DIABETES MELLITUS

Diabetes mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood
(hyperglycemia) resulting from defects in insulin secretion, insulin action, or both.
Risk Factors for Diabetes Mellitus
Family history of diabetes (ie, parents or siblings with diabetes)
Obesity (ie, ≥20% over desired body weight or BMI ≥27 kg/m2)
Race/ethnicity (eg, African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific Islanders)
Age ≥45 y
Previously identified impaired fasting glucose or impaired glucose tolerance
Hypertension (≥140/90 mm Hg)
HDL cholesterol level ≤35 mg/dL (0.90 mmol/L) and/or triglyceride level ≥250 mg/dL (2.8 mmol/L)
History of gestational diabetes or delivery of babies over 9 lb
 CLASSIFICATION
Type 1 diabetes, type 2 diabetes, gestational diabetes, and diabetes mellitus associated with other
conditions or syndromes.
Pathophysiology
Insulin is an anabolic, or storage, hormone.
When a person eats a meal, insulin secretion increases and moves glucose from the blood into muscle, liver, and
fat cells.
In those cells, insulin:
Transports and metabolizes glucose for energy
Stimulates storage of glucose in the liver and muscle (in the form of glycogen)
Signals the liver to stop the release of glucose
Enhances storage of dietary fat in adipose tissue
Accelerates transport of amino acids (derived from dietary protein) into cells
 DURING FASTING PERIODS (BETWEEN
MEALS AND OVERNIGHT) ????????????
❖Pancreas continuously releases a small amount of insulin (basal insulin).

❖Initially, the liver produces glucose through the breakdown of glycogen

(glycogenolysis).

❖After 8 to 12 hours without food, the liver forms glucose from the breakdown
of noncarbohydrate substances, including amino acids (gluconeogenesis).
 TYPE 1
DIABETES
Type 1 diabetes affects approximately 5% to 10% of people with the disease.
It is characterized by an acute onset, usually before 30 years of age.
Type 1 diabetes is characterized by destruction of the pancreatic beta cells.
Combined genetic, immunologic, and possibly environmental (eg, viral) factors are thought to
contribute to B- cell destruction.
Genetic tendency has been found in people with certain human leukocyte antigen (HLA)
types.
There is also evidence of an autoimmune response in type 1 diabetes.
Regardless of the specific cause, the destruction of the beta cells results
in decreased insulin production, unchecked glucose production by the
liver, and fasting hyperglycemia.

If the concentration of glucose in the blood exceeds the renal threshold

for glucose, usually 180 to 200 mg/dL (9.9 to 11.1 mmol/L), the
kidneys may not reabsorb all of the filtered glucose; the glucose then
appears in the urine (glycosuria).

When excess glucose is excreted in the urine, it is accompanied by

excessive loss of fluids and electrolytes.

This is called osmotic diuresis.

Because insulin normally inhibits glycogenolysis and
gluconeogenesis, these processes occur in an
unrestrained fashion in people with insulin deficiency
and contribute further to hyperglycemia.

In addition, fat breakdown occurs, resulting in an

increased production of ketone bodies, which are the
byproducts of fat breakdown.
 TYPE 2 DIABETES
Type 2 diabetes affects approximately 90% to 95% of people with the
disease.
It occurs more commonly among people who are older than 30 years of age
and obese
The two main problems related to insulin in type 2 diabetes are insulin
resistance and impaired insulin secretion.
Despite the impaired insulin secretion that is characteristic of type 2 diabetes,
there is enough insulin present to prevent the breakdown of fat and the
accompanying production of ketone bodies.
Therefore, DKA does not typically occur in type 2 diabetes.
Because type 2 diabetes is associated with a slow,
progressive glucose intolerance, its onset may go
undetected for many years.

If the patient experiences symptoms, they are

frequently mild and may include fatigue, irritability,
polyuria, polydipsia, poorly healing skin wounds,
vaginal infections, or blurred vision (if glucose levels
are very high).
Gestational diabetes mellitus (GDM) is any degree of glucose intolerance
with its onset during pregnancy.
Women considered to be at high risk or average risk should have either an
oral glucose tolerance test (OGTT) or a glucose challenge test (GCT)
followed by OGTT in women who exceed the glucose threshold value of
140 mg/dL.

