Characterized by hyperglycaemia Defects in insulin production Autoimmune or other destruction of beta cells Insulin insensitivity Impaired action of insulin on target tissues

1. Slides current until 2008
Diagnosis, classification and
prevention of diabetes
Section 1 | 1 of 4
Curriculum Module II–1 | Diagnosis, classification and
presentation of diabetes

2. Diagnosis and types
Curriculum Module II-1
Slide 2 of 48
Slides current until 2008
Definition of diabetes
Characterized by hyperglycaemia
• Defects in insulin production
• Autoimmune or other
destruction of beta cells
• Insulin insensitivity
• Impaired action of insulin on
target tissues

3. Diagnosis and types
Curriculum Module II-1
Slide 3 of 48
Slides current until 2008
Definition of diabetes
Chronic hyperglycaemia associated
with long-term damage to:
• Eyes
• Kidneys
• Nerves
• Heart and blood vessels

4. Diagnosis and types
Curriculum Module II-1
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Slides current until 2008
The diabetes epidemic
• 230 million affected in 2006
• 350 million within 20 years
• Most rapid in Indian and Asian
subcontinents
IDF Diabetes Atlas

5. Diagnosis and types
Curriculum Module II-1
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Classification
• Type 1 diabetes
– autoimmune
– LADA
– idiopathic
• Type 2 diabetes

6. Diagnosis and types
Curriculum Module II-1
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Other specific types
• MODY
• Defects in insulin action
• Diseases of the pancreas
• Endocrine disorders
• Drug- or chemical-induced
• Infections
Classification

7. Diagnosis and types
Curriculum Module II-1
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• Uncommon forms of immune-
mediated diabetes
• Other genetic syndromes
• Gestational diabetes
Classification

8. Diagnosis and types
Curriculum Module II-1
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Insulin
Gluconeogenesis
Glycogenolysis
Glycogen synthesis
Glucose uptake
Glycogen
synthesis
Blood glucose
Insulin and glucose disposal
Free fatty acid release

9. Diagnosis and types
Curriculum Module II-1
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Glucose uptake
Glycogenolysis
Gluconeogenesis (amino acids)
Ketone production (fatty acids)
Glucose uptake
Protein degradation  amino acids
Blood glucose
Insulin deficiency in
type 1 diabetes
Triglyceride degradation  fatty acids

10. Diagnosis and types
Curriculum Module II-1
Slide 10 of 48
Slides current until 2008
Glucose uptake
Glycolysis
Gluconeogenesis (amino acids)
Glucose uptake
Protein degradation  amino acids
Blood glucose
Insulin insensitivity in
type 2 diabetes

11. Diagnosis and types
Curriculum Module II-1
Slide 11 of 48
Slides current until 2008
Blood glucose
Glucose uptake
Insensitivity to insulin in
type 2 diabetes
Glucose uptake
Glycolysis
Gluconeogenesis (amino acids)
Glucose uptake
Protein degradation  amino acids

12. Diagnosis and types
Curriculum Module II-1
Slide 12 of 48
Slides current until 2008
Blood glucose
Converted to triglycerides
Effect of insulin resistance in
type 2 diabetes
Glucose uptake
Glycolysis
Gluconeogenesis (amino acids)
Glucose uptake
Protein degradation  amino acids
Glucose uptake

13. Diagnosis and types
Curriculum Module II-1
Slide 13 of 48
Slides current until 2008
Pathogenesis of type 1 diabetes
• Immunological activation
• Progressive beta-cell destruction
• Insufficient beta-cell function
• Dependent on exogenous insulin
• Risk of ketoacidosis

14. Diagnosis and types
Curriculum Module II-1
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Slides current until 2008
Pathogenesis of type 1 diabetes
• Genetic susceptibility
• Immune factors
– other autoimmune disease
– antigen-specific antibodies
• Environmental trigger
– viruses
– bovine serum albumin
– nitrosamines: cured meats
– chemicals: vacor (rat poison),
streptozotin

