Assignment

on
Diabetes

SUBMITTED TO

Mohammad Injamul Hoq

Department of Public Health
Program: Master of Public Health (Autumn 2020)
University of Creative Technology Chittagong

SUBMITTED BY

Mohammad Abdul Sukkur

ID-200722013
Program: Master of Public Health (Autumn 2020)
Department of Public Health
University of Creative Technology Chittagong

Date of Submission: 21/09/2020

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 Table of Contents
Particulars Pages
1.Introduction 03
2. Global Facts 03
3. Bangladesh Perspectives 04
4. Symptom of the Disease 05
5. Development of the Disease 06
6. Stage 07
7. Risk Factors 07
8. Diagnosis 09
9. Control & Prevention Strategies 12
10. Management 13
11. Treatment 15
12. Conclusion 19

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1. Introduction
Diabetes mellitus, commonly known as diabetes, is a metabolic disease that causes high
blood sugar. The hormone insulin moves sugar from the blood into your cells to be stored or
used for energy. With diabetes, body either doesn’t make enough insulin or can’t effectively
use the insulin it does make. Untreated high blood sugar from diabetes can damage your
nerves, eyes, kidneys, and other organs.
There are a few different types of diabetes:
 Type 1 diabetes is an autoimmune disease. The immune system attacks and destroys
cells in the pancreas, where insulin is made. It’s unclear what causes this attack.
About 10 percent of people with diabetes have this type.
 Type 2 diabetes occurs when your body becomes resistant to insulin, and sugar builds
up in your blood.
 Prediabetes occurs when your blood sugar is higher than normal, but it’s not high
enough for a diagnosis of type 2 diabetes.
 Gestational diabetes is high blood sugar during pregnancy. Insulin-blocking
hormones produced by the placenta cause this type of diabetes.
A rare condition called diabetes insipid us is not related to diabetes mellitus, although it has a
similar name. It’s a different condition in which your kidneys remove too much fluid from
your body. Each type of diabetes has unique symptoms, causes, and treatments. Learn more
about how these types differ from one another.

2. Global Facts
Diabetes is a chronic, metabolic disease characterized by elevated levels of blood glucose (or
blood sugar), which leads over time to serious damage to the heart, blood vessels, eyes,
kidneys and nerves. The most common is type 2 diabetes, usually in adults, which occurs
when the body becomes resistant to insulin or doesn't make enough insulin. In the past three
decades the prevalence of type 2 diabetes has risen dramatically in countries of all income
levels. Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a
chronic condition in which the pancreas produces little or no insulin by itself. For people
living with diabetes, access to affordable treatment, including insulin, is critical to their
survival. There is a globally agreed target to halt the rise in diabetes and obesity by 2025. 
About 422 million people worldwide have diabetes, the majority living in low-and middle-
income countries, and 1.6 million deaths are directly attributed to diabetes each year. Both

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the number of cases and the prevalence of diabetes have been steadily increasing over the
past few decades.

3. Bangladesh Perspectives
Bangladesh is a developing country where 75% of total population lives in rural area.
Subsequently they have poor healthcare access as 26% of rural professionals remain vacant
and nearly 40%, absent. Although official documents indicate that 80% of the population has
access to affordable essential drugs, there is plenty of evidence of a scarcity of essential
drugs in government healthcare facilities. Nearly 45% rural people take medical assessment
from unqualified health workers including medical assistants, mid-wives, village doctors,
community health workers in comparison to that by qualified medical graduates (only 10%-
20%). More than 75% women having complications sought treatment from an unqualified
provider. These are mostly because concern over medical costs, and pronounced
socioeconomic disparities found for care-seeking behavior in both urban and rural
Bangladesh. However, the government’s expenditure on health is the third largest in the
country, after education and defense. Diabetes is a complicated chronic disease; non-
compliant patients are in a risk of moderate to severe complications, to much extent
unexplored to maximum people of Bangladesh. Annually diabetes is responsible for 5% of
all deaths globally, and its prevalence is increasing steadily. As reported by International
Diabetes Federation (IDF), approximately 75–80% of people with diabetes die due to
cardiovascular complications. Diabetes is one of the four major types of no communicable
diseases (NCDs) that make the largest contribution to morbidity and mortality worldwide.
According to WHO global health days 2016, about 422 million people globally had diabetes,
with most living in the developing countries, and unfortunately, more than 80% of diabetes
deaths occur in low- and middle-income countries. And 80% of people with diabetes live in
low- and middle-income countries. The prevalence of diabetes is increasing in Bangladesh in
both urban and rural areas. A recent scoping review (1994-2013) revealed that the prevalence
of type 2 diabetes varied from 4.5% to 35.0% in Bangladesh. It increases healthcare use and
expenditure and imposes a huge economic burden on the healthcare systems. The
International Diabetes Federation estimated 7.1 million people with diabetes in Bangladesh
and almost an equal number with undetected diabetes. This number is estimated to double by
2025. It may lead to stroke, heart attack, chronic kidney diseases, neuropathy, visual
impairment and amputations. Although most of these complications can largely be prevented
through inexpensive, easy-to-use and cost-effective interventions. During 90s, the country