Goals for blood glucose levels during pregnancy are 105 mg/dL or less
before meals and 130 mg/dL or less 2 hours after meals
 CLINICAL MANIFESTATIONS
Classic clinical manifestations of all types of diabetes include the “three Ps”:
polyuria, polydipsia, and polyphagia.
Polyuria (increased urination) and polydipsia (increased thirst) occur as a result of the
excess loss of fluid associated with osmotic diuresis.
Patients also experience polyphagia (increased appetite) that results from the catabolic
state induced by insulin deficiency and the breakdown of proteins and fats.
Other symptoms include fatigue and weakness, sudden vision changes, tingling or
numbness in hands or feet, dry skin, skin lesions or wounds that are slow to heal,
and recurrent infections.
The onset of type 1 diabetes may also be associated with sudden weight loss or
nausea, vomiting, or abdominal pains, if DKA has developed.
ASSESSMENT AND DIAGNOSTIC FINDINGS

Fasting plasma glucose (FPG), random plasma glucose(RPG),

and glucose level 2 hours after receiving glucose (2-hour
postload) may be used.
FBS OR RBS
The OGTT and the intravenous (IV) glucose tolerance test are no
longer recommended for routine clinical use.
CRITERIA FOR THE DIAGNOSIS OF
DIABETES MELLITUS
Symptoms of diabetes plus casual plasma glucose
concentration equal to or greater than 200 mg/dL (11.1
mmol/L).
Casual is defined as any time of day without regard to
time since last meal.
The classic symptoms of diabetes include polyuria,
polydipsia, and unexplained weight loss.
 OR
Fasting plasma glucose greater than or equal to 126 mg/dL (7.0
mmol/L).
Fasting is defined as no caloric intake for at least 8 hours.

OR
Two-hour postload glucose equal to or greater than 200 mg/dL
(11.1 mmol/L) during an oral glucose tolerance test.
ASSESSING THE PATIENT WITH
DIABETES
History
Physical Examination
Blood pressure (sitting and standing to detect orthostatic changes)
Body mass index (height and weight)
Fundoscopic examination and visual acuity
Foot examination (lesions, signs of infection, pulses)
Skin examination (lesions and insulin-injection sites)
Neurologic examination
 Vibratory and sensory examination using monofilament
 Deep tendon reflexes

Oral examination
LABORATORY EXAMINATION
HgbA1C (A1C) A normal A1C level is below 5.7 percent; 6.5 percent or above
indicates diabetes; 5.7 to 6.4 percent is prediabetes.
Fasting lipid profile
Test for microalbuminuria
Serum creatinine level
Urinalysis
Electrocardiogram
MEDICAL MANAGEMENT
The main goal of diabetes treatment is to normalize insulin activity and blood
glucose levels to reduce the development of vascular and neuropathic
complications.
Intensive treatment is defined as three or four insulin injections per day or
continuous subcutaneous insulin infusion, insulin pump therapy plus
frequent blood glucose monitoring and weekly contacts with diabetes
educators.
Diabetes management has five components: nutritional therapy, exercise,
monitoring, pharmacologic therapy, and education.
NUTRITIONAL THERAPY

Nutrition, meal planning, and weight control are the foundation of diabetes
management.
The most important objectives in the dietary and nutritional management of diabetes
are control of total caloric intake to attain or maintain a reasonable body weight,
control of blood glucose levels, and normalization of lipids and blood pressure to
prevent heart disease.
A weight loss as small as 5% to 10% of total weight may significantly improve blood
glucose levels (in case of obesity).
 CALORIC REQUIREMENTS
Calorie-controlled diets are planned by first calculating a person's energy needs and caloric
requirements based on age, gender, height, and weight.
To promote a 1- to 2-pound weight loss per week, 500 to 1000 calories are subtracted from the
daily total.
The calories are distributed into carbohydrates, proteins, and fats, and a meal plan is then
developed, taking into account the patient's lifestyle and food preferences.
Some patients may be underweight at the onset of type 1 diabetes because of rapid weight loss
from severe hyperglycemia.
The goal initially may be to provide a higher-calorie diet to regain lost weight and blood glucose
control.
 CALORIC DISTRIBUTION
The caloric distribution currently recommended is higher in
carbohydrates than in fat and protein.
Currently, the American Dietetic Association recommend that for all
levels of caloric intake, 50% to 60% of calories should be derived
from carbohydrates, 20% to 30% from fat, and the remaining 10% to
20% from protein.
Fiber. Increased fiber in the diet may improve blood glucose levels,
decrease the need for exogenous insulin, and lower total cholesterol
and low-density lipoprotein levels in the blood
OTHER DIETARY CONCERNS
Alcohol Consumption
Sweeteners
There are two main types of sweeteners: nutritive and nonnutritive.
The nutritive sweeteners contain calories, and the nonnutritive sweeteners have few or no
calories in the amounts normally used.
Nutritive sweeteners include fructose (fruit sugar), sorbitol, and xylitol, all of which provide
calories in amounts similar to those in sucrose (table sugar).
They cause less elevation in blood sugar levels than sucrose does and are often used in “sugar-
free” foods.
Sweeteners containing sorbitol may have a laxative effect.
Nonnutritive sweeteners include saccharin, aspartame
 EXERCISE

