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DM TYPE II

preliminary

Diabetes mellitus is a disease characterized by the occurrence of hyperglycemia and impaired


carbohydrate, fat, and protein metabolism which is associated with absolute or relative deficiencies
of work and / or insulin secretion. Symptoms complained of in patients with Diabetes Mellitus are
polydipsia, polyuria, polyphagia, weight loss, tingling. 2 International Diabetes Federation (IDF)
states that the prevalence of diabetes mellitus in the world is 1.9% and has made DM as the seventh
leading cause of death in the world whereas in 2012 the incidence of diabetes me litus in the world
was 371 million where the proportion of types of diabetes mellitus 2 is 95% of the world's
population suffering from diabetes mellitus. Basic Health Research Results in 2008, showed that the
prevalence of DM in Indonesia increased to 57%. The high prevalence of type 2 diabetes mellitus
caused by risk factors that cannot change, for example gender, age, and the second genetic factor
are changeable risk factors such as smoking habits, education, employment, physical activity,
smoking habits, alcohol consumption, body mass index , waist circumference and age.4,8 Diabetes
Mellitus is called the silent killer because this disease can affect all organs of the body and cause
various kinds of complaints. The diseases that will be caused include eye vision, cataracts, heart
disease, kidney disease, sexual impotence, wounds that are difficult to heal and rot / gangrene, lung
infections, vascular disorders, strokes and so on. Not infrequently, people with DM who have severe
amputation due to decay occur. To reduce the incidence and severity of type 2 diabetes mellitus
prevention is carried out such as lifestyle modification and treatment such as oral hyperglycemic
drugs and insulin

Definition of Type 2 Diabetes Mellitus

Diabetes mellitus is a metabolic disorder that is genetically and clinically including heterogeneous
with manifestations in the form of loss of carbohydrate tolerance, if it has developed fully clinically,
diabetes mellitus is characterized by fasting and postprandial hyperglycemia, atherosclerosis and
microangiopathic vascular disease. 1.7 Type 2 Diabetes Mellitus is a hyperglycemic disease due to
cell insensitivity to insulin. Insulin levels may decrease slightly or be in the normal range. Because
insulin is still produced by beta pancreatic cells, type II diabetes mellitus is considered as non-insulin
dependent diabetes mellitus.6,9 Type 2 Diabetes Mellitus is a metabolic disorder characterized by an
increase in blood sugar due to decreased insulin secretion by pancreatic beta cells and / or impaired
insulin function (insulin resistance) .3

Prevalence of Type 2 Diabetes Mellitus

The incidence of Type 2 DM

in women higher than men. Women are more at risk of developing diabetes because physically
women have a greater chance of increasing their body mass index. Results

Basic Health Research in 2008, shows the prevalence of DM in Indonesia

increased to 57%, in 2012 the incidence of diabetes mellitus in the world


is 371 million people, where the proportion of diabetes mellitus type 2

is 95% of the world population suffering from diabetes mellitus and only 5%

of these suffer from type 1 diabetes mellitus 1.4

Pathogenesis

Diabetes mellitus is a disease caused by a deficiency

relative and absolute insulin. Insulin efficiency can occur through 3 pathways, namely:

a. Damage to pancreatic B cells due to external influences (viruses, chemicals, etc.)

b. Desensitization or decrease in glucose receptors in the pancreatic gland

c. Desensitization or damage to insulin receptors in peripheral tissues.

Pathophysology

In the pathophysiology of type 2 DM there are a number of circumstances role, namely:

1. Insulin resistance

2. Pancreatic B cell dysfunction

Type 2 diabetes mellitus is not caused by a lack of insulin secretion, but because insulin target cells
fail or are unable to respond to insulin normally. This condition is commonly referred to as "insulin
resistance" .1,8 Insulin resistance occurs mostly as a result of obesity and lack of physical activity and
aging. In patients with type 2 diabetes mellitus, too much hepatic glucose production can occur but
there is no autoimmune destruction of Langerhans B cells such as type 2 diabetes mellitus.
Deficiency of insulin function in patients with type 2 diabetes mellitus is only relative and not
absolute. 4.5

In the early stages of developing type 2 diabetes mellitus, B cells showed a disruption in first-phase
insulin secretion, meaning that insulin secretion failed to compensate for insulin resistance. If not
handled properly, in the next development there will be damage to pancreatic B cells. Damage to
pancreatic B cells will occur progressively often will cause insulin deficiency, so that eventually
patients need exogenous insulin. In patients with type 2 diabetes mellitus, these two factors are
generally found, namely insulin resistance and insulin deficiency.

