Why DIABETES?

   One of the commonest health problem
   Affects almost all systems of the body
   5%– 10% of total hea...
Trend of The disease

   Each year 7 million people develop
    diabetes (each 10 seconds 2 people
    develop DM)
   2....
Future

   By 2007,246 million people were
    affected worldwide
   By 2025 380 million people are
    expected to have...
Content

●   Introduction                   -    Group 1& 2
●   Regulation of blood glucose    -    Group 3 & 4
●   Predis...
Groups 1 & 2
What is Diabetes mellitus ?
   DM is the most common metabolic disorder
    encountered in clinical practice.

   Diabet...
Classification of DM
     Type 1 - Insulin dependent DM
          Insulin deficiency due to autoimmune
mediate   pancreat...
Clinical differences between Type 1
and Type 11 Diabetes
                       Type 1                  Type 11

Ketosis p...
Epidemiology

   More than 120 million people worldwide are
    suffering from DM.
   It is estimated that it will affec...
Prevalence of diabetes in Sri Lanka
Symptoms

 Weight  loss.
 Polyuria – increased urine excretion.

 Polydipsia – excessive thirst and
  water ingestion.
Causes
   Increased prevalence of DM is related to;

     excessive caloric intake
     reduced physical activity.
Nature of the Disease


 Usually irreversible.
 Strongly linked to obesity.

 Patients can have a reasonably normal
  l...
Insulin

   Coded by chromosome 11 and synthesized in
    the beta cells of the pancreatic islets.

   About 50% of secr...
Action of Insulin
   Prime target organ is the liver.

   Is the key hormone involved in the storage and
    controlled ...
Metabolic Changes
 Abnormal carbohydrate metabolism.
 (Normal blood glucose level 3.6- 6.1 mmol /l)

 Abnormal   lipid h...
Complications of Diabetes

   Macrovascular diseases
         Coronary heart disease
         Peripheral vascular disea...
Prevention & Treatment
   Combination
    approach.

       Increased exercise
           Decreases need for
          ...
Group 3/4
•Normal plasma glucose: 3.9-8.3 mM
•Plasma glucose is tightly regulated by
  hormones:
Insulin: ↓Plasma glucose

Glucagon
...
Correlation Between Plasma
Glucose & Insulin Levels
Metabolism of Insulin

•Insulin has no plasma carrier proteins
•Short plasma half-life (3-5 min)
• ~50% of insulin is remo...
Biological Effects of Insulin


• Major target tissues for insulin:
 liver, skeletal muscle, & adipose
  tissue.
• Insuli...
GLUCAGON

The most important hormone
in increasing plasma
glucose.

Glucagon is a single chain
polypeptide (29 amino
acids...
REGULATION OF GLUCAGON SECRETION
ROLE OF GLUCAGON IN GLUCOSE REGULATION

Glucagon opposes the metabolic actions of insulin.

The major site of action: live...
Fat:
↑Ketogenesis(ketoneproduction)

Protein:
↓Hepatic protein synthesis
↑protein catabolism in the liver


Glucagon DOES ...
REGULATION OF BLOOD GLUCOSE BY INSULIN & GLUCAGON
Overall:

•Insulin
↓plasma glucose by promoting glucose
uptake
 & its storage.

•Glucagon
↑plasma glucose by increasing
 l...
GLUCOSE REGULATION DURING
EXERCISE-
ROLE OF EPINEPHRINE
Group 5 & 6
Diet
     Starch
   White bread, sugared breakfast cereals
    & potatoes, which all have especially
    high glycemic in...
Diet continue...
   Refined sugars
    Nothing increases blood sugar more readily
    than ingesting sugar.
    So high ...
Emotional Stress
   Highly stressed life deeply influences the
    metabolism of the body. Even grief, anxiety,
    worry...
Obesity
    When a person is overweight,
    the cells in the body become less
    sensitive to the insulin due to the
  ...
Sedentary Life
              A sedentary life style is
               damaging to health & bears
               responsib...
Smoking

   smoking 16 to 25 cigarettes a day
    increases your risk for Type 2 diabetes to
    three times that of a no...
Ethnicity
                       Incidence high in
                           African, Americans, Asians, American
     ...
Genetic Predisposition
               People who belong to family background
                having history of diabetes a...
Gestational Diabetes
 Human placental     Peripheral tissues
 Lactogen
                                           Insulin ...
Infections

