Diabetes is a lifelong (chronic) disease and is a group of metabolic disorder characterized by high levels of sugar in blood (hyperglycemia).

1. DIABETES MELLITUS
AB Rajar
Associate Professor
Community Medicine
Muhammad Medical College

2. LEARNING OBJECTIVES
• Introduction
• Key facts /Problem statement/Global Burden
• Burden in Pakistan
• Classification
• Epidemiological Factors
• Prevention and control measures
• Complications

3. INTRODUCTION
• Diabetes is a lifelong (chronic) disease and is a group of metabolic
disorder characterized by high levels of sugar in blood
(hyperglycemia).
• It is caused due to deficiency of insulin or resistance to insulin or
both.
• Insulin is secreted by β-cells of pancreas to control blood sugar levels

4. DEFINITION.
• It is a syndrome characterized by disordered metabolism and chronic
hyperglycemia due to either an absolute deficiency of insulin
secretion or reduction in its bio-effectiveness or both

5. GLOBAL BURDEN
• WHO estimates that diabetes was the 7th leading cause of death in
2016.
• The number of people with diabetes rose from 108m (1980) – 422m
in 2014.
• The global prevalence among adults over 18,rose from 4.7% in 1980
to 8.5% in 2014.
• B/w 2000 & 2016, there was a 5% increase in premature mortality
from diabetes.
• In 2016, an estimated 1.6 million deaths were directly caused by
diabetes.

6. The current prevalence of type 2 DM in Pakistan is 11.77%.
In males 11.20% and in females 9.19%.
Province Male Female
Sindh 16.2% 11.70 %
Punjab 12.14% 9.83%
Baluchistan 13.3% 8.9%
KPK 9.2% 10.34%
Urban -14.81% and 10.34% - rural
PAKISTAN
• Type 2 Diabetes Mellitus in Pakistan: Current Prevalence and Future Forecast,Meo SA, Zia I, Bukhari IA,
Arain SA. Type 2 diabetes mellitus in Pakistan: Current prevalence and future forecast. J Pak Med Assoc. 2016;66(12):1637-1642.

7. Pakistan

8. Pakistan

9. WHO Classification
• 1.Diabetes Mellitus [DM].
• Insulin-dependent DM { IDDM Type 1}
• Non-Insulin dependent DM {NIDDM Type 2}
• Malnutrition related DM {MRDM}
• Others: [ secondary to pancreatic, hormonal],drug induced and other
abnormalities}
• 2. Impaired Glucose Tolerance (IGT)
• 3. Gestational Diabetes Mellitus (GDM)

10. EPIDEMIOLOGICAL FACTORS
• AGENT FACTORS:
• Pancreatic disorders.
• Defects in the formation of insulin.
• Destruction of Beta-cells by viral infections and chemicals.
• Decreased insulin sensitivity.
• Genetic defects.
• Auto-immunity.

11. EPIDEMIOLOGICAL FACTORS
• HOST FACTORS:
• Age:
• Increased incidence with age.
• Sex:
• Affects both sexes almost equally
• Genetic factors:
• In NIDDM,concordance is about 90% in identical twins.
• In NDDM, concordance is only 50%.

12. EPIDEMIOLOGICAL FACTORS
• HOST FACTORS:
• Genetic markers:
• IDDM is associated with HLA-DR3 and DR4 and also with HLB8 & B15.
• NIDDM is not HLA-associated.

13. EPIDEMIOLOGICAL FACTORS
• HOST FACTORS:
• Immune Mechanism:
• Both cell mediated and humeral activity against islet cells.
• Obesity:
• Risk Factor for NIDDM.
• Pregnancy:
• Risk factor for NIDDM.

14. SOCIAL AND ENVIRONMENTAL FACTORS
• Sedentary life style
• Low dietary fibers.
• Malnutrition in early infancy and childhood may result in failure of
beta cells function.

15. SOCIAL AND ENVIRONMENTAL FACTORS
• Stress:
• Surgery, Trauma and stress of situations may bring out the disease.
• Viral infections:
• E.g. Antibodies to Coxsackie,s virus B4 (20-30%) Rubella, Mumps.
• Chemical agents:
• Rodenticide VACLOR.
• Alcohol:
• Produce DM by damaging the pancreas and liver.

16. Risk factors of diabetes
• 1. Those that cannot be modified
• a. Advancing age
• b. Family history of diabetes
• 2.Those that are modifiable
• a. Overweight and obesity
• b. Alcohol use
• c. Tobacco use
• d. Physical inactivity
• e. A stressful lifestyle
• f. Unhealthy diet

17. LAB DIAGNOSIS
• Criteria for the Diagnosis of diabetes mellitus
Normal Impaired
fasting glucose
Impaired glucose
tolerance test
Diabetes mellitus
Fasting plasma glucose (mg/dl) <110 >110 but <126 ----- > 126
2 hours after glucose load (mg/dl) <140 ------ >140 but < 200 > 200
Random (mg/dl) ----- ------ ------ > 200 with
symptoms
Fasting: no solid or liquid food except water for at least 8 hours.
Random: any time of day, unrelated to meal.

