This document provides information about an upcoming event celebrating World Diabetes Day hosted by the Egyptian Society of Metabolic Syndrome. It includes contact information for Dr. Usama Ragab, who is a speaker at the event. The event will take place on November 16, 2023 at the Sharkia Medical Syndicate. The document also contains slides on topics related to diabetes classification, diagnosis, and epidemiology.

1. Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
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Egyptian Society of Metabolic Syndrome (ESMA)
World Diabetes Day Celebration 2023
16 NOV 2023 – Sharkia Medical Syndicate

2. Cost related to
diabetes
D R . U S A M A R A G A B Y O U S S I F 2

3. Represents 2 million people.
Diabetes is mostly (85–95%) T2D.1
• T2D approximately doubles the risk
of death2
• Diabetes caused 6.7 million deaths
in 20211
• CVD is the principal cause of death
in T2D2,3
1.76
1.85
1 1.5 2.0
T2D is increasingly prevalent and CVD is the leading
cause of death in this population
3
1. IDF Diabetes Atlas, 2021. 10th Edition. http://www.idf.org/diabetesatlas.
2. Nwaneri et al. Br J Diabetes Vasc Dis 2013;13:192–207. 3. Morrish et al. Diabetologia 2001;44(suppl 2):S14–21.
• Globally, 537 million people are living
with diabetes1
• Rising to 783 million by 20451
Relative risk for
all-cause mortality
Relative risk for
CV mortality

4. Diabetes in Middle-East and North Africa

5. 5 | IDF Diabetes Atlas 2021– 10th edition www.idf.org @IntDiabetesFed
Top 10 countries with diabetes
In adults aged 20–79 years and diabetes-related health expenditure, 2021

6. Top 10 countries or territories for number of adults (20–79 years)
with diabetes in 2021 and 2045

7. Definition
Diabetes is a chronic, metabolic disease characterized by elevated
levels of blood glucose
Affects also fat and protein metabolism
Which leads over time to serious damage to the heart, blood
vessels, eyes, kidneys and nerves.

8. Many definitions BUT
Blood glucose still the
basis for diabetes
diagnosis

9. Concept of classification
Insulin
deficiency
Insulin not
working
Both
Any with a
cause
Diabetes in
pregnant
ladies

10. Diabetes can be classified into the
following general categories
1. Type 1 diabetes
2. Type 2 diabetes
3. Specific types of diabetes due to other causes
4. Gestational diabetes mellitus (diabetes diagnosed in the second
or third trimester of pregnancy that was not clearly overt
diabetes prior to gestation)
Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

11. Type 1 vs Type 2
DM
Completely different

12. Type 1 DM
•Immune mediated
•Idiopathic
•Includes LADA
Pancreatic beta
cell destruction,
usually leading
to absolute
insulin
deficiency

13. | 13
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

14. | 14
Type 1 Diabetes
CLASSIFICATION AND DIAGNOSIS OF DIABETES
2.5 Screening for presymptomatic T1D using screening tests that
detect autoantibodies to insulin, glutamic acid decarboxylase
(GAD), islet antigen 2, or zinc transporter 8 is currently
recommended in the setting of a research study or can be
considered an option for first-degree family members of a proband
with type 1 diabetes. B
2.6 Development of and persistence of multiple islet
autoantibodies is a risk factor for clinical diabetes and may serve as
an indication for intervention in the setting of a clinical trial or
screening for stage 2 type 1 diabetes. B
Classification and Diagnosis of Diabetes: Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

15. Type 2 DM
Due to a non-autoimmune progressive loss of
adequate ß-cell insulin secretion frequently on
the background of insulin resistance and
metabolic syndrome
May range from
• predominantly insulin resistance with relative insulin
deficiency to
• predominantly insulin secretory defect with insulin
resistance

16. Sometimes diabetes cannot
fit onto certain category
T1D before 6 months of age
Young obese child
Young NON obese, NON catabolic,
MILD, with family history
Diabetes developing after
intervention

17. Specific types of Diabetes
1. Genetic defects of beta -cell function= monogenic diabetes
syndromes (such as neonatal diabetes and maturity-onset diabetes of
the young)
2. Genetic defects in insulin action e.g., insulin dystrophy
3. Diseases of the exocrine pancreas (such as cystic fibrosis and
pancreatitis)
4. Drug- or chemical-induced diabetes (such as with glucocorticoid use,
in the treatment of HIV/AIDS, or after organ transplantation)
5. Endocrinopathies e.g., Cushing syndrome…
6. Genetic syndromes associated with diabetes e.g., Down syndrome

18. Monogenic
diabetes
• Certain genetic defect
• Mostly AD
• Defect leads to abnormal beta
cell function
• Different types
• Includes neonatal diabetes and
MODY

