Module 9

DM in Special groups
(Young, elderly & Pregnancy)
 Objective

• To discuss the basic principles of management of diabetes mellitus in the

young population.
• To discuss the basic principles of management of diabetes mellitus in the
older people.
• To discuss the basic principles of management of diabetes mellitus during
pregnancy.
 DM in the young
• Diabetes mellitus in childhood and adolescence is most often type1 diabetes. But they have the
chance of developing T2DM and other specific types of diabetes.
• Now-a-days T2DM is developing in the young at a very high rate.
• Diagnostic and management issues in this group of population is different from that of adult..

Type1 diabetes is growing by 3% per year in children and

Type1
diabetes

adolescents, and by 5% per year among pre-school

children. Of these type1 diabetic children the highest
number of cases (26%) live in Europe. Finland, Sweden,
Denmark, Norway and the UK have higher incidence rates
for type1 diabetes in children.
Globally, there are close to 500,000 children under the
age of 14 years with type1 diabetes. Every year, 79,000
children under the age of 14 years develop type1 diabetes
 DM in the young
• Diabetes mellitus in childhood and adolescence is most often type1 diabetes. But they have the
chance of developing T2DM and other specific types of diabetes.
• Now-a-days T2DM is developing in the young at a very high rate.
• Diagnostic and management issues in this group of population is different from that of adult..

Type2 diabetes was once seen as a disease of adults. Today,

Type2
diabetes
this type of diabetes is growing at alarming rates in children
and adolescents. In the USA, it is estimated that type2
diabetes represents between 8 and 45% of new-onset diabetes
cases in children depending on geographic location. Over a 20-
year period, type2 diabetes has doubled in children in Japan, so
that it is now more common than type1.
Type2 diabetes in children is becoming a global public health
issue with potentially serious outcomes. Type2 diabetes affects
children in both developed and developing countries. Over half
of children with diabetes develop complications within 15 years
 Screening for diabetes in children
Whom to screening for Diabetes among Children?
All types of DM Children with symptoms of diabetes.
Children wit Risk factor(s) of DM
 Obesity (BMI > 85th percentile for age & sex.
 Family history of T2DM
 Mother was DM/GDM during the child's gestation
T2DM
 Ethnic susceptibility.
 Features of Insulin resistance: Example Anacthosisnigricance,
hypertension, dyslipidemia, polycystic ovarian syndrome
(PCOS), low birth weight.
 Screening for diabetes in children
Some points on screening for DM in children
 Diabetes in children usually presents with classical symptoms. Fasting blood
glucose (FBG) or a random blood sugar (RBS) are often suffice to level them
as diabetic. OGTT should be avoided because that may result in very high
blood gulose after glucose load.
 Children with obesity plus 2 other risk factor should be screened at the age
10 years or at onset of puberty.
 If normal than once in every 3 years.
 In many tropical countries, including Bangladesh, there is a substantial
number of young lean diabetic cases with or without pancreatic calcification
that are assigned as specific type diabetes; previously they were called
'Malnutrion Realated Diabetes Mellitus' (MRDM).
 Principles of diabetes management in
childhood
Management of the diabetes in children needs special skill in this field.
Three fundamental components/domines of DM management in children

Diabetic Medical Drugs.

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1

Education 2 Nutrition
(DE), Therapy
(MNT)
They do not differ much from those of adults. However, they mostly need
insulin because they are either of type1 DM or of other types with severe insulin
deficiency.
 Principles of diabetes management in
childhood
• Targets of diabetes management in the young (based on ISPAD guideline).
• Targets are of three dominoes-

1. 3.
2.
Glycemic Targets of
Targets of
Targets Diabetic
Growth
Education

1. Glycemic Targets
Pre-meal (Fasting) Post-meal Bed time Hypoglycemia HbA1c%
5.0 - 8.0 5.0 - 10.0 6.7 - 10.0 No < 7.5
Targets of 2. Growth and 3. Diabetic Education
2.Growth Within +/- 2.5 SD of Growth Chart
Teaching, training, and empowerment to take part in treatment such as SMBG & insulin
3. DE
administration.
Medical nutrition therapy (MNT) of DM in
Children
A meal plan is based on the individual’s usual food intake, insulin therapy,
exercise patterns etc.