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has a relatively low diabetes affected population. According to the International Diabetes
Federation, the prevalence will be 13% by 2030. Bangladesh was ranked as the 8th highest
diabetic populous country in the time period of 2010-2011. About 129,000 deaths were
attributed to diabetes in Bangladesh in 2015, as reported by leading research organization
ICDDR, B.

4. Symptom of the Disease

Diabetes symptoms are caused by rising blood sugar.
General symptoms
The general symptoms of diabetes include:
 increased hunger
 increased thirst
 weight loss
 frequent urination
 blurry vision
 extreme fatigue
 sores that don’t heal
Symptoms in men
In addition to the general symptoms of diabetes, men with diabetes may have a decreased sex
drive, erectile dysfunction (ED), and poor muscle strength.
Symptoms in women with diabetes can also have symptoms such as urinary tract infections,
yeast infections, and dry, itchy skin.
Type 1 diabetes
Symptoms of type 1 diabetes can include:
 extreme hunger
 increased thirst
 unintentional weight loss
 frequent urination
 blurry vision
 tiredness
It may also result in mood changes.
Type 2 diabetes
Symptoms of type 2 diabetes can include:

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  increased hunger
 increased thirst
 increased urination
 blurry vision
 tiredness
 sores that are slow to heal
It may also cause recurring infections. This is because elevated glucose levels make it harder
for the body to heal. Gestational diabetes Most women with gestational diabetes don’t have
any symptoms. The condition is often detected during a routine blood sugar test or oral
glucose tolerance test that is usually performed between the 24th and 28th weeks of
gestation. In rare cases, a woman with gestational diabetes will also experience increased
thirst or urination. The bottom line Diabetes symptoms can be so mild that they’re hard to
spot at first. Learn which signs should prompt a trip to the doctor.

5. Development of the Diabetes

Family and community can significantly be affected by patients’ failure to properly adhere to
glycemic control. A study has found that compliance to treatment was significantly improved
when patients were surrounded by supporting friends and family members who provided
self0esteem, and decreased stress of patients. This was also associated with significant
decrease of depression among patients. On the other hand, some studies have found
completely opposite findings, and reported that social support can negatively impact the
ability to live and deal with the disease. Generally, the nature of social support impact on the
disease is has essential consequences and needs to be properly studied.
Social support has been suggested by most researchers to be a significant component of
health care and management. Close friends and family members are the most important
providers of this support. Moreover, adolescents with type I diabetes have been found to
mostly benefit from social support that resulted in better compliance with treatment and
lifestyle modifications. An RCT on adolescent diabetics found that behavioral therapy with
the assistance of families significantly improved the relationship of the patient with the
family and positively impacted communication, but had no effects on compliance and
glycemic control.
On the other hand, several researchers have been interested in studying the negative effects
of social support on patients. These effects include the feeling of criticism or even guilt by
patients. Moreover, social support can become a barrier in self-management. It is also

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difficult when family members want different things than what is required to control the
patient’s disease, for example, not all family members agree to stick to a healthy diet, making
it harder for the patient to stick with the disease. Such problems are considered significant
limitations that turn social surroundings into sources of stress that will negatively influence
the disease.

