Power point presentation on Type 2 Diabetes Mellitus

Presentation on Diabetes Mellitus

1. A presentation on DIABETES MELLITUS

2. OUTLINE Definition Prevalence The pancreas Types of Diabetes Symptoms of diabetes mellitus Diagnostic criteria for DM Risk factors Complications of diabetes Management of diabetes Physical activity in diabetes Case study

3. Definition Diabetes (DYE-ah-BEE- teez ) mellitus: a group of metabolic disorders characterized by hyperglycemia and disordered insulin metabolism . It is defined as Fasting Blood Sugar ≥ 126mg/ dL or Random Blood Sugar ≥200mg/ dL Diabetes = siphon (in Greek), referring to the excessive passage of urine that is characteristic of untreated diabetes Mellitus = sweet, honey-like Insulin

4. PREVALENCE of diabetes One of four priority non-communicable diseases (NCDs) targeted by world leaders. Globally: DM caused 1.5million death in 2012 43% of these deaths occur under the age of 70 The prevalence of DM among adults has risen from 108 million (4.7%) in 1980 to 422 million (8.5%) in 2014 (WHO, 2016) DM will be the 7 th leading cause of death in 2030 ( Mathers and Loncars , 2006)

5. THE PANCREAS 1 2 3

6. FUNCTIONS OF THE PANCREAS Exocrine Functions contains exocrine glands that produce  enzymes important to digestion. trypsin and chymotrypsin Amylase  lipase  Endocrine functions  consists of islet cells (islets of Langerhans ) that create and release important hormones  directly into the bloodstream Insulin Glucagon Other hormones; amylin , somatostatin , & pancreatic polypeptide

7. TYPES OF DIABETES MELLITUS Type 1 Diabetes : Type 2 Diabetes Gestational Diabetes (GDM) Impaired Glucose Tolerance (IGT) and Impaired Fasting Glyceamia (IFG) Other types (drug-induced, pancreatitis)

8. Feature Type 1 Type 2 Prevalence in diabetic population 5% to 10% of cases 90% to 95% of cases Age of onset <30 years >45 years (increasing in children and adolescents) Associated conditions Autoimmune diseases, viral infection, inherited factors Obesity, aging, inherited factors Major defect Destruction of pancreatic beta cells; insulin deficiency Insulin resistance; insulin deficiency (relative to needs) Insulin secretion Little or none Varies; may be normal, increased, or decreased Requirement for insulin therapy Always Sometimes Other names Juvenile-onset diabetes Insulin-dependent diabetes mellitus (IDDM) Ketosis-prone diabetes Adult-onset diabetes Noninsulin-dependent diabetes mellitus (NIDDM) Ketosis-resistant diabetes Features of Type 1 and Type 2 Diabetes

9. PATHOPHYSIOLOGY OF DM

10. DIABETIC METABOLISM

11. RISK FACTORS

12. testing FOR blood sugar levels Wash your hands or clean your finger or other site with alcohol. If you are using alcohol, let it dry before you prick your finger.   Prick the site with a lancing device.   Put a little drop of blood on a test strip.   Follow the instructions for inserting the test strip and using the blood glucose meter.   The blood glucose meter reads your blood sugar level. Blood Glucose Meter

13. Fasting blood glucose mg/ dL Random glucose mg/ dL 2hr-Oral Glucose Tolerance Test mg/ dL Glycosylated Haemoglobin A1C (HbA1C) (%) Normal < 100 < 200 < 140 Pre-diabetes 100 -126 (IFG) 140 – 199 5.7% - 6.4% Diabetes ≥ 126 ≥ 200 ≥ 200 ≥6.5% DIAGNOStic criteria

14. ACUTE COMPLICATIONS OF DIABETES Diabetic Ketoacidosis in Type 1 Diabetes Hyperosmolar Hyperglycemic State in Type 2 Diabetes Hypoglycemia

15. Chronic complications of diabetes mellitus Chronic complications Macrovascular Microvascular Peripheral vascular diseases Ischaemic heart disease Stroke Retinopathy Neuropathy Nephropathy

16. COMPLICATIONS OF DIABETES

17. DIABETIC FOOT Grade 0 – No ulcer in the high risk foot Grade 1 – Superficial ulcer involving the full skin thickness but not underlying tissues Grade 2 – Deep ulcer, penetrating down the ligaments and muscle, but no bone involvement or abscess formation Grade 3 – deep ulcer with cellulitis or abscess formation, often with osteomyelitis Grade 4 – Localized gangrene Grade 5 – extensive gangrene involving the whole foot

