Diabetes Mellitus in the year 2000. Diabetes Mellitus in the year 2000 Report of the Expert...

Diabetes Mellitus

in the year2000

DiabetesMellitus

in the year2000

Report of the Expert Committee on

the Diagnosis and Classificationof

Diabetes Mellitus

DiabetesMellitus

in the year2000

Definition

Description

Classification

Diagnostic criteria

Testing for diabetes

DefinitionDiabetes Mellitus is a group of metabolic disease characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.

The chronic hyperglycemia of diabetes is associated with log-term damage, dysfunction, and failure of various organs, especially the eyes, Kidneys, nerves, heart, and blood vessels.

Description

Insulin deficiency

Blood glucose

Insulin resistance

Symptoms: Polyuria and polydipsia.Weight loss with polyphagia.Blurred vision.Infection susceptibility.DKA or NKHS.

Types&

Stages

Type 1

Type 2

Other SpecificTypes

Diabetes MellitusNot Insulin Insulin insulin requiring requiring

requiring for control for survival

Impaired Glucose Toleranceor

Impaired Fasting Glucose

Normalglucose

regulation

These patients can briefly return to normoglycemia

Type 1 diabetes presenting in pregnancy may require insulin for survival

HyperglycemiaNormal

Stages

Types

Gestational Diabetes

Vacor toxicity may require insulin for survival

Stage&

Aetiology

Islet cell destruction:AutoimmuneIdiopathic

Predominantly insulinresistancePredominantly insulin secretorydefects

Other specific disorders( eg MODY, Endocrinopathies )

Diabetes Mellitus

Not Insulin Insulin insulin requiring requiring

requiring for control for survival

Impaired Glucoseand / or fasting hyperglycemia

Normal glucosetolerance

( achieved without Pharmacological agents)

HyperglycemiaNormal

Aetiology

Gestational Diabetes

Type 2 diabetes

Other specific types of diabetes

Gestational diabetes

Type 1 diabetes

Etiologicclassification

of

diabetesmellitus

II- Type 2 diabetes.

III- Other specific types.

IV- Gestational diabetes mellitus.

I- Type 1 diabetes:


of

diabetesmellitus

I- Type 1 diabetes:

A. Immune mediated:

Cellular-mediated autoimmunity.

Markers:Islet cell autoantibodies ( ICAs ).Autoantibodies to insulin ( IAAs ).Autoantibodies to glutamic acid decarboxylase ( GAD ).Autoantibodies to the tyrosine phosphatase IA-2 and IA-2B.

HLA:HLA-DR/DQ alleles can be eitherpredisposing or protective. Beta cell

B lymphocyte T lymphocyte


of

diabetesmellitus

I- Type 1 diabetes:

Multiple genetic:

Graves’ diseaseHashimoto’s thyroiditisAddison’s diseaseVitiligoPernicious anemia

Autoimmune destruction

Environmental:

Viral infectionObesity


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diabetesmellitus

I- Type 1 diabetes:

Beta cell destruction:

Rapid infants and childrenSlow adults

Presentation:

DKA children and adolescentsHyperglycemia adultsHyperglycemia to DKA Adults

Presentation


of

diabetesmellitus

I- Type 1 diabetes:

B. Idiopathic:

No autoimmunityDKAMinority of patientsStrongly inheritedNo HLA associationInsulin requirement may come and go


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diabetesmellitus


Pathology:

•Relative insulin deficiency ( initially).

•No Autoimmune destruction of -cell.

•Obesity ( insulin resistance ).

•No DKA (some times with stress ie infection).

•Pass undiagnosed.

•Macro- & micro-vascular complications.

