2. DIABETES
MELLITUS
2
Definition:
Diabetes is a chronic disease that occurs when the pancreas is no
longer able to make insulin, or when the body cannot make
good use of the insulin it produces.
Insulin is a hormone made by the pancreas, that acts like a key
to let glucose from the food we eat pass from the blood stream
into the cells in the body to produce energy. All carbohydrate
foods are broken down into glucose in the blood. Insulin helps
glucose get into the cells.
3. Types of diabetes:
There are three main types of diabetes – type 1, type 2 and gestational.
TYPE 1 DIABETES:
can develop at any age, but occurs most frequently in children and adolescents. When you have type 1
diabetes, your body produces very little or no insulin, which means that you need daily insulin injections to
maintain blood glucose levels under control.
TYPE 2 DIABETES:
is more common in adults and accounts for around 90% of all diabetes cases. When you have type 2 diabetes,
your body does not make good use of the insulin that it produces. The cornerstone of type 2 diabetes treatment
is healthy lifestyle, including increased physical activity and healthy diet. However, over time most people
with type 2 diabetes will require oral drugs and/or insulin to keep their blood glucose levels under control.
Gestational diabetes (GDM):
is a type of diabetes that consists of high blood glucose during pregnancy and is associated with complications
to both mother and child. GDM usually disappears after pregnancy but women affected and their children are
at increased risk of developing type 2 diabetes later in life.
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4. Specific Types of DM
• It is formerly known as secondary DM
• It may occur in some conditions as:
- Over-production of anti-insulin hormones (cortisol, glucagon,
epinephrine, growth hormone, & thyroid hormones).
- Surgical excision of the pancreas.
-Hemochromatosis:It results from iron toxicity (bronze diabetes).
-Drug–induced diabetes as thiazide diuretics, adrenergic
receptor agonists as salbutamol & oral contraceptive pills.
5. type 1 diabetes
5
Around 10% of all people with diabetes have type 1 diabetes.
Type 1 diabetes is a disease in which the body does not make enough insulin to control blood sugar levels.
Type 1 diabetes was previously called insulin-dependent diabetes or juvenile diabetes
6. Type 1 diabetes
6
is an autoimmune disease. This means it begins when the body's immune system
attacks cells in the body. In type 1 diabetes, the immune system destroys insulin-producing cells (beta
cells) in the pancreas.
Type 1 diabetes occurs when some or all of the insulin-producing cells in the pancreas are
destroyed. This leaves the patient with little or no insulin. Without insulin, sugar accumulates in the
bloodstream rather than entering the cells. As a result, the body cannot use this glucose for energy. In
addition, the high levels of glucose that remain in the blood cause excessive urination and dehydration,
and damage tissues of the body
Type 1 diabetes is not caused by the amount of sugar in a person's diet before the disease develops.
Type 1 diabetes is a chronic disease. It is diagnosed most commonly between ages 10 and 16. Type 1
diabetes equally affects males and females.
10. Insulin Resistance
• In fat cells:
•the inhibitory effectsof insulin on lipolysis is reduced with
• release of free fatty acids in the blood plasma.
• In muscle cells:
• glucose uptake is reduced
• local storage of glucose as glycogen is also reduced.
• In liver cells:
• results in impaired glycogen synthesis.
•failure to suppress glucose production by gluconeogenesis.
11. Insulin Resistance
• Insulin resistance and type 2 diabetes
- Insulin resistance alone will not lead to diabetes.
- Risk for development of Type 2 diabetes commonly observed
in :
insulin resistant individuals + show impaired β-cell function
elderly obese physically inactive individuals
3-5% of pregnant women who develop gestational diabetes.
• These patients are unable to sufficiently compensate for insulin resistance with
increased insulin release
12. Metabolic syndrome
• Abdominal obesity is associated with a threatening
combination of metabolic abnormalities :
• Insulin resistance, hyperinsulinemia
• Glucose intolerance
• Dyslipidemia(TAG>= 150 mg/dl, low HDL and elevated VLDL)
• Hypertension
13.
14.
15. Management of type 1 diabetes
People with type 1 diabetes require daily insulin treatment, regular blood glucose monitoring and a
healthy lifestyle to manage their condition effectively.
