Diabetes Management

Thomas Donner, MD, Associate Professor

Michelle Sheldon-Rubio, RN, Clinical Instructor

University of Maryland School of Medicine

Division of Endocrinology, Diabetes and Nutrition

What is Diabetes?

• A disease in which the body either fails to produce any insulin (type 1), or the insulin that it does produce is unable to adequately trigger the conversion of food into energy (type 2).

Insulin

• Insulin is a hormone which is produced by the pancreas in the abdomen. Insulin is released into the bloodstream to help a sugar (glucose) travel into cells of the body where it is used as energy.

Hyperglycemia

• When glucose is unable to enter cells in the body, glucose levels build up in the blood to cause hyperglycemia. The longer blood glucose levels are high and the higher these glucose levels remain, the more rapidly complications from diabetes can develop.

Symptoms of Diabetes

• Excessive thirst

• Frequent urination

• Weight loss

• Blurred vision

• Fatigue

• Sometimes there are no symptoms (type 2)

Diabetes Mellitus in the US: Overview

Prevalence of Diabetes in the United States

Prevalence of Obesity in the United States

Prevalence of Diabetes in the United States According to Age

and Sex

Risk Factors Associated with Central Obesity

• Diabetes

• High triglycerides

• Low HDL (good) cholesterol

• Hypertension

• Cardiovascular disease (heart attacks and strokes)

Most Patients with Diabetes Die of Cardiovascular Disease

• 2- to 4-fold more likely to have heart disease

• 2- to 4-fold more likely to have a stroke

• 2- to 8-fold more likely to have heart failure

• ~ 70% of all diabetes-related deaths are associated with vascular disease

How can patients prevent the complications of diabetes?

• Regular check-ups with health care providers

• Home blood sugar testing

• Keep blood sugar levels close to normal

• Keep blood pressure and cholesterol normal

How can blood sugar levels be kept normal?

• Diet and exercise

• Weight loss in those who are overweight

• Medications when needed

Nutrition Therapy, Exercise, Lifestyle Changes

• Nutrition therapy• Decrease fat content and total calories• Weight reduction in obese patients• Decrease saturated fat• Increase fiber

• Exercise

• Increase energy expenditure withmoderate-intensity exercise

• Smoking cessation to reduce cardiovascular risk factors

• Training in self-management and SMBG

• SMBG – self monitoring blood glucoseIV.1

Benefits of Exercise

• Decreases insulin resistance which lowers blood sugar

• Improves weight, blood pressure, LDL (bad) and HDL (good) cholesterol

• May increase risk of low blood sugar in patients on insulin or pills which increase insulin release

• Patients at risk should be pre-screened for coronary artery disease with a stress test

Benefits of Modest Weight Loss

cardiovascular risk (heart attacks and strokes)

blood sugar levels blood pressure LDL and triglycerides (bad cholesterols) HDL (good) cholesterol severity of sleep apnea symptoms of degenerative joint disease

How can blood sugar levels be kept normal?

• Medications– Many different pills are now available which

can be used in combination with diet and exercise

– Insulin may be necessary in patients whose own bodies are not producing enough insulin

Oral Pharmacologic Therapy

• Monotherapy– Insulin secretogogues: sulfonylureas,

nateglinide and repaglinide– Metformin (glucophage)– Alpha-glucosidase inhibitors (acarbose,

miglitide)– Thiazolidinediones (actos and avandia)

• Combination therapy

GLUCOSE ABSORPTION

GLUCOSE PRODUCTIONMetformin

(Thiazolidinediones)

MUSCLE

PERIPHERAL GLUCOSE UPTAKE

Thiazolidinediones(Metformin)

PANCREAS

INSULIN SecretionSulfonylureasMeglitinidesNateglinide

InsulinPramlintide

ADIPOSE TISSUE

LIVER

alpha-glucosidase inhibitors

Sonnenberg and Kotchen. Curr Opin Nephrol Hypertens 1998;7(5):551–5

INTESTINE

Sites of Action by Therapeutic Options Presently Available to Treat Type 2 Diabetes

Cardiovascular Disease in Type 2 Diabetes

Treatment of HTN in Diabetes

• Goal BP is <130/80

• Specific blood pressure medications (ACE-inhibitors and ARBs) have been shown to be especially protective against kidney and cardiovascular disease)

2005 ADA Cholesterol Recommendations

• Goals:

Bad– LDL < 100– Triglycerides < 150

Good– HDL > 50

• Treatment:– Initial lifestyle modification

• Weight loss, moderation of saturated fats and excessive carbohydrates, exercise

– Medications (especially statin drugs) are indicated if lifestyle modification does not get levels to goal

Aspirin Therapy

• Has been shown to reduce the risk of cardiovascular events by 10-20% in patient with diabetes

• Baby aspirin (81 mg) has most of the benefit of an adult-sized (325 mg) pill

• Recommended in patients with diabetes over age 30 who have another heart disease risk factor or have known heart disease

Summary

• Diabetes is a common disease that can cause serious complications.

• Control of blood sugar levels, blood pressure and cholesterol will dramatically reduce the risk of developing these complications.

• Patient education about healthy lifestyle choices and diabetes management is an important feature of good diabetes control.