1. Diabetes
Mellitus
in the year
2000

2. Report of the Expert Committee on the Diagnosis and Classification of
Diabetes
Mellitus
in the year
2000
Report of the Expert Committee on
the Diagnosis and Classification of
Diabetes Mellitus

3. Diabetes
Mellitus
in the year
2000
Definition
Description
Classification
Diagnostic criteria
Testing for diabetes

4. Definition Diabetes Mellitus is a group of metabolic disease
characterized by hyperglycemia resulting from
defects in insulin secretion, insulin action, or both.
The chronic hyperglycemia of diabetes is associated
with log-term damage, dysfunction, and failure of
various organs, especially the eyes, Kidneys, nerves,
heart, and blood vessels.

5. Insulin deficiency Insulin resistance Description Blood glucose
Symptoms: Polyuria and polydipsia.
Weight loss with polyphagia.
Blurred vision.
Infection susceptibility.
DKA or NKHS.

6. Types Type 1 Type 2 Types & Stages Normal Hyperglycemia Other Specific
glucose
regulation
Impaired Glucose Tolerance or
Impaired Fasting Glucose
Diabetes Mellitus
Not Insulin Insulin
insulin requiring requiring
requiring for control for survival
Type 1
Type 2
Other
Specific
Types
These patients can briefly return to normoglycemia
Vacor toxicity may require insulin for survival
Gestational
Diabetes
Type 1 diabetes presenting in pregnancy may require insulin for survival

7. Other specific types of diabetes
Normal
Hyperglycemia
Stage
&
Aetiology
Normal glucose
tolerance
( achieved without
Pharmacological agents)
Impaired Glucose
and / or fasting
hyperglycemia
Diabetes Mellitus
Not Insulin Insulin
insulin requiring requiring
requiring for control for survival
Aetiology
Islet cell destruction:
Autoimmune
Idiopathic
Predominantly insulin
resistance
Predominantly insulin secretory
defects
Other specific disorders
( eg MODY, Endocrinopathies )
Type 1 diabetes
Type 2 diabetes
Other specific types of diabetes
Gestational Diabetes
Gestational diabetes

8. III- Other specific types.
Etiologic
classification of
diabetes
mellitus
I- Type 1 diabetes:
II- Type 2 diabetes.
III- Other specific types.
IV- Gestational diabetes mellitus.

9. Etiologic classification of A. Immune mediated: diabetes mellitus
I- Type 1 diabetes:
A. Immune mediated:
Cellular-mediated autoimmunity.
Markers:
Islet cell autoantibodies ( ICAs ).
Autoantibodies to insulin ( IAAs ).
Autoantibodies to glutamic acid
decarboxylase ( GAD ).
Autoantibodies to the tyrosine
phosphatase IA-2 and IA-2B.
HLA:
HLA-DR/DQ alleles can be either
predisposing or protective.
B lymphocyte
T lymphocyte
Beta cell

10. Autoimmune destruction
Etiologic
classification of
diabetes
mellitus
I- Type 1 diabetes:
Autoimmune destruction
Environmental:
Viral infection
Obesity
Multiple genetic:
Graves’ disease
Hashimoto’s thyroiditis
Addison’s disease
Vitiligo
Pernicious anemia

11. Etiologic classification of diabetes Presentation mellitus
I- Type 1 diabetes:
Presentation
Beta cell destruction:
Rapid infants and children
Slow adults
Presentation:
DKA children and adolescents
Hyperglycemia adults
Hyperglycemia to DKA Adults

12. Etiologic classification of diabetes B. Idiopathic: mellitus
I- Type 1 diabetes:
B. Idiopathic:
No autoimmunity
DKA
Minority of patients
Strongly inherited
No HLA association
Insulin requirement may come and go

13. II- Type 2 diabetes. Etiologic classification of Pathology: diabetes
mellitus
II- Type 2 diabetes.
Pathology:
Relative insulin deficiency ( initially).
No Autoimmune destruction of  -cell.
Obesity ( insulin resistance ).
No DKA (some times with stress ie infection).
Pass undiagnosed.
Macro- & micro-vascular complications.
Insulin is normal or high.

14. II- Type 2 diabetes. Etiologic classification of Pathology: diabetes
mellitus
II- Type 2 diabetes.
Pathology:
Relative insulin deficiency ( initially).
No Autoimmune destruction of  -cell.
Obesity ( insulin resistance ).
No DKA (some times with stress ie infection).
Pass undiagnosed.
Macro- & micro-vascular complications.
Insulin is normal or high.

15. II- Type 2 diabetes. Etiologic classification of Pathology: diabetes
mellitus
II- Type 2 diabetes.
Pathology:
Relative insulin deficiency ( initially).
No Autoimmune destruction of  -cell.
Obesity ( insulin resistance ).
No DKA (some times with stress ie infection).
Pass undiagnosed.
Macro- & micro-vascular complications.
Insulin is normal or high.

