Diabet

es
Dr. Abhishek
Bhargav
DNB (MED), MNAMS, FRSH (UK)
Consulting Physician &
 WHAT YOU NEED TO KNOW
ABOUT DIABETES

 Commonly known as having Sugar or

Madhumeh in Hindi.
 It is a disease in which the body
either does not produce enough
insulin or is unable to use the insulin
 DIABETES
 India …………….the Diabetic Capital of the
world!!!
 It is estimated that 20.8 million people in
US or 7% of the population has diabetes.
 Nearly 1/3 are unaware of it and are
undiagnosed.
 Throughout the world, estimate is 150
million people have diabetes.
 80 to 90% have Type 2 diabetes.
 TYPES OF DIABETES:
 TYPE 1 OR INSULIN DEPENDENT
DIABETES.
 TYPE 2 OR NON INSULIN DEPENDENT
OR
MATURITY ONSET DIABETES.
 GESTATIONAL DIABETES
 Type 1
 Onset generally before 30 yrs
 Lean body habitus
 Requirement of insulin
 Propensity to develop ketoacidosis
Type 1 diabetes: before & after
insulin
Type 1 diabetes: before & after
insulin
 Type 2
 Generally after 30 yrs
 Usually obese (80%)
 Elderly may be lean
 May not require insulin initially
 Assoc Insulin resistance, HTN, CVD,
Dyslipidemia, PCOS
 TYPE 2 DIABETES

Co- morbid conditions:

 Hypertension
 Dyslipidemia
 Athero sclerosis
 Coronary artery disease
 Peripheral vascular disease
 Risk factors
 Age 45 and over
 Family Hx ( first degree relatives with type 2)
 Ethnicity ( African American, Hispanic, South
Asian, Pacific Islander, and Native American)
 Hx of gestational diabetes.
 Delivery of infants weighing 9 or more lbs.
 Poly Cystic Ovary Syndrome ( PCOS )
 Overweight esp. with abdominal obesity
 Presence of cardio vascular disease,
hypertension, impaired glucose
 Physical inactivity
 Gestational Diabetes

Gestational Diabetes
temporary condition during pregnancy
occurs in 3.5 - 3.8% of all pregnancies
Increases risk for developing other types
later in life for both mother and child
 Gestational Diabetes
Risk Factors

A previous diagnosis of GDM

Age over 35 years
Obesity
A history of polycystic ovary syndrome
Hirsutism (excessive body and facial hair)
Acanthosis nigricans (a skin disorder
characterized by the appearance of darkened
patches of skin)
Being a member of a population considered to be
at high risk for diabetes, including women of
Aboriginal, Hispanic, South Asian, Asian or African
descent.
 PRE DIABETES

 Fasting Blood sugar 120 to 125 on 2

separate occasions
 2 hour OGTT 140 to 199
 Usually asymptomatic
 SIGNIFICANCE OF
DETECTING PRE DIABETES

 Converts to diabetes in 4 to 7 years

 Can be delayed with life style
changes
and weight loss of 5 to 10% of body
weight.
 Medication use may be indicated
 Early treatment can delay
complications from diabetes
 METABOLIC SYNDROME

 Hypertension
 Dyslipidemia (low HDL, High TG)
 Waist measurement more than 35”
for women and more than 40” for
men
 For Asian women, waist more than
32.5” and higher than 35” for men
 Insulin resistance
 Symptoms
 May be  Recurrent
asymptomatic intermittent
 Polyuria blurred vision.
 Polydypsia  Generalized pruritis
 Polyphagia or vulvo vaginitis
 Weight gain
 Peripheral
neuropathy
 Unexplained
weight loss
 Sexual dysfunction
such as ED.
 Recurrent skin
infections
 Diagnosis
 Fasting plasma glucose 126 or above
on at least 2 separate occasions.
 Random plasma glucose of 200
mg/dl or more on 2 separate
occasions.
 Abnormal GTT (Plasma Glucose of
200 mg or more at 2 hours)
 Tests
 FBS/ PPBS
 HbA
1c

 Home blood glucose (HBG)

 Urine testing

 GTT
 HbA1C - Use &
Interpretation
 Mean RBS HbA1C
 345 12
 310 11
 275 10
 240 9
 205 8
 170 7
 135 6
 Treatment

