2. ADA Guidelines for Diagnosis Normal serum glucose: 70-110 Diabetes FBS > 126 on 2 occasions Random glucose > 200 with symptoms Pre-diabetes FBS > 100 Random glucose 140- 200 2
3. Type 1 Diabetes Autoimmune reaction in which beta cells that produce insulin are destroyed Genetic predisposition: HLA linkage Environmental triggers can stimulate an autoimmune response Viral infections: mumps, rubella, coxsackievirus 3
4. Treatment Type 1 Diabetes Diet Exercise Insulin Monitoring 4
5. Type 2 Diabetes- Etiology Insulin resistance Decreased production of insulin by beta cells Liver releases too much glucose Genetics http://www.diabetes.org 5
6. Type 2 Diabetes- symptoms Few symptoms initially Fatigue Altered vision Nocturia Skin infections, vaginal infections, poor wound healing 6
7. Type 2 Diabetes Risk Factors Obesity Family history Over age 45 High-risk ethnic group: African, Native American, Hispanic Delivery of baby > 9 pounds History of: gestational diabetes, polycystic ovary syndrome Hypertension 7
8. Type 2 diabeteschildren & adolescents Incidence on the rise No symptoms in early stage of disease Symptoms: frequent infections, weight loss with increased appetite, blurry vision, polyuria, bed wetting 8
9. Acanthosis nigricans Area of darkened skin & velvety thickening on the child’s neck, armpits, groin, or other areas of skin folds. Sign of insulin resistance Found in 90% of children with type 2 Most often seen in African American & Hispanics 9
11. Type 2 diabetes in children Prevention: Exercise 1 hr/day, healthy diet Test high risk groups age 10 years or more every 2 years Overweight Family history Hispanic, African American, Asian American 11
13. Gestational diabetes Last half of pregnancy placenta produces insulin antagonist (human placental lactogen) Leads to increased placental destruction of insulin Insulin production needs to increase 2-3 X non- pregnant level 13
14. Gestational Diabetes: Diagnosis 1 hour glucose challenge test using a 50 gram oral glucose if results > 140 mg/dl will have to retest with: 3 hour glucose tolerance test using 100 gram oral glucose: diagnosis confirmed when any 2 or more glucose values are over 140 mg/dl 14
16. Gestational diabetes- effects on infant Macrosomia- 9.9 lbs or > Hypoglycemia- for first 72 hours of life Infant accustomed to increase in glucose which leads to hyperinsulinemia in the infant. At birth the glucose supply from mother is no longer present but infants pancreas continues to produce large amounts of insulin. 16
17. Gestational Diabetes No longer have diabetes after delivery of infant Women with gestational diabetes have up to a 45% risk of recurrence with next pregnancy and up to 63% risk of developing type 2 diabetes later in life 17
19. Diet education Initially should be done by dietitian Never skip meals if on oral sulfonylureas Learn to recognize food portions Alcohol suppresses liver production of sugar 19
20. Diet Education Remember: No foods are forbidden for people with diabetes It’s not carbs the patient should worry about It’s the amount of carbs consumed Portion control !!!! 20
21. Carbohydrate Healthy carbs come from fruit, veggies, whole grains, legumes and low-fat milk Need to monitor intake and divide throughout the day Sugar is allowed within reason Fiber is recommended 21
22. Food Labels Locate serving size Locate total grams of carbohydrate 15 g = 1 carb choice Ignore sugar grams 22 X
23. Exercise Regular Consistent Aerobic: 30 min/day most days Resistance training: 2-3 times/week Type 1- increases insulin sensitivity Type 2- wt loss, decrease insulin resistance 23
24. Self-Monitoring of Blood Glucose(SMBG) Modern meters Small blood volume (0.3 to 4 L) Ability to use alternate sites Shorter results time: 5 to 10 seconds Very accurate if maintained properly 24
25. Monitoring Glycemic Control A1C formerly know as Hgb A1C Blood test measuring glycosylated Hgb A Glycosylation: glucose binds irreversibly to Hgb A1C reflects mean glucose level past 2-3 months Check every 3-6 months Normal < 6% Goal for diabetic < 7% 25
26. Targets for Glucose ControlType 1 and Type 2 Diabetes 70-130 mg/dL <180 mg/dL 100-140 mg/dL 7% Fasting/Pre-meal glucose Post-meal glucose 2 hr. after start of meal Bedtime glucose A1C 26
28. Insulin Therapy Type 1- always required Type 2- during periods of stress, illness, surgery and when all other treatments fail 28
29. Insulin 36% with type 2 diabetes use insulin within 5 years of diagnosis 50% require Weight gain can be significant: 5-10 kg 1st yr Insulin dose needed varies Most serious side effect is hypoglycemia 29
30. Terms describing time & effect of insulin Onset: time span after administration when insulin will begin to effect the blood glucose level Peak: time span after administration when the insulin will have the greatest effect on the blood glucose level Duration: time span after administration when insulin will continue to effect the blood glucose level 30
31. Basal & Bolus Basal Insulin: insulin required to suppress hepatic glucose production between meals Bolus Insulin: insulin required to maintain normal glucose disposal after meals Normal process of pancreas in healthy person 31
32. Storage of Insulin Open vial at room temperature 30 days No direct sunlight Do not store in freezer Keep out of glove compartment Extra vial in door of refrigerator 32
33. Mixing Insulin Always draw up clear first to prevent contamination of fast acting insulin Can be pre-drawn and stored in refrigerator for 1 week Store needle upright & agitate syringe before administering 33
35. Sliding Scale Used with intensive insulin therapy and during hospitalization to maintain euglycemia Accu-check should be no more than ½ hour prior to the administration of the corrective insulin dose 35
36. Sites for injection Abdomen Back of arm Middle anterior thigh Upper buttocks 36
37. Rotation of sites Insulin injections should be given in the same region at a specific time of day & rotated within that region Due to difference in absorption rates of sites 37
38. Insulin devises Insulin pump- receives rapid acting insulin continuously per subcutaneous route Insulin pen- good for visually impaired and people with problems with dexterity 38
41. Insulin Pump: During hospitalization Have physician write orders to leave the pump in place Don’t discontinue the pump unless insulin therapy is given IV or subcutaneously 41
42. Insulin Pump: During hospitalization Patient should change their site every 2-3 days and Whenever blood glucose is over 240 mg/dl for 2 tests in a row 42
43. Oral Antihyperglycemic Agentsfor Type 2 Diabetes 43 Class Sulfonylureas Biguanides Thiazolidinediones Meglitinides α-Glucosidase inhibitors DPP-4 Inhibitors
