1. FAMILY MEDICINE COURSE
TOPIC: Diabetes Mellitus

2. OBJECTIVES: At the end of this session, students will be able to:
Identify D/D of a case presented with the symptoms of polyuria and polydipsia.
Identify the prevalence of diabetes mellitus (DM) in Saudi community.
Discuss the classification of DM .

3. OBJECTIVES (Continued):
4. Discuss briefly about the diagnostic criteria for DM.
5. Identify the patho-physiological changes in a diabetic patient.
6. Enumerate and discuss the importance presenting signs & symptoms of DM.

4. OBJECTIVES (Continued):
7. Investigate appropriately a patient suspecting of DM.
8. Advice initial management plan for a patient diagnosed first with DM.
9. Identify important complication of DM
10. Discuss different medication used in DM management .
11. Identify importance of life style changes in diabetic patients.
12. Discuss screening criteria for DM.

5. CASE:
A 30-year-old man, who works as a clerk in a company , has presented to the clinic today with the complaint of increased thirst, and increased urination . These complaints initiated for last few weeks. He admitted that he was in Makkah for Omra and started to have these symptoms, but he assumed that these symptoms were due to hard works and running from here to there in Makkah. But he is worried that the symptoms are continuing even he is back home and having usual sedentary life.

6. CASE (Continued):
He also complaint of generalized weakness, otherwise on other complaint. He is not known to have any other chronic illness.
On Examination:
Look well. His height is 160 cm and his weight is 98 kg.
Systematic examination reviled normal, apart from being obese.

7. Write down on a paper before moving to the next slides
Summarize the case.
What are the possible causes of his symptoms? (Differential diagnosis )
Write down on a paper before moving to the next slides

8. Summary of the case:
A 30-year-old man, not known to have any problem before, with sedentary life.
C/o generalized weakness, polyuria and polydipsia of recent onset.
His height is 160 cm and his weight is 98 kg.

9. Differential diagnosis for polyuria and polydipsia.
Diabetes mellitus.
Diabetes insipidus.
Nephropathy( hypokalemic).
Hyperparathyroidism.
Cushing's disease/Syndrome.
Compulsive water drinking.
Pheochromocytoma.

10. What
is the prevalence
of DM?

11. Prevalence of DM World wide
More than 350 million people have diabetes.
Predicted to be the 7th leading cause of death by the year 2030.
80% of diabetic deaths occur in low and middle income countries.
One third of people with diabetes are undiagnosed.

12. Prevalence of DM In saudi arabia In 1988, 4% of Saudis were diabetic.
Nearly 25% of Saudis are diabetic in 2015.
4 million are in risk.

13. What is diabetes mellitus ?
A group of heterogeneous metabolic disorders which is characterized by abnormal metabolism of glucose due to defect in : insulin secretion or insulin action

14. How to diagnose diabetes ?

15. hyperglycemia, results should be confirmedزby repeat testing
Criteria for the diagnosis of diabetes.
FPG≥126mg/dl
A1C≥6.5%
classic symptom +
RPG≥200mg/dl
2-h≥200 mg/dl
*In the absence of unequivocal
hyperglycemia, results should be confirmedزby repeat testing

16. Who are normal
People i.e. not diabetic?

17. FBS: < 5.5 mmols/L (< 100 mgs)
2PP: < 7.8 mmols/L (<140 mgs)
HbA1c: < 5.6 %

18. How about asymptomatic adults ?

19. Pre-diabetic Patients?
Who are
Pre-diabetic Patients?

20. Pre-diabetic condition :
The term used for individuals with impaired fasting glucose (IFG) and/or impaired glucose tolerance (IGT).
And indicates an increased risk for the future development of diabetes.

