Introduction to diabetes, more information at http://health.utah.gov

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 body's 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
youth
Accounts 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
mother's 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 Epidemic
The 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
2006
No 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 in
people aged 20 years or older— United States, 2005 (CDC)

21. Diabetes Rate Increases with Age
Estimated 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 Diabetes
Fasting 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 Complications
Diabetes 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 Damage
Chronic high blood sugar can lead
to 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 Damage
Caused by blood vessel damage
that inhibits oxygen and nutrient
flow 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 Damage
Chronic high blood sugar can lead to
large 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%

35. Preventing Complications
 Hemoglobin A1C  Dilated eye exam
 Foot examinations  Dental exam
 Blood pressure  Vaccinations/Flu shots
 Microalbumin/kidney  Blood glucose
 Lipid profile  General physical exam

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.

39. 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.

40. 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

41. 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)

42. 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

43. 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

44. 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 risk
Supervised by an Exercise Physiologist, CDE
Call 801-581-6696 for more information

45. 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 !!!

46. Resources
 www.ndep.nih.gov
 www.diabetes.org
 www.cdc.gov/diabetes
 www.niddk.nih.gov
 www.health.utah.gov/diabetes

47. THANK YOU!!
Sheldon Smith, MS, CDE
University of Utah
Division of Physical Therapy
Diabetes/Pre-diabetes Exercise Program
801-581-6696