2014 Winter Lecture Series Choices Foundation for Health Education and Research.

2014 Winter Lecture Series

Choices Foundation for

Health Education and Research

Management ofthe Diabetes Epidemic

Prevention, Early Recognition, and Treatment Options

Bonnie Elkhair, FNP

Choices Integrative Healthcare

of Sedona

The Diabetes Epidemic

• Around the world, every 10 seconds, one person dies from complications of diabetes.

• Around the world, every 10 seconds, two people develop diabetes.

• According to the National Institutes of Health, more than 6 million Americans currently have Diabetes and don’t know it.

Prevalence of Diabetes in America*

In 2010:25.8 million people

8.3% of the population

1.9 million new dx

In 2012:29.1 million people

9.3% of the population

1.7 million new dx

*American Diabetes Association www.diabetes.org

The Diabetes Epidemic*

• Diabetes Mellitus is the 7th leading cause of death in the United States.

• Diabetes Mellitus affects 25.9% of Americans age 65 or older,11.8 million seniors.

• Type 2 Diabetes accounts for 95% of all cases of diabetes in the United States.


PREDIABETES

• Reflects failing pancreas compensation for underlying insulin resistance

• 86 million Americans affected

• About 1 in 3 adults affected

• 9 of 10 cases not diagnosed

• 15-30% of Prediabetic patients will develop Type 2 Diabetes within 5 years

Effects of Uncontrolled Diabetes*

• Microvascular Complications – Target nerves, eyes, feet, kidneys

• BLINDNESS• LIMB AMPUTATION• DIALYSIS

• Macrovascular Complications– Target brain, heart1. Heart Attack

• Diabetic risk of heart attack 2-4X higher than general population• Diabetic patient just as likely to die from heart attack as person

who has already had one heart attack

2. Stroke• Diabetic risk of stroke 2X higher than general popuation


Financial Cost of Diabetes*

$245 Billion annually for medical costs, lost work and wages, for diabetic patient care

Medical costs of people with diabetes are twice as high as medical costs for people without diabetes

*Center for Disease Control

Normal Carbohydrate Metabolism

1. Carbohydrate food is digested in the stomach.

2. Sugar from the stomach flows into the bloodstream, to the cells.

3. Cells use the sugar to produce energy to fuels our cells and our selves.

4. Insulin secreted by the pancreas keeps blood sugar at healthy balanced levels.

Type 1 Diabetes Mellitus

• Dysfunctional pancreas doesn’t produce insulin

• Glucose accumulates in the blood stream causing damage to other organs

• An auto-immune response• Can occur at any age• No known prevention• Accounts for 5% of all cases of diabetes

Type 2 Diabetes Mellitus

• Insufficient insulin is released by pancreas, AND/OR

• Body develops resistance to the insulin made by the pancreas

• Can develop at any age

• Can be prevented

Metabolic Syndrome

RISK FACTOR for diabetes type 2, heart disease, stroke

Diagnosis requires at least 3 of 5 factors:1. Elevated blood glucose2. Elevated triglycerides3. Decreased HDL4. Hypertension5. Central Obesity

(male WC>40 inches, female WC >35 inches)

Risk Factors for Diabetes

• Overweight

• Family history of diabetes

• African American, Latino, Native American, Asian American, Pacific Islander race

• Having Gestational Diabetes

Symptoms of Diabetes

• Increased thirst

• Frequent urination

• Increased hunger

• Weight loss

• Fatigue

• Blurred vision

• Irritability

Detecting and Diagnosing Diabetes

June, 2009

International Committee:

American Diabetes Association

European Association for Study of Diabetes

International Diabetes Federation


• A1C (Glycated hemoglobin A1c test)

– Measures % of blood sugar attached to hemoglobin, (the oxygen carrying protein found in red blood cells)

– Average blood sugar over past 3 months– No fasting required for test– Score 6.5% or higher (twice) for Diabetes– Score 5.7-6.4% for Prediabetes– Score less than 5.7% is normal


• Fasting Plasma Glucose– Requires 8 hour fast (no intake but water)– Score 126 or higher is Diabetes (twice)– Score 100-126 is Prediabetes

• Oral Glucose Tolerance Test– Requires 8 hour fast (no intake but water)– Requires lab draw for fasting plasma glucose, then– Requires repeat lab draw two hours after having special

sweet drink– Score 200 or more on second lab draw is Diabetes– Score 140-199 on second lab draw is Prediabetes


