Diabetes Slides Pat Thompson Sept 15 2011

Diabetes

DiabetesPrevalence of Diabetes: 25.8 million adults in the US 8.3%. UK rates are around 3.5-5.0%Metabolic Syndrome: Risk factors related to obesity.Type I: Beta cells produce little or no insulin.Type II: Fat, Liver, and muscle cells do not respond to insulin (insulin resistance) Gestational Diabetes: High sugars in Preg.

Pathophysiology of DiabetesWhen you eat, your body breaks food down into glucose. Glucose is a type of sugar that is your bodys main source of energy.6

Pathophysiology of DiabetesAs blood glucose rises, the body sends a signal to the pancreas, which releases insulin.

7

Pathophysiology of DiabetesActing as a key, insulin binds to a place on the cell wall (an insulin receptor), unlocking the cell so glucose can pass into it. There, most of the glucose is used for energy right away.

7

Blood glucose regulationBlood glucose goes up and down throughout the day:

8As your blood glucose rises (after a meal), the pancreas releases insulin.

Type 2 diabetesYour cells dont use insulin properly. The insulin cant fully unlock the cells to allow glucose to enter (insulin resistance).Your pancreas may not produce enough insulin (insulin deficiency).13

Natural History of Diabetes

Years of Diabetes

*IGT = impaired glucose tolerance.

Obesity IGT* Diabetes Uncontrolled Hyperglycemia

Relative -Cell Function

100 (%)

-20

-10

0

10

20

30

PlasmaGlucose

Insulin Resistance

Insulin Secretion

120 (mg/dL)

Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.

Fasting Glucose

Post-Meal Glucose

Natural History of Type 2 Diabetes

Diagnosing diabetesFasting plasma glucose test (FPG) results28

Risk factors for type 2 diabetesAre overweight.Are 45 or older.Are physically inactive.Have a parent or sibling with type 2 diabetes.Are African American, Native American, Hispanic American, or Pacific Islander.Have abnormal cholesterol levels.Have had gestational diabetes, or given birth to a baby greater than 9 lbs.Have high blood pressure.Type 2 is more common in people who:14

Hyperglycemia Can Cause Serious Long-Term Problems

Blood Glucose Targets for AdultsPre-meal or fasting: 80-120

2 hours post-meal: 80-140

Bedtime: 80-140 or 100-140

When & How Often Should I Be Testing?

On insulin: 4 times per day.

Not on insulin: 2 times per day.

Test at Alternating Times of the Day Before or 2 Hours After Eating

Meal plan works like thisBreakfastLunchDinnerCHOMaximum

Meal plan works like thisBreakfastLunchDinnerCHOCHOCHO

Hypoglycemic Symptoms

How to care for yourself when youre hypoglycemicEat or drink 15 grams of fast-acting, low-fat carbohydrate right away. Quick energy sourcesThe following items are quick energy sources that contain about 15 grams of carbohydrate: cup fruit of orange, apple, or grapefruit juice1/3 cup grape, prune, or cranberry juice2 tbsp raisins6 crackers3-5 pieces hard candy1 cup skim milk1 piece bread3-4 glucose tablets, or 1 tube glucose gel cup regular soft drink (not diet)11 jellybeans96

HbA1c: the blood test with a memoryWhat is HbA1c?Hemoglobin is a protein that makes your red blood cells red-colored.When hemoglobin picks up glucose from your bloodstream, the hemoglobin becomes glycosylated. Glycosylated hemoglobin is HbA1c. The HbA1c test measures the percentage of HbA1c in your blood a number that corresponds to your average blood glucose for the previous 3 months.HbA1c in your bloodstream.45

Introduction to self-managementKey pieces of diabetes self-management:Monitoring blood glucoseTaking medicationFollowing a meal planGetting regular exercise34

Good News About Physical Activity

Cant exercise?PoolsExercise balls or exercise bandsWalking tapeStationary bikesExercise videosYogaLocal Recreation Centers or school facilitiesTV Programs like: Sit and Be Fit M,W, F at 8:30AM on channel 9

Exercise is boring.Vary your routine and dont be afraid to try something new.Participate in things you like to do.Exercise with a friendUse music or books on tape to make the time pass more quickly.

