diabetes melitus & sindroma metabolik pit
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METABOLIC SYNDROME & DIABETES MELLITUSthe problems and short course management
MIF TAHU RACHMAN
PADJADJARAN UNIVERSITYRSHS BANDUNG
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• 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
Learning objectives
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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
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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 celldysfunction and insulin resistance
• Gestational diabetes mellitus
• Diabetes diagnosed in the second or third trimester of pregnancy thatis not clearly overt diabetes
• Other specific diabetes types
• Drug or chemical induced, e.g steroids, treatment of HIV/AIDS or afterorgan 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.
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Differences between type 1and type 2 diabetesFeatures Type 1 Diabetes Type 2 Diabetes
Onset Sudden Gradual
Age at onsetAny age
(mostly young)Mostly in adults
Body habitus Thin or normal Often obese
Ketoacidosis Common Rare
Autoantibodies Usually present Absent
Endogenous insulin Low or absent Normal, decreased or increased
Prevalence Less prevalent in AsiaMore prevalent.90-95% of all people withdiabetes in Asia
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Are you ready ???
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Why are we seeing such an increasein the number of people with Type 2diabetes worldwide?
Unhealthy lifestyle Aging population Urbanisation
Dietary changes Sedentary lifestyleIDF Diabetes Atlas 2014Cockram 2000. HKMJ ; 6 (1): 43-52Mohan 2007. Indian J Med Res; 125: 217-230
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High blood glucose is the 3rd biggest riskfactor contributor to cardio-vasculardeaths globally
WHO 2011. Global Atlas on CVD prevention and Control
Attributable deaths due to selected risk factors (000’)
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Diabetes is developing fast in Indonesia
RISKESDAS Survey 2007
Laporan RISKESDAS 2013
2007 2013
1.5% 2.1%
4.2% 4.8%
10.2% 29.9%
Diagnosed diabetes
Undiagnosed diabetes
Impaired glucose tolerance
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Diabetes is developing fast in Indonesia
RISKESDAS Survey 2007
Laporan RISKESDAS 2013
2007 2013
1.5% 2.1%
4.2% 4.8%
10.2% 29.9%
Diagnosed diabetes
Undiagnosed diabetes
Impaired glucose tolerance
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Diabetes is developing fast in Indonesia
2007 2013
1.5% 2.1%
4.2% 4.8%
10.2% 29.9%
Diagnosed diabetes
Undiagnosed diabetes
Impaired glucose tolerance
RISKESDAS Survey 2007
Laporan RISKESDAS 2013
Approximately 10 million peoplewith diabetes in Indonesia
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0
20
40
60
80
100
Target HbA1c 7% Target HbA1c 6.5%
Over
target
81.01%
67.85%
…and diabetes control is suboptimal
Soewondo P, Soegondo S, Suastika K, Pranoto A, Soeatmadji DW, Tjokroprawiro A. The DiabCare Asia 2008 study-Outcomes on control and complications of type 2 diabetic patients in Indonesia Med J Indones 2010 19; 4: 235-244.
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Early detection and monitoring
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13
Muscle and fat
Glucose Homeostasis
INPUT NUTRISI
Liver
Normoglycemia
Islet
Beta cellproducesinsulin
Alpha cellproducesglucagon
FASTING
NORMAL
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14
Normoglycemia
Alpha cellproducesglucagon
Beta cellproducesinsulin
Muscle and fat
Liver
Glucose Homeostasis
INPUT NUTRISI
Insulin resistance
(decreased glucose uptake)
Diminished
insulin Hyperglycemia
Excess glucose output
TYPE 2 DM
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Insulin Resistance: Associated Conditions
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Metabolic Syndrome – A MultifacetedSyndrome
High
blood glucose
High
bloodpressure
Abnormal
lipid levels
Obesity
Heart diseaseStroke
Kidney failure
Depression?
Cancer?
Urineprotein
Inflammatory markers
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Adapted from Type 2 Diabetes BASICS. International Diabetes Center 2000
Type 2 diabetes is a progressivedisease
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Classical diabetes symptoms
Polyuria
Unexplainedweight loss
Polydipsia
Blurred vision
• 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
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Other diabetes symptoms
Numbnessand/or tingling
Fatigue
Itchy skin
Impotence
• In hands, legs and feet
• Regardless of exercise
• Affects legs, feet, and hands
• Physical and physiological
Adapted from Konsensus PERKENI 2015. Pengelolaan dan pencegahan diabetes melitus tipe 2 di Indonesia.
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ADA - Standards of Medical Care in Diabetes – 2016. Diabetes Care, Vol. 39, Supplement 1, January 2016.
