IngléS TéCnico I 061009 Dm

October 6th, 2009Profesor: Karla M. López Ahumada

TODAY´S GOALSTODAY´S GOALS

1. Return homework and quizzes2. Take quizz 7 for those justified3. Share information about the first nutrición

conference in Monterrey4. Cover all aspects of diabetes mellitus

Diabetes MellitusDiabetes Mellitus

A heterogeneous group of disorders characterized A heterogeneous group of disorders characterized by an elevation in the level of glucose in the blood.by an elevation in the level of glucose in the blood.

In Diabetes there may be a decrease in the body’s In Diabetes there may be a decrease in the body’s ability to respond to insulin and/or a decrease or ability to respond to insulin and/or a decrease or absence of insulin produced by the pancreas.absence of insulin produced by the pancreas.

It is characterized by hyperglycemia, glycosuria and It is characterized by hyperglycemia, glycosuria and ketonuria.ketonuria.

Diabetes MellitusDiabetes Mellitus

The resulting hyperglycemia may lead to acute The resulting hyperglycemia may lead to acute metabolic complications such as diabetic metabolic complications such as diabetic ketoacidosis and hyperosmolar nonketotic ketoacidosis and hyperosmolar nonketotic syndrome. syndrome.

Long term hyperglycemia may contribute to chronic Long term hyperglycemia may contribute to chronic microvascular complications, neuropathic microvascular complications, neuropathic complications, and macrovascular diseases.complications, and macrovascular diseases.

How will you know if you are a How will you know if you are a diabetic? diabetic?

If you urinate frequently, experience excessive thirst and If you urinate frequently, experience excessive thirst and unexplained weight loss. unexplained weight loss.

If your casual blood sugar (plasma glucose) level is higher If your casual blood sugar (plasma glucose) level is higher than 200mg/dl. than 200mg/dl.

If you have fasting plasma glucose level of not more than If you have fasting plasma glucose level of not more than 120mg/dl. 120mg/dl.

children of diabetics children of diabetics

obese people obese people

people with hypertension people with hypertension

people with high cholesterol levelspeople with high cholesterol levels

people with sedentary lifestyles people with sedentary lifestyles

Types of DiabetesTypes of Diabetes

Type 1 : Insulin-dependent diabetes mellitusType 1 : Insulin-dependent diabetes mellitus

Type 2 : Non-insulin-dependent diabetes mellitusType 2 : Non-insulin-dependent diabetes mellitus

Gestational diabetes mellitusGestational diabetes mellitus

Types of DiabetesTypes of Diabetes

Type 1: About 5% to 10% of people with Diabetes. A form of diabetes Type 1: About 5% to 10% of people with Diabetes. A form of diabetes wherein there is inadequate amounts of insulin are produced by the wherein there is inadequate amounts of insulin are produced by the pancreas, resulting in the need for insulin injections to control the blood pancreas, resulting in the need for insulin injections to control the blood glucose. It is also characterized by sudden onset usually before the age glucose. It is also characterized by sudden onset usually before the age of 30 years.of 30 years.

Type 2: About 90% to 95% of people with Diabetes. Cause by a decrease Type 2: About 90% to 95% of people with Diabetes. Cause by a decrease in the sensitivity of the cells to insulin and the decrease in the amount of in the sensitivity of the cells to insulin and the decrease in the amount of insulin produced. It can be treated with diet, oral hypoglycemic agents insulin produced. It can be treated with diet, oral hypoglycemic agents and insulin injections. It occurs most frequently in people who are over and insulin injections. It occurs most frequently in people who are over 30 years of age and obese. 30 years of age and obese.

EpidemiologyEpidemiology In México, diabetes has been the first leading cause of death since the In México, diabetes has been the first leading cause of death since the

year 2000.year 2000. In the U.S., diabetes is the third leading cause of death by disease, In the U.S., diabetes is the third leading cause of death by disease,

mostly because of the high rate of coronary artery disease among mostly because of the high rate of coronary artery disease among people with diabetes.people with diabetes.

Diabetes is the leading cause of new blindness (among 25 to 74 years Diabetes is the leading cause of new blindness (among 25 to 74 years old) and nontraumatic amputations in the United States.old) and nontraumatic amputations in the United States.

25% of patients on dialysis have diabetes.25% of patients on dialysis have diabetes.

Hispanic, black, and some Native American populations have a higher Hispanic, black, and some Native American populations have a higher rate of diabetes than the white populations.rate of diabetes than the white populations.

