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Chapter 8

Chapter 8. Diabetes Mellitus. Diabetes Mellitus (Latin for “Sweet Urine”). The more common form, type 2 diabetes, is now epidemic; more than 18 million Americans have diabetes, and another 41 million have prediabetes Uncontrolled diabetes leads to a variety of health complications

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Chapter 8

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  1. Chapter 8 Diabetes Mellitus

  2. Diabetes Mellitus (Latin for “Sweet Urine”) The more common form, type 2 diabetes, is now epidemic; more than 18 million Americans have diabetes, and another 41 million have prediabetes Uncontrolled diabetes leads to a variety of health complications Diagnosed with two FBG ≥126 mg/dL or any BG >200 mg/dL

  3. Type 1 Diabetes An autoimmune disease Peak age of onset is during adolescence Peak season of onset is winter Glutamic acid decarboxylase (GAD) antibodies destroy the islet or beta cells of the pancreas; this leads to total destruction of insulin production Persons with type 1 diabetes are usually thin and ketone-prone Most commonly found in persons with Northern European heritage

  4. Type 1 Diabetes: Dependent on Insulin for Life Type 1 diabetes ALWAYS requires insulin (even without food intake or nausea and vomiting) to avoid diabetic ketoacidosis (DKA) ONLY EXCEPTION: “honeymoon period” that may happen shortly after diagnosis and last until complete destruction of beta cell’s ability to produce insulin occurs DKA occurs when glucose cannot be used for energy needs because of insufficient insulin; excess breakdown of body fat results in buildup of ketones with lowered pH of blood DKA is an emergency situation; hospitalization is required for IV fluids, treatment of acidosis, and glucose and/or insulin provision

  5. Type 2 Diabetes 90% to 95% of all cases of diabetes mellitus are type 2 Usually related to insulin resistance; hyperinsulinemia is usually found (to compensate for the insulin resistance) Strongly genetic; most often found in persons with ancestors who lived near the equator—Spanish, African, Native American, Asian, Pacific Islander—but it occurs around the world The “thrifty gene” helps explain etiology Genetic predisposition requires environmental factors to result in type 2 diabetes (especially low physical activity with low-fiber intake and obesity)

  6. Gestational Diabetes Occurs during pregnancy after placenta is formed and is caused by placental hormones working in opposition to insulin There is no increased risk in birth defects, because fetal organs are formed before the placenta Similar to type 2 diabetes and family history of type 2 diabetes usually evident Possible role of zinc and selenium deficiency

  7. Hormones Involved in BG Management Insulin: lowers BG by allowing cell uptake Counterregulatory hormones: “stress hormones”: raise BG levels by allowing stored glycogen to be released as BG Glucagon: first hormone released to raise BG; in excess can cause nausea and vomiting (as in injectable form to treat severe low BG with unconsciousness Epinephrine, or adrenalin: causes increased heart rate, physical tremors Cortisol: causes warm, sweaty feeling Growth hormone

  8. Possible Risk Factors for Diabetes Type 1 Uncontrolled celiac disease Vitamin D deficiency Type 2 Excess weight Physical inactivity Low-fiber intake, processed foods High levels of saturated and trans fats, red meat Either no or excess alcohol intake High-glycemic index diet Arsenic toxicity

  9. Signs and Symptoms of Diabetes Polyphagia (excess hunger); may also have symptoms of hypoglycemia Skin disorders, such as darkened patches of skin or skin tags Increased frequency of infections Delayed wound healing Unexplained weakness and fatigue Polyuria (excess urination; occurs when BG >180 mg/dL “the renal threshold”) Polydipsia (excess thirst) due to polyuria Weight loss with BG >180 mg/dL as wasted energy with polyuria (sudden weight loss likely type 1) Blurred vision

  10. Common Symptoms of Hypoglycemia

  11. Hypoglycemia Unawareness Most likely to occur with young children, the elderly, persons who have frequent episodes of hypoglycemia, and those who take beta-blocker medication Suspect hypoglycemia if there is a change in usual behavior, such as a person becoming irritable or very quiet or shows confusion or becomes weak or faints Fainting from hypoglycemia is most likely to occur with excess insulin injections; treat with glucagon injection if the person is unconscious/unresponsive

  12. Treatment for Insulin Reaction with Unconsciousness Keeping glucagon kit (syringe with saline and vial with glucagon tablet) on hand is advised for anyone using insulin; use if hypoglycemia results in unconscious state with inability to swallow A natural counterregulatory hormone that allows glycogen stores to be used for blood glucose needs; insulin use can overwhelm the body’s ability to raise BG from natural glucagon production After glucagon tablet is dissolved by injecting saline into vial, fill syringe with solution and inject; roll person on his or her side or stomach because of concerns of possible vomiting After consciousness regained, follow with oral intake of CHO (include protein or fat source if next meal is several hours away [e.g., during the night])

  13. Measures of Good Control The Diabetes Control and Complications Trial (DCCT) showed that normalization of blood glucose (<7.2% HgbA1c or <155 mg/dL average) helps prevent complications up to 75% Self-monitoring blood glucose (SMBG) Normal: always <140 (even after meals) Acceptable: maximum 180 mg/dL to prevent exceeding renal threshold and dehydration Persons with type 2 diabetes and HTN need to control both blood glucose and blood pressure

