2

24
These notes are important as said in the class by Dr.Eman. Diabetes Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger). There are three main types of diabetes: Type 1 diabetes: results from the body's failure to produce insulin, and presently requires the person to inject insulin. (Also referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenile diabetes.) Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. (Formerly referred to as non-insulin-dependent diabetes mellitus, NIDDM for short, and adult-onset diabetes.) Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM. Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of glucocorticoids, and several forms of monogenic diabetes. All forms of diabetes have been treatable since insulin became available in 1921, and type 2 diabetes may be

description

 

Transcript of 2

Page 1: 2

These notes are important as said in the class by Dr.Eman.

Diabetes

Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of polyuria (frequent urination), polydipsia (increased thirst) and polyphagia (increased hunger).

There are three main types of diabetes:

Type 1 diabetes: results from the body's failure to produce insulin, and presently requires the person to inject insulin. (Also referred to as insulin-dependent diabetes mellitus, IDDM for short, and juvenile diabetes.)

Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. (Formerly referred to as non-insulin-dependent diabetes mellitus, NIDDM for short, and adult-onset diabetes.)

Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM.

Other forms of diabetes mellitus include congenital diabetes, which is due to genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid diabetes induced by high doses of glucocorticoids, and several forms of monogenic diabetes.

All forms of diabetes have been treatable since insulin became available in 1921, and type 2 diabetes may be controlled with medications. Both type 1 and 2 are chronic conditions that usually cannot be cured. Pancreas transplants have been tried with limited success in type 1 DM; gastric bypass surgery has been successful in many with morbid obesity and type 2 DM. Gestational diabetes usually resolves after delivery. Diabetes without proper treatments can cause many complications. Acute complications include hypoglycemia, diabetic ketoacidosis, or nonketotic hyperosmolar coma. Serious long-term complications include cardiovascular disease, chronic renal failure, retinal damage. Adequate treatment of diabetes is thus important, as well as blood pressure control and lifestyle factors such as smoking cessation and maintaining a healthy body weight.

Globally as of 2010 it is estimated that there are 285 million people diabetes with type 2 making up about 90% of the cases.

Page 2: 2

Types

Most cases of diabetes mellitus fall into three broad categories: type 1, type 2, and

gestational diabetes. A few other types are described. The term diabetes, without qualification, usually refers to diabetes mellitus. The rare disease diabetes insipidus has similar symptoms as diabetes mellitus, but without disturbances in the sugar metabolism (insipidus meaning "without taste" in Latin).

The term "type 1 diabetes" has replaced several former terms, including childhood-onset diabetes, juvenile diabetes, and insulin-dependent diabetes mellitus (IDDM). Likewise, the term "type 2 diabetes" has replaced several former terms, including adult-onset diabetes, obesity-related diabetes, and non-insulin-dependent diabetes mellitus (NIDDM). Beyond these two types, there is no agreed-upon standard nomenclature. Various sources have defined "type 3 diabetes" as: gestational diabetes, insulin-resistant type 1 diabetes (or "double diabetes"), type 2 diabetes which has progressed to require injected insulin, and latent autoimmune diabetes of adults (or LADA or "type 1.5" diabetes).

Type 1 diabetes

Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta cells of the islets of Langerhans in the pancreas leading to insulin deficiency. This type of diabetes can be further classified as immune-mediated or idiopathic. The majority of type 1 diabetes is of the immune-mediated nature, where beta cell loss is a T-cell mediated autoimmune attack. There is no known preventive measure against type 1 diabetes, which causes approximately 10% of diabetes mellitus cases in North America and Europe. Most affected people are otherwise healthy and of a healthy weight when onset occurs. Sensitivity and responsiveness to insulin are usually normal, especially in the early stages. Type 1 diabetes can affect children or adults but was traditionally termed "juvenile diabetes" because it represents a majority of the diabetes cases in children.

