Diabetes in a One Hour Nutshell

The Diabetes Network of St Louis (DNSL) –Funded by

the Missouri Foundation for Health Coco~ Bopp, MEd, CHES, CPFT

Adapted from a presentation by

Garry Tobin, MD & Eric Armbrecht, PhDJune 2010

Diabetes (DM) Defined

• Two fasting sugars > 126 milligrams %.

• Two Hour post 75 grams of glucose sugar greater than 200.

• Impaired glucose tolerance is defined as a two post 75 gram challenge between 140 and 200 milligrams %.

Type 1 Diabetes

• is autoimmune destruction of the insulin-producing Beta cells in the pancreas.

• represents a breakdown in the body’s ability to determine foreign invaders such as a virus from the bodies own cells.

• can occur at any age

• is 5-10% of all cases of diabetes

• Insulin RX is needed

Type 2 DIABETES

• Is the most common form of DM

• There is an increased incidence in people of color and tracks with Obesity

• Over time the stress on the pancreas leads to loss of insulin production resulting in most Type 2 Diabetics requiring insulin Rx

• The decline in insulin production can be stabilized by good blood sugar control.

TYPE 3 DIABETES

• Results from recurrent bouts of inflammation leading to a loss of the function of the pancreases hormonal and digestive functions.

• Generally insulin RX is needed

• A severe form of this disease would occur after surgical resection of the pancreas for either benign or malignant diseases.

Targets for the treatment of Diabetes

• Fasting blood glucose between 70 (or 80) -110 milligrams %

• 2 hour post meal glucose < 140 > 70 milligrams %. The corresponding level in pregnancy is even tighter and is a 1 hour post meal < 120 milligrams %.

• Hemoglobin A1c: 6.5%-7.0% or better. The hemoglobin A1c is an average measure of the glucose over the last 90 days.

Targets for treatment of Diabetes

• Blood pressure < 130/80

• LDL cholesterol< 100 possibly even < 70 of other high risk features.

• Avoidance of hypoglycemia

• Daily exercise.

• Diet rich in poly-unsaturated fats and foods high in antioxidants.

• Ideal body weight.

Overview of the DNSL Course

• 6 session, 12 week course meeting every 2 weeks for people with diabetes.

• The course focuses individuals on taking responsibility for their health

•

How to manage symptoms Communicating better with health professionals,

family & friends Nutrition & exercise Goal setting & problem solving Managing stress, frustration, and fatigue Patients are encouraged to solve their own

problems with information, but not orders, from professionals.

Overview of the sessions

• Session 1: Overview of course & Monitoring, Hemoglobin A1C

• Session 2: Long term complications of diabetes: hypertension, kidney disease, heart disease

• Session 3: Foot care• Session 4: Medications for diabetes• Session 5: Benefits of a healthy diet & regular

exercise• Session 6: Review, community resources and

graduation

Underline = focus of this presentation

Patient Education is Partnered with Self Management

Patient Education Self Management

Manage life with disease.

Increase skills & self-confidence.

Problem solve and make decisions.

Form a patient-provider partnership.

• Set goals to better manage diabetes.

Become more knowledgeable about diabetes at each sessionUse the knowledge to implement goals. Individualize goals and plans for improvement.Use specific tools (e.g., Care Plans, Action Plans).

Action Planning and Goal Setting

Action Planning is: Something YOU want to do and can achieve Reasonable Behavior-specific

Goal setting answers: What? How much? When? How often? Confidence level of 7 or more (scale of 1 – 10)

Monitor blood sugar levels!Hit Your Target and achieve goals!

Fasting 80 – 110 mg/dl

Two hours after meals – less than 140

These are national standards ADA High sugar attaches to proteins and

tissues in the body leading to complications of the disease.Hemoglobin A1c is shown on the next set of slides.

Hemoglobin A1C

Sugar Attaches to Red Blood Cells

Red Blood Cells Live For 3 Months High sugars (which lead to a

high A1C) indicate excess sugar is attaching to red blood cells.

Three Month Average for the blood sugar.

Why We Care about the A1C

• It tells how well blood sugar levels are controlled.

• High blood sugar = affected body tissues

• High A1C = high risk of complications

American Diabetes Association

Goal: Less than 7.0% ( average sugars < 150) or in

selected cases < 6.0% ( average sugars < 130)

without significant low blood sugars

Long Term ComplicationsOf Diabetes

Heart disease is the leading cause of death in type 2 Diabetes

ESSION 2 Hypertension, cardiac risk and kidndisease

Maintain Blood pressure in the setting of DM < 130/80 mm HgDrug options– ACE/ ARB

Control Cholesterol and blood fatsTotal Cholesterol < 200HDL ( GOOD) > 35LDL ( BAD) < 100 and in some settings < 70Triglycerides < 180

Normalization of Blood sugars A1c < 7.0% etc

Micro-albumin Screening is an early marker of an at risk kidney: Urine micro-albumin screen

Normal < 30 mg/ gramEarly 30-300 mg/ gramAdvanced > 300 mg/ gram

Patient’s Job Physician’s Job1. Make sure that you obtain yearly 1. To order tests and

fasting lipid panel, urine microalbumin, and interpretand annual eye exam and that you understand results

