Introduction to Diabetes Mellitus Presented by LMC Diabetes and Endocrinology

1. Introduction to Diabetes MellitusPresented by LMC Diabetes and Endocrinology

2. Objectives • Overview of Diabetes Mellitus (DM) • Complications • Management of Diabetes Mellitus • Patient Management

3. Overview of DM - What is Diabetes? Diabetes is a condition where your body does not produce or use insulin properly in the body, resulting in high blood sugars

4. Overview of DM - What is Diabetes? In a person without DM…… • Insulin, a hormone produced by the pancreas, is secreted in response to carbohydrate digestion • Insulin acts like a key - it allows sugar to enter into the body’s cells to create energy In a person with DM…. • The secretion and/or the process of insulin opening the cells to allow sugar in is not working properly  high blood sugars

5. Overview of DM - Types of Diabetes • Type 1 Diabetes - autoimmune disease where the pancreas does not produce insulin • Type 2 Diabetes – occurs when your body does not produce and/or use the insulin in the body properly • Gestational Diabetes-occurs during pregnancy • Pre-Diabetes – the beginning stages of type 2 diabetes

6. Type 1 Diabetes • Occurs in approx. 10% of people with DM • Formerly known as Juvenile Diabetes • Insulin therapy is initiated immediately

7. Type 2 Diabetes • Occurs in approximately 90% of people with Diabetes • Used to be known as “Adult Onset” but a growing number of young people are developing Type 2 Diabetes due to lifestyle factors • Management: healthy eating, exercise, medication and/or insulin injections • Progressive disease

8. Overview of DM – Risk Factors for Type 2 Diabetes • Age >40 • Being overweight • Having an “apple” shaped body • Family history (very strong) • Gestational diabetes or baby >9 lbs • Ethnicity (African, Asian, South Asian, Aboriginal descent)

9. Overview of DM – Symptoms on presentation Common symptoms : • Fatigue • Increased thirst • Increased urination • Unexplained weight loss • Blurred vision

10. Overview of DM - Diagnosis of Prediabetes* * Prediabetes = IFG, IGT or A1C 6.0 - 6.4%  high risk of developing T2DM

11. Overview of DM – Diagnosis? 2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose

12. Diabetes Complications Prolonged high blood sugars can affect: • Eyes - Retinopathy • Heart and cardiovascular system • Kidney - nephropathy • Nervous system - neuropathy • Sexual organs - erectile dysfunction BEST WAY TO REDUCE COMPLICATIONS IS WITH GLYCEMIC CONTROL

13. Complication Prevention (therapies that may be used) • Kidneys • Control Blood Pressure • ACE or ARB (i.e. Altace) • Cardiovascular disease • ECASA – 81 mg • ACE or ARB (i.e. Altace) • Cholesterol Lowering Medication • Foot Care • Patient should check feet daily, wear proper shoes and socks • Patient to see MD if a cut, blister or crack on the foot is not healing

14. Complication Prevention (therapies that may be used) Neuropathy – peripheral • 10-g monofilament or assessment of loss of sensitivity to vibration at the dorsum of the great toe • Anticonvulsants, antidepressants, topical nitrate spray Retinopathy • Annual screening with ophthalmologist • Fenofibrate may be added to a statin in some patients Erectile Dysfunction • A PDE5 inhibitor, if there are no contraindications

15. Monitoring/Preventing Complications:What are the ABC’s? • A= A1C (3 month blood sugar average) <7% An AIC <7% reduces the risk of patients developing complications of diabetes (type 1 &2), specifically, an AIC of < 7% showed in people with type 2 DM: • 76% reduction in eye disease • 50% reduction in kidney disease • 60% reduction in nerve disease • B= Blood Pressure <130/80 • C= LDL “Bad” Cholesterol <2.0 mmol/L

16. Management of DM - Blood Sugar Targets • FPG / pre meal : 4-7 mmol/L • 2 hours after eating: 5-10 mmol/L • If HbAIC not at target: 5-8 mmol/L

17. Management of DM - Medications • For a full review of pharmacological approaches, please review the 2013 CDA Clinical Practice Guidelines • Medications are decided based on the person’s: • Blood sugar level • Individual characteristics • Properties of the medication

