Prof. Dr. Saad S Al- Ani

Senior Pediatric Consultant

Head of Pediatric Department

Khorfakkan Hospital

Sharjah ,UAE

saadsalani@yahoo.com

Childhood

Diabetes Mellitus

Its Complications

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 2

Throughout the world, incidences of diabetes are on the rise, and consequently so is diabetes amongst children

Most children are affected by type 1 diabetes in childhood

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 3

Number of children and young adults affected by type 2 diabetes is beginning to rise

Approximately 90% of young people with diabetes suffer from type 1 and the number of patients who are children varies from place to place

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 4

A figure of 17 per 100,000 children developing diabetes each year has been reported

As metabolic syndrome, obesity and bad diets spread, so too have the first incidences of type 2 diabetes, previously incredibly rare.

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 5

How is diabetes caused in children

The actual causes of the diabetic condition are little understood

Inherited genetic characteristics are triggered by environmental factors such as diet or exercise

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 6

What symptoms do children with diabetes exhibit

A number of symptoms may give early warning that diabetes has developed

One or more of the following symptoms may be associated with diabetes: □ Thirst □ Tiredness □ Weight loss □ Frequent urination

Amongst children, specific symptoms may include: □ Stomach aches □ Headaches □ Behavioral problems

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 7

What symptoms do children with diabetes exhibit (Cont.)

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 8

How are children with diabetes treated

The only certain method of treating diabetes in children is insulin treatment

Because type 1 typically means that the vast majority of islet cells have been destroyed and insufficient or zero insulin can be produced,

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 9

How are children with diabetes treated

Fast-acting insulin will generally be administered during the day, and nocturnal levels will be controlled by a slow-acting dose

Insulin pumps are also common amongst children

Good glucose control is essential in the management of all diabetics’ conditions.

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 10

How are children with diabetes treated

Treating type 2 diabetes in children depends entirely on how far their condition has developed

An abrupt lifestyle change incorporating a healthier diet and exercise at an early stage

Complications of DM Prof.Dr.Saad S Al Ani 11

What can the parents of children with diabetes do

Keeping a strict eye on the blood glucose levels

04/12/2023

Avoiding lows and highs

Activity levels need to be closely monitored

Complications of DM Prof.Dr.Saad S Al Ani 12

What can the parents of children with diabetes do

04/12/2023

Patients and their families alike should know that support is available

Understanding how the disease affects the child, being adaptable and patient, are essential to successfully managing diabetes

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 13

Childhood Diabetes Mellitus

Complications

Where we

are?

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 14

Conclusions :One-fourth of girls with type 1 diabetes scored above the cutoff for DEB and one-third reported skipping their insulin dose entirely at least occasionally after overeating. Both DEB and insulin restriction were associated with poorer metabolic control, which may increase the risk of serious late diabetes complications.

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 15

Abstract  OBJECTIVE: To investigate the incident and prevalence of type 2 diabetes mellitus (T2DM) and prediabetes in obese children in the last ten years. METHODS: The clinical data of hospitalized children with newly diagnosed diabetes mellitus (DM) or obesity between October 2000 and September 2010 were retrospectively studied. RESULTS: A total of 503 newly onset cases were diagnosed as DM in the past ten years, of which 31 were diagnosed as T2DM. The prevalence of T2DM in the second five-year duration increased significantly compared with that in the first five-year duration (0.18‰ vs 0.05‰; P<0.01). The number of cases of type 1 diabetes mellitus (T1DM) and T2DM increased by 1.35 fold and 4.20 fold, respectively in the second five-year duration. A total of 1301 obese patients received oral glucose tolerance tests, and 29 cases were diagnosed with T2DM and 255 cases with prediabetes. Of the 255 cases of prediabetes, 133 had dyslipidemia, 138 had non-alcoholic fatty liver disease and 53 had hypertension. CONCLUSIONS: The prevalence rates of T1DM and T2DM increased significantly in the last 5 years. The prevalence of T2DM increased more significantly than T1DM. There was a higher prevalence of prediabetes in obese children. Childhood obesity predicts a higher risk of T2DM and cardiovascular disease in the future.

