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DIABETES Ch 15, DIABETES MELLITUSGroup 7; Section 3022Bernard BoatengLatoya NewbyLinda LawrenceNehemiah Dorce

Disease State: Diabetes Lenz Ch. 1211/15/11DIABETES Overview3Diabetes was listed as Sixth leading cause of death in the United states in 2002

An estimated 20.8 million people or 7.3% of the United States population currently has diabetes

About 90 to 95% of patients have type 2 diabetes (Non-insulin-dependant diabetes Mellitus)

Pharmacists are well positioned to assist patients at risk

Prevalence4In 2003,Prevalence of physician-diagnosed diabetes was more than 14 million new cases

In 2005 alone, over 1.5 million new cases in adults were diagnosed

American Indians or Alaska natives 15.3%

Non Hispanic Blacks 11.7%

Mexican Americans 9.6%

World wide prevalence was 2.8% in 2000Prevalence Cont5World wide prevalence projection 4.4% by 2030

Individuals with pre-diabetes are at risk for

diabetes Mellitus, Heart disease and stroke

Many people with pre-diabetes do not know.

73% of patients with diabetes have blood pressure of 130/80 mm of Hg or use prescription medication for Hypertension

Total direct and indirect cost associated with diabetes was approximately $132 billion annually

Type 1 and type 2 diabetesType 1Type 26Insulin-dependant Juvenile-onsetAssociated with HLA typesFamily history of obesity not commonAge at onset < 30yrsTreatment Physical activityMNTNon-insulin-dependantAdult-onsetDefect in insulinObesity Common (60-90%)

Age at onset > 40yrsTreatmentPhysical activityMNT & Insulin

Normal and diabetic plasma glucose7A normal FPG is < 100mg/dlAn FPG of 100 to 125mg/dl is IFGAn FPG 126mg/dl indicates provisional diagnosis of diabetes that must be confirmedDiabetes resulting from stress in pregnancy are classified as gestational diabetesImpaired glucose tolerance diagnosed when FPG < 126g/dl Risk Factors 8Overweight ( 25 kg/m2)Physical InactivityHypertension DyslipidemiaHDL-C < 35mg/dlTriglyceride > 250 mg/dlCardiovascular diseasesFamily History of diabetes Risk Factors / signs and symptoms9Age > 45 yearsHistory of vascular diseaseRapid progression (days to weeks ) of PolyuriaPolydipsiaFatigueWeight lossketoacidosis

Treatment10TYPE 1Proper eating habitsExerciseInsulin

TYPE 2Weight lossProper eating planExerciseOral Antidiabetic agentsPossibly InsulinPhysical Activity recommendations Type 1 11GoalPrevent the onset of disease and increase work capacityTypesLarge muscle activitiesIntensitymoderate to vigorousDurationAt least 30 minutes

Frequencymost days of the weekResistance trainingAll major muscle groupsLife style ActivitiesWalking the dogtaking stairsyard workhouse duties etc.Physical Activity recommendations Type 2 12GoalsImprove insulin sensitivityReduce risk of cardiovascular diseaseReduce body weightTypesLarge muscle activitiesIntensityvery low to moderate Duration5-10 min initially, 20-60 min

Frequency2-4 times per week ( for initial 2 to 8 weeks )Resistance training All major muscle groups1 set 15-20 repetitions, 2 to 3 times per week rest at least 48 hrs between session.Nutrition and diabetes Mellitus(MNT)13Four Goals of American Diabetes Association (ADA)Attain and maintain optimal metabolic outcomes including blood glucose, blood lipid and blood pressure

Prevent and treat chronic complications by modifying nutrient intake and treat obesity, dyslipidemia, cardiovascular , hypertension, and nephropathy

Improve health through healthy food choices and physical activities

Address individual nutritional needs taking into consideration the patients cultural life style needs while respecting the patients wishes and willingness to change.

