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Diabetes Review

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Title: Diabetes Review


1
Diabetes Review
  • Judy Bornais RN, BScN, MSc, CDE

2
Prevalence
  • More than 2 million Canadians have diabetes1
  • By 2010 that number is expected to rise to 3
    million 1
  • 31 rise in prevalence in Ontario since 1995 2
  • Estimated that 1 in 5 individual over 45 years of
    age have diabetes and 1 in 3 over the age of 75 3
  • Studies suggest that up to 30 of people with
    diabetes are undiagnosed6

3
Did You Know?
  • About half of all people diagnosed with diabetes
    have already had the disease for as long as 7
    years1
  • 20 - 30 of those individuals diagnosed already
    have developed complications 3

4
  • Cardiovascular disease is 2-4 times more
    prevalent in patients with diabetes than in those
    without1
  • Cardiovascular disease accounts for at least 60
    of the deaths in patients with diabetes2

5
  • When a patient develops vascular complications
    like MI or stroke, the outcome is worse in the
    individual with diabetes3

6
The Burden of Cardiovascular Disease in Diabetes
Mortality rate in patients with diabetes more
than doubled versus those without diabetes
Balkau B, et al. Lancet 1997
7
Does the outcome depend on the Type of Diabetes?
  • Two large studies, UKDPS and DCCT, indicate that
    both Type 1 and Type 2 can result in macro and
    microvascular complications such as
  • Coronary heart disease
  • Stroke
  • Peripheral vascular disease
  • Nephropathy
  • retinopathy
  • Neuropathy

8
Clinical Impact of Diabetes
The leading cause of new cases of end stage renal
disease (ESRD)
A leading cause of cardiovascular events in adults
The leading cause of new cases of blindness in
working age adults
The leading cause of non-traumatic lower
extremity amputations
9
Life Expectancy
  • Diabetes reduces survival by almost 12 years4

10
Diabetes is a Major Health Care Issue
11
How does this impact you?
  • Patients with diabetes, had higher rates of
    hospitalization than the general population with
    an excess risk of about 30
  • In Essex County, in 1999 there were
  • 18, 982 cases of people who visited a health
    care provider for their diabetes7

12
There is hope!
  • Complications of diabetes can be delayed and in
    some cases avoided with tight
  • glycemic control
  • lifestyle modification
  • vascular protection
  • Health care professionals roleand the battle
    begins

13
Not so long ago in a galaxy remarkably like ours
, the evil Diabetes Empire ruled over a
terror-stricken population. Striking without
warning Diabetes would leave suffering ,
mutilation and death in its wake. Diabetes had
thus ruled unopposed for generations.
14
A mere 80 years ago Rebel Fighters , Banting and
Best devised a weapon to battle the Empire. The
weapon was called Insulin. While powerful ,
insulin was difficult to deliver and tricky to
use . Diabetes learned to exploit these
weaknesses over the years. The war raged on.
15
To win the battle we mustUnderstand Diabetes
Management
  • Diabetes management involves balancing food,
    medication, and activity to achieve blood glucose
    levels that are near the normal range
  • Hormones, stress, illness, food - raises blood
    sugars
  • Insulin, medications (type 2), exercise lowers
    blood sugars

16
Types of Diabetes?
  • You have a patient who takes Novolin 20/80 twice
    a day. What type of diabetes does your patient
    have?
  • Individual can have either type 1 or type 2.
    Taking insulin does not classify the individual
    as having type 1diabetes.

17
What happens in Diabetes
  • Type 1 Diabetes
  • The pancreas no longer produces insulin. The
    person is totally dependant on exogenous insulin
  • Type 2 Diabetes
  • The pancreas is not making enough insulin and/or
  • the body is resistant (no longer sensitive to
    insulin)

18
Treatment for Diabetes
  • Type 1 Diabetes
  • Insulin
  • Type 2 Diabetes
  • diet and exercise
  • oral hypoglycemics
  • oral hypoglycemics and insulin
  • insulin

19
The Phantom Menace Diabetes New Ally -
Hypoglycemia
  • Hypoglycemia a new threat in Glucose Wars.
  • No easy way to predict or treat (no glucose tabs
    or glucagon).
  • Low blood sugar perceived as greater threat than
    hyperglycemia by caregivers.

