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  1. 1. Diabetes Mellitus
  2. 2. <ul><li>Introduction </li></ul><ul><li>Epidemiology </li></ul><ul><li>Classification </li></ul><ul><li>Pathophysiology </li></ul><ul><li>Diagnosis </li></ul><ul><li>Emergencies </li></ul><ul><li>Gestational diabetes </li></ul>
  3. 3. <ul><li>Diabetes is a chronic non communicable disease characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. </li></ul><ul><li>Insulin is an anabolic hormone needed for metabolism of fat, protein and carbohydrate </li></ul>
  4. 4. <ul><li>Insulin Effects </li></ul><ul><li>Enhances </li></ul><ul><li>♦ Fat storage </li></ul><ul><li>(lipogenesis) </li></ul><ul><li>♦ Liver and muscle storage </li></ul><ul><li>of glucose as glycogen </li></ul><ul><li>(glycogenesis) </li></ul><ul><li>Inhibits </li></ul><ul><li>♦ Fat mobilization for </li></ul><ul><li>energy (lipolysis and </li></ul><ul><li>ketogenesis) </li></ul><ul><li>♦ Glucose release from </li></ul><ul><li>the liver and muscle </li></ul><ul><li>(glycogenolysis) </li></ul><ul><li>♦ Glucose formation from </li></ul><ul><li>amino acids </li></ul><ul><li>(gluconeogenesis) </li></ul>
  5. 5. <ul><li>Epidemiology </li></ul><ul><li>100 million people worldwide </li></ul><ul><li>85-90% - Type 2 </li></ul><ul><li>17 million people in US (6.2% of population) </li></ul><ul><li>5 to 10% - Type 1diabetes </li></ul><ul><li>5.9 million people are undiagnosed </li></ul><ul><li>Approximately 1 million new cases/year </li></ul>
  6. 6. <ul><li>The prevalence of diabetes increases with age </li></ul><ul><li>30–39 years’ age group - 6%, </li></ul><ul><li>40–49 years’ age group - 13 % </li></ul><ul><li>70 years and above - 20 % </li></ul><ul><li>prevalence among women above the age of 40 years is high. </li></ul>
  7. 7. <ul><li>Classification </li></ul><ul><li>1.Type 1 diabetes </li></ul><ul><li>2.Type 2 diabetes </li></ul><ul><li>3.Specific types </li></ul><ul><li>a.Genetic defects of cell function </li></ul><ul><li>b.Genetic defects in insulin action </li></ul><ul><li>c.Disease of exocrine pancreas </li></ul><ul><li>d.Endocrinopathies </li></ul><ul><li>e.Drug induced </li></ul><ul><li>f.Infections </li></ul><ul><li>g.genetic syndromes </li></ul><ul><li>4.Gestational diabetes </li></ul>
  8. 8. <ul><li>Type 1 diabetes </li></ul><ul><ul><li>Deficiency of insulin secretion </li></ul></ul><ul><ul><li>Possible autoimmune process with destruction of beta pancreatic cells </li></ul></ul><ul><ul><li>Genetic predisposition and possible links to viral infections and environmental factors </li></ul></ul><ul><ul><li>Require insulin supplementation, prone to develop DKA </li></ul></ul><ul><ul><li>Usually younger patients </li></ul></ul>
  9. 9. <ul><li>TYPE 2 Diabetes </li></ul><ul><ul><li>Resistance to action of insulin on target organs </li></ul></ul><ul><ul><li>Insulin production may or maynot be normal </li></ul></ul><ul><ul><li>Increased risk with obesity high fat, high caloric diets </li></ul></ul><ul><ul><li>Stronger genetic predisposition </li></ul></ul><ul><ul><li>Variety of initial presentations: nephropathy, retinopathy, neuropathies </li></ul></ul><ul><ul><li>Disease can be delayed or prevented with life style changes </li></ul></ul><ul><ul><li>Emergencies like hyperosmolar coma can occur </li></ul></ul>
  10. 10. <ul><li>Normal insulin structure </li></ul><ul><li>Insulitis </li></ul>
  11. 11. RISK FACTORS DM 2
  12. 12. Temporal development of type 1 diabetes <ul><li>Type 1 diabetes </li></ul>
