1. Why DIABETES? One of the commonest health problem Affects
almost all systems of the body 5% 10% of total health care
expenditure is spent on DM
2. Trend of The disease Each year 7 million people develop
diabetes (each 10 seconds 2 people develop DM) 2.3.8 million people
die out of DM each year (one person per each 10 seconds)
3. Future By 2007,246 million people were affected worldwide By
2025 380 million people are expected to have the disease
6. What is Diabetes mellitus ? DM is the most common metabolic
disorder encountered in clinical practice. Diabetes - Greek word
means a passer through a siphon. Mellitus Greek word for sweet
7. Classification of DM Type 1 - Insulin dependent DM Insulin
deficiency due to autoimmune mediate pancreatic islet cell
destruction. Type 2 - Non insulin dependent DM Due to tissue
insulin resistance. Associated with ; - increasing age - obesity -
ethnicity - family history.
8. Clinical differences between Type 1 and Type 11 DiabetesType
1Type 11Ketosis proneYes UncommonInsulin requirementYes- absolute
insulin Often later in disease-deficiencyinsulin
deficiency+_deficiency Onset of symptomsAcute Often
insidiousObeseUncommonCommonAge at onset - years Usually <
30>30Family history of10% 30% diabetes Concordance in 30- 50%
90-100% monozygotic twins
9. Epidemiology More than 120 million people worldwide are
suffering from DM. It is estimated that it will affect 220 million
by year 2020.
10. Prevalence of diabetes in Sri Lanka
11. Symptoms Weightloss. Polyuria increased urine excretion.
Polydipsia excessive thirst and water ingestion.
12. Causes Increased prevalence of DM is related to; excessive
caloric intake reduced physical activity.
13. Nature of the Disease Usually irreversible. Strongly linked
to obesity. Patients can have a reasonably normal life style.
14. Insulin Coded by chromosome 11 and synthesized in the beta
cells of the pancreatic islets. About 50% of secreted insulin is
extracted and degraded in the liver and kidney
15. Action of Insulin Prime target organ is the liver. Is the
key hormone involved in the storage and controlled release of the
chemical energy available from food within body.
20. Normal plasma glucose: 3.9-8.3 mM Plasma glucose is tightly
regulated by hormones: Insulin: Plasma glucoseGlucagon Epinephrine
Cortisol Plasma glucose Growth hormone
21. Correlation Between Plasma Glucose & Insulin
Levels
22. Metabolism of InsulinInsulin has no plasma carrier proteins
Short plasma half-life (3-5 min) ~50% of insulin is removed during
thefirst pass through the liver
23. Biological Effects of Insulin Major target tissues for
insulin: liver, skeletal muscle, & adipose tissue. Insulin
glucose uptake in muscle and adipose tissue by regulating glucose
transporter (GLUT4). Glucose transporter in the liver (GLUT 2) is
not regulated by insulin.
24. GLUCAGONThe most important hormone in increasing plasma
glucose.Glucagon is a single chain polypeptide (29 amino
acids).
25. REGULATION OF GLUCAGON SECRETION
26. ROLE OF GLUCAGON IN GLUCOSE REGULATIONGlucagon opposes the
metabolic actions of insulin.The major site of action: liver.The
important metabolic effects of glucagon in the liver
include:Carbohydrates: gluconeogenesis(glucose production)
glycogenolysis(glycogen breakdown) glycogen synthesis
27. Fat: Ketogenesis(ketoneproduction)Protein: Hepatic protein
synthesis protein catabolism in the liver Glucagon DOES NOT affect
muscle proteins.
28. REGULATION OF BLOOD GLUCOSE BY INSULIN & GLUCAGON
29. Overall:Insulin plasma glucose by promoting glucose
uptake& its storage.Glucagon plasma glucose by increasingliver
glucose output.
30. GLUCOSE REGULATION DURING EXERCISE- ROLE OF
EPINEPHRINE
31. Group 5 & 6
32. DietStarch White bread, sugared breakfast cereals &
potatoes, which all have especially high glycemic index values
& low fiber contents predispose diabetes. Potatoes ,in
particular, can become dietery handgrenades for diabetics when
served as French fries.
