1. Diabetes: What Everyone Needs to Know!
Rose M. Flinchum, MSEd., MS, RN,
Clinical Nurse Specialist – Board Certified
Certified Diabetes Educator

2. What is Diabetes?
A condition in which the body cannot make or cannot use insulin properly

3. Fasting BS Random BS Diabetes Pre - Diabetes No Diabetes Over 200 With
Symptoms
126 and
above
Diabetes
140 – 200
Pre - Diabetes
Under 100
Under 140
No Diabetes

4. Types of Diabetes Mellitus
Prediabetes
Impaired Fasting Glucose
Impaired Glucose Tolerance
Gestational DM
Other

5. Risk Factors Type 2 DM

6. More Risk Factors Overweight (Abdominal) Over 45 years old
Sedentary Lifestyle
Non-White Race
Family History of DB
Family History of High BP
History of High BP (self)
High Cholesterol
History of Gestational DB
Delivered a baby > 9 lbs.
Goals:
Women < 35
Men < 40

7. What Happens in Type 2 DM Diabetes Stomach empties 50%
faster than normal
Pancreas can’t make
enough insulin
Type 2
Diabetes
Muscle cells and other tissues are
resistant to insulin
Liver puts too
much sugar
into the blood

8. Signs / Symptoms of Type 2 Diabetes

9. Additional Symptoms Skin Infections Frequent Urination Slow Healing
Yeast Infections
Urinary Infections
Dry Skin; Itching
Numbness; Tingling
Feeling / Acting “Evil”
High Blood Pressure
Cholesterol Problems
Frequent Urination
Thirst
Appetite Changes
Blurred Vision
Tiredness; Sleepiness
Weight Changes
Headaches

10. Insulin Resistance
Skin Tags
Acanthosis Nigricans

11. Polycystic Ovarian Syndrome
Fertility problems
Acne
Hair loss
Facial Hair
Weight problems
Deadly triangle
High Blood Pressure
High Cholesterol
High Blood Sugar

12. Metabolic Syndrome Definition
“A Clustering of Multiple
Cardiometabolic
Risk Factors”

13. Criteria ATP III (AHA/ NHLB) WHO AACE IDF Abdominal Obesity
M > 102 cm
W > 88 cm
BMI > 30 or
W : H Ratio
M > 0.9
W> 0.85
BMI > 25
*M > 94 cm
*W > 80 cm
or BMI > 30
+ 2 others
Triglycerides
> 150 mg/dl
same
Same or on meds
HDL
M < 40
W < 50
M < 35
W < 39
M < 40 (or on
W < 50 meds)
Blood Pressure
> 130/85
or on meds
> 140/90
> 130/85 or on meds
Fasting Glucose
> 100 mg/dl
T2 DM, IFG or IGT *
+2 others
Btw. 110 – 126 mg/dl
> 100 or T2DM
Other
Urinary Albumin Excretion Rate > 20 or alb:creatine ratio > 30
2 hr PP > 140; PCOS; family hx; other

14. 90% of T2DM: IR and MS
NGT = Normal Glucose Tolerance
IFG/IGT = Impaired Fasting Glucose/Impaired Glucose Tolerance
IR = Insulin Resistance
MS = Metabolic Syndrome
-Cell failure occurs following an adaptative phase of hypersecretion in response to the development of insulin resistance.
Adapted from International Diabetes Center (IDC), Minneapolis, Minnesota.

15. Increases in Diabetes

18. Diabetes in the United States
Estimated prevalence: Nearly 24 million
Nearly 8% of the U.S. population
Almost 25% of persons over age 60
% have type 2
25% do not know they have it!
57 million have pre-diabetes
24% have Metabolic Syndrome
Projected 44-68% increase in diabetes by 2015
8% per year
Prevalence of Diabetes
The Centers for Disease Control and Prevention (CDC) has compiled data on diabetes in the United States obtained from several surveys, including the National Health Interview Survey (NHIS), the Third National Health and Nutrition Examination Survey (NHANES III), the National Hospital Discharge Survey, and surveys conducted through the Behavioral Risk Factor Surveillance System (BRFSS). Based on data from these sources, the CDC estimates that 17 million people, or 6.2% of the population, had diabetes in A third of these cases were undiagnosed. Almost 9% of people 20 years old and 20.1% of people 65 years old had diabetes.
The estimated worldwide prevalence of diabetes in 1997, derived from World Health Organization (WHO) data, was 124 million people, with the majority (97%) having type 2 diabetes. According to the same projections, the number of people with diabetes is expected to increase to 221 million in Other less conservative projections by King et al used WHO data combined with demographic estimates and projections issued by the United Nations to place the number of people worldwide with diabetes at million in 1995 and 300 million in 2025.
References:
The Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2002.
Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year Diabet Med. 1997;14:S7-S85.
King H, Aubert RE, Herman WH. Global burden of diabetes, : prevalence, numerical estimates, and projections. Diabetes Care. 1998;21(9):