Timing and amount of food will depend on type of insulin, physical activity,
lifestyle and results of blood glucose monitoring.

All children with diabetes should be referred to a dietitian for counseling at diagnosis of
diabetes and also subsequently if they have problem with their diet adjustment.
Age-specific calorie calculating charts are available for measuring diet allowance.
 Drugs of DM in Children
Drugs of DM in children on the basis of type & age

• Insulin only • Insulin only • Insulin or • Insulin or

metformin metformin or
other agents

T1DM T2DM T2DM T2DM

(any age) (< 10 years) (10 - 19 years) (>18 years)
 Diabetes education for Yong Diabetic

Diabetes education is
fundamental in treatment
of young diabetics.
Diabetes education needs
to be a continuous process
and repeated for it to be Providing emotional
effective. support is very important.

They are to be trained to Diabetes education

develop skill in all aspects according to age group
of diabetes, especially
insulin injection technique,
dietary practice, home
monitoring of blood
glucose etc.
 Diabetes education for Yong Diabetic

• They are totally dependent on parents • Taught insulin injections and blood • Independent, responsible self-
and care providers for injections, food glucose monitoring. Trained on management appropriate to the level
and monitoring. Advised to stop or recognizing hypoglycemic symptoms of maturity and understanding should
minimize erratic eating and activity. and understanding self management. be promoted. Strategies to manage
Educated on prevention, recognition Taught to adapt to school programs, transition to adulthood and progressive
and management of acute school meals, exercise and sports. hand-over of responsibility are to be
complications, specially hypoglycemia, Teacher/ school authority should be developed
because it is very common involved. The parents are advised on
complication in this age group the gradual development of the child’s
independence.

Infants and School going

Adolescents
toddlers children
 Sports and exercise of young diabetics.
Children with type1 diabetes with good
blood glucose control can do all levels of
exercise, including leisure activities, Extra attention and support of parents,
recreational sports, and competitive teachers, school attendants and trainers
professional performance. may be necessary

Exercise is more important for young type2

diabetic, specially who are obese. The
emphasis must be on adjusting the
therapeutic regimen with the level of
exercise and diet, and avoiding
hypoglycemia.

Sport and exercise according to age group

3-5 years may take part in free play, walking, running etc.
6-9 years may start learning to play team sports such as football, cricket etc.
above 10 years may be able to take part in all complex sports, like basketball, football, tennis, hockey etc.
 Hypertension in the young with DM

Hypertension in childhood Treatment of high-normal Drug treatment should be

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2
is defined as systolic or blood pressure is given started as soon as
diastolic blood pressure> through lifestyle measures. hypertension is confirmed.
95th percentile for age, sex If target blood pressure is ACE inhibitor is the
and height. ‘High-normal’ not reached within 3-6 preferred agent. The goal
blood pressure is defined months, pharmacologic of treatment is a blood
as systolic or diastolic treatment should be pressure consistently
blood pressure >90th but initiated <90th percentile for age,
<95th percentile for age, sex and height, whichever
sex and height. Elevated is lower
BP should be confirm on 3
separate days.
 Dyslipidemia in the young with DM

If there is a family history of If family history is not of After the age of 10 years,

