2. Introduction to Diabetes
What is diabetes?
Types of diabetes
Diabetes statistics
Risks for diabetes
Diagnosing diabetes
Complications of diabetes
Diabetes prevention and control
3. What is Diabetes ?
When you eat carbohydrates they are digested
and broken down into glucose which goes into
your blood stream. The pancreas is then
signaled to secrete insulin to transport this
glucose from the blood into the muscle, fat and
liver cells for energy and/or storage. In a
person without diabetes, glucose levels stay
“normal” (70-120 mg/dl).
Diabetes Mellitus (DM) is a chronic
condition characterized by abnormally
high levels of glucose in the blood.
High levels of glucose can be caused by
either inadequate insulin production or
ineffective insulin or both.
4. Types of Diabetes
There are three official types of DM:
Type 1
Type 2
Gestational
Pre-diabetes is not considered a “type” of
diabetes, but is treated nonetheless
5. Type 1 Diabetes
Due to an absolute insulin deficiency
Previously called Insulin-Dependent Diabetes
Mellitus (IDDM) or Juvenile-Onset DM
Originally diagnosed in children and youth but
now can be diagnosed in adults (Type 1 ½)
Exogenous insulin must be used for these
individuals in the form of shots or a pump.
Accounts for 5-10% of all diabetes cases
6. Cause for Type 1 Diabetes
Genetics? Environment?
Viruses? These can trigger an autoimmune
response in which the body's immune
system attacks and destroys the insulin
producing beta cells of the pancreas.
7. Type 2 Diabetes
Due to a combination of ineffective insulin
and/or a lack of insulin production
Previously called Non-Insulin-Dependent DM
(NIDDM) or Adult-Onset DM
Historically linked to abdominal adiposity
It used to be seen in only adults but is now seen in
youth
Accounts for 90-95% of all diabetes cases
8. Cause for Type 2 Diabetes
Insulin resistance is the primary culprit
The pancreas secretes insulin but this insulin is not
100% effective at helping glucose move into
muscle, fat and liver cells
The body “resists” the effect of insulin, and
consequently sugar remains in the blood
Now there is a link between abdominal
adiposity and inflammation
9. Gestational Diabetes
During pregnancy, women can develop insulin resistance
Most common among African Americans, Hispanic/Latino
Americans, and American Indians. It is also more common
among obese women and women with a family history of
diabetes.
Insulin does not cross the placenta but glucose and other
nutrients do. This allows the baby to grow and
develop but since it is getting more energy than
it needs, the extra energy is stored as fat.
10. Gestational Diabetes
Affects about 4% of all pregnant women
Suggested causes:
Hormones from the placenta may block the action of the
mother's insulin in her body causing insulin resistance
The stress of the pregnancy may also cause insulin
resistance
GD usually disappears after pregnancy
GD increases risk for Type 2 diabetes
later in life
11. Diabetes Facts 2011
Diabetes affects 25.8 million people
8.3% of the U.S. population
DIAGNOSED: 18.8 million people
UNDIAGNOSED: 7.0 million people
Nearly 30% of people with diabetes do not
know they have it!
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
12. Diabetes: A Growing Epidemic
The prevalence of diagnosed diabetes increased from 0.9% in 1958 to 6.3% in 2008. In 2008,
18.8 million people had diagnosed diabetes, compared to only 1.6 million in 1958.
14. Diabetes by Age and Sex in US 2007
Age 20 years or older: 25.6 million or 11.3% of all
people in this age group have diabetes.
Age 65 years or older: 10.9 million or 26.9% of all
people in this age group have diabetes.
Men: 13.0 million or 11.8% of all men aged 20 years or
older have diabetes.
Women: 12.6 million or 12.8% of all women aged 20
years or older have diabetes.
