1. Diabetes Update Pennsylvania Association of Developmental Disabilities Nurses
Gutman Diabetes Institute
Einstein Medical Center, Philadelphia
Patricia C. Adams, RN, CDE
Abilify (aripiprazole)
Clozaril (clozapine)
Geodon (ziprasidone)
Risperdal and Risperdal Consta (risperidone)
Seroquel (quetiapine)
Symbyax (Zyprexa [olanzapine] and Prozac [fluoxetine] combination)
Zyprexa and Zyprexa Zydis (olanzapine)
The
Gutman Diabetes Institute

2. Objectives Distinguish the different types of diabetes
Discuss appropriate administration of insulin
Discuss prevention and treatment of hypoglycemia
Review of ADA recommendations for anti- psychotic drugs and obesity
Mean age of RN 46
UKPDS released 1998 Type 2
DCCT released 1993 type 1
DPP 2002
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3. Diabetes Update Diabetes - Epidemic Proportions Glucose Toxicity
25.8 million Americans (8.3% of population)
18.8 million have been diagnosed
7.0 million are unaware they have the disease
Lipid Toxicity
3/8/2011
1 in 4 hospitalized patients has diabetes and 1/3 only learn of their disease during hospitalization. Hyperglycemia is an independent predictor of infection in patients undergoing heart surgery. Almost 1/3 cardiac surgery patients have diabetes.
DM major cause of heart disease & stroke
Leading cause of kidney failure, non traumatic lower limb amputations, & new cases of blindness among adults in the US.
Need to identify elevated blood glucose in all hospitalized patients
174 billion: Total costs of diagnosed diabetes in the United States in 2007
$116 billion for direct medical costs
$58 billion for indirect costs (disability, work loss, premature mortality)
After adjusting for population age and sex differences, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes.
The American Diabetes Association has created a Diabetes Cost Calculator that takes the national cost of diabetes data and provides estimates at the state and congressional district level.
Factoring in the additional costs of undiagnosed diabetes, prediabetes, and gestational diabetes brings the total cost of diabetes in the United States in 2007 to $218 billion.
$18 billion for people with undiagnosed diabetes 
$25 billion for American adults with prediabetes 
$623 million for gestational diabetes
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4. Diabetes Areas Requiring Control Glycemic Control
A1C < 7% (ADA Standards)
< 6.5% (AACE Standards)
Blood Pressure Control
Goal is 130/80
ACE vs ARB; Diuretics
Lipid Management
Statins
Blood pressure goal is 130/80. Strong linear relationship between blood pressure and mortality. The lower the pressure, the longer you live. May take several drugs to achieve goal blood pressure. All diabetes and hypertension patients should be treated with an ACE inhibitor or ARB. Add a thiazide if blood pressure control not achieved.
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5. Cardiovascular Risk Lipids Total Cholesterol < 200
HDL > 45 (Men) > 55 (Women)
LDL < 100; <70 (Hx of cardiac disease)
Triglycerides (Tg) < 150
Aspirin (81 – 325) mg daily >21 yrs)
Now the thinking is that an HDL>60 is preferred.
Gutman Diabetes Institute

6. Recommendations: Dyslipidemia/Lipid Management
Treatment recommendations and goals
Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients:
with overt CVD (A) / LDL < 70
without CVD who are >40 years of age and have one or more other CVD risk factors (A) / LDL < 100
This set of seven slides summarize recommendations for screening, treatment, and goals for dyslipidemia/lipid management in patients with diabetes
Slide 3 of 7 – Treatment Recommendations and Goals (Slide 2 of 6)
Statin therapy should be added to lifestyle therapy, regardless of baseline lipid levels, for diabetic patients
With overt CVD (A)
Without CVD who are over the age of 40 years and have one or more other CVD risk factors (A)
Discuss the impact of dm on density of cholesterol
ADA. VI. Prevention, Management of Complications. Diabetes Care 2011;34(suppl 1):S29.
Reference
American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S29.

