This document provides an overview of diabetes mellitus including its definition, classification, epidemiology in India, diagnosis, and management. It discusses the two main types of diabetes - type 1 caused by lack of insulin production and type 2 caused by insulin resistance. Diagnosis involves blood glucose testing as well as HbA1c levels. Management focuses on lifestyle changes like diet and exercise as well as oral medications and insulin for blood glucose control to prevent complications.

1. DIAGNOSIS AND
MANAGEMENT OF
DIABETES MELLITUS
MODERATOR:
DR. JAIRAM RAWTANI
(SENIOR PROFESSOR)
PRESENTED BY:
DR. AMRITA GHOSH
(PG RESIDENT)

2. LEARNING OBJECTIVES
 Definition
 Epidemiology
 Types (classification)
 Diagnosis of Diabetes Mellitus
 Management of Diabetes Mellitus

3. DEFINITION
 It is a chronic
metabolic disorder
characterised by an
elevated blood
glucose level
(hyperglycaemia)
due to impaired
insulin production,
insulin action or
both.

4. EPIDEMIOLOGY
 In India, there are estimated 77 million
people above the age of 18 years who are
suffering from diabetes and nearly 25 million
are at a higher risk of developing diabetes in
near future.
 The estimates in 2019 showed that the
number is expected to rise to over 134
million by the year 2045.
 57% of these individuals remain undiagnosed.

5.  Over the past three
decades, the burden of
diabetes in terms of
deaths and Disability-
adjusted life year
(DALYs) has more than
doubled in India. As per
the Global Burden of
Disease (GBD) Data
Visualizations, the
recorded death rate
and DALY rate of
diabetes in 2019 were
19.64 per 100,000 and
919.02 per 100,000
population,
respectively, including
males and females.

6. COMPLICATIONS PREVALENCE
(IN PERCENTAGES)
Diabetic retinopathy 22.4
Diabetic neuropathy 26.1
Diabetic nephropathy 26.9
Coronary artery
disease
21.4
Peripheral vascular
disease
6.3

7. CLASSIFICATION
OF DIABETES
MELLITUS

8. TYPE 1 DIABETES MELLITUS
IMMUNE MEDIATED
IDIOPATHIC
TYPE 2 DIABETES MELLITUS
•MODY
•GENETIC DEFECTS OF INSULIN ACTION
•PANCREATIC DISEASES
•ENDOCRINOPATHIES
•DRUGS OR CHEMICALLY INDUCED
DIABETIC PRONE STATES
•GESTATIONAL DIABETES MELLITUS
•IMPAIRED GLUCOSE TOLERANCE
•IMPAIRED FASTING GLYCAEMIA

9. TYPE 1 DIABETES MELLITUS
(insulin dependent diabetes mellitus)
 Occurs when the immune system
mistakenly attacks and destroys the
insulin-producing beta cells of the Islet of
Langerhans in pancreas.
 Hence the body produces little to no
insulin, requiring lifelong insulin
replacement therapy.
 Typically manifests in childhood (juvenile
diabetes) or early adulthood.

10. TYPE 2 DIABETES MELLITUS
(non-insulin dependent diabetes mellitus)
 Characterised by insulin resistance, where
the body’s cells become less responsive to
the effects of insulin.
 About 60% patients are obese and have
high plasma insulin levels.
 Usually develops in adulthood but now it
is increasingly seen even in children and
adolescents.

11. DIAGNOSIS AND MANAGEMENT
OF DIABETES MELLITUS

12. DIAGNOSIS(ADA CRITERIA)
If both fasting and 2-hour values are above the
normal levels, on the same occasion.

13. Tests should be conducted when:
 Anyone with a body mass index >25, regardless of age.
 Anyone who has additional risk factors like high blood
pressure; sedentary lifestyle; a history of polycystic
ovarian syndrome, having delivered a baby who
weighed >3.5 kg; history of diabetes in pregnancy;
high cholesterol levels; a history of heart disease;
having any close relative with diabetes.
 Anyone older than 45 years of age is advised to
receive an initial blood glucose screening, and then, if
the results are normal, are to be screened every three
years thereafter.

14. LABORATORY INVESTIGATIONS
Blood Glucose
Estimation
( fasting and post
prandial)
Random Blood
Glucose
Estimation
Oral Glucose
Tolerance
Test(OGTT)
Glycated
Haemoglobin
( HbA1C)
Urine Analysis
Fructosamine
Assay
Insulin Assay C-peptide Assay Lipid Profile

15. BLOOD GLUCOSE
ESTIMATION
CHOICE OF SAMPLE:
 Plasma or serum from
venous blood samples has
the advantage over whole
blood.
 The glucose concentration
is 10-15% higher in plasma
or serum than in whole
blood because structural
components of blood cells
are absent.
 The blood is collected using
an anti-coagulant
(potassium oxalate) and an
inhibitor of glycolysis
(sodium fluoride)

