Diabetes Care Module

SHIMLA NURSING COLLEGE
MODULE ON DIABETES CARE
ADULT HEALTH NURSING- I & II

DIABETES CARE MODULE - 6 SESSIONS WITH CONTENT

SESSION -1
INTRODUCTION
 The earlist known record of diabetes was written on 3rd
Dynasty
Egyptian Papyrus by Physician ‘Hesy- Ra’. He started recurring
urination as a sign of this illness.
 The Indian physician Sushruta in the 6th
century B.C. noticed the sweet
nature of urine in such patients and termed the condition
MADHUMEHA.
 As per Indian Council of Medical Research – India Diabetes (ICMR
INDIAB) study published in 2023, the prevalence of diabetes is 10.1
crores.
 Responding to the increasing burden of diabetes around the world, the
World Health Organization has launched the Global Diabetes Compact.
The launch coincides with the 100th anniversary of the discovery of
insulin.
 The WHO Global Diabetes Compact has the vision of reducing the risk
of diabetes, and ensuring that all people who are diagnosed with diabetes
have access to equitable, comprehensive, affordable and quality
treatment and care. The work undertaken as part of the Compact will
also support the prevention of type 2 diabetes from obesity, unhealthy
diet and physical inactivity.
 The WHO Global Diabetes Compact was launched at a Global Diabetes
Summit, co-hosted by the World Health Organization and the
Government of Canada, with the support of the University of Toronto,
on 14 April 2021.
 Diabetes is one of the top five leading causes of death in most developed
countries and substantial evidence is accumulating to suggest that it

will reach epidemic proportions in developing and newly
industrialised countries [1]. It has been estimated that 2.1% of the
world population may have diabetes, predicted to rise to 3% by the
year 2010 [2]. The World Health Organisation (WHO) predict that the
current diabetic population of 177 million (estimate 2000) people will
increase to 370 million by the year 2030 [3].
 Diabetes has become a major health issue in South-East Asia. It has
been estimated by the International diabetes federation (IDF) that 23
million people currently have diabetes, which accounts for a sixth of
the world's diabetic population. India has the largest diabetic
population and one of the highest diabetes prevalence rates in the
world. The prevalence rates for type 2 diabetes in India are still
increasing sharply with the number of sufferers predicted to rise from
19.4 million in 1995 to 80.9 million in 2030
 The number of people with diabetes rose from 108 million in 1980 to
422 million in 2014. Prevalence has been rising more rapidly in low-
and middle-income countries than in high-income countries.
 Diabetes is a major cause of blindness, kidney failure, heart attacks,
stroke and lower limb amputation.
 Between 2000 and 2019, there was a 3% increase in diabetes mortality
rates by age.
 In 2019, diabetes and kidney disease due to diabetes caused an
estimated 2 million deaths.
 A healthy diet, regular physical activity, maintaining a normal body
weight and avoiding tobacco use are ways to prevent or delay the onset
of type 2 diabetes.
 Diabetes can be treated and its consequences avoided or delayed with
diet, physical activity, medication and regular screening and treatment
for complications.
DIABETES is a group of metabolic disease characterized by hyperglycemia
resulting from defect in insulin secretion, insulin action or both.
Globally: 382 million people had diabetes in 2013, by 2035 this number will rise
to 592 million.
India: 65.1 million people had diabetes in 2013, by 2035 this number will increase
by 70.6%.
The adult pancreas is a transversely oriented retroperitoneal organ extending from
the “C” loop of the duodenum to the hilum of the spleen.

Exocrine Secretions: Pancreatic juice enzymes promote the digestion of
carbohydrates, proteins and fats.
Endocrine secretion: Insulin and glucagon-enter portal vein-transported directly
to the liver-regulate metabolism of carbohydrates, proteins, and fats.
 15-20% alpha cells synthesize and secrete GLUCAGON
 70-80% beta cells synthesize and secrete INSULIN
 1-8% delta cells synthesize and secrete STOMATOSTATIN and
GASTRIN
 1-2% F-cells Secrete PANCREATIC POLYPEPTIDE which decreases the
absorption of food from the GIT
 Polypeptide hormone Produced by Beta cells of islets of Langerhans of
pancreas.
 Insulin is a protein made of 2 chains-alpha and beta.
 Anabolic hormone
Regulation of insulin secretion:
Factors stimulate insulin secretion: Glucose, Amino acids, Gastrointestinal
hormones.
Factors inhibit insulin secretion: Epinephrine
Action of insulin
 Stimulate activity of glycolytic enzymes
 Reduces the activity of the enzymes of gluconeogenesis
 Increased synthesis of glycogen
 Increased uptake of glucose by resting skeletal muscles
 Reduction of blood glucose level
 Reduction of lipolysis and stimulation of lipid synthesis
Pancreas secretes 40-50 units of insulin daily in two steps: Secreted at low levels
during fasting, increased level after eating, an early burst of insulin occurs within
10 minutes of eating, the proceeds with increasing release as long as
hyperglycemia is present
Classification by American diabetic association 2009
 Type-1 diabetes
 Type-2 Diabetes
 GDM
 Secondary DM

Diabetes is a chronic disease that occurs either when the pancreas does not
produce enough insulin or when the body cannot effectively use the insulin it
produces. Insulin is a hormone that regulates blood glucose. Hyperglycaemia,
also called raised blood glucose or raised blood sugar, is a common effect of
uncontrolled diabetes and over time leads to serious damage to many of the body's
systems, especially the nerves and blood vessels.
In 2014, 8.5% of adults aged 18 years and older had diabetes. In 2019, diabetes
was the direct cause of 1.5 million deaths and 48% of all deaths due to diabetes
occurred before the age of 70 years. Another 460 000 kidney disease deaths were
caused by diabetes, and raised blood glucose causes around 20% of
cardiovascular deaths (1).
Between 2000 and 2019, there was a 3% increase in age-standardized mortality
rates from diabetes. In lower-middle-income countries, the mortality rate due to
diabetes increased 13%.
By contrast, the probability of dying from any one of the four main
noncommunicable diseases (cardiovascular diseases, cancer, chronic respiratory
diseases or diabetes) between the ages of 30 and 70 decreased by 22% globally
between 2000 and 2019.
DIABETES RISK FACTORS:
Non-modifiable risk factors for Type 2 diabetes: Risk factors that increase your
risk for developing prediabetes and Type 2 diabetes that can’t be changed are:
 Family history: Some factors that increase the risk of diabetes are
inherited from our parents or close biological relatives. If you have a blood
relative with diabetes, your risk for developing it is significantly increased.
Share your family health history with your doctor to find out what it may
mean for you.
 Race or ethnic background: If you’re of African-American, Asian-
American, Latino/Hispanic-American, Native American or of Pacific-
Islander descent, you have a greater chance of developing diabetes.
 Age: The older you are, the higher your risk for prediabetes and Type 2
diabetes. Type 2 diabetes generally occurs in middle-aged adults, most
frequently after age 40. But health care professionals are diagnosing more
and more children and adolescents with Type 2 diabetes.
 Gestational diabetes: If you developed diabetes during pregnancy, you
are at increased risk of developing diabetes again later in life.
Modifiable risk factors for Type 2 diabetes

You can — and should — do something about your modifiable risk factors. You
can reduce your risk for diabetes or delay its development by making healthy
changes:
 Weight: Being overweight or obese increases your risk of developing
diabetes. Losing 5% to 10% of your body weight—in addition to getting
regular physical activity—can significantly reduce your risk of developing
diabetes. Your risk decreases even more as you lose more weight. For most
people, a body mass index calculator will provide a good target weight for
your height. Learn how to manage your weight.
 Physical activity: Physical inactivity is a key modifiable risk factor for
prediabetes and Type 2 diabetes. Regular physical activity helps lower
insulin resistance. This means your body can use its own insulin more
effectively. Even a brisk 30-minute walk at least five days a week has been
shown to significantly reduce the risk of diabetes and heart disease. For
your overall cardiovascular health, aim for:
o At least 150 minutes per week of moderate-intensity aerobic
physical activity;
o Or 75 minutes per week of vigorous-intensity aerobic physical
activity (or a combination of the two);
o And muscle-strengthening at least two days per week.
 Blood pressure: In addition to causing damage to the cardiovascular
system, untreated high blood pressure has been linked to complications
from diabetes. People with diabetes and HBP should maintain a blood
pressure of less than 130/80 mm Hg. Normal blood pressure is below
120/80 mm Hg. Learn more about high blood pressure and how to control
it.
 Cholesterol (lipid) levels: Diabetes is associated with atherosclerosis
(hardening of the arteries) and blood vessel disease. Low HDL “good”
cholesterol and/or high triglycerides can increase the risk for Type 2
diabetes and cardiovascular disease. Following a healthy eating plan,
getting regular physical activity and reaching and maintaining a healthy
weight can help improve abnormal lipid levels. Sometimes, medications
are also needed.
 Smoking: If you smoke, there are a number of tools, medications and
online resources that you can use to help you quit. Talk to your health care
team about the best options for you.
 Diet: It’s important to eat healthy foods in the right amounts. Diet is one
of the most important modifiable risk factors for prediabetes and Type 2

diabetes. The American Heart Association recommends an eating plan that
includes fruits and vegetables, whole grains, skinless poultry, fish,
legumes, non-tropical vegetable oils and unsalted nuts and seeds. A healthy
diet should also replace saturated fats with monounsaturated and
polyunsaturated fats, avoid trans fats, reduce cholesterol and sodium (salt)
and limit red and processed meats, refined carbohydrates and sweetened
beverages.
 Alcohol: Heavy use of alcohol can cause inflammation in the pancreas and
limit its ability to produce enough insulin. Alcohol can cause liver damage
and adds more sugar and starch to your diet that must either be used or
stored as fat. Moderate your alcohol intake. That means no more than one
drink per day for women or two drinks per day for men.
 Stress and well-being: Everyone feels stress, but people react differently.
Managing the stress in our lives is an important part of healthy living, not
only for diabetes but for heart disease and many other conditions. Find
ways to address the causes of your stress and make time for things you
enjoy. Learn how to take care of your mental health.
 Sleep: Adults should get seven to nine hours of sleep a night. Sleep
benefits your whole body, including your heart and brain. It improves
mood, memory and reasoning. Research also has shown that too little or
too much sleep is linked to a high A1C in people with Type 2 diabetes. If
you have insomnia (trouble going to sleep or waking up too soon) or sleep
apnea (problems breathing while asleep), work with your health care team
to diagnose and treat them. Learn why sleep is essential to overall health.
Gestational Diabetes: Risk for gestational diabetes (diabetes while pregnant) if:
 Had gestational diabetes during a previous pregnancy.
 Have given birth to a baby who weighed over 9 pounds.
 Are overweight.
 Are more than 25 years old.
 Have a family history of type 2 diabetes.
 Have a hormone disorder called polycystic ovary syndrome (PCOS).
 Are an African American, Hispanic or Latino, American Indian, Alaska
Native, Native Hawaiian, or Pacific Islander person.
Gestational diabetes usually goes away after give birth, but increases risk for type
2 diabetes. Baby is more likely to have obesity as a child or teen, and to develop
type 2 diabetes later in life.
Before get pregnant, may be able to prevent gestational diabetes with lifestyle
changes. These include losing weight if overweight, eating a healthy diet, and
getting regular physical activity.