"Brittle" diabetes, also known as unstable diabetes or labile diabetes, is a term that was traditionally used to describe to dramatic and recurrent swings in glucose levels, often occurring for no apparent reason in insulin-dependent

Comparison of type 1 and 2 diabetesFeature Type 1 diabetes Type 2 diabetesOnset Sudden Gradual

Age at onset Mostly in Children

Mostly in adults

Body habitus Thin or normal Often obeseKetoacidosis Common Rare

Autoantibodies Usually present AbsentEndogenous insulin Low or absent Normal, decreased

or increasedConcordance

in identical twins50% 90%

Prevalence ~10% ~90%

Page 3: 2

diabetes. This term, however, has no biologic basis and should not be used.[7] There are many different reasons for type 1 diabetes to be accompanied by irregular and unpredictable hyperglycemias, frequently with ketosis, and sometimes serious hypoglycemias, including an impaired counterregulatory response to hypoglycemia, occult infection, gastroparesis (which leads to erratic absorption of dietary carbohydrates), and endocrinopathies (eg, Addison's disease). These phenomena are believed to occur no more frequently than in 1% to 2% of persons with type 1 diabetes.

Type 2 diabetes

Type 2 diabetes mellitus is characterized by insulin resistance which may be combined with relatively reduced insulin secretion. The defective responsiveness of body tissues to insulin is believed to involve the insulin receptor. However, the specific defects are not known. Diabetes mellitus due to a known defect are classified separately. Type 2 diabetes is the most common type.

In the early stage of type 2 diabetes, the predominant abnormality is reduced insulin sensitivity. At this stage hyperglycemia can be reversed by a variety of measures and medications that improve insulin sensitivity or reduce glucose production by the liver.

Gestational diabetes

Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several respects, involving a combination of relatively inadequate insulin secretion and responsiveness. It occurs in about 2%–5% of all pregnancies and may improve or disappear after delivery. Gestational diabetes is fully treatable but requires careful medical supervision throughout the pregnancy. About 20%–50% of affected women develop type 2 diabetes later in life.

Even though it may be transient, untreated gestational diabetes can damage the health of the fetus or mother. Risks to the baby include macrosomia (high birth weight), congenital cardiac and central nervous system anomalies, and skeletal muscle malformations. Increased fetal insulin may inhibit fetal surfactant production and cause respiratory distress syndrome. Hyperbilirubinemia may result from red blood cell destruction. In severe cases, perinatal death may occur, most commonly as a result of poor placental perfusion due to vascular impairment. Labor induction may be indicated with decreased placental function. A cesarean section may be performed if there is marked fetal distress or an increased risk of injury associated with macrosomia, such as shoulder dystocia.

A 2008 study completed in the U.S. found that the number of American women entering pregnancy with preexisting diabetes is increasing. In fact the rate of diabetes in expectant mothers has more than doubled in the past 6 years. This is particularly problematic as diabetes raises the risk of complications during

Page 4: 2

pregnancy, as well as increasing the potential that the children of diabetic mothers will also become diabetic in the future.

Other types

Pre-diabetes indicates a condition that occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 diabetes. Many people destined to develop type 2 diabetes spend many years in a state of pre-diabetes which has been termed "America's largest healthcare epidemic."

Latent autoimmune diabetes of adults is a condition in which Type 1 diabetes develops in adults. Adults with LADA are frequently initially misdiagnosed as having Type 2 diabetes, based on age rather than etiology.

Signs and symptoms

Page 5: 2

Test

Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following:

Fasting plasma glucose level ≥ 7.0 mmol/L (126 mg/dL). Plasma glucose ≥ 11.1 mmol/L (200 mg/dL) two hours after a 75 g oral

glucose load as in a glucose tolerance test . Symptoms of hyperglycemia and casual plasma glucose ≥ 11.1 mmol/L

(200 mg/dL). Glycated hemoglobin (HbA1C) ≥ 6.5%.

