LMC DiabetesLMC Diabetes

Introduction to Diabetes Mellitus

Presented by LMC Diabetes and Endocrinology

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Objectives

1. Overview of Diabetes Mellitus (DM)2. Complications3. Management of Diabetes Mellitus4. Patient Management

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Overview of DM - What is Diabetes?

Diabetes is a condition where your body does not produce or use insulin properly in the body,

resulting in high blood sugars

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Overview of DM - What is Diabetes?

In a person without DM…… Insulin, a hormone

produced by the pancreas, is secreted in response to carbohydrate digestion

Insulin acts like a key - it allows sugar to enter into the body’s cells to create energy

In a person with DM…. The secretion and/or

the process of insulin opening the cells to allow sugar in is not working properly high blood sugars

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Overview of DM - Types of Diabetes

• Type 1 Diabetes - autoimmune disease where the pancreas does not produce insulin

• Type 2 Diabetes – occurs when your body does not produce and/or use the insulin in the body properly

• Gestational Diabetes-occurs during pregnancy• Pre-Diabetes – the beginning stages of type 2

diabetes

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Type 1 Diabetes

• Occurs in approx. 10% of people with DM

• Formerly known as Juvenile Diabetes

• Insulin therapy is initiated immediately

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Type 2 Diabetes

• Occurs in approximately 90% of people with Diabetes

• Used to be known as “Adult Onset” but a growing number of young people are developing Type 2 Diabetes due to lifestyle factors

• Management: healthy eating, exercise, medication and/or insulin injections

• Progressive disease

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Overview of DM – Risk Factors for Type 2 Diabetes

• Age >40• Being overweight • Having an “apple” shaped

body• Family history (very strong)• Gestational diabetes or

baby >9 lbs• Ethnicity (African, Asian,

South Asian, Aboriginal descent)

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Overview of DM – Symptoms on presentation

Common symptoms :

• Fatigue• Increased thirst • Increased urination• Unexplained weight

loss• Blurred vision

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Overview of DM - Diagnosis of Prediabetes*

Test Result Prediabetes Category

Fasting Plasma Glucose(mmol/L)

6.1 - 6.9

Impaired fasting glucose (IFG)

2-hr Plasma Glucose in a 75-g Oral Glucose Tolerance Test (mmol/L)

7.8 – 11.0 Impaired glucose tolerance (IGT)

GlycatedHemoglobin(A1C) (%)

6.0 - 6.4 Prediabetes

* Prediabetes = IFG, IGT or A1C 6.0 - 6.4% high risk of developing T2DM

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FPG ≥7.0 mmol/LFasting = no caloric intake for at least 8 hours

or

A1C ≥6.5% (in adults)Using a standardized, validated assay, in the absence of factors that affect the

accuracy of the A1C and not for suspected type 1 diabetesor

2hPG in a 75-g OGTT ≥11.1 mmol/Lor

Random PG ≥11.1 mmol/L Random= any time of the day, without regard to the interval since the last meal

2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose

Overview of DM – Diagnosis?

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Diabetes Complications

Prolonged high blood sugars can affect:

• Eyes - Retinopathy• Heart and cardiovascular

system• Kidney - nephropathy• Nervous system - neuropathy • Sexual organs - erectile

dysfunctionBEST WAY TO REDUCE COMPLICATIONS IS WITH

GLYCEMIC CONTROL

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Complication Prevention (therapies that may be used)

• Kidneys – Control Blood Pressure– ACE or ARB (i.e. Altace)

• Cardiovascular disease– ECASA – 81 mg– ACE or ARB (i.e. Altace)– Cholesterol Lowering Medication

• Foot Care– Patient should check feet daily, wear proper shoes and

socks– Patient to see MD if a cut, blister or crack on the foot is not

healing

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Complication Prevention (therapies that may be used)

Neuropathy – peripheral• 10-g monofilament or assessment of loss of sensitivity to

vibration at the dorsum of the great toe• Anticonvulsants, antidepressants, topical nitrate sprayRetinopathy• Annual screening with ophthalmologist• Fenofibrate may be added to a statin in some patientsErectile Dysfunction• A PDE5 inhibitor, if there are no contraindications

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Monitoring/Preventing Complications:What are the ABC’s?

