3. HISTORY & ETYMOLOGY
Diabetes:
to pass through
mellitus:
honey
Diabetes mellitus means “Sweet urine”

4. Epidemiology:
8th leading cause of death

5. INTRODUCTION
“Diabetes mellitus is a syndrome of chronic hyperglycemia due
to relative insulin deficiency,resistance or both”
• 2 MAJOR types
1. Type 1 diabetes
2. Type 2 diabetes
3. Gestational diabetes
4. Diabetes due to other causes

6. TYPE 1 DIABETES MELLITUS
• IDDM/juvnenile diabetes
• Immune mediated
• Beta cells are destroyed
• Severe insulin deficiency
• Insulin administration is must
• Onset age is before 30

7. TYPE 2 DIABETES MELLITUS
• NIDDM
• High Blood glucose level due to
decreased insulin production
Insufficient insulin action
Insulin resistance
• Onset age after 35

8. GESTATIONAL DIABETES
• Occurs in pregnant women
• Glycemic levels should be mantained during pregnancy
• Uncontrollable GD can cause
Macrosomia
Shoulder dystocia
Neonatal hypoglycemia

9. TYPE 4 DM
• Due to other causes
 Genetic defects
 Medications
 pancreatectomy

10. What is Insulin? What does it do?
-Peptide Hormone, regulates
blood sugar.
-Causes body cells to take up
glucose from the blood.
-Insulin receptors found on:
• Liver cells
• Skeletal muscles
• Adipose tissue

12. ETIOLOGY
1.GENETIC SUSCEPTIBILITY;
• Inheritence
• HLA system.more than 90% of patients with type 1 DM carry HLA-
DR3-DQ2,HLA-DR4-DQ8
• Another CFLA-4 gene has also been implicated in type 1 DM
• MODY-dominantly inherited,early onset(type 2 diabetes mellitus)

13. 2.VARIOUS FACTORS
• Poor nutrition impairs beta cell development &
function,predisposing to diabetes in later life
• Any disease that cause extensive damage to
pancreas may lead to diabetes e.g, chronic
pancreatitis

14. 3.AUTOIMMUNITY
• Type 1 DM is an immune mediated diseases
• Include HLA associations
• Association with other organ specific autoimmune diseases
e.g,autoimmune thyroid disease
• Antibodies against islet constituents are present in 90% of newly
presenting patients

15. 4.Abnormalities of Insulin
secretion and action

16. RISK FACTORS
Drugs:
Glucorticoids
thyroid hormone
beta adrenergic agonists
• Overweight
• Growth hormone excess-hypertyroidism
• Hypertension
• Smoking

18. DIAGNOSIS
Glucagon

19. TESTS
• Fasting plasma glucose level
• Plasma glucose level
• Detection of antibodies against islet of antigens in the
serum
• GLUCOSE screening
• Oral glucose test

20. American diabetes association
recommends normal plasma glucose
level
FASTING
70–130 mg/dL (3.9-7.2
mmol/L)
AFTER MEALS
less than 180 mg/dL (10
mmol/L)

21. GLUCOSE TOLERANCE TEST-WHO
CRITERIA
NORMAL IMPAIRED
GLUCOSE
TOLERANCE
DIABETES
MELLITUS
FASTING <7mmol/L <7mmol/L >7mmol/L
2H AFTER
GLUCOSE INTAKE <7.8mmol/L <7.8-11mmol/L 11mmol/L OR
more

22. Management of Diabetes Mellitus
• Nutrition
• Physical activity/exercise
• Blood glucose
• Medications
• Behavior modification

23. 1.Diet
• a basic part of management in every case
• to ensuring appropriate nutrition.
• ensuring weight control
• Fibre content of diet containing CHOs should
be high
• Excessive salt intake should be avoided
• Proteins & fats should be taken in lesser
amounts

24. Food pyramid by American diabetes
association

25. 2.Exercise
• Physical activity promotes weight reduction
• improves insulin sensitivity
• thus lowers blood glucose levels.

26. 3.Oral Anti-Diabetic Agents
There are currently
following classes of oral
anti-diabetic agents:
1) Sulphonylureas
2) Biguanides
3) Alpha-glucisidase
inhibitors
4) Glitazones
5) Other insulin secreting
drugs

27. TREATMENT OF DIABETES MELLITUS
 If glycaemic control is not achieved with lifestyle modification
within 1 –3 months, ORAL ANTI-DIABETIC AGENT should be
initiated.
 Combination oral agents is indicated in Patients who are not
reaching targets after 3 months on monotherapy
 If targets have not been reached after optimal dose of
combination therapy for 3 months, consider adding
intermediate-acting/long-acting insulin .