Tips for Safe Physical Activity

Long-Term Complications

Hyperglycemia Can Cause Serious Long-Term Problems

Diabetes-CVD FactsNearly all adults with diabetes have one or more cholesterol problems, such as:high triglycerideslow HDL (good) cholesterolhigh LDL (bad) cholesterol 4

Good News for Type 1 Diabetes

Good News for Type 2 Diabetes

Take Steps to Reduce Risk Factors for Heart Disease

Aspirin TherapyRecommended dose: 81-325 mg /day

Should not be used in people with: Aspirin allergies, a history of gastric bleeding, clotting disorders, or people already taking a blood-thinning agent.

Diabetes Can Lead to Nerve and Small Blood Vessel Damage

Getting regular medical care Schedule for routine medical care76

Scheme for Lowering Glucose in Type II

Find Diabetes Educators in Your Area

*Data from 2011 National Diabetes Fact SheetDiagnosed 18.8 million, Undiagnosed 7.0 million, Prediabeteic 79 million. Race and ethnic differences: After adjusting for pop age differences 2007-20097.1% non-Hispanic Whites, 8.4% Asian Americans, 12.6% Non-Hispanic blacks, 11.8% Hispanics. 1-2 Kids of Latino may develop Diabetes.

Metabolic Syndrome: Syndrome X or Insulin resistance: It is a name for a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes. BP130/85 or higher, FBS 100 or greater, Large waist circumference Men 40 or more, Women 35 or more. Low HDL m under 40, W under 50, Trig 150 or higher.

Type I: Is a lifelong chronic disease in which there are high levels of sugar in the blood. Most common in children, adolescents, or young. Symptoms: Polyuria, Polyphagia, Polydypsia, having blurry eyesight, feeling tired or fatigued, losing the feeling in your feet, losing weight without trying, urinating often. Diabetic Ketoacidosis: deep rapid breathing, dry skin and mouth, flushed face fruity breath odor, nausea or vomiting, stomach pain.

Type II: More common form 85-90% of diabetes is this type. Caused by the way your body make or uses insulin. Insulin is needed to move blood glucose into cells, where it is stored and later used for energy. No symptoms at first, early symptoms may include: bladder, kidney, skin or other infections that heal slowly. Fatigue, Hunger, Increased thirst, increased urination, blurred vision, erectile dysfunction, pain or numbness in feet or hands. Fasting blood glucose of 126 two times, A1C Normal 5.7%. Pre-Diabetes 5.7%-6.4%, Diabetes 6.5% or higher. Oral glucose tolerance test 200 after two hours of ingestion.

Gestational Diabetes: It usually starts halfway through the pregnancy. Women in the 24th-28th week of pregnancy go through a glucose tolerance test.

********Diabetes screening is recommended for: Overweight children who have other risk factors for diabetes, starting at age 10 and repeated every 2 years, Overweight adults BMI greater than 25 who have other risk factors and Adults over ager 45 every 3 years.

See your health care provider every three months. Have BP checked, skin and bones on your feet and legs, assess for numbness and tingling, examine the eyes, have A1C done every 6 months if your diabetes is well controlled otherwise every 3 months, Lipids done yearly (aim for LDL levels below 70-100). Yet yearly tests on microalbuninuria and serum creatine. Eye exam yearly, Dental yearly. Main Tx: Diet and ExerciseTeach Blood glucose monitoring, what to eat, portion size, when to eat, how to take meds, how to recognize and treat low and high blood sugars, how to handle sick days, and keep up to date on new research and treatment options. Most people who have good blood sugar control check the blood sugar a few times a week. Daily if they are not controlled, in the am fasting, before meals, and at bedtime. Increased monitoring of blood sugars with sickness or stress. Diet and weight control : Gastric bypass surgery and laparoscopic gastric banding.**KEY MESSAGE: Over time, high blood glucose can lead to serious medical problems. In 2004 68% of diabetes-related deaths were among people aged 65 years and older.Stroke was noted on 16% of diabetes-related death certificates among people aged 65 and older.

Hypertension 2008: Adults aged 20 year or older with self-reported diabetes, 67% had blood pressures greater than or equal to 140/90 or used prescription meds.Blindness: Diabetes is the leading cause of new cases of blindness among adults aged 20-74 years. 4.2 million (28.5%) of the people with diabetes 40 years or older had diabetic retinopathy, and of these, 4.4% had advanced retinopathy that leads to sever vision loss.

Kidney disease: Diabetes is the leading cause of kidney failure, accounting for 44% of new cases in 2008. 48,374 people with diabetes began treatment for end-stage kidney disease in the US. A total of 202,290 people with end-stage kidney disease were living on dialysis or with a kidney transplant in the US.

