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Wednesday, September 17, 2008
Glycemic control and vascular complications in type 2 diabetes mellitus

INTRODUCTION

Morbidity from diabetes is a consequence of both macrovascular disease (atherosclerosis) and microvascular disease (retinopathy, nephropathy, and neuropathy). Prospective, randomized clinical trials such as the Diabetes Control and Complications Trial (DCCT), the United Kingdom Prospective Diabetes Study (UKPDS), and the Kumamoto study have demonstrated that intensive therapy aimed at lower levels of glycemia results in decreased rates of retinopathy, nephropathy, and neuropathy in type 1 and 2 diabetes patients [1-3] .

The importance of tight glycemic control for protection against cardiovascular disease in diabetes has also been established in the DCCT/EDIC study for type 1 diabetes [1] . However, the role of glycemic control in reducing cardiovascular risk has not been established for type 2 diabetes. The effects of glycemic control on microvascular and macrovascular complications in type 2 diabetes will be reviewed here. Glycemic control and vascular complications in type 1 diabetes is discussed separately. (See "Glycemic control and vascular complications in type 1 diabetes mellitus", which also reviews the mechanism by which hyperglycemia might cause these complications). The treatment of diabetes is also discussed elsewhere. (See "Overview of medical care in adults with diabetes mellitus").

HYPERGLYCEMIA AND MICROVASCULAR DISEASE
— Hyperglycemia is an important risk factor for the development of microvascular disease in patients with type 2 diabetes, as it is in patients with type 1 diabetes. This has been shown in several observational studies [4-6] . In addition, improving glycemic control improves microvascular outcomes, as illustrated by the following randomized trials:

United Kingdom Prospective Diabetes Study
— The UKPDS was designed to compare the efficacy of different treatment regimens (diet, sulfonylurea drug, metformin, and insulin) on glycemic control and the complications of diabetes in about 4000 newly diagnosed patients with type 2 diabetes [2,7] . The target fasting blood glucose concentration was 108 mg/dL (6 mmol/L) or less. Patients in the intensive-therapy group received a sulfonylurea (chlorpropamide, glibenclamide, or glipizide) or insulin; metformin was added to the sulfonylurea if optimal control was not achieved with the latter alone, and insulin was initiated if the combination of oral agents remained ineffective. The conventional-therapy group was treated with diet alone; drugs were added if there were hyperglycemic symptoms or if the fasting blood glucose concentration was greater than 270 mg/dL (15 mmol/L). The following findings were noted:





  • Over 10 years, the average A1C value was 7.0 percent in the intensive-therapy group compared with 7.9 percent in the conventional-therapy group (11 percent reduction) (show figure 1).
  • The risk for any diabetes-related end point (see abstract for definition of endpoints [2] ) was 12 percent lower in the intensive-therapy group (P = 0.029) and 10 percent lower for any diabetes-related death (P = 0.34) (show figure 2). It was estimated that 19.6 patients would have to be treated to prevent any single end point in one patient in 10 years.
  • Most of the risk reduction in the intensive therapy group was due to a 25 percent risk reduction in microvascular disease (P = 0.001) (show figure 3); there was no reduction in macrovascular disease. (See "Macrovascular disease" below, section on UKPDS).
  • The benefits of intensive therapy appeared to be independent of the type of treatment administered.
  • Patients in the intensive therapy group had more hypoglycemic episodes and weight gain; weight gain was greater in those receiving insulin (4.0 kg) than in those receiving chlorpropamide (2.6 kg) or glibenclamide (1.7 kg).

The reduction in microvascular complications in patients receiving intensive therapy was of a smaller magnitude than in patients with type 1 diabetes in the DCCT [1] . In the DCCT, for example, the incidence of new retinopathy was 12 percent with intensive therapy versus 54 percent with conventional therapy. One possible explanation for this difference is that the difference in A1C values was smaller between the intensive and conventional therapy groups in the UKPDS (7.0 versus 7.9 percent) compared to the DCCT (7.2 versus 9.1 percent).

posted by ummu Fauzan @ 9:00 AM   10 comments
Sunday, January 21, 2007
Hyperglycaemia
Hyperglycaemia

Overview
Hyperglycaemia is a higher than normal high level of glucose in the blood. It is generally only seen in people with type 1 diabetes (insulin dependent diabetes). In this condition, which affect 1% of the population, the body produces little or no insulin. Insulin is essential for the building up of importent large molecules, such as protein and fats, from small molecules such as glucose and amino acids. The condition requaries life-long treatment, constant checking of the level of sugar (glucose) in the blood, and a regular watch for complications.

