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1. Diabetes Lecture 7 DR. BLEND BAYAR KHALIL M.B.Ch.B - H.D.D Member of ESE Head of NCD

2. Lecture Objectives Diabetes : definition , types ,epidemiology Risk factors , complications , prevention 10/13/2021

3. Definition Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Hyperglycemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body's systems, especially the nerves and blood vessels. ( WHO ) In other words , is metabolic disease in which the body’s inability to produce any or enough insulin causes elevated levels of glucose in the blood. 10/13/2021

4. Diabetes Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body’s cells for use as energy. If you have diabetes, your body either doesn’t make enough insulin or can’t use the insulin it makes as well as it should. When there isn’t enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. 10/13/2021

5. World’s Diabetes day It is marked every year on 14 November, the birthday of Sir Frederick Banting, who co-discovered insulin along with Charles Best in 1922. WDD is the world's largest diabetes awareness campaign reaching a global audience of over 1 billion people in more than 160 countries. 10/13/2021

6. History of Diabetes Approximately 1550BC An Egyptian papyrus mentions a rare disease that causes the patient to lose weight rapidly and urinate frequently. This is thought to be the first reference to diabetes. 250 BC The creation of the term “diabetes” is credited to Apollonius of Memphis, which refers to a disease which drains patients of more fluid than they can consume. 131-201 CE A Greek physician, Galen of Pergamum, theorises that diabetes is an affliction of the kidneys. After this period, diabetes is rarely mentioned. 1025 A Persian polymath called Avicenna (980-1037) publishes “The Canon of Medicine” in 1025, providing a detailed account on diabetes mellitus. The sweet urine of people with diabetes is described, as is abnormal appetite, diabetic gangrene and sexual dysfunction. 10/13/2021

7. The Epidemic Called Diabetes 1 person is diagnosed with diabetes every 3 seconds 1 person dies from complication of diabetes every 6 seconds 1 person loss a limb because of diabetes every 24 seconds 4110 diabetic patients newly diagnosed for next 24 hours 66 diabetic patients will go blind for next 24 hours 122 diabetic pati e nts diagnosed with ESRD for next 24 hours 225 diabetes-related amputations for next 24 hours 614 diabetic pati e nts will die for next 24 hours(50% < age 60) “ diabetes is a cardiovascular disease.”(affect multiple organs). Number of people with type 2 diabetes is increasing in every countries. www.idf.org www.diabetes.org/uedocuments/NationalDiabetesFactSheetRev.pdf. Accessed May 11, 2006.

8. Diabetes around the world

9. Type 2 diabetes: a global epidemic Type 2 diabetes accounts for 85–95% of diabetes cases 50 100 150 200 250 300 350 1985 Global prevalence of diabetes (millions) 400 2040 > 600 million 2000 1990 1995 2005 2010 2015 2020 2025 2007 246 million 1985 30 million 2000 150 million 2015 422 DM million +IFG and IGT= 733 ١

10. Kurdistan Statistics In Iraq; There were 1.3 million cases of diabetes in Iraq in 2015. IDF: Prevalence of diabetes in adults is 7.6% (20-79 yrs old) . Iraq MoH : prevalence of diabetes is 13,9% . In Kurdistan; Prevalence of type 1, type 1, gestational, prediabetes could reach 11.5%. Duhok DOH predicts 12.5%. (21005 pt.) - (160000) Cost per person with diabetes per year: USD 400 ???.

11. Top 10 causes for morbidity and mortality in Iraq Top 10 causes for morbidity and mortality in Iraq

12. Epidemiology of Diabetes 1 person is diagnosed with diabetes every 3 seconds 1 person dies from complication of diabetes every 6 seconds 1 person loss a limb because of diabetes every 24 seconds 4110 diabetic patients newly diagnosed for next 24 hours 66 diabetic patients will go blind for next 24 hours 122 diabetic patients diagnosed with ESRD for next 24 hours 225 diabetes-related amputations for next 24 hours 614 diabetic patients will die for next 24 hours(50% < age 60) 10/13/2021

