Know Your Know Your DiabetesDiabetes

Thomas Repas D.O.Thomas Repas D.O.Diabetes, Endocrinology and Nutrition Center, Affinity Medical Group, Neenah, WisconsinDiabetes, Endocrinology and Nutrition Center, Affinity Medical Group, Neenah, Wisconsin

Member, Inpatient Diabetes Management Committee, St. Elizabeth’s Hospital, Appleton, WIMember, Inpatient Diabetes Management Committee, St. Elizabeth’s Hospital, Appleton, WIMember, Diabetes Advisory Group, Wisconsin Diabetes Prevention and Control Program Member, Diabetes Advisory Group, Wisconsin Diabetes Prevention and Control Program

Website: www.endocrinology-online.comWebsite: www.endocrinology-online.com

DDiabetes careiabetes care is an ongoing team is an ongoing team

approach requiring the combined and approach requiring the combined and intensive efforts of patients, their intensive efforts of patients, their

families, diabetic educators, doctors, families, diabetic educators, doctors, nurses, dieticians and others.nurses, dieticians and others.

Remember:Remember:

Diabetes care Diabetes care starts with starts with

you!you!

““WhenWhen it comes to it comes to controlling diabetes, the controlling diabetes, the

patient is the key to patient is the key to everything.everything.

Diabetes patients must in Diabetes patients must in effect become professors of effect become professors of their disease, learning to their disease, learning to control their blood sugar control their blood sugar

levels over time.”levels over time.”

American Association of Clinical Endocrinology “Patients First” Campaign 2002

Diabetes 101

There are two main There are two main types of diabetes…types of diabetes…

Type 1 and Type 2Type 1 and Type 2

What is the difference What is the difference between type 1 and between type 1 and

type 2 diabetes?type 2 diabetes?

Type 1 diabetesType 1 diabetes the pancreas the pancreas makes no insulin. Usually (but not always) makes no insulin. Usually (but not always) occurs in younger people. Type 1 diabetes occurs in younger people. Type 1 diabetes is always treated with insulin.is always treated with insulin.

Type 2 diabetesType 2 diabetes the pancreas makes the pancreas makes insulin, but the body does not respond to it, it is insulin, but the body does not respond to it, it is

INSULIN RESISTANT. Sometimes, the pancreas INSULIN RESISTANT. Sometimes, the pancreas begins to fail and also does not produce enough begins to fail and also does not produce enough insulin. It frequently (but not always) occurs in insulin. It frequently (but not always) occurs in

adults.adults.Type 2 diabetes can be treated with diet, pills Type 2 diabetes can be treated with diet, pills

and/or insulin.and/or insulin.

90% of all diabetes is type 290% of all diabetes is type 2

An Important PointAn Important Point We never diagnose the type of diabetes by We never diagnose the type of diabetes by

whether a person is on insulin or notwhether a person is on insulin or not.. Although all type 1’s are on insulin, a large number of type 2’s are Although all type 1’s are on insulin, a large number of type 2’s are

on insulin, tooon insulin, too This is why we don’t use the terms insulin dependent and non-This is why we don’t use the terms insulin dependent and non-

insulin dependent anymore, it was too confusing for both doctors insulin dependent anymore, it was too confusing for both doctors and patients alikeand patients alike

We also don’t use the terms juvenile onset or adult We also don’t use the terms juvenile onset or adult onset anymore either. onset anymore either. We now know there are now many juvenile onset type 2’s and adult We now know there are now many juvenile onset type 2’s and adult

onset type 1’sonset type 1’s We always diagnose the type of diabetes by the We always diagnose the type of diabetes by the

cause and never by whether on insulin or by the cause and never by whether on insulin or by the age of the patientage of the patient

What causes diabetes?What causes diabetes?

The pancreas fails to make insulin because antibodies (autoimmunity) attack the insulin producing cells. There is a slight genetic tendency to inherit the disease as well a a possible environmental trigger (which we don’t completely understand yet).

Type 1 diabetesType 1 diabetes

Type 2 diabetesType 2 diabetes

Early on in the course of the disease (and sometimes even before someone is a type 2 diabetic) the pancreas makes enough insulin, but the body fails to respond to it because of insulin resistance.

Later, the pancreas is unable to make enough insulin and blood sugars increase.

There is a strong genetic tendency to develop type 2 diabetes but lifestyle factors also play a significant role.

Can Diabetes be Can Diabetes be Prevented?Prevented?

Prevention of Type 2 DiabetesPrevention of Type 2 Diabetes Several well designed studies have proven that type 2 Several well designed studies have proven that type 2

diabetes can be prevented or delayed in those people at diabetes can be prevented or delayed in those people at risk.risk.

