INTRODUCTION

Available data from many countries of the Eastern

Mediterranean Region (EMR) indicate that diabetes mellitus
has become a problem of great magnitude and a major public
health concern. Studies have demonstrated that, in some
countries, diabetes affects up to 10% of the population aged 20
years and older. This rate may be doubled if those with
impaired glucose tolerance (IGT) are also included.
However, despite the high prevalence of diabetes and its
complications and the availability of successful prevention
strategies, essential health care requirements and facilities for
self-care are often inadequate in this Region. Action is needed
at all levels of health care and in the various aspects of diabetes
care to bridge this gap and to improve health care delivery to
people with diabetes. Education of the health care team on the
management of diabetes and on how to educate people with
diabetes is one major aspect that requires strengthening.
Even though resources vary widely within the Region, the
primary resource in diabetes care is now recognized to be the
people with diabetes themselves, supported by well trained and
enthusiastic health care professionals. This resource can be
strengthened nearly everywhere by education.
 WHAT IS DIABETES MELLITUS?
Diabetes is a condition that happens when your blood
sugar (glucose) is too high. It develops when your pancreas
doesn’t make enough insulin or any at all, or when your
body isn’t responding to the effects of insulin properly.
Diabetes affects people of all ages. Most forms of diabetes
are chronic (lifelong), and all forms are manageable with
medications and/or lifestyle changes.

Glucose (sugar) mainly comes from carbohydrates in your

food and drinks. It’s your body’s go-to source of energy.
Your blood carries glucose to all your body’s cells to use for
energy.

When glucose is in your bloodstream, it needs help — a

“key” — to reach its final destination. This key is insulin (a
hormone). If your pancreas isn’t making enough insulin or
your body isn’t using it properly, glucose builds up in your
bloodstream, causing high blood sugar (hyperglycemia).

Over time, having consistently high blood glucose can

cause health problems, such as heart disease, nerve
damage and eye issues.
The technical name for diabetes is diabetes mellitus.
Another condition shares the term “diabetes” — diabetes
insipidus — but they’re distinct. They share the name
“diabetes” because they both cause increased thirst and
frequent urination. Diabetes insipidus is much rarer than
diabetes mellitus.
• BURDEN OF DIABETES:
The burden of diabetes refers to the overall impact and
consequences of diabetes on individuals, communities,
and healthcare systems. Diabetes is a chronic medical
condition characterized by elevated levels of blood glucose
(sugar) resulting from the body's inability to produce
enough insulin or effectively use the insulin it produces.
There are two main types of diabetes: Type 1 and Type 2.

Here are some key aspects of the burden of diabetes:

Global Prevalence: Diabetes has reached epidemic

proportions worldwide. According to the International
Diabetes Federation (IDF), approximately 463 million
adults (20-79 years) were living with diabetes in 2019, and
this number is expected to rise.

Health Consequences: Diabetes can lead to a range of

serious health complications, including heart disease,
stroke, kidney disease, vision impairment, nerve damage,
and amputations. It significantly increases the risk of
premature death.

Economic Impact: The economic burden of diabetes is

substantial. The costs include direct medical expenses for
the treatment of diabetes and its complications, as well as
indirect costs related to productivity losses due to
disability and premature death.

Impact on Quality of Life: Managing diabetes can be

challenging, requiring individuals to make lifestyle changes,
take medications, and monitor blood glucose levels
regularly. This can impact the quality of life for those living
with diabetes and their families.

Healthcare System Strain: The increasing prevalence of

diabetes places a strain on healthcare systems globally. The
demand for diabetes-related healthcare services,
medications, and interventions is rising, leading to
increased healthcare costs.

Health Disparities: Diabetes disproportionately affects

certain populations, including those with lower socio-
economic status, certain ethnic groups, and those with
limited access to healthcare resources. Addressing health
disparities is crucial to effectively tackle the burden of
diabetes.

Preventive Measures: Given the significant impact of

diabetes, there is a growing emphasis on preventive
measures, including lifestyle interventions (such as healthy
eating and regular physical activity) and early detection
and management of diabetes to reduce complications.

Efforts to address the burden of diabetes involve public

health campaigns, education, policy initiatives, and
research to improve prevention, early diagnosis, and
management strategies. It's important for individuals,
healthcare professionals, and policymakers to work
collaboratively to mitigate the impact of diabetes on both
the individual and societal levels.
 SIGN AND SYMPTOMS OF DIABETES
MELLITUS:

The signs and symptoms of diabetes mellitus can vary depending

on the type of diabetes and the individual. Here are common signs
and symptoms associated with diabetes:

Common Signs and Symptoms:

 Frequent Urination (Polyuria): Increased levels of glucose in the

blood can lead to the kidneys working harder to filter and absorb
excess sugar. This can result in increased urine production, leading
to frequent urination.
 Excessive Thirst (Polydipsia): Due to the increased urination,
individuals with diabetes may experience excessive thirst as the
body tries to compensate for fluid loss.

 Unexplained Weight Loss: In cases of Type 1 diabetes, the body

may start to break down muscle and fat for energy, resulting in
unexplained weight loss despite increased appetite.
 Increased Hunger (Polyphagia): The body's inability to use
glucose properly can lead to a constant feeling of hunger, even if
the person is eating regularly.
 Fatigue: Diabetes can cause a lack of energy due to the body's
inability to use glucose effectively for energy. Persistent fatigue is
a common symptom.

 Blurred Vision: Elevated blood sugar levels can affect the fluid
balance in the eyes, leading to blurred vision. This symptom may
come and go.
 Slow Healing of Wounds: Diabetes can affect the body's ability to
heal and regenerate tissues, leading to slower wound healing.

 Frequent Infections: High blood sugar levels can weaken the

immune system, making individuals with diabetes more
susceptible to infections, particularly urinary and skin infections.
 Tingling or Numbness in Extremities: Over time, high blood sugar
levels can damage nerves, leading to tingling or numbness,
particularly in the hands and feet.

 Dry Skin and Itching: Diabetes can affect the skin, leading to
dryness and itching.
It's important to note that some individuals with diabetes may not
experience obvious symptoms, especially in the early stages.
Therefore, regular check-ups and blood sugar monitoring are
crucial for early detection and management.
TYPES OF DIABETES
MELLITUS
Several patients may present with similar symptoms but
be diagnosed with different types of diabetes mellitus.
1. Type 1 Diabetes Mellitus.
2. Type 2 Diabetes Mellitus.
3. Gestational Diabetes Mellitus.
4. Other Types.

1. Type 1 Diabetes Mellitus:

Type 1 diabetes, or T1DM, is characterized by insufficient insulin
secretion. It usually results from autoimmune destruction of the
beta cells in the pancreas. Thus, they cannot make sufficient in-
sulin to survive. People with type 1 diabetes need exogen-
ous (sources outside the body) insulin to survive. People suffer-
ing from type 1 diabetes mellitus represent only 5% to 10% of
all people with diabetes (Maitra, 2009).

In the past, type 1 diabetes was called “insulin-dependent dia-

betes.” The ADA changed the nomenclature as more patients
with type 2 became dependent on insulin for sugar regulation,
which was confusing to both patients and healthcare providers;
so the name reverted back to “type 1.”

Type 1 diabetes has also been called juvenile diabetes because

it typically appears in children and young adults. Type 1 dia-
betes can present as an acute illness; however, the destruction
of the beta cells may have been occurring for weeks prior to the
acute symptoms.

Symptoms of Type 1 diabetes typically start mild and get pro-

gressively worse or more intense, which could happen over sev-
eral days, weeks or months. This is because your pancreas
makes less and less insulin.

Symptoms of Type 1 diabetes include:

 Excessive thirst.

 Frequent urination, including frequent full diapers in in-

fants and bedwetting in children.

 Excessive hunger.

 Unexplained weight loss.

 Fatigue.

 Blurred vision.

 Slow healing of cuts and sore.

2.Type 2 Diabetes Mellitus:

Type 2 diabetes, or T2DM, is the most common form of dia-
betes, and is characterized by insulin resistance, or sluggish re-
sponse of insulin after food consumption. Type 2 diabetes rep-
resents 90% of all people with diabetes. Insulin resistance is
the reduced response of skeletal muscle cells to take up insulin.
Type 2 diabetes is characterized by two main defects: insulin
resistance, in which many cells in the body become less re-
sponsive to insulin; and beta cell deterioration, which leads to
sluggish production of insulin by the pancreas. Type 2 diabetes
was once called “adult-onset diabetes” because the disease de-
velops slowly and typically appears in older adults.

Even before the disease shows clinical signs and symptoms,

mildly elevated blood glucose (BG) levels can be detected in
tests. This stage of the disease is called prediabetes

Given the rapid increase in the number of people with this con-
dition, and the increasingly younger age when the disease is
diagnosed, healthcare providers need to be skilled in detection,
management, education, and prevention strategies in order to
decrease the overall burden on health and finances to patients
and their families.

Symptoms:

Symptoms of type 2 diabetes often develop slowly. In fact, you

can be living with type 2 diabetes for years and not know it.
When symptoms are present, they may include:

 Increased thirst.

 Frequent urination.

 Increased hunger.

 Unintended weight loss.

  Fatigue.

 Blurred vision.

 Slow-healing sores.

 Frequent infections.

 Numbness or tingling in the hands or feet.

 Areas of darkened skin, usually in the armpits and neck.

3. Gestational Diabetes Mellitus:

Gestational diabetes mellitus (GDM) is diabetes that develops
for the first time during pregnancy and is seen as persistent hy-
perglycemia. Due to the overall stress of the pregnancy, and
with additional risk factors similar to those of type 2 diabetes,
such as obesity, sedentary lifestyle, high-fat diet, age, ethnicity,
and genetic predispositions, almost 21% of all pregnancies may
develop hyperglycemia.

Recommendations for GDM include:

 Screen for undiagnosed T2DM at the first prenatal visit in

those with risk factors, using standard criteria.
 In pregnant women not previously known to have dia-
betes, screen for GDM at 24 to 28 weeks’ gestation with a 75-g,
2h OGTT using the following stricter diagnostic cutoff points:
o Fasting >92mg/dL in the morning after an overnight
fast of at least 8 hours
o 1 hour >180mg/dL
o 2hour >153mg/dL
 If undiagnosed T2DM is suspected to have existed at the
time of pregnancy, rescreen at 6 to 12 weeks’ postpartum, us-
ing standard criteria.
 Women diagnosed with GDM should have lifelong screen-
ing for the development of T2DM or prediabetes at least every
3 years (ADA, 2012).

 Signs and symptoms

Extreme thirst is a possible symptom of gestational diabetes.
Gestational diabetes may not present any obvious signs or
symptoms, as many of the changes can be similar to those that
occur during pregnancy.
However, possible signs and symptoms include:
 fatigue
 blurred vision
 extreme thirst
 nausea
 frequent bladder, vaginal, or skin infections
 frequent urination
 sugar in the urine
Any woman experiencing new or unusual symptoms during
pregnancy should speak to her doctor. The doctor may be able
to determine whether she has developed gestational diabetes
or any other condition.

4. Other Types:
Types of diabetes that fall into the “other” class of diabetes
mellitus include MODY, LADA, endocrinopathies, and impaired
fasting glucose (IFG).

MODY (Maturity onset diabetes of the young ) is a genetic muta-

tion in an autosomal dominant gene that affects insulin produc-
tion. Individuals with this diagnosis are generally children less
than age 25 with a family history of diabetes for generations.
These children still produce some insulin and are clinically closer
to a type 2. They may or may not require insulin.

LADA (Latent autoimmune diabetes of adults) presents in young

adults in their twenties and can be confused as type 2 because
of age; however, they do not produce any insulin and are clinic-
ally similar to type 1, requiring insulin. They have often been
labeled as “diabetes 1.5” because they are clinically between
type 1 and type 2.

Endocrinopathies may include polycystic ovarian syndrome,

pancreatic cancer or tumors, and other hormonal disruptions in
insulin production. Impaired fasting glucose presents as an FBG
higher than 100 mg/dl but less than 126 mg/dl, so it does not
qualify as full diabetes mellitus.
 CAUSES OF DIABETES MEL-
LITUS

Diabetes mellitus is a chronic metabolic disorder characterized

by elevated levels of blood glucose, often referred to as high
blood sugar. There are several causes and risk factors associ-
ated with the development of diabetes mellitus:

 Genetic Factors:
 Family history: A person with a family history of diabetes
is at a higher risk of developing the condition.