Exercise lowers blood glucose levels by increasing the uptake of glucose by body
muscles and by improving insulin utilization.
Exercise Recommendations
Ideally, a person with diabetes should exercise at the same time (preferably when
blood glucose levels are at their peak) and in the same amount each day.
Regular daily exercise, rather than sporadic exercise, should be encouraged.
Exercise recommendations must be altered as necessary for patients with diabetic
complications such as retinopathy, autonomic neuropathy, sensorimotor neuropathy,
and cardiovascular disease.
EXERCISE PRECAUTIONS
Patients who have blood glucose levels exceeding 250 mg/dL and who have ketones
in their urine should not begin exercising until the urine test results are negative for
ketones and the blood glucose level is closer to normal.
Exercising with elevated blood glucose levels increases the secretion of glucagon,
growth hormone, and catecholamines.
The liver then releases more glucose, and the result is an increase in the blood glucose
level.
The physiologic decrease in circulating insulin that normally occurs with exercise
cannot occur in patients treated with insulin.
Initially, patients who require insulin should be taught to eat a 15-g carbohydrate
snack (a fruit exchange) or a snack of complex carbohydrates with a protein
before engaging in moderate exercise to prevent unexpected hypoglycemia. The
exact amount of food needed varies from person to person and should be
determined by blood glucose monitoring.
Another potential concern for patients who take insulin is hypoglycemia that occurs
many hours after exercise.
To avoid postexercise hypoglycemia, especially after strenuous or prolonged
exercise, the patient may need to eat a snack at the end of the exercise session
and at bedtime and monitor the blood glucose level more frequently.
Patients taking insulin and participating in extended periods of exercise should test
their blood glucose levels before, during, and after the exercise period, and they
should snack on carbohydrates as needed to maintain blood glucose levels
Monitoring Glucose Levels and Ketones
Blood glucose monitoring is a cornerstone of diabetes management, and self-
monitoring of blood glucose (SMBG) levels has dramatically altered diabetes care.

Plasma glucose values are 10% to 15% higher than whole blood glucose values

Continuous glucose monitoring system (CGMS)

CANDIDATES FOR SELF-MONITORING
OF BLOOD GLUCOSE
SMBG is a useful tool for managing self-care for everyone with diabetes,
It is also recommended for patients with the following conditions:
Unstable diabetes (severe swings from very high to very low blood glucose levels
within a 24-hour day)
A tendency to develop severe ketosis or hypoglycemia
Hypoglycemia without warning symptoms
For patients not taking insulin, SMBG is helpful for monitoring the effectiveness of
exercise, diet, and oral antidiabetic agents.
PHARMACOLOGIC THERAPY
Insulin Therapy
In type 1 diabetes, exogenous insulin must be administered for life because the body loses
the ability to produce insulin.
In type 2 diabetes, insulin may be necessary on a long-term basis to control glucose levels
if meal planning and oral agents are ineffective.
In addition, some patients in whom type 2 diabetes is usually controlled by meal planning
alone or by meal planning and an oral antidiabetic agent may require insulin temporarily
during illness, infection, pregnancy, surgery, or some other stressful event.
In many cases, insulin injections are administered two or more times daily to control the
blood glucose level.
 PREPARATIONS

A number of insulin preparations are available.

