Chapter 8Chapter 8

Diabetes MellitusDiabetes Mellitus

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Learning ObjectivesLearning Objectives

Describe the different types of diabetes Describe the different types of diabetes mellitus.mellitus.

Describe the symptoms and clinical Describe the symptoms and clinical findings of diabetes mellitus.findings of diabetes mellitus.

Discuss differences in the nutritional Discuss differences in the nutritional management of the various forms of management of the various forms of diabetes.diabetes.

Describe the importance of the self-Describe the importance of the self-monitoring of blood glucose.monitoring of blood glucose.

Discuss the role and special concerns of Discuss the role and special concerns of exercise in diabetes management.exercise in diabetes management.

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Diabetes Mellitus Diabetes Mellitus (Latin for “Sweet Urine”)(Latin for “Sweet Urine”)

The more common form, type 2 diabetes, The more common form, type 2 diabetes, is now epidemic; more than 18 million is now epidemic; more than 18 million Americans have diabetes, and another 41 Americans have diabetes, and another 41 million have prediabetesmillion have prediabetes

Uncontrolled diabetes leads to a variety of Uncontrolled diabetes leads to a variety of health complicationshealth complications

Diagnosed with two FBG Diagnosed with two FBG ≥≥126 mg/dL or 126 mg/dL or any BG >200 mg/dLany BG >200 mg/dL

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Type 1 Diabetes: Type 1 Diabetes: Dependent on Insulin for LifeDependent on Insulin for Life

Type 1 diabetes ALWAYS requires insulin (even without Type 1 diabetes ALWAYS requires insulin (even without food intake or nausea and vomiting) to avoid diabetic food intake or nausea and vomiting) to avoid diabetic ketoacidosis (DKA)ketoacidosis (DKA) ONLY EXCEPTION: “honeymoon period” that may happen ONLY EXCEPTION: “honeymoon period” that may happen

shortly after diagnosis and last until complete destruction of shortly after diagnosis and last until complete destruction of beta cell’s ability to produce insulin occurs beta cell’s ability to produce insulin occurs

DKA occurs when glucose cannot be used for energy needs DKA occurs when glucose cannot be used for energy needs because of insufficient insulin; excess breakdown of body because of insufficient insulin; excess breakdown of body fat results in buildup of ketones with lowered pH of bloodfat results in buildup of ketones with lowered pH of blood

DKA is an emergency situation; hospitalization is required DKA is an emergency situation; hospitalization is required for IV fluids, treatment of acidosis, and glucose and/or for IV fluids, treatment of acidosis, and glucose and/or insulin provisioninsulin provision

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Type 2 DiabetesType 2 Diabetes

90% to 95% of all cases of diabetes mellitus are 90% to 95% of all cases of diabetes mellitus are type 2type 2

Usually related to insulin resistance; Usually related to insulin resistance; hyperinsulinemia is usually found (to compensate hyperinsulinemia is usually found (to compensate for the insulin resistance)for the insulin resistance)

Strongly genetic; most often found in persons with Strongly genetic; most often found in persons with ancestors who lived near the equator—Spanish, ancestors who lived near the equator—Spanish, African, Native American, Asian, Pacific African, Native American, Asian, Pacific Islander—but it occurs around the worldIslander—but it occurs around the world

The “thrifty gene” helps explain etiologyThe “thrifty gene” helps explain etiology Genetic predisposition requires environmental Genetic predisposition requires environmental

factors to result in type 2 diabetes (especially low factors to result in type 2 diabetes (especially low physical activity with low-fiber intake and obesity)physical activity with low-fiber intake and obesity)

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Gestational DiabetesGestational Diabetes

Occurs during pregnancy after placenta is Occurs during pregnancy after placenta is formed and is caused by placental hormones formed and is caused by placental hormones working in opposition to insulinworking in opposition to insulin

No difference in pregnancy outcomes if BS No difference in pregnancy outcomes if BS are controlledare controlled

Similar to type 2 diabetes and family history Similar to type 2 diabetes and family history of type 2 diabetes usually evidentof type 2 diabetes usually evident

