Diabetes in the school Diabetes in the school settingsetting

How sweet it is!How sweet it is!

LaureenLaureen

M Fleck, DNS, FNPM Fleck, DNS, FNP--BC. CDE, NCSNBC. CDE, NCSN

Diabetes: Type 1Diabetes: Type 1

Primarily due to pancreatic Primarily due to pancreatic beta cell destruction.beta cell destruction.Patients are prone toPatients are prone toketoacidosisketoacidosisInability to transport glucose Inability to transport glucose into cellsinto cellsInadequacy may result in Inadequacy may result in growth deficiency and/or growth deficiency and/or failure to thrive.failure to thrive.Insulin only treatmentInsulin only treatment

Insulin Insulin

Insulin is a hormone produced in the beta cells Insulin is a hormone produced in the beta cells of the islets ofof the islets of LangerhansLangerhans in the pancreas.in the pancreas.Insulin stimulates the the entry of amino acids Insulin stimulates the the entry of amino acids into cells, enhancing protein synthesis.into cells, enhancing protein synthesis.Insulin enhances fat storage, and stimulates the Insulin enhances fat storage, and stimulates the entry of glucose into cells ,creates energy and entry of glucose into cells ,creates energy and results in storage of glucose as glycogen in results in storage of glucose as glycogen in muscle and liver cells.muscle and liver cells.

Insulin RequirementsInsulin Requirements

The starting dose of insulin is usually between O.5 The starting dose of insulin is usually between O.5 –– 1.0 1.0 U/kg/day.U/kg/day.Adjustments are made slowly and incrementally, based Adjustments are made slowly and incrementally, based on blood sugar monitoring.on blood sugar monitoring.Daily habits are considered (activity level) and therefore Daily habits are considered (activity level) and therefore no typical dose can be determined.no typical dose can be determined.Divided doses; based on type of insulin and frequency Divided doses; based on type of insulin and frequency of dosing that is desired.of dosing that is desired.

Types of insulinTypes of insulin

Rapid acting:Rapid acting: humaloghumalog,, novalognovalog,, apridraapridraShort acting: regularShort acting: regularIntermediate acting: NPHIntermediate acting: NPHLong acting:Long acting: ultralenteultralenteLong acting:Long acting: lantuslantus,, levemirlevemirPrePre--mixed: 70/30 75/25mixed: 70/30 75/25Inhaled:Inhaled: ExuberaExubera ( no more!)( no more!)

Short Acting InsulinShort Acting Insulin

SolubleSolubleClearClearOnset 30 minutesOnset 30 minutesPeak 1 Peak 1 -- 3 hours3 hoursDuration up to 8 hoursDuration up to 8 hours

Intermediate Acting InsulinIntermediate Acting Insulin

Crystals in suspension Crystals in suspension (need re(need re--suspending)suspending)CloudyCloudyNPH onset 1NPH onset 1 11//22 hourshoursPeak 4 Peak 4 -- 12 hours12 hoursDuration up to 24 hoursDuration up to 24 hours

(Basal Bolus)(Basal Bolus)

6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5

Breakfast Lunch Evening Meal Sleep

Two Injections of 70/30 Mix Per Two Injections of 70/30 Mix Per DayDay

6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5

Breakfast Lunch Evening Meal Sleep

Insulin Pumps/ CSIIInsulin Pumps/ CSII

Type of pumpType of pumpInsulin Carbohydrate Insulin Carbohydrate RatioRatioTroubleshootingTroubleshootingStop infusionStop infusion

Storage of InsulinStorage of Insulin

Before useBefore use store in fridgestore in fridge

InIn--use vialsuse vials store in fridge store in fridge 3 months,3 months,

out of fridge out of fridge (4(4--6 weeks)6 weeks)

InIn--use pensuse pens out of fridge (4 weeks) out of fridge (4 weeks)

Diabetes: Type 2Diabetes: Type 2

Most persons are over 40 and obeseMost persons are over 40 and obeseOver 90% of people with diabetes have type2Over 90% of people with diabetes have type2The body doesnThe body doesn’’t use the insulin it makes (insulin t use the insulin it makes (insulin resistance) or the body doesnresistance) or the body doesn’’t make enough insulin to t make enough insulin to cover the carbohydrate load consumedcover the carbohydrate load consumedMeal planning, activity, and/or medication is used to Meal planning, activity, and/or medication is used to manage diseasemanage disease