Conclusions: The prevalence rates of T1DM and T2DM increased significantly in the last 5 years. The prevalence of T2DM increased more significantly than T1DM. There was a higher prevalence of prediabetes in obese children. Childhood obesity predicts a higher risk of T2DM and cardiovascular disease in the future.

The prevalence of type 2 diabetes mellitus and prediabetes in children

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 16

J Pediatr Endocrinol Metab. 2010 Jun;23(6):589-96.

J Pediatr Endocrinol Metab. 2010 Jun;23(6):589-96. Subclinical metabolic abnormalities associated with obesity in prepubertal Mexican schoolchildren. Romero JB, Briones E, Palacios GC, Castelán K. Source Departamento de Pediatría, Unidad Médica de Alta Especialidad, Hospital de Especialidades, Saltillo, Coahuila, Mexico. Abstract Childhood obesity has increased to epidemic levels and is considered a public health problem due to its association with a number of metabolic abnormalities, which are being detected at earlier stages of life. The objective was to evaluate the association between the presence of subclinical metabolic abnormalities (SMA) and obesity in a sample of pre-pubertal Mexican schoolchildren. Children of both sexes and 6 to 13 years old were questioned for signs of puberty, underwent anthropometric measurement and had their Body Mass Index (BMI) calculated. Two groups were formed: those with obesity (case group) and those with normal weight paired by age and chosen randomly (control group). Fasting insulin, glucose and cholesterol were measured. 92 children were included, 46 in each group, mean age 9.9 and 9.5 years old, respectively (p = 0.97). A higher frequency of hyperinsulinism was found in the case group: Fasting insulin > 15 mU/ml, 75% vs. 21% (case group vs. control group, respectively); fasting glucose to insulin ratio < 6, 72% vs. 24%; HOMA IR > 2.7, 83% vs. 14%; and decrease in QUICKI (< 0.3), 80% vs. 19% (p = 0.000). Hypercholesterolemia was 25% vs. 15% (p = 0.22), impaired fasting glucose 28% vs. 8% (p = 0.01), and family history of diabetes mellitus (DM) 35% vs. 9% (OR = 5.6; 95% CI = 1.5-22.2; p = 0.002). In this sample of Mexican schoolchildren, obesity was associated to a higher frequency of SMA, such as hyperinsulinism and impaired fasting glucose, and to a family history of DM.

Subclinical metabolic abnormalities associated with obesity in prepubertal Mexican schoolchildren

In this sample of Mexican schoolchildren, obesity was associated to a higher frequency of SMA, such as hyperinsulinism and impaired fasting glucose, and to a family history of DM

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 17

• Korean Circ J. 2010 Mar;40(3):125-30. doi: 10.4070/kcj.2010.40.3.125. Epub 2010 Mar 24.

Left ventricular function in children and adolescents with type 1 diabetes mellitus.

Kim EH, Kim YH.

Source

Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea.

Abstract

BACKGROUND AND OBJECTIVES:

Adult studies have reported that patients with diabetes mellitus (DM) show ultrastructural and functional myocardial deterioration. The aim of this study was to assess whether cardiac functional deterioration can be detected in pediatric patients with type I DM and whether or not a relatively short duration of DM and hyperglycemia influences cardiac function.

SUBJECTS AND METHODS:

Forty-seven children and adolescents with DM and 38 healthy subjects (control group) were enrolled. Glycosylated hemoglobin (HbA1c), DM-induced complications, and left ventricular (LV) function as assessed using conventional and unconventional echocardiography {tissue Doppler imaging (TDI) and vector velocity imaging (VVI)} were evaluated.

