1. DIABETES

2. Introduction :
Diabetes mellitus is a chronic metabolic disorder
characterized by too much glucose in the blood and
urine due to defective insulin action or deficiency in
its secretion.
In diabetes, glucose does not enter body cells, but
accumulates in the blood. After it reaches a certain
limit, it starts appearing in urine. It draws out more
water with it and hence there is excessive urination.
Insulin, a hormone produced by the beta cells of the
Islets of Langerhans of the pancreas helps to utilize
glucose for the production of energy by the body.

3. PREVALENCE
 Diabetes is certain to be one of the most challenging health problems in the 21st
century.
 FAST FACTS OF DIABETES: In America –
29.1 million people or 9.3% of the USA population have diabetes.
DIAGNOSED: 21.0 Million People
UNDIAGNOSED: 8.1 Million people(27.8 % of people with diabetes are under
diagnosed).
 In India: 62 Million indian or 7.1% of india’s adult.
An estimate shows that nearly 1Million Indians die due to Diabetes every year.
The average age on onset is 42.5 years.
 In India , the prevalence rate of diabetes in Gujarat is : 3.9% of the total diabetic
patients.
(by Diabetes Epidemiology Study Group in India, DESI)

4. TYPES:
There are two main types of diabetes.
1. Insulin – dependent diabetes mellitus. (Type – I)
2. Non-insulin dependent diabetes mellitus. (Type – II)
3. Malnutrition related diabetes mellitus (MRDM)
4. Secondary diabetes may result from other hormonal
disorders.
5. Gestational Diabetes

5. 1. Insulin – dependent diabetes (IDDM or Type – I): This type of diabetes usually
affects children or adolescents and is known as juvenile onset diabetes. There is little or no
production of insulin and as a result, such individuals require daily insulin injections. There
is usually a sudden onset. The symptoms get severe, when insulin injections are
discontinued. The diabetic develops a life – threatening metabolic complication referred to
as ketoacidosis
2. Non-insulin dependent diabetes. (NIDDM or Type II): This usually affects
overweight or obese adults and is known as adult onset diabetes. Non insulin dependent
diabetes, develops slowly and is usually milder and more stable.
The insulin production may be normal or even high. However the insulin produced is not as
effective as normal insulin. In subjects with this type of diabetes, diet, exercise or oral anti-diabetic
drugs may be enough to control the raised blood sugar.
3. Malnutrition related diabetes mellitus (MRDM):This type of diabetes is mainly
seen in some tropical countries like India and it occurs in young people between 15 – 30 years
of age. In this type of diabetes, the pancreas fails to produce adequate insulin. As a result,
these diabetics require insulin.

6. In contrast to type 1 diabetics, these patients generally do not develop ketoacidosis, when
insulin injections are discontinued. In this type of diabetes, the pancreas fails to produce
adequate insulin. As a result, these diabetics require insulin.
4. Secondary diabetes may result from other hormonal disorders.
5. Gestational Diabetes: Diabetes developed during pregnancy is described as
gestational diabetes. It occurs in about 1% of pregnant women. Gestational diabetes
increases the diabetes related complications during pregnancy, and also the subsequent
development of diabetes after the delivery.
.

7. PREDISPOSING FACTORS AND
SYMPTOMS:
1.Heredity - The strongest predisposing factor is family history.
Offspring of diabetics have insulin resistance and decreased insulin
sensitivity.
2. Obesity - The chances of developing diabetes in obese
individuals is 3 times higher than in non obese individuals. Waist
circumference expands with increasing body waist. If waist
circumference is greater than 94 cm in women and 80 cm in men,
the person is twice as likely to have more than 2 risk factors.
3. Age and sex - Individuals over 35 years of age have a 2 – 3
fold increase in developing diabetes especially if they are 50%
above desirable weight. The prevalence of diabetes is more in
men in India and more in females in western countries.
4. Under nutrition - Under nutrition impairs b cell function by
increasing the susceptibility of individuals to genetic and
environmental influences.

8. 5. Physical Activity - Lack of physical activity increases
the chance to develop obesity which increases the risk for
developing diabetes. Physically inactive individuals have
a 40% chance of developing diabetes mellitus.
6. Stress - Stress precipitates diabetes in susceptible
individuals. In stress the body releases adrenaline,
noradrenaline, cortisone that raise blood glucose levels
and counteract available insulin.
7. Intake of simple sugars - A high intake of sugar is
associated with a prevalence of obesity and hence
diabetes mellitus. Sugar also depletes chromium which is
essential for regulating blood sugar levels.
8. Alcohol - Short term risk of heavy or continuous
alcohol intake include hypoglycaemia, glucose
intolerance and ketone accumulation.