Unfortunately,
THERE IS NO CURE!
 TREATMENT OPTIONS

LIFE STYLE CHANGES

 EDUCATION

 WEIGHT REDUCTION

 DIET

 DIET + EXERCISE

 DIET + EXERCISE + MEDICINES

 The multi-disciplinary team
 The cornerstone in diabetes management:
 Diabetologist
 Family Physician
 a specialised nurse
 a specialised dietician
 a chiropodist
 a specialised social worker
 a psychologist
 close collaboration with other relevant
departments
 Goals
 HbA1c < 7
 Post-prandial blood glucose values <
200mg/dl
 Pre-prandial blood glucose values <
140mg/dl
 Glycaemic goals less strict for very young
children
 Goals realistic and individualised in
puberty
 Prevent end organ damage
 Diabetes education
 Initial ‘survival’ education:
 the causes of diabetes
 OHAs

 insulin management

 injection technique

 blood glucose measurements

 acceptable blood glucose values

 advice about hypo- and hyperglycaemic

episodes
 dietary advice
 Diabetes education

 The knowledge and skills of the

patient should be regularly assessed
 Re-education should be performed

accordingly
 Treatment
Education
Diabetes education
is an important first
step. All people with
diabetes need to
learn about their
condition in order to
make healthy
lifestyle choices and
manage their
diabetes
 Treatment

Lifestyle Management
Learning to reduce stress levels in day-
to-day life can help people with
diabetes better manage their disease.
 Treatment

Physical Activity
Regular physical activity helps your
body lower blood glucose levels,
promotes weight loss, reduces stress
and enhances overall fitness.
 Effects of exercise

 Increases insulin sensitivity

 Improves the physical state

 Reduces the risk of cardiac diseases

 Reduces the risk of hypertension

 Does not improve metabolic control

 Increases the risk of hypoglycaemia

 Treatment

Weight Management
Maintaining a healthy weight is
especially important in the
management of type 2 diabetes.
Food Guide Pyramid:
Asian
Food Pyramid:
Vegetarian
 Treatment

Nutrition
What, when and how much you eat all
play an important role in regulating
how well your body manages blood
glucose levels.
 Diet: principles
 Number of meals:
 3 main meals
 3 snacks

 adapted to age, physical activity

and insulin regimen
 Energy intake:
 1000 calories (4180 Kj) + 100
calories/year of age
 50–55% of energy from
carbohydrates
 30% of energy from fat

 15–20% of energy from protein

 Carbohydrates

 Glycaemic index (GI):

 carbohydrate ranking system
 based on post-prandial blood glucose

response
 low GI = slow, sustained blood glucose

response (e.g. rice, pasta)

 high GI = rapid and high blood-glucose

response (e.g. white bread,

candy/sweets, cornflakes, honey, sugar)
 Dietary Recommendations
 Fiber 20-35g/d
 Sodium <3g-4g/d
 Cholesterol <300mg/d
 Caloric sweeteners including sucrose
acceptable
 Alcohol may increase the risk for
hypoglycemia & hence if required
should be taken with food
 OHA
 Insulin Secreatagogues
 Biguanides
 Alfa glucosidase inhibitors
 thiazolidinedones
 Insulin Secreatagagues
 Sulfonylureas
 Non sulfonylureas

 MOA: increase insulin

 SE: hypoglycemia, weight gain
 CI: renal/liver disease
 Expected reduction in HBA1c: 1-2%
 Biguanides
 MOA: decrease hepatic glucose
production, weight loss, decrease insulin
resistance
 Eg: metformin
 Expected reduction in HBA1c: 1-2%
 Dose: 500- 2000 mg/d
 ADV: no hypoglycemia
 SE: lactic acidosis, nausea
 CI: creat > 1.5mg/dl
 Alfa Glucosidase Inhibitor
 Decrease glucose absorption
 Eg: Acarbose, Miglitol, Voglibose
 Expected reduction in HBA1c: 0.5%
 ADV: no hypoglycemia, can use in
Type 1
 SE: GI flatulence
 CI: Renal/liver disease
 Thiazolidenedione
 MOA: decrease Insulin resistence,
Increase Insulin utilization
 Eg: Rosiglitazone, Pioglitazone
 Expected reduction in HBA1c: 1-2%
 ADV: Decrease Insulin & Sulfo
requirements
 SE: LFT derangement
 CI: CCF
DRUG DOSE (mg) ACTION