EpidemiologyEpidemiology

Diabetes in 2007Diabetes in 2007

• 23.6 million — Number of Americans who had diabetes 23.6 million — Number of Americans who had diabetes • 12.2 million — Number of Americans 60 and older with 12.2 million — Number of Americans 60 and older with

diabetes diabetes • 5.7 million — Number of undiagnosed cases of diabetes 5.7 million — Number of undiagnosed cases of diabetes • 1.6 million — Number of new cases of diabetes in adults1.6 million — Number of new cases of diabetes in adults• 186,300 — Number of people younger than 20 with diabetes186,300 — Number of people younger than 20 with diabetes• $174 billion — Economic cost of diabetes$174 billion — Economic cost of diabetesSource: American Diabetes AssociationSource: American Diabetes Association

Local EpidemiologyLocal Epidemiology

Find local statistics of diabetesYear 2006 or newer% of diabetics by state, gender or ageIdentify your source, always!Be creative when designing a diagram

What is Insulin?What is Insulin?

Hormone secreted by the beta cells, which are one of four types of cells Hormone secreted by the beta cells, which are one of four types of cells in the islets of the pancreas. It is considered to be an anabolic, or in the islets of the pancreas. It is considered to be an anabolic, or storage, hormone. When a meal is eaten, insulin secretion increases and storage, hormone. When a meal is eaten, insulin secretion increases and moves glucose from the circulation into muscle, liver, and fat cells.moves glucose from the circulation into muscle, liver, and fat cells.

During “fasting periods” (between meals and overnight) there is a lower During “fasting periods” (between meals and overnight) there is a lower production of insulin accompanied by an increased release of another production of insulin accompanied by an increased release of another pancreatic hormone the glucagon. The net effect of the balance pancreatic hormone the glucagon. The net effect of the balance between insulin and glucagon levels is to maintain a constant level of between insulin and glucagon levels is to maintain a constant level of glucose in the blood through release of glucose from the liver.glucose in the blood through release of glucose from the liver.

The Pancreas….The Pancreas….

How does it work?How does it work?

Insulin Functions….Insulin Functions….

Stimulates storage of glucose in the liver and muscle (in the Stimulates storage of glucose in the liver and muscle (in the form of glycogen).form of glycogen).

Enhances storage of dietary fat in adipose tissue.Enhances storage of dietary fat in adipose tissue.

Accelerates transport of amino acids (derived from dietary Accelerates transport of amino acids (derived from dietary protein) into the cells.protein) into the cells.

Insulin also inhibits the breakdown of stored glucose, Insulin also inhibits the breakdown of stored glucose, protein, and fat. protein, and fat.

Classification of Diabetes Mellitus and Related Glucose Classification of Diabetes Mellitus and Related Glucose IntoleranceIntolerance

Current ClassificationCurrent Classification Previous ClassificationsPrevious Classifications Clinical CharacteristicsClinical Characteristics

Type 1: Insulin – Type 1: Insulin – dependent diabetes dependent diabetes mellitus (IDDM)mellitus (IDDM)

Juvenile diabetesJuvenile diabetes

Ketosis prone diabetesKetosis prone diabetes

Brittle diabetesBrittle diabetes

Etiology includes Etiology includes genetic, immunologic, genetic, immunologic, and or environmental and or environmental factorsfactors

Need insulin to preserve Need insulin to preserve lifelife

Acute complication of Acute complication of hyperglycemia: diabetic hyperglycemia: diabetic ketoacidosisketoacidosis

Type 2: Non-insulin-Type 2: Non-insulin-dependent diabetes dependent diabetes (NIDDM)(NIDDM)

Adult onset diabetesAdult onset diabetes

Maturity onset diabetesMaturity onset diabetes

Ketosis resistant Ketosis resistant diabetesdiabetes

Stable diabetesStable diabetes

Etiology includes Etiology includes obesity, heredity, and obesity, heredity, and environmental factorsenvironmental factors

Oral hypoglycemic Oral hypoglycemic agents may improve agents may improve blood glucose levelblood glucose level

Acute complication: Acute complication: hyperosmolar nonketotic hyperosmolar nonketotic syndromesyndrome



Diabetes mellitus Diabetes mellitus associated with other associated with other conditions or syndromesconditions or syndromes

Secondary diabetesSecondary diabetes Accompanied by Accompanied by conditions known or conditions known or suspected to cause the suspected to cause the disease: pancreatic disease: pancreatic diseases; hormonal diseases; hormonal abnormalities; drug such abnormalities; drug such as glucocorticoids and as glucocorticoids and estrogen containing estrogen containing preparationspreparations

Gestational diabetesGestational diabetes Gestational diabetesGestational diabetes Onset during pregnanacy Onset during pregnanacy 22ndnd and 3 and 3rdrd trimester trimester

Due to hormones Due to hormones secreted by placenta , secreted by placenta , which inhibit the action which inhibit the action of insulinof insulin

Risk factor: obesity, age Risk factor: obesity, age over 30, family hx of over 30, family hx of diabetes, previous large diabetes, previous large babies (over 9lb)babies (over 9lb)



