What questions are asked in viva diabetes mellitus while case presentation give detailed answers from park text book
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Viva Questions on Diabetes Mellitus - Detailed Answers from Park's Textbook of Preventive and Social Medicine
Q1. Define Diabetes Mellitus.
Answer: The term diabetes describes a group of metabolic disorders characterized and identified by the presence of hyperglycaemia in the absence of treatment. The heterogeneous aetio-pathology includes defects in insulin secretion, insulin action, or both, and disturbances of carbohydrate, fat and protein metabolism.
(Park's Textbook of Preventive and Social Medicine, p. 444)
Q2. What is the WHO Classification of Diabetes (2019)?
Answer: The WHO 2019 classification prioritizes clinical care and helps health professionals choose appropriate treatment (especially whether to start insulin):
| Type of Diabetes | Brief Description |
|---|---|
| Type 1 Diabetes | Beta-cell destruction (mostly immune-mediated), absolute insulin deficiency; onset most common in childhood and early adulthood |
| Type 2 Diabetes | Most common type; various degrees of beta-cell dysfunction and insulin resistance; commonly associated with overweight and obesity |
| Hybrid forms of diabetes | |
| - Slowly evolving, immune-mediated diabetes of adults | Similar to slowly evolving type 1 in adults but often has features of metabolic syndrome, a single GAD autoantibody, retains greater beta-cell function (previously called LADA) |
| - Ketosis-prone type 2 diabetes | Presents with ketosis and insulin deficiency but later does not require insulin; not immune-mediated |
| Other specific types | |
| - Monogenic defects of beta-cell function | Caused by specific gene mutations; several clinical manifestations; may occur in neonatal period or early adulthood |
| - Monogenic defects in insulin action | Features of severe insulin resistance without obesity |
| - Diseases of exocrine pancreas | Trauma, tumor, inflammation of pancreas causing hyperglycaemia |
| - Endocrine disorders | Excess secretion of insulin-antagonist hormones |
| - Drug or chemical induced | e.g., steroids, thiazides |
| Gestational Diabetes Mellitus (GDM) | Hyperglycaemia first detected during pregnancy, below the diagnostic threshold for diabetes |
| Unclassified Diabetes | When there is insufficient information for classification |
Q3. What are the Diagnostic Criteria for Diabetes as per WHO (2019)?
Answer: (Table 3 from Park's)
| Measurement | Diagnostic Cut-off Value |
|---|---|
| Fasting venous or capillary plasma glucose | ≥7.0 mmol/L (126 mg/dL) |
| 2-hour post-load venous plasma glucose | ≥11.1 mmol/L (200 mg/dL) |
| 2-hour post-load capillary plasma glucose | ≥12.2 mmol/L (220 mg/dL) |
| Random plasma glucose | ≥11.1 mmol/L (200 mg/dL) |
| HbA1c | ≥6.5% (48 mmol/mol) |
- For asymptomatic individuals: a single abnormal test is insufficient - a repeat confirmatory test is required.
- For symptomatic individuals: a single test result is sufficient for diagnosis.
Q4. What are the Intermediate Hyperglycaemia Categories (Pre-Diabetes)?
Answer: WHO (2019) recognizes two intermediate categories that do NOT meet criteria for diabetes but are at high risk:
a) Impaired Fasting Glucose (IFG):
- Fasting plasma glucose: 6.1-6.9 mmol/L (110-125 mg/dL)
b) Impaired Glucose Tolerance (IGT):
- Fasting plasma glucose: <7.0 mmol/L
- AND 2-hour post-load plasma glucose: 7.8-11.0 mmol/L (140-199 mg/dL)
These persons are at increased risk for developing diabetes and cardiovascular disease. These are not clinical entities in themselves but are risk categories.
Q5. What is the Epidemiology/Burden of Diabetes Mellitus?
Answer (from Park's):
- Diabetes is the most common serious metabolic disorder in the world.
- It is one of the five most important determinants of cardiovascular disease epidemic in Asia.
- Population-based surveys in Bangladesh, India and Indonesia have shown a considerable increase in prevalence in both urban and rural dwellers.
- Diabetic Asian populations have ethnic/genetic vulnerability that manifests when exposed to unfavourable lifestyles (evidence from migrant studies).
- Age-adjusted mortality among diabetics is 1.5 to 2.5 times higher than in the general population.
