The document discusses diabetes mellitus, a chronic disease characterized by hyperglycemia due to insulin deficiency or resistance, and highlights its global and national burden, especially in Pakistan. It presents various types, epidemiological factors, risk factors, complications, and prevention strategies related to diabetes, emphasizing the need for early diagnosis and management to mitigate health impacts. The treatment methods include dietary management, oral hypoglycemic medications, and insulin therapy, alongside the significant complications that can arise if not properly managed.

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

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

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

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

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

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

7. Pakistan

8. Pakistan

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

26. PREVENTION AND CONTROL

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

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

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

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

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