Section 3 PPI - Diabetes & Current ADA Guidelines

Glycemic

anything pertaining to controlling/regulating blood glucose levels

Glycolysis

breakdown of glucose for energy

Glyconeogenesis

formation of new glycogen from glucose

primarily occurs in liver/muscles

Glycogenolysis

breakdown of stored glycogen into glucose for energy

the process of breaking down stored glycogen in the liver so that glucose may be produced for use in energy metabolism

Gluconeogenesis

formation of new glucose from non-carb sources

ex: amino acids, glycerol, lactate (lactic acid), Acetyl-CoA

Lipgenesis

formation of fat tissue

Polyuria

frequent/increased production of urine

Polyphagia

increased hunger

Polydipsia

increase thirst

Glucose

A simple sugar that is an important source of energy

Digestion

Blood circulation

Liver

Adipose (fat) tissue

Muscle

Liver and Muscles

Major pathways of glucose metabolism: (6)

Digestion

Carbohydrates are broken down into glucose and are absorbed into the lymph and blood stream and travel to tissue cells

breakdown of food substances into simpler forms that can be absorbed and used

Blood circulation

Almost all tissue take in glucose for energy (ATP)

RBCs utilize glucose for energy → transport glucose throughout the body in blood stream to deliver to other tissues

Glycolysis:

Glucose + Oxygen → Energy + Carbon Dioxide + Water

Liver

Organ where excess glucose is stored as glycogen (Glycogenesis), or is combined with fatty acids to produce triglycerides

Adipose tissue

Tissues that stores fat, specifically triglycerides from liver (Lipogenesis)

Muscles

Tissues that store excess glucose as glycogen for future needs (Glycogenesis)

LIver and Muscles

Where is glycogen stored?

stored glycogen is broken down to provide immediate energy and to maintain fasting blood glucose levels (Glycogenolysis)

insulin and glucagon

Homeostatic balance of glucose is controlled by 2 hormones:

Islet of Langerhans (pancreas)

Where in the body is insulin and glucagon produced?

70-110 mg/dL

Insulin & Glucagon help maintain blood glucose with a homeostatic range of:

Insulin

A hormone produced in the beta cells of the Islet of Langerhans

Moves glucose into tissue cells, by acting upon the cell membrane receptors to allow movement of glucose into the cell

decreases/lowers plasma glucose

How does insulin work to maintain homeostatic balance?

Glucagon

A hormone produced in the alpha cells of the Islet of Langerhans

Converts glycogen to glucose in the liver & non-carbohydrates (protein & fats) into glucose

increase/raise plasma glucose

How does glucagon work to maintain homeostatic balance?

glycogenolysis and gluconeogenesis

Glucagon promotes

Insulin inhibits

glycogenesis and glycolysis

(lipogenesis)

Glucagon inhibits

Insulin promotes

Microvascular problems

Macrovascular problems

Coronary artery disease

Thrombotic tendencies

Ketoacidosis

What are the 5 consequences of decreased/absence of insulin?

Nephropathy

Retinopathy

Poor circulation in extremities

Neuropahty

Microvascular problems (small vessels become coated with sugars) lead to:

Dyslipidemia

Macrovascular problems (large blood vessels) become coated leads to:

increase of "bad" fats whin the blood

What is Dyslipidemia?

Arteriosclerosis

Atherosclerosis

What 2 diseases are associated with the buildup of sugar in the large blood vessels (macrovascular problems)?

