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Seminar on

Diabetes Mellitus

Sonsy Mathew INE, SME Gandhinagar

What is Diabetes Mellitus?

A chronic condition associated with abnormally high blood sugar Results from either deficiency of or a resistance to insulin- a hormone produced by the pancreas whose function is to lower blood sugar

D M - Definitions
Diabetes Mellitus is a complex chronic disease involving disorders of carbohydrate, protein, and fat metabolism and the development of macro vascular, micro vascular and neurological complications. It is a chronic systemic disease characterized by either a deficiency of insulin or a decreased ability of the body to use insulin. It is a group of metabolic disease characterized by elevated levels of glucose in the blood (hyper glycaemia) resulting from defects in insulin secretion or insulin action or both.

DM - Incidence
affects both males and females equally according to new estimates from researchers at the World Health Organization (WHO) the number of people with diabetes will double worldwide by 2030 the greatest relative increases will be in the Middle East, sub-Saharan Africa, and India India had 32 million diabetic subjects in 2000 and this would increase to 80 million by 2030 when compared to other states, incidence of diabetes in Kerala is higher. The incidence may be 10 to 15 per cent among elderly urban population

Types of Diabetes
Type I DM Type II DM Prediabetes Gestational Diabetes Secondary Diabetes

Types of DM

- Type I DM

earlier known as Juvenile Onset or Insulin dependent Diabetes age group < 30 peek onset - age 11 13

Etiology
hereditory genetic basis related to HLA antigen viral infection auto immunity destruction of pancreatic F cells

Pathophysiology of Type 1DM

antibodies attack islets!

Types of DM

- Type II DM

earlier known as Adult Onset or Non-insulin dependent Diabetes age group > 30 onset - gradual

Etiology
insulin resistance decreased production of insulin by pancreas increased hepatic production of glucose alteration in the production of hormones and cytokines by adipose tissue

Pathophysiology of Type 2 DM

_ Hepatic glucose output

INSULIN

Blood glucose Peripheral Tissue Uptake

diet

Types of DM

- Gestational

develops during pregnancy onset - 24 -28 weeks occur in 4%

Etiology
Carbohydrate intolerence

Types of DM

- Other Types

Genetic defects of beta cell function MODY1. - MODY 5,characterized by autosomal dominant inheritance, early onset of mild hyperglycemia. Genetic defects in insulin action eg. Type A insulin resistance, Lipoatrophic diabetes. Diseases of exocrine pancreas - pancreatitis, pancreatectomy, neoplasia Endocrinopathies - acromegaly, cushings syndrome, pheochromocytoma Drug or chemical induced- Nicotinic acid, glucocorticoids, thyroid hormone infection - congenital rubella, cytometgalovirus, coxsackie Uncommon forms of immune mediated diabetes - "stiff man syndrome" Turner's syndrome, porphyria

TYPE 1 Age of onset Body weight Prevalance Etiology <30 years Normal or under weight 0.5% Unknown Heridity: associated with HLA-Human Leukocyte antigen' Only 50% concordance in twins

TYPE 2 > 30 years Over weight Accounts for 90 of all cases Unknown Heridity : not associated with H LA types 95% concordance in twins

Auto immune diseases: 70% circulatinq Auto immune diseases: 10% ICA islet cells antibodies (ICA) Viral infections are possible trigger ketosis Insulin Treatment Common no evidence of viral infections Rare

Require to prevent Ketosis and sustain May require insulin for hyperglycemia health during stress Diet and insulin Oral hypoglycemic agents or Diet and insulin

Clinical manifestation
Polyuria Polydypsia Polyphagia Weight loss Recurrent blurred vision Pruritis skin infections, vaginitis Ketonuria Weakness fatigue dizziness often asymptomatic

Diagnosis of DM
Fasting blood Glucose Random blood glucose Post prandial blood glucose Oral glucose tolerance test IV GTT or cortisone glucose tolerance test Glycosylated haemoglobin Glycosylated albumin Connecting Peptide Ketonuria Proteinuria