13. Diabetes facts About 347 million people worldwide have diabetes. There is an emerging global epidemic of diabetes that can be traced back to rapid increases in overweight, obesity and physical inactivity 10/13/2021

14. Diabetes facts Diabetes is predicted to become the seventh leading cause of death in the world by the year 2030. Total deaths from diabetes are projected to rise by more than 50% in the next 10 years. 10/13/2021

15. Diabetes Facts 80% of diabetes deaths occur in low- and middle-income countries. In developed countries most people with diabetes are above the age of retirement, whereas in developing countries those most frequently affected are aged between 35 and 64. 10/13/2021

16. Prevalence of Diabetes ( 2014 ) 10/13/2021

17. 10/13/2021

18. International Diabetes Federation World map Diabetes mellitus 10/13/2021

19. International Diabetes Federation World map Diabetes mellitus 10/13/2021

20. Classification of Diabetes Type 1 diabetes ( β -cell destruction and complete lack of insulin- polygenic cause, divided to Type 1A and Type1B), type of antibody (islet cell ,insulin, GAD65, and IA-2 or GAD65, IA-2, and ZnT8). Type 2 diabetes(due to a progressive insulin secretory defect on the background of insulin resistance, polygenic cause). Gestational diabetes mellitus (GDM). Other specific types of diabetes Genetic defects in β -cell function, insulin action(MODY, Type A and B insulin resistance , LADA). Diseases of the exocrine pancreas(pancreatitis and CA, cystic fibrosis, haemochromatosis). Drug- or chemical-induced(corticosteroids, diazoxide, adrenergic agonists- intravenous salbutamol, thiazides, interferon). Endocrinopathies, infections, metabolic, genetic syndrome.

21. Types of Diabetes Type 1 Type 2 Gestational diabetes Prediabetes 10/13/2021

22. Type 1 Diabetes Type 1 diabetes (previously known as insulin-dependent, juvenile or childhood-onset) is characterized by deficient insulin production and requires daily administration of insulin. Neither the cause of Type 1 diabetes nor the means to prevent it are known. Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger, weight loss, vision changes, and fatigue. These symptoms may occur suddenly. 10/13/2021

23. Type 2 diabetes type 2 diabetes (formerly called non-insulin-dependent, or adult-onset) results from the body’s ineffective use of insulin. The majority of people with diabetes have type 2 diabetes. This type of diabetes is largely the result of excess body weight and physical inactivity. Symptoms may be similar to those of type 1 diabetes, but are often less marked. As a result, the disease may be diagnosed several years after onset, after complications have already arisen. Until recently, this type of diabetes was seen only in adults but it is now also occurring increasingly frequently in children. 10/13/2021

24. Gestational diabetes Gestational diabetes is hyperglycemia with blood glucose values above normal but below those diagnostic of diabetes. Gestational diabetes occurs during pregnancy Women with gestational diabetes are at an increased risk of complications during pregnancy and at delivery. These women and possibly their children are also at increased risk of type 2 diabetes in the future. Gestational diabetes is diagnosed through prenatal screening, rather than through reported symptoms. 10/13/2021

25. Gestational diabetes mellitus (GDM): pregnant women who have never had diabetes before , but who have high blood glucose (sugar) levels during pregnancy are said to have gestational diabetes . According to a 2014 analysis by the centers for disease control and prevention, the prevalence of GDM is higher as 9.2%. 1995 CDC-- T1DM=4%, T2DM=8%, GDM=88%. Definition according to ADA 2015 Hypoglycemia, hypocalcemia Macrosomia Maternal complications Caesarian section Preeclampsia Risk of developing diabetes after pregnancy Fetal complications Congenital anomalies Birth trauma and birth injury Hypertension(safe--methyldopa, deltiazem, clonidin , prazosin. BP= 110-129/65-79mmHg) Polycythemia or hyperinsulinemia Diagnosis of GDM OGTT one step :- 75 OGTT fasting ≥92mg/dl 1hr≥180mg/dl 2hr≥153mg/dl 3hr≥140mg/dl Goal to control GDM Fasting < 95mg/dl 1hr < 140mg/dl 2hr < 120mg/dl A1C < 6% Metformin(NICE-Canadian Guideline safe) most type of insulin category B Lantus – apidra – category C