  13. 13. Concept of hyperinsulinemia in type 2 diabetes
  14. 14. <ul><li>Insulin resistance </li></ul><ul><li>Major defect in individuals with type 2 diabetes </li></ul><ul><li>Reduced biological response to insulin </li></ul><ul><li>Strong predictor of type 2 diabetes </li></ul><ul><li>Closely associated with obesity </li></ul><ul><li>Cell dysfunction </li></ul><ul><li>Major defect in individuals with type 2 diabetes </li></ul><ul><li>Reduced ability of  -cells to secrete insulin in response to hyperglycemia </li></ul>
  15. 15. Insulin resistance Genetic susceptibility, obesity, Western lifestyle Type 2 diabetes IR  -cell dysfunction 
  16. 16. <ul><li>LADA </li></ul><ul><li>Latent Autoimmune Diabetes in Adults (LADA) is a form of type 1 diabetes which is diagnosed in individuals who are older than the usual age of onset of type 1 diabetes. It is frequently confused with type 2 diabetes </li></ul><ul><li>Age at Diagnosis 30 to 35 years </li></ul><ul><li>Non-Ketotic presentation </li></ul><ul><li>Insulin dependency gradually </li></ul><ul><li>Positive for GAD antibodies </li></ul><ul><li>Low C- peptide levels </li></ul><ul><li>Unlikely to have family history </li></ul><ul><li>Responds well to metformin and thiazilidones </li></ul>
  17. 17. <ul><li>Clinical presentations </li></ul><ul><li>Polyuria </li></ul><ul><li>Polydipsia </li></ul><ul><li>Polyphagia </li></ul><ul><li>Weight loss </li></ul><ul><li>Blurred vision </li></ul><ul><li>Poor wound healing </li></ul><ul><li>Shoulder periarthritis </li></ul><ul><li>Tingling sensation or numbness in both feet </li></ul><ul><li>Ketoacidosis in type 1 diabetes </li></ul><ul><li>Increase in infections </li></ul><ul><ul><li>Candidal vaginitis/balanitis </li></ul></ul><ul><ul><li>UTI </li></ul></ul><ul><ul><li>Malignant Otitis Externa </li></ul></ul>
  18. 18. History taking in diabetes <ul><li>Present problem and duration of symptoms </li></ul><ul><li>If a known diabetic: </li></ul><ul><li>Duration of diabetes </li></ul><ul><li>Mode of presentation at the time of diagnosis </li></ul><ul><li>Details of treatment- </li></ul><ul><li>OHAs- compliance, any adverse effects… </li></ul><ul><li>Insulin- storage, mode and site of administration, rotation of sites, Techniques use of pedevices… </li></ul>
  19. 19. <ul><li>Diagnosis </li></ul><ul><li>ADA criteria </li></ul><ul><li>The Fasting plasma glucose test is most reliable when done in the morning. </li></ul><ul><li>Having IFG means a person has an increased risk of developing type 2 diabetes but does not have it yet. </li></ul><ul><li>A level of 126 mg/dL or above, confirmed by repeating the test on another day, means a person has diabetes. </li></ul><ul><li>Fasting plasma glucose Result (mg/dL) </li></ul><ul><li>99 or below Normal </li></ul><ul><li>100 to 125 Pre-diabetes(impaired fasting glucose) </li></ul><ul><li>126 or above Diabetes * </li></ul>
  20. 20. <ul><li>The oral glucose tolerance test </li></ul><ul><li>Requires fasting for at least 8 hours before the test. </li></ul><ul><li>The plasma glucose level is measured immediately before and 2 hours after a person drinks a liquid containing 75 grams of glucose dissolved in water. </li></ul><ul><li>2-Hour Plasma Glucose Result (mg/dL) Diagnosis </li></ul><ul><li>139 and below Normal </li></ul><ul><li>140 to 199 Pre-diabetes (impaired glucose tolerance) </li></ul><ul><li>200 and above Diabetes * </li></ul>
