DIABETES MELLITUS

DEFINITION
• Diabetes Mellitus (DM) is a chronic medical condition that affects
how the body regulates blood sugar (glucose). Glucose is a primary
source of energy for the cells, and insulin, a hormone produced by the
pancreas, plays a key role in allowing glucose to enter the cells for
energy. In people with diabetes, either the body does not produce
enough insulin or the cells become resistant to the insulin that is
produced, leading to elevated levels of glucose in the blood
(hyperglycemia).
• There are three main types of diabetes mellitus: Type 1, Type 2, and
Gestational Diabetes. Each type has different causes, mechanisms,
and management strategies
Type 1 Diabetes (T1D)

• Cause: Type 1 diabetes is an autoimmune disease where the body’s

immune system mistakenly attacks and destroys the insulin-producing
beta cells in the pancreas. This results in little or no insulin production.
• Onset: It often develops in childhood or adolescence but can occur at any
age.
• Management: People with Type 1 diabetes require lifelong insulin therapy
(either via injections or insulin pumps) to control their blood sugar levels.
• Characteristics:
• Abrupt onset of symptoms
• Insulin dependency
• Typically diagnosed in younger individuals
Type 2 Diabetes (T2D)
•Cause: Type 2 diabetes is primarily caused by insulin resistance, where the body's cells do not
respond to insulin as effectively. Over time, the pancreas cannot produce enough insulin to
compensate for this resistance.
•Onset: It typically develops in adults over the age of 45, although it is increasingly seen in younger
populations due to rising rates of obesity and sedentary lifestyles.
•Risk Factors: Family history, obesity, physical inactivity, unhealthy diet, older age, and ethnic
background (with higher prevalence in African American, Hispanic, and Native American populations).
•Management: T2D can often be managed through lifestyle changes such as diet and exercise, but
may also require oral medications or insulin injections.
•Characteristics:
•Gradual onset of symptoms
•Insulin resistance followed by beta-cell dysfunction
•Often associated with obesity
Gestational Diabetes (GDM)

•Cause: Gestational diabetes develops during pregnancy when the body cannot produce enough
insulin to meet the increased needs of pregnancy. It is typically diagnosed in the second or third
trimester.
•Onset: It usually occurs in women who have never had diabetes before, and often resolves after
childbirth. However, women who have had gestational diabetes are at higher risk of developing Type 2
diabetes later in life.
•Management: GDM can often be managed with dietary changes, physical activity, and in some
cases, insulin or oral medications.
•Characteristics:
•Occurs only during pregnancy
•Increases the risk of complications for both mother and baby
•Resolves post-delivery, but requires close monitoring during pregnancy
Other Specific Types of Diabetes

There are other less common types of diabetes, including:

• Monogenic Diabetes: Resulting from mutations in a single gene.
• Maturity-onset Diabetes of the Young (MODY): A form of diabetes
that typically develops before age 25 and is inherited through a single
gene mutation.
• Cystic Fibrosis-related Diabetes: A form of diabetes that affects
people with cystic fibrosis.
Pathophysiology of Diabetes
Mellitus
• Diabetes results from the body's inability to maintain normal blood
glucose levels. Glucose levels are controlled through the secretion and
action of insulin, which helps cells absorb glucose. In diabetes:
• Type 1 Diabetes: The immune system destroys pancreatic beta cells,
leading to insulin deficiency.
• Type 2 Diabetes: The body's cells become less responsive to insulin
(insulin resistance), and the pancreas can’t compensate by producing
enough insulin.
• Gestational Diabetes: Hormonal changes during pregnancy lead to
insulin resistance, and the pancreas can't keep up with the increased
demand for insulin.
CLINICAL FEATURES
•Polyuria – Frequent urination due to osmotic diuresis caused by high blood glucose levels.
•Polydipsia – Excessive thirst due to dehydration from frequent urination.
•Polyphagia – Increased hunger due to the body’s inability to properly use glucose for energy,
leading to a feeling of starvation.
•Unexplained Weight Loss – Especially in Type 1 diabetes, due to the breakdown of fat and
muscle as the body cannot use glucose properly.
•Fatigue – Reduced energy levels due to poor utilization of glucose by the body's cells.
•Blurry Vision – Caused by changes in the lens of the eye from high blood glucose, leading to
difficulty focusing.
•Dry Mouth – Often due to dehydration from frequent urination.
•Slow Healing of Wounds – High blood glucose levels impair the body’s ability to heal wounds
and fight infections.
•Recurrent Infections – Increased susceptibility to infections such as urinary tract infections,
skin infections, and yeast infections.
•Tingling or Numbness – Due to diabetic neuropathy, where high blood glucose damages
nerves, often in the hands or feet.
•Skin Changes – Such as dryness, infections, or Acanthosis Nigricans (dark, velvety patches
of skin, often on the neck or armpits).
TYPE SPECIFIC FEATURE
Type 1 Diabetes (T1D):
• Rapid Onset of symptoms (over days to weeks).
• Ketoacidosis: Abdominal pain, vomiting, fruity-smelling breath, deep rapid breathing
(Kussmaul respiration).
• Weight Loss despite increased appetite and food intake.
Type 2 Diabetes (T2D):
• Gradual Onset of symptoms, often subtle.
• Acanthosis Nigricans: Dark, thickened skin, especially in body folds.
• Hyperosmolar Hyperglycemic State (HHS): Severe dehydration, confusion, altered
mental state without significant ketoacidosis.
• Fatigue and blurred vision may be more common as people may not notice symptoms
early.
Gestational Diabetes:
• Often asymptomatic, but may present with increased thirst or
frequent urination.
• Risk of high birth weight and complications for both mother and
baby.
Other Features:
• Dry, itchy skin due to dehydration and poor circulation.
• Gastroparesis (delayed stomach emptying) causing nausea, bloating,
and vomiting in advanced cases.
SYMPTOMS
• Common symptoms of undiagnosed or poorly controlled diabetes include:
• Polyuria (frequent urination)
• Polydipsia (excessive thirst)
• Polyphagia (increased hunger)
• Unexplained weight loss (in Type 1)
• Fatigue
• Blurred vision
• Slow healing of wounds or infections
• Numbness or tingling in hands and feet (more common in Type 2)
CLINICAL EXAM
• The clinical examination for Diabetes Mellitus involves checking for signs of
hyperglycemia and complications. Here's a brief overview:
• General Appearance: Assess level of consciousness, body weight, and signs of
dehydration.
• Vital Signs: Measure blood pressure, heart rate, and temperature.
• Skin: Look for acanthosis nigricans, dry skin, infections, or poor wound healing.
• Mouth and Eyes: Check for dry mouth, gum disease, and signs of retinopathy.
• Cardiovascular: Check pulses, heart sounds, and capillary refill.
• Respiratory: Listen for abnormal breath sounds, especially Kussmaul breathing.
• Abdomen: Palpate for signs of hepatomegaly or gastroparesis.
• Neurological: Test for peripheral neuropathy and check reflexes and sensation.
• Feet: Examine for ulcers, infections, or deformities.
INVESTIGATIONS
• The investigations for Diabetes Mellitus help confirm the diagnosis, assess disease control, and identify complications. The
primary tests and screenings include:
• 1. Blood Glucose Tests
• Fasting Plasma Glucose (FPG): Measures blood glucose after an overnight fast.
• Diagnosis: ≥ 126 mg/dL (7.0 mmol/L) indicates diabetes.
• Oral Glucose Tolerance Test (OGTT): Measures blood glucose 2 hours after drinking a sugary solution.
• Diagnosis: ≥ 200 mg/dL (11.1 mmol/L) at 2 hours indicates diabetes.
• Random Blood Glucose: A blood test at any time of day.
• Diagnosis: ≥ 200 mg/dL (11.1 mmol/L) along with symptoms of diabetes (polyuria, polydipsia) is diagnostic.
• 2. HbA1c (Glycated Hemoglobin) Test
• Purpose: Reflects average blood glucose levels over the past 2-3 months.
• Diagnosis: HbA1c ≥ 6.5% indicates diabetes.
• Target for management: Typically 7% or less for most patients.
• 3. Urine Tests
• Urine Glucose: Can detect glucose in urine, though not specific to diabetes and less commonly used for diagnosis.
• Urine Ketones: Elevated ketones in the urine may indicate diabetic ketoacidosis (DKA), especially in Type 1 diabetes.
• Urinary Albumin-to-Creatinine Ratio (UACR): Detects early signs of kidney damage (diabetic nephropathy). Elevated levels can
indicate kidney problems.
INVESTIGATIONS
• 4. Lipid Profile
• Purpose: Diabetes increases the risk of cardiovascular disease. The lipid profile checks for:
• Elevated total cholesterol
• Low HDL cholesterol
