B Y : A N D R E W S N O W D E N

P E P : 4 3 7 0

Diabetes Mellitus

Overview

What is Diabetes Mellitus Epidemiology Etiology Clinical Aspects Treatment of Disease Ethics Effects of Exercise Exercise Testing Prescription Summary References

Diabetes Mellitus?

In a healthy person the body secretes proper amounts of insulin and glucagon in order to maintains proper blood glucose levels

Insulin is secreted by the beta cells of the pancreas in response to high blood sugar

Glucagon is secreted by the alpha cells of the pancreas when blood glucose is low

However in a diabetic it is a constant struggle to maintain these hormone levels below a hyperglycemic state

Diabetes Mellitus?

There are many types of diabetes

Type I, Type II, Pre-diabetes, gestational diabetes

Diabetes is basically too much glucose for your body to withstand and not enough insulin produced to counteract the increased sugar.

Diabetes comes from the Greek term diabanein which means to pass through and is referring to the excess urine passed due to the condition

Mellitus is also Greek and roughly translates to “excessively sweet urine” or glycosuria

Epidemiology

As per data from a 2011 ADA statistical analysis

25.8 million children and adults in the United States—8.3% of the population—have diabetes.

79 million people in the U.S. have pre-diabetes

95% of all diabetics are Type II

1.9 million new cases in the U.S. were reported in 2010

WHO estimates these numbers will double by 2030

Etiology

Type I

An autoimmune disease that causes the immune system to attack its own insulin produced leaving the individual with little to no insulin

Is thought to be caused by a combination of genetic susceptibility and environmental factors

The exact etiology of diabetes mellitus of this kind is not fully understood.

Etiology

Type II

Type 2 diabetes develops when the body becomes resistant to insulin or when the pancreas stops producing enough insulin.

Hereditary or Inherited Traits

Age: 80% of cases occur after 50 years

Poor Diet (Malnutrition Related Diabetes)

Obesity and Fat Distribution

Sedentary Lifestyle

Stress

Serum lipids and lipoproteins

Hypertension

Prevalence

Men and Woman have almost equal prevalence of diabetes, 13 million men and 12.6 million women in the U.S.

Racial makeup:7.1% of non-Hispanic whites 8.4% of Asian Americans 12.6% of non-Hispanic blacks 11.8% of Hispanics

Morbidity and Mortality: diabetes was listed as the underlying cause on 71,382 death certificates and was listed as a contributing factor on an additional 160,022 death certificates

Clinical Aspects (symptoms)

Type 1 Diabetes Frequent urination

Unusual thirst

Extreme hunger

Unusual weight loss

Extreme fatigue and Irritability

Type 2 Diabetes Any of the type 1 symptoms

Frequent infections

Blurred vision

Cuts/bruises that are slow to heal

Tingling/numbness in the hands/feet

Recurring skin, gum, or bladder infections

Clinical Aspects (Diagnosis)

A number of laboratory tests are available to confirm the diagnosis of diabetes.

Finger stick blood glucose

Fasting plasma glucose

Oral glucose tolerance test

Glycosylated hemoglobin or hemoglobin A1c

Clinical Aspects (Test and Evaluation)

Finger stick blood glucose This is a rapid screening test that may be performed anywhere

A finger stick blood glucose test is not as accurate as testing the patient's blood in the laboratory but is easy to perform

The test involves sticking the patient's finger for a blood sample, which is then placed on a strip

This method is only accurate to within about 10% of true actual laboratory values

Finger stick blood glucose values may be inaccurate at very high or very low levels, so this test is only a preliminary screening study

This is the way most people with diabetes monitor their blood sugar levels at home

Clinical Aspects (Test and Evaluation)

Fasting plasma glucose

The patient will be asked to eat or drink nothing for 8 hours before having blood drawn

Blood is taken much the same way as a finger stick test

If the blood glucose level is greater than or equal to 126 mg/dL without eating anything, they probably have diabetes.

If fasting plasma glucose level is greater than 100 but less than 126 mg/dL, then the patient has what is called impaired fasting glucose. This is considered to be pre-diabetes

Clinical Aspects (Test and Evaluation)

Oral glucose tolerance test

This test involves drawing blood for a fasting plasma glucose test, then drawing blood for a second test at two hours after drinking a very sweet drink containing 75 grams of sugar

If the blood sugar level after the sugar drink is greater than or equal to 200 mg/dL, the patient has diabetes.

If the blood glucose level is between 140 and 199, then the patient has impaired glucose

tolerance and is pre-diabetic

Clinical Aspects (Test and Evaluation)

Glycosylated hemoglobin or hemoglobin A1c

This is a long term test and is measured for as leased 120 days (the average life-span of the red blood cells on which the test is based)

Excess blood glucose hooks on to the hemoglobin in red blood cells and stays there for the life of the red blood cell

The percentage of hemoglobin that has had excess blood sugar attached to it can be measured in the blood

A hemoglobin A1c test is the best measurement of blood sugar control in people known to have diabetes

The hemoglobin A1c test is generally measured about every three to six months for people with known diabetes

Complications

Over time diabetes can cause problems with other body functions, such as your kidneys, nerves, feet, and eyes. Having diabetes can also put you at a higher risk for heart disease and bone and joint disorders.

