1. Maja Ravnik-Oblak Diabetes mellitus type 2

2. DIABETES MELLITUS very old diagnosed disease very frequent chronic disease unpredictable disease very psychological burdersome disease

5. EPIDEMIOLOGY y. 2000 151 million patients y. 2010 285 million patients y. 2030 439 million patients

6. PREVALENCE OF DIABETES MELLITUS IN EUROPE (y. 2000) inhabitants:654,9 milijona adults (20-79 yrs):462,7 milijona diabetics (adults):22,5 milijona prevalence (adults):4,9 % type 1 diabetics:1,29 milijona prevalence of typ 1:0,19 %

7. PREVALENCE OF DIABETES MELLITUS IN SLOVENIA (1990-2000) YEAR 199019962000 DIABETICS 62.82176.48089.000 POPULATION 1.998.0901.986.9891.985.557 PREVALENCE 3,14%3,85%4,48% NEW PATIENTS 4.8375.274 INCIDENCE 0,24%0,27% Vrtovec, Urbančič, Koselj, Vončina (2001)

8. DIABETES MELLITUS IMPACT ON PSYCHOSOCIAL STATUS OF A PATIENT CHRONIC DISEASE  chronic treatment  regular outpatient controls (GP, diabetologist, ophthalmologist, other specialists)  regular lab controls  permanent education

9. DIABETES MELLITUS AND MENTAL DISTURBANCES fear of very low and very high lood glucose values fear of occurrence of chronic diabetic complications feeling of guilt for failure to comply therapists instructions and failure to achieve therapeutic goals CHRONIC STRESS

10. PSYCHOSOCIAL WELL-BEING OF DIABETIC PATIENTS 42 % of diabetic patients reported bad psychosocial well-being WHO 5-item questionnaire

11. DEFINITION Diabetes is a group of metabolic disorders with hyperglycemia due to insufficient secretion of insulin and / or its non- efficiency. Chronic hyperglycemia is associated with chronic failures and dysfunction of various organs including renal (kidney) failure, nerve damage, heart disease, stroke, and blindness.

12. SYMPTOMS ANS SIGNS OF DIABETES MELLITUS dry mouth, thirst polyuria, nocturia weight loss (despite of increased appetite) fatigue visual disturbances genital pruritus

13. ORGANIC SYNDROME OF TYPE 2 DIABETES MELLITUS diabetic peripheral neuropathy: 8-15 % diabetic retinopathy: 5-10%  cataract macroangiopathy

14. DETECTION randomly: systematic checking examination of blood for other reasons targeted: history systematic reviews of groups with increased risk

15. DIAGNOSTIC METHODS fasting blood glucose random blood glucose blood glucose in 120. minute of oral glucose test with 75 g glucose (OGTT) symptoms – YES (1 values) symptoms – NO (2 values on 2 different testing days)

16. DIAGNOSTIC VALUES OF BLOOD GLUCOSE Diabetes unlikely IGT IFG Fasting BG ≥ 7,0 < 6,1 6,1- 6,9 Random BG ≥ 11,1 < 6,1 BG in l20. min. OGTT ≥ 11,1 7,8-11.1 < 7,8

17. GLYCATED HEMOGLOBIN- HbA 1c Hemoglobin is a protein that is a normal constituent of red blood cells. Erythrocytes in blood containing chains of hemoglobin, which binds sugars non-encimatic and irreversible. Glucose which binds to hemoglobin, is proportional to the concentration of glucose in the blood. HbA1c reflects blood sugar for about eight last weeks. The average blood glucose = 2x % HbA 1c – 6 Referal value: 4,4 % - 6,4 %

18. AETIOLOGICAL CLASSIFICATION OF DM AND OTHER GLUCOSE INTOLERANCE DIABETES MELLITUS I. Diabetes mellitus type 1 II. Diabetes mellitus type 2 III. Other types IV. Gestational diabetes Impaired glucose tolerance (IGT) Impaired fasting glucose (IFG)

