Diabetes 101

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Diabetes 101

• Janet Renaldi, RN, CDE
• St Lukes Magic Valley
• Diabetes Education Program

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Prevalence of Diabetes

• 23 million in the US with Type 2 diabetes
• 1 million in the US with Type 1 diabetes
• 57 million in the US with pre-diabetes
• CDC predicts doubling of diabetes by 2030
• 40 of persons 40-74 have pre-diabetes
• 40-50 million in the US with metabolic syndrome

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Cost of Diabetes

• 174 billion spent in 2007
• Over 33 of Medicare budget
• 2/3 is spent on complications
• 13,243/yr to treat a person with DM
• 2,560/yr to treat a non-diabetic
• 883/month for prescriptions
• Agency for Healthcare Research and
  Quality 2006
• Economic Cost of Diabetes in the US in 2007

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Types of Diabetes

• Type 1
• Type 2
• Type 2 in youth
• GDM (gestational)
• Pre diabetes, Impaired glucose tolerance,
  Metabolic syndrome

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Type 1 Diabetes

• Auto immune disease
• 5-10 of population with DM
• Historically called juvenile diabetes
• Occurs in children and adults
• 9 of 10 people DO NOT have relative with Type 1
  DM
• Requires daily insulin and BG testing, balanced
  with food and activity

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Type 1 Diabetes

• Signs at diagnosis are weight loss, urine
  ketones, yeast infections, increased thirst and
  urination, fatigue, hyperglycemia
• IGA, insulin antibodies or C-peptide lab tests
  identify Type 1 DM
• Thought to be triggered by increase hormones
  levels or viral infection

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Type 2 Diabetes

• Insulin resistance common
• Historically called adult onset
• Pancreas still makes insulin
• One-third are undiagnosed
• Signs are often mild or non-existent
• Treated by diet, exercise, pills and insulin

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Risk Factors for Diabetes

• Sedentary lifestyle
• Family history
• Overweight
• Age
• Polycystic Ovary Disease
• High risk ethnic group
• Hypertension

• Cardiovascular Disease
• Triglycerides gt250
• HDL lt40
• Waist measurement gt35 women, gt40 men
• History of GDM or baby gt 9 lbs

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Diagnosis of Type 2

• 2 FBG values gt125 mg/dl on different days OR
  RBG gt200mg/dl
• A1c gt6.4 is diagnostic of DM
• Up to 50 of beta cells are non-functional at
  diagnosis of Type 2 DM
• Screen if overweight and over 45

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Diabetes and Obesity
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Obesity Rates in US
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Insulin Resistance

• A supply and demand problem
• Insulin is a metabolic hormone produced by the
  beta cells of the pancreas
• Blood glucose is a product of glycogen release
  from liver and muscles and food intake
• Insulin carries glucose out of the blood, unlocks
  fat and muscle cells, and allows glucose to enter
  cell and provide fuel

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Insulin Resistance

• Signs can be seen 10-15 years prior to diagnosis
  of DM
• Insulin is a fat storing hormone
• High levels of insulin required to overcome
  cellular insulin resistance cause overworked
  pancreas and lead to burnout
• Gut fat vs. butt fat, HTN, elevated lipids, fatty
  liver disease, PCOS, sleep apnea

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Type 2 Diabetes in Youth

• 30-50 at present, lt5 prevalence prior to 1994
• Most common in minority groups (94)
• Risk factors obesity, family history, girls
• Mean age 12-14 (range 4-19)
• Acanthosis nigricans common

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Type 2 Diabetes in Youth

• Screen at age 10 or onset of puberty if
  overweight PLUS 2 of the following
• Family history of DM
• High risk race
• Re-screen every 2 years
• Signs of insulin resistance
• Maternal history of DM or GDM

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Childhood Obesity
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Gestational Diabetes

