Diabetes Mellitus was defined as a metabolic disease caused by the body's inability to produce insulin or enough insulin, leading to elevated blood glucose levels. Symptoms of diabetes were discussed. Prediabetes was associated with increased cardiovascular risk, so screening and treatment of modifiable risk factors is suggested. Lifestyle interventions and metformin were shown to reduce progression to diabetes in those with prediabetes. The document provided recommendations on physical activity, smoking cessation, metabolic surgery, cardiovascular disease screening and treatment, and management of hypoglycemia and diabetic ketoacidosis.

1. Diabetes Mellitus
Dr Ihab suliman
10/9/2022

2. Definition:
• “A metabolic disease in which the body’s
inability to produce any or enough insulin
causes elevated levels of glucose in the
blood.”

3. Symptoms of
Diabetes:

4. U.S. Prevalence:

5. Diabetes and Obesity:

6. Cost of Diabetes (US):

7. Global prevalence:
http://www.idf.org/atlasmap/atlasmap

8. Prediabetes:

9. Prediabetes:
• Diabetes prevention program
– Lifestyle intervention group vs medicated group with
Metformin vs placebo group
– 3,243 participants were overweight and had
prediabetes
– Lifestyle intervention reduced diabetes by 58%
– Metformin reduced diabetes by 31%
• Effective in both sexes ages 25-44 yoa and BMI of 30 +
Summary: Type 2 diabetes can be prevented/delayed with
activity and diet.

18. Prevention of Vascular Disease and Mortality
PREVENTION OR DELAY OF TYPE 2 DIABETES
3.8 Prediabetes is associated with heightened cardiovascular risk;
therefore, screening for and treatment of modifiable risk
factors for cardiovascular disease are suggested. B

20. Physical Activity
FACILITATING BEHAVIOR CHANGE AND WELL-BEING TO IMPROVE HEALTH OUTCOMES
5.27 Children and adolescents with type 1 or type 2 diabetes or
prediabetes should engage in 60min/day or more of moderate- or
vigorous-intensity aerobic activity, with vigorous muscle-
strengthening and bone- strengthening activities at least 3 days/week. C
5.28 Most adults with type 1 C and type 2 B diabetes should engage in
150 min or more of moderate to vigorous-intensity aerobic activity per week,
spread over at least 3 days/week, with no more than 2 consecutive
days without activity. Shorter durations (minimum 75min/week) of vigorous
intensity or interval training may be sufficient for younger and more
physically fit individuals.

21. Smoking Cessation: Tobacco & E-cigarettes
FACILITATING BEHAVIOR CHANGE AND WELL-BEING TO IMPROVE HEALTH OUTCOMES
5.33 Advise all patients not to use cigarettes and other tobacco products
or e- cigarettes. A
5.34 After identification of tobacco or e-cigarette use, include smoking
cessation counseling and other forms of treatment as a routine
component of diabetes care. A
5.35 Address smoking cessation as part of diabetes education programs
for those in need. B

22. Metabolic Surgery
OBESITY MANAGEMENT FOR THE TREATMENT OF TYPE 2 DIABETES
8.17 Metabolic surgery should be a recommended option to treat type 2
diabetes in screened surgical candidates with BMI $40 kg/m2 (BMI
$37.5 kg/m2 in Asian Americans) and in adults with BMI 35.0–39.9 kg/m2
(32.5– 37.4 kg/m2 in Asian Americans) who do not achieve durable weight
loss and improvement in comorbidities (including hyperglycemia) with
nonsurgical methods.. A
8.18 Metabolic surgery may be considered as an option to treat type 2
diabetes in adults with BMI 30.0–34.9 kg/m2 (27.5–32.4 kg/m2 in
Asian Americans) who do not achieve durable weight loss and
improvement in comorbidities (including hyperglycemia) with
nonsurgical methods. A

23. CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
Recommendations
for the Treatment of
Confirmed
Hypertension in
People with
Diabetes (2 of 2)
Cardiovascular Disease and Risk Management:
Standards of Medical Care in Diabetes - 2022. Diabetes Care 2022;45(Suppl. 1):S144-S174