7. Diabetes Update Type 1 Type 2 Gestational Approximately 5%
7 – 14% of all pregnancies
5 – 10% have type 2 following delivery
20 – 50% chance of developing diabetes in the next 5 – 10 years
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8. What is a normal blood glucose level?
Diabetes
> 126 mg/dl
< 126 mg/dl
> 100 mg/dl
< 100 mg/dl
Pre-Diabetes
Normal
70 mg/dl
A1C > 6.5%
FPG> 126 mg/dl
OGTT > 200 mg/dl (75g glucose load)
RPG > 200 mg/dl with symptoms of hyperglycemia
Ask participants, “What is a ‘normal’ blood glucose level?”
Acceptable levels of glycemic control have progressively declined with improved understanding of the mechanism of diabetes complications. Currently, the “normal” range of blood glucose is 70 to 99 mg/dl. Patients with fasting blood glucose values 100 to 125 mg/dl are classified with impaired fasting glucose (IFG) or pre-diabetes. Fasting blood glucose values consistently above 126 mg/dl are associated with increased rates of diabetes complication and constitute the basis for clinical diagnosis.
Diabetes Care 2005;28:S4-S36
Diabetes Care 2005;28:S37-S42
Criteria for the diagnosis of diabetes
A1C 6.5%. The test should be performed in a laboratory using a method that is NGSP
certified and standardized to the DCCT assay.* OR
FPG 126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*
2-h plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be
performed as described by the World Health Organization, using a glucose load containing
the equivalent of 75 g anhydrous glucose dissolved in water.*
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random
plasma glucose 200 mg/dl (11.1 mmol/l).
*In the absence of unequivocal hyperglycemia, criteria 1–3 should be confirmed by repeat testing.
Position Statement
care.diabetesjournals.
Diabetes Care, Clinical Practice Recommendations, 2011

9. *At-risk BMI may be lower in some ethnic groups.
Criteria for Testing for Diabetes in Asymptomatic Adult Individuals
Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and have additional risk factors:
Physical inactivity
First-degree relative with diabetes
High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)
Women who delivered a baby weighing >9 lb or were diagnosed with GDM
Hypertension (≥140/90 mmHg or on therapy for hypertension)
HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl (2.82 mmol/l)
Women with polycystic ovarian syndrome (PCOS)
A1C ≥5.7%, IGT, or IFG on previous testing
Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)
History of CVD
The three primary criteria for testing for diabetes in asymptomatic adult individuals (Table 4) are summarized on two slides; this slide (Slide 1 of 2) includes:
Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2) and have additional risk factors
Testing should be considered in adults of any age with BMI ≥25 kg/m2 and one or more of the known risk factors listed on this slide
It is important to know that the at-risk BMI may be lower in some ethnic groups, such as Asians
*At-risk BMI may be lower in some ethnic groups.
ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.
Reference
American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S14. Table 4.

10. Diabetes in Severe Mental Illness
2 – 3 fold increased mortality rate associated with physical illness
Most common cause of death – CVD
More likely to be overweight, smoke, inactive
More likely to have family hx diabetes,
Limited access to primary care, cardiovascular risk screening
European article also found Lack of disease ownership by psychiatrist vs primary care.
Diabetes is already leading cause of CVD and independent risk factor
Adults tx with SGA, 2 times greater risk for diabetes, dislipidemia, htn, cvd
Gutman Diabetes Institute

