Diabetes Mellitus Part 1: Concepts and Clinical Management

• Diabetes Mellitus is a chronic disorder affecting food energy conversion
• About 38 million people in the US have diabetes, which is 1 in every 10 people
• 1 in 5 people are unaware that they have diabetes
• It is a chronic, metabolic disorder that affects how the body turns food into energy
• It is related to insulin deficiency and insulin resistance
• Iatrogenic diabetes is caused by the treatment of another illness
• Diabetes goes away when the treatment is stopped
• The most common cause is steroids

Causes of Iatrogenic Diabetes

• Glucocorticoids
• Antipsychotics
• Antiretroviral
• Immune Inhibitors
• Pre-diabetes is a condition where blood glucose levels are above normal but not high enough for a diagnosis of type 2 diabetes
• It is a condition with elevated blood glucose levels
• 29% of the adult US population has pre-diabetes, which is 98 million people
• US Diabetes Prevalence: 11.2% of the US population has diabetes
• The annual cost of diabetes in the US is $413 billion
• Diabetes is 77% higher in African Americans
• American Indians have the highest prevalence
• It is worse for minorities due to lack of healthcare and lifestyle issues, and a lack of knowledge
• Early death risk is 60% higher with diabetes
• Medical costs are twice as high
• Complications include heart disease, stroke, kidney failure, blindness, and amputation

Obesity Statistics

• 42.4% of US adults are classified as obese
• 30.7% of the US adult population is overweight
• 16.1% of children and adolescents ages 2 to 19 are overweight
• 9.3% of children and adolescents have obesity
• 6.1% of children and adolescents have severe obesity

Diabetes Impact on CV Health

• CV Events are a diabetes impact
• Coronary Artery Disease can occur
• Heart Failure can occur
• Arrhythmias can occur
• Sudden Death can occur
• Body Fat Classifications are Visceral and Subcutaneous

Visceral Fat

• 10-20% in men and 5-7% in women
• It is the first to go in weight loss
• Accumulates with stress
• Surrounds Organs
• It is a predictor of metabolic syndrome
• More insulin-resistant
• Releases high amount of pro inflammatory cytokines

Subcutaneous Fat

• 80% of total body fat
• "Stubborn" fat
• Estrogen increases this type of fat
• May play a protective role
• Less metabolically active
• Normal buffer system for excess energy intake

Pancreas

• The pancreas is an organ in the abdominal cavity with two roles. The first is exocrine: to produce digestive enzymes and bicarbonate, delivered to the small intestine via the pancreatic duct. The second is endocrine: to secrete insulin and glucagon into the bloodstream to regulate blood glucose levels.

Role of Glucose in the Body

• Energy source
• Brain fuel
• Glycogen storage
• Regulator
• Overall metabolism
• Monosaccharide: A single sugar molecule such as glucose or fructose, the simplest type of sugar

Glycemic Effects

• Sources include dietary and endogenous production
• When food is ingested CHO 'glucose is absorbed from intestines into the blood
• When blood glucose increases, the pancreas is triggered to secrete insulin

Gestational Diabetes

• Glucose intolerance occurring during pregnancy
• Increased insulin resistance due to placental hormones
• Inadequate insulin secretion for increased insulin needs
• Potential progression to diabetes is >30% over 15 years
• GDM increased from 6.0% in 2016 to 8.3% in 2021, according to CDC, 2023
• Maternal Obesity and GDM: Obesity promotes insulin resistance

GDM Complications

• Macrosomia in the baby (Big baby)
• Preeclampsia in the mom
• Trauma
• Shoulder dystocia
• Baby hypoglycemia, feed soon after birth
• Marcosomia is an exceptionally large infant with excessive fat deposition in the subcutaneous tissue, most frequently seen in fetuses of diabetic (GDM or DM) mothers
• Preeclampsia is an abnormal condition associated with pregnancy, marked by high blood pressure, proteinuria (protein in the urine), edema, and headache
• Maturity-Onset Diabetes of the Young (MODY) is less common.
• It is autosomal dominant
• It is caused by mutation in a single gene
• Typically develops before age 25

Type 1 Diabetes Mellitus

• Autoimmune destruction of insulin-producing beta cells
• It is insulin-dependent DM
• 80%-90% of 𝛽 cells functions are lost before symptoms
• Type I Diabetes Mellitus Causes: immune response to self antigens in pancreatic 𝛽cells, exposure to virus, exposure to certain climates, gestation period and maternal weight
• 3 P's of Diabetes Type I (MAIN CUES): Polyuria (Excessive Urination), Polydipsia (excessive thirst), Polyphagia (excessive hunger)
• Less common DM I Cues: Tiredness, Weight loss, GI symptoms
• Polyuria: excessive urination
• Polydipsia: excessive thirst
• Polyphagia: excessive hunger
• Type 2 Diabetes Mellitus is characterized by insulin resistance and beta cell dysfunction.
• 𝛽 (beta) cell dysfunction.
• Reduced glucose uptake by muscles and fat cells
• Increased glucose release and production by the liver