 Genetic mutations: Certain genetic factors may predispose

individuals to diabetes.

 Environmental Factors:
 Lifestyle choices: Sedentary lifestyle, lack of physical activ-
ity, and poor dietary habits contribute to the development
of type 2 diabetes.
  Obesity: Excess body weight, especially abdominal obesity,
is a significant risk factor for type 2 diabetes.

 Insulin Resistance:
Insulin is a hormone that helps regulate blood sugar levels. In
type 2 diabetes, the body's cells become resistant to the effects
of insulin, leading to elevated blood sugar levels.
  Autoimmune Factors:
Type 1 diabetes is an autoimmune condition where the immune
system mistakenly attacks and destroys insulin-producing beta
cells in the pancreas.

 Pancreatic Issues:
Pancreatic diseases or damage: Conditions affecting the pan-
creas, such as pancreatitis or pancreatic surgery, can impair in-
sulin production and contribute to diabetes.
 Hormonal Changes:
 Hormonal disorders: Certain hormonal conditions, such as
polycystic ovary syndrome (PCOS), can increase the risk of
insulin resistance and type 2 diabetes.

 Age and Ethnicity:

 Age: The risk of diabetes increases with age, especially
after 45.

 Ethnicity: Some ethnic groups, such as African Americans,

Hispanic/Latino Americans, Native Americans, and Asian
Americans, have a higher predisposition to diabetes.
  Gestational Diabetes:
Women who develop gestational diabetes during pregnancy
are at an increased risk of developing type 2 diabetes later in
life.

 Other Medical Conditions:

Certain medical conditions, such as high blood pressure and
dyslipidemia (abnormal levels of lipids in the blood), are associ-
ated with an increased risk of diabetes.

 Medications:
Some medications, such as corticosteroids and certain anti-
psychotic drugs, may increase the risk of diabetes.

Understanding and addressing these risk factors can play a cru-

cial role in preventing or managing diabetes mellitus. Lifestyle
modifications, including a healthy diet, regular exercise, and
weight management, are essential components of diabetes pre-
vention and management strategies. Additionally, early detec-
tion and appropriate medical care are important for effective
management of diabetes and its complications.
 PATHOPHYSIOLOGY OF
DIABETES MELLITUS:

Diabetes mellitus is a chronic heterogeneous meta-

bolic disorder with complex pathogenesis. It is char-
acterized by elevated blood glucose levels or hyper-
glycemia, which results from abnormalities in either
insulin secretion or insulin action or both.

 PATHOPHYSIOLOGY OF TYPE 1 DIABETES

MELLITUS:
Insulin is normally synthesised in the pancreas
by the b-cells of the islets of Langerhans in re-
sponse to a glucose stimulus. Type 1 diabetes is
fundamentally caused by the autoimmune de-
struction of these insulin-producing cells. This
results in an absolute deficiency of the hor-
mone, with patients having a lifelong depend-
ency on exogenous sources.

Current understanding of the pathogenesis of

type 1 diabetes is based on a hypothesis first
postulated by the American immunologist
George Eisenbarth in the 1980s. It is thought
that autoimmune b-cell destruction is triggered
by an infective or environmental stimulus in ge-
netically predisposed individuals. Recent re-
search has also focused on the role of weight
gain and insulin resistance as important accel-
erators of b-cell destruction in type 1 and type 2
diabetes.

Type 1 diabetes is often considered a disease of

rapid onset; however its development is a much
slower process involving progressive immunolo-
gical damage. Dr Eisenbarth proposed that an
infective or environmental trigger results in
insulitis — an invasion of pancreatic islets by
T-lymphocytes leading to b-cell destruction. This
process can last for months or years and is char-
acterised by the development of islet cell anti-
bodies (detected in 85% of patients at dia-
gnosis). After approximately 80% of pancreatic
b-cells have been destroyed, clinical symptoms
will begin to develop — often manifesting at a
time of increased insulin demand (eg, during an
infection).
 PATHOPHYSIOLOGY OF TYPE 2 DIABETES
MELLITUS:
Type 2 Diabetes Mellitus (T2DM), one of the most
common metabolic disorders, is caused by a combin-
ation of two primary factors: defective insulin secre-
tion by pancreatic β-cells and the inability of insulin-
sensitive tissues to respond appropriately to insulin.
Because insulin release and activity are essential pro-
cesses for glucose homeostasis, the molecular mech-
anisms involved in the synthesis and release of in-
sulin, as well as in its detection are tightly regulated.
Defects in any of the mechanisms involved in these
processes can lead to a metabolic imbalance re-
sponsible for the development of the disease. This re-
view analyzes the key aspects of T2DM, as well as
the molecular mechanisms and pathways implicated
in insulin metabolism leading to T2DM and insulin
resistance. For that purpose, we summarize the data
gathered up until now, focusing especially on insulin
synthesis, insulin release, insulin sensing and on the
downstream effects on individual insulin-sensitive or-
gans. The review also covers the pathological condi-
tions perpetuating T2DM such as nutritional factors,
physical activity, gut dysbiosis and metabolic
memory. Additionally, because T2DM is associ-
ated with accelerated atherosclerosis development,
we review here some of the molecular mechanisms
that link T2DM and insulin resistance (IR) as well as
cardiovascular risk as one of the most important
complications in T2DM.
 DIAGNOSIS OF DIABETES
MELLITUS:
The diagnosis of diabetes carries considerable con-
sequences and should therefore be made with confid-
ence. If the patient has classical symptoms (such as in-
creased thirst and urine volume, unexplained weight loss,
pruritus vulvae or balanitis) or drowsiness or coma, asso-
ciated with marked glycosuria, the diagnosis can be read-
ily established by demonstrating fasting hyperglycaemia.
If the fasting blood glucose concentration is in the dia-
gnostic range shown in Table 1, an oral glucose tolerance
test (OGTT) is not required. In such instances however, a
confirmatory test should be performed as incomplete
fasting may give rise to spurious diagnosis. The diagnosis
can also be established if a random blood glucose estima-
tion exceeds the diagnostic values indicated in Figure 1.
An OGTT is performed if the diagnosis is uncertain and
the blood glucose values are in the equivocal range. It is
often sufficient to measure the blood glucose values only
after fasting and 2 hours after a 75 g oral (anhydrous)
glucose load. The diagnostic criteria are shown in. The re-
quirements for diagnostic confirmation for a person
presenting with severe symptoms and gross hyper-
glycaemia will differ from those of the asymptomatic pa-
tient whose blood glucose levels are just above the dia-
gnostic cut-off values. For the asymptomatic patient, at
least one additional test result with a value in the dia-
betic range is desirable. Clinical diagnosis should never be
based on the presence of glycosuria alone. The diagnosis
of diabetes in pregnancy follows the same criteria.

The diagnosis of diabetes mellitus involves assessing

blood glucose levels. There are different tests used for
this purpose, and the choice of test depends on various
factors, including the individual's symptoms, risk factors,
and the type of diabetes suspected. The common dia-
gnostic tests for diabetes include:

 Fasting Plasma Glucose (FPG) Test:

This test measures blood glucose levels after an
overnight fast. A fasting blood glucose level of 126 milli-
grams per deciliter (mg/dL) or higher on two separate oc-
casions generally indicates diabetes.

 Oral Glucose Tolerance Test (OGTT):

The OGTT involves fasting overnight and then drinking a
solution containing a specific amount of glucose. Blood
glucose levels are measured at intervals after drinking
the solution. A blood glucose level of 200 mg/dL or higher
two hours after drinking the glucose solution is indicative
of diabetes.

 Hemoglobin A1c Test:

This test reflects average blood glucose levels over the
past two to three months. An A1c level of 6.5% or higher
is considered diagnostic of diabetes. This test is often
used for long-term monitoring of blood glucose control in
individuals with diabetes.

 Random Plasma Glucose Test:

A blood sample is taken at any time, regardless of when
the individual last ate. A random blood glucose level of
200 mg/dL or higher, along with symptoms of diabetes,
may indicate the presence of the condition.

It's important to note that a diagnosis of diabetes is typ-

ically confirmed based on the results of repeated testing
on different days to rule out transient elevations in blood
glucose levels.
Pregnant women may undergo glucose screening tests
between 24 and 28 weeks of pregnancy. If the initial
screening suggests elevated glucose levels, an OGTT may
be performed to confirm the diagnosis of gestational dia-
betes.
Individuals with symptoms such as increased thirst, fre-
quent urination, unexplained weight loss, or those at
high risk due to factors like family history or obesity, may
be recommended for diabetes testing even in the ab-
sence of clear symptoms.

If diabetes is diagnosed, further tests may be conducted

to determine the type of diabetes (Type 1 or Type 2) and
to assess the overall health of the individual, including
tests for complications such as kidney function, lipid
levels, and eye examinations. Early diagnosis and appro-
priate management are crucial for controlling blood gluc-
ose levels and preventing or minimizing complications as-
sociated with diabetes. It's important to consult a health-
care professional for proper evaluation and guidance.
 SCREENING OF
DIABETES MELLITUS
Screening for any disease is fruitful when there is benefit
from its early diagnosis and intervention. This activity dis-
cusses the screening for diabetes mellitus, which is one of
those diseases that affect millions worldwide.

Diabetes Mellitus includes three groups of diseases-

Type 1 diabetes mellitus

Type 2 diabetes mellitus

Gestational diabetes
TYPE 1 DIABETES MELLITUS
Type I diabetes is diagnosed after hyperglycemia
symptoms like polyuria, polydipsia, weight loss, and leth-
argy. It can also present as diabetic ketoacidosis in re-
source-constrained areas. Screening for type I diabetes is
still in its infancy, although trials with tests for insulin,
zinc transporter 8, antibodies to islet cells, IA-2 and
GAD65 are underway.
TYPE 2 DIABETES MELLITUS
Type 2 diabetes may initially have few symptoms; how-
ever, long-term effects lead to a myriad of different prob-
lems late in the course of the disease leading to debilitat-
ing sequelae. More than 30 million people in the US
have diabetes. Due to an initial silent course, it often
remains undetected for quite a long time before the ap-
pearance of symptoms. The screening for the disease
aims at prevention and early treatment of the
disease with the assumption that there is a long term
benefit for its identification early in the disease pro-
cess. The long-term benefit of screening vs. clinically de-
tected diabetes is being explored. Several studies with
weak evidence suggest merits with the use of screening
tests.

Screening for type 2 diabetes can be by either fasting

blood sugar, hemoglobin (A1C), glucose tolerance testing,
and random plasma sugar. Urine glucose may be useful,
but it is an inferior test to screen for diabetes, although
research is reconsidering this claim.
The screening is said to be positive if there are two ab-
normal tests from the same sample or two separate
samples for the first three tests below:

1) HbA1C over 6.5 percent

2) Fasting plasma glucose greater than or equal to 126

mg/dl
3) 2-hour glucose greater than or equal to 200 mg/dl in
an oral glucose tolerance test with 75 mg glucose load.

4) Random blood glucose greater than or equal to 200

mg/dl in symptomatic patients (thirst, polyuria, weight
loss, blurry vision)

For the diagnosis of diabetes mellitus, symptomatic pa-

tients require no further tests.

HbA1C values can be affected by factors that increase or

decrease the RBC lifespan. Anaemic states falsely in-
crease HbA1C values, whereas their treatment falsely de-
creases it. Kidney disease can affect the values and may
increase or decrease values based on the treatment the
patient is getting. Erythropoietin can falsely lower HbA1c
values. Haemoglobin variants like Hbs and HbC also
cause variation in HbA1c values.

The US Preventive Services Task Force's recommendation

is to screen for diabetes between 40 to 70 years who are
overweight or obese and repeat testing every three years
if results are normal.

