Lecture W10 Diabetes and Metabolic Diseases PDF

Summary

This lecture provides a detailed overview of diabetes and metabolic syndrome. It covers topics of pathophysiology, presentation, and management of these conditions, particularly relevant to the Australian population.

Full Transcript

Diabetes and metabolic syndrome Brooke Coombes [email protected] Learning outcome • Describe the pathophysiology and presentation of diabetes and metabolic syndrome and their complications • Recognise symptoms of hypoglycaemia & hyperglycaemia • Describe the common macro/microvascular comp...

Diabetes and metabolic syndrome Brooke Coombes [email protected] Learning outcome • Describe the pathophysiology and presentation of diabetes and metabolic syndrome and their complications • Recognise symptoms of hypoglycaemia & hyperglycaemia • Describe the common macro/microvascular complications of diabetes • Discuss the management of diabetes and role of physiotherapy Prevalence in Australia ABS (Australian Bureau of Statistics) 2018. National Health Survey: First Results, 2017–18. ABS cat. no. 4364.0.55.001. Canberra: ABS. Impact • Diabetes is associated with many complications • 2-4 times more likely to develop heart disease or stroke • Hypertension, retinopathy, neuropathy, kidney disease • Life expectancy reduced by 8.2 and 7.5 years in men and women, respectively, when T2DM is diagnosed at the age of 50 years • Financial & economic consequences Definition • Diabetes is a group of metabolic diseases characterized by • Hyperglycaemia resulting from defects in insulin secretion, insulin action, or both • Long term damage, dysfunction and organ failure associated the chronic hyperglycaemia, especially Glucose (sugar) • Main source of energy for cells that make up brain, muscle, fat and other tissues • Brain requires a continuous supply of glucose – hence blood glucose is tightly regulated • Glucose comes from 2 major sources – food & liver • Liver stores and makes glucose Insulin • Insulin regulates how much glucose is in the blood • Insulin enables glucose to enter cells Glucose regulation • Insulin is a hormone that is secreted from pancreatic β cells • Glucagon is secreted by pancreatic alpha cells • Insulin & glucagon have opposite action Glucose regulation • After eating, glucose is absorbed into the bloodstream • Glucose in the blood triggers the pancreas to secrete insulin • Insulin enables glucose to enters cells • Liver stores glucose (as glycogen) àblood glucose drops à pancreas releases less insulin Glucose regulation • When glucose levels are low (e.g. haven’t eaten in a while): • Liver breaks down stored glycogen into glucose à keeps glucose level within a normal range Glucose regulation • In Type 1 Diabetes, the immune system destroys Beta cells in pancreas à body secretes little to no insulin à acute hyperglycaemia Glucose regulation • In Type 2 Diabetes, glucose isn’t taken up by cells (they are resistant to the action of insulin) • This stimulates the pancreas (Beta cells) to release more insulin à hyper-insulinaemia • Eventually the Beta cells become impaired and can’t make enough insulin to meet the body’s demands (insulin secretion problem) à hyperglycaemia 2 1 Glucose dysregulation in diabetes • Hyperinsulinaemia is seen early • Hyperglycaemia tends to develop slowly over months or years • Over time, treatment requirements escalate • Diabetes is a chronic progressive disease Davidson’s Principles and Practice of Medicine 23rd Ed Classification • 4 classes of diabetes • Additional related conditions/terms • Type 1 Diabetes • Pre-diabetes (high risk of diabetes) • Type 2 Diabetes • Metabolic syndrome • Gestational Diabetes (GDM) • Other Type 1 Diabetes (T1D) - Terminology • Formerly called: • Insulin-dependent Diabetes Mellitus • Juvenile Onset Diabetes Type 1 Diabetes (T1D) - Pathophysiology • Insulin secretion deficiency • Autoimmune disease involving destruction of β-cells à pancreas does not produce enough insulin • Genetic and/or environmental factors (eg viruses) • May have associated autoimmune disorders including thyroid disease, coeliac disease Type 1 Diabetes (T1D) - Presentation • Hyperglycaemic symptoms (thirst, polyuria, nocturia, fatigue), infections & weight loss • +/- Symptoms of ketoacidosis (rapid breathing, flushed cheeks, abdominal pain, sweet acetone smell, vomiting, dehydration hypotension, tachycardia, hypothermia, drowsiness)= medical emergency • Most cases detected soon after symptoms develop • Most common onset 5-7 years, but can onset in adults Type 2 Diabetes (T2D) - Terminology • Formerly called: • Adult Onset Diabetes • Non-insulin dependent Diabetes Mellitus (NIDDM) Type 2 Diabetes (T2D) – Pathophysiology • Insulin resistance (with or without insulin secretory defect) • 2 interrelated problems • Cells respond poorly to insulin and take in less sugar • Over time the pancreas doesn’t produce enough insulin Type 2 Diabetes (T2D) – Risk factors • Caused by genetic, environmental and lifestyle factors • Obesity • Inactivity • Family history • Ethnicity • Age • Prediabetes • Polycystic ovary syndrome Type 2 Diabetes (T2D) – Risk factors • • • Overweight or obese • Risk of T2D increases 10-fold in people with BMI > 30kg/m2 Fat distribution – storing fat around waist rather than hips • Risk of T2D rises if waist circumference > 101cm (men) or 89cm (women) Blood lipids – Risk of T2D increases if low HDL cholesterol and high triglycerides • Inactivity • Physical activity helps control your weight (uses glucose) • Physical activity makes your cells more sensitive to insulin • Ethnicity –Black, Hispanic, Native American, Asian and Pacific islanders > White people ↑ risk of T2DM according to BMI: Slide sourced from ADA Type 2 Diabetes (T2D) - Presentation • Symptoms develop slowly (can be present for years before Dx) • Hyperglycaemic symptoms (thirst, polyuria, nocturia, fatigue), infections & weight loss • Often not diagnosed until complications appear • e.g. numbness or tingling in hands/feet • Many cases undiagnosed Gestational Diabetes • Diagnosed during pregnancy in otherwise ‘non-diabetic’ women • Characterised by insulin resistance • Hormones block insulin action • Typically presents between 24th-28th week of pregnancy • Usually resolves after delivery • Increased risk of T2D developing later Pre-diabetes • Pre-diabetes is a condition in which blood glucose is higher than normal, but not high enough to be classified as diabetes • If left untreated, pre-diabetes often progresses to T2D Metabolic syndrome • Cluster of the most dangerous cardiovascular risk factors: • Diabetes or pre-diabetes • Abdominal obesity • Dyslipidaemia • High BP Metabolic syndrome IDF =International Diabetes Federation Metabolic syndrome • 20-25% of world’s adult population have metabolic syndrome • Adults with metabolic syndrome are • 3 times likely to have a heart attack or stroke • 5 fold greater risk of developing T2D • The more components of the metabolic syndrome – the higher the cardiovascular mortality rate Diagnosis of diabetes The Royal College of Pathologists of Australasia criteria Investigations • Fasting plasma glucose (FPG) • Glycated haemaglobin (HbA1c) • Oral glucose tolerance test (OGTT) • Ketones • Continuous glucose monitoring (CGM) • Islet autoantibodies Investigations • Plasma glucose or blood glucose • Measure of ‘acute’ blood glucose control • Easy to measure, but day-day variation Investigations • Glycated haemaglobin (HbA1c) • Gold standard measure of glycaemic control • Reflects blood glucose control over last 2-3 months (life of the red blood cell) • Test every 3-6 months • HbA1c aim: <7% Investigations • Oral glucose tolerance test (OGTT) • Blood glucose measured after fasting and then again 2hrs after drinking a standardized glucose rich drink Investigations • Ketones • People with T1D measure ketones (in urine or blood) if hyperglycaemia is suspected Investigations • Continuous glucose monitoring (CGM) Investigations • Islet autoantibodies • As T1D involves autoimmune destruction of pancreatic β cells • If islet autoantibodies are present, supports diagnosis of T1D Complications of diabetes Complications of diabetes • People with diabetes AND pre-diabetes have increased risk of CVD i.e. heart disease, stroke, high BP, atherosclerosis • This is known as “macrovascular complications” (disease of large vessels) Complications of diabetes • Diabetes also damages small blood vessels • Retinopathy • Nephropathy • Peripheral neuropathy • Autonomic neuropathy • Known as “Microvascular disease” • Prevalence increases with duration of diabetes and degree of metabolic control Complications of diabetes • Diabetes results in low grade inflammation and accumulation of advanced glycation end-products (AGEs) à alter cross-linking in connective tissues • Impaired wound healing - risk of ulcers/amputation • Tissue stiffness – rheumatological problems • Chronic pain Impact on physical activity Complications of diabetes • Sleep apnoea • Hearing impairment • Alzeimers disease and other dementia • Psychosocial issues Diabetic peripheral neuropathy • Affects 50% of patients with diabetes • Glove & stocking distribution • Sensory loss - numbness • +/- Neuropathic pain - burning/shooting/allodynia • Mononeuropathy eg carpal tunnel syndrome Autonomic neuropathy • Parasympathetic or sympathetic nerves may be affected in one or more visceral systems • Cardiovascular – orthostatic hypotension, resting tachycardia, fixed heart rate • Gastrointestinal/urinary – dysphagia, nausea, incontinence • Thermoregulation – cold feet, dependent oedema Charcot neuropathy • Progressive condition affecting bones of foot • Inflammation (red, hot swollen foot) then bony destruction --> subluxation, pathological fractures à deformity à remodeling of fracture • Treatment – • Acute phase - immobilization, eg aircast, avoid WB • Post-acute phase –progressive loading of tissues Rheumatological and musculoskeletal conditions • Widespread chronic pain (>3 sites) in 1 in 3 people with