21. FBS: mmols/L ( mgs)
HbA1c: %
2-h PG after 75-g OGTT: mmols/L (140–199 mg/d)

22. Screening for DM !!
Criteria for testing for diabetes in asymptomatic adults
1. Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2)
and have additional risk factors:
first-degree relative with diabetes
high-risk race/ethnicity
women who delivered a baby weighing .9 lb or were diagnosed with GDM hypertension.
Criteria for testing for diabetes or prediabetes in asymptomatic adults
1. Testing should be considered in all adults who are overweight (BMI $25 kg/m2 or $23 kg/m2 in
Asian Americans) and have additional risk factors:
c physical inactivity
c first-degree relative with diabetes
c high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian
American, Pacific Islander)
c women who delivered a baby weighing .9 lb or were diagnosed with GDM
c hypertension ($140/90 mmHg or on therapy for hypertension)
c HDL cholesterol level,35 mg/dL (0.90mmol/L) and/or a triglyceride level.250 mg/dL
(2.82 mmol/L)
c women with polycystic ovary syndrome
c A1C $5.7%, IGT, or IFG on previous testing
c other clinical conditions associated with insulin resistance (e.g., severe obesity,
acanthosis nigricans)
c history of CVD
2. For all patients, particularly those who are overweight or obese, testing should
begin at age 45 years.
3. If results are normal, testing should be repeated at a minimum of 3-year intervals, with
consideration of more frequent testing depending on initial results (e.g., those with
prediabetes should be tested yearly) and risk status.
women with polycystic ovary syndrome
history of CVD

23. Usually pre-diabetic conditions are detected through this screening .
Screening for DM !!
Criteria for testing for diabetes in asymptomatic adults
2. For all patients, particularly those who are overweight or obese, testing should
begin at age 45 years.
3. If results are normal, testing should be repeated at a minimum of 3-year intervals.
Usually pre-diabetic conditions are detected through this screening .

24. How to Classify
DM?

25. Diabetes Mellitus Classification:
Type 1: β-cell destruction, usually leading to absolute insulin deficiency; Immune-mediated diabetes.
Type 2: Ranging from predominantly insulin resistance with relative insulin deficiency to predominantly an insulin secretary defect with insulin resistance)
Gestational diabetes mellitus (GDM): diagnosed in the second or third trimester of pregnancy
Others:
1. Type 1 diabetes (due to b-cell destruction )
2. Type 2 diabetes ( insulin secretory defect on the background
of insulin resistance)

26. Others /Specific types Drug-induced diabetes
Diabetes can be classified into the following general categories:
Others /Specific types
Genetic disorders
Endocrine disorders
Monogenic diabetes syndromes
Neonatal diabetes
Maturity-onset diabetes of the young [MODY] *
Acromegaly
Cushing’s syndrome
Pheochromocytoma *
Pancreatic disorders
Drug-induced diabetes
Pancreatic agenesis
Cystic fibrosis
Pancreatitis
Tumor *
Steroids
Beta blockers
thiazide diuretics *

27. What are the patho- physiologyof
Diabetes Mellitus?

28. Pathophysiology-IFG Impaired fasting glucose:
Patients whose plasma glucose levels are higher than normal but not diagnostic of DM
Risk factors for developing DM and cardiovascular disease and are associated with the insulin-resistance syndrome.
Pathophysiology-IFG

29. Pathophysiology-Type 1 DM:
5% to 10% of all diabetes cases.
Childhood or early adulthood
Results from immune- mediated destruction of pancreatic β-cells.
Long preclinical period (up to 9 to 13 years) marked by the presence of immune markers when β-cell destruction is thought to occur.
Hyperglycemia : 80% to 90% of β- cells are destroyed, till absolute insulin deficiency occurs.
Pathophysiology-Type 1 DM:

30. Pathophysiology-Type 1 DM (Cont)
Honeymoon Phase: transient remission followed by established disease with associated risks for complications and death.
The factors that initiate the autoimmune process are unknown,
Mediated by macrophages and T lymphocytes with circulating autoantibodies to various β-cell antigens (e.g., islet cell antibody, insulin antibodies)
Pathophysiology-Type 1 DM (Cont)

