METABOLIC SYNDROME &

DIABETES MELLITUS

the problems and short course management

MIF TAHU RACHMAN
PADJADJARAN UNIVERSITY
RSHS BANDUNG

Learning objectives

IDEAL BODY WEIGHT ? BMI ? WAIST CIRCUMFERENCE ?

METS : OVERWEIGHT

DIABETES MELLITUS

MANAGEMENT : DIET, EXERCISE, MEDICINE

(A B C D H H COST & EFFECTIVENESS)

BEHAVIOUR MODIFICATION #BeMo

Common definitions
Abbreviation

Definition

NGT

Normal Glucose Tolerance (Gula Darah Normal)

FPG

Fasting Plasma Glucose (Gula Darah Plasma Puasa)

PPG

Post-Prandial Plasma Glucose (Gula Darah Plasma Post Prandial)

IGT

Impaired Glucose Tolerance (Toleransi Glukosa Terganggu)

IFG

Impaired Fasting Glucose (Gula Darah Puasa Terganggu)

HbA1c

Average amount of glucose in the bloodstream over a 2-3 months

period

Classification of diabetes
Type 1 diabetes
Beta cell destruction, usually leading to absolute insulin deficiency
Type 2 diabetes
Progressive insulin secretory defect on the background of beta cell
dysfunction and insulin resistance
Gestational diabetes mellitus
Diabetes diagnosed in the second or third trimester of pregnancy that
is not clearly overt diabetes
Other specific diabetes types
Drug or chemical induced, e.g steroids, treatment of HIV/AIDS or after
organ transplantation
Genetic defects in beta cell function or in insulin action
Diseases of the exocrine pancreas (e.g. cystic fibrosis)
ADA - Standards of Medical Care in Diabetes 2016. Diabetes Care, Vol. 39, Supplement 1, January 2016.

Differences between type 1

and type 2 diabetes
Features

Type 1 Diabetes

Type 2 Diabetes

Sudden

Gradual

Age at onset

Any age
(mostly young)

Mostly in adults

Body habitus

Thin or normal

Often obese

Ketoacidosis

Common

Rare

Usually present

Absent

Low or absent

Normal, decreased or increased

Less prevalent in Asia

More prevalent.
90-95% of all people with
diabetes in Asia

Onset

Autoantibodies
Endogenous insulin
Prevalence

Are you ready ???

Why are we seeing such an increase

in the number of people with Type 2
diabetes worldwide?

Unhealthy lifestyle

Aging population

Dietary changes

IDF Diabetes Atlas 2014

Cockram 2000. HKMJ; 6 (1): 43-52
Mohan 2007. Indian J Med Res; 125: 217-230

Urbanisation

Sedentary lifestyle

High blood glucose is the 3rd biggest risk

factor contributor to cardio-vascular
deaths globally

Attributable deaths due to selected risk factors (000)

WHO 2011. Global Atlas on CVD prevention and Control

Diabetes is developing fast in Indonesia

2007

2013

Diagnosed diabetes

1.5%

2.1%

Undiagnosed diabetes

4.2%

4.8%

Impaired glucose tolerance

10.2%

29.9%

RISKESDAS Survey 2007

Laporan RISKESDAS 2013

Diabetes is developing fast in Indonesia

2007

2013

Diagnosed diabetes

1.5%

2.1%

Undiagnosed diabetes

4.2%

4.8%

Impaired glucose tolerance

10.2%

29.9%

RISKESDAS Survey 2007

Laporan RISKESDAS 2013

Diabetes is developing fast in Indonesia

2007

2013

Diagnosed diabetes

1.5%

2.1%

Undiagnosed diabetes

4.2%

4.8%

Impaired glucose tolerance

10.2%

29.9%

RISKESDAS Survey 2007

Laporan RISKESDAS 2013

Approximately 10 million people

with diabetes in Indonesia

and diabetes control is suboptimal

100
80
60

67.85%
81.01%

40

Over
target

20
0

Target HbA1c 7% Target HbA1c 6.5%

Soewondo P, Soegondo S, Suastika K, Pranoto A, Soeatmadji DW, Tjokroprawiro A. The DiabCare Asia 2008 studyOutcomes on control and complications of type 2 diabetic patients in Indonesia Med J Indones 2010 19; 4: 235-244.

