This document discusses various types of diabetes in young people. It begins by defining diabetes mellitus and describing the worldwide rise in prevalence. It then covers the main etiological types including Type 1, Type 2, other genetic defects, and diabetes resulting from diseases of the exocrine pancreas. Risk factors for Type 2 diabetes in children and adolescents are outlined. Maturity-onset diabetes of the young (MODY) is explained in detail, including the genetic defects involved and treatments. Diagnosis and management of diabetes in youth are also addressed.
Cardiovascular disease - more common in diabetic patients than in the general population
Dyslipidemia – common in patients with both types of diabetes.
Aggressive lipid treatment goals have been recommended for patients with type 2 diabetes
Diabetic Dyslipidemia is highly prevalent in the Indian diabetic population
Dyslipidemia in diabetes differs significantly with hypertriglyceridemia and small dense LDL-C
Cardiovascular disease - more common in diabetic patients than in the general population
Dyslipidemia – common in patients with both types of diabetes.
Aggressive lipid treatment goals have been recommended for patients with type 2 diabetes
Diabetic Dyslipidemia is highly prevalent in the Indian diabetic population
Dyslipidemia in diabetes differs significantly with hypertriglyceridemia and small dense LDL-C
GLP-1 is an incretin (hormone that increases insulin secretion in response to a meal), which is a 30-amino acid peptide secreted in response to the oral ingestion of nutrients by intestinal L cells.
GLP-1 receptors (GLP-1R) are located in islet cells, central nervous system, and other organs. GLP-1 is metabolized by the enzyme dipeptidyl peptidase-4 (DPP-4).
Incretin effect is a phenomenon whereby a glucose load delivered orally produces a much greater insulin secretion than the same glucose load administered intravenously.
This presentation is an overview of the entire GLP-1 system, followed by an introduction to leveraging its therapeutic potential using GLP-1 analogues (Exenatide, Liraglutide, Lixisenatide, Albiglutide, Dulaglutide) and DPP-4 inhibitors (Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin, Anagliptin, Teneligliptin, Alogliptin, Trelagliptin, Omarigliptin).
Shashikiran Umakanth delivered this talk at Manipal on 30th November, 2015
My Nephrology Registrar Seminar Talk from September 2013
Topics Covered
Pathogenesis of Diabetic Nephropathy
Other Renal Disease in Diabetes
Treatment of Diabetic Kidney Disease + The Joint Renal Diabetic Clinic
MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of...Dr. Om J Lakhani
Talk on MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of Metformin In CKD).
Presented on 25th June 2017 at THE METFORMIN MEET in Vadodara, India
GLP-1 is an incretin (hormone that increases insulin secretion in response to a meal), which is a 30-amino acid peptide secreted in response to the oral ingestion of nutrients by intestinal L cells.
GLP-1 receptors (GLP-1R) are located in islet cells, central nervous system, and other organs. GLP-1 is metabolized by the enzyme dipeptidyl peptidase-4 (DPP-4).
Incretin effect is a phenomenon whereby a glucose load delivered orally produces a much greater insulin secretion than the same glucose load administered intravenously.
This presentation is an overview of the entire GLP-1 system, followed by an introduction to leveraging its therapeutic potential using GLP-1 analogues (Exenatide, Liraglutide, Lixisenatide, Albiglutide, Dulaglutide) and DPP-4 inhibitors (Sitagliptin, Vildagliptin, Saxagliptin, Linagliptin, Anagliptin, Teneligliptin, Alogliptin, Trelagliptin, Omarigliptin).
Shashikiran Umakanth delivered this talk at Manipal on 30th November, 2015
My Nephrology Registrar Seminar Talk from September 2013
Topics Covered
Pathogenesis of Diabetic Nephropathy
Other Renal Disease in Diabetes
Treatment of Diabetic Kidney Disease + The Joint Renal Diabetic Clinic
MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of...Dr. Om J Lakhani
Talk on MANAGEMENT OF DIABETES IN CHRONIC KIDNEY DISEASE (Special reference to Use of Metformin In CKD).
