1. Chapter 33 Diabetes Mellitus and the Metabolic Syndrome
Essentials of Pathophysiology
Chapter 33 Diabetes Mellitus and the Metabolic Syndrome

2. Pre lecture Quiz Type 2 diabetes is more common than type 1.F
Type 2 diabetes is more common than type 1.
All cells can use fatty acids interchangeably with glucose for energy.
Insulin is produced by the pancreatic beta cells in the islets of Langerhans.
Hyperglycemia is characterized by headache, difficulty in problem solving, disturbed or altered behavior, coma, and seizures.
Chronic complications of diabetes mellitus refer only to type 1 diabetes mellitus.

3. Pre lecture Quiz Alpha Insulin ketoacidosis Metabolic one
______________ lowers the blood glucose concentration by facilitating the movement of glucose into body tissues.
Glucagon, a polypeptide molecule produced by the _____________ cells of the islets of Langerhans, maintains blood glucose between meals and during periods of fasting.
Type __________ diabetes mellitus is characterized by destruction of the pancreatic beta cells and is characterized by an absolute lack of insulin, an elevation in blood glucose, and a breakdown of body fats and protein.
The ________________ syndrome is a condition of abnormalities that are identified through specific criteria such as abdominal obesity, elevated triglycerides, elevated blood pressure, elevated fasting plasma glucose, and decreased high-density lipoprotein cholesterol (HDL).
Diabetic ____________________ occurs when ketone production by the liver exceeds cellular use and renal excretion.
Alpha
Insulin
ketoacidosis
Metabolic
one

4. Anabolism and Catabolism
available foodstuffs
Anabolism
stored foodstuffs
(in blood)
insulin,
(in cells)
anabolic
steroids
glucose
glycogen
Catabolism
amino acids
proteins
glucagon,
epinephrine,
free fatty acids
cortisol
triglycerides
liver can convert amino acids
and free fatty acids into
ketones

5. Insulin and Glucagon Are the Main Controls
available foodstuffs
Anabolism
stored foodstuffs
(in blood)
insulin ,
(in cells)
anabolic
steroids
glucose
glycogen
Catabolism
amino acids
proteins
glucagon ,
epinephrine,
free fatty acids
triglycerides
cortisol
liver can convert amino acids
and free fatty acids into
ketones

6. Question
Tell whether the following statement is true or false. Anabolic reactions release energy.

7. Answer
False Rationale: Anabolic reactions use energy to build/produce/synthesize (like building proteins from amino acids). Catabolic reactions break down substances, releasing energy in the process (like digestion).

8. Scenario Two women have benign pancreatic tumors.
In one, the tumor is an insulinoma that secretes insulin
In the other, the tumor is a glucagonoma that secretes glucagon
Questions:
What differences do you expect to see between these two women? Why?
Both of the women have arthritis, but only one is being treated with corticosteroids. Which one? Why is the other not receiving corticosteroids?

9. The Pancreas pancreas exocrine endocrine pancreas pancreas
releases digestive
releases hormones
juices through a
into the blood
duct
to the
duodenum

10. endocrine pancreas: islets of Langerhans alpha beta cells delta cells
PP cells
cells
insulin
pancreatic
glucagon
somatostatin
and amylin
polypeptide

12. Functions of Pancreatic Hormones
Glucagon: causes cells to release stored food into the blood
Insulin: allows cells to take up glucose from the blood
Amylin: slows glucose absorption in small intestine; suppresses glucagon secretion
Somatostatin: decreases GI activity; suppresses glucagon and insulin secretion

14. Question
Which pancreatic hormone decreases blood glucose levels?
Glucagon
Insulin
Amylin
Somatostatin

15. Answer
Insulin
Rationale: Insulin allows cells to take glucose from the blood and use it for energy/to make ATP. Because it stimulates movement of glucose out of the blood and into the cells, blood glucose levels decrease when insulin is released.

16. Discussion Think back on your day so far.
When do you think you had your highest insulin levels?
When do you think you had your lowest insulin levels?
When did you have your highest glucagon levels?

18. Review the figure on insulin’s actions.
Discussion
Review the figure on insulin’s actions.
If someone lacks insulin, what happens to his:
Blood glucose levels?
Blood amino acid levels?
Blood pH?
Intracellular fat levels?
Intracellular protein levels?
Cell growth?

19. Discussion
Review the following diagrams on anabolism/catabolism and insulin’s mechanism of action.
Questions:
Identify five things that could go wrong to cause increased blood glucose
Which of the cases you identified would be least likely to respond to insulin?