29. ORAL ANTIDIABETICS

30. INSULIN THERAPY
• Sources
Human insulin
Beef insulin
Pork insuln
“prepared by DNA recombinant technology by
injecting proinsulin gene into E.coli”
INSULIN PREPARATIONS
1. Rapid acting insulins
2. Short acting or regular insulins
3. Intermediate acting 4. long acting

33. “SLIDING SCALE THERAPY OF
INSULIN”
The term “sliding scale”refers to the
progressive increase in the pre-meal or
nighttime insulin dose, based on pre-
defined blood glucose ranges. Sliding scale
insulin regimen approximate daily insulin
requirement.
The insulin dose to be administered becomes greater when
blood sugar readings are higher.

34. COMMON SLIDING SCALE REGIMEN:
• Long-acting insulin (glargine/detemir) BD or TID +
short acting insulin (aspart, glulisine, lispro,
Regular) before meals and at bedtime
• Long-acting insulin (glargine/detemir) OD
• Regular and NPH, BD
• Pre-mixed, or short-acting insulin analogs or
Regular and NPH,BD

35. The general principles of sliding scale
therapy are:
• The amount of carbohydrate to be eaten at each meal is pre-set
• The basal (background) insulin dose doesn’t change. You take the
same long-acting insulin dose no matter what the blood glucose
level.
• The bolus insulin is based on the blood sugar level before the meal
or at bedtime
• Pre-mixed insulin doses are based on the blood sugar level before
the meal

37. Calculating Insulin Dose
Bolus – Carbohydrate coverage
• The bolus dose for food coverage is prescribed as an insulin to carbohydrate
ratio.The insulin to carbohydrate ratio represents how many grams of
carbohydrate are covered or disposed of by 1 unit of insulin.
• one unit of rapid-acting insulin will dispose of 12-15 grams of carbohydrate.
– range can vary from 4-30 grams or more of carbohydrate depending on an
individual’s sensitivity to insulin
For Example #1, assume:
You are going to eat 60 grams of carbohydrate for lunch
Grams of CHO disposed by 1 unit of insulin= 10
To get the CHO insulin dose, plug the numbers into the formula:
CHO insulin dose =
Total grams of CHO in the meal (60 g)
÷ grams of CHO disposed by 1 unit of insulin (10) = 6 units
You will need 6 units of rapid acting insulin to cover the carbohydrate.

38. Total Daily Insulin Requirement
The general calculation for the body’s daily insulin requirement is:
Total Daily Insulin Requirement(in units of insulin)
= Weight in Pounds ÷ 4
Alternatively, if you measure your body weight in kilograms:
Total Daily Insulin Requirement (in units of insulin)
= 0.55 X Total Weight in Kilograms
Example 1:
If you are measuring your body weight in pounds:
Assume you weigh 160 lbs.
In this example:
TOTAL DAILY INSULIN DOSE = 160 lb ÷ 4 = 40 units of insulin/day
Example 2:
If you are measuring your body weight in kilograms:
Assume your weight is 70Kg
In this example:
TOTAL DAILY INSULIN DOSE = 0.55 x 70 Kg = 38.5 units of insulin/day

39. INSULIN ADMINISTRATION
Almost always being administered via SC route
usually in arm,thigh or abdomen
Administered usually by an insulin syringe
Can be administered by insulin pump,also
known as portable pen injector

40. Insulin pump
Insulin pen

41. SITES OF INSULIN
ADMINISTRATION

42. INSULIN DOSE-summary
• Initial dose, monotherapy: Total daily requirement: 0.1
unit/kg/day subcutaneously upto 0.6 unit per kg
• When insulin is used alone, twice daily injections are
recommended for better glycemic control
• The total daily insulin dose is administered as a mixture of
rapid/short-acting and intermediate-acting insulins in 1-2
injections.
• With the 2-injection regimen, generally two-thirds of the
daily dose is given before breakfast and one-third is given
before the evening meal.
• Intensive regimen: monotherapy: Total daily insulin
requirements may progress to 2.5 units/kg or higher in
patients with obesity and insulin resistance.