26. Complications of gestational diabetes Most women who have gestational diabetes deliver healthy babies. However, untreated or uncontrolled blood sugar levels can cause problems for you and your baby. Complications in your baby can occur as a result of gestational diabetes, including: Excess growth. Extra glucose can cross the placenta, which triggers your baby's pancreas to make extra insulin. This can cause your baby to grow too large (macrosomia). Very large babies are more likely to require a C-section birth. Low blood sugar . Sometimes babies of mothers with gestational diabetes develop low blood sugar (hypoglycemia) shortly after birth because their own insulin production is high. Type 2 diabetes later in life . Babies of mothers who have gestational diabetes have a higher risk of developing obesity and type 2 diabetes later in life. Death. Untreated gestational diabetes can result in a baby's death either before or shortly after birth. Complications in the mother also can occur as a result of gestational diabetes, including: Preeclampsia. This condition is characterized by high blood pressure, excess protein in the urine, and swelling in the legs and feet. Preeclampsia can lead to serious or even life-threatening complications for both mother and baby. Subsequent gestational diabetes. Once you've had gestational diabetes in one pregnancy, you're more likely to have it again with the next pregnancy. You're also more likely to develop diabetes , typically type 2 diabetes , as you get older. 10/13/2021

27. Prediabetes Prediabetes is a serious health condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes. If you have prediabetes, the cells in your body don’t respond normally to insulin. Your pancreas makes more insulin to try to get cells to respond. Eventually your pancreas can’t keep up, and your blood sugar rises, setting the stage for prediabetes and type 2 diabetes down the road. 10/13/2021

28. Diabetes Symptoms Diabetes symptoms vary depending on how much your blood sugar is elevated. Some people, especially those with prediabetes or type 2 diabetes, may sometimes not experience symptoms. In type 1 diabetes, symptoms tend to come on quickly and be more severe. 10/13/2021

29. Diabetes symptoms Some of the signs and symptoms of type 1 diabetes and type 2 diabetes are: Increased thirst Frequent urination Extreme hunger Unexplained weight loss Presence of ketones in the urine (ketones are a byproduct of the breakdown of muscle and fat that happens when there's not enough available insulin) Fatigue Irritability Blurred vision Slow-healing sores Frequent infections, such as gums or skin infections and vaginal infections Urinate (pee) a lot, often at night 10/13/2021

30. Diabetes symptoms 10/13/2021

31. Diabetes symptoms Symptoms of Type 1 Diabetes People who have type 1 diabetes may also have nausea, vomiting, or stomach pains. Type 1 diabetes symptoms can develop in just a few weeks or months and can be severe. Type 1 diabetes usually starts when you’re a child, teen, or young adult but can happen at any age. Symptoms of Type 2 Diabetes Type 2 diabetes symptoms often take several years to develop. Some people don’t notice any symptoms at all. Type 2 diabetes usually starts when you’re an adult, though more and more children and teens are developing it. Because symptoms are hard to spot, it’s important to know the risk factors for type 2 diabetes. Make sure to visit your doctor if you have any of them. Symptoms of Gestational Diabetes Gestational diabetes (diabetes during pregnancy) usually doesn’t have any symptoms. If you’re pregnant, your doctor should test you for gestational diabetes between 24 and 28 weeks of pregnancy. If needed, you can make changes to protect your health and your baby’s health. 10/13/2021

32. Causes of Diabetes To understand diabetes, first you must understand how glucose is normally processed in the body. How insulin works ? Insulin is a hormone that comes from a gland situated behind and below the stomach (pancreas). The pancreas secretes insulin into the bloodstream. The insulin circulates, enabling sugar to enter your cells. Insulin lowers the amount of sugar in your bloodstream. As your blood sugar level drops, so does the secretion of insulin from your pancreas. 10/13/2021

