A recent study found increases in inflammatory activity in adipose tissue from IR compared with equally obese IS individuals. Adipose tissue is now recognized as an endocrine organ involved in regulating physiologic and pathologic processes including inflammation. Adipose tissue synthesizes and secretes hormones leading to a chronic sub-inflammatory state.
All patients with type 1 diabetes take insulin, however around 30% of type 2’s take insulin too. In fact, around 60-70% of people on insulin have type 2 diabetes.
Back in 1958 less than 1% of the US population had diabetes. In 2008 over 6% has diabetes In 2010 over 8% has diabetes
With age: as people get older they have an increased their incidence of diabetes increases. Why? Less activity, increased fat weight, increase in co-morbidities (HTN, CHOL, OA etc)
> 300 million people in us ~therefore 20% of US population have pre diabetes!!!
That’s in a state of ~3,000,000 people. Summit county has a prevalence of 3.5% (lowest) Tooele and Garfield Counties have a prevalence of 7.8% (highest).
Excess blood sugar pulls water from your body like a sponge causing dehydration. The rate of urination increases, people become very thirsty and skin can become very dry. Hunger, weight loss, fatigue are caused by lack of fuel getting to the cells. The body is starving. Blurry vision can be due to excessive sugar causing blood to thicken and making vision poor. Tingling/numbness due to nerve damage. Slow healing wounds due to decrease circulation
Patients with IFG and/or IGT are now referred to as having "pre-diabetes" indicating the relatively high risk for development of diabetes in these patients.
A1c level needs to be <7%. Or as low as possible without the risk of hypoglycemia. Regular visits to diabetes care team, including a primary care doctor, podiatrist, dentist, ophthalmologist, diabetes educator (RN, dietician and exercise specialist)
ADA suggests < 7% for non pregnant and pregnant adults
Exercise burns sugar by moving it from the blood to the body’s cells/tissues/organs/muscles and that’s why it can be an important diabetes management strategy.
1. Introduction to Diabetes 10th Annual Diabetes Training October 20, 2011 SHELDON SMITH, MS, CDE
2. Introduction to Diabetes What is diabetes? Types of diabetes Diabetes statistics Risks for diabetes Diagnosing diabetes Complications of diabetes Diabetes prevention and control
3. What is Diabetes ? When you eat carbohydrates they are digested and broken down into glucose which goes into your blood stream. The pancreas is then signaled to secrete insulin to transport this glucose from the blood into the muscle, fat and liver cells for energy and/or storage. In a person without diabetes, glucose levels stay “normal” (70-120 mg/dl). Diabetes Mellitus (DM) is a chronic condition characterized by abnormally high levels of glucose in the blood. High levels of glucose can be caused by either inadequate insulin production or ineffective insulin or both.
4. Types of Diabetes There are three official types of DM:  Type 1  Type 2  Gestational  Pre-diabetes is not considered a “type” of diabetes, but is treated nonetheless
5. Type 1 Diabetes Due to an absolute insulin deficiency Previously called Insulin-Dependent Diabetes Mellitus (IDDM) or Juvenile-Onset DM Originally diagnosed in children and youth but now can be diagnosed in adults (Type 1 ½) Exogenous insulin must be used for these individuals in the form of shots or a pump.Accounts for 5-10% of all diabetes cases
6. Cause for Type 1 Diabetes Genetics? Environment? Viruses? These can trigger an autoimmune response in which the bodys immune system attacks and destroys the insulin producing beta cells of the pancreas.
7. Type 2 Diabetes Due to a combination of ineffective insulin and/or a lack of insulin production Previously called Non-Insulin-Dependent DM (NIDDM) or Adult-Onset DM Historically linked to abdominal adiposity It used to be seen in only adults but is now seen in youthAccounts for 90-95% of all diabetes cases
8. Cause for Type 2 Diabetes Insulin resistance is the primary culprit The pancreas secretes insulin but this insulin is not 100% effective at helping glucose move into muscle, fat and liver cells The body “resists” the effect of insulin, and consequently sugar remains in the blood Now there is a link between abdominal adiposity and inflammation
9. Gestational Diabetes During pregnancy, women can develop insulin resistance Most common among African Americans, Hispanic/Latino Americans, and American Indians. It is also more common among obese women and women with a family history of diabetes. Insulin does not cross the placenta but glucose and other nutrients do. This allows the baby to grow and develop but since it is getting more energy than it needs, the extra energy is stored as fat.
10. Gestational DiabetesAffects about 4% of all pregnant womenSuggested causes:  Hormones from the placenta may block the action of the mothers insulin in her body causing insulin resistance  The stress of the pregnancy may also cause insulin resistanceGD usually disappears after pregnancyGD increases risk for Type 2 diabetes later in life
11. Diabetes Facts 2011Diabetes affects 25.8 million people8.3% of the U.S. populationDIAGNOSED: 18.8 million peopleUNDIAGNOSED: 7.0 million peopleNearly 30% of people with diabetes do not know they have it! http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
12. Diabetes: A Growing EpidemicThe prevalence of diagnosed diabetes increased from 0.9% in 1958 to 6.3% in 2008. In 2008, 18.8 million people had diagnosed diabetes, compared to only 1.6 million in 1958.
