Diabetes Mellitus

1. Diabetes Mellitus

2. What is Diabetes? Diabetes Mellitus (sugar diabetes) is a disease characterized by high levels of sugar (glucose) in the blood Fasting glucose ≥ 7.0 (mmol/L)

3. Blood sugar and health Sugar (glucose) is an important source of energy Insulin is produced by the pancreas when blood sugar is high What is eaten is absorbed into the blood Insulin keeps blood sugar level within the normal range for health

4. Islet of Langerhans: Pancreas contains insulin-making cells in “islets” Insulinb-cells

5. Diabetes in a ‘nutshell’ • Insufficient insulin to meet the body’s needs • Either a complete lack (type 1) or relative lack (type 2) • Results in raised blood glucose levels • Untreated diabetes results in short-term symptoms and serious long-term complications • Treatment aims to keep blood glucose levels as close to the normal range as safely possible

6. Complications of Diabetes • Short term: • Symptoms of diabetes • Dehydration • Diabetic Coma • Infections • Long term: • Kidney • Eye • Heart • Circulation • Amputation

7. Symptoms of Diabetes People with diabetes often have typical complaints (symptoms): • Thirst and frequent drinking • More frequent urination, particularly at night • Unexplained weight loss • Fatigue • Blurred vision • Frequent infections : skin, genital

8. There are 2 main types of diabetes: • Type 1 (15%): Due to total lack of insulin – insulin treatment is required for life • Type 2 (85%): Plenty of insulin which does not work very well in the body. Insulin treatment may be required at some stage but is not required in all patients

9. Type 1 Young age Normal BMI, not obese No immediate family history Short duration of symptoms (weeks) Can present with diabetic coma (diabetic ketoacidosis) Insulin required Type 2 Middle aged, elderly Usually overweight/obese Family history usual Symptoms may be present for months/years Do not present with diabetic coma Insulin not necessarily required Previous diabetes in pregnancy Differences between type-1 and type-2 Diabetes Mellitus These differences are not absolute

10. The Miracle of Insulin February 15, 1923 Patient J.L., December 15, 1922

11. Treatment of Type-1 Diabetes Mellitus: Insulin must be administered into the subcutaneous pocket between fat & muscle & avoid injection into fat or muscle. Can be administered by needle and syringe or by pen device

12. Islet replacement treatment • Aim to replace the need for insulin treatment • (Kidney) Pancreas transplantation • Islet transplantation – not available in Ireland • Anti-rejection drugs required • Stem cell transplantation - experimental

13. Treatment of Type-2 Diabetes Diet/exercise Oralmonotherapy Oral combination Oral +/- insulin Insulin Diet and exercise may control condition for some time Variety of tablets available when diet & exercise no longer work Tablets can be used in combination with each other or with insulin Insulin can also be used alone

14. Prevalence of Diabetes • Diabetes is very common • It is becoming more common (particularly type-2) • 10% of the health budget spent on diabetes

15. Reason for increasing prevalence of type-2 diabetes The disease is reaching epidemic proportions because: • Rates of overweight/obesity have increased • We have become a physically inactive species • Our diets are increasingly unhealthy

16. Overweight and obesity are diagnosed by measuring weight and height (Body Mass Index (BMI)): Weight in Kg Height in metres2 Normal = 20-25 Overweight = 25-30 Obese = more than 30 Everyone should know their BMI! BMI =

17. Can Diabetes be Prevented? To be able to prevent a disease we need to be able to indentify people at particular risk of developing it

18. Risk factors for type 2 diabetes Certain people are more at risk of diabetes: • Those who are overweight/obese • People with a family history of diabetes • Women who had diabetes during pregnancy or have had a baby weighing more than 9lbs • Physically inactive people • People who have high blood pressure or high cholesterol • Age more than 45 years

19. Can Diabetes be Prevented? Risk of Type 2 Diabetes can be reduced: • Losing weight • Taking regular exercise : walking for 30 mins per day • Eating healthier food:  Less fat (burgers, fries, crisps, sweet foods)  More fibre (fruit and vegetables, wholegrain alternatives for rice, bread) • Cutting down on alcohol consumption Ultimate aim is to reduce the longterm complications

20. Diabetes Mellitus: Self Monitoring SMBG Patients can draw blood frequently to monitor their glucose levels. A glucose monitor is used to check the sugar as required

21. Glycosylated Hemoglobin: HbAlc Blood test that measures the amount of glucose that has been incorporated into the hemoglobin protein of the red blood cell (RBC). Reflects the lifespan of a RBC, so test will reveal the effectiveness of diabetes therapy for the preceding 8-12 weeks. HbA1c levels remain more stable than sugar levels. Not affected by short-term fluctuations in sugar Normal is 4-6% Evaluated periodically (1-2 per year if well controlled, more frequently if not)

22. Retinopathy Nephropathy Neuropathy Microalbuminuria A1c and relative risk of complications(type 1 diabetes): 20 15 13 Aim for AIc of < 7% 11 9 Relative Risk (%) 7 5 3 1 6 7 8 9 10 11 12 A1c (%) DCCT, Diabetes Control and Complications Trial. 1. Adapted from Skyler JS. Endocrinol Metab Clin North Am. 1996;25:243-254. 2. DCCT. N Eng J Med. 1993;329:977-986. 3. DCCT. Diabetes. 1995;44:968-983.

23. How to prevent the complications Factors other than blood sugar increase likelihood of complications and should be managed Complications can be delayed/prevented by: • Controlling blood sugars: sticking to diet/exercise programme, taking medication as prescribed • Controlling blood pressure: diet, salt restriction, medication • Controlling cholesterol levels: diet, statin tablets • Stopping smoking • Taking aspirin?