Diabetes mellitus

1. TYPE 2
DIABETES MELLITUS
PRESENTED BY-SIMARPREET KAUR
L-2018-Hsc-53-BND

2. INTRODUCTION
 Diabetes mellitus (DM) is a group of metabolic disorders
that prevents the body to utilize glucose completely or
partially.
 It is characterized by a raised glucose concentration in
the blood and alterations in carbohydrate, protein and fat
metabolism.
 Type 2 diabetes begins with insulin resistance, a
condition in which cells fail to respond to insulin
properly. As the disease progresses, a lack of insulin may
also develop.

3. PATHOPHYSIOLOGY
 When we eat food, carbohydrates in the food are
broken down into sugar (glucose). Glucose travels in
our bloodstream all over the cells.
 When blood sugar levels rise beyond a certain point,
the body signals pancreas to release insulin.
 Insulin is a hormone produced by β-cells of pancreas.
It is necessary for driving glucose into the cells.
 Cell membranes have little locks (receptors). Insulin
fits into those locks like a key.
 Binding of insulin to its receptor triggers a signaling
cascade that brings glucose transporters to the cell
membrane.
 Glucose enters the cell through the transporters. It is
then consumed as energy source or stored for later
use.

4. PATHOPHYSIOLOGY
 In T2DM, pancreas produces enough insulin but something
goes wrong either with receptor binding (structure of
receptor changes) or signaling cascade in the target cells.
 As a result, the blood sugar get locked out of cells and
stays in the bloodstream.
 When glucose concentration in the blood remains high
over time, the kidneys reach a threshold of reabsorption,
and the body excretes glucose in
the urine (glycosuria).This increases the osmotic
pressure of the urine and inhibits reabsorption of water
by the kidney, resulting in increased urine production
(polyuria) and increased fluid loss,
causing dehydration and increased thirst (polydipsia). In
addition, intracellular glucose deficiency stimulates
appetite leading to excessive food intake (polyphagia).

5. ETIOLOGY
 GENETICS- Familial tendency to T2DM
 LIFESTYLE- T2DM is associated with people who
are obese, underactive and overeat.
 STRESS- Stress leads to release of hormones
such as adrenaline and cortisol.
Adrenaline increases the breakdown of glycogen
and suppresses insulin secretion.
Cortisol leads to an increased protein breakdown
and inhibit sugar utilization by the tissues thus
increasing blood sugar levels.
 ABDOMINAL FAT-People with a high waist-hip
ratio indicating abdominal obesity (android type)
have greater risk of T2DM.
TYPE 2
DIABETES
GENETICS
OBESITY
SEDENTARY
LIFESTYLE
STRESS

6. SYMPTOMS
SYMPTOM EXPLANATION
POLYUREA Excessive urinary output, especially at
night
POLYDIPSEA Excessive thirst due to loss of water
from the body
POLYPHAGIA Increased appetite, urge for sweet
items of food due to heavy loss of sugar
in urine
PRURITIS VULVAE Irritation in the genitalia caused by
local deposition of sugar from urine
PARAESTHESIA Tingling sensation in the hands and feet
BLURRING OF VISION Excess sugar deposits on the eye lens
causing refraction changes

7. COMPLICATIONS- ACUTE
 Blood glucose concentration <70 mg/dl
 Symptoms- Sweating, trembling, hunger,
confusion, drowsiness, incoordination and
nausea
 Causes- Unpunctual or inadequate meals,
unexpected or unusual exercise and ingestion of
alcohol, excessive dose of insulin
HYPOGLYCAEMIA

8. COMPLICATIONS- ACUTE
 Blood glucose level higher than 200 mg/dl
 Symptoms- Polyphagia, polydipsia, polyuria,
fatigue, restlessness
 Causes- Inadequate insulin, insulin resistance
HYPERGLYCAEMIA

9. COMPLICATIONS- ACUTE
 When there is not enough insulin and the body cannot utilize
carbohydrates to provide energy, it breaks down increased amounts of fats
for energy through β-oxidation.
 Metabolic products- ketones are formed
 (Increased production of ketones is known as ketosis)
 These excess ketones accumulate in the blood (ketonemia)
 Ketones have a low pKa and therefore turn the blood acidic
 Ketones are also excreted in the urine (ketonuria)
 Ketoacidosis includes all the disorders associated with increased fat
breakdown.
KETOACIDOSIS

