1. DIABETES CASE PRESENTATIONS 1 st - diagnosis

2. Case 1 Male, 24 yrs old Male, 24 yrs old Presents in the ER for nausea, vomiting, abdominal pain, shortness of breath Presents in the ER for nausea, vomiting, abdominal pain, shortness of breath No known medical conditions, BMI = 21kg/m2 No known medical conditions, BMI = 21kg/m2 In the last month has noticed increased thirst and passing water and lost almost 15 kg In the last month has noticed increased thirst and passing water and lost almost 15 kg Clinical examination: dehydration, BP = 125/65 mmHg, HR = 110/min Clinical examination: dehydration, BP = 125/65 mmHg, HR = 110/min?

3. Case 2 Female, 39 yrs old Female, 39 yrs old Presents at the GP accusing fatigue and frequent urination Presents at the GP accusing fatigue and frequent urination No known medical conditions, BMI=29 kg/m2, has 5 children (healthy, normal birth weight) No known medical conditions, BMI=29 kg/m2, has 5 children (healthy, normal birth weight) Has an aunt with diabetes Has an aunt with diabetes?

4. Case 3 Male, 34 years old Male, 34 years old Presents at the dermatologist for reccurent Staphyloccocus infection Presents at the dermatologist for reccurent Staphyloccocus infection Does not present other symptoms Does not present other symptoms Smoker, sedentary lifestyle, BMI = 32 kg/m2 Smoker, sedentary lifestyle, BMI = 32 kg/m2 Father with diabetes and hypertension Father with diabetes and hypertension?

5. Case 4 Female, 65 yrs old Female, 65 yrs old Presents to the ophthalmologist for decreased eyesight Presents to the ophthalmologist for decreased eyesight Fundoscopy shows microaneurisms, hemorrhages and macular edema Fundoscopy shows microaneurisms, hemorrhages and macular edema BP = 155/90 mmHg, BMI = 35 kg/m2 BP = 155/90 mmHg, BMI = 35 kg/m2 Has a sister and mother with diabetes Has a sister and mother with diabetes?

6. Case 5 Male, 51 yrs old Male, 51 yrs old Needs surgery for disc herniation Needs surgery for disc herniation Tests before surgery find: blood glucose level = 176 mg/dl Tests before surgery find: blood glucose level = 176 mg/dl BMI = 33 kg/m2, TA = 160/80 mmHg BMI = 33 kg/m2, TA = 160/80 mmHg Sedentary due to chronic back pain Sedentary due to chronic back pain?

7. Case 6 Female, 41 yrs old Female, 41 yrs old Presents at the GP for the annual check-up; at the age of 37 she had gestational diabetes and she checks her blood glucose level annually Presents at the GP for the annual check-up; at the age of 37 she had gestational diabetes and she checks her blood glucose level annually BMI = 29,5 kg/m2 BMI = 29,5 kg/m2 Fasting blood glucose level = 118 mg/dl Fasting blood glucose level = 118 mg/dl?

8. Diagnosis of diabetes Symptomatically: Symptomatically: Classic symptoms (polyuria, polydipsia, polyphagia, weight loss) Classic symptoms (polyuria, polydipsia, polyphagia, weight loss) Ketoacidosis Ketoacidosis Acute infectious complication Acute infectious complication Chronic complication: Chronic complication: Eyes Eyes Kidneys Kidneys Neurological Neurological Macrovascular Macrovascular Asymptomatically: Asymptomatically: Random tests Random tests Active screening Active screening

9. Criteria for the diagnosis of diabetes mellitus Symptoms of diabetes plus casual plasma glucose concentration ≥200 mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. Symptoms of diabetes plus casual plasma glucose concentration ≥200 mg/dl (11.1 mmol/l). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.or FPG ≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h. FPG ≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.or 2-h post-load glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water. 2-h post-load glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.

