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Based on Central Bureau of Statistics Indonesia 2003, Indonesia estimated

population aged over 20 years as many as 133 million inhabitants. With the

prevalence of DM of 14.7% in urban areas and 7.2% in rural areas. Furthermore,

based on the pattern of population growth, estimated in 2030 there will be 194 million

people aged 20 years and assuming a prevalence of DM in urban (14.7%) and rural

(7.2%), it is estimated there are 12 million persons with diabetes in urban areas and

8.1 million in rural areas.

Report of Health Research Association in 2007 by the Ministry of Health,

showed that the prevalence of DM in urban Indonesia for over 15 years of age by

5.7%. The prevalence found in Papua smallest at 1.7%, and the largest in the Province

of North Maluku and West Kalimantan, which reached 11.1%. While the prevalence

of impaired glucose tolerance (IGT), ranged from 4.0% in Jambi province to 21.8% in

the Province of West Papua.

The data above show that the number of people with diabetes in Indonesia is

very large and very heavy loads to be handled by a specialist / sub spesialist or even

by all the existing health workers.

Given that the DM will have an impact on the quality of human resources andincreasing health costs are sufficiently large, then all parties, both society and

government, was supposed to participate in the response of DM, especially in

prevention.

Etiology

Insufficient production of insulin (either absolutely or relative to the body's

needs), production of defective insulin (which is uncommon), or the inability of cellsto use insulin properly and efficiently leads to hyperglycemia and diabetes. This latter

condition affects mostly the cells of muscle and fat tissues, and results in a condition

known as "insulin resistance." This is the primary problem in type 2 diabetes. The

absolute lack of insulin, usually secondary to a destructive process affecting the

insulin producing beta cells in the pancreas, is the main disorder in type 1 diabetes.

In type 2 diabetes, there also is a steady decline of beta cells that adds to the

process of elevated blood sugars. Essentially, if someone is resistant to insulin, the
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body can, to some degree, increase production of insulin and overcome the level of

resistance. After time, if production decreases and insulin cannot be released as

vigorously, hyperglycemia develops.

Glucose is a simple sugar found in food. Glucose is an essential nutrient that

provides energy for the proper functioning of the body cells. Carbohydrates are

broken down in the small intestine and the glucose in digested food is then absorbed

by the intestinal cells into the bloodstream, and is carried by the bloodstream to all the

cells in the body where it is utilized. However, glucose cannot enter the cells alone

and needs insulin to aid in its transport into the cells. Without insulin, the cells

become starved of glucose energy despite the presence of abundant glucose in the

bloodstream. In certain types of diabetes, the cells' inability to utilize glucose gives

rise to the ironic situation of "starvation in the midst of plenty". The abundant,

unutilized glucose is wastefully excreted in the urine.

Insulin is a hormone that is produced by specialized cells (beta cells) of the

pancreas. (The pancreas is a deep-seated organ in the abdomen located behind the

stomach.) In addition to helping glucose enter the cells, insulin is also important in

tightly regulating the level of glucose in the blood. After a meal, the blood glucose

level rises. In response to the increased glucose level, the pancreas normally releases

more insulin into the bloodstream to help glucose enter the cells and lower blood

glucose levels after a meal. When the blood glucose levels are lowered, the insulin

release from the pancreas is turned down.

It is important to note that even in the fasting state there is a low steady release

of insulin than fluctuates a bit and helps to maintain a steady blood sugar level during

fasting. In normal individuals, such a regulatory system helps to keep blood glucose

levels in a tightly controlled range. As outlined above, in patients with diabetes, the

insulin is either absent, relatively insufficient for the body's needs, or not used

properly by the body. All of these factors cause elevated levels of blood glucose

(hyperglycemia).
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Classification of Diabetes Mellitus

The three main types of diabetes are

type 1 diabetes

type 2 diabetes

gestational diabetes

Other types of diabetes

Type 1 Diabetes

Type 1 diabetes is an autoimmune disease. An autoimmune disease results

when the bodys system for fi ghting infectionthe immune systemturns against a

part of the body. In diabetes, the immune system attacks and destroys the insulin-

producing beta cells in the pancreas. The pancreas then produces little or no insulin. A

person who has type 1 diabetes must take insulin daily to live.

At present, scientists do not know exactly what causes the bodys immune

system to attack the beta cells, but they believe that autoimmune, genetic, and

environmental factors, possibly viruses, are involved. Type 1 diabetes accounts for

about 5 to 10 percent of diagnosed diabetes in the United States. It develops most

often in children and young adults but can appear at any age.


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Symptoms of type 1 diabetes usually develop over a short period, although

beta cell destruction can begin years earlier. Symptoms may include increased thirst

and urination, constant hunger, weight loss, blurred vision, and extreme fatigue. If not

diagnosed and treated with insulin, a person with type 1 diabetes can lapse into a life-

threatening diabetic coma, also known as diabetic ketoacidosis.

Type 2 Diabetes

The most common form of diabetes is type 2 diabetes. About 90 to 95 percent

of people with diabetes have type 2. This form of diabetes is most often associated

with older age, obesity, family history of diabetes, previous history of gestational

diabetes, physical inactivity, and certain ethnicities. About 80 percent of people with

type 2 diabetes are overweight.

Type 2 diabetes is increasingly being diagnosed in children and adolescents,

especially among African American, Mexican American, and Pacific Islander youth.

When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin,

but for unknown reasons the body cannot use the insulin effectively, a condition

called insulin resistance. After several years, insulin production decreases. The result

is the same as for type 1 diabetesglucose builds up in the blood and the body cannot

make effi cient use of its main source of fuel.