16. FASTING BLOOD GLUCOSE:
 Glucose estimated in the early morning before
taking any breakfast i.e., in a fasting state.
 Fasting state means glucose is estimated after an
overnight fasting of 8-12 hours.
 Normal FBG: <5.6mmol/L or 70-110mg/dL
POST PRANDIAL BLOOD GLUCOSE:
 Glucose estimation done after about 2 hours
after taking a good meal.
 Normal PPBS: <140mg/dL

17. RANDOM BLOOD GLUCOSE:
 RBG/RBS is the glucose estimation done at any
time of the day without any prior preparations.
 Random blood sugar estimation is mostly
required during any emergency situations.
 A random BG concentration >11.1mmol/L or
>200mg/dl accompanied by classical symptoms
of DM is sufficient for diagnosis.

18. METHODS TO
MEASURE BLOOD
GLUCOSE:
 GOD/POD
 Orthotoludiene
test
 Benedict’s test

19. ORAL GLUCOSE
TOLERANCE TEST (OGTT)
The diagnosis of diabetes can be made based on
individual’s response to glucose load.
PREPARATION OF THE SUBJECT FOR GTT:
 The person should have been taking carbohydrate
rich diet for atleast 3 days prior to the test.
 Drugs known to interfere carbohydrate metabolism
should be discontinued for atleast 2 days.
 Strenous exercise should be avoided.
 He should be in an overnight fasting state.
 During GTT, person should be comfortably seated and
refrain from smoking.

20. CONDUCTING THE GTT:
 At about 8 am, a sample of blood is collected
in the fasting state. Urine sample is also
obtained. This is denoted as the “0 HOUR
SAMPLE”
 GLUCOSE LOAD DOSE: the dose is 75g
anhydrous glucose( 82.5g of glucose
monohydrate) in 250-300 ml water.
 Dose is fixed for an adult, irrespective of
weight.
 In children, the glucose dose is adjusted as
1.75g/kg body weight.

21. SAMPLE COLLECTION:
 As per current WHO recommendation, 2 samples are
collected, one at fasting state (0 hour) and another at 2-hour
post glucose load.
INTERPRETATIONS:
NORMAL
PERSON
CRITERIA FOR
DIAGNOSING
DIABETES
CRITERIA FOR
DIAGNOSING
IGT
FASTING <100mg/dL
(<5.6mmol/L)
>126mg/dL
(>7.0mmol/L)
100-126mg/dL
1 HOUR (PEAK)
AFTER
GLUCOSE
<140mg/dL Not prescribed Not prescribed
2 HOURS AFTER
GLUCOSE
<120mg/dL >200mg/dL 140-199mg/dL

22. OGTT CURVE:

23. INDICATIONS OF
OGTT
 Patient has symptoms
of DM, but fasting
blood glucose value is
inconclusive (between
100 and 126mg/dl)
 During pregnancy, with
a history of big baby
(>4kg) or a history of
miscarriage.
 To rule out benign renal
glucosuria
CONTRAINDICATIONS
OF OGTT
 In a patient with
confirmed DM
 GTT has no role in
follow up. Only used
for initial diagnosis.
 In acutely ill patients
INDICATIONS OF
OGTT
CONTRAINDICATIONS
OF OGTT

24.  Insulin level
 Carbohydrate
starvation
 Exercise
 In liver disease
 In acute infections
 Hyperthyroidism
 Diagnosis of
diabetes mellitus
 Detection of
impaired glucose
tolerance
 Monitoring
gestational diabetes
mellitus
 Assessment of
insulin resistance
 Treatment
evaluation
FACTORS
AFFECTING OGTT
SIGNIFICANCE OF
OGTT IN DIABETES

25. GLYCATED HAEMOGLOBIN
(HbA1c)
 Glycated or glycosylated haemoglobin
refers to the glucose derived products of
normal adult haemoglobin.
 Best index of long-term control of blood
sugar levels.
 2 variants:
• HbA1-95%
• HbA2-4%
HbA-99%
• Fetal haemoglobin
HbF-1%

26.  In the laboratories, only HbA1 is measured
 The glycated haemoglobins are together called
HbA1 fraction. Of these, 85% is HbA1c.
DIAGNOSTIC IMPORTANCE OF
HbA1c:
 The rate of synthesis of HbA1c is directly
related to the exposure of RBC to glucose.
Hence it serves as an indicator of blood
glucose, over a period approximately to the
half-life of RBC.
 Normally, HbA1c concentration is about 3-5%
of total haemoglobin. In diabetic patients,
HbA1c is elevated to as high as 15%.

27. INTERPRETATION OF HbA1c:
< 5.5% Normal
6-6.9% Very good control of DM by treatment
measures
7-7.9% Adequate control
8-8.9% Inadequate control
≥9% Very poor control
5.6-6.4% Impaired glucose tolerance
Any value above 5.5% is to be closely monitored.