•Insulin is normal or high.


of

diabetesmellitus


Risk factors:

AgeObesityLack of physical activity

WomenH/O G.D.MHypertensionDyslipidemiaEthnic and racial subgroupsStrong genetic predisposition

Diabetes


of

diabetesmellitus


Genetic defects of -cell function:Chromosome 12, HNF-1 (MODY3)Chromosome 7, glucokinase (MODY2)Chromosome 20, HNF-4 (MODY1)Mitochondrial DNAOthers

Genetic defects in insulin action:Type A insulin resistanceLeprechaunismRabson-Mendenhall syndromeLipoatrophic diabetesOthers

Disease of the exocrine pancreas:PancreatitisTrauma/pancreatectomyNeoplasiaCystic fibrosisHemochromatosisFibrocalculous pancreatopathyOthers


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diabetesmellitus


Endocrinopathies:AcromegalyCushing’s syndromeGlucagonomaPheochromocytomaHyperthyroidismSomatostatinomaAldosteronomaOthers

Drug or chemical-induced:VacorDilantinThiazidesDiazoxideNeoplasiaPentamidine - interferonNicotinic acidCystic fibrosisGlucocorticoidsThyroid hormoneHemochromatosis -adrenergic agonistsFibrocalculous pancreatopathyOthers


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diabetesmellitus


Infections:Congenital rubellaCytomegalovirusOthers

Uncommon forms of immune-mediated diabetes:“ Stiff-man “ syndromeAnti-insulin receptor antibodiesOthers

Other genetic syndromes some times associated with diabetes:Down’s syndromeKlinefelter’sTurner’s syndromeWolfram’s syndromeFriedreich’s ataxiaHuntington’s choreaLaurence-Moon-Biedl syndromeMyotonic dystrophyPorphyria Prader-Willi syndrome Others


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diabetesmellitus


Definition:Any degree of glucose intolerance with onset or first recognition during pregnancy.

Prevalence:- 1 ~ 14% of the total pregnancies.- 90% of pregnancies complicated by diabetes.

Importance:- Perinatal morbidity and mortality- Maternal complications- Risk factor for glucose intolerance


of

diabetesmellitus


Diagnostic criteria:

1964 O’Sullivan and Mahan

1979 NDDG (National Diabetes Data Group)

1997 American Diabetes Association’s Fourth International Workshop-Conference on Gestational Diabetes Mellitus.


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diabetesmellitus


Screening

American Diabetes Association’s (1997) fourth international workshop-conference on gestational diabetes recommendations

Screen all pregnant women( 24-28 weeks of gestation )

Excluding:Low risk group:

< 25 years of ageNormal body weight- ve family history- ve H/O abn. glucose metabolismH/O poor obstetric outcomeEthnic group of low diabetes risk

Including:High risk group:

Marked obesityH/O GDMGlycosuriaStrong FH

Including:Average risk group:


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diabetesmellitus


Screening


Low risk group:

No screening

Average risk group:

Two step approach

High risk group:

One step approach

Glucose Challenge TestGCT

( 50 gm oral glucose load )Glucose after 1hr

Oral Glucose Tolerance Test

OGTT75 or 100

FBS, 1hr, & 2hrs

Glucose Challenge TestGCT

( 50 gm oral glucose load )Glucose after 1hr

Oral Glucose Tolerance Test

OGTT75 or 100

FBS, 1hr, & 2hrs


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diabetesmellitus


Screening


Low risk group:

No screening

Average risk group:

Two step approach

High risk group:

One step approach

Oral Glucose Tolerance TestOGTT

75 or 100FBS, 1hr, & 2hrs

Oral Glucose Tolerance TestOGTT

75 or 100FBS, 1hr, & 2hrs


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diabetesmellitus


Diagnostic criteria

mg/dl mmol/lFasting 95 5.31-h 180 10.02-h 155 8.63-h 140 7.8

mg/dl mmol/lFasting 95 5.31-h 180 10.02-h 155 8.6

100-g Glucose load

75-g Glucose load


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diabetesmellitus

Impaired glucose tolerance IGTImpaired fasting glucose IFG

IGT WHO criteria IGF FPG = 110 - 126 mg/dL

6.1 - 7.0 mmol/L

Normal DiabeticIGTIGF

Why


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diabetesmellitus


Prevalence of Retinopathy by DecilesNHANES III

0

5

1 0

1 5

FPG 90 93 96 98 101 104 109 1202h PG 86 94 102 112 120 133 154 195HbA1c 5.1 5.2 5.4 5.5 5.6 5.7 5.9 6.2

