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Diabetes

Mellitus
The hype, the harm, the hope…

Dr. Marian K. Denopol


Diabetologist
Epidemiology of
Diabetes
Diabetes: The Global
Threat

1995 2000 2010

Type 1 3.5 million 4.4 million 5.5 million


Type 2 114.8 million 146.8 million 215.3 million

TOTAL 118.4 151.2 220.7


million million million
Geographic Prevalence of Type
2 Diabetes

Prevalence (%)
No data
available
<2
2 – 4.99
5 – 7.99
8 – 10.99
11 – 13.99
> 14
The morbidity and
mortality of
diabetes mellitus
 Diabetes mellitus is a major cause of:
 Blindness in the Western world
 Kidney failure requiring dialysis and
kidney
transplant
 Non-traumatic amputation
 Cardiovascular disease
 7th leading cause of mortality
Diabetes in the
Philippines
 Diabetes Prevalence Survey 1982
 Age group 20 – 65 = 4.1 %

 Metro Manila = 8.4 %

 Urban areas = 6.8 %

 Rural areas = 2.5 %


Characteristics of Type 1
and
Type
Type 1
2 Diabetes
Type
2

Fast onset Slow


of disease develop
ment
Prevalence
0.5% Prevalen
ce
young 5-10%
adult
Pathophysiology of Type 2
Diabetes: 2 Defects
Genes Genes

Impaired Insulin Insulin Resistance


Secretion

± Environment ± Environment

IGT IGT

Type 2 Diabetes

IGT = Impaired Glucose Tolerance


Development of Type 2
Diabetes
Stage 3:
Type 2
diabetes
Macroangiopathy Microangiopathy
Stage 2: Postprandial BG
Impaired Gluconeogenesis
glucose
tolerance Glucose transport
Insulin secretion deficiency
Stage 1: Lipogenesis/ Atherogenesis Triglycerides
Normal Adiposis
Hyperinsulinaemia HDL cholesterol
glucose
tolerance Waist-to-hip ratio Insulin resistance Arterial
hypertension
Diabetes genes

Matthaei S et al. Endocr Rev (2000): 21 (6): 58


Postprandial plasma glucose
hypothesis
Two open questions

Is postprandial plasma
glucose a driving force...

in the in the
pathogenesis of development of
type 2 diabetes? CV events?
Multiple mechanisms of
vascular damage
associated with dysglycaemia
Insulin resistance
 FFA Lipaemia Obesity
Pancreas Skeletal
Hyper- muscles Adipo-
insulinaemia TNF-α cytes

FFA
Hypertension Dyslipidaemia
VLDL ( triglycerides)
Advanced C-reactive
Genetic
glycation protein HDL
predisposition  Fibrinogen
end products
PAI-1
Hyperglycaemia Liver
Glycated
protein Thrombosis

FFA: free fatty acid; HDL: high-density lipoprotein,


PAI: plasminogen activator inhibitor, TNF: tumour Libby P, et al. Circulation 2002;106:2760–63.
necrosis factor, VLDL: very low-density lipoprotein
Classification of Diabetes
 Type 1 diabetes
 Beta cell destruction
 Usually autoimmune
 Type 2 diabetes
 Insulin resistance and insulin secretion
defect
 Impaired glucose tolerance (IGT)
 Metabolic stage intermediate between
normal
glucose homeostasis and diabetes
 Considered as a risk factor for the
development of
diabetes and cardiovascular disease
 Gestational Diabetes
Glucose Tolerance
Categories
Diagnosis of Type 2 Diabetes:
Who should be screened?
 All adults > 45, and, if normal, at 3-year
intervals
 Younger age and more frequently for those at
higher risk:
 Obese (> 20% above ideal body weight)
 1st degree relative with diabetes
 High-risk ethnic group
 History of gestational diabetes or
delivered baby > 9 lb.
 Hypertension (BP 140/90 mm Hg)
 Dyslipidemia (HDL <35 mg/dl and/or
triglyceride > 250
mg/dl)
Risk Factors for Development
of Type 2 DM
 Genetic Factors  Environmental
Factors
 Family History
 Race  Age > 45 years
 Obesity ≥ 130%
of IBW
 Gestational DM
 IGT
 Lifestyle
Changing Therapies to Address
Diabetes Progression
Therapies to address Type 2 DM progression

Insulin with or
Lifestyle Mono Combination of
Oral agents
without oral
change theraphy agents
Diabetic Secondary
Complications: Overview

Macro-
angiopathy

Micro-
angiopathy

Metabolic-toxic
damage
(neuropathy)
Macrovascular
complications
Cerebrovascular Stroke (22%*)
circulation
Angina
Coronary MI (34.7%*)
Sudden death
arteries
Renal damage
Renal
arteries

Peripheral vascular
Peripheral disease
arteries Gangrene
and amputation (2.7%*)

*Causes of death in diabetic population


MI: myocardial infarction
Diabetes
Management
Managing Your Diabetes

• Diet
• Exercise
• Medications
• Monitoring
• Education
Diabetes is Devastating
and Deadly
• Leading cause of blindness in adults

• Cardiovascular disease and stroke 2 –


4x

• Leading cause of end-stage renal


disease

• Amputations
Diabetes is the 4t15
h
– 40x cause of death by
leading
disease; 7th leading cause of death in US.
Why take action
Each year, about 160,000 people
die from diabetes and its complications.
• Cardiovascular disease: 75% of
deaths
• Stroke: risk is 2.5x higher
• Hypertension: 60-65% risk
• Kidney disease: 19-34% of diabetes
population
• Blindness: 14-40% of diabetes
population
• Amputations: 50% of diabetes
Management Algorithm for
Overweight and Obese Type 2
Diabetes Mellitus
Diet, Failure

Add biguanide, TZD, or α -glucosidase inhibitor


Exercise,
Failure

and Weight Combine two of these or add sulphonylurea


or glinide
Check
Control* Failure Adherance
at
each step
Add insulin OR change to insulin**

Reference: Type 2 Diabetes Practical Targets & Treatments, 3rd Ed.


