Diabetes Mellitus

NFSC 370D. 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:

DefinitionsFPG: CPG:

OGTT: Oral Glucose Tolerance Test (75g)Hemoglobin A1c (glycated hemoglobin, glycosylated hemoglobin)

DiagnosesPre-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 casesMost 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 casesHyperglycemia/insulin resistance

Typically diagnosed over age 40*Associated w/

Consequences of DiabetesHyperglycemia

DehydrationPolydipsia, polyuriaPolyphagiaBlurred 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 insulinFat is mobilized for ELiver responds (to fat mobilization) by producing ketone bodiesAccumulate in blood Excreted in urine

Severe ketoacidosis

Symptoms of Ketoacidosis:Shortness of breathBreath that smells fruityNausea and vomitingA 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 life-threatening.

Symptoms Of Hypoglycemia ShakinessDizziness Sweating HungerHeadachePale 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/dlIf 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)

KidneysRetina

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 meals2. monitor blood glucose regularly3. 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

FatDGs for fat/Sat’d fatElevated LDL Sat’d fat restricted to 7% and cholesterol <200 mg/day

AlcoholCan Moderate amounts WITH meals OKCount as fat exchanges (juice/mixers count as CHO)

Meal Planning -- INDIVIDUALIZED Timing and composition of meals

Consistent from day to day – improves glu controlEvening snack – sustains glu throughout the nightCoordinated w/ physical activity and insulin

Taught in stages Family included in educational processExchange lists or CHO countingNo skipping meals *

Physical ActivityBenefits CV systemAffects 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 ExerciseInsulin should be taken 1 hour before exerciseExercise 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 minutesPeak: 1 hourDuration: 2-4 hoursReduces risk of hypoglycemia between meals and during the night.

Regular or Short-acting insulin (human)Onset: ½ to 1 hourPeak: 2-3 hoursDuration: 3-6 hours

Intermediate-Acting Insulin (“background insulin”) (NPH & Lente) On average:

Onset: 2-4 hoursPeak: 4-12 hoursDuration: 12-18 hours

Long-Acting Insulin (ultralente)Onset: 6-10 hoursPeak: noneDuration: 20-24 hours

Pre-mixed Insulins70/30: 70% NPH/ 30% Regular50/50: 50% NPH/ 50% Regular

The Honeymoon Phase:

Self-Monitoring Blood Glucose (SMBG)Check B.S. throughout the day using a glucometerFrequently 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 TherapyDCCT – Diabetes Control and Complications TrialTwo injections/SMBG vs 3 or more injections, SMBG before insulin. Consistent meal intake still important

HyperglycemiaDawn 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 requirementClose monitoring of B.S., urinary ketones

Severe Hyperglycemia and Ketoacidosis Medical Emergency

Untreated Type 1 DM /omitted insulin dose/overeatingRebound 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 recommendedCHO counting is also appropriateEmphasize total kcaloric intake if obeseModerate wt. loss (10-20 lb) can reverse insulin resistance. (and improve blood lipids/bl. Pressure)

Hypocaloric diet may be beneficial soon after onset/diagnosisLipids: emphasize mufa’s

Exercise: Improves glucose control, lipid levels, blood pressure. DG appropriate

MedicationsOHA’s Oral Hypoglycemic Agents

sulfonylurea drugs ( beta cell insulin secretion and cellular responsiveness to insulin) May interact w/EtOH

Glucotrol, Diabeta, Micronase, DiabeneseGlucophage (metformin): decreases hepatic glucose production and intestinal glucose absorpion; also improves insulin sensitivityPrecose (acarbose) – delays GI absorption of glucoseAvandia (newer drug) can be used alone or in combination with a sulfonylurea or metformin

Combination TherapySelf-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.

Diabetes and the ElderlyGreater risk for hypo/hyperglycemia (reduced appetite, blunted thirst mechanism, altered kidney/liver function, multiple meds, mental deterioration)Insulin resistance progresses with ageMay 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

Diagnosissymptoms vary from person to person, but are constant from episode to episode

Treatment