15. Diagnosis and types
Curriculum Module II-1
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Beta-cell
mass
Pathogenesis of type 1 diabetes
Time (months - years)
Trigger
Genetic
Pre-diabetes ‘Honeymoon’
Chronic
phase
Clinical
diabetes
Immunological
abnormalities

16. Diagnosis and types
Curriculum Module II-1
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Slides current until 2008
Idiopathic type 1 diabetes
Non-autoimmune type 1 diabetes
• No autoimmune markers
• Permanent insulinopenia
• Ketoacidosis
• People of African and Asian origin

17. Diagnosis and types
Curriculum Module II-1
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Epidemiology of type 1 diabetes
• Increasing in recent years
• Geographic variation
• Relative affluence
• Lack of treatment
IDF Diabetes Atlas

18. Diagnosis and types
Curriculum Module II-1
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• Age of onset peaks
– preschool
– puberty
• Autumn/winter peaks
Epidemiology of type 1 diabetes

19. Diagnosis and types
Curriculum Module II-1
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Type 2 diabetes
• 90%-95% of people with
diabetes
• Insulin insensitivity and
relative insulin deficiency
• Obesity or overweight
• Complications often present
at diagnosis

20. Diagnosis and types
Curriculum Module II-1
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Pathogenesis of type 2 diabetes
• Multiple genes involved
• Hyperinsulinaemia
• Poor fetal nutrition   beta-cell
formation
• Low birth weight/weight change
• “Thrifty gene”
• 7% beta-cell loss

21. Diagnosis and types
Curriculum Module II-1
Slide 21 of 48
Slides current until 2008
Age (years)
Endogenous
insulin
Insulin
requirements
Beta-cell loss
The natural history of
type 2 diabetes
 Insulin
requirements
with age
Primary
failure

22. Diagnosis and types
Curriculum Module II-1
Slide 22 of 48
Slides current until 2008
Age (years)
Endogenous
insulin
Insulin
requirements
Beta-cell loss
Insulin
insensitivity
Hyper-
insulinaemia
The natural history of
type 2 diabetes
 Insulin
requirements
with age

23. Diagnosis and types
Curriculum Module II-1
Slide 23 of 48
Slides current until 2008
Age (years)
Endogenous
insulin
Insulin
requirements
Secondary
failure
The natural history of
type 2 diabetes
Effect of
oral drugs
 Insulin
requirements
with age
Beta-cell loss
Hyper-
insulinaemia
Insulin
insensitivity

24. Diagnosis and types
Curriculum Module II-1
Slide 24 of 48
Slides current until 2008
Epidemiology of type 2 diabetes
• Dramatic increase
• Aging population
• Disturbing trends parallel obesity
epidemic
• Especially in adolescents and
minority groups
• Increasing in young people

25. Diagnosis and types
Curriculum Module II-1
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ACTIVITY
Slides current until 2008
• What are the most common risk
factors for type 2 diabetes for
people in your country?
• Are any of these risk factors
modifiable?

26. Diagnosis and types
Curriculum Module II-1
Slide 26 of 48
Slides current until 2008
Risk factors for type 2 diabetes
• Age > 40 years
• First-degree relative with diabetes
• Member of high risk population
• History of impaired glucose tolerance,
impaired fasting glucose
• Vascular disease
• History of gestational diabetes
• History of delivery of macrosomic
baby
CDA 2003

27. Diagnosis and types
Curriculum Module II-1
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• Hypertension
• Dyslipidaemia
• Abdominal obesity
• Overweight
• Polycystic ovary disease
• Acanthosis nigricans
• Schizophrenia
Risk factors for type 2 diabetes

28. Diagnosis and types
Curriculum Module II-1
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• Polydipsia
• Polyuria
• Nocturia
• Visual disturbance
• Fatigue
• Weight loss
• Infections
Signs and symptoms