13. Prevalence of Diabetes by State and Year 1995 2000 2005
14. Diabetes by Age and Sex in US 2007 Age 20 years or older: 25.6 million or 11.3% of all people in this age group have diabetes. Age 65 years or older: 10.9 million or 26.9% of all people in this age group have diabetes. Men: 13.0 million or 11.8% of all men aged 20 years or older have diabetes. Women: 12.6 million or 12.8% of all women aged 20 years or older have diabetes.
15. Diabetes: A Growing Epidemic - 2010 An estimated 79 million adults have pre-diabetes (borderline DM, IFG, IGT) Alarming rise in incidence of type 2 in children: up to almost 50% of new childhood diabetes cases in some areas "Clinicians need to pay attention not just to the skinny children who are developing obvious type 1 diabetes, but to the overweight children of perhaps two diabetic parents," he said, "and be careful because they may be developing type 2 diabetes even though their age is not in the range that we typically consider for type 2 diabetes." , Dr. David Nathan, Harvard Med School. Among those diagnosed, less than 50% are at recommended control levels http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.aspx#Pre-diabetesY20
16. The Diabetes Epidemic in Utah Over 120,000 people in Utah have diagnosed DM  1 out of every 17 adults  6.0 % of the Utah population  Add 45,000 Utah’ns with diabetes who have NOT been diagnosed = 165,000  1 out of every 13 adults  8% of the Utah population The Utah Department of Health 2008
17. What Contributes to this Epidemic ??? More people are overweight or obese Growth in minority populations in whom the prevalence and incidence of diabetes are increasing A growing elderly population
18. Obesity Trends* Among U.S. Adults Behavioral Risk Factor Surveillance System 1990, 1998, 2006 (*BMI ≥30, or about 30 lbs. overweight for 5’4” person) 1998 1990 2006No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
19. Body Mass Index Chart
20. Diabetes as it Relates to Race/Ethnicity Estimated age-adjusted total prevalence of diabetes inpeople aged 20 years or older— United States, 2005 (CDC)
21. Diabetes Rate Increases with AgeEstimated percentage of people aged 20 years or older with diagnosed and undiagnosed diabetes, by age group, United States, 2005–2008 Source: 2005–2008 National Health and Nutrition Examination Survey
22. Determining Your Diabetes Risk  Take this test to see if you are at risk for having or developing Type 2 diabetes  http://diabetes.org/risk-test.jsp
23. Symptoms of Diabetes Extreme thirst Frequent urination Dry skin (above and beyond Utah standards) Extreme hunger Unexplained weight loss (Type 1) Constant fatigue Blurry vision Tingling or numbness in the hands or feet Wounds that are slow to heal
24. Diagnosing DiabetesFasting Plasma Glucose Test (FPG) FPG <100 mg/dl = normal fasting glucose FPG 100–125 mg/dl = IFG (impaired fasting glucose or pre- diabetes) FPG ≥ 126 mg/dl = provisional diagnosis of diabetes Source: Diabetes Care 29:S43-S48, 2006
25. Diagnosing Diabetes Oral glucose tolerance test: 8-12 hr fast followed by a 75 gm glucose drink and testing two hours later  2-hr post load glucose <140 mg/dl = normal glucose tolerance  2-hr post load glucose 140–199 mg/dl = IGT (impaired glucose tolerance or pre-diabetes)  2-hr post load glucose ≥ 200 mg/dl = provisional diagnosis of diabetes Source: Diabetes Care 29:S43-S48, 2006
26. Diagnosing Diabetes 1. FPG 126 mg/dl (7.0 mmol/l) * OR 2. Symptoms of hyperglycemia and a casual plasma glucose 200 mg/dl (11.1 mmol/l) OR 3. 2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT**These criteria should be confirmed by repeat testing on a different day Source: Diabetes Care: 31:S12-S54, 2008
27. Glucose Guidelines for Diabetes American Diabetes Association  Fasting: 70-130 mg/dl  2 hr post meal: < 180 mg/dl  HbA1C: < 7% American Association of Clinical Endocrinologists  Fasting: < 110 mg/dl  2 hr post meal: < 140 mg/dl  HbA1C: < 6.5%
28. Diabetes ComplicationsDiabetes can be associated with serious complications and premature death, but individuals with diabetes can take measures to reduce the likelihood of such occurrences
29. Microvascular DamageChronic high blood sugar can leadto small blood vessel lining damage Diabetic Retinopathy (eyes)  Up to 24,000 new cases of blindness each year Diabetic Nephropathy (kidneys)  DM is the leading cause of kidney failure each year Microvascular complications are usually controlled by managing blood glucose levels
30. Nerve DamageCaused by blood vessel damagethat inhibits oxygen and nutrientflow to nerves Peripheral Neuropathy (peripheral nerves)  Foot ulcers or amputations: More than 60% of non- traumatic lower limb amputations occur in people with DM Autonomic Neuropathy (autonomic nerves)  Decreased digestive, sweat, sexual, cardiovascular or bladder function
31. Macrovascular DamageChronic high blood sugar can lead tolarge blood vessel lining damageCardiovasular, Cerebrovascular and Peripheral Artery Disease  People with DM have a 2 to 4 fold increase in the risk of heart disease and stroke compared to people without diabetes  Over 75% of people with diabetes have HTN and abnormal cholesterol levels  An estimated 1 out of every 3 people with diabetes over the age of 50 have PAD Macrovascular complications are usually managed by controlling blood pressure and cholesterol
32. Among adults in the US: Diabetes is the leading cause of…  Kidney failure  Non-traumatic lower limb amputations  New cases of blindness Diabetes is a major cause of heart disease and stroke Diabetes is the 7th leading cause of death (that is likely under-reported)
33. Complications … More Grim Facts 60-70% of adults with diabetes have nerve damage The risk for death among people with diabetes is about 2x that of people without diabetes of similar age. People with poorly controlled diabetes (A1C greater than 9 %) are nearly 3x more likely to have severe periodontitis than those without diabetes. Poorly controlled diabetes before and during the first trimester of pregnancy among women with type 1 diabetes can cause major birth defects and spontaneous abortions.
