Definition • Diabetes mellitus is a syndrome characterised by chronic hyperglycaemia and disturbance of carbohydrate, fat and protein metabolism associated with absolute or relative deficiency in in insulin secretion and\or insulin action.
Insulin allows glucose (sugar) to enter body cells to convert it into energy. Insulin is also needed to synthesize protein and store fats. In un controlled diabetes, glucose and lipids (fats) remain in the blood stream and, with time damage the body’s vital organs and contribute to heart disease.
Classification Diabetes is classified into three main types: • Type 1 previously called insulin-dependent diabetes mellitus (IDDM) • Type 2 previously called non-insulin-dependent diabetes mellitus(NIDDM) • Gestational Diabetes Mellitus(GDM)
Type 1 Diabetes Occurrence: • Autoimmune disease wherein the immune system attacks B-cells of pancreas and destroys them. The pancreas then produce little or no insulin. • Scientists do not know exactly what causes the body’s immune system to attack the B-cells, but they believe that both genetic factors and environmental factors and possibly viruses, are involved.
Characteristics: • Often develops in children and young adults, but the disorder can appear at any age. • Symptoms usually develop over a short period, although B-cell destruction can begin year earlier. • If not diagnosed and treated with insulin, a person can lapse into a life-threatening diabetic coma, also known as diabetic ketoacidosis.
Type 2 diabetes Occurrence: • The most common form of diabetes. • Due to reduce insulin secretion or peripheral resistance to action of insulin. • The result is the same as for Type 1 diabetes, glucose builds up in the blood and the body cannot make efficient use of its main source of fuel.
Often part of a metabolic syndrome that includes obesity, elevated blood pressure, and high levels of blood lipids.
Characteristics: • Contributes 90 to 95% of total diabetes and one-third not been diagnosed. • This form of diabetes usually develops in adults. • About 80% of people with Type 2 diabetes are overweight. • Increase in incidence of childhood obesity leads to Type 2 diabetes becoming more common in young people
Symptoms & Management for Type 1 and Type 2 Diabetes Symptoms: • Increased thirst and urination. • Constant hunger. • Weight loss. • Blurred vision • Extreme fatigue. • Slow healing of wounds or sores.
Management: • Diet • Exercise • Insulin for Type 1 and OHAs or insulin in Type 2 • Education • Monitoring blood glucose and therapy
Gestational Diabetes: Occurrence: • Develops in pregnancy and disappears after delivery, however with increased risk in getting later in life • Insulin resistance due to pregnancy. • Genetic predisposition.
Management: • Diet: provide adequate calories which will not lead to hyperglycemia or ketonemia. • Exercise: that does not cause fetal distress, contractions or hypertension. • Insulin: to maintain blood glucose, fasting<=95mg/dl (<=5.3 mmol/l); one hour post prandially <=120mg/dl(<=6.7 mmol/l).
Diagnosis The fasting plasma glucose test in the preferred test for diagnosis Type 1 or Type 2 diabetes. However, a diagnosis of diabetes is made by an one of the three positive tests, with a second positive on a different day:
A random Plasma glucose value (taken any time of day) of 200mg/dl or more, along with the presence of diabetes symptoms. • A plasma glucose value of 126/mgdL or more, after a person has fasted for 8 hours
An oral glucose tolerance test (OGTT) plasma glucose value of 200 mg/dL or more in the blood sample, taken 2 hours after a person has consumed a drink containing 75 grams of glucose dissolved in water. This test, taken in a laboratory or the doctor’s office, measures plasma glucose at timed intervals over a 3-hour period.
Gestational Diabetes Diagnosed based on plasma glucose values measured during the OGTT. Glucose levels are normally lower during pregnancy, so the threshold values for diagnosis of diabetes in pregnancy are lower. If women has two plasma glucose values equal to or more than any of the following values after a 100gm OGTT, she has gestational diabetes:
1-hour level of 180 mg/dL • 2-hour level of 155 mg/dL or 3-hour level of 140 mg/dL • Fasting plasma glucose level of 95mg/dL
People with impaired glucose metabolism, a state between normal and diabetes are at risk for developing diabetes, heart attacks, and strokes. There are two forms of impaired glucose metabolism.
Impaired Fasting Glucose (IFG): • Fasting plasma glucose level of 110 to 125 mg/dL, a level higher than normal but less than the level indicating a diagnosis of diabetes.
Impared Glucose Tolerance (IGT) Means that blood glucose during the oral glucose tolerance test is higher than normal but not high enough for a diagnosis of diabetes. IGT is diagnosed when the glucose level is 141 to 199 mg/dL, 2 hours after a person is given a drink containing 75 grams of glucose.