   Mumps, Coxsackie B, Cytomegalovirus,
    Kilham rat virus and rubella infections
    can damage the pancre...
Barker and Hales hypothesis

   Evidence, mainly from animals, suggests
    that maternal and therefore fetal
    malnutr...
Other factors

   Endocrine
       Acromegaly 25%
       Cushing’s Disease 30%
       Glucagonoma 90%
   Drugs that d...
Groups 7 & 8
“ The history of diabetic symptoms
   is of the greatest importance and an accurate
   appreciation of their severity far ...
Clinical
                presentation


         Acute                Sub acute
       Symptoms               Symptoms
•Ac...
Acute presentation
     Young people often present with a 2-3 weeks
    history and report the classical triad of
    symp...
Sub acute presentation
   Clinical onset        over several months, years
   In older patients
   Classical triad of s...
balanitis




                              Visual blurring




            Pruritus vulvae
Other symptoms
   Somnolence (the tendency to fall asleep)
   Myopia
   Nausea, headache
   Tiredness, fatigue
   Mal...
Complications
                                        Macrovascular
   Microvascul
         ar                          ...
Asymptomatic diabetes

   No symptoms or ill health.
   Accidently detected ;
     as glycosuria or hyperglycemia on rou...
Diabetes and pregnancy




              Group 9 and 10
1.   Already diagnosed diabetes mellitus
     woman getting pregnant – Preexisting
     diabetes.

2.   A woman who hasn’t...
Gestational diabetes
   Gestational diabetes is defined as “Any degree of glucose intolerance
    with onset or first rec...
Gestational diabetes
During            Human placental lactogen
pregnancy         level &
                  Cortisol level...
Risk factors
    • Obesity    BMI > 30



    • Family history of diabetes

    • Previous babies having high birth weight...
Maternal complications
   Pre-eclampsia (pregnancy induce hypertension )
   Antepartum hemorrhage due to placental abbru...
Fetal & neonatal complications
  Increase risk of miscarriage & congenital fetal
abnormalities
        Neural tube defec...
Diagnosis of maternal diabetes
   Glucose challenge test (>140mg/dl)
   Oral glucose tolerance test.
   Random blood su...
Management
  Diabetic women are advised to maintain the blood sugar level close to
  normal range for 2 to 3 months in adv...
Newborn,
      Anticipate & treat asphyxia
      Cross monitoring blood glucose level for the first 72h
      Early bre...
References

   Obstetrics by Ten Teachers
DIABETIC
KETOACIDOSIS




          GROUP 11 & 12
          07/08 BATCH
Introduction
 Major medical emergency
 Principally with type 1 diabetes
 High blood sugar with ketones in urine and blo...
Main cause – Type 1 diabetes

Usually occurs in following circumstances

  • Undiagnosed diabetes
  • Interruption to insu...
Mechanism of Diabetes Ketoacidosis
In adipose cells insulin inhibit the action of intracellular enzyme “Hormone-sensitive ...
Development of Signs and
Symptoms
   Diabetic ketoacidosis appears to require
    Insulin deficiency coupled with a relat...
   This induces osmotic diuresis that leads
    to volume depletion and dehydration that
    characterize the ketoacidoti...
Symptoms & signs
   Nausea
   Vomiting
   Excessive thirst
   Frequent urination
   Weakness
   Ketone / Fruity smel...
Diagnosis

   Ketonuria or ketonemia is demonstrated
   Dipstick method for hyperglycemia
   Centrifugation blood for k...
Investigations

   Urea & Electrolytes, Blood glucose,
    Plasma bicarbonate
   Arterial blood gases to assess the
    ...
Treatment

Replace lost fluid & electrolytes
  suppressing high blood sugar & ketone
  production with insulin
 Fluid rep...
Prevention

   Manage diabetes yourself
   Monitoring blood sugar levels
   Adjust insulin dose as needed
   Check uri...
References

