Diabetes

Mellitus
The hype, the harm, the hope…

Dr. Marian K. Denopol

Diabetologist
Epidemiology of Diabetes
Diabetes: The Global Threat

1995 2000 2010

Type 1 3.5 million 4.4 million 5.5 million

Type 2 114.8 million 146.8 million 215.3 million

TOTAL 118.4 million 151.2 million 220.7 million

 Geographic Prevalence of Type 2
Diabetes

Prevalence (%)
No data available
<2
2 – 4.99
5 – 7.99
8 – 10.99
11 – 13.99
> 14
The morbidity and mortality of
diabetes mellitus
 Diabetes mellitus is a major cause of:
 Blindness in the Western world

 Kidney failure requiring dialysis and kidney

transplant
 Non-traumatic amputation
 Cardiovascular disease
 7th leading cause of mortality
 Diabetes in the Philippines
 Diabetes Prevalence Survey 1982
 Age group 20 – 65 = 4.1 %

 Metro Manila = 8.4 %

 Urban areas = 6.8 %

 Rural areas = 2.5 %

Characteristics of Type 1 and
Type 2 Diabetes
Type
Type 1 2

Fast onset Slow

of disease developmen
t
Prevalence
0.5% Prevalence
5-10%
young
adult
Pathophysiology of Type 2 Diabetes: 2
Defects
Genes Genes

Impaired Insulin Insulin Resistance

Secretion

± Environment ± Environment

IGT IGT

Type 2 Diabetes

IGT = Impaired Glucose Tolerance

Development of Type 2 Diabetes
Stage 3:
Type 2
diabetes
Macroangiopathy Microangiopathy
Stage 2: Postprandial BG
Impaired Gluconeogenesis
glucose
tolerance Glucose transport
Insulin secretion deficiency
Stage 1: Lipogenesis/ Atherogenesis Triglycerides
Normal Adiposis
Hyperinsulinaemia HDL cholesterol
glucose
tolerance Waist-to-hip ratio Insulin resistance Arterial
hypertension
Diabetes genes

Matthaei S et al. Endocr Rev (2000): 21 (6): 585-618

Postprandial plasma glucose hypothesis
Two open questions

Is postprandial plasma
glucose a driving force...

in the in the
pathogenesis of development of
type 2 diabetes? CV events?
Multiple mechanisms of vascular damage
associated with dysglycaemia
Insulin resistance
 FFA Lipaemia Obesity
Pancreas Skeletal
Hyper- muscles Adipo-
insulinaemia TNF- cytes

FFA
Hypertension Dyslipidaemia
VLDL ( triglycerides)
Advanced C-reactive
Genetic
glycation protein HDL
predisposition  Fibrinogen
end products
PAI-1
Hyperglycaemia Liver
Glycated
protein Thrombosis

FFA: free fatty acid; HDL: high-density lipoprotein,

PAI: plasminogen activator inhibitor, TNF: tumour Libby P, et al. Circulation 2002;106:2760–63.
necrosis factor, VLDL: very low-density lipoprotein
 Classification of Diabetes
 Type 1 diabetes
 Beta cell destruction
 Usually autoimmune
 Type 2 diabetes
 Insulin resistance and insulin secretion
defect
 Impaired glucose tolerance (IGT)
 Metabolic stage intermediate between
normal
glucose homeostasis and diabetes
 Considered as a risk factor for the
development of
diabetes and cardiovascular disease
 Gestational Diabetes
Glucose Tolerance Categories

NORMAL IFG/IGT DM

FPG <110 mg/dl 110-125 mg/dl  126 mg/dl

20 PG < 140 mg/dl 140-199 mg/dl  200 mg/dl

 Diagnosis of Type 2 Diabetes:
Who should be screened?
 All adults > 45, and, if normal, at 3-year
intervals
 Younger age and more frequently for those at
higher risk:
 Obese (> 20% above ideal body weight)
 1st degree relative with diabetes
 High-risk ethnic group
 History of gestational diabetes or delivered baby > 9 lb.
 Hypertension (BP 140/90 mm Hg)
 Dyslipidemia (HDL <35 mg/dl and/or triglyceride > 250

mg/dl)
 Previous IGT or IFG
Risk Factors for Development of Type 2
DM
 Genetic Factors  Environmental
Factors
 Family History
 Race  Age > 45 years
 Obesity  130% of
IBW
 Gestational DM
 IGT
 Lifestyle
Changing Therapies to Address Diabetes
Progression
Therapies to address Type 2 DM progression

Insulin with or
Lifestyle Mono Combination of
Oral agents
without oral
change theraphy agents
Diabetic Secondary Complications:
Overview

Macro-
angiopathy

Micro-
angiopathy

Metabolic-toxic
damage
(neuropathy)
Macrovascular complications
Cerebrovascular Stroke (22%*)
circulation
Angina
Coronary MI (34.7%*)
Sudden death
arteries
Renal damage
Renal
arteries

Peripheral vascular
Peripheral disease
arteries Gangrene
and amputation (2.7%*)

*Causes of death in diabetic population

MI: myocardial infarction
Diabetes Management
 Managing Your Diabetes

• Diet
• Exercise
• Medications
• Monitoring
• Education
Diabetes is Devastating and Deadly
• Leading cause of blindness in adults

• Cardiovascular disease and stroke 2 – 4x

• Leading cause of end-stage renal disease

• Amputations 15 – 40x

Diabetes is the 4th leading cause of death by

disease; 7th leading cause of death in US.
 Why take action
Each year, about 160,000 people
die from diabetes and its complications.
• Cardiovascular disease: 75% of deaths
• Stroke: risk is 2.5x higher
• Hypertension: 60-65% risk
• Kidney disease: 19-34% of diabetes population
• Blindness: 14-40% of diabetes population
• Amputations: 50% of diabetes population
Management Algorithm for Overweight
and Obese Type 2 Diabetes Mellitus
Diet, Failure

Add biguanide, TZD, or -glucosidase inhibitor

Exercise,
Failure

and Weight Combine two of these or add sulphonylurea

or glinide
Check
Control* Failure Adherance at
each step
Add insulin OR change to insulin**

Reference: Type 2 Diabetes Practical Targets & Treatments, 3 rd Ed.

