DIABETES

What is diabetes?

Metabolic disease resulting from inability of body to use or produce insulin High blood glucose Low cellular glucose/glycogen stores

Insulin Produced by Islet of Langerhans in the

pancreas Increases uptake of glucose in liver, muscle

and fat Stores glucose as glycogen in liver and

muscle

What is diabetes?

Type 1 Lack of insulin production Commonly found in children and adults of

normal weight Treatment

Daily insulin necessary

What is diabetes?

Type 1 Etiology

Previously no known etiology but recent research suggests viral infection may cause autoimmune destruction of insulin producing beta cells

Genetics

What is diabetes?

Type 2 Insulin not recognized by receptors

throughout body Can have decreased insulin production Commonly seen in overweight adults

Disease is encroaching on younger populations Treatment

Lifestyle modification Pills Insulin

What is diabetes?

Type 2 Etiology

Lifestyle Factors Obesity (55%) Hypertension Cholesterol Age Sedimentary Lifestyle

Genetics

Presentation

Hyperglycemia Extreme thirst Frequent urination Dry skin Hunger Blurred vision Drowsiness Decreased healing

Presentation

Hyperglycemia Causes:

Excess food intake Insufficient medication Illness/Stress Sedintary Lifestyle

Very high levels of sugar may lead to diabetic coma

Chronic hyperglycemia can lead to eye, kidney, nerve and vasculature damage

Presentation

Hyperglycemia Extreme thirst Frequent urination Dry skin Hunger Blurred vision Drowsiness Decreased healing

Diagnosis

Normal Pre-diabetes Diabetes

A1C 4-5.9% 6.0-6.4% >6.5%

Fasting Glucose <100mg/dL 100-125mg/dL >126mg/dL

Glucose Tolerance

<140mg/dL 140-199mg/dL >200mg/dL (1)

Both the fasting glucose and 75 g glucose tolerance test were suitable for diagnosing diabetes [2]

Both the fasting glucose and 75 g glucose tolerance test are suitable for diagnosing diabetes

Recommended to screen asymptomatic adults with BP greater than 135/80 mm Hg (treated or untreated)

Treatment

Lifestyle Changes Increase physical activity

Cholesterol BP Heart Function Weight Loss Insulin Sensitivity

Diet 45-60 grams of carbohydrates/meal <15 grams of carbohydrates/snack

Treatment

Insulin Treats Type 1 and Type 2 Types

“Meal” Insulin Long-Acting Insulin Insulin Mixes Vials or pins

Insulin Care Must be refrigerated Never freeze Discard vial 4 weeks after first use Pen expirations vary widely

Treatment- Oral

Metformin (Glucophage) Prevents release of stored sugars First option oral treatment Can cause weight loss Side Effects:

Upset stomach Diarrhea

Treatment- Oral

Sulfonylureas Increase insulin production in Type 2

patients Low blood sugar risk dependant on dose Use if patient not eligible for or intolerable

of MetforminBrand Name Generic

DiabetaMicronaseGlynase

glyburide

GlucotrolGlucotrol XL

glipizide

Amaryl glimepiride

Treatment- Oral

Glitazones (Avandia, Actos) Increase efficacy of insulin Side Effects:

Weight gain Swelling

6-12 before full benefit High Cost

Alpha-glucosidase Inhibtors Slow absorption of carbohydrates from gut

Treatment- Oral

Meglitinides (Prandin, Starlix) Increase insulin production

Short acting Used if reaction to sulfonylureas Take with meals Side Effects:

Hypoglycemia High Cost

Hypoglycemia

Shaking Tachycardia Diaphoresis Dizziness Anxiety

Hunger Impaired Vision Fatigue Headache Irritability

Frequent side effect of excess insulin, meglitinides, and sulfonylureas

Also caused by increased exercise or inadequate food inatke

Can result in insulin shock Symptoms:

Long Term Effects

Heart disease and stroke 2-4x increased risk 65% die from MI or stroke 33% have peripherial artery disease

Retinopathy Leading cause of new cases of blindness in

patients ages 20-74

Long Term Effects

Retinopathy Commonly latent until late stages of

disease requiring laser treatment Regular fundus exams needed Pathophysiology

Abnormal blood vessel permeability Ischemic vascular occlusion Neovascularization

Long Term Effects

Macular Edema Neovascularization

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Long Term Complications

Nephropathy Leading cause of kidney failure (44% in

2005) First sign is proteinuria

Albumin excretion 30-300mg/day is diagnostic Increased likelihood of hypoglycemia from

medication Amputation

>60% of non-traumatic lower-limb amputations are due to diabetes

Long Term Complications

Neuropathy 60-70% have mild forms of nerve damage Can lead to foot complications like ulcers

and infection Inspection

Erythema, warmth, callus formation Bony deformities, join mobility, gait Pulse Loss of sensation

=Refer to podiatrist

Long Term Complications

Neuropathy Prophylaxis

- Avoid going barefoot, even in the home - Test water temperature before stepping into a

bath - Trim toenails to shape of the toe; remove

sharp edges with a nail file. Do not cut cuticles. - Wash and check feet daily - Shoes should be snug but not tight and

customized if feet are misshapen or have ulcers - Socks should fit and be changed daily

McCullogh, David. Foot Care in diabetes mellitus. Up to Date. May 2010.

Diabetes in North Carolina

In 2008 NC ranked 17th highest in the US for adult diabetes prevalence with 9.3% of the population diagnosed (643,000)

An estimated 1.25 million adults in NC have some type of hyperglycemia

The estimated cost of diabetes in NC was 5.3 billion in 2006

7th leading cause of death (2,150) and contributed to 6,226 deaths in 2007

References

2009 Diabetes Fact Sheet. NC Diabetes Prevention and Control Branch. http://www.ncdiabetes.org/factsFigures/index.asp

Diabetes Basics and Living with Diabetes. American Diabetes Association. http://www.diabetes.org/

US Preventive Services Task Force. Screening for Type 2 Diabetes Mellitus in Adults: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 2008;148:855-68. http://www.annals.org/cgi/reprint/148/11/846.pdf

References

Olivia Linthavong. What is Diabetes? Diabetes Maintenance and Prevention Program at the Open Door Clinic. 2009.

Olivia Linthavong. Carbohydrate Counting Handout. Diabetes Maintenance and Prevention Program at the Open Door Clinic. 2009.

Genuth, S, Alberti, KG, Bennett, P, et al. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003; 26:3160.

Drugs for Type 2 Diabetes. Treatment Guidelines from the Medical Letter 2008; 6(71). http://medlet-best.securesites.com.libproxy.lib.unc.edu/restrictedtg/t71.pdf