DIABETES MELLITUS

National Health Mission

Deptt. of Health & Family Welfare
Govt. of Odisha.
 Overview of the presentation

 What is Diabetes?
 Different types of Diabetes (Type 1, Type 2 and Gestational
diabetes).
 Risk factors for Type 2 diabetes.
 Common signs and symptoms for Type 2 diabetes.
 Screening for Diabetes
 Criteria for diagnosing Diabetes
 Details about Hypoglycaemia
 Management and Control of diabetes.
 What is Diabetes Mellitus?

• All food that we eat is broken down into a sugar called

glucose. Glucose is carried by the blood to all the parts of the
body to give energy. The hormone which helps glucose move
from the blood into the cells, is called INSULIN.
• DM is a metabolic disorder in which there are high blood
glucose level over a prolonged period.

• It is due to pancreas not providing enough insulin or cells fails

to respond to insulin.
Insulin helps to keep the blood sugar levels normal. In diabetes, the body
does not produce insulin or cannot use the insulin properly. The glucose
builds up in the blood, resulting in high blood glucose levels. Normally, a
blood glucose level taken randomly (that is at any time of the day) of
over 140 mg/dl should lead to a suspicion of diabetes.

Diabetes is a problem of INSULIN production and/or function and not a

problem of SUGAR.
 CLASSIFICATION

• Diabetes is classified into three types namely:

- Type 1 Diabetes
- Type 2 Diabetes
- Gestational Diabetes
 CLASSIFICATION (Contd.)
Types of Diabetes What is it? Who gets it?

Type 1 Diabetes (T1DM) Pancreas does not produce The disease can affect people of
any age but usually in adults
enough insulin i.e.
deficient

Onset is sudden, mostly in

children , body size is thin
or normal and prevalence is
10%.
 CLASSIFICATION (Contd.)
Types of Diabetes What is it? Who gets it?

Type 2 Diabetes (T2DM) This is the most common type of This type of diabetes used to be
diabetes. Insulin resistant cells fails seen only in adults but it is now
to respond to insulin. also occurring increasingly in

Onset is gradual, mostly in adults, children and adolescents. It is

body size is obese and prevalence strongly associated with ageing

is 90%. populations, family history, excess

body weight, unhealthy lifestyle-
poor dietary habits, lack/low of
physical activity, tobacco and
alcohol consumption, etc.
 CLASSIFICATION (Contd.)
Types of Diabetes What is it? Who gets it?

Gestational Diabetes (GDM) Diabetes which occurs among women Women who are prone to getting diabetes
during pregnancy. later. The children of women with
Gestational Diabetes are at an increased
risk of type 2 diabetes in the future
In this section, we will only discuss about Type 2
Diabetes as it is the most common
 RISK FACTORS FOR Type 2 Diabetes
• Advancing age- It occurs most frequently in adults, but is seen increasingly in adolescents
as well
• Family history of diabetes
• Being overweight/obese (BMI is > 23kg/m2)
• Unhealthy eating habits
• Lack of physical activity
• High Blood Pressure
• High levels of harmful blood fats/Hyperlipidemia- Triglyceride and/or cholesterol levels
are higher than normal
• Addictions like tobacco use, drugs and harmful use of alcohol
• If the woman during pregnancy had diabetes or even mild elevation of blood sugar level
during pregnancy
• Women with polycystic ovarian syndrome
• Stress and depression
 COMMON SIGNS AND SYMPTOMS OF Type 2 Diabetes

• Frequent urination
• Increased hunger
• Excessive thirst
• Unexplained weight loss
• Lack of energy, extreme tiredness
• Lack of interest and concentration
• Blurred vision
• Repeated or severe infections such as vaginal infections
• Slow healing of wounds, dry or itchy skin
• Impotence in men
 DAMAGE TO ORGANS DUE TO HIGH BLOOD GLUCOSE