A positive result, in the absence of unequivocal hyperglycemia, should be confirmed by a repeat of any of the above-listed methods on a different day. It is preferable to measure a fasting glucose level because of the ease of measurement and the considerable time commitment of formal glucose tolerance testing, which takes two hours to complete and offers no prognostic advantage over the fasting test. According to the current definition, two fasting glucose measurements above 126 mg/dL (7.0 mmol/L) is considered diagnostic for diabetes mellitus.

People with fasting glucose levels from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) are considered to have impaired fasting glucose. Patients with plasma glucose at or above 140 mg/dL (7.8 mmol/L), but not over 200 mg/dL (11.1 mmol/L), two hours after a 75 g oral glucose load are considered to have impaired glucose tolerance. Of these two pre-diabetic states, the latter in particular is a major risk factor for progression to full-blown diabetes mellitus as well as cardiovascular disease.

Glycated hemoglobin is better than fasting glucose for determining risks of cardiovascular disease and death from any cause.

Diabetes diagnostic criteria Condition 2 hour

glucoseFasting glucose

HbA1c

mmol/l(mg/dl) mmol/l(mg/dl) %Normal <7.8 (<140) <6.1 (<110) <6.0

Impaired fasting glycaemia

<7.8 (<140) ≥ 6.1(≥110) & <7.0(<126)

6.0-6.4

Impaired glucose tolerance

≥7.8 (≥140) <7.0 (<126) 6.0-6.4

Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126) ≥6.5

Page 6: 2

Oral manifestations

http://www.authorstream.com/Presentation/gingiva-120877-oral-manifestation-diabetes-mellitus-dentistry-new-microsoft-powerpoint-education-ppt/ (See the slide of oral manifestations)

Dental treatment consideration

- GENERAL MANAGEMENT CONSIDERATIONS

The dentist plays a major role in referral of patients with diabetes to physicians for additional evaluation.1 Any undiagnosed dental patient who has the cardinal signs and symptoms of diabetes (that is, polydipsia, polyuria, polyphagia, weight loss, weakness), or who presents with an oral manifestation (for example, xerostomia or candidiasis), should be referred to a physician for diagnosis and treatment.

With a glucometer, a dentist can test blood glucose from a patient’s fingertip. If the result is consistent with hyperglycemia, then immediate follow-up with a physician is indicated. Even if the patient were to have a normal glucose level with such testing, immediate follow-up with a physician would still be indicated, particularly if the patient had the above signs or symptoms or oral manifestations suggestive of uncontrolled, undiagnosed diabetes.

If the physician to whom a dentist has referred a patient subsequently diagnoses the patient with diabetes mellitus, then the patient may be spared from life-threatening complications. However, an important caveat must be mentioned here: the glucometer is not accepted as a diagnostic device and the dentist is not qualified medicolegally to make a diagnosis.

All patients with diagnosed diabetes must be identified by history. A thorough understanding of their medical treatment—including medications, regimen and the degree of glycemic control, as well as any systemic complications resulting from diabetes—then must be methodically established. In the case of systemic complications from diabetes mellitus (for example, hypertension, cardiovascular disease, retinopathy, renal insufficiency or failure), the dentist must consult with the patient’s physician to discuss any modifications to the dental treatment plan, particularly when surgical procedures are anticipated.

Page 7: 2

For example, in the patient with cardiovascular disease, monitoring blood pressure is extremely important, as is the possible modification of anticoagulant drugs (for example, aspirin) before and after surgery. A current recommendation in medical therapy is the use of aspirin (75–325 mg/day) in all adult patients with diabetes and macrovascular disease.46 The avoidance of nephrotoxic drugs in dental management (for example, acetaminophen in high doses, acyclovir, aspirin, nonsteroidal anti-inflammatory drugs) is recommended in patients with renal disease, as well as obtaining a complete blood cell count, monitoring the blood pressure at every appointment, assessing the risk of endarteritis (renal dialysis shunt) or endocarditis, and managing the patient receiving dialysis who is on heparin therapy.1

