Documente Academic
Documente Profesional
Documente Cultură
4-Hour Session
Revised August 2004
Objectives
Describe and contrast 2 principle types of diabetes List the diagnostic criteria for diabetes Describe acute and chronic complications of diabetes Describe how to prevent complications of diabetes Describe diabetes self-management skills
Why Diabetes?
18 million cases in the United States Estimated that 1/3 are unaware of diagnosis Third leading cause of death in the U.S. Leading cause of blindness *Patient education is the cornerstone of diabetes treatment and management* *Complications can be prevented or delayed through intensive treatment*
Diabetes is
A metabolic disease in which the body does not produce or properly use insulin to regulate the level of glucose (sugar) in the blood. In other words, your body cannot use the fuel in the blood for energy..
Quick Review
Glucose: a sugar made in the body after food is digested. It is the bodys main source of energy (fuel for the body) Insulin: a hormone produced by the pancreas that allows glucose to get into the cells to be used for energy (acts like a key)
Type 1 DM
Signs and Symptoms
Usually sudden and severe in onset Increased urination Increased thirst Increased appetite Weight loss Blurred vision Fatigue/weakness Nausea/vomiting Vaginal itching/infections Skin rashes
Type 2 DM
Signs and Symptoms
Onset more insidious Early symptoms may go unnoticed (3-5yrs) Increased urination, thirst, & hunger Blurred vision Fatigue Sores that heal slowly Sexual dysfunction (erectile dysfunction) Infections (vaginal in women)
Research
Studies show that an increased glucose level in the blood over many years can cause irreversible damage to the eyes, kidneys, heart, blood vessels and the feet.
Medications
Insulin helps sugar (glucose) move into cells, where it is used to produce energy Without insulin, glucose cannot enter the cells
CELL
CELL
Insulin helps glucose move into cells, where it is used to produce energy If not enough insulin is produced (insulin deficiency), not enough glucose can move into cells When insulin is not used properly (insulin resistance), cells do not respond by taking in glucose Cells slowly waste away from lack of glucose
CELL
CELL
Normally, the body regulates blood glucose levels by removing excess glucose after a meal...
Ingested carbohydrates are metabolized into glucose and absorbed into the blood, causing high blood sugar (hyperglycemia)
The pancreas produces and secretes insulin, which helps move glucose into cells
Muscle, fat, and liver cells take up glucose from the blood
and releasing stored glucose back into the blood between meals
Gastrointestinal tract is empty; glucose must be supplied by the body for energy
The pancreas produces and secretes glucagon, stimulating the liver to release the glucose stored during meals
Type 2 diabetes evolves from 2 primary defects: insulin deficiency and insulin resistance
Progression of untreated type 2 diabetes
Pancreatic dysfunction leads to insulin deficiency Blood glucose levels remain high
Treatment Options
First treatment is controlling diet and getting plenty of exercise Next option is use of oral medications Final option is use of insulin
This is needed in Type 1 diabetes patients because their bodies do not make insulin
Drug therapy is needed in addition when diet and physical activity fail to correct hyperglycemia
Oral hypoglycemic Insulin for type 1 or agents for type 2 type 2 diabetes diabetes
Medication Types
There are several ways in which these medications work
Causes your body to secrete insulin, decreases your bodys resistance to insulin, decreases glucose production in your liver, prevents absorption of sugars in your diet
Classes of drugs
Sulfonylureas and insulin-secreting agents Biguanides Alpha-glucosidase inhibitors Thiazolidinediones
Sulfonylureas
Brand names
Amaryl DiaBeta Diabinase Glucotrol (XL) Glynase PresTab Micronase
Generic names
glimepride glyburide chlorpropamide glipizide glyburide glyburide
Sulfonylureas
Increase insulin release from your pancreas Help improve muscle sensitivity to insulin Pancreas must be actively making insulin to work Often taken 30 minutes before meals
