Diabetes

2. Dr S. Vijayalakshmi
Assistant Professor, Community Medicine
MGMCRI, Pondicherry

3. Framework
•Definition of Diabetes Mellitus
•Classification of Diabetes
•Epidemiological features
•Clinical features
•Diagnosis
•Management
•Prevention

4. Diabetes is an epidemic,
 chronic metabolic disorder of multiple etiology
in which the body can’t metabolize carbohydrate, fats and
proteins
 because of defects in insulin secretion and/or action.

5. Classification of Diabetes

8. Problem Statement
World
 150 million cases
 Expected to double by yr 2025
SEAR
 30 million cases
 Expected to triple by yr 2025
India
 Prevalence 2.4%(rural),4.0-11.6%(urban)
 Diabetes Capital of the world

9. (Source: WHO 2011 NCD country profile)

10. - industrialization
- socio-economic development
- population growth
- age structure
- urbanization
Reasons for rising prevalence in developing countries

11. Agent Host Environment
IDDM Age : <30 yrs- IDDM
>30 years- NIDDM
Sedentary life style
NIDDM Sex: both Low dietary fibres
Type 1 HLA-DR3, DR4 Malnutrition
GDM Alcohol
Obesity stress
Viral infection- beta
cell destruction
EPIDEMIOLOGICAL FACTORS

17. Diagnosis of Pre-diabetes and Diabetes
Test Fasting Plasma
Glucose (FPG)
Oral Glucose
Tolerance Test
(OGTT)
Random
Plasma
Glucose
(with
symptoms)
How
perfor
med
Blood glucose is
measured after at
least
an 8 hr fast
75 gm glucose load
(drink) is ingested
after at least an 8hr
fast, Blood glucose
is measured at 2
hrs
Blood
glucose is
measured
at any time
regardless
of eating
Normal < 110mg/dl < 140 mg/dl (7.8
mmol/L)
17

18. Diagnosis of Pre-diabetes and Diabetes
Test Fasting Plasma
Glucose (FPG)
Oral Glucose Tolerance
Test (OGTT)
Random
Plasma
Glucose
(with
symptoms)
Pre-
diabetes
IFG
110-125 mg/dl
Pre-
diabetes
IGT
140-199 mg/dl
(7.8-11 mmol/L)
Diabetes
Mellitus
≥ 126 mg/dl (7
mmol/L)
≥ 200mg/dl (11.1
mmol/L)
≥ 200mg/dl
(11.1
mmol/L)
(with
symptoms)
18

19. HbA1C
Percentage of HbA to which Glucose
is attached
Normal: <5.7 %
Pre-diabetic: 5.7-6.4 %
Diabetic: >6.5 %

20. Type I or Type II Diabetes Mellitus

21. Investigations during Follow up
1.Urine sugar,2 hr PP (once a week)
2.Blood Sugar-FBS,PPBS (once in 3-6 months)
3.Lipid profile (Once in a yr)
4.ECG (Once a yr)
5.Urine albumin
6.Blood Urea, Serum creatinine
7.Retinoscopy (Once in a yr)
8.Glycated Hb (Once in 3-6 months)

23. Management of diabetes mellitus
TREATMENT OF
DIABETES
DIET
LIFESTYLE
MODIFICATIONS
OHA INSULIN

24. Why Diet Management?
 To control weight
 To complete nutritional requirements
 To maintain blood glucose levels in normal limits
 To correct any associated blood lipid
abnormalities

25. Diet in Diabetes

26. Diet in diabetes
1.Calories from food
~55% from carbohydrate
~30% from fat
~15% from protein
2.Calorie calculation
Overweight (sedentary)- 20 kC/kg
Normal wt (sedentary)- 30 kC/kg
Normal wt (heavy worker)- 35 kC/kg
Underweight- 40 kC/kg

27. Diet in diabetes
1. Avoid sweets
2. Avoid overeating
3. Avoid fasting
4.Avoid alcohol

28. 5. 4-5 small frequent meals
(Same amount, same time daily)
6. Almonds : to lower cholesterol level
7. Fruits: Take apple, guava
8. Avoid excessive salt

29. Lifestyle modifications
Regular exercise
Walking
Other aerobic exercises
Maintenance of weight
Stop smoking
Foot care

30. Oral anti-diabetic drugs
If satisfactory control is not possible with
Diet and Lifestyle changes alone
Sulfonylureas (Tolbutamide,Glibenclamide)
Biguanides (Metformin)
Alpha-glucosidase inhibitors (Acarbose)
Thiazolidinediones (Rosiglitazone,Pioglitazone)

32. Insulin
Different species
Bovine -Human (recombinant)
Different preparations
Soluble insulin (“plain insulin”)
Rapid-acting insulin analogues
» Lispro
» Aspart
Prolonged acting insulins
» Protamine Insulin (NPH, Isophane)
» Zinc insulin
» Glargine

33. Technique of injection
• Painless 30/31G needles
• Subcutaneous
– Abdomen
– Thighs
– Arms
• Patients should be trained

34. Insulin Therapy
• Subcutaneous
– ~30 min for onset of action
– 60-90 min for peak action
• Should be given 30 min BEFORE meals
• Start with small dose and increase as
needed

35. Complications of Insulin therapy
• Hypoglycemia
• Local
– Lipohypertrophy
– Injection site abscess
• Insulin resistance
– Insulin antibodies
• Weight gain
– In overdosage
– Insulin stimulates hunger

37. Primary Prevention
a. Population strategy
Primordial prevention
Weight maintenance
Diet
Exercise
b. High risk strategy
Avoid diabetogenic drugs (corticosteroids)
Reduce the factors causing atheroslerosis
(smoking,hypertension,high cholesterol)

40. Secondary Prevention:Targets for screening of
diabetes?
Asymptomatics with:

41. Targets for screening of diabetes?
1. History of gestational D.M or
delivery of infant weighing over 4.5 kg
2. Pregnant women
3. Adults with Tuberculosis
4. Persons on diabetogenic drugs like steroids,thiazide diuretics
5. Women with Polycystic Ovary Syndrome(PCOD/PCOS)
6. History of premature vascular disease
Symptomatics and:

42. Secondary Prevention
Early diagnosis and treatment
Maintain blood glucose level
Maintain ideal weight (Height in cm-100)
Blood pressure measurement
Routine blood glucose monitoring
Urine for ketones and proteins
Glycated Hb estimation
(6 monthly, should be <6%)

43. Secondary Prevention
 Keep sugar in your pocket
 Weight,Blood pressure measurement,Visual acuity
 Feet care
 Self Care: Adhere to diet,drugs,exercise,
investigations, periodic check–ups, recognition of
symptoms of hypoglycemia
 Identification card with treatment details

44. 44

45. Feet Care
Wash feet daily,dry them,inspect them,
sprinkle talcum powder
Avoid walking bare foot,even at home
Wear soft cotton socks and canvas shoes
Avoid tight fitting shoes,chappals
Cut nails carefully after bath
See for the sensations

46. Feet Care
 Do not use hot water bottles or heating pads or any
electrical device for heating the feet
 Do not use a pumice stone to remove callousness
 Do not sit with your legs crossed
 Do not use commercial wart or corn removers on
your feet

47. Feet Care
 Do not perform "bathroom surgery" by using
razor blades or other sharp instruments on your feet
 Do not ignore any(minor also) foot problem
 Use cream or lotion that keeps your skin soft and
free of cracks

48. Regular Self Glucose Monitoring
Tertiary Prevention
 Disability limitation if any disability
 Diabetes clinic