33. The role of glucose Glucose , a sugar , is a source of energy for the cells that make up muscles and other tissues. Glucose comes from two major sources: food and your liver. Sugar is absorbed into the bloodstream, where it enters cells with the help of insulin. Your liver stores and makes glucose. When your glucose levels are low, such as when you haven't eaten in a while, the liver breaks down stored glycogen into glucose to keep your glucose level within a normal range. 10/13/2021

34. Causes of Diabetes Causes of type 1 diabetes The exact cause of type 1 diabetes is unknown. What is known is that your immune system which normally fights harmful bacteria or viruses , attacks and destroys your insulin-producing cells in the pancreas. This leaves you with little or no insulin. Instead of being transported into your cells, sugar builds up in your bloodstream. Type 1 is thought to be caused by a combination of genetic susceptibility and environmental factors, though exactly what those factors are is still unclear. Weight is not believed to be a factor in type 1 diabetes. 10/13/2021

35. Causes of Diabetes Causes of prediabetes and type 2 diabetes In prediabetes , which can lead to type 2 diabetes , and in type 2 diabetes, your cells become resistant to the action of insulin, and your pancreas is unable to make enough insulin to overcome this resistance. Instead of moving into your cells where it's needed for energy, sugar builds up in your bloodstream. Exactly why this happens is uncertain, although it's believed that genetic and environmental factors play a role in the development of type 2 diabetes too. Being overweight is strongly linked to the development of type 2 diabetes, but not everyone with type 2 is overweight. 10/13/2021

36. Causes of Diabetes Common factors that cause of having Type 2 diabetes . 10/13/2021

37. Risk factors 10/13/2021

38. Causes of Diabetes Causes of gestational diabetes During pregnancy, the placenta produces hormones to sustain your pregnancy. These hormones make your cells more resistant to insulin. Normally, your pancreas responds by producing enough extra insulin to overcome this resistance. But sometimes your pancreas can't keep up. When this happens, too little glucose gets into your cells and too much stays in your blood, resulting in gestational diabetes. 10/13/2021

39. Risk factors of Diabetes Risk factors for type 1 diabetes Although the exact cause of type 1 diabetes is unknown, factors that may signal an increased risk include: Family history. Your risk increases if a parent or sibling has type 1 diabetes. Environmental factors. Circumstances such as exposure to a viral illness likely play some role in type 1 diabetes. The presence of damaging immune system cells (autoantibodies). Sometimes family members of people with type 1 diabetes are tested for the presence of diabetes autoantibodies. If you have these autoantibodies, you have an increased risk of developing type 1 diabetes. But not everyone who has these autoantibodies develops diabetes. Geography. Certain countries, such as Finland and Sweden, have higher rates of type 1 diabetes. 10/13/2021

40. Risk factors of Diabetes Risk factors for prediabetes and type 2 diabetes Researchers don't fully understand why some people develop prediabetes and type 2 diabetes and others don't. It's clear that certain factors increase the risk, however, including: 10/13/2021

41. Risk factors of Diabetes Risk factors for gestational diabetes Pregnant women can develop gestational diabetes. Some women are at greater risk than are others. Risk factors for gestational diabetes include: Age. Women older than age 25 are at increased risk. Family or personal history. Your risk increases if you have prediabetes , a precursor to type 2 diabetes , or if a close family member, such as a parent or sibling, has type 2 diabetes. You're also at greater risk if you had gestational diabetes during a previous pregnancy, if you delivered a very large baby or if you had an unexplained stillbirth. Weight. Being overweight before pregnancy increases your risk. Race or ethnicity. For reasons that aren't clear, women who are Black, Hispanic, American Indian or Asian American are more likely to develop gestational diabetes. 10/13/2021