13ADA Dietary recommendations 14Carbohydrate50-60% total calorie intakeMost should come from whole grainProtein Most American Adults consume 50% more than required15-20% of total calorie intake

Dietary fatsLess than 10% of total calorie intakeLimit saturated fat and cholesterol intakeIndividuals with low-density lipoprotein(LDL) greater than 100mg/dl should take less than 7% of calorie intakeFiber 20-30g/daySafety considerations15ADA recommendationsAll patients must undergo extensive medical evaluation before undergoing any physical program

All patients with diabetes should have a comprehensive foot examination along with education regarding self examination

Persons with diabetes use footwear that cushions and distribute pressure evenly on the foot

Patients who exercise late in the evening may need to increase consumption of carbohydrate before going to bed

15Group 10: Joseph Bishay, Chantel Grubbs, Meranda Maley, Shanae Perry, Jasmine StantonOsteoporosis

Chapter 16http://youtu.be/r7brjctJbr816OSTEOPOROSIS Porous Bone

Characterized by the thinning of bone tissue and a loss of bone density over time, which results in an increased risk of fractures of:HipSpineWrist

Often called a silent disorder until it causes one or more bone fractures

DEFINITONPREVELANCE & HEALTH RISKS Affects 44 million Americans age 50 years and older80% of cases are from womenWhite/Asian women have a higher prevalence compared to African American/Hispanic women.

Environmental Risk Factors:Physical inactivityLow calcium and vitamin D intakeDecreased mobilityFamily history of osteoporosisFemale genderCaucasian or AsianSmall stature

ECONOMIC COSTSThe annual direct care expenses for osteoporotic fractures range from $12.2 to $17.2 billion.

Men account for 18% of this amount (~ $3.2 billion)

Hip fractures alone account for 63% ($11.3 billion) of this annual costIn 2002, the treatment for each hip fracture was roughly $30,100 to $43,400

Hospital care and nursing home care account for a majority of the total direct costs associated with osteoporotic fractures

Pathophysiology of OsteoporosisAs we continue to age our bones continue the process of remodeling. Remodeling is important because it helps to maintain our bone health and prevents us from having fractures. In the remodeling process, older fatigued bone and damaged bone is replaced by new bone.Two cells are involved in remodeling:Osteoblast Osteoclasts

PathophysiologyOsteoclasts- are the cells that break down or reabsorb the old bone. This is done by erosion and cavity formation in the old bone.Osteoblasts- are the cells that build up or generate new bone to replace the old bone that osteoclasts had previously broken down. These cells fill the cavities made by the osteoclasts.At the age of 30 is when most people reach their peak bone mass. After this time the remodeling process results in small deficits in bone formation which begin to increase with age. Prevention and TreatmentBecome proactive! Osteoporosis is a PREVENTABLE disease!

Prevention strategies include:Adequate calcium intakePhysical activityMaintaining a healthy body weightSmoking abstinenceWomen who smoke have lower estrogen levels, often reaching menopause sooner.Alcohol control

Preventive MedicationsCalcium productsVitamin DEstrogensCalcitoninOral Bisphosphonates

Rx Treatment medications:BonivaHelps increase bone mass and reduce the chances of fractureFosamaxA bisphosphonate that acts as a specific inhibitor of osteoclast (break down bone).

Adherence Recommendations Ensure the patient has a clear understanding of the risks for osteoporosis and the strategies to prevent the disease.

Recommend that multiple adherence strategies work better than a single approach.

Establish contact with patient to assess the patients progress.

Help set achievable goals

Obtain baseline assessment of calcium and vitamin D intake.

Institute a self monitoring program such as keeping a log of food intake and exercise participation.

Identify patient specific barriers to the lifestyle changes. Nutrition & OsteoporosisDASH Eating Plan:Emphasizes eating fruits, vegetables, low-fat or fat-free dairy foods, whole grains, poultry, and nuts.Minimize intake of fat, cholesterol, and sodium

Important nutrients for bone growth include:CalciumVitamin DPhosphorusMagnesiumZincIron

CalciumImportant nutrient for strong bones.Low calcium intake is associated with low bone mass, rapid bone loss, and high fracture rates.

