Dr S. VijayalakshmiAssistant Professor, Community Medicine

MGMCRI, Pondicherry

Framework•Definition of Diabetes Mellitus

•Classification of Diabetes

•Epidemiological features

•Clinical features

•Diagnosis

•Management

•Prevention

Diabetes is an epidemic,

chronic metabolic disorder of multiple

etiology

in which the body can’t metabolize

carbohydrate, fats and proteins

because of defects in insulin secretion

and/or action.

Classification of Diabetes

Problem Statement

World 150 million cases Expected to double by yr 2025

SEAR 30 million cases Expected to triple by yr 2025

India Prevalence 2.4%(rural),4.0-11.6%(urban) Diabetes Capital of the world

(Source: WHO 2011 NCD country profile)

- industrialization

- socio-economic development

- population growth

- age structure

- urbanization

Reasons for rising prevalence in developing countries

Agent Host Environment

IDDM Age : <30 yrs- IDDM>30 years- NIDDM

Sedentary life style

NIDDM Sex: both Low dietary fibres

Type 1 HLA-DR3, DR4 Malnutrition

GDM Alcohol

Obesity stress

Viral infection- beta cell destruction

EPIDEMIOLOGICAL FACTORS

Diagnosis of Pre-diabetes and Diabetes

Test Fasting Plasma Glucose (FPG)

Oral Glucose Tolerance Test

(OGTT)

Random Plasma Glucose

(with symptoms)

How performed

Blood glucose is measured after at least an 8 hr fast

75 gm glucose load (drink) is ingested after at least an 8hr fast, Blood glucose is measured at 2 hrs

Blood glucose is measured at any time regardless of eating

Normal < 110mg/dl < 140 mg/dl (7.8 mmol/L)

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Diagnosis of Pre-diabetes and Diabetes

Test Fasting Plasma Glucose (FPG)

Oral Glucose Tolerance Test (OGTT)

RandomPlasma Glucose

(with symptoms)

Pre-diabetes

IFG

110-125 mg/dl

Pre-diabetes

IGT

140-199 mg/dl(7.8-11 mmol/L)

Diabetes Mellitus

≥ 126 mg/dl (7 mmol/L)

≥ 200mg/dl (11.1 mmol/L)

≥ 200mg/dl(11.1 mmol/L)(with symptoms)

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HbA1CPercentage of HbA to which Glucoseis attached

Normal: <5.7 %

Pre-diabetic: 5.7-6.4 %

Diabetic: >6.5 %

Type I or Type II Diabetes Mellitus

Investigations during Follow up1.Urine sugar,2 hr PP (once a week)

2.Blood Sugar-FBS,PPBS (once in 3-6 months)

3.Lipid profile (Once in a yr)

4.ECG (Once a yr)

5.Urine albumin

6.Blood Urea, Serum creatinine

7.Retinoscopy (Once in a yr)

8.Glycated Hb (Once in 3-6 months)

Management of diabetes mellitus

TREATMENT OF DIABETES

DIET LIFESTYLEMODIFICATIONS OHA INSULIN

Why Diet Management?

To control weight

To complete nutritional requirements

To maintain blood glucose levels in normal limits

To correct any associated blood lipid abnormalities

Diet in Diabetes

Diet in diabetes

1.Calories from food

~55% from carbohydrate~30% from fat~15% from protein

2.Calorie calculation

Overweight (sedentary)- 20 kC/kgNormal wt (sedentary)- 30 kC/kgNormal wt (heavy worker)- 35 kC/kg Underweight- 40 kC/kg

Diet in diabetes

1. Avoid sweets 2. Avoid overeating

3. Avoid fasting

4.Avoid alcohol

5. 4-5 small frequent meals (Same amount, same time daily)

6. Almonds : to lower cholesterol level

7. Fruits: Take apple, guava

8. Avoid excessive salt

Lifestyle modifications Regular exercise

Walking

Other aerobic exercises

Maintenance of weight

Stop smoking

Foot care

Oral anti-diabetic drugs

If satisfactory control is not possible with Diet and Lifestyle changes alone

Sulfonylureas (Tolbutamide,Glibenclamide)

Biguanides (Metformin)

Alpha-glucosidase inhibitors (Acarbose)Thiazolidinediones (Rosiglitazone,Pioglitazone)

InsulinDifferent species

Bovine -Human (recombinant)Different preparations

Soluble insulin (“plain insulin”)Rapid-acting insulin analogues

» Lispro» Aspart

Prolonged acting insulins» Protamine Insulin (NPH, Isophane)» Zinc insulin» Glargine

Technique of injection

• Painless 30/31G needles

• Subcutaneous– Abdomen– Thighs– Arms

• Patients should be trained

Insulin Therapy

• Subcutaneous– ~30 min for onset of action– 60-90 min for peak action

• Should be given 30 min BEFORE meals

• Start with small dose and increase as needed

Complications of Insulin therapy• Hypoglycemia• Local

– Lipohypertrophy– Injection site abscess

• Insulin resistance– Insulin antibodies

• Weight gain– In overdosage– Insulin stimulates hunger

Primary Prevention

a. Population strategy

Primordial prevention Weight maintenance Diet Exercise

b. High risk strategy

Avoid diabetogenic drugs (corticosteroids) Reduce the factors causing atheroslerosis (smoking,hypertension,high cholesterol)

Secondary Prevention:Targets for screening of diabetes?

Asymptomatics with:

Targets for screening of diabetes?

1. History of gestational D.M or delivery of infant weighing over 4.5 kg

2. Pregnant women

3. Adults with Tuberculosis

4. Persons on diabetogenic drugs like steroids,thiazide diuretics

5. Women with Polycystic Ovary Syndrome(PCOD/PCOS)

6. History of premature vascular disease

Symptomatics and:

Secondary PreventionEarly diagnosis and treatmentMaintain blood glucose levelMaintain ideal weight (Height in cm-100)Blood pressure measurementRoutine blood glucose monitoringUrine for ketones and proteins Glycated Hb estimation

(6 monthly, should be <6%)

Secondary Prevention Keep sugar in your pocket Weight,Blood pressure measurement,Visual acuity Feet care Self Care: Adhere to diet,drugs,exercise, investigations, periodic check–ups, recognition of symptoms of hypoglycemia Identification card with treatment details

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Feet Care

Wash feet daily,dry them,inspect them, sprinkle talcum powder

Avoid walking bare foot,even at home

Wear soft cotton socks and canvas shoes

Avoid tight fitting shoes,chappals

Cut nails carefully after bath

See for the sensations

Feet Care

Do not use hot water bottles or heating pads or any

electrical device for heating the feet

Do not use a pumice stone to remove callousness

Do not sit with your legs crossed

Do not use commercial wart or corn removers on

your feet

Feet Care

Do not perform "bathroom surgery" by using

razor blades or other sharp instruments on your feet

Do not ignore any(minor also) foot problem

Use cream or lotion that keeps your skin soft and

free of cracks

Regular Self Glucose Monitoring

Tertiary Prevention Disability limitation if any disability Diabetes clinic