1. These notes are important as said in the class by
Dr.Eman.
Diabetes
Diabetes mellitus, often simply referred to as diabetes, is a group of metabolic
diseases in which a person has high blood sugar, either because the body does
not produce enough insulin, or because cells do not respond to the insulin that is
produced. This high blood sugar produces the classical symptoms of polyuria
(frequent urination), polydipsia (increased thirst) and polyphagia (increased
hunger).
There are three main types of diabetes:
Type 1 diabetes: results from the body's failure to produce insulin, and
presently requires the person to inject insulin. (Also referred to as insulin-
dependent diabetes mellitus, IDDM for short, and juvenile diabetes.)
Type 2 diabetes: results from insulin resistance, a condition in which cells
fail to use insulin properly, sometimes combined with an absolute insulin
deficiency. (Formerly referred to as non-insulin-dependent diabetes
mellitus, NIDDM for short, and adult-onset diabetes.)
Gestational diabetes: is when pregnant women, who have never had
diabetes before, have a high blood glucose level during pregnancy. It may
precede development of type 2 DM.
Other forms of diabetes mellitus include congenital diabetes, which is due to
genetic defects of insulin secretion, cystic fibrosis-related diabetes, steroid
diabetes induced by high doses of glucocorticoids, and several forms of
monogenic diabetes.
All forms of diabetes have been treatable since insulin became available in 1921,
and type 2 diabetes may be controlled with medications. Both type 1 and 2 are
chronic conditions that usually cannot be cured. Pancreas transplants have been
tried with limited success in type 1 DM; gastric bypass surgery has been
successful in many with morbid obesity and type 2 DM. Gestational diabetes
usually resolves after delivery. Diabetes without proper treatments can cause
many complications. Acute complications include hypoglycemia, diabetic
ketoacidosis, or nonketotic hyperosmolar coma. Serious long-term complications
include cardiovascular disease, chronic renal failure, retinal damage. Adequate
treatment of diabetes is thus important, as well as blood pressure control and
lifestyle factors such as smoking cessation and maintaining a healthy body
weight.
Globally as of 2010 it is estimated that there are 285 million people diabetes with type 2
making up about 90% of the cases.

2. Types
Most cases of diabetes
mellitus fall into three Comparison of type 1 and 2 diabetes
broad categories: type 1, Feature Type 1 diabetes Type 2 diabetes
type 2, and Onset Sudden Gradual
Age at onset Mostly in Children Mostly in adults
gestational diabetes. A few Body habitus Thin or normal Often obese
other types are described. Ketoacidosis Common Rare
The term diabetes, without Autoantibodies Usually present Absent
qualification, usually refers Endogenous insulin Low or absent Normal, decreased
to diabetes mellitus. The or increased
rare disease diabetes Concordance 50% 90%
insipidus has similar in identical twins
symptoms as diabetes Prevalence ~10% ~90%
mellitus, but without
disturbances in the sugar metabolism (insipidus meaning "without taste" in Latin).
The term "type 1 diabetes" has replaced several former terms, including
childhood-onset diabetes, juvenile diabetes, and insulin-dependent diabetes
mellitus (IDDM). Likewise, the term "type 2 diabetes" has replaced several former
terms, including adult-onset diabetes, obesity-related diabetes, and non-insulin-
dependent diabetes mellitus (NIDDM). Beyond these two types, there is no
agreed-upon standard nomenclature. Various sources have defined "type 3
diabetes" as: gestational diabetes, insulin-resistant type 1 diabetes (or "double
diabetes"), type 2 diabetes which has progressed to require injected insulin, and
latent autoimmune diabetes of adults (or LADA or "type 1.5" diabetes).
Type 1 diabetes
Type 1 diabetes mellitus is characterized by loss of the insulin-producing beta
cells of the islets of Langerhans in the pancreas leading to insulin deficiency.
This type of diabetes can be further classified as immune-mediated or idiopathic.
The majority of type 1 diabetes is of the immune-mediated nature, where beta
cell loss is a T-cell mediated autoimmune attack. There is no known preventive
measure against type 1 diabetes, which causes approximately 10% of diabetes
mellitus cases in North America and Europe. Most affected people are otherwise
healthy and of a healthy weight when onset occurs. Sensitivity and
responsiveness to insulin are usually normal, especially in the early stages. Type
1 diabetes can affect children or adults but was traditionally termed "juvenile
diabetes" because it represents a majority of the diabetes cases in children.
"Brittle" diabetes, also known as unstable diabetes or labile diabetes, is a term
that was traditionally used to describe to dramatic and recurrent swings in
glucose levels, often occurring for no apparent reason in insulin-dependent
diabetes. This term, however, has no biologic basis and should not be used. [7]