20
Targets Blood Sugar Ranges4
Fasting / preprandial glucose (mmol/L) 2-hour postprandial glucose (mmol/L)
Targets for most patients with diabetes
Normal range
21
Targets Blood Sugar Ranges4
Fasting / preprandial glucose (mmol/L) 2-hour postprandial glucose (mmol/L)
Target for most patients 4.0 7.0 5.0 10.0
Normal range 4.0 - 6.0 5.0 8.0
22
Hypoglycemia
  • Blood sugars less than 4.0 mmol/L
  • What are the Signs Symptoms of a low blood
    sugar?

23
Signs and Symptoms of Hypoglycemia
  • sweating
  • shaking
  • weakness
  • hunger
  • nausea
  • irritability
  • confusion

24
Symptoms of Hypoglycemia5
  • Neurogenic (autonomic)
  • Sweating (47 84)
  • Trembling (32-78)
  • Palpitations (8-62)
  • Hunger (39-49)
  • Anxiety (10-44)
  • Nausea (5-20)
  • Tingling (10-39)
  • Neuroglycopenic
  • Difficulty concentration (31-75)
  • Weakness (28-71)
  • Vision change (24-60)
  • Confusion (13-53)
  • Tiredness (38-46)
  • Difficulty speaking (7-41)
  • Dizziness (11-41)
  • Headache (24-36)

25
SEVERITY OF HYPOGLYCEMIA4
  • MILD
  • Autonomic symptoms are present
  • Individual is able to self-treat
  • MODERATE
  • Autonomic and neuroglycopenic symptoms are
    present
  • Individual is able to self-treat
  • SEVERE
  • Individual requires assistance of another person
  • Unconsciousness may occur
  • Plasma glucose is typically lt 2.8 mmol/L

26
How do you treat a low blood sugar?
  • A) Chocolate bar?
  • B) A hard candy?
  • C) Juice?
  • D) Glucose tabs?

27
How do you treat a low blood sugar?
  • A)
  • B) A hard candy (2-3)
  • C) Juice (3/4 cup)
  • D) Glucose tabs (3 glucose tabs)

28
Treatment for Hypoglycemia
29
When do Hypos occur?
  • Episodes of hypoglycemia most commonly occur
    before meals or when the insulin effect is
    peaking.
  • Patient is on Humalog/Novorapid at breakfast eats
    less than normal when would you expect the
    hypoglycemia?
  • Patient takes NPH at bedtime when are they most
    likely to have a low?

30
Medications can blunt response to hypoglycemia6
  • Salicylates (Aspirin in large doses gt4g/day)
  • Sulfonomide antibiotics (Probenecid Benemid,
    Benuryl, Probalan)
  • Tricyclic antidepressants (Amitriptyline
    Elavil Anafranil, Sinequan, Triadapin, Impril,
    Novopramine, Nortriptyline Aventyl Triptil)
  • Phenylbutazone (for rheumatoid arthritis,
    osteoarthritis or gouty arthritis)
  • Warfarin (Coumadin)
  • Fibrates

.
31
Medications can blunt response to hypoglycemia
  • Pentamidine (Nebupent, Pentacarinat)
  • Acetaminophen (Tylenol)
  • ACE Inhibitors (Captopril, Lisinopril, Enalapril,
    Ramipril)
  • Beta Blockers (Acebutolol, Carvedilol, Labetalol,
    Metoprolol)
  • Celexa (antidepressant)

.
32
Hyperglycemia
  • Elevated blood sugars outside of the
    normal/target ranges i.e. a blood sugar over 10.0
    mmol/L (2 hours post-prandial)
  • What are the Signs Symptoms of hyperglycemia?

33
Signs and Symptoms of Hyperglycemia
Extreme thirst
Fatigue
Frequent urination
Weight loss
Blurred vision
34
Treatment for Hyperglycemiathe forces strike back
  • Obtain near normal blood sugar levels through
  • Insulin,
  • Medications
  • Exercise

35
The Phantom Menace Fatalists the Other Ally
of Diabetes
  • A large faction of caregivers and individuals
    with diabetes believed that all complications
    were genetically programmed would occur no
    matter what the blood glucose levels were !
  • Treated to relieve symptoms only.
  • Waited for complications to show up. Fate and
    luck !