33. Diet continue... Refined sugars Nothing increases blood
sugar more readily than ingesting sugar. So high fructose corn
syrup, candy & sweets suchas cakes are not good for diabetics
at all . Saturated fats Fats do compound many risk factors for
& complications from diabetes such as obesity, hardening of
arteries & heart attack or stroke. Eg: butter, margarine, whole
milk
34. Emotional Stress Highly stressed life deeply influences the
metabolism of the body. Even grief, anxiety, worry, death of any
close person, etc. may alter the blood sugar level and lead to the
disease. Energy mobilization is a primary result of the fight &
flight response. So stress stimulates the release of various
hormones like glucocorticoids which elevate blood glucose
level.
35. Obesity When a person is overweight, the cells in the body
become less sensitive to the insulin due to the high circulating
levels of leptin. There is some evidence that fat cells are more
resistant to insulin than myocytes.If a person has more fat cells
than muscle cells, then the insulin become less effective
overall,& glucose remain circulating in the blood instead of
being taken in to the cells to be used as energy.
36. Sedentary Life A sedentary life style isdamaging to health
& bearsresponsibility for the growingobesity problems.
Inactivity & being overweightgo hand in hand towards adiagnosis
of type 2 diabetes. Muscle cells have more insulinreceptors than
fat cells, so aperson can decrease insulinresistance by
exercising.
37. Smoking smoking 16 to 25 cigarettes a day increases your
risk for Type 2 diabetes to three times that of a non-smoker..
Increases complications esp. Retinopathy, Cardiovascular
conditionsThere is also evidences thatlinks cigarette smoking
withmicrovascular diseases indiabetes.Smoking can cause
chronicpancreatitis which leads todiabetes.
38. Ethnicity Incidence high in African, Americans, Asians,
American Indians, Hispanic, Caucasians, Latinos, Mexican-American,
EuropeansAge It has been observed that as one grows older,
particularly above 45 years of age, in them the chances to develop
diabetes are increased.It is chiefly because due to old age, the
person becomes less active, tends to gain weight, leading to
pancreatic dysfunction.
39. Genetic Predisposition People who belong to family
background having history of diabetes are 25% more prone to develop
diabetes. The concordance of type 1 DM in identical twins ranges
between 30% and 70%The major susceptibility gene for type 1DM is
located in the HLA region onchromosome 6 The concordance of type 2
DM in identical twins is between 70% and 90% if both parents have
type 2 DM, the risk approaches 40%
40. Gestational DiabetesHuman placental Peripheral
tissuesLactogenInsulin resistanceEstrogen PancreasProgesterone
Increased Fat stores Prolactin Changes in insulin receptormost
women revert to normal glucose tolerance post-partum, but have a
substantial risk (30 60%) of developing diabetes mellitus later in
life.
41. Infections Mumps, Coxsackie B, Cytomegalovirus, Kilham rat
virus and rubella infections can damage the pancreas. Coxsackie
virus is the commonest viral cause Some viruses can trigger or
maintain autoimmune beta cell damage.
42. Barker and Hales hypothesis Evidence, mainly from animals,
suggests that maternal and therefore fetal malnutrition during a
critical early phase of fetal development can reduce Beta-cell mass
and permanently impair insulin secretory reserve.
45. The history of diabetic symptomsis of the greatest
importance and an accurateappreciation of their severity far
exceeds anestimation of the blood sugar as a means ofassessing the
need for treatment.(John Malins, Clinical Diabetes Mellitus, Eyre
& Spottiswoode, 1968)
46. Clinical presentationAcuteSub acuteSymptoms Symptoms Acute
& Sub acute presentations often overlap.But, Asymptomatic
diabetes can occur.
47. Acute presentationYoung people often present with a 2-3
weeks history and report the classical triad of
symptoms.ThirstPolyuria1.Thirst2.Polyuria3.Weight lossIf not
Ketonuria treated Ketoacidosis
48. Sub acute presentation Clinical onsetover several months,
years In older patients Classical triad of symptoms are typically
present.But complain of, visual blurring pruritus vulvae (female)
balanitis (male) lack of energy dry mouth dysphagia
49. balanitis Visual blurring Pruritus vulvae
50. Other symptoms Somnolence (the tendency to fall asleep)
Myopia Nausea, headache Tiredness, fatigue Malaise Hyperphagia -
predilection for sweet foods
52. Asymptomatic diabetes No symptoms or ill health. Accidently
detected ;as glycosuria or hyperglycemia on routine investigations
(for other purposes). Both are not diagnostic of diabetes but
indicates a high risk of developing diabetes.