3. There are many different reasons for type 1 diabetes to be accompanied by
irregular and unpredictable hyperglycemias, frequently with ketosis, and
sometimes serious hypoglycemias, including an impaired counterregulatory
response to hypoglycemia, occult infection, gastroparesis (which leads to erratic
absorption of dietary carbohydrates), and endocrinopathies (eg, Addison's
disease). These phenomena are believed to occur no more frequently than in 1%
to 2% of persons with type 1 diabetes.
Type 2 diabetes
Type 2 diabetes mellitus is characterized by insulin resistance which may be
combined with relatively reduced insulin secretion. The defective responsiveness
of body tissues to insulin is believed to involve the insulin receptor. However, the
specific defects are not known. Diabetes mellitus due to a known defect are
classified separately. Type 2 diabetes is the most common type.
In the early stage of type 2 diabetes, the predominant abnormality is reduced
insulin sensitivity. At this stage hyperglycemia can be reversed by a variety of
measures and medications that improve insulin sensitivity or reduce glucose
production by the liver.
Gestational diabetes
Gestational diabetes mellitus (GDM) resembles type 2 diabetes in several
respects, involving a combination of relatively inadequate insulin secretion and
responsiveness. It occurs in about 2%–5% of all pregnancies and may improve
or disappear after delivery. Gestational diabetes is fully treatable but requires
careful medical supervision throughout the pregnancy. About 20%–50% of
affected women develop type 2 diabetes later in life.
Even though it may be transient, untreated gestational diabetes can damage the
health of the fetus or mother. Risks to the baby include macrosomia (high birth
weight), congenital cardiac and central nervous system anomalies, and skeletal
muscle malformations. Increased fetal insulin may inhibit fetal surfactant
production and cause respiratory distress syndrome. Hyperbilirubinemia may
result from red blood cell destruction. In severe cases, perinatal death may
occur, most commonly as a result of poor placental perfusion due to vascular
impairment. Labor induction may be indicated with decreased placental function.
A cesarean section may be performed if there is marked fetal distress or an
increased risk of injury associated with macrosomia, such as shoulder dystocia.
A 2008 study completed in the U.S. found that the number of American women
entering pregnancy with preexisting diabetes is increasing. In fact the rate of
diabetes in expectant mothers has more than doubled in the past 6 years. This is
particularly problematic as diabetes raises the risk of complications during
pregnancy, as well as increasing the potential that the children of diabetic mothers will
also become diabetic in the future.

4. Other types
Pre-diabetes indicates a condition that occurs when a person's blood glucose
levels are higher than normal but not high enough for a diagnosis of type 2
diabetes. Many people destined to develop type 2 diabetes spend many years in
a state of pre-diabetes which has been termed "America's largest healthcare
epidemic."
Latent autoimmune diabetes of adults is a condition in which Type 1 diabetes
develops in adults. Adults with LADA are frequently initially misdiagnosed as
having Type 2 diabetes, based on age rather than etiology.
Signs and symptoms