36
Review of Complications of Diabetes
  • Neuropathy
  • Retinopathy
  • Nephropathy
  • Macro vascular complications
  • Foot Problems (ulcers amputations)
  • Dental Skin Problems

37
A New Hope The DCCT
  • 1993 New England J. of Medicine
  • Glucose hypothesis proven to be true
  • Never too late to improve control
  • Any improvement in control is beneficial
  • A powerful way to employ insulin (medications) in
    the battle with Diabetes

38
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39
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40
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41
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42
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43
Summary DCCT
  • 69 reduction in Neuropathy
  • Trend toward reduction in risk of heart disease

44
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45
Improved Insulin and Delivery
  • 1985 modernization of insulin by genetic
    engineering to produce Human insulin
    Humulin Novolin
  • 1995 Introduction of insulin analogues Lispro
    Humalog Aspart - Novorapide
  • 2005 Introduction of new long acting insulin
  • Glarzine Lantus
  • 2006 Another long acting insulin
  • Levermir (expected to be available in Jan./06)

46
Challenge of Insulin
  • To mimic the pancreas
  • 2 patterns
  • a basal secretion of insulin
  • intermittent bolus of insulin in response to food

47
Goals of Insulin Therapy
  • To control blood glucose levels
  • Prevent the development and progression of
    long-term complications from hyperglycemia
  • Minimize effects of hypoglycemia
  • Mimic endogenous insulin

48
Insulins are divided into 5 main types
  • Rapid-acting
  • Short-acting
  • Intermediate-acting
  • Long-acting
  • Premixed

49
Rapid-Acting Insulin (new analogues)
  • Insulin Lispro (Humalog)
  • Insulin Aspart (Novorapid)

50
Insulin lispro (Humalog) Insulin aspart
(Novorapid)
  • May be taken before or after meals
  • appearance clear
  • onset 10 -15 min
  • peak 45 min - 3 hrs
  • duration 3 - 5 hrs
  • Take WITH meals

51
Short-acting or Regular (R) Insulin
  • Novolin ge Toronto (R) or Humulin R
  • appearance clear
  • onset 1/2 hr - 1 hr
  • peak 2 - 5 hrs
  • duration 6 - 8 hrs
  • Take 30 minutes before meals

52
Intermediate-acting or NPH/Lente
  • Novolin NPH or Humulin N
  • Novolin Lente or Humulin L
  • appearance cloudy
  • onset 1 - 3 hrs
  • peak 4 - 12 hrs
  • duration 18 - 24 hrs

53
Long-acting Two types
  • Ultra Lente
  • Novolin Ultra Lente or Humulin U
  • appearance cloudy
  • onset 4 - 6 hrs
  • peak 8 - 20 hrs
  • duration 24 gt

54
Long-acting Two types
  • Glargine (Lantus) NEW!
  • Levemir
  • appearance clear
  • onset 3-4 hrs
  • peak no peak
  • duration 24 hrs
  • acts like basal insulin
  • Can not be mixed with any other insulin

55
Example profiles interstitial glucose
fluctuations from the mean
Glucose
25
450
Patient 1 NPH insulin
20
360
15
270
(mg/dl)
(mmol/l)
10
180
5
90
0
0
Glucose
0600
0800
1000
1200
1400
1600
1800
2000
2200
0000
0200
0400
0600
25
450
Patient 2 Insulin detemir
20
360
15
270
(mmol/l)
(mg/dl)
10
180
5
90
0
0800
1000
1200
1400
1600
1800
2000
2200
0000
0200
0400
0600
0600
CGMS profiles
Russell-Jones D et al. Clinical Therapeutics
200426724-36
Time
56
Hypoglycaemia Relative Risk (Insulin detemir
vs. NPH)
Insulin detemir
NPH insulin
10

1.2


18
39
16
50
Baseline
1
8
Relative risk
0.8
6
0.6
HbA1c
4
0.4
2
0.2
0
0
All
Major
Minor
All nocturnal
Between-group difference, plt 0.05
Kolendorf et al. Diabetes 200453(Suppl. 2)A130.
57
Action Times of Insulin
58
Premixed 10/90, 20/80, 30/70, 40/60, 50/50
  • 20/80
  • Intermediate or NPH insulin
  • Acts as the background insulin throughout the day
    or night
  • Example
  • 20/80
  • Short-acting or Regular insulin
  • Works on the meal you take it with

59
When is the ideal time to give a patient their
premixed 30/70 insulin?
  • a) 30 minutes before their meal
  • b) With their meal
  • c) After their meal

60
PremixedHumalog Mix 25Novomix 30
  • Example
  • 25/75
  • Fast acting insulin
  • Works on the meal you take it with
  • 25/75
  • Intermediate or NPH insulin
  • Acts as the background insulin throughout the day
    or night

