1. Diabetes
Mellitus

2. universal symbol of DM
Definition:

3. Diabetes mellitus (DM), also known as simply diabetes,
is a group of metabolic diseases in which there are high
blood sugar levels over a prolonged period.
Epidemology:
Prevalence of diabetes worldwide in 2000 (per
1,000 inhabitants) — world average was 2.8%

4. Disability-adjusted life year for diabetes mellitus per
100,000 inhabitants in 2004
As at 2013, 382 million peoplehave diabetes
worldwide.Type 2 makes up about 90% of the cases.This
is equal to 8.3% of the adult populationwith equal rates in
both women and men
In 2012 it resulted in 1.5 million deaths worldwide
making it the 8th leading cause of death. More than 80%

5. of diabetic deaths occurring in low and middle-income
countries.
Diabetes mellitus occurs throughoutthe world, but is
more common (especially type 2) in more developed
countries. The greatest increase in rates was expected to
occur in Asia and Africa, where most peoplewith
diabetes will probablylive in 2030. The increase in rates
in developing countriesfollows the trend of urbanization
and lifestyle changes, including a "Western-style" diet.
This has suggested an environmental (i.e., dietary) effect,
but there is little understandingof the mechanism(s) at
present.
Aetiology:

6.  Genetic defects of β-
cell function
o Maturity onset
diabetes of the
young
o Mitochondrial
DNA mutations
 Genetic defects in
insulin processing or
insulin action
o Defects in
proinsulin
conversion
o Insulin gene
mutations
 Endocrinopathies
o Growth hormone
excess (acromegaly)
o Cushing syndrome
o Hyperthyroidism
o Pheochromocytoma
o Glucagonoma
 Infections
o Cytomegalovirus
infection
o Coxsackievirus B
 Drugs
o Glucocorticoids
o Thyroid hormone
o β-adrenergic

7. o Insulin receptor
mutations
 Exocrine pancreatic
defects
o Chronic
pancreatitis
o Pancreatectomy
o Pancreatic
neoplasia
o Cystic fibrosis
o Hemochromatosis
o Fibrocalculous
pancreatopathy
agonists
o Statins
Symptoms:

8. Types:

9. Diabetes mellitus is classified into four broad categories:
type 1, type 2, gestational diabetes, and "other specific
types
Comparison of type 1 and 2 diabetes
Feature Type 1 diabetes Type 2 diabetes
Onset Sudden Gradual
Age at onset Mostly in children Mostly in adults
Body size Thin or normal Often obese
Ketoacidosis Common Rare
Autoantibodies Usually present Absent
Endogenous insulin Low or absent
Normal, decreased
or increased
Concordance
in identical twins
50% 90%

10. Prevalence ~10% ~90%
Diagnosis:
WHO diabetes diagnostic criteria
Condition
2 hour
glucose
Fasting
glucose
HbA1c
Unit mmol/l(mg/dl) mmol/l(mg/dl) %
Normal <7.8 (<140) <6.1 (<110) <6.0
Impaired fasting
glycaemia
<7.8 (<140)
≥ 6.1(≥110) &
<7.0(<126)
6.0–
6.4
Impaired glucose
tolerance
≥7.8 (≥140) <7.0 (<126)
6.0–
6.4
Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126) ≥6.5

11. Patho physiology:
The fluctuation of blood sugar (red) and the sugar-
lowering hormone insulin (blue) in humans during the
course of a day with three meals — one of the effects of a
sugar-rich vs a starch-rich meal is highlighted.

12. Management of
diabetes
mellitus:
Goal:
The overall goal of diabetes managementis to help
individuals with diabetes and their families gain the
necessary knowledge, life skills, resources and support
needed to achieve optimal health . This requires a team
effort that includes diabetes health care professionals
and the individuals who must deal with this chronic
condition on a daily basis. The registered dietitian is a key
member of the health care team , who plays an integral
role in the individualization of management strategies for
people with diabetes and those at risk for developing it.