Chlorpropamide 100-500 > 48

Glibenclamide 5-10 12-18

Glimepride 1-8 24

Glipizide 5-10 24

Glyclazide 40-80 12-24

Repaglinide 0.5-16 2-6

Nateglinide 180-360 2-4

 Problems with oral therapy
 Only moderately effective
(~1-2% lowering of HBA1c)

 Type 2 diabetes is a progressive disease

 (~1% rise in HBA1c in 4 years)

 Progressive addition of therapies necessary

to achieve target blood sugars

 Specific problems:
 Long acting sulphonylureas: prolonged
hypoglycaemia
 Metformin: lactic acidosis
 INSULIN
 Insulin:
 subcutaneous
 multiple dose rapid-acting insulin before meals,
or
 combination of rapid- and intermediate-acting
insulin twice daily
 insulin requirements may exceed
1.5–2 IU/kg/24 hours
 Insulin
 All children with Type 1 diabetes
must have insulin
 Consequences of long-term insulin

omission:
 growth retardation
 delayed puberty

 poor metabolic control

 microvascular complications

 short life expectancy

 poor quality of life

Low C peptide levels

Give Insulin
 Types Of Insulin
 Short acting: 3-6hrs
 Intermediate acting: 10-18 hrs
 Long acting: 18-24 hrs
 Combinations: 10-16 hrs
 Short Acting
 Lispro :before or after meal
 Aspart:before or after meal
 Regular: 30 mins before meal
 Glulisine: launching shortly in India
 Intermediate Acting
 NPH
 Lente
 Long Acting
 Ultra lente
 Glargine: No peak
 Detemir
 Combinations
 75/25- 75% protamine lispro, 25%
lispro
 30/70- 70% NPH/aspart, 30%
regular/aspart
 50/50- 50% NPH/aspart, 50%
regular/aspart
Insulin types and duration
of action
Insulin Onset Peak Maximal
of
preparation action duration
action (h) (h)
(h or
min)
 Short-acting 1–3 6–8
 Intermediate-acting 4–12 18–24
30 min.
 Premixed insulin 30/70 5–9 18–24
1–2 h
 Premixed insulin 50/50 1–3 18–24
0.5–1 h
 Rapid-acting insulin 1–3 3–5
analogue 0.5–1 h
10–20
min.
 Short-acting insulin
 Clear solution
 Indications for use:
 daily management of
diabetes, alone or in
combination with
intermediate-acting insulin
 hyperglycaemia
 sick-day management
 intravenous therapy
 Intermediate-acting insulin
 Cloudy solution (should be thoroughly
mixed before use)
 Indications for use:
 daily management of diabetes,
alone or in combination with
short-acting insulin
 Pre-mixed insulin
 Cloudy solution (should be thoroughly
mixed before use)
 Indications for use:
 daily management of diabetes,
alone or in combination with
short-acting insulin
 Storage of insulin
 Stable at room temperature for
weeks
 Should not be exposed to

temperatures > 25ºC or under

freezing point
 Unused vials and cartridges should

be stored in the refrigerator

 Should never be exposed to sunlight

 Should never be frozen

 Injection sites
 Short acting insulin:
 injected subcutaneously into the abdomen at
a 45° angle

 Intermediate-acting and pre-mixed

insulins:
 injected subcutaneously in the front of the
thighs or into the buttocks at a 45° angle
 Insulin absorption
 Factors influencing insulin absorption:
 injection site
 injection depth

 insulin type

 insulin dose

 physical exercise

 skin temperature
 Insulin requirements
 Remission period
 < 0.5 IU/kg/24 hours

 Pre-pubertal period

 0.6–1.0 IU/kg/24 hours

 Pubertal period
 1.0–2.0 IU/kg/24 hours
 Long-term management
 Twice daily or multiple insulin
injections
 Regular blood glucose measurements

 At least 4 visits to out-patient clinic

every year
 HbA
1c measurements once every 3
months
 Regular screening for diabetes related

complications
 Insulin regimens
 Insulin regimens should be:
 adjusted to age, maturity and motivation
 as simple as possible

