Diabetes Lecture 1 – April 4th

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Diabetes Lecture 1 – April 4th, 2013

Diabetes

Diabetes is an epidemic; it’s exploding everywhere

Fat (obesity) & diabetes: they are always fighting each other because the moresubcutaneous body fat an individual has, the harder it is for your own insulin to

bring your blood sugar (glucose) down and put it in the cell

Glucose needs to be put into the cell because it gives you energy

o Glucose is the body’s fuel

Definition of diabetes: elevated blood glucose

o Two problems:

Problem with secretion and/or

Problem with utilization

FYI: Diabetes is Greek; it means to siphon and that refers to the amount of urine

because with certain types of diabetes you are going to have an increase in urineo Mellitus is Latin; it means “outpouring of sweet urine”

o The take home message from the slide: excess urination – excess

urination from a problem

Diabetes is a chronic problem; it’s increasing in the country and it is very costly

o The amount of people diagnosed are increasing so the healthcare

industry is initiating procedures and policies to prevent and/or stop

diabetes that’s already happening for those in the country that have

diabetes

Diabetes is an increase in blood sugar from a defect in secretion and/or

utilization of insulin

What happens with insulin: insulin comes from your pancreas from the beta

cells

o When you ingest the food, the beta cells recognize that food is coming

and in response, the beta cells squirt out/push out insulin into the

vascular system

o Insulin takes the food and brings into the cell (glucose) and we use it as

energy

When we don’t eat, or when we are sleep deprived and we eat something – no

matter what it is – 10 minutes after you feel as if you have more energy

o

This is because whatever you ingested – nutritious or not – insulin is

being secreted and it’s bringing that food into the cell and giving youenergy that’s the normal response

Your pancreas secretes it’s own insulin approximately 1 to 2 units per hour –

secreting, secreting, secreting

o Whether you are eating or not, the pancreas is secreting insulin

o You have so many locks and keys in your body that if you haven’t eaten

for 8, 10, 12 or 24 hours – your pancreas is still secreting insulin



o

There is check and balance however; it never lets anything get too high

or too low until you are diagnosed with diabetes

Then the problem is secretion and/or utilization

As we covered, insulin is the hormone that is produced from the pancreas by the

beta cells and the insulin is what controls your blood sugar/blood glucose

o

Insulin regulates the blood glucose by: Producing

Storing

o With increased blood sugar/blood glucose, insulin gets secreted to bring

the blood sugar/blood glucose down, and put the blood sugar/blood

glucose back into the cell

o However, in diabetes, the body has a difficult time with utilization and

secretion of this insulin, depending on whether you are Type 1 or Type 2

Overall, Diabetes is a group of metabolic diseases characterized by high levels of

blood glucose resulting from defects in secretion or insulin action (utilization), or

both Three organs involved in the regulation and utilization of glucose:

o Liver

The liver stores and releases glucose ingested from our diet

The liver also makes its own glucose in a process called

gluconeogenesis

When the blood sugar is down, the liver releases glucose

When the blood sugar is up, the liver stops releasing and

producing glucose because it recognizes that there is

enough in the serum to do what it needs to do

So when you think of the liver think of: storage of extra glucose

and release of glucose as needed

o Pancreas

The pancreas is where the beta cells are

The beta cells release insulin

The pancreas also has alpha cells; the alpha cells release

glucagon

Here is how you know when the alpha cells are working:

Glucagon gets released when the sugar is gone

So in cases of hypoglycemia – low blood sugar – the alpha

cells in the pancreas will “spit out” glucagon to raise the

serum blood sugar to keep it at about 70 to 110/70 to 120

Once again, the pancreas supplies two hormones: insulin and

glucagon

Beta cells release insulin

o

Insulin allows the glucose to enter into the cell,

where it is used for fuel and energy for the body

Alpha cells release glucagon



o

Glucagon gets released to increase blood sugar

levels in periods of hypoglycemia

o

Skeletal muscle tissue

Glucose is stored in your muscle cells

The muscles are the place where there are the most insulin

receptor sites – two-thirds of the receptor sites are located there

Insulin has to bind to a receptor in the muscle and then it

allows it to enter into the cell except if there is insulin

resistance

o Insulin resistance is where the body has a problem

utilizing the insulin

Looking at slide 7:

o Glucose enters the blood stream and blood sugar levels rise

You eat food, glucose goes in, your blood sugar starts to go up

o The pancreas is signaled to release INSULIN into the blood

Immediately your pancreas is going to squirt out insulin (inresponse)

o INSULIN is the key to unlock the cells & allow the glucose to enter the

cells

o The blood sugar levels drop

o Glucose yields energy for the body cells

You are able to carry on with your activities except with insulin

resistance where you have a secretion problem

Euglycemia

o Normal blood sugar range

Want to keep it 70-110 or 80-120

o

What happens: When you eat, your blood sugar level starts to go up As your blood sugar goes up, the pancreas squirts out insulin

