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  1. 1. These notes are important as said in the class byDr.Eman.DiabetesDiabetes mellitus, often simply referred to as diabetes, is a group of metabolicdiseases in which a person has high blood sugar, either because the body doesnot produce enough insulin, or because cells do not respond to the insulin that isproduced. This high blood sugar produces the classical symptoms of polyuria(frequent urination), polydipsia (increased thirst) and polyphagia (increasedhunger).There are three main types of diabetes: Type 1 diabetes: results from the bodys failure to produce insulin, and presently requires the person to inject insulin. (Also referred to as insulin- dependent diabetes mellitus, IDDM for short, and juvenile diabetes.) Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency. (Formerly referred to as non-insulin-dependent diabetes mellitus, NIDDM for short, and adult-onset diabetes.) Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM.Other forms of diabetes mellitus include congenital diabetes, which is due togenetic defects of insulin secretion, cystic fibrosis-related diabetes, steroiddiabetes induced by high doses of glucocorticoids, and several forms ofmonogenic diabetes.All forms of diabetes have been treatable since insulin became available in 1921,and type 2 diabetes may be controlled with medications. Both type 1 and 2 arechronic conditions that usually cannot be cured. Pancreas transplants have beentried with limited success in type 1 DM; gastric bypass surgery has beensuccessful in many with morbid obesity and type 2 DM. Gestational diabetesusually resolves after delivery. Diabetes without proper treatments can causemany complications. Acute complications include hypoglycemia, diabeticketoacidosis, or nonketotic hyperosmolar coma. Serious long-term complicationsinclude cardiovascular disease, chronic renal failure, retinal damage. Adequatetreatment of diabetes is thus important, as well as blood pressure control andlifestyle factors such as smoking cessation and maintaining a healthy bodyweight.Globally as of 2010 it is estimated that there are 285 million people diabetes with type 2making up about 90% of the cases.
  2. 2. TypesMost cases of diabetesmellitus fall into three Comparison of type 1 and 2 diabetesbroad categories: type 1, Feature Type 1 diabetes Type 2 diabetestype 2, and Onset Sudden Gradual Age at onset Mostly in Children Mostly in adultsgestational diabetes. A few Body habitus Thin or normal Often obeseother types are described. Ketoacidosis Common RareThe term diabetes, without Autoantibodies Usually present Absentqualification, usually refers Endogenous insulin Low or absent Normal, decreasedto diabetes mellitus. The or increasedrare disease diabetes Concordance 50% 90%insipidus has similar in identical twinssymptoms as diabetes Prevalence ~10% ~90%mellitus, but withoutdisturbances in the sugar metabolism (insipidus meaning "without taste" in Latin).The term "type 1 diabetes" has replaced several former terms, includingchildhood-onset diabetes, juvenile diabetes, and insulin-dependent diabetesmellitus (IDDM). Likewise, the term "type 2 diabetes" has replaced several formerterms, including adult-onset diabetes, obesity-related diabetes, and non-insulin-dependent diabetes mellitus (NIDDM). Beyond these two types, there is noagreed-upon standard nomenclature. Various sources have defined "type 3diabetes" as: gestational diabetes, insulin-resistant type 1 diabetes (or "doublediabetes"), type 2 diabetes which has progressed to require injected insulin, andlatent autoimmune diabetes of adults (or LADA or "type 1.5" diabetes).Type 1 diabetesType 1 diabetes mellitus is characterized by loss of the insulin-producing betacells of the islets of Langerhans in the pancreas leading