Prof Dr .Dilek Gogas Yavuz, MD

Marmara University Department of Internal Medicine

Section of Endocrinology and Metabolism

CLASSIFICATION

AND DIAGNOSIS OF

DIABETES MELLITUS

Diabetes Mellitus Diabetes Mellitus Increasing Prevalence of Diagnosed CasesIncreasing Prevalence of Diagnosed Cases

Pe

rso

ns

Wit

h D

iag

no

sed

P

ers

on

s W

ith

Dia

gn

os

ed

Dia

be

tes

(m

illio

ns

)D

iab

ete

s (

millio

ns

)

Diabetes OverviewDiabetes Overview. October 1995 (updated 1996). NIDDK publication NIH 96. October 1995 (updated 1996). NIDDK publication NIH 96--1468.1468.

Kenny SJ et al. In: Kenny SJ et al. In: Diabetes in AmericaDiabetes in America. 2nd ed. 1995:47. 2nd ed. 1995:47--67.67.

YearYear

88

77

66

55

44

33

22

00

11

19581958 19631963 19681968 19791979 19841984 19891989 19941994

8,000,0008,000,000

5X increase5X increase

1.0

7.9

22.4

13.1

13.4

1997 = 124 million

World

66.1

1.3

14.1

32.9

22.5

17.5

2010 = 221 million

132.3

Global Estimates and Projections of Diabetes (in millions) 1997-2010

Increase (78%)

(31%)

(72%)

(47%)

(78%)

(100%)

(30%)

Türkiyede Diyabet

1.991 1.991 milyonmilyon kikişşii (1998)(1998)

NNüüfusfus: 64.4 : 64.4 milyonmilyon kikişşii

2.217 milyon kişi (2000)

4.551 4.551 milyonmilyon kikişşii (2025)(2025)

WHO Diabetes Report 2000

Prevelance 6% in Turkey

DIABETES IN TÜRKİYE

Estimated diabetes prevalance according to WHO

Type 2 diabetes prevalance in TURKEY 1997-2010

7,4

13,7

3

5

7

9

11

13

15

1998 2010

Pre

vala

nc

eof

dia

ber

es (%

)

TURDEP I and II

1-diabetes type 2 %7.2

2-impaired glucose tolerance %6.7

TURDEP-1- 19971 TURDEP-2- 2010

1-diabetes type 2 %13,7

2- impaired glucose tolerance %13,9

1. Turdep I Population-Based Study of Diabetes and Risk Characteristics in Turkey.Satman et al. Diab Care,2002. 25:1551–1556. 2. TURDEP II. Satman et al.2010.

prevalence

Definition of Diabetes

“A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.”

“Hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels.”

ADA Diabetes Care (Suppl 1) 2007

Etiologic classification of diabetes mellitus

1.Type 1 diabetes (B-cell destruction usually leading to absolute insulin deficiency)

a.Immune mediatedb.Idiopathic

2.Type 2 diabetes (combination of resistance to insulin action and an inadequate compensatory

insulin secretory response)

3.Other spesific types(diabetes secondary to recognized genetic defects, diseases of the exocrine

pancreas, other endocrinopathies, or to drugs)

4. Gestational diabetes Mellitus

3.Other spesific types

A. Genetic defects of B-cell function

MODY3,MODY2,MODY1

Mitekondrial DNA defects

B.Genetic defects in insulin action

type A insulin resistance

leprechaunism

Rabson-Mendenhall syndrome

lipoatrophic diabetes

C.Diseases of the exocrine pancreas

pancreatitis

trauma/ pancreatectomyNeoplasia,Cystic fibrosis

hemochromatosisfibrocalculous pancreatopathy

D. Endocrinopathies

AcromegalyCushings SyndromeGlucagonoma,pheochromocytoma

Hyperthyroidism,somatostatinomaaldosteronoma

E. Drug or chemical induced

Vacor, pentamidine

nicotinic acid,glucocorticoids

thyroid hormons,diazoxide

B-adrenergic agonists

thiazides,dilantin,a-interferon

F. Infections

congenital rubella

cytomegalovirus

G.Uncommon forms of immune-mediated DM

stiff man syndrome

anti-insulin receptor antibodies

H. Genetic syndromes sametimes associated

with diabetes

Down’s syndrome

Klenifelter Syndrome

Turner’s syndrome

Wolframs Syndrome

friedrich’s ataxia

myotonic dystrophy

porphyria

Incidence of Diabetes Mellitus

7% Type 1 ( formerly Insulin dependent diabetes mellitus)

90% Type 2 (formerly Non-insulin dependent diabetes mellitus)

Gestational Diabetes

5% of all pregnancies

Fasting plasma glucose > 126 mg/dl (7mmol/L)

Symptoms of diabetes + plasma glucose >200 mg/dlSymptoms:polyuria,polydipsia,unexplained weight loss

2 hour plasma glucose >200 mg/dl during OGTT

A1C ≥6.5%

American diabetes association 20112

Diabetes care 2012 suppl 1

Criteria for the diagnosis of diabetes mellitus

OGTT: oral glukoz tolerance test

Categories of Fasting plasma glucose (FPG)

< 110 mg/dl = normal fasting glucose

>110 mg/dl- <126 mg/dl =impaired fasting

glucose

>126 mg/dl =provisional diagnosis of diabetes

the diagnosis must be confirmed

Fasting is defined as no caloric intake for at least eight hours

Oral glucose tolerance test (OGTT)

