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1、Diabetes Mellitus,Dr.Rasha SalamaPhD Public Health,Suez Canal University,Egypt Diabetes MSc,Cardiff University,United Kingdom,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 diabete
2、s mellitus describes a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate,fat and protein metabolism resulting from defects in insulin secretion,insulin action,or both.The effects of diabetes mellitus include longterm damage,dysfunction
3、 and failure of various organs.,What is 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 nonketotic hyperosmolar state may develop and lead to stupor,coma and,in absence of effec
4、tive 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.,Diabetes,The longterm effects of diabetes mellitus include progressive development
5、of the specific complications of retinopathy with potential blindness,nephropathy that may lead to renal failure,and/or neuropathy with risk of foot ulcers,amputation,Charcot joints,and features of autonomic dysfunction,including sexual dysfunction.People with diabetes are at increased risk of cardi
6、ovascular,peripheral vascular and cerebrovascular disease.,Diabetes Long-term Effects,The development of diabetes is projected to reach pandemic proportions over the next10-20 years.International Diabetes Federation(IDF)data indicate that by the year 2025,the number of people affected will reach 333
7、 million 90%of these people will have Type 2 diabetes.In most Western societies,the overall prevalence has reached 4-6%,and is as high as 10-12%among 60-70-year-old people.The annual health costs caused by diabetes and its complications account for around 6-12%of all health-care expenditure.,Burden
8、of Diabetes,Type 1 Diabetes Mellitus Type 2 Diabetes MellitusGestational DiabetesOther types:LADA(MODY(maturity-onset diabetes of youth)Secondary Diabetes Mellitus,Types of Diabetes,Was previously called insulin-dependent diabetes mellitus(IDDM)or juvenile-onset diabetes.Type 1 diabetes develops whe
9、n the bodys immune system destroys pancreatic beta cells,the only cells in the body that make the hormone insulin that regulates blood glucose.This form of diabetes usually strikes children and young adults,although disease onset can occur at any age.Type 1 diabetes may account for 5%to 10%of all di
10、agnosed cases of diabetes.Risk factors for type 1 diabetes may include autoimmune,genetic,and environmental factors.,Type 1 diabetes,Was previously called non-insulin-dependent diabetes mellitus(NIDDM)or adult-onset diabetes.Type 2 diabetes may account for about 90%to 95%of all diagnosed cases of di
11、abetes.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.Type 2 diabetes is associated with older age,obesity,family history of diabetes,history of gestational di
12、abetes,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.Type 2 diabetes is increasingly being diag
13、nosed in children and adolescents.,Type 2 diabetes,A form of glucose intolerance that is diagnosed in some women during pregnancy.Gestational diabetes occurs more frequently among African Americans,Hispanic/Latino Americans,and American Indians.It is also more common among obese women and women with
14、 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
15、have a 20%to 50%chance of developing diabetes in the next 5-10 years.,Gestational diabetes,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 f
16、or 1%to 5%of all diagnosed cases of diabetes.,Other types of DM,Latent Autoimmune Diabetes in Adults(LADA)is a form of autoimmune(type1 diabetes)which is diagnosed in individuals who are older than the usual age of onset of type 1 diabetes.Alternate terms that have been used for LADA include Late-on
17、set Autoimmune Diabetes of Adulthood,Slow Onset Type 1 diabetes,and sometimes also Type 1.5 Often,patients with LADA are mistakenly thought to have type2 diabetes,based on their age at the time of diagnosis.,LADA,LADA(cont.),About 80%of adults apparently with recently diagnosed Type 2 diabetes but w
18、ith GAD auto-antibodies(i.e.LADA)progress to insulin requirement within 6 years.The potential value of identifying this group at high risk of progression to insulin dependence includes:the avoidance of using metformin treatmentthe early introduction of insulin therapy,LADA(cont.),MODY Maturity Onset
19、 Diabetes of the YoungMODY is a monogenic form of diabetes with an autosomal dominant mode of inheritance:Mutations in any one of several transcription factors or in the enzyme glucokinase lead to insufficient insulin release from pancreatic-cells,causing MODY.Different subtypes of MODY are identifi
20、ed based on the mutated gene.Originally,diagnosis of MODY was based on presence of non-ketotic hyperglycemia in adolescents or young adults in conjunction with a family history of diabetes.However,genetic testing has shown that MODY can occur at any age and that a family history of diabetes is not a
21、lways obvious.,MODY,MODY(cont.),Within MODY,the different subtypes can essentially be divided into 2 distinct groups:glucokinase MODY and transcription factor MODY,distinguished by characteristic phenotypic features and pattern on oral glucose tolerance testing.Glucokinase MODY requires no treatment
22、,while transcription factor MODY(i.e.Hepatocyte nuclear factor-1alpha)requires low-dose sulfonylurea therapy and PNDM(caused by Kir6.2 mutation)requires high-dose sulfonylurea therapy.,MODY(cont.),Secondary causes of Diabetes mellitus include:Acromegaly,Cushing syndrome,Thyrotoxicosis,Pheochromocyto
23、maChronic pancreatitis,CancerDrug induced hyperglycemia:Atypical Antipsychotics-Alter receptor binding characteristics,leading to increased insulin resistance.Beta-blockers-Inhibit insulin secretion.Calcium Channel Blockers-Inhibits secretion of insulin by interfering with cytosolic calcium release.