6. Stage
Two leading US diabetes groups have issued a joint position statement revealing the four
stages of type 2 diabetes. The model emphasises the importance of type 2 diabetes prevention
during the first phase, when signs of insulin resistance begin to emerge.The American
Association of Clinical Endocrinologists (AACE) and the American College of
Endocrinology (ACE) combed through clinical evidence and research to come up with the
four phases. They developed a model which they call “dysglycemia-based chronic disease”
or DBCD. Dysglycemia is a broad term referring an abnormality in blood glucose levels. The
position statement also includes recommendations to reduce people’s risk of developing type
2 diabetes, with a focus on diet and exercise. The statement’s four stages of type 2 diabetes
are insulin resistance, prediabetes, type 2 diabetes and type 2 diabetes and vascular
complications, including retinopathy, nephropathy or neuropathy and, or, related
microvascular events. Professor Jeffrey Mechanick from Icahn School of Medicine at Mount
Sinai, who has previously been a president of AACE as well as the ACE, said: “We’re not
getting rid of the term type 2 diabetes. We’re viewing type 2 diabetes, cardiovascular disease
and also prediabetes and insulin resistance, all as one framework, which we’re calling
dysglycemia-based chronic disease.” Prof Mechanick said the position statement highlighted
the importance of prediabetes as part of an “expanding the framework for type 2 diabetes”.
He added: “When you view prediabetes in that kind of continuum, then it has a lot of
importance. The context for the importance is a preventive care model. Rather than waiting
for a patient to evolve through this continuum, all the way to morbid forms of type 2 diabetes
where tertiary prevention would be implemented, which is costly, wouldn’t it make sense to
intervene earlier?” The model can be viewed here.
Editor’s note: Type 2 diabetes prevention is indeed important in lowering health risks for at-
risk people, and our Low Carb Program is helping people with prediabetes lose weight,
reduce their HbA1c and avoid developing type 2 diabetes. Earlier this year, the Low Carb

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Program’s one-year health outcomes were published in the Journal of Medical Internet
Research.

7. Risk Factors
Chances of developing type 2 diabetes depend on a combination of risk factors such as genes
and lifestyle. Although you can’t change risk factors such as family history, age, or ethnicity,
you can change lifestyle risk factors around eating, physical activity, and weight. These
lifestyle changes can affect your chances of developing type 2 diabetes. Read about risk
factors for type 2 diabetes below and see which ones apply. Taking action on the factors you
can change can help you delay or prevent type 2 diabetes.
 are overweight or obese
 are age 45 or older
 have a family history of diabetes
 are African American, Alaska Native, American Indian, Asian American,
Hispanic/Latino, Native Hawaiian, or Pacific Islander
 have high blood pressure
 have a low level of HDL (“good”) cholesterol, or a high level of triglycerides
 have a history of gestational diabetes or gave birth to a baby weighing 9 pounds or
more
 are not physically active
 have a history of heart disease or stroke
 have depression NIH external link
 have polycystic ovary syndrome NIH external link, also called PCOS
 have acanthosis nigricans—dark, thick, and velvety skin around neck or armpits
Can also take the Diabetes Risk Test to learn about risk for type 2 diabetes.
To see if weight puts at risk for type 2 diabetes, find height in the Body Mass Index (BMI)
charts below. If weight is equal to or more than the weight listed, have a greater chance of
developing the disease.
If you are not Asian American
If are Asian American If are Pacific Islander
or Pacific Islander
 At-risk BMI ≥ 25  At-risk BMI ≥ 23  At-risk BMI ≥ 26
Height Weight Height Weight Height Weight
 4'10" 119  4'10" 110  4'10" 124
 4'11" 124  4'11" 114  4'11" 128
 5'0" 128  5'0" 118  5'0" 133

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If you are not Asian American
If are Asian American If are Pacific Islander
or Pacific Islander
 At-risk BMI ≥ 25  At-risk BMI ≥ 23  At-risk BMI ≥ 26
Height Weight Height Weight Height Weight
 5'1" 132  5'1" 122  5'1" 137
 5'2" 136  5'2" 126  5'2" 142
 5'3" 141  5'3" 130  5'3" 146
 5'4" 145  5'4" 134  5'4" 151
 5'5"  150  5'5" 138  5'5" 156
 5'6" 155  5'6" 142  5'6" 161
 5'7" 159  5'7" 146  5'7" 166
 5'8" 164  5'8" 151  5'8" 171
 5'9"  169  5'9" 155  5'9" 176
 5'10"  174  5'10" 160  5'10" 181
 5'11"  179  5'11" 165  5'11" 186
 6'0"  184  6'0" 169  6'0" 191
 6'1"  189  6'1" 174  6'1" 197
 6'2"  194  6'2" 179  6'2" 202
 6'3"  200  6'3" 184  6'3" 208
 6'4"  205  6'4" 189 6'4" 213

8. Diagnosis
Diagnosis

There are several ways to diagnose diabetes. Each way usually needs to be repeated on a
second day to diagnose diabetes. Testing should be carried out in a health care setting (such
as doctor’s office or a lab). If doctor determines that blood sugar level is very high, or if have
classic symptoms of high blood sugar in addition to one positive test, doctor may not require
a second test to diagnose diabetes.