• Random Plasma Glucose– No fasting required– Score 200 or higher suggests diabetes

American Association of Clinical Endocrinologists

AACE Consensus Statement:Comprehensive Diabetes Management Algorithm 2013*

1. Optimize A1c, target <6.5 if patient tolerates2. Obesity Treatment3. Therapeutic Lifestyle Changes4. Prescription monotherapy if A1c 6.5 to 7.5 5. Add second agent if A1c >7.56. Add third agent if A1c 8.0, also consider adding basal insulin7. Add basal and some bolus insulin if A1c >9.08. Use full basal plus bolus insulin management if A1c >109. Minimize risk of hypoglycemia

*AACE Comprehensive Diabetes Management, Endocr Pract. 2013;19(Suppl 2)

Diabetes Management Options

• Work with your healthcare professional

• Lose weight

• Choose healthy foods

• Exercise

• Take medications

• Take supplements


WORK WITH YOUR HEALTHCARE PROFESSIONAL

1. Regularly scheduled clinic visits

2. Surveillance labs at least annually

3. EKG at diagnosis of diabetes, then periodically

4. Wellness exams annually

5. Lifestyle counseling

6. Eye exams

7. Foot exams


LOOSE WEIGHT.

Excess body fat causes body cells to

become resistant to insulin.

Decrease Diabetes Risk

WEIGHT LOSS

of 7% of total body weight will

decrease risk of diabetes by 58%

even if you can’t get to your

ideal body weight.*

*American Diabetes Association

Diabetes Management OptionsCHOOSE HEALTHY FOODS.

dark leafy greens, cucumbers, bell peppers, zucchini, asparagus, broccoli, cabbage, Brussels sprouts, radishes, spinach, eggplant, yogurt, cherries, berries, grapefruit, apples, pears, tomatoes, sweet potatoes, winter squash, fish, monounsaturated fats, flaxseed, walnuts

AVOID UNHEALTHY FOODS:processed and refined foods, snack foods, white bread, sweetened drinks, sugary deserts, trans-fats

LOW GLYCEMIC INDEX CARBOHYDRATEShttp://www.health.harvard.edu/newsweek/Glycemic_index_and_glycemic_load_for_100_foods.htm

http://www.health.harvard.edu/newsweek/Glycemic_index_and_glycemic_load_for_

Exercise for Diabetes Management

A SINGLE EXERCISE SESSION CAN…*1. Increase bioavailability of nitric oxide, thus

decreasing post exercise stress2. Increase oxygen consumption, thus

boosting fat metabolism3. Increase metabolism of carbohydrates during

exercise4. Improve glucose intolerance, improve insulin

sensitivity, and reduce blood glucose

* Asano RY, Sales MM, et al. Acute effects of physical exercise in type 2 diabetes: A review. World J Diabetes. 2014 Oct 15;5(5):659-65.

Medications for Diabetes Type 1 Management

Insulin.

Medications for Diabetes Type 2 Management

1. Biguanides (Metformin)decreases amount of glucose produced by the liver, increases muscle sensitivity to insulin

2. Sulfonylureas (Diabinese, Glucatrol, Micronase, Glynase, Diabeta, Amaryl)stimulates beta cells of the pancreas to release more insulin

3. Meglitinides (Prandin, Starlix)stimulates beta cells of the pancreas to release more insulin

4. Thiazolidinediones (Avandia, Actos)decreases amount of glucose produced by the liver, increases muscle and fat sensitivity to insulin

5. DPP-4 Inhibitors (Januvia, Onglyza, Tradjenta, Nesina)Dipeptidyl peptidase-4 prevents breakdown of GLP-1 (a naturally occurring compound that reduces blood glucose)

6. GLP-1 Inhibitors (Vicotoza, Byetta, Bydureon)Glucagon-like-peptide-1 receptor agonist improves insulin sensitivity

6. SGLT2 Inhibitors (Invokana, Farxiga)Sodium-glucose transporter 2 blocks reabsorption of glucose in the kidneys, causing excess glucose to be eliminated in urine

7. Alpha-glucosidase inhibitors (Acarbose, Glyset)blocks breakdown of starches such as bread, potatoes, pasta, in the intestine

8. Bile Acid Sequestrants (Welchol)lowers blood sugar by removing cholesterol by binding with bile acids in the digestive system

9. Insulin, alone or in combination with one or more of the above medications

Classes of Diabetes Type 2 Medication

• Increase insulin sensitivity of liver, fat and muscle cells.