16. II- Type 2 diabetes. Etiologic classification of Pathology: diabetes
mellitus
II- Type 2 diabetes.
Pathology:
Relative insulin deficiency ( initially).
No Autoimmune destruction of  -cell.
Obesity ( insulin resistance ).
No DKA (some times with stress ie infection).
Pass undiagnosed.
Macro- & micro-vascular complications.
Insulin is normal or high.

17. II- Type 2 diabetes. Etiologic classification of Pathology: diabetes
mellitus
II- Type 2 diabetes.
Pathology:
Relative insulin deficiency ( initially).
No Autoimmune destruction of  -cell.
Obesity ( insulin resistance ).
No DKA (some times with stress ie infection).
Pass undiagnosed.
Macro- & micro-vascular complications.
Insulin is normal or high.

18. II- Type 2 diabetes. Etiologic classification of diabetes
mellitus
II- Type 2 diabetes.
Risk factors:
Age
Obesity
Lack of physical activity
Women
H/O G.D.M
Hypertension
Dyslipidemia
Ethnic and racial subgroups
Strong genetic predisposition
Diabetes

19. III- Other specific types.
Etiologic
classification of
diabetes
mellitus
III- Other specific types.
Genetic defects of -cell function:
Chromosome 12, HNF-1 (MODY3)
Chromosome 7, glucokinase (MODY2)
Chromosome 20, HNF-4 (MODY1)
Mitochondrial DNA
Others
Genetic defects in insulin action:
Type A insulin resistance
Leprechaunism
Rabson-Mendenhall syndrome
Lipoatrophic diabetes
Disease of the exocrine pancreas:
Pancreatitis
Trauma/pancreatectomy
Neoplasia
Cystic fibrosis
Hemochromatosis
Fibrocalculous pancreatopathy

20. III- Other specific types.
Etiologic
classification of
diabetes
mellitus
III- Other specific types.
Endocrinopathies:
Acromegaly
Cushing’s syndrome
Glucagonoma
Pheochromocytoma
Hyperthyroidism
Somatostatinoma
Aldosteronoma
Others
Drug or chemical-induced:
Vacor
Dilantin
Thiazides
Diazoxide
Neoplasia
Pentamidine
 - interferon
Nicotinic acid
Cystic fibrosis
Glucocorticoids
Thyroid hormone
Hemochromatosis
 -adrenergic agonists
Fibrocalculous pancreatopathy

21. III- Other specific types.
Etiologic
classification of
diabetes
mellitus
III- Other specific types.
Infections:
Congenital rubella
Cytomegalovirus
Others
Uncommon forms of immune-mediated diabetes:
“ Stiff-man “ syndrome
Anti-insulin receptor antibodies
Other genetic syndromes some times associated with diabetes:
Down’s syndrome
Klinefelter’s
Turner’s syndrome
Wolfram’s syndrome
Friedreich’s ataxia
Huntington’s chorea
Laurence-Moon-Biedl syndrome
Myotonic dystrophy
Porphyria
Prader-Willi syndrome

22. IV- Gestational diabetes mellitus.
Etiologic
classification of
diabetes
mellitus
IV- Gestational diabetes mellitus.
Definition:
Any degree of glucose intolerance with onset
or first recognition during pregnancy.
Prevalence:
- 1 ~ 14% of the total pregnancies.
- 90% of pregnancies complicated by diabetes.
Importance:
- Perinatal morbidity and mortality
- Maternal complications
- Risk factor for glucose intolerance

23. IV- Gestational diabetes mellitus.
Etiologic
classification of
diabetes
mellitus
IV- Gestational diabetes mellitus.
Diagnostic criteria:
1964 O’Sullivan and Mahan
1979 NDDG (National Diabetes Data Group)
1997 American Diabetes Association’s Fourth
International Workshop-Conference on
Gestational Diabetes Mellitus.

24. Screen all pregnant women
Etiologic
classification of
diabetes
mellitus
IV- Gestational diabetes mellitus.
Screening
American Diabetes Association’s (1997) fourth international
workshop-conference on gestational diabetes recommendations
Screen all pregnant women
( weeks of gestation )
Including:
Average risk group:
Including:
High risk group:
Marked obesity
H/O GDM
Glycosuria
Strong FH
Excluding:
Low risk group:
< 25 years of age
Normal body weight
- ve family history
- ve H/O abn. glucose metabolism
H/O poor obstetric outcome
Ethnic group of low diabetes risk