Arteriosclerosis

blood vessels are hardened, narrowed, thickened (makes them narrow due to scarring)

Atherosclerosis

formation/accumulation of fatty plaques in blood vessels (from triglycerides)

accumulates in areas of arteriosclerosis scarring

Ketoacidosis

decreased level of insulin causes a buildup of keto acid

a byproduct of the body breaking down fats because it cannot use glucose

Diabetes Mellitus

disease characterized by hyperglycemia, glucosuria, polydipsia, polyphagia, and polyuria

Prediabetes

Type I DM

Type II DM

Gestational

Secondary

5 Diabetes Classification:

Prediabetes

Blood glucose levels are above normal but not high enough to be considered diabetic

aka impaired

type II diabetes

Prediabetics are at risk of:

modest weight loss

modified diet

regular exercies

Individuals can delay development of type II diabetes through:

Type I Diabetes

- insulin dependent (little to no insulin)

- strong genetic link

- cause: autoimmune destruction of the beta cells of the pancreas leading to little or no production of insulin

- require regular injections of insulin to permit entry of glucose into cells

Symptoms: hyperglycemia, glucosuria, polyuria, polydipsia, polyphagia

5-10%

Percentage of type I diabetes cases

- typically seen in younger ages (but not always)

autoimmune destruction of beta cells leading to little or no production of insulin

What is the cause of type I diabetes?

abrupt onset

What is the rate of onset of type I diabetes?

thin/normal body types

What is the most common body type of type I diabetes?

administering insulin by injection, pump, or inhalation

What is the treatment of type I diabetes?

Type II Diabetes

-non-insulin dependent

-caused by receptor level resistance to insulin, insufficient insulin production, and fluctuating insulin production

Symptoms: hyperglycemia, glucosuria, polyuria, polydipsia, polyphagia

90-95%

Percentage of type II diabetes cases

insulin resistance of tissue cells

insufficient insulin production

fluctuating insulin production

What are the causes of type II diabetes?

slow/gradual onset

What is the rate of onset of type II diabetes?

obese/overweight body types

What is the most common body type of type II diabetes?

lifestyle changes

insulin administration

other meds (Metformin, GLP-1)

What is the treatment of type II diabetes?

Type I

Which type of diabetes is more severe?

Type II

Which type of diabetes is at epidemic proportions in US?

Gestational Diabetes

a form of diabetes mellitus that occurs during some pregnancies due to the woman not being able to make enough insulin during late pregnancy

Symptoms (mother): excessive weight gain, preeclampsia, need for C-section, increased risk of developing type II later

(fetus): abnormally large baby, hypoglycemia after birth

5-10% of all pregnant women diagnosed

Percentage of gestational diabetes cases

insulin resistance of mother's tissue cells

What is the cause of Gestational diabetes?

end of 2nd trimester

What is the point of diagnosis for Gestational diabetes?

**hint: blood sugar is normal, but not is high

type II

If blood sugar is high at 1st prenatal visit, what type of diabetes?

excessive weight gain

preeclampsia

need for C-section

increased risk of developing type II later

What are the S/S and complications seen in the mother with gestational diabetes?

macrosomia

shoulder injury at delivery

neonatal hypoglycemia

increased risk of developing type II later

What are the S/S and complications see in the fetus with gestational diabetes?

neonatal hypoglycemia

Low blood sugar in newborns

Due to baby is no longer getting increased amounts of glucose from mom (through placenta), but is still producing a lot of insulin

Need to slowly ween off so insulin drops slowly instead of all at once

Secondary Diabetes

a type of diabetes caused by another disease or certain drugs or chemicals (develops secondary to other disease or medical conditions)

Causes: increased glucose production or decreased insulin production

Secondary Diabetes

Causes:

increased glucose production (endocrine disorders, medications, hormones, transit)

decreased insulin production (exocrine disorders and PTDM)

polyuria

polyphagia

polydipsia

What are the 3 P's of diabetes?

Fasting

Random

GTT (2hr)

GTT (1hr/2hr/3hr)

Hgb A1C

5 Diagnostic Tests for Diabetes:

Fasting

Random

GTT (2hr)

3 Diagnostic Tests used for Non-pregnant Diabetes

GTT 1hr/2hr/3hr

Which diagnostic test is for Gestational Diabetes (GDM)?