11. ADA Consensus
Baseline monitoring at initiation of antipsychotic medications
Personal/family hx diabetes, obesity, dislipidemia, hypertension, CVD
Calculate BMI
Waist circumference
BP, Fasting blood glucose, Fasting Lipid profile
Interval monitoring
4, 8, & 12 weeks after initiation of therapy
Weight gain > 5% consider change in therapy
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12. ADA Consensus Consideration of metabolic risks when starting SGAs
Patient, family, and care giver education
Baseline screening
Regular monitoring
Refer to specialized services, when needed
Morrato, Newcomer, et looked into rate of testing after release of ADA consensus statement. Of interest is the following points
Metabolic testing remained suboptimal for SGA users. Retrospective look at insurance claims
Study 2001 – 2006, by end of % of SGA useres received no baseline glucose monitoring; 90% received no lipid assessment
Causes of low adherence to evidence based treatment recommendations
“Low awareness, lack of medical consensus, low self efficacy to enact change and failure to overcome the inertial of previous practice. Another explanation offered is that physicians treat guidelines more as options as opposed to true standards and professional organizations such as the ADA, APA cannot enforce adherence”
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13. Blood Glucose Regulation
Pancreas
Muscle
Insulin
Secretion
Release of GIP & GLP - 1 + +
Intestine:
Glucose
Absorption
BLOOD GLUCOSE
Peripheral
Glucose
Uptake
Incretins are intestinal hormones that are released in response to ingestion of food. They stimulate (text uses amplify) an insulin response in a glucose dependent state. Also, have role in satiety, gastric emptying. Inhibited by enzyme DDP-IV
GIP Gastric inhibitory peptide
GIP 1 Glucagon like peptide 1
Secretion liver -  gluconeogenesis,  peripheral glucose uptake muscle and fat
Stimulated by  glucose
Amplified by GLP1, GIP
Inhibited by  glucose,  Free Fatty Acids,
Glucagon – increases hepatic gluconeogenesis
Stimulated by  glucose
Inhibited by Somatostatin, insulin +
Brain &
Nervous System
Fat
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14. Type 1 Diabetes Type 2 Diabetes Initially little insulin production
Evolves into no insulin production
Exogenous insulin required daily
Auto-immune response
Genetic component
5 - 10% prevalence
Slow, Insidious
6.5 years to manifest as elevated FBG
Elevated postprandial blood glucose levels
Damage vessel endothelium
Insulin Resistance
Beta Cell Deterioration
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15. Type 1 & 2 Comparison Type 1 Type 2 Age of Onset Usually <30
Rapid
Slowly - years
Insulin Availability
Little to None
Some
Progressive
Insulin Resistance
Develops w/Time
Usually present
Treatment
Exogenous insulin always needed
Daily injections
MNT, Activity, Oral Agents, Insulin
Complications
Develop w/Time
Present at Dx
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16. Type 2 Diabetes: A Dual-Defect Disease
Genes
Genes
Impaired insulin
secretion
Insulin
resistance
± Environment
IGT
IGT
Type 2 diabetes
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17. Genes
Vs.
Jeans
Dr. James Gavin!
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18. The Progressive Nature of Type 2 Diabetes
Normal
Impaired glucose tolerance
Type 2 diabetes
Late type 2 diabetes complications
Insulin sensitive
Hyperglycaemia
Normal insulin secretion
Insulin resistance
Normoglycaemia
β-cell exhaustion
Insulin resistance
Fasting plasma glucose Insulin sensitivity Insulin secretion
Adapted from Bailey CJ et al. Int J Clin Pract 2004;58:867–876. Groop LC. Diabetes Obes Metab 1999;1 (Suppl. 1):S1–S7.

19. How Do Oral Diabetes Medicines Work?
Glucosidase
Inhibitors
TZD’S
DPP IV Inhibitors
Secretagogues
Biguanides
Increase insulin action
Increase insulin secretion
Decrease hepatic glucose
Decrease breakdown of GLP-1- increase insulin secretion
The classes of oral agents used for treating type 2 diabetes act on the major sites of defects associated with the disease. Their actions range from increasing insulin secretion (by the secretagogues) to suppressing hepatic glucose output (the biguanides) to delaying gastrointestinal glucose absorption (the -glucosidase inhibitors) to increasing insulin sensitivity (the thiazolidinediones).
5 new drug classes either under development or recently approved by FDA for diabetes management – long-acting GLP-1 analogues, (Byedtta) dipeptidyl peptidase (DPP) IV inhibitors (Januvia, Onglyza), islet hormone therapy (Symlin), and endocannabinoid receptor antagonists (rimonabant-Acomplia).
In the pipeline – Pill allow urine loss in urine
Trade Generic
Diabeta Glyburide
Micronase
Glucatrol glipizide
Amaryl Glimepiride
Prandin Repaglinide
Starlix Nateglinide
Precose Acarbose
Miglitol Glyset
Pio Actos
Sitagliptin Januvia
Saxagliptin Onglyza
Slow glucose absorption
Glyburide Glipizide
Glimepiride
Repaglinide
Nateglinide
Pioglitazone
Rosiglitazone
Metformin
Metformin XR
Metformin/Glyburide
Acarbose
Miglitol
Sitaglipton
Saxaglipton
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20. Terminology: Physiologic Insulin Use AKA “Think like a Pancreas”
Basal
Amount needed to prevent excess gluconeogenesis and ketogenesis
Prandial
Amount needed to cover discrete meals and/or nutritional supplements
Tube Feedings, IV dextrose, TPN
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21. Human Insulins
Regular
NPH
70/30
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22. Insulin Analogs Humalog (Lispro) Humalog Mix 75/25 NovoLog (Aspart)
NovoLog Mix 70/30
Apidra (Glulisine)
Lantus (Glargine)
Levemir (Detemir)
*** review question. Know the different brands!
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23. Administer insulin as one would physiologically secrete insulin (Mimick the pancreas’ function)
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24. Basal / Bolus Insulin Therapy
Novolog u100: _____ units with 1st
______units with 2nd
______units with 3rd meal @_____
Lantus u100 :
_____ units in the morning @_____
Call your physician or diabetes educator:
Blood glucose test times: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Before breakfast
1 hour after breakfast
2 hours after breakfast
Before lunch
1 hour after lunch
2 hours after lunch
Before dinner (supper)
1 hour after dinner (supper)
2 hours after dinner (supper)
Bedtime
Early
Sleeping
Meal times: Hours of sleep:
_____ _____ _____ ______________
Supplemental insulin: _____________________
BG test outcomes
No. of Units
Time
Insulin sensitivity factor:______
Insulin to carb ratio:__________
Urine ketone tests:____________
____________________________

