2 Pancreatic Hormones

What do Alpha cells secrete?

• Secrete glucagon

• Increases BS

What do beta cells secrete?

Insulin

What are Delta cells?

• Secrete somatostatin

• Regulates insulin and glucagon secretion

• Regulates GI function

How does insulin inhibit the breakdown of stored glucose, protein, and fat?

I you do not have enough insulin → body cannot get glucose into cells → starts to break down fats and protein → ketones

What happens if you go more than ___ to ___ hours without food?

If you go more than 8-12 hours without food → liver starts to break down amino acids to get glucose

What is Glycogenolysis?

• Lysis: breakdown

• Glycogenolysis: the breakdown of glycogen

• Done by the liver to release glucose into the bloodstream.

What is Gluconeogenesis?

• Genesis: regeneration of tissue

• Gluconeogenesis: formation of glucose through breakdown of amino acids and noncarbohydrate substances (fat and protein)

What is Glycogenesis?

Glycogen formation

What is glycogenolyaia?

Liver converts stored glycogen into glucose

What can cause diabetes?

• Defects in insulin secretion, action, or both

• Not enough insulin or insulin does not work

How is high glucose regulated in the body?

High BS → pancreas releases insulin → 1) insulin helps open the tissue cells to take glucose in and 2) insulin tells liver to make glycogen

How is low glucose regulated in the body?

Low BS → tells pancreas → to release glucagon → glucagon tells liver to take glucose and store it as glycogen → glucagon tells liver to break down glycogen → glucose → sugar goes up

Pathophysiology of Type 1 Diabetes

1. Destruction of beta cells

2. Insulin deficiency

3. Muscles can't get glucose

4. Fat starts to break down

5. Glucose builds up due to no insulin being let into cell

6. Hyperglycemia

7. Affects kidneys and causes ketones (keto acids due to breakdown of fat)

8. If too many ketones

9. Dabetic coma

What happens when the blood sugar is > 180?

1. When glucose is over 180

2. Acts as a diuretic

3. Glucose gobbles up water particles

4. Water is pulled out of cells into blood stream (water follows glucose)

5. Excreted by the kidneys

6. Main symptom of hyperglycemia is polyuria

7. Volume depletion

8. Polydipsia (excess thirst)

What are the risk factors of Type 1 Diabetes?

• Family history

• Environmental factors → viruses

• Presence of damaging immune system cells → if you are tested for autoimmune cells and test positive → does not mean you have Type 1 but are at higher risk

• Geography → Sweden and Finland

• Race or ethnicity → Caucasians have highest rate of Type 1

What are the risk factors of Type 2 diabetes?

• Increased weight

• Inactivity

• Family history of DM

• Race or ethnicity → AA, hispanics, American Indians, Asian American

• Older age → less exercise + weight gain

• Previous gestational diabetes

• Polycystic ovary syndrome

• High blood pressure over 140/90

• Abnormal cholesterol and triglyceride levels (low HDL and high LDL)

What is Gestational Diabetes?

• Onset during pregnancy, usually in the second or third trimester

• Hormones secreted by the placenta can inhibit the action of insulin

• Above-normal risk for perinatal complications, especially macrosomia (abnormally large babies, over 9 lbs)

• Glucose intolerance transitory but may recur in subsequent pregnancies

How do we treat gestational diabetes?

Diet and insulin if needed strictly to maintain normal BS

When is screening for gestational diabetes indicated?

• Screening tests (glucose challenge test) should be performed on all pregnant women

• Between 24 and 28 wks of gestation

Is gestational diabetes long lasting?

• No only occurs during pregnancy

• Is a risk factor for diabetes

• 35–60% will develop diabetes (usually type 2) within 10–20 yrs, especially if they have obesity

• Once they have had gestation, should be screened for diabetes every 3 yrs

What are some risk factors for gestational diabetes?