• Kidneys – causing kidney failure

• Heart and blood vessel disease- causing heart attack and stroke
• Nerves (Neuropathy) – Diabetes can damage blood vessels
throughout the body. It causes numbness, tingling in hands and/or
feet, making it hard to feel injuries. Diabetes also makes it harder
for wounds to heal, easily leading to foot ulcers and infections.
Fungus on the feet can also lead to infection. A foot infection can
spread to the whole leg if not treated. The leg may become so
infected that it needs to be removed (amputated). But good foot
care and managing blood sugar levels can prevent amputations.
 (Contd.)
• Eyes (Retinopathy) - Diabetes can damage blood vessels in the
eyes, leading to gradual loss of vision or blindness. If an eye clinic
is available, a person with diabetes should have their eyes tested
once a year. If vision becomes blurry, keeping sugar levels down
may help the eyes recover.
• Oral cavity – Diabetes worsens gum infections which, in turn,
makes diabetes worse. People with diabetes should brush their
teeth at least twice a day with a toothbrush or a chewstick
(miswak, neem stick). A person with diabetes will benefit from
seeing a dentist.
 SCREENING FOR DIABETES
• The ANM, will undertake screening of all adults 30 years of age and above for
diabetes. This will take place on a fixed day at the sub-centre. Regular monitoring
of blood sugar helps in making an early diagnosis of diabetes. This is helpful in
taking early corrective measures leading to better control of blood sugar levels.
You are already familiar with the use of glucometer in the sub-centre. For the
purpose of screening, any patient with a random blood sugar over 140 mg/dl
should be referred to the medical officer for further diagnosis and management.

• It is the medical officer’s responsibility to develop a treatment plan for the patient,
based on the level of blood glucose and the presence of other conditions such as
high levels of blood pressure and high levels of fat. The treatment plan includes not
just anti-diabetic medication but also a plan for addressing any modifiable risk
factors. It is part of your role to ensure that the patient adheres to the treatment and
makes changes in her/his lifestyle to reduce modifiable risk factors.
 Details of the tests for Diagnosing Type 2 Diabetes

• Please remember that the following tests will be done by a

laboratory technician at the PHC level and above.
• Most blood glucose tests actually measure the amount of
glucose in the liquid part of your blood called the blood
plasma, rather than the amount of glucose in your whole
blood. This is called plasma glucose.
 Diagnosing Type 2 Diabetes (Contd.)

1. Fasting Blood Glucose (FBG)

• Before taking the blood test, the person should have taken no
food for at least 8 hours. The easiest way to do this is to
arrange an appointment for the patient to have the blood test
first thing in the morning. They should fast overnight and
must not have anything to eat until after the test. Fasting
plasma glucose is described as a fasting blood glucose level of
≥ 126 mg/dl.
 Diagnosing Type 2 Diabetes (Contd.)

2. Random Blood Glucose- Sugar level or blood glucose measured

at any time of day without regard to time since the last meal. It
does not take into account what the patient has been eating or
drinking. It is therefore less sensitive than the other tests.
However, it is the easiest to perform.
• Where a random plasma glucose level more than and equal to 100
mg/dl and less than 200 mg/dl is detected, a FPG should be
measured, or an OGTT performed, or an HbA1c measured.
• However, as explained earlier, for the purpose of SCREENING,
random blood sugar over 140 mg/dl is taken as requiring further
follow-up.
 Diagnosing Type 2 Diabetes (Contd.)

3. Two- hour venous plasma glucose after ingestion of 75g

oral glucose load (Oral Glucose Tolerance Test- OGTT)

• The Oral Glucose Tolerance Test (OGTT) is a method which

is used to diagnose Type 2 diabetes by measuring how well
the body’s cells are able to absorb a fixed amount of sugar or
glucose.
 Diagnosing Type 2 Diabetes (Contd.)

4. HbA1c (Glycosylated, or Glycated haemoglobin)

• It is a form of haemoglobin in the RBCs. The HbA1c level is
proportional to average blood glucose over the previous two
to three months. It is an excellent indicator of how well the
patient has managed his/her diabetes over the last four weeks
to three months. It is recommended for monitoring blood
sugar control in diabetic patients. However, the test is more
costly than blood glucose measurement. WHO recommends
an HbA1c goal of less than 6.5 % for people with diabetes.
 What is Hypoglycaemia (Low Blood Glucose)?

• Among those with Diabetes a condition called –

Hypoglycaemia or low blood sugar levels can occur.
Hypoglycaemia occurs when blood sugar (glucose) level falls
below a level of 70 milligrams per decilitre (mg/dl) or less. If
not treated, hypoglycaemia can be life-threatening. The only
way to know if someone has hypoglycemia is to check blood
glucose. Testing blood sugar levels regularly can help
understand when sugar levels are dropping too low.
 Hypoglycemia (Contd.)

• Symptoms are tremors, nervousness or anxiety, sweating,

irritability, confusion, rapid/fast heartbeat, dizziness, hunger,
nausea, blurred/impaired vision, headaches, weakness or
fatigue, lack of coordination, falls, seizures, unconsciousness
and can lead to other harmful injuries and even death.
 Hypoglycemia (Contd.)