15. Diabetes: A Growing Epidemic - 2010
An estimated 79 million adults have pre-diabetes
(borderline DM, IFG, IGT)
Alarming rise in incidence of type 2 in children:
up to almost 50% of new childhood diabetes
cases in some areas
"Clinicians need to pay attention not just to the skinny children who are developing obvious type
1 diabetes, but to the overweight children of perhaps two diabetic parents," he said, "and be
careful because they may be developing type 2 diabetes even though their age is not in the range
that we typically consider for type 2 diabetes." , Dr. David Nathan, Harvard Med School.
Among those diagnosed, less than 50% are at
recommended control levels
http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.aspx#Pre-diabetesY20
16. The Diabetes Epidemic
in Utah
Over 120,000 people in
Utah have diagnosed DM
1 out of every 17 adults
6.0 % of the Utah population
Add 45,000 Utah’ns with diabetes who
have NOT been diagnosed = 165,000
1 out of every 13 adults
8% of the Utah population
The Utah Department of Health 2008
17. What Contributes to this Epidemic ???
More people are overweight or obese
Growth in minority populations in whom the
prevalence and incidence of diabetes are
increasing
A growing elderly population
18. Obesity Trends* Among U.S. Adults
Behavioral Risk Factor Surveillance System
1990, 1998, 2006
(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)
1998
1990
2006
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
20. Diabetes as it Relates to Race/Ethnicity
Estimated age-adjusted total prevalence of diabetes in
people aged 20 years or older— United States, 2005 (CDC)
21. Diabetes Rate Increases with Age
Estimated percentage of people aged 20 years or older
with diagnosed and undiagnosed diabetes,
by age group, United States, 2005–2008
Source: 2005–2008 National Health and Nutrition Examination Survey
22. Determining Your Diabetes Risk
Take this test to see if you are at risk for
having or developing Type 2 diabetes
http://diabetes.org/risk-test.jsp
23. Symptoms of Diabetes
Extreme thirst
Frequent urination
Dry skin (above and beyond Utah standards)
Extreme hunger
Unexplained weight loss (Type 1)
Constant fatigue
Blurry vision
Tingling or numbness in the hands or feet
Wounds that are slow to heal
24. Diagnosing Diabetes
Fasting Plasma Glucose
Test (FPG)
FPG <100 mg/dl = normal
fasting glucose
FPG 100–125 mg/dl = IFG
(impaired fasting glucose or pre-
diabetes)
FPG ≥ 126 mg/dl = provisional
diagnosis of diabetes
Source: Diabetes Care 29:S43-S48, 2006
25. Diagnosing Diabetes
Oral glucose tolerance test:
8-12 hr fast followed by a 75 gm glucose drink and
testing two hours later
2-hr post load glucose <140 mg/dl = normal glucose tolerance
2-hr post load glucose 140–199 mg/dl = IGT (impaired glucose
tolerance or pre-diabetes)
2-hr post load glucose ≥ 200 mg/dl = provisional diagnosis of
diabetes
Source: Diabetes Care 29:S43-S48, 2006
26. Diagnosing Diabetes
1. FPG 126 mg/dl (7.0 mmol/l) *
OR
2. Symptoms of hyperglycemia and a casual
plasma glucose 200 mg/dl (11.1 mmol/l)
OR
3. 2-h plasma glucose 200 mg/dl (11.1 mmol/l)
during an OGTT*
*These criteria should be confirmed by repeat
testing on a different day
Source: Diabetes Care: 31:S12-S54, 2008
27. Glucose Guidelines for Diabetes
American Diabetes Association
Fasting: 70-130 mg/dl
2 hr post meal: < 180 mg/dl
HbA1C: < 7%
American Association of Clinical Endocrinologists
Fasting: < 110 mg/dl
2 hr post meal: < 140 mg/dl
HbA1C: < 6.5%
28. Diabetes Complications
Diabetes can be associated with serious complications and premature
death, but individuals with diabetes can take measures to reduce
the likelihood of such occurrences
29. Microvascular Damage
Chronic high blood sugar can lead
to small blood vessel lining damage
Diabetic Retinopathy (eyes)
Up to 24,000 new cases of blindness each year
Diabetic Nephropathy (kidneys)
DM is the leading cause of kidney failure each year
Microvascular complications are usually
controlled by managing blood glucose levels
30. Nerve Damage
Caused by blood vessel damage
that inhibits oxygen and nutrient
flow to nerves
