1. Know Your Diabetes Thomas Repas D.O. Diabetes, Endocrinology and Nutrition Center, Affinity Medical Group, Neenah, Wisconsin Member, Inpatient Diabetes Management Committee, St. Elizabeth’s Hospital, Appleton, WI Member, Diabetes Advisory Group, Wisconsin Diabetes Prevention and Control Program Website: www.endocrinology-online.com

2. D iabetes care is an ongoing team approach requiring the combined and intensive efforts of patients, their families, diabetic educators, doctors, nurses, dieticians and others.

3. Remember: Diabetes care starts with you!

4. “ When it comes to controlling diabetes, the patient is the key to everything. Diabetes patients must in effect become professors of their disease, learning to control their blood sugar levels over time.” American Association of Clinical Endocrinology “Patients First” Campaign 2002

5. Diabetes 101

6. There are two main types of diabetes… Type 1 and Type 2

7. What is the difference between type 1 and type 2 diabetes?

8. Type 1 diabetes the pancreas makes no insulin. Usually (but not always) occurs in younger people. Type 1 diabetes is always treated with insulin.

9. Type 2 diabetes the pancreas makes insulin, but the body does not respond to it, it is INSULIN RESISTANT. Sometimes, the pancreas begins to fail and also does not produce enough insulin. It frequently (but not always) occurs in adults. Type 2 diabetes can be treated with diet, pills and/or insulin. 90% of all diabetes is type 2

10. An Important Point We never diagnose the type of diabetes by whether a person is on insulin or not. We never diagnose the type of diabetes by whether a person is on insulin or not. Although all type 1’s are on insulin, a large number of type 2’s are on insulin, too Although all type 1’s are on insulin, a large number of type 2’s are on insulin, too This is why we don’t use the terms insulin dependent and non- insulin dependent anymore, it was too confusing for both doctors and patients alike This is why we don’t use the terms insulin dependent and non- insulin dependent anymore, it was too confusing for both doctors and patients alike We also don’t use the terms juvenile onset or adult onset anymore either. We also don’t use the terms juvenile onset or adult onset anymore either. We now know there are now many juvenile onset type 2’s and adult onset type 1’s We now know there are now many juvenile onset type 2’s and adult onset type 1’s We always diagnose the type of diabetes by the cause and never by whether on insulin or by the age of the patient We always diagnose the type of diabetes by the cause and never by whether on insulin or by the age of the patient

11. What causes diabetes?

12. The pancreas fails to make insulin because antibodies (autoimmunity) attack the insulin producing cells. There is a slight genetic tendency to inherit the disease as well a a possible environmental trigger (which we don’t completely understand yet). Type 1 diabetes

13. Type 2 diabetes Early on in the course of the disease (and sometimes even before someone is a type 2 diabetic) the pancreas makes enough insulin, but the body fails to respond to it because of insulin resistance. Later, the pancreas is unable to make enough insulin and blood sugars increase. There is a strong genetic tendency to develop type 2 diabetes but lifestyle factors also play a significant role.

14. Can Diabetes be Prevented?

15. Prevention of Type 2 Diabetes Several well designed studies have proven that type 2 diabetes can be prevented or delayed in those people at risk. Several well designed studies have proven that type 2 diabetes can be prevented or delayed in those people at risk. The Diabetes Prevention Program showed that in a three year period the numbers of new type 2 diabetics was reduced by 58% through diet, exercise and weight loss alone. The Diabetes Prevention Program showed that in a three year period the numbers of new type 2 diabetics was reduced by 58% through diet, exercise and weight loss alone. Average weight loss was only 12 lbs (7% of body weight) Average weight loss was only 12 lbs (7% of body weight) Patients exercised only 30 minutes a day for 5 days a week Patients exercised only 30 minutes a day for 5 days a week We do not understand the causes of type 1 diabetes well enough yet to be able to prevent this We do not understand the causes of type 1 diabetes well enough yet to be able to prevent this

16. Prediabetes or Metabolic Syndrome Consists of a syndrome of several factors that cluster together: Consists of a syndrome of several factors that cluster together: Abnormal blood sugars Abnormal blood sugars High Blood Pressure High Blood Pressure High Triglycerides High Triglycerides Low HDL or “good” Cholesterol Low HDL or “good” Cholesterol A body shaped like an apple instead of a pear A body shaped like an apple instead of a pear People with any three of these are at increased risk of developing type 2 diabetes

17. So why is uncontrolled diabetes so bad?

18. Retinopathy: eye damage that can cause blindness Nephropathy: kidney damage or failure Neuropathy: nerve damage Coronary artery disease: Heart attack Cerebrovascular disease: Stroke Other: gastroparesis (digestive problems), poor healing (infections), circulation problems, amputations, erectile dysfunction Diabetes that is not controlled can result in:

19. Keep in mind, diabetes complications are not inevitable! Through intensive management and monitoring, diabetes complications can be minimized or prevented. Through intensive management and monitoring, diabetes complications can be minimized or prevented. It is normal to feel frustrated and overwhelmed about diabetes