T2D • Adhesive capsulitis, tendinopathy, dupuytren’s contracture, limited joint mobility syndrome, osteoarthritis • Prevalence ~2 x greater in T2D than general population Psychological issues • Depression, anxiety • Fear of hypo’s • Fear of amputation • Fear of injury Impact on quality of life Hypoglycaemia • People with diabetes are at risk of hypoglycaemia, especially if: • Taking insulin or sulphonylurea drugs • Malabsorption problems eg coeliac disease, or eating disorder • Concurrent illness or other medical conditions eg renal impairment • Prolonged aerobic exercise Hypoglycaemia • Defined as blood glucose < 4mmol/L (‘4 is the floor’) • Symptoms of hypoglycaemia • Autonomic – sweating, trembling, pounding heart, hunger, anxiety • Drowsiness, speech difficulty, incoordination, irritability • Nausea, headache, tiredness Hypoglycaemia Treatment of hypoglycaemia • Depends on severity and conscious level • Try to identify the cause • Oral carbohydrate eg milk, juice, jelly beans • Repeat blood glucose measurement 5-15mins later • If remains < 4mmol/L after 3 cycles contact a doctor • Not to drive if <5mmol/L Management of diabetes Management of diabetes • Goals • Aim for HbA1c <7% • Reduce risk of microvascular and macrovascular complications + other risk factors • Promote self-management • Improve quality of life Management of diabetes • Multidisciplinary team • Endocrinologist, GP, Dietician, Diabetes Educator, Accredited Exercise Physiologist (AEP), Psychologist, Podiatrist, Physiotherapist • Regular follow-up • * Approx. 80% of all patients visiting physiotherapists in outpatient settings have diabetes, prediabetes or risk factors associated with diabetes (Hansen et al 2013) Management of diabetes • Diet + lifestyle modification • Medication • Oral antidiabetic drugs • Injections In T1D urgent treatment with insulin is required In T2D, first approach involves diet/lifestyle Medication • Drugs to reduce hyperglycaemia include: • Metformin (helps body be more sensitive to insulin) • Sulphonylureas (promotes insulin secretion) • Insulin injection –short/long acting, different dosing regimes, insulin pumps • Varied side effect profiles eg insulin has increased risk of weight gain, & hypoglycaemia Exercise for people with Pre-diabetes • >3000 “Pre-diabetics” monitored for 2.8 years • Randomised to • • Lifestyle intervention (150mins brisk walking/wk + diet) • Metformin • Placebo Results – Risk of developing T2D compared to placebo was • 58% lower risk for lifestyle group • 31% lower risk for metformin group Knowler et al. (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346: 393-403 Exercise for people with T2D • Exercise (12 weeks combined resistance and endurance training) shown to reduce HbA1c by 0.7-0.8% in T2D • By comparison, treatment by metformin showed same reduction • Exercise training did not change body weight (may be due to reduced fat mass but increased muscle mass) Mechanisms of effect • Acute effects of a single bout of exercise à Immediate lowering of blood glucose • Dependent on intensity /duration of activity • Stimulates glucose uptake from blood into skeletal muscle • Increased insulin sensitivity – up to 72hrs following a single bout Colberg (2019) Physical activity, exercise and diabetes Mechanisms of effect • Exercise also has benefits on • Chronic low grade inflammation (antiinflammatory effects) • Endothelial (vasodilatory) dysfunction • Reducing hypertension Colberg (2019) Physical activity, exercise and diabetes Exercise prescription for people with T2D • People with T2D should permanently (lifelong) exercise 5 days per week • Combination of aerobic and resistance exercise • 210 mins moderate intensity or 125 mins vigorous intensity • Plus 2 or more resistance training sessions per week • Exercise ideally on most days of the week Exercise prescription for people with T2D • Avoiding physical activity carries greater risks than engaging in physical activity, however precautions are needed and should consider any comorbidities • Physiotherapists should be aware of absolute and relative contraindications to exercise • Pre-participation screening can help detect risks Screening in people with diabetes • Refer to GP before initiating exercise if (Hansen et al 2013) • Untreated hypertension (BP>140/90 mmHg) • Angina • Previously undetected heart rhythm disturbances • Untreated intermittent claudication • Fasting hyperglycaemia (FBG > 16.8 mmol/L) • frequent hypoglycamic episodes • Untreated wounds in legs • Cachexia or sudden weight loss • Untreated autonomic or peripheral neuropathy or visual disturbances Screening in people with diabetes • Pre-participation screening eg. PAR-Q • Measure resting BP, HR (if BP > 140/90 mmHg or HR > 100bpm or <60bpm with clinical symptoms require further attention) • Exercise testing with continuous ECG monitoring is often done, esp if diabetes > 10 yr, hypertension, smoker, dyslipidaemia, retinopathy, nephropathy, diagnosed or suspected CAD, PAD, CVD, autonomic nephropathy