1 - 1 Diagnosis, Classification and Prevention

Diagnosis, classification and prevention of diabetes
Section 1 | 1 of 4 Curriculum Module II1 | Diagnosis, classification and presentation of diabetes
Slides current until 2008
Diagnosis and types
Definition of diabetes
Curriculum Module II-1 Slide 2 of 48
Characterized by hyperglycaemia
Defects in insulin production Autoimmune or other destruction of beta cells Insulin insensitivity
Impaired action of insulin on target tissues

Diagnosis and types
Definition of diabetes
Chronic hyperglycaemia associated with long-term damage to:

Eyes
Kidneys
Nerves
Heart and blood vessels
Diagnosis and types
The diabetes epidemic
230 million affected in 2006

350 million within 20 years Most rapid in Indian and Asian subcontinents
IDF Diabetes Atlas

Diagnosis and types
Classification
Type 1 diabetes
autoimmune LADA idiopathic Type 2 diabetes
Diagnosis and types
Classification
Other specific types MODY Defects in insulin action
Diseases of the pancreas

Endocrine disorders Drug- or chemical-induced
Infections
Diagnosis and types
Classification
Uncommon forms of immunemediated diabetes Other genetic syndromes Gestational diabetes
Diagnosis and types
Insulin and glucose disposal
Gluconeogenesis Glycogenolysis Glycogen synthesis Insulin
Blood glucose
Glycogen synthesis
Glucose uptake Free fatty acid release

Diagnosis and types
Insulin deficiency in type 1 diabetes
Glucose uptake Glycogenolysis Gluconeogenesis (amino acids) Ketone production (fatty acids)
Blood glucose
Glucose uptake Protein degradation amino acids

Triglyceride degradation fatty acids
Diagnosis and types
Insulin insensitivity in type 2 diabetes

Glucose uptake
Glycolysis
Gluconeogenesis (amino acids)
Blood glucose
Glucose uptake Protein degradation amino acids

Diagnosis and types
Insensitivity to insulin in type 2 diabetes

Glucose uptake Glycolysis
Blood glucose
Glucose uptake Protein degradation amino acids Glucose uptake

Diagnosis and types
Effect of insulin resistance in type 2 diabetes

Glucose uptake Glycolysis
Blood glucose
Converted to triglycerides
Glucose uptake Protein degradation amino acids Glucose uptake

Diagnosis and types
Pathogenesis of type 1 diabetes Immunological activation
Progressive beta-cell destruction Insufficient beta-cell function Dependent on exogenous insulin Risk of ketoacidosis
Diagnosis and types
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
Diagnosis and types

Trigger Immunological abnormalities
Genetic Beta-cell mass
Clinical diabetes
Pre-diabetes Honeymoon Chronic phase Time (months - years)
Diagnosis and types
Idiopathic type 1 diabetes
Non-autoimmune type 1 diabetes

No autoimmune markers Permanent insulinopenia Ketoacidosis People of African and Asian origin
Diagnosis and types
Epidemiology of type 1 diabetes
Increasing in recent years Geographic variation Relative affluence
Lack of treatment
IDF Diabetes Atlas

Diagnosis and types
Age of onset peaks preschool
puberty
Autumn/winter peaks
Diagnosis and types
Type 2 diabetes
90%-95% of people with diabetes Insulin insensitivity and relative insulin deficiency Obesity or overweight Complications often present at diagnosis
Diagnosis and types
Multiple genes involved Hyperinsulinaemia
Poor fetal nutrition beta-cell formation

Low birth weight/weight change Thrifty gene 7% beta-cell loss
Diagnosis and types
The natural history of type 2 diabetes
Beta-cell loss Insulin requirements Primary failure
Insulin requirements with age Endogenous insulin
Age (years)
Diagnosis and types

Beta-cell loss
Hyperinsulinaemia
Insulin requirements
Insulin insensitivity
Age (years)
Diagnosis and types

Beta-cell loss Hyperinsulinaemia Secondary failure Effect of oral drugs
Insulin requirements
Insulin insensitivity
Age (years)
Diagnosis and types
Dramatic increase Aging population
Disturbing trends parallel obesity epidemic

Especially in adolescents and minority groups Increasing in young people
ACTIVITY
Diagnosis and types

What are the most common risk factors for type 2 diabetes for people in your country?
Are any of these risk factors modifiable?
Diagnosis and types
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
Diagnosis and types
Risk factors for type 2 diabetes Hypertension

Dyslipidaemia Abdominal obesity
Overweight
Polycystic ovary disease
Acanthosis nigricans
Schizophrenia
Diagnosis and types
Signs and symptoms Polydipsia

Polyuria Nocturia
Visual disturbance
Fatigue
Weight loss
Infections
Diagnosis and types
Diagnosing diabetes
Normal
Impaired fasting glucose*