Blood glucose monitoringBlood glucose monitoring

Vital in evaluation of Vital in evaluation of insulin/food ratioinsulin/food ratioMonitors are inexpensiveMonitors are inexpensiveFasting and 2 hours Fasting and 2 hours after the main meal, after the main meal, exercise and any exercise and any symptomatic conditionssymptomatic conditionsA1c quarterly: most A1c quarterly: most accurate indicatoraccurate indicator

NutritionNutrition

Balance of CHO (55%), PRO (10%), and Fat Balance of CHO (55%), PRO (10%), and Fat (30%)(30%)There is no There is no ““diabetic dietdiabetic diet””..Carbohydrate counting and effects on blood Carbohydrate counting and effects on blood sugar are significant.sugar are significant.Sugar can be counted!Sugar can be counted!Snacks are incorporated into meal plan.Snacks are incorporated into meal plan.

OralOral

HypoglycemicHypoglycemic

AgentsAgents

SulphonylureasSulphonylureas ((AmarylAmaryl,, GlucatrolGlucatrol))

PrandialPrandial Glucose Regulators (Glucose Regulators (StarlixStarlix,, PrandinPrandin))

BiguanidesBiguanides ((GlucophageGlucophage))

AlphaAlpha glucosidaseglucosidase inhibitors (inhibitors (PrecosePrecose))

ThiazolidinedionesThiazolidinediones ““GlitazonesGlitazones””ActosActos,, AvandiaAvandia

Combinations of aboveCombinations of above

MetforminMetformin

Improves insulin sensitivityImproves insulin sensitivityDecreases insulin resistanceDecreases insulin resistanceAllows weight lossAllows weight lossGI upset typical at onset of therapyGI upset typical at onset of therapy

Indications forIndications for

metforminmetformin

Obese type 2 patients inadequately controlled Obese type 2 patients inadequately controlled by nonby non--pharmacological therapy (meal pharmacological therapy (meal planning)planning)

Obese insulin resistant persons with PCOSObese insulin resistant persons with PCOS

Alone or in conjunction with otherAlone or in conjunction with other OHAsOHAs or or insulininsulin

MetforminMetformin ContraindicationsContraindications

Any impairment of renal functionAny impairment of renal functionImpaired hepatic functionImpaired hepatic functionAlcoholism Alcoholism –– acute or chronicacute or chronicConditions leading to tissue hypoxia (CHD, cardiac Conditions leading to tissue hypoxia (CHD, cardiac failure, PVD, COPD)failure, PVD, COPD)Pregnancy/breast feedingPregnancy/breast feedingMajor surgery/traumaMajor surgery/traumaSevere infectionSevere infectionIntravenous contrast mediaIntravenous contrast media

GlitazonesGlitazones TZDsTZDs

Exact mechanism unknown Exact mechanism unknown –– act within insulin act within insulin responsive cells to increase the activity of glucose responsive cells to increase the activity of glucose transport mechanismstransport mechanisms

Insulin sensitizer (muscle and adipose tissue)Insulin sensitizer (muscle and adipose tissue)

Inhibit hepaticInhibit hepatic gluconeogenesisgluconeogenesis

Do not stimulate insulin secretionDo not stimulate insulin secretion

DTP4 inhibitorDTP4 inhibitor

JanuviaJanuvia

PreventionPrevention

Can we impact the progression of the Can we impact the progression of the development of type 2 diabetes?development of type 2 diabetes?

Primary PreventionPrimary Prevention

EducationEducationHealth insurance:Health insurance:

Coverage for labs, test strips, monitoring and Coverage for labs, test strips, monitoring and counselingcounselingAccess to healthcareAccess to healthcareFollow up and evaluation of interventionsFollow up and evaluation of interventions

Obesity is a Risk FactorObesity is a Risk Factor

High blood pressureHigh blood pressureHigh cholesterolHigh cholesterolType 2 diabetesType 2 diabetesCoronary heart diseaseCoronary heart diseasePregnancyPregnancyStrokeStrokeAsthma, etc.Asthma, etc.

