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Diabetes

Author- Chester Ryan Azurin

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Introduction

Diabetes, or diabetes mellitus (DM), is a chronic metabolic disorder in which the body is unable to appropriately regulate the level of sugar, specifically glucose, in the blood, either by poor sensitivity to the protein insulin, or due to inadequate production of insulin by the pancreas.[1] DM itself is not a high-mortality condition. However, DM is associated with numerous systemic complications that affect various parts of the body [2] becoming an important risk factor for a number of non-communicable diseases creating a high attributable burden of disability and leading to other causes of death. [3]

There are various types of DM, with two main types (Type 1 & Type 2) accounting for most diabetes cases.

Evidence strongly support the significant role of physiotherapists play in DM prevention, treatment and management and its associated complications. [4] Physiotherapy management, including exercise prescription and education, may help patients participation improve and maintain physical well-being - this can significantly impact their activities of daily living and health-related quality of life. [5]

Clinically Relevant Anatomy, Pathophysiology and Classification

DM is broadly classified into three types by aetiology and clinical presentation, type 1 diabetes, type 2 diabetes, and gestational diabetes (GDM).[6] There are also other rarer types of diabetes, which according to Diabetes UK, have similar significance. [7]

Diabetes Mellitus primarily affects the Islets of Langerhans of the pancreas, where glucagon (from the alpha cells) and insulin (from the beta cells) are produced. Glucagon raises the blood glucose level, while insulin lowers it. [8]

Type 1 DM (Insulin Dependent) accounts for 5% to 10% of DM and is characterised by autoimmune destruction of insulin-producing beta cells in the islets of the pancreas, the loss of function of the beta cells leads to an absolute insulin deficiency. T1DM is most commonly seen in children and adolescents though it can develop at any age. For more information, read Diabetes Mellitus Type 1.

Type 2 DM (Non-insulin Dependent) accounts for around 90% of all cases of diabetes.[9] In T2DM, the response to insulin is diminished, and this is defined as insulin resistance. As such, insulin is ineffective and is initially countered by an increase in insulin production to maintain glucose homeostasis, but over time, insulin production decreases, resulting in T2DM. T2DM is most commonly seen in persons older than 45 years. It is increasingly now seen in children, adolescents, and younger adults due to rising levels of obesity, physical inactivity, and energy-dense diets. Check Diabetes Mellitus Type 2 for more details on this type.

Gestational Diabetes Mellitus (first detected during pregnancy) can occur anytime during pregnancy.[10] Generally affects pregnant women during the second and third trimesters. According to the American Diabetes Association (ADA), GDM complicates 7% of all pregnancies. Women with GDM and their offspring have an increased risk of developing type 2 diabetes mellitus in the future. [6] There is a PP page on Gestational diabetes.

Other types of diabetes include different types of maturity onset diabetes of the young (MODY or T4DB), neonatal diabetes, Wolfram syndrome, type 3c disease, steroid-induced diabetes, cystic-fibrosis related diabetes, and latent autoimmune diabetes in adults (LADA). [7] In addition, a new diabetes type (T5DB) was recognised by the International Diabetes Federation in 2025.[11]

Epidemiology

Diabetes is a worldwide epidemic and a substantial public health issue. According to the latest International Diabetes Federation (IDF) Diabetes Atlas (2025) reports, 11.1% – or 1 in 9 – of the adult population (20-79 years) is living with diabetes, and there were 589 million people living with diabetes worldwide in 2024.[12]

With changing lifestyles and increasing obesity, the prevalence of DM has increased worldwide. It is projected that by 2050, more than 853 million people will have diabetes. [12] About 29% of the population above 65 years of age has diabetes.[6] With an increase in age, the prevalence of DM also increases; this mostly concerns Type 2 diabetes and may be connected to age-related factors such as insulin resistance, impaired pancreatic function as well as sarcopenia and reduced levels of physical activity.[13] Type 2 diabetes accounts for nearly 90% of cases, with a worldwide prevalence of 537 million.[9]

Complications

Complications are similar for type 1 and type 2 diabetes patients, yet the frequency or timing of occurrence can vary.[14] Complications from diabetes can be broken up into two categories: microvascular (diabetic microangiopathy)[15] and macrovascular. Microvascular prevalence of complications is much higher than that of macrovascular complications.[14]

Microvascular complications may include:[16]

Macrovascular complications may include:[14]

Clinical Presentation

Patients with diabetes mellitus most commonly present with:

  • increased thirst,
  • increased urination,
  • lack of energy and fatigue,
  • bacterial and fungal infections
  • delayed wound healing.
  • may also complain of numbness or tingling in hands or feet or with blurred vision.
  • Can have modest hyperglycaemia, which can proceed to severe hyperglycaemia or ketoacidosis due to infection or stress. Type 1 DM patients can often present with ketoacidosis (DKA) coma as the first manifestation in about 30% of patients.[20]
  • Persons with DM (usually Type 1) may experience weight loss because of the improper fat metabolism and breakdown of fat stores.