The symptoms of type 2 diabetes develop gradually. Their onset is not as

sudden as in type 1 diabetes. Symptoms may include fatigue, frequent urination,

increased thirst and hunger, weight loss, blurred vision, and slow healing of wounds

or sores. Some people have no symptoms.

Gestational Diabetes

Some women develop gestational diabetes late in pregnancy. Although this

form of diabetes usually disappears after the birth of the baby, women who have had

gestational diabetes have a 40 to 60 percent chance of developing type 2 diabetes

within 5 to 10 years. Maintaining a reasonable body weight and being physically

active may help prevent development of type 2 diabetes.

About 3 to 8% of pregnant women in the United States develop gestational

diabetes. As with type 2 diabetes, gestational diabetes occurs more often in some

ethnic groups and among women with a family history of diabetes. Gestational

diabetes is caused by the hormones of pregnancy or a shortage of insulin. Women


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with gestational diabetes may not experience any symptoms.

Other Types of Diabetes

A number of other types of diabetes exist. A person may exhibit

characteristics of more than one type. For example, in latent autoimmune diabetes in

adults (LADA), also called type 1.5 diabetes or double diabetes, people show signs of

both type 1 and type 2 diabetes.

Other types of diabetes include those caused by :

Genetic defects of the beta cellthe part of the pancreas that makes insulin

such as maturity-onset diabetes of the young (MODY) or neonatal diabetes

mellitus (NDM)

Genetic defects in insulin action, resulting in the bodys inability to control

blood glucose levels, as seen in leprechaunism and the Rabson-Mendenhall

syndrome

Diseases of the pancreas or conditions that damage the pancreas, such as

pancreatitis and cystic fibrosis

Excess amounts of certain hormones resulting from some medical

conditionssuch as cortisol in Cushings syndromethat work against the

action of insulin

Medications that reduce insulin action, such as glucocorticoids, or chemicals

that destroy beta cells

Infections, such as congenital rubella and cytomegalovirus

Rare immune-mediated disorders, such as stiff-man syndrome, an autoimmune

disease of the central nervous system

Genetic syndromes associated with diabetes, such as Down syndrome and

Prader-Willi syndrome

Latent Autoimmune Diabetes in Adults (LADA)

People who have LADA show signs of both type 1 and type 2 diabetes.

Diagnosis usually occurs after age 30. Researchers estimate that as many as 10

percent of people diagnosed with type 2 diabetes have LADA. Some experts believe

that LADA is a slowly developing kind of type 1 diabetes because patients have

antibodies against the insulin-producing beta cells of the pancreas.


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Most people with LADA still produce their own insulin when first diagnosed, like

those with type 2 diabetes. In the early stages of the disease, people with LADA do

not require insulin injections. Instead, they control their blood glucose levels with

meal planning, physical activity, and oral diabetes medications. However, several

years after diagnosis, people with LADA must take insulin to control blood glucose

levels. As LADA progresses, the beta cells of the pancreas may no longer make

insulin because the bodys immune system has attacked and destroyed them, as in

type 1 diabetes.

Diabetes Caused by Genetic Defects of the Beta Cell

Genetic defects of the beta cell cause several forms of diabetes. For example,

monogenic forms of diabetes result from mutations, or changes, in a single gene. In

most cases of monogenic diabetes, the gene mutation is inherited. In the remaining

cases, the gene mutation develops spontaneously. Most mutations in monogenic

diabetes reduce the bodys ability to produce insulin. Genetic testing can diagnose

most forms of monogenic diabetes.

NDM and MODY are the two main forms of monogenic diabetes. NDM is a

form of diabetes that occurs in the first 6 months of life. Infants with NDM do not

produce enough insulin, leading to an increase in blood glucose. NDM can be

mistaken for the much more common type 1 diabetes, but type 1 diabetes usually

occurs after the fi rst 6 months of life.

MODY usually first occurs during adolescence or early adulthood. However,

MODY sometimes remains undiagnosed until later in life. A number of different gene

mutations have been shown to cause MODY, all of which limit the pancreas ability

to produce insulin. This process leads to the high blood glucose levels characteristic

of diabetes.

Diabetes Caused by Genetic Defects in Insulin Action

A number of types of diabetes result from genetic defects in insulin action.

Changes to the insulin receptor may cause mild hyperglycemiahigh blood

glucoseor severe diabetes. Symptoms may include acanthosis nigricans, a skin

condition characterized by darkened skin patches, and, in women, enlarged and cystic

ovaries plus virilization and the development of masculine characteristics such as

excess facial hair. Two syndromes in children, leprechaunism and the Rabson-


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Mendenhall syndrome, cause extreme insulin resistance.

Diabetes Caused by Diseases of the Pancreas

Injuries to the pancreas from trauma or disease can cause diabetes. This

category includes pancreatitis, infection, and cancer of the pancreas. Cystic fibrosis

and hemochromatosis can also damage the pancreas enough to cause diabetes.

Diabetes Caused by Endocrinopathies

Excess amounts of certain hormones that work against the action of insulin

can cause diabetes. These hormones and their related conditions include growth

hormone in acromegaly, cortisol in Cushings syndrome, glucagon in glucagonoma,

and epinephrine in pheochromocytoma.

Diabetes Caused by Medications or Chemicals

A number of medications and chemicals can interfere with insulin secretion,

leading to diabetes in people with insulin resistance. These medications and chemicals

include pentamidine, nicotinic acid, glucocorticoids, thyroid hormone, phenytoin

(Dilantin), and Vacor, a rat poison.

Diabetes Caused by Infections

Several infections are associated with the occurrence of diabetes, including

congenital rubella, coxsackievirus B, cytomegalovirus, adenovirus, and mumps.

