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Diabetes Mellitus
Overview
What is Diabetes Mellitus Epidemiology Etiology Clinical Aspects Treatment of Disease Ethics Effects of Exercise Exercise Testing Prescription Summary References
Diabetes Mellitus?
In a healthy person the body secretes proper amounts of insulin and glucagon in order to maintains proper blood glucose levels
Insulin is secreted by the beta cells of the pancreas in response to high blood sugar
Glucagon is secreted by the alpha cells of the pancreas when blood glucose is low
However in a diabetic it is a constant struggle to maintain these hormone levels below a hyperglycemic state
Diabetes Mellitus?
There are many types of diabetes
Type I, Type II, Pre-diabetes, gestational diabetes
Diabetes is basically too much glucose for your body to withstand and not enough insulin produced to counteract the increased sugar.
Diabetes comes from the Greek term diabanein which means to pass through and is referring to the excess urine passed due to the condition
Mellitus is also Greek and roughly translates to “excessively sweet urine” or glycosuria
Epidemiology
As per data from a 2011 ADA statistical analysis
25.8 million children and adults in the United States—8.3% of the population—have diabetes.
79 million people in the U.S. have pre-diabetes
95% of all diabetics are Type II
1.9 million new cases in the U.S. were reported in 2010
WHO estimates these numbers will double by 2030
Etiology
Type I
An autoimmune disease that causes the immune system to attack its own insulin produced leaving the individual with little to no insulin
Is thought to be caused by a combination of genetic susceptibility and environmental factors
The exact etiology of diabetes mellitus of this kind is not fully understood.
Etiology
Type II
Type 2 diabetes develops when the body becomes resistant to insulin or when the pancreas stops producing enough insulin.
Hereditary or Inherited Traits
Age: 80% of cases occur after 50 years
Poor Diet (Malnutrition Related Diabetes)
Obesity and Fat Distribution
Sedentary Lifestyle
Stress
Serum lipids and lipoproteins
Hypertension
Prevalence
Men and Woman have almost equal prevalence of diabetes, 13 million men and 12.6 million women in the U.S.
Racial makeup:7.1% of non-Hispanic whites 8.4% of Asian Americans 12.6% of non-Hispanic blacks 11.8% of Hispanics
Morbidity and Mortality: diabetes was listed as the underlying cause on 71,382 death certificates and was listed as a contributing factor on an additional 160,022 death certificates
Clinical Aspects (symptoms)
Type 1 Diabetes Frequent urination
Unusual thirst
Extreme hunger
Unusual weight loss
Extreme fatigue and Irritability
Type 2 Diabetes Any of the type 1 symptoms
Frequent infections
Blurred vision
Cuts/bruises that are slow to heal
Tingling/numbness in the hands/feet
Recurring skin, gum, or bladder infections
Clinical Aspects (Diagnosis)
A number of laboratory tests are available to confirm the diagnosis of diabetes.
Finger stick blood glucose
Fasting plasma glucose
Oral glucose tolerance test
Glycosylated hemoglobin or hemoglobin A1c
Clinical Aspects (Test and Evaluation)
Finger stick blood glucose This is a rapid screening test that may be performed anywhere
A finger stick blood glucose test is not as accurate as testing the patient's blood in the laboratory but is easy to perform
The test involves sticking the patient's finger for a blood sample, which is then placed on a strip
This method is only accurate to within about 10% of true actual laboratory values
Finger stick blood glucose values may be inaccurate at very high or very low levels, so this test is only a preliminary screening study
This is the way most people with diabetes monitor their blood sugar levels at home
Clinical Aspects (Test and Evaluation)
Fasting plasma glucose
The patient will be asked to eat or drink nothing for 8 hours before having blood drawn
Blood is taken much the same way as a finger stick test
If the blood glucose level is greater than or equal to 126 mg/dL without eating anything, they probably have diabetes.
If fasting plasma glucose level is greater than 100 but less than 126 mg/dL, then the patient has what is called impaired fasting glucose. This is considered to be pre-diabetes
Clinical Aspects (Test and Evaluation)
Oral glucose tolerance test
This test involves drawing blood for a fasting plasma glucose test, then drawing blood for a second test at two hours after drinking a very sweet drink containing 75 grams of sugar
If the blood sugar level after the sugar drink is greater than or equal to 200 mg/dL, the patient has diabetes.
If the blood glucose level is between 140 and 199, then the patient has impaired glucose
tolerance and is pre-diabetic
Clinical Aspects (Test and Evaluation)
Glycosylated hemoglobin or hemoglobin A1c
This is a long term test and is measured for as leased 120 days (the average life-span of the red blood cells on which the test is based)
Excess blood glucose hooks on to the hemoglobin in red blood cells and stays there for the life of the red blood cell
The percentage of hemoglobin that has had excess blood sugar attached to it can be measured in the blood
A hemoglobin A1c test is the best measurement of blood sugar control in people known to have diabetes
The hemoglobin A1c test is generally measured about every three to six months for people with known diabetes
Complications
Over time diabetes can cause problems with other body functions, such as your kidneys, nerves, feet, and eyes. Having diabetes can also put you at a higher risk for heart disease and bone and joint disorders.