WHO aims to stimulate and support the adoption of effective measures for the
surveillance, prevention and control of diabetes and its complications,
particularly in low- and middle-income countries. To this end, WHO:
 Provides Scientific Guidelines For The Prevention Of Major
Noncommunicable Diseases Including Diabetes;
 Develops Norms And Standards For Diabetes Diagnosis And Care;
 Builds Awareness On The Global Epidemic Of Diabetes, Marking World
Diabetes Day (14 November); And
 Conducts Surveillance Of Diabetes And Its Risk Factors.

 In April 2021 WHO launched the Global Diabetes Compact, a global
initiative aiming for sustained improvements in diabetes prevention and
care, with a particular focus on supporting low- and middle-income
countries.
 In May 2021, the World Health Assembly agreed a Resolution on
strengthening prevention and control of diabetes. In May 2022 the World
Health Assembly endorsed five global diabetes coverage and treatment
targets to be achieved by 2030.
 An article in Current Diabetes Reports says, "An estimated 9.1% of the
overall U.S. population has diagnosed diabetes, 5.2% has undiagnosed
diabetes, and an additional 38.0% has prediabetes." The World Health
Organization estimates diabetes as the seventh leading cause of death
worldwide. These numbers are expected to continue to rise with increases
in elderly population, sedentary lifestyle and widespread obesity.
DIABETES PREVENTION
The best way to stop the diabetes epidemic is prevention. The Centers for Disease
Control and Prevention report that one in four people who have diabetes don't
know it. This is why it is important for nurses to provide patient education, not
only to those diagnosed with diabetes, but those who are at high risk for
developing diabetes. Nurses can help by:
 Educating patients about risk factors, like family history, advancing age,
excess weight and a sedentary lifestyle.
 Partnering with patients to develop personal prevention strategies like
limiting sugar and carbohydrates, increasing activity, aiming toward their
ideal body weight, and setting small weight loss goals.
 Teaching patients about critical lab values and how to recognize and report
signs and symptoms of hypoglycemia or hyperglycemia.
 Providing education and counseling for patients who are borderline diabetic
or have metabolic syndrome as well as patients diagnosed with diabetes.
The Front Lines
Nurses are at the forefront of diabetes care. They are often present at diagnosis
and may care for patients throughout the life of the disease. Watch patients' lab
values closely, particularly the A1C, C-reactive protein and fasting blood glucose
values. Provide information on topics related to diabetes to both patients and
caregivers.

Diabetes Education Topics
Lifestyle Disease and Management
Healthy food choices
· Foods to eat (nuts, oatmeal)
· Foods to avoid (sugar, white flour)
Symptoms
· Polyuria
· Polydipsia
· Polyphagia
Exercise tips
·How much, how often, what type
·Ways to increase activity throughout
the day
Types of diabetes
· Type I
· Type II
· Gestational
· Pre-diabetes
· Metabolic syndrome
Smoking
· Impact of smoking on diabetes
· Smoking cessation strategies
Management
· Blood glucose monitoring
·Hypoglycemia signs and management
· Insulin administration
Diabetes and Mood: Diabetes does not just affect blood sugar — it can lead to
mental health changes, causing emotional strain and therefore
impacting relationships. It can cause mood swings, confusion, anxiety,
depression and stress. With end-stage disease, diabetes contributes to caregiver

burden or distress. Nurses can listen to concerns and connect them with resources.
Check out the Defeat Diabetes Foundation to find local diabetes support groups.
Diabetes Nurse Educator: Nurses who want to specialize in diabetes education
can become a Certified Diabetes Care and Education Specialist through
the National Certification Board for Diabetes Educators, or become a diabetes
nurse (although that requires an MSN). These roles are vital to help patients:
 Identify their risk factors
 Identify if they have diabetes or prediabetes
 Work through the emotional and physical response to a diagnosis
 Identify resources in their community
 Manage their disease throughout all stages of life to minimize nerve damage
and other symptoms
Patients with diabetes must follow a lifelong care plan that includes a modified
diet, weight management, medications and lifestyle changes. It's a complex
disease, and it often falls to the nurse to educate patients about how to manage
diabetes and recognize signs that their plan is not working for them.
Finally, diabetes research continually advances our understanding of the disease
and provides new treatment approaches. It is the responsibility of the nurse to stay
abreast of these new developments and incorporate them into practice. RN to
BSN programs provide the latest information on diabetes, training in evidence-
based nursing care, and skills necessary to educate patients with all levels
of health literacy.

SESSION -2
PATHOPHYSIOLOGY AND DIAGNOSIS OF DIABETES
Diabetes is on the rise worldwide, and is a serious, lifelong disease that can lead
to heart disease, stroke, and lasting nerve, eye and foot problems. Diabetes around
the world in 2021
537 million adults (20-79 years) are living with diabetes - 1 in 10. This
number is predicted to rise to 643 million by 2030 and 783 million by 2045.
Over 3 in 4 adults with diabetes live in low- and middle-income countries.
Diabetes is responsible for 6.7 million deaths in 2021 - 1 every 5 seconds.
Diabetes caused at least USD 966 billion dollars in health expenditure –
a 316% increase over the last 15 years.
541 million adults have Impaired Glucose Tolerance (IGT), which places
them at high risk of type 2 diabetes.
An organ in body called the pancreas produces insulin, a hormone that controls
the levels of blood sugar. When have too little insulin in body, or when insulin
doesn't work right in body, can have diabetes, the condition where have
abnormally high glucose or sugar levels in blood.
Normally when eat food, glucose enters bloodstream. Glucose is body's source of
fuel. Pancreas makes insulin to move glucose from bloodstream into muscle, fat,
and liver cells, where body turns it into energy.
People with diabetes have too much blood sugar because their body cannot move
glucose into fat, liver, and muscle cells to be changed into and stored for energy.
There are three major types of diabetes. Type 1 diabetes happens when the body
makes little or no insulin. It usually is diagnosed in children, teens, or young
adults.

But about 80% of people with diabetes have what's called Type 2 diabetes. This
disease often occurs in middle adulthood, but young adults, teens, and now even
children are now being diagnosed with it linked to high obesity rates.
In Type 2 diabetes, fat, liver, and muscle cells do not respond to insulin
appropriately.
Another type of diabetes is called gestational diabetes. It's when high blood sugar
develops during pregnancy in a woman who had not had diabetes beforehand.
Gestational diabetes usually goes away after the baby is born. But, still pay
attention. These women are at a higher risk of type 2 diabetes over the next 5
years without a change in lifestyle. If doctor suspects have diabetes, will probably
have a hemoglobin A1c test. This is an average of blood sugar levels over 3
months. You have pre-diabetes if your A1c is 5.7% to 6.4%. Anything at 6.5% or
higher indicates you have diabetes.
Type 2 diabetes is a wakeup call to focus on diet and exercise to try to control
blood sugar and prevent problems. If do not control blood sugar, could develop
eye problems, have problems with sores and infections in feet, have high blood
pressure and cholesterol problems, and have kidney, heart, and problems with
other essential organs.
People with Type 1 diabetes need to take insulin every day, usually injected under
the skin using a needle. Some people may be able to use a pump that delivers
insulin to their body all the time.
People with Type 2 diabetes may be able to manage their blood sugar through
diet and exercise. But if not, they will need to take one or more drugs to lower
their blood sugar levels.
The good news is, people with any type of diabetes, who maintain good control
over their blood sugar, cholesterol, and blood pressure, have a lower risk of
kidney disease, eye disease, nervous system problems, heart attack, and stroke,
and can live, a long and healthy life.

Diabetes can affect many major organs, including your heart, eyes, kidneys, and
brain. When the disease isn't well-controlled, it can lead to many
serious comorbidities, which are conditions that occur alongside diabetes. For
people with type 1 and type 2 diabetes, finding a treatment plan that works is vital
to avoid these problems
Heart: The heart is part of the cardiovascular or circulatory system. This body
system also includes blood vessels, which transport oxygen and nutrients to
organs and tissues. Blood vessels also help remove carbon dioxide, toxins, and
waste.
There are four main parts of the circulatory system. Each part has a specific job:
 Capillaries: These are your body's smallest blood vessels. They carry
oxygen and nutrients to distant parts of the body and deliver waste products
to the kidneys and liver. They also transport carbon dioxide to the lungs so
it can be exhaled.
 Veins: Your veins carry blood that has had the oxygen removed back to
the heart.
 Arteries: Arteries transport oxygen-rich blood from the heart throughout
the circulatory system.
 Heart: The heart is the muscle that pumps blood throughout the entire
body.
The American Heart Association lists diabetes as one of the seven major
controllable risk factors for cardiovascular disease (CVD). CVDs include all
types of heart disease, stroke, and blood vessel disease.
The most common type of CVD is coronary artery disease (CAD). It is caused
by the build-up of plaque (cholesterol) in the walls of the arteries. Diabetes can
put you at higher risk for CAD because it can cause problems with your platelets,
the cells that help your blood clot. When you have diabetes, you may also form
plaques that are more prone to breaking off and blocking blood flow.
People with diabetes are twice as likely to develop cardiovascular disease than
people without diabetes.
Over time, diabetes can also cause damage to the blood vessels and nerves that
control the heart. The longer you have diabetes, the higher the chances you will
develop heart disease.
People with diabetes often have other conditions that increase the risk of heart
disease, including: High blood pressure, High cholesterol, High triglycerides

Kidneys: The kidneys are bean-shaped organs located below the rib cage and
beside the spine. Each is roughly the size of a fist. They are part of the renal
system, which also includes:
 Ureters are the tubes that take urine from your kidneys to bladder
 The bladder stores urine until it can be expelled
 The urethra removes urine from the body
The kidneys work as a filtration system. They remove waste, extra fluid, and acid
from the body. Healthy kidneys help keep a good balance of water, salts, and
minerals in the blood.
The kidneys also produce vitamin D and erythropoietin. Vitamin D helps your
body absorb calcium and promotes a healthy immune system. Erythropoietin is a
hormone that stimulates the production of red blood cells.
Over time, high blood sugar caused by diabetes can damage blood vessels in your
kidneys. This can impair their ability to clean the body, leading to a build-up of
waste and fluid in the blood. This type of kidney disease is known
as diabetic nephropathy.
If left untreated, diabetic nephropathy can cause kidney failure, which can be life-
threatening.
About 18% of adult diagnosed with diabetes have chronic kidney disease in its
advanced stages, according to the Centers for Disease Control and Prevention.
Brain: High blood sugar can affect cognition, specifically thinking and memory.
Research has also shown that diabetes can change the structure of your brain.
Because of this, people with diabetes are at increased risk of cognitive decline
and are 50% more likely to develop dementia than those without diabetes.
Studies have shown that people with diabetes have lower levels of gray matter
density and volume in various parts of the brain. Gray matter is a major part of
the central nervous system. It plays a role in daily functioning. Reduced gray
matter density or volume can affect a variety of brain and nerve functions.
Diabetes can also damage small blood vessels in the brain. This can lead
to strokes or the death of brain tissue.
Lungs: Uncontrolled diabetes may reduce lung function. This can lead to mild
complications like asthma or more severe complications like pulmonary fibrosis.