24、Corticosteroids-Cause peripheral insulin resistance and gluconeogensis.Fluoroquinolones-Inhibits insulin secretion by blocking ATP sensitive potassium channels.Naicin-They cause increased insulin resistance due to increased free fatty acid mobilization.Phenothiazines-Inhibit insulin secretion.Protea
25、se Inhibitors-Inhibit the conversion of proinsulin to insulin.Thiazide Diuretics-Inhibit insulin secretion due to hypokalemia.They also cause increased insulin resistance due to increased free fatty acid mobilization.,Secondary DM,Prediabetes is a term used to distinguish people who are at increased
26、 risk of developing diabetes.People with prediabetes have impaired fasting glucose(IFG)or impaired glucose tolerance(IGT).Some people may have both IFG and IGT.IFG is a condition in which the fasting blood sugar level is elevated(100 to 125 milligrams per decilitre or mg/dL)after an overnight fast b
27、ut is not high enough to be classified as diabetes.IGT is a condition in which the blood sugar level is elevated(140 to 199 mg/dL after a 2-hour oral glucose tolerance test),but is not high enough to be classified as diabetes.,Prediabetes:Impaired glucose tolerance and impaired fasting glucose,Progr
28、ession to diabetes among those with prediabetes is not inevitable.Studies suggest that weight loss and increased physical activity among people with prediabetes prevent or delay diabetes and may return blood glucose levels to normal.People with prediabetes are already at increased risk for other adv
29、erse health outcomes such as heart disease and stroke.,Prediabetes:Impaired glucose tolerance and impaired fasting glucose(cont.),Diagnosis of Diabetes Mellitus,Values of Diagnosis of Diabetes Mellitus,Research studies have found that lifestyle changes can prevent or delay the onset of type 2 diabet
30、es among high-risk adults.These studies included people with IGT and other high-risk characteristics for developing diabetes.Lifestyle interventions included diet and moderate-intensity physical activity(such as walking for 2 1/2 hours each week).In the Diabetes Prevention Program,a large prevention
31、 study of people at high risk for diabetes,the development of diabetes was reduced 58%over 3 years.,Prevention or delay of diabetes:Life style modification,Studies have shown that medications have been successful in preventing diabetes in some population groups.In the Diabetes Prevention Program,peo
32、ple treated with the drug metformin reduced their risk of developing diabetes by 31%over 3 years.Treatment with metformin was most effective among younger,heavier people(those 25-40 years of age who were 50 to 80 pounds overweight)and less effective among older people and people who were not as over
33、weight.Similarly,in the STOP-NIDDM Trial,treatment of people with IGT with the drug acarbose reduced the risk of developing diabetes by 25%over 3 years.Other medication studies are ongoing.In addition to preventing progression from IGT to diabetes,both lifestyle changes and medication have also been
34、 shown to increase the probability of reverting from IGT to normal glucose tolerance.,Prevention or delay of diabetes:Medications,Management of Diabetes Mellitus,The major components of the treatment of diabetes are:,Management of DM,Diet is a basic part of management in every case.Treatment cannot
35、be effective unless adequate attention is given to ensuring appropriate nutrition.Dietary treatment should aim at:ensuring weight controlproviding nutritional requirementsallowing good glycaemic control with blood glucose levels as close to normal as possiblecorrecting any associated blood lipid abn
36、ormalities,A.Diet,The following principles are recommended as dietary guidelines for people with diabetes:Dietary fat should provide 25-35%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 l