Risk factors for diabetes include:

• Hypertension

• HDL < 35 mg/dL or TG > 250 mg/dL

• First-degree relative with diabetes

• High-risk race/ethnicity (African American, Latino, Nat-

ive American, Asian American, Pacific Islander)

• Asian Americans with a BMI of greater than or equal to

23 kg/m

• Women who have delivered child greater than 9 lbs (4

kg) or with gestational diabetes

• HbA1c = 5.7%, impaired fasting glucose (IFG) or im-

paired glucose tolerance (IGT)

Other: acanthosis nigricans, PCOS, history of coronary

vascular disease (CVD), physical inactivity
The recommendations for those with a high risk of
developing diabetes are candidates for more early/
frequent screening, early behavior intervention, and in-
tensive treatment.

The recommended interval for the screening of

asymptomatic patients is three years. The interval can be
short in patients who have obesity and other major risk
factors for developing diabetes.

The American Diabetes Association recommends screen-

ing for diabetes in adults aged 45 years or older and
screening in persons with multiple risk factors regardless
of age.

The American Association of Clinical Endocrinologists,

American Academy of Family Physicians, Diabetes Aus-
tralia, Diabetes UK, and the Canadian Task Force on Pre-
ventive Health Care have recommendations that differ in
their approach to screening but acknowledge and stress
risk factors compared to an older age.
 GESTATIONAL
DIABETES MELLITUS

Gestational diabetes adversely impacts the lives of both

fetus and mother, making screening for it an essential
part of obstetric care. Screening is necessary with the
presence of one of the risk factors for diabetes. In addi-
tion to the risk factors discussed above, others include:

History of prediabetes(impaired glucose tolerance/fasting

glucose, HbA1C>5.7)

Prior history of gestational diabetes

BMI>30 kg/m^2

Family history of diabetes

Multiple gestations

Old maternal age

Glycosuria at the first prenatal visit

History of unexplained miscarriage or malformation

In the US, all women are screened for gestational dia-

betes, as most of them have at least a few of these risk
factors.

HbA1C and fasting blood glucose have not been found

useful for the screening of gestational diabetes. A glucose
tolerance test is helpful in effective screening for this con-
dition. There are two ways of screening for gestational
diabetes can be done:

One-step method: Glucose tolerance test with 75 mg

glucose load. (overnight fast required)

Two-step method: First, by 50 g glucose challenge test

which, if positive, is followed by a confirmatory second 3-
hour glucose tolerance test with 100 g glucose load.

The one-step 75 g glucose tolerance test is simpler and

the most widely used method. The test is positive if it
satisfies any one of the following:

Fasting glucose ≥92 mg/dL (5.1 mmol/L)

1hr glucose ≥180 mg/dL (10.0 mmol/L)

2hr glucose ≥153 mg/dL (8.5 mmol/mol)

PREVENTION OF
 DIABETES MELLITUS
Simple steps to lowering your risk

 Control your weight

Excess weight is the single most important cause of type
2 diabetes. Being overweight increases the chances of de-
veloping type 2 diabetes seven-fold. Being obese makes
you 20 to 40 times more likely to develop diabetes than
someone with a healthy weight.

Losing weight can help if your weight is above the

healthy-weight range. Losing 7-10% of your current
weight can cut your chances of developing type 2 dia-
betes in half.
  Get moving—and turn off the television

Inactivity promotes type 2 diabetes. Working your

muscles more often and making them work harder
improves their ability to use insulin and absorb gluc-
ose. This puts less stress on your insulin-making
cells. So trade some of your sit-time for fit-time.
Long bouts of hot, sweaty exercise aren’t necessary
to reap this benefit. Findings from the Nurses’
Health Study and Health Professionals Follow-up
Study suggest that walking briskly for a half hour
every day reduces the risk of developing type 2 dia-
betes by 30%. More recently, The Black Women’s
Health Study reported similar diabetes-prevention
benefits for brisk walking of more than 5 hours per
week. This amount of exercise has a variety of other
benefits as well. And even greater cardiovascular
and other advantages can be attained by more, and
more intense, exercise.

Television-watching appears to be an especially-det-

rimental form of inactivity: Every two hours you
spend watching TV instead of pursuing something
more active increases the chances of developing
diabetes by 20%; it also increases the risk of heart
disease (15%) and early death (13%). The more
television people watch, the more likely they are to
be overweight or obese, and this seems to explain
part of the TV viewing-diabetes link. The unhealthy
diet patterns associated with TV watching may also
explain some of this relationship.

 Tune Up Your Diet

 Four dietary changes can have a big impact on the
risk of type 2 diabetes mellitus.

A diet for people living with diabetes is based on eating

healthy meals at regular times. Eating meals at regular
times helps to better use insulin that the body makes or
gets through medicine.
A registered dietitian can help you put together a diet
based on your health goals, tastes and lifestyle. The
dietitian also can talk with you about how to improve
your eating habits. Options include choosing portion sizes
that suit the needs for your size and activity level.
Recommended foods
Make your calories count with nutritious foods. Choose
healthy carbohydrates, fiber-rich foods, fish and "good"
fats.
Healthy carbohydrates
During digestion, sugars and starches break down into
blood glucose. Sugars also are known as simple
carbohydrates, and starches also are known as complex
carbohydrates. Focus on healthy carbohydrates, such as:
 Fruits.
 Vegetables.

 Whole grains.

 Legumes, such as beans and peas.

 Low-fat dairy products, such as milk and cheese ..

Avoid less healthy carbohydrates, such as foods or

drinks with added fats, sugars and sodium.

Fiber-rich foods
Dietary fiber includes all parts of plant foods that your
body can't digest or absorb. Fiber moderates how your
body digests food and helps control blood sugar levels.
Foods high in fiber include:
 Vegetables.
 Fruits.
 Nuts.
 Legumes, such as beans and peas.
 Whole grains.
Heart-healthy fish
Eat heart-healthy fish at least twice a week. Fish such as
salmon, mackerel, tuna and sardines are rich in omega-3
fatty acids. These omega-3s may prevent heart disease.
Avoid fried fish and fish with high levels of mercury, such
as cod.
'Good' fats
Foods containing monounsaturated and polyunsaturated
fats can help lower your cholesterol levels. These include:
 Avocados.
 Nuts.

 Canola, olive and peanut oils.

But don't overdo it, as all fats are high in calories.

Foods to avoid
Diabetes raises your risk of heart disease and stroke by
raising the rate at which you develop clogged and
hardened arteries. Foods containing the following can
work against your goal of a heart-healthy diet.
 Saturated fats. Avoid high-fat dairy products and
animal proteins such as butter, beef, hot dogs, sausage
and bacon. Limit coconut and palm kernel oils.
 Trans fats. Avoid trans fats found in processed

snacks, baked goods, shortening and stick margarines.

 Cholesterol. Cholesterol sources include high-fat

dairy products and high-fat animal proteins, egg yolks,

liver, and other organ meats. Aim for no more than
200 milligrams (mg) of cholesterol a day.
 Sodium. Aim for no more than 2,300 mg of sodium a

day. Your health care provider may suggest you aim for
a smaller amount if you have high blood pressure.
Putting it all together: Creating a plan
You may use a few different approaches to create a
healthy diet to help you keep your blood sugar level
within a typical range. With a dietitian's help, you may
find that one or a combination of the following methods
works for you:

The plate method

The American Diabetes Association offers a simple

method of meal planning. It focuses on eating more ve-
getables. Follow these steps when preparing your plate:
 Fill half of your plate with nonstarchy vegetables,
such as spinach, carrots and tomatoes.
 Fill a quarter of your plate with a lean protein, such

as tuna, lean pork or chicken.

 Fill the last quarter with a carbohydrate, such as

brown rice or a starchy vegetable, such as green peas.

 Include "good" fats such as nuts or avocados in small

amounts.
 Add a serving of fruit or dairy and a drink of water or

unsweetened tea or coffee.

Counting carbohydrates
Because carbohydrates break down into sugar, they have
the greatest effect on your blood sugar level. To help con-
trol your blood sugar, you may need to learn to figure out
the amount of carbohydrates you are eating with the
help of a dietitian. You can then adjust the dose of insulin
accordingly. It's important to keep track of the amount of
carbohydrates in each meal or snack.
A dietitian can teach you how to measure food portions
and become an educated reader of food labels. You also
can learn how to pay special attention to serving size and
carbohydrate content.
Choose your foods

A dietitian may recommend you choose specific

foods to help plan meals and snacks. You can
choose a number of foods from lists that include cat-
egories such as carbohydrates, proteins and fats.
One serving in a category is called a choice. A food
choice has about the same amount of
carbohydrates, protein, fat and calories — and the
same effect on your blood sugar — as a serving of
every other food in that same category. For
example, the starch, fruits and milk list includes
choices that are all between 12 and 15 grams of
carbohydrates.
Glycemic index

Some people who live with diabetes use the glycemic in-
dex to select foods, especially carbohydrates. This
method ranks carbohydrate-containing foods based on
their effect on blood sugar levels. Talk with your dietitian
about whether this method might work for you.
A sample menu
When planning meals, take into account your size and
activity level. The following menu is for someone who
needs 1,200 to 1,600 calories a day.

Breakfast (8:00-8:30AM): 4 Idli + Sambar 1/2 cup/ 1

table spoon Green chutney/ Tomato Chutney
Mid-Meal (11:00-11:30AM): green gram sprouts 1 cup
Lunch (2:00-2:30PM): 3 Roti+1/2 cup salad + Fish curry
( 100 gm fish)+ 1/2 cup cabbage subji.
Evening (4:00-4:30PM): 1 Portion fruit(Avoid high en-
ergy fruits. Eg: Banana, Mango, Chikku.)
Dinner (8:00-8:30PM):2 Roti / chappati.+ Tomato subji
1/2 cup.
 What are the results of this
kind of diet?

Embracing a healthy-eating plan is the best way to

keep your blood sugar level under control and pre-
vent diabetes complications. And if you need to lose
weight, you can tailor the plan to your specific
goals.

Aside from managing your diabetes, a healthy diet

offers other benefits too. Because this diet recom-
mends generous amounts of fruits, vegetables and
fiber, following it is likely to lower your risk of cardi-
ovascular diseases and certain types of cancer. And
eating low-fat dairy products can reduce your risk of
low bone mass in the future.
 Don’t smoke
Add type 2 diabetes to the long list of health problems
linked with smoking. Smokers are roughly 50% more
likely to develop diabetes than non-smokers, and heavy
smokers have an even higher risk. Managing diabetes is
challenging, and smoking can make it even more so.
Nicotine increases your blood sugar levels and makes
them harder to handle. People with diabetes who smoke
often need larger doses of insulin to keep their blood
sugar close to their target levels.
Diabetes causes serious health complications such as
heart disease, kidney failure, blindness, and nerve
damage that can lead to amputation (removal by
surgery) of a toe, foot, or leg. If you have diabetes and
smoke, you’re more likely to have complications—and
worse complications—than people who have diabetes
and don’t smoke.
 Light to moderate alcohol consumption
 Evidence has consistently linked moderate alcohol
consumption with reduced risk of heart disease. The
same may be true for type 2 diabetes. Moderate
amounts of alcohol—up to a drink a day for women,
up to two drinks a day for men—increases the effi-
ciency of insulin at getting glucose inside cells. And
some studies indicate that moderate alcohol con-
sumption decreases the risk of type 2 diabetes but
excess alcohol intake actually increases the risk. If
you already drink alcohol, the key is to keep your
consumption in the moderate range, as higher
amounts of alcohol could increase diabetes risk. If
you don’t drink alcohol, there’s no need to start—you
can get the same benefits by losing weight, exer-
cising more, and changing your eating patterns risk
of type 2 diabetes.
 TREATMENT OF DIABETES
MELLITUS
Working closely with your doctor, you can manage
your diabetes by focusing on six key changes in your
daily life.

1. Eat healthy: This is crucial when you have dia-

betes, because what you eat affects your blood
sugar. No foods are strictly off-limits. Focus on eating
only as much as your body needs. Get plenty of ve-
getables, fruits, and whole grains. Choose nonfat
dairy and lean meats. Limit foods that are high in
sugar and fat. Remember that carbohydrates turn
into sugar, so watch your carb intake. Try to keep it
about the same from meal to meal. This is even more
 important if you take insulin or drugs to control your
blood sugars.

2.Exercise: If you're not active now, it’s time to start.