5. Test
Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and
is diagnosed by demonstrating any one of the following:
Fasting plasma glucose level ≥ 7.0 mmol/L (126 mg/dL).
Plasma glucose ≥ 11.1 mmol/L (200 mg/dL) two hours after a 75 g oral
glucose load as in a glucose tolerance test.
Symptoms of hyperglycemia and casual plasma glucose ≥ 11.1 mmol/L
(200 mg/dL).
Glycated hemoglobin (HbA1C) ≥ 6.5%.
A positive result, in the absence of unequivocal hyperglycemia, should be
confirmed by a repeat of any of the above-listed methods on a different day. It is
preferable to measure a fasting glucose level because of the ease of
measurement and the considerable time commitment of formal glucose tolerance
testing, which takes two hours to complete and offers no prognostic advantage
over the fasting test. According to the current definition, two fasting glucose
measurements above 126 mg/dL (7.0 mmol/L) is considered diagnostic for
diabetes mellitus.
People with fasting glucose levels from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) are
considered to have impaired fasting glucose. Patients with plasma glucose at or
above 140 mg/dL (7.8 mmol/L), but not over 200 mg/dL (11.1 mmol/L), two hours
after a 75 g oral glucose load are considered to have impaired glucose tolerance.
Of these two pre-diabetic states, the latter in particular is a major risk factor for
progression to full-blown diabetes mellitus as well as cardiovascular disease.
Glycated hemoglobin is better than fasting glucose for determining risks of
cardiovascular disease and death from any cause.
Diabetes diagnostic criteria
Condition 2 hour Fasting HbA1c
glucose glucose
mmol/l(mg/dl) mmol/l(mg/dl) %
Normal <7.8 (<140) <6.1 (<110) <6.0
Impaired fasting <7.8 (<140) ≥ 6.1(≥110) & 6.0-
glycaemia <7.0(<126) 6.4
Impaired glucose ≥7.8 (≥140) <7.0 (<126) 6.0-
tolerance 6.4
Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126) ≥6.5

6. Oral manifestations
http://www.authorstream.com/Presentation/gingiv
a-120877-oral-manifestation-diabetes-mellitus-
dentistry-new-microsoft-powerpoint-education-
ppt/ (See the slide of oral manifestations)
Dental treatment consideration
- GENERAL MANAGEMENT CONSIDERATIONS
The dentist plays a major role in referral of patients with diabetes to physicians
for additional evaluation.1 Any undiagnosed dental patient who has the cardinal
signs and symptoms of diabetes (that is, polydipsia, polyuria, polyphagia, weight
loss, weakness), or who presents with an oral manifestation (for example,
xerostomia or candidiasis), should be referred to a physician for diagnosis and
treatment.
With a glucometer, a dentist can test blood glucose from a patient’s fingertip. If
the result is consistent with hyperglycemia, then immediate follow-up with a
physician is indicated. Even if the patient were to have a normal glucose level
with such testing, immediate follow-up with a physician would still be indicated,
particularly if the patient had the above signs or symptoms or oral manifestations
suggestive of uncontrolled, undiagnosed diabetes.
If the physician to whom a dentist has referred a patient subsequently diagnoses
the patient with diabetes mellitus, then the patient may be spared from life-
threatening complications. However, an important caveat must be mentioned
here: the glucometer is not accepted as a diagnostic device and the dentist is not
qualified medicolegally to make a diagnosis.
All patients with diagnosed diabetes must be identified by history. A thorough
understanding of their medical treatment—including medications, regimen and
the degree of glycemic control, as well as any systemic complications resulting
from diabetes—then must be methodically established. In the case of systemic
complications from diabetes mellitus (for example, hypertension, cardiovascular
disease, retinopathy, renal insufficiency or failure), the dentist must consult with
the patient’s physician to discuss any modifications to the dental treatment plan,
particularly when surgical procedures are anticipated.
For example, in the patient with cardiovascular disease, monitoring blood
pressure is extremely important, as is the possible modification of anticoagulant
drugs (for example, aspirin) before and after surgery. A current recommendation
in medical therapy is the use of aspirin (75–325 mg/day) in all adult patients with