The Diabetes Prevention Program showed that in a three The Diabetes Prevention Program showed that in a three year period the numbers of new type 2 diabetics was year period the numbers of new type 2 diabetics was reduced by 58% through diet, exercise and weight loss reduced by 58% through diet, exercise and weight loss alone. alone. Average weight loss was only 12 lbs (7% of body weight)Average weight loss was only 12 lbs (7% of body weight) Patients exercised only 30 minutes a day for 5 days a weekPatients exercised only 30 minutes a day for 5 days a week

We do not understand the causes of type 1 diabetes well We do not understand the causes of type 1 diabetes well enough yet to be able to prevent thisenough yet to be able to prevent this

Prediabetes or Metabolic Prediabetes or Metabolic SyndromeSyndrome

Consists of a syndrome of several factors Consists of a syndrome of several factors that cluster together:that cluster together: Abnormal blood sugarsAbnormal blood sugars High Blood PressureHigh Blood Pressure High TriglyceridesHigh Triglycerides Low HDL or “good” CholesterolLow HDL or “good” Cholesterol A body shaped like an apple instead of a A body shaped like an apple instead of a

pearpear

People with any three of these are at increased risk of developing type 2 diabetes

So why is uncontrolled So why is uncontrolled diabetes so bad?diabetes so bad?

•Retinopathy: eye damage that can cause blindness•Nephropathy: kidney damage or failure•Neuropathy: nerve damage •Coronary artery disease: Heart attack•Cerebrovascular disease: Stroke•Other: gastroparesis (digestive problems), poor healing (infections), circulation problems, amputations, erectile dysfunction

Diabetes that is not controlled Diabetes that is not controlled can result in:can result in:

Keep in mind, diabetes Keep in mind, diabetes complications are not complications are not

inevitable!inevitable! Through intensive Through intensive

management and management and monitoring, monitoring, diabetes diabetes complications can complications can be minimized or be minimized or preventedprevented..

It is normal to feel frustrated and It is normal to feel frustrated and overwhelmed about diabetesoverwhelmed about diabetes

So what can you do to So what can you do to control your diabetes and control your diabetes and prevent complications?prevent complications?

Know your Know your ABC’sABC’s

AA= = A1CA1C

BB==Blood PressureBlood Pressure

CC==CholesterolCholesterol

A= A= A1C or “Hemoglobin A1C”A1C or “Hemoglobin A1C”

Blood sugar “sticks” to hemoglobin making Blood sugar “sticks” to hemoglobin making it glycosalated or hemoglobin A1Cit glycosalated or hemoglobin A1C

By measuring A1C’s we can get an idea of By measuring A1C’s we can get an idea of the average blood sugar control for the the average blood sugar control for the past three monthspast three months

Should be obtained every 3 to 6 monthsShould be obtained every 3 to 6 months Goal: ADA < 7; AACE < 6.5Goal: ADA < 7; AACE < 6.5

B= B= Blood PressureBlood Pressure

Should be measured every visit or every 3 Should be measured every visit or every 3 to 6 monthsto 6 months

Goal: < 130/80Goal: < 130/80 In patients with kidney disease the goal In patients with kidney disease the goal

should be even lower should be even lower

C = C = CholesterolCholesterol

Should be measured no less than every Should be measured no less than every year in patients whose levels are at goalyear in patients whose levels are at goal

For those who are not, every 3 to 6 For those who are not, every 3 to 6 monthsmonths

Goal: Goal: LDL (bad cholesterol) < 100 mg/dlLDL (bad cholesterol) < 100 mg/dl HDL (good cholesterol) > 45 mg/dlHDL (good cholesterol) > 45 mg/dl Triglycerides < 200 mg/dlTriglycerides < 200 mg/dl

Screening for ComplicationsScreening for Complications

Eye examsEye examsFoot examsFoot examsKidney testsKidney tests

All diabetic All diabetic patients should patients should

have a dilated eye have a dilated eye exam by an eye exam by an eye specialist every specialist every

year.year.

Diabetic Foot CareAnd Exams

•Learn proper daily foot self careLearn proper daily foot self care•Remove shoes/socks every visit and remind your doctor to check your feetRemove shoes/socks every visit and remind your doctor to check your feet•At least every year have a formal foot exam with monofilament testingAt least every year have a formal foot exam with monofilament testing

Kidney TestsKidney Tests At least once a year, diabetics should have a specific At least once a year, diabetics should have a specific

type of urine test called urine microalbumintype of urine test called urine microalbumin Urine microalbumin is an early screening for kidney Urine microalbumin is an early screening for kidney

problems and diseaseproblems and disease Urine microalbumin will be abnormal many years before Urine microalbumin will be abnormal many years before

actual kidney failure occursactual kidney failure occurs When the kidneys begin to not function properly they When the kidneys begin to not function properly they

begin to get “leaky” and lose protein and other begin to get “leaky” and lose protein and other compounds in the urinecompounds in the urine

It is important to look for this because if caught early it is It is important to look for this because if caught early it is reversible with medication, thus delaying or preventing reversible with medication, thus delaying or preventing kidney failurekidney failure

Other Ways to Prevent Other Ways to Prevent ComplicationsComplications

If you smoke…If you smoke…

STOP!STOP!

