Diabetes mellitus is a chronic metabolic disorder characterized by high blood sugar (hyperglycemia) in human body. This results from lack of insulin in the body or failure of body cells to respond to circulating insulin. Persistent hyperglycemia results in progressive multiple organ damage giving rise to both acute and chronic complications.
The Classification of Diabetes based on Aetiology
| Type 1 diabetes | Results from destruction most commonly autoimmune, of the pancreatic beta cells. Insulin is required for survival. |
| Type 2 diabetes | Characterized by insulin resistance and/or abnormal insulin secretion, either of which may predominate, but both of which are usually present. It is the most common type of diabetes. |
| Other specific types of Diabetes | These are less common and include genetic disorders, infections, and diseases of the exocrine pancreas, endocrinopathies or as a result of drugs. |
| Gestational diabetes | Appearing or recognized for the first time in pregnancy. |
Risk Factors for Diabetes
| Modifiable | Non-Modifiable |
| Obesity: general central | Age (>40 yrs.) |
| Physical inactivity and unhealthy diets | First degree relative with diabetes |
| Impaired glucose tolerance /Impaired fasting glycaemia | Previous gestational diabetes |
| Dyslipidaemia | Ethnicity |
| Alcohol abuse and Tobacco use | Hypertension |
General Objectives of Diabetes Management
- To relieve symptoms
- To correct associated health problems and to reduce morbidity, mortality and economic costs of diabetes
- To prevent as much as possible acute and long-term complications; to monitor the development of such complications and to provide timely intervention
- To promote of self-care practices and empowerment of people with diabetes
- To reduce of the personal, family and societal burden of diabetes
Diagnosis
If the patient has classical symptoms (such as increased thirst and urine volume, unexplained weight loss, pruritus vulvae or balanitis) or drowsiness or coma, associated with marked glycosuria, the diagnosis can be readily established by demonstrating fasting hyperglycemia. If the fasting blood glucose concentration is in the diagnostic range shown in below able, an oral glucose tolerance test (OGTT) is not required.
Laboratory Assessment should Include:
- a blood glucose measurement as a minimum requirement to confirm the diagnosis
- urine examination for ketones, protein and glucose
- serum creatinine measurement in all hypertensive patients and those with proteinuria
- electrocardiography and measurement of total serum cholesterol and triglycerides in high-risk individuals
- HBA1C measurement and quantitative measurement of urine protein as optional investigations that may be performed as part of the initial assessment where facilities and resources allow.
Management of Type 1 Diabetes
Diabetes education
Education, when delivered in a patient centered, age appropriate manner, provides a knowledge base, which becomes a vehicle for optimal self-management.
Psychosocial support
Diabetes in a child or adolescent may be associated with acute distress and in some cases prolonged distress for both the individual and the family. Pre-existing psychological, social, personal, family or environmental problems are likely to be exacerbated.
Physical activity
Regular physical activity is an essential component of a healthy lifestyle for all children and adolescents, including those with diabetes. The benefits are similar to those in type 2 diabetes.
Nutrition
Nutrition education for children and adolescents is an ongoing process that needs to be provided at a time that is suitable to meet the individual needs of the families.
Insulin therapy and blood glucose monitoring
- Patients with type 1 diabetes should be started on insulin rather than oral glucose lowering agents.
- Discuss patient preferences for twice daily or multiple injection regimes.
- Arrive at regime in partnership with the patient, as patients arriving at informed shared decisions with their practitioner are more likely to be successfully controlled with the chosen regime.
- Twice daily regimes using isophane (NPH) insulin or long acting insulin analogues (insulin glargine) may be more suitable for those who require assistance, or have a dislike of injecting.
- Multiple injection regimes using unmodified or “soluble” insulin or rapid-acting insulin analogues are suitable for well-motivated individuals with a good understanding of disease control, or those with active or erratic lifestyles.
- Patients should be given instruction in injection technique using a device best suited to the patient’s requirements.
- Give advice on how to change the regime in case of illness.
Review assessment
- All diabetics should be reviewed at least annually and more frequently if there are any factors which may cause concern to the patient or their doctor.
- The aim of regular review should be to assess and decrease the risk of known complications of diabetes such as peripheral vascular disease, nephropathy and retinopathy.
- Before a management plan can be agreed, an initial assessment of the health and lifestyle of the patient must be undertaken.
Management of Type 2 Diabetes
Management of Type 2 diabetes entails the following components:
- Treatment of hyperglycemia
- Treatment of hypertension and dyslipidemias
- Prevention and treatment of microvascular complications
Treatment of hyperglycemia
a. Non -pharmacological
- Education
- Diet
- Physical activity
b. Pharmacological
- Oral glucose lowering agents(oral hypoglycemic agents)
- Insulin
- Combination Therapies – Oral glucose lowering agents and insulin
Treatment of hypertension and dyslipidemias
a. Non- pharmacological
- Education
- Diet
- Physical activity
b. Pharmacological
- Aspirin therapy
- Beta-blockers
- Angiotensin Converting Enzyme (ACE) inhibitors
Prevention and treatment of microvascular complications
Microvascular complications mainly involve the kidney, eyes, lower extremities and nerves. They may be present at the time of diagnosis of diabetes as the detection of the diseases is frequently delayed. These complications can be prevented or their progression delayed by optimal treatment of hyperglycemia and hypertension.
Dietary treatment should aim at:
- ensuring weight control
- providing nutritional requirements
- allowing good glycemic control with blood glucose levels as close to normal as possible
- correcting any associated blood lipid abnormalities
- ensuring consistency and compatibility with other forms of treatment if used, for example oral agents or insulin.
Management of Diabetes in Special Situations
Pregnancy
- Gestational diabetes mellitus (GDM) is any degree of glucose intolerance first recognized in pregnancy. If inadequately managed GDM is associated with increased risk of perinatal morbidity and mortality.
- Excellent glycemic control both before pregnancy and during the 1st to 3rd trimesters has resulted in a marked reduction in the rates of congenital malformation and perinatal morbidity.
Fasting for religious purposes
- Check the level of glycemic control using HbA1c or fasting blood glucose. Those in very poor control should be discouraged from embarking upon fasting Drug dosage adjustment is required for patients with fasting blood glucose 5 mmol/L.
- If on insulin or insulin secretagogues, drugs dosages and timing will require adjustment during the period of food denial to meet calorie intake.
- Vigorous activity should be avoided during period of fast.
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