TYPE 2 DIABETES

MELLITUS
FROM PREVALENCE TO
CLINICAL GUIDELINES


Definition
Type 2 diabetes is a chronic
progressive metabolic disorder
Characterized by defects in both
insulin action (insulin resistance)
and insulin secretion (-cell
failure)
Type 2 Diabetes
Type 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
Western
Europe (2002) : 5 % in the middle-
aged and older population
USA (2002) : 8 %
United Kingdom : 2% (over 40s)
Development countries : 1,5 2 %
Indonesia
Manado : 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 classification
WHO (1965)
- Childhood diabetics
- Young diabetics
- Adult diabetics
- Elderly diabetics
ADA (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 diabetes
Type 2 diabetes
Other type diabetes
Gestational 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
Hepatic glucose
production
Pancreas
Liver
Insulin
secretion
Hyperglycemia
Muscle
Glucose
uptake
Insulin
resistance
=
Insulin
deficiency
=
Features of type 2 diabetes
Usually presents in over-30s
Onset 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 positive
Almost 100% concordance in identical
twins
Diet, exercise and oral medication can
often control hyperglycemia; insulin may
be required later in the disease

Metabolic syndrome clinical features of
insulin resistance
Insulin resistance
Hyperinsulinemia
Impaired glucose tolerance or type 2
diabetes
Hypertension
Obesity with abdominal distribution

Lanjutan:
Dyslipidemia (high VLDL, low HDL, small
dense LDL)
Pro-coagulant endothelial markers
Hyperuricemia
Polycystic ovarii syndrome
Early and accelerated atherosclerosis
Clinical symptoms of diabetes
Specific complaints No specific complaints
Fasting glucose
At time glucose
> 126 < 126
> 200 < 200
> 126
> 200
110-125
110-199
< 110
Repeat : at time glucose
or fasting
glucose
Fasting glucose
At time glucose
> 126
> 200
< 126
< 200
OGTT
2h pp
> 200 140-199
Normal IGT Impaired FG DIABETES MELLITUS
< 140
Algorythm
of Diagnosis
Diagnostic criteria for diabetes
Plasma glucose at time > 200 mg/dl
Fasting plasma glucose > 126 mg/dl
2-hour plasma glucose > 200 mg/dl
(after 75-g oral glucose test)


Plasma glucose for diagnosis

Glucose level (mg/dl)

Sample

Not DM

Uncertain
DM

DM
Plasma glucose at time Vein
blood
< 110 110-199 > 200
Capillary
blood
< 90 90-199 > 200
Fasting plasma glucose Vein
blood
< 110 110-125 > 126
Capillary
blood
< 90 90-109 > 110
Principles of management of type 2
diabetes

Education
Food planning
Exercise
Pharmacological intervention
Education
What is type 2 diabetes ?
Controlling
Monitoring
Knowledge improvement
Food planning
Food composition ?
Ideal bodyweight Body Mass Index
Asia Pacific Classification
Underweight < 18,5
Normoweight 18,5-22,9
Overweight > 23,0
At risk 23,0-24,9
Obese 1 25,0-29,9
Obese 2 > 30
Food composition
Carbohydrate
Protein
Lipid
60-70%
20-25%
10-15%
Exercise
C = Continous
R = Rythmical
I = Interval
P = Progressive
E = Endurance
Pharmacological intervention
Drugs Mechanism of action Adverse effects Decrease of
HbA1c
Sulfonylurea insulin secretion BW
Hypoglycemia
1,5 - 2,5%
Glinide insulin secretion 1,5 2,5%
Metformin hepatic glucose
production
Diarrhea
Dyspepsia
Lactic acidosis
1,5 2,5%
Alpha-glucosidase
inhibitor (acarbose)
glucose absorption Flatulence
Diarrhea stool

0,5 1,0%
Tiazolidindione insulin sensitivity Edema 1,3%
Insulin hepatic glucose
production,
Stimulation of glucose
utilization
Hypoglycemia
BW
Potential normal
Hypoglycemic agents
Fasting glucose (mg/dl) 80 - 109 110 - 125 > 126
2h-pp glucose (mg/dl) 80 - 144 145 - 179 > 180
HbA1C (%) < 6,5 6,5 8 > 8
Total cholesterol (mg/dl) < 200 200 - 239 > 240
LDL cholesterol (mg/dl) < 100 100 - 129 > 130
HDL cholesterol (mg/dl) > 45
Triglyceride (mg/dl) < 150 150 199 > 200
BMI (kg/m
2
)
18,5 22,9
23 - 25 > 25
BP < 130/80
130-140/80-90
> 140/90
Parameter Optimal Moderate Poor
Diabetes control criteria
Prevention of diabetes
Primary prevention
High risk group
Secondary prevention
Screening
Tertiary prevention
Prevention of deformity

Screening for diabetes
1. Age : > 45 years old
2. Weight : RBW > 110%, BMI > 23 kg/m
3
3. Hypertension ( > 140/90 mmHg)
4. Family history of diabetes
5. Recurrent abortion, congenital
malformation, low birth weight (> 4000 g)
6. HDL-cholesterol < 35 mg/dl,
triglyceride > 250 mg/dl
THANK YOU