Diabetes Mellitus | Types of Diabetes Mellitus | Dr Najeeb

okay today we are going to talk about diabetes and today's first lecture is just an introduction to diabetes which is not detail of the diabetes this is just an introduction to the diabetes mellitus right with little introduction to the diabetes mellitus as a overview after that we will shift to the fundamentals right we will talk about that how blood glucose level is regulated in a healthy person within normal limits right and blood glucose level and role of different hormones hormonal interplay there are hormones which prevent the hyperglycemia and there are hormones which prevent the hypoglycemia in a normal person right so we will be talking about that too right so first of all first of all that how do you define diabetes right before we go that I want to tell you that it's something very serious you know every five second one person the world is dying due to acute or chronic complications of diabetes again it's worth repeating it's such a serious disease that every five seconds every five seconds one person in the world is dying due to this disease I I always say that rather than saying that someone died of heart attack sometimes we should write this man died due to yes due to complications of diabetes because many of the myocardial infarctions and or end-stage renal disease or different type of Strokes right right they may be induced due to complete as a complication of diabetes mellitus right so actually we can say that so many people die due to complications of diabetes mellitus right now what is really diabetes it is not one disease it is not single disease it's a group of many many diseases right and all of them are lumped together in a bag again I will say diabetes mellitus is not one single disease right it's a metabolic the arrangement in our body this is a group of metabolic diseases and this group of metabolic diseases are put together due to certain commonalities now what are the commonalities common common thread common thread in all the diabetic patient is tendency for chronic hyperglycemia what is that tendency for yes chronic chronic hyper glycemia right this is one thing this is a Common Thread right or we can say that this thread is yes This Thread if this I call this hyper glycemia this is a death death string chronic hyperglycemia right now second thing which is important in this group of disorders is number one yes either in there is reduced insulin production or there is resistance to the action of insulin resistance to the action of insulin so we can say that all those patients who are called suffering with diabetes mellitus remember whenever I say diabetes onward I mean diabetes mellitus because there is another condition which is called diabetes insipidus that is entirely different disease that is not characterized by hyperglycemia diabetes insipidus is a condition in which there is polyuria due to reduced production of antidiuretic hormone or reduced action of antidive uretic hormone we will not be talking about diabetes insipidus we will be talking about diabetes mellitus and when I talk about diabetes mellitus I will just mention onward diabetes so whenever I said only diabetes it means diabetes mellitus what I said up to now and diabetes mellitus it's a group of diseases common thing in all of them is hyperglycemia and in this hyperglycemia what is there either there is reduced production of insulin or there is increased resistance to the action of insulin let me put it here if this is pancreas and here are the beta cells and they produce insulin right and that is going through the blood to the cells and acting on its receptors right now either there is reduced production or there is reduced action right or any combination of both things or any combination of both things that in some of the types of diabetes mellitus there is reduced production as well as there is increased resistance to the action of insulin is that right now we come back let's make it right let's make it diabetic Star right in this diabetic monster right we'll put it here this is our death string here there is reduced production of reduced production of insulin mean and here what is there increase resistance to insulin right and in this death string in this group of diseases there are many different types of diabetes for example yes the classical example in which there is reduced production of insulin is type 1 diabetes that is type one diabetes mellitus right in this case of course we will go we will discuss type 1 diabetes in detail in future but right now what I am saying the type 1 diabetes mellitus is a classical example in which there is severe reduction in production of insulin why produced why insulin is so less produced or sometimes absolutely absent because beta cells which produce insulin they have attacks by the immune system and destroyed atom or we can say that beta cells of pancreas are destroyed due to autoimmune reaction this is one example then on the Other Extreme we can put type 2 diabetes and type 2 diabetes the main problem is the major problem is resistance to the action of insulin at least in the initial stages of disease what is happening that beta cell the pancreas are there they might be producing insulin in normal level or even more than normal but cells are not responding to insulin right cells become deaf to the insulin right so these are the two extreme cases type 1 diabetes and type two diabetes classical thing and type one is there is absolute or very very dangerous reduction in production of insulin due to autoimmune destruction of beta cells of pancreas right and type 2 diabetes what we say classically in this case what happens that there is insulin is being produced at least in the early phase of disease right when that because it this disease goes for many many years or over decades right so at least in the beginning of the disease or early stages of the disease insulin is being produced the real problem is in the beginning that tissues are not responding to insulin is that right so these are the only two conditions or two diseases then there are mold mold diseases type 1 type 2 after that I can say okay someone said gestational diabetes okay we put here gestational diabetes gestational diabetes mellitus or diabetes what is this this is a condition in which during the pregnancy there is tendency for hyper glycemia or there is hyperglycemia is that right we will discuss in detail later but what happens in gestational diabetes in this case there is problem in production of insulin as well as there is peripheral resistance that tissues are not responding well to the insulin then there is another condition with very interesting name we call it Lada okay who will tell me Lada stands for what latent does yes L stands for latent autoimmune Auto immune yes diabetes of adults of adults okay let me tell you now interesting thing if I talk about all the pressure in the world who are suffering with diabetism lighters and if those patients are having real problem is underlying production of insulin right most of them will be youngsters type 1 diabetes but if you find a man who is 40 year old right a man 40 year old or 50 year old and autoimmune process destroys this beta cell Which is less often right so actually at a very late age he has developed autoimmune destruction of beta cell so his condition will be somewhat similar to type one diabetes so such patients are called not type 1 diabetes because usually this is seen in younger patients because this is very late onset off type 1 diabetes like disease this is late onset of type 1 type 1 live disease but very late onset so we call it Lada right basically both are similar condition autoimmune destruction of beta cell then I would put rather than putting gestational here I will put gestational little down and again I'll put something which is very similar with type 2 right which is very similar with type 2 but develops at younger age again type 1 classically develops in General type 2 classically develops in older age everyone knows that every good doctor knows type 1 diabetes at younger age and type 2 is that usually later ahead but if someone develop a disease like Thai type 2 diabetes but at younger age is that right for example someone has diabetical diabetes mellitus in the age of 20. but his real problem is not beta cell destruction is real problem is increased resistance