- In Caucasians: excess mortality mainly from cardiovascular disease (especially coronary heart disease).
- In Asian and American Indian populations: renal disease is a major contributor.
- Lower limb amputation is at least 10 times more common in diabetics; more than half of all non-traumatic lower limb amputations are due to diabetes.
- Gestational diabetes poses high health risk to both mother and foetus.
Q6. What are the Risk Factors (Determinants) of Diabetes Mellitus?
Answer (from Park's):
Non-modifiable:
- Age (Type 2 increases with age)
- Genetic/family history (strong for Type 2)
- Ethnicity (Asians at higher risk)
- History of gestational diabetes
Modifiable:
- Obesity and overweight (strongest modifiable risk factor for Type 2)
- Sedentary lifestyle / physical inactivity
- Over-nutrition (high calorie, high sugar, low fibre diet)
- Alcohol (indirectly increases risk)
- Diabetogenic drugs: oral contraceptives, thiazides, corticosteroids
- Factors promoting atherosclerosis: smoking, hypertension, hypercholesterolaemia, hypertriglyceridaemia
Q7. What are the Complications of Diabetes Mellitus?
Answer (from Park's):
Microvascular:
- Diabetic retinopathy - leading cause of blindness
- Diabetic nephropathy - leading cause of end-stage renal disease
- Diabetic neuropathy
Macrovascular:
- Coronary heart disease (more common than in general population)
- Peripheral arterial disease
- Cerebrovascular disease / Stroke
Other complications:
- Obesity, Cataracts
- Erectile dysfunction
- Non-alcoholic fatty liver disease
- Increased susceptibility to infections (especially tuberculosis)
- Non-traumatic lower limb amputation (10x more common than non-diabetics)
- Gestational risks: congenital malformations, macrosomia, perinatal mortality
Q8. What is the Screening Strategy for Diabetes?
Answer (from Park's - "SCREENING FOR DIABETES" section):
The WHO recommends opportunistic screening of persons above 30 years of age as part of the National Programme. Screening is recommended for:
- Persons with a family history of diabetes
- Overweight/obese individuals
- Those with hypertension or dyslipidaemia
- Women with history of gestational diabetes or large-for-gestational-age babies
- Individuals with impaired fasting glucose or IGT on prior testing
Tests used for screening: Fasting plasma glucose, Random plasma glucose, HbA1c, Oral Glucose Tolerance Test (OGTT)
Q9. What are the Levels of Prevention of Diabetes Mellitus?
Answer (from Park's):
1. Primary Prevention
a) Population Strategy:
- Primordial prevention - prevent emergence of risk factors
- Maintain normal body weight through healthy nutrition and physical exercise
- Adequate protein intake, high dietary fibre, avoid sweet foods
- Integrate into community NCD prevention programmes (e.g., coronary heart disease)
- Scope for primary prevention of Type 1 is limited
b) High-Risk Strategy:
- No special high-risk strategy for Type 1 diabetes; no practical justification for genetic counselling
- For Type 2: correct sedentary lifestyle, over-nutrition, and obesity
- Avoid alcohol and diabetogenic drugs (oral contraceptives)
- Reduce atherosclerotic risk factors: smoking cessation, blood pressure control, cholesterol management
2. Secondary Prevention
- Early detection and adequate treatment
- Aims: (a) maintain blood glucose as close to normal as practicable, (b) maintain ideal body weight
- Treatment based on: (a) diet alone, (b) diet + oral antidiabetic drugs, or (c) diet + insulin
- Good blood glucose control protects against complications
3. Tertiary Prevention
- Prevention of complications and disability
- Foot care, eye examination, kidney function monitoring
- Rehabilitation of patients with disabilities (amputees, those with blindness)
Q10. What is the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS)?
Answer (from Park's):
- India is experiencing rapid health transition with large and rising burden of NCDs (CVD, DM, cancer, stroke, chronic lung diseases).
- In 2016, NCDs accounted for 60% of deaths in India.
- The National Programme on Prevention and Control of Diabetes, CVDs and Stroke was later integrated with the National Cancer Control Programme to form NPCDCS.
- During the 11th Five Year Plan: covered 100 identified districts in 21 states.
- During the 12th Five Year Plan: all districts of the country covered in a phased manner.