7. diabetes and macrovascular disease.46 The avoidance of nephrotoxic drugs in
dental management (for example, acetaminophen in high doses, acyclovir,
aspirin, nonsteroidal anti-inflammatory drugs) is recommended in patients with
renal disease, as well as obtaining a complete blood cell count, monitoring the
blood pressure at every appointment, assessing the risk of endarteritis (renal
dialysis shunt) or endocarditis, and managing the patient receiving dialysis who is
on heparin therapy.1
With respect to surgical procedures, the dentist should also test the patient’s
blood sugar with a glucometer to avert emergency-related events such as insulin
shock (profound hypoglycemia) or ketoacidosis with severe hyperglycemia
before, during or after an invasive procedure. Any patient with diabetes who is
going to receive extensive periodontal or oral surgery procedures other than
single, simple extractions should be given dietary instructions after surgery; these
instructions should be established in concert with the patient’s physician and
nutritionist. It is important that the total caloric content and the protein-
carbohydrate:fat ratio of the diet remain the same so that proper glycemic control
of the diabetes is maintained. The patient’s physician should be consulted about
dietary recommendations and dosage modifications to medications during the
postoperative phase of dental treatment. In the case of an acute oral infection,
not only may antibiotics be indicated—particularly in poorly controlled diabetes—
but also modifications in the patient’s medications may be needed (for example,
increasing the insulin dose to prevent hyperglycemia related to the pain and
stress from infection).
Typically, patients also should receive short morning appointments to reduce
stress. The release of endogenous epinephrine from stress can have a counter-
regulatory effect on the action of insulin, thereby markedly stimulating the
breakdown of glycogen in muscle (and to a lesser extent in liver) and leading to
hyperglycemia.47 In the adult patient with diabetes and no history of
hypertension, or in the adult patient with diabetes who has well-controlled
hypertension, epinephrine can be administered in the usual ranges.1 Importantly,
the inclusion of epinephrine is advisable because it will promote better dental
anesthesia and thus may significantly reduce the release of far greater amounts
of endogenous epinephrine in response to pain and stress.
Finally, the dentist must play a major role in modifying a patient’s destructive
health habits, especially those that introduce a comorbidity factor. For example, a
large body of evidence from epidemiologic, case-controlled and cohort studies
provides convincing documentation of the causal link between cigarette smoking
and health risks such as diabetes48 and oral cancer.49,50 Much of the research
documenting the impact of smoking on health did not discuss separately results
on subsets of individuals with diabetes, suggesting the identified risks are at least
equivalent to those found in the general population.
Other studies of people with diabetes consistently found a heightened risk of
morbidity and premature death associated with the development of

8. macrovascular disease complications among smokers.48 Smoking also is related
to the premature development of microvascular complications of diabetes and
may play a part in the development of type 2 diabetes. 48 Large, randomized
clinical trials have demonstrated the efficacy and cost-effectiveness of counseling
in changing smoking behavior. Such studies, combined with the others specific to
people with diabetes, suggest that smoking-cessation counseling is effective in
reducing tobacco use.51,52 A summary of important general management
considerations for the patient with diabetes is shown in the box.
TABLE 1 : TREATMENT FOR ORAL CANDIDIASIS.
TABLE 2 : TOPICAL MEDICATION FOR ANGULAR CHEILITIS.

9. SUMMARY OF GENERAL MANAGEMENT CONSIDERATIONS FOR THE
PATIENT WITH DIABETES.
- MANAGEMENT OF THE ORAL COMPLICATIONS OF DIABETES
Risk of disease progression.
The comprehensive management of oral infections in patients with diabetes is
beyond the scope of this article. Other sources are available that provide advice
and examples of detailed therapeutic regimens. 1,53 Nevertheless, clinical
recommendations on the treatment of some common oral manifestations of
diabetes are provided below.
In general, adults with well-controlled type 1 or type 2 diabetes may have no
more significant risk of experiencing oral disease progression than do those
without diabetes, and, hence, can be treated similarly. For example, a coronal
carious lesion that has not yet penetrated dentin in a patient with well-controlled
diabetes may require no immediate intervention, whereas a similar lesion in a
poorly controlled patient (moderate to severe hyperglycemia) may need
immediate operative treatment, given its higher risk of progression. In general,
the risk of progression of oral complications is related to glycemic control and is
assessed in part by the interpretation of HbA1c values and postprandial blood
sugar levels.
Treatment regimens for candidiasis.
Given the centrality of candidiasis as a marker of marginally or uncontrolled
diabetes, and its secondary relationship to salivary dysfunction, some
representative topical and systemic medications for the treatment of oral
candidiasis are shown in Tables 1⇑ and 2⇑. It generally is advised that the
dentist first assess the sugar content in some of the antifungal preparations
before prescribing them. For example, clotrimazole troches should be avoided as