Impaired glucose Impaired glucose intoleranceintolerance

Borderline diabetesBorderline diabetes

Chemical diabetesChemical diabetes

Subclinical diabetesSubclinical diabetes

Asymptomatic diabetesAsymptomatic diabetes

Blood glucose levels Blood glucose levels between normal and that between normal and that of diabetes 25% of diabetes 25% eventually develop eventually develop diabetesdiabetes

May be obese or May be obese or nonobese; obese should nonobese; obese should reduce weight reduce weight

Previous abnormality of Previous abnormality of glucose toleranceglucose tolerance

Potential abnormality of Potential abnormality of glucose toleranceglucose tolerance

Latent diabetesLatent diabetes

PrediabetesPrediabetes

Previous history of Previous history of hyperglycemia (eg. hyperglycemia (eg. Pregnancy or illness)Pregnancy or illness)

No hx of glucose No hx of glucose intolerance but increase intolerance but increase risk of diabetes due to risk of diabetes due to family hx, obese, racefamily hx, obese, race

Etiology of Type 1 DiabetesEtiology of Type 1 Diabetes

Combination of Genetic, Immunologic, and possibly Combination of Genetic, Immunologic, and possibly Environmental factors contribute to beta cells destruction.Environmental factors contribute to beta cells destruction.

Genetic Genetic – People do not inherit type 1 DM itself; rather, they inherit a – People do not inherit type 1 DM itself; rather, they inherit a genetic predisposition, or tendency, toward developing type 1 DM. This genetic predisposition, or tendency, toward developing type 1 DM. This genetic tendency has been found in people with certain HLA (human genetic tendency has been found in people with certain HLA (human leukocyte antigen) types. 95% of patients with type 1 diabetes exhibit leukocyte antigen) types. 95% of patients with type 1 diabetes exhibit specific HLA types (DR3 or DR4). The risk of developing type 1 DM is specific HLA types (DR3 or DR4). The risk of developing type 1 DM is increased 3-5 times in people who have one of these two HLA types.increased 3-5 times in people who have one of these two HLA types.


Immunologic Immunologic – Abnormal response in which antibodies are – Abnormal response in which antibodies are directed against normal tissues as if they are foreign. Auto directed against normal tissues as if they are foreign. Auto antibodies against islet cells and against endogenous antibodies against islet cells and against endogenous (internal) insulin have been detected in people at the time (internal) insulin have been detected in people at the time of diagnosis.of diagnosis.

EnvironmentalEnvironmental – Certain viruses or toxins may precipitate the – Certain viruses or toxins may precipitate the autoimmune process that leads to beta cell destruction.autoimmune process that leads to beta cell destruction.


The exact mechanisms that lead to insulin resistance and impaired insulin secretion The exact mechanisms that lead to insulin resistance and impaired insulin secretion in type 2 are still unknown at this time. But they say Genetic factor play an in type 2 are still unknown at this time. But they say Genetic factor play an important role in developing insulin resistance.important role in developing insulin resistance.

There are certain risk factors:There are certain risk factors:

Age (insulin resistance tends to occur with age over 65)Age (insulin resistance tends to occur with age over 65)

ObesityObesity

Family historyFamily history

Ethnic group (Hispanic and American Indians)Ethnic group (Hispanic and American Indians)

World Health Organization Diagnostic Criteria for World Health Organization Diagnostic Criteria for Diabetes Mellitus in AdultsDiabetes Mellitus in Adults

On at least two occasions:On at least two occasions:

1.1. Random plasma glucose > 200mg/dlRandom plasma glucose > 200mg/dl

2.2. Fasting plasma glucose > 140mg/dlFasting plasma glucose > 140mg/dl

3.3. 2-hour sample during 75g OGTT (Oral Glucose Tolerance Test) 2-hour sample during 75g OGTT (Oral Glucose Tolerance Test) > 200mg/dl> 200mg/dlOGTT OGTT – The patient ingest high CHO (150-300g) meals for 3 days preceding the test. – The patient ingest high CHO (150-300g) meals for 3 days preceding the test.

After an overnight fast, a blood sample is drawn. Then a 75g CHO load, usually After an overnight fast, a blood sample is drawn. Then a 75g CHO load, usually in the form of carbonated sugar beverage (Glucola), is given to patient. The in the form of carbonated sugar beverage (Glucola), is given to patient. The patient is instructed to sit quietly, avoid exercise, smoking, coffee, and any patient is instructed to sit quietly, avoid exercise, smoking, coffee, and any other oral intake except water. WHO recommends that after 2 hours a blood other oral intake except water. WHO recommends that after 2 hours a blood sample is drawn after glucose ingestion. sample is drawn after glucose ingestion.