You don't have to join a gym and do cross-training. Just
walk, ride a bike, or play active video games. Your goal
should be 30 minutes of activity that makes you sweat
and breathe a little harder most days of the week. An
active lifestyle helps you control your diabetes by bring-
ing down your blood sugar. It also lowers your chances
of getting heart disease. Plus, it can help you lose extra
pounds and ease stress.
3. Get checkups: See your doctor at least twice a
year. Diabetes raises your odds of heart disease. So
learn your numbers: cholesterol, blood pressure, and
A1c (average blood sugar over 3 months). Get a full
eye exam every year. Visit a foot doctor to check for
problems like foot ulcers and nerve damage.
4.Manage stress: When you're stressed, your blood
sugar levels go up. And when you're anxious, you
may not manage your diabetes well. You may forget
to exercise, eat right, or take your medicines. Find
ways to relieve stress -- through deep breathing,
yoga, or hobbies that relax you.
5.Stop smoking: Diabetes makes you more likely to have
health problems like heart disease, eye disease, stroke,
kidney disease, blood vessel disease, nerve damage, and
foot problems. If you smoke, your chance of getting these
problems is even higher. Smoking also can make it harder
to exercise. Talk with your doctor about ways to quit. 6.
Watch your alcohol. It may be easier to control your
blood sugar if you don’t get too much beer, wine, and li-
quor. So if you choose to drink, don't overdo it. The Amer-
ican Diabetes Association says that women who drink al-
cohol should have no more than one drink a day and men
should have no more than two. Alcohol can make your
blood sugar go too high or too low. Check your blood
sugar before you drink, and take steps to avoid low blood
sugars. If you use insulin or take drugs for your diabetes,
eat when you're drinking. Some drinks -- like wine coolers
-- may be higher in carbs, so take this into account when
you count carbs.
 TREATMENT OF DIABETES MELLITUS

ORAL HYPOGLYCEMIC AGENTS

Oral antihyperglycemic medications are a mainstay of
treatment for type 2 diabetes mellitus, along with
injectable glucagon-like peptide-1 (GLP-1) receptor
agonists. Oral antihyperglycemic medications may
 Enhance pancreatic insulin secretion (secreta-
gogues)
 Sensitize peripheral tissues to insulin (sensitizers)

 Impair gastrointestinal absorption of glucose

 Increase glycosuria
Medications with different mechanisms of action may be
synergistic.
Sulfonylureas
Sulfonylureas (eg, glyburide, glipizide, glimepiride)
are insulin secretagogues. They lower plasma glucose
by stimulating pancreatic beta-cell insulin secretion and
may secondarily improve peripheral and
hepatic insulin sensitivity by reducing glucose toxicity.
First-generation sulfonylureas
(acetohexamide, chlorpropamide, tolazamide,
tolbutamide) are more likely to cause adverse effects
and are used infrequently. All sulfonylureas promote
hyperinsulinemia and weight gain of 2 to 5 kg, which
over time may potentiate insulin resistance and limit
their usefulness. All also can cause hypoglycemia. Risk
factors include age > 65 years, use of long-acting
medications (especially chlorpropamide, glyburide,
or glipizide), erratic eating and exercise, and renal or
hepatic insufficiency.
Hypoglycemia caused by long-acting medications may
last for days after treatment cessation, occasionally
causes permanent neurologic disability, and can be
fatal. For these reasons, some physicians hospitalize
hypoglycemic patients, especially older
ones. Chlorpropamide also causes the syndrome of
inappropriate ADH secretion . Most patients taking
sulfonylureas alone eventually require additional
medications to achieve normoglycemia, suggesting that
sulfonylureas may exhaust beta-cell function. However,
worsening of insulin secretion and insulin resistance is
probably more a feature of diabetes mellitus itself than
of medications used to treat it.
Short-acting insulin secretagogues
Short-acting insulin secretagogues
(repaglinide, nateglinide) stimulate insulin secretion in
a manner similar to sulfonylureas. They are faster
acting, however, and may stimulate insulin secretion
more during meals than at other times. Thus, they may
be especially effective for reducing postprandial
hyperglycemia and appear to have lower risk of
hypoglycemia. There may be some weight gain,
although apparently less than with sulfonylureas.
Patients who have not responded to other oral
medications (eg, sulfonylureas, metformin) are not likely
to respond to these medications.
Biguanides
Biguanides (metformin) lower plasma glucose by
decreasing hepatic glucose production (gluconeogenesis
and glycogenolysis). They are considered
peripheral insulin sensitizers, but their stimulation of
peripheral glucose uptake may simply be a result of
reductions in glucose due to their hepatic effects.
Biguanides also lower lipid levels and may also decrease
gastrointestinal nutrient absorption and increase beta-
cell sensitivity to circulating glucose. Metformin is the
only biguanide commercially available in the United
States. It is at least as effective as sulfonylureas in
reducing plasma glucose, rarely causes hypoglycemia,
and can be safely used with other medications
and insulin. In addition, metformin does not cause
weight gain and may even promote weight loss by
suppressing appetite. However, the medication
commonly causes gastrointestinal adverse effects (eg,
dyspepsia, diarrhea), which for most people recede with
time. Less commonly, metformin causes vitamin
B12 malabsorption, but clinically significant anemia is
rare.
Contribution of metformin to life-threatening lactic
acidosis is very rare, but the medication is
contraindicated in patients at risk of acidemia (including
those with significant renal insufficiency, hypoxia or
severe respiratory disease, alcohol use disorder, other
forms of metabolic acidosis, or dehydration). The
medication should be withheld during surgery,
administration of IV contrast, and any serious illness.
Many people receiving metformin monotherapy
eventually require an additional medication.
Thiazolidinediones
Thiazolidinediones (TZDs—pioglitazone, rosiglitazone)
decrease peripheral insulin resistance
(insulin sensitizers). The medications bind a nuclear
receptor primarily present in fat cells (peroxisome-
proliferator-activated receptor-gamma [PPAR-γ]) that is
involved in the transcription of genes that regulate
glucose and lipid metabolism. TZDs also increase high-
density lipoprotein (HDL) levels, lower triglycerides, and
may have anti-inflammatory and anti-atherosclerotic
effects. TZDs are as effective as sulfonylureas
and metformin in reducing hemoglobin A1C. TZDs may
be beneficial in treatment of metabolic associated
steatotic liver disease (MASLD; formerly nonalcoholic
fatty liver disease [NAFLD]).
Though one TZD (troglitazone) caused acute liver failure,
currently available medications have not proven
hepatotoxic. Nevertheless, periodic monitoring of liver
function is recommended. TZDs may cause peripheral
edema, especially in patients taking insulin, and may
worsen heart failure in susceptible patients. Weight
gain, due to fluid retention and increased adipose tissue
mass, is common and may be substantial (> 10 kg) in
some patients. Rosiglitazone may increase risk of heart
failure, angina, myocardial infarction, stroke, and
fracture. Pioglitazone may increase the risk of bladder
cancer (although data are conflicting), heart failure, and
fractures.
Alpha-glucosidase inhibitors
Alpha-glucosidase inhibitors (acarbose, miglitol)
competitively inhibit intestinal enzymes that
hydrolyze dietary carbohydrates; carbohydrates are
digested and absorbed more slowly, thereby
lowering postprandial plasma glucose. Alpha-
glucosidase inhibitors are less effective than other
oral medications in reducing plasma glucose, and
patients often stop the medications because they
may cause dyspepsia, flatulence, and diarrhea. But
the medications are otherwise safe and can be
used in combination with all other oral
antihyperglycemic medications and with insulin.

Dipeptidyl peptidase-4 inhibitors

Dipeptidyl peptidase-4 inhibitors
(eg, alogliptin, linagliptin, saxagliptin, sitagliptin)
prolong the action of endogenous glucagon-like
peptide-1 (GLP-1) by inhibiting the enzyme
dipeptidyl peptidase-4 (DPP-4), which is involved in
the breakdown of GLP-1. GLP-1 is a peptide made
in the small intestine that
stimulates insulin secretion and
inhibits glucagon secretion; prolonging its action
thereby lowers plasma glucose. There is a slight
increase in risk for pancreatitis with DPP-4
inhibitors, but they are otherwise considered safe
and well-tolerated. The hemoglobin A1C decrease
is modest with DPP-4 inhibitors .
Sodium-glucose co-transporter 2 inhibitors
Sodium-glucose co-transporter 2 (SGLT2) inhibitors
(bexagliflozin, canagliflozin, dapagliflozin, empaglifl
ozin, ertugiflozin) inhibit SGLT2 in the proximal
tubule of the kidney, which blocks glucose
reabsorption, thus causing glycosuria and lowering
plasma glucose. SGLT2 inhibitors may also cause
modest weight loss and lowering of blood pressure.
SGLT-2 inhibitors decrease mortality, major
adverse cardiovascular events, and heart failure
hospitalizations in patients with an increased risk for
cardiovascular disease. In addition SGLT-2
inhibitors prevent progression of chronic kidney
disease in patients with diabetes and reduced
glomerular filtration rate or albuminuria.
The most common adverse effects are
genitourinary infections, especially mycotic
infections. Orthostatic symptoms can also occur.
SGLT-2 inhibitors can cause diabetic
ketoacidosis (DKA) in patients with either type 1 or
type 2 diabetes, and ketoacidosis may occur at
lower blood glucose levels than in other causes of
DKA. Diagnosis of euglycemic DKA caused by
SGLT-2 inhibitors is often delayed due to lower
blood sugars. One large study showed an increase
in lower limb amputation with canagliflozin (1).

Dopamine agonist
Bromocriptine is a dopamine agonist that lowers
hemoglobin A1C about 0.5% by an unknown mechanism.
Although approved for type 2 diabetes, it is not
commonly used because of potential adverse effects.

INSULIN THERAPY
pancreatic beta-cells) and will
develop ketoacidosis without it. Insulin is also used in
the management of many patients with type 2 diabetes.
Insulin replacement in type 1 diabetes should ideally
mimic beta-cell function to provide basal and prandial
requirements (physiologic replacement or basal-bolus
dosing). To achieve this, different preparations
of insulin and methods of administration can be used.
Except for use of regular insulin, which is given IV
in hospitalized patients, insulin is almost always
administered subcutaneously. An
inhaled insulin preparation is also available for patients
who prefer not to inject themselves. It has a slightly
more rapid onset of action compared to subcutaneously
injected rapid acting insulin.
Insulin is typically administered as either:
 Multiple daily subcutaneous injections administered

by the patient, with 2 preparations of insulin used

depending on the anticipated glycemic control needs
 An insulin pump that delivers a rapid- or short-act-

ing insulin and administers a basal rate of in-

sulin and additional boluses with meals or for cor-
recting a high blood glucose level
Both strategies require close attention to diet and
exercise as well as to insulin timing and dose.
When insulin is needed for patients with type 2
diabetes, glycemic control can often be achieved with
basal insulin combined with non-
insulin antihyperglycemic medications, although some
patients may require prandial insulin.