1. Insulin:
All people with type 1 diabetes need to take insulin to control their blood glucose levels. There are
different types of insulin depending on how quickly they work, when they peak, and how long they last.
Insulin is commonly delivered with a syringe, insulin pen or insulin pump.
Types of insulin are many and include:
Short-acting (regular) insulin
Rapid-acting insulin
Intermediate-acting (NPH) insulin
Long-acting insulin
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16. Injections.
You can use a fine needle and
syringe or an insulin pen to inject
insulin under your skin. Insulin
pens look similar to ink pens and
are available in disposable or
refillable varieties.
An insulin pump.
You wear this device, which is about the size of a
cell phone, on the outside of your body.Atube
connects a reservoir of insulin to a catheter that's
inserted under the skin of your abdomen. This type
of pump can be worn in a variety of ways, such as on
your waistband, in your pocket or with specially
designed pump belts. When you eat, you program
the pump with the amount of carbohydrates you're
eating and your current blood sugar, and it will give
you what's called a bolus dose of insulin to cover
your meal and to correct your blood sugar if it's
elevated
Insulin administration
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18. Two common insulin treatment plans include:
Twice-daily insulin: using both short-acting and intermediate-acting insulin.
Basal bolus regimen: short-acting insulin taken with main meals (usually three times a day)
and intermediate-acting insulin given once or twice daily (evening or morning and evening).
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19. 19
LIPOATROPHY LIPODYSTROPHY LIPOHYPERTROPHY
is the term describing the
localized loss of fat
tissue.
This may occur as a
result of subcutaneous
injections of insulin in the
treatment of diabetes.
is a problem with the way
your body uses and
stores fat. It's called
acquired when you aren't
born with it. It often
affects the fat that's just
under your skin, so it can
change the way you look.
It also can cause other
changes in your body
is an abnormal
accumulation of fat
underneath the surface of
the skin. It's most
commonly seen in people
who receive multiple daily
injections, such as people
with type 1 diabetes.
20. The body absorbs insulin at different speeds from each of the sites. This information can be
useful when planning insulin injections:
20
•Abdomen: Insulin enters the bloodstream most quickly after an abdominal injection.
•Upper arms: The body absorbs insulin with moderate speed but slower than an
injection in the abdomen.
•Lower back and thighs: Insulin enters the bloodstream most slowly from these sites.
•Administer rapid-acting insulin into the abdomen right after a meal for the fastest
results.
Exercise can increase the absorption rate of insulin. If planning a workout or
physical activity, account for these when planning injections.
For example, a baseball pitcher should avoid injecting into their throwing arm. The
physical activity can affect the absorption of insulin into the body.
Wait to for at least 45 minutes after the injection to exercise a part of the body that is
near the injection site.
21. • Artificial pancreas
In September 2016, the Food and DrugAdministration approved the first artificial pancreas for people
with type 1 diabetes who are age 14 and older. It's also called closed-loop insulin delivery. The
implanted device links a continuous glucose monitor, which checks blood sugar levels every five
minutes, to an insulin pump. The device automatically delivers the correct amount of insulin when the
monitor indicates it's needed.
Pancreas transplant.
With a successful pancreas transplant, you would no longer need insulin. But pancreas transplants
aren't always successful — and the procedure poses serious risks. Because these risks can be more
dangerous than the diabetes itself, pancreas transplants are generally reserved for those with very
difficult-to-manage diabetes, or for people who also need a kidney transplant.
Islet cell transplantation.
Researchers are experimenting with islet cell transplantation, which provides new insulin-producing
cells from a donor pancreas.Although this experimental procedure had some problems in the past,
new techniques and better drugs to prevent islet cell rejection may improve its future chances of
becoming a successful treatment.
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22. Type 2 diabetes
22
It is generally characterized by insulin resistance, where the body does not fully respond to
insulin. Because insulin cannot work properly, blood glucose levels keep rising, releasing more
insulin. For some people with type 2 diabetes this can eventually exhaust the pancreas, resulting in
the body producing less and less insulin, causing even higher blood sugar levels (hyperglycaemia).
Symptoms of type 2 diabetes
24. Role of Vitamin D
• Low vitamin D levels have been shown to
impair insulin synthesis & secretion
•Vitamin D supplementation increases pancreatic insulin
release & reduces insulin resistance.
