DIABETES MELLITUS

Bautista, Ma. Rowena R Guo, May

Physiology
Pancreas Liver Kidney

Pancreas
Located across the back of the abdomen, just behind and below the stomach

Functions

Digestive function-produce pancreatic juice containing enzyme to digest food in the intestine.
This is called exocrine.

Endocrine and Metabolic function- produce hormones like insulin and glucagon to regulate blood sugar. This is called endocrine.

Endocrine

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S S S

It regulates the blood sugar connected with glucose metabolism.

Insulin is release from pancreas Lower and balance the glucose concentration Also secrete glucagon

Islets of Langerhans

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S S S

Scattered clusters of cells

Beta cells secrete insulin Alpha cells secrete glucagon Delta cells secrete somatostatin and gastrin

Insulin

S Is the primary hormone regulating the plasma glucose

concentration.
S Is a protein S Secrete by beta cells

S Twice as many insulin secreting than glucagon

Insulin

S Metabolized by insulinase in the liver, kidney and

placenta.
S 50% of insulin secreted by pancreas S Promotes glycogen synthesis in the liver and inhibits its

breakdown.

Cont.

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S

The plasma glucose level rise

Stimulates beta cells to increase the amount of insulin Insulin binds with receptor

Target organs

Insulin

Liver

S A central and crucial role in the regulation of

carbohydrate metabolism.
S Maintain blood glucose levels S Uses glucose as fuel and has ability to store it as

glycogen

Liver Disease Occurring as a Consequence of Diabetes Mellitus

S Glycogen Deposition
S Glycogen synthesis in the liver is impaired in diabetes due

to defective activation of glycogen synthase. S 80% of diabetic patients.

Liver

S Nonalcoholic steatohepatitis or NASH is a common, often

silent liver disease. It resembles alcoholic liver disease, but occurs in people who drink little or no alcohol. The major feature in NASH is fat in the liver, along with inflammation and damage.
S NASH are most commonly with obese women with

diabetes.

Kidney

High blood sugar can overwork the kidneys

Tiny blood vessels that act as filters Diabetes can damage the kidneys and cause them to fail

Kidney

S Waste products go through blood vessels (capillaries) in

the kidney.
S Later on the waste products become urine S Useful substances stay

Kidney

S High levels of blood sugar make the kidney filter too

much blood
S Later, they will start to leak and useful substances are

lost in the urine

DIABETES MELLITUS

S DIABETES MELLITUS literally means flowing through of

honey
S Diabetes Mellitus is a group of common chronic diseases

that cause hyperglycemia and other metabolic problems due to a lack of the hormone insulin or an inadequate response to insulin and a relative excess of its opposing hormone, glucagon.

TYPES OF DIABETES MELLITUS

GESTATIONAL DIABETES OR GDM DIABETES MELLITUS TYPE 1 DIABETES MELLITUS TYPE 2

GESTATIONAL DIABETES MELLITUS

GESTATIONAL DIABETES or GDM

Epidemiology
S

Is the onset or first recognition of diabetes during pregnancy Occurs in about 4% of pregnant women in US annually and about 50% of these women will later develop type 2 diabetes.

Risk Factors of GDM

S

older women

S women with previous history of glucose intolerance S

any pregnant woman with an elevated fasting or random blood glucose level

S Have a family history of diabetes S Gave birth to a baby that weighed more than 9 pounds S Have high blood pressure S Have too much amniotic fluid S have had unexplained miscarriage or stillbirth

Pathophysiology of GDM

S Glucose regulation in normal pregnant women is not as tightly

controlled in nonpregnant women, especially in second and third trimesters

S It resembles type 2 diabetes more than type 1 diabetes S Insulin levels normally increase gradually during pregnancy

wherein tissue response to these high insulin levels is lower than normal (insulin resistance is present)
S Also, a defect in beta-cell insulin secretion

DIAGNOSIS

S All pregnant women should receive an oral glucose

tolerance test between the 24th and 28th week of pregnancy to screen for the condition. Women who have risk factors for gestational diabetes may have this test earlier in the pregnancy.

MANAGEMENT OF GDM

S Eat meals and snacks according to meal plan

S Get regular physical activity

S Check blood sugar often S Take the medicine as prescribed by the doctor

DIABETES MELLITUS TYPE 1

DIABETES MELLITUS TYPE 1

S Results from destruction of insulin secreting beta cells in the

pancreas
S Beta cells destruction usually results from an autoimmune process

in which the patients immune system attacks and destroys beta cells for unknown reasons. autoimmune destruction of pancreatic beta cells and lipoprotein abnormalities

S Characterized by total insulin deficiency resulting from

S Age of onset is 11 years but it can occur at any age S Risk factors includes genetic and environmental factors like

certain viruses and dietary toxins

PATHOPHYSIOLOGY OF TYPE 1 DIABETES

SYMPTOMS

INSULIN PUMPS/INSULIN

DIABETES MELLITUS TYPE 2

TYPE 2 DIABETES MELLITUS

S Most common form of diabetes in the US

S Characterized by insulin deficiency, insulin resistance and

abnormally high hepatic glucose production

S Risk factor is obesity secondary to lack of physical

activity and high fat, high calorie diet

S Genetics can also play a major role in susceptibility to

type 2 diabetes.

