DIABETES

JI PATRICK ROSS DULAY

November
• 14, 2017
The celebration of WDD was held at the Quezon
Memorial Circle with an estimated 1000 participants
from the government, nongovernment, and private
sectors.
• Parade/walk around the circle
• Zumba exercise
• Free screening
• Formation of a human blue circle which is the global
symbol of diabetes awareness
• provide important information and educate
participants on diabetes and its risk factors.

•
[Link]
•  
• 6th leading cause of death among
Filipinos based on the data from
the 2013 Philippine Health
Statistics.

• 6 million Filipinos are diagnosed

to have diabetes, as declared by
the Philippine Center for Diabetes
Education Foundation in 2016. 
•  
DOH, as the country’s
leading public health
government agency
• spearheads nationwide efforts in the prevention
and control of diabetes and its complications.
• provides free diabetes risk screening:
 barangay health stations
 rural health units/health centers
 public hospitals
 other government health facilities. 
 provides free medicines such as oral anti-diabetes
medicines and insulin
Diabetes
 Defects: insulin production, insulin
action, or both.

 Chronic Hyperglycemia with

disturbance of carbohydrate, fat
and protein metabolism.

 The effects of diabetes mellitus

include long–term damage,
dysfunction and failure of various
organs.

 S/s: Polydipsia, polyuria,

Polyphagia, blurring of vision, and
weight loss.
How is diabetes classified?

• Four major clinical types

according to etiology:
Type 1

• formerly insulin dependent diabetes

mellitus or Juvenile diabetes mellitus
• results from auto-immune beta-cell
destruction, leading to absolute
insulin deficiency. Typically but not
exclusively in children.
 •Genetic defects in beta cell
Secondary diabetes
function or insulin action,
• Diabetes of the exocrine
pancreas (pancreatitis, cystic
fibrosis),
• Drug- or chemical-induced
diabetes (such as from the
treatment of AIDS, after organ
transplantation, glucocorticoids)
• Other endocrine diseases
(Cushing’s syndrome,
hyperthyroidism)
Type 2 non-insulin dependent
• formerly
diabetes mellitus or
• Adult-onset DM: results from a
progressive insulin secretory
defect on the background of
insulin resistance

• Gestational diabetes
mellitus (GDM): diabetes first
diagnosed during pregnancy
Insulin.mp4
 OMINOUS OCTET
 Decrease incretin effect
 Decrease insulin secretion
 Alpha cell defect
 Increase in hepatic
glucose production
 Neurotransmitter
dysfunction
 Decrease glucose uptake
in muscles
 Decrease glucose
excretion in the kidneys
 Increase Lipolysis
What is the criteria for
normal blood sugar?
• Normal blood is sugar:

• FBS (100 mg/dL), or

• RBS(140 mg/dL), or
• OGTT 75-gm (140 mg/dL)
• Hba1c (<5.5)
What is Pre-
blood sugar level is higher than
diabetes?
normal but not yet high enough
to be type 2 diabetes.
Without lifestyle changes,
people with prediabetes are very
likely to progress to type 2
diabetes.
If you have prediabetes, the
long-term damage of diabetes —
especially to your heart, blood
vessels and kidneys — may
already be starting.
Causes
Exact cause of prediabetes is
unknown.
Family history and genetics
appear to play an important role.
Inactivity and excess fat.
Symptoms
 generally has no signs or
symptoms.

 One possible sign that you may

be at risk of type 2 diabetes is
darkened skin on certain parts of
the body. Affected areas can
include the neck, armpits,
elbows, knees and knuckles.
DIAGNOSIS OF PRE-DIABETES
• The criteria for pre-diabetes is:

• FBS of 100 -125 mg/dL

• RBS 140 -199 mg/dL
• OGTT 75-gm equal to 140 -199
mg/dL
• Hba1c greater than or equal to
6.5%
Who should undergo laboratory testing for
diabetes/prediabetes?
 diabetes mellitus.

>40 years old

Earlier testing - at least one
other (other than age) risk factor
for diabetes.

Testing should ideally be carried

out within the healthcare setting
(clinics, hospitals, local health
centers) because of the need for
follow-up and discussion of
abnormal results by qualified
Should universal screening
be done? and how?
• All individuals being seen at any
physician’s clinic or by any healthcare
provider should be evaluated
annually for risk factors for type 2
diabetes and pre-diabetes.