10. these have a relatively high sugar content that may warrant against their use in
patients with diabetes (see Table 1⇑ for treatment guidelines54). Some
representative topical medications, such as creams, for the treatment of angular
cheilitis are shown in Table 2⇑. Some of these combination creams contain
corticosteroids that provide an anti-inflammatory and antipruritic effect to aid
healing; however, steroids can have an antagonistic or counterregulatory effect
on the action of insulin and, thus, have the potential to cause hyperglycemia.
Nonetheless, it is unlikely that such combination creams will cause a significant
elevation of blood glucose, particularly if these are applied to a relatively small
area of angular cheilitis.
Management of salivary gland dysfunction and xerostomia.
The rationale for the treatment of xerostomia is to provide salivary stimulation or
replacement therapy to keep the mouth moist, prevent caries and candidal
infection, and provide palliative relief. The management approach for dry mouth
can include the use of saliva substitutes and stimulants; this approach may
minimize progression of, or prevent the development of, dental caries. 55
Management of recurrent HSV infections.
For the patient with diabetes and recurrent orofacial HSV infection, treatment
should be initiated as early as possible in the prodromal stage to reduce the
duration and symptoms of the lesion. Oral acyclovir, prophylactically and
therapeutically, may be considered when frequent recurrent herpetic episodes
interfere with daily function and nutrition. In the patient with diabetes and renal
insufficiency or renal failure, acyclovir should be avoided because of its potential
for nephrotoxicity.1
Management of burning mouth syndrome.
For the adult patient with burning mouth syndrome, multiple factors may interact
synergistically. In uncontrolled diabetes, xerostomia and candidiasis can
contribute to the symptoms associated with burning mouth. In addition to the
treatment of these conditions, an improvement in glycemic control is essential to
mitigate the symptoms. Given in low dosages, benzodiazepines, tricyclic
antidepressants and anticonvulsants can be helpful in reducing or eliminating the
symptoms after several weeks or months. The dosage of these drugs is adjusted
to the patient’s symptoms. A potential side effect includes xerostomia.
Consultation with the patient’s physician is necessary because of the potential of
these drugs for addiction and dependence. Commonly used medications include
amitriptyline, nortriptyline, clonazepam and gabapentin. Interestingly,
amitriptyline has also been used to treat autonomic neuropathy in diabetes.
Surgical considerations and periodontal management.