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A1C
The A1C test measures your average blood sugar for the past 2 to 3 months. The advantages
of being diagnosed this way are that don't have to fast or drink anything.
 Diabetes is diagnosed at an A1C of greater than or equal to 6.5%

Result A1C
Normal less than 5.7%
Prediabetes 5.7% to 6.4%
Diabetes 6.5% or higher
FASTING PLASMA GLUCOSE (FPG)
This test checks your fasting blood sugar levels. Fasting means after not having anything to
eat or drink (except water) for at least 8 hours before the test. This test is usually done first
thing in the morning, before breakfast.
 Diabetes is diagnosed at fasting blood sugar of greater than or equal to 126 mg/dl

Result Fasting Plasma Glucose (FPG)

Normal less than 100 mg/dl
Prediabetes 100 mg/dl to 125 mg/dl
Diabetes 126 mg/dl or higher
ORAL GLUCOSE TOLERANCE TEST (ALSO CALLED THE OGTT)
The OGTT is a two-hour test that checks your blood sugar levels before and 2 hours after
you drink a special sweet drink. It tells the doctor how your body processes sugar.
 Diabetes is diagnosed at 2 hour blood sugar of greater than or equal to 200 mg/dl
Result  Oral Glucose Tolerance Test (OGTT)
Normal  less than 140 mg/dl
Prediabetes  140 mg/dl to 199 mg/dl
Diabetes  200 mg/dl or higher
RANDOM (ALSO CALLED CASUAL) PLASMA GLUCOSE TEST
This test is a blood check at any time of the day when you have severe diabetes symptoms.
 Diabetes is diagnosed at blood sugar of greater than or equal to 200 mg/dl
 Diagnosis of GDM
Diagnosis of GDM
GDM carries risks for the mother and neonate. Not all adverse outcomes are of equal clinical
importance. The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study (13), a
largescale (;25,000 pregnant women) multinational epidemiological study, demonstrated that
risk of adverse maternal, fetal, and neonatal outcomes continuously increased as a function of

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maternal glycemia at 24–28 weeks, even within ranges previously considered normal for
pregnancy. For most complications, there was no threshold for risk. These results have led to
careful reconsideration of the diagnostic criteria for GDM. GDM screening can be
accomplished with either of two strategies: the “one-step” 2-h 75-g OGTT or the “two-step”
approach with a 1-h 50-g (nonfasting) screen followed by a 3-h 100-g OGTT for those who
screen positive. Different diagnostic criteria will identify different magnitudes of maternal hyperglycemia
and maternal/fetal risk. In the 2011 Standards of Care (14), ADA for the first time
recommended that all
pregnant women not known to have prior diabetes undergo a 75-g OGTT at 24–28 weeks of
gestation based on an IADPSG consensus meeting (15). Diagnostic cut points for the fasting,
1-h, and 2-h PG measurements were defined that conveyed an odds ratio for adverse
outcomes of at least 1.75 compared with women with the mean glucose levels in the HAPO
study, a strategy anticipated to significantly increase the prevalence of GDM (from 5–6% to ;
15–20%), primarily because only one abnormal value, not two, is sufficient to make the
diagnosis. The ADA recognized that the anticipated increase in the incidence of GDM
diagnosed by these criteria would have significant impact on the costs, medical infrastructure
capacity, and potential for increased “medicalization” of pregnancies previously categorized
as normal, but recommended these diagnostic criteria changes in the context of worrisome
worldwide increases in obesity and diabetes rates with the intent of optimizing gestational
outcomes for women and their babies. It is important to note that 80–90% of women in both
of the mild GDMstudies (whose glucose values overlapped with the thresholds recommended
herein) could be managed with lifestyle therapy alone. The expected benefits to these
pregnancies and offspring are inferred from intervention trials that focused on women with
lower levels of hyperglycemia than identified using older GDM diagnostic criteria and that
found modest benefits including reduced rates of large-for-gestational age (LGA) births
(16,17). However, while treatment of lower threshold hyperglycemia can reduce LGA, it has
not been shown to reduce primary cesarean delivery rates. Data are lacking on how treatment
of lower threshold hyperglycemia impacts prognosis of future diabetes for the mother, or on
future obesity, diabetes risk, or other metabolic consequences for the offspring. The
frequency of follow-up and blood glucose monitoring for these
Diagnostic criteria
Currently, four different diagnostic criteria are valid for diabetes:
 The HbA1C test is recommended for diagnosis of diabetes using a test method certified by the
respective national authorities (point of care HbA1C tests are not suitable for the purpose of