Presented on 25th June 2017 at THE METFORMIN MEET in Vadodara, India
Non-pharmacological Management of Diabetes Mellitus.pptxSamson Ojedokun
Diabetes mellitus DM, is a metabolic disorder of biomolecules characterized by chronic hyperglycemia due to defects in insulin synthesis or utilization or both
DM requires lifelong therapy. A multidisciplinary approach is needed to control glycemia, as well as to limit the development of its devastating complications and manage such complications when they do occur.
Increases cost of living and reduces life expectancy
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
3. WHAT IS DIABETES?
•Diabetes mellitus is characterized by chronic
hyperglycemia with disturbances of
carbohydrate, fat, and protein metabolism
resulting from defects in insulin secretion, insulin
action, or both.
4. • The worldwide prevalence of DM has risen dramatically overthe past
two decades, from an estimated 30 million cases in 1985 to 382
million in 2013, India – 65.1 million
6. Classification
•Type 1 – beta cell destruction - 1A and 1B
•Type 2 (may range from predominantly insulin
resistance with relative insulin deficiency to a
predominantly secretory defect with or without
insulin resistance)
7. Other specific types of diabetes
• Genetic defects of beta cell development or function
characterized by mutations in:
• 1. Hepatocyte nuclear transcription factor (HNF) 4α
(MODY 1)
• 2. Glucokinase (MODY 2)
• 3. HNF-1α (MODY 3)
• 4. Insulin promoter factor-1 (IPF-1; MODY 4)
• 5. HNF-1β (MODY 5)
8. •6. NeuroD1 (MODY 6)
•7. Mitochondrial DNA
•8. Subunits of ATP-sensitive potassium channel
•9. Proinsulin or insulin
•10. Other pancreatic islet regulators/proteins
such as KLF11, PAX4, BLK,GATA4, GATA6, SLC2A2
(GLUT2), RFX6, GLIS3
9. Genetic defects in insulin action
• 1. Type A insulin resistance- triad of
hyperandrogenism, insulin resistance, acanthosis
nigricans(HAIR-AN)
• 2. Leprechaunism- Donohue syndrome- IUGR,
characteristic bird facies, fasting hypoglycaemia and
impaired glucose tolerance despite giving more than
100 times of insulin
10.
11. • RABSON-MENDENHALL SYNDROME - abnormalities in the
teeth and nails and pineal gland hyperplasia
• LIPOATROPHIC ATROPHY -a genetically heterogeneous group
of rare syndromes characterized by insulin-resistant diabetes
associated with a regional or complete absence of
subcutaneous adipose tissue and presence of
hypertriglyceridemia
I. Köbberling-Dunnigan syndrome(dominant)
II. Berardinelli-Seip syndrome(recessive)
III. Lawrence syndrome(total)
12. Diseases of the exocrine pancreas
• Pancreatitis
• Pancreatectomy
• Neoplasia
• Cystic fibrosis
• Hemochromatosis
• Fibrocalculous pancreatopathy
• Mutations in carboxyl ester lipase
13. Pancreatic diabetes
•PANCREATECTOMY:-
i. Loss of beta cells
ii. Decrease in secretion of insulin, glucagon and
epinephrine as well
iii. More prone to hypoglycemia
iv. Recovery from hypoglycemia is more
v. Leaner than type 1 DM
14. Pancreatic diabetes
• PANCREATITIS :-
I. 5% in chronic pancreatitis and 40-50% in chronic relapsing
pancreatitis
II. Glucagon level is markedly increased
• FIBROCALCIFIC PANCREATITIS :-
I. 80-90-% have overt diabetes
Cause – not established, but compromised blood flow to islets
from fibrotic scarring of exocrine pancreas may play a role
15. Pancreatic diabetes
•In a small series of patients with chronic
pancreatitis, a partial hepatic insulin resistance
was shown in the presence of pancreatic
polypeptide (PP) deficiency, which was reversible
by PP infusion
16. Pancreatic diabetes
• CYSTIC FIBROSIS :-
I. 50 %
II. Progressive insulin deficiency develops because of
fibrotic destruction of islets and a marked decrease
in β-cell mass
III. Islet amyloid deposition
IV. Mutations in CFTR gene(cystic fibrosis
transmembrane conductance regulator)
17. Pancreatic diabetes
•PANCREATIC CANCER :-
I. loss of β-cell mass
II. 2 fold rise in diabetes patients
III.Insulin-like growth factor (IGF) axis
IV.Islet amyloid polypeptide (IAPP)
25. WHY DIABETES IN YOUNG?
• Increase in the incidence and prevalence of diabetes mellitus type
1– In US the incidence is approximately 18 per 100,000 and incidence
is 1.7 per 1000 in children and adolescents.