31. Pathophysiology-Type2
More than 90% of DM cases
Presence of both insulin resistance and relative insulin deficiency.
Insulin resistance is manifested by increased lipolysis and free fatty acid production, increased hepatic glucose production, and decreased skeletal muscle uptake of glucose.
β-Cell dysfunction is progressive and contributes to worsening blood glucose control over time.
Type 2 DM occurs when a diabetogenic lifestyle (excessive calories, inadequate exercise, and obesity) is superimposed upon a susceptible genotype
Pathophysiology-Type2

32. Pathophysiology-Others
Uncommon (1% to 2% of cases)
Endocrine disorders
Acromegaly,
Cushing’s syndrome),
Gestational diabetes mellitus (GDM),
Diseases of the exocrine pancreas:
Pancreatitis
Medications :
Glucocorticoids
Pentamidine
Niacin
α- interferon

33. Patho-physiological changes in a diabetic patient

34. Patho-physiological changes in a diabetic patient

35. What are the classic symptoms of
Diabetes mellitus?

36. What are the classic symptoms of DM?
Polyuria
Polyphagia
Polydipsia
The Classic Symptoms
•Polyphagia (frequently hungry)
•Polyuria (frequently urinating)
•Polydipsia (frequently thirsty)

37. What are the other signs & symptoms of DM?
Blurred vision
Fatigue
Weight loss
Poor wound healing (cuts, scrapes, etc.)
Dry mouth
Dry or itchy skin
Impotence (male)
Recurrent infections:
vaginal yeast,
groin rash,
external ear infections (swimmers ear)

38. Other Signs and symptoms of diabetes mellitus
Clinic ER
1- acute abdomen
2-nausa and vomiting
(diabetic ketoacidosis )
3-confiusion
(sever hyperosmolar hyperglycemia
1- polyuria
2-polydipsia
3-polyphagia
4-nocturia
5- weight loss( mostly in type 1)
6- visual disturbance
7- fatigue

39. How to evaluate a patient with DM?

40. Components of the comprehensive diabetes evaluation :
1-Medical history.
2-Physical examination.
3-Laboratory evaluation.
4-Referrals.

41. Components of the comprehensive diabetes
: evaluation
Age and onset of diabetes
Eating patterns and nutritional status.
physical activity.
Presence of common comorbidities.
Psychosocial problems
Dental disease
Previous and current treatment regimens (if any) .
DKA frequency( severity, and cause)
Hypoglycemic eps
History of diabetes-related complications
(1)
Medical history
Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic laboratory finding).
Eating patterns, physical activity habits, nutritional status, and weight history .
Presence of common comorbidities, psychosocial problems, and dental disease
Review of any previous treatment regimens .
Current treatment of diabetes .
Results of glucose monitoring and patient’s use of data
DKA frequency, severity, and cause
Hypoglycemic episodes
History of diabetes-related complications .

42. diabetes-related complications
Short-term
complications
long-term
complications *
Hypoglycaemia
Diabetic ketoacidosis (DKA
Hyperosmolar hyperglycaemic state (HHS) . * *
Microvascular
Macrovascular
Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of foot
lesions; autonomic, including sexual dysfunction and gastroparesis)
Macrovascular: coronary heart disease, cerebrovascular disease, and peripheral arterial disease *
Retinopathy *
Coronary heart disease *
Nephropathy *
Cerebrovascular disease *
Neuropathy *
Peripheral arterial disease

43. Components of the comprehensive diabetes : evaluation*
Height, weight, BMI
Blood pressure
Fundoscopic examination
Thyroid palpation
Skin examination
Comprehensive foot examination
(2)
Physical
examination *
Height, weight, BMI
Blood pressure
Fundoscopic examination
Thyroid palpation
Skin examination (for acanthosis nigricans and insulin injection sites)
Comprehensive foot examination
Inspection
Palpation of dorsalis pedis and posterior tibial pulses
Presence/absence of patellar and Achilles reflexes
Determination of proprioception, vibration, and monofilament sensation *

