1. Unit 13 Diabetes Now

2. Key Concepts and Facts  Diabetes is related to abnormal utilization of glucose by the body.  The three main forms of diabetes are type 1, type 2, and gestational diabetes.  Rates of type 2 diabetes increase as obesity does.  Weight loss and physical activity can prevent or delay the onset of type 2 diabetes in many people.

3. The Diabetes Epidemic  Diabetes is a growing epidemic  Related to the global increase in obesity  Diabetes affects 200 million worldwide  18 million in U.S.

4. Sugar Intake and Diabetes  Moderate intake of simple sugars does not cause diabetes  Diabetics do not need a "No Sugar" diet  Intake of total carbohydrates must be controlled –not e  High-sugar diets increase blood triglyceride levels and may increase diabetes risk

5. Types of Diabetes  Three forms of diabetes: type 1, type 2, and gestational diabetes.  Type 2 is the most common  Diagnosis: fasting levels of blood glucose are 126 mg/dl and higher  In all cases, the central defect is elevated blood glucose level= high blood sugar due to inadequate supply or ineffective utilization of insulin

6. Insulin  A Hormone  Produced by pancreas  Reduces blood glucose levels  Facilitates passage of glucose into cells  Low insulin means cells starve  Cell membranes are sensitive to the action of insulin  Cells starve if membranes lose sensitivity Electron microscopy image

7. Type 2 Diabetes  Occurs mainly in overweight and obese, inactive people  9% of Americans over age 20  Most frequent in older age groups  But becoming more common in young adults, children and teens  More significant genetic component

8. Acanthosis Nigricans

9.  Acanthosis nigricans  Most often a sign of elevated insulin levels  May precede the development of diabetes  Or indicate diabetes has developed

10. Symptoms of Diabetes  Blurred vision  Frequent urination  Weight loss  Extreme hunger and thirst  Increased fatigue  Irritability  Type 1: Very high blood sugar ► coma ► death

11. FOCUS: Type 2 Diabetes  Poorly controlled or untreated diabetes produces:  Blurred vision  Frequent urination  Weight loss  Increased susceptibility to infection  Delayed wound healing  Extreme hunger and thirst

12. Effects of high glucose  elevated blood levels of triglycerides  increased blood pressure  hardening of the arteries  Type 2: high insulin production ► can exhaust pancreas Medications stimulate pancreas to produce more insulin Eventually may need insulin injections

13. Prediabetes and Insulin Resistance  Elevated fasting blood glucose levels between 110 and 126 mg/dl characterize prediabetes  Prediabetes increases odds of developing type 2 diabetes by 10% per year

14. Insulin resistance  Common risk factors for insulin resistance –Obesity –Low levels of physical activity –Genetic predisposition

15. Insulin resistance  Insulin lowers blood glucose by binding to cell membrane receptors  Receptors activated by insulin, allow glucose into cells  Cell membranes ‘resist’ the effects of insulin  Lowers the glucose transported into cells  Leads to elevated blood glucose

16. Insulin resistance  When blood glucose levels become high, pancreas secretes more insulin  Higher insulin keeps glucose levels under control for years  Pancreas becomes exhausted from over-work  Insulin production slows and glucose accumulates in blood  When fasting blood glucose levels reach 126 mg/dl or higher, this is Type 2 diabetes

18. Metabolic Syndrome  13% of Americans age 20-39 have metabolic syndrome  25% of US adult population have metabolic syndrome  Diabetes risk increased 25-fold  Metabolic syndrome precedes diabetes  Last chance to avoid/postpone diabetes

19. Health Consequences of Diabetes  Heart Disease  Hypertension  Blindness  Kidney failure  Stroke  Loss of limbs due to poor circulation  Men: erectile dysfunction  Women: high risk pregnancies

20. The Diabetes Prevention Program A Randomized Clinical Trial to Prevent Type 2 Diabetes in Persons at High Risk The DPP Research Group

21. Study Interventions Eligible participants Randomized Standard lifestyle recommendations Intensive Metformin Placebo Lifestyle (n = 1079) (n = 1073) (n = 1082)

22. Lifestyle Intervention An intensive program with the following specific goals: > 7% loss of body weight and maintenance of weight loss> 7% loss of body weight and maintenance of weight loss – Dietary fat goal -- <25% of calories from –fat – Calorie intake goal -- 1200-1800 kcal/day > 150 minutes per week of physical activity> 150 minutes per week of physical activity

