Diabetes Mellitus

Diagnosis and Monitoring

What is diabetes?
 Diabetes mellitus (DM) is a group of diseases characterized by
high levels of blood glucose resulting from defects in insulin
production, insulin action, or both.

 The term diabetes mellitus describes a metabolic disorder of

multiple aetiology characterized by chronic hyperglycaemia with
disturbances of carbohydrate, fat and protein metabolism
resulting from defects in insulin secretion, insulin action, or both.

 The effects of diabetes mellitus include long–term damage,

dysfunction and failure of various organs.
Why are we seeing such an increase
in the number of people with Type 2
diabetes worldwide?

Unhealthy lifestyle Aging population Urbanisation

Dietary changes Sedentary lifestyle

IDF Diabetes Atlas 2014
Cockram 2000. HKMJ; 6 (1): 43-52
Mohan 2007. Indian J Med Res; 125: 217-230
 High blood glucose is the 3rd biggest risk
factor contributor to cardio-vascular
deaths globally

Attributable deaths due to selected risk factors (000’)

WHO 2011. Global Atlas on CVD prevention and Control

Diabetes is developing fast in Indonesia

2007
Diagnosed Diabetes 1.5%

Undiagnosed Diabetes 4.2%

Impaired Glucose Tolerance 10.2%

RISKESDAS Survey 2007

Laporan RISKESDAS 2013
Diabetes is developing fast in Indonesia

2007 2013
Diagnosed Diabetes 1.5% 2.1%

Undiagnosed Diabetes 4.2% 4.8%

Impaired Glucose Tolerance 10.2% 29.9%

More than 10 million people live

RISKESDAS Survey 2007
with diabetes in Indonesia in 2015
Laporan RISKESDAS 2013
…and diabetes control is suboptimal

67.85%

Soewondo P, Soegondo S, Suastika K, Pranoto A, Soeatmadji DW, Tjokroprawiro A. The DiabCare Asia 2008 study-
Outcomes on control and complications of type 2 diabetic patients in Indonesia Med J Indones 2010 19; 4: 235-244.
Classification of diabetes
 Type 1 diabetes
 Beta-cell destruction, usually leading to absolute insulin
deficiency
 Type 2 diabetes
 Progressive insulin secretory defect on the background of beta-
cell dysfunction and insulin resistance
 Gestational diabetes mellitus
 Diabetes diagnosed in the second or third trimester of
pregnancy that is not clearly overt diabetes
 Other specific diabetes types
 Drug- or chemical-induced, e.g steroids, treatment of HIV/AIDS
or after organ transplantation
 Genetic defects in beta cell function or in insulin action
 Diseases of the exocrine pancreas (e.g. cystic fibrosis)

ADA - Standards of Medical Care in Diabetes – 2016. Diabetes Care, Vol. 39, Supplement 1, January 2016.
Type 1 diabetes
 Was previously called insulin-dependent diabetes mellitus (IDDM) or
juvenile-onset diabetes.

 Type 1 diabetes develops when the body’s immune system destroys

pancreatic beta cells, the only cells in the body that make the
hormone insulin that regulates blood glucose.

 This form of diabetes usually strikes children and young adults,

although disease onset can occur at any age.

 Type 1 diabetes may account for 5% to 10% of all diagnosed cases

of diabetes.

 Risk factors for type 1 diabetes may include autoimmune, genetic,

and environmental factors.
Type 2 diabetes
 Was previously called non-insulin-dependent diabetes mellitus
(NIDDM) or adult-onset diabetes.
 Type 2 diabetes may account for about 90% to 95% of all
diagnosed cases of diabetes.
 It usually begins as insulin resistance, a disorder in which the
cells do not use insulin properly. As the need for insulin rises, the
pancreas gradually loses its ability to produce insulin.
 Type 2 diabetes is associated with older age, obesity, family
history of diabetes, history of gestational diabetes, impaired
glucose metabolism, physical inactivity, and race/ethnicity.
 African Americans, Hispanic/Latino Americans, American Indians,
and some Asian Americans and Native Hawaiians or Other Pacific
Islanders are at particularly high risk for type 2 diabetes.
 Type 2 diabetes is increasingly being diagnosed in children and
adolescents.
Differences between type 1 and type
2 diabetes

Features Type 1 Diabetes Type 2 Diabetes

Onset Sudden Gradual

Any age
Age at onset Mostly in adults
(mostly young)
Body habitus Thin or normal Often obese