Insulin preparations
Most insulin preparations are recombinant human,
mostly eliminating the once-common allergic reactions
to the medication when it was extracted from animal
sources. A number of analogs are also available. These
analogs were created by modifying the
human insulin molecule to alter absorption rates and
duration and time to action.
Insulin types are commonly categorized by their time to
onset and duration of action (see table Onset, Peak, and
Duration of Action of Human Insulin Preparations ).
However, these parameters vary within and among
patients, depending on many factors (eg, site and
technique of injection, amount of subcutaneous fat,
blood flow at the injection site).
Rapid-acting insulins, including lispro and aspart, are
rapidly absorbed because reversal of an amino acid pair
prevents the insulin molecule from associating into
dimers and polymers. They begin to reduce plasma
glucose often within 15 minutes but have short duration
of action (< 4 hours). These insulins are best used at
mealtime to control postprandial spikes in plasma
glucose. Inhaled regular insulin is a rapid-
acting insulin that is taken with meals. It has a slightly
more rapid onset of action compared to subcutaneously
injected rapid-acting insulin but dosing is less flexible,
and periodic pulmonary examinations are required.
Regular insulin is slightly slower in onset (30 to 60
minutes) than lispro and aspart but lasts longer (6 to 8
hours). It is the only insulin form for IV use.
Intermediate-acting insulins include insulin isophane
(Neutral protamine Hagedorn, or NPH) and U-500
regular. The onset of action for insulin isophane is about
2 hours after injection; peak effect is 4 to 12 hours after
injection, and duration of action is 18 to 26 hours.
Concentrated regular insulin U-500 has a similar peak
and duration of action (peak 4 to 8 hours; duration 13 to
24 hours) and can be dosed 2 to 3 times per day.
Long-acting insulins, such
as insulin glargine, insulin detemir, and U-
300 insulin glargine, unlike insulin isophane, have no
discernible peak of action and provide a steady basal
effect over 24 hours. Insulin degludec (another long-
acting insulin) has an even longer duration of action of
over 40 hours. It is dosed daily, and although it requires
3 days to achieve steady state, the timing of dosing is
less rigid.
Combinations of insulin isophane and
regular insulin and of insulin lispro and
lispro protamine (a form of lispro modified to act
like insulin isophane) are commercially available in
premixed preparations (see table Onset, Peak, and
Duration of Action of Human Insulin Preparations ).
Other premixed formulations include
aspart protamine (a form of aspart modified to act
like insulin isophane) with insulin aspart and a
formulation of premixed degludec and aspart.
Different insulin types can be drawn into the same
syringe for injection but should not be premixed in
bottles except by a manufacturer. On occasion,
mixing insulins may affect rates of insulin absorption,
producing variability of effect and making glycemic
control less predictable, especially if mixed > 1 hour
before use. Insulin glargine should never be mixed with
any other insulin.
Many prefilled insulin pen devices are available as an
alternative to the conventional vial and syringe
method. Insulin pens may be more convenient for use
away from home and may be preferable for patients
with limited vision or manual dexterity. Spring-loaded
self-injection devices (for use with a syringe) may be
useful for the occasional patient who is fearful of
injection, and syringe magnifiers are available for
patients with low vision. "Smart" or
"connected" insulin pens and pen caps communicate
with a smart phone application to track
administered insulin and make dosing
recommendations.
Insulin pumps
Lispro or aspart can also be given continuously using
an insulin pump (1). In people with insulin resistance,
higher concentration U500 is sometimes used.
Continuous subcutaneous insulin infusion pumps can
eliminate the need for multiple daily injections, provide
maximal flexibility in the timing of meals, and
substantially reduce variability in glucose levels.
Disadvantages include cost, mechanical failures leading
to interruptions in insulin supply, and the inconvenience
of wearing an external device. Frequent and meticulous
self-monitoring and close attention to pump function are
necessary for safe and effective use of the insulin pump.
Sensor-augmented pump therapy is the use
of continuous glucose monitoring (CGM) in conjunction
with an insulin pump. Several systems are available, in
which glucose sensor data is communicated to
an insulin pump and an algorithm
adjusts insulin delivery through the pump. Systems with
"low-glucose suspend" algorithms can
stop insulin delivery when the sensor detects that
glucose is low or is predicted to go low.
Hybrid closed-loop insulin delivery systems, or
automated insulin delivery (AID) systems, are more
sophisticated systems in which an algorithm calculates
and adjusts the basal insulin dose based on CGM sensor
input, which is then delivered by the
connected insulin pump .
The available systems still require user input for
mealtime bolus doses. There are several "fully closed-
loop" systems being investigated, in which the pump
automatically calculates both basal and
bolus insulin doses with little to no input from the user.
A new closed-loop system that uses meal
announcements, rather than carbohydrate counting has
been developed recently.
Complications of insulin treatment
The most common complication is
 Hypoglycemia

Uncommon complications include

 Hypokalemia

 Local allergic reactions

 Generalized allergic reaction

 Local fat atrophy or hypertrophy
 Circulating anti-insulin antibodies
Hypoglycemia is the most common complication
of insulin treatment, occurring more often as patients
try to achieve strict glucose control and approach near-
normoglycemia or when blood glucose is not
appropriately monitored. Symptoms of mild or moderate
hypoglycemia include headache, diaphoresis,
palpitations, light-headedness, blurred vision, agitation,
and confusion. Symptoms of more severe hypoglycemia
include seizures and loss of consciousness. In older
patients, hypoglycemia may cause stroke-like symptoms
of aphasia or hemiparesis and is more likely to
precipitate stroke, myocardial infarction, and sudden
death.
Patients should be taught to recognize symptoms of
hypoglycemia. Patients with type 1 diabetes mellitus of
long duration may be unaware of hypoglycemic episodes
because they no longer experience autonomic symptoms
(hypoglycemia unawareness).
In patients treated with insulin or glucose-lowering
medications (eg, sulfonylureas), a blood glucose
level < 70 mg/dL (< 3.9 mmol/L) is considered
hypoglycemia and should be treated to avoid further
decreases in glucose level and consequences of
hypoglycemia. Symptoms of hypoglycemia usually
respond rapidly to the ingestion of sugar.
Hypoglycemia is treated with the administration of a
form of sugar (oral glucose or sucrose or IV dextrose)
and/or glucagon or dasiglucagon. Patients at risk for
hypoglycemia should have glucagon or dasiglucagon at
home and elsewhere, and household members and
trusted others should be instructed on management of
hypoglycemic emergencies.
Hyperglycemia may result from too high a
bedtime insulin dose, which can drive glucose down and
stimulate a counter-regulatory response, leading to
morning hyperglycemia (Somogyi phenomenon). A more
common cause of unexplained morning hyperglycemia,
however, is a rise in early morning growth hormone
(dawn phenomenon). In this case, the
evening insulin dose should be increased, changed to a
longer-acting preparation, or injected later.
Hypokalemia may be caused by intracellular shifts of
potassium due to insulin-induced stimulation of the
sodium-potassium pump, but it is
uncommon. Hypokalemia more commonly occurs in
acute care settings when body potassium stores may be
depleted and IV insulin is used.
Local allergic reactions at the site of insulin injections
are rare, especially with the use of human insulins, but
they may still occur in patients with latex allergy
because of the natural rubber latex contained in vial
stoppers. They can cause immediate pain or burning
followed by erythema, pruritus, and induration—the
latter sometimes persisting for days. Most reactions
spontaneously disappear after weeks of continued
injection and require no specific treatment, although
antihistamines may provide symptomatic relief.
Generalized allergic reaction is extremely rare with
human insulins but can occur when insulin is restarted
after a lapse in treatment. Symptoms develop 30
minutes to 2 hours after injection and include urticaria,
angioedema, pruritus, bronchospasm, and anaphylaxis.
Treatment with antihistamines often suffices,
but epinephrine and IV glucocorticoids may be needed.
If insulin treatment is needed after a generalized
allergic reaction, skin testing with a panel of
purified insulin preparations and desensitization should
be done.
Local fat hypertrophy, or lipohypertrophy, is a common
reaction caused by the lipogenic effect of insulin.
Lipohypertrophy can lead to variability
of insulin absorption and can be avoided by rotating
injection sites.
Lipoatrophy, a loss of subcutaneous adipose tissue, is
thought to result from an immune reaction to a
component of insulin preparation. It has become very
rare with the use of human insulins and can be treated
with corticosteroids.
Circulating anti-insulin antibodies are a very rare cause
of insulin resistance in patients taking
animal insulin and sometimes in those taking human
and analog insulins. Insulin resistance due to circulating
anti-insulin antibodies can sometimes be treated by
changing insulin preparations (eg, from animal to
human insulin) and by administering corticosteroids or
immunosuppressants and sometimes plasmapheresis if
necessary.

Insulin regimens for type 1 diabetes

Regimens range from twice a day split-mixed (eg, split

doses of rapid- and intermediate-acting insulins) to
more physiologic basal-bolus regimens using multiple
daily injections (eg, single fixed [basal] dose of long-
acting and variable prandial [bolus] doses of rapid-
acting insulin) or an insulin pump.

Intensive treatment, defined as glucose monitoring ≥ 4

times a day and ≥ 3 injections a day or
continuous insulin infusion, is more effective than
conventional treatment (1 to 2 insulin injections a day
with or without monitoring) for preventing diabetic
retinopathy, nephropathy, and neuropathy. However,
intensive therapy may result in more frequent episodes
of hypoglycemia and weight gain and is more effective
in patients who are able and willing to take an active
role in their self-care.

In general, most patients with type 1 diabetes mellitus

can start with a total dose of 0.2 to 0.8 units
of insulin/kg/day. Patients with obesity may require
higher doses. Physiologic replacement involves giving 40
to 60% of the daily insulin dose as an intermediate- or
long-acting preparation to cover basal needs, with the
remainder given as a rapid- or short-acting preparation
to cover postprandial increases. This approach is most
effective when the dose of rapid- or short-
acting insulin is adjusted for preprandial blood glucose
level and anticipated meal content.
A correction factor, also known as the insulin sensitivity
factor, is the amount that 1 unit of insulin will lower a
patient's blood glucose level over 2 to 4 hours; this
factor is often calculated using the "1800 rule" when
rapid-acting insulin is used for correction (1800/total
daily dose of insulin). For regular insulin, a "1500 rule"
can be used. A correction dose (current glucose level -
target glucose level/ correction factor) is the dose
of insulin that will lower the blood glucose level into the
target range. This correction dose can be added to the
prandial insulin dose that is calculated for the number
of carbohydrates in a meal, using the carbohydrate-to-
insulin ratio (CIR). The CIR is often calculated using the
"500 rule" (500/total daily dose).
To illustrate calculation of a lunchtime dose, assume the
following:
Preprandial fingerstick glucose: 240 mg/dL (13.3


mmol/L)
 Total daily dose of insulin: 30 units basal in-
sulin+ 10 units bolus insulin per meal = 60 units
total, daily
 Correction factor (insulin sensitivity factor):
1800/60 = 30 mg/dL/unit (1.7 mEq/L/unit, or 1.7
mmol/L)
 Estimated carbohydrate content of upcoming meal:

50 g
 Carbohydrate:insulin ratio (CIR): 500/60 = 8:1
 Target glucose: 120 mg/dL (6.7 mmol/L)

Prandial insulin dose = 50 g carbohydrate divided by 8

g/unit insulin = 6 units
Correction dose = (240 mg/dL - 120 mg/dL)/30
correction factor = 4 units ([13.3 mmol/L - 6.7
mmol/L]/1.7 = 4)
Total dose prior to this meal = prandial
dose + correction dose = 6 + 4 = 10 units rapid-
acting insulin.

Such physiologic regimens allow greater freedom of

lifestyle because patients can skip or time-shift meals
and maintain normoglycemia. These recommendations
are for initiation of therapy; thereafter, choice of
regimens generally rests on physiologic response and
patient and physician preferences. The carbohydrate-to-
insulin ratio (CIR) and sensitivity factors need to be fine-
tuned and changed according to how the patient
responds to insulin doses. This adjustment requires
working closely with a diabetes specialist.

Insulin regimens for type 2 diabetes

Regimens for type 2 diabetes mellitus also vary. In many

patients, glucose levels are adequately controlled with
lifestyle changes and non-insulin antihyperglycemic
medications, but insulin should be added when glucose
remains inadequately controlled by ≥ 3 medications, if
the patient is suspected of having insulin deficiency, or
the blood sugar level is very high. Although uncommon,
adult-onset type 1 diabetes may be the cause. In most
cases, in women who become pregnant, insulin should
replace non-insulin antihyperglycemic medications.

COMPLICATIONS

DIABETIC RETINOPATHY
Diabetes can damage your eyes over time and cause
vision loss, even blindness. The good news is managing
your diabetes and getting regular eye exams can help
prevent vision problems and stop them from getting
worse.
Eye diseases that can affect people with diabetes include
diabetic retinopathy, macular edema (which usually
develops along with diabetic retinopathy), cataracts, and
glaucoma. All can lead to vision loss, but early diagnosis
and treatment can go a long way toward protecting your
eyesight.