Cellular Function in Healthy Body vs T2DM

• In a healthy body, cells efficiently absorb glucose from the blood for energy, with insulin helping to regulate this process. In type 2 diabetes (T2DM), the body's cells become resistant to insulin, causing glucose to accumulate in the bloodstream instead of being used by cells for energy. This leads to higher blood sugar levels and can affect various organs over time.
• Insulin is a hormone regulating glucose uptake in cells.
• It is a hormone made by 𝛽 cells in the Islets of Langerhans of the pancreas.
• It is the key to open the cell membrane
• Insulin Regulation Normal Pathophysiology: Insulin is produced by the pancreas in response to rising blood glucose levels, typically after eating. Insulin facilitates glucose uptake into cells for energy and storage, helping to lower blood sugar levels. It also promotes the storage of fat and regulates protein synthesis.
• Insulin regulation in Type I Pathophysiology: the body's immune system mistakenly attacks and destroys the insulin-producing beta cells in the pancreas. As a result, the pancreas can no longer produce insulin. Without insulin, glucose cannot enter cells for energy, leading to high blood sugar levels.
• Insulin regulation type II pathophysiology: the body develops insulin resistance, meaning the cells become less responsive to insulin. The pancreas initially compensates by producing more insulin, over time, the beta cells become impaired and cannot produce enough insulin to overcome the resistance. This results in elevated blood glucose levels.

T2DM Modifiable Risks

• Obesity
• Hypertension
• Sedentary Lifestyle
• Elevated Cholesterol

T2DM non-modifiable risks

• Age
• Family History
• Race, Ethnicity
• Medical Conditions

DM: Metabolic Syndrome

• Cluster of risk factors that raises your risk for heart disease and other health problems, such as Diabetes:
• Increased BP
• High Triglycerides
• Large Waistline
• Low HDL (Good) Cholesterol
• Elevated Fasting Blood Sugar

Diabetes Screening Tests

• Hemoglobin A1C
• Fasting Blood Sugars (FBS)
• Oral glucose tolerance test (OGTT)
• Hemoglobin A1C test: A test that shows the amount of glucose that sticks to the red blood cell It reflects glucose exposure over the previous 3 months
• Stages of Glucose Tolerance: Normal, Prediabetes, and Diabetes
• Glucose tolerance test: A test of the body's ability to metabolize glucose that involves the administration of a measured dose of glucose to the fasting stomach and the determination of blood glucose levels in the blood or urine at intervals thereafter and that is used especially to detect diabetes.

Normal Glucose Tolerance

• A1C is <5.7%
• FBS is 99mg/dL or less
• Glucose Tolerance test is 140 mg/dL or less

Type 2 Diabetes Mellitus Cues

• Increased urination (polyuria)
• Increased thirst (Polydipsia)
• Increased hunger (Polyphagia)
• Fatigue
• Blurred Vision
• Frequent infections
• Erectile Dysfunction
• pain/tingling in hands and feet
• Diabetes Glucose Tolerance: A1C: 6.5% or above, FBS: 126 mg/dL or above, Glucose Tolerance Test: 200 mg/dL or above
• Prediabetes glucose tolerance: A1C: 5.7-6.4%, FBS: 100-125 mg/dL, Glucose Tolerance Test: 140-199 mg/dL
• Prandial Insulin: Rapid Acting or Mealtime Insulin (humalog or regular insulin), insulin given before meals or insulin given according to amount of carbs ingested, hold if NPO or feedings are interrupted
• Type of insulin that controls glucose production between meals and overnight, is about 50% of daily needs, nearly constant levels and continuous release.
• Bolus Insulin is a type of insulin that is given at mealtimes to control the spike in blood glucose levels that occurs after eating and can also be used for correcting high blood sugar levels at any time during the day

Insulin regulatory functions

• Promotes cellular uptake of glucose, amino acids (protein) and fats.
• Regulate carbohydrates.
• Metabolize lipid and protein.
• Promotes cell division and growth.
• Insulin Mechanism of Action: Allows glucose transport into cells of all tissues, converts glycogen to fat; produces intracellular shift of potassium and magnesium to reduce elevated serum levels of these electrolytes
• Hemoglobin A1C: Measures average blood glucose over 120 days
• Fasting Blood Sugar (FBS): Blood glucose level after 8 hours fasting
• Oral Glucose Tolerance Test (OGTT): Test for glucose tolerance after glucose ingestion, NPO x 8 hours prior to the test, BGM prior to the test, Drink glucose solution, BGM after 2 hours

