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Diabetes Mellitus

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Title: Diabetes Mellitus Author: USER Last modified by: USER Created Date: 1/18/2012 7:15:00 AM Document presentation format: (3:4) – PowerPoint PPT presentation

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Title: Diabetes Mellitus


1
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2
  • over the past few decades, diabetes has emerged
    as an important medical problem in developing
    regions of the world
  • In a more recent report on global diabetes
    estimates and projections for the years
    20002030,Wild et al. showed that the worldwide
    prevalence of diabetes for all age groups would
    increase from 2.8 in 2000 to 4.4 in 2030, with
    a corresponding 114 increase in the numbers,
    from 171 million to 366 million. The greatest
    relative increases will occur in developing
    regions, namely India and the Middle Eastern
    Crescent

3
  • Important contributors include an increase in the
    urban population in developing countries and an
    increase in the proportion of people gt65 years of
    age across the world

4
  • Diabetes mellitus (DM) is a common syndrome and
    caused by lack or decreased effectiveness of
    endogenous insulin
  • The chronic hyperglycemia of diabetes is
    associated with long-term damage, dysfunction,
    and failure of various organs, especially the
    eyes, kidneys, nerves, heart, and blood vessels.

5
Classification of primary diabetes
  • Type 1 (insulin-dependent (IDDM), juvenile
    onset)
  • Only 510 of those with diabetes
  • May occur at any age but more common in patients
    lt30y.
  • results from a cellular-mediated autoimmune
    destruction of the ß-cells of the pancreas

6
  • Some patients, particularly children and
    adolescents, may present with ketoacidosis as the
    first manifestation of the disease.
  • These patients are also prone to other autoimmune
    disorders such as Hashimotos thyroiditis,
    vitiligo, autoimmune hepatitis and pernicious
    anemia.

7
Type 2 (non-insulin dependent (NIDDM), maturity
onset)
  • 9095 of those with diabetes
  • the cause is a combination of resistance to
    insulin action and an inadequate compensatory
    insulin secretory response
  • a degree of hyperglycemia sufficient to cause
    pathologic and functional changes in various
    target tissues, but without clinical symptoms,
    may be present for a long period of time before
    diabetes is detect

8
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9
Islet Cell Dysfunction and Abnormal Glucose
Homeostasis in Type 2 Diabetes
10
  • Most patients with this form of diabetes are
    obese, obesity itself causes some degree of
    insulin resistance
  • Insulin resistance may improve with weight
    reduction and/or pharmacological treatment of
    hyperglycemia but is seldom restored to normal

11
The risk of developing this form of diabetes
increases with
  • age,
  • obesity,
  • and lack of physical activity.
  • In women with prior GDM
  • Individuals with hypertension or dyslipidemia

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Type 1 DM
  • Younger
  • More lean
  • Insulin-deficient
  • Low triglycerides

Type 2 DM
  • Older
  • Overweight
  • Insulin-resistant
  • High TGs/Low HDL-C

14
Gestational diabetes mellitus (GDM)
  • GDM is defined as any degree of glucose
    intolerance with onset or first recognition
    during pregnancy.
  • GDM complicates 4 of all pregnancies in the
    U.S., resulting in 135,000 cases annually

15
Presentation of DM
  • Acute Ketoacidosis
  • Sub-acute Weight loss, polydipsia, polyuria,
    lethargy, irritability, infections (candidiasis,
    skin infection, recurrent infections slow to
    clear), genital itching, blurred vision, tingling
    in hands/feet.

16
  • With complications Presentation with skin
    changes, peripheral neuropathy with risk of foot
    ulcers, amputations, nephropathy, eye disease
  • Asymptomatic DM may be detected on routine
    screening during well man/woman checks .

