Diabetes mellitus fp notebook

8/7/2019 Diabetes mellitus fp notebook

1/11

Diabetes Mellitus Aka: Diabetes Mellitus

1. See Also

1. Diabetes Mellitus Glucose Management2. Type I Diabetes Mellitus

3. Type II Diabetes Mellitus4. Insulin Resistance Syndrome5. Diabetes Mellitus Education

2. Definition

1. Metabolic disorder of carbohydrate economy

2. Deficiency of pancreatic beta cell Insulin secretion3. Resistance to Insulin effect peripherally

3. Epidemiology (U.S. statistics for 2004 per ADA)

1. Prevalence1. Type I Diabetes Mellitus : 750,000

2. Type II Diabetes Mellitus : 13 million

3. Gestational Diabetes : 135,0004. Undiagnosed with diabetes: 5.2 million

2. Incidence

1. Type 1: 30,000 new cases per year2. Type 2: 850,000 new cases per year

3. Gestational Diabetes Mellitus: 4% of all pregnancies

4. Fastest growing groups

1. Ages 30 to 39 years2. Type II Diabetes in children

4. Types

1. Type I Diabetes Mellitus

1. Juvenile Diabetes Mellitus2. Insulin Dependent Diabetes Mellitus (IDDM)

2. Type II Diabetes Mellitus1. Adult onset Diabetes Mellitus

2. Non-Insulin Dependent Diabetes Mellitus (NIDDM)

3. Pediatric Type II Diabetes Mellitus(Pediatric NIDDM)

4. Maturity onset Diabetes of youth (MODY)5. Symptoms

1. Classic (75% of cases ofType I Diabetes Mellitus)

1. Polyuria or nocturia2. Polydipsia

3. Unexplained Weight Loss2. Other symptoms

1. Increased appetite

2. Blurred vision

3. Frequent Urinary Tract Infections4. Frequent yeast infections

5. Fatigue

6. Dry or pruritic skin
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7. Numbness or tingling in the extremities

6. Diagnostic Criteria

1. Random Serum Glucose1. Serum Glucose over 200 mg/dl with symptoms

2. FastingSerum Glucose

1. Serum Glucose exceeds 126 mg/dl on 2 different days3. Postprandial Glucose (2 hours post meal)

1. Serum Glucose over 200 mg/dl

2. Precedes fasting glucose increase3. More predictive ofDiabetes Mellitus Complications

4. Casual Plasma Glucose (random glucose)

1. Same criteria as postprandial glucose

5. Oral Glucose Tolerance Test(OGGT)1. Two hour Glucose Tolerance Test (75 gram) >200 mg/dl

2. Consider in patients with Insulin Resistance

1. Patients with pre-diabetes to qualify for education

7. Other monitoring1. HomeSerum Glucose monitoring

1. Over 50% of values should fall in target range8. Management: Severe Hyperglycemia at diagnosis

1. Start Insulin at onset if severe hyperglycemia

2. Criteria

1. Blood Glucose >300 mg/dl2. Hemoglobin A1C >9.0

3. Protocol based on Urine Ketones

1. Urine Ketone s positive1. Evaluate forDiabetic Ketoacidosis

2. Check Metabolic panel andSerum Ketones

2. Urine Ketone s negative1. Type I vs Type II is not critical initially

1. Both get Insulin at this hyperglycemia level

2. Type II suspected1. Consider adding Metformin

2. Insulin can likely be weaned later

1. Glucose toxicity causes low Insulin

level2. EndogenousInsulin will later

normalize

2. Start Lantus Insulin at 10 units SQ today1. Low risk ofHypoglycemia

3. Teach glucose testing, Insulininjection today

1. Formal Diabetic Education within 1 week2. Consider endocrinology consultation later

4. Give prescriptions today

1. Meter, strips, lancets, Insulin, syringes

9. Management: Initial Education