There are several reasons why this may happen. These are-
• Missing or skipping a meal
• Long gap between two meals or delay in eating meals
• Taking more than recommended dosage of insulin or tablet
• Side- effects of some anti-diabetic drugs and
• Increased physical activity.
 Hypoglycemia (Contd.)

• If someone is having signs of hypoglycemia, it's important to

treat it right away.
• Hypoglycaemia can be treated by consuming a small amount
of sugar-rich foods as soon as symptoms appear. For such an
emergency, diabetic patients should be advised to always
carry something to eat such as loose sugar, rock candy (misri)
or toffee etc.
 Management of Hypoglycaemia
• If a patient’s blood glucose drops below 70 mg/dL, remember the 15/15 rule and treat
hypoglycemia, without any delay.
• The 15/15 Rule
1. Check blood glucose level (<70 mg/dl).
2. The patient has to eat or drink 15 grams of carbohydrates (such as sugar-rich foods). If blood
glucose levels cannot be checked at the moment, the patient should be given 15 grams of
carbohydrates to be safe. Give any of the following food items to the patient.
- 5 or 6 pieces of toffee
- 1 tablespoon of sugar or honey
- 2-3 teaspoons (1 teaspoon is 5 grams) of glucose powder as is or diluted in water
- 3-4 teaspoons of sugar/powdered sugar
- ½ cup fruit juice or normal cold drink
3. Wait 15 minutes. Check the blood sugar once again. If the blood sugar level, is still below 70
mg/dl, again eat one of the food items listed above and check blood glucose sugar after 15
minutes.
4. If blood glucose level is still lower than 70 mg/dl or the patient still has symptoms of
hypoglycemia, then the patient should be taken to the PHC for management.
 Management of Hypoglycaemia (Contd.)

• Ways to prevent Hypoglycaemia

• Creating awareness on hypoglycaemia
• Regular blood sugar testing/monitoring
• Taking correct dosage of medicines that are prescribed by the
Medical Officer or a trained medical doctor
• Eating small and frequent meals
• Not skipping or delaying meals
• Checking blood sugar before exercise
• Not going empty stomach for morning walk
 Management of Hypoglycaemia (Contd.)

• Please Note- People with diabetes should be advised to

always carry one of the above food items with them to avoid
hypoglycaemia. Sugar packets, rock candy (misri) or toffees,
etc are easy to carry. People may also wear/carry some form
of identification, mentioning they are diabetics. In addition,
people in the community should be made aware of the people
living with diabetes in their community. This will help in
prompt management in case of emergency situations like
hypoglycaemia.
 Management of Diabetes
• No matter what type of diabetes a person has, glucose control is
key to managing the diabetes. Management of Diabetes should be
initiated as soon as diagnosis is established even if the patient is
asymptomatic. Patient education on diabetes management and life
style modifications is the corner stone of effective diabetes control
and management and prevention of complications.
• The management should include the following:
• Non- pharmacologic (lifestyle changes) and
• Pharmacologic (medication/drug) therapy, both are required to
prevent and manage type 2 diabetes
 1. Life-style management (The ASHA will support ANM in
spreading health messages in the community)

• Change in lifestyle behaviours is effective in preventing or

delaying the occurrence of Type 2 diabetes. Eating a healthy diet,
being physically active, avoiding the use of tobacco in any
form/avoiding exposure to second-hand smoke, reducing the
intake of alcohol amongst heavy drinkers, managing stress,
reducing weight amongst overweight/obese individuals, etc. are
the lifestyle changes. The details of these messages has been
covered in detail in the chapter on Health Promotion. Those who
have diabetes should regularly take small frequent meals as
missing or skipping a meal can lead to low blood sugar level.
 2. Pharmacological / Medication for Type 2 Diabetes
• The Medical Officer at the Primary Health Centre (PHC) will decide on the
drug therapy for the patient. Whether a person requires medicines for his high
level of blood sugar and which medicine is best for the patient would depend
on:
• The blood sugar reading
• If the target organs in the body such as heart, kidneys, eyes and nerves are
affected
• Presence of co- morbidities or concurrent medical conditions such as high
blood pressure (on anti-hypertensive treatment), heart disease, kidney disease,
nerve and eye damage, and other risk factors like use of unhealthy dietary
habits, lack of physical activity/low physical activity, tobacco, alcohol,
overweight/obesity and high levels of harmful blood fats/hyperlipidaemia (on
lipid control with statins), etc
• Other considerations such as age, sex (male/female) and body weight.
 Contd.