19. The diagnosis of
monogenic
diabetes should
be considered in
children and
adults
diagnosed with
diabetes in early
adulthood with
the following
Diabetes diagnosed within the first 6 months of life
(with occasional cases presenting later, mostly INS and
ABCC8 mutations)
Diabetes without typical features of type 1 or type 2
diabetes (negative diabetes-associated autoantibodies,
no obesity, lacking other metabolic features, especially
with strong family history of diabetes)
Stable, mild fasting hyperglycemia (100–150 mg/dL
[5.5–8.5 mmol/L]), stable A1C between 5.6% and 7.6%
(between 38 and 60 mmol/mol), especially if no obesity

22. PERSONAL USE ONLY
*Neonatal diabetes is a form of diabetes with onset <6 months of age, requires genetic testing, and may be amenable
to therapy with oral sulfonylurea in place of insulin therapy
Clinical
features
Type 1 diabetes Type 2 diabetes Monogenic diabetes
Age of onset
(yrs)
Most <25 by can occur at any age (but
not before the age of 6 months)
Usually >24 but incidence increasing in
adolescents, paralleling increasing rate of
obesity in children & adolescents
Usually <25
Neonatal diabetes <6 months*
Weight Usually thin, but with obesity epidemic,
can have overweight or obesity
>90% at least overweight Similar to general population
Islet auto-
antibodies
Usually present Absent Absent
C-peptide Undetectable/low Normal/high Normal
Insulin
production
Absent Present Usually present
First line
treatment
Insulin Non-insulin antihyperglycemic agents,
gradual dependence on insulin may occur
Depends on subtype of MODY
Family history
of diabetes
Infrequent (5-10%) Frequent (75-90%) Multigenerational, autosomal
pattern of inheritance
DKA Common Rare Rare (except for neonatal
diabetes*)
2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic
Syndrome 2018

23. Pancreatic diabetes
• Commonly misdiagnosed as T2D
• Has been called “type 3c diabetes” or pancreoprivic diabetes
• Easily use pancreatic diabetes as umbrella term
• Due to loss of structural and functional insulin secretion in context of
exocrine pancreatic dysfunction
• It includes:
Pancreatitis (acute and chronic),
trauma or pancreatectomy,
neoplasia,
fibrocalculous pancreatopathy
idiopathic forms

24. Post
Pancreatitis
Diabetes
Mellitus
(PPDM)
Even single but may lead to PPDM
Both acute and chronic pancreatitis can
lead to PPDM
Risk is highest with recurrent bouts.
PPDM versus T1DM: pancreatic exocrine
insufficiency
Risk of microvascular complication is the
same

25. Cystic
fibrosis–
related
diabetes
(CFRD)
CFRD is the most common comorbidity in
people with cystic fibrosis
CFRD occur in about 20% of adolescents
and 40–50% of adults.
Worse nutritional status, more severe
inflammatory lung disease, and greater
mortality.
Insulin insufficiency is the primary defect in
CFRD.
Moran A, et al. Pediatr Diabetes 2018;19(Suppl. 27):64–74

26. Cystic
fibrosis–
related
diabetes

27. Pregnancy

28. Diabetes in Pregnancy: 2 Categories
Pregestational diabetes Gestational diabetes
Pregnancy in
pre-existing diabetes
• Type 1 diabetes
• Type 2 diabetes
Diabetes diagnosed in
pregnancy
2018 Diabetes Canada CPG – Chapter 36. Diabetes and Pregnancy

29. PERSONAL USE ONLY
Universal screening for GDM
@ 24-28 weeks gestational age
Screen earlier if risk factors for GDM
2018 Diabetes Canada CPG – Chapter 36. Diabetes and Pregnancy
Gestational Diabetes (GDM)
Screening

30. Screening of
GDM
The “one-step” 75-g OGTT derived from the
IADPSG criteria, or
The older “two-step” approach with a 50-g
(non-fasting) screen followed by a 100-g OGTT
for those who screen positive based on the
work of Carpenter-Coustan’s interpretation of
the older O’Sullivan and Mahan criteria.

31. One-step Strategy

32. Two-step Strategy

33. Because the old definition is sometimes having limitations
BG threshold should be in mind
rather than timing
Risk for DM or prediabetes
should always be in mind

34. ‫سكر‬
‫خفيف‬

35. Diagnostic
pathway for
Diabetes in
Pregnancy

36. Diagnosis of
Diabetes

37. | 37
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

38. PERSONAL USE ONLY
Confirmatory test NOT required
• In the case of symptomatic hyperglycemia, the diagnosis has been made
and a confirmatory test is not required before treatment is initiated.
• To avoid rapid metabolic deterioration in individuals in whom type 1
diabetes is likely (younger or lean or symptomatic hyperglycemia,
especially with ketonuria or ketonemia), the initiation of treatment should not
be delayed in order to complete confirmatory testing
2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome
2hPG, 2-hour plasma glucose; AlC, glycated hemoglobin; FPG, fasting plasma glucose; OGTT, oral glucose
tolerance test; PG, plasma glucose.