Early detection and monitoring

Beta cell
Islet

Normoglycemia

produces
insulin

NORMAL

Muscle and fat

Glucose Homeostasis

Alpha cell
produces
glucagon

FASTING

Liver

INPUT NUTRISI

13

TYPE 2 DM
Diminished
insulin

Beta cell

14

Normoglycemia
Hyperglycemia

produces
insulin

Glucose Homeostasis

Insulin resistance
(decreased glucose uptake)

Liver

Alpha cell
produces
glucagon

Muscle and fat

INPUT NUTRISI

Excess glucose output

Insulin Resistance: Associated Conditions

Metabolic Syndrome A Multifaceted

Syndrome
Inflammatory markers
Heart disease
Stroke
Kidney failure
Depression?
Cancer?

High
blood
pressure
Abnormal
lipid levels

Urine
protein
High
blood glucose

Obesity

Type 2 diabetes is a progressive

disease

Adapted from Type 2 Diabetes BASICS. International Diabetes Center 2000

Classical diabetes symptoms

Polyuria
Blurred vision
Polydipsia
Unexplained
weight loss

Excessive urination at night

Visual disturbance
Excessive Thirst
Even if food intake is normal

http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/symptoms/con-20034795

Other diabetes symptoms

Numbness
and/or tingling

In hands, legs and feet

Fatigue

Regardless of exercise

Itchy skin

Affects legs, feet, and hands

Impotence

Physical and physiological

Adapted from Konsensus PERKENI 2015. Pengelolaan dan pencegahan diabetes melitus tipe 2 di Indonesia.

ADA - Standards of Medical Care in Diabetes 2016. Diabetes Care, Vol. 39, Supplement 1, January 2016

Cut-points: Diabetes, IGT and IFG

Fasting Plasma Glucose
(FPG)

mg/dL
Diabetes

126

100

IFG
Impaired
Fasting Glucose

IGT
Impaired Glucose
Tolerance

NGT
Normal Glucose
Tolerance

140

Diabetes

200

2-hour Plasma Glucose

ADA - Standards of Medical Care in Diabetes 2016. Diabetes Care, Vol. 39, Supplement 1, January 2016.

mg/dL

Diagnosis of Type 2 Diabetes

KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2. 2015

Fasting* Plasma Glucose 126 mg/dl
or
2-hour post 75g OGTT 200 mg/dl
or
Classical symptoms of diabetes** & Random plasma glucose concentration
200 mg/dl
or
HbA1c 6.5% (standardised assay***)
*Classical symptom of diabetes (polyuria, polydipsia, weight loss), only need 1 abnormal
BG, otherwise need 2 x abnormal BG level on different days
**Fasting is defined as no caloric intake for at least 8 hours
***Standarised to National Glycohaemoglobin Standardization Program (NGSP)
Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia. 2015

What is good glycaemic control?

Overall aim to achieve glucose levels as close to normal as possible
Minimise development and progression of microvascular and
macrovascular complications
ADA1

FPG
<130 mg/dL

IDF2

FPG
<110 mg/dl

PERKENI3

FPG
<130 mg/dl

HbA1c
< 7.0 %
HbA1c
< 6.5 %
HbA1c
< 7.0 %

PPG
<180 mg/dL
PPG
<145 mg/dL
PPG
<180 mg/dl

1. American Diabetes Association Diabetes Care 2015;38 (Suppl 1):S8-S15

2. IDF Clinical Guidelines Task Force. International Diabetes Federation 2005. 3. Konsensus PERKENI 2015.

HbA1c correlation with blood glucose

level

The relationship between A1C and eAG is described by the formula 28.7 X A1C
46.7 = eAG
HbA1c

eAG

mg/dL

mmol/l

6.0

126

7.0

6.5

140

7.8

7.0

154

8.6

7.5

169

9.4

8.0

183

10.2

8.5

197

11.0

9.0

212

11.8

9.5

226

12.6

10.0

240

13.4

David M. Nathan, Judith Kuenen, Rikke Borg, Hui Zheng, David Schoenfeld, and Robert J. Heine, for the A1c-Derived Average
Glucose (ADAG) Study Group. Diabetes Care 2008

Risk of complications increases

as Hb1Ac increases
Incidence per 1.000
patient-years

80

Microvascular disease

60
40

Myocardial infarction

20
0
5

10

11

97

126

154

183

212

240

269

Mean HbA1c (%)

Mean mg/dl

Adjusted for age, sex, and ethnic group.

Stratton IM et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35):
prospective observational study. BMJ 2000;321:40512

Optimising blood glucose control

Good control is
7.0% HbA1c

-14%

HbA1c
-1%

Source: UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM

et al. BMJ. 2000;321(7258):405-412.