19. AETIOLOGICAL CLASSIFICATION OF DM AND OTHER CATEGORIES OF GLUCOSE REGULATION III. Other types of diabetes mellitus 1. Genetic defects of β-cell function 2. Genetic defects in insulin action 3. Diseases of the exocrine pancreas 4. Endocrinopathies 5. Drug or chemical induced 6. Infections 7. Uncommon forms of immune-mediated diabetes 8. Other genetic syndromes sometimes associated with diabetes

20. PATHOGENESIS OFDIABETES MELLITUS TYPE 2 inadequate secretion of insulin from pancreatic beta cells increased insulin resistance (mainly in muscles) increased formation of glucose in the liver by gluconeogenesis

21. ETIOPATHOGENESIS OF TYPE 2 DIABETES MELLITUS environmental factors and genetics

22. INCIDENCE OD TYPE 2 DIABETES MELLITUS  sharp rise after 50 year of age  women: men = 55 % : 45 %  difference between races  increase after change of mode life

23. DIABETES MELLITUS AND CHRONIC COPMPLICATIONS diabetic retinopathy diabetic nephropathy diabetic polyneuropathy  erectile dysfunction

24. METABOLIC SYNDROME (SYNDROME X) A quarter of the world’s adults have metabolic syndrome People with metabolic syndrome are twice as likely to die from, and three times as likely to have a heart attack or stroke compared with people without the syndrome People with metabolic syndrome have a five-fold greater risk of developing type 2 diabetes

25. METABOLIC SYNDROME (SYNDROME X) waist circumference:  men≥ 94 cm  women≥ 80 cm triglycerides  1,7 ≥ mM HDL  men<1,0 mmol/l  women <1,3 mmol/l blood pressure ≥130 in/ali ≥ 85 mm Hg (or treatment of BP) glycaemia ≥5,6 mmol/l (or diabetes mellitus) CRITERIA FOR DIAGNOSIS : 3 of 5

26. NATURAL COURSE OF DIABETES MELLITUS TYPE 2 obesityIGTDiabetesuncontrolled hyperglycaemia 2,8 5,6 8,3 11,1 14,0 16,4 19,4 50 100 150 200 250 glycaemia (mmol/l) relative function (%) -10 -5 0 0 5 5 10 15 20 25 30 post-prandial glycaemia fasting blood glucose insulin resistance insulin level beta cell function years

27. TREATMENT OF DIABETES MELLITUS TYPE 2 non-pharmacological measures  healthy eating  normal body weight  physical activity  drugs  tablets  insulin

28. TREATMENT WITH DRUGS promoters of insulin secretion sulfonylureas glinidi promoters of tissue sensitivity to insulin biguanides (metformin) (tiazolidinedione) alpha glucosidase inhibitors in the gut acarbose drugs acting on the incretin system inhibitors of the enzyme DPP-4 incretin mimetics insulins

33. Case man, 70 yrs, pensioner, height 168 cm, weight 75 kg family history: no diabetes mellitus history: gallstones surgery, mild prostatic hyperthrophy treatment : no drugs problem: friend, diabetic patient, measured him blood glucose 10 mmol/l (with glucometer) approach?

34. Case man, 56 yrs, height 170 cm, weight 95 kg, bank officer family history: mother, brother and 2 paternal aunts are diabetics history: 1 year hot feet at night problem: during pneumonia he had glycaemia 12 mmol/l approach?

35. Case woman, 65yrs, height 154 cm, weight 72 kg, retired seamstress family history: mother is diabetic history: 15 years hypertension and hyperlipidaemia problem: because of deterioration of vision she visited ophatalmologist, who found initial cataract and diabetic retinopathy, fasting blood glucose 10,5 mmol/, HbA1c 8,1 %. type of diabetes?

36. Case man, 52 yrs, height 174 cm, weight 63 kg, central heating installer family history: no data history: 5 years ago pancreatitis problem: few months thirst, weighf loss 3 kg, frequent urinations, 1-2 x during night, because of thristy he drank 2 l of water-wine mixture per day + occasionally beer, glycaemia 16 mmol/l type of diabetes mellitus?

37. DIABETES MELLITUS AND DEPRESSION condition for successful treatment : the two diseases should be treated at the same time!