17
Natural History of DM 2
Years from diagnosis
0
10
5
15
-10
-5
Onset
Diagnosis
Insulin resistance
Macrovascular complications
Type 2 diabetes
Pre-diabetes
Adapted from Ramlo-Halsted BA, Edelman SV. Prim
Care. 199926771-789 Nathan DM. N Engl J
Med. 20023471342-1349
18
Impact of Diabetes Mellitus
Diabetes
The leading cause of new cases of end stage renal
disease
A 2- to 4-fold increase in cardio-vascular
mortality
The leading cause of new cases of blindness in
working-aged adults
The leading cause of nontraumatic lower extremity
amputations
www.hypertensiononline.org
19
Criteria for the Diagnosis of Diabetes
20
  • Global Prevalence of
  • Diabetes

21
Estimated global prevalence of type 1 and type 2
diabetes
22
Global Prevalence Estimates, 2000 and 2030
4.4
2.8
Reference Wild S, Roglic G, Green A, Sicree R,
King H. Global prevalence of diabetes. Diabetes
Care. 2004 27(5) 1047-1053.
23
Diabetes in the World
Year2000
millions
Reference Wild S, Roglic G, Green A, Sicree R,
King H. Global prevalence of diabetes. Diabetes
Care. 2004 27(5) 1047-1053.
24
Diabetes in the World
Year2010
millions
Reference Wild S, Roglic G, Green A, Sicree R,
King H. Global prevalence of diabetes. Diabetes
Care. 2004 27(5) 1047-1053.
25
Prevalence of Diabetes by Country
gt 18 years only. Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 1999-2003. Atlanta, GA
United States, Department of Health and Human
Services. Dunstan DW, Zimmet PZ, Welborn TA,
Courten MP, Cameron AJ, Sicree RA, et al. The
raising prevalence of diabetes and impaired
glucose tolerance. Diabetes Care. 2002 25(5)
829-834. Warsy AS, el-Hazmi MA. Diabetes
mellitus, hypertension and obesity-common
multifactorial disorders in Saudis. Eastern
Mediterranean Health Journal. 1999 5(6) 1236-42.
26
Prevalence of Diabetes in Adults United States,
BRFSS 1998 - 2003
BRFSS Behavioral Risk Factor Surveillance
System (gt18 years). Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 1998-2003. Atlanta, GA
United States, Department of Health and Human
Services.
27
Global Incidence of IDDM
28
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31
RISK FACTORS OF DM
32
GENETIC RISK
  • There is ample evidence that type 2 diabetes has
    a strong genetic component.
  • Type 2 diabetes clusters in families.
  • The lifetime risk of developing type 2 diabetes
    is about 40 in offspring of one parent with type
    2 diabetes the risk approaches 70 if both
    parents have diabetes.

33
  • Intriguingly, the risk in the offspring seems to
    be greater if the mother rather than the father
    has type 2 diabetes
  • a first-degree relative of a patient with type 2
    diabetes has a threefold increased risk of
    developing the disease

34
ADULT OBESITY
  • Obesity and weight gain are major risk factors
    for type 2 diabetes, and they have been blamed
    for or implicated in the rising prevalence of
    diabetes worldwide.
  • A community-based survey in Saudi Arabia in
    19952000 of people aged 3070 years found that
    36.9 were overweight and 35.5 were obese.
  • Men were more likely to be overweight and women
    were more likely to be obese

35
CHILDHOOD OBESITY
  • The sharp increase in the prevalence of
    overweight and obesity worldwide is not only
    limited to adults, but also extends to
    adolescents and children and even to preschool
    children. This increase in weight led to an
    increase in the incidence of type 2 diabetes in
    childhood, to a point that it is becoming more
    common than type 1 diabetes in a few countries,
    such as in Japan and Taiwan

36
Dietary risk factors
  • Studies utilizing a variety of epidemiological
    approaches have implicated a range of
    lifestyle-related environmental factors in the
    etiology of type 2 diabetes