   Kumar & Clark;Clinical Medicine
   Davidson;Clinical medicine
   Harper’s illustrated biochemistry
Groups 13-14
•   Have a considerably reduced life expectancy
•   70%- due to cardio vascular diseases
•   Followed by 10% -renal failur...
•   Complications
     1.Macrovascular
       Hypertension
         Smoking
    Lipid abnormalities
     2.Microvascular
 ...
Diabetic Retinopathy

 •   Impairment of loss of vision
 •   Due to damage to blood vessels of retina
 •   Cause of long s...
Diabetic nephropathy
•   Important cause of morbidity mortality
•   Among the most common causes of the end
    stage rena...
Diabetic neuropathy

•   Usually causing weakness & numbness
•   Symptoms are depended on nerves
    which damage
•   Most...
Complications on foot
    Main cause of the AMPUTATION is diabetes mellitus
    Why it will end up with amputation ????
...
   2) Damage the nerves

        Loss of sensation (peripheral neuropathy)

        Injuries cannot be noticed

      ...
   4)     Affects joints

         Making them stiffer

        Charcot’s joints
Effects of diabetes to blood vessels
  Diabetes
   mellitus
                                            Part of plaque

 ...
Effect of diabetes to heart
                   Diabetes mellitus

                   Atherosclerosis

Blood glucose     ...
GROUP 15-16




DIAGNOSIS of
DIAGNOSIS OF DIABETES
If patient complains of symptoms suggesting diabetes
      Test urine for GLUCOSE & KETONES

     ...
URINE TESTS
BENEDICT’S TEST
    To assess urine sugar level
    To 5ml Benedict’s solution add 8-10 urine drops,
    Boil and allow...
DIPSTICK METHOD
•   A plastic strip coated with reagents
•   Reagent strip measure glucose level using glucose oxidase
   ...
BLOOD TESTS
Random blood glucose level
•   Measure the blood glucose level other than post prandial
    stage or fasting.
•    If it i...
Fasting Plasma Glucose
After 12hr fasting measure the blood glucose level
  in venous blood.

         4 mmol/L 6.1       ...
OGTT (Oral Glucose Tolerance
  Test)
      Unrestricted carbohydrate diet for 3 days before test
      8 Hour overnight ...
HbA1C
   Measure the glycated hemoglobin proportion which
    indicates the glycaemic condition
   Glycosylation of hemo...
HbA1 Mean plasma glucose
c % mg/dl
6     135
7     170
8     205
9     240
10    275
11    310
12    345
Fructosamine Test
   Fructosamine = glycosylated plasma proteins,
               mainly albumin
   Indicate previous 2-3...
DIAGNOSIS OF COMPLICATIONS OF
DIABETES
     Diagnosis of Diabetic Neuropathy
              Lower limbs
     Peripheral p...
Diagnosis of Diabetic Nephropathy

     Microalbuminuria test
      In normal people

          Albumin excretion =30mg/d...
Diagnosis of Diabetic Retinopathy


         Eye examination
   Visual acuities (near and distance)
   Ophthalmoscopy (w...
Group 17 & 18
 Diet is an essential part of
   the management of
diabetes

 Diet is based on healthy
  eating principles
Reasons for diet


•Weight control

•Blood glucose control

•Prevention and management of short-term
and long-term complic...
Basic Principles of Diabetic
Diet

•Ensure regular meals

• Base meals on starchy carbohydrates

• Aim for more fruit and ...
Eat starchy foods regularly

    Bread
    Potatoes
    Rice
    Cereals
    Plantain

    CHO –to form 45-60% of to...
Eat fruit and vegetables


   Fresh
   Frozen
   Tinned
   Dried
   Juice

   Encourage food rich in antioxidants - ...
Reduce protein intake

   Restriction of protein intake to 0.6 -0.8 g/ kg/ day
   Replace red meat with chicken ,fish or...
• Aim for low sugar diet
    –Not a sugar free diet
    –Instead of sweet cakes/ biscuits offer
     fruit loaf, plain bis...
Nutrition Claims – Sugar


‘No added Sugar’ – No sugar from any
                    source added


‘Low Sugar’ – No more t...
Choose more high fibre foods
To help maintain blood glucose levels and cholesterol levels
                                ...
Reduce animal or saturated fat intake