to the action of insulin right it means insulin is there but is unable to produce its section insulin is there but unable to produce its action so that disease but if it started very young age classically it should start at older age if it starts at younger age we call it maturity onset diabetes mellitus right or we just call it Modi Modi stands for maturity onset diabetes of young people right again I will repeat and I will see who will tell me the right answer first of all we talk about the two extreme this common string is hyper glycemia is that right this is the death string and it has many many death stones it has many many death stones death Stones mean different types of diabetes right one extreme is type 1 diabetes in which real problem is under severe reduction in production of insulin due to autoimmune destruction of beta cells Other Extreme is that there is problem with the action of insulin on the peripheral tissues right and at least initially insulin is present in the patient's blood gradually it might decrease so this is type 2 diabetes so classically doctors a good doctor usually knows about type 1 diabetes and type 2 diabetes then of course there are some doctors which are very good right if we talk about very good doctor he will be aware of some slightly different situations very good doctor should be aware of that sometimes you might come across a patient who has diabetes mellitus sometimes the doctor or as a nurse you may come across a patient who has diabetes mellitus and it is at adult age but this diabetes mellitus is behaving like type one like as if there is severe deficiency of insulin production real problem is or at least initially the real big problem is not peripheral resistance so we'll call it Lada what is that latent autoimmune diabetes of adults is that right so another way we can say the real difference in type 1 and Lada is one difference is that both of them are due to extreme deficiency of insulin but one is at younger age another is at adulthood now we come to the other end every doctor knows about type 2 diabetes is that right and every doctor knows that most of the type 2 diabetes patients are at older age usually 35 40 plus but if you come across a very young person right and that person is having a type of diabetes mellitus which is behaving like type 2 diabetes it means this person is having maturity onset diabetes but in a young person this person is having maturity onset diabetes but in a young person right so we can say we have talked about four types of diabetes now we come to fifth type of Diabetes we have already discussed and that was gestational diabetes gestational diabetes mellitus or diabetes then gestational diabetes is easy to understand the of course all of you must be knowing this is only limited to the females okay gestational diabetes then there is another type of diabetes which may be secondary to some situation right for example if I take some drug and that drug produces hyper glycemia and if I'm taking the drug chronically if I'm taking that drug for long time right then what will happen that I will have a tendency for chronic hyperglycemia and we say that there is drug induced diabetes mellitus right so such kind of diabetical mellitus right they are called secondary diabetes mellitus there are so many types of secondary diabetes mellitus but just as an example we talk about one drug a very commonly used drug is beta blockers beta blockers classically propranolol proprano LOL now propranolol it blocks basically beta receptors right and on the pancreas in the pancreas in the islet of langerhans on the beta cells there are beta2 receptors right this is pancreas here is your beta cell and on the beta cell there are yes this should be seven parts of receptors this receptor is basically beta2 adrenergic receptor is that right now what happens that if we give beta blocker this receptor is not functioning right there are alpha receptors there too if these adrenergic receptors are not functional right insulin will not be released properly there will be dysfunction in in production and release of insulin and person will develop a tendency for chronic hyper glycemia so we will say this is an example of secondary diabetes mellitus another example we can take drug like thiazides patients who are long term on the thiazides it's diuretic that can also produce picture like diabetes mellitus right then we can talk about some endocrine disease like crushing syndrome where chronically there is elevation of cortisol hormone right and when cortisol hormone is high Chronicle in your body yes cortisol hormone and glucose metabolism what cortisol is doing or steroid hormones right what they are doing to your body as far as metabolism is concerned they produce catabolism of the proteins they produce Life policies breakdown of the lipids so breakdown of adipose tissue and lipolysis produces free fatty acids and a minus acids are also broken down due to catabolism of the proteins and both of them free fatty acid and minor acid or their derivatives they are supplied to the liver and in the liver steroids increase the process of yes gluconeogenesis and liver start producing glucose right so what we can say in Cushing syndrome there is a tendency even in acromegaly and some other endocrine diseases there is a tendency for hyperglycemia and such hyperglycemia is called secondary hyper glycemia so what did we learn up to now we just learned that diabetes is a dangerous disease and every fifth second every fifth second it is killing one person globally about 500 million people are suffering from it globally about 500 million people are suffering with the diabetes mellitus and in USA they say there are about 30 6 30 7. million people suffering with diabetes mellitus so when we talk talk about diabetes it puts a lot of global load there's a lot of morbidity there is lot of mortality related with it I would say diabetes is a monster every year how many people die due to this disease who will tell me about 60 to 7 million people 60 to 7 million people die of diabetes so I must say that this is basically diabetic monster and this diabetic monster with a death string of hyperglycemia having death stones in it these death stones are different types of diabetes with two fundamental underlying process either diabetes is not being produced or insulin is not being produced or insulin is unable to produce the effect on the tissues or both problems might occur right and type 1 diabetes insulin is insulin is not being produced and type 2 diabetes what is real thing insulin at least at the initial stages initial years of the disease insulin is being produced but tissues are not responding to insulin right then we talked about other types of diabetes right now why we are how diabetes skills how diabetes skills due to its dangerous complications right as I told you this our first lecture is not diabetes in detail I will talk in detail later but let's talk about this monster and this monsters complications okay first of all we should know this this is very dangerous this diabetic monster if unfortunately let's suppose we imagine a person who has diabetes for a long time he has diabet is for long time this CR there is not only chronic hyperglycemia because a simple doctor an innocent doctor things diabetes disturb carbohydrate metabolism right but the real doctor knows that even though main problem is hyperglycemia but actually secondary to the insulin failure not only hyperglycemia occur not only carbohydrate metabolism is Disturbed but protein and lipid metabolism is also Disturbed severely so what we can say in this monster okay this I don't know how to make it look very angry but this in this monster a simple and innocent doctor will think that carbohydrate metabolism is Disturbed but actually yes what is there lipid metabolism is also Disturbed and protein metabolism is also Disturbed of course we will discuss all these disturbances in the metabolism later right in later lectures but up to now what is diabetes it's a group of diseases metabolic diseases the Common Thread common thing is hyperglycemia due to decreased production or decreased action of insulin or any combination of this and eventually it disturbs not only carbohydrate metabolism but protein metabolism and lipid metabolism also and I will definitely explain these things later but because it is just fundamentals of diabetes