Diabetes Mellitus
p. 1 of 5
Definitions: Diabetes mellitus is a chronic metabolic disorder characterized by
hyperglycemia due to defective insulin secretion, insulin action or both. Chronic
hyperglycemia is associated with significant long-term sequelae particularly: damage,
dysfunction and failure of organs, especially: kidneys, eyes, nerves, heart and blood
vessels. There is no known cure for diabetes.
Dysglycemia is blood glucose (BG) that is abnormal without a defining threshold.
Classic Symptoms:
 polyuria (↑ urination),
 polydipsia (glucose in urine),
 unexplained weight loss
Classification of Diabetes:
Type 1 result of pancreatic beta cell destruction; prone to ketoacidosis. Includes
autoimmune cases.
Type 2: ranges from insulin resistance with relative insulin desufficiency to secretory
defect with resistance.
Gestational: glucose intolerance during pregnancy
Other Specific Types: wide variety of uncommon conditions.
Diagnosis:
Fasting (>8 hrs) Plasma Glucose: FPG ≥ 7.0 mmol/L
Random Plasma Glucose ≥11.1 mmol/L & symptoms of Diabetes
Oral Glucose (75g) Tolerance Test, 2h Plasma Glucose ≥ 11.1 mmol/L
A confirmatory lab glucose test must be done, in the absence of hyperglycemia with
acute metabolic decompensation..
Diagnosis of Impaired Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT)
FPG 6.1 – 6.9mmol/l or 2hPG in a 75g OGTT 7.8 - 11.0mmol.L
Diagnosis of Diabetes FPG ≥ 7.0mmol/l or 2hPG in a 75g OGTT ≥ 11.1mmol.L
Glucosated Hemoglobin (HgbA1C) is essentially glucose bound to hemoglobin and gives
a 3 month picture of past glucose control. HgbA1C has a lack of standardization and this
precludes its use in the diagnosis of diabetes.
Prediabetes: Metabolic Syndrome:
leads to a significant risk of developing diabetes and CVA:
 Abnormal abdominal obesity,
 hypertension,
 dyslipidemia (high cholesterol and/or triglycerides),
 insulin resistance and dysglycemia
(Reference: NCEP ATP III Criteria [JAMA.2001;285:2486-2497])
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Diabetes Mellitus p. 2 of 5
Metabolic Syndrome
Risk Factor
FPG (Fasting Plasma Glucose)
BP (Blood Pressure)
TG (Triglycerides)
HDL-C: Men (High Density Lipoprotein)
Women
Abdominal Obesity: Men
Women
Defining Level (≥ 3 risk determinants)
≥ 6.1 mmol/L
≥ 130 / 85 mmHg (Diabetes goal: ≤130/80)
≥ 1.7 mmol/L
< 1.0 mmol/L
< 1.3 mmol/L:
Waist Circumference: >102 cm (40”)
> 88 cm (35”)
Risk Factors for Type 2 Diabetes (Key: * = associated with metabolic syndrome)
 Age ≥ 40 yrs.
 1st Degree relative with diabetes
 Aboriginals, Hispanic, S. Asian, Asian, African descent
 IGT or IFG*
 Complications associated with Diabetes
 Vascular disease*
 GDM history
 Macrosomic infant history
 Hypertension*
 Dyslipidemia*
 Overweight*
 Abdominal Obesity*
 Polycystic Ovary Syndrome*
 Acanthosis nigricans* (‘tanned’ lower legs)
 Schizophrenia (3x higher than general population)
 Other: genetic defects of Beta cells / insulin action; diseases of pancreas;
endocrinopathies; infections (congenital rubella, cytomegalovirus, etc.); drug or
chemical induced; genetic syndromes
Screening for Diabetes:
Adults: screen for risks annually.
Obese children ≥ 10 yrs. old with risks, screen biannually.
FPG every 3 years if ≥ 40yrs. with no other risks; Earlier / more frequently if more risks.
Pregnant women: screened at 24-28 wks gestation; if multiple risks, in 1st trimester;
Urine dipstick test at each prenatal visit screen for glycosuria & other problems.