Diabetic Retinopathy
This common eye disease is the leading cause of
blindness in working-age adults. Diabetic retinopathy is
caused when high blood sugar damages blood vessels in
the retina (a light-sensitive layer of cells in the back of
the eye). Damaged blood vessels can swell and leak,
causing blurry vision or stopping blood flow. Sometimes
new blood vessels grow, but they aren’t normal and can
cause further vision problems. Diabetic retinopathy
usually affects both eyes.
Risk Factors for Diabetic Retinopathy
Anyone with type 1, type 2, or gestational
diabetes (diabetes while pregnant) can develop diabetic
retinopathy. The longer you have diabetes, the more
likely you are to develop it. These factors can also
increase your risk:
  Blood sugar, blood pressure, and cholesterol levels
that are too high.
 Smoking.
 Race/ethnicity: African Americans, Hispanics/Lati-
nos, and American Indians/Alaska Natives are at
higher risk.
Help for Low Vision
If you have diabetic retinopathy, low-vision aids such as
magnifying glasses and special lenses can help. Ask your
eye doctor to refer you to a low-vision specialist.
Stages of Diabetic Retinopathy
Diabetic retinopathy has 2 main stages:
Early stage: (nonproliferative): Blood vessel walls in the
retina weaken and bulge, forming tiny pouches (you
won’t be able to detect them, but your eye doctor can).
These pouches can leak blood and other fluid, which can
cause a part of the retina called the macula to swell
(macular edema) and distort your vision. Macular edema
is the most common cause of blindness in people with
diabetic retinopathy. About half of people with diabetic
retinopathy will develop macular edema.
Advanced stage (proliferative): In this stage, the retina
begins to grow new blood vessels. These new vessels are
fragile and often bleed into the vitreous (the clear gel
between the lens and retina). With minor bleeding, you
may see a few dark spots that float in your vision. If
there’s a lot of bleeding, your vision may be completely
blocked.
You may not notice symptoms in the early stage. That’s
why it’s very important to get a dilated eye exam at least
once a year to catch any problems early when treatment
is most effective.
Symptoms in the advanced stage can include:
 Blurry vision
 Spots or dark shapes in your vision (floaters)
 Trouble seeing colors
 Dark or empty areas in your vision
 Vision loss

How Diabetic Retinopathy Is Diagnosed

During your eye exam, your eye doctor will check how
well you see the details of letters or symbols from a
distance. Your doctor will also look at the retina and
inside of your eyes and may use a dye to reveal leaky
blood vessels. If it turns out you have diabetic
retinopathy, your eye doctor may want to check your
vision more often than once a year.
You should be checked for diabetic retinopathy
immediately if you’re diagnosed with type 2 diabetes. If
you have type 1 diabetes, you should be checked within 5
years of your diagnosis and then regularly thereafter,
typically every year. The sooner you’re treated for
diabetic retinopathy, the better that treatment will work.
Call your eye doctor if you notice changes in your vision,
especially if they happen suddenly. Changes may include:
 Blurring
 Spots
 Flashes
 Blind spots
 Distortion
 Difficulty reading or doing detail work

Diabetic Retinopathy Treatment

Treating diabetic retinopathy can repair damage to the
eye and even prevent blindness in most people.
Treatment can start before your sight is affected, which
helps prevent vision loss. Options include:
  Laser therapy (also called laser photocoagulation).
This creates a barrier of scar tissue that slows the
growth of new blood vessels.
 Medicines called VEGF inhibitors, which can slow
down or reverse diabetic retinopathy.
 Removing all or part of the vitreous (vitrectomy).
 Reattachment of the retina (for retinal detachment,
a complication of diabetic retinopathy).
 Injection of medicines called corticosteroids.
Other Eye Diseases
Cataracts
Glaucoma
Prevent or Delay Eye Diseases
You can protect your vision and lower your chance for
vision loss with these steps:
 Get a dilated eye exam at least once a year so your
eye doctor can spot any problems early when they’re
most treatable.
 Keep your blood sugar levels in your target
range as much as possible. Over time, high blood
sugar not only damages blood vessels in your eyes, it
can also affect the shape of your lenses and make
your vision blurry.
 Keep your blood pressure and cholesterol levels in
your target range to lower your risk for eye diseases
and vision loss. Also good for your health in general!
 Quit smoking Quitting lowers your risk for diabetes-
related eye diseases and improves your health in
many other ways too.
 Get active Physical activity protects your eyes and
helps you manage diabetes.
 DIABETIC NEPHROPATHY
Diabetic nephropathy is a serious complication of type 1
diabetes and type 2 diabetes. It's also called diabetic
kidney disease. In the United States, about 1 in 3 people
living with diabetes have diabetic nephropathy.

Diabetic nephropathy affects the kidneys' usual work of

removing waste products and extra fluid from the body.
The best way to prevent or delay diabetic nephropathy is
by living a healthy lifestyle and keeping diabetes and
high blood pressure managed.

Over years, diabetic nephropathy slowly damages the

kidneys' filtering system. Early treatment may prevent
this condition or slow it and lower the chance of
complications.

Diabetic kidney disease can lead to kidney failure. This

also is called end-stage kidney disease. Kidney failure is
a life-threatening condition. Treatment options for
kidney failure are dialysis or a kidney transplant.

Symptoms

In the early stages of diabetic nephropathy, there might

not be symptoms. In later stages, symptoms may include:
  High blood pressure that gets harder to control.
 Swelling of feet, ankles, hands or eyes.
 Foamy urine.
 Confusion or difficulty thinking.
 Shortness of breath.
 Loss of appetite.
 Nausea and vomiting.
 Itching.
 Tiredness and weakness.
Diabetic nephropathy causes

Diabetic nephropathy is a common complication of type

1 and type 2 diabetes.

Over time, diabetes that isn't well controlled can damage

blood vessels in the kidneys that filter waste from the
blood. This can lead to kidney damage and cause high
blood pressure.

High blood pressure can cause more kidney damage by

raising the pressure in the filtering system of the kidneys.
 Risk factors

If you have diabetes, the following can raise your risk of

diabetic nephropathy:

Uncontrolled high blood sugar, also called hy-

perglycemia.
Uncontrolled high blood pressure, also called hyper-
tension.
 Smoking.
 High blood cholesterol.
 Obesity.
 A family history of diabetes and kidney disease.

Complications

Complications of diabetic nephropathy can come on

slowly over months or years. They may include:

Body fluid buildup. This could lead to swelling in the

arms and legs, high blood pressure, or fluid in the
lungs, called pulmonary edema.
 A rise in the levels of the mineral potassium in the
blood, called hyperkalemia.
Heart and blood vessel disease, also called cardi-
ovascular disease. This could lead to a stroke.
Fewer red blood cells to carry oxygen. This condition
also is called anemia.
Pregnancy complications that carry risks for the
pregnant person and the growing fetus.
Damage to the kidneys that can't be fixed. This is
called end-stage kidney disease. Treatment is either
dialysis or a kidney transplant.
Diagnosis

Diabetic nephropathy usually is diagnosed during the

regular testing that's part of managing diabetes. Get
tested every year if you have type 2 diabetes or have had
type 1 diabetes for more than five years.

Routine screening tests may include:

Urinary albumin test: This test can detect a blood

protein called albumin in urine. Typically, the kidneys
don't filter albumin out of the blood. Too much albu-
 min in your urine can mean that the kidneys aren't
working well.
Albumin/creatinine ratio: Creatinine is a chemical
waste product that healthy kidneys filter out of the
blood. The albumin/creatinine ratio measures how
much albumin compared to creatinine is in a urine
sample. It shows how well the kidneys are working.
Glomerular filtration rate (GFR): The measure of
creatinine in a blood sample may be used to see how
quickly the kidneys filter blood. This is called the glom-
erular filtration rate. A low rate means the kidneys
aren't working well.
Other diagnostic tests may include:

Imaging tests: X-rays and ultrasound can show the

makeup and size of the kidneys. CT and MRI scans
can show how well blood is moving within the kid-
neys. You may need other imaging tests, as well.
Kidney biopsy: This is a procedure to take a sample
of kidney tissue to be studied in a lab. It involves a
numbing medicine called a local anesthetic. A thin
needle is used to remove small pieces of kidney tissue.
 Treatment

The first step in treating diabetic nephropathy is to treat

and control diabetes and high blood pressure. Treatment
includes diet, lifestyle changes, exercise and prescription
medicines. Controlling blood sugar and blood pressure
might prevent or delay kidney issues and other
complications.

Medications

In the early stages of diabetic nephropathy, your

treatment might include medicines to manage the
following:

Blood pressure: Medicines called angiotensin-con-

verting enzyme (ACE) inhibitors and angiotensin 2 re-
ceptor blockers (ARBs) are used to treat high blood
pressure.
Blood sugar: Medicines can help control high blood
sugar in people with diabetic nephropathy. They in-
clude older diabetes medicines such as insulin. Newer
drugs include Metformin (Fortamet, Glumetza, oth-
ers), glucagon-like peptide 1 (GLP-1) receptor agonists
and SGLT2 inhibitors.
Ask your health care professional if treatments such
as SGLT2 inhibitors or GLP-1 receptor agonists might
work for you. These treatments can protect the heart
and kidneys from damage due to diabetes.
High cholesterol: Cholesterol-lowering drugs called
statins are used to treat high cholesterol and lower
the amount of protein in urine.
Kidney scarring: Finerenone (Kerendia) might help
reduce tissue scarring in diabetic nephropathy. Re-
search has shown that the medicine might lower the
risk of kidney failure. It also may lower the risk of dy-
ing from heart disease, having heart attacks and
needing to go to a hospital to treat heart failure in
adults with chronic kidney disease linked to type 2
diabetes.
 DIABETIC NEUROPATHY
Diabetic neuropathy is a type of nerve damage that can
occur if you have diabetes. High blood sugar (glucose)
can injure nerves throughout the body. Diabetic
neuropathy most often damages nerves in the legs and
feet.

Depending on the affected nerves, diabetic neuropathy

symptoms include pain and numbness in the legs, feet
and hands. It can also cause problems with the digestive
system, urinary tract, blood vessels and heart. Some
people have mild symptoms. But for others, diabetic
neuropathy can be quite painful and disabling.

Diabetic neuropathy is a serious diabetes complication

that may affect as many as 50% of people with diabetes.
But you can often prevent diabetic neuropathy or slow its
progress with consistent blood sugar management and a
healthy lifestyle.

Symptoms
There are four main types of diabetic neuropathy. You
can have one type or more than one type of neuropathy.

Your symptoms depend on the type you have and which

nerves are affected. Usually, symptoms develop
gradually. You may not notice anything is wrong until
considerable nerve damage has occurred.
Peripheral neuropathy:
This type of neuropathy may also be called distal
symmetric peripheral neuropathy. It's the most common
type of diabetic neuropathy. It affects the feet and legs
first, followed by the hands and arms. Signs and
symptoms of peripheral neuropathy are often worse at
night, and may include:
 Numbness or reduced ability to feel pain or temper-
ature changes
 Tingling or burning feeling
 Sharp pains or cramps
 Muscle weakness
 Extreme sensitivity to touch — for some people, even
a bedsheet's weight can be painful
 Serious foot problems, such as ulcers, infections, and
bone and joint damage
Autonomic neuropathy:
The autonomic nervous system controls blood pressure,
heart rate, sweating, eyes, bladder, digestive system and
sex organs. Diabetes can affect nerves in any of these
areas, possibly causing signs and symptoms including:
 A lack of awareness that blood sugar levels are low
(hypoglycemia unawareness)
 Drops in blood pressure when rising from sitting or
lying down that may cause dizziness or fainting (ortho-
static hypotension)
 Bladder or bowel problems
 Slow stomach emptying (gastroparesis), causing
nausea, vomiting, sensation of fullness and loss of appet-
ite
 Difficulty swallowing
 Changes in the way the eyes adjust from light to dark
or far to near
 Increased or decreased sweating
 Problems with sexual response, such as vaginal dry-
ness in women and erectile dysfunction in men

Proximal neuropathy (diabetic polyradiculopathy):

This type of neuropathy often affects nerves in the thighs,
hips, buttocks or legs. It can also affect the abdominal
and chest area. Symptoms are usually on one side of the
body, but may spread to the other side. Proximal
neuropathy may include:
 Severe pain in the buttock, hip or thigh
 Weak and shrinking thigh muscles
 Difficulty rising from a sitting position
 Chest or abdominal wall pain

Mononeuropathy (focal neuropathy):

Mononeuropathy refers to damage to a single, specific
nerve. The nerve may be in the face, torso, arm or leg.
Mononeuropathy may lead to:
 Difficulty focusing or double vision
 Paralysis on one side of the face
 Numbness or tingling in the hand or fingers
 Weakness in the hand that may result in dropping
things
 Pain in the shin or foot
 Weakness causing difficulty lifting the front part of
the foot (foot drop)
 Pain in the front of the thigh
Causes
The exact cause of each type of neuropathy is unknown.
Researchers think that over time, uncontrolled high blood
sugar damages nerves and interferes with their ability to
send signals, leading to diabetic neuropathy. High blood
sugar also weakens the walls of the small blood vessels
(capillaries) that supply the nerves with oxygen and
nutrients.