Researchers don't know why people with diabetes can have lung problems. Some
think inflammation may be the root cause.
Some studies suggest that drugs that treat low blood sugar may contribute to lung
disease in people with diabetes. One found that different medications may affect
the lungs in different ways. For example, the common diabetes drug Glucophage
(metformin) is thought to work against lung disease, while insulin may make lung
disease worse.
Pancreas: Diabetes and the pancreas are closely linked. This is because pancreas
produces insulin. High blood sugar can happen when pancreas doesn’t produce
enough or any insulin.
Type 1 diabetes is caused by this lack of insulin production. Type 2 diabetes, on
the other hand, happens when your body builds up insulin resistance. This puts
strain on the pancreas as it tries to produce more insulin than it normally needs
to.
Pancreatic cancer can be a consequence of diabetes, but it can also be the cause.
People with type 2 diabetes are at increased risk of developing pancreatic cancer,
and pancreatic cancer can also lead to the development of diabetes.
Mouth and Teeth: Glucose is present in saliva. When diabetes is not controlled,
high glucose levels in saliva help harmful bacteria grow. These can combine with
food to form a soft, sticky film called plaque. Some types of plaque cause tooth
decay or cavities. Others cause gum disease and bad breath.
When have diabetes, gum disease can be more severe and take longer to heal.
Having gum disease can also make blood glucose hard to control.
Plaque can harden over time into tartar, making it more difficult to brush and
clean between teeth. When this happens, the gums may become red and swollen,
and bleed easily. These are signs of a gum disease called gingivitis.
Untreated gingivitis can advance to a gum disease called periodontitis. When
have this condition, the gums pull away from the teeth and form pockets. These
pockets become infected, and the infection can last a long time.
Untreated periodontitis can destroy the gums, bones, and tissue that support the
teeth. Your teeth may become loose and might need to be removed.
Stomach and Small Intestines: High blood sugar levels can damage the vagus
nerve. This is the nerve that runs from the brainstem down to the abdomen. When
the vagus nerve is damaged, it can cause a condition known as gastroparesis.

When you have this condition, your stomach empties food much slower than it's
supposed to. This can lead to complications like:
 Dehydration
 Stomach acid that leaks into the food pipe, a condition known
as gastroesophageal reflux disease (GERD)
 Malnutrition from the body not digesting food properly
 Unpredictable changes in blood sugar levels
Roughly 20% to 50% of people with diabetes will experience gastroparesis.
Eyes: Sometimes, eye symptoms like blurry vision are the first symptoms of
diabetes. Over time, diabetes can lead to diabetic retinopathy. This condition can
cause vision problems and blindness.
High blood sugar can damage the retina and surrounding blood vessels. The retina
is a layer of tissue in the back of the eye that is sensitive to light. When this
happens, your body tries to compensate by producing new, abnormal blood
vessels that are much weaker and prone to bleeding.
Diabetic retinopathy can cause other eye problems, such as:
 Diabetic macular edema: The new, weaker blood vessels leak fluid and
blood into the retina. This causes swelling of the macula, the center of the
retina.
 Neovascular glaucoma: This secondary type of glaucoma occurs when
new blood vessels close over the part of the eye where the cornea meets
the iris. The cornea is the clear tissue at the front of your eye. The iris is
the colored part of your eye.
If have diabetes and are experiencing vision problems, seek medical care right
away. These vision problems may be irreversible, and treatment can stop them
from progressing to total blindness.
Skin: High blood sugar can cause poor circulation. This can damage skin and
make it hard for your body to repair wounds.
Anyone can get a skin condition, but certain conditions only happen to people
with diabetes. These include:
 Diabetic dermopathy: This causes small, round, brown lesions on the
shins. Roughly 55% of people with diabetes will develop this condition.
 Necrobiosis lipoidica diabeticorum: In the early stages, this condition
causes red bumps to form on the lower legs. In later stages, the lesions

become flat-topped and shiny and may be yellow or brown. Less than 1%
of people with diabetes will develop this condition.
 Diabetic blisters: Diabetic blisters look like blisters that form after a burn,
but they are not painful. They tend to develop in clusters.
 Eruptive xanthomatosis: This skin condition appears as small yellow and
red bumps.
Foot ulcers are also common in people with diabetes. They are typically found on
the big toes and balls of the feet and can be mild or severe. Their severity is
usually measured on a scale of 0 to 5. A possible healed lesion is a 0, while 5 is a
severe case of gangrene (tissue death).
Sexual Organs: Circulatory system damage causes a decrease in blood flow.
This, along with damage to nerves and their ability to send signals, can impair
blood flow to the penis. This can cause erectile dysfunction in males with
diabetes.
Sperm health also relies on body's ability to process glucose. When have diabetes,
this ability is compromised, which can lead to poor sperm health. Mature sperm
may not be able to fertilize an egg, and they may also be less mobile.
Both males and females with diabetes can experience fertility issues. In males,
diabetes can lead to low testosterone levels. This can affect sperm count and lead
to a decrease in sex drive.
Among females, diabetes can also cause nerve damage that can lead to vaginal
dryness. Blood vessel damage can also result in a lack of blood flow to female
reproductive organs.
In females without diabetes, insulin helps drive the production of the hormones
that maintain reproductive tissues and regulate ovulation. When you have
diabetes, this process doesn't work as well.
Diabetes has also been linked to polycystic ovary syndrome (PCOS). This
condition is caused by high testosterone levels. It can impair ovulation or the
release of an egg. This makes it difficult to get pregnant

Regulation of Blood glucose and insulin

Type 1 diabetes
Type 1 diabetes (previously known as insulin-dependent, juvenile or childhood-
onset) is characterized by deficient insulin production and requires daily
administration of insulin. In 2017 there were 9 million people with type 1
diabetes; the majority of them live in high-income countries. Neither its cause nor
the means to prevent it are known.

Type 2 diabetes
Type 2 diabetes affects how body uses sugar (glucose) for energy. It stops the
body from using insulin properly, which can lead to high levels of blood sugar if
not treated.
Over time, type 2 diabetes can cause serious damage to the body, especially
nerves and blood vessels.
Type 2 diabetes is often preventable. Factors that contribute to developing type 2
diabetes include being overweight, not getting enough exercise, and genetics.
Early diagnosis is important to prevent the worst effects of type 2 diabetes. The
best way to detect diabetes early is to get regular check-ups and blood tests with
a healthcare provider.
Symptoms of type 2 diabetes can be mild. They may take several years to be
noticed. Symptoms may be similar to those of type 1 diabetes but are often less
marked. As a result, the disease may be diagnosed several years after onset, after
complications have already arisen.
More than 95% of people with diabetes have type 2 diabetes. Type 2 diabetes was
formerly called non-insulin dependent, or adult onset. Until recently, this type of
diabetes was seen only in adults but it is now also occurring increasingly
frequently in children.
Gestational diabetes
Gestational diabetes is hyperglycaemia with blood glucose values above normal
but below those diagnostic of diabetes. Gestational diabetes occurs during
pregnancy.
Women with gestational diabetes are at an increased risk of complications during
pregnancy and at delivery. These women and possibly their children are also at
increased risk of type 2 diabetes in the future.
Gestational diabetes is diagnosed through prenatal screening, rather than through
reported symptoms.

SCREENING FOR DIABETES MELLITUS

Anyone who has symptoms of diabetes or is at risk for the condition should be
tested. People are routinely tested for gestational diabetes during their second
trimester or third trimester of pregnancy.
Blood tests to diagnose prediabetes and diabetes:
 The fasting plasma glucose (FPG) test measures your blood sugar after
you’ve fasted for 8 hours.
 The A1C test provides a snapshot of your blood sugar levels over the
previous 3 months.
 A 75-gram oral glucose tolerance test is also used. This checks the BG 2
hours after ingesting a sugary drink containing 75 grams of carbs.
To diagnose gestational diabetes, your doctor will test blood sugar levels between
the 24th week and 28th week of pregnancy. There are two types of tests:
 Glucose challenge test: During a glucose challenge test, blood sugar is
checked an hour after drink a sugary liquid. If your results are standard, no
more testing is done. If blood sugar levels are high, need to undergo a
glucose tolerance test.

 Glucose tolerance test: During a glucose tolerance test, blood sugar is
checked after fast overnight. Then you’re given a sugary drink and blood
sugar is re-tested after 1 hour and again after 2 hours. Gestational diabetes
is diagnosed if any of these three readings come back noting high blood
sugar.

SESSION -3
DIABETES TREATMENT OPTIONS
Diabetes is a chronic, metabolic disease characterized by elevated levels of blood
glucose (or blood sugar), which leads over time to serious damage to the heart,
blood vessels, eyes, kidneys and nerves. The most common is type 2 diabetes,
usually in adults, which occurs when the body becomes resistant to insulin or
doesn't make enough insulin. In the past 3 decades the prevalence of type 2
diabetes has risen dramatically in countries of all income levels. Type 1 diabetes,
once known as juvenile diabetes or insulin-dependent diabetes, is a chronic
condition in which the pancreas produces little or no insulin by itself. For people
living with diabetes, access to affordable treatment, including insulin, is critical
to their survival. There is a globally agreed target to halt the rise in diabetes and
obesity by 2025.
About 422 million people worldwide have diabetes, the majority living in low-
and middle-income countries, and 1.5 million deaths are directly attributed to
diabetes each year. Both the number of cases and the prevalence of diabetes have
been steadily increasing over the past few decades.

