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Endocrine System

KNH 406

Diabetes Mellitus

7% of population; 1/3 undiagnosed

$132 billion in health care

Sixth leading cause of death

Complications of diabetes (DM)

Diabetes Mellitus

Group of disorders

Defects in insulin production, action, or both

Results in glucose intolerance

Long-term damage correlated with failure of eyes,

kidneys, nerves, heart, blood vessels

Diabetes Mellitus

Managed by health care team

Treatment individualized for patient and family

Diabetes Self Management Education (DSME) vital

element of care

Type 1 DM

5-10% of diagnosed cases

Immune mediated – cellular-mediated autoimmune

destruction of beta cells

Ideopathic

Type 1 DM

Pathophys/clinical manifestations

Inability of cells to use glucose for energy

Hyperglycemia and cells starve

Polyuria

Polydipsia

Polyphagia

Type 1 DM


Lipolysis

Fatty acids transformed to ketones

pH falls

Ketosuria

Metabolic acidosis/ ketoacidosis

Type 1 DM


Hypovolemia

Potassium, sodium, magnesium, phosphorus lost

Decreased Hg, Hct, protein, WBC, creatinine, serum osmolality

Weight loss

Hypovolemic shock

Deep, labored breathing

Type 1 DM

Diabetic Ketoacidosis (DKA)

Dehydration

Electrolyte imbalances

Hyperglycemia

h

Type 1 DM

DKA -Treatment

Administration of IV fluids, insulin, electrolytes

Risk for micro- and macrovascular complications

Increased morbidity and mortality

Type 1 DM

Macrovascular complications

CVD – 65% of deaths

Coexistence of hypertension & dyslipidemia

Underlying metabolic syndrome

Treat hypertension and lipids

Type 1 DM

Microvascular complications

Nephropathy

Retinopathy

Neuropathy

Type 1 DM

Nephropathy - treatment

May be delayed by intensive diabetes management

Protein restriction

ACE inhibitors

Kidney failure treatment – dialysis or transplant

Type 1 DM

Retinopathy

Most frequent cause of new blindness

Associated with duration of DM

Likely if nephropathy present

Macular edema d/t hypertension

glaucoma & cataracts

Progression slowed with glycemic and BP control

Type 1 DM Neuropathy

Autonomic and peripheral

GI, genitourinary tract, CV system

Gastroparesis, delayed gastric emptying, vagus nerve damage affecting peristalsis

Constipation alternates with diarrhea

Bladder and/or sexual dysfunction

Recurrent UTIs

Resting tachycardia

Orthostatic hypotension

Silent heart disease

Type 1 DM Diagnosis/ lab measures

Casual plasma glucose ≥ 200 mg/dL + symptoms

Fasting plasma glucose ≥ 126 mg/dL

2 hr. postprandial glucose 140-199 mg/dL – OGTT

Type 1 DM Measures of Glycemic Control

Self-monitoring of blood glucose and A1C

Recommended A1C and plasma glucose goal

Frequency and recommendations


Glycated Hemoglobin (A1C)

Higher glucose

Avg. concentration previous 2-4 mo.

Not recommended for dg of DM

Measured at least 2X per year

Inappropriate for pt. with anemias


SMBG

Drop of blood via finger prick

3 or more times daily

Assists in adjustment for eating and medication patterns

Identifies food, exercise, other patterns that affect glycemic

control


Fructosoamine

Glycemic control over 1-3 wk. period

Not reliable with renal or liver disease

Urine testing for glucose

Renal threshold - glucose > 250

Urine testing for ketones

Should be tested when glucose > 300

Type 1 DM Treatment

risk factors

Daily exogenous insulin

Nutrition therapy

Exercise

Type 1 DM Treatment - Types of Insulin

Meant to mimic normal physiological action of insulin

Classified based on onset of action, peak time, duration of

action

Dosage typically based on body weight, adjusted based on

blood glucose levels

Type 1 DM Treatment - Insulin Regimens

Fixed/conventional/standard

Flexible/intensive

Continuous infusion (CSII)


