diabetes fundamentals series
TRANSCRIPT
Diabetes Fundamentals Series
www.DiabetesEd.net
2021
Beverly Dyck Thomassian, RN, MPH, BC-ADM, CDEPresident, Diabetes Education Services
Welcome to Diabetes Fundamentals
� Series of 6 courses designed to provide you with the building blocks of diabetes care
� Within 24 hours of the live broadcast, we will have the recorded version posted on our DiabetesEd University (DEU).
� Updated PowerPoint handouts will have 2021 in Description
� Earn CE certificate by completing the survey, critical thinking tool and test in your DEU Student Center
� Please contact Bryanna with any questions! [email protected]
Course Objectives
1. Discuss factors contributing to
increased prevalence of diabetes
2. Describe pathophysiological defects
associated with the development of
diabetes mellitus.
3. Differentiate the different types:
prediabetes, Type 1, Type 2 and
GDM
4. Discuss new language guidelines
5. Describe the impact of insulin
resistance
Foundations of Care – Well Being
Diabetes Care and Education
� Healthy Eating
� Monitoring
� Being Active
� Problem Solving
� Taking Medications
� Reducing Risks
� Healthy Coping
Also known as the ADCES 7 Self-Care Behaviors
Improving Care & Promoting Health
� Start with person centered communication.� Incorporate ind preferences, literacy, life
experiences
� Treatment decisions timely, based on evidence and tailored to individual
� Align care with Chronic Care Model to ensure proactive practice and informed, activated patient.
� Assess social determinants of health: context, including food insecurity, housing stability, financial barriers and apply to treatment decisions.
CDC Announces
35% of
Americans will
have Diabetes
by 2050
Boyle, Thompson, Barker, Williamson
2010, Oct 22:8(1)29
www.pophealthmetrics.com
Diabetes in America 2021
� 30.3 million or > 9.4%
� 27% don’t know they have it
� 37% of US adults have pre diabetes (846mil)
Socioeconomics – Diabetes Diagnosis
� Prevalence varied
significantly by education
level, an indicator of SES
status
� 7.5% - More than high school
education
� 9.7% - High school education
� 13% - Less than high school
education
CDC 2020
Diabetes in America 2021 - CDC� 13% of adults have diabetes (34 mil)
� 21% of those don’t know they have diabetes
� 35% adults have pre diabetes (88 mil)
� 85% of those don’t know they have prediabetes
CDC 2020 Report www.DiabetesEd.net
Diagnosed Diabetes by Ethnic Group
� Highest prevalence among
� Indigenous people
� Mexican and Puerto Ricans
� Asian Indians and Filipinos
U.S. Weight - 68% experiencing overweight or BMI >30
� 34% BMI 25-29
� 34% BMI 30 +� 1/3 of all people with extra weight
don’t get diabetes
� We burn 100 cals less a day at work
� Overall, food costs ~ 10-15% of income
� Calorie Intake is on the rise
Now, let’s get to the Nitty Gritty
Poll Question 1� In the fasting state, hyperglycemia is
directly related to:
a. Increased hepatic glucose
production
b. Defective insulin stimulation of
target tissue glucose disposal
c. Decreased adipocyte lipolysis
d. Loss of pancreatic alpha-cell function
Hormones Effect on Glucose
Hormone
� Glucagon (pancreas)
� Stress hormones (kidney)
� Epinephrine (kidney)
� Insulin (pancreas)
� Amylin (pancreas)
� Gut hormones - incretins (GLP-1) released by L cells of intestinal mucosa, beta cell has receptors)
Effect
Signs of Diabetes
� Polyuria
� Polydipsia
� Polyphasia
� Weight loss
� Fatigue
� Skin and other
infections
� Blurry vision
Glycosuria, H2O losses
Dehydration
Fuel Depletion
Loss of body tissue, H2O
Poor energy utilization
Hyperglycemia increases
incidence of infection
Osmotic changes
PreDiabetes Matters
� 3.7 Prediabetes is associated with heightened
cardiovascular risk; therefore, screening for
and treatment of modifiable risk factors for
cardiovascular disease are suggested.