RESULTS:

The conventional echocardiographic parameters, with the exception of early peak mitral inflow velocity, the findings of pulsed wave TDI at the annular level, and regional ventricular function by VVI, were not significantly different between the two groups. Using the conventional and unconventional indices of systolic and diastolic function, no significant relationship was found between the duration of DM and the echocardiographic parameters. The deceleration time (DT) and E'/A' had an inverse correlation with HbA1c (p=0.042 and p=0.016, respectively).

CONCLUSION:

Patients with DM in childhood and early adolescence rarely have insight on the significance of DM, and their diet is difficult to control. An alteration of myocardial function induced by DM may begin earlier than generally thought, and these changes are accelerated when glycemic control is poor. We recommend the early institution of close observation of patients with diabetes for alterations in cardiac function, in addition to other diabetic complications.

Left ventricular function in children and adolescents with type 1 diabetes mellitus.

CONCLUSION:Patients with DM in childhood and early adolescence rarely have insight on the significance of DM, and their diet is difficult to control. An alteration of myocardial function induced by DM may begin earlier than generally thought, and these changes are accelerated when glycemic control is poor. We recommend the early institution of close observation of patients with diabetes for alterations in cardiac function, in addition to other diabetic complications

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 18

J Res Med Sci. 2013 Feb;18(2):132-6.

Prevalence and related risk-factors of peripheral neuropathy in children with insulin-dependent diabetes mellitus.

Hasani N, Khosrawi S, Hashemipour M, Haghighatiyan M, Javdan Z, Taheri MH, Kelishadi R, Amini M, Barekatein R.

Source

Department of Obstetrics and Gynecology, Isfahan University of Medical Sciences, Isfahan, Iran.

Abstract

BACKGROUND:

Diabetes mellitus (DM) is a common metabolic disorder that can cause various complications including, peripheral neuropathy (PNP). Some possible risk-factors such as blood glucose level, hyperglycemia, duration of diabetes, and lipid profiles are assumed to be important in diabetic PNP incidence. The aim of this study is to evaluate the prevalence and possible risk-factors of PNP in children with insulin dependent DM.

MATERIALS AND METHODS:

Among diabetic children, 146 patients (up to 18-years old) were evaluated in this cross-sectional study. All patients were examined for signs and symptoms of neuropathy and nerve conduction studies were performed. Blood level of glucose and lipid profiles were also tested. The relation between variables was compared by independent t-test and logistic regression test.

RESULTS:

The mean age of diabetic children was 11.9 ± 3.3 years whereas mean diabetes duration was 3.8 ± 2.9 years. PNP was detected in 40 patients (27.4%) that 62.5% of them have subclinical and 37.5% have clinical neuropathy. According to logistic regression analysis, duration ofdiabetes was the most important factor in prevalence of PNP (5.7 ± 3.5 and 3.1 ± 2.5 years in patients with and without neuropathy respectively, P < 0.001, 95% confidence interval [1.15-1.54]).

CONCLUSION:

As most of the patients had subclinical PN, neurological assessment is recommended to detect subclinical neuropathy in asymptomatic type 1 diabetic children and it seems that the best way to prevent this complication is still rigid blood glucose control and periodic evaluations.

Prevalence and related risk-factors of peripheral neuropathy in children with insulin-dependent diabetes mellitus

CONCLUSION:As most of the patients had subclinical PN, neurological assessment is recommended to detect subclinical neuropathy in asymptomatic type 1 diabetic children and it seems that the best way to prevent this complication is still rigid blood glucose control and periodic evaluations.

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 19

PLoS One. 2013 Apr 10;8(4):e60057. doi: 10.1371/journal.pone.0060057. Print 2013.

Skin and soft tissue infections and associated complications among commercially insured patients aged 0-64 years with and without diabetes in the U.S.

Suaya JA, Eisenberg DF, Fang C, Miller LG.

Source

GlaxoSmithKlineVaccines, Philadelphia, Pennsylvania, United States of America. Jose.2.Suaya@GSK.com

Abstract

INTRODUCTION:

Skin and soft tissue infections (SSTIs) are common infections occurring in ambulatory and inpatient settings. The extent ofcomplications associated with these infections by diabetes status is not well established.

