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DIABETES BY: ROSE MARIE LEE

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DIABETES BY: ROSE MARIE LEEOBJECTIVESWHAT IS DIABETES?TYPES OF DIABETES ETIOLOGY INSULIN AND ITS FUNCTIONSNORMAL GLUCOSE METABOLISMGLUCOSE METABOLISM IN DIABETESSYMPTOMS OF DIABETESCOMPLICATIONS OF DIABETESDIABETIC KETOACIDOSIS AND HYPEROSMOLAR COMATHE DIABETIC FOOTDIAGNOSIS OF DIABETESMEDICAL MANAGEMENT NURSING MANAGEMENT WHAT IS DIABETES?Diabetes mellitus (DM) is impaired insulin secretion and variable degrees of peripheral insulin resistance leading to hyperglycemia. Early symptoms are related to hyperglycemia and include polydipsia, polyphagia, polyuria, and blurred vision. Later complications include vascular disease, peripheral neuropathy, nephropathy, and predisposition to infection. Diagnosis is by measuring plasma glucose. Treatment is diet, exercise, and drugs that reduce glucose levels, including insulin and oral antihyperglycemic drugs. Complications can be delayed or prevented with adequate glycemic control; heart disease remains the leading cause of mortality in DM- Merck Manual (2014).What is Diabetes?8.5% of the US population have diabetes - 25.8 million children and adults.

Researchers from the Jefferson School of Population Health (Philadelphia, PA) published a study which estimates that by 2025 there could be 53.1 million people with the disease.18.8 million people have been diagnosed with diabetesAbout 7 million people with diabetes have not been diagnosed.About 79 million people have pre-diabetes1.9 million people aged 20 years or more were newly diagnosed with diabetes in 2010215,000 (0.26%) people younger than 20 years have diabetesApproximately 1 in every 400 kids and teenagers has diabetes11.3% of people aged 20+ years have diabetes; a total of 25.6 million individuals26.9% of people aged 65+ years have diabetes; a total of 10.9 million people11.8% of men have diabetes; a total of 13 million people10.8% of women have diabetes; a total of 12.6 million people

Age-adjusted* percentage of people aged 20 years or older with diagnosed diabetes, by race/ethnicity, United States, 20102012

*Based on the 2000 U.S. standard population.Source: 20102012 National Health Interview Survey and 2012 Indian Health Services National Patient Information Reporting System.

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Types of diabetesPre-diabetesPre-diabetes- The vast majority of patients with type 2 diabetes initially had pre-diabetes. Their blood glucose levels where higher than normal, but not high enough to merit a diabetes diagnosis. The cells in the body are becoming resistant to insulin.

Studies have indicated that even at the pre-diabetes stage, some damage to the circulatory system and the heart may already have occurred.May be referred to as impaired glucose tolerance10Type 1 diabetesInsulin-dependent diabetes mellitus (IDDM)The body does not produce insulin. Some people may refer to this type as insulin-dependent diabetes, juvenile diabetes, or early-onset diabetes. People usually develop type 1 diabetes before their 40th year, often in early adulthood or teenage years.Type 1 diabetes is nowhere near as common as type 2 diabetes. Approximately 10% of all diabetes cases are type 1.This is an auto-immune destruction of pancreatic beta-cells that produce insulin.Susceptibility genes include those within the major histocompatibility complex (MHC)especially HLA-DR3,DQB1*0201 and HLA-DR4,DQB1*0302, which are present in > 90% of patients with type 1 DMSeveral viruses (including coxsackievirus, rubella virus, cytomegalovirus, Epstein-Barr virus, and retroviruses) have been linked to the onset of type 1 DM. Viruses may directly infect and destroy cells, or they may cause -cell destruction indirectly by exposing autoantigens, activating autoreactive lymphocytes, mimicking molecular sequences of autoantigens that stimulate an immune response (molecular mimicry), or other mechanisms. Diet may also be a factor. Exposure of infants to dairy products (especially cow's milk and the milk protein casein), high nitrates in drinking water, and low vitamin D consumption have been linked to increased risk of type 1 DM. Early (< 4 mo) or late (> 7 mo) exposure to gluten and cereals increases islet cell autoantibody production. Mechanisms for these associations are unclear.

Type 2 diabetesNon- Insulin dependent Diabetes Mellitus (NIDDM)The body does not produce enough insulin for proper function, or the cells in the body do not react to insulin (insulin resistance).Approximately 90% of all cases of diabetes worldwide are of this type.Obesity and weight gain are important determinants of insulin resistance in type 2 DM. They have some genetic determinants but also reflect diet, exercise, and lifestyle. An inability to suppress lipolysis in adipose tissue increases plasma levels of free fatty acids that may impair insulin-stimulated glucose transport and muscle glycogen synthase activity. Adipose tissue also appears to function as an endocrine organ, releasing multiple factors (adipocytokines) that favorably (adiponectin) and adversely (tumor necrosis factor-, IL-6, leptin, resistin) influence glucose metabolism. Intrauterine growth restriction and low birth weight have also been associated with insulin resistance in later life and may reflect adverse prenatal environmental influences on glucose metabolism