TZD=thiazolidinedione
Asian
*If control Pacific
is poor, Type may
oral agents 2 Diabetes
be startedPolicy Group.
early.**In certain situations, insulin may be required.
Management Algorithm for
Normal Weight Type 2 Diabetes
Mellitus
Diet, Failure

Add sulphonylurea, biguanide, α -glucosidase


Exercise, inhibitor or glinide
Failure

and Weight
Combine sulphonylurea or glinide with
biguanide and/or α -glucosidase
Control* inhibitor and/or add TZD** Check
Failure
Adherance
at
Add insulin OR change to insulin***
each step

TZD=thiazolidinedione
*If control is poor, oral agents may be started early.**Use of TZD may be appropriate earlier in
Patients with features of metabolic syndrome.***In certain situations, insulin may be required.
Approximately 10% of patients on
oral agents have secondary
failure each year: When glycemic
goals are not achieved with oral
agents, treatment with insulin is
indicated.
HIGH BLOOD SUGAR
It can be caused by:
• Eating too much

• Taking too little


diabetes medicine

• Being sick or hurt


HIGH BLOOD SUGAR
How it may feel:

Blurry vision.
Thirsty, dry throat.

Always very tired.


Frequent urination.
HIGH BLOOD SUGAR
What to do:
• Check your urine or
blood sugar and check
for ketones
• Follow your plan for food
and medicine very
carefully. Drink plenty of
water
• Call the doctor if:
▫ Sugar over 240 or urine
sugar over 2%
▫ Moderate to large
ketones
▫ Vomiting or unable to
eat or drink
Healthy Eating
*
• Eat meals at same time
each day
• Don’t skip meals
• Use less
▫ Fat • Sugar
▫ Salt • Alcohol
• Eat about the same
amounts of
carbohydrate food each
day.
• Learn about healthy
eating from your
nutritionist or diabetes
educator
Exercise and Diabetes
Exercise is good for you

• Exercise lowers
blood sugar
• It helps you lose
weight and keep it
down
• It helps keep your
bones strong and
heart healthy.
• Exercise helps you
deal with stress and
have more energy.
Special Tips
• Check with your doctor before starting
exercise
• Start slowly to warm up
• After exercise cool down for 5-10 minutes.
• Exercise on a regular schedule
• Check your blood sugar before and after
exercise
• Carry a snack or ask your doctor about
decreasing your diabetes medicine.
• Drink plenty of water
• Wear well fitting shoes and socks; have
identification.
Monitoring
Diabetes Control is Important

• Know your own symptoms of high


and low blood sugar
• Know your target blood sugar
• Have your doctor check your
glycohemoglobin.
Monitoring
Check Your Blood Sugar
• Check for sugar
exactly as you were
taught
• Urine checks are not
as accurate; they
don’t find low blood
sugar
• Know when to
check; days and
Steps for Staying Well
Keep your blood sugar under control

• Follow your food plan


• Get regular physical
activity
• Take your insulin or
diabetes pills
• Test your blood or
urine sugars and use
the results
Steps for Staying Well
Control your Blood Pressure and Blood Fat
• Lose extra weight
• Eat less salt if your
blood pressure is
high.
• Eat less animal fat
• Take medicine as
prescribed
Steps for Staying Well
Protect Yourself

• Don’t smoke
• Check your feet
everyday
• Wear diabetes
identification
• See your doctor
regularly
Steps for Staying Well
Avoid Injury. Protect your feet.
• Always wear shoes
• Avoid walking bare foot
• Cut toenails straight
across. Don’t use razors,
scissors or knives
• Smooth edges with an
emery board
• Check shoes for stones,
tacks or other foreign
bodies
• Don’t sit with legs
crossed
• Don’t use heating pads,
Steps for Staying Well
Check with your Doctor or Nurse.
• Let your doctor or nurse check your
feet at every visit.
• Take off your shoes and socks to
remind them.
• Call the doctor if there are any
changes on your feet
Footsteps
Keep your feet clean
• Wash every day in
warm water
• Don’t use HOT
water
• Dry well between
toes
• Put lotion on top
and bottom of
feet: not between
Stress and Diabetes
Pressure and Stress are common:
• Everyone feels stress
at times
• Life’s pressures can
seem too big to
handle
• Stress can lead to
feeling sad, tense,
tearful or tired
Stress and Diabetes
Stress can affect diabetes
control:
Blood Sugar
• Your blood sugar
300
may change when
250
200
you feel stressed
150
100
• You may forget to
50
0
take care of your
Time diabetes.
Managing
diabetes is harder
when you are
under stress.
Stress and Diabetes
What to do to avoid or manage stress:
• Get support. Keep
family and friends
involved with your
diabetes care.
• Set realistic goals.
Find balance
between work,
family and your
diabetes care.
• Be positive. Focus
Thank
You…