19. Management of DM – Self Monitoring Blood Glucose (SMBG) Allows patients to: • Understand the effect of food, exercise, medication and stress • Assist in self management and empowering the patient • Keep on track with their blood sugar to reach target AIC of <7% • Provide physician and diabetes educator with information to adjust their therapy appropriately – can target pre meal and/or post meal blood sugars

20. Management of DM – How often to test? The more, the better Diet alone and/or Medication: • Individualize to patients’ situation • Difficult to assess patient if testing at the same time each day • Suggestion: test before and 2 hrs after a different meal each day Insulin Therapy: • 4-7 x /day for MDI • Before each insulin injection for safety • 2 hrs pc are helpful if the patient is willing to increase frequency of testing

21. Management of DM - Smart Testing • Smart testing empowers patients to analyze their values, not just record them • When the blood sugars are out of target empower the patient to ask why? • The patient can then self manage themselves to assist in meeting the target AIC!

22. Management of DM - Activity • Newly diagnosed patient comes in for glucometer teaching • Doctor suggested patient to test once/day • What do you suggest?

23. Management of DM - Activity Answer • Very subjective answer Possible answers: • First ask the patient what he/she feels comfortable with • Explain the benefit of testing blood sugars • Explain the use of a logbook/downloading the meter • Test before and after one meal/day – rotate the meal from day to day to get a clear picture of what is happening throughout the day without having to test 7 times/day

24. Management of DM -Hypoglycemia Mild to Moderate = blood sugar <4.0 mmol/LSevere = blood sugar < 2.8 mmol/L

25. Management of DM - Hypoglycemia • Causes of hypoglycemia include: • Increased physical activity • Not eating on time • Eating less than normal • Taking too much medication/insulin • The effects of drinking alcohol • Ask your patient to self-reflect: why did my blood sugars go low? – How can I prevent this in the future?

26. Management of DM – Hypoglycemia Treatment • Checkblood glucose right away. If no meter but symptoms are present, patient should treat! • If blood sugar is < 4 mmol/L patient to eat or drink15 g of a fast acting carbohydratesuch as: • 3 glucose tablets, 1/2 cup of juice , 3 packets of sugar dissolved in water, 6 Life Savers™ (chewed up) • Patient should wait 15 minutes, then checkblood sugar again. If blood sugar is still < 4mmol/L, treat again. • If the next meal is more than one hour a way patient should eata snack (15g of carbohydrates and a protein source ex: 1 oz of cheese and 7 soda crackers).

27. Management of DM - Nutrition • Nutrition therapy can reduce AIC by 1.0 to 2.0% and may be even more beneficial when combined with other aspects of diabetes care • Weight loss and exercise increases insulin sensitivity • Patients should aim for a BMI of 18.5-24.9 and/or a 5-10% weight loss of current weight • Patients should aim for a waist circumference of <102 cm for men and < 80 cm for women • Types and portions of food can assist to control blood sugars

28. Management of DM – Healthy Living with Diabetes • Healthy living includes: • Regular Meals • Balanced Meals • Portion Control • Physical Activity

29. Management of DM - Regular Meals • 3 meals/day spaced 4-6 hours apart • Why? Skipped or delayed meals can cause low blood sugars (if on certain diabetes meds) or higher blood sugars (sugar is released by the liver with prolonged fasting). • If the next meal > 5 hours away– suggest a healthy snack to prevent overeating and to keep blood sugars balanced (snack:<100-150 calories, <3-5 g fat). breakfast breakfast vs. lunch lunch dinner dinner

30. Management of DM – How To Approach Food Canada’s Food Guide To Health Eating – The Food Groups: • Grains • Fruits and Vegetables • Meat and Alternatives • Dairy • (other) *Healthy Eating Goal: 3 out of the 4 food groups/meal *Problem: Doesn’t account for the carbohydrates

31. Management of DM – How To Approach Food • When managing diabetes with food, it is important to look at food in these food groups: • Carbs • Protein • Vegetables • Fat

32. Management of DM – Balance and Portion Control: Space on Your Plate vs.

33. Management of DM – What is a carb? Carbohydrates = Sugar/Glucose • Sources of Carbohydrates : • Grains and Starch (rice, legumes, bread, corn, potato, pasta, bread, chipati) • Fruit, fruit juice, and dried fruit • Milk and Yogurt • Sugars (syrup, pop, candy, baked goods) Are all carbs considered equal? No!