Fixed/conventional/standard

Constant dose of basal insulin

With short or rapid (bolus) insulin

“Mixed dose” or split mixed dose

Must synchronize insulin with food intake


Flexible

Multiple daily injections

Bolus insulin before meals

Basal insulin once or twice daily

More flexibility


Continuous infusion

Basal rapid or short

Boluses are given before meals

Type 1 DM Insulin Regimens

Syringes or pens

Syringes disposable - U-100 insulin

Pens refillable - 150-300 U insulin

Insulin pumps

Powered by battery

Inhaled insulin

FDA approved Jan. 2006 – Exubera

Short acting

Type 1 DM Insulin – side effects

Hypoglycemia

Loss of consciousness, confusion

Treatment:

Mild

Severe

Weight gain

Lipohypertrophy at site of injection

Drugs that alter effect

Type 1 DM Physical activity

Benefits far exceed risks

Can cause hypoglycemia or hyperglycemia

Monitor blood glucose before and after

Make appropriate adjustments for CHO and insulin

Moderate exercise < 30 min. – likely no adjustment

Type 1 DM Nutrition Therapy

Should be individualized!

Based on:

Self care treatment plan

Learning ability

Current lifestyle

Type 1 DM

Nutrition Therapy

CHO

Alcohol kcal considered additional

Meal planning

Individualized

Type 1 DM

Nutrition therapy

Carbohydrate counting

Consistent amount of CHO at meals and snacks

Count starches, fruits, milk/yogurt, sweets

Count amount of food containing 15 g CHO or

Total grams of CHO

3 skill levels

Type 1 DM

Nutrition therapy

Exchange System

Exchange Lists for Meal Planning

Substitution of different foods with each of 3 groups

Each food on particular list can be substituted with food on

same list

Type 1 DM

Short-term illness

Supplemental insulin

Replacement fluids

Electrolytes

Glucose

SMBG

Urine testing

Prevent progression

Less than 24 hrs.

Type 2 DM

90-95% of diagnosed cases

Adults, elderly, persons of color

Increased risk traits

Type 2 DM

Etiology

Heredity

Obesity

Physical inactivity

High or low birth weight

Poor placental growth

Type 2 DM

Pathophysiology

Insulin resistance

Pancreas increases production

Pancreas stops producing insulin

Insulin deficiency

Glucose intolerance

DM develops in obese

Hyperglycemia develops

Type 2 DM

Metabolic syndrome

Central obesity

Insulin resistance

Dyslipidemia

Hypertension

Type 2 DM

Clinical Manifestations

Insidious

Criteria for testing based on risk factors including PCOS

Disease may progress

Type 2 DM

Hyperglycemic Hyperosmolar Nonketotic

Syndrome (HHNS)

Blood glucose ≥ 600 mg/dL

Infection

Dehydration

Symptoms

Treatment

Type 2 DM Treatment

Glycemic control depends on:

Hepatic glucose production

Glucose uptake by periphery

Absorption of glucose from food

Nutrition therapy

Physical activity

Medications

Type 2 DM Treatment - medications

Seven classes

Alpha-glucosidase inhibitors (AGIs)

Amylin analogs

Biguanides

Incretin mimetics

Meglitinides

Sulfonylurea agents

Thiazolidinediones

Consider drug-nutrient interactions

Type 2 DM Physical Activity

Prescribed for all

Enhances blood glucose uptake

Enhances weight loss efforts

30-45 min. 3-5 days/week, no more than 2 consecutive days of rest

Adjust CHO and insulin

Consider CHO snack pre & post exercise

Type 2 DM Nutrition Therapy

Plan based on metabolic priorities

Lifestyle and behavior modification

Weight management

Monitor total CHO

< 20% pro.

Dietary fat goals for CVD

14 grams fiber/1000 kcal

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