Nerve Damage: About 60-70% of the people with diabetes have mild to sever forms of nervous system damage. Amputation: Diabetes for 10 years or more increases this risk and neuropathy or a previous ulcer is the most significant risk factor of developing lower extremity disease. Callouses can cause up to 30% more pressure on the feet and should be followed up by a professional. More than 60% of non-traumatic lower-limb amputation were performed in people with diabetes.

Cost of Diabetes Care: in 2007 $218 billion dollars in the US: 18 billion for undiagnosed diabetes, 25 billion for adults with prediabetes, and 623 million for gestational diabetes. National Diabetes Fact Sheet, 2011 the most recent comprehensive assessment of the impact of diabetes.

Supporting Points Over time, hyperglycemia can damage large blood vessels, leading to stroke, heart attack, and loss of circulation in the arms and legs. According to the ADA, heart disease is the leading cause of diabetes-related deaths. People with diabetes are two to four times more likely to die of heart disease than those without diabetes. Hyperglycemia also can damage small blood vessels and nerves, causing blindness, kidney disease, and other problems. Diabetes is the leading cause of kidney disease (nephropathy) and blindness (retinopathy) in adults under age 75. Diabetes also is a major cause of lower limb amputation. Other complications (not shown) include dental disease, complications of pregnancy, and sexual dysfunction. Untreated diabetes can cause serious complications even if a person feels fine. Type 2 diabetes has been called a silent killer because many people are not aware they have the disease until they develop serious complications. People with diabetes can reduce the risk of long-term complications by following their recommended diabetes care plans. For both type 1 and type 2 diabetes, major studies have shown that people who maintain their blood glucose as close to normal as possible reduce their risk of serious long-term complications.*****ADA Recommended Targets for blood glucose control in non-pregnant individuals with diabetes: Plasma glucose before eating: normal < 110 , Target 90-130, When to take action if, 90 or greater than 150. 2 hours after eating: less than 130, Target , 180, When to take action If , 200. Bedtime: Less than 120, Target 110-150, When to take action if 180.

Monitoring blood sugars depends on your treatment plan. Type II insulin injections 2-3 times usually before giving an injection and always at bedtime. Pump therapy 4-8 times a day usually before meals and after meals and always at bedtime. Changing tx or routine: 3 or more times a day********KEY MESSAGE: Regular physical activity provides numerous physical and psychological benefits for people with diabetes.

Supporting PointsAn individualized plan of regular physical activity can help people with diabetes to: Lose weight or maintain a stable body weight. Regular physical activity can enhance weight loss or aid in weight maintenance, especially when combined with an appropriate calorie-controlled nutrition plan. Physical activity helps the body burn more calories and may increase metabolism by building muscle mass. Reduce the risk of cardiovascular disease. Regular physical activity strengthens the heart and blood vessels helping to lower blood pressure and heart rate, provides more oxygen to the blood, and improves blood lipids, especially high-density lipoprotein (HDL) cholesterol. These and other favorable effects of physical activity reduce the risk of heart attack and stroke. Achieve better blood glucose control. During and after physical activity, glucose is removed from the blood for energy, which lowers blood glucose levels. Regular physical activity also can increase insulin sensitivity in target tissues, which may reduce or eliminate the need for diabetes medications in some people. Improve physical and mental well-being. Patients who are physically active gain energy, strength, and stamina. Regular physical activity can boost self-esteem and reduce stress, encouraging people to take further positive steps toward diabetes self-management.***KEY MESSAGE: To prevent injuries and complications, people with diabetes need to take precautions to ensure safe physical activity.

Supporting PointsTo ensure safe physical activity, remind people to: Test blood glucose before and after physical activity. Exercising while blood glucose is outside the target range (too high or too low) increases the risk of acute complications. In people with type 1 diabetes, exercise can lead to hyperglycemia and ketoacidosis, especially if the blood insulin level is low. Exercise also increases the risk of hypoglycemia, especially in people who use insulin or some oral diabetes medications (sulfonylureas or meglitinides). Always warm up and cool down. Before physical activity, people should warm up with easy, low-intensity movements. Once muscles are warm, gentle stretching is recommended. When ready to cool down, the activity should not be stopped abruptly. Rather, advise people to slow down the activity, then stretch their muscles again while they are still warm. Reduce the risk of injury with appropriate clothing and equipment, including well-fitting athletic shoes and absorbent socks. People with diabetes should examine their feet daily and after physical activity to check for redness, blisters, cuts, and sores. Advise them to check inside their shoes before wearing and remove any foreign objects, such as a pebble. Prevent dehydration. People should begin physical activity well hydrated, and replace body fluids during activity. Water is the best fluid replacement. Adequate hydration helps to prevent muscle cramping and maintain body temperature and blood volume. Wear or carry diabetes identification, such as a Medic Alert bracelet or an information card that can assist with treatment should an emergency occur. Also, advise people to bring money for a phone call or consider carrying a cell phone during physical activity.