D-phenylalanine Derivatives
Nateglinide (Starlix) Increase insulin release from pancreas Short acting Take with each meal Do not take if meal skipped
Meglitinides
Repaglinide (Prandin) Helps pancreas secrete more insulin right after meals, thus reducing post-meal blood sugar Works fast and short duration of action Take before meals Do not take if meal skipped
Biguanides
Metformin (Glucophage, Glucophage XR) Decrease glucose production in the liver Increase muscle sensitivity to insulin Decrease insulin need May help with weight loss Improve cholesterol values
Thiazolidinediones
Pioglitazone (Actos) Rosiglitazone (Avandia) Help make your cells more sensitive to insulin
Medications may have to be combined to keep pace with this progressive disease
Insulin: Rapid-Acting
Rapid-acting: insulin lispro (Humalog) and insulin aspart (Novolog) Starts working in 5-15 minutes Lowers blood glucose most in 45-90 minutes Finishes working in 3-4 hours
Insulin: Short-acting
Short-acting, regular (R) insulin Starts working in 30 minutes Lowers blood glucose most in 2-5 hours Finishes working in 5-8 hours
Insulin: Intermediate-acting
Intermediate-acting, NPH (N) or Lente (L) insulin Starts working in 1-3 hours Lowers blood glucose most in 6-12 hours Finishes working in 16-24 hours
Insulin: Long-acting
Long-acting, insulin glargine (Lantus) Starts working in 1 hour Lowers blood glucose evenly for 24 hours Finishes working in 24 hours and is taken once per day at bedtime Lantus should not be mixed together in a syringe with any other form of insulin
Dont change needle types or site because it may change absorption Keep insulin in refrigerator Reduce pain
Allow bottle to warm before injection (or leave one in use out), allow alcohol to dry, dont reuse needles, dont wipe needle with alcohol
Summary
Type 2 diabetes is a progressive, but manageable, disease Type 2 diabetes evolves from 2 primary defects:
insulin deficiency insulin resistance
Uncontrolled hyperglycemia leads to serious complications Risk for complications can be reduced by tight glucose control
Summary, cont
Disease progression can be managed through a partnership between physician and patient Treatment options:
increased physical activity and nutritional therapy sulfonylureas other oral agents or insulin (as monotherapy or in combination)
Emotional Aspects
How did you feel when you first heard your diabetes diagnosis?
Fear Relief Worry Desperate Hope Out-of-Control Overwhelmed Frustrated Helpless Hopeless Guilt Alone Resentment Anger Grief
Plan of Action
Information Get care/Get treatment Experiment with control Pay attention to your emotions Plan for changes Make changes
Exercise
Effects of Exercise
Improvement in blood glucose control Improved insulin sensitivity Reduction in body fat Cardiovascular benefits Stress reduction Prevention of Type 2 diabetes
Contraindications to Exercise
Active retinal hemorrhage ; retinopathy therapy Presence of illness or infection Blood glucose level > 250 to 300 mg/dl with presence of ketones or Blood glucose level 80-100 mg/dl
Exercise Programming
Aerobic: Large muscle group activities
50-80% HR Max (220-Age x .5-.8) Monitor Rate of Perceived Exertion (RPE) 4-7 days a week 20-60 minutes/session
Strength/Anaerobic
Free weights, weight machines 1-3 times a week
Flexibility: Stretching/Yoga
Maintain/increase range of motion Improve gait/balance and coordination
Helpful Hints
Keep sources of rapidly acting CHO available during exercise Consume plenty of fluids before, during and after exercise Practice good foot care and wear proper exercise shoes and cotton or moisturewicking socks Carry medical identification
Eye Care
See your ophthalmologist once a year for a dilated eye exam
Report blurred or double vision Seeing dark spots Narrowed field of vision
Skin Care
Bathing Precautions -Keep dry parts of your skin moist -Mild soap and lukewarm water Protect Skin -Avoid scratches, cuts and other injuries -DO NOT GO BAREFOOT! -Protect you skin from the sun, sunscreen Treat injuries promptly -Wash cuts with soap and water -Notify provider if cuts dont heal or signs of infection.
