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					DIABETES
What is diabetes?
   Metabolic disease resulting from inability of body
    to use or produce insulin
     High blood glucose
     Low cellular glucose/glycogen stores

   Insulin
     Produced  by Islet of Langerhans in the pancreas
     Increases uptake of glucose in liver, muscle and fat

     Stores glucose as glycogen in liver and muscle
What is diabetes?
   Type 1
     Lack of insulin production
     Commonly found in children and adults of normal
      weight
     Treatment
       Daily   insulin necessary
What is diabetes?
   Type 1
     Etiology
       Previously  no known etiology but recent research suggests
        viral infection may cause autoimmune destruction of insulin
        producing beta cells
       Genetics
What is diabetes?
   Type 2
           not recognized by receptors throughout body
     Insulin

     Can have decreased insulin production

     Commonly seen in overweight adults
       Disease     is encroaching on younger populations
     Treatment
       Lifestyle   modification
       Pills
       Insulin
What is diabetes?
   Type 2
     Etiology
       Lifestyle   Factors
             Obesity (55%)
             Hypertension
             Cholesterol
             Age
             Sedimentary Lifestyle
       Genetics
Presentation
   Hyperglycemia
     Extreme  thirst
     Frequent urination

     Dry skin

     Hunger

     Blurred vision

     Drowsiness

     Decreased healing
Presentation
   Hyperglycemia
     Causes:
       Excess  food intake
       Insufficient medication
       Illness/Stress
       Sedintary Lifestyle

     Very high levels of sugar may lead to diabetic coma
     Chronic hyperglycemia can lead to eye, kidney, nerve
      and vasculature damage
Presentation
   Hyperglycemia
     Extreme  thirst
     Frequent urination

     Dry skin

     Hunger

     Blurred vision

     Drowsiness

     Decreased healing
Diagnosis
                      Normal                Pre-diabetes           Diabetes
A1C                   4-5.9%                6.0-6.4%               >6.5%
Fasting Glucose       <100mg/dL             100-125mg/dL           >126mg/dL
Glucose Tolerance     <140mg/dL             140-199mg/dL           >200mg/dL (1)



Both the fasting glucose and 75 g glucose tolerance test are
suitable for diagnosing diabetes
Both the fasting glucose and 75 g glucose tolerance test were suitable for diagnosing
Recommended to screen asymptomatic adults with BP greater
diabetes [2]
than 135/80 mm Hg (treated or untreated)
Treatment
   Lifestyle Changes
     Increase   physical activity
       Cholesterol
       BP
       Heart   Function
       Weight Loss
       Insulin Sensitivity

     Diet
       45-60 grams of carbohydrates/meal
       <15 grams of carbohydrates/snack
Treatment
   Insulin
     Treats Type 1 and Type 2
     Types
         “Meal” Insulin
         Long-Acting Insulin
         Insulin Mixes
         Vials or pins
       Insulin Care
         Must be refrigerated
         Never freeze
         Discard vial 4 weeks after first use
         Pen expirations vary widely
Treatment- Oral
   Metformin (Glucophage)
     Prevents  release of stored sugars
     First option oral treatment

     Can cause weight loss

     Side Effects:
       Upset stomach
       Diarrhea
Treatment- Oral
   Sulfonylureas
     Increase insulin production in Type 2 patients
     Low blood sugar risk dependant on dose

     Use if patient not eligible for or intolerable of
      Metformin
       Brand Name                Generic
       Diabeta                   glyburide
       Micronase
       Glynase

       Glucotrol                 glipizide
       Glucotrol XL

       Amaryl                    glimepiride
Treatment- Oral
   Glitazones (Avandia, Actos)
     Increase efficacy of insulin
     Side Effects:
       Weight  gain
       Swelling

     6-12 before full benefit
     High Cost

   Alpha-glucosidase Inhibtors
     Slow   absorption of carbohydrates from gut
Treatment- Oral
   Meglitinides (Prandin, Starlix)
     Increase   insulin production
       Short   acting
     Used if reaction to sulfonylureas
     Take with meals

