Anatomy and Physiology

Every cell in the human body needs energy in order to function. The
body’s primary energy source is glucose, a simple sugar resulting from the
digestion of foods containing carbohydrates (sugars and starches). Glucose from
the digested food circulates in the blood as a ready energy source for any cells
that need it. Insulin is a hormone or chemical produced by cells in the pancreas,
an organ located behind the stomach. Insulin bonds to a receptor site on the
outside of cell and acts like a key to open a doorway into the cell through which
glucose can enter. Some of the glucose can be converted to concentrated
energy sources like glycogen or fatty acids and saved for later use. When there
is not enough insulin produced or when the doorway no longer recognizes the
insulin key, glucose stays in the blood rather entering the cells.
Digestive System

The functions of the digestive system are:

• Ingestion - eating food
• Digestion - breakdown of the food
• Absorption - extraction of nutrients from the food
• Defecation - removal of waste products

The digestive system also builds and replaces cells and tissues that are
constantly dying.

Digestive Organs
The digestive system is a group of organs (Buccal cavity (mouth),
pharynx, oesophagus, stomach, liver, gall bladder, jejunum, ileum and colon) that
breakdown the chemical components of food, with digestive juices, into tiny
nutrients which can be absorbed to generate energy for the body.
The Buccal Cavity
Food enters the mouth and is chewed by the teeth, turned over and mixed
with saliva by the tongue. The sensations of smell and taste from the food set up
reflexes, which stimulate the salivary glands.

The Salivary glands

These glands increase their output of secretions through three pairs of
ducts into the oral cavity, and begin the process of digestion.
Saliva lubricates the food enabling it to be swallowed and contains the
enzyme ptyalin which serves to begin to break down starch.

The Pharynx
Situated at the back of the nose and oral cavity receives the softened food
mass or bolus by the tongue pushing it against the palate which initiates the
swallowing action.
At the same time a small flap called the epiglottis moves over the trachea
to prevent any food particles getting into the windpipe.
From the pharynx onwards the alimentary canal is a simple tube starting
with the salivary glands.

The Esophagus
The esophagus travels through the neck and thorax, behind the trachea
and in front of the aorta. The food is moved by rhythmical muscular contractions
known as peristalsis (wave-like motions) caused by contractions in longitudinal
and circular bands of muscle. Antiperistalsis, where the contractions travel
upwards, is the reflex action of vomiting and is usually aided by the contraction of
the abdominal muscles and diaphragm.
The Stomach
The stomach lies below the diaphragm and to the left of the liver. It is the
widest part of the alimentary canal and acts as a reservoir for the food where it
may remain for between 2 and 6 hours. Here the food is churned over and mixed
with various hormones, enzymes including pepsinogen, which begins the
digestion of protein, hydrochloric acid, and other chemicals; all of which are also
secreted further down the digestive tract.

The stomach has an average capacity of 1 litre, varies in shape, and is

capable of considerable distension. When expanding this sends stimuli to the
hypothalamus which is the part of the brain and nervous system controlling
hunger and the desire to eat.

The wall of the stomach is impermeable to most substances, although

does absorb some water, electrolytes, certain drugs, and alcohol. At regular
intervals a circular muscle at the lower end of the stomach, the pylorus opens
allowing small amounts of food, now known as chyme to enter the small
intestine.

The Liver
The liver, which acts as a large reservoir and filter for blood, occupies the upper
right portion of abdomen and has several important functions:

• Secretion of bile to the gall bladder

• Carbohydrate, protein and fat metabolism
• The storage of glycogen ready for conversion into glucose when
energy is required.
• Storage of vitamins
• Phagocytosis - ingestion of worn out red and white blood cells, and
some bacteria
The Gall Bladder
The gall bladder stores and concentrates bile which emulsifies fats making
them easier to break down by the pancreatic juices.