• Stimulate insulin production by the pancreas.

• Slow the digestion of carbohydrates.

Medications that Increase Insulin Sensitivity

GOAL: sensitize liver, fat and muscle cells to insulin, making cells less resistant to insulin

Biguanide (Metformin)Decreases amount of glucose produced by the liver.Increases muscle and fat cell sensitivity to insulin.

In use since the 1920s.Most widely used prescription in the world for Type 2 Diabetes.

Can cause diarrhea.

Increased risk of lactic acidosis in patients with excess alcohol use

Must be discontinued prior to radiological procedures involving injection of dye, major medical procedures, and dental procedures, waiting 48 hours before resuming treatment

Medications that Increase Insulin Sensitivity

GOAL: sensitize liver, fat and muscle cells to insulin, making cells less resistant to insulin

Thiazolidindediones (TZD) Actos (pioglitazone), Avandia (rosiglitazone)

• Decrease blood glucose levels by making muscle, fat and liver cells more sensitive to insulin

• On the market since 1999, in popular use since 2007

• Increased risk of bone fracture, CHF, bladder cancer

Medications that Stimulate Insulin Production by the Pancreas

GOAL: Stimulate the pancreas to make produce more insulin.

1. Sulfonylureas (Diabinese, Glucatrol, Micronase, Glynase, Diabeta, Amaryl)stimulates beta cells of the pancreas to release more insulin

2. Meglitinides (Prandin, Starlix)stimulates beta cells of the pancreas to release more insulin

Can cause weight gain.Has highest risk for serious hypoglycemia of any non-insulin therapy.

Medications that Slow Digestion of Carbohydrates

GOAL: Slow the digestive process of ingested starches and sugars.

Alpha-glucosidase inhibitor (Acarbose, Glyset)Blocks breakdown of starches such as bread, potatoes, pasta, in the intestineCan cause nausea and flatulence

Bile Acid Sequestrant (Welchol)May lower blood sugar by removing cholesterol by binding with bile acids during digestionSecond line therapy commonly combined with metformin, sulfonyureas, or insulinHas not been studies with all anti-diabetes medicationsNot for patients with history of intestinal blockage or history of pancreatitis

Peptide Analogs

DPP-4 Inhibitor (Januvia, Onglyza, Tradjenta, Nesina)Dipeptidyl Peptidase-4 enzymePrevents breakdown of hormone incretin

Slows digestionSimulates insulin production

GLP-1 Inhibitor (Vicotoza, Byetta, Bydureon)Glucagon-like peptide-1Incretin Mimetic

Increases insulin secretion in response to eatingDecreases gastric emptyingDecreases liver fat contentCause decrease appetite and cause weight loss

Amylin Agonist (Symlin, pramlintide)Anti-hyperglycemic Synthethic AnalogUsed in addition to insulin

Increases risk of hypoglycemiaIncreases risk of pancreatitis

Newest Medication for Diabetes Type 2 Management

SGLT2 Inhibitors (Invokana, Farxiga)

New drug class since 2014Sodium-glucose transporter 2 Blocks reabsorption of glucose in the kidneysCauses glucose to be eliminated in urineIncreases risk of urinary tract infectionsIncreases risk of genital fungal infectionsCan cause kidney damageIncreases risk of bladder cancer

Insulin Injections

Basal insulin

Preferred over NPH insulin due to flat serum insulin concentrations over 24 hours

starting dose 0.1-0.2 units/kg for A1c <8.0

starting dose 0.2-0.3 units/kg for A1c 8-10

SMBG twice daily

Patients self-increase insulin doses by 2-unit steps

Basal-Bolus insulin regimens

Flexibility for patients with variable mealtimes and/or variable meal carbohydrate content

starting dose about 5 units SQ 10-15 minutes prior to meal

Patients self increase doses by 2-3 units every 2-3 days based on two hour post prandial glucose readings

Side Effects of Insulin Injections

HYPOGLYCEMIA• 7-15% of insulin treated patients with T2DM experience at least one

hypoglycemic episode per year

Frequency of hypoglycemia increases with• Intensive insulin targets• Comorbid use of sulfonylurea• Decreased caloric intake• Exercise• Alcohol consumption• Renal dysfunction• Diabetes duration• Cognitive impairment

