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 middleaged and older population
USA (2002) : 8 %
United Kingdom : 2% (over 40s)
Development countries : 1,5 2 %

Indonesia
Manado
Tasikmalaya
Kec. Sesean
(Tana Toraja)
Surabaya
Jakarta
Makassar

: 6,1%
: 1,1%
: 0,8%
: 1,43-1,47%
: 12,8%
: 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

Pancreas

Insulin = Insulin
secretion deficiency

Hyperglycemia

Hepatic glucose
production

Liver

Glucose Insulin
uptake = resistance

Muscle

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
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
Dyslipidemia (high VLDL, low HDL, small dense LDL)
Pro-coagulant endothelial markers
Hyperuricemia
Polycystic ovarii syndrome
Early and accelerated atherosclerosis

Algorythm

Clinical symptoms of diabetes

of Diagnosis
Specific complaints

No specific complaints

Fasting glucose

> 126

< 126

> 126

110-125

At time glucose

> 200

< 200

> 200

110-199

< 110

Repeat : at time glucose

or fasting glucose

Fasting glucose

> 126

< 126

OGTT

At time glucose

> 200

< 200

2h pp
> 200

DIABETES MELLITUS

140-199

IGT

Impaired FG

< 140

Normal

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)

Plasma glucose at time

Fasting plasma glucose

Sample

Not DM

Uncertain
DM

DM

Vein blood

< 110

110-199

> 200

Capillary
blood

< 90

90-199

> 200

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

20-25%
10-15%

60-70%

Exercise

C
R
I
P
E

= Continous
= Rythmical
= Interval
= Progressive
= Endurance

Pharmacological intervention

Hypoglycemic agents
Drugs

Mechanism of action

Adverse effects

Decrease of
HbA1c

Sulfonylurea

insulin secretion

BW
Hypoglycemia

1,5 - 2,5%

Glinide

insulin secretion

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

1,5 2,5%

Diabetes control criteria

Parameter

Optimal

Moderate

Poor

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/m2)

18,5 22,9

23 - 25

> 25

BP

< 130/80

130-140/80-90

> 140/90

Prevention of diabetes
Primary prevention
High risk group
Secondary prevention
Screening
Tertiary prevention
Prevention of deformity

Screening for diabetes

1.
2.
3.
4.
5.

Age : > 45 years old

Weight : RBW > 110%, BMI > 23 kg/m3
Hypertension ( > 140/90 mmHg)
Family history of diabetes
Recurrent abortion, congenital
malformation, low birth weight (> 4000 g)
6. HDL-cholesterol < 35 mg/dl,
triglyceride > 250 mg/dl

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