TZD=thiazolidinedione
*If control isAsian Pacific
poor, oral Type
agents 2 Diabetes
may be started Policy Group.
early.**In certain situations, insulin may be required.
Management Algorithm for Normal
Weight Type 2 Diabetes Mellitus
Diet, Failure

Add sulphonylurea, biguanide, -glucosidase

Exercise, inhibitor or glinide
Failure

and Weight
Combine sulphonylurea or glinide with
biguanide and/or -glucosidase inhibitor
Control* and/or add TZD** Check
Failure
Adherance at
each step
Add insulin OR change to insulin***

TZD=thiazolidinedione
*If control is poor, oral agents may be started early.**Use of TZD may be appropriate earlier in
Patients with features of metabolic syndrome.***In certain situations, insulin may be required.
 Approximately 10% of patients on oral
agents have secondary failure each year:
When glycemic goals are not achieved with
oral agents, treatment with insulin is
indicated.
 HIGH BLOOD SUGAR
It can be caused by:
• Eating too much

• Taking too little diabetes

medicine

• Being sick or hurt

 HIGH BLOOD SUGAR
How it may feel:

Blurry vision.
Thirsty, dry throat.

Always very tired.

Frequent urination.
 HIGH BLOOD SUGAR
What to do:
• Check your urine or blood sugar
and check for ketones
• Follow your plan for food and
medicine very carefully. Drink
plenty of water
• Call the doctor if:
▫ Sugar over 240 or urine sugar
over 2%
▫ Moderate to large ketones
▫ Vomiting or unable to eat or
drink
▫ Fever of 101o or more.
 Healthy Eating
*
• Eat meals at same time each day
• Don’t skip meals
• Use less
▫ Fat • Sugar
▫ Salt • Alcohol
• Eat about the same amounts of
carbohydrate food each day.
• Learn about healthy eating from
your nutritionist or diabetes
educator
• Be at a healthy weight for you.
 Exercise and Diabetes
Exercise is good for you

• Exercise lowers blood sugar

• It helps you lose weight and
keep it down
• It helps keep your bones
strong and heart healthy.
• Exercise helps you deal with
stress and have more
energy.
 Special Tips
• Check with your doctor before starting exercise
• Start slowly to warm up
• After exercise cool down for 5-10 minutes.
• Exercise on a regular schedule
• Check your blood sugar before and after exercise
• Carry a snack or ask your doctor about decreasing your
diabetes medicine.
• Drink plenty of water
• Wear well fitting shoes and socks; have identification.
 Monitoring
Diabetes Control is Important

• Know your own symptoms of high and low blood

sugar
• Know your target blood sugar
• Have your doctor check your glycohemoglobin.
 Monitoring
Check Your Blood Sugar
• Check for sugar exactly as
you were taught
• Urine checks are not as
accurate; they don’t find
low blood sugar
• Know when to check; days
and time. Write down the
results.
 Steps for Staying Well
Keep your blood sugar under control

• Follow your food plan

• Get regular physical activity
• Take your insulin or diabetes
pills
• Test your blood or urine
sugars and use the results
 Steps for Staying Well
Control your Blood Pressure and Blood Fats
• Lose extra weight
• Eat less salt if your blood
pressure is high.
• Eat less animal fat
• Take medicine as
prescribed
 Steps for Staying Well
Protect Yourself

• Don’t smoke
• Check your feet everyday
• Wear diabetes
identification
• See your doctor regularly
 Steps for Staying Well
Avoid Injury. Protect your feet.
• Always wear shoes
• Avoid walking bare foot
• Cut toenails straight across. Don’t
use razors, scissors or knives
• Smooth edges with an emery
board
• Check shoes for stones, tacks or
other foreign bodies
• Don’t sit with legs crossed
• Don’t use heating pads, hot water
bottles, or iodine. They can cause
harm.
• Don’t soak your feet
 Steps for Staying Well
Check with your Doctor or Nurse.
• Let your doctor or nurse check your feet at every
visit.
• Take off your shoes and socks to remind them.
• Call the doctor if there are any changes on your
feet
 Footsteps
Keep your feet clean
• Wash every day in warm
water
• Don’t use HOT water
• Dry well between toes
• Put lotion on top and
bottom of feet: not
between toes
 Stress and Diabetes
Pressure and Stress are common:
• Everyone feels stress at
times
• Life’s pressures can seem
too big to handle
• Stress can lead to feeling
sad, tense, tearful or tired
 Stress and Diabetes
Stress can affect diabetes
control:
• Your blood sugar may
Blood Sugar
Blood Sugar
change when you feel
300
300
250
250
stressed
200
200
150
• You may forget to take
150
100
100 care of your diabetes.
50
50
0 Managing diabetes is
0
Time
Time harder when you are
under stress.
• You may eat or drink
too much.
 Stress and Diabetes
What to do to avoid or manage stress:
• Get support. Keep
family and friends
involved with your
diabetes care.
• Set realistic goals. Find
balance between work,
family and your diabetes
care.
• Be positive. Focus on
what you can control.
Thank You…