61
When is the ideal time to give a patient their
premixed Humalog Mix 25 insulin?
  • a) 30 minutes before their meal
  • b) With their meal
  • c) After their meal

62
Giving Insulin
  • Vial and syringe
  • Which insulin do you draw up first if you are
    mixing insulins?
  • Clear then cloudy to avoid contaminating the
    clear insulin
  • Insulin Pens

63
Site Selection Where can I give my injections?
  • 4 major areas
  • upper outer area of arm
  • abdomen - avoid 1 inch area around navel
  • front and sides of thighs
  • upper outer surfaces of the buttocks

64
Site Selection Do you rub the site after
injection?
  • Note do not rub the site after injection,
  • just apply light pressure to stop the
  • bleeding if necessary

65
Case study
  • You have a 19 year old female who has Type 1
    diabetes who receives Novolin 30/70 before
    breakfast and supper. She is late awakening and
    doesnt eat her breakfast and is going to
    university to return home for lunch. What do you
    do?

66
Types of oral hypoglycemics
  • Biguanides Decrease glucose release in the liver
    and decrease insulin resistance in muscles
  • Metformin (Glucophage) take with meals
  • duration of action 8-12 hours
  • Key No risk for hypoglycemia when taken alone
    and at the recommended dose
  • Contraindicated in patients with renal or
    hepatic dysfunction or cardiac failure
  • Alcohol not recommended

67
Types of oral hypoglycemics
  • Insulin Secretagogues Sulfonylureas increase
    insulin secretion and potentiate insulin action
    on liver and peripheral tissues
  • Glyburide (Diabeta) lasts 18-24 hours
  • Gliclazide (Diamicron) last 12 -24 hours
    (Diamicron MR) last 24 hours
  • Glimepiride (Amaryl) lasts 24 hours
  • KEY cannot skip meals - risk of hypoglycemia

68
Types of oral hypoglycemics
  • Insulin Secretagogues Non sulfonylureas
  • (Meglitidines) increase insulin secretion
  • Repaglinide (GlucoNorm) lasts approx 3 hours
  • Nateglinide (Starlix) lasts approx.1.5-3 hours
  • KEY Less risk of hypoglycemia in the context of
    missed meals

69
Types of oral hypoglycemics
  • Alpha glucosidase inhibitors slow
  • absorption of carbohydrates
  • Acarbose (Prandase) lasts to cover the meal
  • Decrease CHO digestion / prolongs uptake of CHO
  • Key Treat hypoglycemia ONLY with dextrose
    tablets, milk or honey

70
Types of oral hypoglycemics
  • Thiazolidinediones decrease insulin resistance
  • Pioglitazone (Actose) lasts 16-24 hours
  • Rosiglitazone (Avandia) lasts 15-20 hours
  • Insulin sensitizers
  • Increase peripheral utilization of insulin (at
    the tissue level)
  • Modify lipoproteins (increase HDLs)
  • Contraindicated in renal, hepatic and CHF
    patients

71
Challenge of Diabetes
  • Imagine as an adult having to check your blood
    sugar on average 5-6 times a day more often
    during periods of illness or stress
  • Imagine having to carry your glucometer/insulin/me
    ds with you at all times
  • Imagine Having to give yourself insulin at a
    restaurant before eating

72
Issues of Cost
  • Blood Glucose strips average 1/strip
  • Lancets 10
  • Box Insulin Pen needles 25-35
  • Cost of insulin cartridge 40-69
  • _ vials 27-39
  • Total 300/month

73
The Empire Strikes Back
  • Insurers ODB , Green Shield , and others
    - Barriers to treatment LU for
    Humalog Section 8 for NovoRapide (Pen 3
    Jr.) Decreased coverage for insulin

    pumps/pump supplies Restricted coverage for
    Glucagon (96 per single injection kit)

74
Attack of the Clones
  • Improved delivery systems Pen
    injectors Ultrafine needles Jet
    injectors
  • Improved glucose surveillance systems Improved
    glucose meters Computer downloading of
    results Ultrafine lancets Dorsal arm testing

75
Diagnosis - grieving
  • May newly diagnosed patients and/or their
    families experience cycle through
  • Denial
  • Anger
  • Bargaining
  • acceptance

76
Sick Day Management
  • Minor illnesses cold, flu, gastroenteritis
    impair glucose control
  • Stress on the body
  • Cause an increase in blood sugar levels for 2
    reasons
  • - an increase in hormones that cause the liver
    to pump out glucose into the blood
  • - hormones also increase the resistance of
    cells to insulin

77
Sick Day Management
  • MONITORING
  • Patients should be testing their blood sugar
    before meals and/or every 4 hours around the
    clock, until no longer sick or as directed by
    their physician or Nurse practitioner
  • Urine should be tested for ketones (Type 1)
    presence means a serious situation.