Foot Care
Clip toenails straight across Keep your feet out of water that is too hot or too cold. No heating pads Do not soak your feet for prolonged periods No OTC remedies for corn/calluses, they may cause burns or ulcers
Wear comfortable shoes that fit Examine feet daily for scratches, wounds, rash, blisters, or any change in sensation or nail color
Dental Care
Keep your teeth clean Dont brush too hard Replace toothbrush every 3-4 months Go to the dentist every 6 months for cleaning and exam Report any signs of redness, pus, patches, or pain
Travel Tips
Carry and wear diabetes identification Have diabetes medical information available:
Prescriptions and Physician information
Follow usual meal, exercise, & medications Insulin storage Easy to carry, easy to eat carb snacks Wear comfortable shoes Take sunblock
Daily to do list
Daily to do list
Check blood glucose with glucometer Take medications as prescribed Follow meal plan Exercise and stress reduction Inspect feet Dental care
Quarterly to do list
Make appointment with health care provider
Take blood glucose diary for review Make list of questions and concerns Blood Pressure check (recommend home BP monitor) Hemoglobin A1C check
Foods contain carbohydrates, fats, and proteins as sources of energy, plus many other important ingredients like water, vitamins, and minerals Carbohydrates (CHO) in food have the most impact on the blood sugar
Although high fat foods can contribute to obesity, heart disease, and higher blood sugars in the long run, they play only a minor role in daily blood sugar control Protein also plays a minor role in blood sugar control- half the protein we eat converts to glucose over a period of several hours but should only make up ~10-20% of our total calories
One serving from the Bread/Starch/Starchy Vegetable group= 15 grams of CHO One serving from the Fruit group= 15 grams of CHO One serving from the Milk group= 12 grams of CHO (round up to 15 grams for simplicity) One serving from the Non-Starchy Vegetable group= 5 grams of CHO (count as free but 3 svgs= 15 grams CHO) *Meat and Fats do not contain CHO but contain protein and/or fat *Alcohol counts as a fat (moderation defined as 2 drinks/day for men and 1 drink/day for women)
Because Starch/Bread/Starchy Vegetables, Fruit, and Milk all contain approximately the same amount of CHO they can be exchanged for one another Therefore, if your meal plan calls for 1 Starch, and you would prefer a piece of Fruit, that is fine
Total = 72 g CHO
LUNCH Bread, whole wheat Turkey breast, sliced Cheese, sliced Banana, medium Crackers, wheat Juice, apple
2 slices 30 g CHO 2 oz (protein) 0 g CHO 1 oz (protein) 0 g CHO 1/2 15 g CHO 5 15 g CHO 4 oz 15 g CHO Total = 75 g CHO
PORTION SIZES
VERY IMPORTANT Many people make good food choices but eat eat excessive portion sizes! Use Daily Meal Planning Guide to look up proper portion sizes and use measuring cups/spoons to ensure accuracy
Label Reading
Complications
COMPLICATIONS
Acute: sudden onset usually reversible
Acute Complications
Hypoglycemia (low blood sugar): glucose less than 70 mg/dl Causes:
Too much insulin Skip or delay meals Heavy exercise Errors in medication administration Weight loss Alcohol
Hypoglycemia Symptoms
Weakness Sweating Shakiness Tremors Nervousness HA/Dizziness/Hunger Irritability Tachycardia, palpitations Convulsions, confusion, coma
Acute Complications
Hyperglycemia (high blood sugar): glucose >200 mg/dl Causes: - forgetting to take medication - not enough medication - eating more than usual - physical illness or emotional stress - less physically active than usual - pregnancy
Hyperglycemia Symptoms
- Increased urination - Increased thirst - Increased hunger - Drowsiness - Fatigue - Hunger - Dry skin
May lead to coma and death if not treated Get transported to an Emergency Room! Tx: insulin, IV fluids, treatment of underlying cause
Chronic Complications
Chronic Complications
Diabetes can damage the lining of blood vessels and nerves by causing scarring and stiffness. The vessel linings can trap cholesterol and plaque leading to blockage (atherosclerosis). **The heart must work harder to pump blood through these blocked vessels leading to chronic complications
Cardiovascular Disease
(heart and blood vessels) Accelerated Atherosclerosis (rapid, younger age). hardening of the arteries or Coronary Artery Disease Heart Attacks Heart Failure Strokes
Lower Extremities
Leg ulcers, gangrene, increased risk of infection **Most common cause of amputations Pain in legs and calves (peripheral vascular disease)
Foot Complications
Poor sensation Poor recovery from injury Decreased sweating Dry skin Ulcerations Infection Gangrene
Nerve Complications
Damage to nerves causes numbness, burning, and pain (peripheral neuropathy) Can lead to trouble walking and maintaining balance
Autonomic Neuropathies
(nerves that control bodily functions)
Impotence Gastroparesis (slow emptying of the stomach) Diabetic diarrhea Neurogenic bladder (loss of bladder tone)
Eye Complications
Retinopathy (hemorrhages in the back of the eye and scar formation) Impaired vision Blindness Leading cause of blindness Cataracts
Kidney Disease
Can no longer filter wastes out of the body Protein spills in the urine No warning signs Diabetes is the most common cause of kidney disease requiring dialysis and transplant Can be detected early with blood and urine tests (chemistries and microalbumin) Prevention with medications (ask your provider)
Questions??