Insulin then comes and takes the glucose and brings it into the

cell to use for fuel or energy that you need to sustain daily

activities

This is a normal process with meals – whatever you happen to eat

o When you eat a fast-acting carbohydrate, such as Snickers bar, M&Ms,

Milky Way – essentially candy bars that are loaded with processed

sugar – immediately your blood sugar starts to go up but the insulin is

squirted out and it brings back into the vascular cell – this goes on all day

long EXCEPT when you have: Lack of insulin, either because it’s not being secreted or it’s not

being utilized properly because those receptors sites in your

muscles – where two-thirds of them are – are not letting the

insulin in

Insulin is being secreted but the receptor sites are closed

and not letting the insulin in



As a result the insulin is continuing to rise in your

bloodstream as opposed to being let in

o What happens in diabetes with secretion and utilization is:

You eat food and the beta cells squirt out just a little bit of insulin

– not enough for the big meal that you have just eaten

So instead of the blood sugar level rising and then coming backdown, the blood sugar level continues to rise

That little bit of insulin that the beta cells squirted out

might bring it down a little bit but not enough

The blood sugar as a result is constantly elevated

The food and nutrition is not being brought into the body

because it is circulating in the vascular system

The blood sugar levels aren’t consistent

o The goal in diabetes is to become euglycemic

Euglycemia is blood sugar levels between 70-110 or 80-120 pre-

meal

Post-prandial (post-meal)

When you hear someone say “do a 2-hour post-prandial

on him” it means give him a normal amount of carbs,

proteins, fats, and 2 hours later draw a glucose on him and

let’s see where he is

Review:

o Insulin helps the glucose get into the cell to use it for fuel and energy

o

Three organs involved in the utilization of insulin

Liver

Pancreas

Muscles

Key place because two-thirds of the insulin receptor sites

are located there

Types of Diabetes

o

Type 1 (slide 9): 5-10% of people have Type 1

A small portion of people have Type 1 Diabetes; the vast majority

of people who have diabetes, have Type 2 Diabetes

When you think if Type 1 Diabetes, you think of subQ

insulin; when you think of Type 2, you think of oral

meds/oral control

o

Remember: an oral controlled diabetic can also beon subQ insulin at some point

50% of Type 2 orally controlled diabetics

will go on to use insulin at some point in

their life

Auto-immune

The body is attacking itself



With any auto-immune disease, your body is attacking

itself

Complete insulin deficiency (insulinopenic)

The pancreas can’t produce or secrete enough of it’s own

insulin

o

Why: because it’s an auto-immune illness It could also be partial insulin deficiency

o Type 1 diabetics could start with partial insulin

deficiency and as the disease progresses, less and

less of their own inherent insulin is made

Absolute dependence upon exogenous (outside) insulin

Type 1 diabetics need exogenous insulin to live; they

cannot live without the administration of insulin

Prone to Diabetic Keto-Acidosis

The take home word here is acidosis

Ketosis-prone when insulin is absento If there is no insulin, the body has to attack it’s own

stores and ingest its own stores

Where are the “storage units”: muscles and

liver

o Ketosis-prone meaning that they produce ketones

When you think of ketones, think

immediately acid; ketone is an acid

With decreased insulin – because it’s a

secretion or utilization problem, and

increased glucose, the body goes to break

down it’s own fat because it needs to feed

the cells – the cells are starving

Where is the glucose? Not in the cell but

circulating in the bloodstream

When this starts to happen, Diabetic Keto-

acidosis begins

One of the things that patients with DKA get is

dehydration (see polyuria)