• Universal screening using laboratory

tests is not recommended as it would
identify very few individuals who are
at risk.
In what setting/s should
testing
 Clinic for diabetes be
done?
 Hospitals
 Local health
centers

• • Testing at
any setting
should be
supervised
by a
qualified
health care
If initial test/s are negative
for diabetes, when should
repeat testing be done?
• Repeat testing should ideally be
done annually.
DIAGNOSIS OF DIABETES
• Criteria:

• • FBS >126 mg/dL after an overnight fast

• • RBS >200 mg/dl in a patient with classic symptoms of

hyperglycemia
 weight loss
 polyuria
 polyphagia
 polydipsia

• Two-hour plasma glucose >200 mg/dl during an Oral Glucose

Tolerance Test

• *Among ASYMPTOMATIC individuals with positive results, any of

the three tests should be REPEATED within two weeks for
confirmation.
What should be done during the
initial evaluation of a diabetic
patient?
• The initial evaluation of the diabetic
patient should include:
• comprehensive medical history
• physical examination
• The following points should be
elicited in the initial medical
history
• • Age and characteristics of
onset of diabetes (e.g., history of
Diabetic ketoacidosis,
asymptomatic laboratory finding)
• • Nutritional status and weight
history
• • Growth and development in
children and adolescents
• • History of Smoking
• • Diabetes education history
• • Review of previous treatment
• Symptoms or history of
diabetes-related complications:
• - Microvascular: retinopathy,
nephropathy, neuropathy,
autonomic, including sexual
dysfuction and gastroparesis
• - Macrovascular: stroke,
coronary artery disease,
peripheral vascular disease
• • Others: psychosocial problems,
dental disease
Diabetes Care Checklist
(Physical Examination)
• • Height, weight, BMI, waist
circumference
• • Blood pressure determination
• • Skin examination (for
acanthosis nigricans and insulin
injection sites)
• • Comprehensive foot
examination
• • Inspection
• • Palpation of dorsalis pedis and
posterior tibial
• pulses,
Foot Evaluation
• A diabetic's risk for developing a foot
ulcer may be as high as 25%.
• The foot exam is an important part of
the initial & ongoing evaluation of any
diabetic.
• Identify risk factors for developing
foot complications from the history or
PE
• Focusing on previous foot ulceration,
neuropathy (loss of protective
sensation), foot deformity, & vascular
disease
Eye Examination
• Some patients may already have
retinopathy at the time of
diagnosis.

• Comprehensive evaluation for

retinopathy by an
ophthalmologist upon diagnosing
diabetes.
Dental History and Oral
Health

• Manifestations of periodontitis such

as bleeding on brushing teeth,
swelling and redness of the gums,
looseness or mobility of teeth, and
teeth that fall off in adult patients.
How soon should glycemic
targets be achieved?
• Ideally targets should be
achieved within six months
of diagnosis or initiation of
treatment as epidemiologic
evidence already shows that
at the time of first diagnosis,
a fourth of all patients with
diabetes already have
microvascular complications.
Are sucrose and sucrose-
containing foods allowed?
• Recommendation:
• Individuals with diabetes need not
avoid sucrose or table sugar as small
amounts do not adversely affect
glycemic control.
• Table sugar when consumed, should
however replace other carbohydrate
in the meal plan.
Are sugar alcohols and non-
nutritive sweeteners safe?
• Recommendation:
• Xylitol, sorbitol, saccharin,
aspartame, cyclamate and sucralose
in the quantities usually consumed
are allowed in the diet of individuals
with diabetes as these have
negligible effects on postprandial
blood glucose
Is alcohol intake
allowed?
• Recommendation:
• Avoid alcohol intake. Advise caution
as alcohol may cause hypoglycemia
in those taking sulfonylureas or
insulin, especially when taken without
food.
Smoking
• Recommendation: Advise all
individuals with diabetes not to
smoke. Refer those who smoke to
smoking cessation programs.
THERAPEUTIC LIFESTYLE
CHANGE: Physical Activity
• General recommendations:

• aerobic physical activity at least 150 min per week, of moderate

to vigorous intensity, spread out 3 days over the week with no
more than 2 consecutive days between bouts of activity.
• Moderate to vigorous resistance
training at least 2-3 days a week
should be undertaken
• Aerobic Exercise: Rhythmic,
repeated and continuous movement
of the same large muscle groups for
at least 10 minutes at a time.

• Resistance Exercise: Activities that

use muscular strength to move a
weight or work against a resistant
load.
How should diabetes mellitus be treated in
the outpatient (Pharmacologic Therapy)

• Among the newly diagnosed diabetics:

• • Asymptomatic with relatively lower levels of blood sugar

should be advised to undertake physical activity and
exercise and weight reduction, with an option of starting
pharmacologic therapy (metformin).

• • Glycemic targets are not reached within 3 months, then

pharmacologic treatment will be started.