29. Diagnosis and types
Curriculum Module II-1
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Diagnosing diabetes
Normal Impaired fasting glucose*
Impaired glucose
tolerance**
Diabetes
FPG <6.1mmol/L
<110mg/dL
6.1 to 6.9mmol/L*
110 to 126mg/dL
≥7.0mmol/L
≥126mg/dL
2hr PG <7.8mmol/L
<126mg/dL
7.8 to 11mmol/L**
126 to 200mg/dL
≥11.1mmol/L
≥200mg/dL
CDA 2003, ADA 2004, WHO 2002

30. Diagnosis and types
Curriculum Module II-1
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Slides current until 2008
Impaired glucose tolerance
Impaired fasting glucose
• Intermediate states
• Increased risk of developing
diabetes
• Prevention strategies to prevent or
delay progression
• Increased risk of cardiovascular
disease

31. Diagnosis and types
Curriculum Module II-1
Slide 31 of 48
Slides current until 2008
Uncertain diagnosis:
Oral glucose tolerance test
• 75 g glucose load after 8 hours
fasting
• Readings taken in fasting state
and at 1 and 2 hours
• Possible problems

32. Diagnosis and types
Curriculum Module II-1
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• Urinary ketones
• Antibodies
• C-peptide
Tests for differential diagnosis

33. Diagnosis and types
Curriculum Module II-1
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Metabolic syndrome
• Cluster of risk factors or syndrome
• Type 2 diabetes
• Different criteria
• Three-fold increase in heart
disease and stroke
• Two-fold increase in cardiovascular
disease deaths

34. Diagnosis and types
Curriculum Module II-1
Slide 34 of 48
Slides current until 2008
Prevention of type 1 diabetes
• Early exposure to cows milk
protein
• Nicotinamide

35. Diagnosis and types
Curriculum Module II-1
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Slides current until 2008
Prevention of type 1 diabetes
Insulin
• Diabetes Prevention Trial
• Diabetes Prediction and
Prevention Project

36. Diagnosis and types
Curriculum Module II-1
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Prevention of type 2 diabetes
Lifestyle modification
• Da Qing Study
• Finnish Diabetes Prevention Study

37. Diagnosis and types
Curriculum Module II-1
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Slides current until 2008
Prevention of type 2 diabetes
Lifestyle vs medication
• Diabetes Prevention Program
• STOP-NIDDM

38. Diagnosis and types
Curriculum Module II-1
Slide 38 of 48
ACTIVITY
Slides current until 2008
Type 2 diabetes can be delayed in
people with IGT
Lifestyle modification is most
effective
What do you think could be done at
community level to prevent or delay
diabetes?

39. Diagnosis and types
Curriculum Module II-1
Slide 39 of 48
Slides current until 2008
Summary
Type 1 diabetes
• Results from progressive beta-
cell destruction
• People with type 1 diabetes need
insulin therapy to live

40. Diagnosis and types
Curriculum Module II-1
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Type 2 diabetes
• Often characterized by insulin
insensitivity and relative rather
than absolute insulin deficiency
• A progressive condition
• Most people with type 2 diabetes
will need insulin within 5 to 10
years of diagnosis
Summary

41. Diagnosis and types
Curriculum Module II-1
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Slides current until 2008
Review question
1. The pathogenesis for type 2 diabetes
includes:
a. Insulin deficiency and insulin
insensitivity
b. Insensitivity to insulin and
autoimmune beta-cell destruction
c. Autoimmune beta-cell destruction
and glucagon deficiency
d. Insulin deficiency and glucagon
deficiency

42. Diagnosis and types
Curriculum Module II-1
Slide 42 of 48
Slides current until 2008
Review question
2. A person with type 2 diabetes, recently
started on insulin, asks if there is a way
to measure if he/she is still producing any
insulin. The correct response would be:
a. Islet cell antibody tests
b. C-peptide test
c. HbA1c test
d. Serum insulin test

43. Diagnosis and types
Curriculum Module II-1
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Review question
3. The Diabetes Prevention Program (DPP):
a. Included people with type 1
diabetes
b. Included only people with IGT
c. Tested the value of exercise
d. Included people with type 2
diabetes