25. Premix (cloudy) Short acting insulin Intermediate acting insulin1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Insulin type: Human u100 Premix R & NPH
Onset (Begins to work) ½ - 1 hour following injection
Peak action (Works the strongest) Dual following injection
Effective duration following injection
Actual maximum duration hrs
Meal and
Snack times
AM / PM
Onset
Peak
Duration
1st meal______
AM/PM
_____
____to____
1st snack______
2nd meal______
2nd snack_____
3rd meal______
3rd snack _____
Bedtime______

26. Insulin Action Times Type Starts Peaks Ends Lispro (Humalog) 5 min.
3 – 4 hr.
Aspart
(Novolog)
3 – 5 hr.
Glulisine
(Apidra)
Regular
30 – 60 min.
2 – 4 hr.
6 – 8 hr.
NPH
1.5 hours
4 – 12 hr.
10 – 16 hr.
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27. Dual (Lispro/Lispro Protamine) Dual (Aspart/Aspart Protamine)
Insulin Action Times
Type
Starts
Peaks
Ends
Glargine
(Lantus)
4 – 6 hr.
None
24 hr.
Levemir
(Detemir)
< 2 hr.
3 – 14 hr
16 – 24 hr.
70/30
0.5 – 1.0 hr.
Dual (NPH/R)
12 – 20 hr.
Mix 75/25
10 min.
Dual (Lispro/Lispro Protamine)
Mix 70/30
Dual (Aspart/Aspart Protamine)
75/25 peaks ½ - 4 hr. Mix 70/30 peaks 1-3/4 – 2-1/4 hr.
Must administer aspart and lispro immediately if mixed with NPH.
Can’t mix Glargine with any other insulin
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28. Insulin and Timing of Meals
70/30 – 30 minutes prior to meal
Regular – 20 to 30 minutes prior to meal
NPH – 20 to 30 minutes prior to meal
Aspart- 5 – 10 minutes prior to meal
Lispro- 5 – 10 minutes prior to meal
Apidra - 5 – 10 minutes prior to meal
Gutman Diabetes Institute