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1. Key Topics

1. SeeDiabetes Mellitus Glucose Management

2. SeeDiabetes Mellitus Education2. Type specific Diabetes Information

1. SeeType I Diabetes Mellitus

2. SeeType II Diabetes Mellitus3. Adjunctive Management

1. SeeHypertension in Diabetes Mellitus

2. SeeCoronary Artery Disease Prevention in Diabetes3. Tobacco Cessation

4. Weight loss

5. Aspirin in all diabetic patients

6. ConsiderACE Inhibitorin all diabetic patients1. Use low dose (2.5 to 5 mg) in normotensive patient

7. Lipid disorders

1. SeeCoronary Artery Disease Prevention in Diabetes

2. SeeLow Fat Diet3. SeeAntiHyperlipidemic

Exercise in Diabetes MellitusAka: Exercise in Diabetes

Mellitus, Diabetes Mellitus and Exercise

1. See Also

1. Diabetes Mellitus

2. Exercise2. Benefits of Exercise in Diabetes Mellitus

1. Exercise lowers Serum Glucose1. Benefits Type I Diabetes Mellitus

2. Benefits Type II Diabetes most significantly

2. Exercise augments Insulin effect1. Facilitates glucose transport across cell

3. Exercise reduces heart disease and stroke risk

1. Increases HDL

2. Lowers LDL3. Lowers Total Cholesterol

4. Decreases SBP and DBP4. Exercise improves general wellness

1. Increases self esteem

2. Improves socialization

3. Risks of Exercise in Diabetes Mellitus1. Hypoglycemia

1. Use caution in Scuba Diving

2. Use caution in rock-climbing
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3. Use caution in long-distance swimming

2. Retinopathy

1. Avoid weight lifting2. Avoid mountain climbing

3. Neuropathy

1. Avoid weight bearing Exercises2. Choose stationary bike or water sports

4. Autonomic Dysfunction

1. Abnormal hemodynamic response to Exercise1. Inappropriate Heart Rateresponse

2. Inappropriate Blood Pressure response

2. May not experience Anginal symptoms with Exercise

3. May not experience hypoglycemic symptoms5. Diabetic Nephropathy

1. Avoid Resistance Training

6. Cardiovascular disease

1. Consider Stress Testing prior to Exercise program4. Starting Exercise

1. Evaluate coronary, nephropathy,Neuropathy, retinopathy1. Confirm no contraindications to starting Exercise

2. Goal energy expenditure (See METS)

1. No weight loss intended: 1000 KCal/week

2. Weight loss intended: 2000 KCal/week3. Progressive Resistance Training

1. Low resistance (40-60% of 1 repetition maximum)

2. Low intensity3. Gradually increase to 15-20 repetitions

5. General ExerciseTips in Diabetes Mellitus

1. Preparation for regularExercise1. Check feet for lesions related to Exercise

2. Pre-Exerciseevaluation (consider Stress Test)

3. Medic-Alert tag4. Exercising diabetics must use Glucometer

5. Pre-planned strategy forHypoglycemia

6. Evaluate Exercise Energy Expenditure (METS)

2. Time Exercise appropriately1. Avoid late-evening Exercise in Type I Diabetes

2. Aerobic Exercise recommended 6 to 7 days per week

1. Duration: 20 to 60 minutes2. Level: 60-80% of maximum Heart Rate

3. Allow time for warm up and cool down

1. Reduces injury risk2. Reduces post-Exercise arrhythmia risk

6. Blood Sugar Management

1. Check pre-Exerciseblood sugar

1. Blood sugar


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1. Snack 15-20 grams carbohydrate before Exercise

