Diabetes

by

Dr. Danish Hasan Qaiser

MBBS, M Phil (Physiology)
Associate Professor Physiology
Hamdard College of Medicine and Dentistry
Hamdard University
Learning Objectives

• Diabetes Mellitus
– Definition
– Types
– Pathophysiology
– Signs and symptoms
– Diagnosis
– Management
• Hypoglycemia
Definition
• Diabetes mellitus is a syndrome characterized by
chronic hyperglycemia and disturbance of
carbohydrate, fat and protein metabolism
associated with absolute or relative deficiency in
insulin secretion and\or insulin action.
• Epidemiology: About 6% US population;
800,000 new cases/year; 7th death cause in the US
(23.3/100,000 population in 2006)
Classification

Diabetes is classified into three main types:

• Type 1 insulin-dependent diabetes mellitus
(IDDM) previously called juvenile DM.
• Type 2 non-insulin-dependent diabetes
mellitus(NIDDM)
• Gestational Diabetes Mellitus(GDM)
Type 1 Diabetes
Occurrence:
• Autoimmune disease wherein the immune system
attacks B-cells of pancreas and destroys them. The
pancreas then produce little or no insulin.
• Scientists do not know exactly what causes the
body’s immune system to attack the B-cells, but
they believe that both genetic factors and
environmental factors and possibly viruses, are
involved.
Characteristics:
• Often develops in children and young adults, but
the disorder can appear at any age.
• Symptoms usually develop over a short period,
although B-cell destruction can begin year earlier.
• If not diagnosed and treated with insulin, a person
can lapse into a life-threatening diabetic coma,
also known as diabetic ketoacidosis.
Diabetes Type 1 Symptoms

• Hyperglycemia
• Excessive thirst (polydipsia)
• Frequent urination (polyuria)
• Significant weight loss
• Electrolyte disturbance
• Ketoacidosis
Type 2 diabetes
Occurrence:
• The most common form of diabetes.
• Due to reduce insulin secretion or
peripheral resistance to action of insulin.
• The result is the same as for Type 1
diabetes, glucose builds up in the blood and
the body cannot make efficient use of its
main source of fuel.
• Often part of a metabolic syndrome
that includes obesity, elevated blood
pressure, and high levels of blood
lipids.
Characteristics:
• Contributes 90 to 95% of total diabetes and one-
third not been diagnosed.
• This form of diabetes usually develops in adults.
• About 80% of people with Type 2 diabetes are
overweight.
• Increase in incidence of childhood obesity leads to
Type 2 diabetes becoming more common in young
people
 Diabetes Type 2 Symptoms

• Insidious onset
• Often goes undiagnosed for years
• Hyperglycemia
• Excessive thirst (polydipsia)
• Frequent urination (polyuria)
• Polyphagia
• Weight loss
Gestational Diabetes:

Occurrence:
• Develops in pregnancy and disappears after
delivery, however with increased risk in
getting later in life
• Insulin resistance due to pregnancy.
• Genetic predisposition.
Insulin affects many organs:
amino acids protein
• It stimulates skeletal muscle fibers. uptake synthesis

• It stimulates liver cells.

glycogen
glucose
synthesis
• It acts on fat cells uptake

• It inhibits production of certain fat

enzyme. synthesis

In each case, insulin triggers

these effects by binding to the enzyme glycogen
insulin receptor. production breaking
 Uncontrolled diabetes

In un controlled diabetes, glucose and

lipids (fats) remain in the blood stream
and, with time damage the body’s vital
organs and contribute to heart disease.
Characteristics of Type I and Type II diabetes

Feature Type I Type II

Age of onset < 20 yrs Maturity onset (>30yrs)

Body mass Low or normal Most obese
Plasma Insulin Low or absent Normal to high (initially) or low
Plasma glucagon High (can be suppressed) High (can not be suppressed)
Plasma glucose Increased Increased
Insulin sensitivity Normal Reduced
Ketosis Prone Rare
Therapy Insulin Weight loss
Oral hypoglycemical medicine
Insulin therapy

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 Diagnosis of Diabetes Mellitus
Diabetes Mellitus = Hyperglycemia

Symptoms of diabetes plus one of the following on 2 occasions:

• Fasting blood glucose > 126 mg/dl

• Random blood glucose > 200 mg/dl
• oral glucose tolerance test (OGTT)
2 hrs blood glucose > 200 mg/dl (a 75 gram glucose intake)

Other categories

• Prediabetes = 2 hour OGTT glucose 140-199 mg/dl or

fasting glucose 100-125 mg/dl
• Gestational diabetes
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 Chronic Complications

Macrovascular Disease Microvascular Disease

Cerebrovascular Retinopathy
Peripheral vascular - Leading cause of vision
Cardiovascular loss/blindness in patients
Atherosclerosis <60 years of age
Co-conspirators - Occurs in 40% of type 1 and 20%
- Hypertension of type 2 diabetes
- Hyperlipidemia Nephropathy
- Leading cause of renal failure
(1/3 of all cases)
Neuropathy
- peripheral neuropathy
- Leading cause of amputations
- Current therapies are inadequate
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 Hyperglycemia Can Cause
Serious Long-Term Problems
 Chronic Complications
Diabetic Foot Ulcers

Causes: Ischemia
Sensory Neuropathy
Infections
Prevention:
Maintain blood glucose control
Hygiene of feet
Inspecting feet daily
Proper fitting of shoes
Visit podiatrist regularly

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 Severe Clinical Complications

Acute : hypoglycemia
diabetic ketoacidosis (Type-I DM)
nonketotic hyperosmolar coma (Type-II DM)