to insulin deficiency.This type of diabetes can be further classified as immune-mediated or idiopathic.The majority of type 1 diabetes is of the immune-mediated nature, where betacell loss is a T-cell mediated autoimmune attack. There is no known preventivemeasure against type 1 diabetes, which causes approximately 10% of diabetesmellitus cases in North America and Europe. Most affected people are otherwisehealthy and of a healthy weight when onset occurs. Sensitivity andresponsiveness to insulin are usually normal, especially in the early stages. Type1 diabetes can affect children or adults but was traditionally termed "juvenilediabetes" because it represents a majority of the diabetes cases in children."Brittle" diabetes, also known as unstable diabetes or labile diabetes, is a termthat was traditionally used to describe to dramatic and recurrent swings inglucose levels, often occurring for no apparent reason in insulin-dependentdiabetes. This term, however, has no biologic basis and should not be used. [7]
  3. 3. There are many different reasons for type 1 diabetes to be accompanied byirregular and unpredictable hyperglycemias, frequently with ketosis, andsometimes serious hypoglycemias, including an impaired counterregulatoryresponse to hypoglycemia, occult infection, gastroparesis (which leads to erraticabsorption of dietary carbohydrates), and endocrinopathies (eg, Addisonsdisease). These phenomena are believed to occur no more frequently than in 1%to 2% of persons with type 1 diabetes.Type 2 diabetesType 2 diabetes mellitus is characterized by insulin resistance which may becombined with relatively reduced insulin secretion. The defective responsivenessof body tissues to insulin is believed to involve the insulin receptor. However, thespecific defects are not known. Diabetes mellitus due to a known defect areclassified separately. Type 2 diabetes is the most common type.In the early stage of type 2 diabetes, the predominant abnormality is reducedinsulin sensitivity. At this stage hyperglycemia can be reversed by a variety ofmeasures and medications that improve insulin sensitivity or reduce glucoseproduction by the liver.Gestational diabetesGestational diabetes mellitus (GDM) resembles type 2 diabetes in severalrespects, involving a combination of relatively inadequate insulin secretion andresponsiveness. It occurs in about 2%–5% of all pregnancies and may improveor disappear after delivery. Gestational diabetes is fully treatable but requirescareful medical supervision throughout the pregnancy. About 20%–50% ofaffected women develop type 2 diabetes later in life.Even though it may be transient, untreated gestational diabetes can damage thehealth of the fetus or mother. Risks to the baby include macrosomia (high birthweight), congenital cardiac and central nervous system anomalies, and skeletalmuscle malformations. Increased fetal insulin may inhibit fetal surfactantproduction and cause respiratory distress syndrome. Hyperbilirubinemia mayresult from red blood cell destruction. In severe cases, perinatal death mayoccur, most commonly as a result of poor placental perfusion due to vascularimpairment. Labor induction may be indicated with decreased placental function.A cesarean section may be performed if there is marked fetal distress or anincreased risk of injury associated with macrosomia, such as shoulder dystocia.A 2008 study completed in the U.S. found that the number of American womenentering pregnancy with preexisting diabetes is increasing. In fact the rate ofdiabetes in expectant mothers has more than doubled in the past 6 years. This isparticularly problematic as diabetes raises the risk of complications duringpregnancy, as well as increasing the potential that the children of diabetic mothers willalso become diabetic in the future.