Monitor and record your blood sugars Monitor and record your blood sugars regularlyregularly

Exercise & lose weightExercise & lose weight Aspirin? Aspirin?

Most diabetics should be on an aspirin a day, ask Most diabetics should be on an aspirin a day, ask your doctor if this is OK for youyour doctor if this is OK for you

Vaccinations?Vaccinations? Flu – every yearFlu – every year Pneumonia – at least oncePneumonia – at least once

More ways to prevent complications…More ways to prevent complications…

What type of options What type of options are available to treat are available to treat

diabetes?diabetes?

Diet & lifestyleDiet & lifestylePillsPillsInsulinInsulinAny combination of Any combination of

aboveabove

Diet & lifestyleDiet & lifestyle

Diet and lifestyle can have a significant Diet and lifestyle can have a significant impact on diabetic controlimpact on diabetic control

Losing as little as 5 or 10 pounds can Losing as little as 5 or 10 pounds can improve diabetes control significantlyimprove diabetes control significantly

Exercise can also help in lowering blood Exercise can also help in lowering blood sugars as well as improving blood sugars as well as improving blood pressure (ask your doctor first)pressure (ask your doctor first)

Instruction in diet and nutrition is an Instruction in diet and nutrition is an important part of diabetes educationimportant part of diabetes education

Oral Medications or “Pills”Oral Medications or “Pills”

There are basically four types of There are basically four types of medications for type 2 diabetes:medications for type 2 diabetes:

Medicines that stimulate the pancreas to release more Medicines that stimulate the pancreas to release more insulininsulin

Medicines that block glucose absorption from foodMedicines that block glucose absorption from food Medicines that decrease glucose production by the Medicines that decrease glucose production by the

liverliver Those that reduce insulin resistance by making cells Those that reduce insulin resistance by making cells

more sensitive to insulinmore sensitive to insulin

Medicines that stimulate the Medicines that stimulate the pancreas to release more insulinpancreas to release more insulin

There are two kinds of these, long acting and those There are two kinds of these, long acting and those taken right before meals:taken right before meals:

Long actingLong acting= sulfonyureas= sulfonyureas Amaryl, Glucotrol XL, GlyburideAmaryl, Glucotrol XL, Glyburide

Before mealsBefore meals= meglitinides= meglitinides Prandin, StarlixPrandin, Starlix

Things to consider: Things to consider: These medications do not know when to “turn off” so they could result in hypoglycemia (more of a problem in the long acting type).

Medicines that block glucose Medicines that block glucose absorption from foodabsorption from food

These are called alpha-glucosidase inhibitorsThese are called alpha-glucosidase inhibitors Precose, GlysetPrecose, Glyset

Things to consider: Things to consider: By themselves, they will not cause By themselves, they will not cause low blood sugars.low blood sugars. Although they can be helpful in Although they can be helpful in controlling blood sugars, they are not used very much controlling blood sugars, they are not used very much because of unpleasant side effects. because of unpleasant side effects.

Medicines that decrease glucose Medicines that decrease glucose production by the liverproduction by the liver

These medicines are called biguanides, there is only These medicines are called biguanides, there is only one medicine of this family availableone medicine of this family available Glucophage (metformin)Glucophage (metformin)

Things to consider: Things to consider: Metformin by itself does not cause low blood sugar. It works well in combination with other pills. It has some insulin sensitizing properties as well. It should not be used in people with liver problems, kidney disease or heart failure.

Medications that reduce insulin Medications that reduce insulin resistanceresistance

This group of medicines are called This group of medicines are called thiazolidinediones or “TZD’s”thiazolidinediones or “TZD’s” Actos, AvandiaActos, Avandia

Things to consider: Things to consider: TZD’s alone do not cause low blood sugar. They work well in combination with other pills. They can cause edema (leg swelling) so should be used cautiously in people who have heart failure and they should be avoided in people with liver problems. Because they reverse insulin resistance, they can do many other beneficial things besides only lower blood sugar.