2. Blood sugar 100 to 250 mg/dl

1. No snack needed3. Blood sugar >250 with ketones (or >300 without)

1. Delay Exercise

2. CheckSerum Ketones3. Treat hyperglycemia and dehydration

2. Pre-Exercise Insulin

1. Take Insulin more than 1 hour before Exercise2. Inject Insulin into a non-exercising site

1. Absorption at abdomen is fastest and most reliable

3. Decrease short-acting Insulin before Exercise

1. Decrease 30% forExerciseless than 1 hour2. Decrease 40% forExercise1-2 hours

3. Decrease 50% forExerciseover 3 hours

3. Decrease risk ofHypoglycemia

1. Avoid Exerciseduring times of peakInsulin activity2. ConsiderHumalogInsulin

3. Insulin injection site may affect absorption rate4. Avoid Sulfonylurea

4. Be aware of your own blood sugar response to Exercise

1. Pre-ExerciseFood

1. Meals should be ingested 1-2 hours before Exercise2. Strenuous or prolonged Exercise

1. Start increasing calorie intake 24 hours before

2. Supplement carbohydrates every 30 minutes during2. Supplement during Exercise with glucose solutions

1. One bottle for each 30 minutes strenuous Exercise

3. Replenish glycogen stores afterExercise1. Based on Exercise duration and intensity

2. Be aware of delayed Hypoglycemia

5. Carry an activity pack while exercising1. Personal identification

2. Mobile phone

3. Adequate water and carbohydrate source

4. Blood Glucose monitor7. Complications: Post-Exercise Hypoglycemia

1. Delayed Hypoglycemia

1. Occurs 6 to 28 hours after strenuous Exercise2. Occurs despite normal blood sugars during Exercise

3. Occurs regardless of age or illness severity

4. Often occurs at night2. Mechanism

1. Glycogen stores depleted and not replenished

2. Increased Insulinsensitivity post-Exercise

8. Resources
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1. Diabetes, Exerciseand Sports Association

1.

2. Mountains for Active Diabetics (extreme sports)1. http://www.mountain-mad.org

9. References

1. Whaley (2006) ACSM's Guidelines forExercise2. White (1997) Lecture: AAFP Sports Medicine, Dallas

3. Baraz (1994) Clin Diab 12(4):94-8

4. Fahey (1996) Am Fam Physician 53:1611-75. Landry (1992) Clin Sports Med 11:403-18

Diabetic EducationAka: Diabetic Education, Diabetes

Mellitus Education

Advertisement

1. Approach: Employ a Pediatric Diabetes Team (Essential)

1. Physician

2. Nurse or Nurse Practitioner

3. Diabetes Educator4. Nutritionist or Dietician

5. Social Worker

6. Psychologist2. Approach: Initial Education

1. Describe Diabetes Mellitus pathophysiology

2. Management principles1. Taking Insulin (when prescribed) is non-negotiable

2. Other issues are negotiable

3. Insulin action and use

4. Blood Glucose Monitoring5. Urine Ketone testing

6. Hypoglycemia

7. Exercise in Diabetes Mellitus8. Nutrition in Diabetes Mellitus

9. Psychological Issues

10. Home Treatment3. Approach: Ongoing Education

1. Should occur at every visit

2. Must be age and education-level appropriate1. Include children age 5 and older in discussion

3. Include skill review
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4. Prevention

1. Seasonal illness prevention

2. Immunization s: Influenza Vaccine3. SeeDiabetic Foot Care

4. SeeExercise in Diabetes Mellitus

5. SeeNutrition in Diabetes Mellitus5. Emergencies

1. Hypoglycemia

2. Type I Diabetes Mellitus Hyperglycemia1. Diabetic Ketoacidosis (DKA)

3. Type II Diabetes Mellitus Hyperglycemia

1. Hyperosmolar Hyperglycemic Nonketotic Coma

6. Chronic Complications1. Diabetic Retinopathy

2. Diabetic Nephropathy

3. Diabetic Neuropathy

4. Coronary Artery Disease

Sports MedicineMario Cesar Moreira de Araujo, MD & Marcelo Riccio Facio, MD

Medstudents' Homepage

Diabetes Mellitus and Exercise

Introduction

Nowadays the development of convinient and efficient ways of self monitoring blood

glucose, ande the admission of benefits of regular exercing permit and enconrage more

diabetics to engage into exercise programs. Consequenty, phisicians will have to be ableto prescribe arrangements in calorie ingestion and insulin dosage, as well imagine

possible hypoglycemia and unexpected prolonged exercise to permit a safe participation

on this activities.
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Diabets Mellitus is a chronic discase characterized by relative or absolute absence of

insulin, with repercussion on glucose metabolism classified in Type I (Insulin Dependent

Diabetes), Type II (Non - Insulin Dependent Diabetes), Secondary Diabetes and GeneticDefects of the Insulin Receptor. Diabetes Mellitus is a very common disoider, with an

estimated prevalence between 2 and 4 % in the Unitede States.

Type I Insulin - Dependent Diabetes Mellitus (IDDM) is better characterized by an auto-

imune disturbance in which panereatic b cells are distructed. Because off the markedhupoinsulinemia patients usually presents hyperglycemia (with acute complications:

polymia, polydipsia and polyfagia) and the risk of developing ketoacidosis.