11. The dentist can perform periodontal surgical procedures, although it is important
for the patient to maintain a normal diet during the postsurgical phase to avoid
hypoglycemia (low blood sugar and insulin shock) and ensure effective repair.
The dental practitioner must review any previous history of complications, assess
the patient’s glycemic control and maintain an ongoing dialogue with the patient’s
physician and nutritionist. The longer the duration of the diabetes, the greater the
likelihood of the patient’s developing severe periodontal disease.
Supportive periodontal therapy should be provided at relatively close intervals
(two to three months). Periodontal infections may complicate the severity of
diabetes mellitus and the degree of metabolic control. The adult patient with well-
controlled diabetes generally does not require antibiotics following surgical
procedures. However, the administration of antibiotics during the post-surgical
phase is appropriate, particularly if there is significant infection, pain and stress.
The selection of antibiotics is predicated on multiple factors (for example,
sensitivity and specificity results, spread of infection), and should be conducted in
consultation with the patient’s physician.
The mainstay of periodontal therapy for patients with diabetes is nonsurgical,
given that surgical procedures may necessitate modification of the patient’s
medications before and after treatment, and also may lead to a prolonged
healing phase owing to diabetes. The combination of nonsurgical débridement
and tetracycline antibiotic therapy in patients with diabetes mellitus who have
advanced periodontitis may have a potential positive influence on glycemic
control. The use of tetracycline in the treatment of periodontal disease was
associated with an improvement in glycemic control as assessed by HbA 1c
assays.26
Several published papers have reported an additional therapeutic benefit from
tetracyclines in periodontal therapy, principally as inhibitors of the connective
tissue–degrading enzymes, the human matrix metalloproteinases. For example,
low-dose doxycycline has been shown to inhibit human gingival crevicular fluid
collagenase at doses that are not antimicrobial, significantly eliminating the risk
of bacterial resistance. Tetracyclines can thus function as inhibitors of bone
resorption or bone loss, and this property is independent of their antimicrobial
use, providing an added dimension to the therapeutic management of
periodontitis.
Oral disease management with corticosteroids.
Therapies with corticosteroids and immunomodulating drugs have the potential
for side effects. Therefore, close collaboration with the patient’s physician is
needed. The use of steroids in the treatment of erosive lichen planus in the adult
patient with diabetes is of considerable concern because steroids can antagonize
the action of insulin and lead to hyperglycemia. The patient should be given
instructions to self-monitor blood glucose levels frequently during steroid therapy.
Prolonged use of topical steroids (for a period of greater than two weeks

12. continuously) may result in mucosal atrophy and secondary candidiasis 1—
conditions that also commonly occur in uncontrolled diabetes. Once the erosive
oral lichen planus has resolved, topical steroids should be tapered to alternate-
day or less-frequent therapy, depending on the control of the erosions and the
tendency toward recurrence. Emerging nonsteroidal immunomodulator drugs (for
example, tacrolimus ointment, topical thalidomide) may be useful in the medical
management of the patient with concomitant oral mucosal disease and
uncontrolled diabetes.
Metabolic syndrome
Metabolic syndrome is a combination of medical disorders that, when occurring
together, increase the risk of developing cardiovascular disease and diabetes.It
affects one in five people in the United States and prevalence increases with
age. Some studies have shown the prevalence in the USA to be an estimated
25% of the population.
Metabolic syndrome is also known as metabolic syndrome X, cardiometabolic
syndrome, syndrome X, insulin resistance syndrome, Reaven's syndrome
(named for Gerald Reaven), and CHAOS (in Australia). A similar condition in
overweight horses is referred to as equine metabolic syndrome; it is unknown if
they have the same etiology.
Risk Factors
Stress
Recent research indicates that prolonged stress can be an underlying cause of
metabolic syndrome by upsetting the hormonal balance of the hypothalamic-
pituitary-adrenal axis (HPA-axis). A dysfunctional HPA-axis causes high cortisol
levels to circulate which results in raising glucose and insulin levels which cause
insulin-mediated effects on adipose tissue, ultimately promoting visceral
adiposity, insulin resistance, dyslipidemia and hypertension with direct effects on
the bone, causing ―low turnover‖ osteoporosis. -axis dysfunction may explain the
reported risk indication of abdominal obesity to cardiovascular disease, type 2
diabetes and stroke. Psychosocial stress is also linked to heart disease.
Overweight and obesity
Central adiposity is a key feature of the syndrome, reflecting the fact that the
syndrome's prevalence is driven by the strong relationship between waist
circumference and increasing adiposity. However, despite the importance of
obesity, patients that are of normal weight may also be insulin-resistant and have
the syndrome.

