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DIABETES MELLITUS

09:18 Dr. Madhusudan Swarnkar

 Learning Objectives

 At the end of this talk you should able to know that:

 What is diabetes mellitus - cause, risk factors,
symptoms, signs, diagnosis……

 The difference between types-1 and -2 diabetes

 What the complications of diabetes are and how they

can be prevented
 Diabetes mellitus
3

 "Diabetes" comes from the Greek word for "siphon", and

implies that a lot of urine is made.
 The second term, "mellitus" comes from the Latin word,
"mel" which means "honey", and was used because the urine
was sweet.

09:18
 Definition:-
It is a heterogeneous metabolic syndrome
characterised by
polyurea, polyphagia, polydypsia,
hyperglycemia and glycosuria
The underlying cause of diabetes is absolute or
relative deficiency in insulin secretion and/or insulin
action that controls metabolism of carbohydrate, fat,
and protein.
4 09:18
 Magnitude of the Problem
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 It is an ‘Iceberg disease’. It is 4th leading cause of death in

USA.
 As per estimates of WHO, worldwide approximately 422
million with people affected diabetes were which are
expected to be almost double by 2025 with highest no of
cases in India and China.
 In developed, industrialized countries, prevalence rates of
as high as 10 to 20% may occur
 Rising prevalence in developing countries associated with
industrialization and urbanization, indicating role of
environmental factors like quality of life09:18
and lifestyle.
 Facts
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 Every six seconds there is one person who dies due to

diabetes, which is 10 deaths every minute, and 600
deaths every hour!

 More deaths occur due to diabetes than HIV, TB, and

Malaria put together.

 Total number of diabetes cases in the world is around

422 million, which is more then USA population. (2014)
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 Facts
7

 world’s highest case load in China having around

110 million and India at around 70 million cases f/b
USA there are over 29 million cases of diabetes,

 46% of these cases are not even diagnosed, that

means that they are not taking any precaution of
medicines since they even do not know that they are
suffering from Diabetes.

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 India
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 It is reaching potentially epidemic proportions in India b/c

Population of India has an increased susceptibility to DM

 DM is associated with various complications and these are

occurring at a relatively younger age within the country.

 In India, the steady migration of people from rural to

urban areas, the economic boom, and corresponding
change in life-style are all affecting the level of diabetes.

 India has the unfortunate privilege of being the “Diabetes

capital” of the world, 09:18
 India..
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 The prevalence rates have been estimated to be 12% in

urban areas and 4% in rural areas.
 diabetes prevalence over the past 4 decades has
increased fourfold and 39 million cases in 2000
expected to increase to 79 million by 2030
 Indians who migrate to affluent countries develop very
high prevalence rates of 10 to 20%,
 indicating high racial predisposition that Indians and
other South Asian populations have for diabetes
 which gets expressed whenever we get affluent
conditions.
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 Classification
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 Primary
 Type 1 or insulin dependent Diabetes Mellitus
 Type 2 or Non-insulin dependent Diabetes Mellitus

 Impaired glucose tolerance and impaired fasting glucose

 Gestational Diabetes Mellitus

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 Classification - Secondary
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 Pancreatic pathology-
 cystic fibrosis, pancreatitis, tumours of pancrease, trauma
 Excessive production of hormones antagonistic to insulin-
 growth hormone (acromegaly), gluacon (glucagonoma),
glucocorticoid (cushing’s syndrome), thyroid hormones
(hyperthyroidism), placental lactogen(Gestational diabetes mellitus)
 Long term use of drugs:
 corticosteroids, thiazide diuretics, phenytoin, OCPs
 Liver diseases can also result in DM
 Genetic syndromes associated with DM
 down syndrome, turner’s synd. Lawrence Moon09:18
Beidel syndrome
IDDM (now called Type - 1 Diabetes or T1D)
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 This comprises 5 to 10% of all diabetes.(most severe form)

 It is due to absolute insulin deficiency as a result of
pancreatic beta cell destruction.
 More prone to acute metabolic decompensation & death
 Associated with other autoimmune diseases
 The age at clinical onset or diagnosis is usually below 30
years (highest among 10-14 years group)& abrupt onset
 Has HLA linked genetic association but F/h usually absent
 Ketones present in untreated
 All patients of this type need exogenous09:18
insulin for survival
 NIDDM (Type - 2 Diabetes or T2D
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 comprising 85 to 90% of all diabetes cases.