13. Contents:
Dietary management
Drug management
Insulin shot
Exercise therapy
Pancreatic transplantation
Dietary management:
Goal:

14. A major goal for diabetescare is to improve glycemic control by
balancingfood intake with endogenousand/orexogenous
insulinlevels. For people with type 1 diabetes, insulin doses
need to be adjusted to balancewith nutritionallyadequate
food intake and physicalactivity. For individualswith type 2
diabetes, impaired glucose tolerance or impaired fasting
glucose, attentionto food portions and weight management
combined with physical activity may help improve glycemic
control. Nutritionand all forms of diabetesmanagement should
be individualized.
Nutritional management seeks to improve
or maintain the following:
• The quality of life for people with diabetes and their families through
management techniques that include the entire family unit in decision-
making, while enhancing the individual’ s personal sense of control and
well-being;

15. • The physiological health of individuals with diabetes ,by establishing
and maintaining blood glucose and lipid levels as near-normal as
possible , and by using vigilance in preventing and/or treating diabetes-
related complications and any concomitant conditions;
• The nutritional status of people with diabetes, by recognizing that
their micro- and macro nutrient requirements are similar to those of
the general population.
General principles:
• Enjoy a variety of foods.
• Emphasize cereals, breads and other whole grain products,
vegetables and fruits.
• Choose lower-fat dairy products, leaner meats and foods
prepared with little or no fat.
• Achieve and maintaina healthybody weight by enjoying
regular physical activity and healthyeating.

16. • Limit salt, alcoholand caffeine
Required diet

18. Healthy diet

20. Exercise therapy
Everybody benefits from regularexercise. In
diabetes it plays an important role in keeping you
healthy.
How can exercise help
helps insulin to work better which will
improve your diabetes control

21. What type of exercise should I
do?
This depends on what you enjoy and your level of
fitness. Here are somesuggestions:

22. Increasing your general physical activity is also
helpful. e.g. taking the stairs instead of the lift,
getting up to change the TV station instead of using
the remote control, house work.
How much exercise do I need to do?
Ideally,about30 minutes every day. If this is not
possible, then this time can be divided
in 3x10 minutes sessions.

23. How intense does the exercise
need to be?
You do not need to puff to gain the benefits of
exercise. Aim for moderateintensity. Thismeans you
should still be able to talk as you exercise without
becoming breathless.
Exercise Tips
, during (only if
prolonged exercise) and after exercise to avoid
dehydration.The fluid may be water , or a sweetened
drink if extra carbohydrateis required. 250ml every

24. 15 minutes or one litre of fluid per houris
recommended.
. Wear comfortableand
well-fitting shoes. Always inspect your feet before
and after exercise. Ulcers or other lesions on the
feet are a serious dangerfor people with diabetes.It
is important to avoid foot damageespecially for
middle-aged and elderly people. It is wise for them
to avoid exercise that causes stress to the feet (e.g.
running). Exercisewhich poses minimal weight or
stress on the feet is ideal such as riding an exercise
bike or brisk walking in good footwear

25. exercise to prevent hypoglycaemia.Extra
carbohydrateis often needed after exercise. Monitor
your blood glucoselevels before, if possibleduring
(at least initially), and after exercise to assess your
requirements for extra food.Discuss adjusting
carbohydrateintake with your dietitian.
It may be
necessary to reduce your insulin dose prior to
exercise. Insulin adjustmentvaries with each
individual.Discuss appropriate adjustments to suit
your exercise schedulewith your doctor or diabetes
educator.
Advice for people with type 1 diabetes
(i.e. fasting
blood glucoselevels greater than 14 mmol/Land
urinary ketones) then it is best to avoid exercise until
your blood glucosehas settled.
elevate a high blood glucoseand

26. increase ketone production.
Advice for people with type 2 diabetes
management.
and assistwith your blood glucosecontrol.

27. Drug management
Metformin is generally recommended as a first line treatment for
type 2 diabetes, as there is good evidence that it decreases

28. mortality.]
Routine use of aspirin, however, has not been found
to improve outcomes in uncomplicated diabetes. Angiotensin
converting enzyme inhibitors (ACEIs) improve outcomes in
those with DM while the similar medications angiotensin
receptor blockers (ARBs) do not.
Type 1 diabetes is typically treated with a combinations of
regular and NPH insulin, or synthetic insulin analogs. When
insulin is used in type 2 diabetes, a long-acting formulation is
usually added initially, while continuing oral medications. Doses
of insulin are then increased to effect.
In those with diabetes some recommend blood pressure levels
below 120/80 mmHg; however, evidence only supports less than
or equal to somewhere between 140/90 mmHg to
160/100 mmHg.

