Diabetes Mellitus Failure to control blood glucose Failure to control blood glucose Long term health complications Long term health complications Atherosclerosis Atherosclerosis Stroke Stroke Neuropathy (damaged nerves) Neuropathy (damaged nerves) Retinopathy, glaucoma Retinopathy, glaucoma Scottish perspective

Control of Blood glucose If blood glucose rises If blood glucose rises Excess is stored in muscles & liver as glycogen Excess is stored in muscles & liver as glycogen If blood glucose falls If blood glucose falls Deficit remediated by breaking glycogen down in liver and releasing into blood stream Deficit remediated by breaking glycogen down in liver and releasing into blood stream Two hormones: Two hormones: Insulin & Glucagon Insulin & Glucagon

Control of Blood glucose Insulin: Insulin: Synthesised by  cells of Islet of Langerhans in pancreas Synthesised by  cells of Islet of Langerhans in pancreas Glucagon Glucagon Synthesised by  cells of Islet of Langerhans in pancreas Synthesised by  cells of Islet of Langerhans in pancreas Blood glucose level sensed in pancreas Blood glucose level sensed in pancreas Regulates secretion of insulin/ glucagon directly Regulates secretion of insulin/ glucagon directly Negative feedback system (p54) Negative feedback system (p54)

INSULIN – target cells Insulin acts on Insulin acts on Liver Liver Adipose tissues (fat) Adipose tissues (fat) Skeletal muscle cells Skeletal muscle cells Insulin increases permeability of fat/ skeletal muscle cell membrane to glucose Insulin increases permeability of fat/ skeletal muscle cell membrane to glucose So stimulates glucose uptake into these tissues So stimulates glucose uptake into these tissues Liver already very permeable Liver already very permeable Insulin stimulates glycogen formation & glucose uptake Insulin stimulates glycogen formation & glucose uptake

INSULIN Insulin acts via an insulin receptor Insulin acts via an insulin receptor Diabetes occurs through two mechanisms Diabetes occurs through two mechanisms 1 – Loss of insulin 1 – Loss of insulin 2 – Loss of insulin receptors 2 – Loss of insulin receptors

Diabetes in Young Adults (15-30 years) Age of diagnosis Type 2 Type 1

unusual genetic type of diabetes called maturity onset diabetes of the young 6 different genes causing this type of diabetes. genetically defined subtype present different clinical course. one subtype responds to sulphonylureas patients replace insulin treatment sometimes after being on insulin for over 30 years, finding the genetic cause of their diabetes has had a major impact on their treatment. maturity onset diabetes of the youngfinding the genetic cause of their diabetes has had a major impact on their treatment. Genetic Nurses in Diabetes treatment

Type 1 Diabetes – Insulin dependent Type 1- Diabetes (5-10%) Type 1- Diabetes (5-10%) Loss of insulin – destruction of pancreatic  cells Loss of insulin – destruction of pancreatic  cells Early onset Early onset Weight loss, fatigue, polydypsia, polyuria, glucosuria, hyperglycaemia Weight loss, fatigue, polydypsia, polyuria, glucosuria, hyperglycaemia Ketosis (sweet breath – due to acetone) Ketosis (sweet breath – due to acetone) Treat with injections of insulin Treat with injections of insulin

Glucose tolerance test A large bolus dose of glucose administered (100g glucose drink) A large bolus dose of glucose administered (100g glucose drink) Blood glucose monitored Blood glucose monitored Rapid fall after peak (9-10mM) levels reached Rapid fall after peak (9-10mM) levels reached If diabetes clearance is very slow – in urine, peak blood glucose level higher If diabetes clearance is very slow – in urine, peak blood glucose level higher

Type 2 Diabetes – Insulin Independent 90-95% cases of diabetes 90-95% cases of diabetes Late onset (after 40yrs age) Late onset (after 40yrs age) 3-7% population affected 3-7% population affected 60% SUMO wrestlers c.f. 5% Japanese population 60% SUMO wrestlers c.f. 5% Japanese population Mainly occurs in overweight individuals Mainly occurs in overweight individuals

Insulin Resistance

Symptoms Insulin resistance Insulin resistance Normal or elevated blood insulin levels Normal or elevated blood insulin levels Failure of insulin to act on target tissues Failure of insulin to act on target tissues Deficiency in insulin receptors Deficiency in insulin receptors Can lead to  cell function becoming compromised due to excessive insulin production Can lead to  cell function becoming compromised due to excessive insulin production Hyperglycaemia, polydypsia, polyuria, glucosuria Hyperglycaemia, polydypsia, polyuria, glucosuria

Progression Elevated blood glucose associated with diabetes damages blood vessels and nerves Elevated blood glucose associated with diabetes damages blood vessels and nerves Small blood vessel damage causes blindness, kidney failure & amputation Small blood vessel damage causes blindness, kidney failure & amputation Larger blood vessel damage can cause heart disease, high blood pressure & stroke Larger blood vessel damage can cause heart disease, high blood pressure & stroke 75% of Type 2 patients die of cardiovascular disease 75% of Type 2 patients die of cardiovascular disease