Standards of Medical Care in Diabetes - 2021. Diabetes Care 2021;44(Suppl. 1)
Poll Question 2
�Pre-diabetes is best defined as
a glucose of:
a. BG of 100-125 mg/dl
b. Any BG above 99 mg/dl
c. Fasting BG 126 -200 mg/dl
d. Fasting BG of 140 mg/dl or
more
Natural History of Diabetes
Healthy
FBG <100
Random <140
A1c <5.7%
Prediabetes
FBG 100-125
Random140- 199
A1c ~ 5.7- 6.4%
50% working pancreas
Diabetes
FBG 126 +
Random 200 +
A1c 6.5% or +
20% working pancreas
Development of type 2 diabetes happens over years or decades
Yes! NO
Poll Question 3
� Diabetes is defined as a random
glucose of
a. 126-199 mg/dl
b. 200 mg/dl or greater
c. 140-199 mg/dl
d. 140 mg/dl or greater
Diagnostic Criteria
� All test should be repeated in the absence of
unequivocal hyperglycemia
� If test abnormal, repeat same test to confirm
diagnosis on a different day
� If one test normal, the other abnormal, repeat
the abnormal test to determine status
� Medicare still using fasting as criteria for
reimbursement for education
A1c Test – To diagnose & eval
� Measures glycation of RBC’s over 2-3
months
� Weighted mean (50% preceding
month)
� Each 1% ~ 29mg/dl
� Accuracy: affected by some anemias,
hemoglobinopathies
� A measurement of glucose in fasting
and postprandial states
� African Americans may have false lows
Poll Question 4
� Each percentage of A1c = how
many mg/dl of blood glucose?
a. 33
b. 27
c. 17
d. 29
A1c and Estimated Avg Glucose (eAG)
A1c (%) eAG__
5 97 (76-120)
6 126 (100-152)
7 154 (123-185)
8 183 (147-217)
9 212 (170 -249)
10 240 (193-282)
11 269 (217-314)
12 298 (240-347)
eAG = 28.7 x A1c-46.7 ~ 29 pts per 1%Translating the A1c Assay Into eAG – ADAG Study
What Kind of Diabetes?
� AJ, a 12 year old female
admitted to the ICU with
a blood glucose of 476
mg/dl, pH of 7.1, anion
gap of 15.
� What further questions
and or testing is needed
to determine if she has
type 1 or type 2
diabetes?
Type 1 Diabetes
26
Diagnostic Criteria for Diabetes
Type 1 rising in Blacks and Asians
https://www.cdc.gov/diabetes/research/reports/children-diabetes-rates-rise.html
Baseline incidence rate per year. Type 2 diabetes (4.8%) type 1 (1.9%).Baseline incidence rate per year. Type 2 diabetes (4.8%) type 1 (1.9%).Baseline incidence rate per year. Type 2 diabetes (4.8%) type 1 (1.9%).Baseline incidence rate per year. Type 2 diabetes (4.8%) type 1 (1.9%).
Incidence of Type 1 in Youth
� General Pop 0.3%
� Sibling 4%
� Mother 2-3%
� Father 6-8%
� Rate doubling every 20 yrs
� Many trials underway to detect
and prevent (Trial Net)
Type 1 – 10% of all Diabetes
• Auto-immune pancreatic beta cells destruction
• Most commonly expressed at age 10 - 14
• Insulin sensitive (require 0.5 - 1.0 units/kg/day)
• Expression due to a combo of genes and
environment:
• Autoimmunity tends to run in families
• Exposure to virus or other environmental
factors
• Signs can include:
• Increased thirst and hunger
• Frequent urination or new bed-wetting at hs
• Unintended weight loss
• Fatigue and irritability
29
Diagnostic Criteria for Diabetes
How do we know someone has Type 1
vs Type 2?� Type 1
� Positive antibodies
� GAD
� ICA
� IAA and others
� Younger people develop quickly
� Older people take longer to develop
� Body wt and presentation
Autoantibodies Assoc w/ Type 1
Panel of autoantibodies –
� GAD65 - Glutamic acid decarboxylase –
� ICA - Islet Cell Cytoplasmic Autoantibodies
� IAA - Insulin Autoantibodies
What Does Type 1 Look Like?