   Use low fat milk
   Use low fat
    spread instead of
    butter
   Use oil h...
Use less fat in cooking


   Dry-roast
   Microwave
   Steam




   FAT - should not exceed 30 % of total energy
     ...
Choose the right sort of fat
 SATURATED            MONO-             POLY-
                       UNSATURATED       UNSATU...
Nutrition Claims – Fat


‘Low Fat’ - . 3g Fat/ 100g or 100mls


‘Less than 5% Fat’ - . 5g fat/ 100g


Reduced Fat’ – 25% l...
Reduce salt intake
•   Cut down on added salt
•   Use alternatives
•   Look out for reduced/low sodium foods, eg bread
•  ...
Alcohol

• Alcohol in moderation can be
included,
no more than:
  – 1-2 units/ day for women
  – 2-3 units/ day for men

•...
Special diabetic foods

   Not recommended
   May contain more fat or energy than other foods
   May be low in fibers
...
If Residents Overweight

• Weight loss is desirable –via exercising

• Encourage to cut down on fatty foods
 e.g. chips, p...
If residents malnourished

• Encourage small frequent meals
and low sugar puddings and snacks:

      – Glass of milk/ mil...
Recommended food meals for a diabetic
patient
  Breakfast –chickpea 1 cup or green gram 1 cup or
         bread two slices...
Key Points

• Ensure regular meals

• Base meals on starchy carbohydrates

• Aim for more fruit and vegetables

• Cut down...
Group 19-20
   CANNOT CURE. But can prevent.
   Kathmandu declaration- life cycle
    approach for prevention & care of DM.
o   Prim...
THANK YOU!
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
All what you have to know about Diabetes Mellitus
Upcoming SlideShare
Loading in...5
×

All what you have to know about Diabetes Mellitus

5,406

Published on

All what you have to know about Diabetes Mellitus is here.Introduction of Diabetes,Regulation of blood glucose,Predisposing factors of DM,Clinical presentation,DM and pregnancy ,Diabetes ketoacidosis ,Complications of DM ,Diagnosis ,Dietary management of DM & Prevention of DM.
Student seminar on Diabetes Mellitus presented by 2007/2008 Batch students of Faculty of Medicine,University of Peradeniya,Sri Lanka.

Published in: Health & Medicine
1 Comment
3 Likes
Statistics
Notes
No Downloads
Views
Total Views
5,406
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
483
Comments
1
Likes
3
Embeds 0
No embeds

No notes for slide

Transcript of "All what you have to know about Diabetes Mellitus"