Hyperglycaemia can happen after you have eaten a big meal or when you are ill. Hyperglycaemia is not usually a serious conditionif the elevationin blood sugar is brief, but extremely high blood sugarscan become a medical emergency if not recognized and treated appropriately.

Symptoms
Symptoms of hyperglycaemia are the same as those of untreated diabetes. They do not appear suddenly, but over a period of time such are : constant thirst and dry mouth, weigh loss, genital itching, frequent urination, tiredness and weakness, blurred vision, tingling or numbness of the hands or feet, cuts and bruises that are slow to heal.

Causes
The following can cause of hyperglycaemia : emotional stress, change in medication, wrong (or missed dose) of insulin, less exercise than usual, change in eating habits, illness such as cold or throat infection.

Treatment
Type 1 diabetes is treated with insulin injections and diet and exercise control. Adjusting the levels of insulin in the blood and drinking fluids will help to bring glucose levels down.

Hyperglycaemia is rare in people with type 2 diabetes, but when it does occur it is a serious medical emergency that requariesurgent treatment.

Prevention
People with type 1 diabetes need to control their blood glucose levels by maintaining the right combination of diet and insulin injections (or tablets).

It is important not to miss or after your dose of insulin and to maintain your fluid and food intake. It is also important that you test your blood glucose levels regularly.


posted by ummu Fauzan @ 7:55 AM   1 comments
Wednesday, October 04, 2006
Diabetes diet
The proper diet is critical to diabetes treatment. It can help someone with diabetes:
* Achieve and maintain desirable weight. Many people with diabetes can control their blood glucose by losing weight and keeping it off.
* Maintain normal blood glucose levels.
* Prevent heart and blood vessel diseases, conditions that tend to occur in people with diabetes.

A doctor will usually prescribe diet as part of diabetes treatment. A dietitian or nutritionist can recommend a diet that is healthy, but also interesting and easy to follow. No one has to be limited to a preprinted, standard diet. Someone with diabetes can get assistance in the following ways:
* A doctor can recommend a local nutritionist or dietitian.
* The local American Diabetes Association, American Heart Association, and American Dietetic Association can provide names of qualified dietitians or nutritionists and information about diet planning.
* Local diabetes centers at large medical clinics, hospitals, or medical universities usually have dietitians and nutritionists on staff.

The guidelines for diabetes diet planning include the following:
* Many experts, including the American Diabetes Association, recommend that 50 to 60 percent of daily calories come from carbohydrates, 12 to 20 percent from protein, and no more than 30 percent from fat.
* Spacing meals throughout the day, instead of eating heavy meals once or twice a day, can help a person avoid extremely high or low blood glucose levels.
* With few exceptions, the best way to lose weight is gradually: one or two pounds a week. Strict diets must never be undertaken without the supervision of a doctor.
* People with diabetes have twice the risk of developing heart disease as those without diabetes, and high blood cholesterol levels raise the risk of heart disease. Losing weight and reducing intake of saturated fats and cholesterol, in favor of unsaturated and monounsaturated fats, can help lower blood cholesterol. For example, meats and dairy products are major sources of saturated fats, which should be avoided; most vegetable oils are high in unsaturated fats, which are fine in limited amounts; and olive oil is a good source of monounsaturated fat, the healthiest type of fat. Liver and other organ meats and egg yolks are particularly high in cholesterol. A doctor or nutritionist can advise someone on this aspect of diet.
* Studies show that foods with fiber, such as fruits, vegetables, peas, beans, and whole-grain breads and cereals may help lower blood glucose. However, it seems that a person must eat much more fiber than the average American now consumes to get this benefit. A doctor or nutritionist can advise someone about adding fiber to a diet.
Points to Remember
A diabetes diet should do three things; achieve ideal weight, maintain normal blood glucose levels, and limit foods that contribute to hear disease.
A nutritionist or dietitian can help plan a diabetes diet.
* Exchange lists are useful in planning a diabetes diet. They place foods with similar nutrients and calories into groups. With the help of a nutritionist, the person plans the number of servings from each exchange list that he or she should eat throughout the day. Diets that use exchange lists offer more choices than preprinted diets. More information on exchange lists is available from nutritionists and from the American Diabetes Association.

