type 2 diabetes mellitus

Diabetes mellitus

1. TYPE 2 DIABETES MELLITUS PRESENTED BY-SIMARPREET KAUR L-2018-Hsc-53-BND

2. INTRODUCTION Diabetes mellitus  ( DM ) is a group of metabolic disorders that prevents the body to utilize glucose completely or partially. It is characterized by a raised glucose concentration in the blood and alterations in carbohydrate, protein and fat metabolism. Type 2 diabetes begins with  insulin resistance , a condition in which cells fail to respond to insulin properly. As the disease progresses, a lack of insulin may also develop.

3. PATHOPHYSIOLOGY When we eat food, carbohydrates in the food are broken down into sugar (glucose). Glucose travels in our bloodstream all over the cells. When blood sugar levels rise beyond a certain point, the body signals pancreas to release insulin. Insulin is a hormone produced by β-cells of pancreas. It is necessary for driving glucose into the cells. Cell membranes have little locks (receptors). Insulin fits into those locks like a key. Binding of insulin to its receptor triggers a signaling cascade that brings glucose transporters to the cell membrane. Glucose enters the cell through the transporters. It is then consumed as energy source or stored for later use.

4. PATHOPHYSIOLOGY In T2DM, pancreas produces enough insulin but something goes wrong either with receptor binding (structure of receptor changes) or signaling cascade in the target cells. As a result, the blood sugar get locked out of cells and stays in the bloodstream. When glucose concentration in the blood remains high over time, the kidneys reach a threshold of  reabsorption , and the body excretes glucose in the urine ( glycosuria ).This increases the osmotic pressure of the urine and inhibits reabsorption of water by the kidney, resulting in increased urine production ( polyuria ) and increased fluid loss, causing  dehydration  and increased thirst ( polydipsia ). In addition, intracellular glucose deficiency stimulates appetite leading to excessive food intake ( polyphagia ).

5. ETIOLOGY GENETICS- Familial tendency to T2DM LIFESTYLE- T2DM is associated with people who are obese, underactive and overeat. STRESS- Stress leads to release of hormones such as adrenaline and cortisol . Adrenaline increases the breakdown of glycogen and suppresses insulin secretion. Cortisol leads to an increased protein breakdown and inhibit sugar utilization by the tissues thus increasing blood sugar levels. ABDOMINAL FAT- People with a high waist-hip ratio indicating abdominal obesity (android type) have greater risk of T2DM.

6. SYMPTOMS SYMPTOM EXPLANATION POLYUREA Excessive urinary output, especially at night POLYDIPSEA Excessive thirst due to loss of water from the body POLYPHAGIA Increased appetite, urge for sweet items of food due to heavy loss of sugar in urine PRURITIS VULVAE Irritation in the genitalia caused by local deposition of sugar from urine PARAESTHESIA Tingling sensation in the hands and feet BLURRING OF VISION Excess sugar deposits on the eye lens causing refraction changes

7. COMPLICATIONS- ACUTE Blood glucose concentration <70 mg/dl Symptoms- Sweating, trembling, hunger, confusion, drowsiness, incoordination and nausea Causes- Unpunctual or inadequate meals, unexpected or unusual exercise and ingestion of alcohol, excessive dose of insulin HYPOGLYCAEMIA

8. COMPLICATIONS- ACUTE Blood glucose level higher than 200 mg/dl Symptoms- Polyphagia , polydipsia , polyuria , fatigue, restlessness Causes- Inadequate insulin, insulin resistance HYPERGLYCAEMIA

9. COMPLICATIONS- ACUTE When there is not enough insulin and the body cannot utilize carbohydrates to provide energy, it breaks down increased amounts of fats for energy through β -oxidation. Metabolic products- ketones are formed (Increased production of ketones is known as ketosis) These excess ketones accumulate in the blood ( ketonemia ) Ketones have a low pKa and therefore turn the blood acidic Ketones are also excreted in the urine ( ketonuria ) Ketoacidosis includes all the disorders associated with increased fat breakdown. KETOACIDOSIS