Complications of DiabetesComplications of Diabetes

Acute Complications: result from an imbalance in the Acute Complications: result from an imbalance in the treatment regimen.treatment regimen.

Hypoglycemia (low blood sugar), which is also called insulin Hypoglycemia (low blood sugar), which is also called insulin reaction or insulin shock.reaction or insulin shock.

Hyperglycemia (high blood sugar), which, if uncontrolled, Hyperglycemia (high blood sugar), which, if uncontrolled, may lead to diabetic ketoacidosis (DKA) in type 1 diabetes or may lead to diabetic ketoacidosis (DKA) in type 1 diabetes or hyperosmolar nonketotic syndrome (HNKS) in type 2 hyperosmolar nonketotic syndrome (HNKS) in type 2 diabetes. diabetes.

Complications of DiabetesComplications of Diabetes

Chronic Complications of type 1 and type 2 diabetes generally occur 10 to Chronic Complications of type 1 and type 2 diabetes generally occur 10 to 15 years after the onset of diabetes.15 years after the onset of diabetes.

Macrovascular (large vessel) disease – affecting coronary peripheral Macrovascular (large vessel) disease – affecting coronary peripheral vascular, and cerebrovascular circulations.vascular, and cerebrovascular circulations.

Microvascular (small vessel) disease – affecting the eyes (retinopathy) Microvascular (small vessel) disease – affecting the eyes (retinopathy) and kidneys (nephropathy).and kidneys (nephropathy).

Neuropathic diseases – affecting sensorimotor and autonomic nerves Neuropathic diseases – affecting sensorimotor and autonomic nerves and contributing to such problems aqs impotence and foot ulcers.and contributing to such problems aqs impotence and foot ulcers.

Misconceptions Related to Diabetes and Its Misconceptions Related to Diabetes and Its TreatmentTreatment

MisconceptionMisconception RealityReality Diabetes is caused by Diabetes is caused by eating too much sugar.eating too much sugar.

Sugar is found only in Sugar is found only in dessert foods.dessert foods.

The reason that diabetes The reason that diabetes develops initially is that there develops initially is that there is a decrease in the amount of is a decrease in the amount of insulin in the body or a insulin in the body or a decrease in the ability of decrease in the ability of insulin to control the blood insulin to control the blood glucose level.glucose level. There are several different There are several different types of sugars (simple types of sugars (simple carbohydrates) that increase carbohydrates) that increase blood glucose level. Dessert blood glucose level. Dessert foods often contain sucrose. foods often contain sucrose. Even if the juice is labeled Even if the juice is labeled “unsweetened”, there is still “unsweetened”, there is still natural fruit sugar in the natural fruit sugar in the product, which causes product, which causes elevations in the glucose elevations in the glucose level.level.


MisconceptionMisconception RealityReality The only diet change The only diet change needed in the treatment of needed in the treatment of diabetes is to stop eating diabetes is to stop eating sugar.sugar.

Once insulin injections are Once insulin injections are started (for treatment of type started (for treatment of type 2 diabetes) they can never be 2 diabetes) they can never be discontinued.discontinued.

It is important for the It is important for the patient to realize that it is not patient to realize that it is not feasible or advisable to feasible or advisable to remove all sources of sugar remove all sources of sugar from the diet. There are from the diet. There are nutritious foods such as fruit nutritious foods such as fruit that contain sugar and that that contain sugar and that should be included in the should be included in the meal plan.meal plan.

During period of acute During period of acute stress (such as stress (such as illness/surgery) or when illness/surgery) or when receiving certain medications receiving certain medications that cause elevations in blood that cause elevations in blood glucose, some patients with glucose, some patients with type 2 diabetes will require type 2 diabetes will require insulin.insulin.


MisconceptionMisconception RealityReality If increasing doses of If increasing doses of insulin are needed to control insulin are needed to control the blood glucose, the the blood glucose, the diabetes must be getting diabetes must be getting “worse”.“worse”.

Blood glucose levels remain Blood glucose levels remain the same throughout the day.the same throughout the day.

Explain to the patient that, Explain to the patient that, unlike other medications that unlike other medications that are given in standard doses, are given in standard doses, there is not a standard dose there is not a standard dose of insulin that is effective for of insulin that is effective for all patients. It is imp’t to all patients. It is imp’t to instruct patients that many instruct patients that many diff. factors may affect the diff. factors may affect the ability of insulin to lower ability of insulin to lower glucose such as glucose such as obesity,puberty,illness.obesity,puberty,illness. Explain to patients that Explain to patients that there is normally a variation there is normally a variation in blood glucose levels, with in blood glucose levels, with the lowest level before meals the lowest level before meals and the highest 1 to 2 hours and the highest 1 to 2 hours after eating.after eating.