Diagnostic Procedures

Fasting glucose level of greater than 126 mg/dl on two separate occasions is considered positive, with fasting defined as no caloric intake for at least 8 hours preceding the test. [21]

The strictest procedure is according to the World Health Organization, which states that the diagnosis is positive if "venous plasma glucose concentration is greater than 11.1 mmol/L  2 hours after a 75g  glucose tolerance test."

The study by Pooja Bhati et al. suggests that biomarkers of inflammation and endothelial function are correlated with Cardiac Vagal Tone and global Heart Rate Variability (HRV), which indicate some pathophysiological link between subclinical inflammation, endothelial dysfunction and cardiac autonomic dysfunction in Type 2 Diabetes Mellitus. [22]

Prevention

Before DM develops there is an intermediate state of hyperglycaemia which is characterised by high glucose levels that do not reach the diagnostic levels of DM. This state, known as prediabetes, is increasingly recognised as a significant metabolic step to developing overt diabetes (Type 2). Indeed, it is estimated that the lifetime prevalence of prediabetes cases that develop to DM is 70%. [23] This has led to proposals for screening, diagnosis, and intervention for people in this preclinical group. [24] Lately, DM prevention programme suggestions include the use of innovative approaches such the use of artificial intelligence (AI) in lifestyle interventions for preventing not only DM, [25] but also its complications once established. [26] However, AI's wider clinical application to DM prevention may still be far reached because of cost, accessibility, device interoperability, and ethical limitations. [27]

Management

For both T1DM and T2DM, the cornerstone of therapy is diet and exercise. A diet low in saturated fat, refined carbohydrates, fructose corn syrup, and high in fibre and monounsaturated fats needs to be encouraged. Aerobic exercise for a duration of 90 to 150 minutes per week is beneficial. The major target in T2DM patients, who are obese, is weight loss. [6] Weight management, nutritional and diet counselling combined with physical therapy/exercise prescription is ideal.

For Type 1 (insulin dependent) Diabetes, intramuscular administration of insulin is needed. Dosage is always expressed in USP units. Humalog is the fastest acting insulin, acting within 15 minutes. The PZI has the longest peak of  8-20 hours and has the longest total duration of 36 hours. On the other hand, the Lantus is the only one "without peak" and lasts for 24 hours.

For Type 2 (non-insulin dependent) Diabetes, popular oral hypoglycaemics include Metformin and Sulfonylureas. Insulin sensitizers such as Rosiglitazone and Pioglitazone are also prescribed. Preventing and controlling type 2 diabetes remains an ongoing challenge.[12]

Physiotherapy Management

Therapeutic exercise programs comprise the major aspect of management. Patient education for proper foot care is an essential part of the physiotherapy programme for diabetic patients.

An RCT study demonstrated significant improvement in clinical symptoms and health-related quality of life (HRQoL) for individuals with type 2 diabetes suffering from Distal Peripheral Neuropathy (DPN). This improvement was observed after ten treatment sessions of Tecar therapy and low-level laser therapy (LLLT), whether applied separately or simultaneously. However, the synergistic use of Tecar and LLLT may lead to more durable therapeutic effects after a long-term follow-up period.[28]

Exercise Therapy

A sound, individually tailored exercise prescription is a cornerstone in the management of Diabetes Mellitus. It includes all movement that improves energy use, whereas exercise should be planned, and physical activity should be well structured. Evidence suggests that exercise has multiple benefits for people with type 2 diabetes, for example, exercise improves blood glucose control, decreases cardiovascular risk factors, facilitates weight loss, and improves mental wellbeing. Additionally, regular exercise can prevent or delay type 2 diabetes development. It also has noticeable health benefits for people with type 1 diabetes, for instance, improved cardiovascular fitness, muscle strength, and insulin sensitivity, etc. There are several challenges related to blood glucose management and those vary with diabetes type, activity type, and having diabetes-related complications.[29]

