Maja Ravnik-Oblak

Diabetes mellitus type 2

DIABETES MELLITUS

very old diagnosed disease

very frequent chronic disease

unpredictable disease

very psychological burdersome disease

EPIDEMIOLOGY

y. 2000 151 million patients y. 2010 285 million patients y. 2030 439 million patients

PREVALENCE OF DIABETES MELLITUS IN EUROPE (y.

2000)

inhabitants: 654,9 milijona adults (20-79 yrs): 462,7 milijona diabetics (adults): 22,5 milijona prevalence (adults): 4,9 % type 1 diabetics: 1,29 milijona prevalence of typ 1: 0,19 %

PREVALENCE OF DIABETES MELLITUS IN SLOVENIA (1990-2000)

YEAR 1990 1996 2000 DIABETICS 62.821 76.480 89.000

POPULATION 1.998.090 1.986.989 1.985.557

PREVALENCE 3,14% 3,85% 4,48%

NEW PATIENTS 4.837 5.274 INCIDENCE 0,24% 0,27%

Vrtovec, Urbančič, Koselj, Vončina (2001)

DIABETES MELLITUSIMPACT ON PSYCHOSOCIAL STATUS OF A

PATIENT

CHRONIC DISEASE chronic treatment

regular outpatient controls

(GP, diabetologist,

ophthalmologist, other

specialists)

regular lab controls permanent education

DIABETES MELLITUS AND MENTAL DISTURBANCES

fear of very low and very high lood glucose values

fear of occurrence of chronic diabetic complications

feeling of guilt for failure to comply therapists instructions and failure to achieve therapeutic goals

CHRONIC STRESS

PSYCHOSOCIAL WELL-BEING OF DIABETIC PATIENTS

42 % of diabetic patients reported bad psychosocial well-being

WHO 5-item questionnaire

DEFINITION

Diabetes is a group of metabolic disorders with hyperglycemia due to insufficient secretion of insulin and / or its non-efficiency. Chronic hyperglycemia is associated with chronic failures and dysfunction of various organs including renal (kidney) failure, nerve damage, heart disease, stroke, and blindness.

SYMPTOMS ANS SIGNS OF DIABETES MELLITUS

dry mouth, thirstpolyuria, nocturiaweight loss (despite of increased appetite)fatiguevisual disturbancesgenital pruritus

ORGANIC SYNDROME OF TYPE 2 DIABETES MELLITUS

diabetic peripheral neuropathy: 8-15 %

diabetic retinopathy: 5-10% cataract

macroangiopathy

DETECTION

randomly:systematic checking

examination of blood for other reasons

targeted:historysystematic reviews of groups with increased risk

DIAGNOSTIC METHODS

fasting blood glucose random blood glucose blood glucose in 120. minute of oral

glucose test with 75 g glucose (OGTT)

symptoms – YES (1 values) symptoms – NO (2 values on 2 different

testing days)

DIAGNOSTIC VALUES OF BLOOD GLUCOSE

Diabetes

Diabetes unlikely

IGT IFG

Fasting BG ≥ 7,0 < 6,1

6,1- 6,9

Random BG ≥ 11,1 < 6,1

BG in l20.

min. OGTT ≥ 11,1

7,8-11.1

< 7,8

GLYCATED HEMOGLOBIN- HbA1c

Hemoglobin is a protein that is a normal constituent of red blood cells. Erythrocytes in blood containing chains of hemoglobin, which binds sugars non-encimatic and irreversible. Glucose which binds to hemoglobin, is proportional to the concentration of glucose in the blood. HbA1c reflects blood sugar for about eight last weeks. The average blood glucose =

2x % HbA1c – 6

Referal value: 4,4 % - 6,4 %

AETIOLOGICAL CLASSIFICATION OF DM AND OTHER GLUCOSE

INTOLERANCE

DIABETES MELLITUS

I. Diabetes mellitus type 1

II. Diabetes mellitus type 2III. Other types IV. Gestational diabetesImpaired glucose tolerance (IGT) Impaired fasting glucose (IFG)