9. Symptoms :
Many diabetics are not aware that they have the disease.
• Polydipsia (Excessive thirst)
• Polyphagia (Increased appetite especially for sweets)
• Polyuria (frequent urination) and nocturia
• Itching
• Easy tiring, weakness or irritability
• Drowsiness

10. • Slow healing of cuts and wounds
• Frequent infections of the skin, gums and vagina
and pain in the legs, feet, urinary tract or fingers
• Blurred vision
• Hyperglycaemia (elevated blood sugar level)
above 140 mg /100 ml, the normal level being
80-100 mg/100 ml – A deficient supply of
functioning insulin affects the metabolism of
carbohydrates, fats and Proteins. As a
consequence glucose enters the circulation and
hyperglycaemia follows.
• Glycosuria (sugar in the urine)

11. Consequences of lack of Insulin:
Lack of insulin produces four fundamental changes in
carbohydrate metabolism which leads to
hyperglycaemia.
1. Reduced entry and oxidation of glucose in muscle
and other tissues.
2. Decreased formation of glycogen in the liver.
3. Decreased synthesis of fat from carbohydrate.
4. Release of glucose into the blood from the
increased breakdown of glycogen in the liver.

13.  Acute complications
o Hypoglycaemia or insulin shock-. It is defined as a condition in which
there is low level of blood glucose which is less than 45 mg/dl.
o Ketoacidosis- When the body cannot utilise carbohydrates to provide
energy, it burns increased amount of fats and certain amino acids which
result in increased formation of metabolic products known as ketone bodies.
 Long term complications-o
Diabetes retinopathy- Increase the risk of developing cataract and
damage to retina. When blood glucose levels is high, nerve cells are
damaged and there is bursting of nerve cells due to the pressure which
cause a scar and eventually their ability to send proper signals to the whole
body is impaired.
o Heart disease- Affects the blood vessels, blood and the heart. Blood
glucose at elevated concentrations tends to deposit in the artery, and the
liver synthesis more triglycerides for energy production which will be
deposited in the blood vessels and the fatty stuff builds up overtime forming
plague known as atherosclerosis become narrower and hardened thereby
decreasing the delivery of oxygen and nutrients to various cells, tissues and
organs.

14. o Diabetic nephropathy- Diabetes also causes changes in the walls of the small
blood vessels affecting them, that mesh together to act as filters and the kidney
cannot filter efficiently due to rise in blood sugar and they do not get enough
oxygen supply as the blood vessels has been blocked with fatty infiltrations and
kidney eventually will fail.
o Diabetic neuropathy- If the blood supply to the legs is reduced by
atherosclerosis which leads to desensitization of nerve cells and if the blood supply
is greatly reduced or completely cut off, there will be slow healing of wounds
which can be treated only with amputation. Less sensitive to pain or injury can
happen due to poor circulation.
o Hypertension- As blood flows through the body, it puts certain pressure on the
inside walls of the arteries whenever the heart contracts the pressure increases and
when it relaxes it goes down. When blood pressure is high, blood is pushed against
the artery with extra force and the walls becomes hard and thick losing elasticity as
hardening and clogging of the arteries due to atherosclerosis. Many diabetics have
high blood pressure due to the risk factor of atherosclerosis

15. DIAGNOSTIC TESTS:
Diabetes may be present when sugar is present in the urine or when the blood sugar after fasting (12
hours after the last meal) or two hours after meals (post - prandial) is higher than 120 mg / 100ml.
Diagnosis of diabetes is confirmed after an oral glucose tolerance test.
 Oral Glucose Tolerance Test (OGTT):
This test is carried out after 12 hours of over night fasting. Glucose– 75g in adults and 1.75g/kg of
body weight in children is orally administered. Before the glucose load and two hours after it, blood
samples are collected and glucose levels are estimated.
In normal persons without diabetes the fasting sugar levels vary between 80 – 110 mg / 100 ml.
The blood sugar levels increase after the glucose load and come down
to basal level within two hours.
Blood sugar level (mg/dl)
IGT DIABETES
Fasting <120 >120
2 hours after 75 gm glucose load 120- 180 >180

16. Urinary Sugar
Glucose is excreted into the urine when the blood glucose levels are elevated beyond 180 mg / 100
ml. Diabetics lose varying amounts of glucose depending on the severity of disease and the dietary
intake of carbohydrates. The approximate amount of urinary sugar can be easily monitored by the
available diagnostic strips (Uristix). The changes in the colour of the reagent or strip indicate sugar
levels in the urine.
Benedict’s Test
Eight drops of urine and 5 ml of Benedict's solution are taken in a test tube and mixed. The test tube
is kept in boiling water for 5 minutes and colour is noted. It is better to carry out this test on the
second urine sample collected in the morning as urine sugar in this sample will more or
less reflect blood sugar level.
Glycosylated haemoglobin - ( Hb A1c )
As the concentration of glucose in blood rises, more glucose gets attached to haemoglobin (a
pigment present in RBC) and the combined molecule is chemically estimated as glycosylated
haemoglobin. It reflects the general trend of glucose levels in the blood during the previous 2 - 3
months. In normal individuals the glycosylated hemoglobin concentrations vary from 4 - 7% while
in diabetics it is 8 - 18% of the total haemoglobin depending on the blood sugar level.