Rare Immune-mediated Types of Diabetes

Some immune-mediated disorders are associated with diabetes. About one-

third of people with stiff-man syndrome develop diabetes. In other autoimmune

diseases, such as systemic lupus erythematosus, patients may have anti-insulin

receptor antibodies that cause diabetes by interfering with the binding of insulin to

body tissues.

Other Genetic Syndromes Sometimes Associated with Diabetes

Many genetic syndromes are associated with diabetes. These conditions

include Down syndrome, Klinefelters syndrome, Huntingtons chorea, porphyria,

Prader-Willi syndrome, and diabetes insipidus.


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Type 1 Beta cell destruction, usually leads to absolute insulin deficiency

Autoimmune

Idiopathic

Type 2 Various cause, start from dominant insulin resistant with relativeinsulin deficiency until dominant defect insulin secretion with

insulin resistant

Other types of

Diabetes

Genetic defect beta cell function

Genetic defect in insulin action

Diseases of the pancreas

Diabetes caused by endocrinopathies

Caused by medications or chemicals Infection

Rare immune-mediated types of diabetes

Other genetic syndromes associated with diabetes

Gestational

Diabetes

Sign and Symptoms- The early symptoms of untreated diabetes are related to elevated blood sugar levels,

and loss of glucose in the urine. High amounts of glucose in the urine can cause

increased urine output and lead to dehydration. Dehydration causes increased thirst

and water consumption.- The inability of insulin to perform normally has effects on protein, fat and

carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that encourages

storage of fat and protein.

- A relative or absolute insulin deficiency eventually leads to weight loss despite an

increase in appetite.- Some untreated diabetes patients also complain of fatigue, nausea and vomiting.- Patients with diabetes are prone to developing infections of the bladder, skin, and

vaginal areas.- Fluctuations in blood glucose levels can lead to blurred vision. Extremely elevated
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glucose levels can lead to lethargy and coma.

Diagnosis

The fasting blood glucose (sugar) test is the preferred way to diagnose diabetes. It

is easy to perform and convenient. After the person has fasted overnight (at least 8

hours), a single sample of blood is drawn and sent to the laboratory for analysis. This

can also be done accurately in a doctor's office using a glucose meter.

Normal fasting plasma glucose levels are less than 100 milligrams per deciliter

(mg/dl). Fasting plasma glucose levels of more than 126 mg/dl on two or more tests on

different days indicate diabetes. A random blood glucose test can also be used to diagnose diabetes. A blood

glucose level of 200 mg/dl or higher indicates diabetes.

When fasting blood glucose stays above 100mg/dl, but in the range of 100-126mg/dl,

this is known as impaired fasting glucose (IFG). While patients with IFG do not have

the diagnosis of diabetes, this condition carries with it its own risks and concerns, and

is addressed elsewhere.

The oral glucose tolerance test

Though not routinely used anymore, the oral glucose tolerance test (OGTT) is

a gold standard for making the diagnosis of type 2 diabetes. It is still commonly used

for diagnosing gestational diabetes and in conditions of pre-diabetes, such as

polycystic ovary syndrome. With an oral glucose tolerance test, the person fasts

overnight (at least eight but not more than 16 hours). Then first, the fasting plasma

glucose is tested. After this test, the person receives 75 grams of glucose (100 grams

for pregnant women). There are several methods employed by obstetricians to do this

test, but the one described here is standard. Usually, the glucose is in a sweet-tasting

liquid that the person drinks. Blood samples are taken at specific intervals to measure

the blood glucose.

For the test to give reliable results:

The person must be in good health (not have any other illnesses, not even a

cold)
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The person should be normally active (not lying down, for example, as an

inpatient in a hospital)

The person should not be taking medicines that could affect the blood

glucose

For three days before the test, the person should have eaten a diet high in

carbohydrates (200-300 grams per day) In the morning of the test, the person should not smoke or drink coffee

The classic oral glucose tolerance test measures blood glucose levels five times over a

period of three hours. Some physicians simply get a baseline blood sample followed

by a sample two hours after drinking the glucose solution. In a person without

diabetes, the glucose levels rise and then fall quickly. In someone with diabetes,

glucose levels rise higher than normal and fail to come back down as fast.

People with glucose levels between normal and diabetic have impaired

glucose tolerance (IGT). People with impaired glucose tolerance do not have diabetes,

but are at high risk for progressing to diabetes. Each year, 1%-5% of people whose

test results show impaired glucose tolerance actually eventually develop diabetes.

Weight loss and exercise may help people with impaired glucose tolerance return

their glucose levels to normal. In addition, some physicians advocate the use of

medications, such as metformin (Glucophage), to help prevent/delay the onset of

overt diabetes.

Recent studies have shown that impaired glucose tolerance itself may be a risk

factor for the development of heart disease. In the medical community, most

physicians are now understanding that impaired glucose tolerance is nor simply a

precursor of diabetes, but is its own clinical disease entity that requires treatment and

monitoring.

Evaluating the results of the oral glucose tolerance test

Glucose tolerance tests may lead to one of the following diagnoses:

Normal response: A person is said to have a normal response when the 2-hour

glucose level is less than 140 mg/dl, and all values between 0 and 2 hours are

less than 200 mg/dl. Impaired glucose tolerance: A person is said to have impaired glucose
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tolerance when the fasting plasma glucose is less than 126 mg/dl and the 2-

hour glucose level is between 140 and 199 mg/dl. Diabetes: A person has diabetes when two diagnostic tests done on different

days show that the blood glucose level is high.Gestational diabetes : A woman has gestational diabetes when she has any two of

the following: a 100g OGTT, a fasting plasma glucose of more than 95 mg/dl, a 1-

hour glucose level of more than 180 mg/dl, a 2-hour glucose level of more than

155 mg/dl, or a 3-hour glucose level of more than 140 mg/dl.