Peripheral Neuropathy (peripheral nerves)
Foot ulcers or amputations: More than 60% of non-
traumatic lower limb amputations occur in people with
DM
Autonomic Neuropathy (autonomic nerves)
Decreased digestive, sweat, sexual, cardiovascular or
bladder function
31. Macrovascular Damage
Chronic high blood sugar can lead to
large blood vessel lining damage
Cardiovasular, Cerebrovascular and Peripheral
Artery Disease
People with DM have a 2 to 4 fold increase in the risk of heart
disease and stroke compared to people without diabetes
Over 75% of people with diabetes have HTN and abnormal
cholesterol levels
An estimated 1 out of every 3 people with diabetes over the age
of 50 have PAD
Macrovascular complications are usually managed by
controlling blood pressure and cholesterol
32. Among adults in the US:
Diabetes is the leading cause of…
Kidney failure
Non-traumatic lower limb amputations
New cases of blindness
Diabetes is a major cause of heart disease
and stroke
Diabetes is the 7th leading cause of death
(that is likely under-reported)
33. Complications … More Grim Facts
60-70% of adults with diabetes have nerve damage
The risk for death among people with diabetes is about 2x
that of people without diabetes of similar age.
People with poorly controlled diabetes (A1C greater than 9
%) are nearly 3x more likely to have severe periodontitis
than those without diabetes.
Poorly controlled diabetes before and during the first
trimester of pregnancy among women with type 1 diabetes
can cause major birth defects and spontaneous abortions.
34. Preventing Complications
Developing self-management skills is at the
foundation of diabetes management:
Self-monitoring of blood glucose
Meal planning/healthy eating/portion size control
Exercise
Medication compliance
Mindfulness practice
Blood sugar control is the key!
For every 1% drop in HbA1c, risk of microvascular
complications decreases by 40%
36. Preventing Complications
Glycemic Control (for microvascular complications)
Control the amount of carbohydrates consumed
Aggressive Lipid Lowering (for macrovascular
complications)
Lower the amount of “bad fats” in your diet
Management of Hypertension (for macrovascular
complications)
Decrease blood pressure and find ways to manage stress
37. HbA1c
The amount of glycated hemoglobin in your blood. This represents
the amount of sugar (glucose) attached to hemoglobin.
It is used to measure your blood sugar control over several months.
You have more glycated hemoglobin if you have had high levels of
glucose in your blood. In general, the higher your HbA1c, the higher
the risk that you will develop problems such as:
Eye disease, Heart disease, Kidney disease, Nerve damage, Stroke
An HbA1c of < 7% is recommended by the ADA.
Usually, doctors recommend testing every 3 or 6 months.
American Diabetes Association. Standards of medical care in diabetes -- 2008. Diabetes Care. 2008;31:S12-S54.
38.
39. Preventing Complications
Mindfulness Practise:
Acceptance and Commitment Therapy (ACT) is a
unique evidence-based psychological intervention
that uses acceptance and mindfulness strategies,
together with commitment and behavior change
strategies, in order to increase what is called
“psychological flexibility”. This refers to being in the
present moment fully as a conscious human being,
and based on what the situation affords, changing or
persisting in behavior that serve the values a person
has.
40. Acceptance and Commitment Therapy
and Diabetes Management
N=81, low income T2DM population
One day (7 hour) workshop
Two groups: DM education alone vs DM education plus ACT Training
Both groups received DM mgmt skills
One group received additional acceptance and mindfulness skills for difficult
thoughts and feelings about their diabetes
3 month trial period
DM plus ACT training group was more likely to use coping strategies. They
reported better self-care and more HbA1c’s within target than DM ed training
group alone.
Conclusions: ACT and DM ed is significantly better than DM ed alone for
yielding good self-mgmt skills and better HbA1c’s in a low income DM
population.
