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Diabetes

Diabetes. Celia Levesque RN, MSN, CNS-BC, CDE, BC-ADM. Diagnostic for diabetes. FBG > 126, PP > 140 FBG 100-126, PP 140-199 FBG 90-100, PP 100-140. Diagnosis. Diabetes Management Goals. Prevent or delay complication Minimize the risk of hypoglycemia

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Diabetes

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  1. Diabetes Celia Levesque RN, MSN, CNS-BC, CDE, BC-ADM

  2. Diagnostic for diabetes • FBG > 126, PP > 140 • FBG 100-126, PP 140-199 • FBG 90-100, PP 100-140

  3. Diagnosis

  4. Diabetes Management Goals • Prevent or delay complication • Minimize the risk of hypoglycemia • Maintain a healthy weight (BMI < 25) • Improve quality of life AACE. Medical Guidelines for the Management of Diabetes Mellitus. Endocrine Paractice 2002;8 (Suppl 1): 41-82.

  5. The HbA1c goal of ACE • < 7% • < 6% • < 6.5%

  6. DCCT ResultsHbA1c and Relative Risk of Diabetic Complications 15 13 ( “X” times more likely) 11 Eye disease 9 Relative Risk of Complications Kidney disease 7 Nerve damage 5 3 1 6 7 8 9 10 11 12 6.5* HbA1c Adapted from DCCT Research Group: N England Journal of Medicine. 1993;329:977-986 *Endocrine Practice 2002, 8 (supp 1), pg. 7. AACE recommends less than or equal to 6.5 HbA1c.

  7. Pancreas • Digestive enzymes (acini) • Hormones (Islets of Langerhans) • Insulin • Glucagon • Amylin • Somatostatin • Pancreatic polypeptide

  8. Basal: continuous small amount to compensate for liver glucose Bolus: surge for food 1st phase: rapid rise in serum insulin levels inhibits glucagon release and therefore liver glucose release 2nd phase: to cover the food ingested Normal Insulin Secretion

  9. J.L. before insulin Age 3 Weight 15 lbs. December 15, 1922

  10. Type 1 • Genetic link • HLA types DR3 or DR4 increases risk • HLA-DR2 decreases risk • Environmental factors • Most factors unknown. • Viral infection such as enterovirus, rubella • Nutritional factors such as cow's milk in infancy • Autoimmune attack • Auto-antibodies against islet cells (ICA) • Insulin (IAA) • Glutamic acid decarboxylase (GAD): a protein found in islet cells

  11. Dr. Frederick Grant Banting (1891-1941 and Medical student Charles Herbert Best 1899 - 1978) discovered insulin. Margorie was the first diabetic dog to receive insulin.

  12. J.L. after insulin. Feb 15, 1923 Weight 29 lbs

  13. Before and after pictures of a 1922 patient of Dr. H. Geyelin.

  14. T2DM • 1 out of 3 born in 2000 will develop T2DM • 1 out of 2 Mexican-Americans born in 2000 will develop T2 DM

  15. Obesity in Children • Prevalence in US: 17.1% • Females: 16% (up from 13.8% in 1999) • Males: 18.2% (up from 14% in 1999)

  16. Type 2 DM • Heterogeneous disorder • Variable plasma insulin levels • Hyperglycemia • Peripheral insulin resistance • Assoc with increased cardiovascular risk

  17. Risk of T2DM • Family hx of T2DM • Obesity • Lack of exercise • Exposure to hyperglycemia in utero

  18. Features of Insulin Resistance • Obesity • Hyperlipidemia • Hypertension • Acanthosis Nigricans • Sleep Apnea

  19. The primary problem early in the disease process of T2DM is: • Insulin deficiency • Insulin resistance • Increased central adiposity • Heart disease

  20. Highest risk for DKA • Type 1 diabetes • Type 2 diabetes • Steroid induced diabetes

  21. “… Doctor, I have a Billy Roberts on line two who wants to know how much insulin he needs to take to cover 6 malt balls… 3 chocolate bunnies… 11 marshmallow eggs… oh.. and a whole handful of gummi worms…”

  22. Goal of Meal Planning • To provide adequate energy, protein, essential fats, minerals, trace elements and vitamins for growth and development • Weight management • Stable blood glucose values • Helps reduce need for meds in T2DM • Should eat the same food as recommended for the general population.