  4. 4. Other typesPre-diabetes indicates a condition that occurs when a persons blood glucoselevels are higher than normal but not high enough for a diagnosis of type 2diabetes. Many people destined to develop type 2 diabetes spend many years ina state of pre-diabetes which has been termed "Americas largest healthcareepidemic."Latent autoimmune diabetes of adults is a condition in which Type 1 diabetesdevelops in adults. Adults with LADA are frequently initially misdiagnosed ashaving Type 2 diabetes, based on age rather than etiology.Signs and symptoms
  5. 5. TestDiabetes mellitus is characterized by recurrent or persistent hyperglycemia, andis diagnosed by demonstrating any one of the following: Fasting plasma glucose level ≥ 7.0 mmol/L (126 mg/dL). Plasma glucose ≥ 11.1 mmol/L (200 mg/dL) two hours after a 75 g oral glucose load as in a glucose tolerance test. Symptoms of hyperglycemia and casual plasma glucose ≥ 11.1 mmol/L (200 mg/dL). Glycated hemoglobin (HbA1C) ≥ 6.5%.A positive result, in the absence of unequivocal hyperglycemia, should beconfirmed by a repeat of any of the above-listed methods on a different day. It ispreferable to measure a fasting glucose level because of the ease ofmeasurement and the considerable time commitment of formal glucose tolerancetesting, which takes two hours to complete and offers no prognostic advantageover the fasting test. According to the current definition, two fasting glucosemeasurements above 126 mg/dL (7.0 mmol/L) is considered diagnostic fordiabetes mellitus.People with fasting glucose levels from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) areconsidered to have impaired fasting glucose. Patients with plasma glucose at orabove 140 mg/dL (7.8 mmol/L), but not over 200 mg/dL (11.1 mmol/L), two hoursafter a 75 g oral glucose load are considered to have impaired glucose tolerance.Of these two pre-diabetic states, the latter in particular is a major risk factor forprogression to full-blown diabetes mellitus as well as cardiovascular disease.Glycated hemoglobin is better than fasting glucose for determining risks ofcardiovascular disease and death from any cause. Diabetes diagnostic criteria Condition 2 hour Fasting HbA1c glucose glucose mmol/l(mg/dl) mmol/l(mg/dl) % Normal <7.8 (<140) <6.1 (<110) <6.0 Impaired fasting <7.8 (<140) ≥ 6.1(≥110) & 6.0- glycaemia <7.0(<126) 6.4Impaired glucose ≥7.8 (≥140) <7.0 (<126) 6.0- tolerance 6.4Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126) ≥6.5
  6. 6. Oral manifestationshttp://www.authorstream.com/Presentation/gingiva-120877-oral-manifestation-diabetes-mellitus-dentistry-new-microsoft-powerpoint-education-ppt/ (See the slide of oral manifestations)Dental treatment consideration- GENERAL MANAGEMENT CONSIDERATIONSThe dentist plays a major role in referral of patients with diabetes to physiciansfor additional evaluation.1 Any undiagnosed dental patient who has the cardinalsigns and symptoms of diabetes (that is, polydipsia, polyuria, polyphagia, weightloss, weakness), or who presents with an oral manifestation (for example,xerostomia or candidiasis), should be referred to a physician for diagnosis andtreatment.With a glucometer, a dentist can test blood glucose from a patient’s fingertip. Ifthe result is consistent with hyperglycemia, then immediate follow-up with aphysician is indicated. Even if the patient were to have a normal glucose levelwith such testing, immediate follow-up with a physician would still be indicated,particularly if the patient had the above signs or symptoms or oral manifestationssuggestive of uncontrolled, undiagnosed diabetes.If the physician to whom a dentist has referred a patient subsequently diagnosesthe patient with diabetes mellitus, then the patient may be spared from life-threatening complications. However, an important caveat must be mentionedhere: the glucometer is not accepted as a diagnostic device and the dentist is notqualified medicolegally to make a diagnosis.All patients with diagnosed diabetes must be identified by history. A thoroughunderstanding of their medical treatment—including medications, regimen andthe degree of glycemic control, as well as any systemic complications resultingfrom diabetes—then must be methodically established. In the case of systemiccomplications from diabetes mellitus (for example, hypertension, cardiovasculardisease, retinopathy, renal insufficiency or failure), the dentist must consult withthe patient’s physician to discuss any modifications to the dental treatment plan,particularly when surgical procedures are anticipated.For example, in the patient with cardiovascular disease, monitoring bloodpressure is extremely important, as is the possible modification of anticoagulantdrugs (for example, aspirin) before and after surgery. A current recommendationin medical therapy is the use of aspirin (75–325 mg/day) in all adult patients with