• There are several classes of medicines that can be used for the
management of hypertension, diabetes and common cancers. Every
state has its Essential Drug List (EDL) for common diseases available.
The essential drugs for Diabetes are expected to be available at the
PHC, CHC and higher heath facilities. This essential drug list is
updated on a regular basis and varies state-wise.
 Contd.
• Drugs for Type 2 diabetes are available free of cost to those patients
who use government health facilities. The drugs are prescribed by the
medical officer and the patient should be given a month’s supply of
drugs. For diabetes, both oral dugs and insulin injections can be
provided based on the decision of the Medical Officer. The patient
should be able to collect refills every month from the nearest health
facility. This could be a Sub-Centre (SC) or a Primary Health Centre
(PHC). The blood sugar reading should be monitored regularly. The
frequency depends on the advice of the medical officer.
 ANM with support of the ASHA will be responsible for:
• Raising awareness on diabetes, generally to prevent the onset of diabetes and
its complications in the community
• Motivating pregnant mothers for blood glucose testing as a part of their
antenatal care. Pregnant women who have diabetes should be encouraged to
have good control of their sugar levels to reduce the risk of complications
during pregnancy as well as congenital defects in the foetus.
• Encourage the patient for early detection of complications-examine their feet
daily for sensations, look for foot injuries, regular eye check-up, maintain
oral hygiene, etc.
• Help in identifying symptoms of hypoglycemia and management of
hypoglycemia.
• Monthly monitoring of blood sugar level
• Providing support to them and their family members through the consultation and
diagnostic processes as required
• Compliance to treatment plan for drugs as prescribed by the medical doctor and
encouraging the patients not to stop or change the dose of medicine without medical
advice
• Check for presence of any side-effects of the medicines being taken
• Ensure that the patient does not share the medicine with other diabetic patients as
every patient is prescribed as per his / her requirement
• The patient’s blood sugar is under control
• Follow-up: Check-up at the PHC/CHC as advised to the patients
• Accompany the ASHA in regularly conducting home-visits by prioritizing those
households which are vulnerable and marginalised where there are treatment
defaulters or those who experience complications and bring these cases to the notice
of the Medical Officer.
 Common anti-diabetic medications

• Most Type 2 diabetes patients are usually initiated on one or

more oral anti-diabetic medicines. Over a period, they will
need two or more oral drugs to control their blood glucose
levels. These are-
- Biguanides (Metformin)
- Sulphonylureas (Glibenclamide)
 Common anti-diabetic medications
Medicine class Name Dosage How it works When to take
Biguanide Metformin 250mg to Lowers the amount After a major meal
2000mg/day of sugar produced
by the liver, Helps
body use insulin
better.
Sulfonylureas e.g. Glibenclamide Glibenclamide Increase the 30 min before
varies from 2.5-
20mg/day given in amount of insulin meals.
one or two doses. released by
pancreas.
 Injectable medicine for diabetes (Insulin)

• Insulin is another form of drug therapy used for diabetic patients.

Insulin is given in the form of injections. It may come in a vial and
syringe; or a device that looks like a pen which is easier to use and
measures the correct dose. There are three types of insulin- Short-
acting, Long-acting and Mixed dose or pre-mixed. People who have
Type 1 diabetes require insulin every day to be healthy. Type 2 diabetic
patients can also be advised to take insulin, in combination with oral
medicines to help achieve good control of diabetes. Medical Officer at
the PHC, will determine the need of insulin, type of insulin and dose
for an individual depending on the blood sugar profile of the diabetic
person.
• As explained earlier patients with diabetes are prone to problems such
as foot ulcers and eye problems. You should be able to provide all
diabetic patients in your community with advice on foot care
 Education of the patient for foot care
• Inspect your feet daily for cracks, blisters, infections, and injuries. If you can’t check your
own feet, have someone else do it for you.
• Cleanse your feet daily as you bathe or shower, using warm water and mild soap. Dry your
feet with a soft towel making sure to dry between the toes. Don’t use hot water. You may
burn your skin as you may not be able to feel the hotness of the water.
• Apply oil to dry skin to keep the skin soft and free of cracks.
• Clip toenails straight across. Use a nail cutter; don’t use scissors
• Always wear something on your feet (socks, slippers, shoes) to protect from injury - even in
your house.
• Choose soft good shoes. Let them be a size bigger that what you feel is appropriate. Wear
socks made of cotton or wool (in winter).
• Treat minor breaks in the skin promptly. Cleanse the area with soap and water, dry, and
cover with clean gauze. Observe for signs of infection such as redness, swelling, warmth,
pain or drainage. Don’t put weight on the foot that has an injury.
• See your doctor to check your feet during your regular visits for diabetes care. Take off your
shoes and socks at every visit.
Thank you