42. Development and progression of type 2 diabetes and related complications 10/13/2021

43. β -Cell Function Declines Regardless of Intervention in T2DM Adapted from UKPDS Group. Diabetes . 1995;44:1249-1258. 20 40 60 80 100 –5 –4 –3 –2 –1 1 2 3 4 5 6 Years Since Diagnosis Sulfonylurea Diet Metformin β-Cell Function (%)* Progressive loss of β -cell function occurs prior to diagnosis * β -cell function measured by HOMA

44. Ominous Octet

45. Management and Treatment How is diabetes managed ? Diabetes affects your whole body. To best manage diabetes, you’ll need to take steps to keep your risk factors under control and within the normal range, including: Keep your blood glucose levels as near to normal as possible by following a diet plan, taking prescribed medication and increasing your activity level. Maintain your blood cholesterol (HDL and LDL levels) and triglyceride levels as near the normal ranges as possible. Control your blood pressure. Your blood pressure should not be over 140/90 mmHg. 10/13/2021

46. Managing Diabetes You hold the keys to managing your diabetes by: Planning what you eat and following a healthy meal plan. Follow a Mediterranean diet (vegetables, whole grains, beans, fruits, healthy fats, low sugar) or Dash diet. These diets are high in nutrition and fiber and low in fats and calories. See a registered dietitian for help understanding nutrition and meal planning. Exercising regularly. Try to exercise at least 30 minutes most days of the week. Walk, swim or find some activity you enjoy. Losing weight if you are overweight. Work with your healthcare team to develop a weight-loss plan. Taking medication and insulin, if prescribed, and closely following recommendations on how and when to take it. Monitoring your blood glucose and blood pressure levels at home. Keeping your appointments with your healthcare providers and having laboratory tests completed as ordered by your doctor. Quitting smoking (if you smoke). 10/13/2021

47. Managing Diabetes How do I check my blood glucose level? Why is this important? Checking your blood glucose level is important because the results help guide decisions about what to eat, your physical activity and any needed medication and insulin adjustments or additions. The most common way to check your blood glucose level is with a blood glucose meter. With this test, you prick the side of your finger, apply the drop of blood to a test strip, insert the strip into the meter and the meter will show your glucose level at that moment in time. Your healthcare provider will tell you how often you’ll need to check your glucose level. 10/13/2021

48. How do I check my blood glucose level 10/13/2021

49. Criteria for Diagnosis Test Normal Prediabetes Diabetes* FPG, mg/dL <100 100 – 125 (IFG) ≥126 2-h PG † , mg/dL <140 140 – 199 (IGT) ≥200 Random PG, mg/dL ≥200 + symptoms of diabetes Hemoglobin A1C, % <5.6 5.7 – 6.4 (screening only) ≥6.5 ‡ *Confirm diagnosis on a separate day by repeating the glucose or A1C testing. Handelsman YH, et al. Endocr Pract . 2015;21(suppl 1):1-87. The idea of ADA is to label more people with prediabetes (decrease threshold for diagnosis)

50. Diabetes Prevention Program Research Group. N Engl J Med 2002;346:393-403. Diabetes Prevention Program Progression to Type 2 Diabetes Still lifestyle modification was the best way to prevent diabetes in future followed by metformin.

51. No changes from 2016 Diabetic patients on treatment to delay or prevent complication FBS= 130 mg/dl RBS 2hour = 180 mg/dl Individualize goals

52. Managing Blood glucose Level What is continuous glucose monitoring? Advancements in technology have given us another way to monitor glucose levels. Continuous glucose monitoring uses a tiny sensor inserted under your skin. You don't need to prick your finger. Instead, the sensor measures your glucose and can display results anytime during the day or night. Ask your healthcare provider about continuous glucose monitors to see if this is an option for you. 10/13/2021

53. Managing Blood glucose Level What should my blood glucose level be? Ask your healthcare team what your blood glucose level should be. They may have a specific target range for you. In general, though, most people try to keep their blood glucose levels at these targets: Before a meal: between 80 and 130 mg/dL. About two hours after the start of a meal: less than 180 mg/dL. 10/13/2021

54. Managing Blood glucose Level What happens if my blood glucose level is low? Having a blood glucose level that is lower than the normal range (usually below 70 mg/dL) is called hypoglycemia. This is a sign that your body gives out that you need sugar. 10/13/2021