Not DM Not sure DM DM

Randomized

blood glucose

Vena plasma < 100 100-199 200

Capillary blood < 90 90-199 200

Fasting blood

glucose

Vena plasma < 100 100-125 126

Capillary blood < 90 90-99 100


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Hemoglobin A1c (A1c)

To explain what an hemoglobin A1c is, think in simple terms. Sugar sticks,

and when it's around for a long time, it's harder to get it off. In the body, sugar sticks

too, particularly to proteins. The red blood cells that circulate in the body live for

about three months before they die off. When sugar sticks to these cells, it gives us an

idea of how much sugar is around for the preceding three months. In most labs, the

normal range is 4%-5.9 %. In poorly controlled diabetes, its 8.0% or above, and in

well controlled patients it's less than 7.0% (optimal is


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A1c(%) Mean blood sugar (mg/dl)

6 135

7 170

8 205

9 240

10 275

11 310

12 345

The American Diabetes Association currently recommends an A1c goal of

less than 7.0%. Other Groups such as the American Association of Clinical

Endocrinologists feel that an A1c of


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therapy also aims to achieve blood pressure


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- Activity mild = +10%

- Medium activity = +20%

- Strenuous o = +30%

- Weight loss fat = -20%

- Weight loss more = -10%

- Weight loss skinny = +20%

- Metabolic Stress = +10-30%

- Pregnancy trimesters I and II = +300 calories

- The third trimester Pregnancy and lactation = +500calories

The results of the total calorie requirement per day is then divided into 3 major

portions for breakfast (20%), lunch (30%), dinner (25%), and 2-3 servings of mild

(10-15%) among a large meal. Changes in eating patterns is done in stages in

accordance with the conditions and habits of the patient.

Physical exercise in people with diabetes can lower HbA1c concentrations,

gives a good effect on body fat, vasodilatation of blood vessels that endothelium-

dependent, thereby reducing cardiovascular events. But in its implementation should

be supervised physical exercise frequency, intensity, duration, and type. Frequency of

physical exercise is good is 3-5 times per week with mild-moderate intensity (60-70%

maximum pulse), a duration of 30-60 minutes with the type of aerobic physical

exercise. Physical exercise in diabetics with uncontrolled blood sugar can lead to

elevated levels of blood glucose and ketone bodies which can lead to fatal effect, so

people with diabetes who perform physical exercise, blood glucose levels should have

no more than 250 mg / dL.

Therapeutic targets in DM


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Pharmacological treatment of people with diabetes can vary. There are three

kinds of insulin sensitizing drugs anti hyperglycemic (biguanid and glitazone), insulin

secretagoue (sulfonylureas and glinid), and inhibiting the absorption of glucose

(alpha-glucosidase inhibitors). Biguanid class that is often used is metformin, serves

to lower blood glucose by improving insulin action at the cellular level, improving

insulin action on the distal insulin receptor, increasing the use of glucose by the

intestinal cells, reduce hepatic glucose production, and lower absorption in the

intestine after a meal glucose .

Metformin have side effects lactic acidosis and digestive disturbances that are

not given in diabetics with serum creatinine over 1.3 mg / dL, liver failure, heart

failure, and the elderly. To avoid the side effects of digestive disorders, metformin

administered with a low initial dose and concurrent with food. Achieved the highest

levels in the blood after 2 hours, 2.5 hours half-life of metformin is then removed

through the kidneys so it is given 2-3 times per day except in the form of extended

release. Metformin does not cause hypoglycemia or weight gain such as the

sulfonylurea class. Metformin can be combined with sulfonylureas or insulin.

Metformin is the first choice for overweight people with dyslipidemia and insulin

resistance because it can reduce insulin resistance, preventing weight gain, and

improve lipid profiles.

Class of Glitazone works by increasing insulin sensitivity. Glitazone an

agonist Peroxisome proliferator-activated receptor (PPAR) selectively in adipose

tissue, skeletal muscle, and liver so that it can stimulate protein for improved insulin

sensitivity and glycemic improvement as well as affect the expression and release of

mediators of insulin resistance such as TNF-alpha and leptin. Achieved the highest

levels in the blood after 1-2 hours. The half-life for rosiglitazone glitazone 3-4 hours,

3-7 hours for pioglitazone. Giving glitazone can be combined with insulin or

metformin secretagoue. Class of sulfonylureas can increase and maintain insulin

secretion. This group is often used as initial treatment of diabetics with impaired

insulin secretion.

Sulfonylureas work by stimulating the pancreatic beta cells to release insulin

is stored so it is not suitable for people with type 1 diabetes. Sulfonylurea have anincreased risk of hypoglycemia, then the gift must be considered in patients with DM


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who are elderly, with renal failure, severe liver dysfunction, or lack of food inputs.

Beak long period depending on usage, chronic users have a half-life is longer than

acute users. Sulfonylureas administered hour before meals and can be combined

with insulin at night.

Glinid group has a structure similar to sulfonylurea and works on sulfonylurea

receptors, but the effect from hypoglycemia is more minimal than the sulfonylureas.

The last class is the alpha-glucosidase inhibitor that works by inhibiting the enzyme

alpha-glucosidase in the proximal small intestine thereby inhibiting the formation of

intraluminal monosaccharides, affecting the plasma insulin response, and inhibits the

increase in blood sugar regulation.

Drug commonly used is acarbose. Acarbose works locally in the

gastrointestinal tract and not in absorption. Acarbose does not stimulate insulin

secretion thus does not cause hypoglycemia. Acarbose 2-hour half-life and is excreted

through the feces. Provision of acarbose on the main meal because as a barrier

competitor when carbohydrate reached the small intestine. Side effects of this class is

the result of maldigestion carbohydrate, meteorismus, flatulance, and diarrhea.