10. KETOACIDOSIS

11. COMPLICATIONS- CHRONIC Diabetes affect the blood vessels, the blood and the heart. Most patients with T2DM tend to be obese and hypertensive and therefore likely to have clinical atherosclerosis. Diabetics generally have high levels of blood lipids (cholesterol, triglycerides, LDL) and reduced HDL levels which make them susceptible to atherosclerosis and stroke. Diabetics have increased platelet adhesiveness and response to aggregating agents, likely to favour atherogenesis . ATHEROSCLEROSIS

12. COMPLICATIONS- CHRONIC Diabetic nephropathy , is the chronic loss of kidney function occurring in those with diabetes mellitus.  Pathophysiologic abnormalities begin with long-standing poorly controlled blood glucose levels. This is followed by multiple changes in the filtration units of the kidneys, the  nephrons . Initially, there is constriction of the efferent arterioles and dilation of afferent arterioles, resulting in glomerular capillary hypertension and hyperfiltration ; this gradually changes to hypofiltration over time.  Also, there are changes within the glomerulus itself such as thickening of the basement membrane that can can progressively expand and consume the entire glomerulus , shutting off filtration. These changes lead to defects in filtration increasing the proteins in urine ( Proteinuria ) and causing uraemia and finally renal failure. DIABETIC NEPHROPATHY

13. COMPLICATIONS- CHRONIC Diabetic neuropathy  refers to various types of nerve damage associated with diabetes mellitus. Symptoms can include motor changes such as weakness, sensory symptoms such as numbness, tingling, or pain, or autonomic changes such as urinary symptoms. DIABETIC NEUROPATHY DIABETIC RETINOPATHY Diabetic retinopathy refers to growth of friable and poor-quality new blood vessels in the retina as well as macular edema (swelling), which can lead to severe vision loss or blindness.

14. DIAGNOSIS Timely and proper diagnosis plays a key role in identifying and managing diabetes without complications. Fasting plasma glucose level - For this test, blood is taken after a period of fasting, i.e. in the morning before breakfast, after the patient had sufficient time to fast overnight. Oral Glucose Tolerance Test (OGTT)- It is a confirmatory test. Steps include- Fasting blood sample is drawn. 75 g glucose dissolved in 250-300 ml of water is given. Blood and urine specimens are collected every 30 minutes for 2 hours after the administration of glucose. PLASMA GLUCOSE LEVELS (mg/dl) FASTING 2 Hr POST LOAD NORMAL <110 <140 IMPAIRED FASTING GLUCOSE 110-125 <140 IMPAIRED GLUCOSE TOLERANCE <126 ≥140 & <200 DIABETES ≥ 126 ≥ 200 REFERENCE-Criteria for the diagnosis of diabetes & intermediate hyperglycaemia , WHO

15. DIAGNOSIS Urinary Sugar Test (Benedict’s Test)- For this test, 8 drops of urine and 5 ml of Benedict’s solution are taken in a test tube and mixed. The test tube is kept in boiling water for 5 minutes and colour is noted. COLOUR REPORT APPROXIMATE SUGAR IN URINE g% Blood mg% Green discoloration 0-trace - <200 Green ppt + 0.25 200-250 Greenish-yellow ppt ++ 0.5 250-300 Yellowish-orange ppt +++ 1.0 300-350 Brick red ppt ++++ >2.0 >350

16. DIAGNOSIS Glycosylated Haemoglobin (HbA1c)- As the concentration of glucose in blood rises, more of it gets attached to hemoglobin forming a glycosylated hemoglobin. A buildup of HbA1c within the RBCs reflects the average level of glucose to which the cell has been exposed during its lifecycle of 120 days and therefore shows the general trend of glucose levels in the blood during the previous 2-3 months. HbA1c DIAGNOSIS <5.7 % NORMAL 5.7-6.5 % PRE-DIABETES >6.5 % DIABETES REFERENCE-American diabetes association

