEDIONES Pioglitazone, Rosiglitazone Reduce insulinresistance.

ORAL HYPOGLYCAEMIC AGENTS


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MEDICATIONINSULIN

TYPES EXAMPLES

Short acting Soluble insulin: H Actrapid,Insulin aspart: NovoRapidInsulin glulisine: ApidraInsulin lispro: Humalog

Intermediateand long acting

Insulin detemir: LevemirInsulin glargine: Lantus

Insulin zinc suspension: Hypurin Bovine LenteIsophane insulin: Insulatard

Biphasic Biphasic insulin aspart: NovoMix 30Biphasic insulin lispro: Humalog Mix25, Humalog Mix50


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ADVICE TO INSULIN USERS

1. As far as possible inject to area around thestomach and triceps.

2. Get a new site of injection near the old site of

injection. 3. Insulin should be injected into subcutaneous

tissue and not muscle.

4.Insulin should be given at the same time andarea everyday. 5.Have a proper record of site rotation.


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SITE OF INSULIN INJECTION


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HYPOGLYCEMIC AWARENESS


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Complications Type 2 DM can be present for many years at

diagnosis and up to 30% people already have atleast one complication at diagnosis, assessmentof complications should begin at diagnosis andannually thereafter

In Type 1 DM assessment for complicationsshould be done wihin 5 years of diagnosis andthen annually

Duration of diabetes and poor metabolic controlare predictors of the development ofmicrovascular complications


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Type 2 diabetes is associated with seriousmicrovascular and macrovascular complications

Retinopathy,glaucoma or

cataracts

Nephropathy

Neuropathy

MICROVASCULAR MACROVASCULAR Cerebrovascular

disease

CHD

Peripheralvasculardisease

World Health Organization/International Diabetes Federation, 1999. Diabetes Care 2001; 24 (Suppl 1): S5 20.


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Kidney Failureor Dialysis

Micro vascular(Small Blood Vessels)

Complications

Blindness,Cataract

Gangrene, NerveDamage & Loss of

Sensation

Ulceration / Amputation

What are the Complications of Diabetes? Disease of theSmall Blood Vessels

Eye

Foot

Kidney

Complications of Diabetes

Complications MAKING DIABETESMANAGEABLE

Persatuan DiabetesMalaysia


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Macro vascular(Large Blood Vessels)

Complications

What are the Complications of Diabetes? Disease of theLarge Blood Vessels

Coronary ArteryDisease

Stroke

Heart

Brain

Leg / FootPeripheral VascularDisease

Heart Attack

Complications of Diabetes

Complications


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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 rather thanabsolute insulin deficiency

A progressive condition

Most people with type 2 diabeteswill need insulin within 5 to 10 yearsof diagnosis

Summary


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Summary

Pre-diabetes (IFG/IGT) A condition that precedes T2DM

Increased risk of cardiovascular disease People with pre-diabetes can prevent or

delay the onset of type 2 diabetes throughlifestyle change and/or medication


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Summary

Clinical manifestations Asymptomatic

Osmotic symptoms Complications

Macrovascular

Microvascular


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Review question

The pathogenesis for type 2diabetes includes:

a. Insulin deficiency and insulininsensitivity (resistance)

b. Insensitivity to insulin and autoimmunebeta-cell destruction

c. Autoimmune beta-cell destruction andglucagon deficiency

d. Insulin deficiency and glucagondeficiency


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Review question

Type 1 diabetes is usually causedby:

a. Injury to the pancreasb. An autoimmune reactionc. Insulin insensitivity in the cellsd. Hypersensitivity to insulin


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THANK YOU

understanding of diabetes

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