78
Sick Day Management
  • MEDICATION
  • Patients should continue to take their insulin,
    even if they are vomiting
  • If the patient uses Humalog or Novorapid and they
    are nauseated, consider giving the injection
    AFTER they eat determine carbohydrates and
    insulin dose.
  • Patients may require additional doses of short or
    rapid acting insulin - notify the physician if
    your patient requires insulin and has been
    vomiting.

79
Sick Day Management Contd
  • LIQUIDS
  • If a patient is losing fluids due to diarrhea,
    fever, or vomiting , or they are drinking less
    than usual or urinating more than usual, they are
    at risk for dehydration.
  • They should drink 8 oz of liquid every hour
    (avoid caffeine)

80
Case Study 2
  • You have a patient with the stomach flu who has a
    temperature of 38.3 C and unable to eat.
  • A) What should you do?
  • B) Do you still give her insulin?

81
Diabetic Ketoacidosis (DKA)
  • Can be caused by
  • Too little insulin and increased food intake
  • Physical or emotional stress
  • Undiagnosed diabetes

.
82
DKA Signs Symptoms
  • Abdominal pain
  • Nausea and vomiting
  • Dehydration
  • Blurred Vision
  • Fruity smelling ketone breath
  • Excessive Thirst
  • Frequent urination ketones present
  • Dry mouth
  • Restlessness, confusion
  • Flushed feeling
  • Rapid breathing or heart beat
  • Sleepiness, difficulty staying awake

83
Ketones What Are They?
  • Normally, our bodies turns the food you eat into
    sugar (glucose)
  • Sugar is the bodies main source of energy
  • Without insulin, body cells cannot use sugar
    present in the blood
  • The body receives a message to use energy from
    fat
  • The body uses the fat for energy by changing it
    into sugar

.
84
Ketones What Are They?
  • When fat is broken down, KETONES are made
  • KETONES are acid chemicals which are harmful to
    the body
  • The body tries to filter them from the
    bloodstream into the urine

.
85
DKA What happens?
  • Not enough insulin
  • ?
  • Sugar not being used for energy
  • ?
  • Break down fat for energy
  • ?
  • Production of ketones
  • ?
  • Ketones (acid chemicals) cause altered pH and
    acidosis
  • ?
  • Ketonuria (to try and get rid of them)
  • ?
  • Dehydration and Loss of Electrolytes

.
86
DKA Treatment?
  • Replacement of fluid losses
  • Correction of hyperglycemia.
  • With low dose IV insulin (to prevent cerebral
    edema
  • Replacement of electrolyte losses (Na and K)
  • Detection of cause and prevention of future
    episodes ketone testing

87
What do all these tests mean?
  • Fasting blood sugar
  • Creatinine
  • Albumin to
  • Creatinine ratio
  • Blood Pressure
  • A1C
  • Lipids
  • Cholesterol//HDL ratio
  • HDL cholesterol
  • LDL cholesterol
  • Triglyceride

88
Fasting Blood Sugar (FBS)
  • Measures the amount of sugar in the blood after
    fasting for 8 hrs
  • Usually done just before breakfast
  • Target Current goal is between 4 7 mmol/L CDA
    guidelines (2003)

.
89
Creatinine
  • A blood test to check kidney function
  • Creatinine clearance - is an estimate of the
    kidneys ability to filter toxins from the blood
  • Target 20 - 120 umol/L
  • Should be checked every year
  • Patients may remain asymptomatic until as much as
    75 of renal function is lost8
  • The older and smaller the patient, the lower
    their creatinine should be

90
Albumin to Creatinine Ratio
  • A urine test to catch early signs of kidney
    damage
  • Detection of microalbuminuria identifies
    individuals at high risk of progressing to later
    stages of renal disease9-10, those at risk for
    cardiovascular events and death4, 11
  • Target lt 2.0 mg/mmol for men4 lt 2.8
    mg/mmol for women4
  • Prevention

91
Blood Pressure (review)
  • The pressure blood puts on the wall of the blood
    vessel
  • Measures systolic pressure (heart contracts)
  • diastolic pressure (heart relaxes)
  • Target 130/80
  • Research from HOT and
  • UKPDS 38 trials