Life style modification
1. Eat healthy. This is crucial when have diabetes, because what eat
affects blood sugar. No foods are strictly off-limits. Focus on eating only as much
as body needs. Get plenty of vegetables, fruits, and whole grains. Choose non fat
dairy and lean meats. Limit foods that are high in sugar and fat. Remember that
carbohydrates turn into sugar, so watch your carb intake. Try to keep it about the
same from meal to meal. This is even more important if you take insulin or drugs
to control your blood sugars.
2. Exercise. If not active now, it’s time to start. Don't have to join a gym and do
cross-training. Just walk, ride a bike, or play active video games. Goal should be
30 minutes of activity that makes sweat and breathe a little harder most days of
the week. An active lifestyle helps you control diabetes by bringing down blood
sugar. It also lowers chances of getting heart disease. Plus, it can help lose extra
pounds and ease stress.
3. Get check ups. See your doctor at least twice a year. Diabetes raises your odds
of heart disease. So learn numbers: cholesterol, blood pressure, and A1c (average
blood sugar over 3 months). Get a full eye exam every year. Visit a foot doctor
to check for problems like foot ulcers and nerve damage.
4. Manage stress. When stressed, blood sugar levels go up. And when anxious,
you may not manage diabetes well. You may forget to exercise, eat right, or take
medicines. Find ways to relieve stress -- through deep breathing, yoga, or hobbies
that relax you.
5. Stop smoking. Diabetes makes more likely to have health problems like heart
disease, eye disease, stroke, kidney disease, blood vessel disease, nerve damage,
and foot problems. If you smoke, chance of getting these problems is even
higher. Smoking also can make it harder to exercise. Talk with doctor about ways
to quit.
6. Watch alcohol. It may be easier to control blood sugar if you don’t get too
much beer, wine, and liquor. So if choose to drink, don't overdo it. The American
Diabetes Association says that women who drink alcohol should have no more
than one drink a day and men should have no more than two. Alcohol can make
your blood sugar go too high or too low. Check your blood sugar before you
drink, and take steps to avoid low blood sugars. If you use insulin or
take drugs for your diabetes, eat when you're drinking. Some drinks -- like wine
coolers -- may be higher in carbs, so take this into account when you count carbs.
Prevention: Lifestyle changes are the best way to prevent or delay the onset of
type 2 diabetes.
To help prevent type 2 diabetes and its complications, people should:
 Reach And Keep A Health Body Weight

 Stay Physically Active With At Least 30 Minutes Of Moderate Exercise
Each Day
 Eat A Healthy Diet And Aoid Sugar And Saturated Fat
 Not Smoke Tobacco

Diabetes and diet
Healthy eating is a central part of managing diabetes. In some cases, changing
your diet may be enough to manage the disease.
Types 1 diabetes
Blood sugar level rises or falls based on the types of foods you eat. Starchy or
sugary foods make blood sugar levels rise rapidly. Protein and fat cause more
gradual increases. Medical team may recommend that limit the amount of
carbohydrates eat each day. You’ll also need to balance carb intake with insulin
doses. Counting carbs helps to balance the carb intake with the insulin doses.
Type 2 diabetes
Eating the right types of foods can both manage blood sugar and help lose any
excess weight. Carb counting is an important part of eating for type 2 diabetes. A
dietitian can help you figure out how many grams of carbohydrates to eat at each
meal. In order to keep blood sugar levels steady, try to eat small meals throughout
the day. Emphasize healthy foods such as:
 fruits
 vegetables
 whole grains
 lean protein such as poultry and fish
 healthy fats such as olive oil and nuts
Certain other foods can hurt efforts to manage blood sugar.
Gestational diabetes: Eating a well-balanced diet is important for both and baby
during these 9 months. Making the right food choices can also help avoid diabetes
medications. Watch portion sizes, and limit sugary or salty foods. Although need
some sugar to feed growing baby, should avoid eating too much. Check out other
do’s and don’ts for healthy eating with gestational diabetes.

The bottom line: Work with a registered dietitian if you have access to one. They
can help design an individualized diabetes meal plan. Getting the right balance of
protein, fat, and carbs can help you manage your blood sugar.
Diabetes and exercise: Along with diet and treatment, exercise plays an essential
role in diabetes management. This is true for all types of diabetes. Staying active
helps cells react to insulin more effectively and lower blood sugar levels.
Exercising regularly can also help:
 Reach And Maintain A Healthy Weight
 Reduce Your Risk Of Diabetes-Related Health Complications
 Boost Mood
 Get Better Sleep
 Improve Memory
If have type 1 or type 2 diabetes, general guidance is to aim for at least 150
minutes of moderate-intensity exercise each week. There are currently no
separate exercise guidelines for people who have gestational diabetes. But if
pregnant, start out slowly and gradually increase activity level over time to avoid
overdoing it.
Diabetes-friendly exercises include:
 Walking, swimming, dancing, cycling
Talk with doctor about safe ways to incorporate activity into diabetes
management plan. You may need to follow special precautions, like checking
blood sugar before and after working out and making sure to stay hydrated.
Consider working with a personal trainer or exercise physiologist who has
experience working with people who have diabetes. They can help to develop a
personalized workout plan tailored to your needs.
Diabetes prevention
Type 1 and type 1.5 diabetes are not preventable because they are caused by an
issue with the immune system. Some causes of type 2 diabetes, such as your genes
or age, aren’t under your control either.
Yet many other diabetes risk factors are manageable. Most diabetes prevention
strategies involve making simple adjustments to your diet and fitness routine.

If you’ve received a diagnosis of prediabetes, here are a few things you can do to
delay or prevent type 2 diabetes:
 Get at least 150 minutes per week of aerobic exercises like walking
or cycling.
 Cut saturated and trans fats, along with refined carbohydrates, out of your
diet.
 Eat more fruits, vegetables, and whole grains.
 Eat smaller portions.
 Try to lose 5% to 7%Trusted Source of your body weight if you have
overweight or obesity.
These aren’t the only ways to prevent diabetes. Discover more strategies that may
help you avoid this chronic health condition.
Diabetes in pregnancy: People who’ve never had diabetes can suddenly develop
gestational diabetes during pregnancy. Hormones produced by the placenta can
make your body more resistant to the effects of insulin.
Pre-gestational diabetes: People can have diabetes before they conceive and
carry it with them into pregnancy. This is called pre-gestational diabetes.

Risks to newborn: Diabetes during pregnancy can lead to complications for your
newborn, such as jaundice or breathing problems. If diagnosed with pre-
gestational or gestational diabetes, need special monitoring to prevent
complications.
Gestational diabetes should go away after you deliver, but it does significantly
increase your risk of getting diabetes later. About half Trusted Source of people
with gestational diabetes will go on to develop type 2 diabetes.
Diabetes in children; Children can get both type 1 and type 2 diabetes. Managing
blood sugar is especially important in young people because diabetes can damage
important organs such as the heart and kidneys.
Type 1 diabetes; The autoimmune form of diabetes often starts in childhood.
One of the main symptoms is increased urination. Kids with type 1 diabetes may
start wetting the bed after they’ve been toilet trained. Extreme thirst, fatigue, and
hunger are also signs of the condition. It’s important that children with type 1
diabetes get treatment right away. The condition can cause high blood
sugar, dehydration, and diabetic ketoacidosis (DKA), which can be medical
emergencies.
Type 2 diabetes: Type 1 diabetes used to be called juvenile diabetes because type
2 was so rare in children. Now that more children have overweight or obesity,
type 2 diabetes is becoming more common in this age group. Some children
living with type 2 diabetes don’t experience symptoms. Others may experience:
 Increased thirst
 Frequent urination
 Extreme fatigue
 Blurry vision
Type 2 diabetes is often diagnosed based on medical history, a physical exam,
and blood work. Untreated type 2 diabetes can cause lifelong complications,
including heart disease, kidney disease, and blindness. Healthy eating and
exercise can help your child manage their blood sugar and prevent these
problems. Type 2 diabetes is more prevalent than ever in young people.

DIAGNOSIS AND TREATMENT
Early diagnosis can be accomplished through relatively inexpensive testing of
blood glucose. People with type 1 diabetes need insulin injections for survival.
One of the most important ways to treat diabetes is to keep a healthy lifestyle.
Some people with type 2 diabetes will need to take medicines to help manage
their blood sugar levels. These can include insulin injections or other medicines.
Some examples include:
 Metformin
 Sulfonylureas
 Sodium-glucose co-transporters type 2 (sglt-2) inhibitors.
Along with medicines to lower blood sugar, people with diabetes often need
medications to lower their blood pressure and statins to reduce the risk of
complications. Additional medical care may be needed to treat the effects of
diabetes:
 Foot care to treat ulcers
 Screening and treatment for kidney disease
 Eye exams to screen for retinopathy (which causes blindness).

INSULIN THERAPY
Insulin is a hormone produced by the pancreas to help the body use and store
glucose (sugar). Glucose is a source of fuel for the body.
In people with diabetes, the body cannot regulate the amount of glucose in the
blood (called glycemia or blood sugar). Insulin therapy can help some people
with diabetes maintain their blood sugar levels.
Carbohydrates from food are broken down into glucose and other sugars. Glucose
is absorbed from the digestive tract into the bloodstream. Insulin lowers blood
sugar by allowing it to move from the bloodstream into muscle, fat, and other
cells, where it can be stored or used as fuel. Insulin also tells the liver how much
glucose to produce when you are fasting (have not had a recent meal). People
with diabetes have high blood sugar because their body does not make enough
insulin or because their body does not respond to insulin properly.
 In people with type 1 diabetes the pancreas produces little to no insulin.
 In people with type 2 diabetes the fat, liver, and muscle cells do not respond
correctly to insulin. This is called insulin resistance. Over time, the pancreas stops
making as much insulin.
Insulin Doses and Types: Insulin therapy replaces the insulin the body would
normally make. People with type 1 diabetes must take insulin every day.
People with type 2 diabetes need to take insulin when other treatments and
medicines fail to control blood sugar levels.
Insulin doses are given in two main ways:
 Basal dose - provides a steady amount of insulin delivered all day and night. This
helps maintain blood glucose levels by controlling how much glucose the liver
releases (mainly at night when the time between meals is longer).
 Bolus dose - provides a dose of insulin at meals to help move absorbed sugar
from the blood into muscle and fat. Bolus doses can also help correct blood sugar
when it gets too high. Bolus doses are also called nutritional or meal-time doses.
Sometimes, a bolus dose must also be taken with large snacks.
There are several types of insulin available. Insulin types are based on the
following factors:
 Onset - how quickly it starts working after injection
 Peak - time when the dose is the strongest and most effective
 Duration - total time the insulin dose stays in the bloodstream and lowers blood
sugar
Below are the different types of insulin:

 Rapid-acting or fast-acting insulin starts working within 15 minutes, peaks in
1 hour, and lasts for 2 to 4 hours. It is taken right before or just after meals and
snacks. It is often used with longer-acting insulin.
 Regular or short-acting insulin reaches the bloodstream 30 minutes after use,
peaks within 2 to 3 hours, and lasts 3 to 6 hours. This is taken a half-hour before
meals and snacks. It is often used with longer-acting insulin.
 Intermediate-acting insulin starts working within 2 to 4 hours, peaks in 4 to 12
hours, and lasts 12 to 18 hours. This is taken mostly either twice a day or once at
bedtime.
 Long-acting insulin starts to work a few hours after injection and works for
about 24 hours, sometimes longer. It helps control glucose throughout the day. It
is often combined with rapid- or short-acting insulin as needed.
 Premixed or mixed insulin is a combination of 2 different types of insulin. It
has both a basal and bolus dose to control glucose after meals and throughout the
day.
 Inhaled insulin is a rapid-acting breathable insulin powder that starts working
within 15 minutes of use. It peaks 30 minutes after taking it and lasts about 3
hours. It is used just before meals.
One or more types of insulin may be used together to help control blood sugar.
Dosing schedule may depend on:
 Body weight
 Type of insulin take
 How much and what eat
 Level of physical activity
 Blood sugar level
 Other health conditions
Insulin cannot be taken by mouth because stomach acid destroys insulin. It is
most often injected under the skin into fatty tissue. There are different insulin
delivery methods available:
 Insulin syringe -- insulin is drawn from a vial into a syringe. Using the needle,
you inject the insulin under the skin.
 Insulin pen -- disposable insulin pens have prefilled insulin delivered under the
skin using a replaceable needle.
 Insulin pump -- a small machine worn on the body pumps insulin under the skin
throughout the day. A small tube connects the pump to a small needle inserted
into the skin.
 Inhaler -- a small device you use to inhale insulin powder through your mouth.
It is used at the start of meals.
 Injection port -- a short tube is inserted into the tissue under the skin. The port
containing tube is adhered to skin using adhesive tape. Fast-acting insulin is
injected into the tube using a syringe or pen. This allows you to use the same
injection site for 3 days before rotating to a new site.