AETIOLOGICAL CLASSIFICATION OF DM AND OTHER CATEGORIES OF GLUCOSE REGULATION

III. Other types of diabetes mellitus1. Genetic defects of β-cell function 2. Genetic defects in insulin action 3. Diseases of the exocrine pancreas 4. Endocrinopathies 5. Drug or chemical induced 6. Infections 7. Uncommon forms of immune-mediated diabetes 8. Other genetic syndromes sometimes associated

with diabetes

PATHOGENESIS OFDIABETES MELLITUS TYPE 2

inadequate secretion of insulin from pancreatic beta cells

increased insulin resistance (mainly in muscles)

increased formation of glucose in the liver by gluconeogenesis

ETIOPATHOGENESIS OF TYPE 2 DIABETES MELLITUS

environmental factors

and

genetics

INCIDENCE OD TYPE 2 DIABETES MELLITUS

sharp rise after 50 year of age women: men = 55 % : 45 % difference between races increase after change of mode life

DIABETES MELLITUS AND CHRONIC

COPMPLICATIONS

diabetic retinopathydiabetic nephropathydiabetic polyneuropathy

erectile dysfunction

METABOLIC SYNDROME (SYNDROME X)

A quarter of the world’s adults have metabolic syndrome

People with metabolic syndrome are twice as likely to die from, and three times as likely to have a heart attack or stroke compared with people without the syndrome

People with metabolic syndrome have a five-fold greater risk of developing type 2 diabetes

METABOLIC SYNDROME (SYNDROME X)

waist circumference: men≥ 94 cm women≥ 80 cm

triglycerides 1,7 ≥ mM

HDL men<1,0 mmol/l women <1,3 mmol/l

blood pressure ≥130 in/ali ≥ 85 mm Hg (or treatment of BP) glycaemia ≥5,6 mmol/l (or diabetes mellitus)

CRITERIA FOR DIAGNOSIS:3 of 5

NATURAL COURSE OF DIABETES MELLITUS TYPE 2

obesity IGT Diabetes uncontrolled hyperglycaemia

2,8

5,6

8,3

11,1

14,0

16,4

19,4

50

100

150

200

250

gly

caem

ia(m

mol/l)

rela

tive

funct

ion

(%

)

-10-10 -5-5 00 55 1010 1515 2020 2525 3030

post-prandial glycaemia

fasting blood glucose

insulin resistance

insulin level beta cell function

years

TREATMENT OF DIABETES MELLITUS TYPE 2

non-pharmacological measures healthy eating normal body weight physical activity

drugs tablets insulin

TREATMENT WITH DRUGS

promoters of insulin secretion sulfonylureas glinidi

promoters of tissue sensitivity to insulin biguanides (metformin) (tiazolidinedione)

alpha glucosidase inhibitors in the gut acarbose

drugs acting on the incretin system inhibitors of the enzyme DPP-4 incretin mimetics

insulins

Case

man, 70 yrs, pensioner, height 168 cm, weight 75 kg

family history: no diabetes mellitus history: gallstones surgery, mild

prostatic hyperthrophy treatment : no drugs problem: friend, diabetic patient,

measured him blood glucose 10 mmol/l (with glucometer)

approach?

Case

man, 56 yrs, height 170 cm, weight 95 kg, bank officer

family history: mother, brother and 2 paternal aunts are diabetics

history: 1 year hot feet at night

problem: during pneumonia he had glycaemia 12 mmol/l

approach?

Case

woman, 65yrs, height 154 cm, weight 72 kg, retired seamstress

family history: mother is diabetic history: 15 years hypertension and

hyperlipidaemia problem: because of deterioration of vision she

visited ophatalmologist, who found initial cataract and diabetic retinopathy, fasting blood glucose 10,5 mmol/, HbA1c 8,1 %.

type of diabetes?

Case

man, 52 yrs, height 174 cm, weight 63 kg, central heating installer

family history: no data history: 5 years ago pancreatitis

problem: few months thirst, weighf loss 3 kg, frequent urinations, 1-2 x during night, because of thristy he drank 2 l of water-wine mixture per day + occasionally beer, glycaemia 16 mmol/l

type of diabetes mellitus?

DIABETES MELLITUS AND DEPRESSION

condition for successful treatment :

the two diseases should be treated at the same time!