Diabetes 101Diabetes 101Janet Renaldi, RN, CDEJanet Renaldi, RN, CDE

St Luke’s Magic ValleySt Luke’s Magic Valley

Diabetes Education ProgramDiabetes Education Program

Prevalence of DiabetesPrevalence of Diabetes

23 million in the US with Type 2 diabetes23 million in the US with Type 2 diabetes 1 million in the US with Type 1 diabetes1 million in the US with Type 1 diabetes 57 million in the US with pre-diabetes57 million in the US with pre-diabetes CDC predicts doubling of diabetes by 2030CDC predicts doubling of diabetes by 2030 40% of persons 40-74 have pre-diabetes 40% of persons 40-74 have pre-diabetes 40-50 million in the US with metabolic 40-50 million in the US with metabolic

syndromesyndrome

Cost of DiabetesCost of Diabetes

$174 billion spent in 2007$174 billion spent in 2007****

Over 33% of Medicare budget Over 33% of Medicare budget **

2/3 is spent on complications2/3 is spent on complications $13,243/yr to treat a person with DM $13,243/yr to treat a person with DM $2,560/yr to treat a non-diabetic$2,560/yr to treat a non-diabetic $883/month for prescriptions $883/month for prescriptions **

* Agency for Healthcare Research and Quality 2006* Agency for Healthcare Research and Quality 2006

** ** Economic Cost of Diabetes in the US in 2007Economic Cost of Diabetes in the US in 2007

Types of DiabetesTypes of Diabetes

Type 1Type 1 Type 2Type 2 Type 2 in youth Type 2 in youth GDM (gestational)GDM (gestational) Pre diabetes, Impaired glucose Pre diabetes, Impaired glucose

tolerance, Metabolic syndrometolerance, Metabolic syndrome

Type 1 DiabetesType 1 Diabetes

Auto immune diseaseAuto immune disease 5-10% of population with DM5-10% of population with DM Historically called “juvenile” diabetesHistorically called “juvenile” diabetes Occurs in children and adultsOccurs in children and adults 9 of 10 people DO NOT have relative 9 of 10 people DO NOT have relative

with Type 1 DM with Type 1 DM Requires daily insulin and BG testing, Requires daily insulin and BG testing,

balanced with food and activitybalanced with food and activity

Type 1 DiabetesType 1 Diabetes

Signs at diagnosis are weight loss, Signs at diagnosis are weight loss, urine ketones, yeast infections, urine ketones, yeast infections, increased thirst and urination, increased thirst and urination, fatigue, hyperglycemiafatigue, hyperglycemia

IGA, insulin antibodies or C-peptide IGA, insulin antibodies or C-peptide lab tests identify Type 1 DMlab tests identify Type 1 DM

Thought to be triggered by increase Thought to be triggered by increase hormones levels or viral infectionhormones levels or viral infection

Type 2 DiabetesType 2 Diabetes

Insulin resistance common Insulin resistance common Historically called “adult onset”Historically called “adult onset” Pancreas still makes insulinPancreas still makes insulin One-third are undiagnosedOne-third are undiagnosed Signs are often mild or non-existentSigns are often mild or non-existent Treated by diet, exercise, pills and Treated by diet, exercise, pills and

insulininsulin

Risk Factors for DiabetesRisk Factors for Diabetes

Sedentary lifestyleSedentary lifestyle Family historyFamily history OverweightOverweight AgeAge Polycystic Ovary Polycystic Ovary

DiseaseDisease High risk ethnic High risk ethnic

groupgroup HypertensionHypertension

Cardiovascular Cardiovascular DiseaseDisease

Triglycerides >250Triglycerides >250 HDL <40HDL <40 Waist Waist

measurement >35 measurement >35 women, >40 menwomen, >40 men

History of GDM or History of GDM or baby > 9 lbsbaby > 9 lbs

Diagnosis of Type 2Diagnosis of Type 2

2 FBG values >125 mg/dl on 2 FBG values >125 mg/dl on different days OR RBG >200mg/dldifferent days OR RBG >200mg/dl

A1c >6.4% is diagnostic of DMA1c >6.4% is diagnostic of DM Up to 50% of beta cells are non-Up to 50% of beta cells are non-

functional at diagnosis of Type 2 DMfunctional at diagnosis of Type 2 DM Screen if overweight and over 45Screen if overweight and over 45

