Diabetes mellitus, dyslipidemia, obesity

Diabetes mellitus (DM)

 * Type 1 − Selective destruction of β-cells of Pancreas (autoimmunity, LADA) − absolute lack of insulin
 * Type 2 − Insulin resistance with a relative deficiency of insulin
 * Secondary − Pancreatogenic (surgical removal of pancreas, destruction by inflammation, tumor, injury) − insufficient or no insulin secretion
 * Gestational − Hyperglycemia during pregnancy (excessive size of the fetus)

Impaired glucose tolerance (IFG − impaired fasting glucose 5,6 − 6,9 mmol/l, IPG − impaired postprandial glycemia after 2 hours 7,8 − 10,9 mmol/l) DM (2).


 * The disease is characterized by hyperglycemia
 * Physiological range of glycemia 3,9–5,5 mmol/l
 * Determination of glycemia, insulin, C-peptide, glycated hemoglobin (HbA1c), possibly antibodies (anti GAD, ICA) − differential diagnosis DM.

Diagnostic criteria

 * Fasting glycemia > 7 mmol/l, postprandial glycemia after 2 hours > 11 mmol/l.

Examination of the patient for diabetic complications

 * Macrovascular (Stroke, acute M.I., ischemic diseases of the lower limbs)
 * Microvascular (retinopathy, nephropathy, neuropathy)

Anamnesis, examination

 * Polydipsia — excessive thirst associated with excessive fluid intake
 * Polyuria — excessive urination
 * Recurrent bacterial and fungal infections — Urogynecological, respiratory, skin;
 * Complications of DM — ophthalmic, neurological, nephrological, vascular, cardiological.

Therapy
Dietary measures − basic therapeutic modality:
 * 1) Normalization of fasting and postprandial glycemia (Regulation of carbohydrate content in the food and rate of carbohydrate absorption − glycemic index)
 * 2) Achieving optimal levels of lipids in blood (TAG, HDL)
 * 3) Ensuring sufficient energy supply
 * 4) Prevention and treatment of late complications

Diet

 * 5 − 6 meals per day − second dinner
 * Bread units (interchangeable unit)
 * 1 BU corresponds to 10 − 12 g of carbohydrates = 2 cubes of sugar (Reducing diabetic diet to 175 g of carbohydrates per day = 16 BU = 32 cubes of sugar)
 * Differences in the diet for type 1 and type 2 DM

Pharmacotherapy

 * Oral antidiabetics
 * Influencing the insulin resistance − Biquanides, Thiazolidinediones (glitazones)
 * Secretagogues − Derivatives of sulfonylurea, Non-sulfonylureas (glinides)
 * Inhibition of digestive enzymes in the GIT (α-glucosidase, lipase)
 * Dipeptidyl peptidase-IV inhibitors (gliptins)
 * Insulins (human, recombinant, analogues)

Dyslipidemia

 * Synonyms − Dyslipoproteinemia, hyperlipidemia, hyperlipoproteinemia
 * Lipidogram (lipid profile) − total cholesterol TC, triacylglycerols TAG, low density lipoprotein LDL, high density lipoprotein HDL, apolipoprotein B (apo B), apolipoprotein AI (apo AI)
 * Dyslipidemia is characterized by an altered Cholesterol level and/or triacylglycerides and/or HDL cholesterol
 * Atherogenic lipid phenotype − TAG, jLDLsd, J.HDL.

Division

 * Etiology
 * Primary − Genetic and lifestyle factors (composition and amount of food, smoking, alcohol, physical activity and body weight)
 * Secondary − Other diseases are involved in the development of dyslipidemia

From the clinical and therapeutic perspective, dyslipidemia is divided into three groups:
 * 1) Isolated hypercholesterolemia
 * 2) * Increased total Cholesterol (TC), mostly in the LDL-cholesterol fraction (LDL−C), with a normal concentration of triacylglycerides (TAG);
 * 3) Isolated hypertriacylglycerolemia
 * 4) * Increased TAG in combination with a normal cholesterol concentration (TC);
 * 5) Combined hyperlipidemia
 * 6) * Simultaneously increased levels of both TC and TAG.

Therapy
Lifestyle changes Diet Pharmacotherapy
 * Restricted diet, no consumption of alcohol, smoking, physical activity
 * Limiting intake of fat to 60 g/day, cholesterol intake 300 mg/day (egg yolk contains 250 mg), consumption of fiber 30 g/day − 500 g of fruits and vegetables, processed foods.
 * Statins (atorvastatin, simvastatin, fluvastatin, rosuvastatin)
 * Fibrates (fenofibrate)
 * Ezetimibe
 * Bile acid resins (Questran)
 * Combination of medications (simvastatin/ezetimibe)

Conclusion
Aiming to reach optimal levels of lipids, weight, and blood pressure to reduce the risk for cardiovascular diseases and mortality.

Obesity

 * Excessive storage of fat in the organism
 * Classification according to quantity (BMI) and quality (android type, gynoid type)
 * Physiologic amount of fat in women is 25−30 % and in men 20−25 %
 * BMI = weight (kg)/height (m)2.

Classification of body weight according to BMI
Anthropometry
 * Waist circumference − site of measurement: visible waist, respectively at the level of iliac crest and last rib
 * Physiologic value − men up to 94 cm, women up to 80 cm
 * Measurement of skin folds − bicipital, tricipital, subscapular, suprailiac
 * Bioelectrical impedance analysis for percentage of fat.

Therapy
Diet therapy
 * Aiming to reduce weight by 5−10 % and maintaining this weight
 * Significant reduction of risk for DM, hypertension, and cancer
 * Reduction of risk for complications of obesity − diseases of the musculoskeletal system, dyspnea and sleep apnea syndrome.
 * Restricted diet − regular meals, 5 − 6 times per day, regulated amount of proteins, less fat and sugar, limited amount of table salt (605 − 1770 kcal/day)
 * Pharmacotherapy − Anti-obesity drugs: sibutramin, orlistat, rimonabant
 * Physical activity − Exercise test (ergometry)

Metabolic syndrome
Raven syndrome, syndrome X
 * According to IDF 2005: waist M 94 cm and more, F 80 cm and more, increased TAG, arterial hypertension, DM or impaired glucose tolerance
 * Significant impact on quality of life, increased morbidity (complications of DM, dyslipidemia...), mortality (CVD)

Anamnesis

 * Family history: DM, endocrinopathies, CVD, Metabolic syndrome
 * Personal history: co-morbidities − DM + complications, CVD, nephropathy, endocrinopathies, infections
 * Gynecological history: deliveries, fetal weight (more than 4 kg), abortions
 * Addictions: smoking, alcohol consumption, drugs
 * Pharmacological history: corticoids, oral contraceptives, hormone replacement therapy, thyroid hormones, psychiatric drugs, oral antidiabetics, insulin

Conclusion

 * Complex approach − psychology, psychopathology, patient habits, background
 * Adjustment of lifestyle − physical activity
 * Diet therapy − planning of meals

Links
Original text is from Wikiskripta – https://www.wikiskripta.eu/index.php?curid=36984

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