1. A SSOCIATION BETWEEN D IABETES M ELLITUS AND M ETABOLIC S YNDROME Coordinator: Conf. Dr. Fazakas Zita Author: Fanfaret Ioan Serban http://diabetesstopshere.org/wp-content/uploads/2010/09/DSHDraft1.jpg

2. B ACKGROUND : 10 FACTS ABOUT DIABETES ACCORDING TO THE WHO 1. About 347 million people worldwide have diabetes. 2. Total deaths from diabetes are projected to rise by more than 50% in the next 10 years. 3. There are two major forms of diabetes. 4. A third type of diabetes is gestational diabetes. 5. Type 2 diabetes is much more common than type 1 diabetes. 6. Cardiovascular disease is responsible for between 50% and 80% of deaths in people with diabetes. 7. In 2004, an estimated 3.4 million people died from consequences of high fasting blood sugar. 8. 80% of diabetes deaths occur in low- and middle-income countries. 9. Diabetes is a leading cause of blindness, amputation and kidney failure. 10. Type 2 diabetes can be prevented.

3. DIABETES COMPLICATIONS ACCORDING TO THE ADA Skin Complications: Infections Itching Acanthosis Nigricans Diabetic Dermopathy Necrobiosis Lipoidica Diabeticorum Eye Complications: Glaucoma Cataracts Retinopathy Blindness Foot Complications: Neuropathy Skin Changes Calluses Foot Ulcers Poor Circulation Amputation Respiratory Complications: Infections Periodontal Disease Hyperglycemia hyperosmolar state Hypoglycemia Neurological Complications: Peripheral Neuropathy Autonomic Neuropathy Charcot's Joint Cranial Neuropathy Compression Mononeuropathy Femoral Neuropathy Focal Neuropathy Thoracic/Lumbar Radiculopathy Unilateral Foot Drop DKA (Ketoacidosis) & Ketones Kidney Disease (Nephropathy): Kidney Failure Cardiovascular Complications: Hypertension Stroke Cardiomyopathy Coronary artery disease Angina/Myocardial infarction Diabetic myonecrosis Peripheral artery disease/intermittent claudication Carotid artery stenosis Diabetic coma

4. METABOLIC SYNDROME ACCORDING TO AHA affects about 35% of adults and places them at higher risk of cardiovascular disease, diabetes, stroke and atherosclerosis; the underlying causes of metabolic syndrome are obesity, being overweight, physical inactivity and genetic factors. Risk factorATP III NCEP (3 of the 5 features) IDF (large waist + any other 2 features) Triglycerides>150 mg/dL HDL cholesterol< 40 mg/dL Blood pressure>130/85 mmHg Fasting glucose>100 mg/dL Waist circumf. Men Woman >102 cm >88 cm >94 cm >80 cm

5. Risk factorWHO (impaired glucose tolerance/ impaired fasting glucose /insulin resistance and any 2 of the following) Blood pressure ≥ 140/90 mmHg Dyslipidemia: Triglycerides High-density lipoprotein >150 mg/dL < 40 mg/dL Central obesity: Male waist/hip ratio Female waist/hip ratio Body mass index > 0. 90 > 0.85 > 30 kg/m 2 Microalbuminuria: Urinary albumin excretion ratio Albumin/creatinine ratio ≥ 20 µg/min ≥ 30 mg/g

6. METABOLIC SYNDROME COMPLICATIONS ACCORDING TO THE AHA Psychological Osteoarthritis of knees and hips Varicose veins Hiatus hernia Gallstones Postoperative problems Back strain Accident proneness Obstructive sleep apnoea Hypertension Breathlessness Ischaemic heart disease Stroke Diabetes mellitus (type 2) Hyperlipidaemia Menstrual abnormalities Increased morbidity and mortality Increased cancer risk Heart failure O BJECTIVE : The aim of the study is to evaluate the link between Diabetes Mellitus and Metabolic Syndrome.

7. M Y WORK

8. M ATERIAL AND M ETHOD : We included 106 patients being in the evidence of three General Pactitioners Cabinets from Tg. Mures. Information was provided from the medical records of all patients diagnosed with both Diabetes type 1 and 2. Patients were evaluated for: 1. gender, 2. age, 3. medical conditions, 4. complications, 5. medical treatment, 6. laboratory analysis.

9. Type 1 diabetes according to WHO is characterized by deficient insulin production and requires daily administration of insulin; symptoms may occur suddenly and include polyuria, polydipsia, constant hunger, weight loss, vision changes and fatigue. Type 2 diabetes according to WHO results from the body’s ineffective use of insulin; comprises 90% of people with diabetes around the world, and is the result of excess body weight and physical inactivity; symptoms may be similar to those of type 1 diabetes, but are often less marked

10. Medical treatment: Involves lowering blood glucose and the levels of other known risk factors that damage blood vessels: Biguanide (metformin) Sulfonylureas Meglitinides Thiazolidinediones Dipeptidyl peptidase-4 (DPP4) inhibitors GLP-1 agonists (exenatide and liraglutide) Insulin treatment American association of diabetes also recommends: blood pressure control, feet care, screening and treatment for retinopathy, blood lipid control, screening for early signs of diabetes-related kidney disease.