37
CARBOHYDRATEAND DIETARY FIBER
  • refined carbohydrates, and sugars in particular,
    might be involved in the etiology of type 2
    diabetes
  • Over 40 studies have examined the role of sugars
    in the etiology of type 2 diabetes, with about
    half suggesting a positive association and a
    comparable number suggesting no association

38
  • On the other hand, there is rather more support
    for the suggestion that foods rich in slowly
    digested or resistant starch or high in dietary
    fiber (nonstarch polysaccharide) might be
    protective In controlled experiments, diets high
    in soluble fiber-rich foods 20 or foods with a
    low glycemic index are associated with improved
    diurnal blood glucose profiles and long-term
    overall improvement in glycemic control, as
    evidenced by reduced levels of glycated hemoglobin

39
  • Some other studies provide indirect support for
    this hypothesis. Diabetes risk appears to be
    lower in Seventh-Day Adventists who are
    vegetarians than in those who are not strict
    vegetarians 22.
  • The diet of vegetarians is characterized by a
    high intake of dietary fiber, but differs in
    other ways from that of nonvegetarians. In
    addition to not eating meat and animal products,
    vegetarians also have less saturated fat,more
    polyunsaturated fat and a diet which differs in
    micronutrient composition when compared with
    nonvegetarians.

40
DIETARY FATS
  • More than 60 years ago, Himsworth 23 suggested
    that high intakes of fat increased the risk of
    diabetes in populations and individuals.
  • In the San Luis Valley Diabetes Study, a high fat
    intake was associated with an increased risk of
    type 2 diabetes and impaired glucose tolerance
    (IGT) 25

41
  • in a follow-up, 1 to 3 years later, fat
    consumption predicted progression to type 2
    diabetes in those with IGT

42
  • On the other hand, no association was found
    between fat intake and risk of type 2 diabetes in
    a 12-year follow-up of women in Gothenburg,
    Sweden
  • The type of dietary fat may also be relevant.
    Saturated fatty acids were positively related to
    fasting and postprandial glucose levels in
    normoglycemic Dutch men, the effect being
    independent of energy intake and obesity.

43
  • In a recent Italian study, intake of butter (rich
    in palmitic and myristic acids) was positively
    associated with fasting glucose levels, and the
    use of olive oil (high in oleic acid) was
    inversely associated with fasting glucose Levels
  • The ratio of polyunsaturated to saturated fatty
    acids in serum phospholipids has been shown to be
    inversely associated with insulin secretion and
    positively associated with insulin action

44
PROTEIN
  • There are no firm epidemiological data concerning
  • the role of protein intake in the etiology of
  • type 2 diabetes,
  • though the fact that meat-eating
  • Seventh-Day Adventists have higher rates than
  • those who do not eat meat has been taken to
  • suggest a possible deleterious effect of animal
  • protein

45
  • The strong positive associations
  • between animal protein and saturated fatty acids
  • and vegetable protein and dietary fiber mean that
  • it is almost impossible to disentangle separate
  • effects in epidemiological studies.
  • High intakes of proteins, especially animal
  • protein, appear to be associated with an
    increased
  • risk of nephropathy in type 1 diabetes 44, so
  • restriction of protein may help to delay
    progression
  • of microalbuminuria to clinical nephropathy

46
OTHER DIETARY FACTORS
  • Several micronutrients, most notably chromium,
  • zinc, magnesium and vitamin E, have been
    implicated
  • in the pathogenesis of type 2 diabetes
  • and/or been shown to be associated with improved
  • glycemic control.
  • However, no epidemiological
  • studies have provided convincing support for the
  • role of any of these nutrients in the etiology of
    the
  • disease. There is, perhaps, rather more support
    for
  • the suggestion vitamin D deficiency may be
    important

47
  • Vitamin D deficiency impairs insulin release,
  • followed, if prolonged, by impairment of insulin
  • secretion and reduction of glucose tolerance
    which
  • progresses to irreversible diabetes.