17. DIETARY MANAGEMENT
Diabetes can be treated by diet alone, or diet and hypoglycaemic
drugs or diet plus insulin depending on the type and severity of
the condition.
The main modes of treatment of diabetes are:
· Diet
· Exercise
· Drugs
· Education

18. Objectives in the management of diabetes are
to:
Reduce the sugar in blood and urine
Maintain ideal body weight
Treat the symptoms
Reduce serum lipids
Provide adequate nutrition
Avoid acute complications

19. Dietary management:
The nutrient content of a diabetic diet has to be planned based on the age, sex, weight, height,
physical activity and physiological needs of the patient. Diet for a diabetic can be planned
using:
1. Food exchange lists:
The diet for a diabetic patient is prescribed in terms of exchange lists. Food exchange lists are
groups of measured foods of the same caloric value and similar protein, fat, carbohydrate and
can be substituted one for another in a meal plan.
The food exchange lists help the patient to restrict the foods intake according to the
insulin prescription so that hyperglycaemia and hypoglycaemia can be prevented and to have
variety in the diet.

20. 2. Glycaemic Index:
The glycaemic index indicates the extent of rise in blood sugar in response to a food in
comparison with the response to an equivalent amount of glucose. The ability of the food
item to raise the blood sugar is measured in terms of glycaemic index.
Glycaemic = Blood glucose area of test food x 100
Index Blood glucose area of reference food
Factors that affect the glycaemic response to food are:
1. Rate of ingestion of food
2. Food form
3. Food components – fat content, fibre content, protein content.
4. Method of cooking and processing food.

21. LOW G.I FOODS (RANGE: 0-54)
Skimmed milk, Apples, Carrot, Orange, Pears, Broccoli,
Cauliflower, Soybean, Oats bran, Whole grain, Onion, Cabbage,
All leafy vegetables, Vermicelli, Whole wheat flour etc.
 MEDIUM G.I FOODS (RANGE: 55-69)
Ice-cream, Papaya, Pineapple, High fibre biscuits, Yam, Sweet
potato, Beetroot, Basmati rice etc.
 HIGH G.I FOODS (RANGE: 70 AND ABOVE)
Pumpkin, White bread, Corn flakes, Water melon, Glucose,
White rice, White potato, Puffed rice, Refined wheat flour etc.

22. Recommended dietary allowances:
Energy: Dietary calories should be 60 – 70 per cent from carbohydrate 15 - 20 per cent from protein and 15 -
25percent from fat.
The recommended calorie intake for a diabetic based on body weight is as follows :
• over weight individual - 20 kcal / kg.wt/day.
• ideal weight - 30 kcal / kg.wt./day.
• underweight - 40 kcal / kg.wt/day.
Carbohydrate: Carbohydrates should constitute 55-60% of calories with emphasis on complex
carbohydrates. In a diabetic, 30 Kcal/kg of ideal body weight is necessary for a person on moderate physical
activity.. The amount of carbohydrate can be conveniently be divided into 4-5 equal parts. One third (33%) of the
diet is served during lunch and another one third (33%) during dinner. Of the remaining one third, 25% can be
served during breakfast and the rest 9% during evening tea or bed time.

23. Protein: It is recommended that 15 – 20% of total calories be derived from proteins. Proteins supply
essential amino acids needed for tissue repair. Proteins do not raise blood sugar during absorption and do not
supply as many calories as fats. One gram of protein per kilogram body weight is adequate.
Fat: Low fat diet increases insulin binding and also reduces LDL and VLDL levels and reduces the incidence
of atherosclerosis which is more common in diabetics. Fat content should be 15 - 25% of total
calories and higher in polyunsaturated fatty acids.
Vitamins and Minerals: These are protective factors which are essential for the body. They are present
in fruits, and vegetables. Salt intake should be between 4-5 g/day as high blood pressure can occur.
Dietary fibre:
Intake of 25g of dietary fibre per 1000 calories is considered optimum for a diabetic. Fibre present in
vegetables, fruits, legumes and fenugreek seed is soluble in nature and more effective in
controlling blood sugar and serum lipid than insoluble fibre present in cereals.
High fibre diets
· Promote weight loss
· Lower insulin requirements
· Decrease serum cholesterol and triglyceride values and lower blood pressure.

