2. OUTLINE
Definition
Prevalence
The pancreas
Types of Diabetes
Symptoms of diabetes mellitus
Diagnostic criteria for DM
Risk factors
Complications of diabetes
Management of diabetes
Physical activity in diabetes
Case study
3. Definition
Diabetes (DYE-ah-BEE-teez) mellitus: a group of
metabolic disorders characterized by hyperglycemia and
disordered insulin metabolism.
It is defined as Fasting Blood Sugar ≥ 126mg/dL or Random
Blood Sugar ≥200mg/dL
Diabetes = siphon (in Greek), referring to the excessive
passage of urine that is characteristic of untreated diabetes
Mellitus = sweet, honey-like
Insulin
4. PREVALENCE of diabetes
One of four priority non-communicable diseases (NCDs) targeted
by world leaders. Globally:
DM caused 1.5million death in 2012
43% of these deaths occur under the age of 70
The prevalence of DM among adults has risen from 108 million
(4.7%) in 1980 to 422 million (8.5%) in 2014 (WHO, 2016)
DM will be the 7th leading cause of death in 2030 (Mathers and
Loncars, 2006)
6. FUNCTIONS OF THE PANCREAS
Exocrine Functions
contains exocrine glands that produce enzymes important to
digestion.
trypsin and chymotrypsin
Amylase
lipase
Endocrine functions
consists of islet cells (islets of Langerhans) that create and
release important hormones directly into the bloodstream
Insulin
Glucagon
Other hormones; amylin, somatostatin, & pancreatic polypeptide
7. TYPES OF DIABETES MELLITUS
Type 1 Diabetes :
Type 2 Diabetes
Gestational Diabetes (GDM)
Impaired Glucose Tolerance (IGT) and Impaired Fasting
Glyceamia (IFG)
Other types (drug-induced, pancreatitis)
8. Feature Type 1 Type 2
Prevalence in diabetic
population
5% to 10% of cases 90% to 95% of cases
Age of onset <30 years >45 years (increasing in
children and adolescents)
Associated conditions Autoimmune diseases, viral
infection, inherited
factors
Obesity, aging, inherited
factors
Major defect Destruction of pancreatic
beta cells;
insulin deficiency
Insulin resistance; insulin
deficiency (relative to
needs)
Insulin secretion Little or none Varies; may be normal,
increased, or decreased
Requirement for insulin
therapy
Always Sometimes
Other names Juvenile-onset diabetes
Insulin-dependent diabetes
mellitus (IDDM)
Ketosis-prone diabetes
Adult-onset diabetes
Noninsulin-dependent
diabetes mellitus
(NIDDM)
Ketosis-resistant diabetes
Features of Type 1 and Type 2 Diabetes
12. testing FOR blood sugar levels
•Wash your hands or clean your finger or
other site with alcohol. If you are using
alcohol, let it dry before you prick your finger.
•Prick the site with a lancing device.
•Put a little drop of blood on a test strip.
•Follow the instructions for inserting the test
strip and using the blood glucose meter.
•The blood glucose meter reads your blood
sugar level.
•Blood Glucose Meter
17. DIABETIC FOOT
Grade 0 – No ulcer in the high risk foot
Grade 1 – Superficial ulcer involving the full
skin thickness but not underlying tissues
Grade 2 – Deep ulcer, penetrating down the
ligaments and muscle, but no bone involvement
or abscess formation
Grade 3 – deep ulcer with cellulitis or abscess
formation, often with osteomyelitis
Grade 4 – Localized gangrene
Grade 5 – extensive gangrene involving the
whole foot
18. Management of diabetes
Diabetes management – Lifelong treatment which involves:
Proper timing of medications
Dietary Management
Physical exercise
19. Class Generic name (brand name) Mechanism of
action
Time taken
Sulfonylureas Gliclazide (Diamicron)
Glimepiride (Amaryl)
Glyburide (Diabeta)
Stimulate the
pancreas to
produce more
insulin
Before meals
(≤30 minutes)
Meglitinides Nateglinide (Starlix)
Repaglinide (GlucoNorm)
Stimulate the
pancreas to
produce more
insulin
Before meals
(≤15 minutes)
Biguanides 1. Metformine (Glucophage)
2. Metformine with extended
release (Glumetza)
Reduce the
production of
glucose by the liver
1. During
meals
2. At Dinner
MEDICATIONS – Oral Hypoglycemic Agents
20. Class Generic name
(brand name)
Mechanism of action Time taken
Thiazolinidediones 1. Pioglitazone
(Actos)
2. Rosiglitazone
(Avandia)
Increase insulin
sensitivity of the body
cells and reduce
gluconeogenesis in
the liver
With or
without food,
at the same
each day
Alpha-glucosidase
inhibitors
Acarbose
(Glucobay)
Slow the absorption
of carbohydrates
(sugar) ingested
With the first
mouthful of
meal
MEDICATIONS – Oral Hypoglycemic Agents
21. Diet-drug interactions
Gastro-
intestinal
Effect
Interactions with Dietary
substances
Metabolic
Effects
Sulfonylureas Nausea,
vomiting,
cramps,
diarrhoea
Avoid using with alcohol due to a
toxic reaction that causes flushing,
throbbing head and neck pain,
shortness of breath, palpitations,
and sweating.