• Occurs in 5-10 of pregnancies
• Similar pathophysiology of Type 2 DM
• Higher insulin resistance with pregnancy hormones
• Screen for GDM at 24-28 weeks
• Increased risk of Type 2 DM
• Suspect GDM with babies gt9 lbs

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Pre Diabetes

• Caused by insulin resistance
• FBG 110 124 mg/dl or RBG 141 199 mg/dl
• Will progress to Type 2 DM
• DPP 58 reduction in Type 2 with 7 weight loss
  and 30 min daily walking
• Diet and exercise used to treat
• Often include Metformin and home BG test

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Type 2 Diabetes Prevention

• DPP (Diabetes Prevention Program)
• Metformin group 31 reduction
• Lifestyle Intervention Group 58 reduction
• Extensive education, monthly visits
• 7 wt loss - low fat, low cal
• 150 min/wk of
• physical activity

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Healthy Eating
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Diet Therapy

• Individualized, one size does not fit all
• Encourage healthy eating, less fat, sugar and
  sodium more fiber
• Portion control
• Carbohydrate counting
• Exchanges not used often, older term
• Plate method
• Low glycemic diet

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Food Nutrients

• Carbohydrates 40-60 of daily kcal
• 100 of carbs convert to BG in 10 min to 2 hours
• Protein 15-25 of daily kcal minimal effect
  of BG, choose lean meats
• Fat 25-35 of daily kcal minimal effect of
  BG, choose low saturated fats

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Diet Therapy
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Carbohydrate Counting

• 1 portion/exchange of carb 15 grams total carb
• Carbs are sugar, natural or added, and starch
• Bread, grain, starchy vegies, fruit, milk, sweets
• Sugar Free is not Carb Free
• Need 130 grams carb/day for brain function

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Carbohydrate Counting

• Count carbs by measured portion, weighed amount,
  label reading or website data
• People with diabetes are given a personal
  Budget of carbs per meal and per snack
• Women - 30 - 45 grams/meal is common
• Men 45 60 grams/meal is common

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Food Label
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Plate Method
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Portion Sizes
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Physical Activity

• CDC guidelines for adults
• 150 min/wk of moderate intensity OR 75 min/wk of
  vigorous intensity with 2 days/wk strength
  training minimum
• For greater health benefit double these times
• Children 60 min/day with 2 days strength
  training

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Moderate Intensity

• Hard enough to raise heart rate and sweat but
  still be able to converse
• 5-6 on a scale of 1-10
• Walking 3-4 mph, mowing lawn, dancing, biking on
  flat surface 10 mph, swimming laps, doubles
  tennis,
• water aerobics,
• shooting baskets

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Vigorous Intensity

• Raises heart rate but only able to say single
  words
• 8-9 on a scale of 1-10
• 1 min vigorous 2 min moderate
• Walking gt4 mph, playing basketball, soccer,
  singles tennis, hiking, jogging, biking gt12 mph,
  cross country skiing, snowshoeing, swimming fast
  laps

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Strength Training

• Work all major muscle groups
• Do to the point that it is difficult to do
  another rep without help
• 1 set 8-12 reps
• Weight lifting, yoga, push ups,
• sit ups, heavy gardening,
• resistance bands

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SMBG BG Testing
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SMBG

• Testing frequency and times variable determined
  by doctor, patient, cost, control of DM
• Target BG levels variable
• FBG 80 110 mg/dl A
• 2 hour pp (after a meal) 100 -140 mg/dl
• Meter variance /- 10-15

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Diabetes Control

• Aim to follow plan 80 of time
• Food, stress illness raise BG and exercise,
  medication lower BG
• Small changes are better than none
• Balance is the key

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Oral Antidiabetic Agents
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Oral Meds

• Sulfonylurea stimulate pancreas
• to produce more insulin (Amaryl, Glucotrol,
  Glyburide)
• TZDs help cells accept insulin, decrease
  insulin resistance (Actos, Avandia)
• Biguanides keep liver from releasing excess
  glycogen (Metformin, Glucophage)