Insulin is injected into these sites on the body:
 Abdomen
 Upper arm
 Thighs
 Hips
Provider will teach how to give an insulin injection or use an insulin pump or
other device. It is important not to always use the same site as this can decrease
how effective the insulin is for you.
Points to Remember: You need to know how to adjust the amount of insulin you
are taking:
 When you exercise
 When you are sick
 When you will be eating more or less food
 When you are traveling
 Before and after surgery
When to Call the Doctor: If you are taking insulin, contact your provider if:
 You think you may need to change your insulin routine
 You have any problems taking insulin
 Your blood sugar is too high or too low and you don't understand why
LATEST INVENTIONS IN DIABETES MANAGEMENT
 In addition to the aforementioned innovations in the management of
diabetes, several drugs are still at different stages of clinical trial for
eventual use. Others are ready and have been recently introduced into the
market.
Drugs Recently Introduced
 Tirzepatide: The drug was recently approved by the FDA under the trade
name mounjaro for the treatment of T2DM. Tirzepatide is an injectable
given under the skin once in a week which targets the receptors of
hormones which play central role in the metabolism of glucose. These
hormones are glucagon-like peptide-1 (GLP-1) and glucose-dependent
insulinotropic polypeptide (GIP). While the GLP-1 reduces blood glucose
by several mechanisms, including stimulating insulin secretion and
suppressing glucagon release during hyperglycemia, GIP stimulates
insulin release during hyperglycemia, but it also stimulates glucagon
release during hypoglycemia.

 Tirzepatide acts as agonist to their receptors, hence elongating their
functions which results in blood glucose control. The efficacy of
tirzepatide was established against a placebo, a GLP-1 receptor agonist
(semaglutide) and two long-acting insulin analogs either as monotherapy
or in combination with other antidiabetic agents. In comparison to the
placebo, it lowered the HbA1c by 11.6% and 1.5% as monotherapy and
combination therapy, respectively. In comparison to other antidiabetic
drugs, at the highest dose of 15 mg, it lowered the HbA1c 0.5% more than
semaglutide, 0.9% more than insulin degludec and 1.0% more than insulin
glargine. Because of the efficacy therein and the once in a week dosing,
tirzepatide provides a desirable paradigm shift in the management of
T2DM.
Drugs in the Pipeline
 Several drug candidates are at different phases of development for the
management of DM. These are listed below.
 LY3502970: LY3502970 is a partial agonist, biased toward G-protein
activation over β-arrestin recruitment at the (GLP-1 receptor (GLP-1R).
The molecule is highly potent and selective against other class B G-
protein-coupled receptors (GPCRs) with a pharmacokinetic profile
favorable for oral administration. It is a product that is currently being
developed by Eli lilly.
 SCO-094: SCO-094 is a drug candidate identified by SCOHIA company
which has a dual target of the receptors of GIP and GLP-1
 Ladarixin (LDX): Ladarixin is an inhibitor of the interleukin-8 receptors
CXCR1 and CXCR2, in new-onset T1DM. It is a drug candidate developed
by Dompe Farmaceutici. Short term LDX treatment of newly diagnosed
patients with T1DM had no appreciable effect on preserving residual beta
cell function.
In the current scenario, digital health management plays a significant role in T1D
care and self-management. Recent technological advances including continuous
glucose monitoring (CGM) and insulin pumps, have sought to ease the burden of
diabetes self-management. However, insulin pumps provide automated insulin
delivery but cost barriers, variable insurance coverage, and authorization hurdles
prevent the wide usage of insulin pumps. Nowadays, smart insulin
pens and artificial pancreas are gaining attention for T1D self-management.

Smart insulin: The introduction of "smart" insulin is promising to
revolutionize diabetes treatment by allowing for more efficient and personalized
glucose control. Smart insulin is a new class of insulin analogs that are intended
to mimic the body's natural insulin secretion in response to glucose levels. These
novel formulations are designed to self-regulate insulin release based on an
individual's blood glucose level. Smart insulin combines a set of core
components: digital dose capture, real-time wireless connectivity, real-time
connectivity with glucose-sensing devices, and integration with insulin-dosing
decision support. Remarkably, the US Food and Drug Administration (FDA)
approved the usage of the first smart insulin pen in 2017. The glucose-responsive
insulin (GRI) is one of the most promising smart insulin candidates. GRI
formulations contain glucose-sensing elements that cause insulin release in
response to hyperglycaemia. This closed-loop system provides several benefits,
including better glycaemic control, a lower risk of hypoglycaemia, and increased
patient convenience. Furthermore, smart insulin therapies seek to eradicate the
need for multiple daily injections by developing long-acting formulations that can
adjust insulin release based on glucose levels over time. These developments may
reduce the burden of frequent injections, improving patient adherence and quality
of life.
ARTIFICIAL PANCREAS: An artificial pancreas, also termed as closed-
loop insulin system, is a medical device that integrates a continuous glucose
monitor, an insulin pump, and a control algorithm to regulate insulin delivery
based on real-time glucose measurements. Recently, in the United States, a single
closed-loop. system (MiniMed 670 G, Medtronic) was approved for 6–13 years
aged T1D patients Remarkably, Food and Drug Administration (FDA), USA
approved another system (t: slim X2 insulin pump with Control-IQ Technology,
Tandem Diabetes Care) for the treatment of T1D patients (up to 14 years or older)
However, the efficacy of artificial pancreas systems in managing T1D and
minimizing the risk of hypoglycaemia is a matter of concern and thus, being
investigated extensively. In 2005, a pioneer and pilot study conducted by Steil
and colleagues reported improved glycaemic control and reduced occurrence of
hypoglycaemia in children with T1D after using an artificial pancreas system .
Furthermore, a randomized clinical trial of 16 weeks revealed that the use of an
artificial pancreas system helps to improve glycaemic control in T1D children. In
a long-term clinical trial, the use of an artificial pancreas system improved
glycaemic control and reduced the risk of hypoglycaemia in adults with T1D over
six months. Apparently, these findings suggest that an artificial pancreas system
may offer significant benefits for individuals with T1D and warrant further
investigation.

Complications related to T1D: In T1D, the pancreas’s insulin-producing β-cells
are unintentionally attacked and destroyed by the body’s immune system and thus
leading to the shortage of insulin, which controls blood sugar levels and cause a
variety of complications The complications of T1D can affect various organs and
systems in the body as shown in Fig
Fig. 4. Potential complications of T1D. T1D is an autoimmune disease that affects
pancreatic β-cells, eyes, skeletal muscle, kidney, gastrointestinal
tract, circulatory system, and liver, and makes them non-functional.
IMMUNOTHERAPY: Immunotherapy refers to the administration of drugs
or other interventions to regulate the immune system, thereby averting the
destruction of insulin-producing β-cells in the pancreas. Such interventions may
involve immune modulators or biologics that selectively target specific immune
cells or pathways. As a potential treatment option for T1D, immunotherapy seeks
to manipulate the immune system to forestall or reverse the destruction of β-cells.
In a pioneer study, Herald and colleagues studied the effect of anti-CD-3 antibody
which target and deactivate the T cells that attack β-cells, on the progression of
T1D, and results showed that anti-CD-3 antibody preserved the β-cell
functionality in newly diagnosed T1D patients. In a randomized, double-blind,
placebo-controlled clinical trial, newly-diagnosed T1D patients were inoculated
with autologous T cells that were genetically engineered to express
a proinsulin peptide. The T-cell vaccine was found to preserve β-cell function and
reduce the deterioration in insulin secretion over a two-year period. Furthermore,
low-dose interleukin-2 (IL-2) therapy has been shown to increase the number of
regulatory T cells (Tregs), which can suppress the autoimmune response that
results in β-cell destruction and thus, enhance the β-cell functionality in patients
with new-onset T1D.
In addition, transplantation of engineered islet cells capable of evading immune
attack has been suggested as potential cell based-immunotherapy for T1D.
Notably, modification of the islet/β-cell surface by immobilizing
the anticoagulant enzymes including urokinase (UK) and thrombomodulin (TM)
or biotinylating the islet membrane to conjugate streptavidin-Fas-ligand (SA-