  14. A1c, the 3-Month Test With hyperglycemia, excess sugar attaches to protein throughout the body Hemoglobin lives for about 3 months; the amount of attached sugar provides an average blood glucose reading Hemoglobin A1c is now referred to simply as A1c Once the old hemoglobin dies off, if the BG becomes normal, there is no attachment of sugar to the protein in the hemoglobin and the next A1c will be a lower reading SMBG after meals is the best method to ensure the next A1c is within normal limits (WNL)

  15. Carbohydrate Counting (Developed with DCCT study; easier and more effective than traditional Exchange List system) With type 1, carbohydrates are balanced with short-acting insulin (usually 1 unit per 15 g carbohydrate) With type 2, carbohydrates per meal are limited to individual tolerance as noted with blood glucose monitoring; generally 30 to 50 g carbohydrate per meal are tolerated

  16. Carbohydrate Counting (continued) Gestational diabetes mellitus is treated as if it were type 2; needs bedtimecarbohydrate snack to prevent ketonuria in morning (prevent “starvation ketosis” with adequate CHO intake and <10 hours between meals)

  17. All Carbohydrates Can Fit The DCCT found that sugar and starch have identical effects on BG For a person with type 1 diabetes, increased insulin may be all that is needed; for a person with insulin resistance, CHO from desserts can replace other CHO sources: Example: 1 cupcake (1/2 cup) +/– 50 g CHO versus 1 cup potato (30 g CHO) and 1 cup milk(15 g CHO) or equivalent

  18. Other Nutritional Management Factors Fiber lowers insulin requirements Soluble fiber lowers lipids Lowering glycemic index of meals with fiber and monounsaturated fats is especially helpful for type 2 diabetes Increased water or other fluids needed if blood glucose is >180 mg/dL to prevent dehydration Cinnamon (1/5 to 1 heaping teaspoon reduces BG 20% to 30% and further lowers LDL-C and triglycerides (Khan et al., 2003; Anderson, 2008)

  19. Role of Exercise in Diabetes Management Type 2 and GDM Lowers insulin resistance Promotes weight goals All types Promotes good circulation Helps use BG for energy needs with resulting lowered BG level* *Caution: decreased insulin dose may be needed to prevent hypoglycemia due to increased physical activity or exercise; BG will rise with exercise if there is inadequate insulin; exercise should be delayed if BG >240 if there are ketones

  20. Oral Hypoglycemic Agents for Type 2 Diabetes Sulfonylureas—first form of pills used; cause the pancreas to release insulin and can cause hypoglycemia needing Tx (newer forms less likely to cause severe hypoglycemia: Glucotrol™, glyburide, Amaryl™) Meglitinides—work similarly to sulfonylureas by increasing insulin release but do so in response to the meal-related BG rise (e.g., Prandin™) Biguanides—insulin sensitizer: Metformin™ with long track-record of safety; does not cause hypoglycemia Thiazolidinediones—insulin sensitizers; have been implicated in weight gain and edema (Avandia™, Actos™)

  21. Insulin Types and Delivery Long-acting (effect lasts 12 to 24 hours): Hx NPH/Lente or “cloudy” insulin with “peak action” of variable time (4 to 6 hours +/–) increasingly being replaced with peakless long-acting “clear” insulin glargine (e.g., Lantus™) to lower risk of hypoglycemia Lantus daily dose based on FBG in low 100s; titrate dose up or down ≥10% every 2 to 3 days until BG goal is achieved; will not cause hypoglycemia if dose is correct, even if there is no food intake

  22. Short-Acting Insulin Regular “R” insulin (effect lasts 4 to 8 hours) must be taken 30 minutes before meals for best results; remains insulin of choice for individuals with delayed gastric emptying (gastroparesis) Lispro insulin (Humalog™/NovoLog™) works within 5 minutes of injection and has shorter duration of action than “R” insulin; decreased risk of hypoglycemia and easier to adjust based on insulin-to-CHO ratio; may be given directly after meals if meal intake is not predictable, such as with children or restaurant meals

  23. Insulin Management Alcohol should be consumed only in moderation with food intake; alcohol increases both insulin sensitivity and risk of hypoglycemia 3:00 AM BG testing: advised weekly, but especially if FBG is variable (rule out dawn phenomenon versus Somogyi effect) or habits are altered (increase in physical activity or exercise, alcohol intake, or both) because of increased risk of nighttime hypoglycemia

  24. Insulin Management(continued) 1800 Rule: TOTAL units of insulin per 24 hours divided into the number 1800 predicts “point” drop in BG for each additional unit of short-acting insulin given; called the sensitivity factor or correction factor and used to correct hyperglycemia (use the number 1500 if “R” insulin is used) A person with type 2 diabetes may use insulin if thin (because of low insulin production), or because own “army of insulin” is not adequate (owing to insulin resistance)

  25. Psychologic Needs Related to Diabetes Management Children with diabetes face normal adolescent adjustments, compounded with demands of diabetes management May lead to family dysfunction May lead to poor diabetes management Excellent communication skills required by health care professionals to support healthy relationship of food and health and family mealtime functioning

  26. Uncontrolled Diabetes Leads to Complications Unconsciousness from insulin reaction Cardiovascular disease Renal disease Eye disease, retinopathy Nerve disease, neuropathy Peripheral with potential loss of limbs Autonomic with gastroparesis, orthostatic HTN, or inability to increase heart rate with exercise Periodontal disease

  27. In the Future Normalized BG levels associated with greatly reduced levels of complications New technology helping to control BG within normal: Continuous BG monitoring ability Artificial pancreas with “talking” by continuous BG monitoring system to insulin pump Beta cell transplants Newer medications and laboratory testing

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