44. COMPLICATIONS OF DIABETES
MELLITUS
Acute
1. diabetic ketoacidosis
2. hyperglycemia hyperosmolar state
3. diabetic coma
4. Hypoglycemia
5. periodontal diseases
Chronic
1. diabetic retinopathy
2. diabetic nephropathy
3. Diabetic neuropathy
4. Diabetic cardiomyopathy
5. Feet problems

45. “ACUTE COMPLICATIONS”

46. DIABETIC KETOACIDOSIS-DKA

47. o Complication of type 1 DM
o Medical emergency,leads to death if not
treated
o DKA develops from lack of insulin
occurs when the body cannot use sugar (glucose) as a fuel
source
 Fat is used for fuel instead. It produces toxic acids in the
blood stream called ketones, eventually leading to diabetic
ketoacidosis if untreated.
DIAGNOSIS: blood & urine tests

48. URINE ANALYSIS TEST

49. cont…
SYMPTOMS:
 Nausea
 Vomiting
 Dehydration
 Abdominal pain
 Dry mouth
 Loss of appetite
 Hyperventilation
 ketotic breath
 unconsciousness (coma)
TREATMENT:
 IV fluids-rapid saline
 For mild ORS & SC insulin
 Insulin 0.1 unit/kg body

50. 2.HYPERGLYCEMIA HYEROSMOLAR
STATE
• Extremely high blood sugar (glucose) level
• Extreme lack of water (dehydration)
• Decreased consciousness (in many cases)
• Without significant ketoacidosis
• Plasma glucose level of 30 mmol/l or greater
SYMPTOMS
• comma
• Confusion
• Dry mouth, dry tongue
• Increased thirst
• Increased urination
• Lethargy
• Nausea
• Weakness
• Weight loss

51. Cont…
Tests that may be done include:
• creatinine levels
• Blood sodium level
• Ketone test
• Blood glucose
TREATMENT
correct the dehydration
Fluids and potassium will be given through a
vein
Insulin to decrease glucose level

52. 3.DIABETIC COMA
• occurs when the blood sugar gets too high and
the body becomes severely dehydrated.
• Hyperglycemic hyperosmolar nonketotic
syndrome
• Most often in older people
• severe loss of body water can lead to shock,
coma, and death
• Death rates can be as high as 40%.

53. Cont..
SYMPTOMS
• Increased thirst
• Increased urination
• High fever
• Weakness
• Drowsiness
• Altered mental state
• Headache
• Inability to speak
• Visual problems
hospitalization with
intravenous fluids and
electrolytes such as
potassium as well as insulin
as ordered by doctor
TREATMENT:

54. 4.HYPOGLYCEMIA
• a low blood glucose level occurring in a person
with DM 1
• Due to medicines used for glucose control
• caused by sulfonylureas in people with DM 2
• lower limit of normal glucose is 70 mg/dl
(3.9 mmol/l)
SYMPTOMS:
TREATMENT
 Oral intake of glucose
 Intravenous glucose
 Glucagon

55. 5.PERIODONTAL DISEASES
 infections of gums and the bones
that hold the teeth in place
 DM causes a decrease in blood
supply to the gums making them
more susceptible to disease
 high blood sugars may cause dry
mouth and make gum
disease worse
 decrease in saliva can cause
an increase in tooth decaying
bacteria and plaque build up.

56. symptoms
• bleeding
• sore gums
• bad breath
TREATMENT
 Maintain good glucose
control.
 Brush and floss your
teeth at least twice a day
 Have a dental checkup
every six months
 Quit smoking

57. “CHRONIC COMPLICATIONS’’

58. 1.DIABETIC RETINOPATHY
• damage to the retina
• growth of friable and poor-quality new blood
vessels in the retina as well as macular edema
• lead to severe vision loss or blindness

59. Cont..
• SYMPTOMS
shapes floating in your field of vision (floaters)
blurred vision.
sudden vision loss.

60. TREATMENTS
Laser treatment Vitrectomy

61. 2.DIABETIC NEPHROPATHY
• Progressive kidney
disease,caused
by angiopathy of capilla
ries in glomeruli
• damage to kidney
filtering system

62. Signs & symptoms
• HT & fluid retention cause
EDEMA
• swelling, usually around
the eyes in the mornings
• excessive frothing of the urine
• Anorexia
• Malaise-general ill feeling
• proteinurea

63. Diagnosis
• positive microalbuminuria test
• Serum creatinine may increase as kidney
damage progress
• A kidney biopsy confirms the diagnosis
TREATMENT
Medicines to lower BP
ACE inhibitors
ARBs
Do not smoke or use tobacco products