let's talk about what are the real problems with the patient right number one diabetes can produce vascular problems some people think it should be considered a disease vascular disease with many other complications right so when we talk about that diabetes damages the vessels right the vascular disease or angiopathy which occurs in the diabetic patient we divide them into two types big vessel disease and small vessel disease why we say big muscle disease as a separate group small vessel disease as a separate group big why we differentiate because underlying mechanisms are different diabetes produces big vessel disease which is called macro macro vascular complications mic macro angiopathy macro NGO Apache or macro vascular complications or we can say big vessel diseases and diabetes mellitus and then it also produces small vessel disease right and that is called micro vascular complications or diseases complications are diseases now microvascular mean smaller vessels classically speaking capillaries but actually true definition of micro microvasculature is the true definition of microvasculature is starts from the arterioles it include the capillaries and then venules but diabetes mellitus specifically and classically damages the capillaries a lot right so there are some complications in diabetic patient due to damage to the small vessels and there are other complications which are due to damage to the big vessels large vessels large vessels mean elastic vessels elastic vessel classical Euro aorta or muscular arteries right so bigger vessels large vessels or mid-size vessels now what are the complications it produces number one is coronary artery disease coronary artery disease right let's suppose if I talk about atheroma at socialclerosis and coronary artery disease right now what really happens you must be knowing that coronary this macrovascular disease is not specific and limited to car to diabetes mellitus it does occur with aging it does occur with the hypertension it does occur in the patient with hyperlipidemias or it and of course it can occur in the patient with diabetes mellitus or there are unfortunate patients who have multiple factors a patient who has diabetes mellitus a patient who has hypertension patient who has unfortunately hyperlipidemias to write so he will develop coronary artery disease is that right but if you have diabetes coronary artery disease behaves very aggressively as compared to other causes of coronary artery disease let's suppose there's a person who has hypertension and here's a person who has diabetes mellitus we are uncontrolled diabetes mellitus patient with hypertension only and patient with diabetes only both of them will develop the atheroseclonotic disease or multiple anthromas right but in patient with diabetes mellitus anthromas will be more severe more diffusely present and at earlier age developing for example if someone has uncontrolled hypertension only he might develop once he develop the hypertensive condition he might develop let's suppose he takes 10 years to develop dangerous thromas but if someone has diabetes mellitus within five six years seven years you will develop very dangerous Earth from us so what I'm trying to say that atherocyclerotic disease or anthromas in patients with diabetes they are more bigger they are more diffusely present in the vessels and they appear earlier is that right so we can say that macrovascular disease when it appears as a manifestation of coronary artery disease in the presence of diabetes disease has diseases accelerator accelerated behavior and more severe behavior and dangerous Behavior right coronary artery disease of course it means in the patients with diabetes if I say coronary artery disease is more common what I really mean by this of course they have stable angina more common they have unstable more common they might suffer with myocardial infarction more commonly they might suffer from Sudden cardiac death more commonly right I always think that someone who has diabetes and dies of the myocardial infarction I think on the gravestone it should be written this gentleman died of the complications of diabetes not just Mi just to increase the awareness right so what I said that in coronary artery disease is one of the manifestation of microvascular complications and they develop in the patient very commonly right I always say I will go to the other complication let's talk about another macro vascular complication that is cerebrovascular complication vertebra vascular complications cerebral vascular events or cerebrovascular accidents what I mean by this that in patients with diabetes mellitus large vessels or medium-sized vessels either they are related with the heart or with the central nervous system they develop what kind of disease atherosclerosis they develop macro angiopathy what is diabetic macro angiopathy number one diabetic micro angiopathic macro macro angiopathy is not limited to diabetes only this is this can occur in patients with hypertension as a patient with hyperlipidemias or with Advanced aging but once it occurs with diabetes it occurs very rapidly very severely and it is more aggressive so cerebrovascular accidents cvas related with diabetes they are very common and again CVS can be stenotic that reduced blood flow to some part of the central nervous system due to narrowing of the vessel because there is a throma and that if that thromba is stable but that has made the vessel narrow we can say there is stenotic cerebrovascular disease or there can be thrombotic that at the top of at the top of a throma collection of you can say platelets and fibrin right they make a mess and make the vessel very narrow make loot The Vessel and produce severe ischemias to some part of the central nervous system right so in that case we say that patient has developed thrombotic CVA of course in patient with diabetes this is more common then we can come to embolic embolic events embolic events mean that maybe thrombus formed in the heart in the left ventricle and piece of a thrombus breakdown and it moves through blood vessels and goes to Central of a system and block a vessel there so this is actually embolus or patient has in carotid vessels patient has very sphere throma at the top of carotid anthromba platelets and fiber fibrin Aggregates occur and we can say a thrombus form here and that thrombus detaches from carotid vessel and goes upward to the cerebral circulation and let's suppose it blocks the middle cerebral artery of course it will produce a very severe CVA cerebrovascular accident and that will be considered embolic again I will repeat if due to diabetes a vessel in the central nervous system become narrow right we'll say this and that lead to severe damage to central nervous system that is tinotic CVA or there is the atheroma in the central nervous system and over the throma platelet plug or thrombus Farm locally and this thrombus grows and closes the vessel will call this condition thrombotic CVA or maybe carotid artery or from left ventricle or from any other major artery some thrombus flows to the central nervous system right that thrombos which has detached detached from its origin and it is moving if it is moving it is no more thrombus it is embolus and if that damages your Center nervous system we say that there is embolic CVA now in patients with the end then there can be of course we should not forget hemorrhagic hemorrhagic severe there can be hemorrhagic CVA also and hemorrhagic CVA of course there is some vessels in the central nervous system and over in that vessel very severe form of atheroma Duality and that a throma damages not only intima but also damages the media and serosa so much that vessel ruptures if that vessel rupture right larger size vessel that might produce hemorrhagic severe right so in patient with their diabetes again we come back there can be microvascular diseases there can be macro vascular diseases when we talk about macrovascular diseases what happens we should really focus on coronary coronary artery disease which which might clinically manifest as stable angina or unstable in China or myocardial infarction or sudden cardiac death then we should talk about other very important organ Central of a system if one of the major vessel in the central nervous system undergoes malfunction if local thrombus is formed and making the vessel very narrow we say stenotic