-37%

-21%

Myocardial
infarction

Microvascular
complications

Deaths related
to diabetes

Practical monitoring scheme

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009

Practical monitoring scheme

cont

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009

Initiating diabetes treatment

The ominous octet

DeFronzo R A Diabetes 2009;58:773-795

Copyright 2011 American Diabetes Association, Inc.

The ominous octet, depicting the mechanism and site of

action of antidiabetes medications based upon the
pathophysiologic disturbances present in T2DM

Adapted from DeFronzo R A et al. Diabetes Care 2013;36:S127-S138

Copyright 2013 American Diabetes Association, Inc.

The ominous octet, depicting the mechanism and site of

action of antidiabetes medications based upon the
pathophysiologic disturbances present in T2DM

SGLT2

Adapted from DeFronzo R A et al. Diabetes Care 2013;36:S127-S138

Copyright 2013 American Diabetes Association, Inc.

Factors to consider when choosing an

antihyperglycaemic agent
Effectiveness in lowering glucose
Safety profile
Tolerability
Cost
Effect on body weight
Other effects (e.g. reduced cardiovascular
outcomes with metformin, empagliflozin)

Nathan DM et al. Management of Hyperglycemia in type 2 Diabetes, a consensus algorithm for the initiation and adjustment of
therapy, a consensus statement from ADA/EASD. Diabetes Care 2006;29(8):1963-72.

ADA/EASD treatment algorithm

American Diabetes Association. Approaches to glycemic treatment. Sec. 7. In Standards of Medical Care in Diabetes 2015.
Diabetes Care 2015;38(Suppl. 1):S41S48

Danish treatment guidelines for type

2 diabetes
HbA1c target value is individual

HbA1c <48 mmol/mol (6.5%) in the first years, where

hypos are of little concern. Aims to reduce complications

HbA1c <53 mmol/mol (7.0%) in later phases, balancing

between hypos and the risk for microvascular complications

HbA1c <58 mmol/mol (7.5%) in long-term patients with

hypos and macrovascular complications (ischaemic heart disease,

peripheral arterial disease, and stroke)

HbA1c 58-75 mmol/mol (7.5 - 9.0%) in elderly patients in

whom only symptoms are treated

Target Pengendalian DM2

Risiko
Kardiovaskular
(-)
IMT (kg/m2)

Risiko
Kardiovaskular
(+)

18,5 - < 23

Glukosa darah
Puasa (mg/dL)

< 100

2 jam PP (mg/dL)

< 140

A1C (%)

< 7,0

< 7,0

Sistolik (mmHg)

130

130

Diastolik (mmHg)

80

80

< 100

< 70

Tekanan darah

Profil Lipid
Total kolesterol (mg/dL)
Trigliserid (mg/dL)
HDL kolesterol (mg/dL)
LDL kolesterol (mg/dL)

Antihyperglycaemic agents that are

currently available in Indonesia
Metformin
Sulfonylureas (SUs) and glinides
-glucosidase inhibitors (AGIs)
Dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors)
Glucagon-like peptide-1 (GLP-1) agonists
Thiazolidinediones (TZDs)

Metformin
Use of metformin based on eGFR
Proposed recommendations for use of metformin based on eGFR
eGFR level (ml/min per 1.73 m)

Action

60

No renal contraindication to metformin.

Monitor renal function annually.

<60 and 45

Continue use.
Increase monitoring of renal function (every 3-6
months).

<45 and 30

Prescribe metformin with caution.

Use lower dose, i.e. 50% or half-max dose.
Monitor renal function every 3 months.
Do not start new patients on metformin.

30

Stop metformin

Additional caution is required in patients at risk of acute renal injury or with anticipated
significant fluctuations in renal status, based on previous history, comorbidities, or
Potentially interacting medications
Lipska et al. Use of metformin in the Setting of Mild-to-Moderate Renal Insufficiency. Diabetes Care. Vo 34, 2011.1

Diabetes and the elderly

Always start with the lowest dose

of any AHA
Increase gradually
Hypoglycaemia may increase the
risk of falls and heart attack in
elderly
Use shorter-acting AHA to reduce
the risk of hypoglycaemia

Remember the possibility of

Forgetfulness
Poor motivation
Depression
Cognitive deficits
Polypharmacy
Reduced manual dexterity
These factors affect the ability to
maintain self-care and achieve
maximum benefits from AHAs

Behaviour Modification : #BeMO

Eat

: intelligently

Pray

: deeply

Love

: your Body

Move

: regularly

WE DO NOT DREAM.

WE SIMPLY WORKING HARD

KEEP AN OPEN MIND AND HEART
AND WE CAN BEAT THE DIABETES