20. So what can you do to control your diabetes and prevent complications?

21. Know your ABC’s

22. A= A1C B=Blood Pressure C=Cholesterol

23. A= A1C or “Hemoglobin A1C” Blood sugar “sticks” to hemoglobin making it glycosalated or hemoglobin A1C Blood sugar “sticks” to hemoglobin making it glycosalated or hemoglobin A1C By measuring A1C’s we can get an idea of the average blood sugar control for the past three months By measuring A1C’s we can get an idea of the average blood sugar control for the past three months Should be obtained every 3 to 6 months Should be obtained every 3 to 6 months Goal: ADA < 7; AACE < 6.5 Goal: ADA < 7; AACE < 6.5

24. B= Blood Pressure Should be measured every visit or every 3 to 6 months Should be measured every visit or every 3 to 6 months Goal: < 130/80 Goal: < 130/80 In patients with kidney disease the goal should be even lower In patients with kidney disease the goal should be even lower

25. C = Cholesterol Should be measured no less than every year in patients whose levels are at goal Should be measured no less than every year in patients whose levels are at goal For those who are not, every 3 to 6 months For those who are not, every 3 to 6 months Goal: Goal: LDL (bad cholesterol) < 100 mg/dl LDL (bad cholesterol) < 100 mg/dl HDL (good cholesterol) > 45 mg/dl HDL (good cholesterol) > 45 mg/dl Triglycerides < 200 mg/dl Triglycerides < 200 mg/dl

26. Screening for Complications

27. Eye exams Eye exams Foot exams Foot exams Kidney tests Kidney tests

28. All diabetic patients should have a dilated eye exam by an eye specialist every year.

29. Diabetic Foot Care And Exams Learn proper daily foot self careLearn proper daily foot self care Remove shoes/socks every visit and remind your doctor to check your feetRemove shoes/socks every visit and remind your doctor to check your feet At least every year have a formal foot exam with monofilament testingAt least every year have a formal foot exam with monofilament testing

30. Kidney Tests At least once a year, diabetics should have a specific type of urine test called urine microalbumin At least once a year, diabetics should have a specific type of urine test called urine microalbumin Urine microalbumin is an early screening for kidney problems and disease Urine microalbumin is an early screening for kidney problems and disease Urine microalbumin will be abnormal many years before actual kidney failure occurs Urine microalbumin will be abnormal many years before actual kidney failure occurs When the kidneys begin to not function properly they begin to get “leaky” and lose protein and other compounds in the urine When the kidneys begin to not function properly they begin to get “leaky” and lose protein and other compounds in the urine It is important to look for this because if caught early it is reversible with medication, thus delaying or preventing kidney failure It is important to look for this because if caught early it is reversible with medication, thus delaying or preventing kidney failure

31. Other Ways to Prevent Complications

32. If you smoke… STOP!

33. Monitor and record your blood sugars regularly Monitor and record your blood sugars regularly Exercise & lose weight Exercise & lose weight Aspirin? Aspirin? Most diabetics should be on an aspirin a day, ask your doctor if this is OK for you Most diabetics should be on an aspirin a day, ask your doctor if this is OK for you Vaccinations? Vaccinations? Flu – every year Flu – every year Pneumonia – at least once Pneumonia – at least once More ways to prevent complications…

34. What type of options are available to treat diabetes?

35. Diet & lifestyle Diet & lifestyle Pills Pills Insulin Insulin Any combination of above Any combination of above

36. Diet & lifestyle Diet and lifestyle can have a significant impact on diabetic control Diet and lifestyle can have a significant impact on diabetic control Losing as little as 5 or 10 pounds can improve diabetes control significantly Losing as little as 5 or 10 pounds can improve diabetes control significantly Exercise can also help in lowering blood sugars as well as improving blood pressure (ask your doctor first) Exercise can also help in lowering blood sugars as well as improving blood pressure (ask your doctor first) Instruction in diet and nutrition is an important part of diabetes education Instruction in diet and nutrition is an important part of diabetes education

37. Oral Medications or “Pills” There are basically four types of medications for type 2 diabetes: Medicines that stimulate the pancreas to release more insulin Medicines that stimulate the pancreas to release more insulin Medicines that block glucose absorption from food Medicines that block glucose absorption from food Medicines that decrease glucose production by the liver Medicines that decrease glucose production by the liver Those that reduce insulin resistance by making cells more sensitive to insulin Those that reduce insulin resistance by making cells more sensitive to insulin

38. Medicines that stimulate the pancreas to release more insulin There are two kinds of these, long acting and those taken right before meals: Long acting= sulfonyureas Long acting= sulfonyureas Amaryl, Glucotrol XL, Glyburide Amaryl, Glucotrol XL, Glyburide Before meals= meglitinides Before meals= meglitinides Prandin, Starlix Prandin, Starlix Things to consider: Things to consider: These medications do not know when to “turn off” so they could result in hypoglycemia (more of a problem in the long acting type).

39. Medicines that block glucose absorption from food These are called alpha-glucosidase inhibitors Precose, Glyset Precose, Glyset Things to consider: By themselves, they will not cause low blood sugars. Although they can be helpful in controlling blood sugars, they are not used very much because of unpleasant side effects.