Other long-term complications of diabetes include skin problems, digestive problems, sexual dysfunction, and problems with your teeth and gums.
Treatment
The major goal in treating diabetes is to minimize any elevation of blood glucose without causing abnormally low levels of blood sugar
Type 1 diabetes is treated with insulin, exercise, and a diabetic diet
Type 2 diabetes is treated first with weight reduction, a diabetic diet, and exercise
When these measures fail to control the elevated blood sugars, oral medications are used
If oral medications are still insufficient, treatment with insulin is considered
Treatment (Medical)
Insulin There are several types of insulin. These types are classified
according to how quickly the insulin begins to work and how long it remains active
Rapid-acting(Humulin): Offer quicker action time than regular insulin
Short-acting: Used before eating to control the large rise of blood glucose that often occurs after a meal
Intermediate-acting: These insulins start being absorbed 3-4 hours after injection, the best use is injection at bedtime to control the morning glucose of the next day
Long-acting: are typically given to control the blood sugar when you are not eating
Treatment (Exercise)
During exercise, contracting muscles produces there own insulin-like effect, causing the rapid uptake of glucose
Diabetics must adjust their pre-exercise insulin dosage and CHO intake before, during, and after exercise to avoid hypoglycemia
Regular exercise is beneficial for diabetics given its ability to reverse many adverse metabolic effects, including the likelihood of becoming obese
Treatment (Diet)
For diabetics it is essential that they properly manipulate blood glucose levels and manage their weight.
If blood glucose isn't kept in check, it can lead to serious problems, such as hyperglycemia and chronic complications, such as nerve, kidney and heart damage
Treatment (Diet)
Recommended foods Healthy carbohydrates
fruits, vegetables, whole grains, legumes and low-fat dairy products
Fiber-rich foods
vegetables, fruits, nuts, legumes ,whole-wheat flour and wheat bran
Heart-healthy fish
Fish such as salmon, mackerel and herring are rich in omega-3 fatty acids, which promote heart health by lowering triglycerides
'Good' fats
Avocados, almonds, pecans, walnuts, olives, and canola, olive and peanut oils
Treatment (Diet)
Foods to avoid
Saturated fats
Found in hot dogs, sausage and bacon and should consist of more than 7 percent of your RDI
Trans fats
These types of fats are found in processed snacks, baked goods, shortening and stick margarines and should be avoided completely
Cholesterol
Found in egg yolks, shellfish, liver and other organ meats and should consist of no more than 200 mg of daily intake
Sodium
Aim for less than 2,000 mg of sodium a day
Treatment (Diet)
The most effective methods at controlling glucose levels are as follows
Counting carbohydrates
It's important to make sure timing and amount of CHO is the same each day if you take diabetes medications or insulin. Otherwise, your blood glucose level may fluctuate
The exchange system
The exchange system, which groups foods into categories such as carbohydrates, meats and meat substitutes, and fats. An exchange has about the same amount of CHO, PRO, FAT and calories and the same effect on your blood glucose
Glycemic index
Foods with a high glycemic index are associated with greater increases in blood sugar than are foods with a low glycemic index
Ethics
Food marketing to adults
Food marketing to children Total amount spent on food marketing to children is about $10
billion a year
About 80% of foods advertised on television shows intended for children are for convenience/fast foods and sweets
Emotive drug market $4 billion a year spent on drug marketing and virtually none on
health or wellness
This advertising does not promote public health
Prescription drug advertising is not educational. It is inherently misleading because it features emotive imagery and omits crucial information about the drugs
Effects of Exercise
Exercise is an acceptable why to manage diabetes
Both type I and II have specific yet similar requirements regarding exercise
Both have distinct hereditary and environmental components
Cultural and geographical factors have roles in the cause of each
Effects of Exercise
Type I
It is not well documented that exercise improves glycemic control in type I diabetes
Regular exercise does result in improvements in insulin sensitivity and glucose metabolism
Improves blood lipids and lipoproteins
Increased caloric expenditure
Increased caloric expenditure resulting in reduction and maintenance of body weight
Effects of Exercise
Type II
Reduced blood glucose and glycosylated hemoglobin levels
Improved glucose tolerance
Improved insulin response to oral glucose stimulus
Improved peripheral and hepatic insulin sensitivity
Improved blood lipid and lipoprotein levels
Decreased blood pressure
Increased caloric expenditure resulting in reduction and maintenance of body weight
Exercise testing
Testing protocols should include the following
Blood glucose levels before during and after tests
Sub-maximal O2 uptake testing such as YMCA cycle ergometer, 1.5 mile walk, or arm-ergometer
Dynamic strength test
Sit and reach and shoulder flexibility
Blood pressure and heart rate
