ETIOLOGIC CLASSIFICATION. Type I diabetes Type II diabetes

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1 DIABETES MELLITUS

2 DEFINITION It is a common, chronic, metabolic syndrome characterized by hyperglycemia as a cardinal biochemical feature. Resulting from absolute lack of insulin. Abnormal metabolism of CHO, Protein, and Fat.

3 ETIOLOGIC CLASSIFICATION Type I diabetes Type II diabetes

4 Other Specific Type Genetic defects of B cell function Genetic defects of insulin action Diseases of exocrine pancreas Endocrinopathies Drug or chemical Infections Syndromes

5 Gestational diabetes mellitus Neonatal diabetes mellitus Transient Permanent

6 TYPE 1 DM Formerly called Insulin- dependent diabetes mellitus. Deficiency of insulin secretion due to pancreatic beta cell damage Tendency for ketoacidosis

7 TYPE 11 DM Formerly known as non insulin dependent diabetes mellitus. Characterized by insulin resistance. Infrequently develops Ketosis. Usually obese.

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9

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11 INCIDENCE May present at any age. Peak age is 5 7 yr and at time of puberty. Trend toward earlier age of onset. 0.7/100,000 per year in Karachi.

12 GENETICS MHC HLA class II region on chromosome 6p21. HLA DR3 and DR4 Sibling sharing one haplotype 5-7% Both haplotype.12-20% Risk to offspring 2-5%

13 INFLUENCE OF INSULIN LIVER GLUCOSE UPTAKE GLYCOGEN SYNTHESIS ABSENT GLUCONEOGENESIS LIPOGENESIS ABSENCE OF KETOGENESIS

14 MUSCLE GLUCOSE UPTAKE GLUCOSE OXIDATION GLYCOGEN SYNTHESIS PROTEIN SYNTHESIS

15 ADIPOSE TISSUE GLUCOSE UPTAKE LIPID SYNTHESIS TRIGLYSERIDE UPTAKE

16 PATHOPHYSIOLOGY Progressive low - insulin catabolic state Postprandial Hyperglycemia Loss of calories & electrolyte Elevated levels of counter regulatory hormone..accelerated lipolysis

17 PRESENTATION OF A DIABETIC CHILD 1. Classical: Polyuria: Polydipsia Persistent diuresis Nocturnal diuresis dehydration Polyphagia: Weight loss Loss of calories Loss of body fat

18 10 yr average, healthy child consumes about 50% of 2000 daily calories as CHO. If he becomes diabetic daily loss of water & glucose may be 5lt & 250 g respectively, representing 1000 cals

19 2. Ketoacidosis 20-40% Abdominal pain, nausea & vomiting Dehydration Acidosis Altered conscious level Ketosis 3. Incidental

20 DIAGNOSIS Non fasting blood sugar >200mg% with typical symptoms is diagnostic. Fasting blood sugar >120mg% or a 2- hour postprandial >200mg% on two occasions. Glucose tolerance test is rarely necessary in children

21 OTHER INVESTIGATIONS Urine examination Glucosuria Ketonuria blood sugar Complete blood picture High HB & hematocrit leucocytosis

22 Serum electrolyte Hyponatremia Hypokalemia Low chloride Acid base balance Low Ph Low bicarbonate level

23 MANAGEMENT Maintain balance between tight glucose control and avoiding hypoglycemia Eliminate Polyuria & nocturia Prevent ketoacidosis Permit normal growth and development

24 COMPONENTS OF MANAGEMENT Initiation & adjustment of insulin Extensive patient & caretaker s education Nutritional management Regular monitoring

25 INSULIN 0.75-I.0 Units/kg subcutaneously Total dose is divided into 2/3 rd morning dose &1/3 rd evening dose Short acting regular insulin 1/3 rd of total dose Intermediate acting insulin 2/3 rd of total dose

26 Total dose 9 units Morning: ⅔ of total dose NPH (⅔) Regular (⅓) Evening: ⅓ of total dose NPH (⅔) Regular (⅓) 6 units 4 units 2 units 3 units 2 units 1 unit

27

28 Quick acting Duration of action 15 minutes 3 to 5 hours Short acting 30 to 60 minutes 5 to 8 hours Intermediate acting 1 to 3 hours.18 to 24 hours Long acting 4 to 8 hours.24 to 36 hours Combination mixture 30 minutes.16 to 24 hours

29 CONT. Lispro & aspart (A) Regular NPH& Lente Glargine (G) Ultralente Three or- four step dosing schedule Insulin pump therapy Inhaled & oral insulin therapy

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31 BASIC EDUCATION Use mother tongue for proper understanding Insulin Type, action & storage Technique,& timing of insulin injection Monitoring RBS Urine ketones

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33

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36 Tuesday Fasting Monday hour after BF Before evening dose 2 hour after dinner Tuesday Wednesday Thursday Friday Saturday Sunday Monday

37 Dietary information Recognition & treatment of hypoglycemia Management during intercurrent infection Regular exercise

38 DIET Minimum restrictions Adopt positive approach Meal & snacks at regular intervals Adequate calories & nutrients

39 50% carbohydrate Complexed carbohydrate sugar free carbonated beverage High fiber diet Polyunsaturated fats Lean cuts of meat, poultry & fish

40 MONITORING Success in daily management is competence acquired by family & child Intermittent adjustment in insulin dosage

41 Self monitoring of blood glucose Daily blood glucose monitoring Continuous glucose monitoring system Glucowatch Biographer

42 Glycosylated Hemoglobin Nondiabetic.less than 6% Diabetics Good control 6-8.5% Fair control..9-10% Poor control.11% or higher

43 FOLLOW UP VISIT Ask any symptom / problem Growth record Weight (every visit) Height (6monthly) Evaluate control, review home record

44 EVERY VISIT Sugar profile, type of insulin & dose Spacing of doses, check injection sites Dietary compliance School progress report Blood pressure

45 3 MONTHLY Glycosylated Hb Joint mobility Fundus Examination Thyroid functions Microalbuminuria

46 COMPLICATIONS Brittle diabetes: Marked fluctuation in diabetic control Hypoglycemia RBS less than 60 mg% Diabetic ketoacidosis

47 Neuropathy : Peripheral neuritis Nephropathy: Progressive renal failure Retinopathy & Blindness Vasculopathy Hypertension, atherosclerosis

48 Lipoatrophy Infections Skin, fungal infection Growth retardation & psychological problem

49 Somogyi phenomenon Hypoglycemia begetting hyperglycemia Dawn phenomenon

50 PROGNOSIS Long term complications usually occur after years. 100% pts..retinopathy

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