40. Medicines that decrease glucose production by the liver These medicines are called biguanides, there is only one medicine of this family available Glucophage (metformin) Glucophage (metformin) Things to consider: Things to consider: Metformin by itself does not cause low blood sugar. It works well in combination with other pills. It has some insulin sensitizing properties as well. It should not be used in people with liver problems, kidney disease or heart failure.

41. Medications that reduce insulin resistance This group of medicines are called thiazolidinediones or “TZD’s” Actos, Avandia Actos, Avandia Things to consider: Things to consider: TZD’s alone do not cause low blood sugar. They work well in combination with other pills. They can cause edema (leg swelling) so should be used cautiously in people who have heart failure and they should be avoided in people with liver problems. Because they reverse insulin resistance, they can do many other beneficial things besides only lower blood sugar.

42. Some Other Effects of TZD’s Beyond Lowering Blood Sugars Improve body’s ability to respond to insulin Improve body’s ability to respond to insulin Improve cholesterol especially by reducing triglyceride and increasing HDL or “good” cholesterol Improve cholesterol especially by reducing triglyceride and increasing HDL or “good” cholesterol Reduce microalbumin in urine Reduce microalbumin in urine Slightly improve blood pressure Slightly improve blood pressure

43. Combination Drugs There are many new combination drugs now available: Glucovance (Glucophage and Glyburide) Glucovance (Glucophage and Glyburide) Metaglip (Glucophage and Glucotrol) Metaglip (Glucophage and Glucotrol) Avandamet (Avandia and Glucophage) Avandamet (Avandia and Glucophage) Things to consider: Things to consider: They can simplify a type 2 diabetes regimen by reducing the number of pills one has to take (two medications in one pill).

44. WHAT!? Did you sayINSULIN?! The use of Insulin in Diabetes

45. Insulin The only treatment available for type 1 diabetes The only treatment available for type 1 diabetes Also used in type 2 diabetes which has been unable to be controlled with pills and diet alone Also used in type 2 diabetes which has been unable to be controlled with pills and diet alone Insulin can be given as injections or through insulin pumps

46. Types of Insulin Rapid acting begin acting almost immediately. Given before meals. Used in pumps. Rapid acting begin acting almost immediately. Given before meals. Used in pumps. Humalog, NovoLog Humalog, NovoLog Short acting given before meals. Takes 30 minutes or more to begin. Short acting given before meals. Takes 30 minutes or more to begin. Regular, Humulin R Regular, Humulin R Intermediate acting usually given twice a day. Supplies our baseline insulin needs Intermediate acting usually given twice a day. Supplies our baseline insulin needs NPH, Humulin N, Lente NPH, Humulin N, Lente Long acting usually given only once a day. Supplies our baseline needs. Long acting usually given only once a day. Supplies our baseline needs. Lantus, Ultralente Lantus, Ultralente Combination a mixture of intermediate and short acting insulin. Given once or twice a day. Should be used only in type 2’s never type 1’s Combination a mixture of intermediate and short acting insulin. Given once or twice a day. Should be used only in type 2’s never type 1’s Humulin 70/30,Humalog 75/25 Humulin 70/30,Humalog 75/25

47. BSLHSB Humalog Lantus Insulin Effect Basal/Bolus Insulin Regimen A basal/bolus regimen closely mimics our natural insulin needs A basal/bolus regimen closely mimics our natural insulin needs Basal insulin= baseline insulin to prevent high blood sugars or ketoacidosis in the fasting state Basal insulin= baseline insulin to prevent high blood sugars or ketoacidosis in the fasting state Bolus insulin= insulin given before meals to prevent high blood sugars after eating Bolus insulin= insulin given before meals to prevent high blood sugars after eating Called by some the “poor man’s pump” Called by some the “poor man’s pump” All type 1’s should be on a basal bolus regimen (and some type 2’s may benefit also) All type 1’s should be on a basal bolus regimen (and some type 2’s may benefit also) Advantages: better BS control and more flexibility Advantages: better BS control and more flexibility Disadvantage: requires four or five shots a day Disadvantage: requires four or five shots a day 6-56

48. Insulin Pumps Are standard of care in type 1 diabetes (and some type 2’s) but are not for everybody Are standard of care in type 1 diabetes (and some type 2’s) but are not for everybody The means of giving insulin closest to a normal functioning pancreas The means of giving insulin closest to a normal functioning pancreas Insulin is given in two ways: a constant or basal delivery and bolus insulin doses given before meals or to correct high’s Insulin is given in two ways: a constant or basal delivery and bolus insulin doses given before meals or to correct high’s Can significantly improve blood sugar control, reducing both high’s and lows Can significantly improve blood sugar control, reducing both high’s and lows Requires that a patient is involved, responsible and willing to check and record BS’s four to six times every day or more Requires that a patient is involved, responsible and willing to check and record BS’s four to six times every day or more

49. A Final Word: If you have diabetes and want better health and a longer life, then remember: If you have diabetes and want better health and a longer life, then remember: You Can Do It! American Association of Clinical Endocrinology “Patients First” Campaign 2002

50. You can take control of your diabetes instead of it taking control of you!