MisconceptionMisconception RealityReality Insulin causes blindness (or Insulin causes blindness (or other diabetic complications.other diabetic complications.

Urine and blood glucose Urine and blood glucose testing are interchangeable. testing are interchangeable. (they provide the same (they provide the same information)information)

It must be explained to the It must be explained to the patient that factors such as patient that factors such as elevated blood glucose and elevated blood glucose and elevated blood pressure elevated blood pressure levels (and not insulin levels (and not insulin therapy) contribute to some therapy) contribute to some of the diabetic complications.of the diabetic complications. Explain to the patient that Explain to the patient that directly testing the blood is directly testing the blood is the most accurate method of the most accurate method of measuring the glucose level. measuring the glucose level. The urine glucose test, w/c The urine glucose test, w/c measures the amt. of glucose measures the amt. of glucose that has spilled into the urine that has spilled into the urine since the bladder last since the bladder last emptied, is only indirect way emptied, is only indirect way of determining glucose level of determining glucose level in the blood. in the blood.


MisconceptionMisconception RealityReality Insulin must be injected Insulin must be injected directly into the vein.directly into the vein.

There is extreme danger There is extreme danger in injecting insulin if there in injecting insulin if there are any air bubbles in the are any air bubbles in the syringe.syringe.

The patient must be The patient must be reassured that insulin is reassured that insulin is injected into the fat tissue on injected into the fat tissue on the back of the arm (or on the the back of the arm (or on the abdomen, thigh, or hip) and abdomen, thigh, or hip) and that the needle is much that the needle is much shorter than that used for shorter than that used for venipuncture.venipuncture.

This maybe related to This maybe related to misconception that insulin is misconception that insulin is injected directly to the vein. injected directly to the vein. Reassure patients that the Reassure patients that the main danger in having air main danger in having air bubbles in the insulin syringe bubbles in the insulin syringe is that the amount of insulin is that the amount of insulin being injected is less than the being injected is less than the required dosage.required dosage.

Morning HyperglycemiaMorning Hyperglycemia

A.A. Insulin WaningInsulin Waning – Progressive rise in blood glucose from bedtime to – Progressive rise in blood glucose from bedtime to morning. morning. TT: TT: Increase evening dose of intermediate or long acting Increase evening dose of intermediate or long acting insulin.insulin.

B.B. Dawn Dawn Phenomenon – Relatively normal blood glucose until about Phenomenon – Relatively normal blood glucose until about 3am when the level begins to rise. 3am when the level begins to rise. TTTT: Change time of injection of : Change time of injection of evening intermediate acting insulin from dinner time to bedtime.evening intermediate acting insulin from dinner time to bedtime.

C.C. Somogyi EffectSomogyi Effect – Normal or elevated glucose at bedtime, a decrease – Normal or elevated glucose at bedtime, a decrease at 2-3am to hypoglycemic levels, and a subsequent increase caused by at 2-3am to hypoglycemic levels, and a subsequent increase caused by the production of counter regulatory hormones.the production of counter regulatory hormones. TTTT: Decrease dose of : Decrease dose of evening intermediate acting insulin or increase evening snack.evening intermediate acting insulin or increase evening snack.

Foot and Leg Problems in DiabetesFoot and Leg Problems in Diabetes

55% to 75% of lower extremity amputations are performed on people with 55% to 75% of lower extremity amputations are performed on people with Diabetes. 50% of these amputations are preventable, provided patients Diabetes. 50% of these amputations are preventable, provided patients are taught preventive foot care measures and practice preventive foot are taught preventive foot care measures and practice preventive foot care on a daily basis.care on a daily basis.

Three diabetic complications contribute to the increased risk of foot Three diabetic complications contribute to the increased risk of foot infections. They are:infections. They are:

A. NeuropathyA. Neuropathy – Sensory neuropathy leads to loss of pain and pressure – Sensory neuropathy leads to loss of pain and pressure sensation, and autonomic neuropathy leads to increased dryness and sensation, and autonomic neuropathy leads to increased dryness and fissuring of the skin (secondary to decreased sweating).fissuring of the skin (secondary to decreased sweating).


B. Peripheral vascular diseaseB. Peripheral vascular disease – Poor circulation of the lower extremities – Poor circulation of the lower extremities contributes to poor wound healing and the development of gangrene.contributes to poor wound healing and the development of gangrene.

C. ImmunocompromiseC. Immunocompromise – Hyperglycemia impairs the ability of specialized – Hyperglycemia impairs the ability of specialized leukocytes to destroy bacteria. Thus, in poorly controlled diabetes there leukocytes to destroy bacteria. Thus, in poorly controlled diabetes there is a lowered resistance to certain infections.is a lowered resistance to certain infections.

