Diabetes Mellitus Lecture Note 2 PDF

PANCREAS ❑Insulin is secreted by beta cells, which are one of four types of cells in the islets of Langerhans in the pancreas. ❑Insulin lowers blood glucose and facilitates a stable, normal glucose range of approximately 70 to 120 mg/dL (3.9 to 6.66 mmol/L). ❑The average amount of insu...

PANCREAS ❑Insulin is secreted by beta cells, which are one of four types of cells in the islets of Langerhans in the pancreas. ❑Insulin lowers blood glucose and facilitates a stable, normal glucose range of approximately 70 to 120 mg/dL (3.9 to 6.66 mmol/L). ❑The average amount of insulin secreted daily by an adult is approximately 40 to 50 U, or 0.6 U/kg of body weight.  FUNCTION OF THE INSULIN Insulin is a hormone produced by the pancreas, specifically by the beta cells of the islets of Langerhans. Its primary functions in the body include: 1. Regulating Blood Glucose Levels: 1. Insulin helps lower blood sugar levels by facilitating the uptake of glucose into cells, particularly in muscle, fat, and liver cells. 2. After a meal, insulin is secreted in response to rising blood sugar, allowing cells to absorb glucose from the bloodstream to use for energy or storage. 2. Promoting Glucose Storage (Glycogenesis): 1. Insulin stimulates the liver to convert excess glucose into glycogen for storage. This stored glycogen can later be broken down into glucose when blood sugar levels drop. 3. Inhibiting Glucose Production (Gluconeogenesis): 1. Insulin suppresses the liver’s ability to produce glucose from non- carbohydrate sources, such as fats and proteins, thereby preventing unnecessary increases in blood glucose. 1. Fat Storage (Lipogenesis): 1. Insulin promotes the storage of fat by stimulating fat cells (adipocytes) to take in fatty acids and store them as triglycerides. 2. It also inhibits the breakdown of fat (lipolysis), reducing the release of free fatty acids into the bloodstream. 2. Protein Synthesis: 1. Insulin plays a role in protein metabolism by promoting the uptake of amino acids into cells, which aids in protein synthesis and muscle building. 3. Regulating Potassium Levels: 1. Insulin helps regulate potassium levels in the blood by stimulating potassium uptake into cells, which helps maintain electrolyte balance. Overall, insulin is essential for maintaining stable blood glucose levels and facilitating the storage and utilization of nutrients. Its dysregulation can lead to conditions like diabetes mellitus. ❑ Insulin promotes glucose transport from the bloodstream across the cell membrane to the cytoplasm of the cell. ❑The rise in plasma insulin after a meal stimulates storage of glucose as glycogen in liver and muscle, inhibits gluconeogenesis, enhances fat deposition of adipose tissue, and increases protein synthesis. For this reason, insulin is an anabolic, or storage, hormone. ❑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 ❑Insulin also inhibits the breakdown of stored glucose, protein, and fat. ❑ Most insulin receptors are located on skeletal muscle, fat, and liver cells. ❑ When insulin is not properly used, the entry of glucose into the cell is impeded, resulting in hyperglycemia. During fasting periods (between meals and overnight), the pancreas continuously releases a small amount of insulin (basal insulin); another pancreatic hormone called glucagon (secreted by the alpha cells of the islets of Langerhans) is released when blood glucose levels decrease and stimulates the liver to release stored glucose. The insulin and the glucagon together maintain a constant level of glucose in the blood by stimulating the release of glucose from the liver.  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).  SUMMARY OF INSULIN : Physiology Insulin Metabolic Functions: 1. Transports and metabolizes GLUCOSE 2. Promotes GLYCOGENESIS 3. Promotes GLYCOLYSIS 4. Enhances LIPOGENESIS 5. Accelerates PROTEIN SYNTHESIS DIABETES MELLITUS ❑It is a chronic multisystem disease related to abnormal insulin production, impaired insulin utilization, or both Diabetes mellitus often simply diabetes, is a syndrome characterized by disordered metabolism and inappropriately high blood sugar (hyperglycaemia) resulting from either low levels of the hormone insulin or from abnormal resistance to insulin's effects coupled with inadequate levels of insulin secretion to compensate.  