20. Anabolism and Catabolism
available foodstuffs
Anabolism
stored foodstuffs
(in blood)
insulin,
(in cells)
anabolic
steroids
glucose
glycogen
Catabolism
amino acids
proteins
glucagon,
epinephrine,
free fatty acids
cortisol
triglycerides
liver can convert amino acids
and free fatty acids into
ketones

21. Types of Diabetes Mellitus
Type 1: pancreatic beta cell destruction predominantly by an autoimmune process
Type 2: a combination of beta cell dysfunction and insulin resistance
Other
Genetic defects in insulin production
Genetic defects in insulin action
Diabetes secondary to other diseases
Drug interactions
Gestational diabetes mellitus

22. Pathogenesis of Type 2 Diabetes

23. Question
Tell whether the following statement is true or false. Type 2 DM is more common than type 1 DM.

24. Answer
True Rationale: Type 1 DM is autoimmune (juvenile diabetes is type 1), and affects only 5–10% of the diabetic population. Type 2 DM is associated with risk factors like obesity, poor diet, and sedentary lifestyle; 90–95% of diabetics suffer from this type.

25. Metabolic Syndrome Abdominal obesity
Increased blood triglyceride levels
Decreased HDL levels
Increased blood pressure
Increased fasting plasma glucose

26. Treatments for Type 2 diabetes

27. Acute Complications of Diabetes
Diabetic ketoacidosis
Hyperglycemic hyperosmolar nonketotic coma
Hypoglycemia
Somogyi effect
Dawn phenomenon

28. Acute Complications of Diabetes (cont.)
Discussion
How would hyperglycemia with ketoacidosis cause:
Heavy breathing?
Polyuria?
Dehydration?
Which of these would you not see in hyperglycemia without ketoacidosis?

29. Scenario You find a man collapsed on the sidewalk.
He is wearing a diabetic alert bracelet and has an insulin syringe in his briefcase
Questions:
Does he need insulin?
Why or why not?
What signs might help you tell whether he has a hyperglycemic or hypoglycemic problem?

30. Chronic Complications of Diabetes Mellitus
Increased glucose levels allow glucose to bind to proteins in:
Hemoglobin  Hb A1C has higher O2 affinity
Basement membranes of blood vessels
Nephropathy
Retinopathy
May cause increased risk of atherosclerosis
Lens  cataracts
(Porth, C. M. [2005]. Pathophysiology [7th ed.]. Lippincott Williams & Wilkins and
Greenspan, F. & Gardner, D. G. [2004]. Basic and clinical endocrinology [7th ed.]. McGraw-Hill.)

31. Author: Please add title.

32. Osmolarity in Diabetes Mellitus
When blood glucose is high, increased blood osmolarity can cause cells to shrink
Nerve cells produce intracellular osmoles to keep their osmolarity balanced with the blood
Hypotonic cell A shrinks A B
Cell B is in osmotic balance
(Porth, C. M. [2005]. Pathophysiology [7th ed.]. Lippincott Williams & Wilkins.)

33. Osmolarity in Diabetes Mellitus (cont.)
When the client brings blood glucose back to normal, the nerve cells are hyperosmolar to the blood and gain water, swelling
Nerve damage may be caused by swelling, demyelination, and lack of O2 secondary to vascular disease A
Cell A is in osmotic balance B
Hypertoniccell B swells
(Porth, C. M. [2005]. Pathophysiology [7th ed.]. Lippincott Williams & Wilkins.)

34. Diabetic Neuropathy Somatic neuropathy Autonomic neuropathy
Diminished perception of vibration, pain, and temperature
Hypersensitivity to light touch; occasionally, severe “burning” pain
Autonomic neuropathy
Defects in vasomotor and cardiac responses
Impaired motility of the gastrointestinal tract
Inability to empty the bladder
Sexual dysfunction

35. Question
Which of the following is not a complication of diabetes mellitus?
Nephropathy
Retinopathy
Neuropathy
All of the above are complications of DM.

36. Answer
All of the above are complications of DM.
Rationale: Nephropathy and retinopathy are caused by increased blood glucose levels that cause binding of excess glucose to the basement membranes of the blood vessels of the kidneys and eyes. Neuropathy is due to swelling and demyelination of nervous tissue.

37. Advanced Diabetic Foot Ulcer
Typical Diabetic Foot Ulcer
Advanced Diabetic Foot Ulcer