Some Other Effects of TZD’s Some Other Effects of TZD’s Beyond Lowering Blood SugarsBeyond Lowering Blood Sugars

Improve body’s ability to respond to insulinImprove body’s ability to respond to insulin Improve cholesterol especially by reducing Improve cholesterol especially by reducing

triglyceride and increasing HDL or “good” triglyceride and increasing HDL or “good” cholesterolcholesterol

Reduce microalbumin in urineReduce microalbumin in urine Slightly improve blood pressureSlightly improve blood pressure

Combination DrugsCombination Drugs

There are many new combination drugs now There are many new combination drugs now available:available: Glucovance (Glucophage and Glyburide)Glucovance (Glucophage and Glyburide) Metaglip (Glucophage and Glucotrol)Metaglip (Glucophage and Glucotrol) Avandamet (Avandia and Glucophage)Avandamet (Avandia and Glucophage)

Things to consider: Things to consider: They can simplify a type 2 diabetes regimen by reducing the number of pills one has to take (two medications in one pill).

WHAT!?Did you say

INSULIN?!INSULIN?!

The use of The use of Insulin in Insulin in DiabetesDiabetes

InsulinInsulin

The only treatment available for type 1 diabetesThe only treatment available for type 1 diabetes

Also used in type 2 diabetes which has been Also used in type 2 diabetes which has been unable to be controlled with pills and diet aloneunable to be controlled with pills and diet alone

Insulin can be given as injections or through insulin Insulin can be given as injections or through insulin pumpspumps

Types of InsulinTypes of Insulin

Rapid acting Rapid acting begin acting almost immediately. Given before meals. Used begin acting almost immediately. Given before meals. Used in pumps.in pumps.

Humalog, NovoLogHumalog, NovoLog Short acting Short acting given before meals. Takes 30 minutes or more to begin.given before meals. Takes 30 minutes or more to begin.

Regular, Humulin RRegular, Humulin R Intermediate acting Intermediate acting usually given twice a day. Supplies our baseline usually given twice a day. Supplies our baseline

insulin needsinsulin needs

NPH, Humulin N, LenteNPH, Humulin N, Lente Long acting Long acting usually given only once a day. Supplies our baseline needs.usually given only once a day. Supplies our baseline needs.

Lantus, UltralenteLantus, Ultralente Combination Combination a mixture of intermediate and short acting insulin. Given a mixture of intermediate and short acting insulin. Given

once or twice a day. Should be used only in type 2’s never type 1’sonce or twice a day. Should be used only in type 2’s never type 1’s

Humulin 70/30,Humalog 75/25Humulin 70/30,Humalog 75/25

B SL HS B

Humalog

Lantus

Insu

lin

Eff

ect

Basal/Bolus Insulin RegimenBasal/Bolus Insulin Regimen A basal/bolus regimen closely A basal/bolus regimen closely

mimics our natural insulin needsmimics our natural insulin needs Basal insulin= baseline insulin to Basal insulin= baseline insulin to

prevent high blood sugars or prevent high blood sugars or ketoacidosis in the fasting stateketoacidosis in the fasting state

Bolus insulin= insulin given before Bolus insulin= insulin given before meals to prevent high blood meals to prevent high blood sugars after eating sugars after eating

Called by some the “poor man’s Called by some the “poor man’s pump”pump”

All type 1’s should be on a basal All type 1’s should be on a basal bolus regimen (and some type 2’s bolus regimen (and some type 2’s may benefit also)may benefit also)

Advantages: better BS control and Advantages: better BS control and more flexibilitymore flexibility

Disadvantage: requires four or five Disadvantage: requires four or five shots a day shots a day

6-56

Insulin PumpsInsulin Pumps Are standard of care in type 1 Are standard of care in type 1

diabetes (and some type 2’s) diabetes (and some type 2’s) but are not for everybodybut are not for everybody

The means of giving insulin The means of giving insulin closest to a normal functioning closest to a normal functioning pancreaspancreas

Insulin is given in two ways: a Insulin is given in two ways: a constant or basal delivery and constant or basal delivery and bolus insulin doses given bolus insulin doses given before meals or to correct before meals or to correct high’shigh’s

Can significantly improve Can significantly improve blood sugar control, reducing blood sugar control, reducing both high’s and lowsboth high’s and lows

Requires that a patient is Requires that a patient is involved, responsible and involved, responsible and willing to check and record willing to check and record BS’s four to six times every BS’s four to six times every day or moreday or more

A Final Word:A Final Word:

If you have diabetes and want better If you have diabetes and want better health and a longer life, then health and a longer life, then remember:remember:

You Can Do It!You Can Do It!

American Association of Clinical Endocrinology “Patients First” Campaign 2002

You can take control of You can take control of your diabetes instead your diabetes instead of it taking control of of it taking control of

you!you!