Risk factors
Anyone who has diabetes can develop neuropathy. But
these risk factors make nerve damage more likely:
 Poor blood sugar control. Uncontrolled blood sugar
increases the risk of every diabetes complication, includ-
ing nerve damage.
 Diabetes history. The risk of diabetic neuropathy in-
creases the longer a person has diabetes, especially if
blood sugar isn't well controlled.
 Kidney disease. Diabetes can damage the kidneys.
Kidney damage sends toxins into the blood, which can
lead to nerve damage.
 Being overweight. Having a body mass index (BMI)
of 25 or more may increase the risk of diabetic neuro-
pathy.
 Smoking. Smoking narrows and hardens the arter-
ies, reducing blood flow to the legs and feet. This makes
it more difficult for wounds to heal and damages the
peripheral nerves.

Complications
Diabetic neuropathy can cause a number of serious
complications, including:
 Hypoglycemia unawareness. Blood sugar levels be-
low 70 milligrams per deciliter (mg/dL) — 3.9 millimoles
per liter (mmol/L) — usually cause shakiness, sweating
and a fast heartbeat. But people who have autonomic
neuropathy may not experience these warning signs.
 Loss of a toe, foot or leg. Nerve damage can cause a
loss of feeling in the feet, so even minor cuts can turn into
sores or ulcers without being noticed. In severe cases, an
infection can spread to the bone or lead to tissue death.
Removal (amputation) of a toe, foot or even part of the
leg may be necessary.
 Urinary tract infections and urinary incontinence. If
the nerves that control the bladder are damaged, the
bladder may not empty completely when urinating. Bac-
teria can build up in the bladder and kidneys, causing ur-
inary tract infections. Nerve damage can also affect the
ability to feel the need to urinate or to control the
muscles that release urine, leading to leakage (incontin-
ence).
 Sharp drops in blood pressure. Damage to the
nerves that control blood flow can affect the body's abil-
ity to adjust blood pressure. This can cause a sharp drop
in pressure when standing after sitting or lying down,
which may lead to lightheadedness and fainting.
 Digestive problems. If nerve damage occurs in the
digestive tract, constipation or diarrhea, or both are pos-
sible. Diabetes-related nerve damage can lead to gastro-
paresis, a condition in which the stomach empties too
slowly or not at all. This can cause bloating and indiges-
tion.
 Sexual dysfunction. Autonomic neuropathy often
damages the nerves that affect the sex organs. Men may
experience erectile dysfunction. Women may have diffi-
culty with lubrication and arousal.
 Increased or decreased sweating. Nerve damage
can disrupt how the sweat glands work and make it diffi-
cult for the body to control its temperature properly.

TREATMENT
Blood sugar management
The American Diabetes Association (ADA) recommends
that people living with diabetes have a glycated hemo-
globin (A1C) test at least twice a year. This test in-
dicates your average blood sugar level for the past 2 to 3
months.

glycated hemoglobin (A1C) goals may need to be indi-

vidualized, but for many adults, the ADA recommends an
A1C of less than 7.0%. If your blood sugar levels are
higher than your goal, you may need changes in your
daily management, such as adding or adjusting your
medications or changing your diet or physical activity.

DIABETIC FOOTCARE
Diabetes puts you at risk of foot infections
Diabetes can cause many undesirable complications in
the feet and lower limb, so it is important for people
with diabetes to have a correct foot care regime to keep
their feet healthy.

In a person with diabetes, foot conditions like hard skin,

ingrown toe nails, blisters or cuts can often lead to
wounds, which can easily deteriorate if no proper care is
taken. Thus, it is important for people with diabetes to
check their feet daily to avoid foot complications.
1. Check feet daily for
 Blisters
 Hard skin
 Wounds
 Sudden changes in skin colour
 Cracks in skin
2. Look out for signs of infection
 Redness
 Pus / Discharge
 Warmth
 Fevers / Chills
 Swelling
 Foul smell
 Pain
How to maintain proper foot hygiene
Wash your feet daily with soap and water.

Wash well in between the toes and ensure

that there are no foreign objects or dirt stuck
inside.

Dry your feet thereafter and ensure that

spaces between the toes are dry.

You can use an alcohol swab to further dry

them out.

White skin in between your toes occurs when

too much moisture is present.

Clean the area with iodine, and separate the

toes with gauze until the white skin goes off.
 3.Moisturise your feet daily

5. File any buildup of hard skin or corns

6. Cut toenails straight across and smoothen nail
edges with a nail file

7. Wear shoes with supportive features and a good fit

8. Check that there is nothing in your shoes before
wearing them
Before wearing your shoes, always check to ensure that
there is nothing hidden in them (for example, sharp ob-
jects or small objects).

Also, always wear socks or stockings with shoes to pre-

vent blisters from forming on your feet due to skin being
continuously rubbed against the shoe.
9. Maintain good blood sugar levels
Blood sugar levels that are too high or too low can be
harmful. Discuss your blood sugar levels with your doctor
and work with your doctor to keep them on target!
10. Go for a yearly Diabetic Foot Screening
It is essential to go for diabetic foot screening at least once a
year. During foot screening, the sensation in your feet is
checked, and you will be informed of your risk level of
developing foot problems.
 CARDIOVASCULAR DISEASES

Diabetes and heart disease often go hand in hand.

Learn how to protect your heart with simple lifestyle
changes that can also help you manage diabetes.
Heart disease is very common and serious. It’s the
leading cause of death for both men and women in the
United States. If you have diabetes, you’re twice as likely
to have heart disease or a stroke than someone who
doesn’t have diabetes—and at a younger age. The longer
you have diabetes, the more likely you are to have heart
disease.
But the good news is that you can lower your risk for
heart disease and improve your heart health by changing
certain lifestyle habits. Those changes will help you
manage diabetes better too.
What Is Heart Disease?
“cardiovascular disease” is similar but includes all types
of heart disease, stroke, and blood vessel disease. The
most common type is coronary artery disease, which
affects blood flow to the heart.
Coronary artery disease is caused by the buildup of
plaque in the walls of the coronary arteries, the blood
vessels that supply oxygen and blood to the heart. Plaque
is made of cholesterol deposits, which make the inside of
arteries narrow and decrease blood flow. This process is
called atherosclerosis, or hardening of the arteries.
Decreased blood flow to the heart can cause a heart
attack. Decreased blood flow to the brain can Heart
disease includes several kinds of problems that affect
your heart. The term cause a stroke.
Hardening of the arteries can happen in other parts of
the body too. In the legs and feet, it’s called peripheral
arterial disease, or PAD. PAD is often the first sign that a
person with diabetes has cardiovascular disease.
How Diabetes Affects Your Heart
Over time, high blood sugar can damage blood vessels
and the nerves that control your heart. People with
diabetes are also more likely to have other conditions
that raise the risk for heart disease:
 High blood pressure increases the force of blood
through your arteries and can damage artery walls.
Having both high blood pressure and diabetes can
greatly increase your risk for heart disease.
 Too much LDL (“bad”) cholesterol in your blood-
stream can form plaque on damaged artery walls.
 High triglycerides (a type of fat in your blood) and
low HDL (“good”) cholesterol or high LDL cholesterol
is thought to contribute to hardening of the arteries.
None of these conditions has symptoms. Your doctor can
check your blood pressure and do a simple blood test to
see if your LDL, HDL, and triglyceride levels are high.
These factors can also raise your risk for heart disease:
 Smoking
 Being overweight or having obesity
 Not getting enough physical activity
 Eating a diet high in saturated fat, trans fat, choles-
terol, and sodium (salt)
 Drinking too much alcohol
People with diabetes are also more likely to have heart
failure. Heart failure is a serious condition, but it doesn’t
mean the heart has stopped beating; it means your heart
can’t pump blood well. This can lead to swelling in your
legs and fluid building up in your lungs, making it hard to
breathe. Heart failure tends to get worse over time, but
early diagnosis and treatment can help relieve symptoms
and stop or delay the condition getting worse.
Testing for Heart Disease
Your blood pressure, cholesterol levels, and weight will
help your doctor understand your overall risk for heart
disease. Your doctor may also recommend other tests to
check your heart health, which could include:
 An electrocardiogram (ECG or EKG) to measure your
heart’s electrical activity. Your heartbeat is the result
of an electrical impulse traveling through your heart.
 An echocardiogram (echo) to examine how thick
your heart muscle is and how well your heart pumps.
 An exercise stress test (treadmill test) to see how
well your heart functions when it’s working hard.
Take Care of Your Heart
These lifestyle changes can help lower your risk for heart
disease or keep it from getting worse, as well as help you
manage diabetes:
 Follow a healthy diet: Eat more fresh fruits and ve-
getables, lean protein, and whole grains. Eat fewer
processed foods (such as chips, sweets, and fast
food) and avoid trans fat. Drink more water, fewer
sugary drinks, and less alcohol.
 Aim for a healthy weigh: If you’re overweight, losing
even a modest amount of weight can lower your
triglycerides and blood sugar. Modest weight loss
means 5% to 7% of body weight, just 10 to 14
pounds for a 200-pound person.
 Get active: Being physically active makes your body
more sensitive to insulin (the hormone that allows
cells in your body to use blood sugar for energy),
which helps manage your diabetes. Physical activity
also helps control blood sugar levels and lowers your
risk of heart disease. Try to get at least 150 minutes
per week of moderate-intensity physical activity,
such as brisk walking.
 Manage your ABCs:
o A: Get a regular A1C test to measure your aver-
age blood sugar over 2 to 3 months; aim to stay
in your target range as much as possible.
o B: Try to keep your blood pressure below
140/90 mm Hg (or the target your doctor sets).
 o C: Manage your cholesterol levels.
o s: Stop smoking or don’t start.
 Manage stress: Stress can raise your blood pressure

and can also lead to unhealthy behaviors, such as

drinking too much alcohol or overeating. Instead,
visit a mental health counselor, try meditation or
deep breathing, get some physical activity, or get
support from friends and family.
Your doctor may also prescribe medicines that can help
keep your blood sugar, blood pressure, cholesterol, and
triglycerides close to your target levels.

DIABETES AND HYPERTENSION

High blood pressure is twice as likely to strike a person
with diabetes than a person without diabetes. Left un-
treated, high blood pressure can lead to heart disease
and stroke. In fact, a person with diabetes and high blood
pressure is four times as likely to develop heart disease
than someone who does not have either of the condi-
tions. About two-thirds of adults with diabetes have
blood pressure greater than 130/80 mm Hg or use pre-
scription medications for hypertension.
Hypertension in midlife could affect late-life thinking
skills. Discover what Johns Hopkins researchers know
about the connection, plus ways to keep your blood pres-
sure under control and your brain at its best.

What is high blood pressure?

Blood pressure is the force of the blood pushing against
the artery walls. Each time the heart beats, it is pumping
blood into these arteries, resulting in the highest blood
pressure when the heart contracts and is pumping the
blood. High blood pressure, or hypertension, directly in-
creases the risk of coronary heart disease (heart attack)
and stroke (brain attack). With high blood pressure, the
arteries may have an increased resistance against the
flow of blood, causing the heart to pump harder to circu-
late the blood.