Gregg, J. A., et al (2007). Improving diabetes self-management through acceptance, mindfulness, and values: A
randomized controlled trial. Journal of Consulting and Clinical Psychology, 75(2), 336-343
41. Diabetes Prevention & Control
The same methods to control diabetes can
also be used to prevent diabetes:
Physical activity
Healthy eating
Maintaining a healthy weight
Medications as determined by healthcare provider
Positive lifestyle intervention reduced the incidence of diabetes
by 58% (Diabetes Prevention Program study)
42. Diabetes Prevention & Control
Healthy eating
5 fruits and vegetables a day
Whole grains and fiber
Sources of lean protein
Watching intake of calories
Avoid saturated fats and trans fats, etc
(aka, the “bad fats”)
MyPyramid can be used a guide to
healthy eating: http://www.mypyramid.gov
43. Diabetes Prevention & Control
Physical activity
At least 60 minutes of moderate to vigorous physical activity a
day for children
At least 150 minutes of moderate to vigorous physical activity
a week for adults
Individuals must check with a physician
prior to starting an exercise program
A baseline exercise tolerance test may
be recommended to assess
cardiovascular health
44. 6 Week Exercise Class for Individuals
with Type 2 Diabetes and
Those Who May Be at Risk
Meets Tuesday/Thursday
3 - 8pm
520 Wakara Way (Research Park)
Rehabilitation and Wellness Clinic
Cost ($100) includes
Pre-program evaluation and
12 supervised sessions
Physician permission required
Participation is at one’s own risk
Supervised by an Exercise Physiologist, CDE
Call 801-581-6696 for more information
45. Bottom Line
For those who live with diabetes, it can be controlled
Working with a healthcare provider is the first step
Help you patients get involved in their care
Gaining support from family is another important
step to take
Diabetes CAN be prevented !!!
47. THANK YOU!!
Sheldon Smith, MS, CDE
University of Utah
Division of Physical Therapy
Diabetes/Pre-diabetes Exercise Program
801-581-6696
Notas do Editor
A recent study found increases in inflammatory activity in adipose tissue from IR compared with equally obese IS individuals. Adipose tissue is now recognized as an endocrine organ involved in regulating physiologic and pathologic processes including inflammation. Adipose tissue synthesizes and secretes hormones leading to a chronic sub-inflammatory state.
All patients with type 1 diabetes take insulin, however around 30% of type 2’s take insulin too. In fact, around 60-70% of people on insulin have type 2 diabetes.
Back in 1958 less than 1% of the US population had diabetes. In 2008 over 6% has diabetes In 2010 over 8% has diabetes
With age: as people get older they have an increased their incidence of diabetes increases. Why? Less activity, increased fat weight, increase in co-morbidities (HTN, CHOL, OA etc)
> 300 million people in us ~therefore 20% of US population have pre diabetes!!!
That’s in a state of ~3,000,000 people. Summit county has a prevalence of 3.5% (lowest) Tooele and Garfield Counties have a prevalence of 7.8% (highest).
Excess blood sugar pulls water from your body like a sponge causing dehydration. The rate of urination increases, people become very thirsty and skin can become very dry. Hunger, weight loss, fatigue are caused by lack of fuel getting to the cells. The body is starving. Blurry vision can be due to excessive sugar causing blood to thicken and making vision poor. Tingling/numbness due to nerve damage. Slow healing wounds due to decrease circulation
Patients with IFG and/or IGT are now referred to as having "pre-diabetes" indicating the relatively high risk for development of diabetes in these patients.
A1c level needs to be <7%. Or as low as possible without the risk of hypoglycemia. Regular visits to diabetes care team, including a primary care doctor, podiatrist, dentist, ophthalmologist, diabetes educator (RN, dietician and exercise specialist)
ADA suggests < 7% for non pregnant and pregnant adults
Exercise burns sugar by moving it from the blood to the body’s cells/tissues/organs/muscles and that’s why it can be an important diabetes management strategy.