     Side Effects:
       Hypoglycemia

     High   Cost
    Hypoglycemia

   Frequent side effect of excess insulin, meglitinides, and
    sulfonylureas
   Also caused by increased exercise or inadequate food inatke
   Can result in insulin shock
   Symptoms:

       Shaking            Hunger
       Tachycardia        Impaired Vision
       Diaphoresis        Fatigue
       Dizziness          Headache
       Anxiety            Irritability
Long Term Effects
   Heart disease and stroke
     2-4xincreased risk
     65% die from MI or stroke

     33% have peripherial artery disease

   Retinopathy
     Leading cause of new cases of blindness in patients
      ages 20-74
Long Term Effects
   Retinopathy
     Commonly   latent until late stages of disease requiring
      laser treatment
     Regular fundus exams needed

     Pathophysiology
       Abnormal   blood vessel permeability
       Ischemic vascular occlusion
       Neovascularization
Long Term Effects


Macular Edema                         Neovascularization




                http://www.google.com/imgres?imgurl=http://www.vrmny.c
Long Term Complications
   Nephropathy
     Leading   cause of kidney failure (44% in 2005)
     First sign is proteinuria
       Albumin excretion 30-300mg/day is diagnostic
       Increased likelihood of hypoglycemia from medication

   Amputation
     >60%   of non-traumatic lower-limb amputations are
      due to diabetes
Long Term Complications
   Neuropathy
     60-70%    have mild forms of nerve damage
     Can lead to foot complications like ulcers and infection

     Inspection
       Erythema,  warmth, callus formation
       Bony deformities, join mobility, gait
       Pulse
       Loss of sensation



              =Refer to podiatrist
Long Term Complications
   Neuropathy
     Prophylaxis
      -  Avoid going barefoot, even in the home
       - Test water temperature before stepping into a bath
       - Trim toenails to shape of the toe; remove sharp edges with
        a nail file. Do not cut cuticles.
       - Wash and check feet daily
       - Shoes should be snug but not tight and customized if feet
        are misshapen or have ulcers
       - Socks should fit and be changed daily

                                   McCullogh, David. Foot Care in diabetes mellitus. Up to Date. May
                                   2010.
Diabetes in North Carolina
   In 2008 NC ranked 17th highest in the US for adult
    diabetes prevalence with 9.3% of the population
    diagnosed (643,000)
   An estimated 1.25 million adults in NC have some
    type of hyperglycemia
   The estimated cost of diabetes in NC was 5.3 billion
    in 2006
   7th leading cause of death (2,150) and contributed
    to 6,226 deaths in 2007
References

   2009 Diabetes Fact Sheet. NC Diabetes Prevention and
    Control Branch.
    http://www.ncdiabetes.org/factsFigures/index.asp
   Diabetes Basics and Living with Diabetes. American
    Diabetes Association. http://www.diabetes.org/
   US Preventive Services Task Force. Screening for Type
    2 Diabetes Mellitus in Adults: U.S. Preventive Services
    Task Force Recommendation Statement. Annals of
    Internal Medicine 2008;148:855-68.
    http://www.annals.org/cgi/reprint/148/11/846.pdf
References
   Olivia Linthavong. What is Diabetes? Diabetes Maintenance
    and Prevention Program at the Open Door Clinic. 2009.
   Olivia Linthavong. Carbohydrate Counting Handout.
    Diabetes Maintenance and Prevention Program at the Open
    Door Clinic. 2009.
   Genuth, S, Alberti, KG, Bennett, P, et al. Follow-up report on
    the diagnosis of diabetes mellitus. Diabetes Care 2003;
    26:3160.
   Drugs for Type 2 Diabetes. Treatment Guidelines from the
    Medical Letter 2008; 6(71). http://medlet-
    best.securesites.com.libproxy.lib.unc.edu/restrictedtg/t71.pd
    f

				
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