  7. 7. diabetes and macrovascular disease.46 The avoidance of nephrotoxic drugs indental management (for example, acetaminophen in high doses, acyclovir,aspirin, nonsteroidal anti-inflammatory drugs) is recommended in patients withrenal disease, as well as obtaining a complete blood cell count, monitoring theblood pressure at every appointment, assessing the risk of endarteritis (renaldialysis shunt) or endocarditis, and managing the patient receiving dialysis who ison heparin therapy.1With respect to surgical procedures, the dentist should also test the patient’sblood sugar with a glucometer to avert emergency-related events such as insulinshock (profound hypoglycemia) or ketoacidosis with severe hyperglycemiabefore, during or after an invasive procedure. Any patient with diabetes who isgoing to receive extensive periodontal or oral surgery procedures other thansingle, simple extractions should be given dietary instructions after surgery; theseinstructions should be established in concert with the patient’s physician andnutritionist. It is important that the total caloric content and the protein-carbohydrate:fat ratio of the diet remain the same so that proper glycemic controlof the diabetes is maintained. The patient’s physician should be consulted aboutdietary recommendations and dosage modifications to medications during thepostoperative phase of dental treatment. In the case of an acute oral infection,not only may antibiotics be indicated—particularly in poorly controlled diabetes—but also modifications in the patient’s medications may be needed (for example,increasing the insulin dose to prevent hyperglycemia related to the pain andstress from infection).Typically, patients also should receive short morning appointments to reducestress. The release of endogenous epinephrine from stress can have a counter-regulatory effect on the action of insulin, thereby markedly stimulating thebreakdown of glycogen in muscle (and to a lesser extent in liver) and leading tohyperglycemia.47 In the adult patient with diabetes and no history ofhypertension, or in the adult patient with diabetes who has well-controlledhypertension, epinephrine can be administered in the usual ranges.1 Importantly,the inclusion of epinephrine is advisable because it will promote better dentalanesthesia and thus may significantly reduce the release of far greater amountsof endogenous epinephrine in response to pain and stress.Finally, the dentist must play a major role in modifying a patient’s destructivehealth habits, especially those that introduce a comorbidity factor. For example, alarge body of evidence from epidemiologic, case-controlled and cohort studiesprovides convincing documentation of the causal link between cigarette smokingand health risks such as diabetes48 and oral cancer.49,50 Much of the researchdocumenting the impact of smoking on health did not discuss separately resultson subsets of individuals with diabetes, suggesting the identified risks are at leastequivalent to those found in the general population.Other studies of people with diabetes consistently found a heightened risk ofmorbidity and premature death associated with the development of
  8. 8. macrovascular disease complications among smokers.48 Smoking also is relatedto the premature development of microvascular complications of diabetes andmay play a part in the development of type 2 diabetes. 48 Large, randomizedclinical trials have demonstrated the efficacy and cost-effectiveness of counselingin changing smoking behavior. Such studies, combined with the others specific topeople with diabetes, suggest that smoking-cessation counseling is effective inreducing tobacco use.51,52 A summary of important general managementconsiderations for the patient with diabetes is shown in the box.TABLE 1 : TREATMENT FOR ORAL CANDIDIASIS.TABLE 2 : TOPICAL MEDICATION FOR ANGULAR CHEILITIS.