They vary according to three main characteristics: time course of action, species
(source), and manufacturer.
Time Course of Action. Insulins may be grouped into several categories based on the
onset, peak, and duration of action
Human insulin preparations have a shorter duration of action than insulin from animal
sources because the presence of animal proteins triggers an immune response that
results in the binding of animal insulin, which slows its availability.
Rapid-acting insulins produce a more rapid effect that is of
shorter duration than regular insulin.

Because of their rapid onset, the patient should be instructed to

eat no more than 5 to 15 minutes after injection.

Because of the short duration of action of these insulin

analogues, patients with type 1 diabetes and some patients
with type 2 or gestational diabetes also require a long-acting
insulin (basal insulin) to maintain glucose control.
Short-acting insulins are called regular insulin (marked
R on the bottle).

Regular insulin is a clear solution and is usually

administered 20 to 30 minutes before a meal, either
alone or in combination with a longer-acting insulin.

Regular insulin is the only insulin approved for IV use.

Intermediate-acting insulins are called NPH insulin (neutral protamine
Hagedorn) or Lente insulin.

Intermediate-acting insulins, which are similar in their time course of

action, appear white and cloudy.

If NPH or Lente insulin is taken alone, it is not crucial that it be taken 30

minutes before the meal.

However, it is important that patients eat some food around the time of
the onset and peak of these insulins.
“Peakless” basal or very long-acting insulins are approved by the
FDA for use as a basal insulin—that is, the insulin is absorbed very
slowly over 24 hours and can be given once a day.

Because the insulin is in a suspension with a pH of 4, it cannot be mixed

with other insulins because this would cause precipitation.

It was originally approved to be given once a day at bedtime; however,

it has now been approved to be given once a day at any time of the
day but must be given at the same time each day to prevent overlap of
action.
COMPLICATIONS OF INSULIN THERAPY
Local Allergic Reactions
Systemic Allergic Reactions.
Insulin Lipodystrophy.
Resistance to Injected Insulin.
Morning Hyperglycemia.
Methods of Insulin Delivery
Methods of insulin delivery include traditional subcutaneous
injections, insulin pens, jet injectors, and insulin pumps