Justice Sonia Sotomayor
Bret Michaels
Mary Tyler Moore
Nick Jonas
Poll Question 5
What factors would make you
suspect type 1 diabetes?
a. History of vitiligo
b. Presents with low HDL
cholesterol
c. Friend tells you she has been
eating "tons of sweets“
d. Unresponsive to statins
Initial Eval – Looking for Autoimmunity
� Type 1 - Autoimmune Conditions� Hashimoto Thyroiditis (hypo)
� Graves disease (hyper)
� Addison’s disease
� Celiac disease
� Vitiligo (loss of skin pigment)
� Autoimmune hepatitis, gastritis
� Myasthenia gravis (muscle weakness)
� Pernicious anemia (vita B-12 deficiency due to lack of due to lack of intrinsic factor in stomach)
� Dermatomyositis
� (distinctive skin rash, muscle weakness, and inflammatory myopathy)
Type 1 Summary� Autoimmune pancreatic destruction
� Need insulin replacement therapy
� Often first present in DKA
� At risk for other autoimmune diseases
� Eval coping strategies
Patti Labelle"divabetic”
“I have diabetes, it
doesn’t have me”
Path to Type 2 Diabetes
BMI Categories
With Underweight Healthy weight Experiencing overweight Experiencing obesity
Insulin Resistance is the Seed
American College of Endocrinology
Factors Associated with Insulin
Resistance
� Abdominal obesity� Sedentary lifestyle� Genetics / Ethnicity� Gestational Diabetes� Polycystic ovary syndrome� Acanthosis Nigricans� Obstructive Sleep Apnea� Cancer� Fatty liver disease
Acanthosis Nigricans
Acanthosis Nigricans (AN)
� Signals high insulin levels in bloodstream
� Patches of darkened skin over parts of body that bend or rub against each other� Neck, underarm, waistline, groin, knuckles, elbows,
toes
� Skin tags on neck and darkened areas around eyes, nose and cheeks.
� No cure, lesions regress with treatment of insulin resistance
Screening Tool
Pre Diabetes & Type 2- Screening
Guidelines (ADA Clinical Practice Guidelines)
1. Start screening all people at age 45 or anyone who is overweight (BMI ≥ 25, Asians BMI ≥ 23 ) with one or > additional risk factor:
� First-degree relative w/ diabetes
� Member of a high-risk ethnic population
� Habitual physical inactivity
� PreDiabetes
� History of heart disease
Diabetes 2 - Who is at Risk?(ADA Clinical Practice Guidelines)
Risk factors cont’d
� HTN - BP > 140/90
� HDL < 35 or triglycerides > 250
� history of Gestational Diabetes
Mellitus
� Polycystic ovary syndrome (PCOS)
� Other conditions assoc w/ insulin
resistance:
� Severe obesity, acanthosis nigricans
(AN)
Poll Question 6
� Frequent skin and yeast infections
in people with diabetes are:
a. A sign of poor hygiene
b. Due to poor diet
c. A sign of ongoing hyperglycemia
d. A result of high sugar intake
What is Type 2 Diabetes?
� Complex metabolic disorder ….
(Insulin resistance and deficiency)
with social, behavioral and environmental risk
factors unmasking the effects of genetic
susceptibility.
New Diagnosis? Call 800 – DIABETES to request “Getting Started Kit”www.Diabetes.org
Natural Progression of Type 2 Diabetes
-20 -10 0 10 20 30
Years of Diabetes
Relative β-Cell
Function
PlasmaGlucose
Insulin resistance
Insulin secretion
126 mg/dLFasting glucose
Postprandial glucose
Prior to diagnosis After diagnosis
Adapted from Bergenstal et al. 2000; International Diabetes Center.
Ominous Octet
Increased glucagon
secretion
Decreased
amylin, β-cell secretion
80% loss at dx
Increase
glucose
production
Increased
lipolysis
Decreased glucose
uptake
I
I
Decreased
satiation neuro-
transmission
Increased renal
glucose reabsorption
Decreased
Gut hormones
Life Study – Mrs. JonesMrs. Jones is 62 years old, with a BMI of 36 and
complains of feeling tired and urinating several times a night. She has an urinary tract infection. Her A1c is 8.3%, glucose 237.
She is hypertensive with a history of gestational diabetes. No ketones in urine.
� What are her risk factors and signs of diabetes?
� You find a few moments to teach and she asks you some questions.
