SUMMARY

Type 2 diabetes is a major public health problem in India. Glucose is an essential nutrient that provides energy for the proper functioning of the body cells. The blood glucose level at any point of time is determined by the balance between the amount of glucose entering the blood stream and the amount leaving it. There is net uptake of glucose by liver when the plasma glucose is high and a net discharge when it is low. Insulin is produced by specialized cells in the pancreas.  In addition to helping glucose enter the cells, insulin is also important in tightly regulating the level of glucose in the blood. The dual defect of insulin deficiency and insulin resistance in type 2 diabetes is caused by interplay between genetic and environmental factors.

Type 1 diabetes refers to cell-mediated autoimmune destruction of pancreatic beta islet cells, which leads to absolute insulin deficiency. People with type 1 diabetes usually develop symptoms over a relatively short period of time. Symptoms in people with type 2 diabetes are often not as noticeable in type 1.   Secondary diabetes may occur as a result of other medical conditions, but the treatment goal is to achieve normoglycemia. Another form of diabetes occurs only in pregnancy and often disappears after the birth of child. Efforts are made to keep blood glucose as close to normal as possible during pregnancy to prevent macrosomia or infant hypoglycemia. The mothers should be counseled following delivery to reduce their risk of developing type 2 diabetes in future.

Glycemic Control Targets

HbA1C   < 6.5 %

Fasting Glucose 70-130 mg/dl

Postprandial < 180 mg/dl

Blood pressure < 130/80 mm/hg

Lipids

LDL Cholesterol < 100 mg/dl

Triglycerides < 150 mg/dl

HDL   Cholesterol > 40 mg/dl (in men), > 50 mg/dl (in women)

 

Follow-up of patient & Frequency of Testing

Blood Glucose Controlled (HbA1c < 7 %) – every 3 months once

Uncontrolled  – every 2 weeks until target sugars achieved

HbA1C Controlled (HbA1C < 7 %) – 6  months to 1 year

Uncontrolled – every 3 months

Tests for Neuropathy

Monofilaments

Biothesiometer

Foot examination

 

Annual

Annual

Once in 3 months

Tests for retinopathy

Fundus examination

Annually, if evidence of retinopathy detected at first visit, follow-up every 3 to 6 months
Tests for Nephropathy

Urinary micro albumin

(or 24 hours urinary protein)

Serum Creatinine

 

Annual

 

Annual

Miscellaneous test

ECG

Treadmill test

Lipid Profile

Plain X-Ray Abdomen

 

Annual

By 5 years after onset of diabetes mellitus, then once in 2 years

Annual. If abnormal every 6 months

If BMI < 20 kg/m2 or  USG Abdomen

 

Practical Aspects

Diabetes Mellitus

Chronic multisystem disease related to abnormal insulin production, impaired insulin utilization, or both

 

Type 1 Diabetes

Abnormal insulin production, insulin dependent, progressive destruction of pancreatic beta cells by body’s own T cells, often occurs before 30 years of age, antibodies cause a reduction of 80-90% of normal beta cell function before manifestation occurs

 

 

Type 1 Diabetes onset

History of recent, sudden weight loss, polydipsia, polyuria, polyphagia

 

Clinical Manifestations -Type 1

Polyuria, polyphagia, polydipsia, wt loss, weakness, fatigue

 

Clinical Manifestations–Type 2

Unspecific symptoms, fatigue, recurrent infections, recurrent vaginal yeast infections, prolonged wound healing, visual changes

 

Type 2 Diabetes

Most prevalent type, over 90% of pts with diabetes, usually occurs in pts over 35, 80-80% of pts are overweight

 

Three major metabolic abnormalities in Type 2 Diabetes

  1. Insulin resistant
  2. Pancreas inability to produce insulin
  3. Inappropriate glucose production from liver

 

Metabolic Syndrome

Elevated insulin levels along with insulin resistance, increased triglycerides and LDL’s, decreased HDL’s, HTN–need at least three of those conditions for metabolic syndrome

 

Fasting Plasma Glucose or Impaired Fasting Glucose

>126 mg/dl=diabetes; >100-<125=pre-diabetes; <100=non-diabetic

Need to have more than one test to diagnose

 

Risk Factors for Metabolic Syndrome

Central obesity, sedentary lifestyle, urbanization, certain ethnicities

 

Gestational Diabetes

Develops during pregnancy, detected 24-28 weeks of gestation, glucose levels back to normal 6 weeks postpartum, if able to maintain pre-pregnancy wt then DM 2 will be unlikely

 

Diagnostic Studies

Fasting plasma glucose, random or casual plasma glucose, two hour OGTT, HbA1C now approved

 

Random or Casual Glucose > 200 mg/dl=diabetes

Two Hour OGTT or Impaired Glucose Tolerance

>200=diabetes; <200->140=pre-diabetes; <140=non-diabetic

 

HbA1C

Normal = 4-6%

Increased risk = 5.7-6.4%

Diabetes = >6.5%