Diabetes and Obesity Diabetes and Obesity

Obesity Rates in USObesity Rates in US

Insulin ResistanceInsulin Resistance

A supply and demand problemA supply and demand problem Insulin is a metabolic hormone produced Insulin is a metabolic hormone produced

by the beta cells of the pancreas by the beta cells of the pancreas Blood glucose is a product of glycogen Blood glucose is a product of glycogen

release from liver and muscles and food release from liver and muscles and food intakeintake

Insulin carries glucose out of the blood, Insulin carries glucose out of the blood, unlocks fat and muscle cells, and allows unlocks fat and muscle cells, and allows glucose to enter cell and provide fuel glucose to enter cell and provide fuel

Insulin ResistanceInsulin Resistance

Signs can be seen 10-15 years prior to Signs can be seen 10-15 years prior to diagnosis of DMdiagnosis of DM

Insulin is a fat storing hormoneInsulin is a fat storing hormone High levels of insulin required to High levels of insulin required to

overcome cellular insulin resistance overcome cellular insulin resistance cause overworked pancreas and lead to cause overworked pancreas and lead to burnoutburnout

Gut fat vs. butt fat, HTN, elevated lipids, Gut fat vs. butt fat, HTN, elevated lipids, fatty liver disease, PCOS, sleep apneafatty liver disease, PCOS, sleep apnea

Type 2 Diabetes in YouthType 2 Diabetes in Youth

30-50% at present, <5% prevalence 30-50% at present, <5% prevalence prior to 1994prior to 1994

Most common in minority groups Most common in minority groups (94%)(94%)

Risk factors obesity, family history, Risk factors obesity, family history, girlsgirls

Mean age 12-14 (range 4-19)Mean age 12-14 (range 4-19) Acanthosis nigricans commonAcanthosis nigricans common

Type 2 Diabetes in YouthType 2 Diabetes in Youth

Screen at age 10 or onset of puberty Screen at age 10 or onset of puberty if overweight PLUS 2 of the following:if overweight PLUS 2 of the following:

Family history of DMFamily history of DM High risk raceHigh risk race Re-screen every 2 yearsRe-screen every 2 years Signs of insulin resistanceSigns of insulin resistance Maternal history of DM or GDMMaternal history of DM or GDM

Childhood ObesityChildhood Obesity

Gestational DiabetesGestational Diabetes

Occurs in 5-10% of pregnanciesOccurs in 5-10% of pregnancies Similar pathophysiology of Type 2 Similar pathophysiology of Type 2

DMDM Higher insulin resistance with Higher insulin resistance with

pregnancy hormonespregnancy hormones Screen for GDM at 24-28 weeksScreen for GDM at 24-28 weeks Increased risk of Type 2 DMIncreased risk of Type 2 DM Suspect GDM with babies >9 lbs Suspect GDM with babies >9 lbs

Pre DiabetesPre Diabetes

Caused by insulin resistance Caused by insulin resistance FBG 110 – 124 mg/dl or RBG 141 – 199 FBG 110 – 124 mg/dl or RBG 141 – 199

mg/dlmg/dl Will progress to Type 2 DM Will progress to Type 2 DM DPP – 58% reduction in Type 2 with 7% DPP – 58% reduction in Type 2 with 7%

weight loss and 30 min daily walkingweight loss and 30 min daily walking Diet and exercise used to treatDiet and exercise used to treat Often include Metformin and home BG Often include Metformin and home BG

test test

Type 2 Diabetes PreventionType 2 Diabetes Prevention

DPP (Diabetes Prevention Program)DPP (Diabetes Prevention Program) Metformin group – 31% reductionMetformin group – 31% reduction Lifestyle Intervention Group – 58% Lifestyle Intervention Group – 58%

reductionreduction * Extensive education, monthly visits* Extensive education, monthly visits