29. Proper Matching Glucose Level 1 2 3 4 Time in Hours
Insulin Peak action
For patients taking rapid-acting insulin (such as lispro or aspart), an effect is seen in blood glucose levels within about 15 minutes. The peak occurs in 30 to 90 minutes, depending on the patient, and the insulin should be out of the patient’s system in about 2 to 4 hours. 1 2 3 4
Time in Hours
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30. Improper Matching Hypoglycemia Hyperglycemia Glucose Level 1 2 3 4
Insulin Peak Action
For patients taking rapid-acting insulin (such as lispro or aspart), an effect is seen in blood glucose levels within about 15 minutes. The peak occurs in 30 to 90 minutes, depending on the patient, and the insulin should be out of the patient’s system in about 2 to 4 hours. 1 2 3 4
Time in Hours
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31. You wouldn’t hold the pancreas, so don’t hold the lantus
Clinical Pearl
Basal insulin
You wouldn’t hold the pancreas, so don’t hold the lantus
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32. Clinical Pearl
Without insulin, in an insulin deficient individual, blood glucose will increase passively by as much as 45 mg/dl per hour even in the absence of food.
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33. Location, Location, Location
Lipohypertrophy can occur from repeated injections in one site.
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34. Glycemic Recommendations for Non-Pregnant Adults with Diabetes (1)
A1C
<7.0%*
Preprandial capillary plasma glucose
70–130 mg/dl* (3.9–7.2 mol/l)
Peak postprandial capillary plasma glucose†
<180 mg/dl* (<10.0 mmol/l)
Recommended glycemic goals for nonpregnant adults (Table 10) are shown on three slides
Slide 1 of 3
These recommendations are based on those for A1C values, with listed blood glucose levels that appear to correlate with achievement of an A1C of <7%
The issue of preprandial versus postprandial self-monitoring of blood glucose (SMBG) is complex; in some epidemiological studies, elevated postchallenge two-hour oral glucose tolerance test (2-h OGTT) glucose values have been associated with increased cardiovascular risk independent of fasting plasma glucose (FPG)
In diabetic subjects, some surrogate measures of vascular pathology, such as endothelial dysfunction, are negatively affected by postprandial hyperglycemia
Postprandial hyperglycemia, like preprandial hyperglycemia, contributes to elevated A1C levels, with its relative contribution being higher at A1C levels that are closer to 7%
However, outcome studies have clearly shown A1C to be the primary predictor of complications, and landmark trials such as the Diabetes Control and Complications Trial (DCCT) and the UK Prospective Diabetes Study (UKPDS) relied overwhelmingly on preprandial SMBG
For individuals who have premeal glucose values within target but A1C values above target, a reasonable recommendation for postprandial testing and targets is monitoring postprandial plasma glucose 1-2 hours after the start of the meal and treatment aimed at reducing PPG values to <180 mg/dl to help lower A1C
*Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.
ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S21. Table 10.
Reference
American Diabetes Association. Standards of medical care in diabetes—2011. Diabetes Care 2011;34(suppl 1):S Table 10.

35. Control Hyperglycemia
Hyperglycemia needs to be controlled.
Any glucose excursion causes endothelial damage
Don’t relax with one good glucose reading
Need to look at trends over 24 – 48 hours
Need basal and prandial insulin coverage
Rare to withhold basal insulin
Insulin sliding scales do not work alone!
Reactive vs proactive
Variations in glucose have been shown to lead to oxidative stress, which may be the mechanism for most diabetes complications – Irl Hirsch. The variability is deleterious to the tubulointerstiitum than a constant high concentration of glucose. The best predictor of oxidative stress is overall glucose variability, not just postprandial hyperglycemia.
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36. Treating Hypoglycemia
DM medication given too early
DM medication dosage too high
Meals delayed or not eaten
Give DM medication at right time
Advocate for adjustment of medication
Offer food when appropriate
In some cases, hypoglycemia in the hospital is related to giving the patient his or her diabetes medications too early. Other times, the medication dosage may be too high for the amount of calories being consumed. Nurses should take care to ensure that these diabetes drugs are given at the most appropriate times. Glucose levels should be monitored, looking for trends, and adjustments should made when needed.
Problems
Nursing solutions
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37. Hypoglycemia Wait 15 minutes, - retest “Test don’t Guess”
Anything under 70 mg/dl is hypoglycemia
Treat
16 grams of carbohydrate – “fast acting”
Glucose gel – 15 grams
Glucose Tabs –4
½ cup juice or regular soda
Wait 15 minutes, - retest
Hypoglycemia is a BG less than 70 mg/dl and requires treatment to prevent further decreasing of blood glucose.
Treatment is by protocol in hospitalized patients.
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38. Hypoglycemia
This represents a patients BG pattern with over treatment of hypoglycemia. These wide variations in BG increase the risk for vascular and nerve complications. Excursions often considered higher risk of CVD.
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39. Medical Nutrition Therapy
No longer a diabetic diet (ADA)
Currently Carb Controlled
Requires Individualization
Need for Consistent Carbohydrates
Some sweets OK
Meals – 4.5to 5 Hours Apart
Divide Protein and Fats
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40. Medical Nutrition Therapy
Consume Fewer Animal Fats
Emphasize Low Fat Dairy Products
Emphasize Monounsaturated Fats
Emphasis upon Fiber
Decrease Use of Sweets
Decrease Use of Alcohol
Emphasize need for everyone to eat this way. Remind about the impact of isolating someone and the emotions associated with diabetes. Be careful of the “Food police”
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41. The Plate Method Fill a quarter of your plate with starch or bread
The Plate Method is an easy to remember technique for meal planning.
This method recommends a healthy distribution of carbohydrates, a lower fat intake, and a greater amount of fruits and vegetables. It can be used to eat healthfully, lose weight, and/or manage your diabetes.
Fill a quarter of your plate with starch or bread
Fill half your plate up with non starchy vegetables
Fill a quarter of your plate with protein (choose lean cuts)
“Carb counting is a complicated process. Requires thorough knowledge of labels, measuring all food. Above system has been proven to be in the “Ball Park”
Females gms CHO a meal
Males 60 – 75 gms CHO a meals
Source: National Diabetes Education Program
To learn more about how meal planning can help prevent or manage your diabetes,
contact the Gutman Diabetes Institute, or

