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Diabetes 101

Diabetes 101 . Janet Renaldi, RN, CDE St Luke’s Magic Valley Diabetes Education Program. 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

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Diabetes 101

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  1. Diabetes 101 Janet Renaldi, RN, CDE St Luke’s Magic Valley Diabetes Education Program

  2. 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

  3. 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

  4. Types of Diabetes • Type 1 • Type 2 • Type 2 in youth • GDM (gestational) • Pre diabetes, Impaired glucose tolerance, Metabolic syndrome

  5. 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

  6. 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

  7. 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

  8. Sedentary lifestyle Family history Overweight Age Polycystic Ovary Disease High risk ethnic group Hypertension Cardiovascular Disease Triglycerides >250 HDL <40 Waist measurement >35 women, >40 men History of GDM or baby > 9 lbs Risk Factors for Diabetes

  9. Diagnosis of Type 2 • 2 FBG values >125 mg/dl on different days OR RBG >200mg/dl • A1c >6.4% 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

  10. Diabetes and Obesity

  11. Obesity Rates in US

  12. 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

  13. 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

  14. Type 2 Diabetes in Youth • 30-50% at present, <5% 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

  15. 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

  16. Childhood Obesity

  17. 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 >9 lbs

  18. 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

  19. 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

  20. Healthy Eating

  21. 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

  22. 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

  23. Diet Therapy

  24. 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

  25. 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

  26. Food Label

  27. Plate Method

  28. Portion Sizes

  29. 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

  30. 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

  31. 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 >4 mph, playing basketball, soccer, singles tennis, hiking, jogging, biking >12 mph, cross country skiing, snowshoeing, swimming fast laps

  32. 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

  33. SMBG – BG Testing

  34. 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%

  35. 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

  36. Oral Antidiabetic Agents

  37. Oral Meds • Sulfonylurea – stimulate pancreas to produce more insulin (Amaryl, Glucotrol, Glyburide) • TZD’s – help cells accept insulin, decrease insulin resistance (Actos, Avandia) • Biguanides – keep liver from releasing excess glycogen (Metformin, Glucophage)

  38. 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

  39. Insulin • Basal – Bolus patterns

  40. 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

  41. 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

  42. Acute Complications • Hypoglycemia

  43. 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

  44. Hyperglycemia • Test urine ketones if on insulin

  45. 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 • Kussmaul’s respirations, vomiting, changes in LOC, fruity odor

  46. 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

  47. 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

  48. DCCT and UKPDS • DCCT – 10 year study with Type 1 DM • A1c <7% 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

  49. ADA Standards of Care

  50. A1C • 3 month ave BG • 1% = 35mg/dl

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