FasL) proteins have been reported to escape the immune attack post-
transplantation in T1D hosts In continuation, surface labelling of islet cells with
immunomodulatory proteins including A20 and programmed death-ligand 1 (PD-
L1)/cytotoxic T-lymphocyte-associated protein 4 (CTLA4) provide protection
from post-transplantation immunological attack in T1D host. Overexpression of
A20 protected the islets from TNFα, interleukin 1 β (IL-1β), and IFNγ-induced
apoptosis. In addition, Wang and colleagues reported that PD-L1/CTLA4-Ig–
expressing engineered MSCs immunologically protect the co-transplanted islets
and thus could be used as accessory cells in islet transplantation to improve the
graft function and to minimize the systemic immunosuppression . Reported
studies clearly indicate that local immunomodulation also plays a crucial role in
the immunotherapy of T1D.
CELL-BASED THERAPY: Cell therapy for diabetes involves the
transplantation of pancreatic islet cells or β-cells. Islet transplantation entails the
transplant of islet cells from a healthy donor’s pancreas into a patient suffering
from T1D. This method has been shown to enhance glucose control and lower
the risk of severe hypoglycaemia in individuals with T1D. However, islet cell
transplantation is associated with disadvantages like the requirement of a large
number of cells for transplantation and the lack of donors. Notably, combinational
cell therapy has been suggested as a potential tool for diabetes therapeutics.
Various combinational diabetes therapies including gene therapy, cell
encapsulation etc. are gaining attention of the researchers worldwide and are
being explored for diabetes therapeutics.
GENE THERAPY: Gene therapy refers to the insertion of genes into cells to
correct genetic abnormalities or enhance cellular function. For individuals with
T1D, gene therapy utilizes viral vectors to deliver genes that boost the growth and
survival of β-cells or to silence genes that contribute to β-cell destruction. A
preclinical investigation showed that the introduction of the pancreatic
transcription factor Pdx-1 gene into pancreatic cells of diabetic mice reinstated
glucose homeostasis and insulin production. Gene therapy
utilizing glucokinase has been suggested as a potential treatment for T1D, as
glucokinase is a crucial enzyme in glucose metabolism. Thus, a preclinical
study demonstrated that gene therapy with glucokinase improved glucose
homeostasis and prevented the development of diabetes in diabetic mice.
Inflammation is known to play a key role in the pathogenesis of T1D. Gene
therapy with anti-inflammatory cytokines like interleukin-10 (IL-10) has been
proposed as a treatment for T1D. In a preclinical study, gene therapy with IL-10
prevented the onset of diabetes in diabetic mice. Furthermore, regulatory T cells
(Tregs) are important in suppressing the autoimmune response that results in the
destruction of β-cells in T1D. In a preclinical study, gene therapy with Tregs
prevented the onset of diabetes and improved glucose homeostasis in diabetic

mice. Gene therapy with insulin-producing cells has also been proposed as a
potential treatment for T1D. In a preclinical study, gene therapy utilizing insulin-
producing cells obtained from human embryonic stem cells prevented the onset
of diabetes in diabetic mice and improved glucose homeostasis.
CELL ENCAPSULATION: Cell encapsulation has emerged as a promising
approach for the transplantation of insulin-producing cells, such as inlet cells,
without immunosuppressive drugs in patients with T1D. This technique involves
using semi-permeable membranes to protect transplanted cells from the immune
system while allowing nutrients and oxygen to pass through. In a clinical trial
study, the implantation of alginate-encapsulated islet cells improved glycaemic
control in patients without causing any major adverse events. In another attempt,
the implantation of polyethylene glycol (PEG)-encapsulated islet cells improved
glycaemic control and prevented immune system attack in mice. Similarly,
another study revealed that the implantation of PEG-encapsulated islet cells
improved glycaemic control and prevented immune system attacks in non-human
primates with T1D. In a pilot clinical trial, the implantation of stem cell-derived
insulin-secreting cells encapsulated in a hydrogel improved glycaemic control in
patients with T1D without causing any major adverse events, while the same stem
cells were utilized in a preclinical study to improve the glycaemic control and
prevent immune system attack in T1D mice.
STEM CELL THERAPY: Stem cell therapy is presently an area of
intense exploration in the context of T1D cell-based therapeutics. The objective
is to revitalize β-cells within the pancreas using stem cells that possess the ability
to differentiate into a diverse range of cell types. Researchers are investigating
various types of stem cells, such as induced pluripotent stem cells, adult stem
cells, and embryonic stem cells, for this purpose. Although early-stage clinical
trials have yielded encouraging results, further investigations are necessary to
ascertain the safety and effectiveness of stem cell therapy.
Stem cells: Stem cells are undifferentiated cells that possess the unique ability to
differentiate into specialized cell types and self-renew. There are several types of
stem cells, including embryonic stem cells (ESCs), induced pluripotent stem cells
(iPSCs), and adult stem cells. Stem cells hold significant potential for medical
applications, particularly in regenerative medicine and cell-based therapies for
different diseases. ESCs are derived from the inner cell mass of early-stage
embryos known as blastocysts. They can differentiate into any type of body cell,
making them useful for studying disease modelling. However, the use of ESCs is
controversial due to ethical concerns surrounding the use of embryos. Meanwhile,
induced pluripotent stem cells (iPSCs) are adult cells that have been
reprogrammed to a pluripotent state like ESCs. Typically, this reprogramming
process is accomplished by introducing particular genes into the cells via viral

vectors or other methods. They are an important tool for modelling diseases and
discovering new drugs due to their capacity to differentiate into any type of cell.
On the other hand, adult stem cells are capable of differentiating into specific cell
types within the tissue where they are found in the body. For
example, hematopoietic stem cells in bone marrow can transform into various
blood cell types. They have been utilized in numerous cell-based therapies, such
as bone marrow transplants for leukaemia and other blood disorders. Further,
totipotent stem cells have the ability to differentiate into any type of cell,
including both embryonic & extra-embryonic tissues. In humans, totipotent stem
cells are present only in the zygote (fertilized egg) and the earliest stages
of embryonic development. Unipotent stem cells, in contrast, can transform into
only one cell type but have the ability to self-renew. Muscle satellite cells, which
can develop into muscle cells, and spermatogonial stem cells, which can
differentiate into sperm cells, are some examples of unipotent stem cells.
GENERATION OF INSULIN-PRODUCING CELLS (IPCS) FROM IPSCS
iPSCs are used to differentiate into IPCs by employing the differentiation
protocols that mimic the natural development of pancreatic β-cells. Based on the
in vivo pancreas development, various multistep differentiation protocols of
iPSCs-derived insulin-producing β-cells involving the differentiation of iPSCs
towards endoderm cells, followed by pancreatic progenitor cells, and ultimately
IPCs have been reported. The differentiation protocols may vary depending on
the cell source and culture conditions; however, they commonly employ growth
factors, signalling molecules, and small molecules to guide differentiation.
However, differentiation efficiency is the major limitation of the iPSCs-derived
IPCs and thus, research on iPSCs-derived IPCs is progressing rapidly to improve
the differentiation efficiency of iPSCs into IPCs. In one such attempt, Amer and
colleagues generated the insulin-producing β-cells by modulating the TGF-β
signalling at the later stage of the differentiation and results showed that time-
specific inhibition and induction of TGF-β signalling are required during β-cell
differentiation to achieve dynamic insulin release against glucose exposure.
Moreover, a recent study by Kroon et al. developed a small molecule-based IPCs
differentiation protocol and they achieved a high yield of functional IPCs that
secreted insulin in response to glucose stimulation.
Generation of IPCs from MSCs: MSCs are multipotent stem cells that can
differentiate into several cell types, including adipocytes, osteocytes,
and chondrocytes. Recent studies have demonstrated that MSCs are also
differentiated into IPCs using various differentiation protocols involving stepwise
induction of endoderm, pancreatic progenitor cells, and IPCs, similar to the
protocols utilized for iPSCs and ESCs. Developed a novel approach to improving
the functional stability of MSC-derived IPCs. They differentiated human MSCs
into IPCs using a protocol that included nicotinamide, BMP-7, and exendin-4.
They then encapsulated the IPCs in a hydrogel made from extracellular

matrix (ECM) proteins, which provided a supportive microenvironment for the
cells. The researchers found that the IPCs in the hydrogel maintained their
function and survival for up to 21 days in vitro, compared to only 7 days for IPCs
without the hydrogel. They also transplanted the IPCs into diabetic mice and
found that the hydrogel-encapsulated IPCs improved glucose tolerance and
reduced hyperglycemia. Furthermore, in a recent study, human adipose-derived
MSCs were exposed to a combination of cytokines and small molecules,
including Activin A, BMP-4, retinoic acid, and the GSK-3β
inhibitor CHIR99021. After 12 days of differentiation, the cells displayed
morphological changes consistent with IPCs and expressed key beta cell markers,
including insulin, PDX1, and NKX6.1. The resulting IPCs also exhibited
glucose-stimulated insulin secretion, suggesting functional beta-cell activity.
Current Status of Stem Cell Therapy for T1D
Stem cells have the potential to differentiate into pancreatic β-cells, making them
a promising source for cell-based therapies for T1D. Stem cells (ESCs, iPSCs,
and adult stem cells) are among those being widely explored for T1D therapeutics
In preclinical studies, ESCs-derived β-cells have demonstrated favorable results
by secreting insulin in response to glucose stimulation and restoring
normoglycemia in diabetic mouse models. However, the clinical translation of
ESC-derived β-cells have been limited by ethical concerns and the risk of immune
rejection. Thus, iPSCs offer a viable alternative to ESCs since they can be derived
from adult somatic cells, thereby eliminating ethical concerns. iPSC-derived β-
cells have also demonstrated the ability to secrete insulin and restore
normoglycemia in diabetic mouse models. Yet, their clinical translation is still in
its early stages, and further research is needed to establish their safety and
efficacy. In addition to iPSCs, adult stem cells,
including MSCs and hematopoietic stem cells (HSCs), have also been
investigated for T1D therapy. Preclinical studies have shown that MSCs have the
potential for β-cell regeneration and immune modulation, while HSCs can
promote β-cell survival and function. Despite these exciting findings, the clinical
translation of adult stem cells for T1D therapy is still in its infancy and requires
further investigation to determine their safety and efficacy.
In recent years, there have been several successful clinical trials of stem cell
therapy for T1D have been carried out. One notable trial was conducted by
Viacyte, Inc., involving the transplantation of pancreatic progenitor cells derived
from stem cells into T1D patients. The implanted cells successfully differentiated
into insulin-producing β-cells and effectively regulated the blood glucose levels
in most patients without exerting serious adverse events. Another clinical trial
involved the transplantation of autologous bone marrow-derived stem cells in
patients with T1D, promoting the regeneration of pancreatic β-cells and
improving glycaemic control in the majority of patients. In another effort, the use

of stem cell educator therapy in T1D involved exposing the blood of 15 patients
to allogeneic umbilical cord blood-derived stem cells using a blood
filtration device. Following treatment, the patients experienced improved blood
glucose control, increased C-peptide levels, and reduced insulin requirements
(Zhao et al., 2022). Another clinical trial involved 63 newly diagnosed T1D
patients who received allogeneic MSC transplantation. Following the
transplantation, the patients experienced improved blood glucose control,
increased C-peptide levels, and reduced insulin requirements.
In the current scenario, the diabetes epidemic has been a serious global health
issue and the lack of an efficient and substantial therapy plays a significant role
in the continuously increasing prevalence of diabetes. Recent advances
in biomedical research led to the development of various diabetes management
and therapeutic approaches (as summarized in Fig. 6)
including immunotherapy, artificial pancreas, cell-based therapy, etc. which hold
great promise for diabetes treatment through uniquely powerful modes of action.
Immunotherapy relies on the modulation of the immune system which in turn,
prevents the destruction of β-cells and preserves insulin production. However,
early clinical studies have shown promising results but there are several
unanswered questions about the optimal timing, dosing, and duration of