CVA if local vessel is having a throma we can call it dangerous unstable malignant anthroma very dangerous trauma and this is so dangerous that it is not only destroying the antima it is destroying the media and also sirosa right and at the top of that at the top of that thrombus that uh throma if platelets and fibrin and thrombus form then we what we will say there is from voltage and if that a thromer ruptures right then hemorrhagic or if trauma is somewhere else right and thrombos form over that for example in carotid and then thrombus detaches and becomes embolus and just embolus is moving in the central of a system and eventually it blocks one of the major vessels we call it embolic and if someone asks you what kind of CVA is most common in patient with diabetes mellitus you must say ischemic CVA what you should say ischemic CVA which is classically either thrombotic or ambolic right thrombotic or embolic problem is that right thromboembolic disease in the central nervous system producing CVA so diabetes are so many ways to kill you it can kill you by producing heart attack myocardial infarction it can damage You by producing what yes what is this producing CVS then it can but okay can you tell me some more large vessel disease yes doctor peripheral vessel disease peripheral vessels disease we should not forget especially in the lower limb especially in the foot in the femoral arteries or popliteal arteries or even more distal arteries right in patients with diabetes very aggressive and very unstable and in big number a throw must develop as compared to the normal population right and those arthromas contribute to the diabetic foot disease because due to those thromas or arthromas with overlying thrombus right or embolus that may lead to ischemia to the foot right we call it foot vasculopathy and diabetic patient so peripheral vascular disease can be there right and classical example is that blood flow in the lower limb in the patient with diabetes may be reduced due to complications of macro vascular yes macro vascular disease and lower limb vessels this peripheral can can develop in Upper Limb but less often but one thing I should not forget large vessel disease I have told you about coronary I've told you about cerebrovascular diseases I've told you about lower limb but one special type of macrovascular disease or complication which develops in patients with diabetes is not to be forgotten you know what is that that is related with the kidney most of the doctor remember that kidney disease kidney diabetic diseases micro angiopathy yes I agree to that but major vessel which supplies the kidney renal vessel that can develop through Mass multiple thromas dangerous from us unstable thromas and from us with thrombai which may even employ so we call it yes that macro vascular disease or in the renal vessel or we simply call it diabetic renovascular disease right again and a very short way I can say that diabetes can have so many complications I was just focusing on the sum of the macro vascular complications and we talked about that all of them are due to accelerated and more sphere atherosclerosis in major vessels important vessels like coronary vessels or cerebral vessels or especially in the foot or renal vessel right then we come to other group of complications right and this is a micro vascular complications in patient with diabetes small vessel disease up to now I told you only large vessel disease now I am going to tell you small vessel disease now here I want to say something very special the small vessel disease which is also called the diabetic micro angiopathy what is it is called diabetic micro angiopathy this diabetic micro angiopathy is specific to diabetes what I mean by specific to diabetes that it only occurs in patients with diabetes of mellitus again I will repeat when I said that there is macrovascular disease that can develop in diabetes but macroboscular disease can also develop in non-diabetic patients but when I say microvascular disease a very special type of microvascular disease which specially involve the kid a capillaries that capillaries basement membranes become very thick to build this basement membrane become very thick because their proteins are altered because there's known enzymatic attachment of glucose or glucose products with those basement membranes and those membranes proteins are altered even though microvascular capillaries baseful membrane become thick but they also become more leaky they are thick but with cracks they are thick basement membranes of the people is but having a lot of cracks due to that reason they are very very leaky right from blood plasma proteins leak out through those basement membranes right right so don't think that if basement membrane is becoming thick it is uh actually becoming strong it is actually it is becoming thick but because it is thick due to our pathological alteration in its proteins collectively we call such altered proteins age ages what is it advanced glycation and products Advanced glycation and product that in the micro vessels in small vessels what really happens basement membrane becomes thick initially this process is reversible but over the time it becomes irreversible because these abnormalities become very stable is that right now classically and clinically if you talk about diabetic microangiopathy if we talk about diabetic micro angiopathy there are few organs which should come to your mind okay let's start from the top number one is diabetic diabetic retinopathy remember in patients with diabetes some other complications can occur due to diabetes like cataract but that is not micro angiopathy right that I will discuss later what happens that micro angiopathy develops in the blood vessels of retina right their retinal vessels develop thick base remembrance and those basement membranes are not only thick but they are lot of micro cracks and through those cracks lipoproteins or lipids or proteins they leak out into retinal neuronal tissue and damage it even produce micro hemorrhages right so that can end up I will say these complication what did I tell here one very dangerous situation micro angiopathy yes retinal right that is micro angiopathy in the retina we simply call it reti no pathy which retinopathy diabetic retinopathy later on in lectures in the future I will tell you how to differentiate diabetic retinopathy from hypertensive retinopathy this is very important as a doctor to know you know retinal vessels are the only vessels in the body which you can look directly in a healthy person there are no other vessels you can look directly right so that when you do look at the retinal vessels right you can in diabetic patient you can find abnormalities there right I will teach you later there will be a full lecture on diabetic retinopathy but right now I'm telling you there's two types of diabetic retinopathy at early stage it is not having proliferation of small vessels it's not having neovascularization but when dab diabetic retinopathy it become Advanced what happens that new vessels Sprout new vessels grow right in the retina and don't be happy every new vessel is good everything new in life is not good I have some experiences yes so these new vessels which develop in in the retina even though the bunch of vessels we call it what we call it diabetic proliferative retinopathy what we call it diabetic proliferative retinopathy which occurs that advanced retinopathy these newly formed proliferative vessels a neovasculature this is super leaky we don't want vessels to be super leaky right and when they leak there a lot they leak a lot of inappropriate substances which should be limited to the blood but unduly lot of proteins or lipids they come into neuronal tissue of the retina and produce lot of complications we'll talk those things later but right now you just remember that one of the most important cause of blindness is diabetic retinopathy and now you are going to tell me without thinking is it a macro muscular disease or microvascular disease it is microvascular disease it is micro vascular disease micro angiopathy right number one number two after the eyes and other tissue which loves to have this angiopathy that is nephropathy your kidneys you know in in kidneys you have millions of about 1.2 million nephrons in each kidney how many nephrons 1.2 million as I say in some lectures that you are millionaire as