Diagnosis, classification and prevention of diabetes
Post on 13-Jan-2016
44 Views
Preview:
DESCRIPTION
Transcript
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
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 2 of 48
Definition of diabetes
Characterized by hyperglycaemia
• Defects in insulin production
• Autoimmune or other destruction of beta cells
• Insulin insensitivity
• Impaired action of insulin on target tissues
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 3 of 48
Definition of diabetes
Chronic hyperglycaemia associated with long-term damage to:
• Eyes
• Kidneys
• Nerves
• Heart and blood vessels
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 4 of 48
The diabetes epidemic
• 230 million affected in 2006
• 350 million within 20 years
• Most rapid in Indian and Asian subcontinents
IDF Diabetes Atlas
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 5 of 48
Classification
• Type 1 diabetes
–autoimmune
–LADA
–idiopathic
• Type 2 diabetes
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 6 of 48
Other specific types
• MODY
• Defects in insulin action
• Diseases of the pancreas
• Endocrine disorders
• Drug- or chemical-induced
• Infections
Classification
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 7 of 48
• Uncommon forms of immune-mediated diabetes
• Other genetic syndromes
• Gestational diabetes
Classification
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 8 of 48
Insulin
GluconeogenesisGlycogenolysisGlycogen synthesis
Glucose uptakeGlycogen synthesis
Blood glucose
Insulin and glucose disposal
Free fatty acid release
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 9 of 48
Glucose uptake Glycogenolysis Gluconeogenesis (amino acids) Ketone production (fatty acids)
Glucose uptake Protein degradation amino acids
Blood glucose
Insulin deficiency in type 1 diabetes
Triglyceride degradation fatty acids
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 10 of 48
Glucose uptake
Glycolysis
Gluconeogenesis (amino acids)
Glucose uptake Protein degradation amino acids
Blood glucose
Insulin insensitivity in ttype 2 diabetes
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 11 of 48
Blood glucose
Glucose uptake
Insensitivity to insulin inttype 2 diabetes
Glucose uptake
Glycolysis
Gluconeogenesis (amino acids)
Glucose uptake Protein degradation amino acids
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 12 of 48
Blood glucoseConverted to triglycerides
Effect of insulin resistance in ttype 2 diabetes
Glucose uptake
Glycolysis
Gluconeogenesis (amino acids)
Glucose uptake Protein degradation amino acids
Glucose uptake
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 13 of 48
Pathogenesis of type 1 diabetes
• Immunological activation
• Progressive beta-cell destruction
• Insufficient beta-cell function
• Dependent on exogenous insulin
• Risk of ketoacidosis
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 14 of 48
Pathogenesis of type 1 diabetes
• Genetic susceptibility
• Immune factors– other autoimmune disease– antigen-specific antibodies
• Environmental trigger– viruses– bovine serum albumin– nitrosamines: cured meats– chemicals: vacor (rat poison),
streptozotin
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 15 of 48
Beta-cell mass
Pathogenesis of type 1 diabetes
Time (months - years)
Trigger
Genetic
Pre-diabetes ‘Honeymoon’
Chronic phase
Clinical diabetes
Immunological abnormalities
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 16 of 48
Idiopathic type 1 diabetes
Non-autoimmune type 1 diabetes
• No autoimmune markers
• Permanent insulinopenia
• Ketoacidosis
• People of African and Asian origin
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 17 of 48
Epidemiology of type 1 diabetes
• Increasing in recent years
• Geographic variation
• Relative affluence
• Lack of treatment
IDF Diabetes Atlas
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 18 of 48
• Age of onset peaks
– preschool
– puberty
• Autumn/winter peaks
Epidemiology of type 1 diabetes
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 19 of 48
Type 2 diabetes
• 90%-95% of people with diabetes
• Insulin insensitivity and relative insulin deficiency
• Obesity or overweight
• Complications often present at diagnosis
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 20 of 48
Pathogenesis of type 2 diabetes
• Multiple genes involved
• Hyperinsulinaemia
• Poor fetal nutrition beta-cell formation
• Low birth weight/weight change
• “Thrifty gene”
• 7% beta-cell loss
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 21 of 48
Age (years)
Endogenous insulin
Insulin requirements
Beta-cell loss
The natural history of type 2 diabetes
Insulin requirements with age
Primary failure
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 22 of 48
Age (years)
Endogenous insulin
Insulin requirements
Beta-cell loss
Insulin insensitivity
Hyper-insulinaemia
The natural history of type 2 diabetes
Insulin requirements with age
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 23 of 48
Age (years)
Endogenous insulin
Insulin requirements
Secondary failure
The natural history of type 2 diabetes
Effect of oral drugs
Insulin requirements with age
Beta-cell loss
Hyper-insulinaemia
Insulin insensitivity
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 24 of 48
Epidemiology of type 2 diabetes
• Dramatic increase
• Aging population
• Disturbing trends parallel obesity epidemic
• Especially in adolescents and minority groups
• Increasing in young people
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 25 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?
