Role of PT in metabolic disorders Diabetes mellitus.pdf

Diabetes Mellitus BY Dr. Mona Abdel Khalek Dr. Mina Atef Dr. Ahmed Abd Elhalim Diabetes Mellitus Definition: metabolic disorder characterized by hyperglycemia due to an absolute or relative lack of insulin or to a cellular resistance to insulin Major classifications • 1. Type 1 Diabetes • 2. Type...

Diabetes Mellitus BY Dr. Mona Abdel Khalek Dr. Mina Atef Dr. Ahmed Abd Elhalim Diabetes Mellitus Definition: metabolic disorder characterized by hyperglycemia due to an absolute or relative lack of insulin or to a cellular resistance to insulin Major classifications • 1. Type 1 Diabetes • 2. Type 2 Diabetes • 3. Gestational Diabetes The bulk of the pancreas is an exocrine gland secreting pancreatic fluid into the duodenum after a meal. Inside the pancreas are millions of clusters of cells called islets of Langerhans. The islets are endocrine tissue containing four types of cells. In order of abundance, they are: beta cells, which secrete insulin and amylin alpha cells, which secrete glucagon delta cells, which secrete somatostatin gamma cells, which secrete a polypeptide. Diagnosis and classification of Diabetes Mellitus • Different blood test • Manifestation Blood Testing for diabetes (1) Fasting Plasma Glucose Test (FPG) - (cheap, fast) *fasting B.G.L. 100-125 mg/dl signals pre-diabetes *>126 mg/dl signals diabetes (2) Oral Glucose Tolerance Test (OGTT) *tested for 2 hrs after glucose- rich drink *140-199 mg/dl signals prediabetes *>200 mg/dl signals diabetes Blood Testing for diabetes • (3) Glycated haemoglobin (HbA1c) • The term HbA1c refers to glycated haemoglobin. It develops when haemoglobin, a protein within red blood cells that carries oxygen throughout your body, joins with glucose in the blood, becoming ‘glycated’. • By measuring glycated haemoglobin (HbA1c), picture of what average blood sugar levels have been over a period of weeks/months. • For people with diabetes this is important as the higher the HbA1c, the greater the risk of developing diabetes-related complications. Blood Testing for diabetes FPG PG IN OGTT HbA1c NORMAL ≤ 100mg/dl < 140mg/dl ≤ 5.7% PREDIABETIC 100-125mg/dl 140-199mg/dl 5.7-6.4% DIABETIC ≥ 126 mg/dl ≥ 200mg/dl ≥ 6.5% Monitor Blood Glucose Level • Glucometer: provides diabetic patients with fast and rather accurate measurements of blood glucose levels. Steps of using Glucometer • Hands should be washed before testing as dirt and residue can lead to inaccuracies. • Insert a single test strip into the glucose meter. • A small drop of blood should be obtained by prinking the finger-tip using the lancet (needle on blood sampling device), where the volume of blood should be sufficient in filling the test field. • Place blood drop onto test strip without smearing it, as smearing can lead to inaccuracies. • Glucose meter will then display the blood glucose level.(Khan et.al 2019) Diabetes Mellitus Diabetes Type 1 Definition • 1. Metabolic condition in which the beta cells of pancreas no longer produce insulin; characterized by hyperglycemia, breakdown of body fats and protein and development of ketosis • 2. Accounts for 5 – 10 % of cases of diabetes; most often occurs in childhood or adolescence • 3. Formerly called Juvenile-onset diabetes or insulindependent diabetes (IDDM) Diabetes Mellitus Pathophysiology • 1. Autoimmune reaction in which the beta cells that produce insulin are destroyed • 2. Alpha cells produce excess glucagon causing hyperglycemia Risk Factors • 1. Genetic predisposition for increased susceptibility • 2. Environmental triggers stimulate an autoimmune response • a. Viral infections (mumps, rubella) • b. Chemical toxins Diabetes Mellitus Manifestations 1. Process of beta cell destruction occurs slowly; hyperglycemia occurs when 80 – 90% is destroyed; often trigger stressor event (e. g. illness) Diabetes Mellitus 2. • • • • Hyperglycemia leads to a. Polyuria (hyperglycemia acts as osmotic diuretic) b. Glycosuria (renal threshold for glucose: 180 mg/dL) c. Polydipsia (thirst from dehydration from polyuria) d. Polyphagia (hunger and eats more since cell cannot utilize glucose) • e. Weight