  9. 9. SUMMARY OF GENERAL MANAGEMENT CONSIDERATIONS FOR THEPATIENT WITH DIABETES.- MANAGEMENT OF THE ORAL COMPLICATIONS OF DIABETESRisk of disease progression.The comprehensive management of oral infections in patients with diabetes isbeyond the scope of this article. Other sources are available that provide adviceand examples of detailed therapeutic regimens. 1,53 Nevertheless, clinicalrecommendations on the treatment of some common oral manifestations ofdiabetes are provided below.In general, adults with well-controlled type 1 or type 2 diabetes may have nomore significant risk of experiencing oral disease progression than do thosewithout diabetes, and, hence, can be treated similarly. For example, a coronalcarious lesion that has not yet penetrated dentin in a patient with well-controlleddiabetes may require no immediate intervention, whereas a similar lesion in apoorly controlled patient (moderate to severe hyperglycemia) may needimmediate operative treatment, given its higher risk of progression. In general,the risk of progression of oral complications is related to glycemic control and isassessed in part by the interpretation of HbA1c values and postprandial bloodsugar levels.Treatment regimens for candidiasis.Given the centrality of candidiasis as a marker of marginally or uncontrolleddiabetes, and its secondary relationship to salivary dysfunction, somerepresentative topical and systemic medications for the treatment of oralcandidiasis are shown in Tables 1⇑ and 2⇑. It generally is advised that thedentist first assess the sugar content in some of the antifungal preparationsbefore prescribing them. For example, clotrimazole troches should be avoided as
  10. 10. these have a relatively high sugar content that may warrant against their use inpatients with diabetes (see Table 1⇑ for treatment guidelines54). Somerepresentative topical medications, such as creams, for the treatment of angularcheilitis are shown in Table 2⇑. Some of these combination creams containcorticosteroids that provide an anti-inflammatory and antipruritic effect to aidhealing; however, steroids can have an antagonistic or counterregulatory effecton the action of insulin and, thus, have the potential to cause hyperglycemia.Nonetheless, it is unlikely that such combination creams will cause a significantelevation of blood glucose, particularly if these are applied to a relatively smallarea of angular cheilitis.Management of salivary gland dysfunction and xerostomia.The rationale for the treatment of xerostomia is to provide salivary stimulation orreplacement therapy to keep the mouth moist, prevent caries and candidalinfection, and provide palliative relief. The management approach for dry mouthcan include the use of saliva substitutes and stimulants; this approach mayminimize progression of, or prevent the development of, dental caries. 55Management of recurrent HSV infections.For the patient with diabetes and recurrent orofacial HSV infection, treatmentshould be initiated as early as possible in the prodromal stage to reduce theduration and symptoms of the lesion. Oral acyclovir, prophylactically andtherapeutically, may be considered when frequent recurrent herpetic episodesinterfere with daily function and nutrition. In the patient with diabetes and renalinsufficiency or renal failure, acyclovir should be avoided because of its potentialfor nephrotoxicity.1Management of burning mouth syndrome.For the adult patient with burning mouth syndrome, multiple factors may interactsynergistically. In uncontrolled diabetes, xerostomia and candidiasis cancontribute to the symptoms associated with burning mouth. In addition to thetreatment of these conditions, an improvement in glycemic control is essential tomitigate the symptoms. Given in low dosages, benzodiazepines, tricyclicantidepressants and anticonvulsants can be helpful in reducing or eliminating thesymptoms after several weeks or months. The dosage of these drugs is adjustedto the patient’s symptoms. A potential side effect includes xerostomia.Consultation with the patient’s physician is necessary because of the potential ofthese drugs for addiction and dependence. Commonly used medications includeamitriptyline, nortriptyline, clonazepam and gabapentin. Interestingly,amitriptyline has also been used to treat autonomic neuropathy in diabetes.Surgical considerations and periodontal management.