• High fat diet
• Decrease in exercise
• Obesity
• Gene mutations
26. CLINCAL STAGES
• Normal glucose level
• Only on OGTT
• IFG/IGT
• Honeymoon period »Intensification»Total diabetes
• Gestational
27. Type 1 diabetes mellitus
• Presence of circulating antibodies like
1. Cytoplasmic circulating antibodies (ICAs)
2. Insulin antibodies (IAAs)
3. Glutamic acid decarboxylase (GAD)antibodies
4. 64-kilodalton (IA-2) autoantibodies to tyrosine
phosphatases ( IS-2 and IA-β)
5. Beta cell–specific zinc transporter(ZnT-8) antibody
28. • Environmental factors, including foods , toxins, and
viruses, have been suggested as triggers of the
autoimmune process in genetically susceptible
persons
• No strong family history.
• The concordance rate in identical twins is only 30% to
50%
29. • Type 1A diabetes shows strong associations with specific haplotypes
or alleles at the DQ-A and DQ-B loci of the human leukocyte antigen
(HLA) complex
• The rate of β-cell destruction is quite variable, being rapid in some
individuals, especially in infants and children, and slower in adults
• Some have modest fasting hyperglycemia that can rapidly change to
severe hyperglycemia or ketoacidosis, and others, particularly adults,
may retain some residual β-cell function for many years and have
sometimes been termed as having “latent autoimmune diabetes”
30. Type 1A
• Type 1 diabetes have low or undetectable levels of
insulin and plasma C-peptide. They are also more
likely to have other concomitant autoimmune
disorders, such as Graves disease, Hashimoto
thyroiditis, Addison disease, vitiligo, or pernicious
anemia.
31. Type 1B
• Idiopathic
• is characterized by low insulin and C-peptide levels similar to those in type 1A
• Prone to ketoacidosis, although they have no clinical evidence of autoimmune
antibodies
• African or Asian origin.
• They may suffer from episodic ketoacidosis, but the pathogenetic basis for their
insulinopenia remains obscure.
32. Type 2
• Most common form of Diabetes
• Specific etiology for this Diabetes is not known
• It is characterized by disorders of insulin action and insulin
secretion, either of which may be predominant feature.
• Ketoacidosis seldom occurs
33. RISK FACTORS FOR DM2 IN CHILDREN AND ADULTS
• Physical inactivity.
• Signs of insulin resistance such as hypertension,
hyperlipidemia, and polycystic ovarian syndrome
• Family history.
• Ethnic background and race
34. • Previous history of gestational diabetes.
• Gender disparity – female:male = 2:1 in type 2 DM in
comparison no gender difference in type 1
• Acanthosis nigricans
• Body mass index ≥27 kg/m2; BMI 85th percentile for age and
gender; weight for height >85th percentile; >120% ideal
body weight
35. • ≥10 y of age (in mid or late puberty)
• African-American, Hispanic, Asian, and American Indian
descent
36. Type 2 DM in young
• First identified in 1970s.
• And now has become a major medical and public health
problem as a result of burgeoning epidemic of childhood
obesity.
37. • Like type 2 diabetes in adults, the increase in youth is the direct result
of greater caloric intake with decreased caloric expenditure.