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2
hypercholesterolemia, or a concern, then the first lipid statin is recommended in
cardiovascular event before, or screening should be patients who do not reach
if family history is unknown, performed at puberty or 10 target with lifestyle changes.
then a fasting lipid profile years of age. If lipids are The goal of therapy is an LDL
should be performed in abnormal, annual monitoring cholesterol value <100 mg/dl.
children (not before 2 years of is recommended. If LDL
age) soon after diagnosis of cholesterol values are within
DM (after diabetes control). the accepted risk levels (<100
mg/dl), a lipid profile should be
repeated every 5 years. Initial
therapy includes blood glucose
control and MNT.
 DM in the older people
The definition of old age is arbitrary. 60 years may be taken as beginning of old age. People over 60
years of age form about 15% of total population globally. Among total diabetics of the world, 60-year
group constitutes about 35%. And among total population over 65 years of age, 25% are diabetics. So
they are putting a great impact on general as well as in diabetic populations

Health Status of Older people

Apparently Good Health Intermediate Health Poor Health
life expectancy More Intermediate Less
Physical/mental fitness More Intermediate Less
Indendance More Intermediate Less
Management Less relaxed Intermediate More relaxed
 DM in the older people
 Management of DM in old people depends on their health status determined by life expectancy,
physical & mental fitness and intendance.
 Those in good health-all general recommendations apply. Intermediate/poor health-testing should be
done when clinically indicated, by simpler procedures, e.g. RPG, FPG or HbA1c.

Treatment goals are set according to Health Status

Health Status Pre-meals (Fasting) (mmol/L) HbA1c%
Good 7.2 < 7.5
Intermediate 8.3 <8.0
Poor 10.0 <8.5

Contribution of PPBG at all HbA1c levels is higher compared to FBG in older people
 MNT and Physical activity in Older people
Points to consider for Points to consider for
MNT Physical activity
• Swallowing or eating difficulties may be present. • Older people are encouraged to be active as
condition allows, from regular exercise to simple
• Adequate fluid is to be ensured to avoid home-based mobility.
dehydration. • Risk assessment should be done before
recommending activity.
• Malnutrition or weight loss should be taken care.
• Risk of injury with fall and hypoglycemia is to be
• Tube feeding or parenteral nutrition may be considered.
needed in some. • Physical (physio )therapy may be needed for
some.
 Drug treatment of DM in Older people
Key points for drug treatment

1. ‘Start low, go slow’, applicable to most medications.

2. Agents which preferentially lower postprandial hyperglycemia may be more effective in achieving glycemic goals without increasing the risk of fasting
hypoglycemia.
3. Swallowing difficulty may limit oral drug intake.
4. Metformin is first-line therapy. (FDA puts strong caution in 80+ population). Metformin may cause unintended weight loss and higher gastrointestinal side-effects.
5. DPP-4 inhibitor/GLP-1 agonist may also be considered.
6. Glibenclamide has the highest risk of hypoglycemia; gliclazide has the lowest. Glibenclamide should be avoided.
7. Glinides and AGI may be considered in postprandial hyperglycemia, Glinides are also useful in erratic eating habits.
8. Insulin may provide anabolic benefit in frail ones. Long acting insulin analogue is safe and efficacious in older people.
9. Rapid/short acting insulin targets post-prandial blood glucose better.
10. Visual, motor and cognitive impairments may hamper insulin injection. Insulin pen devices can simplify administration.
11. Complex regimens should be avoided to reduce errors
 Acute emergencies of DM in Older people
• Hypoglycemia and sick day management plan should be strengthened.
• Older people are more prone to hypoglycemia. BG <6.0 mmol/L is to be avoided.
• HbA1c <7.0% should be taken as warning of possible over treatment.

