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Diabetes: An Overview

Diabetes affects millions globally, with significant numbers remaining undiagnosed. Type 1 diabetes, often diagnosed in youth, results from autoimmune destruction of insulin-producing cells, while Type 2 diabetes, accounting for 90% of cases, is often linked to obesity and insulin resistance. Gestational diabetes complicates pregnancies and increases future diabetes risk. Diagnosis involves blood sugar testing, and management focuses on lifestyle changes, medication, and monitoring. Awareness and education are crucial in combating this prevalent condition.

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Diabetes: An Overview

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  1. Diabetes: An Overview Christine Rubie MS, RD, LD

  2. Facts and Figures • Currently affects 18.2 million people • 5.2 million are undiagnosed • 1.3 million new cases per year • At the current rate, 1 out of every 3 children born in the year 2010 will get DM in their lifetime

  3. Classifications • Type 1 • Previously juvenile-onset DM • Most cases diagnosed before 30 years of age • Autoimmune • Beta cell destruction with resulting absolute deficiency of insulin • ~10% of DM cases • Symptoms: significant weight loss, polyuria, polydipsia

  4. Type 1 • Risk in general population: 1:400 to 1:1000 • Combination of genes for disease susceptibility and disease resistance • 40% of caucasians express the genes, less than 1% develop type 1 DM • 50% discordance rate between identical twins

  5. Type 1 • A trigger is necessary for gene expression • Immunological attack on beta cells and insulin • Hyperglycemia and symptoms develop after >90% destruction of the secretory capacity of the beta cell

  6. Type 1 • “Honeymoon Period” • Noninsulin dependancy • Maintains normal glycemia • Continued beta cell destruction • Insulin required in 3-12 months

  7. Type 2 diabetes • 90% of DM cases • 30-50% of childhood-onset diabetes • 50% of men and 70% of women are obese at diagnosis • Insulin resistance • Endogenous insulin may be normal, increased,or decreased • Frequently asymptomatic at diagnosis

  8. Type 2 • 30% remain undiagnosed • Microvascular complications exist in ~20% at time of diagnosis • May be present 6.5 years at time of diagnosis • Pima Indians have a 50% prevalence rate

  9. Type 2 • Specific defects • Beta cell dysfunction resulting in insulin deficiency • Insulin receptor abnormalities • Postreceptor defects • Insulin resistance

  10. Type 2 • 50% reduction in beta cell mass • Abnormal beta cell recognition of glucose • Beta cells chronically exposed to hyperglycemia become less efficient in their response

  11. Type 2 • Insulin resistance • BG is maintained by hepatic glucose production when fasting • Insulin suppresses hepatic glucose • Type 2: decrease in sensitivity and response • Type 2: persistant hepatic glucose production

  12. DM Diagnosis • Prediabetes • Fasting: 110-125 mg/dL • Random: 140-199 mg/dL • Diabetes • Fasting: >126 • Random: >200 • Confirmed with a second lab test and/or symptoms

  13. Gestational Diabetes • Affects 2-14% of pregnancies • Glucose intolerance that develops or is first discovered during pregnancy • Diagnostic classification changes after pregnancy • Increased future risk for type 2 DM • 50%-80% within 1 decade

  14. GDM • Pregnancy is an insulin resistant state • Resistance is progressive and is related to circulating hormones (human placental lactogen, prolactin, estrogen, and cortisol) • Parallel to fetal and placental growth

  15. GDM • Risk Factors • Marked obesity • History of GDM • Strong family history of DM • Glycosuria • Ethnic group of high prevalence • Hispanic, African American, Mexican, Native American, South or East Asian, Pacific Islands

  16. GDM • Screening • High risk: as early as possible • Average risk: 24-28 weeks gestation • Diagnosis • 1 hour 50g load: >140, 3 hour OGTT is scheduled • 3 hour 100g load: 2 or more BG’s meet or exceed, GDM is diagnosed • Values: Fasting-95 mg/dL, 1 hour-180 mg/dL, 2 hour-155 mg/dL, 3 hour-140 mg/dL

  17. GDM • Fetal risks • First trimester: congenital malformations • Increased endocrine system workload • Macrosomia (<9 pounds) • Shoulder dystocia and traumatic birth • Hyperglycemia at birth

  18. GDM BG Goals • Test 4 times daily • Fasting, 1 hour postprandial • Fasting: <90 • 1 hour pp: <130

  19. DM Risk Factors • Genetics • Age (>45 years) • Overweight/Obesity • Physical Inactivity • Ethnicity • Prior GDM or babies over 9#

  20. Blood Sugar Testing • Varying times per day • 1-7 times • BG goals: • Fasting 80-120 • Preprandial: <110 • 2 hours postprandial: <140

  21. DM Management • Dietary • Carbohydrate control • Individualized recommendations • No standardized menus • Total carbohydrates- NOT sugar • Use of alternative sweeteners • NO SUGARY DRINKS!!!!!!!!!!!!!!!

  22. DM Management • Exercise • Improved BG control with weight loss of 10% • 30 minutes/day as many days as possible • Doesn’t have to be consecutive

  23. DM Management • Oral Medications • Sulfonylureas, Meglitinides, Biguanides, Thiazolidinediones (TZD’s), Alpha-Glucosidase Inhibitors, Amylin Agonists • Secretagogues, sensitizers, suppress hepatic glucose production, delay glucose absorption • Insulin • Rapid-acting to long-acting

  24. Oral Medications • Sulfonylureas • Glyburide, Glipizide (Glucotrol), Glimepiride (Amaryl) • Increase insulin release from the pancreas • Can cause hypoglycemia • BG < 70

  25. Oral Medication • Meglitinides • Repaglinide (Prandin) and Nateglinide (Starlix) • Increases insulin release but the effect is glucose-dependant and diminishes at low blood glucose concentrations • Can cause hypoglycemia

  26. Oral Medications • Biguanides • Metformin (Glucophage), Glucovance (Glyburide/Metformin), Metaglip (Glipizide/Metformin), Avandamet ( Metformin/ Rosiglitazone) • Reduce hepatic glucose production and decrease insulin resistance • Not a hypoglycemic agent

  27. Oral Medications • Thiazolidinediones (TZD’s) • Pioglitazone (Actos), Rosiglitazone (Avandia) • Decrease insulin resistance • Not a hypoglycemic agent

  28. Oral Medications • Alpha-Glucosidase Inhibitors • Acarbose (Precose) and Miglitol (Glyset) • Inhibit alpha-glucosidase enzymes in the small intestine and pancreatic alpha-amylase • Reduces the rate of starch digestion and subsequent glucose absorption

  29. Injectable Medications • Symlin and Byetta • Synthetic Amylin: hormone secreted by the pancreatic cells in response to hyperglycemia • Inhibits gastric emptying and suppresses glucagon secretion • Adjunctive therapy

  30. Insulin • Basal vs. bolus • Variation in peak time and duration • Vial and syringe vs. insulin pens • Pump therapy

  31. Insulin guidelines • Absorbed most readily in the abdomen, followed by the arms, thighs, and buttocks • Best injected at room temperature • Keep backups in the refrigerator • Vials last ~1 month at room temperature, pens last ~2 weeks

  32. Carbohydrate Counting • 1500 Rule • Weight in kilograms • Wt (kg) X 0.6 = TDD (total daily dose) • .6 (Type 1) – 1.0 (Type 2) • 1500/ TDD= BG1 (How much 1 unit of insulin drops the BG) • BG1 X .33 = How many grams of carbohydrate is equal to 1 unit of insulin

  33. DM Emotions • Anger • Fear • Depression • Denial • Acceptance

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