Symptoms of Hypoglycemia
Neurogenic (autonomic)
Neuroglycopenic
Trembling
Palpitations
Difficulty concentrating
Confusion
Sweating
Anxiety
Weakness
Drowsiness
Hunger
Nausea
Vision Changes
Headache
Tingling
Difficulty speaking
Dizziness
Tiredness
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Diabetes Mellitus p. 3 of 5
Hypoglycemic reactions:
Mild: Autonomic symptoms; client can self-treat.
Moderate: Autonomic and neuroglycopenic symptoms; client can self treat.
Severe: Requires assistance. Unconsciousness may occur. PG <2.8 mmol/L
Hypoglycemia Treatments:
Give carbohydrates – avoid over treatment.
For Mild to Moderate hypoglycemia:
15g glucose (monosaccharide) or sucrose (white sugar) increases PG in 20 min.
Milk and orange juice are slower.
Glucose gel is quite slow and must be swallowed.
For Severe Hypoglycemia: Conscious – 20g glucose orally, test in 15 min. and re-treat
with 15g oral glucose if PG <4.0
Unconscious at home: Glucagon IM/SC; Call EMS (IV D50W should be given).
To prevent repeated hypoglycemia, have client eat usual snack or meal for that time of
day or if meal is >1 hr away, eat a snack including 15g carbohydrate and a protein source.
Hospitalized patients on insulin and at risk for hypoglycemia should have IV access
readily available or a PRN order for glucagon.
Risks for Hypoglycemia:
 Prior episode of severe hypoglycemia
 Current low HgbA1C (<6.0%)
 Hypoglycemia awareness
 Long duration of diabetes
 Autonomic neuropathy
 Adolescence
 Preschool-age unable to detect/treat hyppoglycemia
Diabetes Life Style Modifications:
BP < 130 mmHg systolic and < 80 mmHg diastolic (<130/80)
10% weight loss over 6 months with maintenance via exercise &/or calorie reduction
(500kcal/d deficit can lead to expected weight loss of 1-2kg/month).
For BMI >30, bariatric surgery may be considered.
Exercise: 150 min./week on 3 non-consecutive days; rhythmic repeated and continuous
movement of the same large muscle groups for at least 10 min. at a time.
Sedentary patients should have a preliminary exercise ECG stress test.
DM Type 2 - ≥ 4 hrs./week, moderate intensity (50-70% maximum heart rate)
DM Type 1 – resistance exercise 3x/week
Long term complications of diabetes mellitus can be reduced by tight glycemic control.
The risk of severe hypoglycemia can be 3x higher with intensive therapy, thus
Normoglycemia* may not be desirable for some clients. (*FPG/preprandial
[before eating] 4.0-6.0; PG 2hr. post-prandial [after eating] 5.0 – 8.0);
HgbA1C ≤6.0% may not be appropriate for some (eg children ≤ 12 yrs; elderly)
The emotional and social impact of hypoglycemic reactions may restrict clients’ efforts in
glycemic control.
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Diet Control:
Diabetes Mellitus p. 4 of 5
 Canada’s Guidelines for Healthy Eating
 Eat a variety of foods
 Emphasize whole grain breads, cereals and products, fruits and vegetables
 Choose lower fat dairy products, leaner meats & foods prepared with little/no fat.
 Limit sodium & caffeine
 Limit alcohol (1-2 drinks/d; ♂<14/wk; ♀<9/wk); intake 2-3 hrs after supper can
cause morning hypoglycemia
 Carbohydrates 50-55% of energy
 Protein 15-20% of energy
 Fat <30% of energy (saturated fats & trans fatty acids <10% of energy); include
monosaturates & foods rich in polyunsaturated omega-3 fatty acids & plant oils.
 Choose low glycemic index foods
Diabetes Delivery of Care:
 Multi- & interdisciplinary team approach: Person with diabetes & their family,
Family MD& NP, Specialist, Nurse Educator, Dietician.
 Initial and ongoing needs-based diabetes education to enhance self-care.
 Support persons should be taught how to give glucagon IM/SC.
 BP should be measured every diabetes visit.
 Individuals with diabetes should be screened regularly for psychological
problems, depression & anxiety, using open-ended questioning re: stress, social
support, beliefs about their disease & behaviours that impair glycemic control.