10. Classification of diabetes mellitus (1) Type 1 Type 1 beta-cell destruction, usually leading to absolute insulin deficiency beta-cell destruction, usually leading to absolute insulin deficiency Autoimmune Autoimmune Idiopathic Idiopathic Type 2 Type 2 may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with or without insulin resistance may range from predominantly insulin resistance with relative insulin deficiency to a predominantly secretory defect with or without insulin resistance

11. Classification of diabetes mellitus (2) Other specific types Other specific types Genetic defects of beta-cell function Genetic defects of beta-cell function Genetic defects in insulin action Genetic defects in insulin action Diseases of the exocrine pancreas Diseases of the exocrine pancreas Endocrinopathies Endocrinopathies Drug- or chemical-induced Drug- or chemical-induced Infections Infections Uncommon forms of immune-mediated diabetes Uncommon forms of immune-mediated diabetes Other genetic syndromes sometimes associated with diabetes Other genetic syndromes sometimes associated with diabetes Gestational diabetes Gestational diabetes

12. Pre-diabetes Impaired fasting glycaemia (IFG): Impaired fasting glycaemia (IFG): Blood glucose level (fasting) = 110 – 125 mg/dl Blood glucose level (fasting) = 110 – 125 mg/dl Impaired glucose tolerance (IGT): Impaired glucose tolerance (IGT): Blood glucose level (2 hrs at OGTT) = 140 – 199 mg/dl Blood glucose level (2 hrs at OGTT) = 140 – 199 mg/dl

13. Risk factors for type 2 diabetes (screening) Age ≥45 years Age ≥45 years Overweight (BMI ≥25 kg/m2) Overweight (BMI ≥25 kg/m2) Family history of diabetes (i.e., parents or siblings with diabetes) Family history of diabetes (i.e., parents or siblings with diabetes) Habitual physical inactivity Habitual physical inactivity Race/ethnicity (e.g., African-Americans, Hispanic-Americans, Native Americans, Asian-Americans, and Pacific Islanders) Race/ethnicity (e.g., African-Americans, Hispanic-Americans, Native Americans, Asian-Americans, and Pacific Islanders) Previously identified IFG or IGT Previously identified IFG or IGT History of GDM or delivery of a baby weighing > 9 lbs History of GDM or delivery of a baby weighing > 9 lbs Hypertension (≥140/90 mmHg in adults) Hypertension (≥140/90 mmHg in adults) HDL cholesterol ≤35 mg/dl (0.90 mmol/l) and/or a triglyceride level ≥250 mg/dl (2.82 mmol/l) HDL cholesterol ≤35 mg/dl (0.90 mmol/l) and/or a triglyceride level ≥250 mg/dl (2.82 mmol/l) Polycystic ovary syndrome Polycystic ovary syndrome History of vascular disease History of vascular disease

14. Definition of Metabolic Syndrome

15. Initial evaluation of the diabetic patient History taking – personal and family history History taking – personal and family history Clinical examination Clinical examination Height, weight (BMI), waist circumference Height, weight (BMI), waist circumference Tests Tests

16. Definition and classification of obesity WHO Classification WHO Classification BMI (kg/m2) Risk of co-morbidities Underweight<18.5 Low (but risk of other clinical problems increased) Normal range Normal range 18.5 - 24.9 18.5 - 24.9 Average Overweight Pre-obese 25 - 29.9 25 - 29.9 Increased Obese Class I Obese Class I 30.0 - 34.9 30.0 - 34.9 Moderate Obese Class II Obese Class II 35.0 - 39.9 Severe Obese Class III Obese Class III > 40.0 Very severe

17. Types of obesity Abdominal (central) obesity Abdominal (central) obesity Men ≥ 94 cm Men ≥ 94 cm Women ≥ 80 cm Women ≥ 80 cm Gluteo-femoral obesity Gluteo-femoral obesity Men < 94 cm Men < 94 cm Women < 80 cm Women < 80 cm

18. Dyslipidemia Types of dyslipidemia (mg/dl) (mg/dl) Cholesterol Triglycerides Hyper- cholesterolemia Border 190 - 249 < 150 moderate 250 - 300 severe > 300 Hyper- triglyceridemia moderate < 190 150 – 400 severe > 400 Mixt hyperlipidemia moderate 190 - 300 150 – 400 severe > 300 > 400