28. HbA1c TESTING
METHODS IN
LABORATORIES:
i. Antibody based
LATEX ENHANCED
IMMUNOASSAY.
ii. Ion exchange HPLC
(High Pressure
Liquid
Chromatography)
iii. Enzyme based
assay

29. ADVANTAGES OF HbA1c
ESTIMATION
Fasting sample is not required, can be done at any time
of the day.
Low intra-individual variability, <2%
HbA1c sample is stable, whereas blood glucose level is
lowered unless precautions are taken.
It reflects long term glucose control.
Better index for predicting complications

30.  High in thalassemia
patients, PCOS
 Low in sickle cell
anaemia, hemolysed
sample, hereditary
HbF. PREVIOUSLY, EVERY
3 MONTHS
NOWADAYS, ONCE
IN EVERY 2 MONTHS
PRECAUTIONS
HOW OFTEN
DONE?

31. URINE ANALYSIS
A.DETECTION OF URINARY GLUCOSE
(GLUCOSURIA):
 First-line screening test for diabetes mellitus
 Normally glucose does not appear in urine until
the plasma glucose rises above 160-180mg/dl.
 In certain individuals due to low renal threshold
glucose may be present despite normal blood
sugar levels.
 Conversely renal threshold increases with age
so many diabetics may not have glycosuria
despite high blood glucose levels.

32. DETECTION OF GLUCOSURIA:
DIASTIX METHOD
BENEDICT’S
TEST

33. B. KETONURIA:
 Refers to the presence of ketones in the urine.
 In individuals with DM, ketonuria may be a sign
of diabetic ketoacidosis(DKA).
 Detection can be done by using urine test strips
or through laboratory analysis of a urine sample.
 Qualitative analysis can be accomplished by
nitroprusside tests ( Acetest or Ketostix),
Rothera’s test etc.
 Ketone bodies may be present in a normal
subject as a result of simple prolonged fasting.

34. C.MICROALBUMINURIA:
 Refers to small amounts of protein, mainly albumin in the
urine.
 Commonly associated with diabetes, particularly in individuals
with poorly controlled blood sugar levels.
 Early marker of diabetic nephropathy
 Also seen in hypertension, chronic kidney disease, heart failure
and certain autoimmune disease.

35. FRUCTOSAMINE ASSAY:
 Serum fructosamine is formed by
nonenzymatic glycosylation of serum proteins,
predominantly albumin.
 Fructosamine levels indicate the average level
of blood glucose control over the past 2-3
weeks.
 Specimen type: Serum
 Collection method: Venipuncture
 Minimum specimen volume: 0.5 mL

36.  Specimen container: Serum separator tube;
also acceptable is pink (K2 EDTA) or green
(lithium heparin)
 Unacceptable conditions: Hemolyzed
specimens (may cause falsely elevated
results)
 Methodology: Colorimetry or quantitative
spectrophotometry
 Transport temperature: Room temperature

37. INSULIN ASSAY:
 It measures the amount of insulin in the
blood, both total and free.
 The Human insulin solid-phase sandwich
ELISA (enzyme-linked immunosorbent assay)
is designed to measure the amount of the
target bound between a matched antibody
pair.
 Also, chemiluminescence
immunoassay(CLIA), radioimmunoassay(RIA)
and on-chip immunoassay is used for it.

38. C-PEPTIDE ASSAY:
 It is a by-product of insulin production.
 Helps to determine if the body is producing
enough insulin.
 Low C-peptide values suggest type 1 diabetes
and high levels indicate type 2 diabetes mellitus.
 Healthy individual: 0.78-1.89ng/ml
Neither measurement of Insulin nor C-peptide is
used to establish diagnosis of Diabetes Mellitus,
its solely related blood glucose estimation.

39. LIPID PROFILE:
 Serum total cholesterol is high
 Serum triglycerides are high
 Serum HDL is low
 Serum LDL is high
 Determination of serum lipids serves
as an index for overall metabolic
control in diabetic patients.

40. MANAGEMENT
OF DIABETES
MELLITUS

41. DIET AND
LIFESTYLE:
 This is the first line of
treatment. A diabetic
patient is advised to take
a balanced diet with high
protein content, low
calories, devoid of refined
sugars and low saturated
fat, adequate PUFA, low
cholesterol and enough
fiber.
 Vegetables are the major
sources of minerals,
vitamins and fiber.
 Patients are advised to
avoid table sugar,
artificial sweeteners are a
choice

42. ORAL HYPOGLYCEMIC AGENTS:

43. INSULIN REPLACEMENT
THERAPY:
 Insulin is the drug of choice in type 1 disease.
 Type 2 disease, where oral drugs are not sufficient.
 Gestational diabetes
 Individuals with type 2 diabetes, during physiological
stress such as surgery, infection or acute illness
 Progressive complications: Nephropathy, Retinopathy,
Maculopathy
 Diabetic ketoacidosis, hyperosmolar hyperglycemic non
ketotic coma
 Chronic renal failure, secondary diabetes(pancreatitis)