Diabetes Mellitus

Česky: Aplikace "rychlého" inzulínu inzulinovým perem (Photo credit: Wikipedia)

I. Definition:

More commonly referred to as "diabetes" or sometimes called "sugar diabetes", is a condition that occurs when the body can't normally use glucose(a type of sugar).Glucose is vital to your health because it's an important source of energy for the cells of your muscles and tissues.It's also your brain's main source of fuel.The level of glucose in the blood are controlled by a hormone called Insulin, which is made by the pancreas. Insulin helps glucose enter the cells.

II. Target Blood Sugar Level:

Source: The American Diabetic Association(ADA) and American Academy of Pediatrics(AAP)

Children of any age with type II diabetes and most adults with type I or II diabetes(non-pregnant).

•      A1c: less than 7.0%
•      Before meals: 70 to 130 mg/dL
•      1 or 2 hours after meals: 100 to 129 mg/dL

Women with type I or type II diabetes who become pregnant.

•     A1c: less than 6.0%
•     Before meals, bedtime, and overnight

Women with type I or type II diabetes who become pregnant

•     A1c: less than 6.0%
•     Before meals, bedtime, and overnight: 60 to 99 mg/dL
•     1 to 2 hours after meals: 100 to 129 mg/dL or lower

Women who have gestational diabetes

•     Before meals: 95 mg/dL or less
•     1 to 2 hours after meals: 120 to 140 mg/dL or lower

Adolescents and young adults with type I diabetes(13 to 19 years old)

•     A1c: less than 7.5%
•     Before meals: 90 to 130 mg/dL
•     Bedtime and overnight: 90 to 150 mg/dL

School-age children with type I diabetes( 6 to 12 years old)

•    A1c: less than 8.0%
•    Before meals: 90 to 180 mg/dL
•    Bedtime and overnight: 100 to 180 mg/dL

Toodlers and preschoolers with type I diabetes(under 6 years old)

•    A1c: less than 8.5%
•    Before meals: 100 to 180 mg/dL
•    Bedtime and overnight: 110 to 200 mg/dL

III. Classification:

A. Type I diabetes

• Also known as juvenile diabetes because it begins most commonly in childhood or adolescence (usually less than 25 years of age) or was also called insulin-dependent diabetes because this type need to have daily injection of insulin.
• A metabolic disease caused by destruction of islets of Langerhans cells secondary to possible autoimmune or viral causative factor.
• It has abrupt onset; accounts for 5-10% of cases
• Insulin production is very little to none

Brittle diabetes 

• Frequent and rapid swing of blood sugar level between hyperglycemia and   hypoglycemia.
• Requires several injection of different types of insulin during the day.

B. Type II diabetes

• Previously referred to as "non insulin-dependent diabetes mellitus"(NIDDM) or sometimes called as age-onset or adult-onset diabetes.
• The most common form of diabetes
• Etiology: resistance at insulin receptor sites usually secondary to obesity; ethnic prevalence.
• Significantly link to a person's lifestyle, weight, and age.
• Sometimes developing over the course of several years(slow or gradual onset); usually older than  40 years of age.
• Accounts for 90-95% of cases: Ketoacidosis rarely occur(ketosis-resistant diabetes; Insulin production is variable.
• Can be controlled by: Weight loss, Exercise, Diet, and Oral insulin.

Gestational diabetes 

• Develop during pregnancy (2nd or 3rd trimester) and generally resolves after delivery.
• Etiology: believed due to hormonal changes, metabolic demands, and genetic and environmental factors.
• Born prematurely, hypoglycemic, or severe jaundice at birth.

Risk Factor of Type II diabetes

• Usually older than 40 years of age
• Have a relative with diabetes mellitus (parent or siblings)
• Overweight or obese(more than 20% above their ideal body weight)
• Physical inactivity
• History of gestational diabetes or have delivered a baby more than 9 lbs(4 Kg)
• A high blood pressure(140/90 or above)
• Polycystic ovary syndrome (PCOS)
• Impared glucose tolerance or impaired fasting glucose on previous testing
• History of CVD
• A high-density lipoprotein(HDL) below 35 mg/dL; triglyceride level above 250 mg/dL
• Predieteacosis nigricans - a dark,velvety rash around the neck or armpit.

IV. Sign and Symptoms:

4 Classic symptoms:    Weight loss in spite of increased eating(unexplained weight loss
                                         Increased urination(polyuria)
                                         Increased thirst(polydipsia)
                                         Feeling very hungry(polyphagia)

• Blurred vision
• Dehydration
• Irritability
• Slow healing sores
• Frequent infections (gums or skin infections and vaginal infections)
• Ketones in urine

V. Complications:

• Hypoglycemia and hyperglycemia
• Nephropathy
• Retinopathy
• Impotence
• Cardiovascular and peripheral vascular disease
• Diabetic ketoacidosis
• Increased risk of infections
• Acceleration of atherosclerosis
• Leading cause of lower limb amputation and end-stage disease
• Major cause of blindness(adults)

VI. Diagnosis:

A. Fasting Plasma Glucose Test:

• Patient has not eaten at least 8 hours,usually in the morning before breakfast.
• A plasma level of 200mg/dL(7.8 mmol/L) or higher indicate diabetes.

B. Postpradial Glucose Test:

• Test is done right after the patient has eaten a meal

C. Oral glucose Tolerance Test:

• Test is done before and after a patient drinks a thick, sweet syrup of glucose and other sugars.
• Plasma level of 11.1 mmol/L(200mg/dL) or higher at two hours after drinking indicates diabetes .

D. Urine Analysis - detects ketones and protein in the urine



VII. Interventions:

Type I diabetes

• Exogenous insulin injection per physican orders
• Subcutaneous insulin infusion pump for continuous admistration of insulin (surgical transplantation)
• Intraperitoneal dialysis for patient with renal failure

Type II diabetes

•     Usually given with oral hypoglycemic agents 

Exercise Therapy

*Benefits

•  Assists in weight reduction
•  Improves blood glucose control and circulation
•  Delays disease onset
•  Reduced cardiovascular risk
•  Improves strength and reduces stress

 *Take caution for exercise-induced hypoglycemia
 *Exercise testing is done prior to exercise  

• 50-60% of their predicted HR unless directed by physician

*Precription 

• Daily aerobic exercise; duration and intensity may be decreased.
• Include: cardio machines, aerobic classes, dancing, running, swimming, walking, or hiking
• Home exercise program: General exercise and strengthening, stretching and self monitoring of cardiac status.

*Diet - control of carbohydrates, protein fat, and caloric intake.
*Acupuncture - can help relieve the pain associated with diabetic neuropathy.
*Herbal remedies - may be helpful in managing diabetes - NO herbal substitute for insulin.

Exercise Precautions:

• Monitor glucose prior to and following exercise; readily carbohydrates snacks.
• Do not inject insulin in exercising muscles or sites close to it. 
• No exercise without eating at least 2 hours before exercise.
• No exercise for poorly controlled blood glucose level or at high level(at or near 250 mg/dL).
• No exercise if  urine test indicates presence of ketones.
• No exercise without adequate hydration.
• No exercise in extreme enviroment temperature(very cold or very hot).
• No exercise poorly controlled complications( as mentioned above).
• No exercise alone; need close supervision.  

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