1. Diabetes Mellitus NFSC 370 D. Bellis McCafferty

2. Diabetes Mellitus: A group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. (ADA Website) Approximately 1/3 the people with diabetes are undiagnosed Major cause of:

3. Definitions FPG: CPG: OGTT: Oral Glucose Tolerance Test (75g) Hemoglobin A1c (glycated hemoglobin, glycosylated hemoglobin)

4. Diagnoses Pre-Diabetes (new diagnosis) FPG OGTT Old terms: Impaired Fasting Glucose (IFG) Impaired Glucose Tolerance: (IGT) Diabetes: Confirmed FPG CPG OGTT:

5. Type 1 Diabetes 5-10% of diabetes cases Most cases diagnosed before age 20 Damage to beta cells of pancreas  little or no insulin produced  Associated conditions: Etiology: Autoimmune, viral, or no known pancreatitis, cystic fibrosis

6. Type 2 Diabetes 90-95% of diabetes cases Hyperglycemia/insulin resistance Typically diagnosed over age 40* Associated w/

7. Consequences of Diabetes Hyperglycemia Dehydration Polydipsia, polyuria Polyphagia Blurred vision Glycosuria (glu spills into urine: >180mg/dl)

8. Ketosis (Primarily Type 1) (loss of KBs and glu in urine  wt loss) Cells aren’t receiving glucose/amino acids 2’ inadequate/no insulin Fat is mobilized for E Liver responds (to fat mobilization) by producing ketone bodies Accumulate in blood  Excreted in urine  Severe ketoacidosis 

9. Symptoms of Ketoacidosis: Shortness of breath Breath that smells fruity Nausea and vomiting A very dry mouth (ADA Website)

10. Nonketotic Coma (Type2) – coma 2° extremely high blood glucose (HHNC hyperosmolar hyperglycemic nonketotic coma) Hypoglycemia – 2 ° too much insulin/OHAs, strenuous activity, inadequate food intake, alcohol intake, vomiting, severe diarrhea. Can be life- threatening.

11. Symptoms Of Hypoglycemia Shakiness Dizziness Sweating Hunger Headache Pale skin color Sudden moodiness or behavior changes, such as crying for no apparent reason Clumsy or jerky movements Difficulty paying attention, or confusion Tingling sensations around the mouth (ADA Website)

12. Chronic Complications of Diabetes Cardiovascular Disease!! Diabetic dyslipidemia (High TG, low HDL, small dense LDL) LDL goal for people with DM: <100mg/dl If LDL  130 mg/dl, LDL-lowering drugs may be initiated. Chronic hyperglycemia also damages structure of blood vessels  poor circulation.

13. Microangiopathies (disorders of capillaries ~ 2’ hyperglycemia) Kidneys Retina Neuropathy (2’ hyperglycemia) delayed gastric emptying 

14. Treatment Of Type 1 Diabetes Goals: Maintain (as close to) normal blood glucose (as possible), blood lipid, and blood pressure levels; prevent/prolong the onset of/treat complications. 1.eat at consistent times, time insulin to match meals 2.monitor blood glucose regularly 3.adjust insulin as needed

15. CHO (intake directly affects blood glucose, but not restricted) Consistent amounts at planned times Coordinated w/ insulin Encourage high quality CHO/ample fiber Concentrated sweets: Missed meals:

16. Protein At first sign if kidney disease, restrict to Fat DGs for fat/Sat’d fat Elevated LDL  Sat’d fat restricted to 7% and cholesterol <200 mg/day

17. Alcohol Can  Moderate amounts WITH meals OK Count as fat exchanges (juice/mixers count as CHO)

18. Meal Planning -- INDIVIDUALIZED Timing and composition of meals Consistent from day to day – improves glu control Evening snack – sustains glu throughout the night Coordinated w/ physical activity and insulin Taught in stages Family included in educational process Exchange lists or CHO counting No skipping meals *

19. Physical Activity Benefits CV system Affects Blood Glucose Mild hyperglycemia + exercise can  Marked hyperglycemia + exercise can  Check BG before exercise: Supplement CHO depending on intensity of the activity (1hr moderate = 15g CHO; more intense = up to 30g CHO. No change if  30 min moderate)

