Diabetes Mellitus

Introduction

Epidemiology
Classification
Pathophysiology
Diagnosis
Emergencies
Gestational diabetes
Diabetes is a chronic non communicable disease
characterized by hyperglycemia resulting from defects in
insulin secretion, insulin action, or both.

Insulin is an anabolic hormone needed for metabolism of fat,

protein and carbohydrate
Insulin Effects Inhibits
♦ Fat mobilization for
Enhances energy (lipolysis and
ketogenesis)
♦ Fat storage
(lipogenesis) ♦ Glucose release from
the liver and muscle
♦ Liver and muscle storage (glycogenolysis)
of glucose as glycogen
(glycogenesis) ♦ Glucose formation from
amino acids
(gluconeogenesis)
Epidemiology

100 million people worldwide

85-90% - Type 2

17 million people in US (6.2% of population)

5 to 10% - Type 1diabetes

5.9 million people are undiagnosed

Approximately 1 million new cases/year
Diabetic burden in India

Major non communicable disease

Emerging as a serious health challenge in India.

Accounted for about 0.7% of India’s disease burden in

1998

Expected to rise from 2.6 crore in 2000 to

approximately 4.6 crore by 2015

Particularly concentrated in the urban population.

The prevalence of diabetes increases with age

30–39 years’ age group - 6%,

40–49 years’ age group - 13 %
70 years and above - 20 %

prevalence among women above the age of 40 years is high.

Classification

1.Type 1 diabetes

2.Type 2 diabetes

3.Specific types
a.Genetic defects of cell function
b.Genetic defects in insulin action
c.Disease of exocrine pancreas
d.Endocrinopathies
e.Drug induced
f.Infections
g.genetic syndromes

4.Gestational diabetes
Type 1 diabetes

◦ Deficiency of insulin secretion

◦ Possible autoimmune process with destruction of beta

pancreatic cells

◦ Genetic predisposition and possible links to viral

infections and environmental factors

◦ Require insulin supplementation, prone to develop DKA

◦ Usually younger patients

TYPE 2 Diabetes

◦ Resistance to action of insulin on target organs

◦ Insulin production may or maynot be normal

◦ Increased risk with obesity high fat, high caloric diets

◦ Stronger genetic predisposition

◦ Variety of initial presentations: nephropathy,

retinopathy, neuropathies

◦ Disease can be delayed or prevented with life style

changes

◦ Emergencies like hyperosmolar coma can occur

Normal insulin
structure Insulitis
RISK FACTORS DM 2
 Type 1 diabetes

Temporal development of type 1 diabetes

Concept of hyperinsulinemia in type 2
diabetes
Insulin resistance
Major defect in individuals with type 2
diabetes
Reduced biological response to insulin
Strong predictor of type 2 diabetes
Closely associated with obesity
β Cell dysfunction
Major defect in individuals with type 2
diabetes
Reduced ability of β -cells to secrete
insulin in response to hyperglycemia
 Genetic
susceptibility,
obesity, Western
lifestyle

Insulin
resistance IR β β -cell
dysfunction

Type 2 diabetes
LADA
Latent Autoimmune Diabetes in Adults (LADA) is a form of type
1 diabetes which is diagnosed in individuals who are older
than the usual age of onset of type 1 diabetes. It is
frequently confused with type 2 diabetes
Age at Diagnosis 30 to 35 years

Non-Ketotic presentation

Insulin dependency gradually

Positive for GAD antibodies

Low C- peptide levels

Unlikely to have family history

Responds well to metformin and thiazilidones

Clinical presentations
Polyuria
Polydipsia
Polyphagia
Weight loss
Blurred vision
Poor wound healing
Shoulder periarthritis
Tingling sensation or numbness in both feet
Ketoacidosis in type 1 diabetes
Increase in infections
Candidal vaginitis/balanitis
UTI
Malignant Otitis Externa
Present problem and duration of symptoms
If a known diabetic:
Duration of diabetes
Mode of presentation at the time of diagnosis
Details of treatment-
OHAs- compliance, any adverse effects…
Insulin- storage, mode and site of administration, rotation of
sites, Techniques use of pedevices…

History taking in diabetes

Diagnosis

ADA criteria

The Fasting plasma glucose test is most reliable when done in

the morning.
Having IFG means a person has an increased risk of
developing type 2 diabetes but does not have it yet.
A level of 126 mg/dL or above, confirmed by repeating the
test on another day, means a person has diabetes.

Fasting plasma glucose Result (mg/dL)

99 or below Normal
100 to 125 Pre-diabetes(impaired fasting glucose)
126 or above Diabetes*
The oral glucose tolerance test

Requires fasting for at least 8 hours before the test.

The plasma glucose level is measured immediately before and 2 hours

after a person drinks a liquid containing 75 grams of glucose
dissolved in water.

2-Hour Plasma Glucose Result (mg/dL) Diagnosis

139 and below Normal

140 to 199 Pre-diabetes

(impaired glucose tolerance)

200 and above Diabetes*

American Diabetes Association recommends
Testing in
People aged 45 or older

People younger than 45 should consider testing if they are

overweight, obese, or extremely obese and have one or
more of the following risk factors:

being physically inactive

having a parent, brother, or sister with diabetes
having a family background that is African American, Alaska
Native, American Indian, Asian American, Hispanic/Latino,
or Pacific Islander
Giving birth to a baby weighing more than 3.5 Kg or being
diagnosed with gestational diabetes

Having high blood pressure—140/90 mmHg or above—or

being treated for high blood pressure

Having an HDL, or “good,” cholesterol level below 35 mg/dl or

a triglyceride level above 250 mg/dl

Having polycystic ovary syndrome, also called PCOS

Having IFG or IGT on previous testing
Having a condition called acanthosis nigricans, characterized
by a dark, velvety rash around the neck or armpits
Having a history of cardiovascular disease—disease affecting
the heart and blood vessels
Gestational diabetes and impaired glucose
tolerance (IGT) in pregnancy affects between 2-
3 % of all pregnancies and both have been
associated with pregnancy complications.

Gestational diabetes
Low-risk status requires no glucose testing, but this
category is limited to those women meeting all of the
following characteristics:

 Age <25 years.

 Weight normal before pregnancy .
 Member of an ethnic group with a low prevalence of
gestational diabetes mellitus .
 No known diabetes in first-degree relatives .
 No history of abnormal glucose tolerance .
 No history of poor obstetric outcome .
High risk category

Marked obesity.
Personal history of gestational diabetes mellitus.
Glycosuria.
A strong family history of diabetes .
50 gm glucose load testing

The screening test for GDM, a 50-g oral glucose challenge, may be
performed in the fasting or fed state. Sensitivity is improved if the
test is performed in the fasting state .

A plasma value above 130- 140 mg% one hour after is commonly
used as a threshold for performing a 3-hour OGTT.

If initial screening is negative, testing is repeated at 24 to 28 weeks.

3 hr oral glucose tolerant test

Prerequisites:
- Normal diet for 3 days before the test.
- No diuretics 10 days before.
- At least 10 hours fast.
- Test is done in the morning at rest.
Giving 75 gm (100 gm by other authors) glucose in 250 ml water
orally
Criteria for glucose tolerance test:
The maximum blood glucose values during pregnancy:
- fasting 90 mg/ dl,
- one hour 165 mg/dl,
- 2 hours 145 mg/dl,
- 3 hours 125 mg/dl.
If any 2 or more of these values are elevated, the patient is considered
to have an impaired glucose tolerance test.
Diabetic ketoacidosis
Hyperglycemic hyperosmolar state
Hypoglycemia

Emergencies