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 26 of 48
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 macrosomic baby
CDA 2003
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 27 of 48
• Hypertension
• Dyslipidaemia
• Abdominal obesity
• Overweight
• Polycystic ovary disease
• Acanthosis nigricans
• Schizophrenia
Risk factors for type 2 diabetes
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 28 of 48
• Polydipsia
• Polyuria
• Nocturia
• Visual disturbance
• Fatigue
• Weight loss
• Infections
Signs and symptoms
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 29 of 48
Diagnosing diabetes
Normal Impaired fasting glucose*
Impaired glucose tolerance**
Diabetes
FPG <6.1mmol/L
<110mg/dL
6.1 to 6.9mmol/L*
110 to 126mg/dL
≥7.0mmol/L
≥126mg/dL
2hr PG <7.8mmol/L
<126mg/dL
7.8 to 11mmol/L**
126 to 200mg/dL
≥11.1mmol/L
≥200mg/dL
CDA 2003, ADA 2004, WHO 2002
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 30 of 48
Impaired glucose toleranceImpaired fasting glucose
• Intermediate states
• Increased risk of developing diabetes
• Prevention strategies to prevent or delay progression
• Increased risk of cardiovascular disease
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 31 of 48
Uncertain diagnosis:Oral glucose tolerance test
• 75 g glucose load after 8 hours fasting
• Readings taken in fasting state and at 1 and 2 hours
• Possible problems
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 32 of 48
• Urinary ketones
• Antibodies
• C-peptide
Tests for differential diagnosis
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 33 of 48
Metabolic syndrome
• Cluster of risk factors or syndrome
• Type 2 diabetes
• Different criteria
• Three-fold increase in heart disease and stroke
• Two-fold increase in cardiovascular disease deaths
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 34 of 48
Prevention of type 1 diabetes
• Early exposure to cows milk protein
• Nicotinamide
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 35 of 48
Prevention of type 1 diabetes
Insulin
• Diabetes Prevention Trial
• Diabetes Prediction and Prevention Project
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 36 of 48
Prevention of type 2 diabetes
Lifestyle modification
• Da Qing Study
• Finnish Diabetes Prevention Study
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 37 of 48
Prevention of type 2 diabetes
Lifestyle vs medication
• Diabetes Prevention Program
• STOP-NIDDM
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 38 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?
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 39 of 48
Summary
Type 1 diabetes
• Results from progressive beta-cell destruction
• People with type 1 diabetes need insulin therapy to live
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 40 of 48
Type 2 diabetes
• Often characterized by insulin insensitivity and relative rather than absolute insulin deficiency
• A progressive condition
• Most people with type 2 diabetes will need insulin within 5 to 10 years of diagnosis
Summary
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 41 of 48
Review question
1. The pathogenesis for type 2 diabetes includes:
a. Insulin deficiency and insulin insensitivity
b. Insensitivity to insulin and autoimmune beta-cell destruction
c. Autoimmune beta-cell destruction and glucagon deficiency
d. Insulin deficiency and glucagon deficiency
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 42 of 48
Review question
2. A person with type 2 diabetes, recently started on insulin, asks if there is a way to measure if he/she is still producing any insulin. The correct response would be:
a. Islet cell antibody tests
b. C-peptide test
c. HbA1c test
d. Serum insulin test
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 43 of 48
Review question
3. The Diabetes Prevention Program (DPP):
a. Included people with type 1 diabetes
b. Included only people with IGT
c. Tested the value of exercise
d. Included people with type 2 diabetes
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 44 of 48
Review question
4. Type 1 diabetes is usually caused by:
a. Injury to the pancreas
b. An autoimmune reaction
c. Insulin insensitivity in the cells
d. Hypersensitivity to insulin
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 45 of 48
Answers
1. a
2. b
3. b
4. b
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 46 of 48
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 glycaemic control 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.
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 47 of 48
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 with the 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.
Slides current until 2008
Diagnosis and typesCurriculum Module II-1
Slide 48 of 48
References
16. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes UKPDS 38. BMJ 1998; 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.
top related