  11. 11. The dentist can perform periodontal surgical procedures, although it is importantfor the patient to maintain a normal diet during the postsurgical phase to avoidhypoglycemia (low blood sugar and insulin shock) and ensure effective repair.The dental practitioner must review any previous history of complications, assessthe patient’s glycemic control and maintain an ongoing dialogue with the patient’sphysician and nutritionist. The longer the duration of the diabetes, the greater thelikelihood of the patient’s developing severe periodontal disease.Supportive periodontal therapy should be provided at relatively close intervals(two to three months). Periodontal infections may complicate the severity ofdiabetes mellitus and the degree of metabolic control. The adult patient with well-controlled diabetes generally does not require antibiotics following surgicalprocedures. However, the administration of antibiotics during the post-surgicalphase is appropriate, particularly if there is significant infection, pain and stress.The selection of antibiotics is predicated on multiple factors (for example,sensitivity and specificity results, spread of infection), and should be conducted inconsultation with the patient’s physician.The mainstay of periodontal therapy for patients with diabetes is nonsurgical,given that surgical procedures may necessitate modification of the patient’smedications before and after treatment, and also may lead to a prolongedhealing phase owing to diabetes. The combination of nonsurgical débridementand tetracycline antibiotic therapy in patients with diabetes mellitus who haveadvanced periodontitis may have a potential positive influence on glycemiccontrol. The use of tetracycline in the treatment of periodontal disease wasassociated with an improvement in glycemic control as assessed by HbA 1cassays.26Several published papers have reported an additional therapeutic benefit fromtetracyclines in periodontal therapy, principally as inhibitors of the connectivetissue–degrading enzymes, the human matrix metalloproteinases. For example,low-dose doxycycline has been shown to inhibit human gingival crevicular fluidcollagenase at doses that are not antimicrobial, significantly eliminating the riskof bacterial resistance. Tetracyclines can thus function as inhibitors of boneresorption or bone loss, and this property is independent of their antimicrobialuse, providing an added dimension to the therapeutic management ofperiodontitis.Oral disease management with corticosteroids.Therapies with corticosteroids and immunomodulating drugs have the potentialfor side effects. Therefore, close collaboration with the patient’s physician isneeded. The use of steroids in the treatment of erosive lichen planus in the adultpatient with diabetes is of considerable concern because steroids can antagonizethe action of insulin and lead to hyperglycemia. The patient should be giveninstructions to self-monitor blood glucose levels frequently during steroid therapy.Prolonged use of topical steroids (for a period of greater than two weeks
  12. 12. continuously) may result in mucosal atrophy and secondary candidiasis 1—conditions that also commonly occur in uncontrolled diabetes. Once the erosiveoral lichen planus has resolved, topical steroids should be tapered to alternate-day or less-frequent therapy, depending on the control of the erosions and thetendency toward recurrence. Emerging nonsteroidal immunomodulator drugs (forexample, tacrolimus ointment, topical thalidomide) may be useful in the medicalmanagement of the patient with concomitant oral mucosal disease anduncontrolled diabetes.Metabolic syndromeMetabolic syndrome is a combination of medical disorders that, when occurringtogether, increase the risk of developing cardiovascular disease and diabetes.Itaffects one in five people in the United States and prevalence increases withage. Some studies have shown the prevalence in the USA to be an estimated25% of the population.Metabolic syndrome is also known as metabolic syndrome X, cardiometabolicsyndrome, syndrome X, insulin resistance syndrome, Reavens syndrome(named for Gerald Reaven), and CHAOS (in Australia). A similar condition inoverweight horses is referred to as equine metabolic syndrome; it is unknown ifthey have the same etiology.Risk FactorsStressRecent research indicates that prolonged stress can be an underlying cause ofmetabolic syndrome by upsetting the hormonal balance of the hypothalamic-pituitary-adrenal axis (HPA-axis). A dysfunctional HPA-axis causes high cortisollevels to circulate which results in raising glucose and insulin levels which causeinsulin-mediated effects on adipose tissue, ultimately promoting visceraladiposity, insulin resistance, dyslipidemia and hypertension with direct effects onthe bone, causing ―low turnover‖ osteoporosis. -axis dysfunction may explain thereported risk indication of abdominal obesity to cardiovascular disease, type 2diabetes and stroke. Psychosocial stress is also linked to heart disease.Overweight and obesityCentral adiposity is a key feature of the syndrome, reflecting the fact that thesyndromes prevalence is driven by the strong relationship between waistcircumference and increasing adiposity. However, despite the importance ofobesity, patients that are of normal weight may also be insulin-resistant and havethe syndrome.