Causes of Hypoglycemia in elderly people with DM

Polyphamacy
Erratic meals and unusual activity
Renal, hepatic impairment
Malabsorption, swallowing problems
Deffective counter regulatory system,antecedent/unware hypoglycemia
Congnative impairment, less expression of symptoms,
Like hypoglycemia, timely recognition and management of hyperglycemic emergencies (DKA, HHS) in older people
must be ensured.
 Co-morbidities of DM in Older people

• Several comorbid conditions are usually present in older people along with
complications of diabetes.
• There may be cognitive impairment, falls, pain, arthritis, fractures, hearing
impairment, functional disability, urinary incontinence, obesity, stroke, CHF,
periodontal disease, cancer, depression, hypertension, dyslipidemia etc. All
these should be addressed as much as possible.
 Hyperglycemia (DM) and Pregnancy

• Hyperglycemia and GDM

• Hyperglycemia during Pregnancy may be one of the 2 types- a. GDM and b. pre-
pregnancy glucose intolerance/DM. Pregnancy with hyperglycemia is a high risk
health staus.
• Care must be given with an aim to make pregnancy as safe as in a non-diabetic
state for both the expectant mother and the baby.
• Such a goal is feasible if blood glucose can be maintained to a non-diabetic level
throughout the pregnancy.
 Hyperglycemia (DM) and Pregnancy

Some key points

1. Diabetes in pregnancy has associations with acute as well as chronic maternal and foetal
complications.
2. Good diabetic control throughout pregnancy as well as improved neonatal management
has lead to a reduction in the incidence of morbidity and mortality associated with
pregnancy in diabetic women.
3. Spontaneous abortions and congenital anomalies are seen much less when good diabetic
control has been established prior to conception and maintained during the first 6-8 weeks
of pregnancy.
4. Multidisciplinary preconception care improves the outcome of pregnancy in terms of both
the mother and the baby.
 DM and pregnancy: Forms & problems
Two forms of diabetes during Pregnancy

Pre-pregnancy diabetes Gestational diabetes

mellitus: mellitus (GDM):
Woman is a known Glucose intolerance is
diabetic before she detected first time
becomes pregnant.
after the woman
becomes pregnant.

Diabetes during pregnancy is mostly due to GDM. Recent global prevalence of hyperglycemia in pregnancy
(both pre-pregnancy and GDM) is about 17% of live births; 84% of those are due to GDM. Pre-pregnancy
diabetes mellitus: Woman is a known diabetic before she becomes pregnant.
 Problems of pregnancy in diabetes in the
mother

• Pregnancy loss- abortion/ intrauterine death

• Pre-eclampsia, eclampsia, polyhydramnios.
• Difficulty in diabetes control
• Deterioration of pre-existing complications, e.g. retinopathy, nephropathy
Problems of pregnancy in diabetes in the Baby

• Macrosomia [birth weight above 4500 grams (some prefer 4000 grams as cut-off), or above 90th percentile
for gestational age] caused by chronic maternal hyperglycemia causing fetal hyper-insulinism that results in
excessive fat deposition and organomegaly. It affects 15-45% pregnancies.
• Intra-uterine growth retardation. Neonatal hypoglycemia due to sudden withdrawal of maternal glucose at
birth in presence of fetal hyper-insulinism. It affects 25-40% pregnancies.
• Polycythemia and hyperbilirubinemia partly due to response to relative hypoxia in utero.
• Neonatal hypocalcemia due to functional hypoparathyroidism.
• Respiratory distress syndrome due to delayed maturation of the enzyme machinery for synthesis of lung
phospholipids.
• Congenital malformations (2-6 times higher than non-diabetic pregnancies; these are much higher for
some particular malformations), e.g. cardiac or renal anomaly, caudal regression, CNS defects etc
 Pre-pregnancy diabetes
Pregnancy in all women with known diabetes must be pre planned.
Diabetic women of child bearing age and desirous of pregnancy, must be thoroughly counseled
Pre-conception counseling must
include intensive education about: Pre-conception treatment of DM
• Importance of tight glycemic control before • Oral anti-diabetic agents (also other non-insulin
injectable agents) must be discontinued.
and during pregnancy
• The women are managed with lifestyle modification and
• Medical nutrition therapy, physical activity insulin (if necessary) to achieve tight metabolic control,
which is defined by HbA1c and blood glucose values.
• Skill on insulin injection techniques, home
• At all times blood glucose should be within the target.
monitoring of blood glucose
• Pregnancy should be postponed until treated for
• Need for close and regular follow-up. complications of diabetes or any associated illnesses
prior to pregnancy.
 Gestational diabetes mellitus (GDM)
Any degree of glucose intolerance with onset or detection for the first time during pregnancy is
called GDM. Placental hormones are responsible for the development of GDM.

