Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. There are several types of diabetes including type 1, type 2, and gestational diabetes. The main goals of diabetes treatment and management are to normalize blood glucose levels through nutrition, exercise, glucose monitoring, pharmacologic therapy such as insulin, and education to reduce the risk of complications.

2. Diabetes Mellitus
 A group of metabolic diseases characterized by hyperglycemia
resulting from defects in insulin secretion, insulin action, or both.
 Diabetes mellitus is a group of metabolic diseases characterized by
elevated levels of glucose in the blood (hyperglycemia) resulting from
defects in insulin secretion, insulin action, or both.
 Normally a certain amount of glucose circulates in the blood.
 The major sources of this glucose are absorption of ingested food in the
gastrointestinal (GI) tract and formation of glucose by the liver from
food substances.

3.  Insulin, a hormone produced by the pancreas, controls the level of
glucose in the blood by regulating the production and storage of
glucose.
 In the diabetic state, the cells may stop responding to insulin or the
pancreas may stop producing insulin entirely.
 This leads to hyperglycemia, which may result in acute metabolic
complications such as diabetic ketoacidosis (DKA) and hyperglycemic
hyperosmolar nonketotic syndrome (HHNS).

4.  Diabetic ketoacidosis (DKA): a metabolic derangement in type 1
diabetes that results from a deficiency of insulin.
 Highly acidic ketone bodies are formed, resulting in acidosis; usually
requires hospitalization for treatment and is usually caused by non
adherence to the insulin regimen, concurrent illness, or infection.

5.  Long-term effects of hyperglycemia contribute to macrovascular
complications (coronary artery disease, cerebrovascular disease, and
peripheral vascular disease), chronic microvascular complications
(kidney and eye disease), and neuropathic complications (diseases of
the nerves).

6. Classification of Diabetes
There are several different types of diabetes mellitus; they may differ in cause,
clinical course, and treatment. The major classifications of diabetes are:
 Type 1 diabetes (previously referred to as insulin-dependent diabetes
mellitus)
 Type 2 diabetes (previously referred to as non-insulindependent
 diabetes mellitus)
 • Gestational diabetes mellitus
 • Diabetes mellitus associated with other conditions or
 syndromes

7.  The terms “insulin-dependent diabetes” and “non-insulindependent
diabetes” and their acronyms (IDDM and NIDDM, respectively) are no
longer used because they have resulted in classification of patients on
the basis of the treatment of their diabetes rather than the underlying
etiology.
 Use of Roman numerals (type I and type II) to distinguish between the
two types has been changed to type 1 and type 2 to reduce confusion

8.  Approximately 5% to 10% of people with diabetes have type 1
diabetes, in which the insulin-producing pancreatic beta cells are
destroyed by an autoimmune process.
 As a result, they produce little or no insulin and require insulin
injections to control their blood glucose levels.
 Type 1 diabetes is characterized by an acute onset, usually before age
30.

9.  Approximately 90% to 95% of people with diabetes have type 2
diabetes, which results from decreased sensitivity to insulin (called
insulin resistance) and impaired beta cell functioning resulting in
decreased insulin production.
 Type 2 diabetes is first treated with diet and exercise.
 If elevated glucose levels persist, diet and exercise are supplemented
with oral hypoglycemic agents.
 In some individuals with type 2 diabetes, oral agents do not control
hyperglycemia, and insulin injections are required.

10.  In addition, some individuals whose type 2 diabetes can usually be
controlled with diet, exercise, and oral agents may require insulin
injections during periods of acute physiologic stress (eg, illness or
surgery).
 Type 2 diabetes occurs more among people who are older than 30
years and obese.
 Diabetes complications may develop in any person with type 1 or type
2 diabetes, not only in patients who take insulin.
 Some patients with type 2 diabetes who are treated with oral
medications may have the impression that they do not really have
diabetes or that they simply have “borderline” diabetes.

