Diabetes

Mellitus

universal symbol of DM

Definition:

Diabetes mellitus (DM), also known as simply diabetes,

is a group of metabolic diseases in which there are high

blood sugar levels over a prolonged period.

Epidemology:

Prevalence of diabetes worldwide in 2000 (per

1,000 inhabitants) — world average was 2.8%

Disability-adjusted life year for diabetes mellitus per

100,000 inhabitants in 2004

As at 2013, 382 million people have diabetes

worldwide.Type 2 makes up about 90% of the cases.This

is equal to 8.3% of the adult population with equal rates in

both women and men

In 2012 it resulted in 1.5 million deaths worldwide

making it the 8th leading cause of death. More than 80%

of diabetic deaths occurring in low and middle-income

countries.

Diabetes mellitus occurs throughout the world, but is

more common (especially type 2) in more developed

countries. The greatest increase in rates was expected to

occur in Asia and Africa, where most people with

diabetes will probably live in 2030. The increase in rates

in developing countries follows the trend of urbanization

and lifestyle changes, including a "Western-style" diet.

This has suggested an environmental (i.e., dietary) effect,

but there is little understanding of the mechanism(s) at

present.

Aetiology:

Genetic defects of β-cell function

o Maturity onset

diabetes of the young

o Mitochondrial

DNA mutations Genetic defects in

insulin processing or

insulin action o Defects in

proinsulin

conversion o Insulin gene

mutations

Endocrinopathies o Growth hormone

excess (acromegaly)

o Cushing syndrome o Hyperthyroidism

o Pheochromocytoma

o Glucagonoma Infections

o Cytomegalovirus

infection o Coxsackievirus B

Drugs

o Glucocorticoids o Thyroid hormone

o β-adrenergic

o Insulin receptor

mutations Exocrine pancreatic

defects

o Chronic pancreatitis

o Pancreatectomy

o Pancreatic neoplasia

o Cystic fibrosis

o Hemochromatosis o Fibrocalculous

pancreatopathy

agonists

o Statins

Symptoms:

Types:

Diabetes mellitus is classified into four broad categories:

type 1, type 2, gestational diabetes, and "other specific

types

Comparison of type 1 and 2 diabetes

Feature Type 1 diabetes Type 2 diabetes

Onset Sudden Gradual

Age at onset Mostly in children Mostly in adults

Body size Thin or normal Often obese

Ketoacidosis Common Rare

Autoantibodies Usually present Absent

Endogenous insulin Low or absent Normal, decreased

or increased

Concordance

in identical twins 50% 90%

Prevalence ~10% ~90%

Diagnosis:

WHO diabetes diagnostic criteria

Condition 2 hour

glucose

Fasting

glucose HbA1c

Unit mmol/l(mg/dl) mmol/l(mg/dl) %

Normal <7.8 (<140) <6.1 (<110) <6.0

Impaired fasting glycaemia

<7.8 (<140) ≥ 6.1(≥110) &

<7.0(<126) 6.0–6.4

Impaired glucose

tolerance

≥7.8 (≥140) <7.0 (<126) 6.0–

6.4

Diabetes mellitus ≥11.1 (≥200) ≥7.0 (≥126) ≥6.5

Patho physiology:

The fluctuation of blood sugar (red) and the sugar-lowering hormone insulin (blue) in humans during the

course of a day with three meals — one of the effects of a sugar-rich vs a starch-rich meal is highlighted.

Management of

diabetes

mellitus:

Goal:

The overall goal of diabetes management is to help

individuals with diabetes and their families gain the

necessary knowledge, life skills, resources and support

needed to achieve optimal health . This requires a team

effort that includes diabetes health care professionals

and the individuals who must deal with this chronic

condition on a daily basis. The registered dietitian is a key

member of the health care team , who plays an integral

role in the individualization of management strategies for

people with diabetes and those at risk for developing it.

Contents:

Dietary management

Drug management

Insulin shot

Exercise therapy

Pancreatic transplantation

Dietary management:

Goal:

A major goal for diabetes care is to improve glycemic control by

balancing food intake with endogenous and/or exogenous

insulin levels. For people with type 1 diabetes, insulin doses

need to be adjusted to balance with nutritionally adequate

food intake and physical activity. For individuals with type 2

diabetes, impaired glucose tolerance or impaired fasting

glucose, attention to food portions and weight management

combined with physical activity may help improve glycemic

control. Nutrition and all forms of diabetes management should

be individualized.