Continuing research may lead to new approaches to diabetes diets. Because one goal of a diabetes diet is to maintain normal blood glucose levels, it would be helpful to have reliable information on the effects of foods on blood glucose. For example, foods that are rich in carbohydrates, like breads, cereals, fruits, and vegetables break down into glucose during digestion, causing blood glucose to rise. However, scientists don't know how each of these carbohydrates affect blood glucose levels. Research is also under way to learn whether foods with sugar raise blood glucose higher than foods with starch. Experts do know that cooked foods raise blood glucose higher than raw, unpeeled foods. A person with diabetes can ask a doctor or nutritionist about using this kind of information in diet planning.
posted by ummu Fauzan @ 12:57 AM   0 comments
Tuesday, October 03, 2006
Diagnosis and classification DM: New criteria.
New recommendations for the classification and diagnosis of diabetes mellitus include the preferred use of the terms "type 1" and "type 2" instead of "IDDM" and "NIDDM" to designate the two major types of diabetes mellitus; simplification of the diagnostic criteria for diabetes mellitus to two abnormal fasting plasma determinations; and a lower cutoff for fasting plasma glucose (126 mg per dL [7 mmol per L] or higher) to confirm the diagnosis of diabetes mellitus.

These changes provide an easier and more reliable means of diagnosing persons at risk of complications from hyperglycemia. Currently, only one half of the people who have diabetes mellitus have been diagnosed. Screening for diabetes mellitus should begin at 45 years of age and should be repeated every three years in persons without risk factors, and should begin earlier and be repeated more often in those with risk factors.

Risk factors include obesity, first-degree relatives with diabetes mellitus, hypertension, hypertriglyceridemia or previous evidence of impaired glucose homeostasis. Earlier detection of diabetes mellitus may lead to tighter control of blood glucose levels and a reduction in the severity of complications associated with this disease.

Diabetes mellitus is a group of metabolic disorders with one common manifestation: hyperglycemia. Chronic hyperglycemia causes damage to the eyes, kidneys, nerves, heart and blood vessels. The etiology and pathophysiology leading to the hyperglycemia, however, are markedly different among patients with diabetes mellitus, dictating different prevention strategies, diagnostic screening methods and treatments. The adverse impact of hyperglycemia and the rationale for aggressive treatment have recently been reviewed.

Previous Classification
Diabetes mellitus that is characterized by absolute insulin deficiency and acute onset, usually before 25 years of age, should now be referred to as type 1 (not type I, IDDM or juvenile) diabetes mellitus.

In 1979, the National Diabetes Data Group produced a consensus document standardizing the nomenclature and definitions for diabetes mellitus. This document was endorsed one year later by WHO. The two major types of diabetes mellitus were given names descriptive of their clinical presentation: "insulin-dependent diabetes mellitus" (IDDM) and "non­insulin-dependent diabetes mellitus" (NIDDM).
However, as treatment recommendations evolved, correct classification of the type of diabetes mellitus became confusing. For example, it was difficult to correctly classify persons with NIDDM who were being treated with insulin. This confusion led to the incorrect classification of a large number of patients with diabetes mellitus, complicating epidemiologic evaluation and clinical management. The discovery of other types of diabetes with specific pathophysiology that did not fit into this classification system further complicated the situation. These difficulties, along with new insights into the mechanisms of diabetes mellitus, provided a major impetus for the development of a new classification system.
The National Diabetes Data Group also established the oral glucose tolerance test (using a glucose load of 75 g) as the preferred diagnostic test for diabetes mellitus. However, this test has poor reproducibility, lacks physiologic relevance and is a weaker indicator of long-term complications compared with other measures of hyperglycemia.6 Furthermore, many high-risk patients are unwilling to undergo this time-consuming test on a repeat basis. The new diagnostic criteria also address this issue.