Medical Management
Drug Therapy
Oral hypoglycemic agents Other agents Insulin

Diet Therapy Exercise

Medical Management
Drug Therapy
Oral hypoglycemic agents

Oral hypoglycemic agents

Type Sulfonylurea 1st Generation Tolbutamide Chlorpropamide pancreatic islets; decrease Acetahexamide glycogenolysis and gluconeogenesis enhances Allergic reactions cellular sensitivity to insulin Nausea, jaundice Stimulate release of insulin from Weight gain, hypoglycemia Mechanism of action Side effects

Contd

Oral hypoglycemic agents

Type Sulfonylurea 2nd Generation Glipizide Mechanism of action

Contd

Side effects

Stimulate release of insulin Weight gain, from Glyburide, hypoglycemia pancreatic islets; decrease GlynaseNausea, jaundice glycogenolysis and Glymipride(Amaryl) gluconeogenesis enhances Allergic reactions cellular sensitivity to insulin

Oral hypoglycemic agents

Type Meqlitinides Ripaglinide(prandin) Stimulate a rapid and short lived release of insulin from Naleglinide (Starlix) the pancreas Biquanide Metformin (Glucophage) Glucophage XR, Riomet, Fortamet Rate of hepatic glucose production augments glucose uptake by tissues, especially muscles Mechanism of action

Contd

Side effects

Weight gain Allergic reactions hypoglycemia

Diarrhea, Lactic acidosis Thrombocytopenia, Anorexia

Oral hypoglycemic agents

Type
Alpha Glucosidose inhibitors Asarbase(Precose) Meglitol(Glyset) Thiazolidinediones Pioglitazole (Actos) Rosiglitazone(Avandia

Contd

Mechanism of action

Side effects

Delay absorption of glucose from Gl tract

Gas, abdominal pain diarrhea

Increase Glucose uptake in muscle , decrease endogenous glucose productions

Weight gain, Oedema not recommended for patients with heart failure.

Dipeptidvl peptidase4(DDP-4) inhibitors Stagliptin(Januvia) Vildagliptin(Galvus)

Enhances the incretin system stimulates release of insulin from pancreatic beta cells and decrease hepatic glucose production.

Upper respiratory tract infection, sore throat head ache diarrhea

Oral hypoglycemic agents

Type Combination therapy Glucovance Avandamet Mechanism of action

Contd

Side effects

Metaglip

Combination of metformin Nausea, diarrhea, and glyburide abdominal pain, Combination of lactic acidosis, weight rosiglitazone and metfomin gain , hypoglycemia Combination of metformin and glipizide Combination of pioglitazone and glimipride

Duetact

Medical Management
Drug Therapy
Oral hypoglycemic agents Other agents

DM - Drug therapy -Other agents

Incretin Mimetic - exenatide (Byetta) Amylin Analog Pramlintide (symlin)

Medical Management
Drug Therapy
Oral hypoglycemic agents Other agents Insulin

DM - Drug therapy - Insulin

Administered in patients in whom other measures have not achieved a decreased level of blood-glucose control

Type of insulin

Time of Peak of onset faction

Duration of action

Insulin appearance

Rapid acting Regular Semilente <1 <1 2-4 4-7 4-6 12-16 Clear Cloudy

Intermediate acting NPH Lente Long acting Ultra Lente 4-8 16-18 36+ Cloudy 1-2 1-4 8-12 8-12 18-24 18-24 Cloudy Cloudy

Preparation Regular & NPH Insulin

When rapid acting or short acting insulin is mixed with longer acting insulin, draw the short acting insulin into the syringe first. Prevents contamination of the shorter acting insulin with the longer acting insulin Draw up clear, then cloudy Insuling glargine (Lantus) should not be mixed with any other insulin

Preparation Regular & NPH Insulin

Methods of Insulin delivery

Traditional subcutaneous injections Insulin pens/Prefilled syringes Jet Injections Insulin pumps Insulin Catheters Insulin Inhalation Future Insulin delivery

Insulin Pump

Internal Insulin Pump

Insulin Injection sites

Complications of Insulin Therapy

Local allergic reactions Systemic allergic reactions Insulin Lipodystrophy Resistance to injected Insulin Morning hyperglycemia