This chapter entends help the medical student to get contact with clinical control of

IDDM and NIDDM patients and is diveded in four basical parts: (1) Normal MetabolismDuring Exercise (2) Utilization of glucose on diabetics that exercise themselves (3)

Beneficts and risks of exercises for diabetics (4) Terapeutic estrategis.

Glucose Metabolism During Exercise

During exercise, muscle utilises metabolic fuels at an increased rate to provide the inergy

required for contraction. In healthy individual, muscle glycogen is the predominant fuel

used during very stenuous, short term exercise, whereas blood-borne glucose and free

fatty acids (FFA) derived from adipose tissue triglycerides are used preferentially duringprolonged exercise of low to moderate intensity. Glucose uptake by muscle increases 4 -

to 5 - fold or more during exercises. Despite this, the level of glucose in the plasma is

maintained as a result of enhanced glucose produciton by the liver.

At the onset of exercise and before increased oxygen transport by the circulatory system,

the anaerobic breakdown of glycogen to form lactate provides an immediate source ofadenosine triphosphate (ATP). Exercise that continues more than 30 minutes increases

the dependence on blood borne energy sources. After 60 a 90 minutes of exercise, FFAare the principal energy source. The utilization of FFA continues to discrease as the

duration of exercises increases. The ability to use glucose and to a greater extent FFA

as an energy source is greatly influenced by endurance training. Trained subjects use ahigher proportion of FFA than untramed subjects and are able to spare glycogen stores

while minimizing lactate production: Occasionally singnificant hyperglycemia and

clinically important hypoglycemia occur in normal individuals. Plasma glucose, nowever,remains within a narrow range when exercising at moderate intensities (30% a 60%) CO2

max.

Energy utilization at exercise is influenced by insulin and by counterregulatory

hormones: glucagon, epinephrine and norepinephrine, cortisol, and growth hormone. Therole of insulin in glucose transport to muscle is markedly reduce during exercise. The

most significant effect of insulin during exercise involves inhibition of hepatic

glycogenolysis / gluconeogenesis and lipolysis. Insulin secretion is also suppressed by the

alpha-adrenergic inhibition of the pancreatic beta cell, allowing for mobilization ofhepatic glucose and avoidance of hypoglycemia. Exercise also increases insulin


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sensitivity by enhancing the binding of insulin to receptor sites on the muscle cell. This

allows for increased glucose uptake without changes in insulin concentration. Increased

numbers of receptor sites area found in more fit individuals with increased insulin bidingand insulin sensitivity lasting for up to 24 hours after exercise.

Greater use of hepatic glucose occurs to prevent hypoglicemia as glucose is used byexercising muscles. This increase in glucose production occurs throught hepatic

glycogenolysis. Subsequently gliconeogenesis becomes increasingly important and isinfluenced by counterregulatory hormones.

In addition, adrenaline may act to maintain normoglycemia increasing muscle

glicogenolysis adiposea tissue lipolysis, there by diminishing the need of blood born

glucose.

Exercise in Type I Diabetes Mellitus

Changes in glucose homeostasis in the type I diabetic are variable and depend on thefollowing factors: degree of insulin administration, prior metabolic control, the presenceor absence of autonomic neuropathy, and caloric intake. Balanced energy supply and

insulin availability can have significant effects on the exercising athlete with type I

diabetes. Excessive insulin levels suppress hepatic glucose production, and lowred serum

glucose levels may be met by deficient glucagon secretion, which is common afterseveral years of disease.

The well-controlled diabetic may commonly work out for approximately 30 to 45

minutes of sustained intense aerobic exercise without problems. Type I patients may have

decreased glycogen stores in the liver and to a lesser extent in skeletal muscle. Lack of

adequate glycogen stores leads to impaired aerobic exercise endurance when comparedwith normals.