A diagnosis of diabetes is suggested when the fasting whole blood glucose level is 5.7 mmol/L or more and/or random blood glucose, taken 2hours after a meal or 75 g glucose load (1.75 g/kg body weight in children), is 7.8 mmol/L or more. The term diabetes, without qualification, usually refers to diabetes mellitus, which is associated with excessive sweet urine (known as "glycosuria") but there are several rarer conditions also named diabetes. The most common of these is diabetes insipidus in which the urine is not sweet (insipidus meaning "without taste" in Latin); it can be caused by either kidney or pituitary gland damage.  TYPE OF DIABETES MELLITUS There are two main types of diabetes mellitus which are differentiated by cause, course and treatment. These are; ❑Type I or insulin dependant /Juvenile Onset Diabetes mellitus (IDDM) ❑Type II or non-insulin Dependant or maturity onset Diabetes mellitus (NIDDM)  Other types are: ❑ Gestational Diabetes ❑ Diabetes secondary to other medical conditions or syndromes. ❑Other specific types of diabetes – Monogenic diabetes syndromes – Diseases of the exocrine pancreas, e.g., cystic fibrosis ❑Drug- or chemical-induced diabetes Eg corticosteroids (prednisone), thiazides, phenytoin (Dilantin), and atypical antipsychotics (e.g., clozapine [Clozaril]).  TYPE I OR INSULIN DEPENDANANT/JUVINILE ONSET DIABETES MELLITUS IDDM ❑Type 1 diabetes is characterized by destruction of pancreatic beta cells; combined genetic, immunologic, and possibly environmental factors are thought to contribute to beta cell destruction. ❑ it occurs in the youth usually before age 30. ❑ Here there is insufficient amount of insulin or cessation in the production of insulin.  TYPE II OR NON- ISULIN DEPENDANT DIABETES OR MATURITY ONSET DIABETES ❑This type of diabetes occurs after the age of 30. ❑There are two main causes of type II diabetes: insulin resistance and impaired insulin production. ❑The most powerful risk factor is obesity, especially abdominal and visceral adiposity. ❑ Majority of people with this type of diabetes are obese ❑In type II diabetes the pancreas usually continues to produce some endogenous (self-made) insulin. ❑However, the insulin that is produced is either insufficient for the needs of the body or is poorly used by the tissues, or both.  ❑The etiology of type II DM is unknown ❑Probably genetic and obesity ❑ It is usually treated with diet or a combination of diet, exercise and oral medications.  GESTATIONAL DIABETES MELLITUS ❑ This type occurs in pregnancy usually in the last trimester. Pregnancy causes weight gain and this increase the level of estrogen and placental hormones which are antagonistic to insulin utilization. ❑ Babies born in these pregnancies are usually large and over weight. There are also signs of maternal polyhydramnios. ❑ Blood glucose returns to normal after delivery of the infant  INCIDENCE ❖As the name suggest in the classification, type I diabetes mellitus is sudden in onset and occurs before age 30. About 5%-10% of people with diabetic has Type I. ❖Type II diabetes takes about 90%-95% of all diabetes; the onset is usually after 30 years. Gestational diabetes occurs in 2% of all pregnancies.  AETIOLOGY ❑Autoimmune disorder (Type 1 diabetes) ❑Idiopathic (Type 1 diabetes) ❑Genetic factors causing a defect in the action or secretion of insulin (Type 2 diabetes) ❑Environmental factors e.g. excessive calorie intake and lack of physical activity (Type 2 diabetes) ❑Pregnancy (Gestational diabetes) ❑Secondary diabetes: Medication e.g. corticosteroid use or abuse Pancreatic disease or pancreatectomy Endocrine disorders e.g. Cushing’s syndrome, acromegaly etc.  