Possible role of zinc and selenium deficiencyPossible role of zinc and selenium deficiency

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Comparison of Type 1 versus Comparison of Type 1 versus Type 2 DiabetesType 2 Diabetes

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Possible Risk Factors for DiabetesPossible Risk Factors for Diabetes

Type 1Type 1 Uncontrolled celiac diseaseUncontrolled celiac disease Vitamin D deficiencyVitamin D deficiency

Type 2Type 2 Excess weightExcess weight Physical inactivity Physical inactivity Low-fiber intake, processed foodsLow-fiber intake, processed foods High levels of saturated and trans fats, red meatHigh levels of saturated and trans fats, red meat Either no or excess alcohol intakeEither no or excess alcohol intake High-glycemic index dietHigh-glycemic index diet Arsenic toxicityArsenic toxicity

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Signs and Symptoms of DiabetesSigns and Symptoms of Diabetes

Polyphagia (excess hunger); may also have symptoms of Polyphagia (excess hunger); may also have symptoms of hypoglycemiahypoglycemia

Skin disorders, such as darkened patches of skin or skin tagsSkin disorders, such as darkened patches of skin or skin tags Increased frequency of infectionsIncreased frequency of infections Delayed wound healingDelayed wound healing Unexplained weakness and fatigueUnexplained weakness and fatigue Polyuria (excess urination; occurs when BG >180 mg/dL “the Polyuria (excess urination; occurs when BG >180 mg/dL “the

renal threshold”)renal threshold”) Polydipsia (excess thirst) due to polyuriaPolydipsia (excess thirst) due to polyuria Weight loss with BG >180 mg/dL as wasted energy with Weight loss with BG >180 mg/dL as wasted energy with

polyuria (sudden weight loss likely type 1)polyuria (sudden weight loss likely type 1) Blurred visionBlurred vision

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Hyperglycemia versus Hyperglycemia versus HypoglycemiaHypoglycemia

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Common Symptoms Common Symptoms of Hypoglycemiaof Hypoglycemia

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Treatment of HypoglycemiaTreatment of Hypoglycemia

15:15 Rule: If hypoglycemia occurs 15:15 Rule: If hypoglycemia occurs (BG <70 mg/dL):(BG <70 mg/dL): treat with 15 g CHO followed by repeat BG in treat with 15 g CHO followed by repeat BG in

15 minutes; 15 minutes; repeat with 15 g CHO as needed repeat with 15 g CHO as needed Maximum rise in BG with 15 g CHO: 50 pointsMaximum rise in BG with 15 g CHO: 50 points Preferable to use “quick-acting” carbohydrate Preferable to use “quick-acting” carbohydrate

source; for example:source; for example: • 4 oz fruit juice or regular soda 4 oz fruit juice or regular soda • 8 oz low-fat milk8 oz low-fat milk• 4 tsp sugar or honey with glass of water4 tsp sugar or honey with glass of water

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BG IssuesBG Issues

Dawn phenomenon: increased release of Dawn phenomenon: increased release of counterregulatory hormones (cortisol and growth counterregulatory hormones (cortisol and growth hormone) decreases insulin’s effectivenesshormone) decreases insulin’s effectiveness Occurs at dawn for normal nighttime sleep pattern; FBG Occurs at dawn for normal nighttime sleep pattern; FBG

will rise naturally as a result of release of glycogen will rise naturally as a result of release of glycogen stores from cortisol and/or growth hormone productionstores from cortisol and/or growth hormone production

Somogyi effect: a high BG always follows a low Somogyi effect: a high BG always follows a low BG because of release of glycogen stores from BG because of release of glycogen stores from liverliver Because this is a temporary rise of BG, avoid Because this is a temporary rise of BG, avoid

overcorrection of hyperglycemia to inhibit a continued overcorrection of hyperglycemia to inhibit a continued cycle of low and high BG readings (will only occur if cycle of low and high BG readings (will only occur if insulin injection is used)insulin injection is used)

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Treatment for Insulin Reaction Treatment for Insulin Reaction with Unconsciousnesswith Unconsciousness