10. KETOACIDOSIS

11. COMPLICATIONS- CHRONIC
 Diabetes affect the blood vessels, the blood and the heart.
 Most patients with T2DM tend to be obese and hypertensive and therefore likely to
have clinical atherosclerosis.
 Diabetics generally have high levels of blood lipids (cholesterol, triglycerides, LDL)
and reduced HDL levels which make them susceptible to atherosclerosis and
stroke.
 Diabetics have increased platelet adhesiveness and response to aggregating agents,
likely to favour atherogenesis.
ATHEROSCLEROSIS

12. COMPLICATIONS- CHRONIC
 Diabetic nephropathy, is the chronic loss of kidney function occurring in
those with diabetes mellitus.
 Pathophysiologic abnormalities begin with long-standing poorly controlled
blood glucose levels. This is followed by multiple changes in the filtration
units of the kidneys, the nephrons.
 Initially, there is constriction of the efferent arterioles and dilation
of afferent arterioles, resulting in glomerular capillary hypertension and
hyperfiltration; this gradually changes to hypofiltration over time.
 Also, there are changes within the glomerulus itself such as thickening of
the basement membrane that can can progressively expand and consume the
entire glomerulus, shutting off filtration.
 These changes lead to defects in filtration increasing the proteins in urine
(Proteinuria) and causing uraemia and finally renal failure.
DIABETIC NEPHROPATHY

13. COMPLICATIONS- CHRONIC
 Diabetic neuropathy refers to various types of nerve damage associated with diabetes
mellitus. Symptoms can include motor changes such as weakness, sensory symptoms such as
numbness, tingling, or pain, or autonomic changes such as urinary symptoms.
DIABETIC NEUROPATHY
DIABETIC RETINOPATHY
 Diabetic retinopathy refers to growth of friable and poor-
quality new blood vessels in the retina as well as macular
edema (swelling), which can lead to severe vision loss or
blindness.

14. DIAGNOSIS
Timely and proper diagnosis plays a key role in
identifying and managing diabetes without
complications.
 Fasting plasma glucose level- For this test, blood is
taken after a period of fasting, i.e. in the morning
before breakfast, after the patient had sufficient time
to fast overnight.
 Oral Glucose Tolerance Test (OGTT)-
It is a confirmatory test. Steps include-
1. Fasting blood sample is drawn.
2. 75 g glucose dissolved in 250-300 ml of water is given.
3. Blood and urine specimens are collected every 30
minutes for 2 hours after the administration of glucose.
PLASMA GLUCOSE
LEVELS (mg/dl)
FASTING 2 Hr POST
LOAD
NORMAL <110 <140
IMPAIRED FASTING
GLUCOSE
110-125 <140
IMPAIRED GLUCOSE
TOLERANCE
<126 ≥140 & <200
DIABETES ≥ 126 ≥ 200
REFERENCE-Criteria for the diagnosis of diabetes
& intermediate hyperglycaemia, WHO

15. DIAGNOSIS
 Urinary Sugar Test (Benedict’s Test)-
For this test, 8 drops of urine and 5 ml
of Benedict’s solution are taken in a
test tube and mixed. The test tube is
kept in boiling water for 5 minutes and
colour is noted.
COLOUR REPORT APPROXIMATE SUGAR
IN
URINE
g%
Blood
mg%
Green
discoloration
0-trace - <200
Green ppt + 0.25 200-250
Greenish-
yellow ppt
++ 0.5 250-300
Yellowish-
orange ppt
+++ 1.0 300-350
Brick red ppt ++++ >2.0 >350

16. DIAGNOSIS
 Glycosylated Haemoglobin (HbA1c)- As the
concentration of glucose in blood rises, more of
it gets attached to hemoglobin forming a
glycosylated hemoglobin. A buildup of HbA1c
within the RBCs reflects the average level of
glucose to which the cell has been exposed
during its lifecycle of 120 days and therefore
shows the general trend of glucose levels in the
blood during the previous 2-3 months.
HbA1c DIAGNOSIS
<5.7 % NORMAL
5.7-6.5 % PRE-DIABETES
>6.5 % DIABETES
REFERENCE-American diabetes association

