DIABETES MELLITUS
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.
ETIOLOGIC CLASSIFICATION Type I diabetes Type II diabetes
Other Specific Type Genetic defects of B cell function Genetic defects of insulin action Diseases of exocrine pancreas Endocrinopathies Drug or chemical Infections Syndromes
Gestational diabetes mellitus Neonatal diabetes mellitus Transient Permanent
TYPE 1 DM Formerly called Insulin- dependent diabetes mellitus. Deficiency of insulin secretion due to pancreatic beta cell damage Tendency for ketoacidosis
TYPE 11 DM Formerly known as non insulin dependent diabetes mellitus. Characterized by insulin resistance. Infrequently develops Ketosis. Usually obese.
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.
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%
INFLUENCE OF INSULIN LIVER GLUCOSE UPTAKE GLYCOGEN SYNTHESIS ABSENT GLUCONEOGENESIS LIPOGENESIS ABSENCE OF KETOGENESIS
MUSCLE GLUCOSE UPTAKE GLUCOSE OXIDATION GLYCOGEN SYNTHESIS PROTEIN SYNTHESIS
ADIPOSE TISSUE GLUCOSE UPTAKE LIPID SYNTHESIS TRIGLYSERIDE UPTAKE
PATHOPHYSIOLOGY Progressive low - insulin catabolic state Postprandial Hyperglycemia Loss of calories & electrolyte Elevated levels of counter regulatory hormone..accelerated lipolysis
PRESENTATION OF A DIABETIC CHILD 1. Classical: Polyuria: Polydipsia Persistent diuresis Nocturnal diuresis dehydration Polyphagia: Weight loss Loss of calories Loss of body fat
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
2. Ketoacidosis 20-40% Abdominal pain, nausea & vomiting Dehydration Acidosis Altered conscious level Ketosis 3. Incidental
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
OTHER INVESTIGATIONS Urine examination Glucosuria Ketonuria blood sugar Complete blood picture High HB & hematocrit leucocytosis
Serum electrolyte Hyponatremia Hypokalemia Low chloride Acid base balance Low Ph Low bicarbonate level
MANAGEMENT Maintain balance between tight glucose control and avoiding hypoglycemia Eliminate Polyuria & nocturia Prevent ketoacidosis Permit normal growth and development
COMPONENTS OF MANAGEMENT Initiation & adjustment of insulin Extensive patient & caretaker s education Nutritional management Regular monitoring
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
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
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
CONT. Lispro & aspart (A) Regular NPH& Lente Glargine (G) Ultralente Three or- four step dosing schedule Insulin pump therapy Inhaled & oral insulin therapy
BASIC EDUCATION Use mother tongue for proper understanding Insulin Type, action & storage Technique,& timing of insulin injection Monitoring RBS Urine ketones
Tuesday ------------------ ------------------- ------------------- ------------------- Fasting Monday ------------------- 2 hour after BF Before evening dose 2 hour after dinner Tuesday ------------------- Wednesday ------------------ Thursday ------------------ Friday ---------------- Saturday ------------------- Sunday ------------------ Monday -------------------
Dietary information Recognition & treatment of hypoglycemia Management during intercurrent infection Regular exercise
DIET Minimum restrictions Adopt positive approach Meal & snacks at regular intervals Adequate calories & nutrients
50% carbohydrate Complexed carbohydrate sugar free carbonated beverage High fiber diet Polyunsaturated fats Lean cuts of meat, poultry & fish
MONITORING Success in daily management is competence acquired by family & child Intermittent adjustment in insulin dosage
Self monitoring of blood glucose Daily blood glucose monitoring Continuous glucose monitoring system Glucowatch Biographer
Glycosylated Hemoglobin Nondiabetic.less than 6% Diabetics Good control 6-8.5% Fair control..9-10% Poor control.11% or higher
FOLLOW UP VISIT Ask any symptom / problem Growth record Weight (every visit) Height (6monthly) Evaluate control, review home record
EVERY VISIT Sugar profile, type of insulin & dose Spacing of doses, check injection sites Dietary compliance School progress report Blood pressure
3 MONTHLY Glycosylated Hb Joint mobility Fundus Examination Thyroid functions Microalbuminuria
COMPLICATIONS Brittle diabetes: Marked fluctuation in diabetic control Hypoglycemia RBS less than 60 mg% Diabetic ketoacidosis
Neuropathy : Peripheral neuritis Nephropathy: Progressive renal failure Retinopathy & Blindness Vasculopathy Hypertension, atherosclerosis
Lipoatrophy Infections Skin, fungal infection Growth retardation & psychological problem
Somogyi phenomenon Hypoglycemia begetting hyperglycemia Dawn phenomenon
PROGNOSIS Long term complications usually occur after 10-15 years. 100% pts..retinopathy