24. Foods to be avoided and permitted for a diabetic:
Foods to be avoided Eaten in Moderation Foods permitted
Simple sugars
(glucose, honey,
syrup, sweets, dried
fruits, cake, candy,
fried foods, alcohol,
nuts Jaggery,
sweetened juices
Fats, cereals,
pulses, meat, egg,
nuts roots, fruits,
artificial sweetener.
Green leafy
vegetables,
fruits except banana,
lemon, clear soups,
onion, mint, spices,
salads plain coffee or
tea, skimmed and
butter milk, spices.

25. Other dietary guidelines to be remembered are.
 Timely intake of in between meal snacks should be
stressed to avoid hypoglycaemia.
 Patients should avoid fasting and feasting.
Alcohol , makes a person obese and stimulates appetite.
The diabetic should avoid alcohol.

26. Exercise
Regular exercise should be an integral part of the daily routine
of the diabetic.
1. Metabolic effects : Exercise Increase-a.
Insulin sensitivity
b. Oxidative enzymes
c. Amino acid uptake
d. Storage of glycogen
e. Maximal oxygen uptake
2. Cardio vascular effects -
a. Decrease in triglycerides
b. Increase in HDL – Cholesterol
c. Lower resting Blood pressure
d. Increase in oxygen transport (decreases blood viscosity)
e. Increases stroke volume and increases cardiac output

27. To control diabetes the recommendation is to increase physical
activity, preferably every day for 20 minutes.
Consult your doctor before you start a physical activity program.
Start you program slowly and increase activity level gradually.
You can choose the physical activity that that you like to do.
persons with diabetes should exercise regularly and this include
walking, jogging, swimming, bicycling. But for diabetic patients
which are on insulin before engaging in physical exercise should
seek medical advice to prevent hypoglycaemia which means low
level of glucose.

28. Drugs
•For IDDM patients, they require insulin injections as there is
little or no insulin secretions.
•Oral drugs, in NIDDM the body produces insulin but it is not
very effective in controlling the high blood sugar levels so anti-diabetic
tablets such as sulphonylureas and biguanides are
prescribed so as to improve the action of insulin produced in the
body.

29. Tips for healty cooking
 Cook of boil meat insted of frying.
 Take the skin of chicken before cooking.
 Use less salt and sugar when preparing food.
 Avoid fat.
 Use fresh or frozen fruit and vegetables when eating or in
between meals.
 Use low fat chesse instead of regular chesse.
 Use low fat milk.
 Drink fruit juice instead of powder juice

30.  Fenugreek and its seed (Trigonella foenum-graecum) - Suppresses the urinary excretion of sugar and
relieves symptoms of DM. Seeds are rich source of fibre as it contains mucilaginous fibre and total fibre
to the extent of 20% and 50% respectively. It also contains trigonelline, which is an alkaloid known to
reduce blood sugar level.
 Asian Ginseng- Enhance release of insulin and increase number of insulin receptors.
 Onion (Allium cepa)- Contains APDS (Allyl Propyl Disulphide) which block the breakdown of insulin
by the liver and reducing blood glucose level.
 Cinnamon- It has insulin like ability to decrease blood glucose level, triglycerides and cholesterol.
 Bittergourd (Momordica charantia) - Lowers blood and urine sugar level as studies have indicated
that it contains Polypeptide P which is a insulin like protein and is also known as plant insulin.
 Blond Psyllium (Blond Plantago)- Blond psyllium seed husk orally seems to significantly reduce
postprandial serum glucose, insulin levels, serum total cholesterol and low-density lipoprotein (LDL)
cholesterol levels in patients with Type II diabetes.

31.  Blueberry (Vaccinium myrtillus)- Natural method of controlling or lowering blood sugar levels when
they are slightly elevated - Sugar Diabetes. Results have shown the leaves have an active ingredient with a
remarkable ability to get rid the body of excessive sugar in the blood. .
 Stevia (Sweet Herb)- Stevia is a non-caloric herb, native to Paraguay, which has been used as a
sweetener and flavor enhancer for centuries. Clinical research suggests that stevioside, a constituent of
Stevia, might reduce postprandial glucose levels.
 Banaba (Lagerstroemia speciosa)- Possesses the powerful compound corosolic acid and tannins,
including lagerstroemin that lends itself to the treatment of diabetes. These ingredients are thought to
stimulate glucose uptake and have insulin-like activity. The latter activity is thought to be secondary to
activation of the insulin receptor. It is a natural plant insulin, can be taken orally.

32. MODIFICATION IN LIFESTYLE

33. REFERENCE:
 http://www.webmd.com/diabetes/types-of-diabetes-mellitus
 http://www.webmd.com/diabetes/features/diabetic-diet-6-foods-control-blood-sugar
 http://www.diabetes.co.uk/treatment.html