Keeping glucagon kit (syringe with saline and vial with Keeping glucagon kit (syringe with saline and vial with glucagon tablet) on hand is advised for anyone using glucagon tablet) on hand is advised for anyone using insulin; use if hypoglycemia results in unconscious state insulin; use if hypoglycemia results in unconscious state with inability to swallowwith inability to swallow A natural counterregulatory hormone that allows A natural counterregulatory hormone that allows

glycogen stores to be used for blood glucose needs; glycogen stores to be used for blood glucose needs; insulin use can overwhelm the body’s ability to raise insulin use can overwhelm the body’s ability to raise BG from natural glucagon productionBG from natural glucagon production

After glucagon tablet is dissolved by injecting saline After glucagon tablet is dissolved by injecting saline into vial, fill syringe with solution and inject; roll person into vial, fill syringe with solution and inject; roll person on his or her side or stomach because of concerns of on his or her side or stomach because of concerns of possible vomitingpossible vomiting

After consciousness regained, follow with oral intake of After consciousness regained, follow with oral intake of CHO (include protein or fat source if next meal is CHO (include protein or fat source if next meal is several hours away [e.g., during the night])several hours away [e.g., during the night])

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AA1c1c, the 3-Month Test, the 3-Month Test

With hyperglycemia, excess sugar attaches to With hyperglycemia, excess sugar attaches to protein throughout the bodyprotein throughout the body

Hemoglobin lives for about 3 months; the amount Hemoglobin lives for about 3 months; the amount of attached sugar provides an average blood of attached sugar provides an average blood glucose readingglucose reading

Hemoglobin AHemoglobin A1c1c is now referred to simply as is now referred to simply as AA1c1c Once the old hemoglobin dies off, if the BG Once the old hemoglobin dies off, if the BG

becomes normal, there is no attachment of sugar becomes normal, there is no attachment of sugar to the protein in the hemoglobin and the next Ato the protein in the hemoglobin and the next A1c1c

will be a lower readingwill be a lower reading SMBG after meals is the best method to ensure SMBG after meals is the best method to ensure

the next Athe next A1c1c is within normal limits (WNL) is within normal limits (WNL) http://

www.youtube.com/watch?v=MOH33-jFOwo

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Measures of Good ControlMeasures of Good Control

The Diabetes Control and Complications Trial The Diabetes Control and Complications Trial (DCCT) showed that normalization of blood (DCCT) showed that normalization of blood glucose (<7.2% HgbAglucose (<7.2% HgbA1c1c or <155 mg/dL average) or <155 mg/dL average)

helps prevent complications up to 75% helps prevent complications up to 75% Self-monitoring blood glucose (SMBG)Self-monitoring blood glucose (SMBG)

Normal: always <140 (even after meals)Normal: always <140 (even after meals) Acceptable: maximum 180 mg/dL to prevent exceeding Acceptable: maximum 180 mg/dL to prevent exceeding

renal threshold and dehydrationrenal threshold and dehydration Persons with type 2 diabetes and HTN need to Persons with type 2 diabetes and HTN need to

control both blood glucose and blood pressurecontrol both blood glucose and blood pressure

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Hemoglobin AHemoglobin A1c1c and Relationship and Relationship

with Blood Glucose Levelswith Blood Glucose Levels

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Uncontrolled Diabetes Uncontrolled Diabetes Leads to ComplicationsLeads to Complications

Unconsciousness from insulin reactionUnconsciousness from insulin reaction Cardiovascular diseaseCardiovascular disease Renal diseaseRenal disease Eye disease, retinopathyEye disease, retinopathy Nerve disease, neuropathyNerve disease, neuropathy

Peripheral with potential loss of limbsPeripheral with potential loss of limbs Autonomic with gastroparesis, orthostatic HTN, Autonomic with gastroparesis, orthostatic HTN,

or inability to increase heart rate with exerciseor inability to increase heart rate with exercise Periodontal diseasePeriodontal disease

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Carbohydrate CountingCarbohydrate Counting