19. Diabetes in the United States
NOT an Equal Opportunity Disease!
Among those diagnosed…
16.5% of Native Americans/Alaskan Natives
11.8% of Black Americans
10.4% of Latinos*
12.6% of Puerto Ricans
11.9% of Mexicans
8.2% of Cubans
7.5% Asian Americans
6.6% Caucasians
Lifetime DM risk (born after 2000)
33% men; 39% women; 50% Hispanic women
Prevalence of Diabetes
The Centers for Disease Control and Prevention (CDC) has compiled data on diabetes in the United States obtained from several surveys, including the National Health Interview Survey (NHIS), the Third National Health and Nutrition Examination Survey (NHANES III), the National Hospital Discharge Survey, and surveys conducted through the Behavioral Risk Factor Surveillance System (BRFSS). Based on data from these sources, the CDC estimates that 17 million people, or 6.2% of the population, had diabetes in A third of these cases were undiagnosed. Almost 9% of people 20 years old and 20.1% of people 65 years old had diabetes.
The estimated worldwide prevalence of diabetes in 1997, derived from World Health Organization (WHO) data, was 124 million people, with the majority (97%) having type 2 diabetes. According to the same projections, the number of people with diabetes is expected to increase to 221 million in Other less conservative projections by King et al used WHO data combined with demographic estimates and projections issued by the United Nations to place the number of people worldwide with diabetes at million in 1995 and 300 million in 2025.
References:
The Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2002.
Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year Diabet Med. 1997;14:S7-S85.
King H, Aubert RE, Herman WH. Global burden of diabetes, : prevalence, numerical estimates, and projections. Diabetes Care. 1998;21(9):

20. Diabetes + Obesity = Diabesity

21. Obesity and Diabetes 1:3 Americans are obese
1:5 Americans are morbidly obese
80% of all Type 2 diabetics are overweight
Obesity in children has
doubled in 20 years
Type 2 diabetes in
children has tripled
in the last 5 years

22. Children and Type 2 Diabetes
Mean age: years old
Girls > Boys
Overweight
94% are in minority groups
74-100% have a strong family history

23. Overweight Kids Become Overweight Adults
50% of overweight children become overweight adults
26-41% overweight preschool children will become overweight adults

24. What about our children?
In a study done involving 111 children, 57% were obese, 12% were super-obese
In families of children who were obese ~ the caregiver thought the child’s weight was a problem in only 44% of the cases
Young-Hayman, D. et al Obesity Research 2000:8:241-8

25. Saturday Morning Influence
61% of all commercials
are for FOOD
90% are for sugared cereals, candy bars,
fast food,
and chips

26. INDIANA Diabetes Obesity
State ranking for prevalence (2008)
Adults: Ranked 38th
Diabetes in Indiana is above the national average:
National Average: 8.0%
Indiana Average: %
State ranking for prevalence (2008)
Ranked 31st
Adults in Indiana (2006)
27.5 % obese
35% overweight

27. …we have pills and insulin to control it, so what is the big deal?
Diabetes…
…we have pills and insulin to control it, so what is the big deal?