Diabetic foot ulcer begins with a soft tissue injury of the foot, the injury Diabetic foot ulcer begins with a soft tissue injury of the foot, the injury or fissure may go unnoticed until a serious infection has developed. or fissure may go unnoticed until a serious infection has developed. Drainage, swelling, redness (from cellulitis) of the leg, or gangrene may Drainage, swelling, redness (from cellulitis) of the leg, or gangrene may be the first sign of foot problems that the patient notices be the first sign of foot problems that the patient notices


Treatment of foot ulcers involves bed rest, antibiotics, and debridement.Treatment of foot ulcers involves bed rest, antibiotics, and debridement. In peripheral vascular diseases, foot ulcers may not heal because of the In peripheral vascular diseases, foot ulcers may not heal because of the

decreased ability of oxygen, nutrients, and antibotics to reach the injured tissue. decreased ability of oxygen, nutrients, and antibotics to reach the injured tissue. Amputation may be necessary to prevent further spread of infection.Amputation may be necessary to prevent further spread of infection.

Foot Assessment and Foot Care instruction are most important in dealing with Foot Assessment and Foot Care instruction are most important in dealing with patient who are high risk of developing foot ulcers.patient who are high risk of developing foot ulcers.

• Duration of diabetes over 10 yearsDuration of diabetes over 10 years• Age over 40 yearsAge over 40 years• History of smokingHistory of smoking• Decreased peripheral pulsesDecreased peripheral pulses• Decreased sensationDecreased sensation• Anatomic deformities or pressure areas (such as calluses)Anatomic deformities or pressure areas (such as calluses)• History of previous foot ulcers or amputation History of previous foot ulcers or amputation

Foot Care….Foot Care….

Preventive foot care includes properly bathing, drying, and Preventive foot care includes properly bathing, drying, and lubricating feet (care must be taken not to allow moisture to lubricating feet (care must be taken not to allow moisture to accumulate from water or lotion between the toes.)accumulate from water or lotion between the toes.)

Feet must be inspected on a daily basis for any redness, blisters, Feet must be inspected on a daily basis for any redness, blisters, fissures, calluses or ulcerations.fissures, calluses or ulcerations.

The interior surface of the shoes should be inspected for any The interior surface of the shoes should be inspected for any rough spots or foreign objects.rough spots or foreign objects.

Feet should be examined on a regular basis by a podiatrist, Feet should be examined on a regular basis by a podiatrist, physician, or nurse.physician, or nurse.

Foot Care….Foot Care….

Patients with thick toenails should see the podiatrist Patients with thick toenails should see the podiatrist routinely for shaving of calluses and trimming of nails.routinely for shaving of calluses and trimming of nails.

Patients should be taught to wear well-fitting, closed toe Patients should be taught to wear well-fitting, closed toe shoes.shoes.

High risk behaviors should be avoided, such as walking High risk behaviors should be avoided, such as walking barefoot, using heating pads on the feet, wearing open toed barefoot, using heating pads on the feet, wearing open toed shoes, and shaving calluses.shoes, and shaving calluses.

Toenails should be trimmed straight across without Toenails should be trimmed straight across without rounding the corners.rounding the corners.

Amputations can be divided into two types: minor and major. Amputations can be divided into two types: minor and major.

Minor or limited amputationsMinor or limited amputations are amputations where only a toe or part of are amputations where only a toe or part of the foot is removed.the foot is removed.

A A ray amputationray amputation is a particular form of minor amputation where a toe and is a particular form of minor amputation where a toe and part of the corresponding metatarsal bone is removed; and the wound is part of the corresponding metatarsal bone is removed; and the wound is usually left open to heal. This sort of operation is performed frequently usually left open to heal. This sort of operation is performed frequently for foot infections in patients with diabetes. A partial foot amputation for foot infections in patients with diabetes. A partial foot amputation through the metatarsal bones is called through the metatarsal bones is called transmetatarsal (TM) transmetatarsal (TM) amputation.amputation.

A Gangrene Foot….A Gangrene Foot….

Transmetatarsal (TM) Transmetatarsal (TM) amputationamputation

Types (Levels) of AmputationsTypes (Levels) of Amputations

Major amputations are amputations where part of the leg is removed. Major amputations are amputations where part of the leg is removed.

These are usually: These are usually: • below the knee, called below the knee, called transtibial (TT) amputation, or transtibial (TT) amputation, or • above the knee, called above the knee, called transfemoral (TF) amputation.transfemoral (TF) amputation.

Occasionally an amputation of just the foot can be performed with a cut Occasionally an amputation of just the foot can be performed with a cut through the ankle joint. through the ankle joint.