• A = A1C (3 month blood sugar average) <7%

An AIC <7% reduces the risk of patients developing complications of diabetes (type 1 &2), specifically, an AIC of < 7% showed in people with type 2 DM:

• 76% reduction in eye disease• 50% reduction in kidney disease• 60% reduction in nerve disease

• B = Blood Pressure <130/80

• C = LDL “Bad” Cholesterol <2.0 mmol/L

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Management of DM - Blood Sugar Targets

FPG / pre meal : 4-7 mmol/L

2 hours after eating: 5-10 mmol/L If HbAIC not at target: 5-8 mmol/L

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Management of DM - Medications

• For a full review of pharmacological approaches, please review the 2013 CDA Clinical Practice Guidelines

• Medications are decided based on the person’s:– Blood sugar level– Individual characteristics– Properties of the medication

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Medication Class of Drug Action & Target Organ Dosage What to Watch out for

glyburide (Diabeta) Diamicron (gliclazide)

Amaryl (glimepiride)

Sulfonylurea Targets the pancreas to stimulate insulin secretion

glyburide: 2.5-20 mg/dayDiamicron: 80-160 mg twice daily

Amaryl: 4-8 mg/dayTaken with meals

Can cause low blood sugars, weight gain (glyburide); Rarely,

rash if allergic to sulfa

metformin (Glucophage)(Glumetza)

Biguanide Targets liver to restore insulin sensitivity

Metformin: 250 -2000 mg/dayTaken with meals

Glumetza: 1000 -2000 mg once per day with evening meal

GI upset: diarrhea, nausea, bloating

Should not be taken if decreased kidney or liver function

Avandia (rosiglitazone)

Actos (pioglitazone)

Glitazone(Thiazolidine-dione

Family)

Increases overall sensitivity to insulin

Avandia: 2-8 mg / dayActos: 15 - 45 mg / day

Weight gain (average of 1-3 Kg), fluid retention

GlucoNorm(repaglinide) Meglitinide Targets the pancreas to

stimulate insulin secretionApproximately 0.5-4 mg

Taken with each meal MUST be taken with food

Prandase(acarbose)

Alpha-glucosidase inhibitor

Targets digestive track to delay absorption of starch

50-100 mgTaken with each meal

Flatulence very common; rarely, bloating

Januvia(sitagliptin)Onglyza

(saxagliptin)

Di-peptidyl peptidase-4

inhibitorTriggers pancreas to secrete more insulin

Januvia: 100 mg / dayOnglyza: 5 mg / day

May cause stomach discomfortand diarrhea

Doses should be lowered if decreased kidney function

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Management of DM – Self Monitoring Blood Glucose (SMBG)

Allows patients to:1. Understand the effect of food, exercise, medication and

stress2. Assist in self management and empowering the patient3. Keep on track with their blood sugar to reach target AIC of

<7%4. Provide physician and diabetes educator with information to

adjust their therapy appropriately – can target pre meal and/or post meal blood sugars

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Management of DM – How often to test? The more, the better

Diet alone and/or Medication:• Individualize to patients’ situation• Difficult to assess patient if testing at

the same time each day • Suggestion: test before and 2 hrs after

a different meal each day Insulin Therapy:• 4-7 x /day for MDI• Before each insulin injection for safety• 2 hrs pc are helpful if the patient is willing to increase

frequency of testing

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Management of DM - Smart Testing

• Smart testing empowers patients to analyze their values, not just record them

• When the blood sugars are out of target empower the patient to ask why?

• The patient can then self manage themselves to assist in meeting the target AIC!

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Management of DM - Activity

• Newly diagnosed patient comes in for glucometer teaching• Doctor suggested patient to test once/day

• What do you suggest?

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Management of DM - Activity Answer

• Very subjective answer

Possible answers:1. First ask the patient what he/she feels comfortable with2. Explain the benefit of testing blood sugars3. Explain the use of a logbook/downloading the meter4. Test before and after one meal/day – rotate the meal from

day to day to get a clear picture of what is happening throughout the day without having to test 7 times/day

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Management of DM -Hypoglycemia

Mild to Moderate = blood sugar <4.0 mmol/LSevere = blood sugar < 2.8 mmol/L

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Management of DM - Hypoglycemia

• Causes of hypoglycemia include:• Increased physical activity• Not eating on time• Eating less than normal• Taking too much medication/insulin• The effects of drinking alcohol

• Ask your patient to self-reflect: why did my blood sugars go low? – How can I prevent this in the future?

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Management of DM – Hypoglycemia Treatment

• Check blood glucose right away. If no meter but symptoms are present, patient should treat!

• If blood sugar is < 4 mmol/L patient to eat or drink 15 g of a fast acting carbohydrate such as:– 3 glucose tablets, 1/2 cup of juice , 3 packets of sugar dissolved in

water, 6 Life Savers™ (chewed up)

• Patient should wait 15 minutes, then check blood sugar again. If blood sugar is still < 4mmol/L, treat again.

• If the next meal is more than one hour a way patient should eat a snack (15g of carbohydrates and a protein source ex: 1 oz of cheese and 7 soda crackers).