Other long-term complications of diabetes include skin problems, digestive problems, sexual dysfunction, and problems with your teeth and gums.

Treatment

The major goal in treating diabetes is to minimize any elevation of blood glucose without causing abnormally low levels of blood sugar

Type 1 diabetes is treated with insulin, exercise, and a diabetic diet

Type 2 diabetes is treated first with weight reduction, a diabetic diet, and exercise

When these measures fail to control the elevated blood sugars, oral medications are used

If oral medications are still insufficient, treatment with insulin is considered

Treatment (Medical)

Insulin There are several types of insulin. These types are classified

according to how quickly the insulin begins to work and how long it remains active

Rapid-acting(Humulin): Offer quicker action time than regular insulin

Short-acting: Used before eating to control the large rise of blood glucose that often occurs after a meal

Intermediate-acting: These insulins start being absorbed 3-4 hours after injection, the best use is injection at bedtime to control the morning glucose of the next day

Long-acting: are typically given to control the blood sugar when you are not eating

Treatment (Exercise)

During exercise, contracting muscles produces there own insulin-like effect, causing the rapid uptake of glucose

Diabetics must adjust their pre-exercise insulin dosage and CHO intake before, during, and after exercise to avoid hypoglycemia

Regular exercise is beneficial for diabetics given its ability to reverse many adverse metabolic effects, including the likelihood of becoming obese

Treatment (Diet)

For diabetics it is essential that they properly manipulate blood glucose levels and manage their weight.

If blood glucose isn't kept in check, it can lead to serious problems, such as hyperglycemia and chronic complications, such as nerve, kidney and heart damage

Treatment (Diet)

Recommended foods Healthy carbohydrates

fruits, vegetables, whole grains, legumes and low-fat dairy products

Fiber-rich foods

vegetables, fruits, nuts, legumes ,whole-wheat flour and wheat bran

Heart-healthy fish

Fish such as salmon, mackerel and herring are rich in omega-3 fatty acids, which promote heart health by lowering triglycerides

'Good' fats

Avocados, almonds, pecans, walnuts, olives, and canola, olive and peanut oils

Treatment (Diet)

Foods to avoid

Saturated fats

Found in hot dogs, sausage and bacon and should consist of more than 7 percent of your RDI

Trans fats

These types of fats are found in processed snacks, baked goods, shortening and stick margarines and should be avoided completely

Cholesterol

Found in egg yolks, shellfish, liver and other organ meats and should consist of no more than 200 mg of daily intake

Sodium

Aim for less than 2,000 mg of sodium a day

Treatment (Diet)

The most effective methods at controlling glucose levels are as follows

Counting carbohydrates

It's important to make sure timing and amount of CHO is the same each day if you take diabetes medications or insulin. Otherwise, your blood glucose level may fluctuate

The exchange system

The exchange system, which groups foods into categories such as carbohydrates, meats and meat substitutes, and fats. An exchange has about the same amount of CHO, PRO, FAT and calories and the same effect on your blood glucose

Glycemic index

Foods with a high glycemic index are associated with greater increases in blood sugar than are foods with a low glycemic index

Ethics

Food marketing to adults

Food marketing to children Total amount spent on food marketing to children is about $10

billion a year

About 80% of foods advertised on television shows intended for children are for convenience/fast foods and sweets

Emotive drug market $4 billion a year spent on drug marketing and virtually none on

health or wellness

This advertising does not promote public health

Prescription drug advertising is not educational. It is inherently misleading because it features emotive imagery and omits crucial information about the drugs

Effects of Exercise

Exercise is an acceptable why to manage diabetes

Both type I and II have specific yet similar requirements regarding exercise

Both have distinct hereditary and environmental components

Cultural and geographical factors have roles in the cause of each

Effects of Exercise

Type I

It is not well documented that exercise improves glycemic control in type I diabetes

Regular exercise does result in improvements in insulin sensitivity and glucose metabolism

Improves blood lipids and lipoproteins

Increased caloric expenditure

Increased caloric expenditure resulting in reduction and maintenance of body weight

Effects of Exercise

Type II

Reduced blood glucose and glycosylated hemoglobin levels

Improved glucose tolerance

Improved insulin response to oral glucose stimulus

Improved peripheral and hepatic insulin sensitivity

Improved blood lipid and lipoprotein levels

Decreased blood pressure

Increased caloric expenditure resulting in reduction and maintenance of body weight

Exercise testing

Testing protocols should include the following

Blood glucose levels before during and after tests

Sub-maximal O2 uptake testing such as YMCA cycle ergometer, 1.5 mile walk, or arm-ergometer