13. Sedentary lifestyle
Physical inactivity is a predictor of CVD events and related mortality. Many
components of metabolic syndrome are associated with a sedentary lifestyle,
including increased adipose tissue (predominantly central); reduced HDL
cholesterol; and a trend toward increased triglycerides, blood pressure, and
glucose in the genetically susceptible. Compared with individuals who watched
television or videos or used their computer for less than one hour daily, those
that carried out these behaviors for greater than four hours daily have a twofold
increased risk of metabolic syndrome.
Aging
Metabolic syndrome affects 44% of the U.S. population older than age 50. With
respect to that demographic, the percentage of women having the syndrome is
higher than that of men. The age dependency of the syndrome's prevalence is
seen in most populations around the world.
Diabetes mellitus
It is estimated that the large majority (~75%, or just above 40 million) of patients
with type 2 diabetes or impaired glucose tolerance (IGT) have metabolic
syndrome - . The presence of metabolic syndrome in these populations is
associated with a higher prevalence of CVD than found in patients with type 2
diabetes or IGT without the syndrome.[32] Hypoadiponectinemia has been shown
to increase insulin resistance, and is considered to be a risk factor for developing
metabolic syndrome.
Coronary heart disease
The approximate prevalence of the metabolic syndrome in patients with coronary
heart disease (CHD) is 50%, with a prevalence of 37% in patients with premature
coronary artery disease ( age 45), particularly in women. With appropriate
cardiac rehabilitation and changes in lifestyle (e.g., nutrition, physical activity,
weight reduction, and, in some cases, drugs), the prevalence of the syndrome
can be reduced.
Lipodystrophy
Lipodystrophic disorders in general are associated with metabolic syndrome.
Both genetic (e.g., Berardinelli-Seip congenital lipodystrophy, Dunnigan familial
partial lipodystrophy) and acquired (e.g., HIV-related lipodystrophy in patients
treated with highly active antiretroviral therapy) forms of lipodystrophy may give
rise to severe insulin resistance and many of metabolic syndrome's components.

14. Schizophrenia and other psychiatric illnesses
Patients with schizophrenia, schizoaffective disorder or bipolar disorder may
have a predisposition to metabolic syndrome that is exacerbated by sedentary
lifestyle, poor dietary habits, possible limited access to care, and antipsychotic
drug-induced adverse effects. It has been found that 32% and 51% of individuals
with schizophrenia meet criteria for metabolic syndrome; the prevalence is higher
in women than in men.
Rheumatic diseases
There are new findings regarding the comorbidity associated with rheumatic
diseases. Both psoriasis and psoriatic arthritis have been found to be associated
with metabolic syndrome.
WHO
The World Health Organization criteria (1999) require presence of one of:
Diabetes mellitus,
Impaired glucose tolerance,
Impaired fasting glucose or
Insulin resistance;
AND two of the following:
Blood pressure: ≥ 140/90 mmHg
Dyslipidemia: triglycerides (TG): ≥ 1.695 mmol/L and high-density
lipoprotein cholesterol (HDL-C) ≤ 0.9 mmol/L (male), ≤ 1.0 mmol/L
(female)
Central obesity: waist:hip ratio > 0.90 (male); > 0.85 (female), or body
mass index > 30 kg/m2
Microalbuminuria: urinary albumin excretion ratio ≥ 20 µg/min or
albumin:creatinine ratio ≥ 30 mg/g
Cholesterol
When you get a lipid panel, there are three main types of cholesterol that are
tested: low density lipoprotein (LDL), high density lipoprotein (HDL), and very low
density lipoprotein (VLDL). Triglycerides, another type of lipid in the blood, are
also tested. The amounts of each lipid in your blood will allow your health care
provider to predict your risk for heart disease in the future.