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Oral Meds

• Incretin mimetic (exenitide, injectable with
  food intake stimulates gut receptors (GLP1) to
  signal pancreatic insulin production
• Slows gastric emptying and releases satiety
  hormones resulting in weight loss
• Nausea occurs in 42 of people
• DPP4 inhibitor (sitagliptin, saxagliptin) makes
  signal last longer to pancreas to increase
  insulin production

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Insulin

• Basal Bolus patterns

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Insulin

• Basal insulin covers release of glycogen from
  liver and muscles
• Lantus, Levemir, Humulin N are basal insulins
• Bolus insulin covers BG spike with carb intake or
  lowers a high BG
• Humalog, Novolog, Apidra, Humulin R
• Mixed insulins Humulin 70/30, Novolog 70/30

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Insulin

• Insulin need is based on body weight
• Measured in units, given as a SQ injection
• Strength 100u/ml (most common), 500u/ml (Humulin
  R)
• Adjust bolus dose based on BG levels, carb
  intake, exercise, illness
• Basal rate is adjusted based on trends

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Acute Complications

• Hypoglycemia

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Treatment of Hypoglycemia

• Rule of 15 15 grams quick acting carb, wait
  15 minutes, BG should rise 15 mg/dl if not
  repeat 15 grams carb
• Follow by a snack of protein and carb within 30
  min
• 15 gram carb items 4 oz juice, reg pop, 4-5 hard
  candies, 3 glucose tabs, 1 Tbls sugar or honey
• Glucagon kit used only if unconscious

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Hyperglycemia

• Test urine ketones
• if on insulin

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Diabetic Ketoacidosis (DKA)

• Most likely when sick, missed insulin doses, new
  diagnosis type 1
• Severe insulin deficiency with excess
  counterregulatory hormones
• Fat lypolysis produces BG and ketones
• Ketones are an acid that lead to metobolic
  acidosis
• Kussmauls respirations, vomiting, changes in
  LOC, fruity odor

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DKA Treatment

• IV insulin 0.1u/kh/hour IV
• IV fluids to correct dehydration deficit 5-10L
• Electrolyte stabilization K, phosphate
• Insulin promotes cellular uptake causing drops in
  serum levels
• Clear ketones
• Correct acidosis

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Chronic Complications

• BG levels affect whole body
• Blood vessels, nerves through oxidative stress
• Eyes, kidneys, heart, feet, digestive tract,
  erectile dysfunction
• Best prevention is good BG control and regular
  medical follow-up

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DCCT and UKPDS

• DCCT 10 year study with Type 1 DM
• A1c lt7 resulted in 35 75 decrease in
  microvascular complications
• Retinopathy, nephropathy, neuropathy
• UKPDS 14 year study with Type 2 DM
• A1c 7 vs 7.9 resulted in 25 decrease in
  microvascular complications

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ADA Standards of Care
A1c Every 3-6 mos. lt6.5 7
Cholesterol Yearly lt200
HDL (good) Yearly gt45 men, gt55 women
LDL (bad) Yearly lt100 or lt70
Triglycerides Yearly lt150
Eye Exam Yearly Dilated
Foot Exam Yearly by PCP Daily by pt
Urine Microalbumin Yearly lt30
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A1C

• 3 month ave BG
• 1 35mg/dl

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Foot Care

• Dont go barefoot
• Inspect feet daily, top and bottom
• Wash, dry feet daily
• Wear supportive shoes, cotton socks
• Use nail clippers
• File calluses with pumice stone

• Dont use heating pad, corn or wart remover
• Dont wear tight shoes, socks
• Use lotion on feet, not between toes

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The Big Picture

• Self Diabetes Management requires daily care,
  education, and a good support team
• It is a lot of work, often frustrating, but the
  rewards are better quality of life today and
  tomorrow