Body compositions
Exercise Prescription
Exercise for relatively healthy type I diabetes
Aerobic: Walking, jogging, cycling, stairs, climbing,
Strength: Moderate-level resistance training such as circuit training using lights with 10-15 repetitions
Intensity: 60-90% maximum heart rate or 50-85% VO2 max
Duration: 20-60 min plus 5-10 min warm up and cool down
Frequency: Daily to ensure optimal blood glucose control
Timing: Timing is very important for those with IDDM. Both blood glucose levels and insulin therapy must be considered at the time of exercise
Avoid exercise at a time of peak insulin action
Exercise Prescription
Activity characteristics of insulin
Once an exercise routine is established, insulin does and caloric intake can be adjusted
Onset (HR) Peak (HR) Duration(HR)
Rapid acting 0.5-1 2-4 6-8
Intermediate 1-3 6-12 18-26
Long acting 4-8 12-18 24-28
Exercise Prescription
Exercise for relatively healthy type II diabetes
Aerobic: Walking, jogging, cycling, stairs, climbing,
Strength: Moderate-level resistance training such as circuit training using lights with 10-15 repetitions
Intensity: 60-90% maximum heart rate or 50-85% VO2 max
Duration: 20-60 min plus 5-10 min warm up and cool down
Frequency: 3-5 times weekly, daily if taking insulin therapy
Exercise Prescription
Mode of progression (Type II)
Rate of increasing activity for type II is dependent an several factors
Age, functional capacity, medical and clinical status and personal preferences and goals
Initial changes in progression should focus on the frequency and duration of activity
Duration should be gradually increased to accommodate the functional capacity and clinical status of the patient
Given that older are and obesity are common elements of type II, a longer period of time may be necessary for patients to adapt to recommended physical activity
Exercise Prescription (complications)
The screening process should reveal complications that would influence recommendations for exercise
Special precautions are recommended for patients with complications resulting from diabetes
Exercise is often neglected due to complications
This can effect the ability to tolerate exercise by the patient
Neglect can and will lead to increased disability
Exercise Prescription (complications)
Retinopathy (damage to the retina)
It is an ocular manifestation of diabetes which affects up to 80% of all patients who have had diabetes for 10 years or more.
Diabetic retinopathy is the leading cause of blindness in American adults
In some people with diabetic retinopathy, blood vessels may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina
Diabetic retinopathy usually
affects both eyes
Exercise Prescription (complications)
Neuropathy (damage to the nerve)
Neuropathy can prevent one from feeling pain in various parts of the body, such as the chest and the feet
People typically describe the pain of peripheral neuropathy as tingling or burning
While they may compare the loss of sensation to the feeling of wearing a thin stocking or glove
It can result from such problems as traumatic injuries, infections, metabolic problems and exposure to toxins. One of the most common causes is diabetes
Exercise Prescription (complications)
Other complications to watch for are
Illness or infection
Foot injuries which can lead to foot ulcers and possible amputations
High blood pressure which can contribute to problems with the eyes and kidneys
Summary
Diabetes mellitus is the improper balance between the hormones insulin and glucagon
There are two main types of diabetes, type I and II
There is also Pre-diabetes and gestational diabetes
Diabetes is an autoimmune disease that causes the immune system to attack its own insulin
13 million men and 12.6 million women in the U.S. have it
95% of all diabetics are Type II
Summary
A number of laboratory tests are available to confirm the diagnosis of diabetes
Diabetes can and will cause any number of contributing complication to ones health
Frequent exercise and a nutritious diet are essential in the warding off of or reversal of diabetes
Depending on the type of diabetes drugs either must be used or may be used depending on the severity of the disease
References
Lippincott, Williams, Wilkins, Initials. (2001). ACSM's resource manual for guidelines for exercise testing and prescription . Baltimore : Respect copyright.Pérez-Martin, E. Raynaud and J. Mercier, Initials. (2001). Insulin resistance and associated metabolic abnormalities in muscle: effects of exercise. International Association For The Study Of Obesity, 2(1), pp. 47-59. Mayo clinic staff, Initials. (n.d.). Type 2 diabetes. Retrieved from http://www.mayoclinic.com/health/type-2-diabetes/DS00585 Merrill, Ph.D., Initials. (2000, February). Creating exercise programs for diabetics. Fitness management, 42-44Department of disability and human development, Initials. (2004, August ). Diabetes and exercise. The national center on physical activity and disabilityAlbright, PH.D., R.D. (Chairperson); Franz, M.S., R.D., C.D.E; Hornsby, Ph.D., C.D.E; Kriska, PH.D., FACSM; Marrero, Ph.D., C.D.E; Ullrich, M.D.; Verity, Ph.D., FACSM, Initials. (2000, July). Exercise and type 2 diabetes. American college of sports medicine, pp. 1345-1351. Farrell, Ph.D., Initials. (2003). Diabetes, exercise and competitive sports. Sports science exchange, 16(3), 1-6.