53. Diabetes and pregnancy Group 9 and 10
54. 1. Already diagnosed diabetes mellituswoman getting
pregnant Preexistingdiabetes.2. A woman who hasnt been
diagnoseddiabetes, exhibit high blood glucoselevels during
pregnancy Gestationaldiabetes
55. Gestational diabetes Gestational diabetes is defined as Any
degree of glucose intolerance with onset or first recognition
during pregnancy" Gestational diabetes generally has few symptoms
and it is most commonly diagnosed by screening during
pregnancy..
57. Risk factors ObesityBMI > 30 Family history of diabetes
Previous babies having high birth weight ( >4.5kg ) Previous
still birth Previous babies with congenital abnormalities
60. Diagnosis of maternal diabetes Glucose challenge test
(>140mg/dl) Oral glucose tolerance test. Random blood sugar.
Normal fasting glucose -7mmol/l
61. Management Diabetic women are advised to maintain the blood
sugar level close to normal range for 2 to 3 months in advance,
before planning for pregnancy. Antenatal care Frequent review
Increase insulin dose Vigorous treatment for infection Regular
urine analysis to detect nephropathyAt term, Should not be allowed
to continue beyond 38 weeks. Caesarean section if needed. Delivery
before 36 weeks Dexamethasone. Monitor the blood glucose &
urine ketone body regularly
62. Newborn, Anticipate & treat asphyxia Cross monitoring
blood glucose level for the first 72h Early breast feeding Look for
congenital malformation. Random blood sugar and give dextrose if
necessary. On descharge Check the fasting blood sugar Complete
family early & follow family planning method.
63. References Obstetrics by Ten Teachers
64. DIABETIC KETOACIDOSIS GROUP 11 & 12 07/08 BATCH
65. Introduction Major medical emergency Principally with type
1 diabetes High blood sugar with ketones in urine and blood Body
cant use glucose due to insulin shortage
66. Main cause Type 1 diabetesUsually occurs in following
circumstances Undiagnosed diabetes Interruption to insulin therapy
Stress due to any illness (Also occurs in type 2 diabetes)
67. Mechanism of Diabetes Ketoacidosis In adipose cells insulin
inhibit the action of intracellular enzyme Hormone-sensitive
lipase
68. Development of Signs and Symptoms Diabetic ketoacidosis
appears to require Insulin deficiency coupled with a relative or
absolute increase in glucagon concentration Increased glucagon
induces maximal gluconeogenesis and also impairs peripheral
utilization of glucose resulting in severe hyperglycemia
69. This induces osmotic diuresis that leads to volume
depletion and dehydration that characterize the ketoacidotic state.
Glucagon activates the ketogenic process and thus metabolic
acidosis.
71. Diagnosis Ketonuria or ketonemia is demonstrated Dipstick
method for hyperglycemia Centrifugation blood for ketonemia ?
Arterial blood gas analysis
72. Investigations Urea & Electrolytes, Blood glucose,
Plasma bicarbonate Arterial blood gases to assess the severity of
acidosis Urinalysis for ketones ECG
73. TreatmentReplace lost fluid & electrolytes suppressing
high blood sugar & ketone production with insulin Fluid
replacement Insulin therapy Potassium NaHCO3 .?
74. Prevention Manage diabetes yourself Monitoring blood sugar
levels Adjust insulin dose as needed Check urine for ketone levels
Be prepared to act quickly
75. References Kumar & Clark;Clinical Medicine
Davidson;Clinical medicine Harpers illustrated biochemistry
76. Groups 13-14
77. Have a considerably reduced life expectancy 70%- due to
cardio vascular diseases Followed by 10% -renal failure
Pathophysiology Non enzymatic glycosylation of protains Polyoyl
pathway Abnormal microvasculr pathway Other factors Haemodynamic
changes
79. Diabetic Retinopathy Impairment of loss of vision Due to
damage to blood vessels of retina Cause of long standing diabetes
Cataract Glucoma
80. Diabetic nephropathy Important cause of morbidity mortality
Among the most common causes of the end stage renal failure
Management is frequently different & benefits of prevention are
substantial
81. Diabetic neuropathy Usually causing weakness & numbness
Symptoms are depended on nerves which damage Most commonly affects
legs
82. Complications on foot Main cause of the AMPUTATION is
diabetes mellitus Why it will end up with amputation ???? Diabetes.
