Diabetes, Obesity, and

Metabolic Syndrome
Alyson Morgan, MS3
Ross University School of Medicine
Diabetes Mellitus
Diabetes Mellitus

Type I Type II
▪ Autoimmune destruction of β- ▪ Insulin resistance w/ or w/o
islet cells deficiency
▪ Typically arises in child- to ▪ Age, obesity, sedentary
young adulthood lifestyle increases incidence
Diagnostic Criteria

1. Classic hyperglycemic sxs + one of following:

1. Random blood glucose ≥200 mg/dL
2. Fasting blood glucose ≥126 mg/dL
3. 2-hour blood glucose ≥200 mg/dL in 75-g OGTT

2. HbA1C ≥6.5% (controversial)

▪ Pre-diabetes: FBG 100-125 mg/dL,2-hour BG 140-199 mg/dL, or

HbA1C 5.7-6.4%
Treatment

Insulin:

▪ Rapid-acting: lispro, aspart, glulisine

▪ Short-acting: regular insulin
▪ Intermediate-acting: NPH
▪ Long-acting: glargine, detemir

▪ Most common complication:

hypoglycemia
Treatment

▪ Sulfonylureas: glyburide, glipizide, glimepiride

– Hypoglycemia, weight gain

▪ Glinides: repaglinide, nateglinide

– Possible hypoglycemia, expensive

▪ Biguanides: metformin
– Lactic acidosis

▪ Thiazolidinediones: pioglitazone, rosiglitazone

– Edema, heart failure, possible MI, weight gain, expensive

▪ Incretin modulators: exenitide, liraglutide

– N/V, pancreatitis, expensive
Treatment

▪ GLP-1 Inhibitors: sitagliptin, saxagliptin, vildagliptin

– Possible angioedema, angioedema

▪ α-Glucosidase Inhibitors: acarbose, miglitol, voglibose

– Abdominal discomfort, flatulence, minimal HbA1C effect

▪ SGLT2 Inhibitors: dapagliflozin, canagliflozin

– UTI, vulvovaginal candidiasis

▪ Goal: HbA1C <7%

Complications

▪ Diabetic Ketoacidosis (DKA) – anion-gap metabolic acidosis

– TIDM
– Sxs: abd pain, Kussmaul breathing, polyuria, polydipsia, blurred vision, N/V, AMS
– Dx: BG >200 mg/dL, anion gap (pH<7.3, HCO 3<15), + ketones
– Tx: aggressive IVFs, insulin (bolus + infusion)
▪ Goal: reduce BG 50-100 mg/dL per hour until ~250mg/dL, then 1/2NS+D5/D10

▪ Hyperglycemic Hyperosmolar Syndrome

– TIIDM
– Sxs: AMS, hypovolemia; often precipitated by infection, trauma, MI
– Dx: BG >600 mg/dL, non-anion gap (pH>7.3, HCO 3>15), no ketones
– Tx: aggressive IVFs, insulin (bolus + infusion), K +
▪ Goal: reduce BG 50-100 mg/dL per hour until <200mg/dL and PO, then subQ insulin
Complications

▪ Retinopathy:
– Screen for hard exudates, microaneurysms, minor hemorrhages, neovascularization of retinal
vessels

▪ Nephropathy:
– Screen urine for increased albuminuria (30-300 mg/g)add ACEi/ARB

▪ Neuropathy:
– Screen with monofilament testmost predictive of ulcer/amputation risk
– Also: cardiovascular autonomic neuropathy, gastrointestinal neuropathy (gastroparesis),
neurogenic bladder
Obesity

▪ >60% of Americans are overweight or obese

– 20-40% increased risk of death

▪ PREVENTION!!! Lifestyle modification

▪ Screening: height, weight, waist circumference, BMI

Classification BMI
Normal 24.9 or less
Overweight 25-29.9
Class I Obese 30-34.9
Class II Obese 35-39.9
Class III Obese 40 or higher
Obesity

▪ Adjunct drug therapy: BMI ≥30 or ≥27 w/ comorbidities

– Orlistat, diethylpropion, benzphetamine, phendimetramine, phentermine +/-
topiramate, lorcaserin, bupropion/naltrexone, fluoxetine, exenatide

▪ Bariatric surgery last resort: BMI ≥40 or ≥35 w/ comorbidities

Surgical Options
Metabolic Syndrome

▪ Coexistence of metabolic RFs for TIIDM and coronary heart disease (CVD)

▪ Diagnostic Criteria: 3+ of the following:

– Central obesity: men >40 in, women >35in
– Triglycerides: ≥150 mg/dL
– HDL levels: men <40 mg/dL, women <35 mg/dL
– HTN: ≥130/85 mmHg
– FBG: ≥110 mg/dL
Metabolic Syndrome

▪ Questionable – treatment of TIIDM or CVD no different

▪ Tx: treat underlying RFs/diseases

References

▪ IM Essentials, Chapter 2.13, 4.32, 4.33