Sedentary life style its risk

 

How to screen for DM?? Screening Strategies for Diabetes and Insulin Resistance

The 2003 Rotterdam  Consensus Group recommends that obese women with PCOS and nonobese PCOS patients with risk factor for insulin resistance, such as a family history of diabetes, should be screened for metabolic syndrome, including glucose intolerance with an oral glucose tolerance test .

The standard 2-hour oral glucose tolerance test (OGTT) provides an assessment of both degrees of hyperinsulinemia and glucose tolerance and yields the highest amount of information for a reasonable cost and risk .

Multiple other testing or screening schema were proposed to assess the presence of hyperinsulinemia and insulin resistance.

 

 In one the fasting glucose-to-insulin ratio is determined, and values less than 4.5 indicate insulin resistance.

Using the 2-hour GTT with insulin levels, 10% of nonobese and 40% to 50% of obese PCOS women have impaired glucose tolerance (IGT=2-hour glucose level ≥ 140 but ≤190 mg/dL) or overt type 2 diabetes mellitus (any glucose level >200 mg/dL). Some research studies utilized a peak insulin level of over 150 μIU/mL or a mean level of over 84 μIU/mL over the three blood draws of a 2-hour GTT as a criteria to diagnose hyperinsulinemia.

The documentation of hyperinsulinemia using either the glucose to insulin ratio or the 2-hour GTT with insulin is problematic. When compared to the gold standard measure for insulin resistance, the hyperinsulemic-euglycemic clamp, it shows that the glucose-to-insulin ratio does not always accurately portray insulin resistance. When hyperglycemia is present, a relative insulin secretion deficit is present. This deficient insulin secretion exacerbates the effects of insulin resistance and renders inaccurate the use of hyperinsulinemia as an index of insulin resistance. Thus, routine measurements of insulin levels may not be particularly useful.

Although detection of insulin resistance, per se, is not of practical importance to the diagnosis or management of PCOS, testing women with PCOS for glucose intolerance is of value because their risk of cardiovascular disease correlates with this finding. An appropriate frequency for such screening depends on age, BMI and waist circumference, all of which increase risk.

Interventions

Two-Hour Glucose Tolerance Test Normal Glucose Ranges (World Health Organization criteria, after 75-gm glucose load)

Fasting            64 to 128 mg/dL

One hour       120 to 170 mg/dL

Two hour             70 to 140 mg/dL

Two-Hour Glucose Values foe Impaired Glucose Tolerance and Type 2 Diabetes (World Health Organization criteria, after 75-gm glucose load)

Normal (2-hour)                               <140 mg/dL

Impaired (2-hour)                             =140 to 199 mg/dL

Type 2 diabetes mellitus (2-hour)  ≥200 mg/dL

Abnormal glucose metabolism may be significantly improved with weight reduction, which may reduce hyperandrogenism and restore ovulatory function .

How useful is weight reduction?? Any correlation with hyperinsulinaemia??

In obese, insulin resistant women, caloric restriction that results in weight reduction will reduce the severity of insulin resistance (a 40% decrease in insulin level with a 10-kg weight loss) .

This decrease in insulin levels should result in a marked decrease in androgen production (a 35% decrease in testosterone levels with a 10-kg weight loss) .

Exercise reduces insulin resistance, independent from any associated weight loss, but data on the impact of exercise on the principal manifestations of PCOS are lacking.

In addition to addressing the increased risk for diabetes, the clinician should recognize insulin resistance or hyperinsulinemia as a cluster syndrome called metabolic syndrome or dysmetabolic syndrome X. recognition or the importance of insulin resistance or hyperinsulinemia as a risk factor for cardiovascular disease led to diagnostic criteria for the dysmetabolic syndrome. The more dysmetabolic syndrome X criteria are present, the higher the level of insulin resistance and its downstream consequences.

The presence of three of the following five criteria confirm the diagnosis, and an insulin-lowering agent and/or other interventions may be warranted .

 

Metabolic Syndrome Diagnostic Criteria

Female waist                          >35 inches

Triglycerides                           >150 mg/dL

HDL                                           <50 mg/dL

Blood pressure                             >130/85 mmHg

Fasting glucose                             110-126 mg/dL

Two-hour glucose (75 gm OGTT):    140-199 mg/dL

Risk factors for the dysmetabolic syndrome include nonwhite race, sedentary lifestyle, BMI greater than 25, age over 40 years, cardiovascular disease, hypertension, PCOS, hyperandrogenemia, insulin resistance, HAIR-AN syndrome, nonalcoholic steatohepatitis (NASH), and a family history of type 2 diabetes mellitus, gestational diabetes, or impaired glucose tolerance.