Fasting Glucose

measuring blood glucose levels in someone who hasn't eaten

- preferred test

- min 8hr fast (no smoking/strenuous exercise before collection)

Normal: 70-99 mg/dL

Pre-DM: 100-125 mg/dL

DM: ≥ 126 mg/dL

Fasting Glucose reference ranges:

Random Glucose

only given in presence of symptoms

- least preferred

- anytime of day (regardless of what was eaten)

≥ 200 mg/dL

Diabetic level of random glucose test:

8hr; 10-16hr

Glucose Tolerance Test (2hr) - DM

Overnight fast of __________ hrs min

_________ hrs recommended

75g

Glucose Tolerance Test (2hr) - DM

Glucola load ingested

2hrs

Glucose Tolerance Test (2hr) - DM

Blood drawn _______hrs after ingestion of glucola

Normal: < 140 mg/dL

Pre-DM: 140-200 mg/dL

DM: ≥ 200 mg/dL

GTT 2hr - DM reference ranges:

GTT 2hr - GDM

Screening & Confirmation of GDM

- fasting required

- 75g glucola ingested

- 3 specimens drawn: Fasting (≥92 mg/dL), 1hr (≥180 mg/dL), 2hr (≥153 mg/dL)

- diagnosis made if 1 out of 3 results met

- not used anymore

Fasting: ≥ 92 mg/dL

1hr ≥ 180 mg/dL

2hr ≥ 153 mg/d

GTT 2hr - GDM reference ranges:

GTT 1hr

What is the screening test for Gestational Diabetes (GDM)?

24-28 weeks (end of 2nd trimester)

Glucose Tolerance Test (1hr) - GDM

When does test take place?

fasting not required

50g

Glucose Tolerance Test (1hr) - GDM

Glucola load ingested

1hr

Glucose Tolerance Test (1hr) - GDM

Blood drawn _______hrs after ingestion of glucola

> 140 mg/dL

Glucose Tolerance Test (1hr) - GDM

Requires 3hr GTT

GTT 3hr GDM

What is the confirmatory test for Gestational Diabetes (GDM)?

fasting is required

Glucose Tolerance Test (3hr) - GDM

Is fasting required for this test?

100g

Glucose Tolerance Test (3hr) - GDM

Glucola load ingested

Fasting, 1hr, 2hr, 3hr

Glucose Tolerance Test (3hr) - GDM

What are the 4 specimens drawn?

Fasting: ≥ 95 mg/dL

1hr: ≥ 180 mg/dL

2hr: ≥ 155 mg/dL

3hr: ≥ 140 mg/dL

GTT (3hr) - GDM reference ranges:

2 out 4 results observed

Glucose Tolerance Test (3hr) - GDM

When is diagnosis of Gestational Diabetes made?

Hemoglobin A1C

formed slowly & irreversibly by hemoglobin's exposure to plasma glucose

- RBC is glycosylated (sugar is attached) and remains for the life cycle of RBC

aka: glycated hgb or glycosylated hgb

Hgb A1C

Diagnostic/Monitoring test that measures what percentage of your hgb is coated with sugar

factors that affect Hgb A1C levels

any variants of anemia (RBCs don't survive long enough)

increased RBC turnover (pregnancy)

chronic blood loss

true

T or F:

Hgb A1C provides long term index of patients average blood glucose levels

Normal: ≤ 5.6%

Pre-DM: 5.7-6.4%

DM: ≥ 6.5%

Diagnostic Ranges for Hgb A1C:

≤ 5.6%

Normal diagnostic range for Hgb A1C:

5.7-6.4%

Prediabetes diagnostic range for Hgb A1C:

≥ 6.5%

Diabetes diagnostic range for Hgb A1C:

< 7%

monitoring range for Hgb A1C

physician may set less/more strict cut-off for individual based on overall health, life expectancy, treatment regiment, and presence of diabetic complication

2x a year if stable, quarterly if unstable or therapy changes

proinsulin

Insulin is stored in the pancreas as the biologically inactive protein:

Insulin and C-peptide

What is the active form & inactive peptide of proinsulin

C-peptide

Product of proinsulin cleavage that is inactive peptide that reflects amount of endogenous insulin produced by pancreas

not affected by insulin antibody interference