RISK FACTORS of TYPE 2 DIABETES

S

obesity secondary to lack of physical activity and high fat, high calorie diet

S Genetics parents or siblings with diabetes S African-American, Hispanic, Native American or Asian

American
S Older than 45 years
S Hypertension S History of gestational diabetes or delivery of baby >9 lbs

Pathophysiology of Type 2 Diabetes Mellitus

Results from a combination of resistance to the effects:
Insulin Resistance
Reduced insulin secretion Elevated hepatic glucose production

4 Related Conditions in Diabetes Mellitus Type 2

1. Prediabetes

2. Metabolic Syndrome
3. Adolescent Diabetes or MODY ( Maturity Onset

Diabetes of the Young)

4. Type 1.5 diabetes or LADA (Latent Autoimmune

Diabetes in Adults)

DIAGNOSIS

S Clinical Presentation Signs and symptoms

S History and Physical Examination

S Fasting Glucose Test (FGT) S Glucose Tolerance Test (GTT) S A1C level

Signs and Symptoms of Type 2 DM

Laboratory Tests
FASTING BLOOD SUGAR

A1C LEVEL

THERAPEUTIC INTERVENTIONS
LIFESTYLE CHANGES
Weight control Exercise Self Monitoring of blood

glucose
Diet

Diet/ Dietary Modifications

S S

Caloric control to maintain ideal body weight 50% to 60% of caloric intake should be from carbohydrates which is 130 g/day with emphasis on complex carbohydrates, high fiber foods rich in water soluble fiber, foods with a high glycemic index should be avoided Protein intake should be between 60 and 85 g.; should be 12% to 20% of daily calories

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Fat intake should not exceed 30% of daily calories (70 90 g/day)
Distribute food fairly evenly throughout the day in 3 or 4 meals with snacks added between and at bedtime as needed in accordance with total food allowance and therapy

Types of Insulin

Oral Antidiabetic Agents and Non Insulin Injectables

Cont. of Oral Antidiadetic Agents and Non-Insulin Injectables

Complications Of Diabetes

S Acute Complications

1
2

Diabetic Ketoacidosis
Hyperglycemic Hyperosmolar State/ Hyperglycemic Hyperosmolar Nonketotic Coma

HYPOGLYCEMIA

HYPERGLYCEMIA

Complications

S Chronic Complications Macrovascular complications

Coronary Artery Disease Peripheral Vascular Disease Cerebral Vascular Disease

Microvascular complications Retinopathy (Damage to the retina in the eye) Neuropathy (Damage to nerves) Nephropathy (Damage to kidney tubules that filter the blood) Other complications Eye complications ( cataracts, glaucoma) Infections ( increased risk of infections)

REFERENCES

American Diabetes Association. Nutrition recommendations and interventions for diabetes: a position statement of the American Diabetes Association. Diabetes Care. 2008;31:S61-S78. Screening for gestational diabetes mellitus: Recommendation statement. Rockville, MD. US Preventive Services Task Force. Ann Intern Med. 2008; 148:759-765. American Association of Clinical Endocrinologists and the American College of Endocrinology,The American Association of Clinical Endocrinologists Medical Guidelines for the Management of Diabetes Mellitus: The AACE System of Intensive Diabetes Self-management2002 Update Endocrine Practice p41-82 Hirsch IB, Bergenstal RM, Parkin CG, et al. A real-world approach to insulin therapy in primary care practice. Clinical Diabetes. 2005b;23:78-86. Ahren B. Gut Peptides and Type 2 Diabetes Mellitus Treatment. Curr Diab Rep.2003: 3:365-372.
David C. Dugdale, III, MD, Professor of Medicine, Division of General Medicine, Department of Medicine, University of Washington School of Medicine. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.

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REFERENCES

Hardman JG, Limbird LE, eds. Goodman & Oilman's The Pharmacologic Basis of Therapeutics.10th ed. New York, NY: McGraw-Hill; 2001:1692-1701

Hardman JG, Limbird LE, eds. Goodman & Oilman's The Pharmacologic Basis of Therapeutics.10th ed. New York, NY: McGraw-Hill; 2001:1692-1701
Berkow R, ed-in-chief. The Merck Manual of Diagnosis and Therapy. 16th ed. Rahway, NJ:Merck & Co., Inc.; 1992:1107-1115,2384 Epidemiology of Diabetes Interventions and Complications (EDIC) Research Group. IntensiveDiabetes Treatment and Cardiovascular Disease in Patients with Type 1 Diabetes. N Engl JMed. 2005;353(25):2643-2653. Cefalu WT, Skyler JS, et al. Inhaled human insulin treatment in patients with type 2 diabetes mellitus. Ann Intern Med. 2001;134(3):203-207