44. Diagnosis and types
Curriculum Module II-1
Slide 44 of 48
Slides current until 2008
Review question
4. Type 1 diabetes is usually caused by:
a. Injury to the pancreas
b. An autoimmune reaction
c. Insulin insensitivity in the cells
d. Hypersensitivity to insulin

45. Diagnosis and types
Curriculum Module II-1
Slide 45 of 48
Slides current until 2008
Answers
1. a
2. b
3. b
4. b

46. Diagnosis and types
Curriculum Module II-1
Slide 46 of 48
Slides current until 2008
References
1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes
Care 2004; 27(suppl 1): S5-S10.
2. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian
Diabetes Association 2003 clinical practice guidelines for the prevention and management of
diabetes in Canada. Can J Diab 2003; 27(suppl 2).
3. Chiasson JL, Josse RG, Gomis R, et al. Acarbose for prevention of type 2 diabetes mellitus:
The STOP-NIDDM randomized trial. Lancet 2002; 346: 393-403.
4. Delahanty LM and Halford BN. The role of Diet Behaviours in Achieving improved glycaemic
control in intensively treated patients in the Diabetes Control and Complications Trial.
Diabetes Care 1993; 16(11): 1453-58.
5. Diabetes Control and Complications Trial Research Group. Effect of intensive diabetes
treatment on the development and progression of long-term complications in adolescents with
insulin dependent diabetes mellitus: Diabetes Control and Complications Trial. The Journal of
Paediatrics 1994; 125(2): 177-88.
6. Diabetes Control and Complications Trial/epidemiology of diabetes interventions and
complications research group intensive diabetes therapy and carotid intima-media thickness in
type 1 diabetes mellitus. New Engl J Med 2003; 348: 2294-303.
7. Diabetes Control and Complications Trial: The effect of intensive treatment of diabetes on the
development and progression of long-term complications in insulin-dependent diabetes
mellitus. N Engl J Med 1993; 329: 977-86.

47. Diagnosis and types
Curriculum Module II-1
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Slides current until 2008
References
8. Ford ES, Giles WH, Dietz WH. Prevalence of the metabolic syndrome among US adults:
findings from the third National Health and Nutrition Examination Survey. JAMA 2002; 297:
356-59.
9. Diabetes Atlas 2006. Brussels: International Diabetes Federation, 2006.
10. Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with
the metabolic syndrome. Diabetes Care 2001; 24(4): 683-9.
11. Pan X, Li G, Hu Y, et al. Effects of diet and exercise in preventing NIDDM in people with
impaired glucose tolerance: The Da Qing IGT and Diabetes Study. Diabetes Care 1997; 20(4):
537-44.
12. Report of a WHO Consultation. Laboratory Diagnosis and monitoring of Diabetes Mellitus.
World Health Organisation 2002. http://whqlibdoc.who.int/hq/2002/9241590483.pdf cited
April 30, 2005.
13. Tuomilehto J, Lindstrom J, Eriksson JG, et al. Prevention of type 2 diabetes mellitus by
changes in lifestyle among subjects with impaired glucose tolerance. N Eng J Med 2001; 344:
1343-50.
14. The Diabetes Prevention Program Research Group. The diabetes prevention Program (DPP).
Diabetes Care 2002; 23(12): 2165-71.
15. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulpfonylureas or
insulin compared with conventional treatment and risk of complications in patients with type 2
diabetes. Lancet 1998; 352: 837-53.

48. Diagnosis and types
Curriculum Module II-1
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Slides current until 2008
References
16. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of
macrovascular and microvascular complications in type 2 diabetes UKPDS 38. BMJ
1998; 317: 703-13.
17. IDF Clinical Guidelines Task Force. Global Guideline for Type 2 Diabetes. Brussels:
International Diabetes Federation, 2005.
18. Harris SB, Ekoe JM, Zdanowicz Y, Webster-Bogaert S. Glycemic Control and
morbidity in the Canadian primary care setting (results of the diabetes in Canada
evaluation study). Diab Research and Clin Pract 2005; 70: 90-7.