 The disease takes a very silent course and is quite often
detected on a routine, screening urine or blood test, with
diagnosis being often made after 40 years age.
 It has a very strong genetic (family history) component.
 obesity is frequently associated with T2D,
 though in developing countries, many of the subjects with
T2D may not be obese
 Associated with under activity & common among women
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Type 1 DM-autoimmune disease Type 2 DM
Pancreatic B cell destruction
Absolute deficiency of insulin
5-10% of all cases
MC subtype diagnosed in pts
<20 yrs of age
Genetic, autoimmune,
environmental
C-peptide very low/undetectable
Medication-insulin absolutely
necessary
Combination of peripheral
resistance to insulin and inadequate
secretory response by the
pancreatic B cells.
Relative insulin deficiency
90-95%have type2.majority OBESE.
ADULT onset. also in children and
adolescents.
Genetic, obesity, sedentary lifestyle,
race, ethnicity.
Detectable
Oral agents, insulin commonly used.
 IGT and IFG
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 These are progressive stages of T2D

 Both IGT and IFG are themselves strong risk factors for
future development of diabetes.
 Proper lifestyle management (Diet, Exercise and Weight
reduction) prevents progression to the later stage.
 In the natural course, about 1/3rd each of IGT subjects will
develop diabetes, or remain as IGT or revert back to
normal.
 The microangiopathic complications (Retinal and Renal)
which are characteristic of diabetes are rare in IGT;
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 Gestational diabetes
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 The condition is present when blood glucose values are

above normal but still below those diagnostic of
diabetes

 GDM is a temporary condition that occurs in

pregnancy and carries long term risk of type 2
diabetes.

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 Malnutrition Related Diabetes
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 In developing countries in the tropics, young people with

diabetes may present with a constellation of clinical
features including
 onset usually below 30 years age,
 average or low body weight (BMI < 30)
 moderate to severe hyperglycaemia,
 usually non - proneness to ketoacidosis unless there are
precipitating conditions as infections,
 the requirements of large dose of insulin for metabolic control
and
 frequently a history of malnutrition in infancy and early
childhood. 09:18
Determinants - Risk Factors for Diabetes (T2D
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 The two most imp. determinants of diabetes are

1. genetic background (family history) and 2. obesity.

 for diabetes, “genetics loads the cannon and obesity

finally fires it”.

 Risk factors may be grouped as

 “Non Modifiable” (Age, Sex, Genetic and Racial factors) and
 “Modifiable” (Obesity, physical activity, nutritional factors,
stress, drugs, infections and chemical toxins, etc).
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 Genetic Factors
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 NIDDM shows strong family aggregation.

 Twin studies and familial studies have provided firm

evidence that the role of genetic factors is relatively high.

 With the current status of knowledge, it seems that

diabetes is a “polygenic” disease and not possibly due to
defect in a single gene.

 History of diabetes among parents, grandparents and first

degree relatives predisposes a person to high risk of
developing diabetes. 09:18
 Host Factors
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 Age : Increasing age increases the risk.

Most cases are detected during the middle age.

 Sex : Type 1 common among men and type 2 among

women.

 Race : South Asian populations including Indians may be

at high risk.

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 Obesity :
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 Obesity - a very strong risk factor for Type 2 DM.

 The role of obesity is independent of racial factors.

 In addition, central distribution of body fat (abdominal,

visceral, apple – shaped fat distribution and measured in
terms of Waist Circumference or Waist Hip ratio) is an
important risk factor, independent of total body weight.

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 Physical inactivity
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 physical activity increases insulin sensitivity.

 The protective effect of physical activity is

independent of obesity;
 Means - an obese person who is physically active and
fit would have lower risk of diabetes (and other life
style diseases) than a normal weight person who is
physically inactive and unfit.

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 Nutritional Factors
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 There is increasing evidence that increased

dietary intake of saturated fat and decreased
intake of fibre can result in lowered insulin
sensitivity and impairment of glucose tolerance.

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 Foetal and Early Childhood Influences
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 poor maternal nutrition during pregnancy, and

malnutrition during early infancy may be associated with
insulin resistance, obesity, impaired glucose tolerance,
raised blood pressure and occurrence of metabolic
syndrome in the same person during his / her adult life.

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 Socio-economic class
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 Prevalence of DM is no longer related to

socioeconomic class

 Previously it was more among higher class than

lower class because of changes in life style due to
advancement in industrialization and urbanization

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 Stress
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 Several states of physical stress and trauma can

lead to glucose intolerance through altered
hormonal mechanisms but whether they can
permanently lead to diabetes is not established.

 Similarly, the role of mental and social stress as

contributory factor in diabetes mellitus has been
suggested but remains unproven.

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 DIAGNOSIS
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Investigation
1. Urine Testing
a} Glucosuria
b} Ketonuria
2. Single Blood Sugar Estimation (Random plasma glucose
conc.>200mg/dl).
3. Screening By Fasting Glucose Test
4. Oral GTT
5. Other Test
a} Glycosylated hb (HbA1c)
b} Screening for diabetes associated complication
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 Diagnostic Criteria
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 Symptoms of diabetes with casual plasma glucose ≥ 200

mg/dl
 Fasting plasma glucose ≥ 126 mg/dl( fasting means no
caloric intake for at least 8 hours)
 Two hours post load glucose ≥ 200mg/dl during an OGTT
(75 gms of anhydrous glucose dissolved in water)
 IFT- fasting plasma glucose 111- 125 mg/dl
 IGT- Two hours post load glucose 140-199 mg/dl
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 Urinary Albumin excretion
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 Microalbuminuria-urinary excretion of the albumin

below the level of detection by routine dipstick testing
but above normal
 Earliest marker of diabetic nephropathy.

