Over 90% of people with diabetes have type2. Over 90% of people with diabetes have type2 attributed to diabetes. 300,000 deaths/year attributed to diabetes …
Diabetes and Obesity Do we have an epidemic?
Laureen M Fleck, DNS, ARNP, CDE, NCSN
Diabetes: Type 1
Primarily due to pancreatic beta cell destruction Patients are prone to ketoacidosis Inability to transport glucose into cells Inadequacy may result in growth deficiency and/or failure to thrive Insulin only treatment
Insulin
Insulin is a hormone produced in the beta cells of the islets of Langerhans in the pancreas Insulin stimulates the the entry of amino acids into cells, enhancing protein synthesis Insulin enhances fat storage, and stimulates the entry of glucose into cells ,creates energy and results in storage of glucose as glycogen in muscle and liver cells
Insulin Requirements
The starting dose of insulin is usually between O5 10 U/kg/day Adjustments are made slowly and incrementally, based on blood sugar monitoring Daily habits are considered activity level and therefore no typical dose can be determined Divided doses; based on type of insulin and frequency of dosing that is desired
Types of insulin
Rapid acting: humalog, novalog, apridra Short acting: regular Intermediate acting: NPH Long acting: ultralente Long acting: lantus, levemir
Pre-mixed: 70/30 75/25 Inhaled: Exubera no more
Short Acting Insulin
Soluble Clear Onset 30 minutes Peak 1 - 3 hours Duration up to 8 hours
Intermediate Acting Insulin
Crystals in suspension need re-suspending Cloudy NPH onset 1 1/2 hours Peak 4 - 12 hours Duration up to 24 hours
Basal Bolus
6
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Breakfast
Lunch
Evening Meal
Sleep
Two Injections of 70/30 Mix Per Day
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Breakfast
Lunch
Evening Meal
Sleep
Insulin Pumps/ CSII
Type of pump Insulin Carbohydrate Ratio Troubleshooting Stop infusion
Storage of Insulin
Before use store in fridge In-use vials store in fridge 3 months, out of fridge 4-6 weeks In-use pens out of fridge 4 weeks
Diabetes: Type 2
Most persons are over 40 and obese Over 90 of people with diabetes have type2 The body doesnt use the insulin it makes insulin resistance or the body doesnt make enough insulin to cover the carbohydrate load consumed Meal planning, activity, and/or medication is used to manage disease
Blood glucose monitoring
Vital in evaluation of
insulin/food ratio Monitors are inexpensive Fasting and 2 hours after the main meal, exercise and any symptomatic conditions A1c quarterly: most accurate indicator
Nutrition
Balance of CHO 55, PRO 10, and Fat 30 There is no diabetic diet Carbohydrate counting and effects on blood sugar are significant Sugar can be counted Snacks are incorporated into meal plan
Oral Hypoglycemic Agents
Sulphonylureas Amaryl, Glucatrol Prandial Glucose Regulators Starlix, Prandin Biguanides Glucophage Alpha glucosidase inhibitors Precose Thiazolidinediones Glitazones
Actos, Avandia
Combinations of above
Biguanides Metformin
Improves insulin sensitivity Decreases insulin resistance Allows weight loss GI upset typical at onset of therapy
Metformin Indications
Obese type 2 patients inadequately controlled by non-pharmacological therapy meal planning
Obese insulin resistant persons with PCOS
Alone or in conjunction with other OHAs or insulin
Metformin Contraindications
Any impairment of renal function Impaired hepatic function Alcoholism acute or chronic Conditions leading to tissue hypoxia CHD, cardiac failure, PVD, COPD Pregnancy/breast feeding Major
surgery/trauma Severe infection Intravenous contrast media
Glitazones TZDs
Exact mechanism unknown act within insulin responsive cells to increase the activity of glucose transport mechanisms Insulin sensitizer muscle and adipose tissue Inhibit hepatic gluconeogenesis Do not stimulate insulin secretion
Treatment of Type 2 Diabetes
Diet Exercise
OHAs
Insulin
Prevention
Can we impact the progression of the development of type 2 diabetes?