Small Intestine
The small intestine measures about 7m in an average adult and consists
of the duodenum, jejunum, and ileum. Both the bile and pancreatic ducts open
into the duodenum together. The small intestine, because of its structure,
provides a vast lining through which further absorption takes place. There is a
large lymph and blood supply to this area, ready to transport nutrients to the rest
of the body. Digestion in the small intestine relies on its own secretions plus
those from the pancreas, liver, and gall bladder.

The Large Intestine

The large intestine averages about 1.5m long and comprises the caecum,
appendix, colon, and rectum. After food is passed into the caecum a reflex action
in response to the pressure causes the contraction of the ileo-colic valve
preventing any food returning to the ileum. Here most of the water is absorbed,
much of which was not ingested, but secreted by digestive glands further up the
digestive tract. The colon is divided into the ascending, transverse and
descending colons, before reaching the anal canal where the indigestible foods
are expelled from the body.

The Pancreas
The Pancreas is connected to the duodenum via two ducts and has two
main functions:
• To produce enzymes to aid the process of digestion.
• To release insulin directly into the blood stream for the purpose of
controlling blood sugar levels.
 The pancreas is an elongated, tapered organ inside our body. It is located
across the back of the abdomen, behind the stomach. The right side of the organ
is called the head and is the widest part of the organ and lies in the curve of the
duodenum, the first division of the small intestine. The tapered left side extends
slightly upward and is called the body of the pancreas and ends near the spleen
and where it is called the tail. The pancreas is a dual-function gland. While most
glands are either exocrine or endocrine, the pancreas has both exocrine and
endocrine functions. Exocrine glands secrete substances outside the body or into
the gut, while endocrine glands secrete substances into the blood. Consequently,
the physiology of the pancreas can be considered in the context of the
substances that the pancreas releases into the gut (it does not excrete
substances outside the body) or into the blood. The pancreas has digestive and
hormonal functions:
Digestive function: From pancreas some enzymes are secreted which
take part in the food metabolism of our body. These enzymes help break down
carbohydrates, fats, proteins, and acids in the duodenum.
Hormonal function: The hormones secreted by the pancreas are
insulin, glucagon and somatostatin. We already have known that insulin and
glucagon regulate the level of glucose in the blood. Somatostatin can inhibit both
insulin and glucagon secretion.
Enzymes suspended in the very alkaline pancreatic juices include
amylase for breaking down starch into sugar, and lipase which, when activated
by bile salts, helps to break down fat. The hormone insulin is produced by
specialised cells, the islets of Langerhans, and plays an important role in
controlling the level of sugar in the blood and how much is allowed to pass to the
cells.
Products from the exocrine portion of the pancreas are called enzymes
and include trypsin, chymotrypsin, pancreatic amylase, and pancreatic lipase.
Major products of the endocrine pancreas are called hormones and include
insulin, glucagon, and somatostatin.
 Insulin is a familiar word as there are many who suffer from diabetes. But
most of us might not have heard of glucagons, which is very much an important
substance for our body. The importance of insulin and glucagon are due to their
action in maintaining the balance of blood glucose levels in our body. Glucose is
a very important element for our body. We need energy for our bodily activities.
This energy is derived from glucose. Glucose is the body's primary source of fuel.
Whatever food we consume that is transformed into glucose in our body. This
glucose is than transported to our body cells by blood to be used as energy
source. So without glucose our body will be out of energy source leading to a
shutting down of all activities. When we work hard or have not taken meal for
long time we feel hungry. This hunger is the state when our body runs short in
glucose and needs immediate refueling. In this circumstances when we take
food, the food gives supply of glucose and our body glucose comes to a stable
situation leading towards the smooth functioning of the body.

Role of Insulin:
When we take food and glucose is made from the food metabolism, this
glucose is than transported to our body cells by blood to be used as energy
source. In this phase we need a hormone named Insulin which assists the
glucose in the blood to enter in the cells. When blood glucose levels rise, cells
named beta cells in pancreas release insulin. Pancreas is an organ located
behind our stomach. Without the presence of insulin our body cells cannot take
up the glucose from the blood leading to glucose crisis in the body cells for
performing activities. If we insulin deficit, the process of glucose metabolism
begins working improperly. Instead of being transported into body cells, glucose
starts building up in the bloodstream. This situation may occur in two conditions.