Nutritional management seeks to improve

or maintain the following:

• The quality of life for people with diabetes and their families through

management techniques that include the entire family unit in decision-

making, while enhancing the individual’ s personal sense of control and

well-being;

• The physiological health of individuals with diabetes ,by establishing

and maintaining blood glucose and lipid levels as near-normal as

possible , and by using vigilance in preventing and/or treating diabetes-

related complications and any concomitant conditions;

• The nutritional status of people with diabetes, by recognizing that

their micro- and macro nutrient requirements are similar to those of

the general population.

General principles:

• Enjoy a variety of foods.

• Emphasize cereals, breads and other whole grain products,

vegetables and fruits.

• Choose lower-fat dairy products, leaner meats and foods

prepared with little or no fat.

• Achieve and maintain a healthy body weight by enjoying

regular physical activity and healthy eating.

• Limit salt, alcohol and caffeine

Required diet

Healthy diet

Exercise therapy Everybody benefits from regular exercise. In

diabetes it plays an important role in keeping you

healthy.

How can exercise help

helps insulin to work better which will

improve your diabetes control

What type of exercise should I

do?

This depends on what you enjoy and your level of

fitness. Here are some suggestions:

Increasing your general physical activity is also

helpful. e.g. taking the stairs instead of the lift,

getting up to change the TV station instead of using

the remote control, house work.

How much exercise do I need to do?

Ideally, about 30 minutes every day. If this is not

possible, then this time can be divided

in 3x10 minutes sessions.

How intense does the exercise

need to be?

You do not need to puff to gain the benefits of

exercise. Aim for moderate intensity. This means you

should still be able to talk as you exercise without

becoming breathless.

Exercise Tips

, during (only if

prolonged exercise) and after exercise to avoid

dehydration. The fluid may be water , or a sweetened

drink if extra carbohydrate is required. 250ml every

15 minutes or one litre of fluid per hour is

recommended.

. Wear comfortable and

well-fitting shoes. Always inspect your feet before

and after exercise. Ulcers or other lesions on the

feet are a serious danger for people with diabetes. It

is important to avoid foot damage especially for

middle-aged and elderly people. It is wise for them

to avoid exercise that causes stress to the feet (e.g.

running). Exercise which poses minimal weight or

stress on the feet is ideal such as riding an exercise

bike or brisk walking in good footwear

exercise to prevent hypoglycaemia. Extra

carbohydrate is often needed after exercise. Monitor

your blood glucose levels before, if possible during

(at least initially), and after exercise to assess your

requirements for extra food. Discuss adjusting

carbohydrate intake with your dietitian.

It may be

necessary to reduce your insulin dose prior to

exercise. Insulin adjustment varies with each

individual. Discuss appropriate adjustments to suit

your exercise schedule with your doctor or diabetes

educator.

Advice for people with type 1 diabetes

(i.e. fasting

blood glucose levels greater than 14 mmol/L and

urinary ketones) then it is best to avoid exercise until

your blood glucose has settled.

elevate a high blood glucose and

increase ketone production.

Advice for people with type 2 diabetes

management.

and assist with your blood glucose control.

Drug management Metformin is generally recommended as a first line treatment for

type 2 diabetes, as there is good evidence that it decreases

mortality.] Routine use of aspirin, however, has not been found

to improve outcomes in uncomplicated diabetes. Angiotensin converting enzyme inhibitors (ACEIs) improve outcomes in

those with DM while the similar medications angiotensin receptor blockers (ARBs) do not.

Type 1 diabetes is typically treated with a combinations of regular and NPH insulin, or synthetic insulin analogs. When

insulin is used in type 2 diabetes, a long-acting formulation is usually added initially, while continuing oral medications. Doses

of insulin are then increased to effect.

In those with diabetes some recommend blood pressure levels

below 120/80 mmHg; however, evidence only supports less than

or equal to somewhere between 140/90 mmHg to 160/100 mmHg.

Insulin shots ● Insulin shot. You’ll use a needle attached to a

syringe—a hollow tube with a plunger—that you fill

with a dose of insulin. Some people use an insulin

pen, a penlike device with a needle and a cartridge of

insulin. Never share insulin needles or insulin pens,

even with family.

● Insulin pump. An insulin pump is a small

device filled with insulin that you wear on your belt

or keep in your pocket. The pump connects to a

small, plastic tube and a small needle. You or your

doctor inserts the needle under your skin. The

needle can stay in for several days.