• • Higher blood sugars, or who are symptomatic should be

started right away on one or more pharmacologic agents
as applicable since diet and lifestyle changes are unlikely
to achieve the target values.
When should combination
therapy be considered?
• Glycemic targets are not achieved
with one drug given at the maximum
effective dose, another drug from
another pharmacologic class should
be added rather than increasing the
first drug to its maximum dose.
What is the preferred drug?
• Initiate treatment with metformin
unless with contraindications or
intolerant of its ADE’s such as the
development of:

• Severe nausea
• Abdominal pain
• Diarrhea
• Treatment of Hypertension
in Adults With Diabetes

• These studies used different drug

classes, including :
angiotensin-converting enzyme
(ACE) inhibitors
angiotensin receptor blockers (ARBs)
Diuretics
β-blockers
• as the initial step in therapy.
• All of these agents were superior
to placebo; however, it must be
noted that many patients
required three or more drugs to
achieve the specified target
levels of blood pressure control.
Overall there is strong evidence
that pharmacologic therapy of
hypertension in patients with
diabetes is effective in producing
substantial decreases in
cardiovascular and
microvascular diseases.
• Because many studies
demonstrate the benefits of ACE
inhibitors on multiple adverse
outcomes in patients with
diabetes, including both
macrovascular and
microvascular complications, in
patients with either mild or more
severe hypertension and in both
type 1 and type 2 diabetes, the
established practice of choosing
an ACE inhibitor as the first-line
The following rule of thumb
• • less
maywith
alsothan
be230 mg/dL -
followed: continue
current dosage

• • 230 to 390 mg/dL - patient

should increase his insulin by
2 units per injection, even if
unable to eat

• • >390 mg/dL) - patient should

increase his insulin by
• 4 units per injection, even if
unable to eat
• • Return dose to normal when
In what situations should the
patient see his doctor or go to the
• Patients
hospital should
right away?be advised to
seek medical advice if:
• • They are unable to eat or drink
• • Have persistent vomiting or
diarrhea
• • Have a blood glucose higher
than 25 mmol/L (or 450 mg/dL)
despite increasing insulin
• • Have very low glucose levels
• • Become drowsy or confused
(make sure carers are aware of
this)
Hospital admission should
• • A suspicion of underlying be
considered
diagnosisinthat
therequires
following
hospital
circumstances:
admission
• • Inability to swallow or keep
fluids down
• • Significant ketosis in a type I
diabetic despite optimal
management and supplementary
insulin
• • Persistent diarrhea
• • Blood glucose persistently >20
mmol/L (or 350 mg/dL) despite
Thank you for listening!
Types of Diabetes
 Type 1 Diabetes Mellitus
 Type 2 Diabetes Mellitus
 Gestational Diabetes
 Other types:
❖ LADA (Latent Autoimmune Diabetes in adults)

maturity-onset diabetes
❖ MODY (

of youth)
5 ft 6in, 66y/o, diabetic, Male, 8 hrs of
sleep, sedentary lifestyle
Tips for Diabetic
Patients
• Eat about the same amount of food every day.

• Eat meals and snacks at regular times every day.

• Try not to skip meals.

• If trying to lose weight, cut down on your portion sizes.

DBW
=167.64cm - 100=67.64
=67.64 x 19%=6.76
=67.64 - 6.76= 61kg

BMR
=1cal/hr x 61kg x 8 hrs sleep
=1415.2 or 1415 cal

Physical activity
=1415 x .30= 425 cal

SDA
=(cBMR + PA) 10%
=(1415 + 425) 10%
=184 cal
TER
=cBMR +PA +SDA
=1415 cal +425 cal +184cal
=2024 cal

Carbohydrates
=2024 x 55% / 4= 278.3= 278 g

Protein
=2024 x 25%/ 4= 126.5= 127 g

Fat
=2024 x 20%/ 9= 44.9=45g
5 ft 6in, 66y/o, diabetic, Male,
8 hrs of sleep,
TER=2 Carb
sedentary
Pro(127g/ Fat
lifestyle
024 (278g/d) d) (45g/d)

Food Exchan Carboh Calorie

Protein Fat
groups ges ydrates s

Veg A 3 —- —- —- —-

Veg B 3 9 3 —- 48

Fruits 4 40 —- —- 160
Milk 1 12 8 10 170
5 ft 6in, 66y/o, diabetic, Male,
8 hrs of sleep, sedentary
lifestyle
Food
Excha Break Dinne
group Snack Lunch Snack
nges fast r
s

Veg A 3 1 2

Veg B 3 1 1 1

Fruit
4 1 2 1
s
Milk 1 1