23. Placebo (n=1082) Metformin (n=1073, p<0.001 vs. Placebo) Lifestyle (n=1079, p<0.001 vs. Metformin, p<0.001 vs. Placebo) Incidence of Diabetes Risk reduction 31% by metformin 58% by lifestyle The DPP Research Group, NEJM 346:393-403, 2002

24. How can someone with Type 2 Diabetes avoid more health problems?  Weight loss alone significantly improves blood glucose control  Regular exercise  Carbohydrate-counting diet  Prioritize complex carbohydrates, especially high fiber foods, vegetables, fruits –Low-fat milk and meats, and fish –Unsaturated fats –Regular small-to-moderate size meals and snacks –Oral medications or insulin, as prescribed Message for grandparents: Don’t fight going on insulin!

25. Diabetes and Heart Disease  Prediabetes and/or Metabolic Syndrome increase risk of heart disease  Diabetes greatly increases risk of heart disease  Diabetics need to follow a heart-healthy diet and lifestyle.

26. Key to Good Health  Type 2 diabetics who take care of themselves can live long, healthy lives  They can avoid blindness, kidney disease, amputations, etc!

27. Preventing Type 2 Diabetes Attain or maintain ideal body weight orAttain or maintain ideal body weight or Lose >7-10% of body weight Dietary goals -- <25% of calories Dietary goals -- <25% of calories from fat from fat Stress complex carbohydrates Calorie intake goal -- 1200-1800 kcal/day Calorie intake goal -- 1200-1800 kcal/day > 150 minutes per week of physical activity> 150 minutes per week of physical activity

28. Curing Diabetes Type 2 Diabetes: Change our obesigenic environment! Can we make physical activity a part of our lifestyle? Can we make it easier to get nutritious foods than junk foods? …and Type 1 Diabetes

29. Type 1 Diabetes  In US, ~1 child in 400 has diabetes  This disease is becoming more common, for unknown reasons  Diagnosis of Type 1 peaks around the ages of 11 to 12 years  Very few new cases after age 40

30. Diabetes, A Death Sentence: Before discovery of insulin in 1921, 100% died within a few years.

31. Characteristics- Type 1  Usually develops before age 20  Genetic, viral and other risk factors  Becoming more common  Disease destroys cells in pancreas that produce insulin  Insulin deficiency– requires insulin by multiple daily injections or insulin pump  10% of all diabetics are Type 1  Formerly called Juvenile Diabetes

32. Incidence of diabetes in children under age 10 years in Norway, 1925–1995, per 100,000. From 2004 to 2012, the average incidence was 33. Gale E A Diabetes 2002;51:3353-3361 Copyright © 2014 American Diabetes Association, Inc.

33. Type 1 Diabetes  A genetic type plus an environmental cause such as viral infection, allergic reaction, rapid growth during infancy, or auto-immune disease cause  Destruction of the Beta cells in the Islets of Langerhans in the pancreas that produce insulin

35. Type 1 Diabetes  Type 1 diabetics measure blood glucose levels several times daily  Adjust insulin dose according to the results  Self-inject insulin several times daily  OR Insulin pumps release insulin as programmed by the user  Pumps improve blood glucose control

36. Insulin pumps release insulin as programmed by the user Pumps improve blood glucose control

37. Insulin Pumps: Developing Fast Insulin pumps combined with continuous glucose monitoring (CGM) are like an external pancreas.

38. Can We Prevent Type 1 Diabetes?  Breastfeeding exclusively for first four months may confer protection against type 1 diabetes  Mothers gaining excess weight during pregnancy may increase risk  Gaining weight rapidly in infancy and childhood may increase risk.  The hygiene hypothesis (google this phrase) –the modern world is too clean, and the immune system needs stimulation to develop normally

39. Curing Diabetes Type 2 Diabetes: Build physical activity into our lifestyle and prevent obesity Type 1 Diabetes: Stop destruction of beta cells Transplant new beta cells into pancreas Ongoing stem cell research

40. We will not cover Hypoglycemia Gestational Diabetes END p. 9

41. Diabetes in the Future  Worldwide rise in type 2 diabetes is predicted but not inevitable  Could be lowered by environmental and lifestyle changes to reduce overweight and increase physical activity  Education on connection between diabetes and body weight may help  Hoped-for future of diabetes is to negate dire forecasts of the experts