Below the knee operation (transtibial amuptation), the bone in the lower Below the knee operation (transtibial amuptation), the bone in the lower leg (tibia) is divided about 12-15 cm below the knee joint. This produces leg (tibia) is divided about 12-15 cm below the knee joint. This produces a good size stump to which a prosthesis can be fitted. a good size stump to which a prosthesis can be fitted.

BELOW KNEE AMPUTATION DUE TO ISCHEMIA BELOW KNEE AMPUTATION DUE TO ISCHEMIA NECROSISNECROSIS

What can you do to control your What can you do to control your blood sugar?blood sugar?

1. Diet Therapy 1. Diet Therapy

* Avoid simple sugars like cakes and chocolates. Instead * Avoid simple sugars like cakes and chocolates. Instead have complex carbohydrated like rice, pasta, cereals and have complex carbohydrated like rice, pasta, cereals and fresh fruits.fresh fruits.* Do not skip or delay meals. It causes fluctuations in blood * Do not skip or delay meals. It causes fluctuations in blood sugar levels.sugar levels.* Eat more fiber-rich foods like vegetables.* Eat more fiber-rich foods like vegetables.* Cut down on salt.* Cut down on salt.* Avoid alcohol. Dietary guidelines recommend no more * Avoid alcohol. Dietary guidelines recommend no more than two drinks for men and no more than one drink per day than two drinks for men and no more than one drink per day for women.for women.

2. Exercise2. Exercise

Regular exercise is an important part of diabetes Regular exercise is an important part of diabetes control.control.

Daily exercise . . .Daily exercise . . .

* Improves cardiovascular fitness* Improves cardiovascular fitness* Helps insulin to work better and lower blood * Helps insulin to work better and lower blood sugarsugar* Lowers blood pressure and cholesterol levels* Lowers blood pressure and cholesterol levels* Reduces body fat and controls body weight* Reduces body fat and controls body weight

Exercise at least 3 time a week for ate least 30 Exercise at least 3 time a week for ate least 30 minutes each session. Always carry quick sugar minutes each session. Always carry quick sugar sources like candy or softdrink to avoid sources like candy or softdrink to avoid hypoglycemia (low blood sugar) during and after hypoglycemia (low blood sugar) during and after exercise.exercise.

3. Control your weight 3. Control your weight

If you are overweight or obese, start If you are overweight or obese, start weight reduction by diet and exercise. weight reduction by diet and exercise. This improves your cardiovascular risk This improves your cardiovascular risk profile.profile.

* It lowers your blood sugar* It lowers your blood sugar* It improves your lipid profile* It improves your lipid profile* It improves your blood pressure * It improves your blood pressure controlcontrol

4. Quit smoking.4. Quit smoking.

Smoking is harmful to your health.Smoking is harmful to your health.

There are drug therapies using oral There are drug therapies using oral hypoglycemic agents. Your doctor can hypoglycemic agents. Your doctor can prescribe one or two agent, depending on prescribe one or two agent, depending on which is appropriate for you.which is appropriate for you.

1. Sulfonylurea – Glibenclamide, Gliclazide, Glipizide, 1. Sulfonylurea – Glibenclamide, Gliclazide, Glipizide, Glimepiride, RepaglinideGlimepiride, Repaglinide

2. Biguanide – Metformin2. Biguanide – Metformin

3. Alpha-glucosidase Inhibitors – Acarbose3. Alpha-glucosidase Inhibitors – Acarbose

4. Thiazolidindione – Troglitazone, Rosiglitazone, Proglitazone. 4. Thiazolidindione – Troglitazone, Rosiglitazone, Proglitazone.

Insulin Therapy….Insulin Therapy….

It is controlled by the M.D. but is also It is controlled by the M.D. but is also monitored by the RD or CDE by encouraging monitored by the RD or CDE by encouraging the patient to keep a food and insulin diary.the patient to keep a food and insulin diary.

RememberRemember

If you have the classic symptoms of diabetes:If you have the classic symptoms of diabetes:

* See your doctor for blood sugar testing* See your doctor for blood sugar testing* Start dieting* Start dieting* Eat plenty of vegetables* Eat plenty of vegetables* Avoid sweets such as chocolates and cakes* Avoid sweets such as chocolates and cakes* Cut down on fatty foods* Cut down on fatty foods* Exercise regularly* Exercise regularly* If you are obese, try to lose some weight* If you are obese, try to lose some weight* Avoid alcohol drinking and stop smoking* Avoid alcohol drinking and stop smoking* If you are hypertensive, consult your doctor for advice * If you are hypertensive, consult your doctor for advice and managementand management

• Eating a healthy diet can:– Help you control your blood sugars and blood

lipids– Help you maintain a healthy weight or lose

weight if you are overweight– Allow you to take less medication or avoid

taking medication for your diabetes

• Eating a healthy diet can:– Prevent complications from high blood sugars

like nerve problems, kidney problems, and vision problems

– Prevent other complications like heart disease and circulatory problems

• Every person with diabetes should receive medical nutrition therapy based on his/her medical needs

• Your dietitian may suggest very specific goals for your weight, diet, and exercise depending on your health status

• Lose weight if you are overweight• Exercise to promote or maintain weight

loss• Monitor carbohydrate intake to maintain

blood sugar control• Obtain carbohydrates mainly from fruits,

vegetables, whole grains, legumes, and low-fat or skim milk

Source: Standards of Medical Care in Diabetes-2007. Position Statement of the American Diabetes Association. Diabetes Care 30 (S1), January 2007.