• High LDL cholesterol and triglycerides
• 5. Kidney Function Tests
• Serum Creatinine and Estimated Glomerular Filtration Rate (eGFR): To assess kidney function
and detect diabetic nephropathy.
• 6. Fundoscopy (Eye Examination)
• Purpose: To detect diabetic retinopathy, a common complication of diabetes.
• Findings: Microaneurysms, hemorrhages, and cotton wool spots are signs of retinopathy.
• 7. Electrocardiogram (ECG)
• Purpose: To screen for cardiovascular disease (increased risk in diabetic patients), such as
ischemic heart disease or arrhythmias.
INVESTIGATIONS
• 8. Nerve Conduction Studies
• Purpose: To assess for diabetic neuropathy, especially if the patient has symptoms like tingling, numbness,
or pain in the extremities.
• 9. C-Peptide Test
• Purpose: Measures insulin production. Helps distinguish between Type 1 and Type 2 diabetes:
• Low or undetectable C-peptide suggests Type 1 diabetes (insulin deficiency).
• Normal or elevated C-peptide suggests Type 2 diabetes (insulin resistance).
• 10. Advanced Screening (for complications)
• Foot Exam: For ulcers, deformities, or signs of peripheral vascular disease.
• Echocardiogram or Stress Test: To evaluate cardiac function in patients with suspected cardiovascular
involvement due to diabetes.
• 11. HbA1c Variants (if necessary)
• Purpose: In rare cases where abnormal hemoglobin variants (e.g., sickle cell trait, thalassemia) interfere
with the HbA1c test, other methods like fructosamine or glycated albumin can be used to assess blood
glucose control.
TREATMENT AND MANAGEMENT
Managing diabetes involves controlling blood glucose levels to prevent
complications. Common approaches include:
• Lifestyle Modifications:
• Diet: A balanced diet low in refined sugars and high in fiber, with an emphasis
on vegetables, whole grains, and lean proteins.
• Exercise: Regular physical activity helps improve insulin sensitivity and overall
health.
• Weight Management: Maintaining a healthy weight is particularly important
for people with Type 2 diabetes.
TREATMENT AND MANAGEMENT
Medications:
• Insulin: Necessary for Type 1 diabetes and sometimes for Type 2
diabetes when oral medications are insufficient.
• Oral Medications: For Type 2 diabetes, common drugs include
metformin (which reduces glucose production by the liver),
sulfonylureas, and GLP-1 agonists.
• SGLT2 Inhibitors and DPP-4 Inhibitors: Newer classes of drugs that
help manage blood sugar levels.
TREATMENT AND MANAGEMENT
•Lifestyle Modifications:
•Diet: Low glycemic index (GI) foods, high in fiber, controlled carbohydrate intake.
•Exercise: At least 150 minutes of moderate-intensity exercise per week.
•Weight Management: Aiming for a BMI of 18.5-24.9 kg/m².
•Smoking Cessation: Smoking exacerbates insulin resistance and cardiovascular risk.
•Pharmacological Management:
•Type 1 Diabetes: Insulin therapy is the cornerstone (multiple daily injections or insulin pumps).
•Type 2 Diabetes: Medications include:
•Metformin (first-line)
•Sulfonylureas (e.g., glibenclamide)
•DPP-4 inhibitors (e.g., sitagliptin)
•GLP-1 receptor agonists (e.g., liraglutide)
•SGLT-2 inhibitors (e.g., empagliflozin)
TREATMENT AND MANAGEMENT
•Monitoring Blood Glucose:
•Self-Monitoring: People with diabetes should regularly check their blood glucose levels using a
glucometer.
•Continuous Glucose Monitoring (CGM): A device that provides real-time glucose readings.
•Education: Diabetes management includes understanding the disease, recognizing symptoms, and
learning how to make healthy lifestyle choices.
COMPLICATIONS
When diabetes is not well-managed, it can lead to serious complications that affect multiple
organs and systems in the body:
• Cardiovascular Disease: People with diabetes are at increased risk of heart attack, stroke, and
peripheral artery disease.
• Kidney Damage (Diabetic Nephropathy): Diabetes is one of the leading causes of kidney failure.
• Nerve Damage (Neuropathy): High blood glucose can damage nerves, particularly in the feet
and hands, leading to loss of sensation and pain.
• Retinopathy: Damage to the blood vessels in the eyes can lead to vision problems and even
blindness.
• Poor Circulation and Foot Problems: Diabetes can cause poor circulation, leading to infections
and sometimes amputations in severe cases.
• Skin Issues: Diabetic patients are more prone to bacterial and fungal infections, as well as slow
wound healing.
Prevention of Diabetes Mellitus:
• Type 2 Diabetes Prevention:
• Healthy Diet:
• Eat a balanced diet with whole grains, fruits, vegetables, lean proteins, and healthy fats.
• Limit refined sugars and processed foods.
• Regular Exercise:
• Aim for at least 150 minutes of moderate-intensity exercise per week.
• Weight Management:
• Achieve and maintain a healthy weight (losing 5-10% of body weight can reduce risk).
• Limit Alcohol and Quit Smoking:
• Reduce alcohol intake and avoid smoking to lower diabetes risk.
• Screening for High-Risk Individuals:
• Monitor blood glucose levels regularly, especially for those with obesity or a family history of diabetes.
• Medications:
• Consider medications like metformin for those with prediabetes or high risk.
• Type 1 Diabetes Prevention:
• Currently non-preventable as it is an autoimmune disease, but early detection and management can reduce
complications.
Prevention of Complications in
Existing Diabetes:
• Glycemic Control:
• Maintain blood glucose levels within target ranges (HbA1c <7% for most).
• Regular Screenings:
• Eye exams (for retinopathy), kidney function tests, foot exams, and
cardiovascular assessments.
• Blood Pressure and Cholesterol Management:
• Control blood pressure (<130/80 mmHg) and cholesterol to prevent
complications.
• By following these strategies, individuals can significantly reduce the
risk of developing Type 2 diabetes or manage existing diabetes to
prevent complications.