* 7% wt loss - low fat, low cal * 7% wt loss - low fat, low cal

* 150 min/wk of * 150 min/wk of

physical activityphysical activity

Healthy Eating Healthy Eating

Diet TherapyDiet Therapy

Individualized, one size does not fit allIndividualized, one size does not fit all Encourage healthy eating, less fat, Encourage healthy eating, less fat,

sugar and sodium – more fibersugar and sodium – more fiber Portion controlPortion control Carbohydrate countingCarbohydrate counting Exchanges – not used often, older termExchanges – not used often, older term Plate methodPlate method Low glycemic dietLow glycemic diet

Food NutrientsFood Nutrients

Carbohydrates – 40-60% of daily kcalCarbohydrates – 40-60% of daily kcal 100% of carbs convert to BG in 10 min 100% of carbs convert to BG in 10 min

to 2 hoursto 2 hours Protein – 15-25% of daily kcal – Protein – 15-25% of daily kcal –

minimal effect of BG, choose lean minimal effect of BG, choose lean meatsmeats

Fat – 25-35% of daily kcal – minimal Fat – 25-35% of daily kcal – minimal effect of BG, choose low saturated fatseffect of BG, choose low saturated fats

Diet TherapyDiet Therapy

Carbohydrate CountingCarbohydrate Counting

1 portion/exchange of carb = 15 1 portion/exchange of carb = 15 grams total carb grams total carb

Carbs are sugar, natural or added, Carbs are sugar, natural or added, and starchand starch

Bread, grain, starchy vegies, fruit, Bread, grain, starchy vegies, fruit, milk, sweetsmilk, sweets

““Sugar Free” is not “Carb Free”Sugar Free” is not “Carb Free” Need 130 grams carb/day for brain Need 130 grams carb/day for brain

functionfunction

Carbohydrate Counting Carbohydrate Counting

Count carbs by measured portion, Count carbs by measured portion, weighed amount, label reading or weighed amount, label reading or website datawebsite data

People with diabetes are given a People with diabetes are given a personal “Budget” of carbs per meal personal “Budget” of carbs per meal and per snackand per snack

Women - 30 - 45 grams/meal is Women - 30 - 45 grams/meal is commoncommon

Men – 45 – 60 grams/meal is common Men – 45 – 60 grams/meal is common

Food LabelFood Label

Plate MethodPlate Method

Portion SizesPortion Sizes

Physical ActivityPhysical Activity

CDC guidelines for adultsCDC guidelines for adults 150 min/wk of moderate intensity OR 150 min/wk of moderate intensity OR

75 min/wk of vigorous intensity with 75 min/wk of vigorous intensity with 2 days/wk strength training minimum2 days/wk strength training minimum

For greater health benefit double For greater health benefit double these timesthese times

Children: 60 min/day with 2 days Children: 60 min/day with 2 days strength trainingstrength training

Moderate IntensityModerate Intensity

Hard enough to raise heart rate and Hard enough to raise heart rate and sweat but still be able to conversesweat but still be able to converse

5-6 on a scale of 1-105-6 on a scale of 1-10 Walking 3-4 mph, mowing lawn, Walking 3-4 mph, mowing lawn,

dancing, biking on flat surface 10 dancing, biking on flat surface 10 mph, swimming laps, doubles tennis, mph, swimming laps, doubles tennis,

water aerobics, water aerobics,

shooting basketsshooting baskets

Vigorous IntensityVigorous Intensity

Raises heart rate but only able to say Raises heart rate but only able to say single wordssingle words

8-9 on a scale of 1-108-9 on a scale of 1-10 1 min vigorous = 2 min moderate1 min vigorous = 2 min moderate Walking >4 mph, playing basketball, Walking >4 mph, playing basketball,

soccer, singles tennis, hiking, jogging, soccer, singles tennis, hiking, jogging, biking >12 mph, cross country skiing, biking >12 mph, cross country skiing, snowshoeing, swimming fast lapssnowshoeing, swimming fast laps

Strength TrainingStrength Training

Work all major muscle groupsWork all major muscle groups Do to the point that it is difficult to do Do to the point that it is difficult to do

another rep without helpanother rep without help 1 set = 8-12 reps1 set = 8-12 reps Weight lifting, yoga, push ups, Weight lifting, yoga, push ups,

sit ups, heavy gardening, sit ups, heavy gardening,

resistance bandsresistance bands

SMBG – BG TestingSMBG – BG Testing

SMBGSMBG

Testing frequency and times variable Testing frequency and times variable – determined by doctor, patient, cost, – determined by doctor, patient, cost, control of DMcontrol of DM