loss (body breaking down fat and protein to restore energy source • f. Malaise and fatigue (from decrease in energy) • g. Blurred vision (swelling of lenses from osmotic effects) Treatment for Type 1 Diabetes • Insulin Therapy • Medical Nutrition Therapy • Physical activity Insulin Therapy • Insulin is the only medication that is effective in lowering blood glucose levels in type 1 diabetes. • The insulin dose depends on basal needs, food intake (especially the total amount of carbohydrate) and amount of physical activity. • Self-blood glucose testing is recommended before each meal and the bedtime snack to help assess the dose and make changes as needed. Medical Nutrition Therapy • Food intake influences the amount of insulin required to meet blood glucose target goals. • Nutritional distribution 50-60% carbohydrate 10-20% protein 30% fat. Saturated fat < 10% of total calories and dietary cholesterol to < 300 mg/day to help reduce the risk of cardiovascular disease. Physical activity • The safe pre-exercise blood glucose (BG) range is from 100-250 mg/dl. • If BG is less or close to 100 mg/dl, have a snack to raise it before exercising. • Avoid exercise if fasting BG is >250 mg/dl and ketones are present. • Identify usual BG response to exercise to determine if insulin must be reduced Physical activity • Be prepared to test in the middle of the night if the exercise is intense or of long duration. • Have carbohydrate (CHO) foods available at all times – before, during and after exercise. • For every hour of exercise, be ready to consume 10-15 grams of carbohydrate. Physical activity • Hypoglycemia (a blood glucose level < 70 mg/dl). • Also called low blood sugar, insulin reaction or insulin shock. • Usually caused by too little food, too much insulin, extra physical activity or delayed meals and snacks. Diabetes Mellitus Diabetes Type 2 • A. Definition: condition of fasting hyperglycemia occurring despite availability of body’s own insulin • B. Was known as non-insulin dependent diabetes or adult onset diabetes – Both are misnomers, it can be found in children and type II DM may require insulin Diabetes Mellitus Diabetes Type 2 Pathophysiology • 1. Sufficient insulin production to prevent DKA; but insufficient to lower blood glucose through uptake of glucose by muscle and fat cells • 2. Cellular resistance to insulin increased by obesity, inactivity, illness, age, some medications Diabetes Mellitus Diabetes Type 2 Risk Factors • 1. History of diabetes in parents or siblings • 2. Obesity (especially of upper body) • 3. Physical inactivity • 4. Race/ethnicity: African American, Hispanic, or American Indian origin • 5. Women: history of gestational diabetes, polycystic ovary syndrome, delivered baby with birth weight > 9 pounds • 6. patient with hypertension; HDL cholesterol < 35 mg/dL, and/or triglyceride level > 250 mg/dl. Diabetes Mellitus Diabetes Type 2 Manifestations 1. patients usually unaware of diabetes • a. Discovers diabetes when seeking health care for another concern • b. Most cases aren’t diagnosed for 5-6 years after the development of the disease • c. Usually does not experience weight loss Diabetes Mellitus 2. Possible symptoms or concerns • a. Hyperglycemia (not as severe as with Type 1) • b. Polyuria • c. Polydipsia • d. Blurred vision • e. Fatigue • f. Paresthesias (numbness in extremities) • g. Skin Infections Complications of Diabetes Mellitus • • • • • • • 1- Coronary Artery Disease 2- Hypertension 3- Stroke 4- Peripheral Vascular Disease 5- Diabetic Retinopathy 6-Diabetic Nephropathy 7-Male erectile dysfunction Complications of Diabetes Mellitus 1- Coronary Artery Disease • 1. Major risk of myocardial infarction in Type 2 diabetics – Increased chance of having a silent MI and delaying medical treatment • 2. Most common cause of death for diabetics (40 – 60%) • 3. Diabetics more likely to develop Congestive Heart Failure Diabetes Mellitus 2- Hypertension • 1. Affects 20 – 60 % of all diabetics • 2. Increases risk for retinopathy, nephropathy Diabetes Mellitus • 3- Stroke: – Type 2 diabetics are 2 – 6 times more likely to have stroke as well as Transient Ischemic Attacks (TIA) or mini stroke Diabetes Mellitus 4- Peripheral Vascular Disease • 1. Increased risk for Types 1 and 2 diabetics • 2. Development of arterial occlusion and thrombosis resulting in gangrene • 3. Gangrene from diabetes most common cause of non-traumatic lower limb amputation Diabetic Foot Ulcer Diabetes Mellitus 5- Diabetic Retinopathy 1. • 2. • • 3. 