Primary Prevention
Education Health insurance:
Coverage for labs, test strips, monitoring and counseling Access to healthcare Follow up and evaluation of interventions
Obesity is a Risk Factor
High blood pressure High cholesterol Type 2 diabetes Coronary heart disease Pregnancy Stroke Asthma, etc
Obesity in Florida
In 2000, 54 of adults are overweight or obese : BMI or equal to 25 kg/m2 of those, 19 are obese in excess of 30 kg/m2 Prevalence of obesity has increased 91 since 1986 25 of men and 30 of women are inactive
Florida DOH census report 2000
National Obesity
59 million in the United States are considered to be obese
1/3 of adults 1/6 of children 300,000 deaths/year attributed to diabetes 1978 25 Americans
overweight 1990 33 Americans overweight 2004 61 Americans overweight/obese
Hypertension Dyslipidemia
Clinical Conditions Associated With Obesity
Osteoarthritis
Type 2 diabetes Coronary artery disease Congestive heart failure Stroke Gallbladder disease
Sleep apnea and respiratory problems Cancers of the breast, colon, prostate, and endometrium Polycystic ovarian syndrome
The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults NIH/NHLBI/NAASO; October 2000 NIH publication No 00-4084 Kenchaiah S, et al N Engl J Med 2002;347:305-313 Gambineri A, et al Int J Obese Relat Metab Disord 2002; 26:883-896
Insulin Resistance Signs
Acanthosis nigricans 7012 High blood pressure 4011 Dyslipidemia 2724 Polycystic ovarian syndrome PCOS 2564 Hyperinsulinemia 2511
Metabolic Syndrome
IFG 100mg/dl TRI 150mg/dl HTN130mm Hg/or 85mm Hg Abdominal obesity 40 men / 35women HDL cholesterol 40 mg/dl
National diabetes education initiative 1/04
Metabolic Syndrome: Clinical Identification
Abdominal Obesity Men Women Blood Pressure Fasting Glucose Triglycerides HDL Men Women
Diagnostic Values
Waist Circumference 40 in 102 cm 35
in 88 cm 130/85 mm Hg 110 mg/dL 150 mg/dL 40 mg/dL 50 mg/dL
Third Report of the National Cholesterol Education Program Expert Panel Executive Summary; May 2001 NIH publication No 01-3670
Visceral Adiposity: The Critical Adipose Depot
Subcutaneous Fat Abdominal Muscle Layer Intraabdominal Fat
Assessing Overweight and Obesity by BMI
Weight Category nderwei 
ght ormal verweight besity Class I II III severe obesity
BMI kg/m2 185 185249 250299 30 300349 350399 40
The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults NIH/NHLBI/NAASO October 2000 NIH publication No 00-4084
Metabolic Syndrome: NCEP/ATP III Definition
Presence of at least 3 of 5 risk factors: Abdominal obesity Elevated blood pressure Elevated fasting glucose Elevated triglycerides Low HDL-C
Third Report of the National Cholesterol Education Program Expert Panel Executive Summary; May 2001 NIH publication No 01-3670
Therapeutic Lifestyle Change: Healthy Meal Planning,and Physical Activity
Diet rich in fruits/vegetables is the mainstay of effective weight and health management Meal replacement facilitates weight loss and weight maintenance 2 shakes or meal bars
2 frozen entrees Physical activity is necessary to expend calories
A moderate amount of physical activity is roughly equivalent to physical activity that uses approximately 150 calories of energy per day, or 1,000 calories per week
News we can use
The endocannabinoid system: What is it?