17. MANAGEMENT- DIETARY RECOMMENDATIONS
 Medical Nutrition Therapy (MNT) for diabetes mellitus requires application of nutritional
and behavioral sciences along with physical activity. Based on factors like age, sex,
physical activity, height, weight, body mass index (BMI) and cultural factors, the diet is
planned.
 Dietary Recommendations:
 Energy: Sufficient to attain or maintain a reasonable body weight for adults, normal
growth and development for children and adolescents, to meet the increased needs
during pregnancy and lactation. Approximately, 25 kcal/kg ideal body weight/day can
be given to a moderately active patient with diabetes.
 Carbohydrates: 55-60 % of energy from carbohydrates is an ideal recommendation.
Carbohydrates should be complex in nature. It is recommended that carbohydrates from
high fibre foods e.g. whole grains, legumes, peas, beans, oats, barley and some fruits
with low glycemic index and glycemic load are recommended.

18. MANAGEMENT- DIETARY RECOMMENDATIONS
 Fibre: Fibre recommendation for general population is 40 g/day (2000 Kcals).
 Proteins: Proteins should provide 12-15 % of the total energy intake for
people with diabetes. Proteins from vegetable sources are recommended.
Supplementation of foods like cereal and pulse (4:1 ratio) can improve the
protein quality and also gives satiety.
 Fats: Fats should provide 20-30 % of total energy intake for people with
diabetes. Fat quality is as important as the quantity.
Saturated fatty acids (SFA) ≤10% energy and 7% in those with raised blood lipid
levels
Polyunsaturated fatty acids (PUFA) 10 % energy,
Monounsaturated Fatty Acids (MUFA) 10-15% energy
REFERENCE- ICMR Guidelines for management of Type 2 Diabetes, 2018

19. MEAL PLANNING STRATEGIES FOR
IMPROVED GLYCEMIC CONTROL
GLYCEMIC INDEX
GLYCEMIC LOAD
CARB COUNTING
DIABETES PLATE METHOD
FOOD ORDER

20. GLYCAEMIC INDEX
 The glycaemic index (GI) of a food is the blood
glucose response after consuming a CHO containing
food relative to a CHO containing reference food viz,
glucose or white bread under standard conditions.
 The common classification of GI foods is as follows
HIGH 70 and above
MODERATE 56-69
LOW 55 and below
REFERENCE- NUTRIENT REQUIREMENTS FOR INDIANS-RDA, 2020

21. GLYCEMIC LOAD (GL)
 Glycemic load (GL) considers the GI and the total amount of
available CHO present in the food consumed.
 Glycemic load (GL)= (Glycemic index/100) * Available CHO
(Available CHO= TOTAL CHO- DIETARY FIBRE)
 Both the GI and GL of the food are important determinants
of the post-prandial plasma glucose response. A food with
very high GI but if consumed in lower amounts, will provide
only a small amount of CHO and hence will have a small GL
and vice versa. Therefore, portion size of the food consumed
is also important in eliciting the glycemic response.
HIGH 20 and above
MODERATE 10-19
LOW 10 and below
REFERENCE- NUTRIENT REQUIREMENTS FOR INDIANS-RDA, 2020

22. GI and GL of common foods
FOODS GI SERVING SIZE AVAILABLE CHO GL/SERVE
WHEAT CHAPATI 52 +/- 4 60 g 32 g 21
WHITE RICE, BOILED 73 +/- 4 150g 40 g 29
POTATO BOILED 78 +/- 4 150g 28 g 14
APPLE 36 +/- 1 120g 15 g 6
WATERMELON 76 +/- 4 120g 6 g 4
MANGO 51 +/- 5 120g 17 g 8
MILK, FULL FAT 39 +/- 3 250ml 12g 3
REFERENCE- NUTRIENT REQUIREMENTS FOR INDIANS-RDA, 2020

23. CARBOHYDRATE COUNTING
 Carbohydrate counting is a method of calculating grams of carbohydrate
consumed at meals and snacks.
 It is not a diet but a method that emphasizes glycemic control based on
the use of multiple doses of short acting insulin according to
carbohydrate intake in a meal.
 1 CHO Count/choice= 10-15 g carbohydrate
 A general guideline is to have
45-60 g of CHO serving at each meal
15-20 g of CHO serving at each snack
GRAM OF CARBS NO. OF CARB CHOICES
0-5 g DO NOT COUNT
6-10 g ½ CARB COUNT
11-20 g 1 CARB CHOICE
21-25 g 1 ½ CARB CHOICES
26-35 g 2 CARB CHOICES
REFERENCE- BAJAJ, 2021