55. Managing Blood glucose Level What happens if my blood glucose level is high? If you have too much glucose in your blood, you have a condition called hyperglycemia. Hyperglycemia is defined as: A blood glucose level greater than 125 mg/dL while in the fasting state (nothing to eat or drink for at least eight hours). A blood glucose level greater than 180 mg/dL one to two hours after eating. 10/13/2021

56. Hypoglycemia Vs Hyperglycemia 10/13/2021

57. How is diabetes treated? Treatments for diabetes depend on your type of diabetes, how well controlled your blood glucose level is and your other existing health conditions. Type 1 diabetes: If you have this type, you must take insulin every day. Your pancreas no longer makes insulin. Type 2 diabetes: If you have this type, your treatments can include medications (both for diabetes and for conditions that are risk factors for diabetes), insulin and lifestyle changes such as losing weight, making healthy food choices and being more physically active . 10/13/2021

58. Treating Diabetes 10/13/2021

59. How is diabetes treated? Prediabetes: If you have prediabetes, the goal is to keep you from progressing to diabetes. Treatments are focused on treatable risk factors, such as losing weight by eating a healthy diet (like the Mediterranean diet) and exercising (at least five days a week for 30 minutes). Many of the strategies used to prevent diabetes are the same as those recommended to treat diabetes (see prevention section of this article). Gestational diabetes: If you have this type and your glucose level is not too high, your initial treatment might be modifying your diet and getting regular exercise. If the target goal is still not met or your glucose level is very high, your healthcare team may start medication or insulin. 10/13/2021

60. Treating Diabetes What oral medications are approved to treat diabetes ? Over 40 medications have been approved by the Food and Drug Administration for the treatment of diabetes. It’s beyond the scope of this article to review all of these drugs. Instead, we’ll briefly review the main drug classes available, how they work and present the names of a few drugs in each class. Your healthcare team will decide if medication is right for you. If so, they’ll decide which specific drug(s) are best to treat your diabetes. Sulfonylureas: These drugs lower blood glucose by causing the pancreas to release more insulin. Glinides (also called meglitinides): These drugs lower blood glucose by getting the pancreas to release more insulin. Biguanides: These drugs reduce how much glucose the liver produces. It also improves how insulin works in the body, and slows down the conversion of carbohydrates into sugar. 10/13/2021

61. Oral Hypoglycemics These agents are useful in the treatment of type 2 DM who do not respond adequately to non-medical interventions (diet, exercise and weight loss). Newly diagnosed Type 2 DM (less than 5 years) often respond well to oral agents, patients with long standing disease (often diagnosed late) often require a combination of agents with or without insulin. The progressive decline in β-cell function often necessitates the addition of insulin at some time in Type II diabetes. Oral agents are never indicated for Type I DM.

62. Oral Hypoglycemics Insulin sensitizers Secretagogues Alpha glucosidase inhibitors Incretins Pramlintide SGLT-2 inhibitors Insulin Afreza , insulin pump , bionic pancreases

63. Medications of Diabetes 10/13/2021

64. ADA 2020 Treatment Algorithm

65. Treating Diabetes Alpha-glucosidase inhibitors: These drugs lower blood glucose by delaying the breakdown of carbohydrates and reducing glucose absorption in the small intestine. Thiazolidinediones: These drugs improve the way insulin works in the body by allowing more glucose to enter into muscles, fat and the liver. GLP-1 analogs (also called incretin mimetics or glucagon-like peptide-1 receptor agonists): These drugs increase the release of insulin, reduce glucose release from the liver after meals and delay food emptying from the stomach. DPP-4 inhibitors (also called dipeptidyl peptidase-4 inhibitors): These drugs help your pancreas release more insulin after meals. They also lower the amount of glucose released by the liver. SGLT2 inhibitors (also called sodium-glucose cotransporter 2 inhibitors): These drugs work on your kidneys to remove glucose in your body through your urine Bile acid sequestrants: These drugs lower cholesterol and blood sugar levels. 10/13/2021