18. TREATMENT
• DIET ALONE
• DIET AND ORAL HYPOGLYCEMIA DRUGS.
• DIET AND INSULIN

19. DIET
• About 60% of diabetic patients can be treated adequately by diet
alone.
• Diet should be balanced (should contain Fat, Protein & carbohydrates)
• Obese, middle aged or elderly pt with mild diabetes 100-1600 kcl/day.
• Elderly diabetic but not overweight 1400-1800 kcal/day.
• Young, active diabetic 1800-3000 kcal/day.
• Estimated proportion:
• Protein -10-15% ( 60-110 grams)
• Fat – 30-35%
• Carbohydrates – 50-55% (100-300 grams)

20. ORAL HYPOGLYCEMIC DRUGS
• Valuable in the treatment of patients with type 2 diabetes (NIDDM)
who fail to respond to simple dietary restriction.
• Sulphonylureas and Biguanides are mainstay of treatment.
• Sulphonylureas
• Biguanides
• Alpha glucosidase inhibitor (Acarbose)
• Non-Sulphonylureas insulin stimulators Repaglinide).
• Note: Oral Hypoglycemic drugs are contraindicated in pregnancy.

21. INSULIN REGIMENS
Conventional split dose method
Intensive insulin therapy
TREATMENT OF TYPE 1 (IDDM) WITH INSULIN.

22. INSULIN REGIMENS
• CONVENTIONAL SPLIT DOSE METHOD
• Usually 2 injections per day
• Morning:
• 2/3 of total dose (2/3NPH + 1/3
regular)
• Evening:
• 1/3 of total dose (2/3NPH + 1/3
regular)
• INTENSIVE INSULIN THERAPY
• Used when above methods cant
control:
• Three injections regimen
• Mixture of NPH & regular in morning
• Regular alone at dinner
• NPH alone at bedtime
• Four injections regimen:
• Regular insulin before each meal
• NPH or long acting at bedtime
• Continuous subcutaneous insulin
infusion
• By small battery driven insulin pump.

23. COMPLICATIONS OF DIABETES
A. Hyperglycemia
B. Diabetes ketoacidosis
C. Non-ketoacidosis (DKA)
ACUTE COMPLICATIONS

24. CHRONIC COMPLICATIONS
• CHRONIC COMPLICATIONS
• Retinopathy, cataract
• Nephropathy
• Peripheral neuropathy
• Autonomic neuropathy
PRESENTATION
• Impaired vision
• Renal failure
• Sensory loss, motor weakness.
• Postural hypotension, impotence
Micro vascular
Macro vascular
• Coronary artery disease
• Cerebral ischemia
• Peripheral vascular disease
• Angina, MI.
• TIA,Stroke.
• Claudication

25. Health impact
• Over time, diabetes can damage the heart, blood vessels, eyes,
kidneys, and nerves.
• Adults with diabetes have a two- to three-fold increased risk of heart
attacks and strokes.
• Diabetic retinopathy is an important cause of blindness accounts 2.6%
of global blindness.
• Combined with reduced blood flow, neuropathy increases the chance
of foot ulcers, infection and eventual need for limb amputation.
• Diabetes is among the leading causes of kidney failure

26. PREVENTION AND CONTROL

27. PREVENTION AND CONTROL
• A. SCREENING FOR DIABETES:
1. Urine test for glucose (sensitivity is just 10-50%)
2. Blood sugar testing:
• Fasting.
• Random.
• 2- hours after 75g oral glucose.

28. PRIMARY PREVENTION ( Has no role in IDDM)
• 1. POPULATION STRATEGY:
• Emphasis must be given on primordial prevention.
• Maintenance of normal body weight
• Elimination of risk factors.

29. PRIMARY PREVENTION ( Has no role in IDDM)
• 2.HIGH-RISK STRATEGY
• Persons at risk for NIDDM are
• Living a sedentary life
• Obese
• High alcohol consumers.
• Oral contraceptive users.

30. SECONDARY PREVENTION
• Treatment based on:
• Diet alone
• Diet and oral antidiabetic drugs.
• Diet and insulin.
• Taking Care Of:
• Percentage of Glycosylated Hb:6 monthly
• Self –care by adhering to diet and drug regimens.
• Home blood glucose monitoring
• Routine checkup of blood pressure, visual acuity and weight.

31. TERTIARY PREVENTION
• Establishment of diabetic clinic.
• Epidemiological research.
• Establish national registries for diabetics.