  1. 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. 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. 3. Future  By 2007,246 million people were affected worldwide  By 2025 380 million people are expected to have the disease
  4. 4. Content ● Introduction - Group 1& 2 ● Regulation of blood glucose - Group 3 & 4 ● Predisposing factors of DM - Group 5 & 6 ● Clinical presentation - Group 7 & 8 ● DM and pregnancy - Group 9 & 10 ● Diabetes ketoacidosis - Group 11 & 12 ● Complications of DM - Group 13 & 14 ● Diagnosis - Group 15 & 16 ● Dietary management of DM - Group 17 & 18 ● Prevention of DM - Group 19 & 20
  5. 5. Groups 1 & 2
  6. 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. 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. 8. Clinical differences between Type 1 and Type 11 Diabetes Type 1 Type 11 Ketosis prone Yes Uncommon Insulin requirement Yes- absolute insulin Often later in disease- deficiency insulin deficiency+_ deficiency Onset of symptoms Acute Often insidious Obese Uncommon Common Age at onset - years Usually < 30 >30 Family history of 10% 30% diabetes Concordance in 30- 50% 90-100% monozygotic twins
  9. 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. 10. Prevalence of diabetes in Sri Lanka
  11. 11. Symptoms  Weight loss.  Polyuria – increased urine excretion.  Polydipsia – excessive thirst and water ingestion.
  12. 12. Causes  Increased prevalence of DM is related to;  excessive caloric intake  reduced physical activity.
  13. 13. Nature of the Disease  Usually irreversible.  Strongly linked to obesity.  Patients can have a reasonably normal life style.
  14. 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. 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.
  16. 16. Metabolic Changes  Abnormal carbohydrate metabolism. (Normal blood glucose level 3.6- 6.1 mmol /l)  Abnormal lipid homoeostasis. Hyperglycemia
  17. 17. Complications of Diabetes  Macrovascular diseases  Coronary heart disease  Peripheral vascular disease  Amputations  Microvascular diseases  Retinopathy  Nephropathy  Neuropathy
  18. 18. Prevention & Treatment  Combination approach.  Increased exercise  Decreases need for insulin  Reduce calorie intake  Improves insulin sensitivity  Weight reduction  Improves insulin action
  19. 19. Group 3/4
  20. 20. •Normal plasma glucose: 3.9-8.3 mM •Plasma glucose is tightly regulated by hormones: Insulin: ↓Plasma glucose Glucagon Epinephrine Cortisol ↑Plasma glucose Growth hormone
  21. 21. Correlation Between Plasma Glucose & Insulin Levels
  22. 22. Metabolism of Insulin •Insulin has no plasma carrier proteins •Short plasma half-life (3-5 min) • ~50% of insulin is removed during the first pass through the liver
  23. 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. 24. GLUCAGON The most important hormone in increasing plasma glucose. Glucagon is a single chain polypeptide (29 amino acids).
  25. 25. REGULATION OF GLUCAGON SECRETION
  26. 26. ROLE OF GLUCAGON IN GLUCOSE REGULATION Glucagon 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. 27. Fat: ↑Ketogenesis(ketoneproduction) Protein: ↓Hepatic protein synthesis ↑protein catabolism in the liver Glucagon DOES NOT affect muscle proteins.
  28. 28. REGULATION OF BLOOD GLUCOSE BY INSULIN & GLUCAGON
  29. 29. Overall: •Insulin ↓plasma glucose by promoting glucose uptake & its storage. •Glucagon ↑plasma glucose by increasing liver glucose output.
  30. 30. GLUCOSE REGULATION DURING EXERCISE- ROLE OF EPINEPHRINE
  31. 31. Group 5 & 6
  32. 32. Diet Starch  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. 33. Diet continue...  Refined sugars  Nothing increases blood sugar more readily than ingesting sugar. So high fructose corn syrup, candy & sweets such as 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. 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. 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. 36. Sedentary Life  A sedentary life style is damaging to health & bears responsibility for the growing obesity problems.  Inactivity & being overweight go hand in hand towards a diagnosis of type 2 diabetes.  Muscle cells have more insulin receptors than fat cells, so a person can decrease insulin resistance by exercising.
  37. 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 conditions •There is also evidences that links cigarette smoking with microvascular diseases in diabetes. •Smoking can cause chronic pancreatitis which leads to diabetes.