• Poor eating habits, eating high-calorie, high-fat, “super-sized” fast
foods
• Spend an increased amount of time watching television or using
computers or playing video games
• Almost all youths with type 2 diabetes are overweight and have a
positive family history of type 2 diabetes
38. Prevalence of DM 2 in children and
adolescents
• The first data on type 2 diabetes in youth are from the Pima Indians,
the group with the world's highest prevalence of type 2 diabetes
• In 1979, the prevalence of type 2 diabetes was 1 in 1,000 children 5
to 14 years of age and 9 in 1,000 youths 15 to 24 years of age
• By 1996, the prevalence had increased to 22.3 per 1,000 in the 10- to
14-year-old age group and 50.9 per 1,000 in the 15- to 19-year-old
group
41. Differential Diagnosis of Type 1 and Type 2 Diabetes in Children
and Adolescents
Type 1: immune-mediated diabetes Type 2: non-immune-mediated diabetes
Not generally overweight Overweight/obese (85%)
Low endogenous insulin Signs of insulin resistance
Low C-peptide High endogenous insulina
Positive insulin and pancreatic autoantibodies High C-peptide levelsa
High ketone levels (30%–40% have ketoacidosis) Low ketone levels (<33% have ketonuria; 5%–
25% have ketoacidosis)
aCan be suppressed for 2 to 3 months after diagnosis
42. When to test for Diabetes in youth??
• As recommended by NIDDK,CDC,ADA and AAP testing for
Diabetes should begin at 10 years of age or at the onset of
puberty if earlier, in overweight, any of the following 2 :
1. f/h/o of 1st or 2nd degree relative
2. Race/ethnicity: African, Hispanic, Asian/South Pacific, and
Native-American descent.
3. Signs of insulin resistance such as hypertension,
hyperlipidemia, or polycystic ovary syndrome (PCOS)
44. Treatment
• In DKA and NKHHS insulin is the main line of treatment.
• Initially tried with medical nutritional therapy, weight loss and increased physical
activity.
• FDA has approved insulin and now metformin for children more than 12 years
• There are currently NIH-funded multicenter clinical trials under way to examine
treatment and prevention strategies of type 2 diabetes in youth.
46. Maturity-Onset Diabetes of the Young
• MODY is a monogenic autosomal dominant, heterogeneous form of
diabetes.
• It is related to a defect in insulin secretion by the β-cells in the
pancreas rather than to an impairment of insulin sensitivity.
• 1% to 3% of people with diabetes have MODY
• 10–30 years of age, although it can be as early as 2 to 3 years of age
47. • The majority of individuals with MODY are not overweight.
• This diagnosis should be entertained in children and
adolescents with a strong family history of diabetes in
multiple generations
50. Glucokinase (MODY2)
Expressed in b-cells and liver
It catalyzes the formation of glucose-6-phosphate from glucose.
Beta cells - “Glucose sensor” Control rate of Glucose phosphorylation
Liver – Helps in storage of glucose as glycogen
Mild stable hyperglycemia
Does not respond to Sulfonylureas
51. Liver-enriched transcription factors
HNF-1a, HNF-1b, and HNF-4a(3,5,1)
Expressed in liver, pancreatic islets, kidneys and genitalia.
In Beta cells they regulate the expression of the insulin gene
Proteins involved in glucose transport and metabolism.
Mutations results in defect of insulin secretion response to
glucose, leading to progressive decline in glycemic control.
MODY 1 &3 responds to sulfonylurea initially.
52. MODY 4
Transcription factor IPF-1
Expressed in pancreatic islets
Central role in development of pancreas.
Mediates glucose-induced stimulation of insulin-
gene transcription
Exocrine pancreatic insufficiency may occur.
53. MODY 6
• Transcription factor Neuro-D1 (BETA2)
Rare
Expressed in pancreatic islets
Activates the transcription of the insulin gene
Required for normal development of the pancreatic islets
54. Phenotypic Expression and Natural History of
MODY
Recognition at young age
1.Mild, asymptomatic increase in blood glucose in a child,
adolescent or young adult(<25 years)
2. Prominent family history of diabetes in 2-3 generations
3. Usually not associated with obesity
Not progressive, or slowly progressive hyperglycemia
Hyperglycemia responsive to diet and/or oral
anti-hyperglycemic agents for years to decades
55. When to suspect MODY
When to suspect MODY
a “type 1″ diabetes patient who has negative blood testing for
autoantibodies.
a “type 1″ diabetes patient who generates a significant amount of
insulin for years beyond diagnosis (detectable blood levels of c-
peptide, proinsulin, and/ or insulin)
a “type 2″ diabetes patient who is normal weight and shows no signs
of insulin resistance.
a diabetes with family history of early onset diabetes for 2-3
generations.