64. 3.DIABEDIC CARDIOMYOPATHY
• disorder of the heart muscle in
people with diabetes
• can lead to inability of the heart to
circulate blood through the body
• Can lead to state HEART FAILURE
• characterized functionally by
ventricular dilation, enlargement
of heart cells & fibrosis

65. Signs & symptoms
• Chest pain
• Abdominal discomfort
• Severe chest congestion
• Cough
• fatigue

66. Treatment
• no effective specific treatment available for
diabetic cardiomyopathy
• intense glycemic control through diet, oral
hypoglycemics & insulin
• Beta blockers with ACE inhibitors can be given

67. 4.DIABETIC NEUROPATHY
“Diabetic neuropathy is damage to nerves that
occurs as a result of diabetes”
• neuropathy include:
• peripheral neuropathy-feet and legs
• focal neuropathy- specific nerve or area at any site
• autonomic neuropathy-GIT,urinary,vascular system
• proximal neuropathy- thighs, hips or buttocks

68. Signs and symptoms of diabetic
peripheral neuropathy include:
• Numbness or tingling
• Pain or burning sensations
• Loss of sensation
Signs and symptoms of
diabetic proximal
neuropathy include:
• Pain, usually on one side,
in the hips or thighs
• Weakness of the legs

69. Signs and symptoms of diabetic
autonomic neuropathy
• nausea or vomiting
• Diarrhea
• Constipation
• Dizziness
• Fainting
• Bloating
• Difficulty swallowing
• orthostatic hypotension

70. Signs and symptoms of diabetic focal
neuropathy
• Chest pain
• Eye pain
• Changes in vision
• Bell's palsy
• Pain in a localized area of the body
DIAGNOSIS OF DIABETIC NEUROPATHY
patient's symptoms
 medical history
physical exam

71. Treatment
• diabetic neuropathy cannot be cured, there are
treatments available to help manage some of the
symptoms
• keep blood glucose levels under good control
• in relieving pain due neuropathy:
– Antidepressant(duloxetine) can be given
– TCA(nortriptyline,desipramine)
– Antiseizure drugs(gabapentin & pregabalin)
– Opoid analgesics in severe cases
• Capsaicin cream is an over-the-counter topical
agent that has been shown to relieve nerve pain.

72. FOOT PROBLEMS
• Two major causes Peripheral artery
disease & peripheral neuropathy
• People with diabetes have an increased
risk of ulcers and damage to the feet
• A number of different kinds of foot
problems can occur in people with
diabetes.

73. Cont..
• Treatment depends on the exact type of foot
problem. Surgery may be required for some
cases.
• Gangrene (dry gangrene) is tissue death due
to absence of blood circulation. It can be life-
threatening if bacterial infection develops

74. Symptoms
• decreased sensation in the nerves of the legs and
feet
• tingling, pain, or burning
EXAMPLES:
• Calluses and corns-thick hardened layeres of skin

75. Cont..
• Fungal infections of
the nails, which can
appear as
thickened,
discolored, and at
times brittle nails
• athlete's foot, a
fungal infection of
the skin of the feet

76. Cont…
• Hammer toes-bent toes
• Bunions- the angling of
the big toe toward the
second toe.
• Ingrown toenails
• Cracking of the skin of the
feet, especially the heels,
due to dry skin

77. Treatment
• depends upon the type of foot problem
• wearing corrective shoes
• antibiotics or antifungals.
• tissue death cannot be reversed but treatments are
available to prevent gangrene
• surgical removal of the dead tissue is typically required,
and antibiotics are given to prevent the development of
life-threatening infections in the dead tissue. In severe
cases of gangrene, amputation of the affected part may
be necessary.

78. Cont…
• Always wash your feet with warm water and dry
them well after washing.
• Be sure that your doctor checks your feet at every
checkup.
• Stop smoking, if you are a smoker. Smoking further
increases the risk of arteriosclerosis and poor
circulation to the feet.

79. WORLD’S DIABETES DAY
14th November

80. Refrences
 Clinical medicine by Kumar & clark 6th edition
 dtc.ucsf.edu
 En.wikipedia.org
 www.mayoclinic.org
 www.nhs.uk
 Bodyandhealth.canada.com
 www.webmd.com
 care.diabetesjournals.org
 scholar.google.com
 www.diabetes.co.uk
 www.diabeteseducator.org
 www.google.com