Changes in the Classification System
The new classification system identifies four types of diabetes mellitus: type 1, type 2, "other specific types" and gestational diabetes. Arabic numerals are specifically used in the new system to minimize the occasional confusion of type "II" as the number "11." Each of the types of diabetes mellitus identified extends across a clinical continuum of hyperglycemia and insulin requirements.
Any patient with two fasting plasma glucose levels of 126 mg per dL (7.0 mmol per L) or greater is considered to have diabetes mellitus.
Type 1 diabetes mellitus (formerly called type I, IDDM or juvenile diabetes) is characterized by beta cell destruction caused by an autoimmune process, usually leading to absolute insulin deficiency.
the onset is usually acute, developing over a period of a few days to weeks. Over 95 percent of persons with type 1 diabetes mellitus develop the disease before the age of 25, with an equal incidence in both sexes and an increased prevalence in the white population. A family history of type 1 diabetes mellitus, gluten enteropathy (celiac disease) or other endocrine disease is often found.
Most of these patients have the "immune-mediated form" of type 1 diabetes mellitus with islet cell antibodies and often have other autoimmune disorders such as Hashimoto's thyroiditis, Addison's disease, vitiligo or pernicious anemia.
A few patients, usually those of African or Asian origin, have no antibodies but have a similar clinical presentation; consequently, they are included in this classification and their disease is called the "idiopathic form" of type 1 diabetes mellitus.

Type 2 diabetes mellitus (formerly called NIDDM, type II or adult-onset) is characterized by insulin resistance in peripheral tissue and an insulin secretory defect of the beta cell.2,7 This is the most common form of diabetes mellitus and is highly associated with a family history of diabetes, older age, obesity and lack of exercise. It is more common in women, especially women with a history of gestational diabetes, and in blacks, Hispanics and Native Americans. Insulin resistance and hyperinsulinemia eventually lead to impaired glucose tolerance. Defective beta cells become exhausted, further fueling the cycle of glucose intolerance and hyperglycemia. The etiology of type 2 diabetes mellitus is multifactorial and probably genetically based, but it also has strong behavioral components.
Types of diabetes mellitus of various known etiologies are grouped together to form the classification called "other specific types." This group includes persons with genetic defects of beta-cell function (this type of diabetes was formerly called MODY or maturity-onset diabetes in youth) or with defects of insulin action; persons with diseases of the exocrine pancreas, such as pancreatitis or cystic fibrosis; persons with dysfunction associated with other endocrinopathies (e.g., acromegaly); and persons with pancreatic dysfunction caused by drugs, chemicals or infections.

TABLE 1 Etiologic Classifications of Diabetes Mellitus
Type 1 diabetes mellitus*
Type 2 diabetes mellitus*
Other specific types:
Genetic defects of beta-cell function
Genetic defects in insulin action
Diseases of the exocrine pancreas
Pancreatitis
Trauma/pancreatectomy
Neoplasia
Cystic fibrosis
Hemochromatosis
Others
Endocrinopathies
Acromegaly
Cushing's syndrome
Glucagonoma
Pheochromocytoma
Hyperthyroidism
Somatostatinoma
Aldosteronoma
Others
Drug- or chemical-induced
Vacor†
Pentamidine
Nicotinic acid
Glucocorticoids
Thyroid hormone
Diazoxide
Beta-adrenergic agonists
Thiazides
Phenytoin
Alfa-interferon
Others
Infections
Congenital rubella
Cytomegalovirus
Others
Uncommon forms of immune- mediated diabetes
Other genetic syndromes sometimes associated with diabetes
Down syndrome
Klinefelter's syndrome
Turner's syndrome
Wolfram syndrome
Friedreich's ataxia
Huntington's chorea
Lawrence-Moon Beidel syndrome
Myotonic dystrophy
Porphyria
Prader-Willi syndrome

Final Comment
The changes recommended by the expert committee for the diagnosis of diabetes mellitus should prove beneficial to patients. Measurement of fasting plasma glucose levels should be more acceptable to patients than the oral glucose tolerance test and can be readily incorporated with fasting lipid determinations. Identifying asymptomatic persons earlier in the disease process will allow earlier institution of lifestyle changes and medical therapy that may decrease the complications of hyperglycemia. The National Diabetes Data Group emphasizes that these changes in diagnostic criteria have not changed the treatment goals in patients with diabetes mellitus. These goals include maintaining a fasting plasma glucose level of less than 120 mg per dL (6.65 mmol per L) and a glucose hemoglobin measurement of less than 7.0 percent.
Figure 1 adapted with permission from Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20: 1183-97.