44. Components of the comprehensive diabetes : evaluation
FBS, 2PP
HbA1C
Fasting lipid profile
Urea and Creatinine
Albumin to Creatinine ratio
TSH in type 1 diabetes
(3)
Laboratory
evaluation
A1C
Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides, as needed
Liver function tests
Test for urine albumin excretion with spot urine albumin-to-creatinine ratio
Serum creatinine and calculated glomerular filtration rate
TSH in type 1 diabetes, dyslipidemia, or women over age 50 years

45. Components of the comprehensive diabetes
: evaluation
Eye care professional .
Family planning for women of
reproductive age.
Dietitian for medical nutrition therapy.
Dentist for comprehensive periodontal examination
Mental health professional, if needed
(4)
Referrals
Eye care professional for annual dilated eye exam
Family planning for women of reproductive age
Registered dietitian for medical nutrition therapy
Dentist for comprehensive periodontal examination
Mental health professional, if needed

46. How can we manage diabetes mellitus ?

47. Gen. Approach to Management
Diabetes management is a team work Individualize management Set Target goals Glycaemic goals BP goals Lipid goals Eye Care Education

48. we need ….
Physician Nutrition Educator Ophthalmologist And in need we can consult : Vascular, Nephrologist, Neurologist

49. Management of diabetes mellitus
Goals are :
To confirm the diagnosis .
To classify the condition .
To reduce diabetic symptoms .
To prevent short and long term complications .
To improve quality of life. * * * * *
By achieving proper glycemic control

50. How can we achieve a proper glycemic control ?

51. Management of diabetes mellitus
proper glycemic control
Non –pharmacological
pharmacological

52. Non –pharmacological Activity Routinely screen
Nutrition therapy is recommended for all patients.
Psychosocial
Nutrition
Education
Non –pharmacological
Activity
Smoking
Adults with diabetes should be advised
to perform at least 150 min/
week of moderate-intensity aerobic
physical activity (50–70% of
maximum heart rate), spread
over at least 3 days/week with no
more than 2 consecutive days
without exercise
Routinely screen for psychosocial
problems such as depression,
diabetes-related distress, anxiety,
eating disorders, and cognitive
impairment. B
Provide routine vaccinations for
children and adults with diabetes
as for the general population.
Annually provide an influenza vaccine
to all patients with diabetes
$6 months of age. C
c Administer pneumococcal polysaccharide
vaccine 23 (PPSV23)
to all patients with diabetes $2
years of age. C
Immunization
least 150 min/
week of moderate-intensity aerobic
physical activity .
routine vaccinations

53. Pharmacological Treatment?

54. Insulin: Manly for type 1 but it will be needed for type 2
Two Groups only:
Oral hypoglycemic drugs : Mainly for Type-2
Insulin: Manly for type 1 but it will be needed for type 2

55. Metformin OR Salfanylurea
Mono
Dual
triple
Comb
Metformin OR Salfanylurea
Metformin + other oral hypoglycemic agent
Metformin + 2 other oral hypoglycemic agent
Metformin + basal insulin + meal time insulin

56. Treatment Goals? Blood pressure control: (ACE inhibitors, ARBs)
Smoking cessation
Lipids control:
Statins
Glycemic control:
Diet and exercise
Diet and oral hypoglycemic drugs
Diet, oral hypoglycemic drugs and insulin

57. Indication of Insulin in Type 2 DM
If HbA1c is ≥ 9 %
After maximum metformin and sulphonylurea, we should consider adding Insulin and taper the Sulphonylurea

58. - Self-monitoring of blood glucose (SMBG) - dose of insulin - Recognition of hypoglycemia symptoms and management - Carrying a card stating name, diagnosis, doses - How to maintain foot hygiene
Education of patient

59. Summary DM is a chronic depilating disease
Management of DM is a team approach
Patient, Physician, Surgeon, Dentists, Dietitian, Health educator, Ophthalmologist, …. All play important roles
The tried of the management is:
Medication
Diet
Exercise
Good control will lead to better outcomes
Other co-morbidities to be tackled well
Eye care professional for annual dilated eye exam
Family planning for women of reproductive age
Registered dietitian for medical nutrition therapy
Dentist for comprehensive periodontal examination
Mental health professional, if needed