1) When body cells become resistant to the action of insulin. Exactly why
the cells become resistant to insulin's effects is still not clearly known.
2) If there is deficit in glucose production in the body by the glucose
producing cells in pancreas.
 These two situations can lead towards the disease condition called
diabetes mellitus.

Role of Glucagon
When there is accesses glucose in our body, this glucose is stored for
future use by out body as fat cells. If in any case there is any shortage of glucose
in our body and there is no supply available than body goes for the alternative
way to fulfill the deficit. When blood glucose levels fall, cells named alpha cells in
pancreas release glucagon. When blood glucose is high, no glucagon is secreted
from the alpha cells. Glucagon has the greatest effect on the liver although it
affects many different cells in the body. When glucose levels are low our liver
releases the stored glucose into the bloodstream to keep blood glucose level
within a normal range and Glucagon's main function is to cause the liver to
release stored glucose from its cells into the blood.

Glucose level: insulin and glucagon

Our body requires that the blood glucose level is maintained in a very
narrow optimal range. Our body tries to maintain the blood glucose normally
between 70 mg/dl and 110 mg/dl. Blood glucose levels below 70mg/dl, is called
"hypoglycemia". A blood glucose level of 180mg/dl or more is called
"hyperglycemia". If the blood glucose is lower than optimal then our body tries to
bring it up to the optimal level. Similarly if the body glucose level is higher than
the optimal level then our body tries to bring it down to the optimal level. So
according to the body glucose level, body decides which one to secrete, insulin
or glucagon? After a meal, the amount of insulin secreted into the blood
increases as the blood glucose rises. Similarly, as blood glucose falls, insulin
secretion by the pancreatic islet beta cells decreases. On the other hand,
glucagon is secreted by the alpha cells of the pancreas when blood glucose is
low. As for example, blood glucose is low between meals and during exercise.
So for compensating the need of the body the glucoagon is secreted. Contrary to
that, when blood glucose is high, no glucagon is secreted from the alpha cells.
So we see that the insulin and glucagon secretion is coordinated. Consumption
of carbohydrates triggers release of insulin from beta cells.
Alpha cells become inhibited and cease to secrete glucagon. Opposite
happens when we have enough glucose supplied to the body. Major control of
blood glucose levels is achieved through actions of the hormones insulin and
glucagon. The slightest rise in plasma glucose leads to a decrease in glucagon
secretion and an increase in insulin secretion. The reverse occurs when plasma
glucose levels fall. Maintaining this balance is very important for our body and
any situation leading to the imbalance create disease condition.

Synthesis of the Disease

Signs and Symptoms

• Hyperglycemia – failure to produce insulin and/or insulin resistance,
glucose cannot be transported to cells due to inadequate insulin, glucose
stays in the blood stream.
• Polyuria – increased urine output due to ketone excretion and glucose in
urine increases osmotic pressure leading to increased fluid loss.
• Polydipsia – excessive thirst due to dehydration secondary to polyuria.
• Polyphagia – excessive hunger secondary to tissue breakdown and
inability of cell to get glucose due to inadequate insulin.
• Blurred/Loss of vision – chronic exposure of ocular lens and retina to
hyperosmolar fluids
• Weakness, fatigue and dizziness – decreased plasma volume leads to
postural hypotension and K loss and protein catabolism contributes to
weakness
• Glucosuria – kidneys compensate to elevated blood glucose levels by
excreting excess glucose in the urine
 • Weight loss – due to wasting of lean body mass secondary to fat and
protein metabolism.