Target BG levels variableTarget BG levels variable FBG: 80 – 110 mg/dl = A+FBG: 80 – 110 mg/dl = A+ 2 hour pp (after a meal): 100 -140 2 hour pp (after a meal): 100 -140

mg/dlmg/dl Meter variance +/- 10-15%Meter variance +/- 10-15%

Diabetes ControlDiabetes Control

Aim to follow plan 80% of timeAim to follow plan 80% of time Food, stress illness raise BG and Food, stress illness raise BG and

exercise, medication lower BGexercise, medication lower BG Small changes are better than noneSmall changes are better than none Balance is the keyBalance is the key

Oral Antidiabetic AgentsOral Antidiabetic Agents

Oral MedsOral Meds

Sulfonylurea – stimulate pancreas Sulfonylurea – stimulate pancreas

to produce more insulin (Amaryl, to produce more insulin (Amaryl, Glucotrol, Glyburide)Glucotrol, Glyburide)

TZD’s – help cells accept insulin, TZD’s – help cells accept insulin, decrease insulin resistance (Actos, decrease insulin resistance (Actos, Avandia)Avandia)

Biguanides – keep liver from releasing Biguanides – keep liver from releasing excess glycogen (Metformin, excess glycogen (Metformin, Glucophage)Glucophage)

Oral MedsOral Meds

Incretin mimetic (exenitide, – injectable – Incretin mimetic (exenitide, – injectable – with food intake stimulates gut receptors with food intake stimulates gut receptors (GLP1) to signal pancreatic insulin (GLP1) to signal pancreatic insulin production production

Slows gastric emptying and releases Slows gastric emptying and releases satiety hormones resulting in weight losssatiety hormones resulting in weight loss

Nausea occurs in 42% of peopleNausea occurs in 42% of people DPP4 inhibitor (sitagliptin, saxagliptin) – DPP4 inhibitor (sitagliptin, saxagliptin) –

makes signal last longer to pancreas to makes signal last longer to pancreas to increase insulin production increase insulin production

InsulinInsulin

Basal – Bolus patternsBasal – Bolus patterns

InsulinInsulin

Basal insulin covers release of Basal insulin covers release of glycogen from liver and musclesglycogen from liver and muscles

Lantus, Levemir, Humulin N are basal Lantus, Levemir, Humulin N are basal insulinsinsulins

Bolus insulin covers BG spike with Bolus insulin covers BG spike with carb intake or lowers a high BGcarb intake or lowers a high BG

Humalog, Novolog, Apidra, Humulin RHumalog, Novolog, Apidra, Humulin R Mixed insulins: Humulin 70/30, Mixed insulins: Humulin 70/30,

Novolog 70/30 Novolog 70/30

InsulinInsulin

Insulin need is based on body weightInsulin need is based on body weight Measured in units, given as a SQ Measured in units, given as a SQ

injection injection Strength 100u/ml (most common), Strength 100u/ml (most common),

500u/ml (Humulin R)500u/ml (Humulin R) Adjust bolus dose based on BG levels, Adjust bolus dose based on BG levels,

carb intake, exercise, illnesscarb intake, exercise, illness Basal rate is adjusted based on trends Basal rate is adjusted based on trends

Acute ComplicationsAcute Complications

Hypoglycemia Hypoglycemia

Treatment of HypoglycemiaTreatment of Hypoglycemia

““Rule of 15” – 15 grams quick acting Rule of 15” – 15 grams quick acting carb, wait 15 minutes, BG should rise carb, wait 15 minutes, BG should rise 15 mg/dl – if not repeat 15 grams carb15 mg/dl – if not repeat 15 grams carb

Follow by a snack of protein and carb Follow by a snack of protein and carb within 30 minwithin 30 min

15 gram carb items: 4 oz juice, reg 15 gram carb items: 4 oz juice, reg pop, 4-5 hard candies, 3 glucose tabs, pop, 4-5 hard candies, 3 glucose tabs, 1 Tbls sugar or honey1 Tbls sugar or honey