With respect to surgical procedures, the dentist should also test the patient’s blood sugar with a glucometer to avert emergency-related events such as insulin shock (profound hypoglycemia) or ketoacidosis with severe hyperglycemia before, during or after an invasive procedure. Any patient with diabetes who is going to receive extensive periodontal or oral surgery procedures other than single, simple extractions should be given dietary instructions after surgery; these instructions should be established in concert with the patient’s physician and nutritionist. It is important that the total caloric content and the protein-carbohydrate:fat ratio of the diet remain the same so that proper glycemic control of the diabetes is maintained. The patient’s physician should be consulted about dietary recommendations and dosage modifications to medications during the postoperative phase of dental treatment. In the case of an acute oral infection, not only may antibiotics be indicated—particularly in poorly controlled diabetes—but also modifications in the patient’s medications may be needed (for example, increasing the insulin dose to prevent hyperglycemia related to the pain and stress from infection).

Typically, patients also should receive short morning appointments to reduce stress. The release of endogenous epinephrine from stress can have a counter-regulatory effect on the action of insulin, thereby markedly stimulating the breakdown of glycogen in muscle (and to a lesser extent in liver) and leading to hyperglycemia.47 In the adult patient with diabetes and no history of hypertension, or in the adult patient with diabetes who has well-controlled hypertension, epinephrine can be administered in the usual ranges.1 Importantly, the inclusion of epinephrine is advisable because it will promote better dental anesthesia and thus may significantly reduce the release of far greater amounts of endogenous epinephrine in response to pain and stress.

Finally, the dentist must play a major role in modifying a patient’s destructive health habits, especially those that introduce a comorbidity factor. For example, a large body of evidence from epidemiologic, case-controlled and cohort studies provides convincing documentation of the causal link between cigarette smoking and health risks such as diabetes48 and oral cancer.49,50 Much of the research documenting the impact of smoking on health did not discuss separately results

Page 8: 2

on subsets of individuals with diabetes, suggesting the identified risks are at least equivalent to those found in the general population.

Other studies of people with diabetes consistently found a heightened risk of morbidity and premature death associated with the development of macrovascular disease complications among smokers.48 Smoking also is related to the premature development of microvascular complications of diabetes and may play a part in the development of type 2 diabetes.48 Large, randomized clinical trials have demonstrated the efficacy and cost-effectiveness of counseling in changing smoking behavior. Such studies, combined with the others specific to people with diabetes, suggest that smoking-cessation counseling is effective in reducing tobacco use.51,52 A summary of important general management considerations for the patient with diabetes is shown in the box.

TABLE 1 : TREATMENT FOR ORAL CANDIDIASIS.

TABLE 2 : TOPICAL MEDICATION FOR ANGULAR CHEILITIS.

Page 9: 2

SUMMARY OF GENERAL MANAGEMENT CONSIDERATIONS FOR THE PATIENT WITH DIABETES.

- MANAGEMENT OF THE ORAL COMPLICATIONS OF DIABETES

Risk of disease progression.

The comprehensive management of oral infections in patients with diabetes is beyond the scope of this article. Other sources are available that provide advice and examples of detailed therapeutic regimens.1,53 Nevertheless, clinical recommendations on the treatment of some common oral manifestations of diabetes are provided below.

In general, adults with well-controlled type 1 or type 2 diabetes may have no more significant risk of experiencing oral disease progression than do those without diabetes, and, hence, can be treated similarly. For example, a coronal carious lesion that has not yet penetrated dentin in a patient with well-controlled diabetes may require no immediate intervention, whereas a similar lesion in a poorly controlled patient (moderate to severe hyperglycemia) may need immediate operative treatment, given its higher risk of progression. In general, the risk of progression of oral complications is related to glycemic control and is assessed in part by the interpretation of HbA1c values and postprandial blood sugar levels.