• Age at time you have baby especially over the age of 30

• Family or personal history

• Increased Weight

• History of previous large babies (> 9 lbs)

• Race or ethnicity

What are some conditions that have been linked to diabetes?

• Pancreatic diseases

• Hormonal abnormalities

• Medications such as corticosteroids

• Estrogen-containing preparations.

Why would someone be put on an antidiabetic?

Depending on the ability of the pancreas to produce any or some insulin

What additional referrals might a diabetic need?

• Diabetes educator → typically a highly trained nurse that coordinates and plans for referrals

• Ophthalmologist → diabetes can affect eyes

• Podiatrist → circulation and feeling in feet

• Dietitian → watching calories and carbs, when you eat, how much

• Cardiologist → kidneys or atherosclerosis

What do you want to teach a diabetic before having them increase their activity?

Know glucose level before exercise

What are signs of kidney failure with diabetics?

1. When you have high sugar

2. Kidneys filter out glucose (normal function)

3. Polyuria

4. Glucose in urine (bc water follows glucose)

5. Type 1 diabetes → acute complication → ketones

6. Kidneys filters out ketones (normal function)

7. If renal damage starts to occur from diabetes

8. Kidneys are being damaged

9. Pores open up and allow larger particles such as protein and albumin

10. Albumin (protein) in urine indicates damage to kidneys

If finding water, glucose, and ketones in the urine normal or a sign of kidney damage?

• Filtering out glucose, water, and ketones are normal function of kidneys

• If it starts filtering out larger particles like albumin → potential sign of renal failure

Goals of Nutritional Management of Diabetes?

• Maintain normal glucose levels

• Prevent or slow the development of chronic complications

• PCC

• Allow the pleasure in eating → lifelong change → something they can stick to

• Normal lipid panel

• Normal BP

What is an Exchange List?

• Allows the client to choose from the list to make up what they want

• Can chose any combo

• Allows variety and helps with individuality

• Used for diabetic nutrition planning

Should diabetics opt for simple or complex carbs?

Complex carbs are digested more slowly and do not spike the BS

What should you recommend someone on insulin do if they have issues with hypoglycemia during exercise?

When on insulin → exercise makes glucose go into cells better → can cause sugar to come down → if you have problem with glucose dropped when exercising → eat 15 g carbs before exercise

What should a diabetic do after strenuous or prolonged exercise?

Check sugar and eat a snack afterheck sugar and eat a snack after

What should you recommend someone on insulin whose sugar is not set to peak during exercise?

Eat 15 g carbs before exercise

What are some glucose checking considerations?

• Assess physical capability (visual impairments, can they do it themselves)

• Assess accuracy of machine

• Frequency and timing of test → less frequent as things stabilize

What is a continuous glucose monitoring system?

• Monitors more quickly

• Replace every 7-14 days

• 6 month implants available

• No wires

• SQ needle inserted into skin with sticky back to stay in

• Can set alarms for too high/too low

What is Hemoglobin A1C testing? What is the goal for diabetics?

• Glucose control for the past 3 months

• Measures the amount of glucose attached to hemoglobin

• Goal: Less than 7% for diabetics

What will you do if the clients blood sugar is high?

Give rapid acting then intermediate acting (NPH)

What are insulin regimens?

• Different combos of insulin

• Trying to mimic the body’s normal pattern of insulin secretion based on food intake and activity pattern

• Usually combo of short and long acting

What is a Conventional Insulin Regimen?

• Helps to avoid complications of hypo/hyper glycemia

• Simplify insulin regimen (take same amount of insulin daily ACHS)

• For conventional to work → need to keep meal patterns (eat about same amount) and activity levels the same each day

• Conventional is often used in hospitals or for people who have bad self care habits

What is an Intensive Insulin Regimen?

• Complex → control blood glucose as much as possible

• Helps to avoid complications of hypo/hyper glycemia

• Based on BS reading, more injections, closer monitoring

• Benefit: allows you to eat at different times due to closer track of glucose → have to be very organized and dedicated → allows more freedom and control over lifestyle

• 3-4 injections daily

What are some complications of Insulin Therapy?