 Patients for multiple injection therapy

should:
 be selected carefully
 understand the relationship between insulin,
food and physical exercise
 be motivated and have family support
 be willing to measure blood glucose several
times each day
 be willing to inject insulin outside home also
 Insulin regimens
 Most widely used insulin regimens:
 twice-daily injections, mixture short and
intermediate, before breakfast and the
evening meal
 three daily injections, mixture short and

intermediate before breakfast, short-

acting before the evening meal and
intermediate-acting before bed
 short-acting insulin before main meals,

intermediate before bed

 Insulin distribution
 Twice daily injection regimen:
 2/3 of daily dose before breakfast,
 1/3 before supper
 both 2/3 intermediate-acting and 1/3 short-acting insulin
 Three-times daily injection regimen:
 40–50% before breakfast (2/3 intermediate- and 1/3 short-
acting)
 10–15% short-acting before supper
 40% intermediate-acting before bed.
 Multiple injection regimen:
 30–40 % (intermediate) before bed
 the rest (short-acting) before main meals
 Insulin adjustments
Twice-daily injection regimen:
 Blood glucose high: Dose of insulin to increase
 Before breakfast or overnight Evening
intermediate-acting
 Before lunch Morning short-acting
 Before dinner Morning intermediate-acting
 Before bed Evening short-acting

 Blood glucose low: Dose of insulin to decrease

 Before breakfast or overnight Evening
intermediate- acting
 Before lunch Morning short-acting
 Before dinner Morning intermediate-acting
 Before bed Evening short-acting
 Insulin adjustments
Three-times daily injection regimen:
 Blood glucose high: Dose of insulin to increase
 Before breakfast or overnight Evening
intermediate- acting
 Before lunch Morning short-
acting
 Before dinner Morning
intermediate-acting
 Before bed Evening short-acting

 Blood glucose low: Dose of insulin to decrease

 Before breakfast or overnight Evening
intermediate- acting
 Before lunch Morning short-
acting
 Before dinner Morning
intermediate-acting
 Before bed Evening short-acting
 Insulin adjustments

Basal-bolus (multiple injection) regimen:

 Blood glucose high: Dose of insulin to increase
 Before breakfast or overnight Evening intermediate-
acting
 Before lunch Morning short-acting
 Before dinner Lunch time short-
acting
 Before bed Evening short-acting

 Blood glucose low: Dose of insulin to decrease

 Before breakfast or overnight Evening intermediate-
acting
 Before lunch Morning short-acting
 Before dinner Lunch time short-
 The remission phase
 Duration from weeks to months
 Shorter in young children

 Decreasing insulin requirements

< 0.5 IU/kg/24 hours

 Once daily insulin injection is often

sufficient in Type 1
 Insulin injections should not be

abandoned in Type 1
 Complications
 Acute
 Chronic
 Acute Complications
 Diabetic Ketoacidosis
 Hyper Osmolar Non Ketotic Coma
 Diabetic Ketoacidosis
 Characterised by:
 absolute insulin deficiency
 increased level of counter regulatory
hormones

 Etiology:
 newly diagnosed
 infections
 insulin omission
 Symptoms and signs

 Dehydration
 Vomiting

 Loss of weight

 Kussmaul respirations

 Acetone smell

 Impaired sensorium

 Shock
 Diagnosis
 Clinical appearance
 Hyperglycaemia

 Ketonuria

 Ketonaemia

 Plasma bicarbonate

< 22 mmol/l
 What kills in DKA
 Aspiration pneumonia

 Cardiac arrhythmias

 Doctors
 ignoring key central cause
 over rapid correction of numbers
 forgetting potassium
 Treatment

 Admission in ICU
 IV Fluids : Normal Saline
 IV Insulin
 Antibiotics

 Correct electrolyte imbalance

 Hyperosmolar non-ketotic
coma (HONK)
 Marked hyperosmolar hyperglycaemia >
500mg/d
 Relative insulin lack
 Hypernatremia
 In Type 2
 Higher mortality!!!
 Treatment
 careful rehydration - avoid rapid changes in
osmolarity
 treatment of underlying disease
 Chronic Complications
 Micro vascular
 Macro vascular
 Others
 Micro vascular
 Retinopathy
 Neuropathy
 Nephropathy
 Complications: eyes
 Hyperglycaemic refractive changes
(reversible)
 Diabetic retinopathy:
 Microaneurysms

 Blot haemorrhages

 Hard exudates

 Soft exudates

 Proliferative retinopathy

 Macular oedema (visual loss w/o retinal

changes)