24. Statin Treatment—Primary Prevention
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.19 For patients with diabetes aged 40–75 years without atherosclerotic
cardiovascular disease, use moderate-intensity statin therapy in
addition to lifestyle therapy. A
10.20 For patients with diabetes aged 20–39 years with additional
atherosclerotic cardiovascular disease risk factors, it maybe reasonable to
initiate statin therapy in addition to lifestyle therapy. C
10.21 In patients with diabetes at higher risk, especially those with multiple
atherosclerotic cardiovascular disease risk factors or aged 50–70
years, it is reasonable to use high-intensity statin therapy. B
10.22 In adults with diabetes and 10-year ASCVD risk of 20% or higher, it
may be reasonable to add ezetimibe to maximally tolerated statin therapy to
reduce LDL cholesterol levels by 50% or more. C

25. Cardiovascular Disease—Screening
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.40 In asymptomatic patients, routine screening for coronary artery
disease is not recommended as it does not improve outcomes as long
as atherosclerotic cardiovascular disease risk factors are treated. A
10.41 Consider investigations for coronary artery disease in the presence
of any of the following: atypical cardiac symptoms (e.g., unexplained
dyspnea, chest discomfort); signs or symptoms of associated vascular
disease including carotid bruits, transient ischemic attack, stroke,
claudication, or peripheral arterial disease; or electrocardiogram
abnormalities (e.g., Q waves).E

26. Cardiovascular Disease—Treatment
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.42 Among patients with type 2 diabetes who have established
atherosclerotic cardiovascular disease or established kidney disease, a
sodium–glucose cotransporter 2 inhibitor or glucagon- like peptide 1 receptor
agonist with demonstrated cardiovascular disease benefit (Table 10.3B
and Table 10.3C) is recommended as part of the comprehensive
cardiovascular risk reduction and/or glucose-lowering regimens. A
10.42a In patients with type 2 diabetes and established atherosclerotic
cardiovascular disease, multiple atherosclerotic cardiovascular
disease risk factors, or diabetic kidney disease, a sodium– glucose
cotransporter 2 inhibitor with demonstrated cardiovascular benefit is
recommended to reduce the risk of major adverse cardiovascular events
and/or heart failure hospitalization. A

27. Cardiovascular Disease—Treatment (continued)
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.42b In patients with type 2 diabetes and established atherosclerotic
cardiovascular disease or multiple risk factors for atherosclerotic
cardiovascular disease, a glucagon-like peptide 1 receptor agonist
with demonstrated cardiovascular benefit is recommended to reduce the
risk of major adverse cardiovascular events. A
10.42c In patients with type 2 diabetes and established atherosclerotic
cardiovascular disease or multiple risk factors for atherosclerotic
cardiovascular disease, combined therapy with a sodium–glucose
cotransporter 2 inhibitor with demonstrated cardiovascular benefit
and a glucagon-like peptide 1 receptor agonist with demonstrated
cardiovascular benefit may be considered for additive reduction in the risk
of adverse cardiovascular and kidney events. A

28. Cardiovascular Disease—Treatment (continued)
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.43 In patients with type 2 diabetes and established heart failure with
reduced ejection fraction, a sodium–glucose cotransporter 2 inhibitor with
proven benefit in this patient population is recommended to reduce risk of
worsening heart failure and cardiovascular death. A
10.44 In patients with known atherosclerotic cardiovascular disease,
particularly coronary artery disease, ACE inhibitor or angiotensin
receptor blocker therapy is recommended to reduce the risk of
cardiovascular events. A

29. Cardiovascular Disease—Treatment (continued)
CARDIOVASCULAR DISEASE AND RISK MANAGEMENT
10.45 In patients with prior myocardial infarction, b-blockers should be
continued for 3 years after the event. B
10.46 Treatment of patients with heart failure with reduced ejection fraction
should include a b-blocker with proven cardiovascular outcomes
benefit, unless otherwise contraindicated. A
10.47 In patients with type 2 diabetes with stable heart failure, metformin
may be continued for glucose lowering if estimated glomerular filtration
rate remains >30 mL/min/1.73 m2 but should be avoided in unstable or
hospitalized patients with heart failure. B