Obesity in FloridaObesity in Florida

In 2000, 54% of adults are overweight or obese : BMI In 2000, 54% of adults are overweight or obese : BMI > or equal to 25 kg/m2> or equal to 25 kg/m2

*of those, 19% are obese in excess of 30 *of those, 19% are obese in excess of 30 kg/m2kg/m2

Prevalence of obesity has increased 91% since 1986.Prevalence of obesity has increased 91% since 1986.25% of men and 30% of women are inactive25% of men and 30% of women are inactive

*Florida DOH census report 2000*Florida DOH census report 2000

National ObesityNational Obesity

59 million in the United States are considered to 59 million in the United States are considered to be obesebe obese

1/3 of adults1/3 of adults1/6 of children1/6 of children

300,000 deaths/year attributed to diabetes300,000 deaths/year attributed to diabetes1978 25% Americans overweight1978 25% Americans overweight1990 33% Americans overweight1990 33% Americans overweight2004 61% Americans overweight/obese2004 61% Americans overweight/obese

HypertensionHypertension

DyslipidemiaDyslipidemia

Type 2 diabetes Type 2 diabetes

Coronary artery diseaseCoronary artery disease

Congestive heart failure*Congestive heart failure*

StrokeStroke

Gallbladder diseaseGallbladder disease

Osteoarthritis Osteoarthritis

Sleep apnea and Sleep apnea and respiratory problemsrespiratory problems

Cancers of the breast, Cancers of the breast, colon, prostate, andcolon, prostate, andendometriumendometrium

Polycystic ovarian Polycystic ovarian syndromesyndrome††

Clinical Conditions Associated Clinical Conditions Associated With Obesity With Obesity

The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH/NHLBI/NAASO; October 2000. NIH publication No. 00-4084.*Kenchaiah S, et al. N Engl J Med. 2002;347:305-313.††GambineriGambineri A, et al.A, et al. IntInt J ObeseJ Obese Relat Metab DisordRelat Metab Disord.. 2002; 26:8832002; 26:883--896. 896.

Insulin Resistance SignsInsulin Resistance Signs

Acanthosis nigricansAcanthosis nigricans 701.2701.2High blood pressure 401.1High blood pressure 401.1DyslipidemiaDyslipidemia 272.4272.4Polycystic ovarian syndrome (PCOS) 256.4Polycystic ovarian syndrome (PCOS) 256.4HyperinsulinemiaHyperinsulinemia 251.1251.1

Metabolic SyndromeMetabolic Syndrome

IFG > 100mg/dlIFG > 100mg/dlTRI > 150mg/dlTRI > 150mg/dlHTN>130mm Hg/or >85mm HgHTN>130mm Hg/or >85mm HgAbdominal obesity 40Abdominal obesity 40”” men / 35men / 35””womenwomenHDL cholesterol < 40 mg/dlHDL cholesterol < 40 mg/dl

National diabetes education initiative 1/04National diabetes education initiative 1/04

Abdominal Obesity Abdominal Obesity MenMenWomenWomen

Blood PressureBlood Pressure

Fasting GlucoseFasting Glucose

TriglyceridesTriglycerides

HDLHDLMenMenWomenWomen

Waist CircumferenceWaist Circumference>40 in (102 cm)>40 in (102 cm)>35 in (88 cm)>35 in (88 cm)

≥≥130/130/≥≥85 mm Hg85 mm Hg

≥≥110 mg/110 mg/dLdL

≥≥150 mg/150 mg/dLdL

<40 mg/<40 mg/dLdL<50 mg/<50 mg/dLdL

Diagnostic ValuesDiagnostic Values

Third Report of the National Cholesterol Education Program Expert Panel. Executive Summary; May 2001. NIH publication No. 01-3670.

Metabolic Syndrome: Clinical Metabolic Syndrome: Clinical IdentificationIdentification

Subcutaneous Fat

Abdominal Muscle Layer Intra- abdominal Fat

Visceral Adiposity:Visceral Adiposity: The Critical Adipose DepotThe Critical Adipose Depot

UnderweightUnderweightNormalNormalOverweightOverweightObesityObesityClass IClass I

IIIIIII (severe obesity)III (severe obesity)

Weight CategoryWeight Category

Assessing Overweight and Obesity by BMI Assessing Overweight and Obesity by BMI

<18.5<18.518.518.5––24.924.925.025.0––29.929.9

≥≥303030.030.0––34.934.9 35.035.0––39.939.9

≥≥4040

BMI (BMI (kg/mkg/m22))

The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. NIH/NHLBI/NAASO. October 2000. NIH publication No. 00-4084.