Adequate calcium intake differs by ageAges 1-3yrs old: 500mg/dayAges 4-8yrs old: 800mg/dayAges 9-18yrs old: 1300mg/dayAges 19-50yrs old: 1000mg/dayAges 51+: 1200mg/day

Most Americans obtain a majority of their calcium from dairy products.Dairy products that are low-fat or non-fat are good choices because they allow for the full amount of calcium but avoid high fat and calorie intake.Other options include:Dark leafy greensBroccoli, collard greens, and spinachSalmonTofuAlmondsOrange JuiceCereals

Surveys show that Americans consume less than half the amount of calcium needed to build and maintain healthy bones.NutritionIts important for healthcare practitioners to teach patients to read food labels to estimate the amount of calcium that a particular food may have.The amount of calcium listed on food labels is stated in a percentage of the daily value of recommended calcium intake.For example: A cup of yogurt contains 30% of the recommended daily value of calcium. Foods that contain 20% or more are considered high in calcium and those that contain 5% or less are considered low in calcium content.NutritionPhysical Activity and OsteoporosisGeneral physical activity for adults is 30 minutes daily and for children 60 minutes daily.Primary Goal: Maintain bone mass through the use of bone loading activities (e.g., playing games, running, turning, and jumping)PHYSICAL ACTIVITY is the only intervention that can potentially increase both bone mass and bone strength and decrease the risk of falling in elderly individuals.Studies have reported that individuals who are physically active can lower their age-related decline and the risk for fractures.

Principles about the Osteogenic EffectDoing activities that impose an increased load to the bones of the upper body will only affect the bones of the lower body. The adaptive response that occurs as a result of increased bone load occurs only when the loading stimulus exceeds that of the individuals usual loading conditions.Jogging opposed to walkingRope jumping opposed to standingIn adults, the benefits of physical activity on the bone health may not persist, if the physical activity is significantly reduced.Stopping physical activity loses bone mineral density that was previously gained.Bone Health & Overtraining in WomenA successful, extreme training can have positive and negative outcomes.Women tend to exercise to the extreme, that cause problems on their health (e.g., amenorrhoic and miss menstrual period)Amenorrhea is the absence of a menstrual period in a woman of reproductive age. Its also a sign of decrease estrogen levels, which can lead to low bone density and predispose women to osteoporosis.Reports have shown that women in their 20s who have became amenorrhoic secondary to high levels of physical activity, have bone mineral densities that are similar to those for women in their 80s.Warnings/Signs of Overtraining

Missed or Irregular menstrual periodsExtreme or unhealthy looking thinnessExtreme or rapid weight lossBehaviors that reflect frequent dieting (eating very little, not eating in front of others, trips to the bathroom after meals)Anxiety about missing and exercise sessionProblems sleepingIncrease chewing of gumsUnusual amount of self-criticismInability to concentrateFeeling cold all the timeConstantly talking about their body weight

Pharmacy Practice ApplicationThe U.S Surgeon General has named osteoporosis a significant public health concern.

Pharmacists should be aware of the risk factors and talk with patients about osteoporosis prevention.

Pharmacists have used risk assessment questionnaires and patient-appropriate health information to increase awareness of the disease. Problems:Not a significant forefront of many pharmacists because of other diseases such as cardiovascular disease and cancer.Patients may not appear unhealthy or at risk.Project ImPACT: OsteoporosisWhat is Project ImPACT?

A study sponsored by the American Pharmacists AssociationAn example of community-based pharmacists operating a successful osteoporosis screening and treatment program in conjunction with physicians.Interventions with patients took place with an initial visit to screen patients and provide health promotion information. Pharmacists referred those patients who required physician follow-up. The project demonstrated that patients were willing to pay for these services offered by pharmacists.

Project ImPACT: ResultsProject results showed:Of the patients screened, there was a significant increase in investigators being able to contact these patients for follow-up interviews 3 to 6 months later.Of the patients screened, 37% were at a high risk for osteoporosis.A total of 78% of the patients indicated that they had no prior knowledge of their risk for future fracturesCh 17 Osteoarthritis Section 301 Chapter 17November 28, 2011Group 11:Amber BrownKirollos HannaMini MathaiMeena RaghebErica StarkearthritisArthritis is the inflammation of a joint, often accompanied by pain and structural changes.Joint inflammation may result from: An autoimmune diseaseA broken boneGeneral "wear and tear" on joints An infection, usually by bacteria or virusThere are over 100 different types of arthritis.