Acarbose can be combined with metformin, glitazone, sulfonylurea, and insulin, but

the administration is in conjunction with metformin may reduce the bioavailability of

metformin.

In addition to anti hyperglicemic oral medication as well, diabetes can be

controlled using insulin. Insulin is needed on rapid weight loss, severe hyperglycemia

with ketosis, diabetic ketoacidosis, hyperglycemic hyperosmolar non ketotic,

hyperglycemia with lactic acidosis, failure by a combination of maximal doses of oral

medications anti hyperglicemic, severe stress (systemic infection, stroke, surgery),

pregnancy with diabetes, impaired renal function or severe liver, contraindications or

allergy to the drug oral anti hyperglicemic. There are four types of insulin based on its

long-acting insulin that is fast, short-acting insulin, intermediate acting insulin and

long acting insulin. Rapid and short-acting insulin is included in the prandial insulin

so it is more useful to decrease glucose after a meal because the peak onset of action

and it works fast. Medium and long-acting insulin, including the basal insulin that

serves to regulate blood glucose levels daily as well as the peak onset of action is

slow work. Long-acting insulin glargine and detemir is a basal insulin without a top

job, this is very beneficial in controlling blood glucose levels daily because it can

reduce the risk of hypoglycemia due to insulin.


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Complication

1. Diabetic Ketoacidosis

Insulin is vital to patients with type 1 diabetes - they cannot live with out a

source of exogenous insulin. Without insulin, patients with type 1 diabetes develop

severely elevated blood sugar levels. This leads to increased urine glucose, which in

turn leads to excessive loss of fluid and electrolytes in the urine. Lack of insulin also

causes the inability to store fat and protein along with breakdown of existing fat and

protein stores. This dysregulation, results in the process of ketosis and the release of

ketones into the blood. Ketones turn the blood acidic, a condition called diabetic

ketoacidosis (DKA). Symptoms of diabetic ketoacidosis include nausea, vomiting,

and abdominal pain. Without prompt medical treatment, patients with diabetic

ketoacidosis can rapidly go into shock, coma, and even death.

Diabetic ketoacidosis can be caused by infections, stress, or trauma all which

may increase insulin requirements. In addition, missing doses of insulin is also an

obvious risk factor for developing diabetic ketoacidosis. Urgent treatment of diabetic

ketoacidosis involves the intravenous administration of fluid, electrolytes, and insulin,

usually in a hospital intensive care unit. Dehydration can be very severe, and it is not

unusual to need to replace 6-7 liters of fluid when a person presents in diabetic

ketoacidosis. Antibiotics are given for infections. With treatment, abnormal blood

sugar levels, ketone production, acidosis, and dehydration can be reversed rapidly,

and patients can recover remarkably well.

2. Hyperglicemia and hyperosmolar state

In patients with type 2 diabetes, stress, infection, and medications (such as

corticosteroids) can also lead to severely elevated blood sugar levels. Accompanied

by dehydration, severe blood sugar elevation in patients with type 2 diabetes can lead

to an increase in blood osmolality (hyperosmolar state). This condition can lead to

coma (hyperosmolar coma). A hyperosmolar coma usually occurs in elderly patients

with type 2 diabetes. Like diabetic ketoacidosis, a hyperosmolar coma is a medical

emergency. Immediate treatment with intravenous fluid and insulin is important in

reversing the hyperosmolar state. Unlike patients with type 1 diabetes, patients with
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type 2 diabetes do not generally develop ketoacidosis solely on the basis of their

diabetes. Since in general, type 2 diabetes occurs in an older population, concomitant

medical conditions are more likely to exist, and these patients may actually be sicker

overall. The complication and death rates from hyperosmolar coma is thus higher than

in DKA.

3. Hypoglycemia

Hypoglycemia means abnormally low blood sugar (glucose). In patients with

diabetes, the most common cause of low blood sugar is excessive use of insulin or

other glucose-lowering medications, to lower the blood sugar level in diabetic patients

in the presence of a delayed or absent meal. When low blood sugar levels occur

because of too much insulin, it is called an insulin reaction. Sometimes, low blood

sugar can be the result of an insufficient caloric intake or sudden excessive physical

exertion.

Blood glucose is essential for the proper functioning of brain cells. Therefore, low

blood sugar can lead to central nervous system symptoms such as:

dizziness, confusion, weakness, and tremors.

The actual level of blood sugar at which these symptoms occur varies with

each person, but usually it occurs when blood sugars are less than 65 mg/dl. Untreated,

severely low blood sugar levels can lead to coma, seizures, and, in the worse case

scenario, irreversible brain death. At this point, the brain is suffering from a lack of

sugar, and this usually occurs somewhere around levels of


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Glucagon causes the release of glucose from the liver (for example, it

promotes gluconeogenesis). Glucagon can be lifesaving and every patient with

diabetes who has a history of hypoglycemia (particularly those on insulin) should

have a glucagon kit. Families and friends of those with diabetes need to be taught how

to administer glucagon, since obviously the patients will not be able to do it

themselves in an emergency situation. Another lifesaving device that should be

mentioned is very simple; a medic alert bracelet should be worn by all patients with

diabetes.

Chronic Complications

These diabetes complications are related to blood vessel diseases and are

generally classified into small vessel disease, such as those involving the eyes,

kidneys and nerves (microvascular disease), and large vessel disease involving the

heart and blood vessels (macrovascular disease). Diabetes accelerates hardening of

the arteries (atherosclerosis) of the larger blood vessels, leading to coronary heart

disease (angina or heart attack), strokes, and pain in the lower extremities because of

lack of blood supply (claudication).

