Diabetes Mellitus
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• Outlines:
• Definition
• Types
• Risk factors for DM
• Clinical picture of DM.
• Diagnostic studies
• Management of Diabetes
• Complications of diabetes (short term and long term
complications).
• Definition of DM
• Metabolic syndrome characterized by hyperglycemia results
from lack,
• or reduced effectiveness, of endogenous insulin produced
by the beta cells of the islets of Langerhans in the pancreas.
• Without sufficient insulin, glucose can’t enter the cells to
produce energy remains in the blood, causing
hyperglycemia, improper metabolism of fats, and proteins
occur.
• Types of diabetes mellitus:
• Primary Diabetes Mellitus
- Type 1 diabètes : (insuline dépendent diabètes mellites) IDDM :
-Is a condition of absolute insulin deficiency
-That requires exogenous insulin for blood glucose control, because
insulin-producing beta cells of the pancreas have been destroyed by
autoimmune process.
-Is usually diagnosed in childhood (diagnosed when older than age 20
ys). The exact cause is unknown (Genetics, viruses, and autoimmune
problems) may play a role.
• Type II ( Non insuline dépendent diabètes mellites) NIDDM :
• The most common type of Diabetes. In this type 2 diabetes insulin may
produced in normal or supernormal levels. But there is an insulin resistance.
• 2-Secondary DM:
-Can be attributed to infection of the pancreas, chronic Pancreatitis,
Pancreatic tumor, or Pancreatectomy.
- Oral contraceptive drugs &steroids
• 3-Gestational DM: is high blood glucose that develops at any time during
pregnancy in a woman who does not have diabetes pregnancy and blood
Glucose return to normal after delivery. Women who have gestational
diabetes are at high risk of type 2 diabetes and cardiovascular disease later in
life.
Type I Diabètes (IDDM) Type II Diabètes (IIDM)
Commonly detected before 30ys
Can occur at any age, but about 50% of the
The pancreas doesn’t produce any
type II diabetes are in older than 65ys.
insulin, and the body is unable to commonly detected after 40.
regulate glucose metabolism The pancreas may able to
patient must receive exogenous daily produce insulin in normal or subnormal
insulin injections to survive. levels
It results from a reduction of beta -cell Blood glucose levels rise due to insulin
function as a result of an autoimmune resistance
Diminished tissues sensitivity to insulin due
process in a susceptible individual.
to decrease the
number of insulin receptors in the cells wall .
Controlled by diet, weight control, exercise,
oral hypoglycemic agents and or insulin
• Risk factors:-
• Family history of diabetes
• Obesity
• Reduced physical activity
• Coexisting illness
• Poor eating habits
• Age –related changes that increased insulin tissue resistance
• Sever mental and psychological stress
• Sedentary life style
• Drug may contribute to insulin resistance or the body's failure to utilize the insulin
that is present (e.g. diuretics, non-steroid anti inflammatory drug).
Clinical manifestations :
The classic symptoms of diabetes
• Such as polyphagia , polyuria,
• Polydipsia (excessive thirst),
• With weight loss ,lethargy ,
• Genital candida infection
• Blurring of vision.
Diagnoses:-
• Diagnostic test:
• 1- Fasting blood sugar level(FBG)
• 2- Post prandial serum glucose test: two hours after ingestion of foods(PPG)
• 3- Oral glucose tolerance test: Is the most specific test normal fasting blood sugar level is
(80-120 mg). when a non diabetic person is given glucose orally, his blood glucose level will
return to normal in about 2 hs. In this test patients is given 75-100 ml of glucose to drink. If
diabetic, his blood glucose level stays higher after two hours of ingesting glucose.
• 4-Urine analysis for glucose.
