SCREENING & PREVENTION

FOR TYPE 2 DIABETES MELLITUS

dr. Limdawati Kwee, SpPD., FPCP

Faculty of Medicine - Maranatha Christian University
SCREENING FOR TYPE 2
DIABETES MELLITUS
T2DM Prevalence in Indonesia: 5.7%

73.7% were undiagnosed

73.7 26.3 26.3

Undiagnosed Diagnosed

Indonesian National Health Survey 2007.

Epidemiology of prediabetes

 USA in 2012 : 86 million adults

 Older than 20 years-old : 37%
 Older than 65 years-old : 51%
 Worldwide (2010) :
 South East Asia : 5.8%
 North American : 11.4 %
 Worldwide (2035) : 471 million

Nidhi B. Prediabetes Diagnosis And Treatment : a Review.

World Journal of Diabetes 2015 March 15; 6(2): 296-303
Health risk associated with prediabetes

 Progression to diabetes
 Annual incidence rate : 7 – 11%
 Nephropathy and kidney disease
 Increased risk of CKD and early nephropathy
 Neuropathies
 Dysfunction of cardiac autonomic activity
 Male erectile dysfunction
 Diabetic retinopathy (8%)
 Macrovascular diseases : unclear
Nidhi B. Prediabetes Diagnosis And Treatment : a Review.
World Journal of Diabetes 2015 March 15; 6(2): 296-303
 Screening

• Screening is recommended to identify people

with previously undiagnosed diabetes so that
they get appropriate care

• Observational studies demonstrate that people

diagnosed as a result of screening have better
outcomes than those presenting spontaneously
with diabetes

Pramono LA et al. Acta Med Indones 2010;42(4):216-23.

Medical Management of Type 2 Diabetes, 7th Edition.
 Screening

 Screening is conducted on those who are

at risk for diabetes but show no symptoms

 Screening seeks to capture undiagnosed T2DM or

pre-diabetes so it can be managed earlier/ more
appropriately
 Mass screening is not recommended due to cost

PERKENI Consensus Guidelines, 2011.

 Case 1

 25 years-old female
 With no diabetic symptoms
 Healthy diet
 Has regular exercise
 BMI 23 kg/m2
 Family history : DM -- father

Do we need to screen this patient for DM ?

 Who Should Be Screened?

1. Overweight people (BMI ≥ 23 kg/m2) and have

additional risk factor(s)

2. In the absence of these criteria, screening for

diabetes should begin at age 45 years

ADA, Medical Management of Type 2 Diabetes, 7th Edition, 2012.

Risk factors

 Sedentary lifestyle  Hypertension

 DM in 1st degree  HDL < 35 mg/dL and
relative /or TG > 250 mg/dL
 Race : Pacific Islander,  PCOS
Asian, African,  Prediabetes (IFG / IGT)
Hispanic, Native  Morbid obesity,
American ancestry
achantosis nigrikans
 Gestational DM or
 History of CVD
deliver baby > 4 kgs
 How often DM screening should
be done ?
 Every three years

 In prediabetes, every one year

What to be measured in DM
screening ?
 Vein plasma vs capillary blood ??

No DM Probable DM DM

Random blood sugar Vein plasma < 100 100 – 199 ≥ 200

Capillary blood < 90 90 – 199 ≥ 200

Fasting blood sugar Vein plasma < 100 100 – 125 ≥ 126

Capillary blood <90 90- 99 ≥ 100

 Case 2

 35 years-old female
 BMI 26 kg/m2
 Diagnosed with Polycystic Ovary Syndrome
 No hypertension / dyslipidemia
 No family history of DM

Do we need to screen this patient for DM ?

 Case 3

 50 years old male

 BMI 22.5 kg/m2
 Healthy diet and lifestyle
 No comorbid
 No family history of DM

Do we need to screen this patient for DM ?

 Case 4

 45 year-old female
 BMI 23 kg/m2
 Triglyceride level 260 mg/dL
 No other comorbid
 Family history of DM (grandmother)

Do we need to screen this patient for DM ?

 Case 5

 54 years-old male
 BMI 24.5 kg/m2
 No symptoms of diabetes
 Comorbid : hypertension, CAD
 No family history of DM

Do we need to screen this patient for DM ?