92
Tips to Lower Blood Pressure Health Promotion
  • Reach/keep a healthy weight
  • Be more active
  • Drink less alcohol/eat less salt
  • Stop smoking
  • Take blood pressure medicine (as prescribed by
    your doctor or nurse practitioner)

93
LIPIDS Important
  • 1. Cholesterol/HDL Ratio
  • The ratio describes how much HDL (good)
    cholesterol is part of the total cholesterol
  • It is a better measure of risk for heart disease
    than Total Cholesterol alone
  • Target less than 4.0 for most individuals with
    diabetes

94
How to lower the cholesterol/HDL ratio and
triglycerides Health Promotion
  • Reach and keep a healthy weight
  • Be active!
  • Choose lower fat foods
  • Reach and keep good blood glucose control
  • Reduce OR stop smoking
  • See their MD to have levels rechecked in 3 months
  • Take medication as prescribed

95
2. HDL Cholesterol (High Density Lipoprotein)
  • Healthy Cholesterol
  • measures good cholesterol levels
  • called good because it carries extra
    cholesterol out of the blood vessels
  • a LOW level is a risk factor for heart disease
    (elevated plasma apo B4 )
  • Lowering triglycerides helps improve HDL levels

96
3. LDL Cholesterol (Low Density Lipoprotein)
  • Unhealthy cholesterol
  • measures bad cholesterol because it tends to
    collect in artery walls, and can speed hardening
    of the arteries
  • Target lt 2.5mmol/L for most individuals with
    diabetes

.
97
Tips to Lower LDL Health Promotion
  • Decrease intake of foods high in cholesterol,
    saturated fats and trans fats
  • Eat more soluble fibre (beans, oats, barley and
    some fruits and vegetables)

98
4. Triglycerides
  • Measures another type of fat that moves in the
    blood along with cholesterol
  • High levels often appear with other well-known
    risk factors for heart disease, such as obesity
    and diabetes
  • Optimal lt 1.5 mmol/L

99
More Tips to Lower Triglycerides
  • Eat fewer sweets
  • Drink less alcohol
  • Lower your blood sugar

100
LIPID TARGETS BASED ON RISK OF A VASCULAR EVENT4
Risk LDL-C (mmol/L) TC HDL-C
High (most DM) lt 2.5 and lt 4.0
Moderate lt 3.5 and lt 5.0
  • Moderate risk younger age with short duration
    of DM, no complications and no other CVD risks.
  • TG are not indicated as a target because almost
    all individuals with hyper-triglyceridemia can be
    identified as having an elevated TCHDL-C.
  • Optimal TG is lt 1.5 mmol/L. Optimal apo B lt 0.9
    g/L for high-risk individuals, and 1.05 g/L for
    moderate-risk individuals

101
Glycosylated Hemoglobin OR Hemoglobin A1C (A1C)
  • A check of long term control
  • Average blood sugar over 3 months
  • Do not need to fast for this test
  • Goal is less than 7

102
WHEN WILL THE BATTLE END?
  • NOT TILL THE CURE IS FOUND
  • MANY DEDICATED SCIENTISTS AND PHYSICIANS WORKING
    DILIGENTLY
  • THE COMPLETION OF THE HUMAN GENOME PROJECT BRINGS
    US ONE STEP CLOSER TO VICTORY
  • NOT UNTIL PREVENTION OF TYPE 2 OCCURS

103
Are you at Risk for Diabetes?
  • Age ? 40 years
  • First-degree relative with diabetes
  • Member of high-risk population (people of
    Aboriginal, Hispanic, South Asian, Asian or
    African descent)
  • History of IGT or IFG
  • Presence of complications associated with
    diabetes
  • Vascular disease
  • History of gestational diabetes or macrosomic
    infant
  • Hypertension, dyslipidemia, overweight or
    abdominal obesity
  • Polycystic ovarian syndrome
  • Acanthosis nigricans
  • Schizophrenia

104
BUT !!! , TILL THEN
  • THE BATTLE MUST STILL BE WAGED
  • HELP YOUR DIABETES PATIENTS RECEIVE THE BEST
    POSSIBLE CARE
  • TILL THE FINAL VICTORY , WHEN TYPE 1 DIABETES
    WILL FADE INTO HISTORY
  • TILL TYPE 2 DIABETES IS PREVENTED
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