METHODS:

Using a very large repository database, we examined medical and pharmacy claims of individuals aged 0-64 between 2005 and 2010 enrolled in U.S. health plans. Diabetes, SSTIs, and SSTI-associated complications were identified by ICD-9 codes. SSTIs were stratified by clinical category and setting of initial diagnosis.

RESULTS:

We identified 2,227,401 SSTI episodes, 10% of which occurred in diabetic individuals. Most SSTIs were initially diagnosed in ambulatory settings independent from diabetes status. Abscess/cellulitis was the more common SSTI group in diabetic and non-diabetic individuals (66% and 59%, respectively). There were differences in the frequencies of SSTI categories between diabetic and non-diabetic individuals (p<0.01). Among SSTIs diagnosed in ambulatory settings, the SSTI-associated complication rate was over five times higher in people with diabetes than in people withoutdiabetes (4.9% vs. 0.8%, p<0.01) and SSTI-associated hospitalizations were 4.9% and 1.1% in patients with and without diabetes, respectively. Among SSTIs diagnosed in the inpatient setting, bacteremia/endocarditis/septicemia/sepsis was the most common associated complication occurring in 25% and 16% of SSTIs in patients with and without diabetes, respectively (p<0.01).

CONCLUSIONS:

Among persons with SSTIs, we found SSTI-associated complications were five times higher and SSTI-associated hospitalizations were four times higher, in patients with diabetes compared to those without diabetes. SSTI prevention efforts in individuals with diabetes may have significant impact on morbidity and healthcare resource utilization .

Skin and soft tissue infections and associated complications among commercially insured patients aged 0-64 years with and without diabetes in the U.S.

CNCLUSIONSAmong persons with SSTIs, we found SSTI-associated complications were five times higher and SSTI-associated hospitalizations were four times higher, in patients with diabetes compared to those without diabetes. SSTI prevention efforts in individuals with diabetes may have significant impact on morbidity and healthcare resource utilization

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 20

Diabetologia

Diabetologia. 2013 May;56(5):995-1003. doi: 10.1007/s00125-013-2850-z. Epub 2013 Feb 7.

Diabetic ketoacidosis at the onset of type 1 diabetes is associated with future HbA1c levels.

Fredheim S, Johannesen J, Johansen A, Lyngsøe L, Rida H, Andersen ML, Lauridsen MH, Hertz B, Birkebæk NH, Olsen B, Mortensen HB, Svensson J; Danish Society for Diabetes in Childhood and Adolescence.

Source

Department of Paediatrics, Herlev Hospital, Arkaden, Turkisvej 14, DK 2730 Herlev, Denmark. sirifredheim@dadlnet.dk

Abstract

AIMS/HYPOTHESIS:

We investigated the long-term impact of diabetic ketoacidosis (DKA) at onset on metabolic regulation and residual beta cell function in a Danish population with type 1 diabetes.

METHODS:

The study is based on data from DanDiabKids, a Danish national diabetes register for children. The register provides clinical and biochemical data on patients with type 1 diabetes diagnosed in 1996-2009 and then followed-up until 1 January 2012. Repeated-measurement models were used as statistical methods.

RESULTS:

The study population comprised 2,964 children <18 years. The prevalence of DKA at diagnosis was 17.9%. Of the total subjects, 8.3% had mild, 7.9% had moderate and 1.7% had severe DKA. DKA (moderate and severe) was associated with increased HbA1c (%) levels (0.24; 95% CI 0.11, 0.36; p = 0.0003) and increased insulin dose-adjusted HbA1c (IDAA1c, 0.51; 95% CI 0.31, 0.70; p < 0.0001) during follow-up, after adjustment for covariates. Children without a family history of diabetes were more likely to present with DKA (19.2% vs 8.8%, p < 0.0001); however, thesechildren had a lower HbA1c (%) level over time (-0.35; 95% CI -0.46, -0.24; p < 0.0001). Continuous subcutaneous insulin infusion (CSII) was associated with a long-term reduction in HbA1c, changing the effect of DKA, after adjustment for covariates (p < 0.0001).