24. CEREALS RAW WT
(g)
CHO
(g)
FIBER
(g)
NET CHO
(g)
CHO
COUNT
BARLEY 25 15 4 17 1
CHAPATI, WHOLE WHEAT 25 16 3 18 1
CORN FLAKES, KELLOGG’S 25 21 0 21 1 ½
OATS, QUAKER 25 17 3 19 1
QUINOA 25 13 4 15 1
RICE, BASMATI (INDIA GATE) 25 19 0 19 1
RICE, BASMATI (KOHINOOR) 25 19 1 20 1
REFERENCE- BAJAJ, 2021

25. BISCUITS QTY (g) CHO
(g)/100 g
FIBER
(g)/100g
NET CHO
(g)/100 g
CHO COUNT
50-50 100 71 0 71 4 ½
BOURBON 100 72 0 72 4 ½
BRITANNIA RUSK 100 79 0 79 5 ½
DARK FANTASY 100 64 0 64 4 ½
GOOD DAY CASHEW 100 63 0 63 4 ½
GOOD DAY CHOCOLATE 100 71 0 71 4 ½
GOOD DAY PISTA 100 65 0 65 4 ½
HIDE N SEEK 100 73 0 73 4 ½
JIMJAM 100 73 0 73 4 ½
LITTLE HEARTS 100 70 0 70 4 ½
MARIE GOLD 100 72 0 72 5 ½
MILK BIKIS 100 75 0 75 5
MILK BIKIS MILKY SANDWICH 100 68 0 68 4 ½
NICE TIME 100 76 0 76 5 ½
NUTRI CHOICE DIGESTIVE 100 68 0 68 4 ½
REFERENCE- BAJAJ, 2021

26. DIABETES PLATE METHOD
 The Diabetes Plate Method is the easiest way to create
healthy meals that can help manage blood sugar. Using
this method, you can create perfectly portioned meals
with a healthy balance of vegetables, protein, and
carbohydrates—without any counting, calculating,
weighing, or measuring.
 To start out, you need a plate that is about 9 inches
across.
1. Fill half your plate with nonstarchy vegetables.
 Nonstarchy vegetables are lower in carbohydrate, so
they do not raise blood sugar very much. They are also
high in vitamins, minerals, and fiber, making them an
important part of a healthy diet. Filling half your plate
with nonstarchy vegetables means you will get plenty of
servings of these superfoods.
 Examples include-Asparagus, broccoli, cauliflower,
brussels sprouts, cabbage, carrots, celery, cucumber, egg
plant, leafy greens, okra, bell peppers, zucchini,
tomatoes etc.
REFERENCE-American Diabetes Association

27. DIABETES PLATE METHOD
2. Fill one quarter of your plate with lean protein foods
 One should choose lean protein sources which are lower in
saturated fats.
Keep in mind that some plant-based protein foods (like
beans and legumes) are also high in carbohydrates.
 Examples of lean protein foods include- Chicken, turkey,
eggs, fish (salmon, tuna, cod), cheese and cottage cheese
 Plant-based sources of protein include- beans, lentils,
nuts and nut butters, tofu etc.
3. Fill one quarter of your plate with carbohydrate foods
 Foods that are higher in carbohydrate have the greatest
effect on blood sugar. Limiting your portion of
carbohydrate foods to one quarter of your plate can help
keep blood sugars from rising too high after meals.
 Examples of carbohydrate foods- whole grains, starchy
vegetables (peas, potato, sweetpotato, yam), beans (black
beans, kidney beans), dairy products etc.

28. DIABETES PLATE METHOD
4. Choose water or a low-calorie drink
 Water is the best choice because it contains no calories or carbohydrates and has no effect
on blood sugar.
 Other zero- or low-calorie drink options include: Unsweetened tea or coffee, Sparkling
water/club soda etc.