• Lipohypertrophy → fatty masses

• Lipoatrophy → Losing fat in area from too many injections in the same spot

• Lipodystrophy → can be either

• Insulin resistance

• Roate sites

• Allergic reaction

What happens if a Type 1 diabetic has an allergic reaction (anaphylaxis) to the insulin?

• Still have to administer insulin

• Give in tiny doses and slowly increase the dose

What is the Dawn Phenomenon?

• Complication of insulin therapy that causes morning hyperglycemia

• At 3 am glucose level starts to rise due to cortisol secretions (morning hormone that help us wake up) and growth hormone levels

  • Cortisol increases glucose

• Intervention: give insulin (NPH) at bedtime instead of dinnertime so they have longer coverage

What is the Somogyi Effect?

• Complication of insulin therapy that causes morning hyperglycemia

• Early morning hypoglycemia

• Glucose drop at midnight → glucagon kicks in to raise glucose → morning hyperglycemia

• Hormones kick in to raise glucose

What is Insulin Waning?

• Insulin wears off throughout night

• Hyperglycemic in AM

• Progressive right in glucose from bedtime to AM

• Intervention: increase pre dinner to bedtime dose

What is a consideration of overnight glucose management and to prevent complications of insulin therapy?

Test BS at bedtime, 3 am, and upon rising

If you check BS at bedtime at high, then check it at 3 am and it is higher, and again at wake and it is still high, what effect does this likely indicate?

Insulin waning

If you check BS at bedtime and it is fine, then at 3 am it is low, then at wake it is high, what effect does this indicate?

Somogyi effect

If you check BS at bedtime and it is fine, then you recheck at 3 am and it is fine or a bit elevated, then by morning it is high, what effect does this likely indicate?

Dawn phenomenon

What are jet injectors?

• No needle, uses pressure to blow insulin into SQ, more painful than needle

• Used in military

• Less chance of insulin waning due to insulin spreading more instead of sitting in puddle like SQ injection

What are insulin pens?

• Screw on new needle each time, set amount by turning dial

• Push button and hold it there for 10 seconds

• Doesn’t require good vision, good for lower vision and someone who can’t draw up injections

• Used for elderly and those with vision or hand dexterity issues

What are some complication of insulin pumps?

• Does not detect if vial gets empty

• Wires can get kinked

• Good for traveling → insulin with them at all times

What are some MOA of anti-diabetics?

• Delays absorption of carbs

• Makes tissues more sensitive to insulin

• Stimulates beta cell to secrete more insulin

  -

• Decrease glucose absorption

• Stop liver from putting out glucose

• Help cells take in glucose

• Increase insulin secretion or decrease glucagon secretion

What is Lactic Acidosis? When is it likely to occur?

• Most likely to happen if you give someone on Metformin is having any kind of Iodine contrast

• Hold Metformin 48 hours before/after test

• Cardiac cath & CT scans use iodine contrast

What is the target blood glucose for hospitals?

140-180

What are some things that can cause the BS to go up?

• Infection

• Stress from being in hospital

• Routine diet being messed up

How often should we take the blood sugar of a patient who is eating and drinking? NPO?

• PO → ACHS with sliding scale

• NPO → Q6 with sliding scale

(T/F): There are low sugar versions of tube feeds and ensures

True

Would you expect someone on TPN to ahem insulin ordered?

• Yes, TPN is super concentrated

• TPN has insulin but they may also be in sliding scale Q6

How may an insulin order different from someone who is insulin resistant vs not?

• If they are insulin resistant → may need higher dose

• How much you give is based off scale → do not need order to give insulin

What are some Macrovasuclar Complications of DM?