Risk factor

The increase in the number of DM patients, most of whom are type 2 diabetes mellitus, is related to
several factors, namely irreversible risk factors, altered risk factors and other factors. According to
American DiabetesAssociation (ADA) that DM is associated with irreversible risk factors including
family history of DM (first degree relative), age ≥45 years, ethnicity, history of giving birth to a baby
with a birth weight> 4000 grams or history of having gestational diabetes and history of birth with
low weight. Other factors associated with diabetes risk are those with polycystic ovarysindrome
(PCOS), metabolic syndrome patients who have a disturbed glucose tolerance (TGT) or impaired
fasting blood glucose (GDPT) before, have a history of cardiovascular diseases such as stroke, CHD,
or peripheral renal Diseases (PAD ), alcohol consumption, stress factors, smoking habits, gender,
consumption of coffee and caffeine.

1.Obesity (obesity) There is a significant correlation between obesity and blood glucose levels, in
the degree of obesity with BMI> 23 can cause an increase in blood glucose levels to 200mg%. 1,2

2. Hypertension An increase in blood pressure in hypertension is closely related to improper


storage of salt and water, or increased pressure from the body in peripheral blood vessel
circulation.
3. Diabetes Mellitus Family History A person suffering from Diabetes Mellitus is thought to have
a diabetes gene. It is suspected that diabetes talent is a recessive gene. Only people who are
homozygous with these recessive genes suffer from Diabetes Mellitus.
4. Dislipedimia Is a condition characterized by an increase in blood fat levels (Triglycerides> 250
mg / dl). There is a relationship between increases in insulin plasma and low HDL (<35 mg / dl)
often found in diabetic patients.
5. Age Based on research, the most age affected by Diabetes Mellitus is> 45 years.
6. Childbirth History A history of recurrent abortion, giving birth to a disabled baby or baby
weight> 4000gram
6. Genetic Factors Type 2 DM originates from genetic interactions and various mental factors
This disease has long been thought to be associated with familial aggregation. The risk of
emperis in the event of type 2 DM will increase two to six times if the parent or sibling
experiences this disease.
7. Alcohol and Cigarettes Changes in lifestyle are associated with an increased frequency of
type 2 DM. Although most of these increases are associated with increased obesity and reduced
physical inactivity, other factors associated with changes from the traditional westernized
environment include changes in consumption of alcohol and cigarettes also play a role in
increasing type 2 diabetes. Alcohol will interfere with blood sugar metabolism, especially in DM
patients, which will complicate the regulation of blood sugar and increase blood pressure. A
person will increase blood pressure when consuming ethyl alcohol more than 60 ml / day which
is equivalent to 100 ml proof whiskey, 240 ml of wine or 720 ml. Risk factors for non-
communicable diseases, including Type 2 diabetes, are divided into two. The first is risk factors
that cannot change, for example age, genetic factors, unbalanced eating patterns of sex, marital
status, education level, occupation, physical activity, smoking habits, alcohol consumption, Body
Mass Index

Clinical symptoms
Symptoms of diabetes mellitus can be distinguished into acute and chronic acute symptoms of
diabetes mellitus, namely: Polyphagia (lots of eating) polydipsia (lots of drinking), Polyuria (a lot
of urination / frequent urination at night), increased appetite your weight drops rapidly (5-10 kg
within 2-4 weeks), easily tired. The chronic symptoms of diabetes mellitus are: Tingling, skin
feels hot or like punctured needles, numbness in the skin, cramps, fatigue, easy drowsiness,
blurred vision, easily shaky and easily loose teeth, decreased sexual ability even in men,
impotence can occur, pregnant women often experience miscarriages or fetal deaths in the
womb or with babies born more than 4kg.