Ketoacidosis Common Rare

Autoantibodies Usually present Absent

Endogenous Normal, decreased or
Low or absent
insulin increased
More prevalent.
Prevalence Less prevalent in Asia 90-95% of all people
with diabetes in Asia
Type 2 diabetes is a progressive disease

Adapted from Type 2 Diabetes BASICS. International Diabetes Center 2000

Gestational diabetes

 ”Any degree of glucose intolerance with onset or first

recognition during pregnancy” (Defintion 1980-2010)

 To take into account unrecognised diabetes preceding the

pregnancy a new criteria was introduced:

 ”Overt diabetes” detected in early pregnancy (Definition since

2010)

Metzger et al. Summary and recommendations of the Fourth International Workshop-Conference Diabetes Care 1998
International Association for Diabetes in Pregnancy Study Groups. Recommendations on the diagnosis and classification
of hyperglycaemia during pregnancy Diabetes Care, Vol. 33: 676-682, 2010
Prediabetes: Impaired glucose tolerance
and impaired fasting glucose
 Prediabetes is a term used to distinguish people
who are at increased risk of developing diabetes.
People with prediabetes have impaired fasting
glucose (IFG) or impaired glucose tolerance (IGT).
Some people may have both IFG and IGT.

 IFG is a condition in which the fasting blood sugar

level is elevated (100 to 125 milligrams per
decilitre or mg/dL) after an overnight fast but is
not high enough to be classified as diabetes.

 IGT is a condition in which the blood sugar level is

elevated (140 to 199 mg/dL after a 2-hour oral
glucose tolerance test), but is not high enough to
be classified as diabetes.
Prediabetes: Impaired glucose tolerance
and impaired fasting glucose (cont.)

• Progression to diabetes among those with

prediabetes is not inevitable. Studies suggest that
weight loss and increased physical activity among
people with prediabetes prevent or delay diabetes
and may return blood glucose levels to normal.

• People with prediabetes are already at increased

risk for other adverse health outcomes such as
heart disease and stroke.
Classical diabetes symptoms

Polyuria • Excessive urination at night

Blurred vision • Visual disturbance

Polydipsia • Excessive thirst

Unexplained • Even if food intake is normal

weight loss

Polyphagia • Excessive hunger

Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2015. Jakarta: PB Perkeni, 2015
http://www.mayoclinic.org/diseases-conditions/hyperglycemia/basics/symptoms/con-20034795
Other diabetes symptoms

Numbness
and/or tingling • In hands, legs and feet

Fatigue • Regardless of exercise

Itchy skin • Affects legs, feet, and hands

Impotence • Physical and physiological

Adapted from Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2015. Jakarta: PB Perkeni, 2015.
 Criteria for testing for diabetes or prediabetes in asymptomatic adults

1. Testing should be considered in all adults who are overweight

and have additional risk factors:
• Physical inactivity
• First-degree relative with diabetes
• Women who delivered a baby weighing over 9 lb or were diagnosed with GDM
• Hypertension (≥140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level <35 mg/dL and/or a triglyceride level >250 mg/dL
• Polycystic ovary syndrome
• HbA1C ≥5.7%, IGT, or IFG on previous testing
• Other clinical conditions associated with insulin resistance (e.g., severe
obesity, acanthosis nigricans)
• History of CVD

2. For all patients, 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.
American Diabetes Association. Classification and diagnosis of diabetes. Sec. 2. In Standards of Medical Care in Diabetes 2016.
Diabetes Care 2016;39 (Suppl. 1): S13–S22
 Cut-points: Diabetes, IGT and IFG
mg/dL
Fasting Plasma Glucose (FPG)

Diabetes

126
IFG
Impaired Fasting
Glucose
IGT
100
Impaired Glucose
Tolerance Diabetes
NGT
Normal Glucose
Tolerance

140 200 mg/dL

2-hour Plasma Glucose

American Diabetes Association. Classification and diagnosis of diabetes. Sec. 2. In Standards of Medical Care in Diabetes 2016.
Diabetes Care 2016;39(Suppl. 1): S13–S22
Diagnosis of Type 2 Diabetes
KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2. 2015

Fasting* Plasma Glucose ≥ 126 mg/dl

or
2-hour post 75g OGTT ≥ 200 mg/dl
or
Classical symptoms of diabetes** & Random plasma glucose
concentration ≥ 200 mg/dl
or
HbA1c ≥ 6.5% (standardised assay***)
*Classical symptom of diabetes (polyuria, polydipsia, weight loss),
only need 1 abnormal BG, otherwise need 2 x abnormal BG level
on different days
**Fasting is defined as no caloric intake for at least 8 hours
***Standarised to National Glycohaemoglobin Standardization
Program (NGSP)

•Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2015. Jakarta: PB Perkeni, 2015.
What is good glycaemic control?

