Diabetes: Disease, Diagnosis and Drugs

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Diabetes Disease, Diagnosis and Drugs

• Dr. Paul Sack
• Division of Diabetes and Endocrinology
• Union Memorial Hospital

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Type 1 Diabetes
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Type 2 Diabetes
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What is Diabetes?
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How Insulin Works
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Question Number 1

• What is the difference between Type 1 and Type 2
  Diabetes?
• Type 1 Diabetics are on insulin and Type 2
  Diabetics are on pills
• Type 1 Diabetes only happens in children and Type
  2 Diabetes only happens in those over the age of
  40
• Type 1 Diabetes is an absolute deficiency of
  insulin while Type 2 Diabetes is a relative
  deficiency of insulin

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Diabetes Statistics

• Over 23 Million Diabetics in the United States
• 7 of the population
• 6 million do not know they have diabetes
• 95 Type 2
• 5 Type 1
• 40 Million have pre-diabetes
• One in every three born in 2000 will develop
  diabetes
• Fifth deadliest disease in the USA

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Type 1 Versus Type 2 Diabetes

• Type 1 Diabetes
• Abolutely no insulin production
• Need multiple doses of insulin to survive
• Usually occurs in younger, thinner people
• Type 2 Diabetes
• Begins with resistance to insulin
• Sugar goes up when there is a relative insulin
  deficiency
• Usually occurs in older, heavier people
• Treated with a combination of diet, exercise,
  pills, or insulin

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Risk Factors for Type 2 Diabetes

• Family History
• Lack of Exercise
• Obesity
• Polycystic Ovarian Syndrome
• Certain Ethnicities
• History of Gestational Diabetes
• History of Pre-Diabetes
• The Metabolic Syndrome

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Symptoms of Diabetes

• NONE
• The Three Ps
• Polyuria
• Polydypsia
• Polyphagia
• Fatigue
• Blurred Vision
• Weight Loss

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How Is Diabetes Diagnosed?

• Random sugar over 200
• Fasting sugar over 126
• Sugar after a glucose challenge of more than 200

Fasting
Glucose Challenge
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Who Should Be Tested?

• Everyone over age 45
• Retest every 3 years
• Younger than 45 if there are risk factors
• Anyone with symptoms

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How Can Diabetes Be Prevented or Delayed?

• WEIGHT LOSS
• 6 Weight Loss 50 Reduction in Diabetes
• EXERCISE
• 150 minutes per week 50 Reduction in Diabetes
• DIETARY CHANGES

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Brief Side Note on Obesity

• National Epidemic
• Mirrors the epidemic of diabetes
• Variety of Factors
• Less active jobs
• Less active social life
• More driving
• Bigger portions
• Fast Food
• Soda

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Question 2

• Which has more grams of carbohydrates? A Burger
  King Bacon Double Cheeseburger or a Subway 6 inch
  Veggie Delite sub?
• Bacon Double Cheeseburger
• Veggie Delite Sub
• They are the same
• What's a carbohydrate?

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Obesity Trends Among U.S. Adults1985
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Obesity Trends Among U.S. Adults1986
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Obesity Trends Among U.S. Adults1986
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Obesity Trends Among U.S. Adults1988
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Obesity Trends Among U.S. Adults1989
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Obesity Trends Among U.S. Adults1990
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Obesity Trends Among U.S. Adults1991
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Obesity Trends Among U.S. Adults1992
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Obesity Trends Among U.S. Adults1993
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Obesity Trends Among U.S. Adults1994
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Obesity Trends Among U.S. Adults1995
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Obesity Trends Among U.S. Adults1996
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Obesity Trends Among U.S. Adults1997
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Obesity Trends Among U.S. Adults1998
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Obesity Trends Among U.S. Adults1999
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Obesity Trends Among U.S. Adults2000
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Obesity Trends Among U.S. Adults2001
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Obesity Trends Among U.S. Adults2002
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Obesity Trends Among U.S. Adults2003
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Obesity Trends Among U.S. Adults2004
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Obesity Trends Among U.S. Adults2005
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Obesity Trends Among U.S. Adults2006
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Obesity Trends Among U.S. Adults2007
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Treatment of Type 2 Diabetes

