Diabetes Mellitus Barbara Schlichte

http://www.youtube.com/watch?v=MMRHGW_K-M8&feature=related

Why I Chose This Topic

Genetics Dad

Father diagnosed with Type 2

Father-in-law died from complications with type 2

Definition of Diabetes Mellitis Epidemiology Clinical Aspects Treatment Effects of Exercise Exercise Testing Exercise Prescription Summary Conclusion

Outline

Diabetes mellitus is a group of diseases characterized by high blood glucose concentrations resulting from defects in insulin secretion, insulin action, or both.

Abnormalities in metabolism of CHO, protein and fat are present.

People with diabetes have bodies that don’t produce or respond to insulin.

Without effective insulin, hyperglycemia (elevated blood glucose) occurs.

What is diabetes mellitus?

Type 1Type 2Gestational

Other types

Types of diabetes mellitus

Absolute deficiency of insulin Marked reduction of beta-cells in pancreas Thought to involve an autoimmune response-

no known means to prevention Exogenous insulin must be supplied Prone to ketoacidosis Accounts for 5% to 10% of diagnosed cases Can occur at any age although most affected

people are children and young adults

Type 1

Relative insulin deficiency-insulin resistant◦ Elevated, reduced or normal insulin levels

Risk factors include: (test on diabetes website)◦ Genetics◦ Older age◦ Obesity (particularly abdominal)◦ Sedentary lifestyle◦ Gestational diabetes◦ Pre-diabetes◦ Race or ethnicity

Type 2

Most cases do not require exogenous insulin

Do not develop ketoacidosis except in cases of unusual stress

Accounts for 90% to 95% of diabetes cases

Usually occurs after the age of 40 but is developing in young adults and youth

NO CURE-only management!

Type 2 con’t

Types of Diabetes

Gestational Other types

Glucose intolerance during pregnancy

Due to contra-insulin effects of pregnancy

20% to 50% of women with gestational diabetes develop type 2 within 5 – 10 years

5

Results from specific genetic syndromes, surgery, drugs, malnutrition, infections, or other illnesses

Depending on pathophysiology, may or may not require insulin

Total: 25.8 million children and adults in the US-8.3% of the population have diabetes

Diagnosed: 18.8 million Undiagnosed: 7 million Pre-diabetes: 79 million New Cases: 1.9 million new cases were

diagnosed in 2010 Cost: $174 billion! In 2007 Medical costs are 2.3 times more for diabetics

Epidemiology

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Non-H

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0.0%30.0%60.0%90.0%

7.1% 8.4% 12.6% 11.8%

Percentage of Ethnic Group with type 2 diabetes

Diabetes Does Discriminate!

Symptoms

Type 1 Type 2

Frequent urination Extreme thirst Extreme hunger Unusual weight

loss Extreme fatigue

and irritability

Any of the type 1 symptoms

Frequent infections Blurred vision Cuts/bruises that are

slow to heal Tingling/numbness in

hands/feet Recurring skin, gum or

bladder infections OR NO symptoms!

Diagnosis Criteria

Diabetes FPG≥126 mg/dlCPG≥200 mg/dl2hPG≥200 mg/dl

Pre-diabetesImpaired fasting glucoseImpaired glucose tolerance

FPG100-125 mg/dl2hPG140-199 mg/dl

Normal FPG<100 mg/dl2hPG<140 mg/dl

*2bPG, 2-hour plasma glucose level

*FPG, fasting plasma glucose * CPG Casual plasma glucose

Diagnosis

Adults with diabetes have heart disease death rates 2 to 4 times higher than those without diabetes

Adults with diabetes have a 2 to 4 times greater risk of having a stroke

Complications-heart disease and stroke

In 2005-2008, 67% of adults with diabetes had high blood pressure

High blood pressure

Diabetes is the leading cause of new cases of blindness in adults ages 20 to 74

Blindness

Leading cause of kidney failure in US◦Accounts for 44% of cases in 2008

Neuropathy-about 60% to 70% of diabetics have some form of nerve damage

Amputation-about 60% of non-traumatic lower limb amputations occur in diabetics

Other complications

Insulin therapy ◦Type 1◦Some type 2

Individual nutritional care plan

Exercise-especially for type 2Oral medication/type 2

Treatment

Generic name Trade Name

Onset Peak Duration

Rapid actingInsulin lisproInsulin aspartInsulin glulisine

HumalogNovoLogApidra

<15 min 30-90 min 1-3 h

Short actingRegular Humulin R

Novolin R 30-60 min 2-3 h

3-6 h

Intermediate actingNPHLente

Humulin NNovolin NHumulin L

2-4 h 4-10 h 10-16 h

Long actingInsulin glargineUltralente

LantusHumulin U

2-4 h Does not peak

18-36 h

Types of insulin

Generic name Trade name Concerns with exercise

BiguanidesMetforminMetformin(liquid)

Glucophage, Glucophage XR,Riomet

Glucosidase inhibitorsAcarboseMiglitol

PrecoseGlyset

May produce hypoglycemia with postprandial exercise

MeglitinidesNategliniderepaglinide

StarlixPrandin

May produce hypoglycemia with postprandial exercise

Oral agents used for treatment of type 2 diabetes

Generic name Trade name Concerns with exercise

SecretagoguesAcetohexamideChlorpromideTolazimideTolbutamideGlimeprideGlipizideGlyburide

Generic onlyDiabineseTolinaseOrinaseAmarylGlucotrol, Glucotrol XLDiabeta, Glynase, PresTab, Micronase

Can produce hypoglycemia during or after exercise

ThiazoladinedionesPioglitazoneRosiglitazoneDipeptidyl peptidase-4 inhibitorsSitagliptin

ActosAvandia

Januvia

No hypoglycemia unless given with another drug

Oral agents-con’t

Generic name Trade name Comments and concerns with exercise

Exantide Byetta Exantide is used in treatment of type 2 and is found to increase postprandial insulin response, delay gastric emptying, suppress glucagon secretion, and reduce appetite

Pramlintide Symlin Pramlintide is a synthetic hormone similar to human amylin. It may be used in combination with insulin therapy for treatment of either type 1 or 2. Pramlintide works by suppressing glucagon secretion and delaying gastric emptying.