• B-Diagnostic criteria:
• The diagnosis of diabetes usually is established if 1 of 3 criteria exists:
* Random plasma glucose concentration is 200mg/dl
* Fasting blood glucose concentration are 126 mg/dl
* Plasma glucose concentration after oral glucose intake is greater than 200
mg/d.+ symptoms of hyperglycemia
• Management of DM
• The goals of treatment :
• To relieve symptoms, Control hyperglycemia
• and Prevent acute and chronic complications
• Treatment of DM through:
• - Diet planning - Weight control
• - Exercise - Medication
• - Self monitoring - Education
• Development of proper diet plan should be individualized based on:
diet history, age, sex, height, weight, life style, physical activity,
working hours, likes and dislikes.
• 15% to 20% as protein, 30% as fat (10% only of saturated fat), and less
than 2gm of sodium because of the higher risk of heart disease with
diabetes. In addition, adequate vitamins and minerals intake is
needed.
• Cholesterol limited to 300mg/day
• Meal spacing: client should divide caloric intake into 5 meals as
follows: 20 % of total caloric intake as breakfast, 30% as lunch, 10% as
mid-afternoon snack, 30% as dinner, and 10% as bed time snack.
• B) Weight control: Obesity is the primary management problem in
NIDDM .Weight reduction has an extremely effect on reducing
symptoms and improves glycemic control in those who are obese.
Obese patients should aim to achieve some weight reduction by
adopting a healthy lifestyle with a combination of correct diet and
regular exercise. Graduate and moderate weight reduction is desirable
in the obese diabetics.
• C) Exercise:
It improves insulin sensitivity, increases glucose uptake in
peripheral tissues, reduces cholesterol and triglyceride levels,
increases bone density, promotion of weight control,
improved cardiovascular status, reduction of insulin or oral
hypoglycemic dosages, improved sense of well being
Exercise need not be strenuous to be effective. Recommended types of
exercise for older adults aerobic exercises (eg. walking). Ideally,
moderate exercise should be done for 30 min each time, for at least three
times a week.
Blood glucose should be tested before and after exercise to avoid
hypoglycemia.
Diabetics on medication should always carry a simple carbohydrate
when exercising.
It is recommended to follow these instruction: Use proper footwear ,
Avoid exercise in extreme heat or cold, Inspect feet daily after exercise,
drinking plenty of fluids, Avoid exercise during periods of poor
metabolic control.
• ) Medications
• 1- Oral hypoglycemic agents:- Anti hyperglycemic drugs include oral
agents
• Sulfonylurea drugs: such as amaryl, micronase (enhance insulin
secretion) have been the primary treatment for elderly individuals
with NIDDM when treatment with diet and /or exercise don’t control
blood glucose level.
• 2- Insulin (It used for type I DM), given by SC or IV injections,
measured in units. Used when the blood glucose level is not controlled
by diet, exercise, and oral sulfonylurea agents, insulin is
recommended to survive.
• Sites of insulin injections
• Lateral surface of arms,
• Anterior aspects of thigh
• Anterior & lateral aspects of
• Abdominal wall
• Insulin reactions
• A-Local reaction: swelling, tenderness, atrophy (loss of subcutaneous fats)
and lipohypertrophy (development of fibro-fatty mass at the injection site)
• B-Hypoglycemia
Three general types based on duration of action:
•Rapid acting insulin (Lispro (Humolog, Novolog Aspart) given 15-30 minutes before
meal
Onset of action“10-20” minutes:
Peak of action:1 - 2 hours
Duration: 3 – 4 hours
• 2- Short acting insulin Regular (clear so can be given IV)
• Onset of action: 0.5 to 1 hour
• Peak of action: 2 – 4 hours
• Duration of action: 6 – 8 hours
Intermediate acting insulin (lente) given 15-30 m before meal
• Onset of action: 1-4 hours
• Peak of action: 4-14 hours
• Duration of action: 18-24 hours
• 4-Long acting insulin: (Ultralente & protamine zinc) given 30-60 m
before meal
• Onset of action : 4-8 hours
• Peak of action: 18 hours
• Duration of action: 24-36 hours