Treatment regimens for candidiasis.

Given the centrality of candidiasis as a marker of marginally or uncontrolled diabetes, and its secondary relationship to salivary dysfunction, some representative topical and systemic medications for the treatment of oral

Page 10: 2

candidiasis are shown in Tables 1⇑ and 2⇑. It generally is advised that the dentist first assess the sugar content in some of the antifungal preparations before prescribing them. For example, clotrimazole troches should be avoided as these have a relatively high sugar content that may warrant against their use in patients with diabetes (see Table 1⇑ for treatment guidelines54). Some representative topical medications, such as creams, for the treatment of angular cheilitis are shown in Table 2⇑. Some of these combination creams contain corticosteroids that provide an anti-inflammatory and antipruritic effect to aid healing; however, steroids can have an antagonistic or counterregulatory effect on the action of insulin and, thus, have the potential to cause hyperglycemia. Nonetheless, it is unlikely that such combination creams will cause a significant elevation of blood glucose, particularly if these are applied to a relatively small area of angular cheilitis.

Management of salivary gland dysfunction and xerostomia.

The rationale for the treatment of xerostomia is to provide salivary stimulation or replacement therapy to keep the mouth moist, prevent caries and candidal infection, and provide palliative relief. The management approach for dry mouth can include the use of saliva substitutes and stimulants; this approach may minimize progression of, or prevent the development of, dental caries.55

Management of recurrent HSV infections.

For the patient with diabetes and recurrent orofacial HSV infection, treatment should be initiated as early as possible in the prodromal stage to reduce the duration and symptoms of the lesion. Oral acyclovir, prophylactically and therapeutically, may be considered when frequent recurrent herpetic episodes interfere with daily function and nutrition. In the patient with diabetes and renal insufficiency or renal failure, acyclovir should be avoided because of its potential for nephrotoxicity.1

Management of burning mouth syndrome.

For the adult patient with burning mouth syndrome, multiple factors may interact synergistically. In uncontrolled diabetes, xerostomia and candidiasis can contribute to the symptoms associated with burning mouth. In addition to the treatment of these conditions, an improvement in glycemic control is essential to mitigate the symptoms. Given in low dosages, benzodiazepines, tricyclic antidepressants and anticonvulsants can be helpful in reducing or eliminating the symptoms after several weeks or months. The dosage of these drugs is adjusted to the patient’s symptoms. A potential side effect includes xerostomia. Consultation with the patient’s physician is necessary because of the potential of these drugs for addiction and dependence. Commonly used medications include amitriptyline, nortriptyline, clonazepam and gabapentin. Interestingly, amitriptyline has also been used to treat autonomic neuropathy in diabetes.

Surgical considerations and periodontal management.

Page 11: 2

The dentist can perform periodontal surgical procedures, although it is important for the patient to maintain a normal diet during the postsurgical phase to avoid hypoglycemia (low blood sugar and insulin shock) and ensure effective repair. The dental practitioner must review any previous history of complications, assess the patient’s glycemic control and maintain an ongoing dialogue with the patient’s physician and nutritionist. The longer the duration of the diabetes, the greater the likelihood of the patient’s developing severe periodontal disease.

Supportive periodontal therapy should be provided at relatively close intervals (two to three months). Periodontal infections may complicate the severity of diabetes mellitus and the degree of metabolic control. The adult patient with well-controlled diabetes generally does not require antibiotics following surgical procedures. However, the administration of antibiotics during the post-surgical phase is appropriate, particularly if there is significant infection, pain and stress. The selection of antibiotics is predicated on multiple factors (for example, sensitivity and specificity results, spread of infection), and should be conducted in consultation with the patient’s physician.