OA vs. RAOsteoarthritis (OA) is the progressive breakdown of the joints' natural shock absorbers (cartilage).Also called "wear and tear" arthritis or degenerative joint disease,

Rheumatoid arthritis (RA) is an autoimmune disease, where the immune system attacks normal tissues in the body, causing inflammation.OA vs. rahttp://www.healthline.com/hlvideo-5min/osteoarthritis-vs-rheumatoid-arthritis-326724706OAOsteoarthritis tends to occur in men and women over the age of 40 and becomes more common with increasing age. Women are more severely affected then men.It can also be found in persons who put exceptional stress on joints. For example: gymnasts, long distance runners, basketball players, soccer players, etc. These individuals are more likely to develop osteoarthritis at earlier ages.

Prevalence of OA in the United States is estimated to be at 21 million Americans or 12% of the population.Disability from arthritis results in 750,000 hospitalizations and 36 million outpatient visits each year.

Osteoarthritis can occur in any joint, but it is most commonly diagnosed in the knees, hips, hands, and spine.

PathophysiologyOsteoarthritis is characterized by narrow joint spacing, absence of articular cartilage, increased bone density, and stiffness of the subchondral bone and bone spur formation along the joint margins.PathophysiologyJoint cartilage degradation leads to pain, which usually results in decreased physical activity, which causes loss in muscular strength, loss of physical functioning and disability. This results in loss of independence and decreased quality of life.

PathophysiologyWeight-bearing joints, such as the knees and hips, can be compromised by structural factors, such as obesity or neuromuscular abnormalities. Inflammatory cytokine interleukin-1 is present in the joints of patients with osteoarthritis (it plays a role in mediating joint inflammation and cartilage degradation). The inflammatory markers interleukin-6, tumor necrosis factor , and C-reactive protein have been shown to be higher in patients with hip or knee osteoarthritis.

Pathophysiology

Risk FactorsIncreased ageOverweight and obesityJoint injuryJoint overuse from certain vocational or sport activitiesQuadriceps muscle weaknessGenetic predispositionDevelopmental abnormalities

Medical conditions that can lead to OABleeding disorders that cause bleeding in the joint, such ashemophiliaDisorders that block the blood supply near a joint can lead toavascular necrosisOther types of arthritis, such as chronicgout,pseudogout, orrheumatoid arthritis

SymptomsMajor symptoms are pain and stiffness. Morning stiffness- pain and stiffness felt upon waking up in the morning. It usually lasts for 30 minutes or less. It is improved by mild activity that "warms up" the joint.During the day, the pain may get worse with activity and feel better when resting. After a while, the pain may be present even while resting.A rubbing, grating, or crackling sound when the joint is moved.Some people might not have symptoms

Signs & testsA physical exam can show:Joint movement may cause a cracking (grating) sound, called crepitationJoint swelling (bones around the joints may feel larger than normal)Limited range of motionTenderness when the joint is pressedNormal movement is often painfulX-ray of affected joints will show a loss of the joint space. In advanced cases, there will be a wearing down of the ends of the bone and bone spurs.Pharmacological Treatment There are no known pharmacological agents available to prevent, delay the progression of, or reverse the pathologic changes that occur in patients with osteoarthritis.Several pharmacological agents have been approved and used to treat the symptoms associated with osteoarthritis, such as oral and topical analgesics, NSAIDs, and nutritional supplements

Pharmacological Treatment Over the counter products, such as acetaminophen, NSAIDs, glucosamine and chondroitin sulfate may help control painCapsaicin (Zostrix) or Menthol (Stopain) skin creams may help relieve pain. Pain relief usually begins within 1 - 2 weeks.Prescription medications, such as, cortisone shots, prescription strength NSAIDs, Tramadol, and narcotics can help relieve severe pain.Pharmacological Treatment Corticosteroids injected right into the joint can be used to reduce swelling and pain. However, relief only lasts for a limited time. More than two or three injections a year may be harmful.Artificial joint fluid (Synvisc, Hyalgan) can be injected into the knee. It may relieve pain for 3 - 6 months.