11
diagnosis), based on a threshold of ≥ 6.5%. The HbA1C test may be influenced by ethnicity,
haemoglobinopathies and anaemias and becomes invalid in conditions with abnormal red cell
turnover.
 Fasting plasma glucose (FPG) levels ≥7mmol/l (126 mg/dl). Fasting is defined as no calorie intake
for the last eight hours.
 A 2-h plasma glucose value during an Oral Glucose Tolerance Test (OGTT) of ≥11.1 mmol/l
(200mg/dl). The test should be performed according to the WHO instructions with an equivalent of
75 g anhydrous glucose dissolved in water. With the classic symptoms of hyperglycaemia or a
hyperglycaemic crisis, a random plasma glucose ≥11.1 mmol/l (200mg/dl). The HbA1C test is
comparatively expensive and not yet readily available everywhere, therefore the FPG and OGTT
criteria are likely to be still widely used particularly in developing regions of the world. A positive
test result for any of the three tests above should be repeated to exclude a laboratory error, unless
history and clinical signs do not leave any doubt about the diagnosis. Preferably, the same test method
should be used. In case of conflicting results from two different tests, the test being positive for
diabetes should be repeated.

9. Control & Prevention Strategies

1. Check your risk of diabetes. Take the Life! risk assessment test and learn more
about risk of developing type 2 diabetes. A 12+ score indicates that are at high risk
and may be eligible for the Life! program - a free Victorian lifestyle modification
program that helps reduce risk of type 2 diabetes and cardiovascular disease, or call
13 RISK (13 7475).
2. Manage your weight. Excess body fat, particularly if stored around the abdomen,
can increase the body’s resistance to the hormone insulin. This can lead to type 2
diabetes.
3. Exercise regularly. Moderate physical activity on most days of the week helps
manage weight, reduce blood glucose levels and may also improve blood pressure
and cholesterol.
4. Eat a balanced, healthy diet. Reduce the amount of fat in your diet, especially
saturated and trans fats. Eat more fruit, vegetables and high-fibre foods. Cut back on
salt.
5. Limit takeaway and processed foods. ‘Convenience meals’ are usually high in salt,
fat and kilojoules. It’s best to cook for using fresh ingredients whenever possible.

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 6. Limit your alcohol intake. Too much alcohol can lead to weight gain and may
increase your blood pressure and triglyceride levels. Men should have no more than
two standard drinks a day and women should have no more than one.
7. Quit smoking. Smokers are twice as likely to develop diabetes as non-smokers.
8. Control your blood pressure. Most people can do this with regular exercise, a
balanced diet and by keeping a healthy weight. In some cases, might need medication
prescribed by doctor.
9. Reduce your risk of cardiovascular disease. Diabetes and cardiovascular disease
have many risk factors in common, including obesity and physical inactivity.
10. See your doctor for regular check-ups. As get older, it’s a good idea to regularly
check your blood glucose, blood pressure and blood cholesterol levels.

10. Management
Basic principles
 Correct diagnosis is essential. Thus emphasis should be placed on using appropriate
diagnostic criteria.
 Treatment should not only consider lowering the blood glucose level but also should
focus on the correction of any associated CVD risk factors such as smoking,
hyperlipidemias, and obesity as well as monitoring of blood pressure and ~treatment
of hypertension.
 Management of non-insulin-dependent diabetes mellitus (NIDDM) requires
teamwork.
 The doctor should work closely with the nurse and other members of the diabetes
health care team, whenever available, and with the person with diabetes.
 Self-care is an essential strategy. Education of the person with diabetes and his/her
family is the cornerstone of management.
 Without appropriate education, the desired therapy targets are difficult, or even
impossible to achieve. People with diabetes should be encouraged and enabled to
participate actively in managing and monitoring their condition.
 Good control is important. Self-monitoring improves the quality and safety of
therapy.
 The health care system should ensure that people with diabetes have access to the
basic requirements essential to practice self-care.
 Record-keeping is critically needed and should be considered a basic requirement for