Hypoglycemia is a common ocurrence in type I diabetics while exercising. In normalsubjects, plasma insulin levels decrease during exercise. Additionally, insulin

counterrulatory hormones (glucagon an epinephrine) promote increased hepatic glucose

production, which matches the amount of glucose used during exercise. In the type I

diabetic, plasma insulin concentrations may not fall during exercise and may evenincrease if exercise occurs within 1 hour of insulin injection. These sustained insulin

levels during exercise enhance peripheral glucose uptake and stimulate glucose oxidation

by exercising muscle. More important, however, is tye inhibition of hepatic glucose

production. Hight insulin levels inhibit both gluconeogenesis and glycolenolysis. Eventhought adrenergic stimulation leads to excess production of counterregulatory hormones,

hepatic glucose production fails to match the rate of peripheral utilization. Duringexercise of moderate duration, these effects may be considered beneficial; however,

longe periods of exercise may result in hypoglycemia.

The type I diabetic is at greatest risk of developing severe hypoglycemia 6 to 14 hours

after strenuous exercise. Muscle and hepatic glycogen must be restored during periods of


10/11

rest. Combined wity increased insulin sensitivity in the postexercise period, depleted

muscle glycogen stores along wity tye activation of glycogen synthetase in muscle

contribute significantly to tye risk of hypoglycemia. Insulin and caloric intake must beadjusted after strenuous exercise to avoid severe nocturnal hypoglycemia. Hypoglycemia

due to increased insulin absorption from injection sites of actively exercising extremities

as been described. Consequently the abdomen has been recommended as the abdomenhas been recommended as the primary injection site in the exercising diabetic.

Absorption of insulin from the abdomen is generally faster and more reliable than using

limb sities for injection and consequently does not prevent the occurrence ofhypoglycemia.

Finally, the type I diabetic does not increase insulin secretion postexercise.

Hyperglycemia after exertion can be profound and prolonged for days owing to insulin

deficiency. In the presence of poor control and ketonuria, further exercise can lead toimpaired glucose uptake and increased lipolysis, ketogenesis, and hepatic glucose

production. The patient may rapidly unless exogenous insulin is given to the patient.

Exercise in Type II Diabetes Mellitus

Initial treatment of type II diabetes consists of weight reduction, dietary control, exercise,and oral hypoglycemic agents. Insulin replacement is seldom necessary but should be

added to the treatment regimen when hyperglycemia remains unchecked by these

methods. Exercise is a major contributor in controlling hyperglycemia through improvedperipheral insulin sensitivity, enhanced insulin binding, and reduced obesity.

Exercise can aid glycemic control and in combination with proper diet help prevent type

II diabetes from occurring in those persons at risk. Exercise does this by improving short-

term insulin sensitivity and reducing insulin resistance, both of which begin to disappeara few days after exercise is discontinued. Althought the number of insulin receptors

remains constant with exercise, the biding of insulin to adipocytes is increased with no

increase noted in binding to myocytes. In both cell types, however, the number and

activity of glucose transport proteins (particularly Glut-4-isoform) are increased withexercise. This results in an increase in insulin-stimulated glucose transport into these cells

following exercise, which improves glycemic control.

With the onset of exercise, the type II patient, does not respont with a decrease in serumglucose concentration as in the nondiabetic. This is due to increased glucose uptake in the

peripheral tissues. As a result, serum glucose is higher, and liver glucose production is

halted to allow for normalization of the hyperglycemia by overall reduction in theglucose level. In constrast to the type I patient, type II diabetics do not usually sufferhypoglycemia because endogenous insulin levels can usually be maintained. Those

athletes on oral hypoglycemic agents or insulin, however, may have problems with

glucose homeostasis during exercise. The athlete may need to lower the medication doseor increase carbohydrate intake (or both) before exercise to prevent hypoglycemia.

Severe hypoglycemia is unusual because individuals are still able to reduce endogenous

insulin production as blood glucose levels decline.


11/11

Bibliography

1. Sports Medicine for Primary Care, Willian E. Moats2. Goodman, The Pharmacological Basis of Therapheutics, Nineth Edition, Goodman &

Gilmans

3. The Medical Clinics of North America, Vol 78, Num 2 , Gray I. Wadler.4. Cecil , Textbook of Medicine. twenth edition, Bennet & Plum

5. Exercise prescription fo Individuals with metabolic disorders (pratical considerations)

John C. Young. SPORTS MED. 19(1) PAG 43 - 54 1995

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