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DIABETES MELLITUS TODAY

DIANA W. GUTHRIE RN, PhD 2006

DEFINITION & THE PROBLEM
• • • • • • CRITERIA FOR DIAGNOSIS DEFINITION PATHOPHYSIOLOGY PREVALENCE OBESITY METABOLIC SYNDROME

Glucose Tolerance Categories
FPG mg/dL
126 100 and <126
Diabetes Mellitus

2-hr PG on OGTT mg/dL
200 140 and <200 Diabetes Mellitus

Prediabetes Glucose
Normal

Prediabetes Tolerance
Normal

<100

<140

The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2002;25(suppl):S5

Diabetes Care.or chemicalinduced. .20:1183-1197. and other rare forms Insulin resistance with b-cell dysfunction Gestational Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. drug. 1997.Etiologic Classification of Diabetes Mellitus Type 1 Type 2 b-cell destruction with lack of insulin Insulin resistance with insulin deficiency Other specific Types Genetic defects in b-cell exocrine pancreas diseases.

Diabetes Care 2000.S.1995 and 2001 1990 1995 2001 Source: Mokdad et al. (Includes Gestational Diabetes) BRFSS.. .Diabetes Trends* Among Adults in the U. 1990.. J Am Med Assoc 2001.286:10.23:1278-83.

Prevalence of Diabetes in Adults United States. BRFSS: 2000 <4% >6% 4–6% .

Obesity Trends* Among U. Adults BRFSS. 1991-2002 (*BMI ≥30.S. or ~ 30 lbs overweight for 5’ 4” woman) 1991 1995 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% .

...286:10. (Includes Gestational Diabetes) BRFSS 2001 Source: Mokdad et al. J Am Med Assoc 2001.S.DNPA DNPA Graphics: Graphics: Diabetes Trends* Among Adults in the U.

S.Obesity Trends* Among U. or~ ~ 30 lbs overweight for 5’4” for person) No Data <10% 10%–14% 15%–19% 20%–24% ≥25% Source: Behavioral Risk Factor Surveillance System. or 30 lbs overweight 5’ 4” woman) (*BMI 30. Adults BRFSS. 2002 (*BMI ≥30. CDC .

GLOBAL PROJECTIONS FOR THE DIABETES EPIDEMIC: 2003-2025 (millions) World 2003 = 194 million 2025 = 333 million Increase 72% .

diabetes. Accessed April 11.gov/diabetes/pubs/pdf/ndfs_2005. 2005.org/utils/printthispage. ADA Diabetes Statistics.8 million Americans have diabetes Diabetes Today: An Epidemic • 1.cdc. . Available at http://www.pdf. December 29. 2005.5 million new cases in 2005 more than 3500 each day • Complications of diabetes are a major cause of mortality and morbidity (2002 statistics) 90% of patients with diabetes are treated by primary care physicians ADA National Diabetes Fact Sheet.• 20.jsp?PageID=STATISTICS_233181. Available at: http://www.

1 billion Mortality $21.3 billion Inpatient care $40.3 billion Health Care Expenditures $91.26(3):917-932. Diabetes Care. 2003.8 billion .Total Cost of Diabetes in the US.4 billion Outpatient care/ home health & medications $37. 2002 Total Cost $132 billion Nursing home & hospice $14.5 billion Disability $18. Indirect Costs $39.8 billion American Diabetes Association.

The Problem .

Bing C. Harvard Magazine.Modern Life Has Both Conveniences and Costs Illustration taken from: Lambert C.50. 2004. . May-June. The Way We Eat Now.

high waist to hip ratio Hyperlipidemia Hyperinsulinemia Hypertension Hyperglycemia Acanthosis Nigricans PCOS .METABOLIC SYNDROME • • • • • • • Obesity.

ACANTHOSIS NIGRICANS .

ACANTHOSIS NIGRICANS .

ACANTHOSIS NIGRICANS .

95 in men) ( 0.Waist/Hip Ratio An Index of Abdominal Versus Peripheral Obesity High WHR ( 0.80 in women) American Diabetes Association .80 in women) Low WHR ( 0.95 in men) ( 0.

.Visceral Fat Distribution Normal vs Type 2 Diabetes Normal Type 2 Diabetes Courtesy of Wilfred Y. Fujimoto. MD.

. .And America Continues to Enjoy Strong Economic Growth…………………………….