42. Juice is a Carbohydrate Too!
Even Light Juice Cocktail Contains ˜ 8 gm CHO
No Sugar Free Juices

43. Sorbitol, xylitol, mannitol
Sugar Free Foods
Non-nutritive sweeteners are OK
Sugar contains 4 kcal/gm
Sugar alcohols contain  2-3 kcal/gm
End in “ol”
May contain more carbohydrate than regular item
Need to read the label
Can cause diarrhea
Sorbitol, xylitol, mannitol

44. Physical Activity Role of Physical Activity
150 mins / week; most days of the week
Cells More Receptive to Insulin
Decreases Insulin Resistance
Lowers Blood Glucose
Integral Part of Diabetes Management
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45. Diabetic Ketoacidosis
Precipitating Factors
Infection
Insulin Omission
Inadequate Amount of Insulin
Newly Diagnosed Diabetes
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46. Diabetic Ketoacidosis
3 Clinical Features
Hyperglycemia - >250 mg/dL
Ketonuria or ketonemia
Acidosis
pH <7.3
and/or serum bicarb <15 mEq/L
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47. Diabetic Ketoacidosis
Absence or reduced effect of insulin
Excess of counter regulatory hormones
Glucagon
Cortisol
Growth hormone
Catecholemines
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48. Diabetic Ketoacidosis
Clinical Presentation
Presence of Acidosis
Abdominal Pain
Nausea
Vomiting
Anorexia
Treatment
Emergency measures / hospitalization
IV fluids
Insulin!!!
Replacement of electrolytes
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49. Diabetic Ketoacidosis
Clinical Presentation
Hyperglycemia 3 – 4 Days
Metabolic Alterations < 24 Hours
Respiratory Symptoms
Kussmaul Respirations
Kussmaul breathing is respiratory compensation for a metabolic acidosis, most commonly occurring in people with diabetes, diabetic ketoacidosis. Blood gases on a patient with Kussmaul breathing will show a low partial pressure of CO2 in conjunction with low bicarbonate because of a forced increased respiration (blowing off the CO2).
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50. Hyperosmolar Hyperglycemic State
Lab Values
Glucose > 600 mg/dl
No Ketones or Only Small Amounts
Plasma Osmolality > 320 mOsm/kg
Treatment focus on fluids,
Insulin still needed for hyperglycemia (glucose toxic)
Correct electrolyte imbalance
ID / Tx underlying comorbidities
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51. Diagnostic Criteria; DKA vs HHS
Mild
Moderate
Severe
Glucose
250
>250
.250
>600 pH
<7.00
>7.30
BiCarb
15-18
10-15
<10
>15
Urine Ketones +
small
Serum Ketones
Anion Gap
>10
>12
<12
Mentation
Alert
Alert/Drowsy
Stupor/Coma
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