Treatment: Lifestyle changesExercise helps maintain joint movement, especially, water exercises, such as swimming.Patients who take part in regular physical activity report less pain and greater abilities to perform activities of daily living.Other changes include: Applying heat and coldEating a healthy, balanced dietGetting restLosing weight, if overweightProtecting the joints

Treatment: Physical therapyPhysical therapy can help improve muscle strength and the motion of stiff joints, and sense of balance. Therapists have many techniques for treating OA. If therapy does not help after 6 - 8 weeks, then it will, likely, not work at all.Massage therapy may also help provide short-term pain relief.

Treatment: BracesSplints and braces can sometimes support weakened joints. Some prevent the joint from moving; others allow some movement. Only use when recommended by the doctor or therapist. Using a brace the wrong way can cause joint damage, stiffness, and pain.Alternative treatmentAcupuncture is a treatment based on Chinese medicine. How it works is not entirely clear. Some studies have found that acupuncture may provide short-term pain relief for people with OA.S-adenosylmethionine (SAMe) is a synthetic form of methionine. It has been marketed as a remedy for arthritis, but scientific evidence to support these claims is lacking.

Treatment: SurgerySevere cases of OA might need surgery to replace or repair damaged joints. Surgical options include:Arthroscopic surgery to trim torn and damaged cartilageOsteotomy- changing the alignment of a bone to relieve stress on the bone or jointArthrodesis- surgical fusion of bones, usually in the spineTotal or partial replacement of the damaged joint with an artificial joint (knee replacement,hip replacement,shoulder replacement,ankle replacement,elbow replacement)

pacePeople with Arthritis Can Exercise (PACE) is a program designed by Arthritis Foundation for patients managing their arthritis and diseases associated with arthritis. It is a community base and non-clinical program that is designed for many different forms of arthritis.For more information on program: website www.arthritis.orgGoals of the Pace programRelieve StiffnessIncrease EnduranceImprove PostureRestore joint range of motionMaintain muscle strengthIncrease flexibility

Group 12:Jalecia Green Joshlynn MclellanAlex Padikken Jinse Cherukara Chronic Lung DiseaseCh. 18The topic of chronic lung disease can include many different pulmonary disorders such as asthma, chronic obstructive pulmonary disease (COPD), chronic bronchitis, emphysema, chronic rhinitis, cystic fibrosis, and drug-induced pulmonary diseases.

We will focus on asthma and COPD as these are two of the most common chronic lung diseases. ASTHMA

Asthma is a disease characterized by wheezing, breathlessness, chest tightness, and nighttime or early morning coughing. It is the most common long-term disease in children.Asthma is characterized by reversible airflow obstruction that can occur at any time in an individual, but most patients are diagnosed with asthma by age 5. Genetic studies of patients with asthma strongly suggest there is a genetic predisposition. An individual who has a parent with asthma is three to six times more likely to develop asthma than a person who does not have a parent with asthma.

Asthma is a chronic inflammatory disorder and is caused by a complex interaction between inflammatory cells and mediators. Cellular elements involved in the inflammatory process include mast cells, eosinophils, T lymphocytes, neutrophils, epithelial cells, and others. In persons susceptible to asthma, the inflammatory process usually occurs as a result of exposure to triggers or events that begin the process. These triggers are commonly an allergy to certain environmental elements or chemicals. After exposure to a trigger, an asthma attack can occur as a result of airway inflammation and hyperreactivity of the bronchial smooth muscles, which causes variable degrees of airway obstruction. COPD COPD refers to a group of pulmonary diseases, including emphysema, chronic bronchitis, and in some cases asthma, that cause airflow blockage and breathing-related problems. COPD progresses with time and is characterized by limited airflow that is not completely reversible. Like asthma, inflammation plays a significant role in the progression of COPD. An inflammatory response in the lungs can occur in patients with COPD as a result of noxious particles or gases. The two most common pulmonary disorders comprising COPD are chronic bronchitis and emphysema. COPD