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Management of DM - Nutrition

• Nutrition therapy can reduce AIC by 1.0 to 2.0% and may be even more beneficial when combined with other aspects of diabetes care

• Weight loss and exercise increases insulin sensitivity• Patients should aim for a BMI of 18.5-24.9 and/or a 5-10%

weight loss of current weight• Patients should aim for a waist circumference of <102 cm

for men and < 80 cm for women• Types and portions of food can assist to control blood sugars

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Management of DM – Healthy Living with Diabetes

• Healthy living includes:• Regular Meals• Balanced Meals• Portion Control• Physical Activity

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Management of DM - Regular Meals• 3 meals/day spaced 4-6 hours apart

– Why? Skipped or delayed meals can cause low blood sugars (if on certain diabetes meds) or higher blood sugars (sugar is released by the liver with prolonged fasting).

• If the next meal > 5 hours away– suggest a healthy snack to prevent overeating and to keep blood sugars balanced (snack:<100-150 calories, <3-5 g fat).

vs.

breakfast

lunch

dinner

breakfast

lunch

dinner

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Management of DM – How To Approach Food

Canada’s Food Guide To Health Eating – The Food Groups:

• Grains• Fruits and Vegetables• Meat and Alternatives• Dairy• (other)

*Healthy Eating Goal: 3 out of the 4 food groups/meal*Problem: Doesn’t account for the carbohydrates

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Management of DM – How To Approach Food

• When managing diabetes with food, it is important to look at food in these food groups:

• Carbs• Protein• Vegetables• Fat

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Management of DM – Balance and Portion Control: Space on Your Plate

vs.

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Management of DM – What is a carb?

Carbohydrates = Sugar/Glucose

• Sources of Carbohydrates :1. Grains and Starch (rice, legumes, bread, corn, potato,

pasta, bread, chipati)2. Fruit, fruit juice, and dried fruit3. Milk and Yogurt4. Sugars (syrup, pop, candy, baked goods)

Are all carbs considered equal? No!

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Management of DM –Fibre

Fibre is a form of carbohydrates that cannot be digested

Benefits:• Helps to slow down digestion of sugar• Helps to lower cholesterol• Increases satiety• Improves bowel function

Sources:• whole grains, legumes, fruits and vegetables

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Management of DM – Glycemic Index (GI)

GI = scale that ranks carbohydrate according to their effect on blood glucose levels

• High GI foods will raise blood sugars quickly - examples: white bread, fruit juice

• Low GI foods are digested more slowly and sugar is released more gradually into the bloodstream. This is more desirable. For example: whole grain bread, legumes

*** Higher fibre foods tend to be lower GI

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What does a recommended portion of

carbohydrate look like?

• To assist with estimating portions: patients can compare their first to a 1 cup portion or a medium size fruit

• Patients should aim for 1 to 1.5 fists of total carbs per meal

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Management of DM - What is a protein?

• Protein's main function is to build, maintain and repair the body's tissue, such as muscles, organs, skin and hair.

• Protein does not raise blood sugars unless eaten in excess.• Sources: Meat, poultry, fish, eggs, cheese, nuts

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What does a recommended

portion of protein look like?

The goal is 3 oz. (the size of the palm of your hand or a deck of cards) per meal

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What does a recommended

portion of vegetables look like?

• Vegetables add bulk, fibre and important vitamins and minerals

• Goals: to consume as much vegetables that is able to fit into two handfuls.

• Sweeter vegetables to consider: carrots, peas, beets, squash, turnips - > 2 cups – count as a carb

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Management of DM – What about fat?

• Fat does not raise blood sugars unless eaten in excess.• Fat, specifically total fat, saturated fat, and trans fat will

negatively affect blood cholesterol levels

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What does a recommended

portion of fat look like?

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Management of DMPortions Review

Each meal aim for:• 1 – 1.5 fist of carb• 2 handfuls of vegetables• 1 palm of protein• 1 thumb of added fat• All should fit nicely on a

balanced plate!

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Management of DM –Summary of factors that slow down sugar

absorption into the bloodstream

1. Low GI foods2. Fibre3. Protein4. Fat5. Appropriate portions of carbs

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Management of DM - The importance of slowing down blood sugar

absorption

1. Increases satiety2. Reduces spike in blood sugar less stress on the pancreas –

can contribute to slowing down progression of diabetes3. Food can becomes a better match to rapid acting insulin

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Management of DM – Activity

Breakfast example• 2 slices whole wheat toast• 2 tsp butter• ½ cup orange juice

How could this breakfast be improved?