•Vitamin D deficiency may influence its effects on insulin
secretion & sensitivity via its effects on intracellular
calcium.
25. Management of type 2 diabetes
25
The cornerstone of managing type 2 diabetes is a healthy lifestyle, which includes
a healthy diet, regular physical activity, not smoking, and maintaining a healthy
body weight.
Medications for type 2 diabetes
The most commonly used oral medications for type 2 diabetes include:
Metformin: reduces insulin resistance and allows the body to use its own
insulin more effectively. It is regarded as the first- line treatment for type 2
diabetes in most guidelines around the world.
Sulfonylureas: stimulate the pancreas to increase insulin production.
Sulfonylureas include gliclazide, glipizide, glimepiride, tolbutamide
and glibenclamide.
27. 2-Random blood sugar test. 3-Fasting blood sugar test
27
Test Fasting Plasma Glucose
(FPG)
Oral Glucose Tolerance Test
(OGTT)
Random/Casual
Plasma Glucose
(with symptoms)
How
performed
Bd glucose is measured
after at least an 8 hr fast
75 gm glucose load (drink) is
ingested after at least an 8hr
fast
Blood glucose is measured at
2 hrs
Blood glucose is measured at any
time regardless of eating
Normal < 100mg/dl (5.6 mmol/L) < 140 mg/dl (7.8 mmol/L)
Pre-diabetes
IGT
140-199 mmol/dl
(7.8-11 mmol/L)
Diabetes
Mellitus
≥ 126 mg/dl (7 mmol/L) ≥ 200mg/dl (11.1 mmol/L) ≥ 200mg/dl
(11.1 mmol/L)
(with symptoms)
Diagnosis of Pre-diabetes and Diabetes:
29. H y p e r g l y c e m i c c o m a
H y p o g l y c e m i c c o m a
C a u s e d b y n e g l e c t i o n o f i n s u l i n ,
s t r e s s b y i n t e r c u r r e n t i l l n e s s
P u l s e r a p i d a n d w e a k
H y p e r v e n t i l a t i o n i n
re s p i ra t i o n
T h e r e is a c e t o n e i n b r e a t h
S k i n is d r y, d e h y d r a t e d
Tre a t e d w it h i n s u l in I.V,
r e p l a c e f lu id l o s s b y
n o r m a l salin e , s o d i u m
b i c a r b o n a t e t o c o r r e c t
a c i d o s i s , r e p l a c e
e l e c t ro l y t e l o s s b y g i v i n g
p o t a s s i u m
C a u s e d b y o v e r d o s e o f i n s u l i n ,
s t r e n u o u s p h y s i c a l a c t i v i t y
P u l s e r a p i d a n d s t r o n g
R e s p i r a t i o n is n o r m a l
N o a c e t o n e i n b r e a t h
S w e a t i n g
T r e a t e d w i t h g l u c o s e
g i v e n I.V o r g l u c a g o n I . m
t o m o b i l i z e h e p a t i c
g l y c o g e n
33. Activated Aldose Reductase Pathway
•Hyperglycemia activates the aldose reductase pathway
which uses NADPH to reduce glucose to sorbitol.
•Cell membranes are NOT permeable to sorbitol, which tends to accumulate
in the cell.
•Intracellular sorbitol accumulation causes osmotic cellular damage and
generates reactive oxygen species which may explain the high incidence of
cataract & some other complications in diabetics.
37. Immune compromise:
The immune response is impaired in individuals with diabetes mellitus. Cellular studies have shown that
hyperglycaemia both reduces the function of immune cells and increases inflammation.
Respiratory infections such as pneumonia and influenza are more common among individuals with
diabetes. Lung function is altered by vascular disease and inflammation, which leads to an increase in
susceptibility to respiratory agents. Several studies also show diabetes associated with a worse disease
course and slower recovery from respiratory infections.
Increased risk of wound infections
Restrictive lung disease is known to be associated with diabetes. Lung restriction in diabetes could result
from chronic low-grade tissue inflammation, microangiopathy, and/or accumulation of advanced
glycation end products. In fact the presence restrictive lung defect in association with diabetes has been
shown even in presence of obstructive lung diseases like asthma and COPD in diabetic patients
Lipohypertrophy may be caused by insulin therapy. Repeated insulin injections at the same site, or near to,
causes an accumulation of extra subcutaneous fat and may present as a large lump under the skin. It may
be unsightly, mildly painful, and may change the timing or completeness of insulin action.
