Diabetes:  Separating Fact From FictionDavid D. Pittman, MD Internal Medicine

www.SpringfieldClinic.comwww.SpringfieldClinic.com

Question #1

True/False:

The incidence of diabetes mellitus is on

the decline.

Question #2

Diabetes can affect individuals of which age group:

a.  children

b.  teenagers

c.  adults

d.  seniors

e.  all of the above

Question #3

True/False:

Once an individual is diagnosed with diabetes, he or she will need to begin taking insulin. 

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Diabetes:  What's the Big Deal?

• Nearly 24 million Americans are affected• Of those, almost 6 million are unaware

that they have diabetes• These numbers are expected to rise

What is Diabetes?

Diabetes is a metabolic disorder characterized by an imbalance of circulating glucose and the body's supply or action of insulin.

Who cares?

Diabetes is the 7th leading cause of death in the U.S.

Serious complications include:  heart disease, stroke, blindness, nerve damage, kidney disease, impotence, and amputations.

Possible Symptoms of Diabetes - or Not

Thirst

Frequent Urination

Fatigue

Blurred vision

Weight Loss

Diagnosis of Diabetes

• Fasting Plasma Glucose Level > 126mg/dL

• Oral Glucose Tolerance Test• Random Plasma Glucose > 200• Hemoglobin A1C > 6.5%

What is Hemoglobin A1C?

Glycosylated hemoglobin is a rough estimate of the amount of "sugar" that "sticks" to a red blood cell (which contains hemoglobin) during it's 90 day lifespan.

It is expressed as a percentage.

Normally < 6%

What does HgBA1c Mean?

HgBA1c            Mean Glucose

    6                          135    7                          170

    8                          205

    9                          240

   10                         275

   11                         310

   12                         345

My Doctor Said that I am "Pre-Diabetic"

• Fasting Plasma Glucose level 100 - 126• 2 hr post-meal glucose 140 - 199• High likelihood of progressing to diabetes

if no action taken.

Type 1 Diabetes

• Children, teenagers, young adults• Insulin deficiency resulting from auto-

immune destruction of insulin-secreting pancreatic beta cells

• Typically present with classic features or emergent hyperglycemia (Diabetic Ketoacidosis -- DKA)

Type 2 Diabetes

• 90 - 95% diabetics worldwide• Typically patients 40yr and older• Family history• Overweight or obese• Insulin resistance and relative insulin

deficiency

Type 2 Diabetes

• Plasma glucose levels remain normal for many years prior to onset of frank Diabetes.

• As insulin resistance builds, pancreatic insulin secretion increases.

• Over time, pancreatic function declines and glucose subsequently increases.

Type 2 Diabetes

• Most patients have co-existing clinical and biochemical features:

           Abdominal obesity            Hypertension            Dyslipidemia

            = Metabolic Syndrome            

Other Types of Diabetes

• Gestational diabetes (7% of US pregnancies)

• Drug induced• Chronic pancreatitis

            

Now What?

• Patient EDUCATION and self-management

• Diabetic educators/RN/dieticians• Multi-Disciplinary team approach

            

Treatment

• Foundation of treatment begins with :

          

            Diet            Weight loss            Exercise

These reduce insulin resistance, glucose levels and improve cardiovascular risk factors.             

Treatment

• Medication• Dramatic changes • Nine separate classes• Older therapies continue to be effective

BiguanidesBiguanides decrease the amount of sugar produced in the liver and also lower the amount of insulin in the body.

SulfonylureasSulfonylureas stimulate the production of insulin in the pancreas and help the body to use the insulin that is currently being produced.

MeglitinidesMeglitinides stimulate the production of insulin in the pancreas, but are shorter-acting than sulfonylureas.

Thiazolidinediones Thiazolidinediones help make the cells in the body more sensitive to insulin.

Alpha-glucosidase inhibitorsAlpha-glucosidase inhibitors block the enzymes that digest starches, resulting in a slower rise in the blood sugar.

DPP-IV inhibitors

DPP-IV inhibitors enhance the body's own ability to lower high blood sugar levels by blocking an enzyme called dipeptidyl peptidase IV (DPP-IV). When DPP-IV is blocked, proteins which increase the release of insulin after blood sugar rises are able to work longer, thus lowering blood sugar.

Onset how quickly the insulin starts to work after it is injected

Peak time the period of time when the insulin is most effective in lowering blood sugar levels

Duration how long the insulin remains working in the body

Insulin type Onset(approximation)

Peak time(approximation)

Duration(approximation)

Rapid acting, Lispro, Aspart, Glulisine insulin

15 minutes 30 to 90 minutes 3 to 5 hours

Short acting, Regular (R) insulin

30 to 60 minutes 2 to 4 hours 5 to 8 hours

Intermediate acting, NPH (N) or Lente (L) insulin

1 to 3 hours 8 hours 12 to 16 hours

Long acting, Glargine, Detemir insulin

1 hour none 20 to 26 hours

Treatment

• Lower blood pressure < 130/80• Use Ace inhibitors (ACEi) or Angiotensin

Receptor Blockers (ARB's)• Lower cholesterol to goal (LDL <

100mg/dL)

Long term Complications

MacrovascularCoronary Arteries

Carotid Arteries

Cerebral Vascular Supply

Peripheral Arteries

Long term Complications

MicrovascularKidneys:  Diabetic nephropathy

Eyes:  Diabetic retinopathy

Peripheral nerves:  Diabetic neuropathy

These disorders tend to correlate with degree of hyperglycemia

Diabetic neuropathy and peripheral arterial disease

retinopathy

dLong-term management of Diabetes depends largely upon individual action and attitudes.

Questions?