37、ess daily.Protein intake can range between 10-15%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 s
38、hould 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.,A.Diet(cont.),Physical activity promotes weight reduction and improves insulin sensitivity,thus lowering blood glucose levels.Togethe
39、r 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 individuals health status and fitness.People should,however,be educated about the potential risk of hypoglycaemia and how to avoid it.,Exercise
40、,There are currently four classes of oral anti-diabetic agents:i.Biguanidesii.Insulin Secretagogues Sulphonylureasiii.Insulin Secretagogues Non-sulphonylureasiv.-glucosidase inhibitorsv.Thiazolidinediones(TZDs),B.Oral Anti-Diabetic Agents,If glycaemic control is not achieved(HbA1c 6.5%and/or;FPG 7.0
41、 mmol/L or;RPG 11.0mmol/L)with lifestyle modification within 1 3 months,ORAL ANTI-DIABETIC AGENT should be initiated.In the presence of marked hyperglycaemia in newly diagnosed symptomatic type 2 diabetes(HbA1c 8%,FPG 11.1 mmol/L,or RPG 14 mmol/L),oral anti-diabetic agents can be considered at the o
42、utset together with lifestyle modification.,B.1 Oral Agent Monotherapy,As first line therapy:Obese type 2 patients,consider use of metformin,acarbose or TZD.Non-obese type 2 patients,consider the use of metformin or insulin secretagoguesMetformin is the drug of choice in overweight/obese patients.TZ
43、Ds and acarbose are acceptable alternatives in those who are intolerant to metformin.If monotherapy fails,a combination of TZDs,acarbose and metformin is recommended.If targets are still not achieved,insulin secretagogues may be added,B.1 Oral Agent Monotherapy(cont.),Combination oral agents is indi
44、cated in:Newly diagnosed symptomatic patients with HbA1c 10Patients who are not reaching targets after 3 months on monotherapy,B.2 Combination Oral Agents,If targets have not been reached after optimal dose of combination therapy for 3 months,consider adding intermediate-acting/long-acting insulin(B
45、IDS).Combination of insulin+oral anti-diabetic agents(BIDS)has been shown to improve glycaemic control in those not achieving target despite maximal combination oral anti-diabetic agents.Combining insulin and the following oral anti-diabetic agents has been shown to be effective in people with type
46、2 diabetes:Biguanide(metformin)Insulin secretagogues(sulphonylureas)Insulin sensitizers(TZDs)(the combination of a TZD plus insulin is not an approved indication)-glucosidase inhibitor(acarbose)Insulin dose can be increased until target FPG is achieved.,B.3 Combination Oral Agents and Insulin,Diabet
47、es Management Algorithm,Oral Hypoglycaemic Medications,In elderly non-obese patients,short acting insulin secretagogues can be started but long acting Sulphonylureas are to be avoided.Renal function should be monitored.Oral anti-diabetic agent s are not recommended for diabetes in pregnancyOral anti
48、-diabetic agents are usually not the first line therapy in diabetes diagnosed during stress,such as infections.Insulin therapy is recommended for both the aboveTargets for control are applicable for all age groups.However,in patients with co-morbidities,targets are individualizedWhen indicated,start
49、 with a minimal dose of oral anti-diabetic agent,while reemphasizing diet and physical activity.An appropriate duration of time(2-16 weeks depending on agents used)between increments should be given to allow achievement of steady state blood glucose control,General Guidelines for Use of Oral Anti-Di
50、abetic Agent inDiabetes,Short-term use:Acute illness,surgery,stress and emergencies Pregnancy Breast-feedingInsulin may be used as initial therapy in type 2 diabetes in marked hyperglycaemia Severe metabolic decompensation(diabetic ketoacidosis,hyperosmolar nonketotic coma,lactic acidosis,severe hyp