RISK FACTORS for Diabetes Mellitus 1. Family History of diabetes 2. Obesity 3. Race/Ethnicity 4. Age of more than 45 5. Previously unidentified IFG/IGT 6. Hypertension 7. Hyperlipidemia 8. History of Gestational Diabetes Mellitus  PATHOPHYSIOLOGY ❑In diabetes where insulin level is low or insensitive, the glucose produce would not be effectively absorbed by the body cells hence high glucose level in the bloood (hyperglycemia). Signs and symptoms: glucosuria, polyuria, polydipsia, polyphagia  TYPE 1- Diabetes Mellitus PATHOPHYSIOLOGY Destruction of BETA cells decreased insulin production uncontrolled glucose production by the liver hyperglycemia signs and symptoms CLASSIC P’s Polyuria Polydipsia Polyphagia  TYPE 2- Diabetes Mellitus PATHOPHYSIOLOGY ❑ Decreased sensitivity of insulin receptor to insulin less uptake of glucose HYPERGLYCEMIA ❑ Decreased insulin production diminished insulin action HYPERGLYCEMIA signs and symptoms  CLINICAL MANIFESTATIONS ❖Polyuria: (increased urination) it occurs as a result of the excess loss of fluid associated with osmotic diuresis. ❖Polyphagia: increased appetite, resulting from catabolic state induced by insulin deficiency and the breakdown of protein and fats. ❖Polydipsia: increased thirst also occurs as a result of fluid lost. Other symptoms include; ❖Fatigue and weakness ❖Sudden vision changes ❖Tingling and numbness in hands or feet ❖Dry skin , Poor skin turgor ❖Recurrent infections ❖Weight loss ❖ nausea /Vomiting ❖Abdominal pains. ❖Poor vision ❖Pruritus vulvae (genital itching in females) ❖Paresthesia (tingling of fingers and feet) ❖Aching and cramps that become common in the legs; ❖Lowered resistance to infection that is , minor infections such as skin boils occur ❖Kitoacidosis ❖Fruity smell of breath. ❖Impotence in men ❖Skin lesions or wound that is slow to heal ❖Foot gangrene ❖Pedal oedema  DIAGNOSTIC INVESTIGATIONS Random Plasma Glucose Test Procedure: Blood glucose level is tested at any time, without fasting. Diabetes: A reading of 200 mg/dL (11.1 mmol/L) or higher, especially with classic symptoms of hyperglycemia (e.g., increased thirst, urination, and fatigue). Fasting Plasma Glucose (FPG) Test Procedure: Measures blood glucose after an overnight fast (at least 8 hours). Normal range: Less than 100 mg/dL (5.6 mmol/L). Pre-diabetes: 100–125 mg/dL (5.6–6.9 mmol/L). Diabetes: 126 mg/dL (7.0 mmol/L) or higher on two separate occasions. 2. Oral Glucose Tolerance Test (OGTT) Procedure: After fasting, the patient drinks a glucose solution, and blood glucose levels are tested 2 hours later. Normal range: Less than 140 mg/dL (7.8 mmol/L). Pre-diabetes: 140–199 mg/dL (7.8–11.0 mmol/L). Diabetes: 200 mg/dL (11.1 mmol/L) or higher. 3. Glycated Hemoglobin (HbA1c) Test Procedure: Measures the average blood glucose level over the past 2 to 3 months by assessing how much glucose is attached to hemoglobin. Normal range: Less than 5.7%. Pre-diabetes: 5.7% to 6.4%. Diabetes: 6.5% or higher. 5. C-Peptide Test Procedure: Measures C-peptide levels, a byproduct of insulin production, to determine how much insulin is being produced by the pancreas. Purpose: Helps differentiate between type 1 (low insulin production) and type 2 diabetes (insulin resistance). 6. Insulin Autoantibodies (IAA) Test Procedure: Detects the presence of antibodies against insulin, which is often seen in type 1 diabetes, particularly in younger patients. Purpose: Useful for diagnosing type 1 diabetes and differentiating it from type 2. 7. Lipid Profile Purpose: Diabetics often have abnormal cholesterol and triglyceride levels. A lipid profile helps assess cardiovascular risk. Components: Total cholesterol, LDL, HDL, and triglycerides. 8. Urine Tests Urine Ketones: Assesses the presence of ketones, especially in type 1 diabetes, indicating diabetic ketoacidosis (DKA). Microalbuminuria: Detects small amounts of protein in the urine, which may indicate diabetic nephropathy (kidney damage). 9. Continuous Glucose Monitoring (CGM) Procedure: Uses a sensor inserted under the skin to measure glucose levels continuously. Purpose: Monitors glucose trends over time, particularly useful for patients using insulin. 10. Fructosamine Test Procedure: Measures the average glucose levels over the past 2 to 3 weeks, useful for short-term glucose control assessment. Purpose: Sometimes used in situations where HbA1c testing is unreliable (e.g., hemoglobin variants or anemia). 11. Genetic Testing Purpose: In cases of suspected MODY (Maturity Onset Diabetes of the Young) or other rare forms of diabetes, genetic testing can confirm diagnosis. 