CONCLUSIONS/INTERPRETATION:

DKA at diagnosis was associated with poor long-term metabolic regulation and residual beta cell function as assessed by HbA1c and IDAA1c, respectively; however, CSII treatment was associated with improvement in glycaemic regulation and residual beta cell function, changing the effect of DKA at onset in our population.

Diabetic ketoacidosis at the onset of type 1 diabetes is associated with future HbA1c levels

CONCLUSIONS/INTERPRETATION:DKA at diagnosis was associated with poor long-term metabolic regulation and residual beta cell function as assessed by HbA1c and IDAA1c, respectively; however, CSII treatment was associated with improvement in glycaemic regulation and residual beta cell function, changing the effect of DKA at onset in our population.

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 21

Emergency Medicine Clinics of North AmericaVolume 31, Issue 3, August 2013, Pages 755–773Pediatric Emergency Medicine

Emerg Med Clin North Am. 2013 Aug;31(3):755-73. doi: 10.1016/j.emc.2013.05.004. Epub 2013 Jul 6.Diabetic ketoacidosis in the pediatric emergency department.Olivieri L, Chasm R.SourceDepartment of Emergency Medicine, University of Maryland Medical Center, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.AbstractDespite many advances, the incidence of pediatric-onset diabetes and diabetic ketoacidosis (DKA) is increasing. Diabetes mellitus is 1 of the most common chronic pediatric illnesses and, along with DKA, is associated with significant cost and morbidity. DKA is a complicated metabolic state hallmarked by dehydration and electrolyte disturbances. Treatment involves fluid resuscitation with insulin and electrolyte replacement under constant monitoring for cerebral edema. When DKA is recognized and treated immediately, the prognosis is excellent. However, when a patient has prolonged or multiple courses of DKA or if DKA is complicated by cerebral edema, the results can be devastating.

Diabetic ketoacidosis in the pediatric emergency department

when a patient has prolonged or multiple courses of DKA or if DKA is complicated by cerebral edema, the results can be devastating.

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 22

http://thediabeteschallenge.org/

Diabetes Mellitus

Its Complications

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 23

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 24

AcuteComplications

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 25

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) is an acute and dangerous complication of diabetes mellitus

Ketoacidosis is much more common in type 1 diabetes than type 2

DKA is always a medical emergency and requires medical attention

http://eatingacademy.com

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 26

Diabetic ketoacidosis (cont.)

Low insulin levels cause the liver to turn fatty acid to ketone

Elevated levels of ketone bodies in the blood decrease the blood's pH, leading to DKA

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 27

Diabetic ketoacidosis(cont.)

On presentation at hospital, the patient in DKA is typically dehydrated, and breathing rapidly and deeply

Abdominal pain is common and may be severe

The level of consciousness is typically normal until late in the process, when lethargy may progress to coma

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 28

Diabetic ketoacidosis(cont.)

Ketoacidosis can easily become severe enough to cause hypotension, shock, and death

Urine analysis will reveal: Significant levels of ketone bodies

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 29

Diabetic ketoacidosis(cont.)

Prompt, proper treatment usually results in full recovery

Death can result from: □ Inadequate or delayed treatment □ Complications (e.g., brain edema).

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 30

Hyperglycemia hyperosmolar state

Hyperosmolar nonketotic state (HNS) is an acute complication sharing many symptoms with DKA, but an entirely different origin and different treatment.

It is more common in type 2 diabetes than type 1

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 31

Hyperglycemia hyperosmolar state (cont.)

Blood glucose levels

above 300 mg/dl

(16 mmol/L))

Water is osmotically drawn

out of cells into the blood

Kidneys eventually begin to dump glucose

into the urine

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 32

Hyperglycemia hyperosmolar state (cont.)