Exercise & NIDDM Insulin sensitivity in fit individuals is greater Insulin sensitivity in fit individuals is greater i.e. cells better able to uptake glucose from blood i.e. cells better able to uptake glucose from blood Insulin sensitivity decreases with age Insulin sensitivity decreases with age This decrease reduced by exercise This decrease reduced by exercise 5-7 days after exercise insulin sensitivity starts to decline 5-7 days after exercise insulin sensitivity starts to decline Regular, moderate, aerobic exercise is important in preventing onset of NIDDM Regular, moderate, aerobic exercise is important in preventing onset of NIDDM Diseases control in 80-90% patients achieved by reducing calorie intake/ exercise Diseases control in 80-90% patients achieved by reducing calorie intake/ exercise Glasgow Research Glasgow Research Glasgow Research Glasgow Research

Osteoporosis Osteoprosis – long term progressive increase in bone porosity/ brittleness Osteoprosis – long term progressive increase in bone porosity/ brittleness Risk of fractures (shatter) Risk of fractures (shatter) Loss of height Loss of height Curvature of spine Curvature of spine Back pain Back pain Post menopausal women Post menopausal women 20-50% over 50s 20-50% over 50s 75% over 90s 75% over 90s

Bone growth Childhood and early adolescence bones extend Childhood and early adolescence bones extend Late adolescence bones increase in density Late adolescence bones increase in density Peak bone density in late twenties/early thirties Peak bone density in late twenties/early thirties 1%/yr (female) decline in density thereafter 1%/yr (female) decline in density thereafter 2-3%/yr decline post menopausal 2-3%/yr decline post menopausal Male bone density declines 0.4%/ yr and only when over age 50 Male bone density declines 0.4%/ yr and only when over age 50 Extra calcium/ Vitamin D in childhood & teens produce greater bone density Extra calcium/ Vitamin D in childhood & teens produce greater bone density Margaret Thatcher – cause of osteoporosis in ? Margaret Thatcher – cause of osteoporosis in ?

Risk Factors Elderly Elderly Early menopause Early menopause Amenorrhoea Amenorrhoea Genetics Genetics Low body fat Low body fat Low calcium in diet Low calcium in diet Vit. D deficiency Vit. D deficiency High alcohol/ caffeine/ fizzy drinks High alcohol/ caffeine/ fizzy drinks High salt High salt  Age related reduction in bone density  Oestrogen promotes calcium uptake  Low oestrogen  Enzymes in fat produce oestrogen from circulating precursors  Body raids calcium stores in bones  Poor calcium absorption  Promote bone loss by using calcium stores to balance pH  Calcium removed along with Na in the urine

Exercise & Osteoporosis – Prevention Mechanical stress increases bone strength (density) Mechanical stress increases bone strength (density) Astronauts have lowered bone density following zero gravity because no mechanical stress Astronauts have lowered bone density following zero gravity because no mechanical stress Weight bearing or resistance exercise will benefit women in late twenties/ early thirties (swimming will not!) Weight bearing or resistance exercise will benefit women in late twenties/ early thirties (swimming will not!) Also benefits coordination reducing risk of falls Also benefits coordination reducing risk of falls

Exercise & Osteoporosis – Treatment 45 min moderate exercise 3 times weekly increases calcium deposition in osteoporosis patients 45 min moderate exercise 3 times weekly increases calcium deposition in osteoporosis patients In conjunction with HRT In conjunction with HRT

Risk of Exercise in Women Excessive exercise particularly in young women can cause osteoporosis Excessive exercise particularly in young women can cause osteoporosis Reduction in body fat leads to reduction in oestrogen synthesis Reduction in body fat leads to reduction in oestrogen synthesis Menstruation ceases Menstruation ceases Oestrogen falls further, reducing calcium absorption Oestrogen falls further, reducing calcium absorption Bone loss is irreversible Bone loss is irreversible

Advice from Osteoporosis Soc. It's a good idea to avoid: It's a good idea to avoid: Too much protein – Too much protein – Excessive protein upsets acid balance. Excessive protein upsets acid balance. Calcium from bones neutralises it. Calcium from bones neutralises it. Eating plenty fruit and veg should keep your body's acid balance stable. Eating plenty fruit and veg should keep your body's acid balance stable. Lots of salt – Lots of salt – high sodium increases calcium lost in urine. high sodium increases calcium lost in urine. Drinking lots of fizzy drinks – Drinking lots of fizzy drinks – phosphoric acid gives flavour to a lot of fizzy drinks phosphoric acid gives flavour to a lot of fizzy drinks too much can cause the body to use calcium to balance levels. too much can cause the body to use calcium to balance levels. Drinking too much caffeine – Drinking too much caffeine – high caffeine intake affects the balance of calcium in the body. high caffeine intake affects the balance of calcium in the body. Milk in coffee will counteract this, limit intake to one or two cups a day. Milk in coffee will counteract this, limit intake to one or two cups a day. Letting your weight drop too low – Letting your weight drop too low – Being underweight increases the risk of broken bones when you fall. Being underweight increases the risk of broken bones when you fall. In younger women, severe weight loss may stop menstrual periods because hormone levels drop which can also increase your risk of breaking a bone In younger women, severe weight loss may stop menstrual periods because hormone levels drop which can also increase your risk of breaking a bone