  23. Nutrition • Variety of food • Plenty of bread, cereals, vegies & fruit • Limit sucrose to 10-35% of total energy intake • Low fat diet for older children • Watch sodium content • Encourage breast-feeding of babies, at least until six months of age

  24. Nutrition Assessment • Diet history • Anthropometric measurements • Physical activity • Medications • Metabolic Control

  25. Nutrients • Carbohydrates • Proteins • Fats • Vitamins • Minerals • Fiber • Water

  26. Carbohydrate • 15 grams equals 1 choice or 1 exchange • Food groups that have carbohydrate • Starch • Fruit • Milk • Vegetable

  27. Starches (15 grams per serving) • ½ cup potato (white or sweet) • ½ cup cooked cereal or grits • 1 piece of bread • ½ hamburger bun • ½ hot dog bun • 1 small roll • 1/3 cup pasta • 1/3 cup starch beans

  28. Fruit (15 grams per serving) • 1 small apple • 1 small orange • 15 grapes • ½ banana • 1 ¼ cup strawberries • 1 ¼ cup watermelon • 1 cup cantaloupe cubes • ½ cup fruit cocktail

  29. Milk (15 grams per serving) • 1 cup milk • 1 cup unsweetened yogurt • Fat free milk/yogurt best • 1 cup whole milk has 1-2 fat exchanges

  30. 1 serving equals 5 grams of carbohydrate Free food when eating 1 or 2 servings Serving size is ½ cup cooked or 1 cup raw Don’t count lettuce and tomato on sandwiches Non-starch vegetables

  31. Carrots Green beans Asparagus Broccoli Tomatoes Cucumbers Cauliflower Bell pepper Non-starchy vegetables

  32. Meat (0 grams of carb) • Peanut butter • Chicken • Beef • Pork • Fish • Cheese • Eggs • Cottage cheese

  33. Fat (0 grams of carb) • Butter, margarine, lard • Cream cheese • Oil, Salad dressing (regular) • Nuts • Bacon • Sour cream • Avocado • Coconut

  34. Free Foods • Non-starchy vegetables • Diet beverages without carbohydrate • Diet jello • Broth • Protein • Fat

  35. Serving SizeGrams of total carbohydrates, multiplied by number of servings = total grams of carbs Total Carbohydrate Includes grams of sugar, sugar alcohol, starch, and dietary fiber. Adapted from Warshaw, H.S., Bolderman,K.M.; ADA, 2001 p 13

  36. MNT benefits DM by: • Helps to reverse long term complications • Improves the quality of life • Reduces HbA1c and decreases the need for medications • Increases life expectancy

  37. Gms of CHO (50%), pro (20%), fat (30%) in 1800 diet • 225, 90, 60 • 200, 80, 70 • 250. 75, 60 • 260, 75, 75

  38. An example of a starch serving… • 1 slice of bacon • 1 small apple • ½ cup green peas • 1 cup of fat free milk

  39. Injectable DM Medications

  40. Rapid Acting Insulin Pharmacodynamics: Medications: Lispro (Humalog) Aspart (Novolog) Glulisine (Apidra) • Onset: 15 min • Peak: 30-90 min • Duration: 3-5 h

  41. Short Acting Insulin Pharmacodynamics: Medications: Novolin R Humulin R How supplied Vial Pen • Onset: 60 min • Peak: 2-4 hours • Duration: 6-8 h

  42. Intermediate Acting Insulin Pharmacodynamics: Medications: Novolin N Humulin N NPH Penfill • Onset: 1-3 hrs • Peak: 6-12 hours • Duration: 12-24 h

  43. Long Acting Insulin Pharmacodynamics: Medications: Lantus glargine Levimer: detemir How supplied Vial Pen • Onset: 4 hrs • Peak: none • Duration: 16-24 h

  44. The best time to take Regular insulin for a meal is: • 30 to 60 m before the meal • At the start of the meal • Any time from 5 m before eating to 5 m after finishing

  45. Insulin Pens

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