Diagnosis, classification and prevention of diabetes

Diagnosis, classification and prevention of diabetes Section 1 1 of 4 Curriculum Module II 1 Diagnosis, classification and presentation of diabetes

Slide 2 of 48 Polyurea

Definition of diabetes Slide 3 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

Definition of diabetes Slide 4 of 48 Chronic hyperglycaemia associated with long-term damage to: Eyes Kidneys Nerves Heart and blood vessels

The diabetes epidemic Slide 5 of 48 230 million affected in 2006 350 million within 20 years Most rapid in Indian and Asian subcontinents IDF Diabetes Atlas

Classification Slide 6 of 48 Type 1 diabetes autoimmune LADA idiopathic Type 2 diabetes

Classification Slide 7 of 48 Other specific types MODY Defects in insulin action Diseases of the pancreas Endocrine disorders Drug- or chemical-induced Infections

Classification Slide 8 of 48 Uncommon forms of immunemediated diabetes Other genetic syndromes Gestational diabetes

Insulin and glucose disposal Slide 9 of 48 Insulin Gluconeogenesis Glycogenolysis Glycogen synthesis Blood glucose Glycogen synthesis Glucose uptake Free fatty acid release

Insulin deficiency in type 1 diabetes Slide 10 of 48 Glucose uptake Glycogenolysis Gluconeogenesis (amino acids) Ketone production (fatty acids) Blood glucose Glucose uptake Protein degradation amino acids Triglyceride degradation fatty acids

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Insulin insensitivity in type 2 diabetes Glucose uptake Glycolysis Slide 12 of 48 Gluconeogenesis (amino acids) Blood glucose Glucose uptake Protein degradation amino acids

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Pathogenesis of type 1 diabetes Slide 15 of 48 Trigger Genetic Immunological abnormalities Beta-cell mass Clinical diabetes Pre-diabetes Honeymoon Chronic phase Time (months - years)

Idiopathic type 1 diabetes Slide 16 of 48 Non-autoimmune type 1 diabetes No autoimmune markers Permanent insulinopenia Ketoacidosis People of African and Asian origin

Epidemiology of type 1 diabetes Slide 17 of 48 Age of onset peaks preschool puberty Autumn/winter peaks

Type 2 diabetes Slide 18 of 48 90%-95% of people with diabetes Insulin insensitivity and relative insulin deficiency Obesity or overweight Complications often present at diagnosis

Slide 19 of 48 Pathogenesis of type 2 diabetes Multiple genes involved Hyperinsulinaemia Poor fetal nutrition beta-cell formation Low birth weight/weight change Thrifty gene

The natural history of type 2 diabetes Slide 20 of 48 Insulin requirements Beta-cell loss Primary failure Insulin requirements with age Endogenous insulin Age (years)

Slide 21 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

ACTIVITY Slide 22 of 48 What are the most common risk factors for type 2 diabetes for people in your country? Are any of these risk factors modifiable?

Slide 23 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

Risk factors for type 2 diabetes Slide 24 of 48 Hypertension Dyslipidaemia Abdominal obesity Overweight Polycystic ovary disease Acanthosis nigricans Schizophrenia

Signs and symptoms Slide 25 of 48 Polydipsia Polyuria Nocturia Visual disturbance Fatigue Weight loss Infections

Diagnosing diabetes Slide 26 of 48 Normal FPG <6.1mmol/L Impaired fasting glucose* Impaired glucose tolerance** [5.6] 6.1 to 6.9mmol/L* Diabetes 7.0mmol/L 2hr PG <7.8mmol/L 7.8 to 11mmol/L** 11.1mmol/L CDA 2003, ADA 2004, WHO 2002

Slide 27 of 48 Diagnosis of Diabetes Symptoms + gluc >11.0 mmol/l 2X FG > 6.9 mmol/l 2X 2hr GTT > 11.0 mmol/l

Impaired glucose tolerance Impaired fasting glucose Slide 28 of 48 Intermediate states Increased risk of developing diabetes Prevention strategies to prevent or delay progression Increased risk of cardiovascular disease

Prevention of type 1 diabetes Slide 29 of 48 Insulin Diabetes Prevention Trial Diabetes Prediction and Prevention Project

Prevention of type 2 diabetes Slide 30 of 48 Lifestyle modification Da Qing Study Finnish Diabetes Prevention Study

Prevention of type 2 diabetes Slide 31 of 48 Lifestyle vs medication Diabetes Prevention Program STOP-NIDDM

ACTIVITY Slide 32 of 48 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?

Summary Slide 33 of 48 Type 1 diabetes Results from progressive betacell destruction People with type 1 diabetes need insulin therapy to live

Summary Slide 34 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

References Slide 35 of 48 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.

References Slide 36 of 48 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.

References Slide 37 of 48 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.