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 the management and follow-up of all cases.
 Objectives and priorities of treatment must be tailored to individual needs; therapy
targets should be individually determined for each case.
General objectives of diabetes management
 To relieve symptoms
 To correct associated health problems and to reduce morbidity, mortality and
economic costs of diabetes.
 To prevent as much as possible acute and long-term complications; to monitor the
 development of such complications and to provide timely intervention
 To improve the quality of life and productivity of the individual with diabetes.
Lifestyle:
 People with diabetes can benefit from education about the disease and treatment,
good
 nutrition to achieve a normal body weight, and sensible exercise, with the goal of
keeping
 Both short-term and long-term blood glucose levels within acceptable bounds. In
addition,
 Given the associated higher risks of cardiovascular disease, lifestyle modifications are
recommended to control blood pressure
Medications:
 Metformin is generally recommended as a first line treatment for type 2 diabetes, as
 there is good evidence that it decreases mortality. Routine use of aspirin, however,
 has not been found to improve outcomes in uncomplicated diabetes. Angiotensin
 converting enzyme inhibitors (ACEIs) improve outcomes in those with DM while the
 similar medications angiotensin receptor blockers (ARBs) do not.
 Type 1 diabetes is typically treated with a combinations of regular and NPH insulin,
 or synthetic insulin analogs. When insulin is used in type 2 diabetes, a long-acting
 formulation is usually added initially, while continuing oral medications. Doses of
 insulin are then increased to effect.
 In those with diabetes some recommend blood pressure levels below
 120/80 mmHg however, evidence only supports less than or equal to
 somewhere between 140/90 mmHg to 160/100 mmHg.

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11. Treatment
Balanced diabetes treatments
A variety of different factors have a role to play in treating diabetes, but the importance of
balanced, coordinated diabetes treatment for all diabetics cannot be underestimated.
Regular and successful treatment decreases the risk of each patient developing diabetes
complications. The basics of diabetes treatment are broken down into each diabetic type
below.
Treatment of Type 1 diabetes
Type 1 diabetes treatment is a daily task. Lack of insulin production by the pancreas makes
Type 1 diabetes is particularly difficult to control.
Treatment requires a strict regimen that typically includes a carefully calculated diet, planned
physical activity, multiple daily insulin injections and home blood glucose testing a number
of times per day.
Treatment of Type 2 diabetes
Treatment typically includes diet control, exercise, home blood glucose testing, and in some
cases, oral medication and/or insulin. Approximately 40% of people with type 2 diabetes
require insulin injections.
Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is
diagnosed by demonstrating any one of the following: [33]
 Fasting plasma glucose level ≥ 7.0 mmol/l (126 mg/dl)
 Plasma glucose ≥ 11.1 mmol/l (200 mg/dl) two hours after a 75 g oral glucose
load as in a glucose tolerance test
 Symptoms of hyperglycemia and casual plasma glucose ≥ 11.1 mmol/l (200 mg/dl)

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A positive result, in the absence of unequivocal hyperglycemia, should be confirmed by a repeat
of any of the above methods on a different day. It is preferable to measure a fasting glucose level
because of the ease of measurement and the considerable time commitment of formal glucose
tolerance testing, which takes two hours to complete and offers no prognostic advantage over the
fasting test.[43] According to the current definition, two fasting glucose measurements above 126
mg/dl (7.0 mmol/l) is considered diagnostic for diabetes mellitus.
Route
Bolus subcutaneous injection or continuous subcutaneous infusion via an insulin pump
device.
C. Dosage and Frequency
The dosage and frequency of insulin administration is dependent upon individual
requirements and influenced by food intake, intensity and frequency of exercise sessions,
pre-exercise plasma glucose levels etc. Regular self-monitoring of plasma glucose levels
with glucose meters or sometimes with a Continuous Glucose Monitoring System (CGMS)
provides an indication of immediate insulin need and is an indispensable part of all intensive
insulin regimens. The general aims of treatment are to keep plasma glucose concentration in
an individually determined range and to prevent large deviations below 3 mmol/l or above 8-
10 mmol/l. It is important that these goals are individualized. In practice it might be difficult
for athletes to attain too strict goals. Very tight control increases the risk of hypoglycemia
during exercise. Insulin requirements in type 1 diabetes usually range between 0.5 and 1.0
U/kg/day, but may need to be reduced in athletes and lean subjects to around 0.2 to 0.6
U/kg/day. Athletes with type 2 diabetes often require higher doses (≥ 1.0 U/kg/day) to
overcome insulin resistance. The frequency of plasma glucose measurements carried out by