Normal Retina
Capillary damage
Microaneurysms

Hard exudates
Proliferation of new vessels
Haemorrhages
 Diabetic retinopathy
 Annual screening:
 after 5 years’ diabetes duration in pre-pubertal
children
 after 2 years’ diabetes duration in adults in Type 1
 Screening method:
 ophthalmoscopy
 fundus photography
 fluorescein angiography
 Retinopathy treatment:
 improved long-term metabolic control
 normalising arterial blood pressure
 laser therapy in case of proliferative retinopathy
 Complications: kidneys

 Susceptible subgroup (20-30%)

 Unusual in the absence of retinopathy
 Closely associated with hypertension
 Microalbuminuria earliest marker
 Diabetic Nephropathy
 Leading cause of increased morbidity and
mortality in diabetes
 Preceded by microalbuminuria
 Correlated with long-term metabolic
control
 Long diabetes duration
 Elevated arterial blood pressure
 Genetic susceptibility
 Diabetic nephropathy
Annual screening:
 after 5 years’ diabetes duration in pre-pubertal
children
 after 2 years’ diabetes duration in adolescents

 Microalbuminuria treatment:
 improved long-term metabolic control
 normalising arterial blood pressure
 smoking discouraged
 ACE-inhibition/ ARBs
 Neuropathy

I. Progressive distal sensori-motor loss

 (glove and stocking)
a) Sensory
b) Motor
 Neuropathy
II. Mono-neuropathies
 any nerve: esp. III, IV, VII, peroneal (foot
drop)
III. Compression neuropathies
 carpal tunnel syndrome
IV. Radiculopathies
V. Autonomic neuropathies
 cardiovascular: postural drop / sudden
death
 intestinal: gastric stasis / nocturnal
 Diabetic Neuropathy

 Annual screening:
 from puberty
 Screening method:
 ankle reflexes
 sensation (temperature

discrimination)
 non-invasive test of nerve function

(biothesiometry)
 Neuropathy treatment:
 Macro vascular
 Coronary Artery Disease
 Peripheral Vascular Disease
 Cerebrovascular Disease
 Complications:
Macrovascular
 Accelerated atherosclerosis
 Strokes / Coronary artery disease /
Peripheral vascular disease

 The diabetic foot

 structural deformity (cheiroarthropathy) 
abnormal pressures
 analgesia (repeated minor trauma)
 ischaemia
 Ulceration  soft tissue infection 
osteomyelitis ± gangrene  amputations
 Diabetic feet
Neuropathic heel ulcer Ischaemic ulcer and gangrene

Toe deformity and ulcer Charcot foot + ‘rocker’ ulcer

 Prevention & Rx
 Diabetes patients are at high risk
 Preventive measures generally have a
greater absolute effect
 Lipid lowering therapy
 Use lower thresholds
 Treat LDL (statins) and
 high Trigs / low HDL-chol
(fibrates)
 Aspirin in all pts > 35 yrs
 Beta-blockade, ACE inhibitors post MI
 Treatment of hypertension
 Lowering BP reduces nephropathy and
retinopathy

 Lowering BP reduces cardiovascular

deaths, strokes, and heart failure (by
30-40%)

 ACE inhibition has additional benefits

 in nephropathy
 possibly in cardiovascular disease
 Other Complications
 Gastrointestinal (gastroparesis,
diarrhea)
 Genitourinary
 Dermatologic
 Infectious
 Cataract
 Glaucoma
 Travelling
 Appointment in the out-patient clinic
4–6 weeks before travel
 Improve metabolic control, if

necessary
 Make sure that the family is capable

of treating hypo- and

hyperglycaemic episodes
 Travelling

 Long flights:
 stick to the ‘home-time’ and
normal routines
 6-hourly injections of short-acting

insulin
 REGULAR MONITORING
 Weight
 BP
 Foot examinations
 Pulse rate
 Sores, calluses
 Test for sensations
 REGULAR MONITORING

 Annual eye exams by

ophthalmologist
 Hemoglobin A1 C every 3 to 6
months
 Annual fasting lipid panels
 Urine test for presence of proteins
 Always Refer in c/o

 ketoacidosis
 severe dehydration

 very young age

 Uncontrolled DM

 infection

 psychosocial problems
 CME
On
ECG & Blood Pressure: Practical Tips for
Family Physicians
At
Blue Waters
Andheri Link Road
On 16th Feb 9.30pm onwards
Followed by Cocktails & Dinner