17. MANAGEMENT- DIETARY RECOMMENDATIONS Medical Nutrition Therapy (MNT) for diabetes mellitus requires application of nutritional and behavioral sciences along with physical activity. Based on factors like age, sex, physical activity, height, weight, body mass index (BMI) and cultural factors, the diet is planned . Dietary Recommendations : Energy: Sufficient to attain or maintain a reasonable body weight for adults, normal growth and development for children and adolescents, to meet the increased needs during pregnancy and lactation. Approximately, 25 kcal/kg ideal body weight/day can be given to a moderately active patient with diabetes. Carbohydrates: 55-60 % of energy from carbohydrates is an ideal recommendation. Carbohydrates should be complex in nature. It is recommended that carbohydrates from high fibre foods e.g . whole grains, legumes, peas, beans, oats, barley and some fruits with low glycemic index and glycemic load are recommended.

18. MANAGEMENT- DIETARY RECOMMENDATIONS Fibre : Fibre recommendation for general population is 40 g/day (2000 Kcals ). Proteins: Proteins should provide 12-15 % of the total energy intake for people with diabetes. Proteins from vegetable sources are recommended. Supplementation of foods like cereal and pulse (4:1 ratio) can improve the protein quality and also gives satiety. Fats: Fats should provide 20-30 % of total energy intake for people with diabetes. Fat quality is as important as the quantity. Saturated fatty acids (SFA) ≤10% energy and 7% in those with raised blood lipid levels Polyunsaturated fatty acids (PUFA) 10 % energy, Monounsaturated Fatty Acids (MUFA) 10-15% energy REFERENCE- ICMR Guidelines for management of Type 2 Diabetes, 2018

19. MEAL PLANNING STRATEGIES FOR IMPROVED GLYCEMIC CONTROL GLYCEMIC INDEX GLYCEMIC LOAD CARB COUNTING DIABETES PLATE METHOD FOOD ORDER

20. GLYCAEMIC INDEX The glycaemic index (GI) of a food is the blood glucose response after consuming a CHO containing food relative to a CHO containing reference food viz , glucose or white bread under standard conditions. The common classification of GI foods is as follows HIGH 70 and above MODERATE 56-69 LOW 55 and below REFERENCE- NUTRIENT REQUIREMENTS FOR INDIANS-RDA, 2020

21. GLYCEMIC LOAD (GL) Glycemic load (GL) considers the GI and the total amount of available CHO present in the food consumed. Glycemic load (GL)= ( Glycemic index/100) * Available CHO (Available CHO= TOTAL CHO- DIETARY FIBRE) Both the GI and GL of the food are important determinants of the post- prandial plasma glucose response. A food with very high GI but if consumed in lower amounts, will provide only a small amount of CHO and hence will have a small GL and vice versa. Therefore, portion size of the food consumed is also important in eliciting the glycemic response. HIGH 20 and above MODERATE 10-19 LOW 10 and below REFERENCE- NUTRIENT REQUIREMENTS FOR INDIANS-RDA, 2020

22. GI and GL of common foods FOODS GI SERVING SIZE AVAILABLE CHO GL/SERVE WHEAT CHAPATI 52 +/- 4 60 g 32 g 21 WHITE RICE, BOILED 73 +/- 4 150g 40 g 29 POTATO BOILED 78 +/- 4 150g 28 g 14 APPLE 36 +/- 1 120g 15 g 6 WATERMELON 76 +/- 4 120g 6 g 4 MANGO 51 +/- 5 120g 17 g 8 MILK, FULL FAT 39 +/- 3 250ml 12g 3 REFERENCE- NUTRIENT REQUIREMENTS FOR INDIANS-RDA, 2020

23. CARBOHYDRATE COUNTING Carbohydrate counting is a method of calculating grams of carbohydrate consumed at meals and snacks. It is not a diet but a method that emphasizes glycemic control based on the use of multiple doses of short acting insulin according to carbohydrate intake in a meal. 1 CHO Count/choice= 10-15 g carbohydrate A general guideline is to have 45-60 g of CHO serving at each meal 15-20 g of CHO serving at each snack GRAM OF CARBS NO. OF CARB CHOICES 0-5 g DO NOT COUNT 6-10 g ½ CARB COUNT 11-20 g 1 CARB CHOICE 21-25 g 1 ½ CARB CHOICES 26-35 g 2 CARB CHOICES REFERENCE- BAJAJ, 2021