29. FOOD ORDER
 For controlling the post prandial blood glucose rise, it is
recommended to follow the food order-
 FIRST- Fibre in vegetable soup or raita
 SECOND- Protein (egg white/ lean chicken/ whole
gram/pulses)
 THIRD- Cereal (wheat/ oats/ millets)
Fibre and protein content in the meal keeps post prandial
blood sugar level rise to a minimum by delayed gastric
emptying and affect glycaemic response of the second
meal.

30. SUPPORTIVE THERAPY
 Fenugreek seeds- Contains saponins and glycosides.It may have
beneficial effect in pancreatic tissues and improve glucose &
carbohydrate absorption as well as decrease insulin resistance. It
delays gastric emptying, increases insulin receptors.It is scientifically
proven that consumption of 25 g fenugreek seeds per day reduces
blood sugar levels.
 Cinnamon-The active ingredient in cinnamon (related to procyanidin
type A polymers) may increase insulin sensitivity. It has potential
benefit of decreasing fasting glucose and lipid levels.
 Aloevera- Aloe gel has been used to treat diabetes and
hyperlipidemia. Its use may decrease fasting glucose and triglyceride
levels and concentration of glycosylated Hb.
 Discuss with you physician before starting any supportive therapy!

31. MANAGEMENT- DRUGS
 When diet, exercise or even weight reduction do not improve the
diabetic symptoms and blood sugar levels, the use of
hypoglycaemic drugs becomes necessary.
TYPES OF DRUG HOW THEY WORK EXAMPLES
SULPHONYLUREAS Stimulate pancreas to
release more insulin
Chloropropamide,
Glipizide, Glimepiride
BIGUANIDES Reduce amount of glucose
produced by liver
Improves insulin sensitivity
Metformin
ALPHA-GLUCOSIDASE
INHIBTORS
Slow body’s breakdown of
sugars and starchy foods
Acarbose (Precose),
Miglitol (Glyset)
THIAZOLIDINEDIONES Increase insulin sensitivity Piogltizone,
Rosiglitazone
MEGLITINIDES Stimulate pancreas to
release more insulin
Repaglinide (Prandin)

32. INSULIN
 People with T2DM make insulin, but their bodies don’t
respond well to it. Insulin cannot be taken as a pill
because it would be broken down during digestion like the
protein in food. It must be injected into the fat under skin
for it to get into your blood.
Characteristics of Insulin
 ONSET- Length of time before insulin reaches the
bloodstream and begins lowering blood sugar.
 PEAK TIME- Time during which insulin is at maximum
strength in terms of lowering blood sugar.
 DURATION- How long insulin continues to lower blood
glucose.

33. TYPES OF INSULIN
TYPE TIME OF ACTION TRADE NAME
ONSET PEAK DURATION
SHORT
ACTING
(REGULAR)
30-60 min 2-3 hr 8-10 hr NOVOLIN R
HUMULIN R
INTERMEDIATE
(NPH)
2-4 hr 4-10 hr 12-18 hr NOVOLIN N
HUMULIN N
LONG ACTING
(GLARGINE)
2-6 hr NO PEAK 20-24 hr LANTUS
BASAGLAR
PREMIXED
70/30
30-60 min 2-6 hr 12-18 hr NOVOLIN 70/30
HUMULIN 70/30

34. DAFNE
(Dose Adjustment For Normal Eating)
 Insulin dose needs to be adjusted according to individual’s physical activity.
 DAFNE is a way of managing DM and provides the skills necessary to estimate
carbohydrate in each meal and to inject the right dose of insulin.
 The patient has to maintain a set pattern for the quality and quantity of meals,
timing of meal and type of physical activity he does to control his blood
glucose level.
 Carbohydrates in each meal should be consistent in quantity as well as
quality for a set dose of insulin!

35. TAKE AWAY NOTE
Successful management of diabetes involves a holistic
approach with coordination between diet, lifestyle
and hypoglycaemic drugs/ insulin.

36. REFERENCES
 WWW.WHO.INT
 WWW.WIKIPEDIA.COM
 American diabetes association
 Diet and diabetes by T.C Raghuram, S Pasricha, R.D Sharma, NIN
 Dietetics by B Srilakshmi
 Diet metrics:Handbook of food exchanges by Meenakshi Bajaj, 2021
 ICMR Guidelines for management of type 2 diabetes, 2018
 Nutrient requirements for indians-RDA 2020
 Tips for diabetes patients by Dr.Bimal Chhajer

37. THANK YOU!