11.  They may believe that, compared with diabetic patients who require
insulin injections, their diabetes is not a serious problem.
 It is important for the nurse to emphasize to these individuals that
they do have diabetes and not a borderline problem with sugar
(glucose).
 Borderline diabetes is classified as impaired glucose tolerance (IGT) or
impaired fasting glucose (IFG) and refers to a condition in which blood
glucose levels fall between normal levels and levels considered
diagnostic for diabetes.

12.  A woman with gestational diabetes may, after delivery, move into the
type 2 category.
 These types also differ in their etiology, clinical course, and
management.

13. TYPE 1 DIABETES
 Type 1 diabetes is characterized by destruction of the pancreatic beta
cells.
 It is thought that combined genetic, immunologic, and possibly
environmental (eg, viral) factors contribute to beta cell destruction.
 Although the events that lead to beta cell destruction are not fully
understood, it is generally accepted that a genetic susceptibility is a
common underlying factor in the development of type 1 diabetes.

14. TYPE 2 DIABETES
 The two main problems related to insulin in type 2 diabetes are insulin
resistance and impaired insulin secretion.
 Insulin resistance refers to a decreased tissue sensitivity to insulin.
 Normally, insulin binds to special receptors on cell surfaces and
initiates a series of reactions involved in glucose metabolism.

15. GESTATIONAL DIABETES
 Gestational diabetes is any degree of glucose intolerance with its onset
during pregnancy.
 Hyperglycemia develops during pregnancy because of the secretion of
placental hormones, which causes insulin resistance.
 For women who meet one or more of the following criteria, selective
screening for diabetes during pregnancy is now being recommended
between the 24th and 28th weeks of gestation: age 25 years or older;
age 25 years or younger and obese; family history of diabetes in first-
degree relatives; or member of an ethnic/racial group with a high
prevalence of diabetes.

16. CLINICAL MANIFESTATIONS
 Clinical manifestations of all types of diabetes include the “three Ps”:
polyuria, polydipsia, and polyphagia.
 Polyuria (increased urination) and polydipsia (increased thirst) occur
as a result of the excess loss of fluid associated with osmotic diuresis.
 The patient also experiences polyphagia (increased appetite) resulting
from the catabolic state induced by insulin deficiency and the
breakdown of proteins and fats.

17.  Other symptoms include fatigue and weakness, sudden vision
changes, tingling or numbness in hands or feet, dry skin, skin lesions
or wounds that are slow to heal, and recurrent infections.
 The onset of type 1 diabetes may also be associated with sudden
weight loss or nausea, vomiting, or abdominal pains, if DKA has
developed.

18. ASSESSMENT AND DIAGNOSTIC FINDINGS
 An abnormally high blood glucose level is the basic criterion for the
diabetes diagnosis.
 Fasting plasma glucose (FPG) levels of 126 mg/dL (7.0 mmol/L) or
more or random plasma glucose levels exceeding 200 mg/dL (11.1
mmol/L) on more than one occasion are diagnostic of diabetes.
 The oral glucose tolerance test and the intravenous glucose tolerance
test are no longer recommended for routine clinical use.

19. In addition to the assessment and diagnostic evaluation performed to
diagnose diabetes, ongoing specialized assessment of patients with known
diabetes and evaluation for complications in patients with newly
diagnosed diabetes are important components of care.

20. Diabetes Management
 The main goal of diabetes treatment is to normalize insulin activity
and blood glucose levels to reduce the development of vascular and
neuropathic complications.
 The trial investigated the impact of intensive glucose control on the
development and progression of complications such as retinopathy,
nephropathy, and neuropathy.
 Careful screening of patients is a key step in initiating intensive
therapy.