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Management of DM – Activity Answer

Breakfast example• 2 slices whole wheat toast• 2 tsp butter• ½ cup orange juice

To Improve:

1. Use peanut butter instead of butter for protein• peanut butter will slow down

the absorption of the carbohydrate

2. Switch orange juice to an orange • perhaps move orange to am

snack to reduce total carb intake

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Management of DM - Alcohol

• If your patient doesn’t drink, they shouldn’t start!• Health Canada’s Recommendation for consumption:

• 2 servings/ day max for men • 1 serving/day max for women

• One serving =• 1.5 fl z of hard liquor• 5 fl oz. of wine• 12 fl oz of beer

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Management of DM Alcohol – Issues to Consider…

1. Alcohol may cause hypoglycemia – may need patient to check blood sugars frequently and throughout the night to monitor

2. Alcohol should always be consumed on a full stomach3. Alcohol raises triglyceride levels – limit/avoid if triglycerides

are elevated

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Management of DM -Benefits of Physical Activity

• Improved blood sugars• Increased insulin sensitivity• Increased glucose uptake• Decreased risk of heart disease• Increased metabolism• Important for bone strength• Weight loss/maintenance• Improved sleep patterns• Increased energy• Etc…

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Management of DM - Exercise Safe

Patients should be encouraged to:1. Discuss exercise with their physician prior to beginning an

exercise routine - discuss having an ECG, if one has not been done recently

2. Measure blood glucose pre and post activity3. Reduce medication/have a snack prior to exercise to avoid

hypoglycemia, if necessary4. Carry ID, Medic Alert bracelet and some form of simple carbs

to treat a low blood sugar (if on orals or insulin)5. Drink water6. Check feet and wear proper shoes

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Management of DM – Balance of Activity: 3 different types

Cardio (walking, hiking, biking, swimming)• 150 minutes/week on at least 3X/wk• Anything more than a walk should be

discussed with the patients’ physician

Strength Training• 2x/week, 1-3 sets of 10-15 reps

Stretching (yoga, pilates)

Patient is encouraged to include all 3 types into their lifestyle

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Management of DM - Activity

• Patient walks for 20 minutes 3X/day

• Please assess and make suggestions

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Management of DM – Activity Answer

• Patient walks for 20 minutes 3X/day

1. Commend patient for getting active2. Make sure that it is safe for the patient to exercise –

according to his/her physician3. Ask patient what he/she likes to do4. Discuss increasing different options:

a. Increasing cardio by time and frequencyb. Adding in different exercises – resistance and stretching

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Patient Management – Setting your patient up for success...

1. Connect with your patient2. Identify patient’s Stage of Change3. Set SMART Goals4. Empower your patient – encourage self management5. Go that extra mile – make your patient feel special

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Patient Management – Connecting with your patient

• Make a good first impression• Make eye contact• Just because you talk about diabetes all day, it doesn’t mean

your patient does • Be empathetic • Be clear in your communication• Offer support• Do a mental health assessment and integrate psychosocial

goals into the care plan• Allow the patient to discuss feelings, experiences, but don’t

let them lead the session

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Patient Management – Stage of Change

1. Pre-contemplation – not ready to make change2. Contemplation – thinking about making change3. Preparation - getting ready to make change soon4. Maintenance – maintaining the change5. Action – making change and positive outcomes have

occurred

Goal Setting Should Always Occur Based on Patient’s Stage of Change

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Patient Management – Goal Setting = SMART Goals

• Specific• Measurable• Attainable• Realistic• Time • Ex: I will run 3 times per week for 30 minutes in the morning

before my shift for the next 3 months VS. I will start to exercise

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Patient Management – Activity

Make these goals into a SMART goals:

1. I will lose 25 lbs.2. I will start to more fruits and vegetables3. I will test my blood sugars

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Patient Management – Activity Answer

SMART goals:

1. I will lose 25 lbs.– I will have a weight loss goal of 1-2 lbs. per week

2. I will start to more fruits and vegetables– I will have a fruit for my morning and afternoon snack– I will have 1 cup of vegetables at lunch and 1 cup of

vegetables at dinner3. I will test my blood sugars

– I will start to test by blood sugars before and after one meal/day and write my numbers in a logbook.

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Patient Management – Counselling through a session....

1. Gather your information2. Prioritize your goals – top 3 3. Ask the patient for their goals – top 34. Set SMART Goals – 3 goals/session – based on both yours and

their goals5. Negotiate with the patient – let the patient talk and think through

how to achieve the goal6. Let the patient discuss barriers7. Don’t feel the need to do too much – you always have a follow

up!8. Make sure you’ve answered all their questions9. Provide your contact information

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Patient Management – Empowering Self Management

• Provide the tools for the patient to make decisions• Explain how and why your making suggestions• Provide an example of how to use the new information to

assist patient in making their own changes at home

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Conclusion

• Diabetes is a multifaceted condition • The diabetes educator play a crucial role in the management

of the patient• From explaining the physiology to the management and

counselling of the patient• Work together to make diabetes more manageable for the

patient!