Side Effects of Insulin Injections

WEIGHT GAIN

• 3-5 pound weight gain compared to other diabetes agents

• Adding amylin analog (Symlin) injection at same time of bolus insulin improves DMT2 may improve gycemia and weight

• Combining incretin therapy (DPP-4, GLP-1) with basal insulin may improve glycemia and weight

Supplements for Diabetes Management

CHROMIUM• Trace mineral, enhances action of insulin*• Involved in metabolism of carbohydrate, protein, fat*• Deficiency impairs body’s ability to use glucose for energy, increases insulin

requirements**• Three hospitalized patients who were fed intravenously showed signs of

diabetes (weight loss, neuropathy, impaired glucose tolerance). Adding chromium to their feeding solutions corrected their diabetes symptoms.**

• Common ingredient in infant formulas and total parental nutrition (TPN)• Deficiency uncommon; additional research needed to determine if clinically

relevant chromium deficiency state exists in humans due to inadequate dietary intake***

• Goal 200 mcg per day• Older adults may be more vulnerable to Chromium depletions

*Mertz W. Chromium occurrence and function in biological systems.Physiol Rev 1969;49:163-239 **Jeejeebhoy KN, Chu RC, et al. Chromium deficiency, glucose intolerance, and neuropathy reversed by chromium supplementation in a

patient receiving long-term total parenteral nutrition. Am J Clin Nutr 1977; 30:531-8.***Chromium Dietary Supplement Fact Sheet, National Institutes of Health, Office of Dietary Supplements,11/4/2013


CHROMIUMFood sources: Brewer’s yeast, broccoli, grape juice, meats, red wine,

whole grains, romaine lettuce, raw onions, ripe tomatoes, oranges, black pepper, molasses, oysters, liver, egg yolks, peanuts, beer

Dietary supplement formsDifferent carrier (transporter) molecules attached to chromium ion1. Glucose-tolerance factor (GTF) Chromium

Biologically active form 1. Chromium Picolinate

No known side effects from supplement use.


GTF CHROMIUM 800-1000 mcg daily for patients with Metabolic Syndrome or Diabetes Type 2.


Alpha-Lipoic Acid*• Helps lower blood sugar• Antioxidant effect relieves peripheral neuropathy burning

tingling numbness pain• General antioxidant support: 20-50 mg/day• Diabetes, Diabetic neuropathy: 800 mg per day in

divided doses

*Ziegler D, Reljanovic M, et al. Alpha-lipoic acid in the treatment of diabetic polyneuropathy in Germany: current evidence from clinical trials. Exp Clin Endocrinol Diabetes. 1999: 107-421-430.

*Melhem MF, Craven PA, et al. Alpha-lipoic acid attenuates hyperglycemia and prevents mesangial matrix expansion in diabetes. J Am Soc Nephrol. 2002;13:108-116.

*Ziegler D, Gries FA. Alpha-lipoic acid in the treatment of diabetic peripheral and cardiac autonomic neuropathy: The SYDNEY 2 trial. Diabetes Care. 2006;29:2356-70


VANADYL SULFATE (VOSO4)*

• Oxidative form of vanadium salts• Improves glucose metabolism• Decreases fasting glucose• Decreases A1c• Improves hepatic and muscle insulin sensitivity in Diabetes

Mellitus Type 2**

*Goldfine AB, Patti ME, et al. Metabolic effects of vanadyl sulfate in humans with non-insulin-dependent diabetes mellitus: in vivo and in vitro studies. Metabolism. 2000 mar;49(3):400-10.

**Cusi K, Cukier S, et al. Vanadyl sulfate improves hepatic and mscle insulin sensitivity in type 2 diabetes. J Clin Endocrinol Metab. 2001 Mar;86(3)14:1410-17.


CINNAMON*

• Lowers fasting plasma glucose• No significant effect on A1c• No adverse affects with taking

supplement

*Allen RW, Schwartzman E, et al. Cinnamon use in type 2 diabetes: an updated systematic review and meta-analysis. Ann Fam Med. 2013 Sep-Oct;11(5)452-9.

*Mang B, Wolters M, et al. Effects of a cinnamon extract on plasma glucose, HbA, and serum lipids in diabetes mellitus type 2. Eur J Clin Invest. 2006 May;36(5):340-4.