Review:

o Type 1 diabetics have an insulin secretion and

utilization problem – they rely on insulin to live;they cannot live without insulin

o It is a genetic predisposition that these patients

have

Lean; recent weight loss

These patients usually look slender



Very often what will bring them to the doctor is a recent

weight loss – a significant weight loss of 10 to 15 lbs and

they will come in with the three Ps:

o Polyuria

When your blood sugar is approximately

180 and above, the glucose spills out intoyour urine

ADH (anti-diuretic hormone) is released

from the brain and ADH tells the body to

get rid of the water so you start to pee

When you pee, out goes the water and out

goes the glucose – that’s a good thing

However, polyuria can lead to dehydration

for these patients with DKA

o Polydipsia

Excessive thirst o

Polyphagia

Eat abnormally excessive amounts of food

due to the decreased storage of calories

Abrupt onset, usually before age 40

Comes on suddenly; this is the guy that goes to the doctor

because he feels bad – something is not right

Traditionally we see this in the younger client

May occur in elderly

Patients with Type 1 diabetes usually have a genetic

predisposition – meaning it can be inherited

If you have a parent that has Type 1 or Type 2, they areprone to having a child with diabetes

There is also a viral theory but that is still being worked

on; the genetic predisposition is more significant

There is no prevention for Type 1 diabetes but the history of the

parents can certainly help – not help prevent it but help watch for

symptoms should it occur in the patient

Diagnosis of Type 1 diabetes is usually with the signs and

symptoms which usually brings the patient in

Review:

Type 1 diabetics have an insulin secretion and utilizationproblem – they rely on insulin to live; they cannot live

without insulin

It is a genetic predisposition that these patients have

The symptoms occur quickly bringing them to a medical

practitioner who does a blood test and diagnosis them

with Type 1 diabetes



Usually this is a younger client

They are prone to DKA (Diabetic Keto-Acidosis) or

Ketosis-prone

o With a decrease in insulin – because their pancreas

is either squirting it little bits at a time, not at all, or

inconsistently – the glucose is rising o The body cells are starving; the body says “I have

to feed the cells!”

Where does it go for food? To your stored

subcutaneous fat

When that stored subcutaneous fat is

broken down, ketones or acids are

released, putting the patient and making

them prone to Diabetic Keto-Acidosis

DKA is something that happens over a

period of hours – you just don’t go into it in5 minutes

The glucose rises, the insulin isn’t

secreted – it happens over a period

of hours

How we monitor that is serum blood

glucose levels

Primary concern with Type 1 Diabetes is insulin

deficiency

Symptoms (slide 11):

o Extreme fatigue

o

Polyuria

o Polydipsia

o

Polyphagia

o

Unusual weight loss

o Irritability

o Type 2 (slide 14) – 80-85% have Type 2

Two problems with Type 2: impaired insulin secretion or insulin

resistance

Insulin resistance = no binding at the receptor site

o Decreased sensitivity to insulin so the blood sugar

does not come down as much as it should/down toa normal number

Impaired secretion: meaning that the pancreas is putting

out some insulin but it’s not enough or it’s inconsistent

Not absolutely dependent upon exogenous (outside) insulin

The key here is that the pancreas produces some insulin



If there is a non-compliance however, Type 2 diabetics

may be dependent on exogenous insulin

Progressive condition

Type 2 diabetes is usually present years before it is

diagnosed because these beta cells start to stop

producing insulin, the receptor sites start to close off By the time someone is diagnosed with Type 2 diabetes,

they say that it is really 3 to 5 years that they’ve had it and

just have not been diagnosed

Diabetes is a condition for life; it’s not something that can

be reversed – it has to be managed

May be relatively free of classical symptoms (three Ps)

Symptoms (slide 11):

o Any of Type 1

o Frequent infections

Sometimes with patients that havefrequent infections, all of a sudden we do a

fasting glucose on them, we see an

elevated number and it all starts to make

sense as to why they keep having these

frequent infections

o Blurred vision

o Cuts/bruises slow to heal

o Tingling or numbness in hands/feet

o Recurring skin, gum, or vaginal/bladder infection

The symptoms are more subtle with Type 2 diabetes

What usually gets the Type 2 diagnosed is a yearly

physical because Type 2 diabetics feel okay – they don’t

feel great but they don’t go to the doctor for a checkup

Come in for the yearly physical and a serum fasting blood

glucose is done

o Magic number for diagnosis of diabetes = 126

Not prone to DKA (Diabetic Keto-Acidosis)