20. Insulin and Exercise Insulin should be taken 1 hour before exercise Exercise and warm temps increase blood flow and insulin absorption. Can  hypoglycemia (even after several hours) Dose should be reduced by 10-20% before exercise (individualized: takes trial and error and close monitoring)

21. Insulin and Insulin Analogs Injections or pump– Type 1: depend on insulin to survive Rapid-acting insulin ( Lispro) Onset: 5 minutes Peak: 1 hour Duration: 2-4 hours Reduces risk of hypoglycemia between meals and during the night. Regular or Short-acting insulin (human) Onset: ½ to 1 hour Peak: 2-3 hours Duration: 3-6 hours

22. Intermediate-Acting Insulin (“background insulin”) (NPH & Lente) On average: Onset: 2-4 hours Peak: 4-12 hours Duration: 12-18 hours Long-Acting Insulin (ultralente) Onset: 6-10 hours Peak: none Duration: 20-24 hours Pre-mixed Insulins 70/30: 70% NPH/ 30% Regular 50/50: 50% NPH/ 50% Regular

23. The Honeymoon Phase:

24. Self-Monitoring Blood Glucose (SMBG) Check B.S. throughout the day using a glucometer Frequently recommended that persons w/Type 1 test 4X/day: before each meal and at bedtime (up to 7x/day) Keep a written record of BG levels and learn how to adjust insulin doses (sliding scale insulin)

25. Conventional Therapy vs. Intensive Therapy DCCT – Diabetes Control and Complications Trial Two injections/SMBG vs 3 or more injections, SMBG before insulin. Consistent meal intake still important

26. Hyperglycemia Dawn Phenomenon Response to overnight fast Counterregulatory hormones  May need  NPH/lente at bedtime or more R in the morning until counterregulatory hormone levels fall Rebound Hyperglycemia AKA “Somagyi Effect” Reponse: Counterregulatory hormone levels go up  Treatment may involve reducing insulin dose

27. Sick Days Minor illnesses (cold/flu) can cause sharp increases in glu.  insulin requirement Close monitoring of B.S., urinary ketones Severe Hyperglycemia and Ketoacidosis Medical Emergency Untreated Type 1 DM /omitted insulin dose/overeating Rebound hyperglycemia Stress (trauma/infection) Hospitalization, IV fluids/lytes to correct acid-base balance, carefully administered insulin, close monitoring.

28. Treatment of Type 2 Diabetes Goals: Maintain normal blood glucose, blood lipid, and blood pressure levels; prevent/prolong the onset of/treat complications. Support optimal quality of life. Strategies:

29. Diet: Same guidelines as Type 1, though timing of meals as not quite as critical. (Less CHO?) Specified kcal level for wt. control or wt. loss usually recommended CHO counting is also appropriate Emphasize total kcaloric intake if obese Moderate wt. loss (10-20 lb) can reverse insulin resistance. (and improve blood lipids/bl. Pressure)

30. Hypocaloric diet may be beneficial soon after onset/diagnosis Lipids: emphasize mufa’s Exercise: Improves glucose control, lipid levels, blood pressure. DG appropriate

31. Medications OHA’s Oral Hypoglycemic Agents sulfonylurea drugs (  beta cell insulin secretion and cellular responsiveness to insulin) May interact w/EtOH Glucotrol, Diabeta, Micronase, Diabenese Glucophage (metformin): decreases hepatic glucose production and intestinal glucose absorpion; also improves insulin sensitivity Precose (acarbose) – delays GI absorption of glucose Avandia (newer drug) can be used alone or in combination with a sulfonylurea or metformin

32. Combination Therapy Self-monitoring of blood glucose (1- 4x/day but only 3 or 4x/week) UKPDS: UK Prospective Diabetes Study: intensive therapy/close monitoring reduces complications/slows progression of Type 2 diabetes.

33. Diabetes and the Elderly Greater risk for hypo/hyperglycemia (reduced appetite, blunted thirst mechanism, altered kidney/liver function, multiple meds, mental deterioration) Insulin resistance progresses with age May require insulin; may lose some independence (giving self shots, eyesight for drawing correct dose, reading glucometer or glucose strips, etc)

34. Hypoglycemia of Nondiabetic Origin Fasting Hypoglycemia Reactive Hypoglycemia Diagnosis symptoms vary from person to person, but are constant from episode to episode Treatment