29. Insulin shots
● Insulin shot. You’ll use a needle attached to a
syringe—a hollow tube with a plunger—that you fill
with a doseof insulin. Some people use an insulin
pen, a penlike device with a needleand a cartridge of
insulin. Never shareinsulin needles or insulin pens,
even with family.
● Insulin pump. An insulinpump is a small
device filled with insulin that you wear on your belt
or keep in your pocket. The pump connects to a
small,plastic tube and a small needle. You or your
doctor inserts the needle underyour skin. The
needle can stay in for several days.
● Insulin jet injector. This device sends a fine
spray of insulin through your skin with high-

30. pressure air instead of a needle. This device sends a
fine spray of insulin through your skin with high-
pressure air insteadof a needle.
● Insulin injection port. You or your doctor
inserts a small tube just beneath your skin, where it
remains in place for several days. You can inject
insulin into the end of the tube instead of through
your skin.

32. Pancreatic
transplantation
A pancreas transplant is occasionally considered for
people with type 1 diabetes who have severe
complications of their disease, including end stage
renal disease requiring kidney transplantation
A pancreas transplant is a surgical procedure to
place a healthy pancreas from a deceased donor into
a person whose pancreas no longer functions
properly. Almost all pancreas transplants are done to
treat cases of type 1 diabetes.
Your pancreas is an organ that lies behind the lower
part of your stomach. One of its main functions is to
make insulin, a hormone that regulates the
absorption of sugar (glucose) into your cells. Type 1
diabetes results when your pancreas can't make
enough insulin, causing your blood sugar to rise to
dangerous levels.
The side effects of a pancreas transplant can be
significant, so a pancreas transplant is typically
reserved for those who have serious diabetes

33. complications. A pancreas transplant is often done in
conjunction with a kidney transplant.
Why it's done
A pancreas transplant offers a potential cure for type
1 diabetes, but it's not a standard treatment. Often
the side effects of the anti-rejection medications
required after a pancreas transplant can be serious.
But if you have any of the following, a pancreas
transplant may be worthwhile:
 Type 1 diabetes that can't be controlled with
standard treatment
 Frequent insulin reactions
 Consistently poor blood sugar control
 Severe kidney damage
Because type 2 diabetes occurs due to the body's
inability to use insulin properly — and not because
of a problem with insulin production in the pancreas

34. — a pancreas transplant isn't a treatment option for
most people with type 2 diabetes.
If you have severe kidney damage due to type 1
diabetes, a pancreas transplant may be combined
with a kidney transplant or be done after successful
kidney transplantation. This strategy aims to give
you a healthy kidney and a pancreas that's unlikely
to contribute to diabetes-related kidney damage in
the future.
Risks
Complications of the procedure
Pancreas transplant surgery carries a risk of
significant complications, including:
 Blood clots
 Bleeding
 Infection
 Excess sugar in your blood (hyperglycemia)
 Urinary complications, including leaking or
urinary tract infections
 Failure of the donated pancreas
 Rejection of the donated pancreas
Anti-rejection medication side effects

35. After a pancreas transplant, you'll take medications
for the rest of your life to help prevent your body
from rejecting the donor pancreas. These
medications can cause a variety of side effects,
including:
 Bone thinning
 High cholesterol
 High blood pressure
 Skin sensitivity
 Puffiness
 Weight gain
 Swollen gums
 Acne
 Excessive hair growth
How you prepare
Choosing a transplant center
If your doctor recommends a pancreas transplant,
you'll be referred to a transplant center. You're also
free to select a transplant center on your own or
choose a center from your insurance company's list
of preferred providers.

36. When you consider transplant centers, you may
want to:
 Learn about the number and type of transplants the
center performs each year
 Ask about the transplant center's organ donor and
recipient survival rates
 Compare transplant center statistics through the
database maintained by the Scientific Registry of
Transplant Recipients (www.ustransplant.org)
 Consider additional services provided by the
transplant center, such as support groups, travel
arrangements, local housing for your recovery
period and referrals to other resources
After you've selected a transplant center, you'll need
an evaluation to determine whether you meet the
center's eligibility requirements for a pancreas
transplant.
When the transplant team assesses your
eligibility, they'll consider the following.
 Are you healthy enough to have surgery and
tolerate lifelong post-transplant medications?
 Do you have any medical conditions that would
hinder transplant success?

37.  Are you willing and able to take medications and
advice as directed?
If you need a kidney transplant, too, the transplant
team will also determine if it's best for you to have
the pancreas and kidney transplants during the same
surgery, or a kidney transplant first, followed by the
pancreas transplant at a later date. The best option
depends on the severity of your kidney damage, the
availability of donors and your preference.
Once you've been accepted as a candidate for a
pancreas transplant, your name will be placed on a
national list of people awaiting a transplant. The
waiting time for a transplant depends on your blood
group and how long it takes for a suitable donor —
one whose blood and tissue types match yours — to
become available.
Staying healthy
Whether you're waiting for a donated pancreas to
become available or your transplant surgery is
already scheduled, it's important to keep your mind
and body healthy.
 Take your medications as prescribed.
 Follow your diet and exercise guidelines.

