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Diabetes Mellitus

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Parameter Diagnosis

What is diabetes?
Diabetes mellitus (DM) is a group of diseases
characterized by high levels of blood glucose resulting
from defects in insulin production, insulin action, or
both.
The term diabetes mellitus describes a metabolic
disorder of multiple aetiology characterized by chronic
hyperglycaemia with disturbances of carbohydrate, fat
and protein metabolism resulting from defects in
insulin secretion, insulin action, or both.
The effects of diabetes mellitus include longterm
damage, dysfunction and failure of various organs.

Diabetes
Diabetes mellitus may present with characteristic
symptoms such as thirst, polyuria, blurring of vision,
and weight loss.
In its most severe forms, ketoacidosis or a nonketotic
hyperosmolar state may develop and lead to stupor,
coma and, in absence of effective treatment, death.
Often symptoms are not severe, or may be absent,
and consequently hyperglycaemia sufficient to cause
pathological and functional changes may be present
for a long time before the diagnosis is made.

Diabetes Long-term
Effects
The longterm effects of diabetes mellitus include
progressive development of the specific
complications of retinopathy with potential
blindness, nephropathy that may lead to renal
failure, and/or neuropathy with risk of foot ulcers,
amputation, Charcot joints, and features of
autonomic dysfunction, including sexual
dysfunction.
People with diabetes are at increased risk of
cardiovascular, peripheral vascular and
cerebrovascular disease.

Burden of Diabetes
The development of diabetes is projected to reach pandemic
proportions over the next10-20 years.
International Diabetes Federation (IDF) data indicate that by
the year 2025, the number of people affected will reach 333
million 90% of these people will have Type 2 diabetes.
In most Western societies, the overall prevalence has
reached 4-6%, and is as high as 10-12% among 60-70-yearold people.
The annual health costs caused by diabetes and its
complications account for around 6-12% of all health-care
expenditure.

Types of Diabetes

Type 1 Diabetes Mellitus


Type 2 Diabetes Mellitus
Gestational Diabetes
Other types:
LADA
MODY (maturity-onset diabetes of

youth)
Secondary Diabetes Mellitus

Type 1 diabetes
Was previously called insulin-dependent diabetes
mellitus (IDDM) or juvenile-onset diabetes.
Type 1 diabetes develops when the bodys immune
system destroys pancreatic beta cells, the only cells in
the body that make the hormone insulin that regulates
blood glucose.
This form of diabetes usually strikes children and young
adults, although disease onset can occur at any age.
Type 1 diabetes may account for 5% to 10% of all
diagnosed cases of diabetes.
Risk factors for type 1 diabetes may include
autoimmune, genetic, and environmental factors.

Type 2 diabetes
Was previously called non-insulin-dependent diabetes
mellitus (NIDDM) or adult-onset diabetes.
Type 2 diabetes may account for about 90% to 95% of all
diagnosed cases of diabetes.
It usually begins as insulin resistance, a disorder in which the
cells do not use insulin properly. As the need for insulin rises,
the pancreas gradually loses its ability to produce insulin.
Type 2 diabetes is associated with older age, obesity, family
history of diabetes, history of gestational diabetes, impaired
glucose metabolism, physical inactivity, and race/ethnicity.
African Americans, Hispanic/Latino Americans, American
Indians, and some Asian Americans and Native Hawaiians or
Other Pacific Islanders are at particularly high risk for type 2
diabetes.
Type 2 diabetes is increasingly being diagnosed in children
and adolescents.

Gestational diabetes
A form of glucose intolerance that is diagnosed in some
women during pregnancy.
Gestational diabetes occurs more frequently among
African Americans, Hispanic/Latino Americans, and
American Indians. It is also more common among obese
women and women with a family history of diabetes.
During pregnancy, gestational diabetes requires
treatment to normalize maternal blood glucose levels to
avoid complications in the infant.
After pregnancy, 5% to 10% of women with gestational
diabetes are found to have type 2 diabetes.
Women who have had gestational diabetes have a 20% to
50% chance of developing diabetes in the next 5-10 years.