• Education
• Decrease insulin requirements
• Improved Diet
• Weight Loss
• Exercise
• Medications
• Increase Insulin to the Body
• Medications

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Diabetic Education

• Understand the disease
• Understand your medications
• Learn how to check your sugar
• Learn how to inject medication
• What to do when you are sick
• How to adjust insulin for what you are eating or
  doing
• Relearn how to eat

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Diabetic Diet

• Carbohydrates
• Includes all starches and simple sugar
• More complex carbohydrates may not raise sugar as
  much
• 45-65 of diet
• Protein
• About 15-20 of diet
• Less with kidney disease
• Fat
• 25-35 of diet
• Saturated Fats less than 7
• GOALS
• Decrease overall caloric intake
• Avoid simple sugars, desserts, junk food
• Some medications require regular meals, some do
  not

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Exercise

• May need medical clearance to start moderate to
  vigorous exercise
• 30 minutes of moderate exercise 5 times a week
• Bike
• Swimming
• Walking
• Stair Step

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Oral Medications for Type 2 Diabetes

• Metformin (Glucophage)
• Decreases liver production of sugar
• Improves insulin sensitivity
• Results in weight loss
• Thiazolidinediones (Avandia or Actos)
• Improves insulin sensitivity
• Sulfonylureas (Glucotrol, Amaryl, etc.)
• Increases insulin secretion from the pancreas
• all the time
• DPP-4 Inhibitors (Januvia)
• Improves insulin secretion when there is food
  around
• Decreases liver production of sugar

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Oral Medications for Type 2 Diabetes

• Meglitinides (Starlix, Prandin)
• Increases insulin secretion from the pancreas
• Alphaglucosidase Inhibitors (Precose)
• Delays absorption of glucose in the gut

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Injection Medications for Type 2 Diabetes

• GLP-1 Analogues (Byetta)
• Decreases liver production of sugar
• Increases insulin secretion only when food is
  around
• Decreases appetite
• Results in weight loss
• Insulin
• Long Acting Lantus, Levemir
• Medium Acting NPH
• Short Acting Regular
• Very Short Acting Humalog, Novolog, Apidra
• Amylin Analogue (Symlin)
• Hormone normally produced with insulin

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Good Diabetic Control

• Morning Sugars 90-130
• Sugars lower than 180 after meals
• Hemoglobin A1c
• 3 month glucose control
• Normal 5
• Good Control Less than 6.5

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Question 3

• Which hurts more (on average)?
• Checking your sugar with a lancet and glucometer
• Taking an injection of insulin

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Potential Complications of Uncontrolled Diabetes

• Heart Disease
• Stroke
• Blindness
• Kidney Disease
• Nervous System Damage
• Amputations
• Dental Disease
• Pregnancy Complications
• Sexual Dysfunction

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Routine Care for the Diabetic

• High Blood Pressure Control
• Less than 130/80
• Cholesterol Control
• Bad Cholesterol (LDL) less than 100
• Good Cholesterol (HDL) more than 40 or 45
• Triglycerides less than 150
• Annual Eye Exams
• Monitoring Kidney Function
• Urine microalbumin/creatinine ratio less than 30
• Monitoring for Neuropathy
• Foot care
• Aspirin
• Monitoring for Macrovascular Disease

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Macrovascular Disease and Diabetes

• What is Macrovascular Disease?
• Narrowing of the large arteries
• Blockage of large arteries can lead to
• Heart attacks
• Strokes
• Peripheral vascular disease
• Risks for Macrovascular Disease
• Uncontrolled sugars
• Uncontrolled blood pressure
• Uncontrolled cholesterol
• Family History
• Age
• Smoker

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Heart Disease and Diabetes

• A diabetic has the same risk to have a heart
  attach as compared to someone who has already had
  one heart attack
• Recommend EKG in all patients
• Recommend Stress Tests in select patients
• Strict control of all risk factors

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Peripheral Vascular Disease and Diabetes

• Current Recommendations
• Screen for a history of claudication
• Assess pulses in feet
• Evaluate with ankle brachial index
• Who should be evaluated?
• Often peripheral arterial disease is asymptomatic
• If no symptoms, does it matter?

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Questions?