Hypoglycemia

• "Insulin Shock"
• "The Lows"
• Usually less than 70 mg/dl
• May cause patient to become unresponsive
• Consider any unconscious person hypoglycemic

Hypoglycemia Etiology

• Reactive hypoglycemia
• Too much insulin/oral diabetics
• Fasting hypoglycemia
• Too little food/delayed eating
• Kidney disease/failure
• Strenuous physical activity
• Excessive alcohol consumption
• Fasting Hypoglycemia: pancreas produces too much insulin, even when someone has not eaten, Too little food/delayed eating
• Hypoglycemia Cues: Sweating, Pallor, irritability, Hunger, Lack of coordination, Sleepiness, Headache, Tachycardia, Excessive Hunger, Dizziness
• Hyperglycemia: Condition with elevated blood glucose levels, Usually above 180-200 mg/dL
• Diabetic Ketoacidosis (DKA): Severe hyperglycemia, usually above 300 mg/dL
• Hyperosmolar Hyperglycemic State (HHS): Extreme hyperglycemia, typically above 600 mg/dL

High Blood Sugar Causes in people without diabetes

• Pancreatic diseases
• PCOS
• Cushings
• Surgery
• Stress
• Trauma
• Infection
• Meds side effects
• Hyperglycemia: Additional Etiology (8-I's): Infection, Infarction, Infraction, Infant, Ischemic, Illegal, Iatrogenic, Idiopathic
• S&S of Hyperglycemia (cues): Dry Mouth, Increased thirst, weakness, headache, Blurred vision, Frequent Urination
• Hyperglycemia Cues acronym: WATER: Weakness, Abdominal pain, Tired, Extra thirsty, Really Hot
• Insulin Shock: Severe hypoglycemia causing unresponsiveness
• 15-15 rule (hypoglycemia treatment): Treat hypoglycemia by checking and repeating treatment, Check blood sugar, Treat depending on severity of symptoms, Wait 15 minutes, Recheck blood sugar, If <70 mg/dL, repeat treatment
• Mild Hypoglycemia Treatment: 1/2 cup OJ or fruit juice, 1/2 cup soda/pop, 1 cup fat-free milk, 5 lifesavers candy, Glucose gel or tablet
• Severe Hypoglycemia Treatment: 1mg glucagon IM or SQ, Onset: 10 mins, May cause vomiting, 25g IVP Dextrose over 1 min, rapid onset, may cause phlebitis
• C-Peptide Test: Measures insulin production levels in the body, normal ranges: 0.5 - 2.7 mg/dL, elevated signals Type 2 DM, Decreased level signals type 1 DM
• Elevated C-Peptide Levels: Type 2 DM, Insulinoma, Cushing's Syndrome, Kidney Disease
• Type 1 DM
• Addison's Disease
• Liver Disease
• Insulinoma: a benign tumor of the pancreas that causes hypoglycemia by secreting additional insulin
• Cushings Syndrome: caused by prolonged exposure to high levels of cortisol
• Addisons Disease: a condition that occurs when the adrenal glands do not produce enough cortisol or aldosterone
• Reactive Hyper-glycemia: Post-meal blood sugar spikes due to insulin issues
• Diabetes Complications: Includes heart disease, stroke, kidney failure
• Insulin Regulation differences exist between Normal, Type 1, and Type 2 diabetes
• Diabetes Risk Factors: Includes obesity, hypertension, and sedentary lifestyle

Hyperglycemia Protocol

• Maintain Airway/Oxygen
• Decrease Blood Glucose
• Improve Dehydration (Initially, isotonic solution)
• Hyperglycemia decrease blood glucose: Insulin drip - Regular, Blood sugar check q1, Monitor for hypokalemia

Rapid Acting Insulin

• Lispro (Humalog)
• Aspart (Novolog)
• Glulisine (Apidra)
• Onset: 10 - 15 mins
• Peak: 1 - 2 hours
• duration: 3 - 5 hrs
• Clear appearance
• Intermediate Acting Insulin: NPH (Humulin-N, Novolin-NPH), Cloudy appearance, Onset: 1 - 3 hrs, Peak: 5-8 hrs, duration: up to 18 hrs
• Slow or Long Acting Insulin: Glargine (Lantus), Detemir (Levemir), Clear appearance, Onset: 90 mins, Peak: none, Durations: up to 24 hours