  13. 13. Sedentary lifestylePhysical inactivity is a predictor of CVD events and related mortality. Manycomponents of metabolic syndrome are associated with a sedentary lifestyle,including increased adipose tissue (predominantly central); reduced HDLcholesterol; and a trend toward increased triglycerides, blood pressure, andglucose in the genetically susceptible. Compared with individuals who watchedtelevision or videos or used their computer for less than one hour daily, thosethat carried out these behaviors for greater than four hours daily have a twofoldincreased risk of metabolic syndrome.AgingMetabolic syndrome affects 44% of the U.S. population older than age 50. Withrespect to that demographic, the percentage of women having the syndrome ishigher than that of men. The age dependency of the syndromes prevalence isseen in most populations around the world.Diabetes mellitusIt is estimated that the large majority (~75%, or just above 40 million) of patientswith type 2 diabetes or impaired glucose tolerance (IGT) have metabolicsyndrome - . The presence of metabolic syndrome in these populations isassociated with a higher prevalence of CVD than found in patients with type 2diabetes or IGT without the syndrome.[32] Hypoadiponectinemia has been shownto increase insulin resistance, and is considered to be a risk factor for developingmetabolic syndrome.Coronary heart diseaseThe approximate prevalence of the metabolic syndrome in patients with coronaryheart disease (CHD) is 50%, with a prevalence of 37% in patients with prematurecoronary artery disease ( age 45), particularly in women. With appropriatecardiac rehabilitation and changes in lifestyle (e.g., nutrition, physical activity,weight reduction, and, in some cases, drugs), the prevalence of the syndromecan be reduced.LipodystrophyLipodystrophic disorders in general are associated with metabolic syndrome.Both genetic (e.g., Berardinelli-Seip congenital lipodystrophy, Dunnigan familialpartial lipodystrophy) and acquired (e.g., HIV-related lipodystrophy in patientstreated with highly active antiretroviral therapy) forms of lipodystrophy may giverise to severe insulin resistance and many of metabolic syndromes components.
  14. 14. Schizophrenia and other psychiatric illnessesPatients with schizophrenia, schizoaffective disorder or bipolar disorder mayhave a predisposition to metabolic syndrome that is exacerbated by sedentarylifestyle, poor dietary habits, possible limited access to care, and antipsychoticdrug-induced adverse effects. It has been found that 32% and 51% of individualswith schizophrenia meet criteria for metabolic syndrome; the prevalence is higherin women than in men.Rheumatic diseasesThere are new findings regarding the comorbidity associated with rheumaticdiseases. Both psoriasis and psoriatic arthritis have been found to be associatedwith metabolic syndrome.WHOThe World Health Organization criteria (1999) require presence of one of: Diabetes mellitus, Impaired glucose tolerance, Impaired fasting glucose or Insulin resistance;AND two of the following: Blood pressure: ≥ 140/90 mmHg Dyslipidemia: triglycerides (TG): ≥ 1.695 mmol/L and high-density lipoprotein cholesterol (HDL-C) ≤ 0.9 mmol/L (male), ≤ 1.0 mmol/L (female) Central obesity: waist:hip ratio > 0.90 (male); > 0.85 (female), or body mass index > 30 kg/m2 Microalbuminuria: urinary albumin excretion ratio ≥ 20 µg/min or albumin:creatinine ratio ≥ 30 mg/gCholesterolWhen you get a lipid panel, there are three main types of cholesterol that aretested: low density lipoprotein (LDL), high density lipoprotein (HDL), and very lowdensity lipoprotein (VLDL). Triglycerides, another type of lipid in the blood, arealso tested. The amounts of each lipid in your blood will allow your health careprovider to predict your risk for heart disease in the future.
