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Diabetes Mellitus

Diagnosis and Monitoring


Wahyu Eko Prasetyo
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 long–term damage,


dysfunction and failure of various organs.
Why are we seeing such an increase
in the number of people with Type 2
diabetes worldwide?

Unhealthy lifestyle Aging population Urbanisation

Dietary changes Sedentary lifestyle


IDF Diabetes Atlas 2014
Cockram 2000. HKMJ; 6 (1): 43-52
Mohan 2007. Indian J Med Res; 125: 217-230
High blood glucose is the 3rd biggest risk
factor contributor to cardio-vascular
deaths globally

Attributable deaths due to selected risk factors (000’)

WHO 2011. Global Atlas on CVD prevention and Control


Diabetes is developing fast in Indonesia

2007
Diagnosed Diabetes 1.5%

Undiagnosed Diabetes 4.2%

Impaired Glucose Tolerance 10.2%

RISKESDAS Survey 2007


Laporan RISKESDAS 2013
Diabetes is developing fast in Indonesia

2007 2013
Diagnosed Diabetes 1.5% 2.1%

Undiagnosed Diabetes 4.2% 4.8%

Impaired Glucose Tolerance 10.2% 29.9%

More than 10 million people live


RISKESDAS Survey 2007
with diabetes in Indonesia in 2015
Laporan RISKESDAS 2013
…and diabetes control is suboptimal

67.85%

Soewondo P, Soegondo S, Suastika K, Pranoto A, Soeatmadji DW, Tjokroprawiro A. The DiabCare Asia 2008 study-
Outcomes on control and complications of type 2 diabetic patients in Indonesia Med J Indones 2010 19; 4: 235-244.
Classification of diabetes
 Type 1 diabetes
 Beta-cell destruction, usually leading to absolute insulin
deficiency
 Type 2 diabetes
 Progressive insulin secretory defect on the background of beta-
cell dysfunction and insulin resistance
 Gestational diabetes mellitus
 Diabetes diagnosed in the second or third trimester of
pregnancy that is not clearly overt diabetes
 Other specific diabetes types
 Drug- or chemical-induced, e.g steroids, treatment of HIV/AIDS
or after organ transplantation
 Genetic defects in beta cell function or in insulin action
 Diseases of the exocrine pancreas (e.g. cystic fibrosis)

ADA - Standards of Medical Care in Diabetes – 2016. Diabetes Care, Vol. 39, Supplement 1, January 2016.
Classical diabetes symptoms

Polyuria • Excessive urination at night

Blurred vision • Visual disturbance

Polydipsia • Excessive thirst

Unexplained • Even if food intake is normal


weight loss

Polyphagia • Excessive hunger

Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2015. Jakarta: PB Perkeni, 2015
http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/symptoms/con-20034795
Other diabetes symptoms

Numbness
and/or tingling • In hands, legs and feet

Fatigue • Regardless of exercise

Itchy skin • Affects legs, feet, and hands

Impotence • Physical and physiological

Adapted from Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2015. Jakarta: PB Perkeni, 2015.
Criteria for testing for diabetes or prediabetes in asymptomatic adults

1. Testing should be considered in all adults who are overweight


and have additional risk factors:
• Physical inactivity
• First-degree relative with diabetes
• Women who delivered a baby weighing over 9 lb or were diagnosed with GDM
• Hypertension (≥140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level <35 mg/dL and/or a triglyceride level >250 mg/dL
• Polycystic ovary syndrome
• HbA1C ≥5.7%, IGT, or IFG on previous testing
• Other clinical conditions associated with insulin resistance (e.g., severe
obesity, acanthosis nigricans)
• History of CVD

2. For all patients, testing should begin at age 45 years.

3. If results are normal, testing should be repeated at a minimum of 3-


year intervals, with consideration of more frequent testing depending
on initial results (e.g., those with prediabetes should be tested yearly)
and risk status.
American Diabetes Association. Classification and diagnosis of diabetes. Sec. 2. In Standards of Medical Care in Diabetes 2016.
Diabetes Care 2016;39 (Suppl. 1): S13–S22
12

Diagnostic Criteria for Prediabetes


and Diabetes in Nonpregnant Adults
Normal High Risk for Diabetes Diabetes
IFG
FPG <100 mg/dL FPG ≥126 mg/dL
FPG ≥100-125 mg/dL
2-h PG ≥200 mg/dL
IGT
2-h PG <140 mg/dL Random PG ≥200 mg/dL +
2-h PG ≥140-199 mg/dL
symptoms*

5.5 to 6.4% ≥6.5%


A1C <5.5%
For screening of prediabetes† Secondary‡

*Polydipsia (frequent thirst), polyuria (frequent urination), polyphagia (extreme hunger), blurred
vision, weakness, unexplained weight loss.
†A1C should be used only for screening prediabetes. The diagnosis of prediabetes, which may
manifest as either IFG or IGT, should be confirmed with glucose testing.
‡Glucose criteria are preferred for the diagnosis of DM. In all cases, the diagnosis should be
confirmed on a separate day by repeating the glucose or A1C testing. When A1C is used for
diagnosis, follow-up glucose testing should be done when possible to help manage DM.
FPG, fasting plasma glucose; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; PG, plasma
glucose.
Q1. How is diabetes screened and diagnosed? 13

Diagnostic Criteria for Gestational


Diabetes

Test Screen at 24-28 weeks gestation

FPG, mg/dL >92


1-h PG*, mg/dL ≥180

2-h PG*, mg/dL ≥153


*Measured with an OGTT performed 2 hours after 75-g oral glucose
load.

FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG, plasma glucose.
Cut-points: Diabetes, IGT and IFG
mg/dL
Fasting Plasma Glucose (FPG)

Diabetes

126
IFG
Impaired Fasting
Glucose
IGT
100
Impaired Glucose
Tolerance Diabetes
NGT
Normal Glucose
Tolerance

140 200 mg/dL

2-hour Plasma Glucose

American Diabetes Association. Classification and diagnosis of diabetes. Sec. 2. In Standards of Medical Care in Diabetes 2016.
Diabetes Care 2016;39(Suppl. 1): S13–S22
Diagnosis of Type 2 Diabetes
KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2. 2015

Fasting* Plasma Glucose ≥ 126 mg/dl


or
2-hour post 75g OGTT ≥ 200 mg/dl
or
Classical symptoms of diabetes** & Random plasma glucose
concentration ≥ 200 mg/dl
or
HbA1c ≥ 6.5% (standardised assay***)
*Classical symptom of diabetes (polyuria, polydipsia, weight loss),
only need 1 abnormal BG, otherwise need 2 x abnormal BG level
on different days
**Fasting is defined as no caloric intake for at least 8 hours
***Standarised to National Glycohaemoglobin Standardization
Program (NGSP)

•Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2015. Jakarta: PB Perkeni, 2015.
What is good glycaemic control?

 Overall aim is to achieve glucose levels as close to normal as possible


 Minimise development and progression of microvascular and
macrovascular complications

ADA1 FPG HbA1c PPG


<130 mg/dL < 7.0 % <180 mg/dL

FPG HbA1c PPG


IDF2 <110 mg/dl
< 6.5 % <145 mg/dL

PERKENI3 FPG HbA1c PPG


<130 mg/dl < 7.0 % <180 mg/dl

1. American Diabetes Association Diabetes Care 2015;38 (Suppl 1):S8-S15


2. IDF Clinical Guidelines Task Force. International Diabetes Federation 2005. 3. Konsensus PERKENI 2015.
Risk of complications increases as
HbA1c increases
80

60 Microvascular disease
Incidence per 1.000
patient-years

40
Myocardial infarction

20

0
5 6 7 8 9 10 11 Mean HbA1c (%)
97 126 154 183 212 240 269 Mean mg/dl

Adjusted for age, sex, and ethnic group.

Stratton IM et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35):
prospective observational study. BMJ 2000;321:405–12
Optimising blood glucose control

Myocardial
Good control is infarction
≤ 7.0% HbA1c
-14%

Microvascular
HbA1c complications
-1% -37%

Deaths related
to diabetes

-21%
Source: UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM
et al. BMJ. 2000;321(7258):405-412.
Management of DM
• The major components of the treatment of diabetes are:

• Diet and
A Exercise

• Oral
B hypoglycaemic
therapy

• Insulin
C Therapy
A. Diet
 Diet is a basic part of management in every case. Treatment cannot
be effective unless adequate attention is given to ensuring
appropriate nutrition.

 Dietary treatment should aim at:


◦ ensuring weight control
◦ providing nutritional requirements
◦ allowing good glycaemic control with blood glucose levels as close to
normal as possible
◦ correcting any associated blood lipid abnormalities
A. Diet (cont.)
The following principles are recommended as dietary
guidelines for people with diabetes:

 Dietary fat should provide 25-35% of total intake of calories but


saturated fat intake should not exceed 10% of total energy.
Cholesterol consumption should be restricted and limited to 300
mg or less daily.

 Protein intake can range between 10-15% total energy (0.8-1


g/kg of desirable body weight). Requirements increase for
children and during pregnancy. Protein should be derived from
both animal and vegetable sources.

 Carbohydrates provide 50-60% of total caloric content of the diet.


Carbohydrates should be complex and high in fibre.

 Excessive salt intake is to be avoided. It should be particularly


restricted in people with hypertension and those with
nephropathy.
Exercise

• Physical activity promotes weight reduction and


improves insulin sensitivity, thus lowering blood
glucose levels.

• Together with dietary treatment, a programme of


regular physical activity and exercise should be
considered for each person. Such a programme
must be tailored to the individual’s health status
and fitness.

• People should, however, be educated about the


potential risk of hypoglycaemia and how to avoid it.
Practical monitoring scheme

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
Practical monitoring scheme cont…

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
Thank You