Chapter 9 Part III Diabetes

Chapter 9: Diabetes

Overview

• Dr. Lisa Kappes, Cardiopulmonary, February 2025

• Discussion includes guidelines for cardiopulmonary rehabilitation and focuses on diabetes from pages 97 to 148, using material adapted from A. L. Albright.

Definition of Diabetes Mellitus

• Diabetes mellitus refers to a collection of metabolic diseases marked by an inadequate production of insulin or the body's failure to utilize insulin efficiently.

• The primary outcomes are often hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar).

Effects of Diabetes

• Diabetes significantly endangers affected individuals by putting them at risk for various complications:

  • Microvascular diseases:

    • Retinopathy (damage to the eyes)

    • Nephropathy (kidney damage)

  • Macrovascular diseases:

    • Cardiovascular issues (heart diseases)

    • Cerebrovascular disorders (stroke)

  • Neuropathies:

    • Autonomic (affecting involuntary functions)

    • Peripheral (nerves outside the brain and spinal cord)

• A critical consequence of diabetes involves protein leakage in the urine, indicating kidney impairment.

Scope and Statistics

• Approximately 26 million people in the United States live with diabetes, with about 25% remaining undiagnosed.

• The prevalence of diabetes has tripled over the past 30 years, with predictions indicating a doubling in the next 15 to 20 years, becoming a global epidemic.

  • Contributing factors include rising obesity rates, sedentary lifestyles, and an aging population.

• Diabetes-related mortality rates are double those of age-matched non-diabetics, leading to healthcare expenses exceeding $174 billion annually.

Pathophysiology of Diabetes

• Types of Diabetes:

  • Type 1 Diabetes:

    • Results from the destruction of beta cells, leading to a deficiency of insulin. This type may be autoimmune or idiopathic.

  • Type 2 Diabetes:

    • Characterized by a spectrum of issues ranging from insulin resistance to deficiencies in insulin secretion.

• Other diabetes variants may include genetic defects affecting beta-cell function or insulin action, pancreatic diseases, drug-induced conditions, infections, or gestational diabetes.

Disorders of Glycemia

• Glycemic levels are classified as follows:

  • Normoglycemia: Normal blood sugar levels.

  • Hyperglycemia: Elevated blood sugar levels.

  • Impaired glucose tolerance: Intermediate stage leading to diabetes mellitus.

  • Diabetes mellitus types: Type 1a, Type 2, gestational diabetes, etc., with different management strategies regarding insulin requirements.

Complications of Diabetes

• Acute Complications:

  • Hyperglycemia may escalate into diabetic ketoacidosis (DKA) or hyperosmolar non-ketotic syndrome, mainly observed in Type I but can occur in Type II.

  • Hypoglycemia can occur from excessive insulin intake or inadequate carbohydrate consumption.

• Chronic Complications:

  • Macrovascular problems affecting the heart and blood vessels.

  • Microvascular complications affecting vision and kidney function.

  • Developing neuropathic conditions affecting both peripheral and autonomic systems.

Clinical Considerations

• Recognizable signs and symptoms include:

  • Polydipsia (excessive thirst)

  • Polyuria (frequent urination)

  • Unexplained weight loss

  • Slower healing of infections and cuts

  • Blurry vision and fatigue.

History and Physical Exam

• A thorough medical history should address:

  • Laboratory evaluations of HbA1c, plasma glucose levels, lipids, and proteinuria.

  • Blood pressure management, self-monitoring of blood glucose, and body weight.

  • A physical examination should focus on potential diabetic complications like elevated heart rate, loss of sensation, and retinal abnormalities.

Diagnostic Testing

• The American Diabetes Association (ADA) recommends testing for:

  • Individuals who are inactive, with a family history of diabetes, members of high-risk racial or ethnic groups, and certain health conditions associated with insulin resistance.

  • Testing parameters include high blood pressure, abnormal lipid profiles, and HbA1c values.

Exercise Testing Recommendations

• Cardiovascular exercise testing is advised for:

  • Individuals aged over 40 or with diabetes for over 10 years,

  • Those with hypertension, dyslipidemia, retinopathy, nephropathy, or known cardiovascular diseases, among other conditions.

Treatment Approaches

• Medical Nutrition Therapy (MNT):

  • Focuses on dietary plans aiming at significant weight loss through meal replacements or surgical interventions.

• Self-Monitoring and Education:

  • Diabetes self-management education (DSME) is crucial, provided by certified professionals.

• Medications:

  • Various insulin types include rapid-acting, short-acting, intermediate-acting, and long-acting insulin, necessitating collaboration among the healthcare team and patient education.

Monitoring and Management

• Continuous oversight of HbA1c levels, regular eye and foot exams, blood pressure, and lipid assessments is essential to maintain optimal blood sugar levels.

• Exercise plays a key role in blood glucose management and cardiovascular risk reduction.

Exercise Recommendations

• Patients should aim for:

  • 150 minutes of moderate exercise weekly or 60 to 75 minutes of vigorous activity, factoring in individual health risk profiles and diabetes complications.

Conclusion

• Management of diabetes necessitates ongoing attention to exercise and blood glucose monitoring to mitigate risks associated with acute hypoglycemia and improve overall health outcomes.