TYPE 2 DIABETES MELLITUSFROM PREVALENCE TO CLINICAL GUIDELINES

DefinitionType 2 diabetes is a chronic progressive metabolic disorder Characterized by defects in both insulin action (insulin resistance) and insulin secretion (-cell failure)

Type 2 DiabetesType 2 diabetes is the most common clinical form of diabetes (about 90-95% of all cases)Prevalence tends to increase in the world

Prevalence of type 2 diabetes WesternEurope (2002) : 5 % in the middle-aged and older populationUSA (2002) : 8 % United Kingdom : 2% (over 40s)Development countries : 1,5 2 %

IndonesiaManado: 6,1%Tasikmalaya: 1,1%Kec. Sesean : 0,8%(Tana Toraja)Surabaya: 1,43-1,47%Jakarta: 12,8%Makassar : 2,9%

Estimates and projections of the prevalence of diabetes (1997-2010)Wareham NJ. Medicine Int 2002; 02(1): 11-13.

History of diabetes classificationWHO (1965)- Childhood diabetics- Young diabetics- Adult diabetics- Elderly diabeticsADA (1968)- Pre diabetes- Suspect diabetes- Chemical/latent diabetes- Overt diabetes

Joslin (1971)- Hereditary- growth/juvenile onset - maturity/adult onset- Non hereditary

Diabetes spectrum of insulin deficiency- Insulin dependent- Non insulin dependent

Classification (ADA 2004)Type 1 diabetesType 2 diabetes Other type diabetesGestational diabetes

Disorders of glycemia : etiologic types and stages

ADA. Diabetes Care 2004; 27:5-10.

Nolan JJ. Medicine Int 2002; 02(1): 6-10.

Metabolic disorders in type 2 diabetes

Features of type 2 diabetesUsually presents in over-30sOnset is gradual Diagnosis often missed (up to 50% of cases)Not associated with ketoacidosis, though ketosis can occur

Lanjutan:Immune markers is only 10%Family history is often positiveAlmost 100% concordance in identical twinsDiet, exercise and oral medication can often control hyperglycemia; insulin may be required later in the disease

Metabolic syndrome clinical features of insulin resistanceInsulin resistance HyperinsulinemiaImpaired glucose tolerance or type 2 diabetesHypertensionObesity with abdominal distribution

Lanjutan:Dyslipidemia (high VLDL, low HDL, small dense LDL)Pro-coagulant endothelial markersHyperuricemiaPolycystic ovarii syndromeEarly and accelerated atherosclerosis

Clinical symptoms of diabetesSpecific complaintsNo specific complaintsFasting glucoseAt time glucose> 126< 126> 200< 200> 126> 200110-125110-199< 110Repeat : at time glucose or fasting glucoseFasting glucoseAt time glucose> 126> 200< 126< 200OGTT2h pp> 200140-199NormalIGTImpaired FGDIABETES MELLITUS< 140Algorythmof Diagnosis

Diagnostic criteria for diabetesPlasma glucose at time > 200 mg/dlFasting plasma glucose > 126 mg/dl2-hour plasma glucose > 200 mg/dl (after 75-g oral glucose test)

Plasma glucose for diagnosis

Glucose level (mg/dl)SampleNot DMUncertain DMDMPlasma glucose at timeVein blood< 110110-199> 200Capillary blood< 9090-199> 200Fasting plasma glucoseVein blood< 110110-125> 126Capillaryblood< 9090-109> 110

Principles of management of type 2 diabetes Education Food planning Exercise Pharmacological intervention

EducationWhat is type 2 diabetes ?ControllingMonitoringKnowledge improvement

Food planningFood composition ?Ideal bodyweight Body Mass IndexAsia Pacific ClassificationUnderweight< 18,5Normoweight18,5-22,9Overweight> 23,0At risk23,0-24,9Obese 125,0-29,9Obese 2> 30

Food composition60-70%20-25%10-15%

ExerciseC= ContinousR= RythmicalI= IntervalP= ProgressiveE= Endurance

Pharmacological intervention

Hypoglycemic agents

DrugsMechanism of actionAdverse effectsDecrease of HbA1cSulfonylurea insulin secretionBWHypoglycemia1,5 - 2,5%Glinide insulin secretion1,5 2,5%Metformin hepatic glucose productionDiarrhea Dyspepsia Lactic acidosis1,5 2,5%Alpha-glucosidase inhibitor (acarbose) glucose absorptionFlatulenceDiarrhea stool0,5 1,0%Tiazolidindione insulin sensitivityEdema1,3%Insulin hepatic glucose production,Stimulation of glucose utilizationHypoglycemia BWPotential normal

Diabetes control criteria

Fasting glucose (mg/dl)80 - 109110 - 125> 1262h-pp glucose (mg/dl)80 - 144145 - 179> 180HbA1C (%)< 6,56,5 8> 8Total cholesterol (mg/dl)< 200200 - 239> 240LDL cholesterol (mg/dl)< 100100 - 129> 130HDL cholesterol (mg/dl)> 45Triglyceride (mg/dl)< 150150 199> 200BMI (kg/m2)18,5 22,923 - 25> 25BP< 130/80130-140/80-90> 140/90

Parameter Optimal Moderate Poor

Prevention of diabetesPrimary prevention High risk groupSecondary prevention Screening Tertiary prevention Prevention of deformity

Screening for diabetesAge : > 45 years oldWeight : RBW > 110%, BMI > 23 kg/m3Hypertension ( > 140/90 mmHg)Family history of diabetesRecurrent abortion, congenital malformation, low birth weight (> 4000 g)HDL-cholesterol < 35 mg/dl, triglyceride > 250 mg/dl

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