4. – Definition a. Retinal changes related to diabetes Hemorrhage, swelling, decreased vision Leading cause of blindness ages 25 – 74 a. Affects almost all Type 1 diabetics after 20 years b. Affects 60 % of Type 2 diabetics Diabetics should be screened for retinopathy and receive treatment (laser photocoagulation surgery) to prevent vision loss Diabetics also have increased risk for cataract development Diabetes Mellitus 6-Diabetic Nephropathy • 1. Definition: glomerular changes in kidneys of diabetics leading to impaired renal function • 2. First indicator: microalbuminuria • 3. Diabetics without treatment go on to develop hypertension, edema, progressive renal insufficiency • a. In type 1 diabetics, 10 – 15 years • b. May occur soon after diagnosis with type 2 diabetes since many are undiagnosed for years • 4. Most common cause of end-stage renal failure . Diabetes Mellitus 7-Male erectile dysfunction – Half of all diabetic men have erectile dysfunction Treatment for Type 2 Diabetes • Glucose Lowering Therapy • Medical Nutrition Therapy • Physical activity Glucose Lowering Therapy • • • • lifestyle modifications insulin therapy oral agents any combination of these factors. Medical Nutrition Therapy • • • • • General Guidelines for Food Intake: Decrease saturated fat intake. Eat 3 meals and 1 snack on a regular schedule. Try not to skip meals. Check blood glucose level 2 hours after eating. (If >180 mg/dl, so there are more carbohydrate than body could handle). Physical activity • Exercise planning: a. Medical evaluation b. Exercise prescription Physical activity Medical evaluation • Men ≥40 years and women ≥50 years who would like to perform heavy exercise must undergo an exercise stress test that is supervised by a physician. • Individuals who did not participate in exercise until the age of 20 years should be advised not to perform heavy exercise, but rather light aerobic exercise, at the start of an exercise program Physical activity Medical evaluation • For individuals at risk, ECG and blood pressure evaluations should be performed by a physician before the individual participates in an exercise program. A treadmill stress test is recommended for these individuals. • Patients that have severe arterial problems like angina pectoris, claudication or proliferative retinopathy should not perform heavy exercise. Exercise prescription • For the elderly and other individuals who struggle with ambulation, non-weight bearing exercises are recommended initially, for example riding a bicycle, swimming or light exercise in the water. These activities will enhance their exercise capacity. Exercise prescription • For other individuals, weight-bearing exercises such as walking, jogging, or rhythmic group dancing are recommended. • Walking is the preferred exercise modality as it is cheap and easy to perform. When starting an exercise program, this may be the exercise of choice. Exercise prescription • Exercise to diaphragm muscles to improve pulmonary capacity. • Improving exercise capacity through walking and strengthening the rectus abdominus reduces fatigue and improves recovery time after exercise. Exercise prescription • Patients suffering from neuropathic pain and who have problems with their lower extremities may prefer swimming, cycling at home or exercises performed while sitting. Phases of an exercise program • The warm-up phase the first 5-10 minutes of an exercise session that prepares individuals for the main conditioning phase of the session. • The second conditioning phase includes 20- 40 minutes of continuous exercise that is performed at a specific intensity. • The cool down phase is period that lasts for 5-10 minutes. • It is crucial that an individual performs the warm-up and cool-down phases to ensure