Tip: During physical activity, a person should be able to sing or carry on a conversation with a partner. If a person is too short of breath to talk during the activity, he or she may be overdoing it and should slow down or rest briefly.*Overview of Long-Term Complications Section

Over time, hyperglycemia can damage blood vessels and nerves, leading to serious medical problems. However, the Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS) showed that the risk of most complications can be reduced by achieving tight glycemic control and controlling other risk factors, such as hypertension, dyslipidemia, and smoking. Although hyperglycemia plays an important role in the etiology of all complications, other risk factors also are important. For this reason, people with diabetes need to be educated about steps to reduce all modifiable risk factors, including high blood pressure, smoking, dyslipidemia, and obesity. Early detection and prompt treatment of complications are crucial to reduce such adverse outcomes as blindness, kidney failure, and amputation. Encourage people to see their diabetes care team for regular follow-up visits to assess their diabetes management skills, evaluate their overall health, and check for the presence of complications.

Further Readings American Diabetes Association. Position statement. Diabetic nephropathy. Diabetes Care. 2002;25(suppl 1):S85S89.American Diabetes Association. Position statement. Implications of the Diabetes Control and Complications Trial Study. Diabetes Care. 2002;25(suppl 1):S25S27American Diabetes Association. Position statement. Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care. 2002;25(suppl 1):S28S32.American Diabetes Association. Position statement. Screening for diabetic retinopathy. Diabetes Care. 2002;25(suppl 1):S90S93.American Diabetes Association. Position statement. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2002;25(suppl 1):S33S49.American Diabetes Association. Position statement. Treatment of hypertension in adults with diabetes. Diabetes Care. 2002;25(suppl 1):S71S73.Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977986.Franz MJ, ed. Diabetes and Complications. A CORE Curriculum for Diabetes Educators. Vol. 1. 4th ed. Chicago, Ill.: American Association of Diabetes Educators; 2001.United Kingdom Prospective Diabetes Study Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352:837853. United Kingdom Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes (UKPDS 38). BMJ. 1998;317:703713.*KEY MESSAGE: Over time, high blood glucose can lead to serious medical problems. Foot care from NIH 2011:

NIH Clinical Management of HTN: Supporting Points Over time, hyperglycemia can damage large blood vessels, leading to stroke, heart attack, and loss of circulation in the arms and legs. According to the ADA, heart disease is the leading cause of diabetes-related deaths. People with diabetes are two to four times more likely to die of heart disease than those without diabetes. Hyperglycemia also can damage small blood vessels and nerves, causing blindness, kidney disease, and other problems. Diabetes is the leading cause of kidney disease (nephropathy) and blindness (retinopathy) in adults under age 75. Diabetes also is a major cause of lower limb amputation. Other complications (not shown) include dental disease, complications of pregnancy, and sexual dysfunction. Untreated diabetes can cause serious complications even if a person feels fine. Type 2 diabetes has been called a silent killer because many people are not aware they have the disease until they develop serious complications. People with diabetes can reduce the risk of long-term complications by following their recommended diabetes care plans. For both type 1 and type 2 diabetes, major studies have shown that people who maintain their blood glucose as close to normal as possible reduce their risk of serious long-term complications.***KEY MESSAGE: The DCCT showed that people with type 1 diabetes who followed an intensive therapy regimen that lowered their A1c values had fewer long-term complications.

Supporting Points The DCCT is the longest and largest study to show that lowering blood glucose to improve A1c results slows or prevents the development of complications in type 1 diabetes. The DCCT examined more than 1,400 people with type 1 diabetes for 10 years. Two groups of patients were followed: one treated conventionally and another treated intensively. The volunteers in the intensive treatment group tested their blood more often and followed a more stringent schedule for insulin injection (multiple daily insulin injections or treatment with an insulin pump). Compared with people who had conventional therapy, the intensive treatment group had 35% to 56% less kidney damage (decreases in microalbuminuria and albuminuria, respectively), 60% less nerve damage (clinical neuropathy), and 76% less eye disease (retinopathy). Improved glycemic control also was associated with fewer cardiovascular events in the DCCT. However, this finding was not statistically significant, perhaps because the study volunteers were young adults in whom the incidence of heart disease would be expected to be low.