Complications

Acute Complications
• Hyperglycemia – glucose cannot be transported to cells because of lack of
insulin.
• Diabetic Ketoacidosis – breakdown of fats produce ketones and ketones
turn the blood acidic. Symptoms include N/V and abdominal pain.
• Dehydration – body excretes large amounts of urine to eliminate
excessive glucose and ketones.
• Electrolyte Imbalance – osmotic diuresis lead to K excreted in urine:
metabolic acidosis loses excessive amounts of Na, phosphate, Cl and
bicarbonate in urine and vomitus.
• Hyperglycemic hyperosmolar nonketotic syndrome – variant of diabetic
ketoacidosis characterized by extreme hyperglycemia, profound DHN,
mild or undetectable ketonuria and absence of acidosis. Osmosis of water
occurs from interstitial spaces and cells leading to increase in blood
osmolality and osmotic diuresis.
• Hypoglycemia – a.k.a. insulin reaction or hypoglycemic reaction. It is due
to excessive use of insulin and other glucose-lowering medications
 Adrenergic Manifestations
 Neuroglycopenic manifestations

Chronic Complications
Macrovascular Complications
• Coronary Artery Diseases – atypical or silent and they often present as
indigestion, or unexplained heart failure, dyspnea on exertion or
epigastric pain. Coronary artery changes influence decreased oxygen
and nutrients to myocardium.
 • Cerebrovascualr Diseases (atheroembolitic infraction) – manifested by
transient ischemic attack and CVA’s. Increased prevalence of stroke in
clients with DM may be related to the development of diabetic
neuropathy and resultant proteinuria, HPN and platelet adhesiveness.
• Hypertension – a major risk factor for stroke and neuropathy.
• Peripheral Vascular Disease – associated with infection and trauma in
lower extremities which could lead to amputation.
• Infections – infected areas heal slowly because the damaged vascular
system cannot carry sufficient oxygen, WBC’s, nutrients and antibodies
to the injured site. UTI and Diabetic foot infection are the common
infections in DM.

Microvascular Complications
• Diabetic Retinopathy – major cause of blindness in DM clients.
Occurs in patients who have DM for at least 5 years. The retina has
the highest rate of oxygen consumption of any tissue in the body. If it
is deprived of such secondary to destruction of its capillaries, tissue
anoxia develops.
• Nephropathy - Initially, diseased small blood vessels in the kidneys
cause the leakage of protein in the urine. Later on, the kidneys lose
their ability to cleanse and filter blood.
• Neuropathy – nerve fibers do not have their own blood supply instead
rely on diffusion of oxygen and nutrients. If they are not nourished,
their transmission of impulse slows.
Risk Factors

Predisposing or Non Modifiable Factors

• Race commonly in African Americans, Hispanic Americans, Asian
Americans, Native Americans than in whites.
• Age – diagnosed after the age of 30, older people.
• Heredity -
• Sex

Precipitating or Modifiable Factors

• Poor eating habits
• Lack of exercise
• Obesity/Sedentary Lifestyle
• Stress
• Environmental factors and viral infections which could trigger an
autoimmune process that destroys beta cells.
Health Promotion and Disease Prevention

• Advice patient about the importance of an individualized meal plan in

meeting weekly weight loss goals and assist with compliance.
• Instruct patient in the importance of accuracy of insulin preparation and
meal timing to avoid hypoglycemia.
• Explain the importance of exercise in maintaining or reducing weight.
• Advise patient to assess blood glucose level before strenuous activity and
to eat carbohydrate snack before exercising to avoid hypoglycemia.
• Assess feet and legs for skin temperature, sensation, soft tissues injuries,
corns, calluses, dryness, hair distribution, pulses and deep tendon
reflexes.
• Advice patient who smokes to stop smoking or reduce if possible, to
reduce vasoconstriction and enhance peripheral flow.
• Avoiding foods high in refined sugars and saturated fats.
• Maintaining ideal body weight, starting in childhood.
• Preventing hypoglycemia and hyperglycemia with stress, illness or
exercise by closely monitoring blood glucose levels and taking early
actions.