Diabetes Mellitus

   Sixteen million Americans (6% of the U.S population) have diabetes, but only 8 million have been diagnosed.

   Diabetes is the fourth leading cause of death by disease in the U.S. Diabetes is the leading cause of end-stage renal disease, blindness, non-traumatic amputation and impotence. Heart disease and stroke are two to six times more common in people with diabetes.

   Recent evidence has shown that the complications of diabetes can be greatly reduced in severity, if not prevented, when people with diabetes control their blood glucose, blood pressure, and weight, reduce lipid abnormalities, exercise regularly, and stop cigarette smoking.

Type 1 Diabetes


(Insulin-Dependent Diabetes Mellitus)

·Approximately 10% of people diagnosed with diabetes have type 1.

·Onset can occur at any age.

·Weight loss, increased urination, and increased thirst sensation my occur abruptly at onset. The patient produces only minimal amounts of insulin and eventually must depend on insulin therapy to sustain life and prevent diabetic ketoacidosis.

·Etiology is related to beta cell defect of failure. Most common form is autoimmune destruction of islet cells. Rate of beta cell destruction is quite variable, being rapid in some individuals – mainly infants and children, and slow in others – mainly adults. Some forms of type 1 diabetes have no known etiology and are classified as “idiopathic diabetes”.

Type 2 Diabetes


(Non-Insulin-Dependent Diabetes Mellitus)

·Approximately 90% of people with diabetes have type 2.

·Onset usually occurs after age 30, but can occur earlier in life.

·There are relatively few classic symptoms and little likelihood of diabetic ketoacidosis. Insulin may be used to control glucose, but is not needed for survival.

·About 75% of patients with type 2 are obese.

·Etiology includes insulin resistance with relative (rather than absolute) insulin deficiency. There are many different causes of this form of diabetes, and it is likely that the proportion of patients in this category will decrease in the future as identification of specific pathogenic processes or genetic defects permit better differentiation among them and a more definitive subclassification into other specific types.

Gestational Diabetes

 

·Characterized by glucose intolerance with onset during pregnancy.

·All pregnant women should be screened at 24 to 28 weeks gestation with a 50 g glucose challenge test (does not need to be fasting). If the plasma glucose at 1h >140mg/dl, do a 3-h oral glucose tolerance test (OGTT) using a 100g load.

·Diagnosis of gestational diabetes is made if two or more plasma glucose levels equal or exceed the following on a 3 h, 100 g load OGTT:

Fasting 1h 2h 3h

105mg/dl 190mg/dl 165mg/dl 145mg/dl

·Six weeks after delivery, the woman should be classified by diagnostic testing into one of the following categories:

  1. Diabetes
  2. Impaired fasting glucose
  3. Impaired glucose tolerance
  4. Normal glycemia.

 

Type 1 Diabetes

 

Patient Education


All patients need training in:

·Meal planning

·Serial monitoring of blood glucose with record keeping

·Insulin use (with adjustment & supplementation guidelines).

·Sick day and DKA management

·Hypoglycemia prevention & treatment

·Exercise precautions

·Chronic complications, with screening guidelines to detect early disease

·Ongoing monitoring, with glycosylated hemoglobin four times a year.

Insulin Preparations


Lispro

·Soluble and very rapidly absorbed

·Onset ~ 15 min, peak 30 – 90 min, duration 3 – 4 hours

·When mixed with NPH, L, or UL must be injected immediately


Regular

·Soluble and rapidly absorbed

·Onset < 1h, peak 2 – 3 hours, and usual effective duration 3 – 6 hours for human regular

·Available in buffered form for pump use


NPH

·Altered to slow absorption

·Precipitated with protamine

·Onset 2 – 4 hours, peak 4 – 10 hours, and usual effective duration 10 – 16 h for human NPH

·Available as premixed 70 % NPH/30 % regular and 50% NPH/50% regular

Lente

·Altered to slow absorption

·Peak and duration of Lente similar to NPH

·More likely than NPH to interact with regular when mixed

·Available in long-acting form (ultralente) which can be used as basal insulin with pre-meal regular or lispro.

Insulin Requirements

Insulin therapy should be administered to provide a basal amount, as well as peaks after each meal. The basal amount may vary by time of day. For example, many insulin-dependent patients have an increased early morning need, known as the “dawn phenomenon”.
Insulin therapy should mimic the natural release of insulin by the beta cells release. Insulin requirements are as follows:

·Starting dose = 0.2 x body weight in pounds

·Average dose= 0.3 x body weight in pounds

·Administer in two, three or more injections.

Insulin Adjustments

Insulin dose adjustments for all regimens are based on daily blood glucose levels and on the peak effect of a given insulin dose.

Assumed peaks are:

·Lispro 1 – 2 hours

·Regular: 2 – 4 hrs

·NPH: 4 – 10 hrs

·Ultralente: 14 – 18 hrs

Adjustments should be made by 20% increments (e.g., 1 U for doses of 5 U; 2 U for doses of 10 U).

Downward Adjustment

Should be done the day following a below range blood glucose to avoid repeat hypoglycemia.

Upward Adjustment

Should be delayed for 2 days to establish a pattern.

People with diabetes should record their blood glucose on a flow sheet with their insulin doses and other comments (e.g., exercise, reactions)

Serial monitoring of blood glucose (SMBG)

   Most, if not all, patients with Type 1 should use intensive insulin therapy with the goal of obtaining near-normalization of blood glucose. In order to meet this goal, one needs to monitor blood glucose pre-meal, at bedtime, and periodically at 3 O’clock in the morning. These results are used to make daily insulin adjustments to obtain blood glucose within an individual’s target range.