39. PERSONAL USE ONLY
Considerations when using A1C for
Diagnosis
• Need validated standardized assay
• Repeat confirmatory test on another day
• Recognize conditions leading to misleading A1C
• A1C is not used for diagnosis in children, adolescents (as the sole
diagnostic test), pregnant women as part of routine screening for GDM,
those with cystic fibrosis (CFRD) or those with suspected T1DM
• Ethnicity and age can affect A1C results
2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome

40. Pitfalls of
A1c
• Decrease RBCs turnover e.g., anemia, asplenia
• Laboratory interference e.g., hypertriglyceridemia,
hyperbilirubinemia, ETOH
• Blood transfusion
False Elevation of HbA1c
• Increase RBCs turnover e.g., acute blood loss,
hemolysis, splenomegaly
• CKD
• EPO and iron treatment
• Inhibition of glycosylation e.g. vitamin C and E
• Dilutional effect
False Reduction of HbA1c
Radin MS. Pitfalls in hemoglobin A1c measurement: when results may be misleading. J Gen Intern Med. 2014 Feb;29(2):388-94.

41. PERSONAL USE ONLY
Pros and Cons of Diagnostic Tests
Test Advantages Disadvantages
FPG Established standard
Fast and easy
Single Sample
Sample not stable
Day-to-day variability
Inconvenient to fast
Glucose homeostasis in single time point
2hPG in 75
g OGTT
Established standard Sample not stable
Day-to-day variability
Inconvenient, Unpalatable
Cost
A1C Convenient
Single sample
Low day-to-day variability
Reflects long term glucose
$$$
Affected by medical conditions, aging, ethnicity
Standardized, validated assay required
Not applicable to every patient type
2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome
A1C, glycated hemoglobin; FPG, fasting plasma glucose; PG, plasma glucose

42. PERSONAL USE ONLY
Dealing with discordance in results
Many people identified as having diabetes
using A1C will not be identified as having
diabetes by traditional glucose criteria,
and vice versa.
When results of more than one test are available (FPG, A1C, 2hPG in a 75-g
OGTT) and the results are discordant, the test whose result is above diagnostic
cut-point should be repeated, and the diagnosis made on basis of the repeat test.
FPG 2hPG
A1C
2018 Diabetes Canada CPG – Chapter 3. Definition, Diagnosis & Classification of Diabetes, Prediabetes, Metabolic Syndrome
A1C, glycated hemoglobin; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; PG,
plasma glucose

43. Health Day A1c
• 2.1b Point-of-care A1C testing for
diabetes screening and diagnosis should
be restricted to U.S. Food and Drug
Administration–approved devices at
laboratories proficient in performing
testing of moderate complexity or higher
by trained personnel. B

44. Years from
diagnosis
0 5
-10 -5 10 15
Onset Diagnosis
Insulin secretion
Sources:
Ramlo-Halsted BA et al. Prim Care. 1999;26:771-789
Nathan DM et al. NEJM 2002;347:1342-1349
Fasting glucose
Insulin resistance
Microvascular complications
Macrovascular complications
Type II diabetes
Pre-diabetes
Postprandial
glucose
Natural History of Type II Diabetes Mellitus

45. https://www.cdc.gov/diabetes/library/socialmedia/infographics/prediabetes.html

46. | 46
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

47. | 47
Criteria for
screening for
diabetes or
prediabetes in
asymptomatic
adults
Classification and Diagnosis of Diabetes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

48. | 48
Prediabetes and Type 2 Diabetes
CLASSIFICATION AND DIAGNOSIS OF DIABETES
2.10 If tests are normal, repeat screening recommended at a
minimum of 3-year intervals is reasonable, sooner with symptoms or
change in risk (i.e., weight gain). C
2.11 To screen for prediabetes and type 2 diabetes, fasting plasma
glucose, 2-h plasma glucose during 75-g oral glucose tolerance test,
and A1C are each appropriate. B
2.12 When using oral glucose tolerance testing as a screen for
diabetes, adequate carbohydrate intake (at least 150 g/day) should
be assured for 3 days prior to testing. A

49. | 49
CLASSIFICATION AND DIAGNOSIS OF DIABETES
Classification and Diagnosis of Diabetes:
Standards of Care in Diabetes - 2023. Diabetes Care 2023;46(Suppl. 1):S19-S40

51. To sum-up
• Diabetes=
• Prediabetes=
• Types of diabetes=
• T1D=
• T2D=
• GDM=

53. Thanks
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863