DIABETES MELLITUS

Definition :
Diabetes mellitus (joslin)
E A syndrome characterized by chronic
hyperglycemia
E And disturbance of carbohydrate, fat, and
protein metabolism
E Associated with absolute or relative
deficiencies in insulin secretion and/ or insulin
action


Classification of Diabetes Mellitus (DM) :
Type 1
Type 2
Other specific types
Gestational diabetes mellitus


General epidemiological points :
Type 1 diabetes is relatively less common
throughout the western pacific region


Type 2 diabetes prevalence rates show marked
differences according to lifestyle, affluence and
urbanisation


Remain low in traditional societies
Rising rapidly in association with urbanisation
& modernisation



g
Type 2 diabetes is becoming increasingly common in
young people



@
50-85% of identified cases had not been
previously diagnosed


Commonality of enviromental risk faktors :


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Changing nutrition
Central obesity
Decreasing physical activity level
Urbanisation
General epidemiological points :
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 %


Epidemiology of DM in Indonesia
Prevalence : urban > rural area
Tasikmalaya : 1,1% (1993)
Sesean (Toraja) : 0,8% (> 30 years)


2020 : 178 million > 20 years


Prevalence of diabetes : 4 %


7 million diabetes patients


INDONESIA :
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


Type 1 diabetes :
Pancreatic islet cell destruction
> 95% : caused by an autoimmune
< 5% : idiopathic
Type 1 diabetes :
Prone to ketoasidosis
Require insulin replacement therapy


Type 2 :
Insulin resistance
-cell insufficiency
Type 2 Diabetes :
E Accounts for over 90% of diabetes cases
E Usually adults over age 40
E Do not require insulin to survive
E Ketosis seldom occurs spontaneously,
if present it is a consequence of associated
stress from trauma, infection or cardiovascular
events
E Genetic influence >

Type 2 diabetes :
Obese type 2 diabetes
Non obese type 2 diabetes
BMI =
Normal range :
BW ( kg )
H ( m )
2
Women : 18.5 - 23.5
Men : 22.5 - 25
Symptoms of diabetes mellitus :
Polyuria
Polydypsia
Polyphagia
Weight loss
General malaise


Clinical features of diabetes at diagnosis

Polyuria and thirst
Weakness or fatigue
Polyphagia with weight loss
Recurrent blurred vision
Vulvovaginitis or pruritus
Peripheral neuropathy
Nocturnal enuresis
Often asymptomatic

Diabetes
Type 1

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Diabetes
Type 2

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


PREVENTION
POPULATION APPROACH
LIFE STYLE
IMPROVE NUTRITION
DURING PREGNANCY
HIGH-RISK APPROACH
DM IN FAMILY / GENETIC
Four pillar in the management of DM
1) Education
2) Dietary management
3) Physical exercise
4) Hypoglycemic agent
* Oral hypoglycemic agent
* Insulin


Composition of food :
Carbohydrate 60 70 %
Protein 10 15 %
Lemak 20 25 %


Physical exercise :
Continuous
Rhythmical
Interval
Progressive
Endurance training


MANAGEMENT
AIM : T2DM
QUALITY OF LIFE
ACCELERATION OF
CHRONIC COMPLICATIONS
RISK OF ACUTE COMPLICATIONS
INTERVENTION TO INSULIN RESISTANCE
LIFE STYLE !
TO POST-PRANDIAL HYPERGLYCEMIA
ACARBOSE
INSULIN SECRETAGOGUE
METFORMIN
Chronic complications of diabetes mellitus

Eyes
Diabetic retinopathy
Cataracts
Kidneys
Intercapillary glomerulosclerosis
Infection
Renal tubular necrosis
Following dye studies (urograms, arteriograms)
Nervous system
Peripheral neuropathy
Distal, symmetric sensory loss
Motor neuropathy
Food drops


Chronic complications of diabetes mellitus


Autonomic neuropathy
Postural hypotension
Resting tachycardia
Loss of sweating
Gastrointestinal neuropathy
Gastroparesis
Diabetic diarrhea
Urinary bladder atony
Erectile dysfunction (may also be secondary to pelvic
vascular disease)
Chronic complications of diabetes mellitus

Skin
Diabetic dermopathy
Candidiasis
Foot and leg ulcers
Neurotropic
Ischemic

Cardiovascular system
Heart disease
Myocardial infarction
Cardiomyopathy
Gangrene of the feet
Ischemic ulcers
Osteomyelitis
Classification of diabetic vascular disease
Small blood vessels
(capillary & precapillary arterioles)
Thickening of the capillary basement
membrane
Microangiopathy :



Microvascular disease (Microangiopathy)
A
Retina
Diabetic retinopathy
Kidney
Diabetic nephropathy
Heart
Cardiopathy
Classification of diabetic vascular disease
An accelerated form of atherosclerosis


Macrovascular disease (Macroangiopathy)
B
Coronary heart disease
Stroke
Peripheral vascular disease
Management of diabetes mellitus
in surgical patients
Management of diabetes mellitus
in surgical patients
Patients managed with diet alone :
Patient whose diabetes is well controlled
by dietary modification & physical activity
may require no special preoperative
intervention
Fasting blood glucose should be
measured on the morning of surgery
If surgical procedure > 1 hour, intra
operative blood glucose (BG) monitoring is
desirable
If surgical is major & diabetes is poorly
controlled (BG>200mg/dl) Insulin i.v &
dextrose should be considered hourly
intra operative BG monitoring is
recommended
Management of diabetes mellitus
in surgical patients
Patients treated with oral anti diabetic agents :

Management of diabetes mellitus
in surgical patients
Drugs Recomendation
2
nd
Sulfonylureas

Metformin
Discontinued 1 day before surgery
Exception for chlopropamide, 2-3 days
before surgery
Discontinued 1-2 days before surgery
Especially in patients undergoing
procedure that increase the risk for
renal hypoperfusion, tissue hypoxia
& lactate accumulation
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

Management of diabetes mellitus
in surgical patients
Insulin
Treated
patients :

Management of diabetes mellitus
in surgical patients
Management of diabetes mellitus
in surgical patients
Management of diabetes mellitus
in surgical patients
Management of diabetes mellitus
in surgical patients

Management of diabetes mellitus in surgical patients

Management of diabetes mellitus in surgical patients

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
DIAGNOSIS
2 HOURS POST-PRANDIAL BLOOD GLUCOSE
140 200 mg%
USA
SINGAPARNA, WEST JAVA
~ 11 %
18.1 %
PREVALENCE
PRESENTATION WITH A COMPLICATION
IS NOT UNCOMMON

TYPE 2 DIABETES MUST HAVE PASSED
THROUGH AN IGT PRIOR TO DIAGNOSIS
> 50 % REMAIN NON-DIABETIC FOR YEARS

1 - 5 % IGT DM PER YEAR

IGT
IMPAIRED GLUCOSE TOLERANCE
IS A CRITICAL STAGE IN THE
DEVELOPMENT OF TYPE 2 DIABETES
Chronic complications of diabetes mellitus

Bones and joints
Diabetic cheirathropathy
Dupuytrens contracture
Charcot joint

Unusual infections
Necrotizing fasciitis Necrotizing myositis
Mucormycosis
Emphysematous cholecystitis
Malignant otitis externa
Obese type 2 Diabetes :
The prevalence of obesity varies
among different racial groups.


Chinese
Japanese


30 40% : Obese


North American
European
African


60 70% : Obese


Pima Indians
Pacific 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 pancreatic
cell seems to be the major defect


Ideal weight
Height - 150
(Height 100 ) 10%
(Height 100 ) -

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