Saunders Co. Edited by Leslie J. Melmed S. 1. Chap. (Minneapolis. Marshall JC. Burger HG. 4th ed. in Endocrinology. Originally published in Type 2 Diabetes BASICS. DeGroot and J. . Jr. International Diabetes Center. Potts JT. Vol. 2000). Rubenstein AH. Philadelphia: W.. and Lipid Disorders. Loriaux DL. Odell WD.Course of Type 2 Diabetes Obesity 350 – 300 – Postmeal Glucose Fasting Glucose 250 – 200 – 150 – 100 – 50 – 250 – 200 – 150 – 100 – 50 – 0– -10 -5 0 5 10 15 20 25 30 b-cell Failure IFG* Diabetes Uncontrolled Hyperglycemia Glucose (mg/dL) Relative Function (%) Insulin Resistance Years of Diabetes *IFG=impaired fasting glucose.B. Larry Jameson. 2001. Carbohydrate Metabolism. Diabetes Mellitus.

2001. “Lipotoxicity” (elevated FFA*.86(9):4047-4058.Factors That May Drive the Progressive Decline of Beta-cell Function Hyperglycemia (glucose toxicity) Insulin Resistance b-cell *FFA=free fatty acids. J Clin Endocrinol Metab. . TG=triglycerides. TG*) Adapted from: Kahn SE.287(18):2414-2423. 2002. Adapted from: Ludwig DS. JAMA.

ß-cell “failure” Glucose and/or fat toxicity Type 2 diabetes . J Clin Invest. et al. J Invest Med. Weyer C. 1999.Progression to Type 2 Diabetes Genetic Factors Insulin resistance Hyperinsulinemia Compensated insulin resistance Normal glucose tolerance Acquired: •Obesity •Sedentary lifestyle •Aging ß-cell decompensation Impaired glucose tolerance Genetic Factors Kruszynska Y. 1996.104:787-794.44:413-428. Olefsky JM.

sdLDL  HDL Endothelial Dysfunction Systemic Inflammation Disordered Fibrinolysis Insulin Resistance Atherosclerosis Hypertension Visceral Obesity 2 Diabetes Adapted from the Consensus Development Type Conference of the American Diabetes Association. 2001. Pradhan AD. Diabetes Care. 1999.22(4):562-568. 1998.The Importance of Targeting Insulin Resistance Over 90% of type 2 diabetics are Insulin Resistant Complex Dyslipidemia  TG. et al.286(3):327-334. . Diabetes Care. JAMA.21(2):310-314. Haffner SM. et al.

ETIOLOGY OF T1DM DQ* D C B A SHORT ARM # 6 CHROMOSOME .

IMPORTANCE OF GLUCOSE CONTROL • • • • DCCT KUMAMOTO UKPDS IN-PATIENT CONTROL .

Complications of Diabetes Macrovascular Brain Cerebrovascular disease • Transient ischemic attack • Cerebrovascular accident • Cognitive impairment Heart Coronary artery disease • Coronary syndrome • Myocardial infarction • Congestive heart failure Extremities Peripheral vascular disease • Ulceration • Gangrene • Amputation Microvascular Eye Retinopathy Cataracts Glaucoma Kidney Nephropathy • Microalbuminuria • Gross albuminuria • Kidney failure Nerves Neuropathy • Peripheral • Autonomic .

Diabetes Res Clin Pract. 1998. 1993. UK Prospective Diabetes Study Group (UKPDS) 33: Lancet. 1995.329:977-986.352:837-853.28:103-117. N Engl J Med. Ohkubo Y et al. 29 .Good Glycemic Control (Lower HbA1c) Reduces Incidence of Complications DCCT Kumamoto 9  7% 69% 70% UKPDS 8  7% 17-21% HbA1c Retinopathy Nephropathy Neuropathy Macrovascular disease * not statistically significant 9  7% 63% 54% 24-33% – 16%* 60% 41%* – – Diabetes Control and Complications Trial (DCCT) Research Group.

HbA1c as Predictor of Retinopathy .

0 IDF <6.5 FBS/Pre 80-120 prandial Mg/dl Plasma 2hr 185 postpran- <100 <110 <120 <135 <140 <140 .5 AACE <6.Glycemic Goals For Diabetes ADA HbA1C% <7.5 Mine <6.

Summary • The evidence is overwhelming that good control does count • Morbidity and mortality can be reduced • There is nothing inevitable about the complications of diabetes .

Summary (cont) • The cost of diabetes is in its complications • Any expense paid up front in better management will pay off handsomely in the long run • The tools for good diabetes care already exist • No tool is more important than the services of a certified diabetes educator .

ADA 2002 . Pres.Summary (cont) • Assessment tools include Self Monitoring of Blood Glucose and HbA1C • Targets should be established for each of these for each patients within the national guidelines • When targets are not reached the help of a specialist should be sought • Christopher D. Saudek MD.

Summary • • • • Insulin administration should mimic nature Natures way is basal insulin 24 hrs. asparte or glulisine can supply bolus • Insulin glargine or detemir can supply the basal with one injection per day • Control of blood sugar will prevent the complications of diabetes . a day And bolus insulin with every feeding Insulin lispro.