28. Costs of Diabetes in the U.S.
$174 billion each year
$116 billion in direct medical costs
$58 billion in indirect costs
Missed work
Lost productivity
1 in 10 healthcare dollars spend on diabetes/complications
Human costs
7th leading cause of death

29. Type 2 DM is Progressive Post-meal glucose Fasting glucose
350
250
Glucose
(mg/DL)
Fasting glucose
150 50
-10 -5 5 10 15 20 25 30
300
Insulin resistance
Relative function
(units)
200
100
At risk for
diabetes
Normal insulin level
Beta cell failure
-10 -5 5 10 15 20 25 30
Years of Diabetes
Adopted from D. Kendall, R. Bergenstal © International Diabetes Center

30. Health Impact of Diabetes in the United States
6th leading cause of death
Leading cause of
kidney failure
73% of adults have
HTN and/or take meds
Diabetes
Heart disease is the
leading cause of
death
Leading cause
of adult blindness
Neuropathy in 60-70% of patients contributes
to high incidence of lower-limb amputation
National Diabetes Fact Sheet, United States, November 2003.
Available at

31. Diabetes Increases Death Rate
Diabetes/CVD
Event rate
Diabetes/No CVD
No Diabetes/CVD
OASIS Study Mortality by Diabetes and CVD Status
Data from the Organization to Assess Strategies for Ischemic Syndromes (OASIS) registry were analyzed to determine the 2-year prognosis of diabetic and nondiabetic patients who were hospitalized with unstable angina or non–Q-wave myocardial infarction. Outcomes that were studied included total mortality, cardiovascular death, new myocardial infarction, stroke, and new congestive heart failure. A total of 1,718 of the 8,013 registry patients had diabetes (21%). Because patients with diabetes were more likely to have established cardiovascular disease (CVD) at baseline, stratified analyses were performed according to prior CVD and diabetes status.
The 2-year mortality rate for diabetic patients was 20.3% for those with prior CVD compared to 13.0% for those without prior CVD. For patients without diabetes, the rate was 12.9% for those with prior CVD compared to 6.9% for those without prior CVD. The P value was <0.001 for a comparison of patients with and without diabetes within the 2 CVD strata. Diabetic patients without prior CVD had the same event rates for total mortality, and all other outcomes, as nondiabetic patients with previous CVD. The CV death rate for diabetic patients with prior CVD was 16.6% compared to 9.3% for those without prior CVD. For patients without diabetes, the rate was 10.5% for those with prior CVD compared to 5.1% for those without prior CVD. The P value was also <0.001 for a comparison of patients with and without diabetes within the 2 CVD strata.
Reference:
Malmberg K, Yusuf S, Gerstein HC, Brown J, Zhao F, Hunt D, Piegas L, Calvin J, Keltai M, Budaj A. Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) Registry. Circulation. 2000;102(9):
No Diabetes/No CVD 3 6 9 12 15 18 21 24
Months
Organization to Assess Strategies for Ischemic Syndromes
Malmberg K, et al. Circulation. 2000;102:

32. Causes of Death in Diabetes
Percent of deaths
Causes of Death in People With Diabetes
Based on data collected from 4 cohort studies in the US conducted between 1965 and 1988, it was determined that the leading causes of death listed on the death certificates of persons with diabetes were diseases of the heart (55%), diabetes (13%), malignant neoplasms (13%), and cerebrovascular disease (10%). Despite variation in the way underlying cause of death was classified, the proportion of persons dying from these causes was similar across the 4 studies. Geiss et al also found that the risk of heart disease mortality and ischemic heart disease mortality was 2 to 4 times higher in persons with diabetes than in persons without diabetes. For persons with diabetes, the excess risk of dying from heart disease and ischemic heart disease was higher than the excess risk of mortality for all other causes combined. While the studies may not have distinguished between insulin-dependent diabetes and non-insulin-dependent diabetes (NIDDM), it was assumed that the diabetes deaths were NIDDM deaths because of the older age of the populations and the increased prevalence of NIDDM in older age groups.
Reference:
Geiss LS, Herman WH, Smith PJ. Mortality in Non-Insulin-Dependent Diabetes. In: National Diabetes Data Group, eds. Diabetes in America. 2nd ed. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1995.
All other
Diabetes
Other heart disease
Cancer
Stroke
Pneumonia/
influenza
Ischemic
heart disease
Geiss LS, et al. In: Diabetes in America.
National Institutes of Health;1995.