Guidelines for Insulin administration

a. Always use an insulin syringe calibrated in the same units as insulin. b. Rotate or gently roll or shake the bottle if it is other than regular insulin. c. Do not inject cold insulin; allow it to come to room temperature. d. Examine intermediate and long acting insulin vials for suspension of insulin (cloudy appearance) do not use if not cloudy. Examine human insulin for a frosty or dumping of precipitate- do not use if present.
Contd

Guidelines for Insulin administration

e. Check for and remove any air bubbles. f. When moving insulin inject air into both bottles- first into intermediate and then into regular. Withdraw the insulin first from the regular vial and the from the long acting insulin vial. g. Insert the needle into fatty tissue closer to muscle than to skin if there is little subcutaneous tissue pinch up the skin and use a 45 angle an 3/8 or AA inch needle

Medical Management
Drug Therapy
Oral hypoglycemic agents Other agents Insulin

Diet Therapy

Diet Therapy

Primary Goal improve metabolic control

Blood glucose Lipid (cholesterol) levels

Diet Therapy
Maintain short and long term body weight Reach and maintain normal growth and development Prevent or treat complications Improve and maintain nutritional status Provide optimal nutrition for pregnancy

Diets for Diabetics

Weight reducing diets
first priority in treating the obese diabetic is by weight loss important that the meals should not be missed

Sugar free diets

used for elderly diabetics who do not need insulin injection

The carbohydrate exchange system

designed to provide a method of regulating the carbohydrates precisely

Special diabetic foods these are sugar free e.g. fructose and sorbitol
unsuitable for the overweight and are expensive.

Artificial sweeteners
eg:- Saccharine, Aspartine, fructose, sorbital

Diet Management for Type I Diabetes

Consistency and timing of meals Timing of insulin Monitor blood glucose regularly

Diet Management for Type II Diabetes

Weight loss Smaller meals and snacks Physical activity Monitor blood glucose and medications

Diet Recommendations
Carbohydrate
60-70% calories from carbohydrates and monounsaturated fats

Protein
10-20% total calories

Fat
<10% calories from saturated fat 10% calories from PUFA <300 mg cholesterol

Fiber
20-35 grams/day

2003 Diabetic Exchange Lists

Food Group CHO (grams) 15 15 12 12 12 15 5 8 8 8 varies 2 0-3 5 8 varies 0 Protein (grams) 3 Fat (grams) 0-1 Calories 80 60 90 120 150 Varies 25

Starch Fruit Milk

Skim Low-Fat Whole

Other Carbohydrate

Nonstarchy Vegetables

2003 Diabetic Exchange Lists

Food Group CHO Protein (grams) Fat (grams) 0-1 3 5 8 5 Calories

Meat

Very Lean Lean Medium Fat High Fat

7 7 7 7

35 55 75 100 45

Fat

2003 Diabetic Exchange Lists

Carbohydrate Exchanges 3 g. protein, 0-1 g. fat
and 80 calories Bread: bagel, bread, English muffin, tortilla Cereal: cold and hot cereal, pasta, rice Starchy vegetables: corn, peas, potato, squash Crackers and snacks Dried beans Starch prepared foods with fat: biscuits, muffins

2003 Diabetic Exchange Lists

Fruit Exchanges
15 grams carbohydrate and 60 calories Fruit and fruit juice

Vegetables
5 g. carbohydrate, 2. G protein and 25 calories

2003 Diabetic Exchange Lists

Milk 12 g. carbohydrate, 8 g. protein and 0-8 g.
fat

Meat and Meat Substitutes Very Lean Meat (7 g protein, 0-1 g. fat and 35
calories) Chicken, turkey white meat Shellfish (clams, crab, lobster, shrimp)

2003 Diabetic Exchange Lists

Lean Meat (7 g protein, 3 g. fat and 55 calories)

Select or choice beef, trimmed of fat Lean pork Poultry, turkey dark meat

2003 Diabetic Exchange Lists

Medium Fat Meat (7 g protein, 5 g. fat and 75
calories)
Most beef products corned beef, ribs, prime grades Chicken dark meat with skin