long as glomeruli of the kidneys are concerned right about 1 million to 1.2 million nephrons you have in each kidney right and in every nephron there is a bunch of capillaries which are called glomeruli those glomerular capillaries those capillaries also loves to develop microangiopathy and diabetic patient I think they love too much sweetness because their what are these things glomerulus the glomerulus there are glomerular capillaries and capillaries are having some substance in between which is called mesengium so this capillary the basement membrane and their messenger all of them develop Advanced glycation products and that will lead to what thing that will lead to and over the years damage to the glomerular become what do you think this will affect more right kidney or left kidney yes doctor both kidneys of course it is hyperglycemia which is damaging of course whatever hyperglycemia is occurring in vasculature of right kidney same is on the left so this micro angiopathy which develops in the blood vessels of the kidney classically in the glomerular even though they can develop in peritubular capillaries also right they produce dysfunctional what is this they produce dysfunctional glomerular and over the time over the years over the many years if patient is not taken care properly this angiopathy becomes sword ones that globalized stop functioning and person enters into end stage renal disease and in USA the most common cause of end-stage renal disease is diabetes diabetic nephropathy so what I'm trying to say that this disease has so many faces to kill you it can kill you by myocardial infarction or certain cardiac death or cerebrovascular accident or it may kill you over many many years I say this disease loves to kill its patient inch by inch this disease this monster of diabetes loves to kill its patient in many different ways and over the managers and inch by inch I told you there was that string of hyperglycemia with the death Stones different types and this Death monster has macro vascular complications and also having micro muscular complications and when we talk about the macro Vasco complication I know I am repeating it's worth repeating that we have that patient may suffer with the heart problems or brain problems Central over system problems or renovascular disease or foot vasculopathy right peripheral vascular disease then it can if it does not kill at least it can make you blind that is a also very miserable situation you know there's so many beautiful things in life which you cannot see if you are blind right so it can produce Blindness by diabetic retinopathy that is the example of micro angiopathy then we talk about diabetic nephropathy now here what is this macro vascular disease but in glomeruli it is microvascular disease glomerulite is microvascular disease and again I will repeat one of the most important cause of end stage renal disease especially in the advanced country that is diabetes mellitus because in poor country unfortunately many patients die due to pyelonephritis right then we come to another that there is one more tissue which loves to have Micro vascular disease that is your nerve neurons we call it diabetic neuropathy diabetic neuro Kathy what is it diabetic neuropathy so we have talked about diabetic retinopathy diabetic nephropathy we are going to talk about diabetic neuropathy and all of them meanwhile what pathology in small vessel microbuscular diabetic disease or we call it micro angiopathy is that right now let us talk about neuropathy this neuropathy it occurs in different forms in patients one of the common manifestation is peripheral neuropathy peripheral polyneuropathy most commonly in lower limbs right in the lower limbs the neurons especially Sensory neurons they may undergo dysfunction right but not only sensory motor neurons can also suffer now if Sensory neurons initially involve the lower limbs or feet usually they develop symmetrical disease whatever is on the right side same is on the left side sensory problem paresthesias hypersensation or hypersensations right paresthesia's tingling pins and needle and later on the main wall the hands that is why diabetic neuropathy is one of the example of poly neuropathies peripheral symmetrical polyneuropathy also called gloves and stalking disease because gloves area and stocking areas these are this is not stalking a girl this is I mean that stocks right so what I'm talking about that these diabetic diabetic neuropathies first of all I talk about what kind of neuropathy polyneuropathy what kind of polyuropathy symmetrical symmetrical mean whatever is happening to the right side of the body similar neurological damages according to the left side of the body and classical example of this is yes gloves and stocking and this also contribute to the diabetic foot disease this also contribute to diabetic foot disease because as I told you previously macro angiopathy in the lower limb produces ischemia to the foot they contribute to the ischemic damage to the diabetic foot but if sensory nerves are damaged then patient might get little bit injury and ignore it and that area may become later on infectious and infection is spread and this little problem yes this little problem might end up eventually into amputation of the some part of the lower limb is that right diabetes is one of the commonest causes of amputation of adult lower lens non-traumatic non-traumatic right of course you can get amputation if you really want there are so many ways one of them is accidents trauma but non-traumatic non-traumatic amputations of the lower limb most commonly occur in the patient are done most commonly in the patient which are diabetic why because diabetes monster attacks a foot in many different ways I don't know this is very bad it loves to damage our heart loves to damage our brain loves to damage peripheral vessels and then it attacks the small vessels and loves to damage the retina loves to damage the kidneys and now it is attacking the neurons so in lower limb if Sensory neurons are dysfunctional that will lead to less awareness of trauma to the lower limb and if motor neurons are damaged in the lower limb then person will develop abnormal mechanics of joints and muscles abnormal mechanics of joints and muscles that men may produce inappropriate pressure points in the lower limb especially on the soul and that might produce yes already blood flow is less at the top neuronal sensitivity is less and then there are abnormal pressure in some areas of the soul that will produce damage and ulcers there and here I must mention that when we talk about the neuropathy about that fourth and we talk about the vasculopathy the vasculopathy is macro vascular and neuropathy is microvascular right and later on later on I will tell you diabetic food there is also tendency of increased infections right later on much later on we will have a full lecture one hour lecture on diabetic foot but let's come back so we were talking about neuropathy polyneuropathy symmetrical neuropathy if it is in lower limb and Upper Limb both then it is gloves and stocking distribution but there are some diabetic patient develop mononuropathy also some diabetic patient develop mononuropathy also and mononuropathy mononuro pathy it means that there is isolated nerve damage that might that that might not be symmetrical for example if I develop my accrual motor nerve damage or I develop damage to the decent nerve right now if isolated reducent nerve damage is there due to diabetes right abduction nerve is six cranial nerve which supplies the lateral rectus right now that is also neuropathy but because one nerve is affected and other nerve is not affected right or on one side median nerve is affected and other side median nerve is not affected then we cannot say that this is symmetrical disease this asymmetrical nerve damage if it is one single nerve we say it is mono new writers this mononucers can occur in the sensory nerves and also can occur in motor nerve then we come to another condition that let's suppose you come across unusual patient who has abducer nerve damage on right eye and oculomotor nerve damage on the left side very unfortunate patient develop median nerve damage to right side and radial nerve damage to the left arm what do you think it is polyneuropathy it is not symmetrical polyneuropathy it is still mononuropathy at multiple places it is