Diabetes mellitus

Diabetes Mellitus

What is diabetes?
Diabetes mellitus (DM) is a group of diseases characterized by high levels of blood glucose resulting from defect in insulin production , insulin action or both. It is described as a metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbance of carbohydrates , fat and protein metabolism resulting from defects in insulin abnormalities
Epidemiology:
The long term effect of DM include long- term damage , dysfunction and failure of various organs
100 million people worldwide
85-90% cases are Type II
17 million people in US (6.2% of population)
90-95% Type II
5.9 million people are undiagnosed
Approximately 1 million new cases/year

Types of diabetes :

Type 1 DM:
Occurs at any age but most common in those aged < 30 years . autoimmune disease- islets cell antibodies may initially present, patients are prone to profound weight loss and ketoacidosis. Insulin is required since diagnosis.

Type 2 DM:

80-90% of patients have this type M:F = 3:2 . Life time risk of developing type 2 DM is 10% and nearly 50% remain undiagnosed.
Risk factors:
Age> 65
Obesity
Family history of DM ( identical twins concordance 100%)
Impaired glucose tolerance test
Past maternal history of gestational diabetes or a baby > 4 kg at birth
Ethnic group – south Asian/Afro-Caribbean have 5-10x increased risk
Progressive disease resulting from impaired insulin secretion and insulin resistance. Life expectancy is decreased by 30- 40% in the age range 40-70. Onset is usually insidious , 50% have complication at diagnosis.( cardio vascular, nephropathy , retinopathy, peripheral neuropathy)




Latent auto immune diabetes of adults ( LAUDA):
6-10%with patients of type 2 DM characterized by anti glutamine & decarboxylase antibodies , associated with higher risk of ketoacidosis and increase risk of progression to insulin dependence , should be suspected if Type 2DM with:
Absence of metabolic syndrome features.
Uncontrolled hyperglycemia despite oral agents.
Other auto immune diseases ( thyroid disease,pernicious anemia )

Maturity onset diabetes of youth ( MODY):

1-2% of DM present with this type, age <25 years with positive family history
Genetic syndrome with autosomal dominant inheritance with gene mutation of glucokinaze enzyme
Gene testing is important to identify MODY as treatment differs according to type.

Gestational Diabetes:

A form of glucose intolerance that is diagnosed in some women during pregnancy. It occurs more frequently among obese women & those with family history of DM.
After pregnancy 5- 10 % of women are found to have type 2 DM
Women who had gestational diabetes have 20-50% chance of developing diabetes in the next 10-15 years.

Secondary diabetes millets:

Exocrine pancreas disease: pancreatitis , surgery, cystic fibrosis, hemochromatosis.
Genetic syndromes: Downs, Turners
Infections: CMV, Congenital rubella
Drugs: Glucocorticoids, Dilantin, beta agonists
Endocrine diseases: Cushing's, Acromegaly, thyrotoxicosis, pheochromacytoma
Others: glycogen storage disease , insulin receptor antibodies.
Management of DM:
I ) Long Term Goals:
Glycemic control:
Blood Glucose: preprandial 90-130 mg/dL, post prandial <180 mg/dL
HBA1C <7% (quarterly)
Glycemic control in DM II patients staged
Stage 1: Diet and exercise
Stage 2: Oral hyperglycemic agents
Stage 3: Combination insulin and oral medications
Blood pressure control: <130/80
Control serum cholesterol levels: <200 mg/dL
Annual urinalysis (microalbuminuria)
Attend Diabetic Education Class


II) life style modification Education:
Education is essential aspect of diabetic care. Diabetes is a chronic condition , and however well it is managed in the clinic, the patient has to manage him/her own disease the rest of the time . everyone with DM should receive education about his disease, the topics that should be covered during routine reviews include:
1-General knowledge:
DM, its progressive nature, and complications
Aims of management
Structure of diabetes services & ways to access them
Equipment required & usage instructions
2-Diet: Patients do not need a separate diet from the rest of the family or expensive diabetic food products. A diabetic diet should:
Adjust total caloric intake according to desired BMI
Recommend ≥ 5 portions of fruit or vegetables/ day
Spread food intake evenly across the day for patients
Readymade meals, processed foods & alcohol are often sources of hidden sugar

The following principles are recommended as dietary guidelines for people with diabetes:

Dietary fat should provide 25-35% of total intake calories but saturated fat intake should not exceed 10% of total energy, cholesterol consumption should be restricted to 300 mg or less/day
Protein intake can range between 10-15% of total energy (0.8-1g/kg of desired body weight). Requirements increase for children and during pregnancy. Protein should be derived both animal & vegetable source.
Carbohydrate provides 50-60% of total caloric intake of the diet . carbohydrates should be complex and high fiber.
Excessive salt intake is to be avoided specially among those with hypertension & nephropathy
3-Immunizations:
Influenza , and pneumococcal vaccine should be applied to all diabetic patients .
4-Psychological problems:
Should discuss concerns about diagnosis of DM or development of complications , counseling refer to self- help resources is needed sometimes. Teenagers with diabetes can be a particularly a difficult group to manage , often control is poor due to combination of rapid growth & rebellion against the diagnosis of diabetes . support information & advise given in specialist clinic .
5-Exercise: Encourage regular exercise
Review activity at work& in getting to & from work, hobbies & physical activity at home
Advise that physical activity can increase insulin sensitivity, decrease blood pressure, and improve blood lipid control
If appropriate we should suggest regular physical activity tailored to individual ability ( brisk walking for 30 minutes/day)
6-Smoking cessation
7- Foot care:
self care & self monitoring:
daily examination of the feet for- color changes , swelling,breaks in the skin , numbness
footwear importance of well fitting shoes.
Hygiene ( daily washing and carful drying ) and nail care
Dangers associated with procedures like corn removal
Methods to help monitoring ( e.g. mirrors if decrease mobility)
When to seek advice: if any color change, swelling, numbness ,or self monitoring is not possible


III) population and community-level interventions:
 Integrating national strategy on non-communicable diseases
 Interventions for communities at high risk of type 2 diabetes
 Conveying messages to the whole population
 Promoting a healthy diet: national action
 Promoting physical activity: national action
 Training those involved in promoting healthy lifestyles