24. CEREALS RAW WT (g) CHO (g) FIBER (g) NET CHO (g) CHO COUNT BARLEY 25 15 4 17 1 CHAPATI, WHOLE WHEAT 25 16 3 18 1 CORN FLAKES, KELLOGG’S 25 21 21 1 ½ OATS, QUAKER 25 17 3 19 1 QUINOA 25 13 4 15 1 RICE, BASMATI (INDIA GATE) 25 19 19 1 RICE, BASMATI (KOHINOOR) 25 19 1 20 1 REFERENCE- BAJAJ, 2021

25. BISCUITS QTY (g) CHO (g)/100 g FIBER (g)/100g NET CHO (g)/100 g CHO COUNT 50-50 100 71 71 4 ½ BOURBON 100 72 72 4 ½ BRITANNIA RUSK 100 79 79 5 ½ DARK FANTASY 100 64 64 4 ½ GOOD DAY CASHEW 100 63 63 4 ½ GOOD DAY CHOCOLATE 100 71 71 4 ½ GOOD DAY PISTA 100 65 65 4 ½ HIDE N SEEK 100 73 73 4 ½ JIMJAM 100 73 73 4 ½ LITTLE HEARTS 100 70 70 4 ½ MARIE GOLD 100 72 72 5 ½ MILK BIKIS 100 75 75 5 MILK BIKIS MILKY SANDWICH 100 68 68 4 ½ NICE TIME 100 76 76 5 ½ NUTRI CHOICE DIGESTIVE 100 68 68 4 ½ REFERENCE- BAJAJ, 2021

26. DIABETES PLATE METHOD The Diabetes Plate Method is the easiest way to create healthy meals that can help manage blood sugar. Using this method, you can create perfectly portioned meals with a healthy balance of vegetables, protein, and carbohydrates—without any counting, calculating, weighing, or measuring. To start out, you need a plate that is about 9 inches across. 1. Fill half your plate with nonstarchy vegetables. Nonstarchy vegetables are lower in carbohydrate, so they do not raise blood sugar very much. They are also high in vitamins, minerals, and fiber, making them an important part of a healthy diet. Filling half your plate with nonstarchy vegetables means you will get plenty of servings of these superfoods . Examples include- Asparagus, broccoli, cauliflower, brussels sprouts, cabbage, carrots, celery, cucumber, egg plant, leafy greens, okra, bell peppers, zucchini, tomatoes etc. REFERENCE-American Diabetes Association

27. DIABETES PLATE METHOD 2. Fill one quarter of your plate with lean protein foods One should choose lean protein sources which are lower in saturated fats.  Keep in mind that some plant-based protein foods (like beans and legumes) are also high in carbohydrates. Examples of lean protein foods include- Chicken, turkey, eggs, fish (salmon, tuna, cod), cheese and cottage cheese Plant-based sources of protein include- beans, lentils, nuts and nut butters, tofu etc. 3. Fill one quarter of your plate with carbohydrate foods Foods that are higher in carbohydrate have the greatest effect on blood sugar. Limiting your portion of carbohydrate foods to one quarter of your plate can help keep blood sugars from rising too high after meals. Examples of carbohydrate foods- whole grains, starchy vegetables (peas, potato, sweetpotato , yam), beans (black beans, kidney beans), dairy products etc.

28. DIABETES PLATE METHOD 4. Choose water or a low-calorie drink Water is the best choice because it contains no calories or carbohydrates and has no effect on blood sugar. Other zero- or low-calorie drink options include: Unsweetened tea or coffee, Sparkling water/club soda etc.