Primary prevention for DMT2

 Lifestyle intervention
 Diet
 Exercise
 Behaviour change intervention
 Obesity management

 Pharmacological intervention

Wu Y et al. Risk Factors Contributing to Type 2 Diabetes and Recent

Advances in the Treatment and Prevention. Int J Med Sci. 2014;
11(11): 1185–1200.
ADA Standards of Medical Care In Diabetes - 2018
Intensive lifestyle intervention

 Finnish Diabetes Prevention Study (2006) :

43% reduction at 7 years
 Da Qing study (2008) :
43% reduction at 20 years
 U.S. Diabetes Prevention Program Outcomes
Study (2015) :
 34% reduction at 10 years
 27 % reduction at 15 years

 Overall : 58% reduction of type 2 DM over 3 years

ADA Standards of Medical Care In Diabetes - 2018

7% weight loss in the first 6 months

 Calorie goals = Daily calories needed to maintain the

participant’s initial weight and subtracting 500–1,000
calories/day (depending on initial body weight).

 Reduce total dietary fat  restrict total calories

 Every 1 kg weight loss  reduced type 2 DM by 16 %

Nidhi B. Prediabetes Diagnosis And Treatment : a Review.

World Journal of Diabetes 2015 March 15; 6(2): 296-303
Nutrition in DM

DO’S DONT’S
Vegetables Red meat
Fruits Highly processed foods
Low saturated fat – plant Refined grains
source :
Nut, legumes
Fish, seafood Sugar – sweetened
beverages
Unrefined grain products
Prevention and Management of Type 2 Diabetes: Dietary Components and
Nutritional Strategies. Sylvia H. L et al. Lancet. 2014 June 7; 383(9933):
1999–2007. doi:10.1016/S0140-6736(14)60613-9.
Prevention and Management of Type 2 Diabetes: Dietary Components and
Nutritional Strategies. Sylvia H. L et al. Lancet. 2014 June 7; 383(9933):
1999–2007. doi:10.1016/S0140-6736(14)60613-9.
Exercise

 Reduce the development of DM up to 30 –

50%
 Goal : 700 kcal/week
 150 minutes of moderate-intensity physical
activity per week divided in 3 – 4x session per
week (10 – 30 minutes)
Behaviour change intervention

 Motivational interviewing
 Filling out decisional balance sheets
 Goal setting
 Developing action plans
 Barrier identification : Continuity
 Relapse prevention
Technology assistance

 Mobile applications for weight loss and diabetes

prevention have been validated for their ability
to reduce A1C in the setting of prediabetes

 The Centers for Disease Control and Prevention

(CDC) Diabetes Prevention Recognition Program
(DPRP)
(http://www.cdc.gov/diabetes/prevention/recogn
ition/index.htm)
Pharmacological Intervention
 Metformin
 45% risk reduction of type 2 DM
 Benefit >> in high BMI and high FPG

 Pioglitazone
 ACTNOW study
 70% risk reduction of type 2 DM in obese patients
 Safety concern :
 Edema and weight gain (13%)
 Liver toxicity
 Increased cardiovascular risks

Nidhi B. Prediabetes Diagnosis And Treatment : a Review.

World Journal of Diabetes 2015 March 15; 6(2): 296-303
Pharmacological Intervention
 α - glucosidase inhibitor
 STOP-NIDDM trial
 25% risk reduction of type 2 DM
 Side effect : GI upset, flatulence, diarrhea

 GLP-1 analogue
 Reduce prevalence of pre diabetes over 1 – 2 years
follow up
 Side effect : nausea, vomiting
 Injectable preparation
Nidhi B. Prediabetes Diagnosis And Treatment : a Review.
World Journal of Diabetes 2015 March 15; 6(2): 296-303
Pharmacological Intervention
 Anti obesity : Orlistat
 Lipase inhibitor  decrease absorption of fat
 XENDOS trial
 37% risk reduction of type 2 DM over 4 years
 Side effect : GI upset, flatulence, diarrhea

Nidhi B. Prediabetes Diagnosis And Treatment : a Review.

World Journal of Diabetes 2015 March 15; 6(2): 296-303
Pharmacological Intervention

ADA Standards of Medical Care In Diabetes - 2018

 CONCLUSION
 Screening seeks to capture undiagnosed T2DM
or pre-diabetes so it can be managed earlier.
 Overweight with risk factors or age > 45 years-
old should have screening for DM
 Screening should be done every 3 years, but
every year in prediabetes.
 The mainstay of primary prevention for DMT2 is
intensive lifestyle interventions