Eye Complications

The major eye complication of diabetes is called diabetic retinopathy. Diabetic

retinopathy occurs in patients who have had diabetes for at least five years. Diseased

small blood vessels in the back of the eye cause the leakage of protein and blood in

the retina. Disease in these blood vessels also causes the formation of small

aneurysms (microaneurysms), and new but brittle blood vessels (neovascularization).

Spontaneous bleeding from the new and brittle blood vessels can lead to retinal

scarring and retinal detachment, thus impairing vision.

To treat diabetic retinopathy a laser is used to destroy and prevent the

recurrence of the development of these small aneurysms and brittle blood vessels.

Approximately 50% of patients with diabetes will develop some degree of diabetic

retinopathy after 10 years of diabetes, and 80% of diabetics have retinopathy after 15

years of the disease. Poor control of blood sugar and blood pressure further

aggravates eye disease in diabetes.

Cataracts and glaucoma are also more common among diabetics. It is also
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important to note that since the lens of the eye lets water through, if blood sugar

concentrations vary a lot, the lens of the eye will shrink and swell with fluid

accordingly. As a result, blurry vision is very common in poorly controlled diabetes.

Patients are usually discouraged from getting a new eyeglass prescription until their

blood sugar is controlled. This allows for a more accurate assessment of what kind of

glasses prescription is required.

Kidney damage

Kidney damage from diabetes is called diabetic nephropathy. The onset of

kidney disease and its progression is extremely variable. Initially, diseased small

blood vessels in the kidneys cause the leakage of protein in the urine. Later on, the

kidneys lose their ability to cleanse and filter blood. The accumulation of toxic waste

products in the blood leads to the need for dialysis. Dialysis involves using a machine

that serves the function of the kidney by filtering and cleaning the blood. In patients

who do not want to undergo chronic dialysis, kidney transplantation can be

considered.

The progression ofnephropathy in patients can be significantly slowed by controlling

high blood pressure, and by aggressively treating high blood sugar levels. Angiotensinconverting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers

(ARBs) used in treating high blood pressure may also benefit kidney disease in

diabetic patients.

Nerve damage

Nerve damage from diabetes is called diabetic neuropathy and is also caused

by disease of small blood vessels. In essence, the blood flow to the nerves is limited,

leaving the nerves without blood flow, and they get damaged or die as a result (a term

known as ischemia). Symptoms of diabetic nerve damage include numbness, burning,

and aching of the feet and lower extremities. When the nerve disease causes a

complete loss of sensation in the feet, patients may not be aware of injuries to the feet,

and fail to properly protect them. Shoes or other protection should be worn as much

as possible. Seemingly minor skin injuries should be attended to promptly to avoid

serious infections. Because of poor blood circulation, diabetic foot injuries may not
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heal. Sometimes, minor foot injuries can lead to serious infection, ulcers, and even

gangrene, necessitating surgical amputation of toes, feet, and other infected parts.

Diabetic nerve damage can affect the nerves that are important for penile erection,

causing erectile dysfunction (ED, impotence). Erectile dysfunction can also be caused

by poor blood flow to the penis from diabetic blood vessel disease.

Diabetic neuropathy can also affect nerves to the stomach and intestines, causing

nausea, weight loss, diarrhea, and other symptoms ofgastroparesis (delayed emptying

of food contents from the stomach into the intestines, due to ineffective contraction of

the stomach muscles).

Prevention for DM type 2

Primary Prevention

Aim from primary prevention :

Primary prevention efforts are aimed at groups who have risk factors, those who have

not been affected by diabetes, but has the potential to get DM and glucose intolerance

groups

Risk factor for DM that cant be modified :

- Ethnic

- Family history with DM

- Age. risk of developing glucose intolerance increases with increasing

age. age> 45 years should be screening for DM

-

a history of having a baby with birth weight > 4000 gr or a history of

suffered from gestational diabetes mellitus (DMG)

- A history of having a baby with low birth weight, < 2,5 kg. Baby with

low birth weight have higher risk compare with baby with normal birth

weight.

Risk factor that can be modified :

- Overweight (BMI > 23 kg/m2)

-

Lack of physical activity
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- Hypertension (>140/90 mmHg)

- Dyslipidemia (HDL < 35 mg/dL and trigliserid > 250 mg/dL)

- Unhealthy diet. Diet with high glucose dan low fibers will increase risk

to suffer prediabetes / glucose intolerance and type II DM

Other risk factors associated with diabetes :

- patients with polycystic ovary syndrome (PCOS) or other clinical

conditions associated with insulin resistance

- patients with metabolic syndrome have a history of impaired glucose

tolerance (IGT) or impaired fasting blood glucose (IFBG) before. have

a history of cardiovascular disease such as stroke, coronary heart

disease or PAD (Peripheral Arterial Disease)

Glucose Intolerance

glucose intolerance is a condition that precedes the onset of diabetes. the

incidence of glucose intolerance reported continues to increase

This term was first introduced in 2002 by the Department of Health and

Human Services (DHHS) and the American Diabetes Associated (ADA).

Previously the term to describe the state of glucose intolerance is the impaired

glucose tolerance (IGT) and impaired fasting blood glucose (IFBG)

glucose intolerance have a greater risk for the onset of cardiovascular

disorders a half times higher than normal people

glucose intolerance diagnosis is made by TTGO account after fasting 8 hours.

established diagnosis of glucose intolerance when blood glucose test results

show that there is one of the following:

- fasting blood glucose between 100125 mg/dl

- blood glucose 2 hours after some liquid glucose between 140 199

mg/dl

in patients with glucose intolerance, anamnesis and physical examination

considered aimed to look for risk factors that can be modified

Primary Prevention Materials

Material consists of primary prevention counseling and management actions aimed at

community groups who have a high risk and glucose intolerance.