Diabetes Care 1997;20, 1183-1197

Re

tin

opa

thy

%Prevalence of Retinopathy by Deciles

Pima Indians

0

5

1 0

1 5

FPG 93 97 100 105 109 11 6 136 2262h PG 106 11 6 126 138 156 185 244 364HbA1c 5.0 5.2 5.3 5.5 5.7 6.0 6.7 9.5

Diabetes Care 1997;20, 11 83-11 97

Retin

op

ath

y %

Prevalence of Retinopathy by DecilesEgyptians

0

5

1 0

1 5

FPG 84 89 93 99 108 130 178 2582h PG 90 99 110 125 155 218 304 386HbA1c 4.9 5.1 5.4 5.6 6.0 6.9 8.5 10.3

Diabetes Care 1997;20, 1183-1197

Re

tin

opa

thy

%


of

diabetesmellitus


• They are known risk factors for future diabetes and cardiovascular disease.

• Intermediate stage for all types of diabetes.

• Associated with insulin resistance syndrome or :

Syndrome X :Insulin resistanceHyperinsulinemiaObesityDyslipidemia ( high triglyceride and/or low HDL )

Hypertension


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diabetesmellitus

Diagnostic criteria for diabetes mellitusThe new criteria

1

2

3

Fasting plasma glucose ( FPG ) at least 8hours fast

= or > 126 mg/dL ( 7.0 mmol/L )

Two hours plasma glucose (2PG ) after 75 anhydrous glucose in water

= or > 200 mg/dL ( 11.1 mmol/L )

Symptoms of diabetes ( polyuria, polydepsia, and weight loss )

+Random Blood Sugar ( RBS )

casual plasma glucose

= or > 200 mg/dL ( 11.1 mmol/L )


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diabetesmellitus

Impaired fasting glucose IFG

For epidemiological studies FPG is:standardization

FacilitationCheep

Diagnosis New criteria WHO criteria

mg/dL mmol/L mg/dL mmol/L

Normal <110 <6.1 < 140 < 7.8

IFG / IGT 110 - <126 6.1- < 7.0 140 - < 200 7.8 - <11.1

? DM = or > 126 = or > 7.0 = or > 200 = or > 11.1

8 hours over night fast. 2 hours post 75 gm glucose load.


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diabetesmellitus

Old and new diagnostic criteria

The criteria New case Diabetes Discovered Prevalence

Known cases No 7.92%

WHO criteria 6.34% 14.26%

New criteria 4.35% 12.27%

Data from NHANES III for individuals 40-74 years old.

The new criteria will lead to 14% ( slightly ) lower estimates of diabetes prevalence.

- 1.99

14%


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diabetesmellitus

Testing healthy individuals

Type 1 diabetes:More than one antibodies ( ICA, IAA, GAD, IA-2 )No effective method can prevent or delay the disease

Screening is not cost-effective

Type 2 diabetes:50% of type 2 are undiagnosed Chronic complications precede diabetes ( Retinopathy 7 years )

Risk factors


of

diabetesmellitus

HbA1c

Not recommended for diagnosis of diabetes,but valuable for glycemic control of diabetes.


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diabetesmellitus

Criteria for testing asymptomatic individuals

• All individual above 45 years of age every 3 years

• Any individual with:

Obese ( > 120% desirable weight or BMI > 27 ).

+ve F/H first degree relatives.

High risk ethnic population.

H/O GDM or big baby ( > 9 lb ).

Hypertension > 140/90

HDL < 35mg/dl ( 0.9 mmol/l ) ±

Triglyceride > 250mg/dl ( 2.82 mmol/l )

Known to have IGT or IFG

Diabetes Mellitus in the year 2000. Diabetes Mellitus in the year 2000 Report of the Expert...

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