• Atherosclerotic in Coronary artery vessels – MI, silent MI (due to nerve damage → may have a heart attack with no pain)

• Cerebral vessels – TIA, CVA, impaired recovery

• Peripheral arterial disease

  • Diminished pulses

  • Intermittent claudication (cramping during exercise)

  • Gangrene (tissue death due to lack of blood flow)

  • Amputation

What is a sign that neuropathy is starting to occur in a diabetic?

• Albumin in urine (high glucose puts stress on filtration system in the kidneys)

• Intervention: glucose control

How is a patient often diagnosed with diabetes?

• By ophthalmologist

• Dr. sees damage in retina → sent to primary care to be tested for diabetes

What is the best way to prevent complications of diabetes?

Keep glucose in control

What are some risk factors for amputations?

• Diabetes more than 5 years

• Age greater than 40 years

• Current smoker and history of smoking → smoking cessation

• Teach about decreased peripheral pulses

• Teach about decreased sensation → may not notice new blister

• Bunions, calluses, hammer toes

• History of previous foot ulcerations or amputation

What are the teaching points for foot care?

• Glucose management

• Inspect and wash feet daily

• Keep skin soft and smooth

• Smooth corns and calluses gently

• Trim toenails weekly or as needed → trimmed, straight across → not into cuticles

• Wear shoes and socks at all times

• Protect feet from hot and cold

• Keep blood flowing to your feet → exercise, elevate if swollen otherwise keep them down

• If can’t see feet → use mirror or have someone else look

• Do not moisturize a lot between toes → bacteria growth

• If can’t reach toes → pediatrist referral

What are the three acute complications of diabetes?

• Hypoglycemia

What is hypoglycemia? Severe hypoglycemia?

• Hypoglycemia: less than 60-70

• Severe hypoglycemia: less than 40

What are some causes of hypoglycemia?

• Excess insulin or medication

• Low food intake

• Physical activity

• Stress

• Infection

• Alcohol

What are the first s+s of hypoglycemia?

• Sweating

• Palpations

• Tachycardia

• Nervousness

• Hunger

• Vision changes

• Tremors

Take these seriously

What are the second s+s of hypoglycemia?

• Headache

• Confusion

• Memory trouble

• Drowsiness

• Slurred speech

• Issues with coordination

What are the third s+s of hypoglycemia?

• Seizures

• Disorientation

• Loss of consciousness

What are s+s of high BS?

• Polyuria

• Polydipsia (increased thirst)

• Irritability

• Blurry vision

• Feeling tired

What re the s+s of low BS?

• Increased hunger

• Sweatiness

• Shakiness

• Dizziness

• Headache

• Paleness

• Feeling tired

• Blurry vision

What is Diabetic Ketoacidosis?

• For Type 1

• Not taking enough insulin

• Ketones with fat breakdown

• If you don’t have insulin to get glucose into cell → body will break down fat → ketones are byproduct

• Cause: low insulin (not taking enough insulin)

What are some causes of DKA?

• Missed or incorrect insulin dose (pump failure)

• Stress

• Illness and infection

• New onset Type 1

What type of breathing will you except someone with Diabetic Ketoacidosis to be in?

Metabolic acidosis → body will try to compensate with → fast, very deep respirations to try and get CO2 out → Kussmaul’s

What is the difference between hyperventilation and Kussmaul’s breathing?

• Hyperventilation can be calmed down

• Kussmaul’s they cannot control even if you talk them down → is a chemical reaction

Any time you see hypotension and tachycardia, look at

Volume (fluids)

What should you teach a client who has a low blood sugar at AM?

Bed time snack

“CDI” for diabetic feet

• Clean

• Dry

• Injury free

“Foot” for Diabetic Feet Footwear

Avoid

• Flip flops, heels, nylon

• OTC

• Overly hot pads and baths (due to neuropathy) → use thermometer to test bath temp

• Toe injuries

Want

• Closed toed

• Comfortable

• Leather shoes with cotton socks

• Well fitting