Diabetes Mellitus

A group of metabolic disorders resulting in hyperglycemia is called diabetes mellitus

 (DM), where relative or absolute deficiency of insulin is seen.

Functional anatomy and Physiology-

Blood glucose is tightly regulated by DM, so a balance is preserved between entry, circulation, absorption and uptake by peripheral tissues.

Insulin is an anabolic hormone with profound effects on the metabolism of carbohydrate, fat and protein.

Types-

DM is better understood by its classification-

There are 2 main commonly seen types-

1. Type 1 DM (insulin-dependent DM) [5-10%]

• Type 1a (autoimmune)
• Type 1b (idiopathic)

2. Type 2 DM ( non-insulin dependent DM)[90%]

Other types are-

3. Gestational diabetes
4. Others-

• Maturity onset diabetes of young (MODY)- genetic defect
• Defect in insulin action ( type A insulin resistance)
• Endocrinopathies (Cushing’s syndrome, glucagonoma, pheochromocytoma, acromegaly, thyrotoxicosis)
• Diseases of exocrine pancreas (chronic pancreatitis, cystic fibrosis, hemochromatosis)
• Drug induced (nicotinic acid, glucocorticoids,thiazides, protease inhibitor)
• Associated with genetic syndromes ( Down’s syndrome, Klinefelter’s syndrome)
• Infection induced ( congenital rubella, mumps, Coxsackievirus B) 
• Uncommon forms of immune mediated DM (stiff-man syndrome, anti-insulin receptor antibodies)

Pathogenesis-

Common pathology-

• Reduced insulin secretion
• Decreased glucose use by the body
• Increased glucose production

Clinical features-

Common features of hyperglycemia-

• Thirst and dry mouth
• Polyuria and nocturia
• Tiredness, fatigue and lethargy
• Weight loss
• Blurry vision
• Genital candidiasis
• Nausea, headache
• Predilection of sweet food
• Irritability, difficulty in concentration, apathy etc.

Contrasting features of type 1 and type 2 DM

Investigation-

Plasma-Glucose level

Sample type	Normal value	Diabetes mellitus
Fasting (> 8 hour)	Below 100 mg/dl	126 mg/dl or more
Random	<140 mg/dl	200 mg/dl or more
2 hour after glucose intake of 75 Gm in water	<140 mg/dl	200 mg/dl or more

Management-

• Lifestyle modification adaptation to fit and healthier habits like regular exercise and weight loss is important to control diabetes.
• Dietary modification to control sugar and cholesterol intake and maintain blood sugar level.
• Regular sugar level monitor.
• Pharmacological management-

Type 1-

1. Insulin injections- Humalog, Novorapid, Lantus etc.
2. Continuous subcutaneous insulin infusion device (CSIID) or insulin pump
3. Insulin analogue- Insulin lispro, Insulin aspart, Insulin glargine.

Type 2-

1. Oral hypoglycemic drugs-

• Enhance insulin secretion-

1. Sulfonylureas
2.  Glucagon-like peptide-1(GLP-1) receptor agonists
3. Dipeptidyl peptidase-4 (DPP-4)

• Overcome insulin resistance-

1. Metformin
2. Thiazolidinediones
3. Others ( SGLT-2 inhibitor; alpha-Glucosidase inhibitor)

2. Insulin injection

• Physiotherapy management-

A physical therapist can help diabetic patients in living a healthy life, regular physical activity promotes glycemic control and enhances insulin

action thus promotes weight loss, management of sores, management of diabetic nephropathy.

• Regular physical activities help prevent or delay diabetes and its complications.
• Exercise recommendation according to fitt principle-

Type	Frequency	Intensity	Time	type
Type 1	3 D vigorous or 5D moderate	Moderate (11-12 RPE) to vigorous (14-17 RPE)	If moderate intensity at least 150 min/wkIf vigorous 60 min/wk	Walk, jog, cycle, row, swim, aquatic activities, seated exercises, team sports
Type 2	7 D/week (no more than 2 days should lapse between bouts of activity	Moderate (11-12 RPE) to vigorous (14-17 RPE)	At least 150 min/wk of moderate to vigorous intensity	Walk, jog, cycle, row, swim, aquatic activities, seated exercises, team sports

Reference-

• Jennifer A. Pryor and Barbara A. Webber ( Physiotherapy for respiratory and cardiac problems)
• Praveen Kumar and Michael Clark ( Clinical medicine)
• Nicki R. Colledge, Brian R. Walker and Stuart H. Ralston ( Davidson’s principles and practice of medicine )
•  J. Larry jamson, Anthony S. Fauci, Dennis L. Casper, Stephen L. Hauser, Dan L. Longo and Joseph Loscalzo (Harrison’s manual of medicine)
• Lee Goldman and Andrew I. Schafer ( Goldman – Cecil medicine)
• Wolters Kluwer ( American college of sports medicine’s exercise testing and prescription)