High Fat Meat (7 g protein, 8 g. fat and 75

calories)
All cheeses Processed meats, hot dogs

Carbohydrate Counting
A serving of carbohydrate is considered 15 grams A serving of fruit or starch or 3 servings of vegetable is = to 1 carbohydrate One milk serving is considered equal to one carbohydrate

Carbohydrate Counting
Example: Meal plan = 9 carbohydrate servings 4 fruit and 5 starches or 3 fruit + 4 starches + 3 vegetables and 1 milk or 2 fruit + 4 starches + 3 vegetables and 2 milk

Medical Management
Drug Therapy
Oral hypoglycemic agents Other agents Insulin

Diet Therapy Exercise

Importance of regular exercise

Exercise lowers blood glucose by increasing carbohydrate metabolism Foster weight reduction and maintenance Increases insulin sensitivity. Increases high density lipoprotein HDL levels Decreases triglyceride levels Lowers blood pressure and Reduces stress and tension

DM Surgical Management
Pancreas transplantation Pancreas Kidney transplantation Pancreatic Islet cell transplantation

Assessment of patient with Diabetes Mellitus

Health history Physical examination

Health history
Present illness Past medical history Drug therapy Blood glucose monitoring Circulatory, cardiac or renal problems Previous hospitalizations Obstetric, history Immunizations Functional assessment Family history Review of systems Allergies

Physical examination
General survey : Level of consciousness, posture and gait, well
being

Vital signs : Tachycardia, hypertension, hypotension, Kussmoul

respiration.

Height and weight: current and usual Skin: Colour, warmth, turgor, lesion, frequent skin boils and
ulceration.

Eyes: Visual acuity, changes in eye grounds, halos around light. Mouth: Sweet, fruity breath odour. Neck: Carotid pulses, bruits, thyroid enlargement. Axilla : Acanthosis nigricans. Hands : BP limited joint mobility, painless stiffness in the hands,
Duputyrens contracture, camel tunnel syndrome, muscle wasting or sensory changes.

Physical examination
Legs: Blisters, lesions, colour, oedema, pulse, deformities,
strength, range of motion, muscle wasting, granuloma annulare hair loss, tenden reflexes.

Feet: inspection peripheral pulses, sensation, callus formation on

weight bearing areas, clawing of the toes, a feature of neuropathy, loss of plantar arch, discoloration of the skin(ischaemia) localized infection and presence of ulcers, fungal infection between nails and toes

Circulation: peripheral pulses, skin temperature, capillary refill,

sense of touch, orthostatic hypotension, numbness and tingling of lower extremities.

Genitals: Sexual dysfunction, vaginal discharge and infection. Neurological: Gait and balance, motor co-ordination, perception of
temperature touch and pain

Nursing Management Nursing Diagnosis

1. Imbalanced nutrition more than body requirement, hyperglycemia related to DM. 2. Risk for fluid volume deficit related to polyuria, secondary to DM 3. Risk for hypoglycemia related to insulin overdose, insufficient food intake or excessive physical activity. 4. Risk for hyperglycemia related to non compliance with treatment and diet. 5. Risk for injury related to decreased tactile sensation and vascular effects of diabetes. 6. Risk for infection related to hyperglycemia

Nursing Management Nursing Diagnosis

7. Knowledge deficit related to DM, therapeutic regimen, exercise, and dietary management. 8. Ineffective therapeutic regimen management related to insufficient knowledge as evidenced by continued hyperglycemia, inaccurate statements regarding diabetes and its management etc. 9. Imbalanced nutrition: more than body requirements as evidenced by hyperglycemia, weight gain 10. Risk for injury related to decreased tactile sensation, episodes of hypoglycemia 11. Risk for peripheral neurovascular dysfunction related to vascular effects of diabetes

Ambulatory and Home care Management

Prevention and Early Detection of Diabetes Insulin Therapy. Oral Agents. Personal Hygiene. Medical Identification and Travel. Patient and Family Teaching.

Diabetes: Complications
Macrovascular
Stroke

Microvascular
Diabetic eye disease (retinopathy and cataracts)

Heart disease and hypertension 2-4 X increased risk Renal disease Peripheral vascular disease

Erectile Dysfunction

Peripheral Neuropathy

Foot problems

Thank You