  38. 38. Ethnicity  Incidence high in  African, Americans, Asians, American Indians, Hispanic, Caucasians, Latinos, Mexican-American, Europeans Age •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. 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 1 DM is located in the HLA region on chromosome 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. 40. Gestational Diabetes Human placental Peripheral tissues Lactogen Insulin resistance Estrogen Pancreas Progesterone •Increased Fat stores •Prolactin •Changes in insulin receptor most women revert to normal glucose tolerance post-partum, but have a substantial risk (30– 60%) of developing diabetes mellitus later in life.
  41. 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. 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.
  43. 43. Other factors  Endocrine  Acromegaly 25%  Cushing’s Disease 30%  Glucagonoma 90%  Drugs that decrease insulin sensitivity  Glucocorticoids  Beta-2 receptor antagonists  OCP
  44. 44. Groups 7 & 8
  45. 45. “ The history of diabetic symptoms is of the greatest importance and an accurate appreciation of their severity far exceeds an estimation of the blood sugar as a means of assessing the need for treatment.” (John Malins, Clinical Diabetes Mellitus, Eyre & Spottiswoode, 1968)
  46. 46. Clinical presentation Acute Sub acute Symptoms Symptoms •Acute & Sub acute presentations often overlap. But,  Asymptomatic diabetes can occur.
  47. 47. Acute presentation Young people often present with a 2-3 weeks history and report the classical triad of symptoms. Thirst Polyuria 1.Thirst 2.Polyuria 3.Weight loss If not  Ketonuria treated Ketoacidosis
  48. 48. Sub acute presentation  Clinical onset over 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. 49. balanitis Visual blurring Pruritus vulvae
  50. 50. Other symptoms  Somnolence (the tendency to fall asleep)  Myopia  Nausea, headache  Tiredness, fatigue  Malaise  Hyperphagia - predilection for sweet foods
  51. 51. Complications  Macrovascular  Microvascul ar diseases diseases Cardiovascular diseases Nehpropathy Eg: Coronary artery diseases Neuropathy Stroke Retinopathy • Foot infections • Erectile dysfunctions gangrene
  52. 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. 53. Diabetes and pregnancy Group 9 and 10
  54. 54. 1. Already diagnosed diabetes mellitus woman getting pregnant – Preexisting diabetes. 2. A woman who hasn’t been diagnosed diabetes, exhibit high blood glucose levels during pregnancy – Gestational diabetes
  55. 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..
  56. 56. Gestational diabetes During Human placental lactogen pregnancy level & Cortisol level increase • Both are insulin antagonists. • Cortisol gluconeogenesis glucose utilization Blood glucose • HPL insulin sensitivity glucose utilization
  57. 57. Risk factors • Obesity BMI > 30 • Family history of diabetes • Previous babies having high birth weight ( >4.5kg ) • Previous still birth • Previous babies with congenital abnormalities
  58. 58. Maternal complications  Pre-eclampsia (pregnancy induce hypertension )  Antepartum hemorrhage due to placental abbruption  Microvascular  Nephropathy  Retinopathy  Neuropathy  Macrovascular  Coronary artery disease  Hyperglycaemia / hypoglycaemia / ketoacidosis  Infection  Thrombo – embolic disease
  59. 59. Fetal & neonatal complications  Increase risk of miscarriage & congenital fetal abnormalities  Neural tube defects, congenital heart diseases & spinal anomalies  Sacral agenesis (caudal regression syndrome)  Fetal macrosomia  Late still birth  Respiratory distress syndrome  Hypoglycaemia  Polycythaemia  Hyperbilirubinaemia  Hypomagnesemia Macrosomia
  60. 60. Diagnosis of maternal diabetes  Glucose challenge test (>140mg/dl)  Oral glucose tolerance test.  Random blood sugar. Normal fasting glucose -<7mmol/l Impaired glucose intolerance -7.8- 11.1mmol/l Random blood glucose -<11.1mmol/l If Diabetes RBG>11.1mmol/l mellitus If FBG>7mmol/l
  61. 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 nephropathy At 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. 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. 63. References  Obstetrics by Ten Teachers
  64. 64. DIABETIC KETOACIDOSIS GROUP 11 & 12 07/08 BATCH
  65. 65. Introduction  Major medical emergency  Principally with type 1 diabetes  High blood sugar with ketones in urine and blood  Body can’t use glucose due to insulin shortage
  66. 66. Main cause – Type 1 diabetes Usually occurs in following circumstances • Undiagnosed diabetes • Interruption to insulin therapy • Stress due to any illness (Also occurs in type 2 diabetes)
