Diabetes Mellitus

What is DM? Definition: Type I vs Type II: Where does insulin come from? What does insulin do?

Epidemiology www.diabetes.org Total: 23.6 million children and adults in the United States—7.8% of the population—have diabetes. Diagnosed: 17.9 million people Undiagnosed: 5.7 million people Pre-diabetes: 57 million people New Cases: 1.6 million new cases of diabetes are diagnosed in people aged 20 years and older each year. 90-95% of those are Type II 5-10% of those are Type I Someone is diagnosed with Type I every 4 hours. Increase incidence of Type II in the pediatric/adolescent population $174 billion: Total costs of diagnosed diabetes in the United States in 2007 (2007 Data)

Diabetes Mellitus Signs & Symptoms 1. 2. 3. 4. 5. 6. 7. The brain needs sugar at a consistent amount, if doesn’t have it, you will have a decreased LOC

Type I DM Lack of Insulin D/t destruction of the Beta cells in the pancreas Destruction due to autoimmune process Need to replace insulin via injection on a daily basis.

Type II DM Defect of insulin secretion or insulin resistance Associated with obesity, hypertension, high cholesterol Incr. in adolescence Tx: diet, exercise, oral meds, insulin injections

Insulin Injections Give to fatty area Usually 2-4 times a day Effects of injected insulin Too much insulin=hypoglycemic Too little insulin=hyperglycemic

Blood Glucose Levels Normal blood sugar 60/80 to 120 Monitoring Only Insulin can be used to Tx Type I

Exercise & Type I DM Muscle receives energy from stored muscle glycogen & fatty acids. Type I diabetics “lack” insulin, thus don’t have the ability for muscles to take up glucose from the blood. (external dose of insulin required) Pt must anticipate glucose needs! BALANCE!!! Must consider when they are going to exercise in relationship to meals and injections. Need less insulin when exercising, due to efficiency. Types of activity, intensity & duration

Exercise & DM Hypoglycemia – too much insulin Blood sugar < 60 mg/dl Symptoms of LOW blood sugar:

Exercise & DM Tx: Severe reaction: unconscious victim

Delayed Hypoglycemia Exercise increases the utilization of glucose Can last up to 72 hours.

Preventing Hypoglycemia Anticipating energy needs: Check blood sugar prior, during & after exercise. Always have sugar available Wear an ID bracelet Prevent dehydration

Insulin Pump Continuous insulin administration Know how to turn it off!!!

Exercise & Type II DM Associated c obesity, hyperinsulinemia & hyperlipidemia Key management in these people is diet & exercise!! Increases insulin sensitivity

Exercise and Type II DM Pts may be at higher risk of hypoglycemia during exercise if they are on certain medications, (sulfonlyureas, etc) or if on insulin. Check blood glucose prior to exercise and have source of sugar available.

DM, Complications & Exercise The right balance of Insulin: Individual error in prediction of needs in comparison of amt of exercise Injected insulin may be absorbed into the bloodstream more rapidly during exercise & a pump can’t adjust to the decreased needs of insulin c exercise as quickly as the body. (hypoglycemic) Not injecting enough (hyperglycemic) Need to replenish calories after a workout to replace glycogen levels to normal

Reasons they should Exercise Beneficial in maintaining ideal body weight and avoiding obesity in the Type I pt. Main therapy in the Type II pt in assisting wt loss Increase insulin sensitivity May decrease CV risk factors such as hyperlipidemia & hypertension Improve sense of well being.

Complications www.diabetes.org Long term effects usually occur after having the disease for >10 yrs Retinopathy Blindness • Diabetes is the leading cause of new cases of blindness among adults aged 20–74 years. • Diabetic retinopathy causes 12,000 to 24,000 new cases of blindness each year. Nephropathy Kidney disease • Diabetes is the leading cause of kidney failure, accounting for 44% of new cases in 2005. • In 2005, 46,739 people with diabetes began treatment for end-stage kidney disease in the United States and Puerto Rico. • In 2005, a total of 178,689 people with end-stage kidney disease due to diabetes were living on chronic dialysis or with a kidney transplant in the United States and Puerto Rico. Neuropathy Nervous system disease (Neuropathy) • About 60% to 70% of people with diabetes have mild to severe forms of nervous system damage.

Complications www.diabetes.org Heart disease and stroke • In 2004, heart disease was noted on 68% of diabetes-related death certificates among people aged 65 years or older. • In 2004, stroke was noted on 16% of diabetes-related death certificates among people aged 65 years or older. • Adults with diabetes have heart disease death rates about 2 to 4 times higher than adults without diabetes. • The risk for stroke is 2 to 4 times higher among people with diabetes. High blood pressure • In 2003–2004, 75% of adults with self-reported diabetes had blood pressure greater than or equal to 130/80 mmHg, or used prescription medications for hypertension.

Complications www.diabetes.org Morbidity and Mortality Deaths Diabetes was the seventh leading cause of death listed on U.S. death certificates in 2006. This ranking is based on the 72,507 death certificates in 2006 in which diabetes was listed as the underlying cause of death. According to death certificate reports, diabetes contributed to a total of 233,619 deaths in 2005, the latest year for which data on contributing causes of death are available. Amputation • More than 60% of nontraumatic lower-limb amputations occur in people with diabetes. • In 2004, about 71,000 nontraumatic lower-limb amputations were performed in people with diabetes. Strength training should be avoided in pts who have had diabetes for more than 10 years -hypertensive tendencies cause problems.

For the ATC Items to have available: Glucometer Gel Tablets Glucagon injection? Know who is diabetic on your teams and know how well they are controlling it! Treat ALL acute diabetic illness c glucose!

For the ATC Drug Interactions to be aware of: Alcohol: NEVER…causes hypoglycemia Anabolic Steroids: same Birth control pills: reduces the effects of insulin

Glucometer Use Frequency: ~ 4x day Proper use Supplies Control test strip Clean skin Puncture Wipe way 1st blood Blood on test strip and wait!

Hypoglycemia S/S: Tx: Don’t forget late onset-hypoglycemia! Monitor in the middle of the night c increase in activity the day before.

Hyperglycemia S/S: Tx: D/T lack of sugar in cells, body turns to fat for energy source. By-product is Ketones. Turns blood acidic. Person will drink a lot of water to offset polyuria….leads to diabetic ketoacidosis.

How can you tell them apart? 1: Onset 2. Skin 3. Breath

TREATMENT OF ALL DIABETIC EMERGENCIES GIVE GLUCOSE TO EVERYONE! Hypoglycemic – get needed sugar into blood stream and to the brain. Hyperglycemic – the extra dose of sugar will not cause damage in the short time before you reach the ER.

RED FLAGS for DM Sweating Palpitations Hunger Tremors Confusion/altered LOC HA Nausea Fatigue Slurred speech Inappropriate behavior Decrease coordination

Information sources American Diabetes Association 1-800-DIABETES www.diabetes.org 1-800-DIABETES