Diabetes Mellitus Classification and Diagnosis By: Dr Mozhgan Karimifar Assistant Prof. of Endocrinology Isfahan University Of Medical Sciences

Diabetes is a huge and growing problem… 53% WORLD 592 million people living with diabetes WORLD 387 million Africa 93% Middle East and North Africa 85% South East Asia 64% South and Central America 55% Western Pacific 46% Europe 33% North America and Caribbean 30% Diabetes is a huge and growing problem…

MIDDLE EAST AND NORTH AFRICA at a glance 36.8 million people have diabetes - 1 in 10 adults 3% of worldwide expenditure - USD 16.8 billion

Prevalence of Diabetes in Iran: 8.64%

The prevalence of DM Although the prevalence of both type 1 and type 2 DM is increasing worldwide, the prevalence of type 2 DM is rising much more rapidly, presumably because of increasing : Obesity reduced activity levels as countries become more industrialized the aging of the population

Classification: 1. Type 1 diabetes (due to β-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes: Monogenic diabetes syndromes (such as…) Maturity-onset diabetes of the young (MODY) Lipodystrophic syndromes Neonatal diabetes Diseases of the exocrine pancreas (such as…) Cystic fibrosis Pancreatitis Drug- or chemical-induced diabetes (such as…) Glucocorticoids, drugs in the treatment of HIV/AIDS or after organ transplantation

Spectrum of glucose homeostasis

Criteria for the diagnosis of diabetes: A1C ≥6.5% The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.* OR FPG ≥126 mg/dL (7.0 mmol/L) Fasting is defined as no caloric intake for at least 8 h.* 2-h PG ≥200 mg/dL (11.1 mmol/L) during an OGTT The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.* In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (11.1 mmol/L) *In the absence of unequivocal hyperglycemia, results should be confirmed by repeat testing. NGSP: National Glycohemoglobin Standardization Program FPG: Fasting Plasma Glucose DCCT: Diabetes Control and Complications Trial OGTT: Oral Glucose Tolerance Test

Criteria for testing for diabetes or prediabetes in asymptomatic adults 1. Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2 or ≥23 kg/m2 in Asian Americans) and have additional risk factors: physical inactivity first-degree relative with diabetes high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander) women who delivered a baby weighing >4 Kg or were diagnosed with GDM hypertension (≥140/90 mmHg or on therapy for hypertension) HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L) women with polycystic ovary syndrome A1C ≥5.7%, IGT, or IFG on previous testing other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) history of CVD

Criteria for testing for diabetes or prediabetes in asymptomatic adults (cont…) 2. For all patients, particularly those who are overweight or obese, testing should begin at age 45 years. 3. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results (e.g., those with prediabetes should be tested yearly) and risk status.

*Persons aged <18 years Testing for type 2 diabetes or prediabetes in asymptomatic children* Criteria Overweight (BMI >85th percentile for age and sex, weight for height >85th percentile, or weight >120% of ideal for height) Plus any two of the following risk factors: Family history of type 2 diabetes in first- or second-degree relative Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander) Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small for-gestational-age birth weight) Maternal history of diabetes or GDM during the child’s gestation Age of initiation: age 10 years or at onset of puberty, if puberty occurs at a younger age Frequency: every 3 years *Persons aged <18 years

Screening for and diagnosis of Gestational DM (GDM) One-step strategy:

Screening for and diagnosis of Gestational DM (GDM) Two-step strategy:

Maturity-onset diabetes of the young (MODY) (1% to 2% of all diabetes) It is inherited in an autosomal dominant pattern. Impaired insulin secretion with minimal or no defects in insulin action. Onset of hyperglycemia at an early age (generally before age 25 years). The diagnosis of monogenic diabetes should be considered in children with the following findings: Strong family history of diabetes but without typical features of type 2 diabetes (nonobese, low-risk ethnic group) Mild fasting hyperglycemia (100–150 mg/dL [5.5–8.5mmol/L]), especially if young and nonobese Diabetes with negative autoantibodies and without signs of obesity or insulin resistance

Latent autoimmune diabetes in adults (LADA) A slowly progressive form of autoimmune or type 1 diabetes that can be treated initially without insulin injections. The diagnosis of LADA is currently based on three criteria: Adult age at onset of diabetes. The presence of circulating islet autoantibodies. (Distinguishes LADA from type 2 diabetes) Lack of a requirement for insulin for at least 6 months after diagnosis. (Distinguishes LADA from classic type 1 diabetes) Fourlano S. Diabetologia (2005) 48: 2206–2212

Prevention of Type 1 DM

Prevention of Type 1 DM None of these interventions have been successful in preventing type 1 DM in humans.

Prevention of Type 2 DM

Type 2 DM is preceded by a period of IGT or IFG, and a number of Prevention Type 2 DM is preceded by a period of IGT or IFG, and a number of lifestyle modifications pharmacologic agents prevent or delay the onset of DM. reduce body weight increase physical activity screened for cardiovascular disease. H 19th

The Diabetes Prevention Program (DPP) intensive changes in lifestyle (diet and exercise for 30 min/d five times/week) in individuals with IGT prevented or delayed the development of type 2 DM by 58% compared to placebo. This effect was seen in individuals regardless of age, sex, or ethnic group.

Metformin prevented or delayed diabetes by 31% compared to placebo

α-glucosidase inhibitors metformin Thiazolidinediones GLP-1 receptor pathway modifiers orlistat prevent or delay type 2 DM but are not approved for this purpose.

Individuals with a strong FH of type 2 DM and individuals with IFG or IGT should be strongly encouraged to maintain a normal BMI and regular physical activity.

both IFG and IGT who are at very high risk for progression to diabetes Metformin(ADA) both IFG and IGT who are at very high risk for progression to diabetes age <60 years BMI ≥35 kg/m2 FH of diabetes in first-degree relative women with a history of GDM

Guidelines for Ongoing, Comprehensive Medical Care for Patients with Diabetes Optimal and individualized glycemic control • Self-monitoring of blood glucose (individualized frequency) • HbA1c testing (2–4 times/year) • Patient education in diabetes management (annual); diabetes- self management education and support • Medical nutrition therapy and education (annual) • Eye examination (annual or biannual) • Foot examination (1–2 times/year by physician; daily by patient; • Screening for diabetic nephropathy (annual) • Blood pressure measurement (quarterly) • Lipid profile and serum creatinine (estimate GFR) (annual) • Influenza/pneumococcal/hepatitis B immunizations • Consider antiplatelet therapy

Treat ment Goals for Adults with Diabetesa Index Goal Glycemic control HbA1c <7.0%c Preprandial capillary plasma glucose 80–130 mg/dL Peak postprandial capillary plasma glucosed <180 mg/dL Blood pressure <140/90 mmHg Lipids Low-density lipoprotein <100 mg/dL High-density lipoprotein >1 mmol/L (40 mg/dL) in men >1.3 mmol/L (50 mg/dL) in women Triglycerides <150 mg/dL eGoal of <130/80 mmHg may be appropriate for younger individuals fIn decreasing order of priority. Goal of <1.8 mmol/L (70 mg/dL) may be appropriate for individuals with cardiovascular disease.

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