29. FOOD ORDER For controlling the post prandial blood glucose rise, it is recommended to follow the food order- FIRST- Fibre in vegetable soup or raita SECOND- Protein (egg white/ lean chicken/ whole gram/pulses) THIRD- Cereal (wheat/ oats/ millets) Fibre and protein content in the meal keeps post prandial blood sugar level rise to a minimum by delayed gastric emptying and affect glycaemic response of the second meal.

30. SUPPORTIVE THERAPY Fenugreek seeds- Contains saponins and glycosides.It may have beneficial effect in pancreatic tissues and improve glucose & carbohydrate absorption as well as decrease insulin resistance. It delays gastric emptying, increases insulin receptors. It is scientifically proven that consumption of 25 g fenugreek seeds per day reduces blood sugar levels. Cinnamon- The active ingredient in cinnamon (related to procyanidin type A polymers) may increase insulin sensitivity. It has potential benefit of decreasing fasting glucose and lipid levels. Aloevera - Aloe gel has been used to treat diabetes and hyperlipidemia . Its use may decrease fasting glucose and triglyceride levels and concentration of glycosylated Hb . Discuss with you physician before starting any supportive therapy!

31. MANAGEMENT- DRUGS When diet, exercise or even weight reduction do not improve the diabetic symptoms and blood sugar levels, the use of hypoglycaemic drugs becomes necessary. TYPES OF DRUG HOW THEY WORK EXAMPLES SULPHONYLUREAS Stimulate pancreas to release more insulin Chloropropamide , Glipizide , Glimepiride BIGUANIDES Reduce amount of glucose produced by liver Improves insulin sensitivity Metformin ALPHA-GLUCOSIDASE INHIBTORS Slow body’s breakdown of sugars and starchy foods Acarbose ( Precose ), Miglitol ( Glyset ) THIAZOLIDINEDIONES Increase insulin sensitivity Piogltizone , Rosiglitazone MEGLITINIDES Stimulate pancreas to release more insulin Repaglinide ( Prandin )

32. INSULIN People with T2DM make insulin, but their bodies don’t respond well to it. Insulin cannot be taken as a pill because it would be broken down during digestion like the protein in food. It must be injected into the fat under skin for it to get into your blood. Characteristics of Insulin ONSET- Length of time before insulin reaches the bloodstream and begins lowering blood sugar. PEAK TIME- Time during which insulin is at maximum strength in terms of lowering blood sugar. DURATION- How long insulin continues to lower blood glucose.

33. TYPES OF INSULIN TYPE TIME OF ACTION TRADE NAME ONSET PEAK DURATION SHORT ACTING (REGULAR) 30-60 min 2-3 hr 8-10 hr NOVOLIN R HUMULIN R INTERMEDIATE (NPH) 2-4 hr 4-10 hr 12-18 hr NOVOLIN N HUMULIN N LONG ACTING (GLARGINE) 2-6 hr NO PEAK 20-24 hr LANTUS BASAGLAR PREMIXED 70/30 30-60 min 2-6 hr 12-18 hr NOVOLIN 70/30 HUMULIN 70/30

34. DAFNE (Dose Adjustment For Normal Eating) Insulin dose needs to be adjusted according to individual’s physical activity. DAFNE is a way of managing DM and provides the skills necessary to estimate carbohydrate in each meal and to inject the right dose of insulin. The patient has to maintain a set pattern for the quality and quantity of meals, timing of meal and type of physical activity he does to control his blood glucose level. Carbohydrates in each meal should be consistent in quantity as well as quality for a set dose of insulin!

35. TAKE AWAY NOTE Successful management of diabetes involves a holistic approach with coordination between diet, lifestyle and hypoglycaemic drugs/ insulin.

36. REFERENCES WWW.WHO.INT WWW.WIKIPEDIA.COM American diabetes association Diet and diabetes by T.C Raghuram , S Pasricha , R.D Sharma, NIN Dietetics by B Srilakshmi Diet metrics:Handbook of food exchanges by Meenakshi Bajaj, 2021 ICMR Guidelines for management of type 2 diabetes, 2018 Nutrient requirements for indians -RDA 2020 Tips for diabetes patients by Dr.Bimal Chhajer

37. THANK YOU!