Metabolic Syndrome: Metabolic Syndrome: NCEP/ATP III DefinitionNCEP/ATP III Definition

Presence of at least 3 of 5 Presence of at least 3 of 5 risk factors:risk factors:

Abdominal obesityAbdominal obesityElevated blood pressureElevated blood pressureElevated fasting glucose Elevated fasting glucose Elevated triglyceridesElevated triglyceridesLow HDLLow HDL--CC

Third Report of the National Cholesterol Education Program Expert Panel. Executive Summary; May 2001. NIH publication No. 01-3670.

Therapeutic Lifestyle Change: Therapeutic Lifestyle Change: Healthy Meal Planning,and Healthy Meal Planning,and

Physical ActivityPhysical Activity

Diet rich in fruits/vegetablesDiet rich in fruits/vegetables is is the mainstay of effective weight the mainstay of effective weight and health management and health management Meal replacementMeal replacement facilitates weight loss and weight maintenance facilitates weight loss and weight maintenance

2 shakes or meal bars2 shakes or meal bars2 frozen entrees2 frozen entrees

Physical activityPhysical activityis necessary to expend calories*is necessary to expend calories*

* A moderate amount of physical activity is roughly equivalent to physical activity that uses approximately 150 calories of energy per day, or 1,000 calories per week.

Clinical practice recommendationsClinical practice recommendations Update 2009Update 2009

Standards of Medical CareStandards of Medical Care

A section onA section on bariatricbariatric surgery has been addedsurgery has been addedTesting for type 2 diabetes should begin at age Testing for type 2 diabetes should begin at age 10 or younger if puberty before age 10 and 10 or younger if puberty before age 10 and repeated every 3 yrsrepeated every 3 yrsPersons with IGT or IFG should be referred Persons with IGT or IFG should be referred for ongoing support for weight loss of 5for ongoing support for weight loss of 5--10% 10% and increase in physical activity to 150 min/wkand increase in physical activity to 150 min/wk

Update 2009Update 2009 Clinical practice recommendationsClinical practice recommendations

Diabetes careDiabetes care

SMBG may be useful in conjunction with non SMBG may be useful in conjunction with non insulin therapies, nutrition therapy alone and insulin therapies, nutrition therapy alone and physical therapy managementphysical therapy managementCGM in conjunction with intensive insulin CGM in conjunction with intensive insulin regimes can be a useful tool in A1C in adults regimes can be a useful tool in A1C in adults >25 with type 1 DM>25 with type 1 DM

Update: clinical practice Update: clinical practice recommendations 2009recommendations 2009

In the school settingIn the school setting

Individual diabetes management plan should be developed by the Individual diabetes management plan should be developed by the parent/guardian and the studentparent/guardian and the student’’s personal diabetes health care teams personal diabetes health care team

All school staff members who have responsibility for a student wAll school staff members who have responsibility for a student w/diabetes /diabetes should receive training of the basics of the studentshould receive training of the basics of the student’’s needss needs

While the school nurse is the coordinator and primary provider oWhile the school nurse is the coordinator and primary provider of diabetes f diabetes care, a small # of school personnel should be trained in routinecare, a small # of school personnel should be trained in routine and and emergency diabetes procedures , and the appropriate response to emergency diabetes procedures , and the appropriate response to high and high and low blood sugars. The school personnel need not be health profeslow blood sugars. The school personnel need not be health professionalssionals

Students should have immediate access to diabetes supplies at alStudents should have immediate access to diabetes supplies at all timesl times

News we can use!News we can use!

Fish and OmegaFish and Omega--3 Fatty Acids3 Fatty AcidsPatients without documented Coronary Heart Disease Patients without documented Coronary Heart Disease (CHD)(CHD)……………………eat fish a least twice a week.eat fish a least twice a week.Patients with documented CHDPatients with documented CHD…………..consume about 1 g of ..consume about 1 g of EPA + DHA per day in capsule form.EPA + DHA per day in capsule form.Patients with high triglyceridesPatients with high triglycerides…………..2..2--4 g of EPA + DHA 4 g of EPA + DHA per day in capsule form. per day in capsule form. Taking high doses could cause excessive bleeding in some Taking high doses could cause excessive bleeding in some people.people.

American Heart Association 2006American Heart Association 2006

News we can use!News we can use!

AntihypertensivesAntihypertensives cut newcut new--onset diabetes by a onset diabetes by a third.third.