Aerobic exercises, especially moderate to high volumes of aerobic activity, are associated with substantially decreased cardiovascular risks and overall mortality risks in both type 1 and type 2 diabetes. Furthermore, it increases cardiorespiratory fitness, decreases insulin resistance, and improves lipid levels and endothelial function for type 1 diabetics, whereas, reduces A1C, triglycerides, blood pressure, and insulin resistance for type 2 diabetics.[29] Resistance exercise typically results in 10-15% improvements in strength, bone mineral density, blood pressure, lipid profiles, skeletal muscle mass, and insulin sensitivity for type 2 diabetic patients but very few evidence found the effect of it on glycaemic control for the type 1 diabetic patients.[29][30] Flexibility and balance exercises are not directly helps to reduce or control the blood sugar but important to improve mobility and prevent various complications like fall.[29]

However, physiotherapists should have specific competencies for their unique role in supporting people with all types of diabetes to implement in physical activity safely instead of having complex medical conditions or physical obstacles.[31]

It is strongly recommended that people with diabetes have a carbohydrate snack at hand every exercise session. A glass of orange juice or milk is a good pickup for a patient who is experiencing hypoglycaemia. It is also recommended that exercise should be conducted in a comfortable temperature and never in extreme temperatures. For Type 1 (Insulin Dependent) patients, should not exercise during the peak times of insulin. Collaborate with the nurse in charge for the patient regarding the type of insulin administered. Type 2 diabetics are advised to have an average of 30 minutes of exercise duration per session. To maintain foot safety, always wear proper footwear and exercise in a safe environment. Type 1 diabetics may need to reduce insulin or increase food intake prior to the start of an exercise program. Physical Therapists must coordinate with the referring physician for this case. During prolonged exercise duration, 10-15 grams of carbohydrate snack is recommended for every 30 minutes. Patients who are on Sulfonylureas are red flags because it can cause exercise-induced hypoglycaemia. Closely coordinate with the referring physician if this was missed prior to referral. Special consideration needed for the women during menstruation to increase insulin during menses, especially if they're not active.[29]

Diabetics are more prone to hypoglycaemia than hyperglycaemia during exercise. Read for more information and classic signs and symptoms,