Type 3 diabetes Gestational diabetesAt least 5% of pregnant women develop diabetes during pregnancy. This disorder is called gestational diabetes. Gestational diabetes is more common among obese women, women with a family history of diabetes, and certain ethnic groups, particularly Native Americans, Pacific Islanders, and women of Mexican, Indian, or Asian descent.If diabetes is poorly controlled early in the pregnancy, the risk of an early miscarriage and significant birth defects is increased. Babies born to women with diabetes tend to be larger than those born to women without diabetes.If diabetes is poorly controlled, babies may be particularly large. A large fetus is less likely to pass easily through the vagina and is more likely to be injured during vaginal delivery. Consequently, cesarean delivery may be necessary. Also, the fetus's lungs tend to mature slowly.The risk of preeclampsia (a type of high blood pressure that occurs during pregnancy) is also increased for women with diabetes, as is the risk of stillbirth.Newborns of women with diabetes are at increased risk of having low sugar, low calcium, and high bilirubin levels in the blood

Characterized by insulin resistance 19

Miscellaneous types: Miscellaneous causes of DM that account for a small proportion of cases include genetic defects affecting -cell function, insulin action, and mitochondrial DNA (eg, maturity-onset diabetes of youth); pancreatic diseases (eg, cystic fibrosis, pancreatitis, hemochromatosis); endocrinopathies (eg, Cushing syndrome, acromegaly); toxins (eg, the rodenticide pyriminyl [Vacor]); and drug-induced diabetes, most notably from glucocorticoids, -blockers, protease inhibitors, and therapeutic doses of niacin.DiabetesSome evidence suggests that niacinamide (but not niacin) might help delay the time that you would need to take insulin in type 1 diabetes. In type 1 diabetes, the body's immune system mistakenly attacks the cells in the pancreas that make insulin, eventually destroying them. Niacinamide may help protect those cells for a time, but more research is needed to tell for sure.Researchers have also looked at whether high-dose niacinamide might reduce the risk of type 1 diabetes in children at risk for the disease. One study found that it did, but another, larger study found it did not protect against developing type 1 diabetes. More research is needed to know for sure.The effect of niacin on type 2 diabetes is more complicated. People with type 2 diabetes often have high levels of fats and cholesterol in the blood. Niacin, often along with other drugs, can lower those levels. However, niacin may also raise blood sugar levels, which is particularly dangerous for someone with diabetes. For that reason, anyone with diabetes should take niacin only when directed to do so by their doctor, and should be carefully monitored for high blood sugar.

Source: Vitamin B3 (Niacin) | University of Maryland Medical Center http://umm.edu/health/medical/altmed/supplement/vitamin-b3-niacin#ixzz3TpCSdu5t University of Maryland Medical Center

21Insulin and its actionsRegulating blood glucoseInsulin helps control blood glucose levels by signaling the liver and muscle and fat cells to take in glucose from the blood. Insulin therefore helps cells to take in glucose to be used for energy. If the body has sufficient energy, insulin signals the liver to take up glucose and store it as glycogen.Insulin is a hormone that is exclusively produced by pancreatic beta cells. Beta cells are located in the pancreas in clusters known as the islets of Langerhans.Type 2 glucose transporters (GLUT2) mediate the entry of glucose into beta cells.As the raw fuel for glycolysis, the universal energy-producing pathway, glucose is phosphorylated by the rate-limiting enzyme glucokinase. This modified glucose becomes effectively trapped within the beta cells and is further metabolized to create ATP, the central energy molecule.The ATP transmits open calcium channels releases Insulin from its vesicles in the beta-cells.

Insulin release is a biphasic process. The initial amount of insulin released upon glucose absorption is dependent on the amounts available in storage. Once depleted, a second phase of insulin release is initiated. This latter release is prolonged since insulin has to be synthesized, processed, and secreted for the duration of the increase of blood glucose.Insulin molecules circulate throughout the blood stream until they bind to their associated (insulin) receptors. The insulin receptors promote the uptake of glucose into various tissues that contain type 4 glucose transporters (GLUT4). Such tissues include skeletal muscles (which burn glucose for energy) and fat tissues (which convert glucose to triglycerides for storage).

WHAT GOES WRONG IN DIABETES?Either the insulin is not secreted to regular levels (as in type 1DM) or the insulin receptors are desensitized. WHAT DOES THIS CAUSE?

TYPE 1 DM These patients (33.33%) first present with diabetic ketoacidosis (discussed later).

Symptoms develop quickly in type 1 diabetes, usually over 2 to 3 weeks or less, and tend to be quite obvious. High blood sugar levels cause the child to urinate excessively. This fluid loss causes an increase in thirst and the consumption of fluids. Some children become dehydrated, resulting in weakness, weight loss, lethargy, and a rapid pulse. Vision may become blurred.

Type 2 DMPeople with type 2 diabetes may not have any symptoms for years or decades before they are diagnosed. Symptoms may be subtle. Increased urination and thirst are mild at first and gradually worsen over weeks or months. Eventually, people feel extremely fatigued, are likely to develop blurred vision, and may become dehydrated.Sometimes during the early stages of diabetes, the blood glucose level is abnormally low at times, a condition called hypoglycemia.Because people with type 2 diabetes produce some insulin, ketoacidosis does not usually develop even when type 2 diabetes is untreated for a long time.