Biotin (Vitamin H)*• One of the B Complex vitamins• Converts carbohydrates to glucose• Combines with chromium to improve blood sugar

control• Food sources include brewer’s yeast, whole grains,

cauliflower, bananas, mushrooms, soybeans, blackeyed peas, cooked eggs, sardines, almonds, peanuts, pecans, walnuts.

*Singer GM, Geohas J. The effect of chromium picolinate and biotin supplementation on glycemic control in poorly controlled patients with type 2 diabetes mellitus: a placebo-controlled, double-blinded, randomized trial. Diabetes Technol Ther. 2006 Dec;8(6):636-43.


FENUGREEK*

• Traditional Asian medicine to stabilize blood sugar• Seed extracts slow down carbohydrate digestion• Lowers post prandial glucose• Daily use lowers A1c• Not for use in pregnancy

*Blumenthal M, Goldberg A, eds. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Lippincott Williams & Wilkins: 2000:130-133.


INSINASE

• Reduced iso-alpha acid (RIAA) and Acacia• Selective Kinase Response Modulators• Inhibits IL-6 cytokines to improve insulin signaling• Decreases insulin resistance• Usual dose is three tablets daily• Not for patients taking anticoagulants.


AMERICAN GINSENG (Panax quinquefolius)

• Light tan, gnarled root with stringy shoots• Yellowish green umbrella shaped flowers produce red berries• Used by early Native Americans to treat headaches, fever, indigestion, infertility• Studied in Diabetes Mellitus Type 2 patients*• Lowers fasting glucose levels• Lowers postprandial glucose levels• May lower or raise blood pressure• Has multiple possible drug interactions• Not for use by BiPolar diabetics due to risk of mania• Not for use by pregnant or breast feeding women• Not for use in history of breast cancer or other hormone sensitive conditions• Must be discontinued seven days prior to surgery due to blood thinner side effect

*Vladimir V, Sievenpiper JL, Koo VY, et al. American ginseng (Panax quinquifolius L) reduces postprandial glycemia in nondiabetic subjects and subjects with type 2 diabetes mellitus. Arch Intern Med. 2000; 160(7):1009-1013.

*Vuksan V, Stavro MP, Sievenpiper JL, et al. Similar postprandial glycemic reactions with escalation of dose and administration time of American ginseng in type 2 diabetes. Diabetes Care. 2000;23:1221-1226


MYRTLE SENG

• Traditional Chinese Medicine formula

• Nutritionally reduces blood glucose levels

• Improves insulin sensitivity

• May aid in weight loss


TAURINE• Organic acid derived from the amino acid cysteine• Available in seafood, meat, milk, eggs• Commonly added to infant formulas• Ingredient in many energy drinks• Stored in the gallbladder in bile, works during initial phase of fat

metabolism• Synthesized in the pancreas, increases fat burning capacity during

rest• Vegetarians with low taurine levels may feel anxiety as main

symptom• No known negative side effects with use of dietary supplement• Begin at 2-3 grams daily, increasing to 6 grams daily


TAURINE “anorexigenic” effect on hypothalamus of rats*• Minimizes feelings of hunger• Improves energy and metabolism• Helps stall body fat gain

TAURINE Antioxidant effects • Lowers chronic inflammation in hypothalamus**• Neutralizes free radicals in pancreatic beta cells• Increases exercise capacity in heart failure patients***

*Solon CS, Franci D, et al. Taurine Enhances the Anorexigenic Effects of Insulin in the Hypothalamus of Rats. Amino Acids. June 2012. 42(6):2403-10. **Arruda A, Milanski M, et al. Low-Grade Hypothalamic Inflammation Leads to Defective Thermogenesis, Insulin Resistance and Impaired Insulin Secrection. Endocrinology.

April 2011. 152(4), 1314-1320.***Beyranvand M, Khalafi M, et al. Effect of Taurine Supplementation on Exercise Capacity of Patients with Heart Failure. Journal of Cardiology. May 2011. 57(3), 333-335.

Living with Type 2 Diabetes

• To guide and support Type 2 Diabetes patients• Free through American Diabetes Association• 12 month program• Available in English and Spanish• Call 1-800-DIABETES• Text Type2 to 69866• Visit diabetes.org/type2program

2014 Winter Lecture Series

Choices Foundation for

Health Education and Research

2014 Winter Lecture Series Choices Foundation for Health Education and Research.

Documents

diabetes type

complications of diabetes

cases of diabetes slide

diabetes accounts

prevalence of diabetes

american diabetes association

diabetes epidemic prevention

financial cost of diabetes