1) Narrow & hardening the blood vesselsPoor circulationLess
ability to fight with infections & healing also slow Foot ulcer
Gangrene
83. 2) Damage the nervesLoss of sensation (peripheral
neuropathy)Injuries cannot be noticedSusceptible for infections 3)
Damage to the nerves controlling oil & moistureSkin drynessEasy
to getting cracksSusceptible for infections
84. 4) Affects joints Making them stifferCharcots joints
85. Effects of diabetes to blood vessels Diabetesmellitus Part
of plaque GlucoseTravel through circulationCholesterol Breakage
ofplaqueLodge in a vessel Deposit in damaged of brain (STROKE)
vesselsLoss of blood supply to Atheroma ( in damaged inner
layer)part of brain atherosclerosis Diameter of blood vessels Blood
flow
86. Effect of diabetes to heartDiabetes mellitus
AtherosclerosisBlood glucoseIn peripheralBlockage ofvesselscoronary
vesselsblood flow blood supply Cardiac muscletopart of failure
heartHeart has to pump (cardiomyopathy) more forcefully Ischemic
heartdiseasehypertensionHeartattack
87. GROUP 15-16 DIAGNOSIS of
88. DIAGNOSIS OF DIABETES If patient complains of symptoms
suggesting diabetes Test urine for GLUCOSE & KETONES Random
Blood Glucose (normal 7.0mmol/l, 126mg/dL-DIABETES if (6.1
180mg/dL
91. DIPSTICK METHOD A plastic strip coated with reagents
Reagent strip measure glucose level using glucose oxidase method.
GLUCOSE OXIDASE GLUCOSEH2O2 (Change the color of theindicator)
92. BLOOD TESTS
93. Random blood glucose level Measure the blood glucose level
other than post prandial stage or fasting. If it is above 11.1mmol
(200mg/dl) considered as diabetes. GLUCOMETER For rapid diagnosis
of blood glucose levels (capillary blood )
94. Fasting Plasma Glucose After 12hr fasting measure the blood
glucose level in venous blood. 4 mmol/L 6.1 7.080 mg/dL
mmol/Lmmol/L 110 126 mg/dL mg/dL Hypoglycemi Normal Impaired
(Hyperglycemic)cFastingDiabetes Glucose
95. OGTT (Oral Glucose Tolerance Test) Unrestricted
carbohydrate diet for 3 days before test 8 Hour overnight fasting
is required. 75g of glucose in 300ml of water is given orally
within 5minutes. Measure plasma glucose BEFORE and 2 hours AFTERthe
glucose load. Time Non Diabetic DiabeticImpaired Glucose _
Tolerance Fasting(07.0mmol/l 6.1-7.0mmol/l min)
(110mg/dl)(126mg/dl) (110-126mg/dl) 120min
11.1mmol/l>7.8-11.1mmol/l(140mg/dl)(200mg/l)(140-200mg/dl)
96. HbA1C Measure the glycated hemoglobin proportion which
indicates the glycaemic condition Glycosylation of hemoglobin
[glucose] This can reflect the glycaemic control of the patient
over 2 to 3 months For every 1% increase of theHbA1c indicate
35mg/dl incease of blood glucose levels. 4.5% 6.5 % Reference range
HbA1c > 8% Poor control
97. HbA1 Mean plasma glucose c % mg/dl 6 135 7 170 8 205 9 240
10275 11310 12345
98. Fructosamine Test Fructosamine = glycosylated plasma
proteins,mainly albumin Indicate previous 2-3 week glyceamic
control Impaired in patients with anemia , hemoglobinopathies &
pregnancy.