With type 1, carbohydrates are balanced with With type 1, carbohydrates are balanced with short-acting insulin (usually 1 unit per 15 g short-acting insulin (usually 1 unit per 15 g carbohydrate)carbohydrate)

With type 2, carbohydrates per meal are limited to With type 2, carbohydrates per meal are limited to individual tolerance as noted with blood glucose individual tolerance as noted with blood glucose monitoring; generally 30 to 50 g carbohydrate per monitoring; generally 30 to 50 g carbohydrate per meal are toleratedmeal are tolerated

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All Carbohydrates Can FitAll Carbohydrates Can Fit

The DCCT found that sugar and starch have The DCCT found that sugar and starch have identical effects on BGidentical effects on BG

For a person with type 1 diabetes, increased For a person with type 1 diabetes, increased insulin may be all that is needed; for a insulin may be all that is needed; for a person with insulin resistance, CHO from person with insulin resistance, CHO from desserts can replace other CHO sources:desserts can replace other CHO sources: Example: 1 cupcake (1/2 cup) +/– 50 g CHOExample: 1 cupcake (1/2 cup) +/– 50 g CHO

versus 1 cup potato (30 g CHO) and 1 cup milkversus 1 cup potato (30 g CHO) and 1 cup milk(15 g CHO) or equivalent(15 g CHO) or equivalent

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Other Nutritional Other Nutritional Management FactorsManagement Factors

Fiber lowers insulin requirementsFiber lowers insulin requirements Soluble fiber lowers lipidsSoluble fiber lowers lipids Lowering glycemic index of meals with fiber and Lowering glycemic index of meals with fiber and

monounsaturated fats is especially helpful for type monounsaturated fats is especially helpful for type 2 diabetes2 diabetes

Increased water or other fluids needed if blood Increased water or other fluids needed if blood glucose is >180 mg/dL to prevent dehydrationglucose is >180 mg/dL to prevent dehydration

Cinnamon (Cinnamon (11//5 5 to 1 heaping teaspoon reduces BG to 1 heaping teaspoon reduces BG 20% to 30% and further lowers LDL-C and 20% to 30% and further lowers LDL-C and triglycerides triglycerides (Khan et al., 2003; Anderson, 2008)(Khan et al., 2003; Anderson, 2008)

Alcohol should be consumed only in moderation Alcohol should be consumed only in moderation with food intake; alcohol increases both insulin with food intake; alcohol increases both insulin sensitivity and risk of hypoglycemiasensitivity and risk of hypoglycemia

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Role of Exercise in Role of Exercise in Diabetes ManagementDiabetes Management

Type 2 and GDMType 2 and GDM Lowers insulin resistanceLowers insulin resistance Promotes weight goalsPromotes weight goals

All typesAll types Promotes good circulationPromotes good circulation Helps use BG for energy needs with resulting lowered Helps use BG for energy needs with resulting lowered

BG level*BG level*

*Caution: decreased insulin dose may be needed to *Caution: decreased insulin dose may be needed to prevent hypoglycemia due to increased physical activity prevent hypoglycemia due to increased physical activity or exercise; BG will rise with exercise if there is or exercise; BG will rise with exercise if there is inadequate insulin; exercise should be delayed if BG inadequate insulin; exercise should be delayed if BG >240 if there are ketones>240 if there are ketones

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Oral Hypoglycemic Agents Oral Hypoglycemic Agents for Type 2 Diabetesfor Type 2 Diabetes

Sulfonylureas—first form of pills used; cause the Sulfonylureas—first form of pills used; cause the pancreas to release insulin and can cause pancreas to release insulin and can cause hypoglycemia needing Tx (newer forms less likely to hypoglycemia needing Tx (newer forms less likely to cause severe hypoglycemia: Glucotrol™, glyburide, cause severe hypoglycemia: Glucotrol™, glyburide, Amaryl™)Amaryl™)

Meglitinides—work similarly to sulfonylureas by Meglitinides—work similarly to sulfonylureas by increasing insulin release but do so in response to the increasing insulin release but do so in response to the meal-related BG rise (e.g., Prandin™)meal-related BG rise (e.g., Prandin™)