● Insulin jet injector. This device sends a fine

spray of insulin through your skin with high-

pressure air instead of a needle. This device sends a

fine spray of insulin through your skin with high-

pressure air insteadof a needle.

● Insulin injection port. You or your doctor

inserts a small tube just beneath your skin, where it

remains in place for several days. You can inject

insulin into the end of the tube instead of through

your skin.

Pancreatic

transplantation A pancreas transplant is occasionally considered for

people with type 1 diabetes who have severe

complications of their disease, including end stage

renal disease requiring kidney transplantation

A pancreas transplant is a surgical procedure to

place a healthy pancreas from a deceased donor into

a person whose pancreas no longer functions

properly. Almost all pancreas transplants are done to

treat cases of type 1 diabetes.

Your pancreas is an organ that lies behind the lower

part of your stomach. One of its main functions is to

make insulin, a hormone that regulates the

absorption of sugar (glucose) into your cells. Type 1

diabetes results when your pancreas can't make

enough insulin, causing your blood sugar to rise to

dangerous levels.

The side effects of a pancreas transplant can be

significant, so a pancreas transplant is typically

reserved for those who have serious diabetes

complications. A pancreas transplant is often done in

conjunction with a kidney transplant.

Why it's done

A pancreas transplant offers a potential cure for type

1 diabetes, but it's not a standard treatment. Often

the side effects of the anti-rejection medications

required after a pancreas transplant can be serious.

But if you have any of the following, a pancreas

transplant may be worthwhile:

Type 1 diabetes that can't be controlled with

standard treatment

Frequent insulin reactions

Consistently poor blood sugar control

Severe kidney damage

Because type 2 diabetes occurs due to the body's

inability to use insulin properly — and not because

of a problem with insulin production in the pancreas

— a pancreas transplant isn't a treatment option for

most people with type 2 diabetes.

If you have severe kidney damage due to type 1

diabetes, a pancreas transplant may be combined

with a kidney transplant or be done after successful

kidney transplantation. This strategy aims to give

you a healthy kidney and a pancreas that's unlikely

to contribute to diabetes-related kidney damage in

the future.

Risks

Complications of the procedure

Pancreas transplant surgery carries a risk of

significant complications, including:

Blood clots

Bleeding

Infection

Excess sugar in your blood (hyperglycemia)

Urinary complications, including leaking or

urinary tract infections

Failure of the donated pancreas

Rejection of the donated pancreas

Anti-rejection medication side effects

After a pancreas transplant, you'll take medications

for the rest of your life to help prevent your body

from rejecting the donor pancreas. These

medications can cause a variety of side effects,

including:

Bone thinning

High cholesterol

High blood pressure

Skin sensitivity

Puffiness

Weight gain

Swollen gums

Acne

Excessive hair growth

How you prepare

Choosing a transplant center

If your doctor recommends a pancreas transplant,

you'll be referred to a transplant center. You're also

free to select a transplant center on your own or

choose a center from your insurance company's list

of preferred providers.

When you consider transplant centers, you may

want to:

Learn about the number and type of transplants the

center performs each year

Ask about the transplant center's organ donor and

recipient survival rates

Compare transplant center statistics through the

database maintained by the Scientific Registry of

Transplant Recipients (www.ustransplant.org)

Consider additional services provided by the

transplant center, such as support groups, travel

arrangements, local housing for your recovery

period and referrals to other resources

After you've selected a transplant center, you'll need

an evaluation to determine whether you meet the

center's eligibility requirements for a pancreas

transplant.

When the transplant team assesses your

eligibility, they'll consider the following.

Are you healthy enough to have surgery and

tolerate lifelong post-transplant medications?

Do you have any medical conditions that would

hinder transplant success?

Are you willing and able to take medications and

advice as directed?

If you need a kidney transplant, too, the transplant

team will also determine if it's best for you to have

the pancreas and kidney transplants during the same

surgery, or a kidney transplant first, followed by the

pancreas transplant at a later date. The best option

depends on the severity of your kidney damage, the

availability of donors and your preference.

Once you've been accepted as a candidate for a

pancreas transplant, your name will be placed on a

national list of people awaiting a transplant. The

waiting time for a transplant depends on your blood

group and how long it takes for a suitable donor —

one whose blood and tissue types match yours — to

become available.