  15. 15. Low Density LipoproteinsLow density lipoproteins, also referred to as LDL, is known as the "badcholesterol". LDLs are produced by the liver and carry cholesterol and other lipids(fats) from the liver to different areas of the body, like muscles, tissues, organs,and the heart. It is very important to keep LDL levels low, because high levels ofLDL indicate that there is much more cholesterol in the blood stream thannecessary, therefore increasing your risk of heart disease. LDLs are calculatedby using an equation involving total cholesterol, triglycerides, and HDLs--all ofwhich are measured directly in the blood:LDL = TC – (triglycerides/5) + HDL)The following guidelines have been set forth by the National CholesterolEducation Program: LDL levels less than 100 mg/dL ( 2.6 mmol/L) are considered optimal. LDL levels between 100 – 129 mg/dL (2.6–3.34 mmol/L) are considered near or above optimal. LDL levels between 130 – 159 mg/dL (3.36–4.13 mmol/L) are considered borderline high. LDL levels between 160 – 189 mg/dL (4.14 - 4.90 mmol/L) are considered high. LDL levels at or above 190 mg/dL (4.91 mmol/L) is considered very high.High Density LipoproteinsHigh density lipoprotein, also known as HDL, is considered the "good"cholesterol. HDL is produced by the liver to carry cholesterol and other lipids(fats) from tissues and organs back to the liver for recycling or degradation. Highlevels of HDL are a good indicator of a healthy heart, because less cholesterol isavailable in your blood to attach to blood vessels and cause plaque formation.According to the National Cholesterol Education Program: Any HDL level above more than 60 mg/dL (1.56 mmol/L) is considered high. A high HDL level is considered very healthy, since it has a protective role in guarding against heart disease. An acceptable HDL range is between 40- 60 mg/dL (1.04–1.56 mmol/L). An undesirable level of HDL is any level below 40 mg/dL (1.04 mmol/L). In this case, low HDL levels may help to contribute to heart disease.Very Low Density LipoproteinsVery low density lipoproteins, or VLDL, are lipoproteins that carry cholesterolfrom the liver to organs and tissues in the body. They are formed by a
  16. 16. combination of cholesterol and triglycerides. VLDLs are heavier than low densitylipoproteins, and are also associated with atherosclerosis and heart disease. Thisnumber is obtained by dividing your triglyceride levels by 5.PrediabetesPrediabetes is the state in which some but not all of the diagnostic criteria fordiabetes are met. It is often described as the ―gray area‖ between normal bloodsugar and diabetic levels. While in this range, patients are at risk for not onlydeveloping type 2 diabetes, but also for cardiovascular complications. It has beentermed "Americas largest healthcare epidemic," affecting more than 57 millionAmericans. Prediabetes is also referred to as borderline diabetes, impairedglucose tolerance (IGT), and/or impaired fasting glucose (IFG).Signs and symptomsPrediabetes typically has no signs or symptoms. Patients should monitor forsigns and symptoms of type 2 diabetes mellitus. These include the following: Constant hunger Unexplained weight loss Weight gain Flu-like symptoms, including weakness and fatigue Blurred vision Slow healing of cuts or bruises Tingling or loss of feeling in hands or feet Recurring gum or skin infections Recurring vaginal or bladder infectionsCause Sleep disorders Family history of diabetes Impaired glucose levels and/or metabolic syndrome Cardiovascular disease Hypertension (high blood pressure) Increased triglycerides levels Low levels of good cholesterol (HDL) Overweight or obese Women who have had gestational diabetes, had high birth weight babies (greater than 9 lbs.), and/or has Polycystic Ovarian Syndrome (PCOS)These are associated with insulin resistance and are risk factors for thedevelopment of type 2 diabetes mellitus. Those in this stratum (IGT or IFG) are at
  17. 17. increased risk of cardiovascular disease. Of the two, impaired glucose tolerancebetter predicts cardiovascular disease and mortality.In a way, prediabetes is a misnomer since it is an early stage of diabetes. It isnow known that the health complications associated with type 2 diabetes oftenoccur before the medical diagnosis of diabetes is made.GeneticsAs the human genome is further explored, it is likely that multiple geneticanomalies at different loci will be found that confer varying degrees ofpredisposition to type 2 diabetes. Type 2 DM, which is the condition for whichprediabetes is a precursor, has 90-100% concordance in twins; there is no HLAassociation. However, genetics play a relatively small role in the widespreadoccurrence of type 2 diabetes. This can be logically deduced from the hugeincrease in the occurrence of type 2 diabetes which has correlated with thesignificant change in western lifestyle.Don’t forget Dr.Eman’s lecture (PDL part 2&3 lastslides) GOOD LUCK