Counseling addressed to:

A. group of people with high risk and glucose intolerance


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Outreach materials include:

1. Weight counseling program. In someone with diabetes risk and have overweight,

weight loss is the main way to reduce the risk of type 2 diabetes or glucose

intolerance. Several studies have shown weight loss 50-10% can prevent or slow the

emergence of type 2 diabetes.

2. A healthy diet

It is recommended given to every person who has a risk.

The amount of calorie intake is intended to achieve the ideal body weight.

Complex carbohydrates are a choice and given divided and balanced so it

does not cause high blood glucose peaks after meals.

Contain less saturated fat and high in soluble fiber.

3. Physical exercise

Regular physical exercise can improve blood glucose control, maintain or lose

weight, and can increase HDL cholesterol levels.

Physical exercise is recommended:

Exercise for at least 150 minutes / week with moderate aerobic exercise (up to

50-70% maximum heart rate), or 0 minutes / week with heavy aerobic exercise

(heart rate reached> 70% maximum). Exercise Physical activity was divided

into 3-4 times / week.

4. Stop smoking

Smoking is one of the risk to get cardiovascular disease. Although snoking is

not correlate directly with glucose intolerance, but smoking can make

complication cardiovascular heavier from glucose intolerance and DM type II.

B. Health policy planning in order to understand the socio-economic impact of this

disease and the importance of providing adequate facilities in primary prevention

efforts

Management aimed to:

- Groups of glucose intolerance

- Risk group (obesity, hypertension, dyslipidemia, etc)

1. Management of glucose intolerance

Glucose intolerance is often associated with metabolic syndrome,

characterized by central obesity, dyslipidemia (high triglycerides or low HDL

cholesterol) and hypertension.


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Most people with glucose intolerance can be improved by lifestyle changes,

losing weight, eating a healthy diet and adequate physical exercise and regular

Diabetes Prevention Program study showed that lifestyle changes more

effectively to prevent the emergence of type 2 diabetes compared with the useof drugs.

Weight loss of 5-10% accompanied by regular physical exercise can reduce

the risk of type 2 diabetes by 58%. While the use of drugs (such as metformin,

tiazolidindion, acarbose) is only able to reduce their risk by 31% and the use

of various drugs for the treatment of glucose intolerance is still a controversy

When accompanied by obesity, hypertension, and dyslipidemia, carried weight

control, blood pressure and lipid profiles in order to reach the target set.

2. Management of various risk factors

a. obesity

b. hypertension

c. dyslipidemia

Secondary Prevention

Secondary prevention is an attempt to prevent or inhibit the onset of

complications in patients who already suffer from DM. Done by providing adequate

treatment and early detection measures since the early management of disease

complications of DM. In secondary prevention outreach programs play an important

role to improve patient compliance in carrying out the program and in towards healthy

behaviors.

For secondary prevention is aimed primarily at new patient. Extension made

since the first meeting and the need to always be repeated at every opportunity and the

next meeting.

One of the most common complications of DM is cardiovascular disease,

which is the leading cause of death in persons with diabetes. In addition to the

treatment of high blood glucose levels, weight control, blood pressure, lipid profile in

blood and antiplatelet administration can reduce the risk of cardiovascular disorders in

people with diabetes.

Tertiary Prevention

Tertiary prevention is aimed at groups of people with diabetes who have

experienced complications in an effort to prevent further disability.


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Efforts to rehabilitate the patient as early as possible, before permanent

disability. As an example of low-dose aspirin (80-325 mg / day) can be given

routinely for persons with diabetes who already have microangiopathic

complications.

In tertiary prevention efforts remain to be done on the patient and family

counseling. Materials including rehabilitation counseling can be done to

achieve optimal quality of life.

Tertiary prevention requires a holistic and integrated health service interrelated

disciplines, particularly at a referral hospital. A good collaboration between experts in

various disciplines (heart and kidney, eye, orthopedic surgery, vascular surgery,

radiology, medical rehabilitation, nutrition, pediatric, etc.) is indispensable in the

success of tertiary prevention.

Others Problems

I. Diabetes with Infection

The presence of infection in patients is very influential on the control of blood

glucose. Infection can worsen blood glucose control, and high blood glucose levels

increase the ease or worsen the infection.

Infection is the case, among others:

- Urinary tract infections

- Respiratory tract infections: pneumonia, pulmonary tuberculosis

- Skin infections: furuncles, abscesses

- Infection of the oral cavity: infection of the teeth and gums

- Ear infections: otitis external malignant

- UTI is an infection that often occurs and is more difficult to control. May result in

pyelonephritis and septicemia. Germs are often leading causes were: Escherichia coli

and Klebsiella. Fungal infections candida species can cause cystitis and renal abscess.

Vaginal pruritus is a manifestation that often occurs due to vaginal yeast infections.

- Pneumonia in diabetes is usually caused by streptococcus, stafilococcus, and gram-

negative bacterial rods. Fungal infection of the respiratory by aspergilossis, and

mucormycosis are also common.


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- People with diabetes are more vulnerable to suffer pulmonary tuberculosis. Chest X-

ray examination, showed at 70% people with diabetes have lower lung lesions and

cavitation. People with diabetes is also often accompanied by tuberculosis drugs

resistance.

- The skin on the lower extremities is a frequent site of infection. Staphylococcus is

the main cause of the infection. Usually infected foot ulcers involves many

microorganisms, which often involved is staphylococcus, streptococcus, gram-

negative rods and anaerobic bacteria.

- The incidence of periodontitis is increased in persons with diabetes and often lead to

tooth loss. Maintaining good oral hygiene is essential to prevent complications of the

oral cavity.

- There are people with diabetes, malignant otitis externa is often not detected as a

cause of infection.