• Depression was associated with diabetes 37
38. Hyperosmolar Hyperglycemic Nonketotic Syndrome:
(or HHNS) occurs most frequently in older adults with type 2 diabetes, especially
residents of long-term care facilities. It occurs in people whose diabetes is not
controlled properly and is usually brought on by an illness or infection.
41. Diabetic neuropathy
41
Diabetic neuropathy is a type of nerve damage that can occur if you have diabetes. High blood sugar
(glucose) can injure nerves throughout your body. Diabetic neuropathy most often damages nerves in your
legs and feet.
Depending on the affected nerves, diabetic neuropathy symptoms can range from pain and numbness in your
legs and feet to problems with your digestive system, urinary tract, blood vessels and heart. Some people
have mild symptoms. But for others, diabetic neuropathy can be quite painful and disabling.
Diabetic neuropathy is a serious diabetes complication that may affect as many as 50% of people with
diabetes. But you can often prevent diabetic neuropathy or slow its progress with consistent blood sugar
management and a healthy lifestyle.
1. -Peripheral neuropathy
This type of neuropathy may also be called distal symmetric peripheral neuropathy. It's the most common
type of diabetic neuropathy. It affects the feet and legs first, followed by the hands and arms. Signs and
symptoms of peripheral neuropathy are often worse at night, and may include:
Numbness or reduced ability to feel pain or temperature changes
Tingling or burning sensation
Sharp pains or cramps
Increased sensitivity to touch — for some people, even a bedsheet's weight can be painful
Serious foot problems, such as ulcers, infections, and bone and joint pain
42. 2-Autonomic neuropathy
The autonomic nervous system controls your heart, bladder, stomach, intestines, sex organs and eyes. Diabetes
can affect nerves in any of these areas, possibly causing:
Alack of awareness that blood sugar levels are low (hypoglycemia unawareness)
Bladder or bowel problems
Slow stomach emptying (gastroparesis), causing nausea, vomiting and loss of appetite
Changes in the way your eyes adjust from light to dark
Decreased sexual response
3-Proximal neuropathy (diabetic polyradiculopathy)
This type of neuropathy — also called diabetic amyotrophy — often affects nerves in the thighs, hips, buttocks or
legs. It can also affect the abdominal and chest area. Symptoms are usually on one side of the body, but may
spread to the other side. You may have:
Severe pain in a hip and thigh or buttock
Eventual weak and shrinking thigh muscles
Difficulty rising from a sitting position
Severe stomach pain
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43. 4-Mononeuropathy (focal neuropathy)
There are two types of mononeuropathy — cranial and peripheral. Mono neuropathy
refers to damage to a specific nerve.
Mono neuropathy may also lead to:
Difficulty focusing or double vision
Aching behind one eye
Paralysis on one side of your face (Bell's palsy)
Numbness or tingling in your hand or fingers, except your pinkie (little finger)
Weakness in your hand that may cause you to drop things
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44. Examination of diabetes in elderly :
44
Weight, abdominal circumference, height and BMI.
Urinalysis for ketones, protein and nitrite (evidence of infection).
Inspect injection sites of patients with type 1 diabetes, looking for evidence of lipoatrophy
and lipodystrophy/ lipohypertrophy.
Cardiovascular:
o Check pulse and blood pressure.
o Listen for carotid bruits and to heart sounds/lung fields if there is any history
consistent with cerebrovascular or cardiac illness.
o Palpate and record the peripheral pulses of the feet.
o Ankle brachial index
45. Eyes:
Ensure regular attendance and appropriate follow-up for diabetes eye screening.
o Check visual acuity, with distance vision glasses, if worn.
Neuropathy:
o Examine the legs for evidence of diabetic amyotrophy.
o Check peripheral limb sensation - eg, using a 10 g nylon monofilament probe.
o Check ankle and knee reflexes using a tendon hammer.
o Inspect footwear (for suitability) and the feet carefully for any evidence of
peripheral neuropathy
causing deformity and ulceration, or hypoperfusion due to peripheral vascular
disease.