12. Blood Pressure and Eye Examinations Diabetes increases the risk of complications like hypertension and retinopathy, so regular monitoring of blood pressure and retinal health is essential. Fasting plasmaglucose2-hr post prandial Fasting plasma HbA1C Status glucose 2-hr plasma post prandial plasma glucose glucose HbA1c Status Fasting plasma glucose 2-hr post prandial plasma glucose 11.1 mmol/L > 6.5 % Diabetes ❖ Prediabetes. Individuals diagnosed with prediabetes are at increased risk for the development of type 2 diabetes. ❖ Prediabetes is defined as impaired glucose tolerance (IGT), impaired fasting glucose (IFG), or both. ❖ It is an intermediate stage between normal glucose homeostasis and diabetes where the blood glucose levels are elevated, but not high enough to meet the diagnostic criteria for diabetes. ❖ A diagnosis of IGT is made if the 2-hour oral glucose tolerance test (OGTT) values are 140 to 199 mg/dL (7.8 to 11.0 mmol/L). ❖ IFG is diagnosed when fasting blood glucose levels are 100 to 125 mg/dL (5.56 to 6.9 mmol/L). ❖ The diagnosis of diabetes mellitus is made through one of the following four methods. 1. A1C of 6.5% or higher. A1C measures the amount of glycosylated hemoglobin as a percentage of total hemoglobin (e.g., A1C of 6.5% means that 6.5% of the total hemoglobin has glucose attached to it). 2. Fasting plasma glucose (FPG) level greater than or equal to 126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours. 3. Two-hour plasma glucose level greater than or equal to 200 mg/dL (11.1 mmol/L) during an OGTT, using a glucose load of 75 g. 4. In a patient with classic symptoms of hyperglycemia (polyuria, polydipsia, unexplained weight loss) or hyperglycemic crisis, a random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L).  Physical Examination ❖Blood pressure (sitting and standing to detect orthostatic changes). ❖Body mass index (height and weight). ❖Foot examination (lesions, signs of infection, pulses) ❖Skin examination (lesions and insulin injection sites). ❖Neurologic examination; ❖Deep tendon reflexes. ❖Ophthalmologic examination may show diabetic retinopathy OR Fundoscopic examination and visual acuity ❖Liver biochemistry to determine liver damage or function  TREATMENT Treatment objectives ❖To relieve symptoms ❖To prevent acute hyperglycaemic complications i.e. ketoacidosis and the hyperosmolar state. ❖To prevent treatment-related hypoglycaemia ❖Fasting blood glucose between 4-7 mmol/L (less intensive glycaemic targets in elderly patients) ▪ 2-hour post-meal blood glucose between 5-9 mmol/L (less intensive glycaemic targets in elderly patients) ▪ Glycated haemoglobin 7 % or less (less intensive glycaemic targets in elderly patients) ❖To ensure weight reduction in overweight and obese individuals ❖To prevent chronic complications of diabetes ❖Blood pressure less than 130/80 mmHg  Management ❑Nutritional ❑Exercise ❑Monitoring ❑Pharmacologic ❑Education  Non-pharmacological treatment DIET: ❖ All patients with diabetes require diet therapy. ❖ All patients (and close relations who cook or control their meals) must be referred to a dietician or diet nurse for individualized meal plans. ❖In general, patients must; Avoid refined sugars as in soft drinks, or adding sugar to their beverages. Artificial sweeteners and 'diet' soft drinks, which do not contain glucose, may however be used. ❖Be encouraged to have complex carbohydrates (e.g. kenkey, yam, plantain etc.) instead. ❖A day's diet must generally consist of; Carbohydrates (60%), protein (15%) and fat (25%) mostly of plant- origin and low in animal fat. ❑ Alcohol. Alcohol inhibits gluconeogenesis (breakdown of glycogen to glucose) by the liver. This can cause severe hypoglycemia in patients on insulin or oral hypoglycemic medications that increase insulin secretion. ❑ Low consumption is permissible in adult patients, moderate to heavy drinking of alcohol increases the total caloric intake and may worsen overweight and obesity. ❑Salt (sodium chloride) < 5 g/day ❑Fruits and vegetables ≥ 400 g/day ❑Soluble fibre (e.g. as found in oats, beans, apples, nuts etc.) ❑A reduced total caloric content (portions) of food and an increase in the amount of fibre e.g. vegetables, fruits and cereals ❑Owing to the special needs of children for a diet that will ensure optimal growth, their diet must be determined by a dietician in consultation with a paediatrician  EXERCISE ❖1. Teach that exercise can lower the blood glucose level ❖ 2. Diabetics must first control the glucose level before initiating exercise programs. ❖3. Offer extra food /calories before engaging in exercise ❖ 4. Offer snacks at the end of the exercise period if patient is on insulin treatment. ❖ 5. Advise that exercise should be done at the same time every day, preferably when blood glucose levels are at their peak ❖ 6. Regular exercise, not sporadic exercise, should be encouraged. ❖ 7. For most patient, WALKING is the safe and beneficial form of exercise ❖Regular, simple exercise e.g. 30 minutes brisk walking at least 3 days a week in ambulant patients should be encouraged. ❖All advice on exercise must give consideration to the patient's age and the presence of complications and other medical conditions.  MONITORING ❖Self-monitoring of blood glucose (SMBG) enables the patient to adjust the treatment regimen to obtain optimal glucose control ❖Patients on insulin should check sugars 2-4 times per day ❖Not on insulin, two or three times per week (according to text) ❖Should check before meals and 2 hours after meals ❖Parameters from physician very important ❖Evaluates trends and efficacy of treatment over 24h period  EDUCATION ❖Education is critical ❖Simple pathophysiology ❖Treatment modalities ❖Recognition, treatment and prevention of acute complications ❖When to call the doctor ❖Foot care, eye care, general hygiene, risk factor management ❖Teaching patients to administer insulin ❖Storing insulin (may not refrigerate if used within one month). Prefilled syringes should be stored standing up. ❖Syringes ❖Concentrations of insulin ❖Mixing insulin ❖No need to aspirate  Pharmacological treatment Sulphonylureas All sulphonylureas are of equal potency and efficacy and are best taken 30 minutes before meals. Glibenclamide oral, 2.5-10 mg as a single dose in the morning (If required, not more than 5 mg of Glibenclamide could additionally be given in the evening maximum total dose 15 mg per day) Or Gliclazide, oral, 40-160 mg 12 hourly Or Glimepiride, oral, 2-6 mg as a single dose in the morning Or Tolbutamide, oral, 250 mg-1 g 8-12 hourly  Biguanides Metformin, oral, 500 mg-1 g 12 hourly with, or soon after, meals Thiazolidinediones Pioglitazone, oral, 15-45 mg, as single daily dose Or Rosiglitazone, oral, 4-8 mg, as single daily dose Insulin Rapid-acting Insulin Insulin aspart Insulin lispro Short-acting Insulin Regular insulin  Intermediate-acting Insulin Isophane (NPH) insulin Long-acting Insulin Insulin glargine Insulin detemir Pre-mixed Insulin Regular insulin 30% PLUS NPH Insulin 70%  NURSING MANAGMENT EXERCISE Regular exercise is especially important for people with diabetes. It helps with blood sugar control, weight loss, and control high blood pressure. People with diabetes who exercise are less likely to experience a heart attack or stroke than diabetics who do not exercise regularly. Patient should be evaluated by physician before starting an exercise program. ❖Choose an enjoyable physical activity that is appropriate for your current fitness level. ❖Exercise every day, and at the same time of day, if possible. ❖Monitor blood glucose levels before and after exercise. ❖Carry food that contains a fast-acting carbohydrate in case you become hypoglycemic during or after exercise. ❖Carry a diabetes identification card and a mobile phone in case of emergency. ❖Drink extra fluids that do not contain sugar before, during, and after exercise. ❖Changes in exercise intensity or duration may need changes in diet or medication dose to keep blood sugar levels from going too high or low.  