Major Objectives of NPCDCS:
- Prevent and control common NCDs through behaviour and lifestyle changes
- Provide early diagnosis and management of common NCDs
- Build capacity at various levels for prevention, diagnosis and treatment
- Train human resources (doctors, paramedics, nurses) to cope with increasing NCD burden
- Establish capacity for palliative and rehabilitative care
Strategies:
- Programme implemented in 20,000 sub-centres and 700 Community Health Centres (CHCs) in 100 districts across 21 states/UTs
- Opportunistic screening of persons above age 30 years
- Establishment of NCD Clinics at CHC and district level
- Mass media, community education and interpersonal communication for behaviour change
- Service delivery through existing public health infrastructure
Q11. What Medicines are Used in Diabetes Mellitus (as per Park's Essential Medicines)?
Answer (from Park's - Section 21.4):
a) Insulins and other antidiabetic agents (21.4.1)
Oral antidiabetic drugs:
- Biguanides: Metformin - first-line drug for Type 2 DM, especially in obese patients
- Sulfonylureas: Glibenclamide, Glipizide - stimulate insulin secretion
- Alpha-glucosidase inhibitors: Acarbose - delays carbohydrate absorption
Insulins:
- Short-acting: Soluble insulin (regular insulin) - for acute control, pre-meals
- Intermediate-acting: NPH insulin (isophane insulin)
- Long-acting: e.g., Insulin glargine - basal insulin
Q12. What is Gestational Diabetes Mellitus (GDM)?
Answer (from Park's):
- Gestational Diabetes Mellitus is defined as hyperglycaemia first detected at any time during pregnancy with blood glucose values above normal but below those diagnostic of diabetes.
- It is distinct from diabetes that was previously diagnosed before pregnancy.
- The WHO 2019 classification places GDM and "diabetes in pregnancy" as separate subcategories of hyperglycaemia first detected in pregnancy.
- Metabolic disorders in pregnant diabetic women pose high health risk to both mother and foetus - including congenital anomalies, macrosomia, perinatal mortality.
Q13. What is the Difference Between Type 1 and Type 2 Diabetes?
Answer (from Park's - Table 1):
| Feature | Type 1 | Type 2 |
|---|---|---|
| Mechanism | Beta-cell destruction, mostly immune-mediated | Beta-cell dysfunction + insulin resistance |
| Insulin | Absolute deficiency | Relative deficiency |
| Age of onset | Childhood and early adulthood | Usually adults (but increasingly in younger age groups) |
| Association | Autoimmune | Overweight/obesity, sedentary lifestyle |
| Ketoacidosis | Common and dramatic | Rare (except ketosis-prone type 2) |
| Frequency | Less common | Most common type |
| Treatment | Always requires insulin | Diet, oral drugs, insulin when needed |
Q14. What is the Relationship Between Diabetes and Tuberculosis?
Answer (from Park's):
- Diabetics are at increased risk of infectious diseases, particularly tuberculosis.
- There is a dedicated section "TUBERCULOSIS AND DIABETES" in Park's textbook highlighting the bidirectional relationship.
- Diabetes impairs immune response and increases susceptibility to TB.
- TB can worsen glycaemic control in diabetics.
- This co-morbidity is particularly significant in developing countries like India.
Summary Table: Key Figures to Remember for Viva
| Parameter | Value |
|---|---|
| Fasting plasma glucose (diagnostic) | ≥126 mg/dL (≥7.0 mmol/L) |
| Random/2-hr post-load plasma glucose (diagnostic) | ≥200 mg/dL (≥11.1 mmol/L) |
| HbA1c (diagnostic) | ≥6.5% |
| IFG (fasting) | 110-125 mg/dL (6.1-6.9 mmol/L) |
| IGT (2-hour post-load) | 140-199 mg/dL (7.8-11.0 mmol/L) |
| Age for opportunistic screening (NPCDCS) | ≥30 years |
| Mortality ratio vs general population | 1.5 to 2.5 times higher |
| Lower limb amputation risk vs non-diabetics | ≥10 times more common |
| NCDs share of deaths in India (2016) | 60% |
| NPCDCS districts (11th Plan) | 100 districts in 21 states |
All answers are sourced from Park's Textbook of Preventive and Social Medicine (ISBN: 9789382219163), pages 443-447 and related chapters on NCD programmes.
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