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 33

Hyperglycemia hyperosmolar state (cont.)

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 34

Hyperglycemia hyperosmolar state (cont.)

Urgent medical treatment is necessary, commonly beginning with fluid volume replacement.

Lethargy may ultimately progress to a coma

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 35

Hypoglycemia

Hypoglycemia, or abnormally low blood glucose,

is an acute complication of several diabetes treatments

In patients with diabetes, this may be caused by several factors such as: □ Too much or incorrectly timed insulin □ Too much or incorrectly timed exercise □ Not enough food

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 36

Hypoglycemia(cont.)

The patient may become agitated, sweaty, weak, and have many symptoms of sympathetic activation of the autonomic nervous system resulting in feelings akin to dread and immobilized panic.

Consciousness can be altered or even lost in extreme cases, leading to coma, seizures, or even brain damage and death

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 37

Hypoglycemia(cont.)

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 38

Hypoglycemia (cont.)

In most cases, hypoglycemia is treated with sugary drinks or food

In severe cases, an injection of glucagon or an intravenous infusion of dextrose is used for treatment, but usually only if the person is unconscious

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 39

Diabetic coma

Diabetic coma is a medical emergency in which a person with diabetes mellitus is comatose (unconscious) because of one of the acute complications of diabetes:

1.Severe diabetic hypoglycemia

2.Diabetic ketoacidosis

3.Hyperosmolar nonketotic coma

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 40

ChronicComplications

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 41

The damage to small blood vessels leads to a microangiopathy, which can cause one or more of the following:

1.Diabetic cardiomyopathy leading to diastolic dysfunction and eventually heart failure.

2.Diabetic nephropathy can lead to chronic renal failure, eventually requiring dialysis.

Microangiopathy

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 42

4.Diabetic retinopathy

can lead to severe vision loss or blindness.

3. Diabetic neuropathy usually in a 'glove and stocking' distribution starting with the feet but potentially in other nerves, later often fingers and hands

(cont.)Microangiopathy

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 43

1.Coronary artery disease, leading to angina or myocardial infarction ("heart attack")

Macrovascular disease leads to cardiovascular disease, to which accelerated atherosclerosis is a contributor:

Macrovascular diseases

2.Diabetic myonecrosis ('muscle wasting')

They are not common in children as in adults

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 44

4.Stroke (mainly the ischemic type)

3.Peripheral vascular disease, which contributes to intermittent claudication (exertion-related leg and foot pain) as well as diabetic foot

(cont.)Macrovascular diseases

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 45

Complications and poor control

Type 1 diabetes rarely results in retinopathy and nephropathy within the first five years, but kidney damage and eye diseases have been found to be more common amongst those with poor control.

Risks of diabetes complications climb once HbA1c levels exceed 9%, and again increase significantly above 12%..

Type 2 diabetes may often result in vascular complications such as heart attacks, stroke and problems with circulation

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 46

Complications and poor control

By closely controlling □ Blood sugar levels □ Blood pressure and cholesterol People with diabetes can help lower their risk of diabetes complications.

A lifestyle involving: □ a good diet □ regular exercise □ no smoking Can also help to reverse diabetes complication risks.

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 47

References

1. "Diabetes Complications". Diabetes.co.uk. Retrieved 22 November 2012.

2. http://emedicine.medscape.com

3.Romero JB. Subclinical metabolic abnormalities associated with obesity in prepubertal Mexican schoolchildren. J Pediatr Endocrinol Metab. 2010 Jun;23(6):589-96.3. http://www.nlm.nih.gov

4. http://www.cdc.gov/diabetes

5. http://www.uptodate.com

6. http://care.diabetesjournals.org

7. http://www.global-sci.org/cjcp

8. http://www.degruyter.com/view/j/jpem

9. http://www.koreancircj.kr

10. http://journals.mui.ac.ir/jrms

11. http://www.plosone.org

,

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 48

04/12/2023 Complications of DM Prof.Dr.Saad S Al Ani 49