immunotherapy and long-term side effects still exist. The artificial pancreas can
automatically regulate insulin delivery based on real-time glucose measurements.
However, more accurate glucose sensors and the optimization of the control
algorithms could make the artificial pancreas a better tool for diabetes treatment.
Cell-based therapy including gene therapy, cell encapsulation, and stem cell
therapy is gaining attention in diabetes therapeutics. In continuation, gene therapy
is able to restore normal insulin production by delivering the genes that promote
the growth and survival of β-cells or silencing the genes that contribute to β-cell
destruction. However, the safety and efficiency of viral vectors, and the potential
for off-target effects are the associated disadvantages of gene therapy. Stem cell
therapy is one of the most promising approaches for the treatment of T1D, with
several studies showing that it can improve glucose control and reduce the need
for exogenous insulin. However, combination therapies that target different
aspects of the disease pathogenesis may be necessary for optimal outcomes.
Despite the challenges, the rapid pace of technological advancements and
scientific discoveries in cellular therapies make them a promising area of research
for the treatment of T1D.
In a few short decades, type 2 diabetes research and technological breakthroughs
have brought about significant advancements in how the condition is treated and
managed. Here are some of the top innovations that are helping people with type
2 diabetes better manage the condition today.
1. Insulin Pumps The first insulin pump came on the market in 1974. Previously,
insulin pumps were only approved for use in those with type 1 diabetes. But if
you have type 2 diabetes and have to inject insulin multiple times a day, a pump
is an alternative to self-injection. “An insulin pump is a medical device that
delivers insulin into the tissue just underneath the skin,” says Megan Porter, RD,
CDCES, a certified diabetes educator in Portland, Oregon.
This computerized device, which is about the size of a deck of cards, can be worn
around your waist, put in a pocket, secured with an armband, or attached to a belt
or bra. “Some pumps deliver the insulin continuously, and others only deliver the
insulin at meals or large snacks,” adds Porter. An insulin pump can also be more
convenient if you’re out or at work, because all you may need to do is push a
button to deliver the insulin instead of giving yourself a shot.
2. Continuous Glucose Monitors (CGMs) These devices have a tiny sensor that
is placed below the surface of the skin to measure the amount of glucose in the
fluid between cells every few minutes and transmit the data wirelessly to a device
or your smartphone.
CGMs are a game-changer: Unlike glucose meters that require a drop of blood to
check what your blood glucose levels are at that moment, CGMs monitor your
levels at set times throughout the day, such as every five minutes. This can help
you and your doctor identify patterns and trends that may be helpful in fine-tuning

your type 2 diabetes treatment plan to optimize management, according to
the American Diabetes Association (ADA). These devices can also alert you
when your glucose level is too low or too high.
The first CGM, which involved wearing a device provided by the doctor for two
weeks or less and then returning it to the clinic or hospital, was approved by the
U.S. Food and Drug Administration (FDA) in 1999. Since then, CGMs have
become increasingly accurate and much more widely available for home use. In
the past five years, there have been even more advances in CGM therapy. In 2018,
the FDA approved the first implantable CGM device, which can be worn up to
three months without changing the sensor, for people with type 1 or 2 diabetes.
“The benefit of using a CGM is that it can be worn for seven or more days, which
means one poke to insert the monitor [during that time frame] replaces checking
blood sugars via a finger poke three or more times per day,” Porter notes. CGMs
make it easier to check your blood sugar before and after meals, and they can help
you understand how your diet, activity, and lifestyle affect your blood sugar
levels.
3. Connected CGM-Insulin Pumps Another option available is a combination
CGM-insulin pump, which enables the pump to use the data from the CGM to
suggest changes in medication dosing or make necessary adjustments on its own.
In 2020, the FDA approved an integrated CGM, which allows it to be connected
to other diabetes management devices, such as insulin pumps and blood glucose
monitors.
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This integration of devices can help improve type 2 diabetes management by
quickly reducing blood sugar and minimizing the amount of time you experience
unsafe and unhealthy blood sugar levels.
4. Diabetes Medications Although insulin has been used in the United States
since the 1920s, according to the FDA, today’s medications can be far more
targeted for specific diabetes issues.
Metformin, which belongs to a class of medications called biguanides, is often
the first medication prescribed for type 2 diabetes. “Metformin decreases glucose
absorption from food and decreases liver production of insulin,” says Porter.
Other options, including oral medications and noninsulin injectables:
 Sodium-glucose cotransporter-2 (SGLT2) inhibitors are oral medications that
lower blood sugar levels by preventing the kidneys from absorbing glucose.

 Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are injectable
medications that help you control appetite and blood sugar levels.
 DPP-4 inhibitors, also called gliptins, are oral medications that help manage
diabetes in several ways, such as by enhancing insulin secretion, slowing down
digestion, and decreasing appetite, which can help with weight loss.
 Thiazolidinediones, also called glitazones, are oral medications that help make
your body’s tissues more sensitive to insulin.
 Sulfonylureas are oral medications that increase the release of insulin from
your pancreas.
 Meglitinides are oral medications that help your body make more insulin around
mealtimes.
 Alpha-glucosidase inhibitors are oral medications that help your body digest
sugar more slowly.
 Combination therapies join multiple drug classes in a single medication. They
may be injected or taken orally.
“And, of course, insulin is still used as a replacement when a person’s body does
not create enough insulin on its own,” Porter adds.
5. Insulin Innovations Insulin has come a long way since it was first discovered.
It now comes in a variety of forms, including rapid-acting, long-lasting, and
premixed formulas, and can be delivered via a number of methods, such as
syringes, pumps, and pens. And innovations are still coming. For instance, there
are now insulin pen devices that can remember the last dose and the time that it
was given, which is especially helpful if you’re busy or tend to forget to take it.
Smart insulin pens have many of the features of insulin pumps but cost less and
don’t have to be attached to your body.
According to the ADA, smart insulin pens can connect to your smartphone or
watch and link to diabetes data-tracking platforms to help you accurately
calculate each dose based on factors such as your blood sugar level, carb amounts,
meal size, and other parameters prescribed by your doctor. These devices can also
remind you to take your dose, keep track of the amount of each dose, and tell you
when your insulin has expired.
6. Easier-to-Use Glucagon Glucagon is used in emergencies to treat very low
blood sugar, or hypoglycemia, a dangerous condition that can lead to confusion,
loss of consciousness, seizures, and even death, according to the National
Institute of Diabetes and Digestive and Kidney Diseases.
Glucagon injections have been available for more than 20 years, but in the past
few years, devices such as injectable pens and glucagon that can be inhaled have
made it much easier for you — or your family or friends — to administer
glucagon in the event of an emergency.

7. Better Support for People With Diabetes In the past, many people with type
2 diabetes were treated by their primary care physician — rather than an
endocrinologist, who is trained to treat diabetes — who may not have had any
special training in the complexities of type 2 diabetes management. Today, there
are many specialists who can help. Since the 1980s, certified diabetes educators
have transformed diabetes management, according to the ADA. These
professionals, who are now called certified diabetes care and education specialists
(CDCES), take a comprehensive approach to teaching diabetes management and
specialize in educating and supporting those with diabetes to optimize their
health.
Diabetes educators can also connect you to dietitians, physical therapists, and
mental health experts trained to help with the condition. “Hopefully, over time,
more people with chronic conditions, such as diabetes, will be referred out to
other healthcare professionals who can help them manage their condition
physically and mentally,” Porter says.
8. Diabetes Smartphone Apps Yes, there’s an app for that — many of them, in
fact. Nowadays, diabetes apps can track your blood sugar levels and show trends;
monitor your diet and suggest recipes; log your exercise; and provide support
from other people with diabetes. “Coaching apps can also give you access to
highly trained diabetes educators and fitness coaches,” Porter says.
But it’s important to check with your doctor, CDCES, or other trusted diabetes
health professional before you choose an app. An article in the journal Diabetes
Care noted that there isn’t sufficient evidence to back up the effectiveness,
accuracy, and safety of many apps, and many are plagued by technical problems.
The authors noted that regulatory agencies and app companies urgently need to
work with diabetes health professionals and researchers to ensure the safety and
effectiveness of diabetes apps.
9. Meal Delivery Services While they weren’t developed specifically for
diabetes, meal delivery companies that offer healthy foods and recipes have
become very popular over the past several years. Now, many companies provide
diabetes-friendly meal kits if you want to eat healthy but don’t want to do a lot of
food shopping and planning.

The Department of Health & Family Welfare, Government of India provides
technical and financial support to the States/UTs under the National Programme
for Prevention and Control of Non Communicable Diseases (NP-NCD), as part
of National Health Mission (NHM), based on the proposals received from the
States/UTs and subject to the resource envelope. Diabetes is an integral part of
the programme. The programme focusses on strengthening infrastructure, human
resource development, health promotion & awareness generation for prevention,
early diagnosis, management and referral to an appropriate level of healthcare
facility for treatment of the Non-Communicable Diseases (NCDs). Under NP-
NCD, 724 District NCD Clinics, 210 District Cardiac Care Units, 326 District
Day Care Centres and 6110 Community Health Centre NCD Clinics have been
set up.

A population-based initiative for prevention, control and screening for common
Non-Communicable Diseases (NCDs) i.e., diabetes, hypertension and common
cancers has been rolled out in the country under NHM and also as a part of
Comprehensive Primary Health Care. Under the initiative, persons more than 30
years of age are targeted for their screening for common NCDs. Screening of
these common NCDs is an integral part of service delivery under Ayushman
Bharat – Health and Wellness Centres which generates awareness on risk factors
of NCDs including diabetes.
Preventive aspect of diabetes is strengthened under Comprehensive Primary
Health Care through Ayushman Bharat Health Wellness Centre scheme, by
promotion of wellness activities and targeted communication at the community
level. In addition, NP-NCD gives financial support under NHM for awareness
generation (IEC) activities for Diabetes to be undertaken by the States/UTs as per
their Programme Implementation Plans (PIPs). Other initiatives for increasing
public awareness about Diabetes and for promotion of healthy lifestyle include
observation of World Diabetes Day and use of print, electronic and social media
for continued community awareness.
Furthermore, healthy eating is promoted through FSSAI. Eat Right Initiative,
Safe and Nutritious Food at Home and ‘Aaj se thoda kum’ awareness activities
are also initiated. This initiative aims to promote both the demand for and the
supply of safe and healthy food in a sustainable way. Fit India and Khleo India
movements are implemented by Ministry of Youth Affairs and Sports, and
various Yoga related activities are carried out by Ministry of AYUSH.
Diabetes patients are getting treatment at various health facilities in the health
care delivery system including District Hospitals, Medical Colleges, Central
Institutes like AIIMS, Central Government hospitals, and private sector hospitals.
The treatment in Government Hospitals is either free or highly subsidized for the
poor and needy.
Under NP-NCD, glucometer and drugs for diabetes are provided as per the
proposals received from the states. Under Free Drugs Service Initiative of NHM,
financial support is provided to States/UTs for provision of free essential
medicines including insulin for poor and needy people. Furthermore, quality
generic medicines including insulin are made available at affordable prices to all,
under ‘Pradhan Mantri Bhartiya Janaushadhi Pariyojana (PMBJP), in
collaboration with the State Governments.