66. Treating Diabetes What insulin medications are approved to treat diabetes ? There are many types of insulins for diabetes. If you need insulin, you healthcare team will discuss the different types and if they are to be combined with oral medications. To follow is a brief review of insulin types. Rapid-acting insulins: These insulins are taken 15 minutes before meals, they peak (when it best lowers blood glucose) at one hour and work for another two to four hours. Short-acting insulins: These insulins take about 30 minutes to reach your bloodstream, reach their peak effects in two to three hours and last for three to six hours. Intermediate-acting insulins: These insulins reach your bloodstream in two to four hours, peak in four to 12 hours and work for up to 18 hours. Long-acting insulins: These insulins work to keep your blood sugar stable all day. Usually, these insulins last for about 18 hours 10/13/2021

67. Treating Diabetes How is insulin taken? How many different ways are there to take insulin? Insulin is available in several different formats. You and your healthcare provider will decide which delivery method is right for you based on your preference, lifestyle, insulin needs and insurance plan. Here’s a quick review of available types. Needle and syringe Insulin pen Insulin pump Artificial pancreas Insulin inhaler Insulin injection port Jet injector 10/13/2021

68. Treating Diabetes How is insulin taken? How many different ways are there to take insulin? Needle and syringe: With this method, you’ll insert a needle into a vial of insulin, pull back the syringe and fill the needle with the proper dose of insulin. You’ll inject the insulin into your belly or thigh, buttocks or upper arm – rotating the injection spots. You may need to give yourself one or more shots a day to maintain your target blood glucose level. Insulin pen: This device looks like a pen with a cap. They come prefilled with insulin or with insulin cartridges that are inserted and replaced after use. Insulin pump : Insulin pumps are small, computerized devices, about the size of a small cell phone that you wear on your belt, in your pocket, or under your clothes. They deliver rapid-acting insulin 24 hours a day through a small flexible tube called a cannula. The cannula is inserted under the skin using a needle. The needle is then removed leaving only the flexible tube under the skin. You replaces the cannula every two to three days. Another type of insulin pump is attached directly to your skin and does not use tubes. 10/13/2021

69. ROADMAP OF INSULIN DISCOVERY

70. How Insulin works ? 10/13/2021

71. Using Insulin Oral medications and insulin work in one of these ways to treat your diabetes: Stimulates your pancreas to make and release more insulin. Slows down the release of glucose from your liver (extra glucose is stored in your liver). Blocks the breakdown of carbohydrates in your stomach or intestines so that your tissues are more sensitive to (better react to) insulin. Helps rid your body of glucose through increased urination. 10/13/2021

72. Using Insulin 10/13/2021

73. Insulin Schedule

74. Treating Diabetes Artificial pancreas : This system uses an insulin pump linked to a continuous glucose monitor. The monitor checks your blood glucose levels every five minutes and then the pump delivers the needed dose of insulin. Insulin inhaler: Inhalers allow you to breath in powdered inhaler through an inhaler device that you insert into your mouth. The insulin is inhaled into your lungs, then absorbed into your bloodstream. Inhalers are only approved for use by adults with Type 1 or Type 2 diabetes. Insulin injection port: This delivery method involves the placement of a short tube into tissue beneath your skin. The port is held in place with an adhesive patch. You use a needle and syringe or insulin pen and inject the insulin through this port. The port is changed every few days. The port provides a single site for injection instead of having to rotate injection sites. Jet injector: This is a needleless delivery method that uses high pressure to send a fine spray of insulin through your skin. 10/13/2021

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76. Controlling multiple parameters is essential for effective treatment of patients with Type 2 diabetes Lipids(cholesterol) C Blood pressure B Body Weight B HbA 1c A Reductions in glycaemic control (HbA 1c ) and other parameters that are sustained over time can benefit the health of patients with Type 2 diabetes 1–5 ,delay complication of diabetes. 1. Stratton IM, et al. BMJ 2000;321:405–12; 2. Pi-Sunyer FX. Postgrad Med 2009;121:94–107; 3. Williamson DF, et al. Diabetes Care 2000;23:1499–504; 4. Patel A, ADVANCE Collaborative Group. Lancet 2007;370:829–40; 5. Pyǒrälä K, et al. Diabetes Care 1997;20:614–20. Hypoglycaemic Risk Durability -Weight Gain Problem with dysglycemia