   Two-hour post prandial (after meal) BG measurements should be added for lispro programs, pregnancy or patients with elevated HBA1c despite good fasting BG.

People with hypoglycemic unawareness follow the same SMBG recommendations as other Type 1 individuals, except their target range is set higher.

Diet Prescription

·Carbohydrate 55 – 60 %

·Fiber 35 – 40 g/day

·Protein 15 – 20% (0.8 g/kg body weight if no kidney disease; 0.4g/kg per day if nephropathy)

·Fat < 30% (of this < 10% should be saturated fat)

·Cholesterol < 300 mg/day

·Sodium < 3g/day

Coordinate the insulin regimen with the timing of meals and the distribution of calories during the day.

   Carbohydrate counting may be used instead of a fixed meal plan. To determine insulin to carbohydrate ratio, insulin must be first adjusted to a fixed carbohydrate meal and once blood glucose is in a normal range, a ratio can be calculated. Patient then free to take insulin based on carbohydrate consumed. On average, 1 unit of insulin covers 7 to 15 g of carbohydrate.

Exercise

Benefits

·Ameliorates cardiac risk factors by increasing HDL cholesterol and decreasing VLDL and LDL cholesterol.

·Improves sense of well being and quality of life.

·Improves strength and endurance for conduct of daily activities.


Risks

·Hypoglycemia, if the insulin level during and post-exercise is high.

·Hyperglycemia and potential ketosis, if insulin levels is too low.

·May precipitate arrhythmic or myocardial event if patient has significant heart disease.

·May hasten development of significant foot or joint problems if neuropathy or other joint disease is present.

·May precipitate acute vitreous hemorrhage if proliferative retinopathy is present.

Exercise

·Perform detailed medical evaluation prior to initiation. (Include ECG with determination of workload capacity if patient is over 40 of age, has had diabetes for more than 20 years, or has heart disease).

·Determine target heart rate as 60 – 75 % of maximal heart rate. (Estimate of maximal heart rate is 220 minus age.)

·Patient should exercise 3 times per week to maintain cardiovascular condition and 5 times per week to maintain and promote weight loss. Each session shinclude:

·Warm up period (5 – 10 min) stretching and rhythmic movements.

·Aerobic period (20 – 30 min) at 60 – 75 % of maximal heart rate.

·Cool down period ( 5 – 10 min)

·If proliferative retinopathy or hypertension is present, patient should avoid lifting, straining and intense upper body exercises.

·If feet are neuropathic, avoid running and high impact aerobics.


For safe exercise in Type 1, the patient should:

·Carry an ID card and bracelet.

·Monitor blood glucose pre- and post- exercise to determine individual response. Note: Delay exercise if blood glucose is < 80mg/dl or > 250 mg/dl, or if urine ketones are present.

·Watch for hypoglycemia during and for several hours after exercise.

·Have immediate access to readily absorbable glucose (e.g., glucose tablets) during and after exercise.

·Drink plenty of fluids pre- and post-exercise to prevent dehydration.

·Take extra carbohydrates:

10 – 15 g per hour of moderate activity
30 – 59 g per hour of strenuous activity

Hypoglycemia

The major side effect of insulin is hypoglycemia. Patients and family/house-hold members should be trained to recognize and treat hypoglycemia.

Symptoms of hypoglycemia are:

 

·Cold and clammy sweating

·Tremors

·Hunger pain

·Irritability

·Impaired level of consciousness, as the patient becomes more hypoglycemic.

If the patient is conscious, the treatment of choice is 10 – 15 g oral glucose (e.g., 2-glucose tablets or 4-oz juice). Repeat in 15 – 20 min if the hypoglycemia persists. If the next meal is more than 1 – 2 hours away, the patient should also eat an extra snack.

If the patient cannot safely swallow, parenteral treatment is required. If an IV is in place, the treatment of choice is 25 ml of 50%glucose. If an IV access is not available, 1 mg IM or SC glucagon should be given.

Ketoacidosis

It results from lack of insulin. The condition presents with:

·Acidosis (pH < 7.2 or bicarb < 15)

·An increased anion gap [(Na+K) – (Cl +HCO3) > 20 mEq/L]

·Ketosis (ketonemia or large ketonuria)

·Hyperglycemia (blood glucose >250 mg/dl)

Findings include vomiting, abdominal pain, polyuria, hyperpnea, dehydration, and coma in severe cases.

Here, the patient needs hospitalization with proper fluid replacement and insulin.

Psychological Issues

Diabetes can affect the mental health of patients. Emotional support is important, especially when there is a major change in the disease course (e.g., diagnosis, initiation of a new treatment regimen, or the development of complications).

Good diabetes control requires adherence to a program of diet, exercise, SMBG, and medication, if needed. This requires a great deal of effort, emotional commitment and dedication on the part of the patient.

Failure to adhere to the diabetes care program is a common problem, which may present as poor diabetes control.

Signs of poor adherence:

 

·Deterioration of blood glucose control

·Frequent need for hospitalization

·Missing diabetes records

·Weight change

   Psychological stress may contribute to deterioration of diabetes control. A patient under stress will often vary his/her lifestyle, including schedules and eating habits, and suffer consequent glucose swings. Stress also can affect glucose control directly.

Eating disorders are more common in diabetes. Skipping insulin to lose weight is an eating disorder unique to people with diabetes.

Enhance patient adherence

·Tailor the diabetes care regimen to the patient and his/her caregivers. Adjust treatment plan for intellectual or financial limitations as needed.

·Discuss recommendations with patient and agree on a treatment plan that the patient is likely to follow.

·Begin with a simple program and increase the complexity as appropriate.

Article By: eDoctorOnline.com Staff
Views: 2623

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