Language of Diabetes Education
Old Way New Way
� Control diabetes
� Test BG
� Patient
� Normal BG
� Non-adherent,
compliant
� Refuse
� Manage
� Check
� Participant
� BG in target range
� Focus on what they
are accomplishing
� Decided, chose
Terminology matters in medical
communication about obesity
� For people with BMI >30, preferred terms
� “person with elevated BMI”.
� “person with obesity”
� “person with excess weight”
� For descriptions of BMI >40
� “class III obesity”
� “severe BMI” and
� “extreme BMI”
Pearl RL, et al. JAMA Surg. Sept2018; doi:10.1001/jamasurg.2018.2702
Let’s use language that (is)
� Imparts hope
� Neutral,
nonjudgmental
� Based on fact,
actions or biology
� Free from stigma
� Respectful, inclusive
� Fosters collaboration
between person and
provider
� Avoids shame and
blame
Mrs. Jones asks you
What Do You Say?
� What is diabetes?
� They say I am a diabetic because I am obese?
� How am I going to control this?
� What is a normal blood sugar?
� Do I have to test my blood sugars?
� My doctor told me to stay away from white foods. Is that true?
Mrs. Jones asks you
What Do You Say?
� You are wondering if your weight caused your diabetes?
� You can manage your diabetes and improve your health at the same time.
� For people without diabetes, fasting blood sugar is less than 100 and A1c is less than 5.7%
� Checking blood sugars can help you figure out if the plan in working.
Empowerment Defined
� “Helping people discover and develop
their inherent capacity to be
responsible for their own lives and
gain mastery over their diabetes”.
� Posits:
� Choices made by the person (not HCPs) have
greatest impact.
� PWD are in control of their self-management
� The consequences of self-management
decisions affect PWD most. It is their right and
responsibility to be the primary decision
makers.
Traditional vs Empowerment Based
Traditional Empowerment
� DM is a physical illness
� HCP is viewed as teacher responsible for outcomes
� Emotional issues are separate components
� Lack of goal attainment is viewed as failure
� Behavior change are externally
� DM is biopsychosocial
� PWD is viewed as problem solver /self manager
� Experiences are integral with clinical content
� Lack of goal attainment is a learning experience
� Behavior change is internally motivated
Diabetes is also associated with
� Fatty liver disease
� Obstructive sleep apnea
� Cancer; pancreas, liver,
breast
� Alzheimer’s
� Depression
Other Types of Diabetes
� Gestational
� Other specific types of diabetes
Other Causes of Hyperglycemia
� Steroids
� Agent Orange
� Tube feedings / TPN
� Transplant medications
� Cystic Fibrosis
Regardless of
cause, requires
treatment
� Insulin always
works
� Sign of
pancreatic
malfunction
Poll Question 7
� Which of the following is true about
gestational diabetes? A. GDM can be identified in the first
trimester.
B. Children of women w/ GDM are at
greater risk of type 1
C. The rates of GDM are decreasing
D. Women can decrease their risk of
getting GDM
Gestational DM ~ 7% of all Pregnancies
� GDM prevalence increased
� ∼10–100% during the past 20 yrs
� Native Americans, Asians,
Hispanics, African-American
women at highest risk
� Immediately after
pregnancy, 5% to 10% of
GDM diagnosed with type 2
diabetes
� Within 5 years, 50% chance of
developing DM in next 5 years.
Increasing Prevalence –
A public health perspective
� Body weight before and during pregnancy
influences risk of GDM and future diabetes
� Children born to women with GDM at greater
risk of diabetes
� Focus on prevention
Screen Pregnant Women
Before 13 weeks
� Screen for undiagnosed Type 2 at the first prenatal visit using standard risk factors.
� Women found to have diabetes at their initial prenatal visit treated as “Diabetes in Pregnancy”
� If normal, recheck at 24-28 weeks
Postpartum after GDM
� 50% risk of getting diabetes in 5 years
� Screen at 4-12 wks post partum (75 gm OGTT)
� Repeat at 3 yr intervals or signs of DM� Encourage Breast Feeding
� Decreases risk of diabetes in mom 50%
� Encourage weight control
� Encourage exercise
� Make sure connected with health care
� Lipid profile/ follow BP
� Preconception counseling
Key points
� At the center of
diabetes is someone
living with it
everyday.
� Focus on their
successes
� Coach and support
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