Avoid using with dietary supplements
that contain ginseng, garlic,
fenugreek, coriander, celery, as they
may increase risk of Hypoglycemia
Hypoglycemia,
weight gain,
allergic skin
reactions
Biguanides
(metformin)
Abdominal
pain, nausea,
vomiting,
diarrhoea,
metallic taste,
anorexia
—
Asymptomatic
vitamin B12
deficiency.
22. Gastro-intestinal
Effect
Interact
ions
with
Dietary
substan
ces
Metabolic Effects
Thiazolidinediones — — Weight gain, fluid retention,
edema, Increased of
bladder cancer
(Pioglitazone ), increased
risk of non-fatal heart
attack (Rosiglitazone)
Alpha-glucosidase inhibitors Abdominal pain,
nausea, Bloating
and flatulence,
cramps, diarrhea.
— Elevated liver enzymes,
hyperbilirubinemia
Diet-drug interactions (2)
23. Rapid-acting: For meals eaten at same time with the injection
Short-acting: For meals eaten within 30-60 mins
Intermediate acting: Covers insulin needs for about half the
day or overnight
Long –acting: Covers insulin needs for about one full day. This
type is often combined, when needed, with rapid- or short-acting
insulin
Premix: Combine specific amounts of intermediate-acting and
short-acting insulin in one bottle or insulin pen. (The numbers
following the brand name indicate the percentage of each type of
insulin)
MEDICATIONS – INSULIN
24. Onset: The length of time before insulin reaches the bloodstream and begins to
lower blood sugar.
Peak: The time period when it best lowers blood sugar
Duration: How long insulin continues to work.
SAMPLES OF INSULIN
Types & Brand
names
Onset Peak Duration
Lispro, Aspart,
Glulisine (R)
15-30mins 30-90mins 3-5hours
Regular, Novolin
(S)
30 min. -1 hour 2-5 hours 5-8 hours
NPH (N) (I) 1-2 hours 4-12 hours 18-24 hours
Detemir,
glargine (L)
1-1 1/2 hours No peak time.
Insulin is delivered
at a steady level.
20-24hours
Humulin 70/30 (P) 30 min. 2-4 hours 14-24 hours
26. Medical nutrition therapy : goals
Maintenance of as near normal BG levels as possible, by balancing food,
medication, and physical activity
Provision of adequate calories for maintaining or attaining reasonable
weight, growth/development in children and adolescent.
Prevention and treatment of the acute or chronic complications of
diabetes Mellitus
Achievement of optimal serum lipid levels
Improvement of overall health through optimal nutrition using the
Dietary Guidelines
29. INSULIN DISTRIBUTION
Total daily insulin dose
Basal Insulin replacement Bolus Insulin replacement
(40% - 50%)
(50% - 60%)
•1 unit of insulin 10 – 15grams of carbohydrate
•1 unit of insulin 50mg/dl of blood glucose
•1/10th unit of insulin 15grams of carbohydrate (in children)
N.B.: Depending on activity level, I unit of insulin 4-30g of
carbohydrate
30. Total daily INSULIN requirement (tdir)
Total daily insulin requirement can be calculated using the formula
below :
TDIR = Weight in pounds ÷ 4 OR Weight in Kg × 0.55
For a reference man of 70kg OR 160pounds;
160 = 40 units OR 70 × 0.55 = 38.5 units
4
For 40 units;
Basal insulin = 40 × 40 = 16 units
100
Bolus insulin = 40 – 16 = 24units
Breakfast, Lunch, Dinner = 24units = 8 units per meal
3
31. For 300g of carbohydrate, the amount of insulin required:
1 unit of Insulin 15g of CHO
X 300g of CHO
X = 300 = 20 units of insulin
15
insulin calculation
32. High blood sugar correction
•To calculate insulin need for HBS correction:
Insulin need = Actual blood sugar level – Target blood sugar level
For example:
If a patient’s blood sugar is 220mg/dl and the target blood sugar is
120mg/dl
Insulin need for correction = 220 – 120 = 100mg/dl
Since 1 unit of insulin 50mg/dl blood sugar
Therefore; 100mg/dl ÷ 50mg/dl = 2units of insulin
35. Physical activity in type 1 dm
Adjust food intake and insulin therapy to prevent hypoglycemia during
physical activity
Checked blood glucose levels both before and after an activity
Insulin doses that precede exercise often need to be reduced
substantially
FBS below 100mg/dL before an activity; consume carbohydrate
FBS levels are 250 mg/dL or higher; No strenuous exercise
FBS levels are 300mg/dL or higher or ketosis is present; No physical
activity
36. Physical activity in type 2 dm
Regular physical activity can improve the metabolic outcomes associated with type
2 diabetes:
Before an exercise program is planned, a medical evaluation should be done
Types of activity recommended should depend on complications present.
