Diabetes MellitusDiabetes Mellitus

Failure to control blood glucoseFailure to control blood glucose Long term health complicationsLong term health complications

AtherosclerosisAtherosclerosis StrokeStroke Neuropathy (damaged nerves)Neuropathy (damaged nerves) Retinopathy, glaucomaRetinopathy, glaucoma

Scottish perspective

Control of Blood glucoseControl of Blood glucose

If blood glucose risesIf blood glucose rises Excess is stored in muscles & liver as Excess is stored in muscles & liver as

glycogenglycogen If blood glucose fallsIf blood glucose falls

Deficit remediated by breaking glycogen Deficit remediated by breaking glycogen down in liver and releasing into blood down in liver and releasing into blood streamstream

Two hormones:Two hormones: Insulin & GlucagonInsulin & Glucagon

Control of Blood glucoseControl of Blood glucose

Insulin:Insulin: Synthesised by Synthesised by cells of Islet of Langerhans cells of Islet of Langerhans

in pancreasin pancreas GlucagonGlucagon

Synthesised by Synthesised by cells of Islet of Langerhans cells of Islet of Langerhans in pancreasin pancreas

Blood glucose level sensed in pancreasBlood glucose level sensed in pancreas Regulates secretion of insulin/ glucagon Regulates secretion of insulin/ glucagon

directlydirectly Negative feedback system (p54)Negative feedback system (p54)

INSULIN – target cellsINSULIN – target cells Insulin acts onInsulin acts on

LiverLiver Adipose tissues (fat)Adipose tissues (fat) Skeletal muscle cellsSkeletal muscle cells

Insulin increases permeability of fat/ Insulin increases permeability of fat/ skeletal muscle cell membrane to glucoseskeletal muscle cell membrane to glucose So stimulates glucose uptake into these tissuesSo stimulates glucose uptake into these tissues

Liver already very permeableLiver already very permeable Insulin stimulates glycogen formation & Insulin stimulates glycogen formation &

glucose uptakeglucose uptake

INSULININSULIN

Insulin acts via an insulin receptorInsulin acts via an insulin receptor Diabetes occurs through two Diabetes occurs through two

mechanismsmechanisms 1 – Loss of insulin1 – Loss of insulin 2 – Loss of insulin receptors2 – Loss of insulin receptors

Diabetes in Young Adults (15-30 years)

Age of diagnosis 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90

Type 2

Type 1

unusual genetic type of diabetes called maturity onset diabetes of the young 6 different genes causing this type of diabetes.genetically defined subtype present different clinical

course. one subtype responds to sulphonylureaspatients replace insulin treatment sometimes after

being on insulin for over 30 years, finding the genetic cause of their diabetes has had a major impact on their treatment.

Genetic Nurses in Diabetes treatment

Type 1 Diabetes – Insulin Type 1 Diabetes – Insulin dependentdependent

Type 1- Diabetes (5-10%)Type 1- Diabetes (5-10%) Loss of insulin – destruction of Loss of insulin – destruction of

pancreatic pancreatic cells cells Early onsetEarly onset Weight loss, fatigue, polydypsia, Weight loss, fatigue, polydypsia,

polyuria, glucosuria, hyperglycaemiapolyuria, glucosuria, hyperglycaemia Ketosis (sweet breath – due to acetone)Ketosis (sweet breath – due to acetone) Treat with injections of insulinTreat with injections of insulin

Glucose tolerance testGlucose tolerance test

A large bolus dose of glucose A large bolus dose of glucose administered (100g glucose drink)administered (100g glucose drink)

Blood glucose monitoredBlood glucose monitored Rapid fall after peak (9-10mM) Rapid fall after peak (9-10mM)

levels reachedlevels reached If diabetes clearance is very slow – If diabetes clearance is very slow –

in urine, peak blood glucose level in urine, peak blood glucose level higherhigher

Type 2 Diabetes – Insulin Type 2 Diabetes – Insulin IndependentIndependent

90-95% cases of diabetes90-95% cases of diabetes Late onset (after 40yrs age)Late onset (after 40yrs age) 3-7% population affected 3-7% population affected

60% SUMO wrestlers c.f. 5% Japanese 60% SUMO wrestlers c.f. 5% Japanese populationpopulation

Mainly occurs in overweight Mainly occurs in overweight individualsindividuals

Insulin ResistanceInsulin Resistance

SymptomsSymptoms

Insulin resistanceInsulin resistance Normal or elevated blood insulin levelsNormal or elevated blood insulin levels Failure of insulin to act on target tissuesFailure of insulin to act on target tissues Deficiency in insulin receptorsDeficiency in insulin receptors Can lead to Can lead to cell function becoming cell function becoming

compromised due to excessive insulin compromised due to excessive insulin productionproduction

Hyperglycaemia, polydypsia, polyuria, Hyperglycaemia, polydypsia, polyuria, glucosuriaglucosuria

ProgressionProgression

Elevated blood glucose associated Elevated blood glucose associated with diabetes damages blood vessels with diabetes damages blood vessels and nervesand nerves Small blood vessel damage causes Small blood vessel damage causes

blindness, kidney failure & amputationblindness, kidney failure & amputation Larger blood vessel damage can Larger blood vessel damage can cause cause

heart disease, high blood pressure heart disease, high blood pressure && strokestroke

75% of Type 2 patients die of 75% of Type 2 patients die of cardiovascular diseasecardiovascular disease

Exercise & NIDDMExercise & NIDDM Insulin sensitivity in fit individuals is greaterInsulin sensitivity in fit individuals is greater

i.e. cells better able to uptake glucose from bloodi.e. cells better able to uptake glucose from blood Insulin sensitivity decreases with ageInsulin sensitivity decreases with age