25.  IV- Gestational diabetes mellitus. Etiologic classification of
Screening
American Diabetes Association’s (1997) fourth international
workshop-conference on gestational diabetes recommendations
Low risk group:
No screening
Average risk group:
Two step approach
High risk group:
One step approach
Glucose Challenge Test
GCT
( 50 gm oral glucose load )
Glucose after 1hr 
Oral Glucose Tolerance Test
OGTT
75 or 100
FBS, 1hr, & 2hrs

26. IV- Gestational diabetes mellitus.
Etiologic
classification of
diabetes
mellitus
IV- Gestational diabetes mellitus.
Screening
American Diabetes Association’s (1997) fourth international
workshop-conference on gestational diabetes recommendations
Low risk group:
No screening
Average risk group:
Two step approach
High risk group:
One step approach
Oral Glucose Tolerance Test
OGTT
75 or 100
FBS, 1hr, & 2hrs

27. IV- Gestational diabetes mellitus.
Etiologic
classification of
diabetes
mellitus
IV- Gestational diabetes mellitus.
Diagnostic criteria
100-g Glucose load
mg/dl mmol/l
Fasting
1-h
2-h
3-h
75-g Glucose load
mg/dl mmol/l
Fasting
1-h
2-h

28. Impaired glucose tolerance IGT Impaired fasting glucose IFG
Etiologic
classification of
diabetes
mellitus
Impaired glucose tolerance IGT
Impaired fasting glucose IFG
Normal
Diabetic
IGT
IGF
IGT WHO criteria
IGF FPG = mg/dL
mmol/L
Why

29. Impaired glucose tolerance IGT Impaired fasting glucose IFG
Etiologic
classification of
diabetes
mellitus
Impaired glucose tolerance IGT
Impaired fasting glucose IFG

30. Impaired glucose tolerance IGT Impaired fasting glucose IFG
Etiologic
classification of
diabetes
mellitus
Impaired glucose tolerance IGT
Impaired fasting glucose IFG
They are known risk factors for future diabetes and
cardiovascular disease.
Intermediate stage for all types of diabetes.
Associated with insulin resistance syndrome or :
Syndrome X :
Insulin resistance
Hyperinsulinemia
Obesity
Dyslipidemia ( high triglyceride and/or low HDL )
Hypertension

31. 1 2 3 Diagnostic criteria for diabetes mellitus Etiologic
classification of
diabetes
mellitus
Diagnostic criteria for diabetes mellitus
The new criteria
Symptoms of diabetes
( polyuria, polydepsia, and weight loss ) +
Random Blood Sugar ( RBS )
casual plasma glucose
= or > mg/dL ( 11.1 mmol/L ) 1 2 3
Fasting plasma glucose ( FPG )
at least 8hours fast
= or > 126 mg/dL ( 7.0 mmol/L )
Two hours plasma glucose (2PG )
after 75 anhydrous glucose in water
= or > 200 mg/dL ( 11.1 mmol/L )

32. Impaired fasting glucose IFG
Etiologic
classification of
diabetes
mellitus
Impaired fasting glucose IFG
For epidemiological studies FPG is:
standardization
Facilitation
Cheep
Diagnosis New criteria WHO criteria
mg/dL mmol/L mg/dL mmol/L
Normal < < < < 7.8
IFG / IGT < < < <11.1
? DM = or > = or > = or > = or > 11.1
 8 hours over night fast.
 2 hours post 75 gm glucose load.

33. Old and new diagnostic criteria
Etiologic
classification of
diabetes
mellitus
Old and new diagnostic criteria
The criteria New case Diabetes
Discovered Prevalence
Known cases No %
WHO criteria % %
New criteria % %
- 1.99
14%
The new criteria will lead to 14% ( slightly )
lower estimates of diabetes prevalence.
Data from NHANES III for individuals years old.

34. Testing healthy individuals
Etiologic
classification of
diabetes
mellitus
Testing healthy individuals
Type 1 diabetes:
More than one antibodies ( ICA, IAA, GAD, IA-2 )
No effective method can prevent or delay the disease
Screening is not cost-effective
Type 2 diabetes:
50% of type 2 are undiagnosed
Chronic complications precede diabetes ( Retinopathy 7 years )
Risk factors

35. HbA1c Etiologic classification of diabetes mellitus
Not recommended for diagnosis of diabetes,
but valuable for glycemic control of diabetes.

36. Criteria for testing asymptomatic individuals
Etiologic
classification of
diabetes
mellitus
Criteria for testing asymptomatic individuals
All individual above 45 years of age every 3 years
Any individual with:
 Obese ( > 120% desirable weight or BMI > 27 ).
 +ve F/H first degree relatives.
 High risk ethnic population.
 H/O GDM or big baby ( > 9 lb ).
 Hypertension > 140/90
 HDL < 35mg/dl ( 0.9 mmol/l ) ±
 Triglyceride > 250mg/dl ( 2.82 mmol/l )
 Known to have IGT or IFG