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DIABETES MELLITUS

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Definition :

Diabetes mellitus (joslin) A syndrome characterized by chronic

hyperglycemia

And disturbance of carbohydrate, fat, and

protein metabolism

Associated with absolute or relative

deficiencies in insulin secretion and/ or insulin

action

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Classification of Diabetes Mellitus (DM) :

Type 1

Type 2

Other specific types

Gestational diabetes mellitus

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General epidemiological points :

Type 1 diabetes is relatively less commonthroughout the western pacific region

Type 2 diabetes prevalence rates show markeddifferences according to lifestyle, affluence and

urbanisation Remain low in traditional societies

Rising rapidly in association with urbanisation& modernisation

Type 2 diabetes is becoming increasingly common inyoung people

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50-85% of identified cases had not been

previously diagnosed

Commonality of enviromental risk faktors :

Changing nutrition

Central obesityDecreasing physical activity level

Urbanisation

General epidemiological points :

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Epidemiology of DM in Indonesia

Prevalence in Indonesia : 1,5 - 2,3 %(age > 15 years)

Increase in prevalence :

Jakarta (urban)1982 : 1,7 %1993 : 5,7 %

Makasar (urban)

1981 : 1,5 %1998 : 2,9 %

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Epidemiology of DM in Indonesia

Prevalence : urban > rural area

Tasikmalaya : 1,1% (1993)

Sesean (Toraja): 0,8% (> 30 years)

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2020 : 178 million > 20 years

Prevalence of diabetes : 4 %

7 million diabetes patients

INDONESIA :

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Type 1 diabetes :

Most common in young individuals

Occurs occasionally in non obese adults

Circulating insulin is virtually absent

The pancreatic cells fail to respond to all

known insulinogenic stimuli

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Type 1 diabetes :

Pancreatic islet cell destruction

> 95% : caused by an autoimmune

< 5% : idiopathic

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Type 1 diabetes :

Prone to ketoasidosis

Require insulin replacement therapy

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Type 2 :

Insulin resistance

-cell insufficiency

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Type 2 Diabetes :

Accounts for over 90% of diabetes cases

Usually adults over age 40

Do not require insulin to survive

Ketosis seldom occurs spontaneously,

if present it is a consequence of associated

stress from trauma, infection or cardiovascular

events

Genetic influence >

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Type 2 diabetes :

Obese type 2 diabetes

Non obese type 2 diabetes

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BMI =

Normal range :

BW ( kg )H ( m )2

Women : 18.5 - 23.5

Men : 22.5 - 25

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Symptoms of diabetes mellitus :

Polyuria

Polydypsia

Polyphagia

Weight loss

General malaise

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Clinical features of diabetes at diagnosis

Polyuria and thirst

Weakness or fatigue

Polyphagia with weight loss

Recurrent blurred vision

Vulvovaginitis or pruritus

Peripheral neuropathyNocturnal enuresis

Often asymptomatic

DiabetesType 1

++

++

++

+

+

+++

-

+

+

-

++

++

++-

++

DiabetesType 2

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Diagnostic criteria of diabetes

Symptoms of diabetes

plus a random blood sugar > 200 mg/dl

Fasting blood sugar > 126 mg/dl

OGTT :

2 hours after 75 gr glucose

Blood glucose > 200 mg/dl

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PREVENTION

POPULATION APPROACH

LIFE STYLE

IMPROVE NUTRITIONDURING PREGNANCY

HIGH-RISK APPROACH

DM IN FAMILY/ GENETIC

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Four pillar in the management of DM

1) Education

2) Dietary management

3) Physical exercise4) Hypoglycemic agent

* Oral hypoglycemic agent

* Insulin

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Composition of food :

Carbohydrate 60 70 %

Protein 10 15 %

Lemak 20 25 %

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Physical exercise :

Continuous

Rhythmical

Interval

Progressive

Endurance training

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MANAGEMENTAIM : T2DM

QUALITY OF LIFEACCELERATION OF

CHRONIC COMPLICATIONS

RISKOF ACUTECOMPLICATIONS

INTERVENTION TO INSULINRESISTANCELIFE STYLE !