Diagnosis Complaints and typical symptoms plus the results of blood glucose testing when> 200
mg / dl, fasting blood glucose> 126 mg / dl is sufficient to establish a diagnosis of DM. For the
diagnosis of DM and other glucose tolerance disorders blood glucose was examined 2 hours
after glucose load. At least 2 times abnormal blood glucose level is needed to confirm the
diagnosis of other days of DM or abnormal Oral Glucose Tolerance Test (OGTT). Confirmation is
not necessary in the typical circumstances of hyperglycemia with acute metabolic
decompensation, such as ketoacidosis, rapid weight loss. There is a difference between a DM
diagnostic test and a screening check. Diagnostic tests are performed on those who show
symptoms of DM, while screening aims to identify those who are asymptomatic, but have a risk
of DM (age> 45 years, overweight, hypertension, DM family history, history of recurrent
abortion, giving birth to babies> 4000 gr , HDL cholesterol <= 35 mg / dl, or triglycerides ≥ 250
mg / dl). Diagnostic tests are performed on those who are positive for screening tests. 11
Screening can be done through examination of blood glucose levels or fasting blood glucose
levels, then can be followed by a standard oral glucose tolerance test (OGTT)
Management of diabetes mellitus
The principle of managing diabetes mellitus in general is five in accordance with the DM
Consensus Management in Indonesia in 2006 is to improve the quality of life of DM patients.
The objectives of DM management are: 2 Short term: loss of complaints and signs of DM,
maintaining a sense of comfort and achieving the target of controlling blood glucose. Long term:
prevented and hampered progression of microangiopathic complications, macroangiopathy and
neuropathy. The ultimate goal of management is a decrease in DM morbidity and mortality. To
achieve this goal, it is necessary to control blood glucose, blood pressure, body weight and lipid
profile, through patient management holistically by teaching self-care and behavior change.
1. Diet The principle of regulating the eating of people with diabetes is almost the same as the
recommended diet for the general public, namely a balanced diet and according to the
individual caloric and nutritional needs. In people with diabetes, it is important to emphasize
the importance of regular eating in terms of meal schedules, type and amount of food,
especially in those who use blood glucose-lowering drugs or insulin. The recommended
standard is food with a balanced composition in terms of carbohydrates 60-70%, fat 20-25% and
protein 10-15%. To determine nutritional status, calculated by BMI (Body Mass Index). The Body
Mass Index (BMI) or Body Mass Index (BMI) is a simple tool or way to monitor the nutritional
status of adults, especially those related to underweight and overweight. To find out the value
of this IMT, it can be calculated by the following formula: Weight Weight (Kg) BMI = ----------------
---------------- ---------------- Height (m) X height of Body (m) 2. Exercise (physical exercise / sport)
2. Exercise is recommended regularly (3-4 times a week) for approximately 30 minutes, which is
in accordance with Continuous, Rhythmical, Interval, Progressive, Endurance (CRIPE). Training
according to the patient's ability. An example is mild walking for 30 minutes. Avoid habits of life
that are lacking in motion or lazy.
3. Health Education Health education is very important in management. Primary prevention
health education must be given to high-risk community groups. Secondary health education is
given to groups of DM patients. While health education for tertiary prevention is given to
patients who have chronic diabetes complications.
4. Medication: oral hypoglycemic, insulin If the patient has made arrangements for eating and
physical exercise but has not managed to control blood sugar levels then consider the use of
hypoglycemic drugs

