Diabetes

ASSOCIATE PROFESSOR DR MARJAN

Learning outcomes:

In the end of this session student should be able to discuss:

• Definition and Pathophysiology
• Epidemiology
• Classification
• Screening
• Diagnosis
• Management
• Prevention
• Complication Of Diabetes mellitus
Normal Glucose Homeostasis

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 Role of Hormones in glucose hemostasis
Insulin glucagon Catechol Gluco Growth Thyroid
amines corticoids Hormone hormone
Glucose No effect No effect No effect No effect No effect ↑
absorption
Peripheral ↑ ↓ ↓ ↓ ↓ ↓
uptake
Glycolysis ↑ ↓ ↓ ↓ ↓ ↓

Gluco ↓ ↑ ↑ ↑ ↑ ↑
neogenesis
Glyco ↑ ↓ ↓ ↑ ↑ ↓
genesis
Glyco ↓ ↑ ↑ ↓ ↓ ↑
genolysis
lipolysis ↓ ↑ ↑ ↑ ↑ ↑

Protein ↓ ↑ ↑ ↑ ↓ ↑
catabolism
NET EFFECT HYPO HYPER HYPER HYPER HYPER HYPER
GLYCAEMIA GLYCAEMIA GLYCAEMIA GLYCAEMIA GLYCAEMIA GLYCAEMIA
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• Hyperglycaemia : is also known
as high blood sugar, or high
blood glucose.
• Hyperglycemia is a biochemical
condition when the plasma
glucose is more than 7 mmol/l.
• happens when the body is
unable to remove glucose from
the blood and turn it into energy.
Differential Diagnosis of Hyperglycaemia :
1. Diabetes Mellitus
2. Diseases of the pancreas : chronic
pancreatitis, carcinoma head of pancreas,
cystic fibrosis.
3. pregnancy,
4. Hormonal tumours : acromegaly, Cushing’s
syndrome, glucagonoma,
pheochromocytoma.
5. Liver diseases : liver cirrhosis and
hemochromatosis.
6. infection and sepsis,
7. bulimia nervosa and drugs.
8. Pharmacologic agents :
corticosteroids, L- asparaginase,
protease inhibitor, pentamidine,
antipsychotic agent, niacin,
thiazide diuretics and beta blockers.
9. Muscle disorders : myotonic dystrophy.
10. Adipose tissue disorders : lipodystrophy and
truncal obesity.
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 Definition of DM

§ DIABETES MELLITUS (DM) : is a systemic metabolic disorder characterized

by a tendency to chronic hyperglycaemia with disturbances in carbohydrate,
fat and protein metabolism that arise from a defect in insulin secretion or action
or both.
• The chronic hyperglycemia of diabetes is associated with long-term damage,
dysfunction, and failure of different organs, especially the eyes, kidneys,
nerves, heart, and blood vessels.
§ HYPERGLYCEMIA is a hallmark sign of DM

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CLASSIFICATION AND DIAGNOSIS OF DIABETES

Classification
Diabetes can be classified into the following general categories:
1. Type 1 diabetes (due to autoimmune ß-cell destruction, usually leading to absolute
insulin deficiency, including latent autoimmune diabetes of adulthood)

2. Type 2 diabetes (due to a progressive loss of ß-cell insulin secretion frequently on

the background of insulin resistance)

3. Specific types of diabetes due to other causes, e.g., monogenic diabetes

syndromes (such as neonatal diabetes and maturity-onset diabetes of the young),
diseases of the exocrine pancreas (such as cystic fibrosis and pancreatitis), and
drug- or chemical-induced diabetes (such as with glucocorticoid use, in the
treatment of HIV/AIDS, or after organ transplantation)

4. Gestational diabetes mellitus (diabetes diagnosed in the second or third trimester

of pregnancy that was not clearly overt diabetes prior to gestation) | 7
- Maturity-onset Diabetes Of The Young (MODY)
Classification of DM

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 Major Characteristics of Type 1 and Type 2 DM

Features Type 1 DM Type 2 DM

Typical age of onset Children; young adult Middle-aged; elderly

Onset Acute Gradual

Habitus Lean Often obese

Weight loss Usual Infrequent

Ketosis – prone Usually Usually not

Plasma insulin Low or absent (cellular- Often normal; may be

concentration mediated autoimmune
destruction of the β-cells of the
pancreas)
Family history of diabetes Less common Common

HLA association DR3, DR4; DQ2, DQ8 none

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 CLASSIFICATION AND DIAGNOSIS OF DIABETES

Hold for table 2.1

Classification and Diagnosis of Diabetes: | 10

Standards of Medical Care in Diabetes - 2021. Diabetes Care 2021;44(Suppl. 1):S15-S33

Diagnostic blood glucose
concentrations (mmol/L)
HbA1C
CLASSIFICATION AND DIAGNOSIS OF DIABETES

A1C
2.1 To avoid misdiagnosis or missed diagnosis, the A1C test should be
performed using a method that is certified by the NGSP and
standardized to the Diabetes Control and Complications Trial (DCCT)
assay. B
2.2 Marked discordance between measured A1C and plasma glucose
levels should raise the possibility of A1C assay interference and
consideration of using an assay without interference or plasma
blood glucose criteria to diagnose diabetes. B
CLASSIFICATION AND DIAGNOSIS OF DIABETES

A1C (continued)
2.3 In conditions associated with an altered relationship betweenA1C
and glycemia, such as hemoglobinopathies including sickle cell
disease, pregnancy (second and third trimesters and the
postpartum period), glucose-6-phosphate dehydrogenase
deficiency, HIV, hemodialysis, recent blood loss or transfusion, or
erythropoietin therapy, only plasma blood glucose criteria should be
used to diagnose diabetes. B
 Epidemiology in Malaysia
• Overall diabetes prevalence in adults≥18 years in NHMS 2015 and 2019
was 13.4% and 18.3% respectively.1,2 (Level II-3) Prevalence for overall
diabetes for adults aged 30 years and above was 24.1% in NHMS 2019.

• Prevalence of overall diabetes among the major ethnic groups in the

NHMS 2019 showed a similar trend as previous data which was 31.4%,
22.6% and 15.1% among the Indians, Malays and Chinese,
respectively.1 (Level II-3)
CRITERIA FOR TESTING FOR T2DM OR PREDIABETES IN ASYMPTOMATIC ADULTS
Short-term aims
• Relief of symptoms and acute complications
Long-term aims
• Achievement of appropriate glycaemic levels with lifestyle management including
weight reduction (where appropriate) and maintain durability of glycaemic control
• Reduction of other CV risk factors
• Identification and treatment of chronic complications
• Optimise quality of life
Lifestyle modification

• Medical nutrition therapy (MNT) with weight loss can prevent T2DM
• Structured lifestyle intervention incorporating partial diet replacement
can improve HbA1c, lipid profile and BP.
• A total diet replacement with weight loss of up to 15% body weight
(approximately 15 kg) can lead to diabetes remission.
• A healthful eating pattern with low glycaemic index (GI) diet may be
relevant in the Malaysian context because excessive rise in post-
prandial glycaemia is frequently observed.
Complications of DM
Acute Complications :
1. DKA
2. Hyperglycaemic Hyperosmolar
non-ketotic states (HHNS)
3. Hypoglycaemia
“Requires URGENT Tx & Mx”
Chronic Complications :
1. Microvascular (diabetic
nephropathy, neuropathy, and
retinopathy)
2. Macrovascular (coronary artery
disease, peripheral arterial
disease, and stroke)
3. Diabetic foot
Pathophysiology of Diabetic
Complications.