38.  Keep all appointments with your health care team.
 Stay involved in healthy activities, including
relaxing and spending time with family and
friends.
What you can expect
During a pancreas transplant
Surgeons perform pancreas transplants during
general anesthesia, so you're unconscious during the
procedure. The anesthesiologist or anesthetist gives
you an anesthetic medication as a gas to breathe
through a mask or injects a liquid medication into a
vein.
The surgical team monitors your heart rate, blood
pressure and blood oxygen throughout the procedure
with a blood pressure cuff on your arm and heart-
monitor leads attached to your chest. After you're
unconscious:

39.  An incision is made down the center of your
abdomen.
 The surgeon places the new pancreas and a small
portion of the donor's small intestine into your
lower abdomen.
 The donor intestine is attached to either your small
intestine or your bladder, and the donor pancreas
is connected to blood vessels that also supply
blood to your legs.
 Your own pancreas is left in place to aid digestion.
 If you're also receiving a kidney transplant, the
blood vessels of the new kidney will be attached to
blood vessels in the lower part of your abdomen.
 The new kidney's ureter — the tube that links the
kidney to the bladder — will be connected to your
bladder. Unless your own kidneys are causing
complications, such as high blood pressure or
infection, they're left in place.
Pancreas transplant surgery usually lasts about three
hours. Simultaneous kidney-pancreas transplant
surgery takes a few more hours.
After a pancreas transplant
After your pancreas transplant, you can expect to:

40.  Stay in the intensive care unit for a few
days. Doctors and nurses monitor your condition
to watch for signs of complications. Your new
pancreas should start working immediately, and
your old pancreas will continue to perform its
other functions. If you have a new kidney, it'll
make urine just like your own kidneys did when
they were healthy. Often this starts immediately.
But in some cases, urine production takes up to a
few weeks.
 Spend about one week in the hospital. Once
you're stable, you're taken to a transplant recovery
area to continue recuperating. Expect soreness or
pain around the incision site while you're healing.
 Have frequent checkups as you continue
recovering. After you leave the hospital, close
monitoring is necessary for three to four weeks.
Your transplant team will develop a checkup
schedule that's right for you. During this time, if
you live in another town, you may need to make
arrangements to stay close to the transplant center.
 Take lifelong medications. You'll take a number
of medications after your pancreas transplant.
Drugs called immunosuppressants help keep your
immune system from attacking your new pancreas.

41. Additional drugs may help reduce the risk of other
complications, such as infection and high blood
pressure, after your transplant.

If you're waiting for a donated pancreas, make sure
the transplant team knows how to reach you at all
times and arrange transportation to the transplant
center in advance.
Results
By Mayo Clinic Staff
After a successful pancreas transplant, your new
pancreas will make the insulin your body needs, so
you'll no longer need insulin therapy to treat
diabetes. But even with the best possible match
between you and the donor, your immune system
will try to reject your new pancreas. So you'll need
medications to suppress your immune system. You'll
likely take these or similar drugs for the rest of your
life. Because medications to suppress your immune
system make your body more vulnerable to
infection, your doctor may also prescribe
antibacterial, antiviral and antifungal medications.
Pancreas transplant survival rates

42. According to the Organ Procurement and
Transplantation Network, transplanted pancreas and
kidney survival rates include the following.
 Simultaneous pancreas-kidney transplant. In
about 87 percent of people who receive a
simultaneous pancreas-kidney transplant, the
transplanted pancreas is still functioning after one
year. After five years, that rate is about 72 percent.
 Pancreas-after-kidney transplant. In about 77
percent of people who receive a pancreas-after-
kidney transplant, the transplanted pancreas is still
functioning after one year. Five years after
transplant, the rate is about 59 percent.
 Pancreas-only transplant. In about 85 percent of
people who receive a pancreas-only transplant, the
transplanted pancreas is still functioning after one
year. After five years, that rate is about 52 percent.
It's unclear why results are better for those who
receive a kidney and pancreas at the same time. But
some research suggests it may be because it's more
difficult to monitor and detect rejection of a pancreas
alone, versus a pancreas and a kidney.
If your new pancreas fails, you can resume insulin
treatments and consider a second transplant. This

43. decision will depend on your current health, your
ability to withstand surgery and your expectations
for maintaining a certain quality of life.