Two numbers are used to measure blood pressure. The

number on the top, the systolic pressure, refers to the
pressure inside the artery when the heart contracts and is
pumping the blood through the body. The number on the
bottom, the diastolic pressure, refers to the pressure in-
side the artery when the heart is at rest and is filling with
blood. Both the systolic and diastolic pressures are recor-
ded as "mm Hg" (millimeters of mercury).According to
the National Heart, Lung, and Blood Institute of the Na-
tional Institutes of Health (NHLBI), high blood pressure
for adults is defined as:

140 mm Hg or greater systolic pressure and

90 mm Hg or greater diastolic pressure

NHLBI guidelines for prehypertension are120 mm Hg –

139 mm Hg systolic pressure and80 mm Hg – 89 mm Hg
diastolic pressure

NHLBI guidelines define normal blood pressure as follow-

sLess than 120 mm Hg systolic pressure andLess than 80
mm Hg diastolic pressure

What are the symptoms of high blood pressure?

Often, people with high blood pressure do not have no-
ticeable symptoms. If the blood pressure is greatly elev-
ated, a person may experience the following. However,
each individual may experience symptoms differently.
Symptoms may include:
  Headache
 Dizziness
 Blurred vision

The symptoms of high blood pressure may resemble

other medical conditions or problems. Always consult
your doctor for a diagnosis.

Preventing high blood pressure

The American Diabetes Association recommends the fol-
lowing to help prevent the onset of high blood pressure:

 Reduce your salt intake

 Engage in stress-relieving activities
 Exercise regularly
 Get to and stay at a healthy weight
 Avoid excessive alcohol intake
 Stop smoking and avoid exposure to secondhand
smoke
 Monitor your blood pressure
Treatment for high blood pressure
Specific treatment for high blood pressure will be determ-
ined by doctor based on:

 age, overall health, and medical history

 Extent of the disease
 tolerance for specific medications, procedures, or
therapies
 Expectations for the course of the disease
 opinion or preference
 Treatment may include exercise, a balanced diet, and
quitting smoking, as well as medications prescribed
by doctor.
Diabetes care: How lifestyle, daily routine affect
blood sugar
Diabetes management requires awareness. Know what
makes your blood sugar level rise and fall — and how to
control these day-to-day factors.
Keeping your blood sugar levels within the range
recommended by your doctor can be challenging. That's
because many things make your blood sugar levels
change, sometimes unexpectedly. Following are some
factors that can affect your blood sugar levels.
Food
Healthy eating is a cornerstone of healthy living — with
or without diabetes. But if you have diabetes, you need
to know how foods affect your blood sugar levels. It's not
only the type of food you eat, but also how much you eat
and the combinations of food types you eat.
What to do:
 Learn about carbohydrate counting and portion
sizes. A key to many diabetes management plans is
learning how to count carbohydrates. Carbohydrates
often have the biggest impact on your blood sugar
levels. For people taking mealtime insulin, it's import-
ant to know the amount of carbohydrates in your food,
so you get the proper insulin dose.
Learn what portion size is appropriate for each food
type. Simplify your meal planning by writing down
portions for foods you eat often. Use measuring cups
or a scale to ensure proper portion size and an
accurate carbohydrate count.
 Make every meal well balanced. As much as pos-
sible, plan for every meal to have a good mix of
starches, fruits and vegetables, proteins, and fats. Pay
attention to the types of carbohydrates you choose.
Some carbohydrates, such as fruits, vegetables and
whole grains, are better for you than others. These
foods are low in carbohydrates and have fiber that
helps keep your blood sugar levels more stable. Talk to
your doctor, nurse or dietitian about the best food
choices and the appropriate balance of food types.
 Coordinate your meals and medications. Too little
food in proportion to your diabetes medications — es-
pecially insulin — may result in dangerously low blood
sugar (hypoglycemia). Too much food may cause your
blood sugar level to climb too high (hyperglycemia).
Talk to your diabetes health care team about how to
best coordinate meal and medication schedules.
 Avoid sugar-sweetened beverages. Sugar-

sweetened beverages tend to be high in calories and

offer little nutrition. And because they cause blood
sugar to rise quickly, it's best to avoid these types of
drinks if you have diabetes.
 The exception is if you are experiencing a low blood
sugar level. Sugar-sweetened beverages, such as soda,
juice and sports drinks can be used as an effective
treatment for quickly raising blood sugar that is too
low.

Exercise
Physical activity is another important part of your
diabetes management plan. When you exercise, your
muscles use sugar (glucose) for energy. Regular physical
activity also helps your body use insulin more efficiently.
These factors work together to lower your blood sugar
level. The more strenuous your workout, the longer the
effect lasts. But even light activities — such as
housework, gardening or being on your feet for extended
periods — can improve your blood sugar.
What to do:
 Talk to your doctor about an exercise plan: Ask
your doctor about what type of exercise is appropriate
for you. In general, most adults should get at least 150
minutes a week of moderate aerobic activity. Aim for
about 30 minutes of moderate aerobic activity a day
on most days of the week.
If you've been inactive for a long time, your doctor may
want to check your overall health before advising you.
He or she can recommend the right balance of aerobic
and muscle-strengthening exercise.
 Keep an exercise schedule: Talk to your doctor about
the best time of day for you to exercise so that your
workout routine is coordinated with your meal and
medication schedules.
 Know your numbers: Talk to your doctor about what

blood sugar levels are appropriate for you before you

begin exercise.
 Check your blood sugar level: Check your blood

sugar level before, during and after exercise, especially

if you take insulin or medications that lower blood
sugar. Exercise can lower your blood sugar levels even
up to a day later, especially if the activity is new to you,
or if you're exercising at a more intense level. Be aware
of warning signs of low blood sugar, such as feeling
shaky, weak, tired, hungry, lightheaded, irritable,
anxious or confused.
If you use insulin and your blood sugar level is below 90
milligrams per deciliter (mg/dL), or 5.0 millimoles per
liter (mmol/L), have a small snack before you start
exercising to prevent a low blood sugar level.
  Stay hydrated: Drink plenty of water or other fluids
while exercising because dehydration can affect blood
sugar levels.
 Be prepared: Always have a small snack or glucose

tablets with you during exercise in case your blood

sugar level drops too low. Wear a medical identifica-
tion bracelet.
 Adjust your diabetes treatment plan as needed: If

you take insulin, you may need to reduce your insulin

dose before exercising and monitor your blood sugar
closely for several hours after intense activity as some-
times delayed hypoglycemia can occur. Your doctor can
advise you on appropriate changes in your medication.
You may also need to adjust treatment if you've in-
creased your exercise routine.
Medication
Insulin and other diabetes medications are designed to
lower your blood sugar levels when diet and exercise
alone aren't sufficient for managing diabetes. But the
effectiveness of these medications depends on the timing
and size of the dose. Medications you take for conditions
other than diabetes also can affect your blood sugar
levels.
What to do:
  Store insulin properly: Insulin that's improperly
stored or past its expiration date may not be effective.
Insulin is especially sensitive to extremes in temperat-
ure.
 Report problems to your doctor: If your diabetes

medications cause your blood sugar level to drop too

low or if it's consistently too high, the dosage or timing
may need to be adjusted.
 Be cautious with new medications: If you're consid-

ering an over-the-counter medication or your doctor

prescribes a new drug to treat another condition —
such as high blood pressure or high cholesterol — ask
your doctor or pharmacist if the medication may affect
your blood sugar levels.
Sometimes an alternate medication may be
recommended. Always check with your doctor before
taking any new over-the-counter medication, so you
know how it may impact your blood sugar level.
Illness
When you're sick, your body produces stress-related
hormones that help your body fight the illness, but they
also can raise your blood sugar level. Changes in your
appetite and normal activity also may complicate
diabetes management.
What to do:
 Plan ahead: Work with your health care team to cre-
ate a sick-day plan. Include instructions on what medic-
ations to take, how often to measure your blood sugar
and urine ketone levels, how to adjust your medication
dosages, and when to call your doctor.
 Continue to take your diabetes medication: How-

ever, if you're unable to eat because of nausea or

vomiting, contact your doctor. In these situations, you
may need to adjust your insulin dose or temporarily re-
duce or withhold short-acting insulin or diabetes med-
ication because of a risk of hypoglycemia. However, do
not stop your long-acting insulin. During times of ill-
ness it is important to monitor your blood sugars fre-
quently, and your doctor may instruct you also to check
your urine for the presence of ketones.
 Stick to your diabetes meal plan: If you can, eating

as usual will help you control your blood sugar levels.

Keep a supply of foods that are easy on your stomach,
such as gelatin, crackers, soups and applesauce.
Drink lots of water or other fluids that don't add
calories, such as tea, to make sure you stay hydrated. If
you're taking insulin, you may need to sip sugar-
sweetened beverages, such as juice or a sports drink,
to keep your blood sugar level from dropping too low.
Alcohol
The liver normally releases stored sugar to counteract
falling blood sugar levels. But if your liver is busy
metabolizing alcohol, your blood sugar level may not get
the boost it needs from your liver. Alcohol can result in
low blood sugar shortly after you drink it and for as long
as 24 hours afterward.
What to do:
 Get your doctor's OK to drink alcohol: Alcohol can
aggravate diabetes complications, such as nerve dam-
age and eye disease. But if your diabetes is under con-
trol and your doctor agrees, an occasional alcoholic
drink is fine.
Moderate alcohol consumption is defined as no more
than one drink a day for women of any age and men
over 65 years old and two drinks a day for men under
65. One drink equals a 12-ounce beer, 5 ounces of wine
or 1.5 ounces of distilled spirits.
 Don't drink alcoholic beverages on an empty
stomach: If you take insulin or other diabetes medica-
tions, be sure to eat before you drink, or drink with a
meal to prevent low blood sugar.
 Choose your drinks carefully: Light beer and dry

wines have fewer calories and carbohydrates than do

 other alcoholic drinks. If you prefer mixed drinks, sugar-
free mixers — such as diet soda, diet tonic, club soda or
seltzer — won't raise your blood sugar.
 Tally your calories: Remember to include the calories

from any alcohol you drink in your daily calorie count.

Ask your doctor or dietitian how to incorporate calories
and carbohydrates from alcoholic drinks into your diet
plan.
 Check your blood sugar level before bed: Because

alcohol can lower blood sugar levels long after you've

had your last drink, check your blood sugar level before
you go to sleep. If your blood sugar isn't between 100
and 140 mg/dL (5.6 and 7.8 mmol/L), have a snack be-
fore bed to counter a drop in your blood sugar level.
Menstruation and menopause
Changes in hormone levels the week before and during
menstruation can result in significant fluctuations in
blood sugar levels.
What to do:
 Look for patterns: Keep careful track of your blood
sugar readings from month to month. You may be able
to predict fluctuations related to your menstrual cycle.
 Adjust your diabetes treatment plan as

needed: Your doctor may recommend changes in your

 meal plan, activity level or diabetes medications to
make up for blood sugar variation.
 Check blood sugar more frequently: If you're likely

approaching menopause or experiencing menopause,

talk to your doctor about whether you need to monitor
your blood sugar level more often. Symptoms of meno-
pause can sometimes be confused with symptoms of
low blood sugar, so whenever possible, check your
blood sugar before treating a suspected low to confirm
the low blood sugar level.
Most forms of birth control can be used by women with
diabetes without a problem. However, oral
contraceptives may raise blood sugar levels in some
women.
Stress
If you're stressed, the hormones your body produces in
response to prolonged stress may cause a rise in your
blood sugar level. Additionally, it may be harder to
closely follow your usual diabetes management routine if
you're under a lot of extra pressure.
What to do:
 Look for patterns: Log your stress level on a scale of
1 to 10 each time you log your blood sugar level. A
pattern may soon emerge.
  Take control: Once you know how stress affects your
blood sugar level, fight back. Learn relaxation tech-
niques, prioritize your tasks and set limits. Whenever
possible, avoid common stressors. Exercise can often
help relieve stress and lower your blood sugar level.
 Get help: Learn new strategies for coping with

stress. You may find that working with a psychologist

or clinical social worker can help you identify stressors,
solve stressful problems or learn new coping skills.
The more you know about factors that influence your
blood sugar level, the more you can anticipate
fluctuations — and plan accordingly. If you're having
trouble keeping your blood sugar level in your target
range, ask your diabetes health care team for help.
 Conclusion
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. The goal of this paper is to give a
general idea of the current status of diabetes research.
The author believes that diabetes is one of the highly
demanding research topics of the new century and wants
to encourage new researchers to take up the challenges.