EC CB1 receptors Cannaboid receptors are found in the CNS, adipose tissue, liver, etc, Stimulation of this system leads to increased food intake and obesity Inhibition of cannaboid receptors leads to decrease food intake
Baylor College of Medicine report on Cardiometabolic Disorders 2006
News we can use
Fish and Omega-3 Fatty Acids
Patients without documented Coronary Heart Disease CHDeat fish a least twice a week Patients with documented CHDconsume about 1 g of EPA DHA per day in capsule form Patients with high triglycerides2-4 g of EPA DHA per day in capsule form Taking high doses could cause excessive bleeding in some people
American Heart Association 2006
News we can use
Antihypertensives cut new-onset diabetes by a third
New ASCOT review: new diabetes onset was not an original outcome to be measured Antihypertensive treatment with an ACE inhibitor or calcium
channel blocker limits new-onset diabetes 34 less likely, while treatment with a beta blocker or thiazide diuretic helps to cause it 2005 and increase the peripheral vascular resistance
Family Practice News, October 2006
News we can use
New DTP4 inhibitors
Januvia Galvas
Merck Novartis
Will be in line with Byetta effectiveness and action Approved and released Update 2/5/08
Cultural Impact
Asian Americans African Americans Latino Americans
Diabetes prevalence is 2-6 times higher among Latino Americans, African Americans, Native Americans, and Asian Americans than among white Americans Diabetes complications rates are higher among patient from ethnic minorities, and the mortality rates are 2-5 times higher than rates among white patients
Journal of Family Practice , September 2007
Cultural Obstacles
Barriers include patients and providers cultural beliefs and misalignment between the American health care system and ethnic healthcare assumptions American approach to treating medical conditions combined with the lack of health insurance for many individuals, contributes to the disparities
A1c level by ethnicity
External influences
Out of pocket expenses
and high treatment costs;
Glucose monitors and supplies Perceived cost of diabetic diet Cost of medications Cost of time influence to treatment plan
Barriers to diabetes care
Asian Americans
First generation Asian Americans tend to have a lower body weight and BMI measurement, they have a greater prevalence of Type 2 DM than the general population
Greater awareness to screen this population Higher rate of complication such as renal disease Keep in mind the second and third generation Asian descendants and the Western influence and adaptation to the American culture The Asian concept and belief in balance is influential in all aspects of daily life
African Americans
Evidence suggests that insulin resistance is higher among African American and Hispanic American populations as compared with white Americans However, once insulin resistance progresses to impaired glucose tolerance, genetics no longer seems to be a factor in the risk of developing Type 2 DM Study of 1199 2006 people aged 55 and older with diabetes participated in the Health and Retirement Study , University of MichiganWhite population 72 A1c, African Americans 807 A1c and Latinos 814
Compared with
under 65 population: W: 746, AA: 896, L: 891 others were Medicare eligible
Latino Americans
14 of Latino Americans are affected by Type 2 DM, compared to 12 of African Americans and 7 of non-Hispanic whites A1c markers indicate Latino Americans have poorer disease control; higher rates of DM complications and greater mortality Mexican Americans are less likely to achieve glycemic control than are non-Hispanic whites PVD is 80 more common among Mexican Americans and Puerto Ricans as among non-Hispanic whites Diabetes Care, 2003
Youth
Barriers to Healthcare
Lack of reliable transportation Unpaid time off from work Need for child care Cost of medication and nutritious foods Difficulty finding affordable and safe places to exercise Attitudes of fatalismdestiny
Summary
Modest weight loss of 5-10 improves overall patient health and metabolic syndrome risk factors Treating obesity, which is a serious chronic disease, can improve metabolic syndrome risk factors and may decrease the risk of CVD and type 2 diabetes Nurses must accept their role as agents of change to help motivate their obese patients to effectively lose weight and maintain weight
loss
References
Agency for Healthcare Administration, State of Florida Diabetes, medical practice guidelines 2001 American Diabetes Association 2008 Clinical practice recommendations 2007 Diabetes Care, 30s1, s5 Diabetes Wellness News 2004Are we raising an obese society? 103 Florida Department of Health 2006 Floridas obesity epidemic Retrieved February 20, 07, from dohmyfloridagov Peterson, K, Silverstein, J, Kaufman, F, Management of Type 2 diabetes in youth: an update American Family Physician,91 658-667 Primary Care Education Consortium 2007 Building cultural competency for improved diabetes care Journal of Family Practice S1, s1-31
Source:motivationalinterview.org