 Adults with diabetes should receive an annual influenza vaccine and considered
for pneumococcal immunization; children should receive both.
 Cardiovascular Risk reduction: pharmacological intervention; lifestyle changes;
reduced weight; optimize BP; lipid control; glycemic control; smoking cessation.
 Annual screening for diabetic neuropathy: Type 2, and Type 1 – test people that
are post-pubertal with diabetes ≥5yrs., using a 10-g monofilament or test for
vibration sensation at the great toe. Carpal tunnel syndrome may present.
 Annual (at least) foot exam for structural abnormalities, neuropathy, vascular
disease, ulceration and infection beginning at puberty.
 Those at high risk for ulceration & amputation require foot care education, proper
footwear, foot trauma avoidance, smoking cessation, & early referrals.
 A fasting lipid profile (Total Cholesterol, HDL-C, Triglycerides & calculated
LDL-C) is done every 1-3 yrs; ≤18yrs. are screened if other risk factors present.
 Annual serum Creatinine levels; those with albuminuria, every 6 mos.
 Infections should be treated aggressively by experts.
 Endoscopic eye exam for retinopathy: Type 1 - annually; Type 2 -every 1-2 yrs.
 All adult males should be periodically screened for erectile dysfunction
 Adolescent & young adult females regularly screened for eating disorders using
nonjudgemental questions about weight / shape concerns, dieting, binge eating &
insulin omission for weight loss.

After 2-3 months of lifestyle management without reaching glycemic targets,
pharmacological interventions usually are initiated.
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Pharmacological Interventions
Diabetes Mellitus p. 5 of 5
Drug Class : Oral
Alpha-glucosidase inhibitor
Acarbose (Prandase®)
Biguanide
Metformin (Glucophage®, generic)
Insulin Secretagogues Sulfonylureas: -gliclazide (Diamicron®, Diamicron® MR, generic)
-glimepride (Amaryl™)
-glyburide (Diabeta®, Euglucon®, generic) (chlorpropamide & tolbutamide rarely used)
-nonsulfonylureas nateglinide (Starlix®) repaglinide (GlucoNorm®)
Insulin Sensitizers (TZDs) pioglitazone (Actos®) rosiglitazone (Avandia®)
Combined rosiglitazone and metformin (Avandamet™)
Antiobesity Agents Orlistat (Xenical®) gastrointestinal lipase inhibitor, or
Sibutramine (Meridia®) norepinephrine and serotonin reuptake inhibitor).
Drug Class: Injectible Insulin
Type
Names
Appearance
Onset
Peak
Duration
Rapid-acting
analogue
Humalog® (insulin lispro)
NovoRapid® (insulin aspart)
clear
10-15
min.
60-90
min
4-5h
Fast-acting
Humulin®-R Novolin® ge
Toronto
clear
0.5 – 1
hr.
2-4
hrs
5-8h
Intermediate- Humulin® L Humulin® N
acting
Novolin® ge NPH
cloudy
1-3 h.
5-8h
up to 18h
Long-acting
Humulin® U
cloudy
3-4h
8-15h
22-26h
Extended
Long-acting
analogue
Lantus® (insulin glargine) –
approved/not available
Premixed:
fixed ratio of
% rapid / fast
acting to %
intermediate
acting
Humalog® Mix25™ Humulin®
(20/80, 30/70) Novolin® ge
(10/90, 20/80, 30/70, 40/60,
50/50)
90
min.
24h
cloudy
Cardiovascular risk reduction: ACE Inhibitor (for BP and kidney protection; not in
pregnancy), antiplatelet therapy (ASA) (helps prevent embolisms), statin or
fibrate (helps reduce cholesterol or triglycerides)
Blood Pressure Control: 1st-ACE inhibitor, 2nd-ARB for co-existing LVH, 3rdcardioselective beta blocker, 4th-thiazide-like diuretic, or 5th-long acting CCB.
Painful neuropathy: tricyclic antidepressants or anticonvulsants
Reference: The Canadian Diabetes Association Clinical Practice Guidelines Expert
Committee. Canadian Diabetes Association 2003 Clinical Practice Guidelines for the
Prevention and Management of Diabetes in Canada. Can J Diabetes. 2003; 27(suppl 2).
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