 Overall aim is to achieve glucose levels as close to normal as possible

 Minimise development and progression of microvascular and
macrovascular complications

ADA1 FPG HbA1c PPG

<130 mg/dL < 7.0 % <180 mg/dL

FPG HbA1c PPG

IDF2 <110 mg/dl
< 6.5 % <145 mg/dL

PERKENI3 FPG HbA1c PPG

<130 mg/dl < 7.0 % <180 mg/dl

1. American Diabetes Association Diabetes Care 2015;38 (Suppl 1):S8-S15

2. IDF Clinical Guidelines Task Force. International Diabetes Federation 2005. 3. Konsensus PERKENI 2015.
Risk of complications increases as
HbA1c increases
80

60 Microvascular disease
Incidence per 1.000
patient-years

40
Myocardial infarction

20

0
5 6 7 8 9 10 11 Mean HbA1c (%)
97 126 154 183 212 240 269 Mean mg/dl

Adjusted for age, sex, and ethnic group.

Stratton IM et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35):
prospective observational study. BMJ 2000;321:405–12
 Optimising blood glucose control

Myocardial
Good control is infarction
≤ 7.0% HbA1c
-14%

Microvascular
HbA1c complications
-1% -37%

Deaths related
to diabetes

-21%
Source: UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM
et al. BMJ. 2000;321(7258):405-412.
Practical monitoring scheme

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
Practical monitoring scheme cont…

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
 Slide
28

Studi Kasus
Case 1.1 (Screening)

Laki-laki berusia 43 tahun datang dengan keluhan sering lelah. Dia seorang eksekutif,
sering makan di restaurant, jarang berolahraga, perokok, tidak konsumsi alkohol, dan
tidak mempunyai riwayat hipertensi. Ibunya penyandang diabetes, ayahnya hipertensi.

TB= 170cm, BB=88 kg, Lingkar perut = 112cm. TD =140/80 mmHg, lain-lain dalam
batas normal.

• Faktor risiko apa saja yang ditemukan pada kasus ini?

• Pemeriksaan penunjang apa yang diperlukan pada pasien ini untuk

mengetahui faktor resiko lain diabetes?

• Pemeriksaan penunjang apa yang diperlukan untuk menegakkan diagnosa

diabetes?
Case 1.2 (Diagnosis)

Seorang pasien pria berusia 55 tahun, datang ke klinik mengeluhkan penurunan berat
badan yang terjadi selama 8 minggu terakhir walaupun selera makannya tetap. Pasien
tersebut juga mengeluhkan rasa lelah dan lemas selama jam kerja dan selalu merasa
haus. Pada malam hari, pasien tersebut terbangun 3-4 kali untuk BAK. Saat ini BB pasien
70 kg, dengan tinggi badan 165cm. Pasien tersebut bekerja di bank, dengan gaya hidup
santai / kurang aktif. Pasien tersebut memiliki ibu yang menderita diabetes, dan ayahnya
meninggal dunia 5 tahun yang lalu karena serangan jantung pada usia 75 tahun. Pasien
tersebut belum pernah melakukan medical check-up dalam 5 tahun terakhir.

• Masalah apa yang ditemukan pada kasus di atas?

• Pemeriksaan laboratorium apa yang akan anda sarankan untuk mendiagnosis
pasien tersebut?
• Anamnesis dan pemeriksaan fisik apa yang diperlukan untuk mengevaluasi
diabetes secara komprehensif?
Case 1.3 (Monitoring)

Tn. LK berusia 51 tahun datang ke klinik anda untuk kontrol diabetesnya.

Riwayat penyakit diabetes sejak 5 tahun yang lalu, dengan obat glibenklamid
tab 2 x 5 mg, diminum tidak teratur. Glukosa darah rata-rata sekitar 200
mg/dL. Didapatkan keluhan kesemutan pada kedua kakinya, tidak ada
pandangan kabur. Kakaknya meninggal dunia karena penyakit jantung pada
usia 50 tahun.
Pada pemeriksaan fisik didapatkan TB 165 cm, BB 72 kg, TD 150/90 mmHg.

• Apa masalah pada pasien ini?

• Pemeriksaan penunjang apa yang diperlukan pada pasien ini untuk
mengetahui kendali glukosa darahnya?
• Kapan anda akan melakukan evaluasi ulang pada pasien ini?
Thank You