• Consume at least 130 grams carbohydrate per day (do not use low-carbohydrate diets to treat diabetes)

• Use sugar substitutes if desired

• Limit saturated fat, trans fat, and dietary cholesterol

Source: Standards of Medical Care in Diabetes-2007. Position Statement of the American Diabetes Association. Diabetes Care 30(Supplement 1): S4-S41, January 2007.

• Lose weight if you are overweight– Lose weight slowly and safely, 1-2 pounds

weekly (____ kg?)– Enjoy foods from all food groups. Avoid fad

diets that eliminate any specific foods or groups of foods.

– Eat smaller portions and exercise more

• Exercise to promote or maintain weight loss (consult with your doctor before beginning)

– 30 minutes most days of the week is recommended (____ days?)

– Include aerobic exercise and resistance training for the best results

– Start slowly and increase the duration and intensity of exercise if you are new to exercise.

Source: Standards of Medical Care in Diabetes-2007. Position Statement of the American Diabetes Association. Diabetes Care 30(Supplement 1): S4-S41, January 2007.

• Monitor carbohydrate intake to maintain blood sugar control–Limit your carbohydrate intake to what is

suggested by your dietitian–Use carbohydrate counting, the exchange

system, or other methods to estimate your carbohydrate intake

Source: Nutrition Recommendations and Interventions for Diabetes. A Position Statement of the American Diabetes Association. Diabetes Care 30 (Supplement 1):S48-S63, January 2007.

• Obtain carbohydrates mainly from fruits, vegetables, whole grains, legumes, and low-fat or skim milk.– These foods are the best carbohydrate

sources• They are usually high in fiber and high in nutrients

your body needs


• Carbohydrate sources– Even sugar and sweetened foods can be

included in your diet when you have diabetes.• Substitute them for another carbohydrate in your

diet now and then• These food are “empty calories” so should be

limitedSource: Nutrition Recommendations and Interventions for Diabetes. A Position Statement of the

American Diabetes Association. Diabetes Care 30 (Supplement 1):S48-S63, January 2007.

• Consume at least 130 grams of carbohydrate each day– Low-carbohydrate diets are not recommended

for diabetes management– Carbohydrates contain important nutrients– Choose most of your carbohydrates from

fruits, vegetables, and whole grains.


• Use sugar substitutes if desired– Use only sugar substitutes that are approved

by the FDA– Sugar substitutes can help you enjoy sweet

treats more often– Sugar substitutes don’t appear to cause

weight loss or control blood sugars


• Limit saturated fats, trans fat, and dietary cholesterol– These types of dietary fats and cholesterol

can contribute to heart disease, which is related to diabetes

– When you use fats, use liquid oils instead of solid fats when possible.

• Trans fat are produced by the food industry by taking liquid oils and changing them into solid fats.– This process improves the shelf life and

stability of flavors of processed foods

• Trans fats are found mainly in packaged and processed foods.

• To limit trans fats– Limit use of packaged crackers and cookies– Limit use of commercial bakery products like cakes,

cookies, etc– Use soft margarine instead of stick margarine– Read food labels for trans fats

• Dietary cholesterol is found mainly in animal foods.– By limiting saturated fats you will also limit

dietary cholesterol

• Fats are higher in calories than carbohydrates, so eating less fat can help you lose weight.

• Use lean meats and poultry and include fish, nuts, and legumes to help reduce your intake of saturated fats and cholesterol

• Where do I start?– Talk to your doctor, dietitian, and diabetes

educator about which changes are most important for you

– Start slowly by changing your habits one at a time

– Seek support from your dietitian and/or diabetes support group

• Good nutrition is one of the keys to managing Type 2 Diabetes

• Nutrition guidelines for Type 2 Diabetes focus on controlling carbohydrate and fat intake

• Weight management and exercise are also key• Seek help to set and reach your nutrition and

exercise goals

American Diabetes Association, Food American Diabetes Association, Food exchangesexchanges

http://store.diabetes.org/products/product_zoom_display.jsp?PRODUCT%3C%3Eprd_id=845524441764101&FOLDER%3C%3Efolder_id=2534374302023960&bmUID=1254847924967

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