50. Prevalence of cardiovascular disease
in younger people with type 1 diabetes

51. Prevalence of cardiovascular disease in middle-
aged people with diabetes

52. Cardiovascular disease mortality in
middle-aged people with diabetes

53. Case
• 77 lady with DM type 2
• IHD, CABG+ MV Repair
• Foot ulcer plus pain Right Foot

56. Describtion
• Arterial Ulcer
• Absent Pulses
• Cold Limbs
• PVD

58. CT Run OFF

59. • PCI to the right Femoral artery was done .
• Diabetic Ulcer started to heal

61. • 1.Which is not a potential etiology of
hypoglycemia in adults?
• a) alcohol
• b) salbutamol
• c) insulinoma
• d) salicylates
• e) adrenal insufficiency

62. • b) salbutamol

63. • 2.Which is the major precipitant of DKA ?
• a) infection
• b) missed doses of insulin
• c) AMI
• d) Pancreatitis
• e) PE

64. • a) infection

65. • 3.Which is not usually a feature of DKA?
• a) seen type 1 diabetics mainly
• b) serum osmalality 275-295mmol/l
• c) fluid deficit usually less than that in HHNS
d) glucose usually lower than that in HHNS
• e) acidosis

66. • b) serum osmalality 275-295mmol/l

67. 4.Which is not true regarding the
management of DKA?
• a) the administration of IV fluid immediately on
arrival is the life saving event
• b) fluid replacement should be 3-4 litres over the
first four hours in a pt who is not shocked.
• c) even if the K+ is >5.5 potassium replacement
should be commenced
• d) the insulin bolus should be about 0.1 units/kg,
with subsequent infusion at 0.1units/kg/hr
• e) cerebral edema responds to mannitol

68. • c) even if the K+ is >5.5 potassium
replacement should be commenced

69. • 5.Which is not a feature of Hyperosmolar,
hyperglycemic non ketotic states?
• a) very high glucose, often greater than 40
mmol/l
• b) PH>7.3
• c) serum osmolality often greater than 350
mmol/L
• d) low bicarbonate
• e) lack of ketones in the urine

70. • d) low bicarbonate

71. • 6.Which statement is false about the fluid deficit in
HHNS?
• a) it is usually 5L
• b) if not shocked then 0.45% saline should be given
• c) fluid replacement should always precede insulin
therapy in the non shocked pt
• d) fluid replacement should be done over a longer
period of time than in DKA
• e) normal saline should be given to the shocked
patient

72. • a) it is usually 5L

73. • 7.Which is not true about non ketotic
hyperosmolar states?
• a) these patients usually present with a GCS >8
• b) total body potassium is not reduced as in DKA
as there is no acidosis
• c) focal neurological deficits are sometimes seen
d) they are prone to arterial and vascular
thrombosis
• e) insulin administration should be at the same
rate as in DKA

74. • b) total body potassium is not reduced as in
DKA as there is no acidosis

75. • 8.Which is not true regarding drug therapy in diabetes?
• a) the use of ACEI even in normotensive patients,
delays the onset of diabetic nephropathy
• b) the use of STATINs in pts with CHD significantly
reduces the risk of future CHD
• c) Sulphonylureas stimulate the pancreatic secretion of
insulin
• d) Acorbase(Glucobay) interferes with GIT absorption
of carbohydrate
• e) Metformin is an oral insulin analogue

76. • e) Metformin is an oral insulin analogue

77. • 9.The nitroprusside dipstick test of the urine
measures?
• a) acetoacetate
• b) beta hydroxybuterate
• c) acetone
• d) A and C
• e) All of the above

78. • d) A and C

79. • 10.Which is not a feature of alcoholic
ketoacidosis?
• a) Dehydration
• b) Positive dipstick for ketones
• c) ABG = acidosis, alkalsos or normal
• d) Increased anion gap, regardless of pH
• e) hyperglycemia

80. • e) hyperglycemia

81. • 11.Which is false regarding alcoholic ketoacidosis?
• a) it is usually seen in chronic alcoholics
• b) usually there has been a recent cessation in drinking
with several days of vomiting and poor oral intake
• c) Thiamine should be given
• d) Mainstay of treatment is IV fluids, including dextrose
• e) Low dose insulin given judiciously hastens recovery

82. • e) Low dose insulin given judiciously hastens
recovery