34. Management of DM –Fibre Fibre is a form of carbohydrates that cannot be digested Benefits: • Helps to slow down digestion of sugar • Helps to lower cholesterol • Increases satiety • Improves bowel function Sources: • whole grains, legumes, fruits and vegetables

35. Management of DM – Glycemic Index (GI) GI = scale that ranks carbohydrate according to their effect on blood glucose levels • High GI foods will raise blood sugars quickly - examples: white bread, fruit juice • Low GI foods are digested more slowly and sugar is released more gradually into the bloodstream. This is more desirable. For example: whole grain bread, legumes *** Higher fibre foods tend to be lower GI

36. What does a recommended portion of carbohydratelook like? • To assist with estimating portions: patients can compare their first to a 1 cup portion or a medium size fruit • Patients should aim for 1 to 1.5 fists of total carbs per meal

37. Management of DM - What is a protein? • Protein's main function is to build, maintain and repair the body's tissue, such as muscles, organs, skin and hair. • Protein does not raise blood sugars unless eaten in excess. • Sources: Meat, poultry, fish, eggs, cheese, nuts

38. What does a recommended portion of protein look like? The goal is 3 oz. (the size of the palm of your hand or a deck of cards) per meal

39. What does a recommended portion of vegetables look like? • Vegetables add bulk, fibre and important vitamins and minerals • Goals: to consume as much vegetables that is able to fit into two handfuls. • Sweeter vegetables to consider: carrots, peas, beets, squash, turnips - > 2 cups – count as a carb

40. Management of DM – What about fat? • Fat does not raise blood sugars unless eaten in excess. • Fat, specifically total fat, saturated fat, and trans fat will negatively affect blood cholesterol levels

41. What does a recommended portion of fatlook like?

42. Management of DMPortions Review Each meal aim for: • 1 – 1.5 fist of carb • 2 handfuls of vegetables • 1 palm of protein • 1 thumb of added fat • All should fit nicely on a balanced plate!

43. Management of DM –Summary of factors that slow down sugar absorption into the bloodstream • Low GI foods • Fibre • Protein • Fat • Appropriate portions of carbs

44. Management of DM - The importance of slowing down blood sugar absorption • Increases satiety • Reduces spike in blood sugar  less stress on the pancreas – can contribute to slowing down progression of diabetes • Food can becomes a better match to rapid acting insulin

45. Management of DM – Activity Breakfast example How could this breakfast be improved? • 2 slices whole wheat toast • 2 tsp butter • ½ cup orange juice

46. Management of DM – ActivityAnswer Breakfast example To Improve: 1. Use peanut butter instead of butter for protein peanut butter will slow down the absorption of the carbohydrate 2. Switch orange juice to an orange perhaps move orange to am snack to reduce total carb intake • 2 slices whole wheat toast • 2 tsp butter • ½ cup orange juice

47. Management of DM - Alcohol • If your patient doesn’t drink, they shouldn’t start! • Health Canada’s Recommendation for consumption: • 2 servings/ day max for men • 1 serving/day max for women • One serving = • 1.5 fl z of hard liquor • 5 fl oz. of wine • 12 fl oz of beer

48. Management of DM Alcohol – Issues to Consider… • Alcohol may cause hypoglycemia – may need patient to check blood sugars frequently and throughout the night to monitor • Alcohol should always be consumed on a full stomach • Alcohol raises triglyceride levels – limit/avoid if triglycerides are elevated

49. Management of DM -Benefits of Physical Activity • Improved blood sugars • Increased insulin sensitivity • Increased glucose uptake • Decreased risk of heart disease • Increased metabolism • Important for bone strength • Weight loss/maintenance • Improved sleep patterns • Increased energy • Etc…

50. Management of DM - Exercise Safe Patients should be encouraged to: • Discuss exercise with their physician prior to beginning an exercise routine - discuss having an ECG, if one has not been done recently • Measure blood glucose pre and post activity • Reduce medication/have a snack prior to exercise to avoid hypoglycemia, if necessary • Carry ID, Medic Alert bracelet and some form of simple carbs to treat a low blood sugar (if on orals or insulin) • Drink water • Check feet and wear proper shoes