Long-term: cardiovascular disease

renal failure
retinal damage

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Laboratory Test

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 Types of Tests for Diabetes

1. RIA (Radioimmunoassay) test for insulin level

2. Fasting blood glucose and Oral Glucose Tolerance Test
(OGTT): a test to monitor the glucose level in response to
insulin effect.
3. Urine glucose test
4. Measurements of plasma and urinary ketone bodies.
5. Blood HbA1C test

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Glycated Hemoglobin (HbA1c) Test
• Indicates blood glucose control over a
period of approximately 3 months.
• Normal range varies depending on the
method the lab uses: usually 4-7%,
correlating to average blood glucose of 60-
150 mg/dl (3.3-8.3 mmol/l)
Goals Of Treatment
• Control high blood glucose (hyperglycemia)
• Avoid low blood glucose (hypoglycemia).
• Treatment of associated conditions, such as high
blood pressure, cholesterol disorder and obesity.
• Prevent or retard the progression of complications
of diabetes such as blindness, kidney failure, heart
disease, stroke and amputation of legs.
Management:
• Diet (60-70% Carbohydrates; 10% fat; 15-20% Protein)
• Exercise(improves insulin sensitivity; burns calories;
benefits cardiovascular effects; goal 30-45 min/3-
5times/week)
• Insulin for Type 1 and Oral Hypoglycemic Agents or
insulin in Type 2
• Education
• Monitoring blood glucose and therapy
• Screening and early treatment of microvascular
complications
 Target Sites for Therapeutic Drug to Treat Type 2 diabetes
LIVER ADIPOSE MUSCLE
TISSUE

PANCREAS

GLUCOSE PRODUCTION
Metformin PERIPHERAL
(Thiazolidinediones) GLUCOSE UPTAKE
INSULIN Secretion Thiazolidinediones
Sulfonylureas (Metformin)
INTESTINE
GLP ACTION Meglitinides
Exendatide Nateglinide
DPP4 Inhibitors Insulin
GLUCOSE ABSORPTION
alpha-glucosidase inhibitors

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Oral Hypoglycaemic Medications
 Prevention & Self-management
Prevention
• Primary: Risk Factors
• Secondary: Early Detection & Treatment
• Tertiary: Self-management dietary control, exercise

Self-monitoring Blood Glucose (SMBG)

• Using reagent strips & photometer that gives a digital
reading
• Recommended 3-4 /day for Type I Diabetics
Urine Tests
•Urine Glucose - Use of tablets, test-tape
•Urine Ketone Levels (monitoring symptoms of ketoacidosis)
•Urine for Albumin (Early recognition of renal disease)
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 PREVENTING COMPLICATIONS

By managing the ABCs of diabetes, people with diabetes can

reduce their risk of complications.

A stands for A1C (a measure of average blood glucose)

B stands for Blood pressure

C stands for Cholesterol

 Definition of hypoglycemia
• Blood glucose level below 3.5 mmol/L in
people with diabetes who are treated with
insulin or oral hypoglycaemic agents
 Causes of Hypoglycemia
Insufficient food or delayed meal
Excess of insulin or snack
and some oral
hypogycemic
agents

insulin

Extra physical activity or

exercise

Alcohol consumed without food or

excess alcohol
 Symptoms
feeling dizzy/shaking profuse sweating

headache

pins and needles

around mouth excessive hunger
DPMI Workforce Development – The Alfred Workforce Development Team June 2005
 Cognitive impairment
• Symptoms of cognitive impairment
Peculiar behaviour

Lack of concentration
Altered vision
Loss of consciousness

DPMI Workforce Development – The Alfred Workforce Development Team June 2005
 Nocturnal hypoglycemia
• Symptoms may include:
– Sweating
– Vivid dreaming
– Restlessness
– Incontinence
– Waking with a headache
– High or low fasting levels
Act quickly
 How to care for yourself when
you’re hypoglycemic

 Eat or drink 15 grams of fast-acting,

low-fat carbohydrate right away.
Quick energy sources
The following items are quick energy sources that contain about
15 grams of carbohydrate:
 ½ cup fruit of orange, apple, or grapefruit juice
 1/3 cup grape, prune, or cranberry juice
 2 tbsp raisins
 6 crackers
 3-5 pieces hard candy
 1 cup skim milk
 1 piece bread
 3-4 glucose tablets, or 1 tube glucose gel
 ½ cup regular soft drink (not diet)
 11 jellybeans
 Never

Never give food to an unconscious person

 Treatment if unconscious

• Position in the left lateral position and withhold

any food or fluids. Seek further medical help.

• If glucagon is available it can be administered

subcutaneously, intramuscularly or
intravenously.
 Oral health care considerations
General:
1. Uncontrolled diabetic patient is prone to:
Tooth decay; periodontal gum disease; oral fungal &
bacterial infection; delayed wound healing
2. Dental procedure may stress patient and worsen the
uncontrolled diabetic condition.
3. Diabetic crisis might be triggered by a dental procedure, the
skill and knowledge to deal with the emergent challenge
from the patient with a diabetic crisis needs to be prepared.

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 Oral health care considerations
Prior to dental care
1. Medical history
2. Scheduling To avoid peak period of insulin activity
3. Dietary instructions
4. Blood glucose monitoring

During dental care

1. Managengement of a hypoglycemic episode
2. Management of hyperglycemic episode

After dental care

1. Infection risk assessment - use of antibiotics
2. Postoperative analgesics - caution for certain drug usage
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THANK YOU