Diabetes and Stroke

Objectives 1. Identify the differences between type 1 and type 2 diabetes. 2. Describe the eight core deficiencies related to type 2 diabetes. 3. Discuss American Diabetes Associations (ADA) position statement for Glycemic targets in hospitalized adult patients with Diabetes. 4. Analyze the financial impact of diabetes on both direct and indirect costs.

di·a·be·tes noun a disease in which the body’s ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine. Diabetes is a disease that occurs when your blood glucose, also called blood sugar, is too high. Blood glucose is your main source of energy and comes from the food you eat. Insulin, a hormone made by the pancreas, helps glucose from food get into your cells to be used for energy. Sometimes your body doesn’t make enough—or any—insulin or doesn’t use insulin well. Glucose then stays in your blood and doesn’t reach your cells.

Statistics 30.3 million people have diabetes (9.4% of the US Population) Diagnosed 23.1 million people Undiagnosed 7.2 million people 90-95% of diagnosed cases have type 2 diabetes In 2016 there were more than 552,000 Alabamians living with diabetes, more than 14% of the population, and thousands more have pre-diabetes. NATIONAL DIABETES STATISTICS REPORT 2017

Increasing Prevalence of Diabetes Over Time Improvements in therapies and medical management over time are factored in 2015 Mississippi Alabama Florida and West Virginia 7-8% 11-12% 19-20% 13-14% 17-18% Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16% Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics

Increasing Prevalence of Diabetes Over Time Improvements in therapies and medical management over time are factored in 2020 West VA surpasses 17-18% 7-8% 11-12% 19-20% 13-14% 17-18% Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16% Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics

Increasing Prevalence of Diabetes Over Time Improvements in therapies and medical management over time are factored in 2025 7-8% 11-12% 19-20% 13-14% 17-18% Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16% Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics

Increasing Prevalence of Diabetes Over Time Improvements in therapies and medical management over time are factored in 2030 West VA will have approx. 20% total population with DM 7-8% 11-12% 19-20% 13-14% 17-18% Percent of Total Population with Diabetes (Diagnosed and Undiagnosed) 9-10% 15-16% Institute for Alternative Futures 2014 Diabetes Model based on Boyle, Projection of the year 2050 burden of diabetes in the US adult population, http://www.pophealthmetrics.com/content/8/1/29 ; CDC, National Diabetes Statistics Report, 2014; CDC diabetes trends; US Census Bureau Population Statistics

Financial Impact of Diabetes The total estimated cost of diagnosed diabetes in 2012 is $245 billion, including $176 billion in direct medical costs and $69 billion in reduced productivity. For the cost categories analyzed, care for people with diagnosed diabetes accounts for more than 1 in 5 health care dollars in the U.S., and more than half of that expenditure is directly attributable to diabetes. Individuals with diagnosed diabetes, on average, have medical expenditures approximately 2.3 times higher than what expenditures would be in the absence of diabetes.

Direct vs. Indirect Impact Direct costs: Hospital inpatient care (43% of the total medical cost) Prescription medications to treat complications of diabetes (18%) Anti-hyperglycemic agents and diabetes supplies (12%) Physician office visits (9%) Nursing/residential facility stays (8%). Indirect costs include: Increased absenteeism ($5 billion) Reduced productivity while at work ($20.8 billion) Reduced productivity for those not in the labor force ($2.7 billion) Inability to work as a result of disease-related disability ($21.6 billion) Lost productive capacity due to early mortality ($18.5 billion).

What is Diabetes? Diabetes is the chronic metabolic disease characterized by elevated glucose levels. There are 2 key types of Diabetes: Absolute insulin deficiency (Type 1) Impaired insulin action (Type 2) Other types ie gestational, secondary r/t disease process, etc and even 1.5 but for this discussion talk about 1&2

The eight core defects in type 2 diabetes “The ominous octet” Decreased insulin secretions Decreased incretin effect Increased lipolysis Increased glucose reabsorption Decreased glucose uptake Neurotransmitter dysfunction Increased hepatic glucose production Increased glucagon secretion Incretins are hormones that are released from the gut into the bloodstream in response to ingestion of food, and they then modulate the insulin secretory response to the products within the nutrients in the food. The insulin secretory response of incretins, called the incretin effect, accounts for at least 50% of the total insulin secreted after oral glucose. Therefore, by definition, incretin hormones are insulinotropic (i.e., they induce insulin secretion) at usual physiological concentrations seen in the plasma after ingestion.

Why does Diabetes Lead to Stroke? Increase levels of glucose in the blood stream leads to increase in clots within the blood vessel walls. Clots narrow and or block blood vessels in the brain or carotid artery cutting off blood supply. Oxygen deprivation to the affected area results in tissue death or stroke. Over time, this glucose can lead to increased fatty deposits or clots on the insides of the blood vessel walls. These clots can narrow or block the blood vessels in the brain or neck, cutting off the blood supply, stopping oxygen from getting to the brain and causing a stroke. Major modifiable risk factors for stroke include hypertension, diabetes, smoking and dyslipidemia. Diabetes is a well-established risk factor for stroke. ... Additionally, mortality is higher and poststroke outcomes are poorer in patients with stroke with uncontrolled glucose levels

Hyperglycemia after Stroke There is considerable clinical evidence that hyperglycemia at the onset of acute ischemic stroke may negatively impact not only acute morbidity but also brain recovery Despite this, no hard evidence exists regarding the optimal method of glucose control Intense glucose control leads to more hypoglycemia events Establishing hyperglycemia treatment guidelines for management in the acute care settings is challenging

American Diabetes Association CPG ADA recommends initiating therapy to maintain a glucose range of 140 to 180 mg/dL Lower target glucose less than 140 mg/dL may be appropriate Patients with persistent hyperglycemia, are critically ill, or who are treated with thrombolytic therapy should be started on an established and standardized intravenous insulin protocol to improve blood glucose control for at least the first 24 to 48 h of hospitalization Patients should be transitioned to a subcutaneous insulin regimen that includes basal long-acting insulin, bolus meal insulin, and correction sliding scale Less than 140 mg/dL may be appropriate for individuals with