adequate preparation and recovery from exercise, respectively. Intensity, duration and frequency of exercise • Generally, the method used to prescribe exercise intensity is to base each session on a specific percentage of an individual’s agepredicted maximum heart rate. • For a healthy beginner, prediction of their maximum heart rate can be determined using 220 - age. Intensity, duration and frequency of exercise • The metabolic equivalent (MET) unit is used to represent exercise intensity. One MET represents 3.5 mL O2 uptake (oxygen consumption) per kg of muscle mass and is considered to be the metabolic rate of an individual at rest Physical Activity Intensity in MET • Light intensity : Less than 3 MET • Moderate intensity: 3-6 METs with the equivalent heart rate being 50-60% of maximal heart rate. • High intensity: greater than 6 METs with the equivalent heart rate being ≥70% of maximum. Moderate & Vigorous Intensity Physical Activities Moderate: • Brisk walking, Recreational swimming, Volleyball, Slow aerobics. Vigorous: • Jogging, Running, Tennis-single, Basketball, Rope skipping, Squash, Fast aerobics, Fast cycling, Stepping, Exercise progression • Intensity, duration, and frequency of an exercise are increased slowly over a number of months. Preparing patient for exercise: • 1. food supplementation:individuals who have a tendency towards hypoglycemia are advised to perform exercise after eating appropriate food so that they can perform exercise without the risk of developing hypoglycemia. Classification of Exercise • Aerobic exercise: Endurance type exercise, rhythmic, sustained for sometimes. Example: Walking, jogging, running, cycling, swimming, etc… Strength (Resistance) exercise: Weight training with free weight, machine, elastic rope, calisthenics, etc… Flexibility exercise: Stretching exercise. Response to 100 g of glucose in mild Type 2 Diabetics 12 months of Training Plasma Glucose (mmol/l) 20 15 10 5 Before After 0 0 30 60 90 Time (min) 120 150 180 Summery 0f Exercise Prescription for Diabetic Exercise Prescription for Diabetic 1/4 Aerobic activity for 30 min. extended (gradually) to 60 min. every day or most days/week. HR during activity should be gradually increased to reach 60 – 70% of HR max. Exercise session should include 5-10 min. of warm-up and a 5 min of cool-down. Exercise must involve most major muscles in both lower and upper parts of the body. Exercise Prescription for Diabetic 2/4 Exercise must be regular. Benefits are diminished after 1 -2 weeks of stopping . Moderate intensity weight training program is recommended to maintain muscle strength ( 8-12 repetitions 2 times /week). For those with feet problems, avoid running. Alternate between walking, swimming, and cycling. Exercise Prescription for Diabetic Use proper shoes, with silica gel or air-filled soles, and always keep feet dry. When using insulin, avoid exercise if glucose levels below 100 mg/dl or above 250 mg/dl. Do not inject insulin into a body part that is expected to be used during exercise. Avoid dehydration by keeping body always hydrated. Hypoglycemia during or after Exercise • It will most likely occur if the patient: – – – – Takes insulin or diabetes pill. Skips a meal. Exercises for a long time. Exercises strenuously. If it occurs, what can be done?    Patient must eat a snack before exercise. Adjusts the medication dose. Remember: Patient should always carry a source of Carbohydrate (CHO) with him ( An apple or orange juice, or a piece of fruit). Contraindications for exercise • • • • • • • 1. Excessive tiredness 2. Hunger 3. Cold sweating 4. Tachycardia 5. Dizziness 6. Nausea and vomiting 7. Hypoglycemia Contraindications for exercise • 8. Chest pain or heaviness on the chest • 9. Impaired consciousness • 10. Excessive sweating and feeling of excessive mouth dryness. • 11. Pain at any location or sensation of cramping • 12. Balance impairment • 13. Blurred vision Contraindications for exercise • 14.Low back pain or bleeding during pregnancy • 15. Fatigue • 16. Hypoglycemia • 17. Dehydration • 18. Uncontrolled hypertension • 19. Arrhythmia with syncope • 20. Unhealed injuries