TO POST-PRANDIALHYPERGLYCEMIA

ACARBOSE

INSULINSECRETAGOGUE

METFORMIN

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Chronic complications of diabetes mellitus

Eyes

Diabetic retinopathy

Cataracts

Kidneys

Intercapillary glomerulosclerosisInfection

Renal tubular necrosis

Following dye studies (urograms, arteriograms)

Nervous system

Peripheral neuropathyDistal, symmetric sensory loss

Motor neuropathy

Food drops

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Autonomic neuropathy

Postural hypotension

Resting tachycardia

Loss of sweatingGastrointestinal neuropathy

Gastroparesis

Diabetic diarrhea

Urinary bladder atonyErectile dysfunction (may also be secondary to pelvic

vascular disease)

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Skin

Diabetic dermopathy

Candidiasis

Foot and leg ulcers

Neurotropic

Ischemic

Cardiovascular system

Heart disease

Myocardial infarction

CardiomyopathyGangrene of the feet

Ischemic ulcers

Osteomyelitis

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Classification of diabetic vascular disease

Small blood vessels

(capillary & precapillary arterioles)

Thickening of the capillary basementmembrane

Microangiopathy :

Microvascular disease (Microangiopathy)A

Retina Diabetic retinopathyKidney Diabetic nephropathy

Heart Cardiopathy

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Classification of diabetic vascular disease

An accelerated form of atherosclerosis

Macrovascular disease (Macroangiopathy)B

Coronary heart disease

Stroke

Peripheral vascular disease

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Management of diabetes mellitusin surgical patients

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Patients managed with diet alone :

Patient whose diabetes is well controlled

by dietary modification & physical activitymay require no special preoperative

intervention

Fasting blood glucose should bemeasured on the morning of surgery

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If surgical procedure > 1 hour, intra

operative blood glucose (BG) monitoring is

desirableIf surgical is major & diabetes is poorly

controlled (BG>200mg/dl)Insulin i.v &dextrose should be considered hourlyintra operative BG monitoring is

recommended


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Patients treated with oral anti diabetic agents :

Management of diabetes mellitus

in surgical patients

Drugs Recomendation

2nd Sulfonylureas

Metformin

Discontinued 1 day before surgeryException for chlopropamide, 2-3 days

before surgery

Discontinued 1-2 days before surgery

Especially in patients undergoing

procedure that increase the risk forrenal hypoperfusion, tissue hypoxia

& lactate accumulation

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At minimum BG should be monitored before &

immediately after surgery

For minor surgery, perioperative hyperglycemia (>200

mg/dL) can be managed with small doses short acting

insulin subcutan (4-10 U)care must be taken to avoid

hypoglycemia

After procedure minor surgery, most usual antidiabetic

drugs can be restarted once patients start eating



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Insulin

Treated

patients :



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Management of diabetes mellitus in surgical patients

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Management of diabetes mellitus in surgical patients

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THERAPIES AIMED AT IMPROVING

GLUCOSE TOLERANCE MAY BE

ABLE TO DELAY OR PREVENT

THIS PROGRESSION TOWARDS

TYPE 2 DIABETES

IGT

IS A CONDITION OF ABNORMAL

GLUCOSE TOLERANCE IS ITSELF

A RISK FACTOR FOR

DEVELOPING TYPE 2 DIABETES

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DIAGNOSIS

2 HOURSPOST-PRANDIALBLOOD GLUCOSE

140 200 mg%

USA

SINGAPARNA, WEST JAVA

~ 11 %

18.1 %

PREVALENCE

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PRESENTATION WITH A COMPLICATIONIS NOT UNCOMMON

TYPE 2 DIABETES MUST HAVE PASSEDTHROUGH AN IGT PRIOR TO DIAGNOSIS

> 50 % REMAIN NON-DIABETIC FOR YEARS

1 - 5 % IGT DM PER YEAR

IGTIMPAIRED GLUCOSE TOLERANCE

IS ACRITICAL STAGE IN THEDEVELOPMENT OF TYPE 2 DIABETES

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Bones and jointsDiabetic cheirathropathy

Dupuytrens contracture

Charcot joint

Unusual infections

Necrotizing fasciitis Necrotizing myositis

Mucormycosis

Emphysematous cholecystitis

Malignant otitis externa

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Obese type 2 Diabetes :

The prevalence of obesity varies

among different racial groups.

ChineseJapanese

30 40% : Obese

North AmericanEuropean

African60 70% : Obese

Pima IndiansPacific Islanders(Nauru, Samoa)

100% : Obese

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Non obese type 2 diabetes

30-40% of type 2 diabetes patients

In Asian population >

Deficient insulin release by the pancreaticcell seems to be the major defect

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Ideal weight

Height - 150

(Height100 )10%

(Height100 ) -4

( )

DM-FKG-2

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