  67. 67. Mechanism of Diabetes Ketoacidosis In adipose cells insulin inhibit the action of intracellular enzyme “Hormone-sensitive lipase”
  68. 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. 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.
  70. 70. Symptoms & signs  Nausea  Vomiting  Excessive thirst  Frequent urination  Weakness  Ketone / Fruity smelly breaths  Hyperventilation  Confusion  Dry skin  Abdominal pain
  71. 71. Diagnosis  Ketonuria or ketonemia is demonstrated  Dipstick method for hyperglycemia  Centrifugation blood for ketonemia ?  Arterial blood gas analysis
  72. 72. Investigations  Urea & Electrolytes, Blood glucose, Plasma bicarbonate  Arterial blood gases to assess the severity of acidosis  Urinalysis for ketones  ECG
  73. 73. Treatment Replace lost fluid & electrolytes suppressing high blood sugar & ketone production with insulin  Fluid replacement  Insulin therapy  Potassium  NaHCO3 ….?
  74. 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. 75. References  Kumar & Clark;Clinical Medicine  Davidson;Clinical medicine  Harper’s illustrated biochemistry
  76. 76. Groups 13-14
  77. 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
  78. 78. • Complications 1.Macrovascular Hypertension Smoking Lipid abnormalities 2.Microvascular Daibetic eye disese Diabetic kidney Diabetic neuropathy The diabetic foot Infections Skin & Joints
  79. 79. Diabetic Retinopathy • Impairment of loss of vision • Due to damage to blood vessels of retina • Cause of long standing diabetes Cataract Glucoma
  80. 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. 81. Diabetic neuropathy • Usually causing weakness & numbness • Symptoms are depended on nerves which damage • Most commonly affects legs
  82. 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 vessels Poor circulation Less ability to fight with infections & healing also slow Foot ulcer Gangrene
  83. 83.  2) Damage the nerves  Loss of sensation (peripheral neuropathy)  Injuries cannot be noticed  Susceptible for infections  3) Damage to the nerves controlling oil & moisture  Skin dryness  Easy to getting cracks  Susceptible for infections
  84. 84.  4) Affects joints Making them stiffer  Charcot’s joints
  85. 85. Effects of diabetes to blood vessels Diabetes mellitus Part of plaque Glucose Travel through circulation Cholesterol Breakage of plaque Lodge in a vessel Deposit in damaged of brain (STROKE) vessels Loss of blood supply to Atheroma ( in damaged inner layer) part of brain atherosclerosis Diameter of blood vessels Blood flow
  86. 86. Effect of diabetes to heart  Diabetes mellitus  Atherosclerosis Blood glucose In peripheral Blockage of vessels coronary vessels blood flow blood supply Cardiac muscle to part of failure heart Heart has to pump (cardiomyopathy) more forcefully Ischemic heart disease hypertension Heart attack
  87. 87. GROUP 15-16 DIAGNOSIS of
  88. 88. DIAGNOSIS OF DIABETES If patient complains of symptoms suggesting diabetes  Test urine for GLUCOSE & KETONES  Random Blood Glucose (normal <200mg/dL, 11.1mmol/L)  Fasting Blood glucose (FBG) if FBG>7.0mmol/l, 126mg/dL-DIABETES if (6.1 <= FBG < 7.0)mmol/l or (110 <= FBG < 126) mg/dL IMPAIRED FASTING GLUCOSE (IFG)  Oral Glucose Tolerance Test (OGTT)  HbA1C This can be utilized as an assessment of glycaemic control in a patient with known diabetic  other tests - Fructosamine test , Ketone body analysis, microalbuminuria test
  89. 89. URINE TESTS
  90. 90. BENEDICT’S TEST  To assess urine sugar level  To 5ml Benedict’s solution add 8-10 urine drops,  Boil and allow to cool then observe color change. Color change % of sugar blue Nil Clear green 0.1 Turbid green 0.3 Green & Yellow 0.5-1.0 Yellow 1.0 Orange 2.0 Brick red >2.0 Maltose, galactose, , sucrose & drugs which contain aldehyde groups such as Aspirin, Penicillin, Vitamin C, antibiotics (+)ve results • detects only blood sugar levels >180mg/dL
  91. 91. DIPSTICK METHOD • A plastic strip coated with reagents • Reagent strip measure glucose level using glucose oxidase method. GLUCOSE OXIDASE GLUCOSE H2O2 (Change the color of the indicator)
  92. 92. BLOOD TESTS
  93. 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. 94. Fasting Plasma Glucose After 12hr fasting measure the blood glucose level in venous blood. 4 mmol/L 6.1 7.0 80 mg/dL mmol/L mmol/L 110 126 mg/dL mg/dL Hypoglycemi Normal Impaired (Hyperglycemic) c Fasting Diabetes Glucose