48
smooking
  • The role of smoking
  • as a risk factor for type 2 diabetes has received
  • relatively little attention. Smoking induces
    insulin
  • resistance 51, and cigarette smokers have
  • been shown to be relatively glucose intolerant
    and
  • Dyslipidemic
  • Thus, smokers might be expected to be at
  • considerably increased risk of type 2 diabetes.

49
PHYSICAL INACTIVITY
  • In cross-sectional epidemiological
  • studies, type 2 diabetes rates have been shown
  • to be lower amongst physically active individuals
  • than amongst those not having regular physical
  • activity

50
  • The protective effect of physical
  • activity against type 2 diabetes has been
    confirmed
  • in several prospective studi

51
Prevalence of Factors Associated with Diabetes,
Puerto Rico BRFSS 2003
BRFSS Behavioral Risk Factor Surveillance
System (gt18 years). Centers for Disease Control
and Prevention. Behavioral Risk Factor
Surveillance System 2003. Atlanta, GA United
States, Department of Health and Human Services.
52
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53
Stages in the Evolution of Major Diabetes
Surveillance Indicators
  • Primary Prevention
  • Physical activity
  • IFG / IGT
  • Diet/nutrition
  • Body composition
  • Preventive Care Practices
  • Foot exam
  • HbA1c testing
  • Dilated eye examination
  • Diabetes education

Prediabetes
Death
Normal
Diabetes
Complications
The future Continued evolution of all
domains. New generation quality of care Community
or system level County and state level Health
service measures for PP
Indicators of Burden DM prevalence and
incidence Acute complications Amputation ESRD CVD
Death
  • Risk Factors for Complications
  • Uncontrolled blood pressure
  • Inadequate glycemic control
  • Hyperlipidemia
  • Smoking
  • Sedentary behavior

Desai et al J Public Health Management Practice,
2003 (suppl). S44-51
54
Treatment
  • In some individuals with diabetes, adequate
    glycemic control can be achieved with weight
    reduction, exercise, and/or oral glucoselowering
    agents.
  • Individuals with extensive -cell destruction and
    therefore no residual insulin secretion require
    insulin for survival.

55
NutritionalManagementof D M
  • Diets rich in monounsaturated fat reduce total
    and low-density lipoprotein cholesterol without
    adverse e?ects on high- density lipoprotein
    cholesterol or triglyceride levels

56
  • a range of carbohydrate (4560) and fat (2535)
    intakes is compatible with good diabetes control
    provided that low glycaemic index carbohydrates
    and foods high in monounsaturated fat are
    promoted.
  • monounsaturated fatty acids should provide
    between 10 and 20 total energy

57
Glycemic index of certain food items
  • Low GI Pasta, Basmati rice, wholegrain products,
    porridge, oat-based cereal bars, lentils and
    pulses including baked beans, and kidney beans
  • High GI Corn Flakes, Rice Krispies, sugared
    cereals, white bread, rice (other than Basmati),
    potatoes, fruit juice, bananas, honey sandwich

58
  • for those people with Type 1 diabetes, especially
  • in those with hypertension, intakes of protein
    should not exceed 1020 total energy because of
    the increased risk of nephropathy
  • It is recommended that a diet rich in foods which
    naturally contain signi?cant quantities of
    antioxidants, especially fruit and vegetables, is
    followed

59
The normal protein requirements are
  • . 2 g/kg per day in early infancy
  • . 1 g/kg per day for a 10-year-old
  • . 0.8 g/kg in later adolescence towards adulthood

60
Nutritional recommendations for childhood and
adolescent Type 1 diabetes
  • Total daily energy intake should be distributed
    as follows
  • (i) Carbohydrate gt50
  • mainly as complex higher ?bre carbohydrate
  • moderate sucrose intake
  • (ii) Fat 3035
  • Mainly monounsaturated fat
  • (iii) Protein 1015 (decreasing with age)
  • Fruit and vegetables (recommend ?ve portions per
    day)
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