2-h postload glucose <140 mg/dl= normal glucose tolerance

2-h PG > 140 mg/dl and < 200 mg/dl= impaired glucose tolerance

2-h PG > 200 mg/dl = DIABETES

HOW TO PERFORMORAL GLUCOSE TOLERANCE TEST ?

dissolve 75 gr glucose in a glass of drinking water(200-300 ml water)

Ask patient to drink in 5 min (zero point)

Check plasma glucose level at the

second hour of glucose load

Blood glucose response after an oral glucose load in Non diabetic and Diabetic subject

Hour

Seru

m g

lucose

(m

g/d

l)

Blood glucose and insulin response

after an oral glucose load (75 g glucose) in type 2 diabetes

Hour

As with most diagnostic tests, a test result

diagnostic of diabetes should be repeated to rule out

laboratory error

• unless the diagnosis is clear on clinical grounds, such

as a patient with a hyperglycemic crisis or classic

symptoms of hyperglycemia and a random plasma glucose

≥200 mg/dL

• It is preferable that the same test be repeated for

confirmation, since there will be a greater likelihood of

concurrence in this case.

•However, if two different tests (such as A1C and FPG)

are both above the diagnostic thresholds, the

diagnosis of diabetes is also confirmed

Prediabetes associated with the metabolic syndrome, which includes

obesity (especially abdominal or visceral obesity), dyslipidemia of the

high-triglyceride and/or low-HDL type, and hypertension

pre-diabetes

FPG 100 - 125 mg/dl =impaired fasting glucose

2-h PG in the OGTT 140 - 199 mg/dl =impaired glucose tolerance

A1C 5.7–6.4%

Categories of increased risk for diabetes

NATURAL HISTORY OF IGT

After 10 years

Normal

Diabetes

IGT

IGT

Glucose Tolerance Categories

Adapted from The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2013 suppl 1.

FPG

126 mg/dL

110 mg/dL

7.0 mmol/L

6.1 mmol/L

Impaired FastingGlucose

Normal

2-Hour PG on OGTT

200 mg/dL

140 mg/dL

11.1 mmol/L

7.8 mmol/L

Diabetes Mellitus

Impaired GlucoseTolerance

Normal

Diabetes Mellitus

Testing to detect type 2 diabetes and assess risk for future

diabetes in asymptomatic people should be considered in

adults of any age who are overweight or obese (BMI ≥25 kg/m2)

and who have one or more additional risk factors for diabetes

TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS

Criteria for testing for diabetes in asymptomatic adult individuals

Testing should be considered in all adults who are overweight (BMI ≥25

kg/m2*) and who have one or more additional risk factors:

• physical inactivity

• first-degree relative with diabetes

•high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian

•women who delivered a baby weighing >4 kg or who were diagnosed with GDM

•hypertension (blood pressure ≥140/90 mmHg or on therapy for hypertension)

•HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)

•women with PCOS

•A1C ≥5.7%, IGT, or IFG on previous testing

•other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)

•history of CVD

Risk Factors for Type 2 Diabetes

Age > 40

Family history of diabetes

Ethnicity

Obesity; abdominal fat distribution

GDM, or give birth infant > 4 kg

Hypertension, hyperlipidemia

Previous Impaired Glucose Tolerance

In those without these risk factors, testing should begin at age 45

years.

If tests are normal, repeat testing at least at 3-year intervals is

reasonable.

To test for diabetes or to assess risk of future diabetes, the A1C,

FPG, or 2-h 75-g OGTT are appropriate.

TESTING FOR DIABETES IN ASYMPTOMATIC PATIENTS

GESTATIONAL DIABETES MELLITUS

GESTATIONAL DIABETES MELLITUS (GDM)

•GDM is defined as any degree of glucose intolerance

with onset or first recognition during pregnancy

•GDM complicate 4-5 % of all pregnancies

•Six months or more after pregnancy ends, the women

should be reclassified

Low risk Medium risk Very high risk

BMI < 25 kg/m 2 BMI25- 29.9 kg/m 2 BMI> 30kg/m 2

BMI: body mass index

Screen for undiagnosed type 2 diabetes at the first prenatal visit in those

with risk factors, using standard diagnostic criteria

DETECTION AND DIAGNOSIS OF GESTATIONAL

DIABETES MELLITUS (GDM)

Screen for undiagnosed type 2 diabetes at the first prenatal visit in

those with risk factors, using standard diagnostic criteria.

In pregnant women not previously known to have diabetes, screen

for GDM at 24–28 weeks’ gestation, using a 75-g 2-h OGTT and the

diagnostic cut points

Screen women with GDM for persistent diabetes at 6–12 weeks’

postpartum, using a test other than A1C.

Women with a history of GDM should have lifelong screening for

the development of diabetes or prediabetes at least every 3 years.

Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24–28 weeks’ gestation in women not previously diagnosed with overt diabetes.

The diagnosis of GDM is made when any of the following plasma glucose values are exceeded:

plasma glucose

• Fasting ≥92 mg/dL• 1 h ≥180 mg/dL• 2h ≥153 mg/dL

Screening for and diagnosis of GDM

The OGTT should be performed in the morning after an overnight fast of at least 8 h.

Because some cases of GDM may represent preexisting

undiagnosed type 2 diabetes, women with a history of GDM should

be screened for diabetes 6–12 weeks’ postpartum, using

nonpregnant OGTT criteria.

Because of their prepartum treatment for hyperglycemia, use of

the A1C for diagnosis of persistent diabetes at the postpartum visit

is not recommended

Women with a history of GDM have a greatly increased

subsequent risk for diabetes and should be followed up with

subsequent screening for the development of diabetes or

prediabetes

Postpartum period

Thank you