#Risk factors Diagnosis Clinical manifestations Acute complications

#Risk factors (LDL) Family history of diabetes Race Obesity (BMI > 30) Age Hypertension hyperlipidaemia Tobacco, Smoking IGT, IFG (prediabetes) History of Gestational DM Cataracts Woman delivered of a baby > 4 kg Polycystic ovary disease Inactivity

Obesity and Pre-Diabetes Diet high in fat, carbohydrates Increase the insulin levels in body. Beta cells pump out more and more insulin and the Beta cells become exhausted. Insulin levels decline Also pre-diabetics have a tendency toward insulin resistant cells Result: diet abuse, less insulin, resistant cells = tips patient into Type II Diabetes.

DIABESITY Persons with diabetes who suffer from obesity http://www.healthnews-stat.com/primages/obesity-F.jpg

Carbohydrates  Carbohydrates – Simple Sugars – contain 1or 2 units ( saccharied units ) Complex Carbohydrates- long chains of simple sugar: polysaccharide starch is a complex carbohydrate

Glycaemic Index (GI) A food's GI indicates the rate at which the carbohydrate in that food is broken down into glucose and absorbed from the gut into the blood. In high GI foods, this occurs quickly, causing your blood glucose (sugar) level to rise rapidly. The Glycaemic Index (GI) ranks food on a scale from 0 - 100 according to the effect they have on blood glucose levels. Lewis 1196

Diagnosis of DM occurs when… Plasma random glucose > 11.1 mmol/L along with symptoms DM. Plasma glucose > 7.0mmol/L after 8hrs fasting. OGTT value > 11.1mmol/L 2 hrs after 75g glucose PO. (Tests most reliable in morning and normally repeated on a different day for confirmation.)

Glucose testing http://static.howstuffworks.com/gif/adam/images/en/fasting-glucose-tolerance-test-picture.jpg

Glycosylated Haemoglobin (HbA1c) Blood test measuring the average blood glucose level over a 2-3 month period. Now the recommended test for screening and diagnosis of diabetes * NZSSD Informs us of how well the patient’s diabetes is controlled. Goal is < 7% or 50 -55mmol/mol Each 1% increase = 11mmol/mol Fructosamine (reaction of glucose and plasma protein) Autoantibody tests (islet cells) Lewis 1186/1362

Clinical Manifestations Type 1 The manifestations of Type I diabetes often come on suddenly and very severely. They include: Excessive thirst - POLYDIPSIA Excessive urination – POLYURIA Excessive eating - POLYPHAGIA Weight loss (even though you may be hungry and eating well) Feeling weak and tired Blurred vision Ketoacidosis

Clinical Manifestations Type 2 Sometimes, people with Type II diabetes don't notice any symptoms or the symptoms are experienced gradually. They include: blurred vision cuts or sores that are slow to heal itchy skin, yeast infections increased thirst dry mouth need to urinate often leg pain # 3 P’s

Osmotic diuresis Hyperglycemia Blood glucose levels above renal threshold (10-12mmol/L Kidneys excrete glucose along with water and electrolytes ( k+) Polyuria Dehydration

Short Term/Acute Complications Acute hyperglycemic complications HHNS (Hyperosmolar Hyperglycaemic Non- ketotic Syndrome) previously HONK DKA (Diabetic Ketoacidosis) Acute hypoglycemic complications Diaphoresis, shakiness LOC Seizure activity, brain death Somogyi effect (Low & High) Dawn Phenomena

LDL Compare hyperglycaemia with hypoglycaemia under the following headings Clinical manifestations Causes Treatment Preventative measures

Stress and Diabetes Mellitus Stress causes release of hormones - ACTH - corticosteroids - Catecholamines Increases: Glucose Heart rate Cardiac contraction Muscle contraction Bronchial relaxation

HHS /HHNS (Hyperosmolar Hyperglycaemic [Nonketotic] Syndrome) Metabolic derangement characterized by: Principally in Type 2 diabetics Hyperglycemia Hyperosmolarity Absence of ketones Preceding probable: Infection most common cause (Pneumonia, UTI) hydration (Dementia, immobility, vomiting) MI Some drugs (Diuretics, H2 blockers)

Diabetic Ketoacidosis (DKA) Clinically, uncontrolled diabetes that requires emergency treatment with intravenous fluids and insulin Biochemically, an increase in the serum concentration of ketones greater than 5 mEq/L, a blood glucose level of greater than 11.1mols, and a blood pH of less than 7.2 Disorder in the breakdown of carbohydrate, fat and protein Hyperglycaemia, dehydration with electrolyte loss and acidosis

Diabetic ketoacidosis (DKA) No glucose in cells to be used as source of energy liver starts converting glycogen to glucose Body starts breaking down fat stores ( lypolysis) Ketones (acids) produced Increased ketones and glucose in blood Metabolic acidosis Osmotic diuresis

Causes of DKA Poor compliance Concurrent illness (e.g., UTI, vomiting) Medical, surgical, or emotional stress Brittle diabetes Idiopathic (no identifiable cause) Insulin infusion catheter blockage Mechanical failure of insulin infusion pump

DKA and HHNS http://www.youtube.com/watch?v=SghkKH1dQvk&feature=related

Hypoglycaemia A reduction in plasma glucose concentration to a level that may induce symptoms of low blood sugar. Caused by: too much insulin or oral hypoglycaemics too little food excessive physical activity stress

Treatment for hypoglycaemia If conscious - 15 gm of fast acting concentrated carbohydrate orally --- 3 – 4 commercially prepared glucose tablets or 60 – 120 ml fruit juice or soft drink or 6 – 10 jelly beans or 2 – 3 teaspoons of sugar or honey Retest after 15 minutes and if less than 3.8 – 4mmol repeat above Follow with a snack of protein and starch if not having a meal in the next 30 minutes

If unconscious ….. Glucagon 1mg subcutaneously or intramuscularly May take up to 20 minutes to wake up. Follow with a carbohydrate snack If no response will require bolus IV glucose 50% 25 – 50ml

Hypoglycaemia

Somogyi Effect Swing to high plasma glucose from overnight low plasma glucose Rebound hyperglycaemia and ketosis AM readings may cause night time adjustment of insulin and compound problem. Treatment involves adjusting supper snacks and less insulin

Dawn Phenomenon Hyperglycaemia in the morning due to release of counter-regulatory hormones growth hormone, cortisol Adolescence and young adulthood RX – adjust times of insulin or increase