Glucagon kit used only if unconscious Glucagon kit used only if unconscious

HyperglycemiaHyperglycemia

Test urine ketonesTest urine ketones

if on insulinif on insulin

Diabetic Ketoacidosis (DKA)Diabetic Ketoacidosis (DKA)

Most likely when sick, missed insulin Most likely when sick, missed insulin doses, new diagnosis type 1 doses, new diagnosis type 1

Severe insulin deficiency with excess Severe insulin deficiency with excess counterregulatory hormonescounterregulatory hormones

Fat lypolysis produces BG and ketonesFat lypolysis produces BG and ketones Ketones are an acid that lead to Ketones are an acid that lead to

metobolic acidosismetobolic acidosis Kussmaul’s respirations, vomiting, Kussmaul’s respirations, vomiting,

changes in LOC, fruity odor changes in LOC, fruity odor

DKA TreatmentDKA Treatment

IV insulin – 0.1u/kh/hour IVIV insulin – 0.1u/kh/hour IV IV fluids to correct dehydration – deficit IV fluids to correct dehydration – deficit

5-10L5-10L Electrolyte stabilization – K+, phosphateElectrolyte stabilization – K+, phosphate Insulin promotes cellular uptake causing Insulin promotes cellular uptake causing

drops in serum levelsdrops in serum levels Clear ketonesClear ketones Correct acidosisCorrect acidosis

Chronic ComplicationsChronic Complications

BG levels affect whole bodyBG levels affect whole body Blood vessels, nerves through Blood vessels, nerves through

oxidative stressoxidative stress Eyes, kidneys, heart, feet, digestive Eyes, kidneys, heart, feet, digestive

tract, erectile dysfunctiontract, erectile dysfunction Best prevention is good BG control Best prevention is good BG control

and regular medical follow-upand regular medical follow-up

DCCT and UKPDSDCCT and UKPDS

DCCT – 10 year study with Type 1 DMDCCT – 10 year study with Type 1 DM A1c <7% resulted in 35 – 75% decrease in A1c <7% resulted in 35 – 75% decrease in

microvascular complicationsmicrovascular complications Retinopathy, nephropathy, neuropathyRetinopathy, nephropathy, neuropathy UKPDS – 14 year study with Type 2 DMUKPDS – 14 year study with Type 2 DM A1c 7% vs 7.9% resulted in 25% decrease A1c 7% vs 7.9% resulted in 25% decrease

in microvascular complicationsin microvascular complications

ADA Standards of CareADA Standards of CareA1cA1c Every 3-6 Every 3-6

mos.mos.<6.5 – 7%<6.5 – 7%

CholesterolCholesterol YearlyYearly <200<200

HDL (good)HDL (good) YearlyYearly >45 men, >55 >45 men, >55 womenwomen

LDL (bad)LDL (bad) YearlyYearly <100 or <70<100 or <70

TriglyceridesTriglycerides YearlyYearly <150<150

Eye ExamEye Exam YearlyYearly DilatedDilated

Foot ExamFoot Exam Yearly by PCPYearly by PCP Daily by ptDaily by pt

Urine Urine MicroalbuminMicroalbumin

YearlyYearly <30<30

A1CA1C

3 month ave BG 3 month ave BG 1% = 35mg/dl1% = 35mg/dl

Foot CareFoot Care

Don’t go barefootDon’t go barefoot Inspect feet daily, Inspect feet daily,

top and bottomtop and bottom Wash, dry feet dailyWash, dry feet daily Wear supportive Wear supportive

shoes, cotton socksshoes, cotton socks Use nail clippersUse nail clippers File calluses with File calluses with

pumice stonepumice stone

Don’t use heating Don’t use heating pad, corn or wart pad, corn or wart removerremover

Don’t wear tight Don’t wear tight shoes, socksshoes, socks

Use lotion on feet, Use lotion on feet, not between toesnot between toes

The Big PictureThe Big Picture

Self Diabetes Management requires Self Diabetes Management requires daily care, education, and a good daily care, education, and a good support teamsupport team

It is a lot of work, often frustrating, It is a lot of work, often frustrating, but the rewards are better quality of but the rewards are better quality of life today and tomorrowlife today and tomorrow