34. Preventing Complications Developing self-management skills is at the foundation of diabetes management:  Self-monitoring of blood glucose  Meal planning/healthy eating/portion size control  Exercise  Medication compliance  Mindfulness practice Blood sugar control is the key!  For every 1% drop in HbA1c, risk of microvascular complications decreases by 40%
36. Preventing Complications Glycemic Control (for microvascular complications)  Control the amount of carbohydrates consumed Aggressive Lipid Lowering (for macrovascular complications)  Lower the amount of “bad fats” in your diet Management of Hypertension (for macrovascular complications)  Decrease blood pressure and find ways to manage stress
37. HbA1c The amount of glycated hemoglobin in your blood. This represents the amount of sugar (glucose) attached to hemoglobin. It is used to measure your blood sugar control over several months. You have more glycated hemoglobin if you have had high levels of glucose in your blood. In general, the higher your HbA1c, the higher the risk that you will develop problems such as:  Eye disease, Heart disease, Kidney disease, Nerve damage, Stroke An HbA1c of < 7% is recommended by the ADA. Usually, doctors recommend testing every 3 or 6 months. American Diabetes Association. Standards of medical care in diabetes -- 2008. Diabetes Care. 2008;31:S12-S54.
38. Preventing ComplicationsMindfulness Practise: Acceptance and Commitment Therapy (ACT) is a unique evidence-based psychological intervention that uses acceptance and mindfulness strategies, together with commitment and behavior change strategies, in order to increase what is called “psychological flexibility”. This refers to being in the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior that serve the values a person has.
39. Acceptance and Commitment Therapy and Diabetes Management N=81, low income T2DM population One day (7 hour) workshop Two groups: DM education alone vs DM education plus ACT Training Both groups received DM mgmt skills One group received additional acceptance and mindfulness skills for difficult thoughts and feelings about their diabetes 3 month trial period DM plus ACT training group was more likely to use coping strategies. They reported better self-care and more HbA1c’s within target than DM ed training group alone. Conclusions: ACT and DM ed is significantly better than DM ed alone for yielding good self-mgmt skills and better HbA1c’s in a low income DM population. Gregg, J. A., et al (2007). Improving diabetes self-management through acceptance, mindfulness, and values: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 75(2), 336-343
40. Diabetes Prevention & Control The same methods to control diabetes can also be used to prevent diabetes:  Physical activity  Healthy eating  Maintaining a healthy weight  Medications as determined by healthcare provider  Positive lifestyle intervention reduced the incidence of diabetes by 58% (Diabetes Prevention Program study)
41. Diabetes Prevention & Control Healthy eating  5 fruits and vegetables a day  Whole grains and fiber  Sources of lean protein  Watching intake of calories  Avoid saturated fats and trans fats, etc (aka, the “bad fats”)  MyPyramid can be used a guide to healthy eating: http://www.mypyramid.gov
42. Diabetes Prevention & Control Physical activity  At least 60 minutes of moderate to vigorous physical activity a day for children  At least 150 minutes of moderate to vigorous physical activity a week for adults  Individuals must check with a physician prior to starting an exercise program  A baseline exercise tolerance test may be recommended to assess cardiovascular health
43. 6 Week Exercise Class for Individuals with Type 2 Diabetes and Those Who May Be at Risk Meets Tuesday/Thursday 3 - 8pm 520 Wakara Way (Research Park) Rehabilitation and Wellness Clinic Cost ($100) includes Pre-program evaluation and 12 supervised sessions Physician permission required Participation is at one’s own riskSupervised by an Exercise Physiologist, CDE Call 801-581-6696 for more information
44. Bottom Line For those who live with diabetes, it can be controlled Working with a healthcare provider is the first step Help you patients get involved in their care Gaining support from family is another important step to take Diabetes CAN be prevented !!!