11. We paid attention to the following laboratory analysis: 1. Blood glucose level 2. Glycated hemoglobin value 3. Low density lipoproteins LDL value 4. High density lipoproteins HDL value 5. Triglycerides TG value 6. Blood pressure level Glycated hemoglobin (HbA1c) reveals blood glucose concentration over several weeks (6 weeks); >6.5% = diabetes; 5.7–6.4% = increased risk of diabetes; A WHO Consultation recently concluded that HbA1c ‘can be used as a diagnostic test for diabetes’.

12. R ESULTS Patients were divided in two groups: Group A included 70 patients following treatment with oral antidiabetic medication, the average age was 64 years. Group B included 36 patients following insulin treatment, the average age was 45 years.

14. In group A The average blood glucose level at diagnosis was 181.5 mg% and after 4 years of treatment:120.3 mg%, p<0.0001 considered extremely significant. In group B The average of the blood glucose level at diagnosis was: 311 mg% and after 4 years of treatment 113.3 mg%, p<0.0001 considered extremely significant.

15. In group A Glycated hemoglobin average value at diagnosis was 6.7% and after 4 years 5.2%, p<0.0001 considered extremely significant. In group B Glycated hemoglobin average value at diagnosis was: 7.9% and after 4 years 5.1%, p<0.0001 considered extremely significant.

16. In group A Glycated hemoglobin is most strongly correlated with blood glucose (r=0.752), serum triglyceride (TG), (r=0.310) and serum low density lipoproteins (LDL), (r=0.271). In group B Glycated hemoglobin is also most strongly correlated with blood glucose (r=0.692), serum triglycerides (TG), (r=0.319) and low density lipoproteins (LDL), (r=0.228).

17. In group A LDL average at diagnosis was 187.7mg%. In group B LDL average at diagnosis was: 157.3 mg%. Copyright:http://www.heart.org/HEARTORG/GettingHealthy/FatsAndOils/Fats101/Levels-of-Cholesterol_UCM_305051_Article.jsp LDL Cholesterol LevelClassification* Less than 100 mg/dLDesirable 100–129 mg/dLNear optimal/above optimal 130–159 mg/dLBorderline high 160–189 mg/dLHigh risk 190 mg/dL and aboveVery high risk

18. In group A HDL average value was 41.1 mg%. In group B HDL average value was: 38.2 mg%. Copyright: http://www.heart.org/HEARTORG/GettingHealthy/FatsAndOils/Fats101/Levels-of-Cholesterol_UCM_305051_Article.jsp HDL Cholesterol LevelClassification Less than 40 mg/dL for men; less than 50 mg/dL for women Major heart disease risk factor 60 mg/dL or higher Gives some protection against heart disease

19. In group A TG average value was: 348.9 mg%. In group B TG average value was: 325.1 mg%. Copyright: http://www.heart.org/HEARTORG/GettingHealthy/FatsAndOils/Fats101/Levels-of-Cholesterol_UCM_305051_Article.jsp Triglyceride LevelClassification Less than 150 mg/dLDesirable 150–199 mg/dLBorderline-high risk 200–499 mg/dLHigh risk 500 mg/dL or higherVery high risk

20. In group A The average level of the blood pressure was 180/100 mmHg. In group B The average level of the blood pressure was 160/90 mmHg. Copyright: http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Understanding-Blood-Pressure- Readings_UCM_301764_Article.jsp Blood Pressure Category Systolic mm Hg (upper #) Diastolic mm Hg (lower #) Normal less than 120andless than 80 Prehypertension120 – 139or80 – 89 High Blood Pressure (Hypertension) Stage 1 140 – 159or90 – 99 High Blood Pressure (Hypertension) Stage 2 160 or higheror100 or higher Hypertensive Crisis (Emergency care needed) Higher than 180orHigher than 110

22. D ISCUSSION Checked at least once a year: Measure blood glucose level and HbA1c Measure bodyweight Measure waist circumference. Measure blood pressure Measure plasma lipids Check condition of the eye Kumar and Clarks Clinical Medicine, 8th Edition Test renal function Test urine for proteinuria/microalbumi nuria Check condition of feet Review cardiovascular risk factors Review self-monitoring and injection techniques Review eating habits

23. C ONCLUSIONS In group A the average age was higher than in group B and included more patients. Patients in group A had higher values of the lipid profile and blood pressure, but lower values of the blood glucose and glycated hemoglobin than patients in group B. Glycated hemoglobin is strongly correlated with blood glucose, TG and LDL. Diabetes Mellitus has a negative influence over the lipid metabolism, carbohydrates and cardiovascular system and there is a strong association between Diabetes Mellitus and Metabolic Syndrome.

24. B IBLIOGRAPHY American Diabetes Association: http://www.diabetes.org/ American Heart Association: http://www.heart.org/ World Health Organization: http://www.who.int/en/ International Diabetes Federation: http://www.idf.org/ Kumar and Clarks Clinical Medicine, 8th Edition The Johns Hopkins Internal Medicine Board Review, 4th Edition ABC.of.Diabetes.6th.Ed Guide to Lab & Diagnostic Tests, Tracey B. Hopkins

25. T HANK YOU FOR YOUR ATTENTION !