  1. Diabetic Ketoacidosis (DKA)
  2. Hyperglycemia
  3. Hypoglycaemia

Resources

References

  1. ↑ WHO. Diabetes. Overview. Available from: https://www.who.int/health-topics/diabetes#tab=tab_1 [accessed 20/11/2025]
  2. ↑ CDC. How diabetes can affect your body. Available from: https://www.cdc.gov/diabetes/communication-resources/how-diabetes-can-affect-your-body.html [accessed 20/11/2025]
  3. ↑ World Economic Forum All rights reserved. The Global Economic Burden of Non-communicable Diseases. 2012.
  4. ↑ Harris-Hayes M, Schootman M, Schootman JC, Hastings MK. The Role of Physical Therapists in Fighting the Type 2 Diabetes Epidemic. J Orthop Sports Phys Ther. 2020 Jan;50(1):5-16.
  5. ↑ Gelaw AY. Exercise and Diabetes Mellitus. Diabetes Food Plan. 2018 Jul 11;167.
  6. ↑ 6.0 6.1 6.2 6.3 American Diabetes Association Professional Practice Committee. 13. Older Adults: Standards of Care in Diabetes—2025. Diabetes Care. 2025;48(Supplement_1):S266–82.
  7. ↑ 7.0 7.1 Diabetes UK. Types of diabetes. Available from: https://www.diabetes.org.uk/about-diabetes/types-of-diabetes [accessed 10/12/25]
  8. ↑ Hantzidiamantis PJ, Awosika AO, Lappin SL. Physiology, Glucose. [Updated 2024 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
  9. ↑ 9.0 9.1 Ahmad E, Lim S, Lamptey R, Webb DR, Davies MJ. Type 2 diabetes. Lancet. 2022 Nov 19;400(10365):1803-20.
  10. ↑ Kunarathnam V, Vadakekut ES, Mahdy H. Gestational Diabetes. [Updated 2025 Sep 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
  11. ↑ Prajitno JH, Sutanto H. Type 5 diabetes as a growing malnutrition driven health crisis in low and middle income countries. J Diabetes Metab Disord. 2025 Jul 10;24(2):162.
  12. ↑ 12.0 12.1 12.2 International Diabetes Federation. Diabetes Facts & Figures. Available from: https://idf.org/about-diabetes/diabetes-facts-figures/ [accessed 20/11/2025]
  13. ↑ Kirkman MS, Briscoe VJ, Clark N, Florez H, Haas LB, Halter JB, Huang ES, Korytkowski MT, Munshi MN, Odegard PS, Pratley RE, Swift CS. Diabetes in older adults. Diabetes Care. 2012 Dec;35(12):2650-64.
  14. ↑ 14.0 14.1 14.2 Deshpande AD, Harris-Hayes M, Schootman M. Epidemiology of diabetes and diabetes-related complications. Phys Ther. 2008 Nov;88(11):1254-64.
  15. ↑ Madonna R, Balistreri CR, Geng YJ, De Caterina R. Diabetic microangiopathy: Pathogenetic insights and novel therapeutic approaches. Vascular pharmacology. 2017 Mar 1;90:1-7.
  16. ↑ Vithian K, Hurel S. Microvascular complications: pathophysiology and management. Clin Med (Lond). 2010 Oct;10(5):505-9.
  17. ↑ Deng Y, Chen S, Hu J. Diabetes mellitus and hearing loss. Mol Med. 2023 Oct 24;29(1):141.
  18. ↑ Ninomiya T. Diabetes mellitus and dementia. Curr Diab Rep. 2014;14(5):487.
  19. ↑ Tamás V, Kempler P. Sexual dysfunction in diabetes. Handb Clin Neurol. 2014;126:223-32.
  20. ↑ EL-Mohandes N, Huecker M. Pediatric Diabetic Ketoacidosis. PubMed. Treasure Island (FL): StatPearls Publishing; 2023.
  21. ↑ American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010 Dec 30;33(Suppl1):S62–9.
  22. ↑ Bhati P, Alam R, Moiz JA, Hussain ME. Subclinical inflammation and endothelial dysfunction are linked to cardiac autonomic neuropathy in type 2 diabetes. J Diabetes Metab Disord. 2019 Dec;18(2):419-28.
  23. ↑ Hostalek U. Global epidemiology of prediabetes - present and future perspectives. Clin Diabetes Endocrinol. 2019 May 9;5:5.
  24. ↑ Perreault L. Artificial Intelligence and Diabetes Prevention. JAMA. 2025 Dec 16;334(23):2073-2074.
  25. ↑ Mathioudakis N, Lalani B, Abusamaan MS, Alderfer M, Alver D, Dobs A, Kane B, McGready J, Riekert K, Ringham B, Shehadeh A, Vandi F, Wanigatunga AA, Zade D, Maruthur NM; AI-DPP Study Group. An AI-Powered Lifestyle Intervention vs Human Coaching in the Diabetes Prevention Program: A Randomized Clinical Trial. JAMA. 2025 Dec 16;334(23):2079-89.
  26. ↑ Contreras I, Vehi J. Artificial Intelligence for Diabetes Management and Decision Support: Literature Review. J Med Internet Res. 2018 May 30;20(5):e10775.
  27. ↑ Kohli M, Pandey P, Jakhmola V, Saha S, Chaudhary M, Ansori ANM, Negi A. Revolutionizing diabetes care: the role of artificial intelligence in prevention, diagnosis, and patient care. J Diabetes Metab Disord. 2025 May 30;24(1):132.
  28. ↑ Javan Amoli M, Khademi Kalantari K, Ahmadpour Emshi Z, Daryabor A, Naimi SS. Comparison of Tecar Therapy and Low-Level Laser Therapy Separately and Simultaneously on Clinical Symptoms and Health-Related Quality of Life in Individuals with Type 2 Diabetes: A 3-Month Follow-up Study. Int J Endocrinol Metab. 2024 May 5;22(1):e143135.
  29. ↑ 29.0 29.1 29.2 29.3 29.4 Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, et al. Physical activity/exercise and diabetes: a Position Statement of the American Diabetes Association. Diabetes Care. 2016;39(11):2065–79.
  30. ↑ Kanaley JA, Colberg SR, Corcoran MH, Malin SK, Rodriguez NR, Crespo CJ, et al. Exercise/physical activity in individuals with type 2 diabetes: A consensus statement from the American College of Sports Medicine. Med Sci Sports Exerc. 2022 Feb 1;54(2):353–68.
  31. ↑ Proctor C, Brown CL. Referral pathway and competency profiles of primary care physiotherapists and kinesiologists for physical activity interventions for diabetes: a modified Delphi study. BMC Primary Care. 2024 Oct 15;25(1):368.
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