  21. 21. <ul><li>American Diabetes Association recommends </li></ul><ul><li>Testing in </li></ul><ul><li>People aged 45 or older </li></ul><ul><li>People younger than 45 should consider testing if they are overweight, obese, or extremely obese and have one or more of the following risk factors: </li></ul><ul><li>being physically inactive </li></ul><ul><li>having a parent, brother, or sister with diabetes </li></ul><ul><li>having a family background that is African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, or Pacific Islander </li></ul>
  22. 22. <ul><li>Giving birth to a baby weighing more than 3.5 Kg or being diagnosed with gestational diabetes </li></ul><ul><li>Having high blood pressure—140/90 mmHg or above—or being treated for high blood pressure </li></ul><ul><li>Having an HDL, or “good,” cholesterol level below 35 mg/dl or a triglyceride level above 250 mg/dl </li></ul><ul><li>Having polycystic ovary syndrome, also called PCOS </li></ul><ul><li>Having IFG or IGT on previous testing </li></ul><ul><li>Having a condition called acanthosis nigricans, characterized by a dark, velvety rash around the neck or armpits </li></ul><ul><li>Having a history of cardiovascular disease—disease affecting the heart and blood vessels </li></ul>
  23. 23. Gestational diabetes <ul><li>Gestational diabetes and impaired glucose tolerance (IGT) in pregnancy affects between 2- 3 % of all pregnancies and both have been associated with pregnancy complications. </li></ul>
  24. 24. <ul><li>Low-risk status requires no glucose testing, but this category is limited to those women meeting all of the following characteristics: </li></ul><ul><li>Age <25 years. </li></ul><ul><li>Weight normal before pregnancy . </li></ul><ul><li>Member of an ethnic group with a low prevalence of gestational diabetes mellitus . </li></ul><ul><li>No known diabetes in first-degree relatives . </li></ul><ul><li>No history of abnormal glucose tolerance . </li></ul><ul><li>No history of poor obstetric outcome . </li></ul>
  25. 25. <ul><li>High risk category </li></ul><ul><li>Marked obesity. </li></ul><ul><li>Personal history of gestational diabetes mellitus. </li></ul><ul><li>Glycosuria. </li></ul><ul><li>A strong family history of diabetes . </li></ul>
  26. 26. <ul><li>50 gm glucose load testing </li></ul><ul><li>The screening test for GDM, a 50-g oral glucose challenge, may be performed in the fasting or fed state. Sensitivity is improved if the test is performed in the fasting state . </li></ul><ul><li>A plasma value above 130- 140 mg% one hour after is commonly used as a threshold for performing a 3-hour OGTT. </li></ul><ul><li>If initial screening is negative, testing is repeated at 24 to 28 weeks. </li></ul>
  27. 27. <ul><li>3 hr oral glucose tolerant test </li></ul><ul><li>Prerequisites : </li></ul><ul><li>- Normal diet for 3 days before the test. </li></ul><ul><li>- No diuretics 10 days before. </li></ul><ul><li>- At least 10 hours fast. </li></ul><ul><li>- Test is done in the morning at rest. </li></ul><ul><li>Giving 75 gm (100 gm by other authors) glucose in 250 ml water orally </li></ul><ul><li>Criteria for glucose tolerance test: </li></ul><ul><li>The maximum blood glucose values during pregnancy: </li></ul><ul><li>- fasting 90 mg/ dl, </li></ul><ul><li>- one hour 165 mg/dl, </li></ul><ul><li>- 2 hours 145 mg/dl, </li></ul><ul><li>- 3 hours 125 mg/dl. </li></ul><ul><li>If any 2 or more of these values are elevated, the patient is considered to have an impaired glucose tolerance test. </li></ul>
  28. 28. Emergencies <ul><li>Diabetic ketoacidosis </li></ul><ul><li>Hyperglycemic hyperosmolar state </li></ul><ul><li>Hypoglycemia </li></ul>