DIABETES MELLITUS By Dr. Sabry Ahmed Salem Prof. of community medicine Environ mental health & occupational medicine

Classification of diabetes mellitus: It can be classified, according to the level of blood glucose, into: I-Clinical diabetes: cases show symptoms and signs and clearly elevated blood glucose, which may be : A-Primary: 1- Type I or Insulin dependent diabetes mellitus (IDDM). 2- Type II or Non-Insulin dependent diabetes mellitus (NIDDM).

B-Other specific types: 1.Pancreatic diseases (Pancreatitis, neoplastic disease, pancreatectomy, cystic fibrosis). 2.Excess endogenous production of hormonal antagonists to insulin: e.g. Growth Hormone (Acromegaly), Glucocorticoids (Cushing Syndrome), Thyroid Hormones (hyper thyroidism), Catecholamines (phaeochramocytoma) and human placental lactogen (pregnancy).

C-Gestational. II- Abnormal glucose tolerance: The cases show mild hyperglycemia, which is not so high to be diagnosed as diabetes. It may be called a symptomatic, chemical, potential, latent, borderline or subclinical diabetes. 1.Medications: corticosteroids and thiazide diuretics. 2. Associated with genetic syndrome: e.g. Diabetes insipidus, Down’s syndrome and Turner’s syndrome.

Epidemiology: Diabetes mellitus is worldwide in distribution and the incidence of both types of primary diabetes i.e IDDM and NIDDM, is increasing. However the prevalence of both types varies in different part of the world and this probably due to differences in genetic and environmental factors. The great majority of cases seen worldwide have primary diabetes and in Europe and North America the ratio of type 2: type 1 is approximately 7:3, in Egypt may be around 4:1.

It is more common is young age than that among old age, with usually sudden onset and severe insulin deficiency and more prone to ketosis. It may be fatal with negligence of insulin therapy as it is insulin dependent. I- IDDM:

It is more common among middle or old age groups of population (any age may be affected). Insulin deficiency is not sense and cases are prone to ketosis. Trauma and infections might be predisposing factors for developing ketosis. This type not dependent on insulin therapy. Obesity is an important risk factor among this type. Diet control and hypoglycemic drugs usually control the cases. Insulin is given in some cases. II-NIDDM:

A-Type 1, IDDM : 1-Genetics: 2- Viruses: 3-Diet: 4- Stress: 5-Immunological factors: II- Type II NIDDM: Causes: 1- Genetics: 2- lifestyle: a- Overeating: b- Malnutrition in utero: C- pregnancy: Aetiology:

1- Familial tendency due to: Inheritance. Exposure of the family members to the same risk factors e.g. diet, obesity and stress. 2- Herd tendency: Exposure of numbers of an ethnic group to common social and environmental factors. High-risk factors for NIDDM:

i.Obesity: ii.the risk is directly associated with extent and duration of obesity. iii.Child bearing period: Affects insulin utilization. c- Diabetogenic drugs: Corticosteriods and oral contraceptive. 3- Personal factors:

1.Duration of diabetes. 2.Early age at onset of disease. 3.Raised blood pressure. 4.Proteinuria. 5.Obesity. 6- Hyperlipidaemia. 7- High glycated hemoglobin. * Factors associated with in creased mortality and morbidity in diabetic patients:

Complications of diabetes: I-Acute complications: 1- Hypoglycemia: 2- Counter-regulatory responses: 3- Diabetic ketoacidosis: 4- Non-ketotic hyperosmolar diabetic coma: 5- lactic acidosis. II- long-term complications: 1.Diabetic retinopathy. 2- Diabetic neuropathy. 3. Diabetic foot. 4- Diabetic nephropathy.

Prevention of diabetes: Preventive measures are mainly based on the high-risk factors: 1- Nutrition education: To avoid excess carbohydrate and fats which leads to obesity, through: i.Adequate feeding for children and avoiding over weight. ii.Avoid cow’s milk during infancy and encourage breast feed. iii.Regular checking of weight, to screen and management of over weight and early obesity.

To prevent the viral infections that may be complicated with pancriatitis, through: Specific immunization and seroprophylaxis when needed, (MR vaccine during child hood) to prevent mumps and rubella infection. Environmental sanitation. 2- Prevention and control of viral infections:

3- Avoid the diabetogenic drugs abuse: These preparation must be used under medical super vision. 4- Premarital examination and counseling: For early case finding and guidance of diabetics: The public must be aware of the risk of inherited susceptibility, when both parents are diabetic.

Objectives: i.To determine the prevalence and epidemiological features of the disease. ii.To study the high risk factors associated with the disease and the high-risk groups. iii.To evaluate the control measures. Control of diabetes: 1- Epidemiological studies II- Case finding program: To detect the cases of hyperglycemia through: i.Health appraisal: during providing medical service. ii.Comprehensive medical examination. iii.Screening tests d- Survey studies.

IV- Health education: a- The public for, - Utilization of health services. - Adequate nutrition. - Healthy lifestyle - Normal weight avoid stress - Exercise. - Knowledge about the disease and the associated risk factors. III-Management and treatment of cases.

b- The borderline cases and high risk groups for: Weight control. Uses diabetogenic drugs under medical supervision. Early detection of hyperglycemia through regular checking blood glucose level. Manifestations of hyperglycemia. c- The cases for: Strictly follow up the scheme of treatment and diet. Signs and symptoms of complicated disease. Seek medical care regularly.