New ASCOT review: new diabetes onset was not an New ASCOT review: new diabetes onset was not an original outcome to be measured .original outcome to be measured .Antihypertensive treatment with an ACE inhibitor Antihypertensive treatment with an ACE inhibitor or calcium channel blocker limits newor calcium channel blocker limits new--onset diabetes onset diabetes (34% less likely), while treatment with a beta blocker (34% less likely), while treatment with a beta blocker oror thiazidethiazide diuretic helps to cause it (2005) and diuretic helps to cause it (2005) and increase the peripheral vascular resistanceincrease the peripheral vascular resistance

Family Practice News, October 2006Family Practice News, October 2006

Cultural ImpactCultural Impact

Asian AmericansAsian AmericansAfrican AmericansAfrican AmericansLatino AmericansLatino Americans

Diabetes prevalence is 2Diabetes prevalence is 2--6 times higher among Latino 6 times higher among Latino Americans, African Americans, Native Americans, and Asian Americans, African Americans, Native Americans, and Asian Americans than among white Americans.Americans than among white Americans.Diabetes complications rates are higher among patient from Diabetes complications rates are higher among patient from ethnic minorities, and the mortality rates are 2ethnic minorities, and the mortality rates are 2--5 times higher 5 times higher than rates among white patients.than rates among white patients.

Journal of Family Practice , September 2007Journal of Family Practice , September 2007

Cultural ObstaclesCultural Obstacles

Barriers include patientBarriers include patient’’s and providers and provider’’s cultural s cultural beliefs and misalignment between the American beliefs and misalignment between the American health care system and ethnic healthcare health care system and ethnic healthcare assumptions.assumptions.American approach to treating medical American approach to treating medical conditions combined with the lack of health conditions combined with the lack of health insurance for many individuals, contributes to insurance for many individuals, contributes to the disparities.the disparities.

External influencesExternal influences

Out of pocket expenses and high treatment Out of pocket expenses and high treatment costs;costs;

Glucose monitors and suppliesGlucose monitors and suppliesPerceived cost of Perceived cost of ““diabetic dietdiabetic diet””Cost of medicationsCost of medicationsCost of time influence to treatment planCost of time influence to treatment plan

Barriers to HealthcareBarriers to Healthcare

Lack of reliable transportationLack of reliable transportationUnpaid time off from workUnpaid time off from workNeed for child careNeed for child careCost of medication and nutritious foodsCost of medication and nutritious foodsDifficulty finding affordable and safe places to Difficulty finding affordable and safe places to exerciseexerciseAttitudes of fatalismAttitudes of fatalism……………….destiny.destiny

YouthYouth

SummarySummary

Modest weight loss of 5%Modest weight loss of 5%--10% improves overall 10% improves overall patient health and metabolic syndrome risk factors.patient health and metabolic syndrome risk factors.Treating obesity, which is a serious chronic disease, Treating obesity, which is a serious chronic disease, can improve metabolic syndrome risk factors and may can improve metabolic syndrome risk factors and may decrease the risk of CVD and type 2 diabetes.decrease the risk of CVD and type 2 diabetes.Nurses must accept their role as agents of change to Nurses must accept their role as agents of change to help motivate their obese patients to effectively lose help motivate their obese patients to effectively lose weight and maintain weight loss. weight and maintain weight loss.

ReferencesReferences

Agency for Healthcare Administration, State of Florida. DiabAgency for Healthcare Administration, State of Florida. Diabetes, medical practice etes, medical practice guidelines ( 2001).guidelines ( 2001).

American Diabetes Association. (2009). Clinical practice recAmerican Diabetes Association. (2009). Clinical practice recommendations 2009. ommendations 2009. Diabetes Care, 30(s1), s5.Diabetes Care, 30(s1), s5.

Diabetes Wellness News. (2004).Are we raising an obese socieDiabetes Wellness News. (2004).Are we raising an obese society? (10)3ty? (10)3

Florida Department of Health. (2009). FloridaFlorida Department of Health. (2009). Florida’’s obesity epidemic. Retrieved s obesity epidemic. Retrieved February 5, 2009, fromFebruary 5, 2009, from

dohdoh..myfloridamyflorida..govgov

Peterson, K., Silverstein, J., Kaufman, F., (2007) ManagemenPeterson, K., Silverstein, J., Kaufman, F., (2007) Management of Type 2 diabetes in t of Type 2 diabetes in youth: youth: an update. American Family Physician, 9(1) 658an update. American Family Physician, 9(1) 658--667.667.

Primary Care Education Consortium (2007). Building cultural Primary Care Education Consortium (2007). Building cultural competency for competency for improved diabetes care. Journal of Family Practice. S1, s1improved diabetes care. Journal of Family Practice. S1, s1--31..31..