FOOT CARE ❖ People with diabetes are prone to foot problems because of the likelihood of damage to blood vessels and nerves and a decreased ability to fight infection. Problems with blood flow and damage to nerves may cause an injury to the foot to go unnoticed until infection develops. Death of skin and other tissue can occur. ❖ If left untreated, the affected foot may need to be amputated. Diabetes is the most common condition leading to amputations. ❖ To prevent injury to the feet, people with diabetes should adopt a daily routine of checking and caring for the feet as follows: ❖ Check your feet every day, and report sores or changes and signs of infection. ❖ Wash your feet every day with lukewarm water not hot, water and mild soap, and dry them thoroughly. ❖ Educate patient not to soak his feet. ❖Client should not check water temperature with his feet but use a thermometer or elbow to prevent burns. ❖Soften dry skin with lotion or petroleum jelly. ❖Protect feet with comfortable, well-fitting shoes. ❖Exercise daily to promote good circulation. ❖See a podiatrist for foot problems or to have corns or calluses removed. ❖Remove shoes and socks during a visit to your health care provider and remind him or her to examine your feet. ❖Stop smoking, which hinders blood flow to the feet. ❖ Take care of your diabetes by working with your health care team to keep your blood glucose level within a normal range. ❖Smooth corns and calluses gently by using a pumice stone ❖ Trim your toenails straight across and file the edges with an emery board or nail file each week or when needed. ❖ Wear shoes and socks at all times and never walk barefoot. ❖ Feel inside your shoes before putting them on each time to make sure the lining is smooth and there are no objects inside. ❖. Protect your feet from hot and cold by wearing shoes at the beach or on hot pavement. ❖ Keep the blood flowing to your feet by wiggling your toes and move your ankles up and down for 5 minutes, 2 or 3 times a day and do not cross your legs for long periods of time. ❖ Educate client to follow health care provider’s advice about foot care and do not self-medicate or use home remedies or over the- counter agents to treat foot problems. Instructions for Patients With Diabetes Mellitus Include the following essential instructions for diabetes management. what to do Blood Glucose ❖Monitor your blood glucose at home and record results in a log. ❖Take your insulin. OA, and/or noninsulin injectable agent as prescribed. ❖Obtain A1C blood test every 3-6 month as an indicator of your long-term blood glucose control.  Blood Glucose cont… ❖ Know the symptoms of hypoglycaemia and hyperglycaemia. ❖Carry some form of rapid-acting glucose at all times so you can treat hypoglycaemia quickly. ❖Instruct family members how and when to use glucagon if patient becomes unresponsive because of hypoglycaemia.  Blood Glucose cont… Do not ❖Skip doses of your insulin, especially when you are sick. ❖Run out of insulin. ❖ Ignore the symptoms of hypoglycaemia and hyperglycaemia.  Exercise DO ❖Learn how exercise and food affect your blood glucose levels. ❖Begin an exercise program after approval from health care provider DO NOT ❖Forget that exercise will lower your blood glucose level  Diet DO ❖Have an individualized meal plan created by a dietician. ❖Follow your diet, eating regular meals at regular times. ❖Choose foods low in saturated and trans fat. ❖Limit the amount of alcohol you drink. ❖ Know your cholesterol level.  Diet Cont…. DO NOT ❖Drink excessive amounts of alcohol because this may lead to unpredictable low blood glucose reactions. ❖ Use a fad diet. ❖ Drink regular soda or lots of fruit juice.  Other Guidelines ❖ Obtain an annual eye examination by an ophthalmologist. ❖ Obtain annual urine testing for protein. ❖ Examine your feet at home. ❖ Wear comfortable, well-fitting shoes to help prevent foot injury. Break in new shoes gradually. ❖ Always carry identification that says you have diabetes. ❖ Have other medical problems treated, especially high blood pressure and high cholesterol. ❖ Quit cigarette smoking.  DO NOT ❖Smoke cigarettes or use nicotine products. ❖Apply hot or cold directly to your feet. ❖ Go barefoot. ❖Put oil or lotion between your toes. Acute Complication / Diabetic Emergencies ❖Diabetic ketoacidosis , ❖Nonketotic hyperosmolar coma , ❖Hypoglycaemia , and ❖Diabetic coma  The long-term complications ❑ Diabetes is the leading cause of adult: ▪ blindness, ▪ end-stage kidney disease, and ▪ nontraumatic lower limb amputations. ❑ It is also a major contributing factor to heart disease and stroke. ❑ Adults with diabetes have heart disease death rates two to four times higher than adults without diabetes. ❑ The risk for stroke is also two to four times higher among people with diabetes. ❑ It is estimated that 67% of adults with diabetes have hypertension. THANKS