Diabetes: An Overview

Christine Rubie MS, RD, LD

Facts and Figures

Currently affects 18.2 million people

5.2 million are undiagnosed

1.3 million new cases per year

At the current rate, 1 out of every 3 children born in the year 2010 will get DM in their lifetime

Classifications

Type 1

Previously juvenile-onset DM
Most cases diagnosed before 30 years of age

Autoimmune
Beta cell destruction with resulting absolute deficiency of insulin

~10% of DM cases
Symptoms: significant weight loss, polyuria, polydipsia

Type 1
Risk in general population: 1:400 to 1:1000 Combination of genes for disease susceptibility and disease resistance

40% of caucasians express the genes, less than 1% develop type 1 DM 50% discordance rate between identical twins

Type 1
A trigger is necessary for gene expression Immunological attack on beta cells and insulin Hyperglycemia and symptoms develop after >90% destruction of the secretory capacity of the beta cell

Type 1

Honeymoon Period
Noninsulin dependancy Maintains normal glycemia Continued beta cell destruction Insulin required in 3-12 months

Type 2 diabetes

90% of DM cases

30-50% of childhood-onset diabetes 50% of men and 70% of women are obese at diagnosis

Insulin resistance Endogenous insulin may be normal, increased,or decreased Frequently asymptomatic at diagnosis

Type 2
30% remain undiagnosed Microvascular complications exist in ~20% at time of diagnosis May be present 6.5 years at time of diagnosis Pima Indians have a 50% prevalence rate

Type 2

Specific defects
Beta cell dysfunction resulting in insulin deficiency Insulin receptor abnormalities Postreceptor defects

Insulin resistance

Type 2

50% reduction in beta cell mass

Abnormal beta cell recognition of glucose Beta cells chronically exposed to hyperglycemia become less efficient in their response

Type 2
Insulin resistance BG is maintained by hepatic glucose production when fasting

Insulin suppresses hepatic glucose Type 2: decrease in sensitivity and response Type 2: persistant hepatic glucose production

DM Diagnosis

Prediabetes
Fasting: 110-125 mg/dL Random: 140-199 mg/dL

Diabetes
Fasting: >126 Random: >200

Confirmed with a second lab test and/or symptoms

Gestational Diabetes
Affects 2-14% of pregnancies Glucose intolerance that develops or is first discovered during pregnancy Diagnostic classification changes after pregnancy Increased future risk for type 2 DM

50%-80% within 1 decade

GDM

Pregnancy is an insulin resistant state

Resistance is progressive and is related to circulating hormones (human placental lactogen, prolactin, estrogen, and cortisol) Parallel to fetal and placental growth

GDM

Risk Factors
Marked obesity History of GDM Strong family history of DM Glycosuria Ethnic group of high prevalence

Hispanic, African American, Mexican, Native American, South or East Asian, Pacific Islands

GDM

Screening

High risk: as early as possible Average risk: 24-28 weeks gestation 1 hour 50g load: >140, 3 hour OGTT is scheduled 3 hour 100g load: 2 or more BGs meet or exceed, GDM is diagnosed
Values: Fasting-95 mg/dL, 1 hour-180 mg/dL, 2 hour-155 mg/dL, 3 hour-140 mg/dL

Diagnosis

GDM

Fetal risks
First trimester: congenital malformations Increased endocrine system workload Macrosomia (<9 pounds)

Shoulder dystocia and traumatic birth

Hyperglycemia at birth

GDM BG Goals

Test 4 times daily

Fasting, 1 hour postprandial

Fasting: <90
1 hour pp: <130

DM Risk Factors
Genetics Age (>45 years) Overweight/Obesity Physical Inactivity Ethnicity Prior GDM or babies over 9#

Blood Sugar Testing

Varying times per day

1-7 times

BG goals:
Fasting 80-120 Preprandial: <110 2 hours postprandial: <140

DM Management

Dietary

Carbohydrate control
Individualized recommendations No standardized menus Total carbohydrates- NOT sugar Use of alternative sweeteners NO SUGARY DRINKS!!!!!!!!!!!!!!!

DM Management

Exercise
Improved BG control with weight loss of 10% 30 minutes/day as many days as possible

Doesnt have to be consecutive

DM Management

Oral Medications

Sulfonylureas, Meglitinides, Biguanides, Thiazolidinediones (TZDs), AlphaGlucosidase Inhibitors, Amylin Agonists

Secretagogues, sensitizers, suppress hepatic glucose production, delay glucose absorption

Insulin

Rapid-acting to long-acting

Oral Medications

Sulfonylureas
Glyburide, Glipizide (Glucotrol), Glimepiride (Amaryl) Increase insulin release from the pancreas Can cause hypoglycemia

BG < 70

Oral Medication

Meglitinides
Repaglinide (Prandin) and Nateglinide (Starlix) Increases insulin release but the effect is glucose-dependant and diminishes at low blood glucose concentrations Can cause hypoglycemia

Oral Medications

Biguanides
Metformin (Glucophage), Glucovance (Glyburide/Metformin), Metaglip (Glipizide/Metformin), Avandamet ( Metformin/ Rosiglitazone) Reduce hepatic glucose production and decrease insulin resistance Not a hypoglycemic agent

Oral Medications

Thiazolidinediones (TZDs)
Pioglitazone (Actos), Rosiglitazone (Avandia) Decrease insulin resistance Not a hypoglycemic agent

Oral Medications

Alpha-Glucosidase Inhibitors
Acarbose (Precose) and Miglitol (Glyset) Inhibit alpha-glucosidase enzymes in the small intestine and pancreatic alpha-amylase

Reduces the rate of starch digestion and subsequent glucose absorption

Injectable Medications

Symlin and Byetta

Synthetic Amylin: hormone secreted by the pancreatic cells in response to hyperglycemia

Inhibits gastric emptying and suppresses glucagon secretion Adjunctive therapy

Insulin
Basal vs. bolus Variation in peak time and duration Vial and syringe vs. insulin pens Pump therapy

Insulin guidelines
Absorbed most readily in the abdomen, followed by the arms, thighs, and buttocks Best injected at room temperature

Keep backups in the refrigerator

Vials last ~1 month at room temperature, pens last ~2 weeks

Carbohydrate Counting

1500 Rule

Weight in kilograms
Wt (kg) X 0.6 = TDD (total daily dose)
.6 (Type 1) 1.0 (Type 2) 1500/ TDD= BG1 (How much 1 unit of insulin drops the BG) BG1 X .33 = How many grams of carbohydrate is equal to 1 unit of insulin

DM Emotions
Anger Fear Depression Denial Acceptance