Only mild or moderate exercise may be prescribed at first
Persons with retinopathy should avoid heavy lifting or straining
Discourage strenuous exercise in persons with nephropathy
In persons with peripheral neuropathy, be cautious repetitive weight-bearing
exercises.
proper hydration should be encouraged before and during exercise
37. CASE STUDY
Bio-Data
Name: K.X.
Address: 4, Ayo Fanimokun Street, Agege, Lagos
Sex: Male
Age: 64years
Social Hx:
A retiree, married with children, who relocated from the north to
Lagos.
Family Hx:
Positive of diabetes (parents)
Past Medical Hx:
Patient has been diagnosed of DM about 5 years ago. Surgery0,
Hypertension0, Asthma0
38. CASE STUDY
Drug Hx:
Nil
Clinical assessment
A middle-age man, conscious, not underweight, not pale, not
dehydrated, with bilateral pedal oedema
Biochemical assessment
K+: 3.3mmol/L (3.5-5.1) FBS: 145 mg/dL
Na+: 132mmol/L (136-145) HbA1c: 8.9%
Cl-: 93mmol/L (98-107) Creatinine: 96 (57-113umol/L)
Urea: 11.5mmol/L (1.9-9.1)
Medical Diagnosis
A case of biventricular failure 20 to dilated cardio-myopathy and
electrolyte imbalance
39. CASE STUDY
Medical treatment
•Sc clexane 40mg daily
•Tab slow K 600mg t.d.s.
•Tab betaloc-201 25mg daily
•IV torsemide 20mg daily
Diet Hx:
Meal skipping
Meal Frequency/day: Twice (Breakfast and Lunch)
Food dislikes: Rice, yam, eba
Food preferences: beans, vegetables, tea, lime, organ meats
(Food likes and dislikes are based on dietary misconceptions)
No alcohol, no tobacco, drinks herbs occasionally
Nutrition Diagnosis
Hyperglycemic crisis as a result of poor management control as
evidenced by blood glucose profile
40. CASE STUDY
PLAN:
•Place on 1800kcal diet/day
•Commence 0.8g of protein/KgIBW/day
•Give dietary allowance for in-between meals (fruits and vegetables)
•Counsel patient on foods allowed, those to avoid and importance of
proper portioning to suit drug regimen
•Provide substitutes for foods to avoid
•Correct patient’s dietary misconception about DM
•Encourage patient to discontinue meal skipping
•Educate patient about dietary prescription and the need for adherence
•Request for serum albumin, protein and lipid profile for further dietary
management
41. Prognosis:
•Compliance to dietary advice by patient
•FBS Range: 85 – 115mg/dL
•RBS Range: 145-190mg/dL
•Leg sore healed after a week
42. Selected REFERENCES
Columbia University Medical Center. (2017). The Pancreas and Its Functions
http://columbiasurgery.org/pancreas/pancreas-and-its-functions (retrieved
13/03/17)
Diabetes Quebec (2015). Antidiabetic Drugs. www.diabete.qc.ca
Mahan, L. K. and Escott-Stump, S. (2008). Krause’s Food and Nutrition
Therapy. Elsevier; Philadephia
Mathers, C.D., and Loncar, D. (2006) Projections of global mortality and
burden of disease from 2002 to 2030. PLoS Med, 3(11):e442
National Institute of Diabetes and Digestive and Kidney Diseases (2016)
Diabetes https://www.niddk.nih.gov/health-
information/diabetes/overview/symptoms-causes (Retrieved 14/02/2017)
Roth, R. A. (2011). Nutrition and Diet therapy. 10th ed. Indiana/Purdue
university; Fort Wayne