Screening in people with diabetes • Evaluation of autonomic neuropathy • HR & BP changes from supine to standing (orthostatic hypotension = SBP drop > 30mmHg or DBP drop > 10mmHg • Slowed HR recovery after exercise Screening in people with diabetes • Evaluation of peripheral vascular status – pain (neuropathic or intermittent claudication), colour, temperature, pulses, nails • Evaluation of neurologic system sensation, neuropathic symptoms • Inspection of feet – colour, cracking, infection, ulcers, blisters • Musculoskeletal risk factors – deformity, muscle wasting, contracture • Falls risk • Evaluation of physical activity levels – pedometer, accelerometer, HR Screening in people with diabetes • Body composition – waist circumference, DEXA • BMI is less valid estimate esp if strength-trained individuals, older people or fluid disturbances • Physical fitness – gold standard =cardiopulmonary exercise test (CPET) – provides V02 & medical safety of exercise • Other submaximal tests e.g. 6MWT • Muscle strength – dynamometry, grip, sit-stand test Screening in people with diabetes • Physiotherapists should also be aware of conditions that might increase the risk of complications during exercise • Hypoglyceamia • Foot trauma, falls, injury • Retina damage Screening in people with diabetes • Hypoglycaemia is a common complication during exercise esp if unstable T2D. Risk factors include • Insulin or sulponylurea medications • Greater exercise volume of muscle recruitment • Pre-ex BG < 5.5 mmol/L • If BG < 4.2 mmol/L consume 15g jellybeans ahead of exercise • Have jellybeans available and monitor for symptoms Exercise for people with T2D Special considerations • Exercise with a partner, take carbohydrate • Ensure adequate fluid intake, environmental temperature • Monitor exercise responses • B-blockers affect heart rate response to exercise Exercise for people with T2D Special considerations if diabetic neuropathy or peripheral vascular disease • Regular foot inspection • Appropriate shoes • Patients who are active (even with weight bearing exercise) do not seem to increase their risk of ulcers • Limit high impact/weight bearing exercise if advanced neuropathy • Gradual increase in loads • May impact gait/balance Exercise for people with T2D Special considerations if retinopathy • Avoid higher intensity exercise • Avoid activities which elevate BP significantly – jarring, head down, valsalva Exercise for people with T1D • Special considerations • Generally, no restrictions if blood glucose (BG) is well controlled • If control is good, exercise helps lower BG • If control is poor, exercise exacerbates increased or decreased BG Exercise for people with T1D Special considerations • GOAL –at least 30 mins of moderate intensity exercise daily • Monitoring blood sugar frequently • Adjusting insulin and consumption of carbohydrates • Ideally exercise at same time of day and similar intensity • Risk of hypoglycaemia is lower with interval training Special considerations for Gestational diabetes Special considerations for Gestational diabetes • Pregnant women with or at risk of GD should engage in 20-30min of moderate intensity exercise on most or all days of the week • Stop exercise if • vaginal bleeding, dizziness, headache, chest pain, muscle weakness, preterm labour, decreased foetal movement, amniotic fluid leakage, calf pain or swelling and dyspnoea without exertion. Checklist prior to exercise • Gather relevant info on day of exercise • How are you feeling today? Any new symptoms, current health • What & when did you last eat? • What medications have you taken? • Check blood glucose level • BP, HR Physiotherapists play a role in • Assessing symptoms, medical history, musculoskeletal, orthopaedic • Monitoring functional ability • Goal setting • Long term behaviour change Communication • Optimal communication can increase motivation, health and wellbeing of people with diabetes. • Careless or negative language can be de-motivating, is often inaccurate and can be harmful. References • Davidson’s Principles and Practice of Medicine (2018) Ralston et al (Ed.) Elsevier Edinburgh • Cox et al (2019) Not a painless condition: Rheumatological and Musculoskeletal Symptoms in T2D and the implications for exercise participation. Current Diabetes Reviews • Hansen et al (2013) Exercise assessment and prescription in patients with T2D in private and home care setting References • Turner et al (2019) Resources to Guide Exercise Specialists Managing Adults with Diabetes Sports Medicine https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6546780/ • Hordern (2012) Exercise prescription for patients with T2D and prediabetes: A position statement from Exercise and Sports Science Australia JSAMS 15(2012) 25-31 • Diabetes Australia (2011) Position statement – A new language for diabetes https://static.diabetesaustralia.com.au/s/fileassets/diabetesaustralia/f4346fcb-511d-4500-9cd1-8a13068d5260.pdf THANK YOU

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