Impaired glucose tolerance**
Diabetes
FPG
<6.1mmol/L
6.1 to 6.9mmol/L*
7.0mmol/L
<110mg/dL
2hr PG <7.8mmol/L <126mg/dL
110 to 126mg/dL
7.8 to 11mmol/L** 126 to 200mg/dL
126mg/dL
11.1mmol/L 200mg/dL
CDA 2003, ADA 2004, WHO 2002

Diagnosis and types
Impaired glucose tolerance Impaired fasting glucose

Intermediate states
Increased risk of developing diabetes Prevention strategies to prevent or delay progression
Increased risk of cardiovascular disease

Diagnosis and types
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
Diagnosis and types
Tests for differential diagnosis
Urinary ketones Antibodies C-peptide
Diagnosis and types
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
Diagnosis and types
Prevention of type 1 diabetes
Early exposure to cows milk protein
Nicotinamide
Diagnosis and types
Insulin Diabetes Prevention Trial Diabetes Prediction and Prevention Project
Diagnosis and types
Lifestyle modification
Da Qing Study Finnish Diabetes Prevention Study
Diagnosis and types
Lifestyle vs medication
Diabetes Prevention Program STOP-NIDDM
ACTIVITY
Diagnosis and types

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?
Diagnosis and types
Summary
Type 1 diabetes
Results from progressive betacell destruction
People with type 1 diabetes need insulin therapy to live
Diagnosis and types
Summary
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
Diagnosis and types
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
Diagnosis and types
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
Diagnosis and types
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
Diagnosis and types
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
Diagnosis and types
Answers
1. a
2. b 3. b 4. b
Diagnosis and types
References
1. 2.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2004; 27(suppl 1): S5-S10. 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). 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. 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. 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. 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. 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.
3. 4.
5.
6.
7.
Diagnosis and types
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.
10. 11.
Diabetes Atlas 2006. Brussels: International Diabetes Federation, 2006.

Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care 2001; 24(4): 683-9. 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. 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. 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. The Diabetes Prevention Program Research Group. The diabetes prevention Program (DPP). Diabetes Care 2002; 23(12): 2165-71. 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.
12.
13.
14. 15.
Diagnosis and types
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. IDF Clinical Guidelines Task Force. Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation, 2005. 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.
17. 18.

1 - 1 Diagnosis, Classification and Prevention

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Diagnosis, classification and prevention of diabetes

Section 1 | 1 of 4 Curriculum Module II1 | Diagnosis, classification and presentation of diabetes

Slides current until 2008

Diagnosis and types

Curriculum Module II-1 Slide 2 of 48

Impaired action of insulin on target tissues

Diagnosis and types

Curriculum Module II-1 Slide 3 of 48

Chronic hyperglycaemia associated with long-term damage to:

Heart and blood vessels

Slides current until 2008

Diagnosis and types

The diabetes epidemic

Curriculum Module II-1 Slide 4 of 48

230 million affected in 2006

IDF Diabetes Atlas

Diagnosis and types

Curriculum Module II-1 Slide 5 of 48

Slides current until 2008

Diagnosis and types

Curriculum Module II-1 Slide 6 of 48

Diseases of the pancreas

Slides current until 2008

Diagnosis and types

Curriculum Module II-1 Slide 7 of 48

Uncommon forms of immunemediated diabetes Other genetic syndromes Gestational diabetes

Slides current until 2008

Diagnosis and types

Insulin and glucose disposal

Curriculum Module II-1 Slide 8 of 48

Gluconeogenesis Glycogenolysis Glycogen synthesis Insulin

Glucose uptake Free fatty acid release

Diagnosis and types

Insulin deficiency in type 1 diabetes

Curriculum Module II-1 Slide 9 of 48

Glucose uptake Protein degradation amino acids

Diagnosis and types

Insulin insensitivity in type 2 diabetes

Curriculum Module II-1 Slide 10 of 48

Glucose uptake Protein degradation amino acids

Diagnosis and types

Insensitivity to insulin in type 2 diabetes

Curriculum Module II-1 Slide 11 of 48

Gluconeogenesis (amino acids)

Glucose uptake Protein degradation amino acids Glucose uptake

Diagnosis and types

Effect of insulin resistance in type 2 diabetes

Curriculum Module II-1 Slide 12 of 48

Gluconeogenesis (amino acids)

Glucose uptake Protein degradation amino acids Glucose uptake

Diagnosis and types

Pathogenesis of type 1 diabetes Immunological activation

Curriculum Module II-1 Slide 13 of 48

Diagnosis and types

Pathogenesis of type 1 diabetes

Curriculum Module II-1 Slide 14 of 48

Diagnosis and types

Pathogenesis of type 1 diabetes

Curriculum Module II-1 Slide 15 of 48

Genetic Beta-cell mass

Diagnosis and types

Idiopathic type 1 diabetes

Curriculum Module II-1 Slide 16 of 48