2. Track blood pressure and take 2. Adjust Medicationsmedications as prescribed

3. Take shoes off at each visit, alert 3. Look at feet and refer physician to problems if needed

4. Monitor sugars and take medications 4. Review goals andrefer if needed

5. Choose what you eat and exercise 5. Review diet plan and refer if needed

Physician = Coach The level of play is dependent on you/the patient

Maintain Blood pressure in the setting of DM < 130/80 mm HgDrug options– ACE/ ARB

Control Cholesterol and blood fatsTotal Cholesterol < 200

HDL ( GOOD) > 35LDL ( BAD) < 100 and in some settings < 70Triglycerides < 180

Normalization of Blood sugars A1c < 7.0% etc

Microalbumin Screening is an early marker of an at risk kidneyUrine microalbumin screen

Normal < 30 mg/ gramEarly 30-300 mg/ gramAdvanced > 300 mg/ gram

Foot Care

• The key to keeping feet healthy = to prevent problems!

Diabetic Foot Conditions Develop due to a Combination of Causes

• Poor Circulation= Blood Flow

• Neuropathy = Nerve Damage

• An injury left untreated

Diabetic Foot Ulcer

• Open sore that will not heal

• Caused from break in skin from blister, cuts, ingrown nails

• Pressure and friction on the bottom part of the foot causing a callous

Poor circulation

• Keeps wound from healing by depriving cells of much needed oxygen and nutrients

• Living tissue then dies, become infected, and spread to muscle and bones

Neuropathy

• Nerves - provide communication between your brain and your muscles, skin, internal organs and blood vessels.

• Damaged - your nerves can't communicate properly, and that miscommunication causes pain, numbness, and a loss of sensation and FALLS

High Pressures (1,300 PSI)

Short Duration (Instant)

Stepped on a tack

Always wear shoes!

Slide take from presentation “Diabetic Foot” by Michael J Mueller, PT, PhD

Motor nerve neuropathy

intrinsic muscles & hammer toe deformity

Control Foot

Diabetic Foot

Robertson et al 2002

Slide take from presentation “Diabetic Foot”

by Michael J Mueller, PT, PhD

Charcot Foot

• With neuropathy, bones in foot can become weak and fracture easily

• A minor injury can go undetected and not get treated

• The muscles and ligaments lose their ability to support the foot correctly

• Can lead to joints becoming dislocated, bones and cartilage being damaged

• Potential for SEVERE deformity

• Increased risk for skin breakdown due to the foot deformity

Acute Charcot Arthropathy

Slide taken from presentation “Diabetic Foot” by Michael J Mueller, PT, PhD

Red foot with arch deformity

Care of your feet• Check your feet daily – look for redness, tenderness, blisters,

cuts. Check in between toes. Use a mirror if trouble seeing bottom of feet

• Wash and dry feet well, esp. between toes

• Apply lotion to top and bottom of feet to keep them from getting dry and cracked

• Cut nails straight across and file sharp edges

• No over the counter corn and callous remover. Do not cut a corn or callous

• Do not go barefoot

• Inspect inside of shoes for foreign objects

• Do not soak feet

Foot care

• Do not use hot water bottle or heating pad

• Do not walk on hot surfaces such as sandy beaches or cement around swimming pools

• No sandals with thong between toes

• Wear socks with all shoes

• Use double antibiotic ointment twice a day for minor cuts, scratches or blisters

• Notify doctor for redness, swelling, fever or if you see any pus coming from foot or toe

• Have doctor inspect your feet at each visit

• See a podiatrist or foot nurse regularly

Components of a foot exam

Skin temperatureMonofilament and vibration or position testing Quality of the pulses Quality of the skin, including the presence of ulcers, calluses and skin breakdown Quality of the nails and nail beds Nail polish should be removed! The presence of foot deformities including bunions, heel, toe and arch deformities

Medications: Basic Rules:

1. Know/understand your options.

2. Know your medications.

3. Know the side effects of your medications.

4. Know when and how to take your medications.

5. Do not be afraid to take your medications.

6. Be honest with your doctor!

Exercise and Diet

Exercise

• No single group can benefit from exercise more than people with diabetes!

This effect is insulin independent

Diabetes Prevention Study 150 minutes of Activity per week

But...

The most important question of all….

What should one eat and

how much?

3 Basic Nutrients In Food

Carbohydrate =

of primary concern

Protein

Fat

What’s up with carbs?

Main nutrient that raises blood sugar.

The process begins in about 15 minutes

100% can be converted to glucose within 2 hours.

The body’s main source of energy.

Note: Protein has little effect on blood sugar.

One Serving of Carbohydrate

= 15 grams

Example of 15 grams of carbs.

Diabetes Recommendations

Males 4 – 5 servings (60 – 75 gms)

Females 3 – 4 servings (45 – 60 gms)

Overweight Subtract 1 carb serving

Exercise 3-5x wk Add 1 carb serving

Snacks 1 – 2 servings (15 – 30 gms)

Per meal recommendations

Using The Food Label

Thank You!From Coco˜