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46. Special tests for diabetic neuropathy:
Filament test. Your doctor will brush a soft nylon fiber (monofilament) over areas of your skin to test
your sensitivity to touch.
Sensory testing. This noninvasive test is used to tell how your nerves respond to vibration and
changes in temperature.
Nerve conduction testing. This test measures how quickly the nerves in your arms and legs conduct
electrical signals. It's often used to diagnose carpal tunnel syndrome.
Muscle response testing. Called electromyography, this test is often done with nerve conduction
studies. It measures electrical discharges produced in your muscles.
Autonomic testing. Special tests may be done to determine how your blood pressure changes while
you are in different positions, and whether you sweat normally.
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47. Nutrition Therapy:
o It is the Most Fundamental Component of the Diabetes Treatment Plan
• Goals: Near Normal Glucose Levels
Normal Blood Pressure
Normal Serum Lipid Levels
Reasonable Body Weight
Promotion of Overall Health
Fat intake :
<35% of total calories
Saturated fat <10% of total calories
Polyunsaturated fats 10% of total calories
Cholesterol consumption < 300 mg
Moderate increase in monounsaturated fats such as olive oil (up to 20% of total calories)
Protein Intake:
Small to medium portion of protein once daily
12-20% of daily calories
From both animal and vegetable sources
Vegetable source less nephrotoxic than animal protein
3-5oz of meat, fish or poultry daily
Patient with nephropathy should limit to less than 12% daily
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48. Diabetes and exercise in the elderly
48
Special Considerations for Exercise in elder people :
1. Avoid exercising during periods of peak insulin activity
2. Always exercise with a partner in case the patient needs help
3. Carry money with you so that you can make a phone call for help
4. Know the signs of hypoglycemia - lightheadedness, diaphoresis, palpitations, loss of motor control, Wear
good foot wear
5. Practice foot inspections for fissures, blisters or reddened areas
6. Inject the insulin into a muscle mass that does not directly participate in the physical work
7. Learn to drop your insulin requirement once you understand how exercise effects your insulin needs
8. Do not take beta-blockers because they mask the symptoms of hypoglycemia
9. Never exercise if your blood glucose is over 300 mg/dl because you are out of control and must see your
physician
10.If your glucose is between 110 - 280 mg/dl, it is okay to start exercise
11.Learn to monitor your blood glucose every thirty minutes of continued exercise
12.Check your blood glucose before and after exercise
13.Carry carbohydrate to treat low blood glucose if you are at risk
14.Exercise before or after breakfast is the best time because blood glucose is elevated at this time (exercise by timing
the session for approximately one hour after a meal (to coincide with peak post-prandial rise in glucose)
51. Parameters Type I Diabetics Type II diabetics
Mode Aerobic/Anaerobic
Aerobic/Anaerobi
c
Frequency 7 days/week 5 days/week
Duration 20-30 minutes 30-60 minutes
Intensity 45% - 85% MHR 45% - 70% MHR
Exercise Prescription
51
If you take insulin, don't take your shot in a
part of your body that you'll be using heavily
during exercise. For example, don't take your
shot in your thigh if you plan to run. This can
lead to the insulin being absorbed too quickly
and cause your blood sugar to drop suddenly
52. Exercising With Diabetes Complications :
52
1. Exercising With Heart Disease :
Caution:
o Very strenuous activity
o Heavy lifting or straining
o Exercise in extreme cold or heat
Choose:
o Moderate activity such as walking, swimming, biking, gardening
o Moderate lifting, stretching
2- Exercising with Retinopathy (eye disease):
Caution
o Strenuous exercise
o Heavy lifting and straining
o High-impact aerobics, jogging
o Bending your head below your waist – toe touching(head down or arm over head)
o BP not exceed 20-30mmhg above baseline
Choose
o Moderate, low-impact activities:
o walking
o cycling
o water exercise
53. 3-Exercising with Nephropathy (kidney disease):
Caution
o Strenuous activity
o BP not exceed 180-200mmhg
o Avoid valsalva maneuver
Choose
o Light to moderate activity like walking, light housework, gardening, water exercise
4-Exercising with Neuropathy (nerve disease):
Caution
o Weight-bearing, high impact, strenuous, or prolonged exercise:
o jogging/running
o step exercise
o jumping
o exercise in heat/cold
o Choose : Low impact, moderate activities:
biking
swimming
chair exercises
stretching
light to moderate daily activities 53
54. Effect of Physical Activity on Blood Glucose
54
Physical activity usually lowers blood glucose
Physical activity can raise your blood glucose if:
your BG is >250 mg/dl before your exercise and you
have ketones.
