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

Diagnosis 1 hour 50g load: >140, 3 hour OGTT is

scheduled 3 hour 100g load: 2 or more BG’s 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

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• Doesn’t have to be consecutive

DM Management Oral Medications

Sulfonylureas, Meglitinides, Biguanides, Thiazolidinediones (TZD’s), Alpha-Glucosidase 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 (TZD’s)

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