Chronic Bronchitis is a disorder of excessive mucus secretion into the bronchial tree that is accompanied by a chronic cough. Emphysema is a pulmonary disorder in which there is abnormal enlargement of the airspaces in the lungs with permanent damage to the bronchial walls. ***!!! POP QUIZ !!!***1. Most patients are diagnosed with asthma by what age? 52. The two most common pulmonary disorders comprising COPD areChronic Bronchitis and Emphysema 3. A disorder of excessive mucus secretion into the bronchial tree that is accompanied by a chronic cough is:Chronic Bronchitis Environmental Risk Factors Leading to Asthma and COPD:Airborne pollens * Tobacco smokeHousehold dust mites*Occupational ChemicalsAnimal dander*Genetic predispositionCockroach allergenMoldTobacco smokeWood smoke

Many of the risk factors associated with asthma and the development of COPD are related to allergens and exposure to cigarette smoke. Therefore, disease prevention strategies should focus on avoiding environmental allergens and chemicals, as well as smoking abstinence. In addition, it is important for patients with asthma and COPD to be compliant with their prescribed medications that treat their disease. PREVENTION AND TREATMENT

Exercise and physical activity in certain environments have been shown to be risks for asthma and lead to exercise-induced asthma (EIA) or exercise-induced bronchospasm (EIB). Many studies show that 70 to 90% of patients with asthma experience EIA. The symptoms of EIA can include shortness of breath, wheezing, coughing, chest discomfort, or a combination that lasts up to 30 minutes after exercise has stopped.

Nutrition and Chronic Lung DiseaseNutritional recommendations for the prevention of asthma primarily focus on avoiding foods and food additives that may be possible triggers for an asthma attack. It is not well documented that food allergens are a trigger for asthma. It is known, however, that food additives, specifically sulfites, can trigger an asthma attack. Foods such as beer, wine dried fruit, and open salad bars have particularly high amounts of metabisulfites. Patients sensitive to these foods should avoid them to prevent asthma exacerbations. Physical Activity and Chronic Lung DiseasePhysical activity guidelines for patients with asthma are the same as those recommended by the American College of Sports Medicine (ACSM) and the Centers for Disease Control and Prevention (CDC) for healthy sedentary individuals. The one major difference in the exercise prescription for patients with asthma compared with patients without asthma is in the measurement of exercise intensity. The ACSM recommends that patients with asthma use the Borg rating of perceived exertion (RPE) scale to assess the intensity of breathlessness associated with physical activity rather than using heart rate. Patients should become familiar with the Borg RPE scale as a means of measuring their exercise intensity because it can help decrease fears of difficulty in breathing while exercising, especially when it is combined with an optimal medication regimen and close measurements of peak flow using a peak flow meter.

Patients with COPD are encouraged to participate in physical activity as a means of maintaining and enhancing their quality of life, as well as for preventing other diseases such as cancer and cardiovascular disease. Physical activity programs for patients with COPD should be highly individualized and flexible to adjust to clinical status changes. Medical condition changes should warrant a reassessment of physical activity program and goals. ***!!! POP QUIZ !!!***1. EIB stands for..Exercised Induced Bronchospasm 2. Which of the following is not an Environmental Risk Factor Leading to Asthma and COPD?

Tobacco SmokeAirborne PollensCockroach Allergen Occupational ChemicalsAll of the above are Environmental Risk Factors Leading to Asthma and COPD E. All of the above are Environmental Risk Factors Leading to Asthma and COPD

Name two foods that have particularly high amounts of metabisulfites. Beer, wine dried fruit, and open salad bars have particularly high amounts of metabisulfites.Cigarette smoking is the most common cause of COPDThere are over 25,000 deaths each year from COPDTotal deaths from COPD are projected to increase by more than 30% in the next ten yearsAn estimated 300 million people worldwide suffer from asthma, with 250,000 annual deaths attributed to the diseaseThe greatest rise in asthma rates was among black children (almost a 50% increase from 2001 to 2009) More than 80% of asthma deaths can be prevented with proper asthma education

Statistics of COPD & Asthma