99. DIAGNOSIS OF COMPLICATIONS OF DIABETES Diagnosis of
Diabetic Neuropathy Lower limbs Peripheral pulses Tendon reflexes
Perception of vibration sensation, light touch and
proprioceptionFeet Callus skin indicating pressure areas Nails Need
for podiatry Ulceration DeformityDiabetic Nephropathy
100. Diagnosis of Diabetic Nephropathy Microalbuminuria test In
normal peopleAlbumin excretion =30mg/day In kidney damage >
300mg/day In diabetic nephropathy ;Albumin excretion
=30-300mg/daymicroalbuminuria
101. Diagnosis of Diabetic RetinopathyEye examination Visual
acuities (near and distance) Ophthalmoscopy (with pupils dilated)
Digital photography
102. Group 17 & 18
103. Diet is an essential part ofthe management of diabetes
Diet is based on healthy eating principles
104. Reasons for diet Weight controlBlood glucose
controlPrevention and management of short-term and long-term
complications of diabetes
105. Basic Principles of Diabetic DietEnsure regular meals Base
meals on starchy carbohydrates Aim for more fruit and vegetables
Cut down on sugar and sugary foods If in doubt read food label
Encourage relatives to bring low sugar foodsReduce salt
106. Eat starchy foods regularly Bread Potatoes Rice Cereals
Plantain CHO to form 45-60% of total energy
[cereals,vegetables,legumes]better use foods which has low
glycaemic index
107. Eat fruit and vegetables Fresh Frozen Tinned Dried Juice
Encourage food rich in antioxidants - vitamins
108. Reduce protein intake Restriction of protein intake to 0.6
-0.8 g/ kg/ day Replace red meat with chicken ,fish or vegetable
protein To contribute 10-20% of total energy
109. Aim for low sugar diet Not a sugar free diet Instead of
sweet cakes/ biscuits offerfruit loaf, plain biscuits, teacakesCut
down on sugar andsugary foods: Use low sugar foods Use drinks
labeled diet, low calorie orsugar- free Choose diet or light
yoghurts instead oflow-fat or whole yoghurts Use sugar free/ low
sugar - jelly, custard, rice pudding as dessert ideas
110. Nutrition Claims Sugar No added Sugar No sugar from any
source added Low Sugar No more than 5gssugar/100gs Reduced Sugar
25% less sugar than regular productFREE SUGER do not exceed 50g per
day
111. Choose more high fibre foods To help maintain blood
glucose levels and cholesterol levelsHelps to maintain a Fruit
healthy gut Vegetables Pulses Wholegrain cereals Oats Wholemeal
bread Brown rice FIBERS 40g per day or morehalf of fiber should be
soluble
112. Reduce animal or saturated fat intake Use low fat milk Use
low fat spread instead of butter Use oil high in unsaturated fat,
eg olive oil, rapeseed oil
113. Use less fat in cooking Dry-roast Microwave Steam FAT -
should not exceed 30 % of total energy restrict cholesterol to
300mg or less per day
114. Choose the right sort of fatSATURATEDMONO-
POLY-UNSATURATED UNSATURATED Full fat dairyproduce (eg Olive oil
Sunflower oilcheese, butter,(products) Rapeseed oilfull cream milk)
Oily fish Groundnut oil Biscuits Savoury snacks Lard Hard
vegetablefat
115. Nutrition Claims Fat Low Fat - . 3g Fat/ 100g or 100mls
Less than 5% Fat - . 5g fat/ 100g Reduced Fat 25% less fat than
similar products
116. Reduce salt intake Cut down on added salt Use alternatives
Look out for reduced/low sodium foods, eg bread Avoid salt
substitutes SODIUM restrict to 6g per day
117. Alcohol Alcohol in moderation can be included, no more
than: 1-2 units/ day for women 2-3 units/ day for men Never give
alcohol on an empty stomach Remember to use diet mixersCaution with
sweet liqueurs
118. Special diabetic foods Not recommended May contain more
fat or energy than other foods May be low in fibers Has sorbitol
may cause diarrhoea Excessive fructose may be used - Fruit sugar
(fructose) when used excessively as asweetener will still affect
blood sugarsin the same way as normal sugar!!
119. If Residents Overweight Weight loss is desirable via
exercising Encourage to cut down on fatty foodse.g. chips, pastry,
crisps, biscuits, cheese and fried foods Encourage low-fat food
options e.g. semi-skimmed milk, low-fat spread Offer fruit/ low fat
yoghurt as a dessert Snacks not essential
120. If residents malnourished Encourage small frequent meals
and low sugar puddings and snacks: Glass of milk/ milky drinks
Crackers and cheese Toast, butter and reduced sugar jam Breakfast
cereals, nuts low fat yoghurt or low sugar milk pudding Plain
biscuits, fruit cake, kurakkan bread,
121. Recommended food meals for a diabetic patient Breakfast
chickpea 1 cup or green gram 1 cup orbread two slices with
polsambol 1 tsp.Lunch Rice two cups , Vegetables 6 tablespoons ,
green leaves cup, fish or chicken 1 piece, fruit 1 servingDinner
Rice 1 cup, vegetable 3 tablespoons, Dhal3 tablespoons, Fruit 1
serving
122. Key Points Ensure regular meals Base meals on starchy
carbohydrates Aim for more fruit and vegetables Cut down on sugar
and sugary foods If in doubt read food label Encourage relatives to
bring low sugar foods
123. Group 19-20
124. CANNOT CURE. But can prevent. Kathmandu declaration- life
cycle approach for prevention & care of DM. o Primary
prevention o Secondary prevention