Dynamic strength test

Sit and reach and shoulder flexibility

Blood pressure and heart rate

Body compositions

Exercise Prescription

Exercise for relatively healthy type I diabetes

Aerobic: Walking, jogging, cycling, stairs, climbing,

Strength: Moderate-level resistance training such as circuit training using lights with 10-15 repetitions

Intensity: 60-90% maximum heart rate or 50-85% VO2 max

Duration: 20-60 min plus 5-10 min warm up and cool down

Frequency: Daily to ensure optimal blood glucose control

Timing: Timing is very important for those with IDDM. Both blood glucose levels and insulin therapy must be considered at the time of exercise

Avoid exercise at a time of peak insulin action

Exercise Prescription

Activity characteristics of insulin

Once an exercise routine is established, insulin does and caloric intake can be adjusted

Onset (HR) Peak (HR) Duration(HR)

Rapid acting 0.5-1 2-4 6-8

Intermediate 1-3 6-12 18-26

Long acting 4-8 12-18 24-28

Exercise Prescription

Exercise for relatively healthy type II diabetes

Aerobic: Walking, jogging, cycling, stairs, climbing,

Strength: Moderate-level resistance training such as circuit training using lights with 10-15 repetitions

Intensity: 60-90% maximum heart rate or 50-85% VO2 max

Duration: 20-60 min plus 5-10 min warm up and cool down

Frequency: 3-5 times weekly, daily if taking insulin therapy

Exercise Prescription

Mode of progression (Type II)

Rate of increasing activity for type II is dependent an several factors

Age, functional capacity, medical and clinical status and personal preferences and goals

Initial changes in progression should focus on the frequency and duration of activity

Duration should be gradually increased to accommodate the functional capacity and clinical status of the patient

Given that older are and obesity are common elements of type II, a longer period of time may be necessary for patients to adapt to recommended physical activity

Exercise Prescription (complications)

The screening process should reveal complications that would influence recommendations for exercise

Special precautions are recommended for patients with complications resulting from diabetes

Exercise is often neglected due to complications

This can effect the ability to tolerate exercise by the patient

Neglect can and will lead to increased disability

Exercise Prescription (complications)

Retinopathy (damage to the retina)

It is an ocular manifestation of diabetes which affects up to 80% of all patients who have had diabetes for 10 years or more.

Diabetic retinopathy is the leading cause of blindness in American adults

In some people with diabetic retinopathy, blood vessels may swell and leak fluid. In other people, abnormal new blood vessels grow on the surface of the retina

Diabetic retinopathy usually

affects both eyes

Exercise Prescription (complications)

Neuropathy (damage to the nerve)

Neuropathy can prevent one from feeling pain in various parts of the body, such as the chest and the feet

People typically describe the pain of peripheral neuropathy as tingling or burning

While they may compare the loss of sensation to the feeling of wearing a thin stocking or glove

It can result from such problems as traumatic injuries, infections, metabolic problems and exposure to toxins. One of the most common causes is diabetes

Exercise Prescription (complications)

Other complications to watch for are

Illness or infection

Foot injuries which can lead to foot ulcers and possible amputations

High blood pressure which can contribute to problems with the eyes and kidneys

Summary

Diabetes mellitus is the improper balance between the hormones insulin and glucagon

There are two main types of diabetes, type I and II

There is also Pre-diabetes and gestational diabetes

Diabetes is an autoimmune disease that causes the immune system to attack its own insulin

13 million men and 12.6 million women in the U.S. have it

95% of all diabetics are Type II

Summary

A number of laboratory tests are available to confirm the diagnosis of diabetes

Diabetes can and will cause any number of contributing complication to ones health

Frequent exercise and a nutritious diet are essential in the warding off of or reversal of diabetes

Depending on the type of diabetes drugs either must be used or may be used depending on the severity of the disease

References

Lippincott, Williams, Wilkins, Initials. (2001). ACSM's resource manual for guidelines for exercise testing and prescription . Baltimore : Respect copyright.Pérez-Martin, E. Raynaud and J. Mercier, Initials. (2001). Insulin resistance and associated metabolic abnormalities in muscle: effects of exercise. International Association For The Study Of Obesity, 2(1), pp. 47-59. Mayo clinic staff, Initials. (n.d.). Type 2 diabetes. Retrieved from http://www.mayoclinic.com/health/type-2-diabetes/DS00585 Merrill, Ph.D., Initials. (2000, February). Creating exercise programs for diabetics. Fitness management, 42-44Department of disability and human development, Initials. (2004, August ). Diabetes and exercise. The national center on physical activity and disabilityAlbright, PH.D., R.D. (Chairperson); Franz, M.S., R.D., C.D.E; Hornsby, Ph.D., C.D.E; Kriska, PH.D., FACSM; Marrero, Ph.D., C.D.E; Ullrich, M.D.; Verity, Ph.D., FACSM, Initials. (2000, July). Exercise and type 2 diabetes. American college of sports medicine, pp. 1345-1351. Farrell, Ph.D., Initials. (2003). Diabetes, exercise and competitive sports. Sports science exchange, 16(3), 1-6.