Transcript Diabetes Mellitus

Diabetes Mellitus
NFSC 370
D. Bellis McCafferty
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:
Definitions
FPG:
CPG:
OGTT: Oral Glucose Tolerance Test (75g)
Hemoglobin A1c (glycated hemoglobin,
glycosylated hemoglobin)
Diagnoses
Pre-Diabetes (new diagnosis)
FPG
OGTT
Old terms:
Impaired Fasting Glucose (IFG)
Impaired Glucose Tolerance: (IGT)
Diabetes: Confirmed FPG
CPG
OGTT:
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
Type 2 Diabetes
90-95% of diabetes cases
Hyperglycemia/insulin resistance
Typically diagnosed over age 40*
Associated w/
Consequences of Diabetes
Hyperglycemia
Dehydration
Polydipsia, polyuria
Polyphagia
Blurred vision
Glycosuria (glu spills into urine:
>180mg/dl)
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 
Symptoms of Ketoacidosis:
Shortness of breath
Breath that smells fruity
Nausea and vomiting
A very dry mouth
(ADA Website)
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 lifethreatening.
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)
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.
Microangiopathies (disorders of
capillaries ~ 2’ hyperglycemia)
Kidneys
Retina
Neuropathy (2’ hyperglycemia)
delayed gastric emptying 
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
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:
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
Alcohol
Can 
Moderate amounts WITH meals OK
Count as fat exchanges (juice/mixers
count as CHO)
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 *
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)
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)
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
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
The Honeymoon Phase:
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)
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
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
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.
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:
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)
Hypocaloric diet may be beneficial soon
after onset/diagnosis
Lipids: emphasize mufa’s
Exercise:
Improves glucose control, lipid levels,
blood pressure. DG appropriate
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
Combination Therapy
Self-monitoring of blood glucose (14x/day but only 3 or 4x/week)
UKPDS: UK Prospective Diabetes Study:
intensive therapy/close monitoring reduces
complications/slows progression of Type 2
diabetes.
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)
Hypoglycemia of Nondiabetic
Origin
Fasting Hypoglycemia
Reactive Hypoglycemia
Diagnosis
symptoms vary from person to person, but
are constant from episode to episode
Treatment