21.  Therefore, the therapeutic goal for diabetes management is to achieve
normal blood glucose levels (euglycemia) without hypoglycemia and
without seriously disrupting the patient’s usual lifestyle and activity.
 There are five components of diabetes management.
 Nutritional management
 Exercise
 Monitoring
 Pharmacologic therapy
 Education

22. NUTRITIONAL MANAGEMENT
 Nutrition, diet, and weight control are the foundation of diabetes
management.
 The most important objective in the dietary and nutritional
management of diabetes is control of total caloric intake to attain or
maintain a reasonable body weight and control of blood glucose levels.

23.  Providing all the essential food constituents (eg, vitamins, minerals)
necessary for optimal nutrition
 Meeting energy needs
 Achieving and maintaining a reasonable weight
 Preventing wide daily fluctuations in blood glucose levels, with blood
glucose levels as close to normal as is safe and practical to prevent or
reduce the risk for complications
 Decreasing serum lipid levels, if elevated, to reduce the risk for
macrovascular disease

24. CALORIC REQUIREMENTS
 Calorie-controlled diets are planned by first calculating the
individual’s energy needs and caloric requirements based on the
patient’s age, gender, height, and weight.
 An activity element is then factored in to provide the actual number of
calories required for weight maintenance.
 To promote a 1- to 2-pound weight loss per week, 500 to 1,000 calories
are subtracted from the daily total.
 The calories are distributed into carbohydrates, proteins, and fats, and
a meal plan is then developed.

25. MONITORING GLUCOSE LEVELS AND KETONES
 Blood glucose monitoring is a cornerstone of diabetes management,
and self-monitoring of blood glucose (SMBG) levels by patients has
dramatically altered diabetes care.
 Frequent SMBG enables people with diabetes to adjust the treatment
regimen to obtain optimal blood glucose control.
 This allows for detection and prevention of hypoglycemia and
hyperglycemia and plays a crucial role in normalizing blood glucose
levels, which in turn may reduce the risk of long-term diabetic
complications.

26. Glycosylated Hemoglobin
 Glycosylated hemoglobin (referred to as HgbA1C or A1C) is a blood
test that reflects average blood glucose levels over a period of
approximately 2 to 3 months.
 When blood glucose levels are elevated, glucose molecules attach to
hemoglobin in the red blood cell.
 The longer the amount of glucose in the blood remains above normal,
the more glucose binds to the red blood cell and the higher the
glycosylated hemoglobin level.
 This complex (the hemoglobin attached to the glucose) is permanent
and lasts for the life of the red blood cell, approximately 120 days.

27.  The normal values differ slightly from test to test and from laboratory
to laboratory and normally range from 4% to 6%.
 Urine Testing for Glucose
 Testing for Ketones
 Ketones (or ketone bodies) in the urine signal that control of type 1
diabetes is deteriorating, and the risk of DKA is high.
 When there is almost no effective insulin available, the body starts to
break down stored fat for energy.
 Ketone bodies are byproducts of this fat breakdown, and they
accumulate in the blood and urine.

28. PHARMACOLOGIC THERAPY
 Insulin Therapy and Insulin Preparations

29. Complications of Insulin Therapy
 LOCAL ALLERGIC REACTIONS
A local allergic reaction (redness, swelling, tenderness, and induration or
a 2- to 4-cm wheal) may appear at the injection site 1 to 2 hours after the
insulin administration.
 SYSTEMIC ALLERGIC REACTIONS
Systemic allergic reactions to insulin are rare. When they do occur, there is
an immediate local skin reaction that gradually spreads into generalized
urticarial.
 INSULIN LIPODYSTROPHY
Lipodystrophy refers to a localized reaction

30.  INSULIN RESISTANCE
Most patients at one time or another have some degree of insulin
resistance.
Alternative Methods of Insulin Delivery
INSULIN PENS
INSULIN PUMPS
Continuous subcutaneous insulin infusion involves the use of
small, externally worn devices that closely mimic the functioning
of the normal pancreas

31.  IMPLANTABLE AND INHALANT INSULIN DELIVERY
 TRANSPLANTATION OF PANCREATIC CELLS
 Thanking you.