Oral Antidiabetic Agents

Sulfonylureas and meglitinides are considered insulin
secretagogues because their action increases the secretion of
insulin by the pancreatic beta cells.
OTHER PHARMACOLOGIC
THERAPY
Two new medications became available in 2005 for use in the pharmacologic
management of diabetes.
Both are injectable medications; neither is a substitute for insulin if insulin is required
to control diabetes.
Pramlintide (Symlin), a synthetic analogue of human amylin, a hormone that is
secreted by the beta cells of the pancreas, has recently been approved for treatment
of both type 1 and type 2 diabetes.
It is used to control hyperglycemia in adults who have not achieved acceptable levels
of glucose control despite the use of insulin at mealtimes.
It is used with insulin, not in place of insulin.
 NURSING MANAGEMENT
Providing Patient Education
❖ Diabetes mellitus is a chronic illness that requires a lifetime of special self-
management behaviors.
❖ Because MNT, physical activity, and physical and emotional stress affect
diabetic control, patients must learn to balance a multitude of factors.
Developing a Diabetic Teaching Plan
❖ Patients with new-onset type 1 diabetes are hospitalized for much shorter
periods or may be managed completely on an outpatient basis.
❖Patients with new-onset type 2 diabetes are rarely hospitalized for initial care.
Teaching Patients to Self-Administer Insulin
Insulin injections are self-administered into the subcutaneous tissue with the use of special insulin syringes.
 STORING INSULIN
o Vials not in use, including spare vials, should be refrigerated.
o NO = Extremes of temperature, freezing, sunlight or in a hot car.
o The insulin vial in use should be kept at room temperature to reduce local irritation at the injection site.
o If a vial of insulin will be used up within 1 month, it may be kept at room temperature.
o The patient should be instructed to always have a spare vial of the type or types of insulin he or she uses.
o Cloudy insulin should be thoroughly mixed by gently inverting the vial or rolling it between the hands
before drawing the solution into a syringe or a pen.
o Bottles of intermediate-acting insulin should also be inspected for flocculation, which is a frosted, whitish
coating inside the bottle.
 SELECTING SYRINGES
Syringes must be matched with the insulin concentration (eg, U-100). Currently, three sizes of U-100 insulin
syringes are available:
1-mL syringes that hold 100 units
0.5-mL syringes that hold 50 units
0.3-mL syringes that hold 30 units
There is a U-500 (500 units/mL) concentration of insulin available by special order for patients who have
severe insulin resistance and require massive doses of insulin.
Most insulin syringes have a disposable 27- to 29-gauge needle that is approximately 0.5 inch long.
A small disposable insulin needle (31 gauge, 8 mm long) is available for very thin patients and children.
 SELECTING AND ROTATING THE
INJECTION SITE
The speed of absorption is greatest in the abdomen and decreases progressively in the arm, thigh,
and hip, respectively.
Systematic rotation of injection sites within an anatomic area is recommended to prevent localized
changes in fatty tissue (lipodystrophy).
In addition, to promote consistency in insulin absorption, the patient should be encouraged to use all
available injection sites within one area rather than randomly rotating sites from area to area.
For example, some patients almost exclusively use the abdominal area, administering each injection
0.5 to 1 inch away from the previous injection.
Another approach to rotation is always to use the same area at the same time of day.
For example, patients may inject morning doses into the abdomen and evening doses into the arms
or legs.
A few general principles apply to all rotation patterns.
First, the patient should try not to use the same site more than once in 2 to 3 weeks.
In addition, if the patient is planning to exercise, insulin should not be injected into the limb
that will be exercised because this will cause the drug to be absorbed faster, which may
result in hypoglycemia.
In the past, patients were taught to rotate injections from one area to the next (eg,
injecting once in the right arm, then once in the right abdomen, then once in the right thigh).
Patients who still use this system must be taught to avoid repeated injections into the same
site within an area.
However, as previously stated, it is preferable for patients to use the same anatomic area
at the same time of day consistently; this reduces day-to-day variation in blood glucose
levels caused by different absorption rates.
ACUTE COMPLICATIONS OF DIABETES
Hypoglycemia (Insulin Reactions)
Hypoglycemia occurs when the blood glucose falls to less than 50 to 60 mg/dL,
because of too much insulin or oral hypoglycemic agents, too little food, or excessive
physical activity.
Clinical Manifestations
The clinical manifestations of hypoglycemia may be grouped into two categories:
adrenergic symptoms and central nervous system (CNS) symptoms.
In mild hypoglycemia: sweating, tremor, tachycardia, palpitation, nervousness, and
hunger.
In moderate hypoglycemia: inability to concentrate, headache, lightheadedness, confusion, memory
lapses, numbness of the lips and tongue, slurred speech, impaired coordination, emotional changes,
irrational or combative behavior, double vision, and drowsiness.
In severe hypoglycemia: disoriented behavior, seizures, difficulty arousing from sleep, or loss of
consciousness.
Management:
Treating with Carbohydrates
Immediate treatment must be given when hypoglycemia occurs. The usual recommendation is for 15 g of
a fast-acting concentrated source of carbohydrate
The blood glucose level should be retested in 15 minutes and retreated if it is less than 70 to 75 mg/dL
If the symptoms persist for longer than 10 to 15 minutes after initial treatment, the treatment is repeated
even if blood glucose testing is not possible.
Once the symptoms resolve, a snack containing protein and starch (eg, milk or cheese and crackers) is
recommended unless the patient plans to eat a regular meal or snack within 30 to 60 minutes.
 INITIATING EMERGENCY MEASURES
In emergency situations, for adults who are unconscious and cannot swallow, an injection of
glucagon 1 mg can be administered either subcutaneously or intramuscularly.
After injection of glucagon, the patient may take as long as 20 minutes to regain
consciousness.
A concentrated source of carbohydrate followed by a snack should be given to the patient
on awakening to prevent recurrence of hypoglycemia (because the duration of the action of
1 mg of glucagon is brief—its onset is 8 to 10 minutes, and its action lasts 12 to 27 minutes)
In hospitals and emergency departments, for patients who are unconscious or cannot
swallow, 25 to 50 mL of 50% dextrose in water (D 50W) may be administered IV.
The effect is usually seen within minutes.
 DIABETIC KETOACIDOSIS
DKA is caused by an absence or markedly inadequate amount of insulin.
This deficit in available insulin results in disorders in the metabolism of
carbohydrate, protein, and fat.
The three main clinical features of DKA are
1. Hyperglycemia
2. Dehydration and electrolyte loss
3. Acidosis
 CLINICAL MANIFESTATIONS
❑The hyperglycemia of DKA leads to polyuria and polydipsia.
❑Blurred vision, weakness, and headache.
❑Orthostatic hypotension
❑Hypotension with a weak, rapid pulse.
❑The ketosis and acidosis of DKA lead to gastrointestinal symptoms such as anorexia, nausea,
vomiting, and abdominal pain.
❑The patient may have acetone breath (a fruity odor), which occurs with elevated ketone levels.
❑ Hyperventilation
❑ The patient may be alert, lethargic, or comatose.
 ASSESSMENT AND DIAGNOSTIC FINDINGS