The mainstay of periodontal therapy for patients with diabetes is nonsurgical, given that surgical procedures may necessitate modification of the patient’s medications before and after treatment, and also may lead to a prolonged healing phase owing to diabetes. The combination of nonsurgical débridement and tetracycline antibiotic therapy in patients with diabetes mellitus who have advanced periodontitis may have a potential positive influence on glycemic control. The use of tetracycline in the treatment of periodontal disease was associated with an improvement in glycemic control as assessed by HbA1c

assays.26

Several published papers have reported an additional therapeutic benefit from tetracyclines in periodontal therapy, principally as inhibitors of the connective tissue–degrading enzymes, the human matrix metalloproteinases. For example, low-dose doxycycline has been shown to inhibit human gingival crevicular fluid collagenase at doses that are not antimicrobial, significantly eliminating the risk of bacterial resistance. Tetracyclines can thus function as inhibitors of bone resorption or bone loss, and this property is independent of their antimicrobial use, providing an added dimension to the therapeutic management of periodontitis.

Oral disease management with corticosteroids.

Therapies with corticosteroids and immunomodulating drugs have the potential for side effects. Therefore, close collaboration with the patient’s physician is needed. The use of steroids in the treatment of erosive lichen planus in the adult patient with diabetes is of considerable concern because steroids can antagonize the action of insulin and lead to hyperglycemia. The patient should be given instructions to self-monitor blood glucose levels frequently during steroid therapy. Prolonged use of topical steroids (for a period of greater than two weeks

Page 12: 2

continuously) may result in mucosal atrophy and secondary candidiasis1—conditions that also commonly occur in uncontrolled diabetes. Once the erosive oral lichen planus has resolved, topical steroids should be tapered to alternate-day or less-frequent therapy, depending on the control of the erosions and the tendency toward recurrence. Emerging nonsteroidal immunomodulator drugs (for example, tacrolimus ointment, topical thalidomide) may be useful in the medical management of the patient with concomitant oral mucosal disease and uncontrolled diabetes.

Metabolic syndrome

Metabolic syndrome is a combination of medical disorders that, when occurring together, increase the risk of developing cardiovascular disease and diabetes.It affects one in five people in the United States and prevalence increases with age. Some studies have shown the prevalence in the USA to be an estimated 25% of the population.

Metabolic syndrome is also known as metabolic syndrome X, cardiometabolic syndrome, syndrome X, insulin resistance syndrome, Reaven's syndrome (named for Gerald Reaven), and CHAOS (in Australia). A similar condition in overweight horses is referred to as equine metabolic syndrome; it is unknown if they have the same etiology.

Risk Factors

Stress

Recent research indicates that prolonged stress can be an underlying cause of metabolic syndrome by upsetting the hormonal balance of the hypothalamic-pituitary-adrenal axis (HPA-axis). A dysfunctional HPA-axis causes high cortisol levels to circulate which results in raising glucose and insulin levels which cause insulin-mediated effects on adipose tissue, ultimately promoting visceral adiposity, insulin resistance, dyslipidemia and hypertension with direct effects on the bone, causing “low turnover” osteoporosis. -axis dysfunction may explain the reported risk indication of abdominal obesity to cardiovascular disease, type 2 diabetes and stroke. Psychosocial stress is also linked to heart disease.

Overweight and obesity

Central adiposity is a key feature of the syndrome, reflecting the fact that the syndrome's prevalence is driven by the strong relationship between waist circumference and increasing adiposity. However, despite the importance of obesity, patients that are of normal weight may also be insulin-resistant and have the syndrome.

Page 13: 2

Sedentary lifestyle

Physical inactivity is a predictor of CVD events and related mortality. Many components of metabolic syndrome are associated with a sedentary lifestyle, including increased adipose tissue (predominantly central); reduced HDL cholesterol; and a trend toward increased triglycerides, blood pressure, and glucose in the genetically susceptible. Compared with individuals who watched television or videos or used their computer for less than one hour daily, those that carried out these behaviors for greater than four hours daily have a twofold increased risk of metabolic syndrome.