*KEY MESSAGE: The UKPDS showed that tight control of blood glucose reduces long-term complications in people with type 2 diabetes.

Supporting Points The UKPDS showed that long-term complications in type 2 diabetes are not inevitable. The UKPDS studied more than 5,000 people with type 2 diabetes for an average of 10 years to learn if intensive management would help delay or prevent complications. Those people who kept their blood glucose levels as close to normal as possible (A1c at 7% or less) had less eye disease, kidney disease, and nerve damage. The UKPDS also showed the importance of blood pressure management in reducing cardiovascular complications. People with type 2 diabetes who followed an intensive regimen to manage blood glucose and blood pressure significantly reduced their risk of macrovascular disease (heart attack and stroke). Controlling high blood pressure further reduced the risk of microvascular complications, such as eye and kidney disease.*KEY MESSAGE: By recognizing and reducing modifiable risk factors for heart disease, people with diabetes can prevent or delay the onset of complications.

Supporting Points Most risk factors for heart disease can be modified through lifestyle changes and, often, use of medications. Modifiable risk factors for heart disease include hyperglycemia, hypertension, high cholesterol, high triglycerides, physical inactivity, obesity, and smoking. Only a few risk factors, such as a family history of heart disease, cannot be changed. Help people with diabetes identify their modifiable risk factors and take steps to reduce them. By working with their diabetes educators, people can choose targeted interventions to improve their individual risk profiles.

Tip: The American Diabetes Association and the American College of Cardiology have recently begun a public education campaign to increase awareness of the link between diabetes and heart disease. The Make the Link campaign provides a number of useful educational resources, available by calling the American Diabetes Association at 800-DIABETES (800-342-2383) or using the Internet site www.diabetes.org/makethelink.**KEY MESSAGE: In people with diabetes, damage to small blood vessels (microvascular complications) and nerves (neuropathy) can occur, increasing the risk of eye disease, kidney disease, sexual dysfunction, and other serious medical problems.

Supporting Points Hyperglycemia, often acting in concert with hypertension, can lead to small blood vessel damage. Microvascular complications include: Eye disease. Eye disease is 25 times more common in people with diabetes than in the general population. Diabetic retinopathy (a term for disorders of the retina associated with diabetes) is the leading cause of blindness in the United States for people between 20 and 74. In addition, people with diabetes are twice as likely to develop glaucoma and cataracts as those without diabetes. Kidney disease. About 20% to 30% of people with diabetes develop nephropathy (kidney damage), and diabetes is the leading cause of end-stage renal disease. Hyperglycemia can lead to nerve damage. Diabetes is the most common cause of peripheral neuropathy. Peripheral neuropathy of the sensory nerves contributes to the development of foot ulcers, which can lead to amputation. Lower extremities tend to be more seriously affected than upper extremities, but neuropathy also can affect the hands and arms. Diabetes-related damage to nerves that supply internal body organs (autonomic neuropathy) also may occur. Autonomic neuropathy can lead to problems with regulation of blood pressure, heart rate, bladder emptying, and digestion. Sexual dysfunction, including erectile dysfunction in men and a number of female sexual problems, is another common long-term complication of diabetes.*When starting insulin therapy use structured programs employing active insulin dose titration that includes: structured education, continuing telephone support, frequent self-monitoring, dose titration to target, dietary understanding, management of hypoglycemia, management of acute changes in plasma glucose control and support from and appropriately trained and experienced healthcare professional.**KEY MESSAGE: The AADE can help people with diabetes find certified diabetes educators, who can lend emotional support and provide counseling in all areas of diabetes care.

Supporting Points The AADE is dedicated to improving the quality of diabetes care and education. The AADE is a nonprofit national organization that provides education and training for certified diabetes educators. These CDEs may be nurses, doctors, pharmacists, psychologists, social workers, dietitians, or other health professionals. To find a certified diabetes educator in their areas, people can call the AADE toll-free at 800-TEAMUP4. Or, they can use the AADE Web site at www.aadenet.org and click on the link for Find an Educator. This online locator helps people to find educators by state, city, or last name. Contact information:American Association of Diabetes Educators 100 West Monroe Street Suite 400 Chicago, IL 60603800-832-6874www.aadenet.org