mononuropathy at multiple places because when we are saying polyneuropathy then there should be symmetrical involvement but if one side is decent nerve damage other side is yes acclimota damage one side is median nerve damage maybe other side is radial nerve damage one side is suril nerve damage in the leg other is perennial nerve damage so this is we these are not polyneuropathies these are mononur patches but at multiple places this condition is also called Mono neuritis Multiplex Multiplex you know like Cinemas multiple screens so multiple nerves are involved we call it mononuropathy multi Multiplex then we come to another condition that unfortunately this not diabetes micro angiopathy not only not only that damages the sensory and motor neurons it can attack the autonomic nervous system also it can attack the autonomic nervous system also and if it damages the autonomic nervous system right there will be other problems for example if autonomic supply to the heart is Damaged right then variation of heart rate will be reduced or increased variation will be reduced variation of heartbeat beat to beat variation will be reduced because if you have healthy autonomic nervous system controlling your heart then of course at allergic Supply a noradine Logic Supply that increases the heart rate and cholinergic Supply decreases the heart rate but if both of them are dysfunctional increase and decrease in heart rate will not be showing variability right so heart rate variability will be reduced then in such patients who have autonomic neuropathy they may develop orthostatic hypotension what is the orthostatic hypotension or postural hypertension that from lying down position for example here you are I hope you are not redheaded but anyway here you are lying down or sitting and if you if first normal your normal person lying down and due to some reason you suddenly stand up what should happen that blood should fall to the lower part of the body due to gravitational effect but lower limb vessels immediately contract when from lying down position a healthy person healthy person suddenly stand up or sit up we expect that due to gravitation effect blood should pour in lower part of the body and there will be there will be more Venus pooling in lower part of the body and if there is more venous pooling in lower part of the body less blood is returning to the heart and cardiac output become less and that may lead to blackouts and your blood pressure May down fall down significantly but in normal healthy person it does not happen why because whenever you change your position from lying down to standing up there is a burst of sympathetic activity to the vessels in the lower part of the body and lower part of the body vessels constrict and squeeze the blood so that it does not pull into lower part of the body and there is appropriate return to the heart and cardiac output is reasonably maintained so that you do not develop for Tiger you don't develop blackouts or complications like this your understanding but if there is a patient with diabetic neuropathy and diabetic Auto neuropathy autonomic neuropathy and that auto neuro autonomic neuropath is damaging the neurons sympathetic neurons to the blood vessels patient may suffer from orthostatic hypotension or postural hypotension because from lying down position when he will stand up sympathetic nervous system is not working and vessels will not so squeeze right and blood will not be returned properly to the heart it will pull into lower part of the body and venous return will be less less cardiac output and when there is less cardiac output patient may develop vertigo even blackouts right then this Auto neuropathy main valve the autonomic nervous system to your gastrointestinal system right if your gastrointestinal system is affected right git motility will become abnormal you know vagus nerve which is the classical example of parasympathetic nervous system vagus nerve is motor to git is this vagus nerve develops it has lot of what type of fibers autonomic fibers right virus now if vagus nerve develop diabetic yes micro vascular very good micro muscular disease vagus nerve develop the motor nerve to the gastrointestinal system fails and might be it will have multiple complications one of the complications may be that this failure of autonovagal Supply to the stomach May contribute to a condition called gastroparesis what is that gastro parasis that stomach has movement is weak and feeble right we call it gastro parasis then there are some very unfortunate I think situation in some diabetic patient that autonomic nervous system going to the urogenital system is damaged that may lead to urinary retention because autonomic nervous system plays a major role in urination is that right cholinergic system help the vasculature of what is this urinary bladder to contract so if it does not contract well that may lead to urinary retention and another very unfortunate situation might be yes importance right that autonomic nervous system is Disturbed to the male organ and that may damage so much that blood flow to the male organ is altered so much that erection cannot be maintained for appropriate penetration right I don't know much about inappropriate penetration but anyway so what I say that it can produce impotence also this is one complication the diabetic patient which as a doctor you should ask but please ask only men right because usually they are shy to talk about you know something very strange women find it easy to talk to their doctor about their urogenital problems men feel more difficulty to talk about it you know why because due to periods and their irregular irregularities and pregnancies and due to other gynecological reasons women are more used to to talk to the health care provider about their problem because men are not so regularly going through such processes so once they developing potential anything like that or some problem they find it very difficult to talk to the doctor right so this as a doctor or as a nurse you should inquire male patients who are diabetic if they have problem related with urogenital system are not so what I wanted to say that it can produce macro boss floor complications it can produce micro vascular complication we are still passing through an introduction to diabetes mellitus because in coming lectures I will go in detail of there will be lecture only on diabetic neuropathy its management its clinical features there will be lecture only on what diabetic nephropathy its clinical features and its management there will be in hopefully lecture complete lecture or diabetic retinopathy its progression its stages its causes and its management right now I am just trying to tell you how bad is diabetes diabetes is everything sweet is not sweet diabetes mellitus diabetes means lot of urine is coming and mellitus mean sweet but every sweet thing is not necessarily too good diabetes mellitus is one condition that we can say this is sweet diabetes unfortunately it's a monster with death strength what was that hyperglycemia two ends of the death strength type 1 diabetes were less insulin is produced or no insulin is produced or type 2 where at least initially insulin is there but there is more resistance to flow and then there are many other death gems inside like type 1 then there's type two then there are Lada latent autoimmune diabetes of adult or there is Modi that is maturity on certain diabetes of young right then there's in between secondary diabetes there are so many causes we will talk later I will of course discuss there will be a full lecture on pathogenesis or type 1 diabetes and there will be another full lecture on the pathogenesis or type 2 diabetes and then there will be another lecture for the pathogenesis of rest of the types of diabetes right but what I was saying that in between type 1 type 2 then there is yes Lada and Modi and then there is secondary and there are gestational diabetes and many other which are less common we'll discuss later right we have lot of time then I told you that I didn't tell you that General clinical features of diabetes but I wanted to tell at least complications which are mentioned that this disease is so dangerous that number one I feel personally it is more dangerous than Corona Corona either kills you or leaves you but this disease if comes once it keep on staying with you sometimes lifetime and it has so many