Aging

Metabolic syndrome affects 44% of the U.S. population older than age 50. With respect to that demographic, the percentage of women having the syndrome is higher than that of men. The age dependency of the syndrome's prevalence is seen in most populations around the world.

Diabetes mellitus

It is estimated that the large majority (~75%, or just above 40 million) of patients with type 2 diabetes or impaired glucose tolerance (IGT) have metabolic syndrome - . The presence of metabolic syndrome in these populations is associated with a higher prevalence of CVD than found in patients with type 2 diabetes or IGT without the syndrome.[32] Hypoadiponectinemia has been shown to increase insulin resistance, and is considered to be a risk factor for developing metabolic syndrome.

Coronary heart disease

The approximate prevalence of the metabolic syndrome in patients with coronary heart disease (CHD) is 50%, with a prevalence of 37% in patients with premature coronary artery disease ( age 45), particularly in women. With appropriate cardiac rehabilitation and changes in lifestyle (e.g., nutrition, physical activity, weight reduction, and, in some cases, drugs), the prevalence of the syndrome can be reduced.

Lipodystrophy

Lipodystrophic disorders in general are associated with metabolic syndrome. Both genetic (e.g., Berardinelli-Seip congenital lipodystrophy, Dunnigan familial partial lipodystrophy) and acquired (e.g., HIV-related lipodystrophy in patients treated with highly active antiretroviral therapy) forms of lipodystrophy may give rise to severe insulin resistance and many of metabolic syndrome's components.

Page 14: 2

Schizophrenia and other psychiatric illnesses

Patients with schizophrenia, schizoaffective disorder or bipolar disorder may have a predisposition to metabolic syndrome that is exacerbated by sedentary lifestyle, poor dietary habits, possible limited access to care, and antipsychotic drug-induced adverse effects. It has been found that 32% and 51% of individuals with schizophrenia meet criteria for metabolic syndrome; the prevalence is higher in women than in men.

Rheumatic diseases

There are new findings regarding the comorbidity associated with rheumatic diseases. Both psoriasis and psoriatic arthritis have been found to be associated with metabolic syndrome.

WHO

The World Health Organization criteria (1999) require presence of one of:

Diabetes mellitus, Impaired glucose tolerance, Impaired fasting glucose or Insulin resistance;

AND two of the following:

Blood pressure: ≥ 140/90 mmHg Dyslipidemia: triglycerides (TG): ≥ 1.695 mmol/L and high-density

lipoprotein cholesterol (HDL-C) ≤ 0.9 mmol/L (male), ≤ 1.0 mmol/L (female)

Central obesity: waist:hip ratio > 0.90 (male); > 0.85 (female), or body mass index > 30 kg/m2

Microalbuminuria: urinary albumin excretion ratio ≥ 20 µg/min or albumin:creatinine ratio ≥ 30 mg/g

Cholesterol

When you get a lipid panel, there are three main types of cholesterol that are tested: low density lipoprotein (LDL), high density lipoprotein (HDL), and very low density lipoprotein (VLDL). Triglycerides, another type of lipid in the blood, are also tested. The amounts of each lipid in your blood will allow your health care provider to predict your risk for heart disease in the future.

Page 15: 2

Low Density Lipoproteins

Low density lipoproteins, also referred to as LDL, is known as the "bad cholesterol". LDLs are produced by the liver and carry cholesterol and other lipids (fats) from the liver to different areas of the body, like muscles, tissues, organs, and the heart. It is very important to keep LDL levels low, because high levels of LDL indicate that there is much more cholesterol in the blood stream than necessary, therefore increasing your risk of heart disease. LDLs are calculated by using an equation involving total cholesterol, triglycerides, and HDLs--all of which are measured directly in the blood:

LDL = TC – (triglycerides/5) + HDL)

The following guidelines have been set forth by the National Cholesterol Education Program:

LDL levels less than 100 mg/dL ( 2.6 mmol/L) are considered optimal. LDL levels between 100 – 129 mg/dL (2.6–3.34 mmol/L) are considered near

or above optimal. LDL levels between 130 – 159 mg/dL (3.36–4.13 mmol/L) are considered

borderline high. LDL levels between 160 – 189 mg/dL (4.14 - 4.90 mmol/L) are considered

high. LDL levels at or above 190 mg/dL (4.91 mmol/L) is considered very high.

