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Diabetes: An Overview

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

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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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