Biguanides—insulin sensitizer: Metformin™ with long Biguanides—insulin sensitizer: Metformin™ with long track-record of safety; does not cause hypoglycemiatrack-record of safety; does not cause hypoglycemia

Thiazolidinediones—insulin sensitizers; have been Thiazolidinediones—insulin sensitizers; have been implicated in weight gain and edema (Avandia™, implicated in weight gain and edema (Avandia™, Actos™)Actos™)

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Insulin Types and DeliveryInsulin Types and Delivery

Long-acting (effect lasts 12 to 24 hours):Long-acting (effect lasts 12 to 24 hours): Hx NPH/Lente or “cloudy” insulin with “peak Hx NPH/Lente or “cloudy” insulin with “peak

action” of variable time (4 to 6 hours +/–) action” of variable time (4 to 6 hours +/–) increasingly being replaced with peakless long-increasingly being replaced with peakless long-acting “clear” insulin glargine (e.g., Lantusacting “clear” insulin glargine (e.g., Lantus™) ™) to lower risk of hypoglycemiato lower risk of hypoglycemia

Lantus daily dose based on FBG in low 100s; Lantus daily dose based on FBG in low 100s; will not cause hypoglycemia if dose is correct, will not cause hypoglycemia if dose is correct, even if there is no food intakeeven if there is no food intake

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Short-Acting InsulinShort-Acting Insulin

Regular “R” insulin (effect lasts 4 to 8 hours) must Regular “R” insulin (effect lasts 4 to 8 hours) must be taken 30 minutes before meals for best resultsbe taken 30 minutes before meals for best results

Lispro insulin (HumalogLispro insulin (Humalog™™/NovoLog/NovoLog™™) works ) works within 5 minutes of injection and has shorter within 5 minutes of injection and has shorter duration of action than “R” insulinduration of action than “R” insulin

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Insulin PumpsInsulin Pumps

Use only short-acting insulin but provided in two Use only short-acting insulin but provided in two modes:modes: Basal insulin: small infusion of insulin continuously Basal insulin: small infusion of insulin continuously

around-the-clock (acts like long-acting insulin)around-the-clock (acts like long-acting insulin) Bolus insulin: meal-coverage insulin delivery based on Bolus insulin: meal-coverage insulin delivery based on

predetermined insulin-to-CHO ratio; substitutes for predetermined insulin-to-CHO ratio; substitutes for short-acting insulin injectionsshort-acting insulin injections

Continuous glucose monitoring device now exists Continuous glucose monitoring device now exists with capability to transmit information or “talk” to with capability to transmit information or “talk” to the insulin pump, thereby acting as an artificial the insulin pump, thereby acting as an artificial pancreas, with release of insulin as needed based pancreas, with release of insulin as needed based on BG levelson BG levels

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Psychologic Needs Psychologic Needs Related to Diabetes ManagementRelated to Diabetes Management

Children with diabetes face normal Children with diabetes face normal

adolescent adjustments, compounded with adolescent adjustments, compounded with demands of diabetes managementdemands of diabetes management May lead to family dysfunctionMay lead to family dysfunction May lead to poor diabetes managementMay lead to poor diabetes management Excellent communication skills required by Excellent communication skills required by

health care professionals to support healthy health care professionals to support healthy relationship of food and health and family relationship of food and health and family mealtime functioningmealtime functioning

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What would you do?What would you do?

Determine what changes, if any, you would have to make if you were diagnosed as having diabetes. Could you consistently follow a low-fat, low-sugar meal plan? How would you feel if you had to reduce the amount of sweets and greasy foods in your diet?

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Study GuideStudy Guide

• Differences between Type 1 and Type 2 DM Age of onset Weight Treatment Beta Cell function

• What causes gestational diabetes?

• Common symptoms of hypoglycemia

• 15/15 Rule

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What is the Hemoglobin A1c test? Complications of uncontrolled DM Describe carbohydrate counting Other nutritional management strategies Benefits of exercise in both types of DM