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Cut-points: Diabetes, IGT and IFG
mg/dL
2-hour Plasma Glucose
F a s t i n g P l a s m a G l u c o s e
( F P G )
mg/dL
140 200
100
126
NGTNormal Glucose
Tolerance
Diabetes
IFGImpaired
Fasting Glucose IGTImpaired Glucose
Tolerance Diabetes
ADA - Standards of Medical Care in Diabetes – 2016. Diabetes Care, Vol. 39, Supplement 1, January 2016.
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Diagnosis of Type 2 DiabetesKONSENSUS: 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
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What is good glycaemic control?
• Overall aim to achieve glucose levels as close to normal as possible
• Minimise development and progression of microvascular andmacrovascular complications
FPG
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HbA1c correlation with blood glucoselevel
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 AverageGlucose (ADAG) Study Group. Diabetes Care 2008
The relationship between A1C and eAG is described by the formula 28.7 X A1C –46.7 = eAG
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Risk of complications increasesas Hb1Ac increases
Stratton IM et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000;321:405–12
0
20
40
60
80
5 6 7 8 9 10 11
Myocardial infarction
Microvascular disease
Adjusted for age, sex, and ethnic group.
I n c i d e n c e
p e r
1 .
0 0 0
p a t i e n t - y e
a r s
12697 154 183 212 240 269
Mean HbA1c (%)
Mean mg/dl
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Optimising blood glucose control
Good control is≤ 7.0% HbA1c
Source: UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM et al. BMJ. 2000;321(7258):405-412.
Deaths relatedto diabetes
Microvascularcomplications
Myocardialinfarction
-14%
-37%
-21%
HbA1c-1%
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Practical monitoring scheme
Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. PenatalaksanaanDiabetes Melitus Terpadu. 2009
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Practical monitoring scheme
cont…
Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. PenatalaksanaanDiabetes Melitus Terpadu. 2009
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Initiating diabetes treatment
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The ominous octet
DeFronzo R A Diabetes 2009;58:773-795
Copyright © 2011 American Diabetes Association, Inc.
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The ominous octet, depicting the mechanism and site of action of antidiabetes medications based upon the
pathophysiologic disturbances present in T2DM
Copyright © 2013 American Diabetes Association, Inc. Adapted from DeFronzo R A et al. Diabetes Care 2013;36:S127-S138
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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-S138Copyright © 2013 American Diabetes Association, Inc.
SGLT2
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Factors to consider when choosing anantihyperglycaemic agent
Effectiveness in lowering glucose
Other effects (e.g. reduced cardiovascularoutcomes with metformin, empagliflozin)
Safety profile
Tolerability
Cost
Effect on body weight
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.
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American Diabetes Association. Approaches to glycemic treatment. Sec. 7. In Standards of Medical Care in Diabetes 2015.Diabetes Care 2015;38(Suppl. 1):S41–S48
ADA/EASD treatment algorithm
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Danish treatment guidelines for type2 diabetesHbA1c target value is individual
HbA1c
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RisikoKardiovaskular
(-)
RisikoKardiovaskular
(+)
IMT (kg/m2) 18,5 - < 23
Glukosa darah
Puasa (mg/dL) < 100
2 jam PP (mg/dL) < 140 A1C (%) < 7,0 < 7,0
Tekanan darah
Sistolik (mmHg) ≤ 130 ≤ 130
Diastolik (mmHg) ≤ 80 ≤ 80
Profil Lipid
Total kolesterol (mg/dL)Trigliserid (mg/dL)
HDL kolesterol (mg/dL)
LDL kolesterol (mg/dL) < 100 < 70
Target Pengendalian DM2
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• Metformin
• Sulfonylureas (SUs) and glinides
• α-glucosidase inhibitors (AGIs)
• Dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors)
• Glucagon-like peptide-1 (GLP-1) agonists
• Thiazolidinediones (TZDs)
Antihyperglycaemic agents that arecurrently available in Indonesia
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MetforminUse of metformin based on eGFR
eGFR level (ml/min per 1.73 m) Action
≥60 No renal contraindication to metformin.Monitor renal function annually.
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Diabetes and the elderly
• Always start with the lowest doseof any AHA
• Increase gradually
• Hypoglycaemia may increase therisk of falls and heart attack inelderly
• Use shorter-acting AHA to reducethe 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 achievemaximum benefits from AHAs
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Behaviour Modification : #BeMO
Eat : intelligently
Pray : deeply
Love : your Body
Move : regularly
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WE DO NOT DREAM….WE SIMPLY WORKING HARD
KEEP AN OPEN MIND AND HEART
AND WE CAN BEAT THE DIABETES
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