The principles of treatment of diabetic foot ulcers can be seen in Table 9

Metabolic control: a state of metabolic control as possible such as control of blood

glucose, lipids and so on

Vascular control: improvement of vascular supply (with surgery or angioplasty),

usually takes on the state of ischemic ulcers

Infection control: an aggressive treatment of infections, if visible clinical signs of

infection (an indication of colonization of the growth of organisms on the swab is not

an infection, if there are no clinical signs)

Wound control: the disposal of infected and necrotic tissue on a regular basis

Pressure control: reducing the pressure. Repeated pressure can cause ulcers, so it

should be avoided. It is very important to do on neuropathic ulcers, and required

removal of callus and put on shoes that fit that serves to reduce the pressure

Education control: A good advices

II. Diabetes with Diabetic Nephropathy


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- Around 20 - 40% of persons with diabetes will have diabetic nephropathy

- Acquisition of persistent albuminuria in the range of 30 -229 mg/24 h (micro

albuminuria) is an early sign of diabetic nephropathy

- Patients who are accompanied with micro albuminuria and turned into a macro

albuminuria (> 300 mg/24 hours), in the end often progress to end-stage chronic renal

failure. Classification of albuminuria can be seen in Table 10.

Diagnosis

- The diagnosis of diabetic nephropathy is suspected when obtained albumin levels>

30 mg in the urine 24 hours on 2 of 3 times the examination within a period of 3-6

months, without other causes of albuminuria.

Table 10. Classification of albuminuria

Category Urine 24 hours

(mg/24hours)

Urine within a

certain time

Randomized urine

(g/mg creatinine)

Normal = 300

Filtering

In type 2 diabetes mellitus at the time of initial diagnosis. If microalbuminuria is

negative, re-evaluation carried out every year.

Method of Inspection

- The ratio of albumin / creatinine in urine during

- Levels of albumin in the urine 24 hours

- Micral test for microalbuminuria


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- Dipstick / tablet reagent for macroalbuminuria

- Urine in a certain time (4 hours or overnight urine)

Management

- Control of blood glucose

- Control your blood pressure

- Dietary protein 0.8 g / kg / day. If a decline in kidney function gets worse, given

dietary protein from 0.6 to 0.8 g / kg / day

- Treatment with angiotensin II receptor, ACE inhibitors, or a combination of both

- If there are contraindications to ACE or angiotensin receptor blockers, calcium

antagonists non dihidropirin can be administered.

- If serum creatinine> 2.0 mg / dL shouldbe involved nephrologys expert.

- Ideally if creatinine clearance


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- Need identified a variety of patients consumed drugs that affect the onset of erectile

dysfunction.

- First-line treatment is psychosexual therapy and oral medications such as sildenafil

and vardenafil.

IV. Diabetes in Pregnancy / Gestational Diabetes Mellitus

- Diabetes mellitus gestational (DMG) is a disorder of carbohydrate tolerance (IGT,

GDPT, DM) which was first known to occur or when the pregnancy is ongoing.

- Assessment of the risk needs to be done since DMG's first visit to check her

pregnancy.

- DMG risk factors include: obesity, a history of never having DMG, glucosuria, a

family history of diabetes, recurrent abortion, a history of having a baby with

congenital defects or birth to a baby weighing> 4000 grams, and a history of

preeclampsia. In patients with risk DMG should be done immediately clear

examination of blood glucose. When we got the result when blood glucose 200 mg /

dL or fasting blood glucose 126 mg / dL in accordance with the limits for the

diagnosis of diabetes, it is necessary to check at any other time for confirmation.Pregnant patients with IGT and GDPT managed as a DMG.

- Diagnosis based on examination results TTGO done with a 75 gram glucose load

after fasting 8-14 hours. Later examination of fasting blood glucose, 1 hour and 2

hours after the load.

- DMG enforced if found to be the results of fasting blood glucose 95 mg / dL, 1

hour after the load


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morbidity and mortality. This can only be achieved if the state of normoglycaemia

can be maintained during pregnancy until delivery,

- Target normoglycaemia DMG is a fasting blood glucose 95 mg / dL and 2 hours

after eating 120 mg / dL. If the target blood glucose levels are not achieved by

setting eating and physical exercise, directly administered insulin.

V. Diabetes with Fasting Worship

- People with diabetes is controlled with meal arrangements alone would not have

difficulty to fast. During fasting, to be seen a change in schedule, the amount and

composition of food intake.

- Elderly diabetic people have a tendency to dehydration when fasting, therefore it is

recommended to drink enough.

- Need to increase patient awareness of symptoms of hypoglycemia. To avoid the

occurrence of hypoglycemia during the day, approached the recommended schedule

of meal times imsak / subuh, reduce physical activity during the day and when

physical activity is recommended in the afternoon.

- People with diabetes are quite restrained with OHO single dose, is also not difficult

to fast. OHO given when fasting. Beware of the occurrence of hypoglycemia in

patients receiving maximal doses of OHO.

- For those who are controlled by OHO divided doses, dosing of drugs administered

in such a way that dose before buka is greater than the dose in sahur.

- For people with type 2 diabetes mellitus who use insulin, used intermediate-acting

insulin is given when breaking it.

- It takes a higher vigilance against the occurrence of hypoglycemia in diabetic insulin

users. Need more stringent monitoring with adjustment of dose and schedule of

insulin injections. When symptoms of hypoglycemia, fasting is stopped.

- For patients who need to use multiple doses of insulin is recommended for not

fasting in Ramadan.

VI. Perioperative Management of Diabetes


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- Operation, especially with general anesthesia is a stress factor triggering the

occurrence of acute complications of diabetes. Therefore any elective surgery in

people with diabetes should be prepared as optimal as possible (target fasting blood

glucose levels

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