different ways to kill you and it kills inch by inch today you are going for the food complication maybe after two days you are going for renal complication maybe after five days you are going to ophthalmologist for retinal complications it's a very sad story and unfortunately this disease is so rapidly spreading that some authorities believe that 10 percent of the adult population in the world is suffering with this disease every 10th person and in some countries in the adults every fifth person is having diabetes mellitus but why this diabetes mellitus is getting so common that in some regions of the world it has a spreading in people as if it is an epidemic thanks God it is yet not pandemic but it it has already achieved a status of epidemic why few reasons which are mentioned are Lifestyle Changes right for example now our nutrition is not as healthy as it used to be in the 100 or 200 or 500 years back right processed food more sugars then nutrition not only nutrition is not healthy then our physical activity is reduced if you are very rich even you do not want to open the door of your car I think you love to have diabetes right for everything we want remote control we don't want to do exercise more than the thumb muscles so this is very sad so overeating of calories and taking the processed food at the top reduced physical activity and then aging population we refuse to die because there is so much Medical Care available that we keep on lingering with the life right so aging population right so aging population nutritional abnormalities reduce physical activity and what else can be there may be the stressors of Modern Life right some people say that why Modern Life has more stress as it is very natural if you are living in a village and all your life you spend in a village 500 years back you know about 100 or 200 people right but when you are living this in global village where so much technology someone dies twenty thousand kilometers away it might have stress on you and in the morning in a big city if you move commute to your job maybe you should see on the way five thousand faces human faces and will learn to ignore them and that adds to the stress so there are so many modern stressors also which are added to our life right so all these things together have Disturbed our metabolism because we are not designed to sit and read the medical books we are not designed to sit and do pass the medical exams we are designed to live in a jungle either we are running after smaller animals or bigger animals are running after us right that is more natural life for whichever metabolism and our whole system is developed right I was telling few days back that physical activity is very important right it is so important that now doctors have discovered and researchers have discovered even your walking can produce neuron growth factors neuron growth factors because all sensation and proprioception going to the central nervous system is telling you might be you are walking in the jungle you know our body is not Eva not evolving so fast as faster technology is evolving right and your central nervous system should be more alert and what happens not only it produces endorphins it it produces growth factors the central nervous systems right so what we were talking about now we come to some miscellaneous complications right which I mentioned there was gastropathy and in gastropathy what is contributory Factor there are multiple reasons for gastropathy which will discuss later but one of the yes we have a question [Music] okay he has come with the question that neurons are neurons and neurons are not blood vessels so why we are saying that neurons are having micro angiopathy you must know that neurons also have Micro vessels not neuron actually nerves have small vessels there are Visa visorum going into nerves and Visa visorum divide into millions of capillaries and those capillaries which give nutrition to the neurons neurons use lot of nutrition right and those capillaries develop Advanced glycation products and that can lead to the trouble right so lets come forward and we were talking about yes other complication gastropathy we have already discussed then there can be cataract cataract please don't tell anyone that cataract with developing diabetic patient right that is due to micro angiopathy that was retinopathy cataract develop due to basically patient with the diabetes especially with the uncontrolled diabetes having very high repeated spikes of hyperglycemia why do they develop cataract one reason is that when hyperglycemia occur lot of glucose enter into lens and there this glucose is converted into sorbitol this glucose is converted into sorbitol and this sorbitol which accumulate in the lens and later on our listen now carefully later on when hyperglycemia go to normal glycemia Sorbitol is trapped in the lens and it cannot come out and it produces osmotic effect and when Sorbitol is there and again hyperglycemia lot of glucose enter into lens and convert into sorbitol when you glycemia occur normal glycemia occur sorbitol cannot leave the lens and this accumulated sorbitol within the lens pulls the water and this orbital and water Plus glycations all of them disturb the damage the lens normal collagen and normal proteins and which become opaque because they disrupt the special arrangement of collagen in the lens and special arrangement of proteins in the lens which keep the lens transparent so lens become parts of the lens lung sorry the lens become opaque so we say cataracts develop and these are also diabetic attracts are if you develop diabetes at early age then this will be pre-senal cataract right then it can produce not only cataract this can produce glaucoma yes what is glaucoma glaucoma is in pathological increase in traocular pressure you know OK let me draw ah I here yes this is your cornea Iris what is this silly body and what is this chloride again what is this cylindric body and there is Iris and in between here is pupil as you know this is cornea right that at this angle in the trabeculi this is a system to drain the aqueous humor right at this angle in trabeculae two types of problem can occur number one advance Advanced glycation glycated products and previcolai yes trabeculi become thick and drainage slits become narrow and you develop glaucoma drainage system is blocked why because this is a normal glycation number two there can be neovascularization here pathological new vessels develop here right at the drainage angle and a consumer cannot drain and that leads to what raised intraocular pressure so if someone asks you what are the ocular complications of diabetes mellitus and yes a good doctor will say diabetic retinopathy then some better than good doctor say can attract also then super good doctor will say glaucoma can occur then there is excellent Doctor Who will say even damage to the muscles which are controlling the movement of the eye damn it to the decent nerve damage to the oculomotor nerve so there are so many complications of diabetes related with the eyes right after this glaucoma we can come to your favorite thing why infections are more common in patients with diabetes OK this is very important question we will have a full lecture on it but right now a little introduction why infections are more common in patient with diabetes I would love to explain this in reference to diabetic foot even though these patients develop infections in many areas in the body more frequently as compared to the normal population but right now I will specially mention the infections in the foot now in diabetic foot why infections are common some reasons are very clear there is neuropathy if there is sensory neuropathy of course they will hurt they will hurt or damage their foot and they will not knowing it and through that injury Point infection can enter number two reason can be that motor motor nerves to the foot and muscles are damaged and due to that reason abnormal mechanics of muscles and joints and the bones interaction produces abnormal pressure point and that may produce ulcers and those ulcers ulcers expose food to the infection right so neuropathy is there then more infection in the foot one more reason is vasculopathy that there is reduced blood flow if there is reduced blood flow it means less nutrients are coming for the repair and less immune components are coming less antibodies less