Other types of DM
Other specific types of diabetes
result from specific genetic
conditions (such as maturityonset diabetes of youth),
surgery, drugs, malnutrition,
infections, and other illnesses.
Such types of diabetes may
account for 1% to 5% of all
diagnosed cases of diabetes.

Diagnosis of Diabetes
Mellitus

Values of Diagnosis of Diabetes


Mellitus

Haemoglobin
Structure of
Hb

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Different Hbs
1.
2.
3.
4.

Fetal Hemoglobin Hb F
Adult Hemoglobin Hb A
Sickle cell disease Hb S
Hemoglobinopathies Hb C,
Hb E

Glucose in the blood reacts with


the
Hemoglobin A to form Glycated
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Glycated Hb - GHb
Different types of Glycation
products are formed from the
HbA0 depending on the
carbohydrate moiety namely
HbA1a1 - Fr 1,6 diphos N-term.
valine
HbA1a2 - Gl 6 phos N-terminal
valine
(Previously called glycosylated Hb.)

HbA1b - Other CHO N-term.

Reference values of
HbA
1. Less than
6% 1c
- Normal
2. 6 to 7.5% - Good control of
DM
3. 7.6 to 9% - Unsatisfactory
control
Values depend on the method of estimation
4.TheyMore
than 9% - Very poor
vary from lab to lab.
control
Note if all GHb is measured instead of HbA1c
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Factors affecting HbA1c

Acute hyperglycemia
Severe aneamia
Gestational diabetes
Life span of the RBC
Abnormal Hb like S-Hb,
Hb C
Serum opalescence
-TG
On the method of
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Estimation of HbA1c
There are many methods of
estimation
HPLC (High Performance Liquid
Chromatography) Gold
standard.
Immuno-turbimetric meth.
HbA1cAb
Affinity chromatography
Electrophoretic methods
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HbA1c is weighted

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Advantages of HbA1c

Index of long-term control over


120 days and not a snap shot
like PG
Can be done at any time of
day
Not influenced by diet,
exercise, emotional
disturbances on test day
Useful index in clinical trials
Useful if missed drugs /
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Limitations of HbA1c

Cannot be an emergency room


test to titrate Insulin or OHA
dosage
Cannot register hypoglycemia
More sensitive to sin than
repentance if it is elevated it
confirms poor control, if it is
boarder line, it cannot assure
good control in the recent past.
Not sensitive enough for use in
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Correlation of MPG Mean Plasma


HbAGlucose =

1c

(33.3 x HbA1C%) - 86
(Nathan et. al. NEJM, vol. 310, No 6, Feb 9, 1994)

HbA1C %
5
7
9
11

Mean BG mg %
80.5
147.1
213.7
280.3

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Glycosylation of hair

Hair glycosylation using thiobarbituric


acid TBA
Glycosylation of hair is in diabetes
mellitus
Both insulin dependent , non-insulin
dependent
Glycosylation of hair is proportionate to
HbA1c
Due to the presence of hexosyl lysome
in hair
Long hair sampleBMJ,
provides
a 288
longpp.term
1996, vol.
669-670
record.
May have forensic application & in

Management of DM
The major components of the
treatment of diabetes are:

Diet and
Exercise

Oral
hypoglycaemic
therapy

Insulin Therapy

Blood Glucose
Monitoring
Type
Frequency
Sample
Type 2 DM

Monthly

FPG / PPG

Type 1 DM

4-6 times
initially

6th hourly
to 4th hourly

Stabilized

Twice a week.

3 samples

Pregnancy

Once a week.

FPG / PPG

Peri-operative

4-6 times
a day

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6th hourly
to 4th hourly

References

National Diabetes Fact Sheet 2003, DEPARTMENT OF


HEALTH AND HUMAN SERVICES Centres for Disease Control
and Prevention

World Health Organization. Definition, Diagnosis and


Classification of Diabetes Mellitus and its Complications. Report of
WHO. Department of Non-communicable Disease
Surveillance. Geneva 1999

Academy of Medicine. Clinical Practice Guidelines. Management of


type 2 diabetes mellitus. MOH/P/PAK/87.04(GU), 2004

NHS. Diabetes - insulin initiation - University Hospitals of


Leicester NHS Trust Working in partnership with PCTs across
Leicestershire and Rutland, May 2008.