77. Complications Long-term complications of diabetes develop gradually. The longer you have diabetes and the less controlled your blood sugar the higher the risk of complications. Eventually, diabetes complications may be disabling or even life-threatening. 10/13/2021

78. 10/13/2021 Retinopathy , nephropathy , neuropathy

79. Q/Do we have specific treatment goals in treating diabetes Dyslipidemia ? Keep LDL <100 mg/dl(high risk group keep <70 mg/dl). TG< 150 mg/dl. HDL> 40mg/dl in men, and >50 mg/dl in women.

80. Recommendations for Statin Treatment in People with Diabetes- ADA 2015 ADA. 8. Cardiovascular Disease and Risk Management. Diabetes Care 2015;38(suppl 1):S52, Table 8 .

81. Can prediabetes, Type 2 diabetes and gestational diabetes be prevented ? 10/13/2021

82. Preventing Diabetes Can Type 1 diabetes be prevented? No. Type 1 diabetes is an autoimmune disease, meaning your body attacks itself. Scientists aren’t sure why someone’s body would attack itself. Other factors may be involved too, such as genetic changes. Can the long-term complications of diabetes be prevented? Chronic complications are responsible for most illness and death associated with diabetes. Chronic complications usually appear after several years of elevated blood sugars (hyperglycemia). Since patients with Type 2 diabetes may have elevated blood sugars for several years before being diagnosed, these patients may have signs of complications at the time of diagnosis. 10/13/2021

83. خه‌له‌تيــــێن نه‌خوشــــــێن شــــــه‌كرێ ئ ە نس ــــــ ولين خ ــ راب ــــ ه ب ێ ژیژی كه لاندن به‌ر ێ بوركانی – بازنك ليمون بو پێـیـــان باشـــه‌ خــــه‌نا , نيفشك بو پێـیـــان باشـــه‌ به‌لگێــــن زه‌یتونـــــا - پێـــێ سوتـــــن باشـــه زراف ێ پ ه ز ی ل گ ه ل خه ناي ێ ب ە س هبوط السكري هنگڤـ ی ــن - هــــژیر - تـــــری - قـــه‌س پ - خیــــار – ك ە ل ە م ی ‌ ڤ ه‌خارنا ئافا باميا - ئــــافا گ هيشـــــكا - ر ێ فا س - ک ـــولند ب خـــافی بن ئازمانك - كوهه برين و نافك - تبلا به‌رانی - نافك (بغدا- دمشق- تركا)

84. Diabetes during Covid-19 How does COVID-19 affect a person with diabetes? Although having diabetes may not necessarily increase your risk of contracting COVID-19, if you do get the virus, you are more likely to have more severe complications. If you contract COVID-19, your blood sugars are likely to increase as your body is working to clear the infection. If you contract COVID-19, contact your healthcare team early to let them know. 10/13/2021

85. Problems can be avoided Adherence to time table is all that is required to avoid problems: Regular meals and slowly Regular taking drugs Regular exercise ” Give a man a fish and he will not go hungry that day. Teach him how to fish and he will not be hungry for the rest of his life.” Chinese saying

86. Summary Diabetes is a slow killer with no known curable treatments. However, its complications can be reduced through proper awareness and timely treatment. Three major complications are related to blindness, kidney damage and heart attack. It is important to keep the blood glucose levels of patients under strict control for avoiding the complications. One of the difficulties with tight control of glucose levels in the blood is that such attempts may lead to hypoglycemia that creates much severe complications than an increased level of blood glucose. Researchers now look for alternative methods for diabetes treatment.

87. Thanks for Listening and Watching 10/13/2021