  95. 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 5 minutes.  Measure plasma glucose BEFORE and 2 hours AFTER the glucose load. Time Non Diabetic Diabetic Impaired Glucose _ Tolerance Fasting(0 <6.1mmol/l >7.0mmol/l 6.1-7.0mmol/l min) (110mg/dl) (126mg/dl) (110-126mg/dl) 120min <7.8mmol/l >11.1mmol/l >7.8-11.1mmol/l (140mg/dl) (200mg/l) (140-200mg/dl)
  96. 96. HbA1C  Measure the glycated hemoglobin proportion which indicates the glycaemic condition  Glycosylation of hemoglobin α [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. 97. HbA1 Mean plasma glucose c % mg/dl 6 135 7 170 8 205 9 240 10 275 11 310 12 345
  98. 98. Fructosamine Test  Fructosamine = glycosylated plasma proteins, mainly albumin  Indicate previous 2-3 week glyceamic control  Impaired in patients with anemia , hemoglobinopathies & pregnancy.
  99. 99. DIAGNOSIS OF COMPLICATIONS OF DIABETES  Diagnosis of Diabetic Neuropathy Lower limbs  Peripheral pulses  Tendon reflexes  Perception of vibration sensation, light touch and proprioception Feet  Callus skin indicating pressure areas  Nails  Need for podiatry  Ulceration  DeformityDiabetic Nephropathy
  100. 100. Diagnosis of Diabetic Nephropathy Microalbuminuria test  In normal people Albumin excretion =30mg/day  In kidney damage > 300mg/day  In diabetic nephropathy ; Albumin excretion =30-300mg/day microalbuminuria
  101. 101. Diagnosis of Diabetic Retinopathy Eye examination  Visual acuities (near and distance)  Ophthalmoscopy (with pupils dilated)  Digital photography
  102. 102. Group 17 & 18
  103. 103.  Diet is an essential part of the management of diabetes  Diet is based on healthy eating principles
  104. 104. Reasons for diet •Weight control •Blood glucose control •Prevention and management of short-term and long-term complications of diabetes
  105. 105. Basic Principles of Diabetic Diet •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 •Reduce salt
  106. 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. 107. Eat fruit and vegetables  Fresh  Frozen  Tinned  Dried  Juice  Encourage food rich in antioxidants - vitamins
  108. 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. 109. • Aim for low sugar diet –Not a sugar free diet –Instead of sweet cakes/ biscuits offer fruit loaf, plain biscuits, teacakes  Cut down on sugar and sugary foods: • Use low sugar foods – Use drinks labeled diet, low calorie or sugar- free – Choose diet or ‘light’ yoghurts instead of low-fat or whole yoghurts • Use sugar free/ low sugar - jelly, custard, rice pudding as dessert ideas
  110. 110. Nutrition Claims – Sugar ‘No added Sugar’ – No sugar from any source added ‘Low Sugar’ – No more than 5gs sugar/100gs ‘Reduced Sugar’ – 25% less sugar than regular product FREE SUGER – do not exceed 50g per day
  111. 111. Choose more high fibre foods To help maintain blood glucose levels and cholesterol levels Helps to maintain a  Fruit healthy gut  Vegetables  Pulses • Wholegrain cereals  Oats • Wholemeal bread • Brown rice  FIBERS – 40g per day or more half of fiber should be soluble
  112. 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. 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. 114. Choose the right sort of fat SATURATED MONO- POLY- UNSATURATED UNSATURATED • Full fat dairy produce (eg • Olive oil • Sunflower oil cheese, butter, (products) • Rapeseed oil full cream milk) • Oily fish • Groundnut oil • Biscuits • Savoury snacks • Lard • Hard vegetable fat
  115. 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. 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. 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’ mixers •Caution with sweet liqueurs
  118. 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 a sweetener will still affect blood sugars in the same way as normal sugar!!
  119. 119. If Residents Overweight • Weight loss is desirable –via exercising • Encourage to cut down on fatty foods e.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. 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. 121. Recommended food meals for a diabetic patient Breakfast –chickpea 1 cup or green gram 1 cup or bread two slices with polsambol 1 tsp. Lunch – Rice two cups , Vegetables 6 tablespoons , green leaves ½ cup, fish or chicken 1 piece, fruit 1 serving Dinner – Rice 1 cup, vegetable 3 tablespoons, Dhal 3 tablespoons, Fruit 1 serving
  122. 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. 123. Group 19-20
  124. 124.  CANNOT CURE. But can prevent.  Kathmandu declaration- life cycle approach for prevention & care of DM. o Primary prevention o Secondary prevention
  125. 125. THANK YOU!
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×