Staying healthy

Whether you're waiting for a donated pancreas to

become available or your transplant surgery is

already scheduled, it's important to keep your mind

and body healthy.

Take your medications as prescribed.

Follow your diet and exercise guidelines.

Keep all appointments with your health care team.

Stay involved in healthy activities, including

relaxing and spending time with family and

friends.

What you can expect

During a pancreas transplant

Surgeons perform pancreas transplants during

general anesthesia, so you're unconscious during the

procedure. The anesthesiologist or anesthetist gives

you an anesthetic medication as a gas to breathe

through a mask or injects a liquid medication into a

vein.

The surgical team monitors your heart rate, blood

pressure and blood oxygen throughout the procedure

with a blood pressure cuff on your arm and heart-

monitor leads attached to your chest. After you're

unconscious:

An incision is made down the center of your

abdomen.

The surgeon places the new pancreas and a small

portion of the donor's small intestine into your

lower abdomen.

The donor intestine is attached to either your small

intestine or your bladder, and the donor pancreas

is connected to blood vessels that also supply

blood to your legs.

Your own pancreas is left in place to aid digestion.

If you're also receiving a kidney transplant, the

blood vessels of the new kidney will be attached to

blood vessels in the lower part of your abdomen.

The new kidney's ureter — the tube that links the

kidney to the bladder — will be connected to your

bladder. Unless your own kidneys are causing

complications, such as high blood pressure or

infection, they're left in place.

Pancreas transplant surgery usually lasts about three

hours. Simultaneous kidney-pancreas transplant

surgery takes a few more hours.

After a pancreas transplant

After your pancreas transplant, you can expect to:

Stay in the intensive care unit for a few

days. Doctors and nurses monitor your condition

to watch for signs of complications. Your new

pancreas should start working immediately, and

your old pancreas will continue to perform its

other functions. If you have a new kidney, it'll

make urine just like your own kidneys did when

they were healthy. Often this starts immediately.

But in some cases, urine production takes up to a

few weeks.

Spend about one week in the hospital. Once

you're stable, you're taken to a transplant recovery

area to continue recuperating. Expect soreness or

pain around the incision site while you're healing.

Have frequent checkups as you continue

recovering. After you leave the hospital, close

monitoring is necessary for three to four weeks.

Your transplant team will develop a checkup

schedule that's right for you. During this time, if

you live in another town, you may need to make

arrangements to stay close to the transplant center.

Take lifelong medications. You'll take a number

of medications after your pancreas transplant.

Drugs called immunosuppressants help keep your

immune system from attacking your new pancreas.

Additional drugs may help reduce the risk of other

complications, such as infection and high blood

pressure, after your transplant.

If you're waiting for a donated pancreas, make sure

the transplant team knows how to reach you at all

times and arrange transportation to the transplant

center in advance.

Results

By Mayo Clinic Staff

After a successful pancreas transplant, your new

pancreas will make the insulin your body needs, so

you'll no longer need insulin therapy to treat

diabetes. But even with the best possible match

between you and the donor, your immune system

will try to reject your new pancreas. So you'll need

medications to suppress your immune system. You'll

likely take these or similar drugs for the rest of your

life. Because medications to suppress your immune

system make your body more vulnerable to

infection, your doctor may also prescribe

antibacterial, antiviral and antifungal medications.

Pancreas transplant survival rates

According to the Organ Procurement and

Transplantation Network, transplanted pancreas and

kidney survival rates include the following.

Simultaneous pancreas-kidney transplant. In

about 87 percent of people who receive a

simultaneous pancreas-kidney transplant, the

transplanted pancreas is still functioning after one

year. After five years, that rate is about 72 percent.

Pancreas-after-kidney transplant. In about 77

percent of people who receive a pancreas-after-

kidney transplant, the transplanted pancreas is still

functioning after one year. Five years after

transplant, the rate is about 59 percent.

Pancreas-only transplant. In about 85 percent of

people who receive a pancreas-only transplant, the

transplanted pancreas is still functioning after one

year. After five years, that rate is about 52 percent.

It's unclear why results are better for those who

receive a kidney and pancreas at the same time. But

some research suggests it may be because it's more

difficult to monitor and detect rejection of a pancreas

alone, versus a pancreas and a kidney.

If your new pancreas fails, you can resume insulin

treatments and consider a second transplant. This

decision will depend on your current health, your

ability to withstand surgery and your expectations

for maintaining a certain quality of life.