When the blood glucose levels get very high, people may develop severe dehydration, which may lead to mental confusion, drowsiness, and seizures, a condition called nonketotic hyperglycemic-hyperosmolar syndrome32

Complications of diabetesBlood vesselsFatty material (atherosclerotic plaque) builds up and blocks large or medium-sized arteries in the heart, brain, legs, and penis.The walls of small blood vessels are damaged so that the vessels do not transfer oxygen to tissues normally, and the vessels may leak.Poor circulation causes wounds to heal poorly and can lead to heart attacks, strokes, gangrene of the feet and hands, erectile dysfunction (impotence), and infections.EyesThe small blood vessels of the retina are damaged, leading to formation of new fragile blood vessels that tend to bleed.Vision decreases, and ultimately, blindness occurs.Diabetic retinopathy is the most common cause of adult blindness in the US

KidneysBlood vessels in the kidneys thicken.Protein leaks into urine.Blood is not filtered normally.The kidneys malfunction, and ultimately, kidney failure occurs.Diabetic nephropathy is a leading cause of chronic kidney disease in the US.NervesNerves are damaged because glucose is not used normally and because the blood supply is inadequateLegs suddenly or gradually weaken.People have reduced sensation, tingling, and pain in their hands and feet.Diabetic neuropathy is the result of nerve ischemia due to microvascular disease, direct effects of hyperglycemia on neurons, and intracellular metabolic changes that impair nerve function. There are multiple types, including :

Symmetric polyneuropathy (with small- and large-fiber variants)Autonomic neuropathyRadiculopathyCranial neuropathyMononeuropathy

Autonomic nervous systemThe nerves that control blood pressure and digestive processes are damagedSwings in blood pressure occur.Swallowing becomes difficult.Digestive function is altered, and sometimes nausea or bouts of diarrhea occur.Erectile dysfunction develops.

SkinBlood flow to the skin is reduced, and sensation is decreased, resulting in repeated injurySores and deep infections (diabetic ulcers) develop.Healing is poor.

BloodWhite blood cell function is impaired.People become more susceptible to infections, especially of the urinary tract and skin.DIABETIC KETOACIDOSISDiabetic ketoacidosis develops when your body is unable to produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) a major source of energy for your muscles and other tissues enter your cells. Without enough insulin, your body begins to break down fat as an alternate fuel. This process produces a buildup of toxic acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.Diabetic ketoacidosis signs and symptoms often develop quickly, sometimes within 24 hours:Excessive thirstFrequent urinationNausea and vomitingAbdominal painWeakness or fatigueShortness of breathFruity-scented breathConfusionHigh blood sugar level (hyperglycemia)High ketone levels in urineHYPEROSMOLAR HYPERGLYCEMIC NON-KETONIC COMAHHC is characterized by hyperglycemia, hyperosmolarity, and dehydration without significant ketoacidosis. Most patients present with severe dehydration and focal or global neurologic deficits.Plasma glucose level of 600 mg/dL or greaterEffective serum osmolality of 320 mOsm/kg or greaterProfound dehydration, up to an average of 9LSerum pH greater than 7.30Bicarbonate concentration greater than 15 mEq/LSmall ketonuria and absent-to-low ketonemiaSome alteration in consciousnessDIABETIC FOOTAdiabetic footis afootthat exhibits any pathology that results fromdiabetesmellitus.Features:CellulitisUlcersAbcessOsteomyelitisGangreneNeuropathic Arthropathy

Diagnosis of diabetesFasting plasma glucose (FPG) levelsHbA1c 6.5% = DMHbA1c 5.7 to 6.4% = prediabetes or at risk of DMGlycosylated Hb (HbA1c)Sometimes oral glucose tolerance testingScreening for disease: Screening for DM should be conducted for people at risk of the disease.People at high risk of type 1 DM (eg, siblings and children of people with type 1 DM) can be tested for the presence of islet cell or anti-glutamic acid decarboxylase antibodies, which precede onset of clinical disease. Risk factors for type 2 DM include age > 45; overweight or obesity; sedentary lifestyle; family history of DM; history of impaired glucose regulation; gestational DM or delivery of a baby > 4.1 kg; history of hypertension or dyslipidemia; polycystic ovary syndrome; and black, Hispanic, Asian American, or American Indian ethnicity.

Screening for complications: All patients with type 1 DM should begin screening for diabetic complications 5 yr after diagnosis. For patients with type 2 DM, screening begins at diagnosis. Typical screening for complications includes

Foot examination Funduscopic examination Urine testing for proteinuria and microalbuminuria Measurement of serum creatinine and lipid profile

Chart115.913.212.897.6

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Sheet1Column1American Indians/ Alaska Natives15.9Non-Hispanic blacks13.2Hispanics12.8Asian Americans9Non-Hispanic whites7.6To resize chart data range, drag lower right corner of range.