Diabetes paired with pancreatic insufficiency
Individual or family history of diabetes paired with developmental
kidney disease or kidney cysts
56. Genetic Testing
Only definitive way to confirm MODY
Blood or saliva
Not all mutations cause diabetes
Each child will have a 50% chance of inheriting the gene
1st degree relatives have a 50% chance of carrying the same
gene mutation
57. Rx for MODY
Rx depends on the involved gene and other factors
MODY 3 and 1 can be treated initially with sulfonylureas,
prompts the body to produce insulin.
Usually GCK-MODY requires no treatment at all.
Other type of MODY Rx is unclear may require multiple
daily Insulin injections.
58.
59. LATENT AUTOIMMUNE DIABETES OF
ADULTHOOD
Late-onset autoimmune diabetes of adulthood
Slow Onset Type 1 diabetes
Type 1.5 diabetes - Type 1 diabetes develops in adults
Mistakenly diagnosed as T2DM
60. Characteristics of LADA
Adult age (usually over 30 years) at time of diagnosis
May initially appear to be non-obese Type 2 diabetes
May initially be controlled with nutrition and exercise
Patient gradually becomes dependent on insulin
Positive for auto-antibodies
Low C-peptide levels in the body
Often does not have a family history of Type 2 diabetes
61. LADA Vs T2DM
C-peptide levels
LADA have low level VS Normal or high in T2DM
Glutamic acid decarboxylase(GAD) autoantibodies – Common in T1DM
Early age of onset
Non obese individuals
No family history of early onset diabetes
Ketosis prone
May requires insulin after initial 6 months
63. Management of LADA
LADA often does not require insulin at the time of diagnosis and may
be managed with diet and exercise.
Due to destruction of the β-cells, they become insulin dependent
more rapidly than “classic” type 2 diabetes
May require multiple daily Insulin injections(after 6 months)
66. • Puberty sets in insulin resistance due to increase in
production of growth hormone and sex hormone.
• Insulin requirements go up by more than 50%
• HBA1c should be monitored.
68. Goals for Glycemic Control for Children, Adolescents, and Young Adults with Diabetes
Blood glucose goal range(mg/dl)
Values by age Before meals Bedtime/overnight HBA1c
Toddlers and preschoolers
Whole blood 90-180 100-200 7-9%
Plasma 100-200 110-220
School age
Whole blood 70-80 90-180 ≤8%
Plasma 80-200 100-200
Adolescents and young
aduts
Whole blood 70-150 80-160 ≤7%
plasma 80-170 90-180
70. INSULIN therapy
• By insulin syringes, pens, pumps and air injectors
• The small insulin needs of infants and toddlers may require
insulin diluted to U10, U25, or U50 as opposed to the
standard U100 preparations (100 U/mL)
• FDA approved lispro and aspart but glargine not below 6
years
• Premixed insulins are not recommended in the pediatric
population unless all other insulin programs have failed
• Insulin pumps
71. Usual Subcutaneous Daily Dosages of Insulin in Children and
Adolescents with Diabetes
Type Non DKA presentation DKA presentation
Type 1 diabetes
Child, prepubertal 0.25-0.5 U/kg per day 0.5-0.75 U/kg per day
Adolescent, pubertal 0.5-0.75 U/kg per day 0.75-1.0 U/kg per day
Type 2 diabetes
Adolescent 20-40 U/kg per day
Lispro/glargine
74. Diabates care
• Optimal and individualized glycemic control
• Self-monitoring of blood glucose
• HbA1c testing (2–4 times/year)
• Patient education in diabetes management (annual);
diabetes-self management education and support
• Medical nutrition therapy and education (annual)
• Eye examination (annual or biannual)
• Foot examination (1–2 times/year by physician; daily by
patient)
75. • Screening for diabetic nephropathy (annual)
• Blood pressure measurement (quarterly)
• Lipid profile and serum creatinine (estimate GFR)
(annual)
• Influenza/pneumococcal/hepatitis B immunizations
• Consider antiplatelet therapy
76. TAKE AWAY MESSAGE
1. Eat healthy food
2. Exercise regularly
3. Avoid fatty/saturated foods
4. Avoid alcohol
5. We are all prone for diabetes