SESSION-4
COMPLICATIONS OF DIABETES
[DIAGNOSIS AND MANAGEMENT]

HYPOGLYCEMIA (LOW BLOOD SUGAR)
Hypoglycemia happens when the level of sugar (glucose) in blood drops below
the range that’s healthy for you. It’s also called low blood sugar or low blood
glucose. Hypoglycemia is common in people with diabetes, especially Type 1
diabetes.
For most people with diabetes, hypoglycemia is when blood sugar level is below
70 milligrams per deciliter (mg/dL) or 3.9 millimoles per liter (mmol/L).
For most people without diabetes, hypoglycemia is when blood sugar level is
below 55 mg/dL or 3.1 mmol/L. Hypoglycemia requires immediate treatment by
eating or drinking sugar/carbohydrates. Severe hypoglycemia can be life-
threatening and requires treatment with emergency glucagon and/or medical
intervention.
Glucose (sugar) mainly comes from carbohydrates in the food and drinks we
consume. It’s body’s main source of energy. Glucose is very important because
it’s the primary source of energy for brain.
If don’t have diabetes, several bodily processes naturally help keep blood glucose
in a healthy range. Insulin, a hormone pancreas makes, is the most significant
contributor to maintaining healthy blood sugar. Glucagon is another important
hormone in this process.
People who have diabetes must use medication, like oral diabetes medications or
synthetic insulin, and/or lifestyle changes to help keep their blood sugar levels in
range.
Low blood sugar often happens due to excess insulin — whether body naturally
makes too much or inject too much synthetic insulin. Other hormonal and
metabolic issues can also lead to low blood sugar.
If blood sugar drops below the healthy range, it causes certain symptoms like
shakiness and a faster heartbeat and can be life-threatening if it goes too low. This
is because your brain needs a continuous supply of glucose to function properly.
Without enough glucose, your brain can’t function.
Hypoglycemia is common in people with diabetes, especially people who take
insulin to manage the condition. One study found that 4 in 5 people with Type 1
diabetes and nearly half of all people with Type 2 diabetes who take insulin
reported a low blood sugar episode at least once over a four-week period.
People with Type 2 diabetes who take meglitinide or sulfonylurea oral diabetes
medications are also at an increased risk for low blood sugar.

Causes: Hypoglycemia happens when blood sugar drops below a healthy range.
Several factors can contribute to this for people with diabetes. Hypoglycemia can
develop if things like food, exercise and diabetes medications are out of balance.
Common situations that can lead to hypoglycemia for people with diabetes
include: Taking too much insulin, the wrong insulin or injecting it into your
muscle instead of in your fat tissue.
Not timing insulin and carb intake correctly (for example, waiting too long to eat
a meal after taking insulin for the meal).
Taking too much or too high of a dose of oral diabetes medications.
Being more active than usual.
Drinking alcohol without eating.
Eating meals later than usual or skipping meals.
Not balancing meals by including fat, protein and fiber.
People who are pregnant and have Type 1 diabetes are also more likely to
experience low blood sugar during the first trimester due to hormone changes.
There are two main types of non-diabetes-related hypoglycemia:
Reactive hypoglycemia and fasting hypoglycemia.
Reactive hypoglycemia happens when experience low blood sugar after a
meal. It typically occurs about two to four hours after a meal. Researchers don’t
yet know the exact cause. But they think it happens due to a sudden spike and
then fall in blood sugar after eating certain foods, especially simple carbohydrate
foods like white rice, potatoes, white bread, cake and pastries.
Bariatric surgery can also result in reactive hypoglycemia. After certain types of
bariatric surgery, such as gastric bypass surgery, your body absorbs sugars very
quickly, which stimulates excess insulin production. This can then cause
hypoglycemia. Your body usually corrects reactive hypoglycemia on its own, but
consuming carbohydrates may help your symptoms go away more quickly.
Fasting hypoglycemia: For the majority of people without diabetes, not
eating food for a long time (fasting) doesn’t lead to hypoglycemia. This is because
your body uses hormones and stored glucose to manage your blood sugar.
However, certain conditions and situations can lead to fasting hypoglycemia in
people without diabetes, including:
Excessive alcohol consumption: Alcohol prevents your body from forming new
glucose cells (gluconeogenesis). If you drink excessive amounts of alcohol over

several days and don’t eat much, your body can run out of stored glucose
(glycogen). This can lead to hypoglycemia because your body can’t properly
regulate your blood sugar.
Critical illness: You can experience hypoglycemia in critical illness states, such
as end-stage liver disease, sepsis, starvation or kidney failure. This is because
your body is using stored glucose for energy faster than your body can create new
glucose cells from the food you eat.
Adrenal insufficiency: Adrenal insufficiency causes lower-than-normal cortisol
levels. As cortisol (a hormone) helps regulate your blood sugar by increasing it,
having low levels of cortisol can lead to hypoglycemia episodes.
Non-islet cell tumor hypoglycemia (NICTH): This is a rare but serious syndrome
in which a tumor releases excess insulin-like growth factor 2 (IGF-2). This is a
hormone that has similar effects as insulin. Excess IGF-2 causes hypoglycemia.
A wide variety of benign (noncancerous) and malignant (cancerous) tumors can
cause NICTH.
Insulinoma: An insulinoma is a rare tumor in your pancreas that produces excess
insulin. It leads to hypoglycemia episodes — most commonly in the early
morning.In rare cases, non-diabetes-related medications can lead to
hypoglycemia, such as beta-blockers and certain antibiotics. If you’re
experiencing hypoglycemia and don’t have diabetes, talk to your healthcare
provider.
Common symptoms of hypoglycemia include shaking or trembling, faster
heart rate, extreme hunger, sweating, dizziness and more.
Symptoms of hypoglycemia (low blood sugar) can start quickly, and they can
vary from person to person. The signs include:
Shaking or trembling, Weakness, Sweating and chills, Extreme hunger
(polyphagia), Faster heart rate, Dizziness or lightheadedness, Confusion or
trouble concentrating, Anxiety or irritability., Color draining from your skin
(pallor), Tingling or numbness in your lips, tongue or cheeks.
Signs of severe hypoglycemia include: Blurred or double vision, Slurred speech,
Clumsiness or difficulty with coordination, Being disoriented, Seizures, Loss of
consciousness.
Severe hypoglycemia is life-threatening. It needs immediate medical treatment.
In rare cases, severe hypoglycemia that isn’t treated can result in a coma and/or
death.

Can also experience low blood sugar while sleeping (nocturnal hypoglycemia).
Symptoms may include: Restless sleep, Sweating through your pajamas or sheets,
Crying out during sleep, having nightmares, Feeling tired, disoriented or confused
after waking up.
In general, symptoms often begin for people with diabetes when their blood
glucose is around 70 mg/dL or lower. If blood sugar is falling rapidly, may
experience symptoms before this point.
If have hypoglycemia unawareness, it’s important to let friends and family know
so that they know how to help if experience a severe low blood sugar episode.
You may also benefit from the following:
Using a continuous glucose monitoring (CGM) device that can alert you when
you have hypoglycemia. More frequent manual blood sugar checks. A service
dog called a diabetes alert dog that’s specially trained to alert you when you have
low blood sugar.
Prolonged severe hypoglycemia is life-threatening and can lead to the following
complications: Multiple organ failure, Cardiac arrhythmias, Cardiac arrest,
Permanent brain damage, Coma, Death.
Operating heavy equipment, such as driving a vehicle, while having low blood
sugar can also be dangerous. You may be more likely to get in an accident. If you
have diabetes, always make sure your blood sugar is in range before operating
heavy equipment.
Diagnosis and Tests: The only way to know if you have hypoglycemia is to
check blood sugar with a blood glucose meter (glucometer). Most of these devices
use a tiny blood sample from a finger prick with a lancet (small needle). If you’re
experiencing symptoms of hypoglycemia and are unable to check blood sugar,
treat the hypoglycemia.
If healthcare provider suspects have hypoglycemia, they may check blood sugar
every few hours during a fast lasting several days. For reactive hypoglycemia,
provider might recommend a test called a mixed-meal tolerance test (MMTT).
For the MMTT, first have a special drink containing protein, fats and sugar. The
drink raises blood glucose, causing body to make more insulin. Then a provider
will check blood glucose multiple times over the next five hours.
Management and Treatment: Treat mild to moderate hypoglycemia by
eating or drinking sugar (carbohydrates). The American Diabetes Association
recommends the “15-15 rule” to treat an episode of mild to moderate
hypoglycemia:

Eat or drink 15 grams of fast-acting carbs to raise blood sugar.
After 15 minutes, check blood sugar.
If it’s still below 70 mg/dL, have another 15 grams of fast-acting carbs.
Repeat until blood sugar is at least 70 mg/dL.
To know how many carbs eating, read food nutrition labels. Some examples of
foods that contain about 15 grams of fast-acting carbs include:
1 small piece of fruit, such as half a banana.
4 ounces (half-cup) of juice or regular soda (not diet).
1 tablespoon of sugar, honey or syrup.
1 tube of instant glucose gel (check the instructions).
3 to 4 glucose tablets (check the instructions).
If have symptoms of hypoglycemia but can’t check blood sugar, use the 15-15
rule until feel better. Children may need fewer grams of carbs to treat
hypoglycemia. Check with your child’s healthcare provider.
Severe hypoglycemia requires different treatment than mild or moderate
hypoglycemia. If someone you know is having a hypoglycemia episode and is
slurring their speech, disoriented or unconscious, don’t give them food or liquid.
They could choke.
Severe hypoglycemia episodes require the use of emergency glucagon. This is a
synthetic form of glucagon that you can administer as an injection or nasal
powder (dry nasal spray), depending on the type. Synthetic glucagon triggers your
liver to release stored glucose, which then raises blood sugar.
If the glucagon is injectable, inject it into their butt, arm or thigh, following the
instructions in the kit. If the glucagon is a nasal powder, follow the instructions
on the package to administer it into their nostril.
When the person regains consciousness (usually in 5 to 15 minutes), they may
experience nausea and vomiting. If they’re laying down, roll them onto their side
to prevent choking in case they vomit. Don’t hesitate to call 911 for help. If
someone is unconscious and glucagon isn’t available or you don’t know how to
use it, call 911 immediately.
Prevention: It’s easiest to do this when healthcare provider understand what
causes blood sugar to drop. Give healthcare provider as much information as

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