 Risk factor for cardiovascular disease in type1&2 DM

 Associated with high BP and poor glycemic control.

 Screening after 5 yrs of diag. in Type1 DM

 Type2 DM-should began at the time of diagnosis,
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Glycated hemoglobin(glycosylated Hb, HbA1c)
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 Hemoglobin to which glucose is attached non-

enzymatically and irreversibly.
 Amount depends on blood glucose level & lifespan of
RBCs.
 Expressed as % of total Hb.
 Normally <5% of Hb is Glycated.
 In D.M recommended HbA1c is less than 7%.
 HbA1c of 6% corresponds to 135mg/dl serum glucose.
 with every rise of 1% serum glucose increase by 35mg/dl.
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 Diabetes owes its importance to the fact that it is a silent killer.
It leads to a large number of serious sequelae which are disabling,
besides drastically reducing the quality of life
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Complications

Diabetes: Complications
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Macrovascular Microvascular
Stroke Diabetic eye
disease
(retinopathy and
cataracts)
Heart disease and
hypertension
2-4 X increased risk
Renal disease

Peripheral Erectile Dysfunction

vascular disease

Peripheral Neuropathy

Foot problems

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 Management of Diabetes
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Insulin ± oral agents

Oral combination

Oral monotherapy

Diet & exercise

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 Prevention and Control
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 The broad strategy for prevention and control of

diabetes will remain the same as for any NCD, including
primary, secondary and tertiary levels of prevention.

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 Primordial Prevention :
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 policies and practices that contribute to good health for

everyone, regardless of whether they have diabetes,
 IEC strategy to educate and motivate the community and
individuals- exercising regularly, eating healthily, avoiding
smoking and controlling blood pressure and lipids.
 create general awareness in the community regarding
diabetes, its risk factors and complications and regarding
its potential for management, treatment and control.
 community awareness drives, using prominent personalities,
who are themselves diabetics, is a promising trend and
should be utilized. 09:18
 Primary prevention
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 include the population strategy, educating both,

 thegeneral community (mass approach) and
 specific groups (group approach)

 “individual high risk strategy”, focusing on

 individuals who have strong family history of DM,
 who are changing from active to more leisurely lifestyle (as the
newly rich), are obese,
 have evidence of IFG or IGT,
 have other cardiovascular risk factors as hypertension and
dyslipidaemia
 women who have history of Gestational DM or history of giving
birth to babies weighing > 4kg. 09:18
 Secondary Prevention :
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 through early diagnosis and prompt treatment, mainly by way

of screening programmes. The strategies could be either
 “population screening” by screening the entire population or a
selected random sample, which is fruitful only if the prevalence
of diabetes is very high or else for research or health planning
purposes.
 “selective screening” undertaken in groups of people at high
risk, as those with family history, obese persons (BMI > 25),
aged more than 40 years in high prevalence populations,
women giving history of GDM, those with history of IGT / IFG,
or those with hypertension or dyslipidaemia.
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 Thirdly, “Opportunistic Screening” employed when

high risk individuals come in contact with the Doctor,
e.g. Obese person, hypertensive, having IHD, having
family history, etc. once such a person reports sick.

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 INDIAN DIABETIC RISK SCORE (IRDS)
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 Developed by Madras Diabetes Research Foundation

 This scoring is done to identify high risk group for Diabetes
and also to raise awareness about diabetes and its risk
factors.
 Scoring method makes the screening procedure more cost
effective by at least 50 percent.
 Cut off point/score at or above 60 constitute very high risk
group, 30 to 50 constitute moderate risk group and less than
30 constitute low risk group.
 Risk score also helps in prevention of type 2 diabetes by
increasing physical exercise and reducing waist
measurement. 09:18
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 WHO has focused this on 2016 World Health Day,

on diabetes because:
 Rapidly increasing low- and middle-income countries.
 Preventable

 Diabetes is treatable.

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 Tertiary Prevention :
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 to follow up the patient,

 to advocate continuous treatment,
 to educate the patient about importance of treatment and
the various precautions to be taken by them.
 presence of diabetes is a major risk factor for
development of IHD and other CVD and hence a tight
control on blood sugar levels for prevention of IHD/ CVD.
 complications of diabetes particularly CVD are much
higher if concomitant hypertension is also present and
hence the need of monitoring and adequate control of BP
in all diabetics as a part of tertiary prevention.
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