Risk Factor for GDM

1. BMI> 23 kg/m2
2. Age> 25 years
3. First degree relative with DM
Bad Obstetric History (BOH) such as delivered baby Large for Gestational age- LGA ( >9lb/4 kg at term delivery) or
4.
Small for Gestational age SGA ( < 5.5lb/2.5 kg at term delivery) , abortion, stillbirth or difficulty to conceive.
5. Previous history of GDM, A1C ≥5.7%, IGT or IFG, physical inactivity,
6. Others: Hypertension, HDL < 35 mg/dl and or TG >250 mg/dl, PCOS, Acanthosisnigricans, history of CVD.
 Schedule of screening for GDM

At 1st prenatal During 24- During 34-

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2
visit: If there is one 28th weeks of 36th weeks of
or more risk gestation: In all gestation: for
factors of DM (or pregnancies negative cases
Mother wants to (Mandatory). during 24-28
know her status). weeks of gestation
and there is one or
more risk factors of
DM (Optional).
 Diagnosis of GDM
OGTT with 75 gms of glucose drink and 3 sample ( Fasting, 1 hour & 2 hour) glucose assay is the standard
test. One or more value above is cut off is considered positive. Currently cases are either leveled as GDM
or over DM as per cut off shown in the table bellow. RBS and HbA1c are also used for diagnosis of GDM.
Diagnosis of GDM/overt DM (based on ADPSG ADA & WHO criteria)
Variables Value Diagnosis
FBG <5.1 mmol/L normal
FBG 5.1 - <7.0 mmol/L GDM
FBG >7.0 mmol/L overt DM
1 hr. PG (75 gm OGTT) <10.0 mmol/L Normal
1 hr. PG (75 gm OGTT) >10.0 mmol/L GDM
1 hr. PG (75 gm OGTT) No specific value overt DM
2 hr. PG (75 gm OGTT) <8.5 mmol/L Normal
2 hr. PG (75 gm OGTT) 8.5 - <11.1 mmol/L GDM
2 hr. PG (75 gm OGTT) >11.1 mmol/L overt DM
RBS (with symptomps of hyperglycemia) No specific value GDM
RBS (with symptomps of hyperglycemia) >11.1 mmol/L overt DM
HbA1c% No specific value GDM
HbA1c% >6.5% overt DM
 Targets of diabetes management during
pregnancy (based on ADA guideline)
 Fasting/pre-meal <5.3 mmol/L
Blood (plasma)
 1 hour post-meal <7.8 mmol/L
glucose
Glycemic Targets  2 hour post-meal <6.7 mmol/L
HbA1c < 6.0% (once in each trimester)
Hypoglycemia No
 Systolic 110 - 129 mm of Hg
Blood Pressure
 Diastolic 65 - 79 mm of Hg
10 - 15 kg( for person with normal weight & single
Weight gain
tone pregnancy)
Mother (& family Teaching, training & empowerment to take part in
Diabetic Education
member) management (SMBG & insulin injection)
 Check up schedule of diabetic pregnancy
(both pre-pregnancy diabetes and GDM)
once every two weeks up to 30th gestational week and thereafter once
Follow up at clinic
every week.
Treatment schedule
Team care Office treatment should comprise of a team of specialists
Diabetologists, obstetricians and nutritionists.
 Retinal and renal assessment 1st visit
check-up in addition  Detailed ultrasound (anomaly scan) - 20th week Ultrasound
Important antenatal
to SMBG audit monitoring of fetal growth and amniotic fluid volume- 28th week
check-up
 Tests of fetal well-being - 38th week.
(Some of these are repeated periodically)
 Lifestyle (MNT and Physical activity)

