This was a lecture in the course "Significant Medical Conditions in Seniors" presented at Peer Learning in Chapel Hill, NC, USA in 2016 by Michael C. Joseph, MD, MPH.

1. DIABETES
Michael C. Joseph, MD, MPH
30 November 2016
(Peer Learning)

2. OUTLINE
 Definition
 Subtypes
 Epidemiology
 Signs & Symptoms
 Complications
 RESOURCES
 CREDITS

3. DEFINITION
 Diabetes mellitus (DM), commonly
referred to as diabetes, is a group of
metabolic diseases in which there are high
blood sugar levels over a prolonged
period.
 Diabetes is due to either the pancreas
not producing enough insulin, or the cells
of the body not responding properly to
the insulin produced.

4. Glucose Metabolism

5. Diabetes Monitoring
 Diagnosis
─ Blood glucose level (Chemistry panel)
─ Urine glucose
─ Oral Glucose Tolerance Test (OGTT) (serial IV
measurements of blood glucose after a standard oral sugar
load)
 Control
─ Blood glucose level (Chemistry panel)
─ Home glucose meter (fingerstick)
─ Glycosylated Hemoglobin (HbA1C)
 Periodic average of blood glucose levels

6. Pre-DIABETES
 Affects almost 1 in 4 adults
 Blood glucose levels are elevated, but
lower than in diabetes
 Treated with diet and exercise
 Converts to Type 2 Diabetes, if
uncontrolled

7. Gestational
DIABETES
 Elevated blood glucose during pregnancy.
 Resolves after the birth of the baby, in non-
diabetic mothers.
 Results in very large newborns (9-13 lbs).
 Associated with Type 2 Diabetes in mothers.
 Also occurs when pregnant women without a
previous history of diabetes develop high
blood-sugar levels.

8. TYPE 1 DIABETES (Juvenile Onset)
 This type is also called “insulin-dependent
diabetes mellitus” (IDDM) or “Juvenile
onset diabetes”.
 The pancreas gland produces little or no
insulin.
 Concordance in identical twins is about 50%.
 Requires frequent testing of blood glucose
and titrated insulin injections.
 Limited insulin pump implementation.

9. TYPE 2 DIABETES
 This most common form is also referred to as
"non-insulin-dependent diabetes mellitus"
(NIDDM) or "adult-onset diabetes“:
─Primarily diagnosed in adults (BUT increasingly in
obese children).
─Concordance in identical twins is about 90%.
─Type 2 DM begins with insulin resistance (poor
absorption of glucose by fat cells). As the disease
progresses, a lack of insulin may also develop.
─The primary causes are obesity and lack of exercise.
─Treated by diet, exercise, oral antidiabetic medications
(with or without insulin), weight-loss surgery.

10. Weight & Diabetes Trends

11. EPIDEMIOLOGY
 Nearly 30 million Americans (1 in 11) have diabetes.
 The epidemic is fueled by the increase in obesity.
 National Health and Nutrition Examination Survey, 2009–2010:
─ More than 2 in 3 adults were overweight or obese.
─ More than 1 in 3 adults were obese.
─ More than 1 in 20 adults had morbid (extreme) obesity.
─ About 1 in 3 children aged 6 to 19 were overweight or obese.
─ More than 1 in 6 children aged 6 to 19 were obese.
 High risk groups include:
─ African-Americans
─ Hispanics/Latinos
─ Native Americans.

12. The Diabetes Burden
(North Carolina)
 About 1.1 million people (13% of the population)
have been diagnosed with diabetes.
 247,000 (1 in 6) people with diabetes do not
know they have it.
 Roughly 2.6 million people have “pre-diabetes”.
 Every year, about 47,000 people are newly
diagnosed with diabetes.
 Diabetes costs an estimated $11 billion each
year.

13. Classic Symptoms
 Weight loss
 Polyuria (increased urination)
 Polydipsia (increased thirst)
 Polyphagia (increased hunger).
 Symptoms may develop rapidly (weeks or
months) in Type 1 DM, while they usually
develop much more slowly and may be
subtle or absent in Type 2 DM.

14. Systemic Symptoms

15. “The Metabolic Syndrome”
 The Metabolic Syndrome is a group of five (5) signs that
are associated with an increased risk of heart disease and
stroke.
 You must have at least three (3) of these risk factors for
this diagnosis:
─ A large waistline (35” in women; 40” in men). This also is called
abdominal obesity or "having an apple shape.“
─ A high triglyceride level (or you are on medicine to treat high
triglycerides). Triglycerides are a type of fat found in the blood.
─ A low HDL cholesterol level (or you are on medicine to treat low
HDL cholesterol). HDL sometimes is called "good" cholesterol,
because it helps to remove cholesterol from your arteries.
─ High blood pressure.
─ High fasting blood glucose (or you're on medicine to treat high
blood sugar).

16. DM Arterial Complications
 Heart disease:
─75% of deaths in diabetics are due to
coronary artery disease.
 Stroke (cerebrovascular disease)
 End-stage kidney disease
 Blindness (diabetic retinopathy)
 Amputation (peripheral arterial
disease)

17. DM Neurological Complications
 Damage to the nerves of the body, known
as diabetic neuropathy, is the most
common complication of diabetes:
─Symptoms can include numbness, tingling,
pain, and altered pain sensation - which can
lead to skin damage.
─Diabetic foot ulcers can be difficult to treat,
occasionally requiring amputation.
─Muscle wasting and weakness may occur.

18. Hypoglycemia
(Low Blood Sugar)
 Rapid breathing and sweating, cold, pale skin are
characteristic of hypoglycemia but not definitive.
 In mild cases effects can range from feelings of unease,
sweating, trembling, and increased appetite.
 Mild to moderate cases are self-treated by eating or
drinking something high in sugar.
 Moderate hypoglycemia may easily be mistaken for
drunkenness.
 Severe cases (hypoglycemic shock) include confusion,
changes in behavior such as aggressiveness, seizures,
unconsciousness, and (rarely) permanent brain damage or
death. Severe cases must be treated with intravenous
glucose or injections with glucagon hormone.

19. Diabetic Emergencies
 Patients (usually with type 1 DM) may also
experience episodes of diabetic
ketoacidosis: a metabolic disturbance
characterized by nausea, vomiting and
abdominal pain, the smell of acetone on the
breath, deep breathing known as Kussmaul
Respirations, and in severe cases a
decreased level of consciousness.
 Another rare but equally severe complication
is a hyperosmolar nonketotic state, which
is more common in type 2 DM, and is mainly
the result of dehydration.

20. RESOURCES
 American Diabetes Association
http://diabetes.org/
 American Society for Metabolic and
Bariatric Surgery (ASMBS)
http://asmbs.org/

21. CREDITS
 American Society for Metabolic and Bariatric
Surgery (ASMBS)
https://asmbs.org/resources/weight-and-
type-2-diabetes-after-bariatric-surgery-
fact-sheet
 American Diabetes Association
http://diabetes.org/
 SLIDESHARE.NET
 http://www.slideshare.net/mldanforth/diabetes-
powerpoint-8673722?qid=210ecc6a-a8ac-4517-
8586-0aa3f218ab9d&v=&b=&from_search=1
 https://en.wikipedia.org/wiki/Diabetes_mellitus