This decrease reduced by exerciseThis decrease reduced by exercise 5-7 days after exercise insulin sensitivity 5-7 days after exercise insulin sensitivity

starts to declinestarts to decline Regular, moderate, aerobic exercise is important in Regular, moderate, aerobic exercise is important in

preventing onset of NIDDMpreventing onset of NIDDM Diseases control in 80-90% patients Diseases control in 80-90% patients

achieved by reducing calorie intake/ achieved by reducing calorie intake/ exerciseexercise

Glasgow ResearchGlasgow Research

OsteoporosisOsteoporosis

Osteoprosis – long term progressive Osteoprosis – long term progressive increase in bone porosity/ brittlenessincrease in bone porosity/ brittleness Risk of fractures (shatter)Risk of fractures (shatter) Loss of heightLoss of height Curvature of spineCurvature of spine Back painBack pain

Post menopausal womenPost menopausal women 20-50% over 50s20-50% over 50s 75% over 90s75% over 90s

Bone growthBone growth Childhood and early adolescence bones Childhood and early adolescence bones

extendextend Late adolescence bones increase in densityLate adolescence bones increase in density Peak bone density in late twenties/early thirtiesPeak bone density in late twenties/early thirties

1%/yr (female) decline in density thereafter1%/yr (female) decline in density thereafter 2-3%/yr decline post menopausal2-3%/yr decline post menopausal Male bone density declines 0.4%/ yr and only Male bone density declines 0.4%/ yr and only

when over age 50when over age 50 Extra calcium/ Vitamin D in childhood & teens Extra calcium/ Vitamin D in childhood & teens

produce greater bone densityproduce greater bone density Margaret Thatcher – cause of osteoporosis in 2010-2020?Margaret Thatcher – cause of osteoporosis in 2010-2020?

Risk FactorsRisk Factors ElderlyElderly Early menopauseEarly menopause AmenorrhoeaAmenorrhoea GeneticsGenetics Low body fat Low body fat

Low calcium in dietLow calcium in diet Vit. D deficiencyVit. D deficiency High alcohol/ High alcohol/

caffeine/ fizzy drinkscaffeine/ fizzy drinks High saltHigh salt

Age related reduction in bone densityAge related reduction in bone density Oestrogen promotes calcium uptakeOestrogen promotes calcium uptake Low oestrogenLow oestrogen

Enzymes in fat produce oestrogen Enzymes in fat produce oestrogen from circulating precursorsfrom circulating precursors

Body raids calcium stores in bonesBody raids calcium stores in bones Poor calcium absorptionPoor calcium absorption Promote bone loss by using calcium Promote bone loss by using calcium

stores to balance pHstores to balance pH Calcium removed along with Na in the Calcium removed along with Na in the

urineurine

Exercise & Osteoporosis – Exercise & Osteoporosis – PreventionPrevention

Mechanical stress increases bone Mechanical stress increases bone strength (density)strength (density) Astronauts have lowered bone density Astronauts have lowered bone density

following zero gravity because no following zero gravity because no mechanical stressmechanical stress

Weight bearing or resistance exercise Weight bearing or resistance exercise will benefit women in late twenties/ will benefit women in late twenties/ early thirties (swimming will not!)early thirties (swimming will not!)

Also benefits coordination reducing risk of Also benefits coordination reducing risk of fallsfalls

Exercise & Osteoporosis – Exercise & Osteoporosis – TreatmentTreatment

45 min moderate exercise 3 times 45 min moderate exercise 3 times weekly increases calcium weekly increases calcium deposition in osteoporosis patientsdeposition in osteoporosis patients

In conjunction with HRTIn conjunction with HRT

Risk of Exercise in WomenRisk of Exercise in Women

Excessive exercise particularly in Excessive exercise particularly in young women can young women can causecause osteoporosisosteoporosis

Reduction in body fat leads to Reduction in body fat leads to reduction in oestrogen synthesisreduction in oestrogen synthesis

Menstruation ceasesMenstruation ceases Oestrogen falls further, reducing Oestrogen falls further, reducing

calcium absorptioncalcium absorption Bone loss is irreversibleBone loss is irreversible

Advice from Osteoporosis Advice from Osteoporosis Soc.Soc.

It's a good idea to avoid:It's a good idea to avoid: Too much protein – Too much protein –

Excessive protein upsetExcessive protein upsetss acid balance acid balance.. CCalcium from bones neutralisealcium from bones neutralisess it. it. Eating plenty fruit and veg should keep your body's acid balance stable. Eating plenty fruit and veg should keep your body's acid balance stable.

Lots of salt – Lots of salt – high sodium increasehigh sodium increasess calcium calcium lost inlost in urine. urine.

Drinking lots of fizzy drinks – Drinking lots of fizzy drinks – phosphoric acidphosphoric acid gives gives flavour flavour toto a lot of fizzy drinks a lot of fizzy drinks too much can cause the body to use calcium to balance levels. too much can cause the body to use calcium to balance levels.

Drinking too much caffeine – Drinking too much caffeine – high caffeine high caffeine intake intake affectaffectss the balance of calcium in the body. the balance of calcium in the body. MMilk ilk inin coffee coffee willwill counteract this counteract this, , limit intake to one or two cups a day. limit intake to one or two cups a day.

Letting your weight drop too low – Letting your weight drop too low – BBeing underweight increases the risk of broken bones when you fall.eing underweight increases the risk of broken bones when you fall. In younger womenIn younger women,, severe weight loss may stop menstrual periods because severe weight loss may stop menstrual periods because

hormone levels drop which can also increase your risk of breaking a bonehormone levels drop which can also increase your risk of breaking a bone