Not prone because Type 2 diabetics have some insulin;

maybe not a lot but they are not prone to DKA

Not breaking down or eating their own fat

Strong family history of diabetes mellitus Not genetic, but family history

o Family history: parents

Usually obese or history of obesity

Again, obesity is an antagonist to insulin; the fatter you

are, the more subcutaneous body fat you have, the harder

it is for that insulin to work



Usually diagnosed after age 40

Traditionally we see this in the older client

Usually peaks in the 50s

Primary concern is insulin resistance

With insulin resistance: insulin is being secreted but the

receptors at the site on the muscles are not letting theinsulin in

The receptor sites are shutting down and not letting the

insulin in so the glucose is then circulating in the

bloodstream and it’s rising

o Is it going into the cell? With Type 2 diabetes,

sometimes yes and sometimes no

We treat Type 2 diabetics with diet and exercise to try and bring

the blood glucose down

If we can’t get into a normal range, we begin oral therapy

with Type 2 diabetics 50% of diabetics will eventually go on to add insulin to

their regime if they are not compliant

Really the major way that we control blood glucose in

Type 2 is through weight loss because again think of fat

and insulin – the more weight you have; they are

antagonists

o Just by losing 10 lbs, it can bring down your blood

pressure, your blood sugar and that antagonist

effect between fat and insulin lessens

First thing we try is we try to put the Type 2 diabetics on a

diet and weight loss

o This is not as easy as it sounds, however, so the

potential for noncompliance is there

Going over slide 13: Type 2 Diabetes

The stomach changes food into glucose

o You eat, food goes in

Glucose enters the bloodstream

The pancreas makes insulin

o As soon as the food goes in, the pancreas squirts

out insulin as a response

Insulin goes into the bloodstream Glucose can’t get into the cells of the body (resistance);

glucose builds up in the blood vessels

The problem here is either not enough insulin is secreted

or we give you plenty of insulin but there’s a resistance



o

Glucose levels in the blood increase and eventually

patients start to experience the signs and

symptoms

In response to Gasha’s question: Type 2 Diabetics are

metabolically prone, while Type 1 Diabetics are auto-

immune o Type 2’s are prone to cardiovascular disease

Prone to an MI, prone to a CVA, prone to

PVD

o Type 2’s tend to have the lifestyle of “the rich and

famous”

Meaning: they eat a lot of refined sugars,

processed foods – that leads to obesity

Remember, obesity is the

antagonist to insulin

They are inactive Inactivity leads to increased blood

sugar; this is why the first thing that

Type 2 diabetics are put on is a diet

and are also told to move – be active

o Get the weight off, exercise,

get the circulation going and

get another serum blood test

to see how you are doing

African-Americans, Hispanics, Native Americans are much more

prone to Type 2 genetically than the other races and cultures

Diagnosis of Diabetes (slide 15): Non-pregnant adult:

FPG (fasting plasma glucose) ≥ 126 mg/dL (fasting = 8 hours) OR

o Fasting = NPO after midnight, 8 hours

OGTT (oral glucose tolerance test; pregnancy) ≥ 200 mg/dL in 2 hr sample OR

(75-g glucose)

Repeat on a different day in absence of unequivocal hyperglycemia

Casual BG ≥ 200 mg/dL w/symptoms

o In other words: right now, you do a serum blood glucose on Prof. Molloy

casually – nobody is asking what she ate, when she ate, etc – and it’s 200and above

From that point on, the diagnosis of diabetes is made

We have to know these numbers

o

You have to know:

Fasting – 8 hours in, NPO – 126 and above and we have a problem

Casual blood glucose - 200 and above, and we have a problem



Remember it is casual blood glucose with symptoms – the

symptoms brought you in

This is serum – not fingerstick

Risk Factors for Diabetes(slide 17): Obesity (any age)

o BMI > 25

o American kids are obese because of inactivity

Heredity

Viruses

o With Type 1

Stress

Diet

o Refined sugar

o

Fast foodso “life of the rich and famous” – not cooking, always eating out

Aging (> 45 years old)

o With Type 2

Race:

o African-American

o Latino

o Native American

o Asian-American

o

Pacific Islanders

o

Alaska Native

Going over slide 19: Diabetes Mellitus – Type 1 Signs & Symptoms

The three Ps:

o Polyuria:urination

o Polydipsia:thirst

o Polyphagia:hunger

Weight loss

Fatigue

Frequency of infections

Rapid onset

Insulin dependent

Familial Tendency

Peak incidence from 10 to 15 years

Going over slide 20: Management – Type 1



Goal: To keep blood sugar in normal range (aka: tight control)

Dependent on insulin for life

American Diabetes Association recommends blood sugar levels between:

o

80 – 120 before meals – Tight control

o

100 – 180 postprandial (after meals)

Diabetes Lecture 1 – April 4th

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