Other injectable meds

Insulin and counter regulatory hormones don’t respond to exercise in the normal manner

Balance between peripheral glucose utilization and hepatic glucose production may be disturbed= hypo/hyperglycemia

Effects of diabetes on ability to exercise

Insulin allows glucose to enter the cells of insulin-sensitive tissue

Oral and injectable agents for type 2 diabetes are meds that help the pancreas secrete more insulin, alter CHO absorption, reduce liver glycogenolysis, increase insulin sensitivity, or a combination of effects

Meds may cause hypoglycemia◦ Pay attention to med timing, food intake, blood

glucose level before and after exercise

Effects of medication on exercise

Muscle contractions increase glucose uptake

Both aerobic and resistance exercises increase GLUT4 abundance and BG uptake

Insulin action and glucose tolerance is increased (type 2)

Dependent on several factors ◦ Use and type of meds to lower blood glucose◦ Timing of meds◦ Blood glucose level prior to exercise◦ Timing, amount, and type of previous food intake◦ Presence and severity of diabetic complications◦ Use of other meds ◦ Intensity, duration and type of exercise

Acute effects of a session of exercise

Weight loss (type 2) Improved insulin sensitivity Possible prevention of type 2 For those with type 2-possible improvement in blood glucose control

Improved CV health ◦Lower triglycerides◦Lowers blood pressure

Chronic effects of exercise

Exercise testing using protocols for populations at risk for CAD recommended in individuals who:◦ Have type 1 and are over 30 yrs◦ Have had type 1 longer than 15 years◦ Have type 2 and are over 35 yrs◦ Have either type 1 or 2 and one or more other

CAD risk factors◦ Have suspected or known CAD, or◦ Have any microvascular or neurological diabetic

complications

Exercise testing

Methods Measures endpoints

AerobicCycle (ramp protocol 17 W/min; staged protocol 25-50 W/3 min stage)Treadmill (1-2 METs/stage)

12-lead ECG, HR

BPRPE (6-20)

Serious dysrhythmias>2 mm ST-segment depression or elevationIschemic thresholdSignificant T-wave change

SBP >250 mmHg or DBP >115 mmHgOnset of peripheral pain

High risk for CAD testing

People with diabetes who don’t meet any of the criteria for CAD may be tested with use of protocols for the general healthy population

Primary objectives are to:◦Identify the presence and extent of CAD◦Determine appropriate intensity range

for aerobic exercise training

Exercise testing

Must be individualized according to med schedule, presence and severity of diabetic complications, and goals of program

Hypoglycemic meds=additional 15 g of CHO before or after exercise

15 to 30 g CHO (fat free) every hour during vigorous or exercise>60 min

Proper hydration Good foot care-proper shoes and socks Athletes will most often know their limits but

trial and error with beginners-monitor BG!!

Exercise programming

Active retinal hemorrhage or recent retinopathy therapy

Illness or infection Blood glucose >250 mg/dl and ketones are present

Blood glucose <70 mg/dl If blood glucose is <100 mg/dl, CHO should be consumed

Exercise contrandications

Modes Goals Intensity/frequency/duration

Time to goal

AerobicLarge muscle activities

Increase aerobic capacity, time to exhaustion, work capacity, BP response to exercise, Reduce CV risk factors

50-80% peak HR50-80% VO2peak

Monitor RPE4-7 sessions/week20-60 min/session

4-6 month

StrengthFree weightsWeight machinesElastic tubing or bands

Increase max repsImprove performance for competitive patients

low resistance, high reps for mostHigh resistance OK for patients with well controlled diabetes

4-6 months

Exercise prescription

Modes Goals Intensity/frequency/duration

Time to goal

AnaerobicHigh-intensity intervals

Only for athletes in good diabetic control

Same as for nondiabetic athletes

FlexibilityStretching/yoga

Maintain/ increase ROMImprove gait

Limited data; 2-3 x’s/week may suffice

4-6 months

NeuromuscularYoga

Improve balance and coordination

FunctionalActivity-specific exercise

Increase ADLsIncrease vocational potentialIncrease self confidence

Individualized to each client

Exercise prescription

Diabetes song http://www.youtube.com/watch?

v=Ni8lwD7Z0c8

Summary

Diabetes is a disease that should be taken seriously

Some type 2 can be managed with diet and exercise

If there are no significant complications with diabetes mellitus, patients can enjoy exercise with very few limitations

Exercise for type 2 patients is a must!!

Conclusion

American College of Sports Medicine, A. D. (2010). Exercise and type 2 diabetes. Medicine and Science in Sports & Exercise.

Diabetes Statistics. (n.d.). Retrieved February 24, 2012, from American Diabetes Association: www.diabetes.org

Durstine, J. M. (2009). ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities. Champaign: Human Kinetics.

Farrell, P. (2003). Diabetes, exercise and competitive sports. Gatorade Sports Science Institute Sports Science Exchange , 1-6.

LaFontaine, T. (2004). Exercise considerations for individuals with type 1 diabetes. Strength and Conditioning Journal , 16-18.

Mahan, L. E.-S. (2008). Krause's Food and Nutrition Therapy. St. Louis: Saunders Elsevier.

  

References