15. Low Density Lipoproteins
Low density lipoproteins, also referred to as LDL, is known as the "bad
cholesterol". LDLs are produced by the liver and carry cholesterol and other lipids
(fats) from the liver to different areas of the body, like muscles, tissues, organs,
and the heart. It is very important to keep LDL levels low, because high levels of
LDL indicate that there is much more cholesterol in the blood stream than
necessary, therefore increasing your risk of heart disease. LDLs are calculated
by using an equation involving total cholesterol, triglycerides, and HDLs--all of
which are measured directly in the blood:
LDL = TC – (triglycerides/5) + HDL)
The following guidelines have been set forth by the National Cholesterol
Education Program:
LDL levels less than 100 mg/dL ( 2.6 mmol/L) are considered optimal.
LDL levels between 100 – 129 mg/dL (2.6–3.34 mmol/L) are considered near
or above optimal.
LDL levels between 130 – 159 mg/dL (3.36–4.13 mmol/L) are considered
borderline high.
LDL levels between 160 – 189 mg/dL (4.14 - 4.90 mmol/L) are considered
high.
LDL levels at or above 190 mg/dL (4.91 mmol/L) is considered very high.
High Density Lipoproteins
High density lipoprotein, also known as HDL, is considered the "good"
cholesterol. HDL is produced by the liver to carry cholesterol and other lipids
(fats) from tissues and organs back to the liver for recycling or degradation. High
levels of HDL are a good indicator of a healthy heart, because less cholesterol is
available in your blood to attach to blood vessels and cause plaque formation.
According to the National Cholesterol Education Program:
Any HDL level above more than 60 mg/dL (1.56 mmol/L) is considered high. A
high HDL level is considered very healthy, since it has a protective role in
guarding against heart disease.
An acceptable HDL range is between 40- 60 mg/dL (1.04–1.56 mmol/L).
An undesirable level of HDL is any level below 40 mg/dL (1.04 mmol/L). In this
case, low HDL levels may help to contribute to heart disease.
Very Low Density Lipoproteins
Very low density lipoproteins, or VLDL, are lipoproteins that carry cholesterol
from the liver to organs and tissues in the body. They are formed by a

16. combination of cholesterol and triglycerides. VLDLs are heavier than low density
lipoproteins, and are also associated with atherosclerosis and heart disease. This
number is obtained by dividing your triglyceride levels by 5.
Prediabetes
Prediabetes is the state in which some but not all of the diagnostic criteria for
diabetes are met. It is often described as the ―gray area‖ between normal blood
sugar and diabetic levels. While in this range, patients are at risk for not only
developing type 2 diabetes, but also for cardiovascular complications. It has been
termed "America's largest healthcare epidemic," affecting more than 57 million
Americans. Prediabetes is also referred to as borderline diabetes, impaired
glucose tolerance (IGT), and/or impaired fasting glucose (IFG).
Signs and symptoms
Prediabetes typically has no signs or symptoms. Patients should monitor for
signs and symptoms of type 2 diabetes mellitus. These include the following:
Constant hunger
Unexplained weight loss
Weight gain
Flu-like symptoms, including weakness and fatigue
Blurred vision
Slow healing of cuts or bruises
Tingling or loss of feeling in hands or feet
Recurring gum or skin infections
Recurring vaginal or bladder infections
Cause
Sleep disorders
Family history of diabetes
Impaired glucose levels and/or metabolic syndrome
Cardiovascular disease
Hypertension (high blood pressure)
Increased triglycerides levels
Low levels of good cholesterol (HDL)
Overweight or obese
Women who have had gestational diabetes, had high birth weight babies
(greater than 9 lbs.), and/or has Polycystic Ovarian Syndrome (PCOS)
These are associated with insulin resistance and are risk factors for the
development of type 2 diabetes mellitus. Those in this stratum (IGT or IFG) are at

17. increased risk of cardiovascular disease. Of the two, impaired glucose tolerance
better predicts cardiovascular disease and mortality.
In a way, prediabetes is a misnomer since it is an early stage of diabetes. It is
now known that the health complications associated with type 2 diabetes often
occur before the medical diagnosis of diabetes is made.
Genetics
As the human genome is further explored, it is likely that multiple genetic
anomalies at different loci will be found that confer varying degrees of
predisposition to type 2 diabetes. Type 2 DM, which is the condition for which
prediabetes is a precursor, has 90-100% concordance in twins; there is no HLA
association. However, genetics play a relatively small role in the widespread
occurrence of type 2 diabetes. This can be logically deduced from the huge
increase in the occurrence of type 2 diabetes which has correlated with the
significant change in western lifestyle.
Don’t forget Dr.Eman’s lecture (PDL part 2&3 last
slides)
GOOD LUCK