33. Diabetes Management Receives a Failing Report Card…
Indicator of Diabetes Mgmt
Percent of Patients
at Goal
A1C
37%
NHANES III %
NHANES %
LDL Cholesterol
23%
Systolic BP
41%
Beaton, S.et al. Diabetes Care 27: , 2004

34. Now the Good News: Diabetes Can Be Prevented
Diabetes Prevention Program
N= 3,234 people with IGT
Ages (mean 51)
Average BMI 34
45% minorities
Goals
Achieve/maintain weight loss of 7%
Maintain moderate physical activity at least 150 minutes/week

36. Preventing Diabetes --or Living Healthy with It!
Lifestyle Changes
Healthy Eating
Regular Exercise
Healthy Weight
Weight Loss (7% of weight)
Medications
Weight Loss Surgery

37. Healthy Eating

38. Reading Food Labels

39. Plate Method Fill ½ of the plate with non-starchy vegetables
Finish with
a fruit
Don’t forget
the dairy!
Choose a carb
serving
Add a serving
of a protein food

40. The Supersizing Phenomenon Portion Control - It Does Matter!
10G Fat
26 Grams Carbs
Portion Size Does Matter:
Portion control can make a great difference in your blood sugars.
Let’s look at what has happened to an order of french fries from 1960 to 1999.
In addition:
The Average Dinner Plate Size in 1956 was 8”.
The Average Dinner Plate Size in 2003 is 10.5”.
The Large Drink at McDonald’s in 1961 was 12 oz.
The Large Drink at McDonald’s in 2003 is 44 oz.
The Average Restaurant Spaghetti Serving in 1969 was 11 oz.
The Average Restaurant Spaghetti Serving in 2003 is 21 oz.
In 1961 bread, chips or other pre-meal foods were either charged for or given free 13% of the time.
In 2003 bread, chips or other pre-meal foods are given free 66% of the time.

41. Activity and Exercise
30 minutes of moderate activity on most days of the week
This does
NOT
Count!

42. Inactivity and Diabetes
Review Bullet Points
Emphasize that there are many ways to increase physical activity
It is important to pick an activity that is enjoyable, otherwise it will be hard to stick with it.
Brisk walking is one of the easiest activities to start with. It requires no special equipment, and can be done indoors (shopping malls) and outdoors.
Explain role/benefits of increasing physical activity. Ask the participants to give some benefits of increasing their physical activity.
Let them have time to answer. If there is no response then give a couple of examples.
Improves circulation and respiratory system
Lowers blood pressure
Increases sensitivity to insulin action
Promotes gradual weight loss
Helps maintain desired weight
Improves energy level (you feel better)
Improves your sleeping
Improves good cholesterol while lowering bad cholesterol
Patients should talk with their physicians to see if there are any health problems that would limit which physical activities they can participate in.
What’s wrong with this picture?
Notes____________________________________________________________________________________________________________________________________________________________________________________________________

43. Healthy Weight

45. Medications Prevention of Diabetes Controlling Diabetes Weight Loss
Metformin (Glucophage)
Controlling Diabetes
Pills, Insulin, and other Injectables
Weight Loss
Orlistat (Alli- OTC)
Meridia
Others

46. “Diabetes Surgery” Lab-Band (1 year) Roux-en-Y Gastric Bypass
64% of patients showed resolution
26% of patients showed improvement
Roux-en-Y Gastric Bypass
76.8% of patients showed resolution
- other studies showed 83% - 98%

47. Surgical Outcomes: Comorbidities
Comorbidity
Resolved
Improved or Resolved
Diabetes
76.8%
86.0%
Hyperlipidemia
70%
Hypertension
61.7%
78.5%
Sleep Apnea
85.7%

48. Prandin is a registered trademark of Novo Nordisk A/S
Prandin is a registered trademark of Novo Nordisk A/S. Starlix is a registered trademark of Novartis Pharmaceuticals Corporation. Glucophage is a registered trademark of Merck Sante S.A.S. and licensed to Bristol-Myers Squibb Company. Precose is a registered trademark of Bayer Pharmaceuticals Corporation. Glycet is a registered trademark of Bayer Pharmaceuticals Corporation, to Pharmacia-Upjohn. Avandia is a registered trademark of GlaxoSmithKline. Actos is a registered trademark of Takeda Chemical Industries, Ltd.
”The distance is nothing; it is only the first step that is difficult.”