❑Blood glucose levels may vary between 300 and 800 mg/dL
❑ ??? 1000 mg/dL or higher (usually depending on the degree of dehydration).
❑Low serum bicarbonate (0 to 15 mEq/L) and low pH (6.8 to 7.3) values.
❑A low partial pressure of carbon dioxide (PCO 2; 10 to 30 mm Hg) reflects respiratory compensation
(Kussmaul respirations) for the metabolic acidosis.
❑Accumulation of ketone bodies (which precipitates the acidosis) is reflected in blood and urine ketone
measurements.
❑Sodium and potassium concentrations may be low, normal, or high, depending on the amount of water
loss (dehydration).
❑Increased levels of creatinine, blood urea nitrogen (BUN), and hematocrit may also be seen with
dehydration.
 MANAGEMENT

Rehydration
6 to 10 L of IV fluid to replace fluid losses caused by polyuria, hyperventilation, diarrhea, and vomiting.
Initially, 0.9% sodium chloride (normal saline) solution is administered at a rapid rate, usually 0.5 to 1 L/h
for 2 to 3 hours.
Half-strength normal saline (0.45%) solution (also known as hypotonic saline solution) may be used for
patients with hypertension or hypernatremia and those at risk for heart failure.
After the first few hours, half-strength normal saline solution is the fluid of choice for continued rehydration
(200 to 500 mL/h) may be needed for several more hours.
When the blood glucose level reaches 300 mg/dL (16.6 mmol/L) or less, the IV solution may be changed to
dextrose 5% in water (D5W) to prevent a precipitous decline in the blood glucose level
 RESTORING ELECTROLYTES

❑The major electrolyte of concern during treatment of DKA is potassium.

❑Although the initial plasma concentration of potassium may be low,
normal, or even high, there is a major loss of potassium from body stores
and an intracellular-to-extracellular shift of potassium.
❑Rehydration also leads to increased urinary excretion of potassium.
❑Insulin administration enhances the movement of potassium from the
extracellular fluid into the cells.
 REVERSING ACIDOSIS
➢Ketone bodies (acids) accumulate as a result of fat breakdown.
➢The acidosis that occurs in DKA is reversed with insulin.
➢Insulin is usually infused intravenously at a slow, continuous rate (eg, 5 units/h).
➢Hourly blood glucose values must be measured.
➢IV fluid solutions with higher concentrations of glucose, such as normal saline (NS) solution
(eg, D5NS, D5·45NS), are administered when blood glucose levels reach 250 to 300
mg/dL
➢Regular insulin, the only type of insulin approved for IV use, may be added to IV
solutions.
➢Even if blood glucose levels are decreasing and returning to normal, the insulin
drip must not be stopped until subcutaneous insulin therapy has been started.
➢Rather, the rate or concentration of the dextrose infusion should be increased.
➢Blood glucose levels are usually corrected before the acidosis is corrected.
➢Therefore, IV insulin may be continued for 12 to 24 hours, until the serum
bicarbonate level increases (to at least 15 to 18 mEq/L) and until the patient can
eat.
➢In general, bicarbonate infusion to correct severe acidosis is avoided during
treatment of DKA because it precipitates further, sudden (and potentially fatal)
decreases in serum potassium levels.
 LONG-TERM COMPLICATIONS OF
DIABETES
Macrovascular Complications:
❑Coronary artery disease
❑Cerebrovascular disease
❑ Peripheral vascular disease
Microvascular Complications:
❑Diabetic Retinopathy
❑Nephropathy
❑Diabetic Neuropathies