16
the athlete themselves is dependent on the type of diabetes and the treatment regimen used.
Self-measurements are helpful in controlling plasma glucose levels and preventing extreme
fluctuations. Athletes must have the relevant knowledge and understanding to be able to use
this information appropriately and make meaningful adjustments to their regimes particularly
in relation to exercise. Consideration must be given to checking plasma glucose levels in the
mornings, before, during and importantly after the end of an exercise session, and before and
after meals. High risk activities (e.g. whenever access to carbohydrates is limited) may
require very frequent glucose checks at 90, 30 and five minutes before their start. This is to
try to avoid hypoglycaemia which would be extremely dangerous during these activities.
Specialist assessment is indispensable before athletes with diabetes engage in high risk
activities. It is recommended either to reduce or even omit insulin doses in the period
surrounding competitive or high intensity prolonged exercise, or to consume extra
carbohydrates before, during or after the exercise session, or use a combination of both
strategies. Frequent glucose monitoring and individualizing treatment regimens based on
individual experience is key in the diabetic athlete. Moderate- and high intensity exercises
have a contrasting effect on plasma glucose levels and require different management
strategies to maintain glycaemia. The response of plasma glucose levels to a combination of
moderate- and high-intensity exercise, a pattern of physical activity referred to as intermittent
high-intensity exercise (IHE) has received less research attention even though this type of
exercise characterizes the activity patterns of most team and field sports. In very high
intensity exercise (about 80% of VO2 max) or when high intensity exercise follows a low
intensity one, there is a tendency of plasma glucose to increase due to excessive circulating
catecholamines necessitating postexercise short acting insulin. Prolonged exercise may also
lead to decreased glucose counter regulation. Athletes with diabetes who are treated with
insulin and sulphonylurea drugs are at increased risk of hypoglycaemia during and after
exercise due to the insulin-sensitizing effect of exercise. These athletes should be educated as
to manage their diabetes around exercise to minimize the possibility of hypoglycaemic
events occurring.

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12. Conclusion
Diabetes continues to be a major contemporary epidemic. In addressing the challenges of
confronting the epidemic a primary therapeutic goal is QoL. Many factors affect the QoL in
diabetic patients including glycemic control, prevention of complications, and
socioeconomic/demographic factors. Lifestyle modifications like weight loss and good
dietary habits can help patients manage their disease better. Insulin pumps have eased the
management of this disease and improved patients’ quality of life drastically. Lastly, patients
should be educated about the importance of support groups that may lead to a better quality
of life. More research is needed to further elucidate the effects of diabetes on patients’ quality
of life and how to improve it.

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References
 https://www.healthline.com/health/diabetes
 https://www.who.int/health-topics/diabetes#tab=tab_1
 Mohiuddin AK. Diabetes Fact: Bangladesh Perspective. International Journal of
Diabetes Research 2019; 2(1): 14-20 Available from: URL:
http://www.ghrnet.org/index.php/ijhr/article/view/2457
 https://www.healthline.com/health/diabetes#symptoms
 Al-Kalif Mohammed Sheker, Methods to Improve Quality of Life in Diabetics, The
Egyptian Journal of Hospital Medicine (April 2018) Vol. 71(1), Page 2253-2256
 https://www.diabetes.co.uk/news/2018/dec/four-stages-of-type-2-diabetes-identified
by-us-doctors-99311412.html
 https://www.niddk.nih.gov/health-information/diabetes/overview/risk-factors-type-2-
diabetes
 https://www.diabetes.org/a1c/diagnosis
 https://www.betterhealth.vic.gov.au/health/ten-tips/10-tips-to-help-prevent-type-2-
diabetes
 Dr A.A.S. Alwan, Regional Adviser, Noncommunicable Diseases, WHO Regional
Office for the Eastern Mediterranean Management Of Diabetes Mellitus Standards Of
Care And Clinical Practice Guidelines
 https://www.diabetes.co.uk/treatment.html

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