1. Diabetes mellitus (DM), also known simply as diabetes, is a group of metabolic diseases in which there are high blood sugar levels over a prolonged period. Diabetes is due to either the pancreas not producing enough insulin, or the cells of the body not responding properly to the insulin produced. Type 1 DM results from the body's failure to produce enough insulin. Type 2 DM begins with insulin resistance, a physiological condition in which cells fail to respond to the normal actions of the hormone insulin. The body produces insulin, but the cells in the body become resistant to insulin and are unable to use it as effectively, leading to hyperglycemia. Beta cells in the pancreas subsequently increase their production of insulin, further contributing to hyperinsulinemia. This often remains undetected and can contribute to a diagnosis of Type 2 Diabetes. Prediabetes indicates a condition that occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 DM. Many people destined to develop type 2 DM spend many years in a state of prediabetes. DIABETES

3. Diagnoses of DM: TESTS Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following: Fasting plasma glucose level ≥ 7.0 mmol/l (126 mg/dl) Plasma glucose ≥ 11.1 mmol/l (200 mg/dl) two hours after a 75 g oral glucose load as in a glucose tolerance test Symptoms of hyperglycemia and casual plasma glucose ≥ 11.1 mmol/l (200 mg/dl) Glycated hemoglobin is a form of hemoglobin that is measured primarily to identify the average plasma glucose concentration over prolonged periods of time. (Hb A1C) ≥ 6.5%. Glucose can become attached to hemoglobin molecules in the red blood cells and tend to persist there for many months. Therefore 2-3 times per year this test should be done to get a long term measure of the effectiveness of diabetic treatment. Levels >7.0 are a problem See diagram in previous slide re other symptoms

4. Blood Sugar (Glucose) The blood sugar concentration or blood glucose level is the amount of glucose (sugar) present in the blood of a human or animal. The body naturally tightly regulates blood glucose levels as a part of metabolic homeostasis. Normal value ranges from 4.4 to 6.1 mmol/L (79.2 to 110 mg/dL) (as measured by a fasting blood glucose test) with an average of about 5.5 mM (5.5 mmol/L or 100 mg/dL, i.e. milligrams/deciliter); however, this level fluctuates throughout the day. The blood glucose target range for diabetics, according to the American Diabetes Association, should be 90–130 (mg/dL) before meals, and less than 180 mg/dL after meals (as measured by a blood glucose monitor).

6. Role of the Pancreas The sources of glucose: food digestion, liver production via breakdown of glycogen, and by new production called gluconeogenesis – e.g. from protein The pancreas supplies “pancreatic juices” to the small intestine which are vital in the digestion of food in the gut – the role of the “exocrine” cells. These enzymes fluids are emptied into the intestine via pancreatic ducts. The “juice” is a fluid containing bicarbonate ions and enzymes that are used to break down the major food groups ingested: Proteins, carbohydrates and fats. Also contains many small “clusters” of cells (about 1-2 million per pancreas also called beta cells) in groups that are called the Islets of Langerhans which secrete about 6 hormones the most common being insulin and glucagon. They are secreted directly into the blood stream. Role of insulin is to allow cells to take glucose from the blood and that of glucagon to do the opposite. They work together to maintain homeostasis in regard to glucose levels. When you are very hungry – have not eaten for many hours – glucagon levels increase and glucose is synthesized and released for cell function. As soon as you begin to eat - within minutes – insulin is released so that glucose is not allowed to be elevated too much and the cells can use it for their functioning.

7. Treatment of Diabetes Direct injection of insulin Use of medications such as Metformin (which works by stopping the new production of glucose by the liver – i.e. of reducing gluconeogenesis) and Januvia (also know as Sitagliptin) which works on maintaining the efficacy of another hormone in the gut called incretin (which helps increase glucose levels) Transplantation of Islet cells into the pancreas is undergoing investigation – especially for type 1 diabetes Control of intake of carbohydrates and other dietary methods Maintain a regular fitness program or exercise regularly

8. Control of Diet Maintain steady levels of glucose at all times Smaller meals spread over the day – e.g. 3 medium and 2 small. Remember the rule - min of 4 hours between meals is best. See the graph re blood sugar Test glucose levels 2x per day up to a limit – do not go overboard with testing Control CHOs as much as possible – i.e. less carbohydrate is best. Avoid most grains (bread) and “complex” carbohydrates are rapidly converted to glucose. Reduce intake of pasta and potatoes as well. Be carful with fruits as well as they are high in fructose. Do not get trapped into using “treat” days and snacking between meals. Advice: NO treats and NO snacks. You will get used to not having these at all. While it may be difficult – diabetes can be controlled with very careful diets and without resort to insulin or drugs