neutrophils less Mac less monocyte or T cells or other defense mechanisms or complement factors so due to vasculopathy what is happening number one again it's worth concentrating because many people very unfortunately undergo what is this and put a non traumatic lower limb amputations right there can be sensory component which is Disturbed so they get more injuries there might be motor system Disturbed abnormal pressure points may like lead to ulcerations and more infection chance then there is vasculopathy reduced blood flow foot becomes ischemic and that lead to reduced nutritional supply for the healing and reduced immune components to fight with the infection this is generally but let me tell you more specific reasons that even a person develop otitis externa or he develop boil hair and it is not healing rather infection is spreading why it is happening the reason being there is sphere if diabetes is uncontrolled there is severe dysfunction in immune system look at the red blood cells not red blood cells sorry neutrophils neutrophils if there is too much glucose they take up they just like become drunken men you have seen drunken man they are one you I think you must have seen it right you have been with your friends they keep sometimes at midnight they are moving in the streets and they don't know where to go and what to do same thing happen with the neutrophils they are drunken with with the oversupply of glucose and this oversupply of glucose to the neutrophil produces dysfunction these drunken neutrophils they don't stick to the endothelium they cannot knock at their door they don't know where is the door where is the house so where there's infection they cannot what stick there then even if they stick there they are very poor in chemotaxes because increased glucose is disturbing all motor proteins which are responsible in the neutrophil for chemotaxis and movement look at it drunken man wandering in the blood vessels first it don't doesn't know where the endothelium he should stick knock his door and even if he reaches door unable to enter and go to the bedroom here the bedroom is where the infection is no chemotaxis it's so drunken and it's so drunken even you put something in the mouth phagocytosis they are unable to eat whatever you put their drool out so these neutrophils are having less stickiness with the endothelium they have less chemo Texas directional movement towards the focus of infection they have less ability for phagocytosis and even if the phagocyte was something they have less ability to kill that organism which is microbi sidel activity that is also reduced so what happens that if you are a diabetic patient and your blood sugar is unfortunately not properly controlled and your neutrophils are always drunken and happy with this so much glucose and that they are going under multiple malfunctions failure to failure to stick with the inflate endothelium in the inflamed area failure to do chemotaxis failure to do the phagocytosis and even if do the phagocytosis failure to what failure to kill the organisms all these things increases our chances to suffer with infection and then even macrophages also become drunken I mean monocyte when monocide move out of blood vessel into inflamed tissue we call them macrophages they become so drunken that one of their important function they do not do that important function is to produce the cytokines to call more neutrophils and call the lymphocytes if I'm a monocyte I should slip out of blood vessel in area of inflammation and I should go into tissue and you should change my name to macrophage and then I should start giving cytokines cytokines are just like calls to more neutrophils it's very interesting at the site of inflammation neutrophil produce the product which call macrophages and macrophages produce a product which call neutrophils so they are calling more forces but these macrophage go and sit there forget how to do fatal phagocytosis and forget to call more neutrophils and forget to call more lymphocytes so lymphocyte dysfunction also develop all such dysfunctions lead to increased chance of infection so what I was talking about that unfortunately in these patients infections are very common so ah unfortunately not only baby some even microbe also love the candies sugar sugar loving microbes and patient with diabetes these sugar loving microbes glycophilic microbes they are in Paradise right why they are in Paradise more sugar to enjoy and all the neutrophils which want to kill them are themselves drunken and all the macrophages forget to call the forces and microbes are proliferating right so there are so many reasons unfortunately in these patients with diabetes to undergo multiple infections and their infections the development infections more easily they they are infections supplied more and they heal very poorly right and this I will add to the diabetic foot also that due to neuropathy and due to vasculopathy and due to ah this failure of immune system or our neutrophil and macrophage system this all lead to more and more infections in the foot diabetic foot will lead to that condition but we will talk about that later in detail right so what we have talked about diabetic fourth then of course it can even lead to do you think it is going to excuse you this to this no it is not only after your eyes this disease can be after your ears also if you ask a good doctor what are the complications related with the ears of the diabetes the good doctor will say otitis externa more good will say more frequency of otitis media also but there are super good doctor he will say of course otitis external is more common of course otitis media is more common but don't forget its cranial nerve vestibulocochlear system right vasculopathic are there also those nerves also suffer with micro angiopathy and sensory neuronal deafness may occur right so what is happening that these patients have macrovascular complications they are micro vascular complications they have many extra complications like gastroparesis europathetices dermalog logical complications of course more infections and blood vessels in the skin also suffer with angiopathy right then they have more infections they can have cataract they can have glaucoma diabetic diabetic food and hearing loss even period or period don't tell disease is very common in them because at the junction of what is this teeth and gum in the in those crevices many microbes love to proliferate and our defenses here are very weak right so so many different types of problems can occur in the patients with diabetes mellitus and before I conclude this lecture I will again say there are so many things which are contributing to diabetes in modern era especially type 2 diabetes is becoming very common why more obesity less physical activity more industrialization and automation right more aging population and of course there are more stresses there right all these things lead to development of type 2 diabetes more commonly in populations right and another thing which I want to tell you you know what is that most of us think that diabetes is a disease of rich countries yes there was a time this disease was the disease of rich country but now even many country with middle class middle class middle you can say mid-range income or low range income they are also developing diabetes very rampantly because of changes their habits right and I think I should take a break now this is enough after the break we are again going to meet and it was just an introduction to diabetes never forget if someone say that a person has diabetes make it sure he has a tendency for chronic hyperglycemia that is the common thread okay class dismiss for a while after some time will again talk thank you everyone thank you

Channel: Dr. Najeeb Lectures

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Keywords: dr najeeb, dr najeeb lectures, usmle step 1, diabetes mellitus, diabetes, diabetes type 1, type 2 diabetes, pathophysiology of diabetes, diabetes mellitus pathophysiology, symptoms of diabetes, diabetes symptoms, signs of diabetes, type 1 diabetes, blood sugar, blood sugar levels, high blood sugar, blood sugar control, what is diabetes, diabetes type 2, diabetes mellitus dr najeeb, diabetic, diabetic ketoacidosis, insulin, najeeb lectures, diabetes 1, diabetes dr najeeb

Id: kWcHr-bchcU

Length: 99min 58sec (5998 seconds)

Published: Sun Jun 18 2023