you’re starting a new vigorous exercise program
55. Intensity Time (minutes) Carbohydrate
Mild Less than 30 May not be needed
Moderate 30-60 15 grams
High Over 60 30-50 grams
•Effect of PhysicalActivity on Blood Glucose
1. Physical activity usually lowers blood glucose
Treatment for Low Blood Glucose: Equal to about 15 grams of
carbohydrate:
½ cup fruit juice
½ cup soft drink
3 glucose tablets
55
56. * Some strategies to avoid hypoglycaemia are listed below:
56
Measure blood sugars before, during, and after exercise.
For planned exercise, if you are on insulin, reduce the short-acting insulin
by 33 to 50%.
For unplanned exercise, take 30 to 20g of carbohydrates extra for each 30
minutes of exercise.
Avoid injecting insulin into the arms and legs and use the abdomen
because the insulin will be absorbed more evenly.
If you exercise in the evening, you may need to add a snack before bedtime
to make certain your sugars don't go too low at night.
57. Diabetic Foot management
Assessment of the foot wounds
57
1. Medical history: including the initiating trauma, duration of the wound
,progression of the signs and symptoms ,prior treatment, history of previous
wounds, evaluation of the blood glucose control, identification of
comorbidties, previous surgical intervention as debridement.
2. Clinical assessment: of the wound include location, depth, extent and area
3. Ulcer surface area:.
Clean transparent films, the ulcer perimeters are traced and the surface area is
calculated using computer image analysis or centimeter square graded paper.
Ulcer volume.:
Either by inserting sterile ruler into the deepest part of the wound or by filling
the ulcer with normal saline using sterile syringe.
1. Neurological examination to detect presence or absence of sensations, dry,
cracked skin indicates autonomic neuropathy.
2. Vascular evaluation including palpation of the foot pulses as posterior tibial
and dorsalis pedis, ankle brachial systolic index
59. Physical modalities to treat diabetic foot
ulcers:
59
1. Pulsed ultrasound therapy around the wound perimeter
significant benefit on treating ulcers three times weekly at
3MHz intensity of 0.2 W/cm2.
2. Ultraviolet: has been used to clear wound from bacteria, to
remove sloughs and to stimulate granulation tissue.
3. Laser therapy: acceleration of collagen and fibroblasts
synthesis.
4. Iontophoresis and electrical stimulation: enhance
migration of fibroblasts, provide antibacterial effect.
5. Hydrotherapy: (Whirlpool) applied for 20 minute daily.
6. Ozone therapy : Bactericidal and fungicidal activity of O3
therapy and the activation of the immune system, stimulate
higher amounts of nitric oxide (NO) which stimulate
vasodilatation
60. Check your feet every day. Look for blisters, cuts, bruises, cracked and
peeling skin, redness, and swelling. Use a mirror or ask a friend or family
member to help examine parts of your feet that are hard to see.
Keep your feet clean and dry. Wash your feet every day with lukewarm
water and mild soap.Avoid soaking your feet. Dry your feet and between your
toes carefully.
Moisturize your feet. This helps prevent cracking. But don't get lotion
between your toes, because it might encourage fungal growth.
Trim your toenails carefully. Cut your toenails straight across. File the edges
carefully to avoid sharp edges.
Wear clean, dry socks. Look for socks made of cotton or moisture-wicking
fibers that don't have tight bands or thick seams.
Wear cushioned shoes that fit well. Always wear shoes or slippers to protect
your feet. Make sure your shoes fit properly and allow your toes to move. A
foot doctor can teach you how to buy properly fitted shoes and to prevent
problems such as corns and calluses. If you qualify for Medicare, your plan
may cover the cost of at least one pair of shoes each year.
Follow your doctor's recommendations for good foot care. To protect the
health of your feet:
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