By: JENNIFER MAYFIELD, M.D., M.P.H.
posted by ummu Fauzan @ 8:00 AM   0 comments
Thursday, September 28, 2006
Gestational diabetes

Gestational diabetes is type of diabetes that is only suffered by pregnat women.

In gestational diabetes, a women's blood sugar is higher than normal because of the other hormones pridcued during pregnancy interfere with the insulin that is produced naturally.

Gestational diabetes usually becomes apparent during the 24th tom 28th, weeks of pregnancy, and in most cases, disappears of it own accord once the baby is born.

Women with gestational diabetes usually do not have an increased risk of having baby with birth defects.

Generally, sufferers of gestational diabetes have normal blood sugar levels during the critical first stages of the pregnancy.
Whilst there can be complications caused by gestational diabetes, these can usually be managed by careful attention to nutrition and blood sugar levels.

Approximately 3 to 5 percent of all pregnant women in the developed world suffer from gestational diabetes.
posted by ummu Fauzan @ 1:47 PM   0 comments
Thursday, August 24, 2006
Blood Sugar Level
What should glucose level be?


The ideal values are:
- 4 to 7 mmol/l before meals.
- Less than 10 mmol/l, 90 minutes after a meal.
- Around 8 mmol/l at bedtime.

If blood glucose is very low (hypoglicemia), where the level of blood sugar in the blood drops below a certain point - about 3 mmol/l, you may need to adjust your food intake or insulin dose. (make sure you discuss this with your doctor).
What hapens during a hypo?
you can experience some or all of the following symptoms:
Paleness, shaking, perspiration, a feeling of weakness, rapid heartbeat, hunger, agitation, dificulty concentrating, irritability, fatigue, blurred vision, temporary loss of consciousness, confusion, convulsion, coma.
most people do get some warning that hypoglicemia is happening.
But for some, hypoglicemia may cause few or none of the milder symptoms before the start of sudden unconciousness or convulsions - particulary if you've had diabetes for many years. This means loss of conciousness can occur without warning. To avoid this, you are advised to: mantain a higher level of glucose in the blood & measure your blood sugar level more frequently.By Dr.Ian W Campbell.

High Blood Sugar (Hyperglicemia)
High Blood Sugar (Hyperglicemia) is most often seen in people who have diabetes that is not well controlled. The symptoms of high blood sugar can be mild, moderate, or severe.

Symptoms of mild high blood sugar include:
. Increased thirst and urination, especially at night.
. Warm, dry skin.
. A rapid heart rate with a weak pulse.

Symptoms of moderate high blood sugar include:
. Dizziness or weakness when sitting or standing.
. Dark, concentrated urine in decreasing amounts.
. Gradual blurring of vision.

Symptoms of severe high blood sugar include:
.Drowsiness and difficulty waking up.
. Increased weakness.
. Sometimes, loss of conciousness.

if your blood sugar levels is remain high, such as above 13.8 mmol/l, and you become dehydrated, you are at risk of getting a life-threatening condition called hyperosmolar state or diabetic ketoacidoses. These are both medical emergencies.

Get medical help immediately if you have symptoms of diabetic ketoacidoses:
. Rapid, deep breathing
. Fruity breath odor.
. Loss of appetite, belly pain, and vomiting.
writen by Caroline S. Rhoads, MD
posted by ummu Fauzan @ 5:55 PM   3 comments
Monday, August 21, 2006
Sliding Scale For Insulin

Blood Sugar Level, if below 8 mmol/l dont give Insulin.

Blood Sugar Level, if between 8.1mmol/l - 11mmol/l: give 4 IU actrapid.

Blood Sugar Level, if between 11.1 mmol/l - 14 mmol/l: give 6 IU actrapid.

Blood Sugar Level, if between 14.1 mmol/l - 17 mmol/l: give 8 unit actrapid.

Blood Sugar Level, if between 17.1 mmol/l - 20 mmol/l: give 10 IU actrapid.

Blood Sugar Level, if above 20 mmol/l : give 10 IU actrapid and recheck after 4 hours.
posted by ummu Fauzan @ 3:25 PM   1 comments
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