1. Janice Herbert-Carter MD, MGA, FACP Associate Professor of Medical Education

2. Objectives: At the conclusion of the session, participants will be able to: Describe signs and symptoms of diabetes mellitus List complications of uncontrolled diabetes Describe lifestyle modifications useful in controlling diabetes Identify medications commonly used to treat diabetes

3. What is Diabetes Mellitus? “Honey sieve” High levels of sugar are found in the blood and urine But it is NOT caused just by eating too much sugar

4. What is Diabetes Mellitus? Type 1 Usually starts in children, teens ALWAYS needs insulin shots Type 2 Most common type (our discussion focus today) Usually starts in middle-aged person with obesity Seen more in young folks now due to obesity epidemic Gestational Begins in pregnancy

5. What is Diabetes Mellitus? The pancreas gland does not make enough insulin to meet the body’s needs In Type 1, the pancreas makes NO insulin In Type 2, the body is resistant to the action of insulin so even a lot is not enough In pregnancy, the stress on the body causes increased need for insulin.

6. Pancreas gland

7. Insulin Hormone produced by beta cells clustered in the Islets of Langerhans in the pancreas gland Released after you eat when blood sugar goes up Helps sugar (glucose) get from blood into the body’s cells When you haven’t eaten, insulin drops, and liver and other organs work to keep blood sugar stable

8. Diagnosis Fasting blood sugar >126 OR Random blood sugar >200 with symptoms OR Glycosylated hemoglobin (huh???) > 6.5

9. Diagnosis What is glycosylated (also called “glycated”) hemoglobin? also called Hemoglobin A1c when blood sugar is too high, it permanently attaches to the hemoglobin in red blood cells gives an idea of how high the blood sugar has been over the past 3 months

10. Signs and symptoms Fatigue Thirst Hunger Excessive urination Weight loss (unintentional, despite eating regularly) Yeast (candida) infections Blurry vision

11. Complications Diabetes affects ALL organ systems.; it is not just about the sugar!

12. Complications Heart Heart attack, chest pain Blood vessels Peripheral arterial ds (poor circulation) leg pain while walking (claudications) amputations Kidney Renal failure/dialysis

13. Complications Eyes Blindness Cataracts Retinal detachment Retinopathy Nerves Peripheral neuropathy (pain, tingling, numbness in fingers, toes) Brain Stroke

14. Complications GI tract (stomach, intestines) Motility disorders Diarrhea, constipation Skin Ulcers Infections Otitis externa Yeast ↑ risk of flu, pneumonia

15. Management Usually involves some combination of Diet Exercise Oral hypoglycemic agents (pills) Insulin (shots)

16. Management : lifestyle modification Diet Low carbs (concentrated sugar) High fiber (veggies, whole grains) Low saturated fat Limit/eliminate alcohol use Timing is important

17. Management : lifestyle modification Exercise Aerobic burns calories, helps heart Strengthening builds muscle Aim for at least 20 minutes 3x/wk Be careful about shoes that fit well, don’t rub Weight loss will occur if you eat less and exercise more

18. Management : Medications Oral agents Metformin (Glucophage) Glipizide (Glucotrol), Glyburide (Micronase, Diabeta) Prandin Avandia, Actos Precose Januvia, Onglyza

19. Management : Medications Different drugs work in different ways: Getting the pancreas to produce more insulin Decreasing the amount of carbs absorbed from food Increasing amounts of a naturally-occurring compound in the body that lowers blood sugar Help insulin work better in muscle and fat and decrease glucose made by the liver

20. Management : Insulin Your doctor may start you on insulin based on various factors: How long you have had diabetes How high your blood glucose level is What other medicines you take Your overall health Starting insulin does NOT mean you or your doctor have failed!!!!

21. Management : Insulin Rapid-acting insulin (Humalog/lispro, Novolog/aspart) begins to work about 5 minutes after injection, and continues to work for 2 to 4 hrs. Rapid- acting insulin covers insulin needs for meals eaten at the same time as the injection. This type is used with longer-acting insulin. Regular or Short-acting insulin (Humulin R) reaches the bloodstream within 30 mins, and is effective for 3 to 6 hrs. and covers insulin needs for meals eaten within 30-60 mins

22. Management : Insulin Intermediate-acting insulin (NPH, Lente) reaches the bloodstream 2 to 4 hrs after injection, and is effective for 12 to 18 hrs. Long-acting insulin (ultralente) reaches the bloodstream 6 to 10 hrs after injection and is effective for 20 to 24 hrs. Long-acting insulin analogues glargine (Lantus) and detemir (Levemir)lower sugar levels evenly over 24 hrs

23. Management: Insulin You may need a combination of different types of insulin to meet your needs throughout the day. Premixed insulin (70/30) can be helpful for people who have trouble drawing up insulin out of two bottles and reading the correct directions and dosages. It is also useful for those who have poor eyesight or dexterity and is convenient for people whose diabetes has been stabilized on this combination.

24. Management: Other In addition to eating right, exercising and taking your meds as prescribed, keeping your f/u appts, you will need to: See an Ophthalmologist at least once a year See a Podiatrist at least once a year See a Dentist at least once a year Keep your blood pressure controlled (<130/80) Have immunizations especially flu and pneumonia Keep up with all other preventative health activities (mammogram, pap smear for women, prostate checks for men, colon cancer checks for everybody >40)

25. Want more info???? http://www.diabetes.org/ http://www.medicinenet.com/diabetes_mellitus/article.ht m http://www.medicinenet.com/diabetes_mellitus/article.ht m http://www.nlm.nih.gov/medlineplus/diabetesmellitus.ht ml http://www.nlm.nih.gov/medlineplus/diabetesmellitus.ht ml http://www.americanheart.org/presenter.r 40jhtml?identifier=4546 http://www.americanheart.org/presenter.r 40jhtml?identifier=4546 http://www.mayoclinic.com/health/type-2- diabetes/DS00585 http://www.mayoclinic.com/health/type-2- diabetes/DS00585