Calorie Daily total calories intake is to be 30 kcal/kg of ideal body weight in first trimester and 38 kcal/kg
requirement of ideal body weight thereafter.
Calorie
Carbohydrate 50-60%, fat 30%, protein 10-20% (may be increased in exchange of carbohydrate).
distribution
MNT Nutrient
Adequate supplementation of iron, folic acid and calcium.
supplements
 Major Meals: Breakfast, lunch, dinner.
 Snacks: Mid-morning, mid-afternoon and bedtime.
Meal pan
(Bedtime snack is essential to prevent fasting ketonuria).
Physical
Moderate physical activity should be encouraged
activity
 Drug therapy

Insulin is the only drug recommended for use in pregnancy

Insulin therapy should be instituted if dietary compliance fails to maintain glycemic target or blood glucose is much higher.
In pre-pregnancy diabetes shift from OAD to insulin when pregnancy is planned.
Insulin Insulin is started at a dose of 0.2-0.5 u/kg day. Human short and intermediate acting insulins, and insulin analogues aspart,
lispro and detemir are recommended during pregnancy.
Dose requirement will show increasing trend with duration of pregnancy ,specially in mid-pregnancy. Multiple dose insulin
therapy can better attain target of blood glucose levels.
SMBG SMBG is required to maintain tight glycemic control.
 Delivery
Timing and mode delivery
Term vaginal delivery is feasible in most diabetic pregnancies by meticulous control of diabetes
Term vaginal
modern obstetric technology, monitoring of fetal well-being (by studying fetal heart rate) and lung
delivery maturity (by testing amniotic fluid).
Delivery
Delivery may be considered earlier in presence of unfavourable conditions, e.g. uncontrolled diabetes,
considered
hypertension, chronic diabetic complications, pre-eclampsia, foetal growth retardation, etc.
earlier
Caesarean
Caesarean section is usually required if the foetal weight > 4.5 kg.
section
 Diabetes management during labor and
delivery

Blood glucose should be between 4-5.5 mmol/L in order to prevent neonatal hypoglycemia. It is best achieved by continuous
During
glucose-insulin infusion, because it is essential to meet the energy expenditure of active labour. Blood glucose should be
delivery monitored hourly.
The infusion is stopped immediately after the delivery of the baby. During this time regular insulin in small dose is given
After
before meals in pre-pregnancy diabetics; pre-pregnancy regular schedule of insulin may be started when the condition is
delivery fully stable.
After In almost all GDM cases insulin is not at all required after delivery; they become euglycemic. There is about 65% chance of
delivery developing GDM in subsequent pregnancy. In all GDM cases OGTT should be done 6-12 weeks after delivery; if it is normal,
GDM OGTT should be repeated every 3-year, as these group of individuals are at high risk of future diabetes (50% in 10 years).
 Hypoglycemia in Newborn
Risk All newborns of diabetic mothers have risk to develop hypoglycemia.
Blood glucose levels must be checked by heel prick within 30-60 minutes of
Check up birth and continued at regular intervals until one is sure that there is no risk for
hypoglycemia.
Definition Neonatal hypoglycemia is defined as blood glucose level less than 40 mg/dl.
If the glucometer readings are between 25 and 40 mg/dl, 10-15 ml of 10%
glucose is given orally; repeated if necessary and feeding is started as soon as
possible.
If the glucometer readings are less than 25 mg/dl, intravenous 10% dextrose at
Treatment the rate of 6 mg/kg/minute is started. Bolus doses are to be avoided as this may
stimulate the already overactive pancreas to secrete more insulin and add to
the problem.
Blood glucose monitoring is continued until the danger of hypoglycemia is
completely over, usually in 24 hours; sometimes it may take 72 hours.
Stay home and Stay Safe

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