Medications - Diabetes Melitus Medication


a. Antidiabetic oral Management of DM patients is done by normalizing blood sugar levels and
preventing complications. More specifically with relieving symptoms, optimizing metabolic
parameters, and controlling body weight. For patients with type 1 diabetes, the use of insulin is
the main therapy. Oral antidiabetic indications are primarily intended for the treatment of mild
to moderate type 2 DM patients who fail to be controlled by regulating energy and
carbohydrate intake and exercise. This class of drugs is added if after 4-8 weeks of diet and
exercise efforts are carried out, blood sugar levels remain above 200 mg% and HbA1c above 8%.
So this drug does not replace dietary efforts, but helps. The selection of the right oral
antidiabetic drugs largely determines the success of diabetes therapy. The choice of therapy
using oral antidiabetic can be done with one type of drug or combination. The selection and
determination of the oral antidiabetic regimen used must consider the severity of DM disease
and the general health condition of the patient including other diseases and complications. In
this case oral hypoglycemic drugs include sulfonylureas, biguanides, alpha glucosidase inhibitors
and insulin sensitizing. 3
b. Insulin Insulin is a small protein with a molecular weight of 5808 in humans. Insulin contains
51 amino acids arranged in two chains that are connected with disulfide bridges, there are
differences in the amino acids of the two chains. For patients who are not diet controlled or oral
hypoglycemic administration, a combination of insulin and other drugs can be very effective.
Insulin is sometimes used as a temporary choice, for example during pregnancy. However, in
worsening type 2 DM patients, total insulin replacement is a necessity. Insulin is a hormone that
affects carbohydrate metabolism and protein and fat metabolism. The function of insulin
includes increasing glucose uptake into cells of most tissues, increasing oxidative glucose
breakdown, increasing glycogen formation in the liver and muscles and preventing glycogen
breakdown, stimulating the formation of proteins and fats from glucose.

Complications of diabetes mellitus


Poorly controlled diabetes will cause acute and chronic complications. According to PERKENI
DM complications can be divided into two categories, namely: 5,11 a. Acute complications -
Hypoglycemia, is a person's blood glucose level below the normal value (<50 mg / dl).
Hypoglycemia is more common in people with type 1 diabetes mellitus that can be experienced
1-2 times per week. Blood sugar levels that are too low cause brain cells not to get an energy
supply so they don't function and can even be damaged. - Hyperglycemia, hyperglycemia is
when blood sugar levels increase suddenly, can develop into a dangerous metabolic state,
including diabetic ketoacidosis, Coma Hiperosmoler Non Ketotik (KHNK) and kemolakto acidosis.
b. Chronic Complications - Macrovascular complications, common macrovascular complications
in people with DM are brain thrombocytes (blood clots in some brain), experiencing coronary
heart disease (CHD), congestive heart failure, and stroke. - Microvascular complications,
microvascular complications mainly occur in patients with type 1 diabetes such as nephropathy,
diabetic retinopathy (blindness), neuropathy, and amputation Prevention Prevention of
diabetes mellitus is divided into four parts, 7: Prevention Premordial Premodial prevention is an
effort to provide conditions to the community that allow disease does not get support from
habits, lifestyle and other risk factors. This precondition must be created with multimitra.
Premodial prevention of DM disease, for example, is to create preconditions so that people feel
that westernized food consumption is a poor diet, a relaxed lifestyle or lack of activity, and
obesity is not good for health. Primary Prevention Primary prevention is an effort aimed at
people who belong to high risk groups, namely those who have not suffered from DM, but the
potential to suffer from DM include: a. Old age group (> 45 years) b. Obesity (BB (kg)> 120% BB
dream or BMI> 27 (kg2)) c. High blood pressure (> 140i90mmHg) d. Family history of DM e.
History of pregnancy with BB babies born> 4000 gr. f. Disiipidemia (HvL <35 mg / dl and / or
triglycerides> 250mg / dl). g. Ever TGT or interrupted fasting blood glucose (GDPT) For primary
prevention must be subjected to factors that influence the emergence of DM and efforts to
eliminate these factors. Therefore it is very important in this prevention. Early on, an
understanding of the importance of regular physical activities, patterns and types of healthy
foods should be instilled to keep the body from being too fat :, and the risk of smoking to
health.

REFERENCE: DIABETES MELITUS TIPE 2 Restyana Noor Fatimah Medical Faculty, Lampung
University. J MAJORITY .Volume 4 Nomor 5. Februari; 2015