OGTT • OGTT is performed using a 75 or 100 gm oral glucose load in the morning after a noncaloric 8-hour fast. Water is allowed, but not coffee or smoking. • Test should be performed on an individual without underlying illness and/or interfering drugs. OGTT is not appropriate for a patient who is malnourished, on a restricted carbohydrate diet, or with acute and chronic illness.
Patient should be ambulatory and not to bed rest, hospitalized , or immobilized. During the test, patient should be resting comfortably. • Patient should consume an unrestricted diet containing at least 150g carbohydrate daily for three days before test. • Just a confirmatory test, not to be done regularly.
Glycated Hemoglobin (HbA1c) Test • Indicates blood glucose control over a period of approximately 3 months. • Normal range varies depending on the method the lab uses: usually 4-7%, correlating to average blood glucose of 60-150 mg/dl (3.3-8.3 mmol/l)
Should be prescribed by health care provider every three months for Type 1 diabetes and at 3-6 months intervals for Type 2, to help determine overall control. • Patient does not need to be fasting to have this blood test performed
Ketone Test • Ketone is by product of fat metabolism; presence of ketone indicates that the body is not metabolizing food properly because of lack of available insulin or carbohydrate; may indicate impeding or established diabetic ketoacidosis (DKA), a condition that requires immediate medical attention.
Method: Dipstick When to test: • When blood glucose level is consistently >300 mg/dl (16.7 mmol/l). • During period of acute illness (illness is a stress that can cause and hyperglycemia). • When symptoms of hyperglycemia accompanied by nausea, vomiting and abdominal pain are present.
Goals Of Treatment • Control high blood glucose (hyperglycemia) • Avoid low blood glucose (hypoglycemia). • Treatment of associated conditions, such as high blood pressure, cholesterol disorder and obesity. • Prevent or retard the progression of complications of diabetes such as blindness, kidney failure, heart disease, stroke and amputation of legs.
Treatment Plan • Management of Blood Glucose: Target Blood Glucose values: (as recommended by the American Diabetes Association)
However, not every person is a candidate for such tight blood glucose control. This should not be attempted in: • Frail, elderly person who have already developed the complications of diabetes such as blindness and end-stage kidney failure. • Elderly patients having frequent low blood glucose episodes.
Management of cholesterol: Target Cholesterol Levels (as recommended by the American diabetes association)
Management of High Blood Pressure • Target blood pressure in diabetic patients should be less than systolic 130/ diastolic 85 mm Hg, as recommended by the American diabetes Association. • The treatment strategy also involves correct nutrition, moderate exercise and proper medication.
Nutrition • Nutrition is an important element in diabetes management. • Diet content should be 10-2-% protein, 60% carbohydrates and 20% fats.
Do’s of diabetic diets • Consistency in diet and meal timings according to medicines. • Multivitamin containing an antioxidant such as vitamin ,beta-carotene, vitamins C and E. • Minimum of 1200 kcal/day for women and 1500 kcal/day for men.
Sodium level (salt intake) should be maintained between 2.4 and 3.0 gm/day for people without hypertension and >2.4 gm/day for people with mild to moderate hypertension. • Fibre of approximately 20- 35 gm/day from a variety of food sources should be consumed
Don’ts of diabetic diets • Avoid alcohol especially if diabetes is not in control. • Avoid in-between meals. Adhere to the time and size of the meal decided. • Avoid fasts and fasting alters body metabolism, adversely affecting the diabetic state.
Exercise • Exercise can improve the health and outlook of life. Regular and controlled exercise not only helps to increase glucose utilization but also helps to maintain desirable health.
Do’s in exercise • Check the patients for blood pressure, blood fat levels, HbA1c, health of heart, circulatory and nervous systems, kidney function, eyes and feet. • Choose exercises that fit the patient’s health. • Exercise should be preceded and followed by 5-10 minutes of slow, continuous, aerobic activities.
Remember the feet.Advice them to wear the comfortable shoes for the sport. • Watch the low blood sugar, insulin or oral diabetes medicine may lead to low blood sugar levels. • Advice the patients to keep a snack handy to avoid low blood sugar levels during the exercise.
Don’ts in exercise • Advise not to snack unnecessarily before exercise. • Uncomfortable shoes should not be worn while exercising. • Avoid exercising in extreme cold or heat. • Exceeding target heart rate of 60 to 80% of estimated maximum heart rate.
Oral Hypoglycemic Agents • OHAs are primarily used in type 2 diabetes adjunct to nutrition therapy and exercise. • Oral agents are broadly classified as follows:
Incidence of HOA failure Primary failure: About one third of of Type 2 patients fail to respond to sulphonylurea treatment within one month of initiation of therapy.
Secondary failure: • Of the patients that initially achieve satisfactory glycaemic control, about 5 to 10% go on to develop secondary failure each year, so that after 10 years only about half of the patients continue to have satisfactory response.