High Density Lipoproteins

High density lipoprotein, also known as HDL, is considered the "good" cholesterol. HDL is produced by the liver to carry cholesterol and other lipids (fats) from tissues and organs back to the liver for recycling or degradation. High levels of HDL are a good indicator of a healthy heart, because less cholesterol is available in your blood to attach to blood vessels and cause plaque formation. According to the National Cholesterol Education Program:

Any HDL level above more than 60 mg/dL (1.56 mmol/L) is considered high. A high HDL level is considered very healthy, since it has a protective role in guarding against heart disease.

An acceptable HDL range is between 40- 60 mg/dL (1.04–1.56 mmol/L). An undesirable level of HDL is any level below 40 mg/dL (1.04 mmol/L). In this

case, low HDL levels may help to contribute to heart disease.

Very Low Density Lipoproteins

Very low density lipoproteins, or VLDL, are lipoproteins that carry cholesterol from the liver to organs and tissues in the body. They are formed by a

Page 16: 2

combination of cholesterol and triglycerides. VLDLs are heavier than low density lipoproteins, and are also associated with atherosclerosis and heart disease. This number is obtained by dividing your triglyceride levels by 5.

Prediabetes

Prediabetes is the state in which some but not all of the diagnostic criteria for diabetes are met. It is often described as the “gray area” between normal blood sugar and diabetic levels. While in this range, patients are at risk for not only developing type 2 diabetes, but also for cardiovascular complications. It has been termed "America's largest healthcare epidemic," affecting more than 57 million Americans. Prediabetes is also referred to as borderline diabetes, impaired glucose tolerance (IGT), and/or impaired fasting glucose (IFG).

Signs and symptoms

Prediabetes typically has no signs or symptoms. Patients should monitor for signs and symptoms of type 2 diabetes mellitus. These include the following:

Constant hunger Unexplained weight loss Weight gain Flu-like symptoms, including weakness and fatigue Blurred vision Slow healing of cuts or bruises Tingling or loss of feeling in hands or feet Recurring gum or skin infections Recurring vaginal or bladder infections

Cause

Sleep disorders Family history of diabetes Impaired glucose levels and/or metabolic syndrome Cardiovascular disease Hypertension (high blood pressure) Increased triglycerides levels Low levels of good cholesterol (HDL) Overweight or obese Women who have had gestational diabetes, had high birth weight babies

(greater than 9 lbs.), and/or has Polycystic Ovarian Syndrome (PCOS)

These are associated with insulin resistance and are risk factors for the development of type 2 diabetes mellitus. Those in this stratum (IGT or IFG) are at

Page 17: 2

increased risk of cardiovascular disease. Of the two, impaired glucose tolerance better predicts cardiovascular disease and mortality.

In a way, prediabetes is a misnomer since it is an early stage of diabetes. It is now known that the health complications associated with type 2 diabetes often occur before the medical diagnosis of diabetes is made.

Genetics

As the human genome is further explored, it is likely that multiple genetic anomalies at different loci will be found that confer varying degrees of predisposition to type 2 diabetes. Type 2 DM, which is the condition for which prediabetes is a precursor, has 90-100% concordance in twins; there is no HLA association. However, genetics play a relatively small role in the widespread occurrence of type 2 diabetes. This can be logically deduced from the huge increase in the occurrence of type 2 diabetes which has correlated with the significant change in western lifestyle.

Don’t forget Dr.Eman’s lecture (PDL part 2&3 last slides)

GOOD LUCK