18. Management of diabetes Diabetes management – Lifelong treatment which involves: Proper timing of medications Dietary Management Physical exercise

19. Class Generic name (brand name) Mechanism of action Time taken Sulfonylureas Gliclazide ( Diamicron ) Glimepiride ( Amaryl ) Glyburide ( Diabeta ) Stimulate the pancreas to produce more insulin Before meals (≤30 minutes ) Meglitinides Nateglinide ( Starlix ) Repaglinide ( GlucoNorm ) Stimulate the pancreas to produce more insulin Before meals (≤15 minutes ) Biguanides Metformine ( Glucophage ) Metformine with extended release ( Glumetza ) Reduce the production of glucose by the liver During meals At Dinner MEDICATIONS – Oral Hypoglycemic Agents

20. Class Generic name (brand name) Mechanism of action Time taken Thiazolinidediones Pioglitazone ( Actos ) 2. Rosiglitazone ( Avandia ) Increase insulin sensitivity of the body cells and reduce gluconeogenesis in the liver With or without food, at the same each day Alpha- glucosidase inhibitors Acarbose ( Glucobay ) Slow the absorption of carbohydrates (sugar) ingested With the first mouthful of meal MEDICATIONS – Oral Hypoglycemic Agents

21. Diet-drug interactions Gastro-intestinal Effect Interactions with Dietary substances Metabolic Effects Sulfonylureas Nausea, vomiting, cramps, diarrhoea Avoid using with alcohol due to a toxic reaction that causes flushing, throbbing head and neck pain, shortness of breath, palpitations, and sweating. Avoid using with dietary supplements that contain ginseng, garlic, fenugreek, coriander, celery, as they may increase risk of Hypoglycemia Hypoglycemia, weight gain, allergic skin reactions Biguanides ( metformin ) Abdominal pain, nausea, vomiting, diarrhoea , metallic taste, anorexia — Asymptomatic vitamin B12 deficiency.

22. Gastro-intestinal Effect Interactions with Dietary substances Metabolic Effects Thiazolidinediones — — Weight gain, fluid retention, edema, Increased of bladder cancer ( Pioglitazone ), increased risk of non-fatal heart attack ( Rosiglitazone ) Alpha- glucosidase inhibitors Abdominal pain, nausea, Bloating and flatulence , cramps, diarrhea. — Elevated liver enzymes, hyperbilirubinemia Diet-drug interactions (2)

23. Rapid-acting: For meals eaten at same time with the injection Short-acting: For meals eaten within 30-60 mins Intermediate acting: Covers insulin needs for about half the day or overnight Long –acting: Covers insulin needs for about one full day. This type is often combined, when needed, with rapid- or short-acting insulin Premix: Combine specific amounts of intermediate-acting and short-acting insulin in one bottle or insulin pen. (The numbers following the brand name indicate the percentage of each type of insulin) MEDICATIONS – INSULIN

24. Onset: The length of time before insulin reaches the bloodstream and begins to lower blood sugar. Peak : The time period when it best lowers blood sugar Duration : How long insulin continues to work. SAMPLES OF INSULIN Types & Brand names Onset Peak Duration Lispro , Aspart , Glulisine ( R ) 15-30mins 30-90mins 3-5hours Regular, Novolin ( S ) 30 min. -1 hour 2-5 hours 5-8 hours NPH (N ) ( I ) 1-2 hours 4-12 hours 18-24 hours Detemir , glargine  ( L ) 1-1 1/2 hours No peak time. Insulin is delivered at a steady level. 20-24hours Humulin 70/30 ( P ) 30 min. 2-4 hours 14-24 hours

25. Disposable insulin injection Insulin pump Insulin pen Insulin Inhaler Insulin delivery

26. Medical nutrition therapy : goals Maintenance of as near normal BG levels as possible, by balancing food, medication, and physical activity Provision of adequate calories for maintaining or attaining reasonable weight, growth/development in children and adolescent. Prevention and treatment of the acute or chronic complications of diabetes Mellitus Achievement of optimal serum lipid levels Improvement of overall health through optimal nutrition using the Dietary Guidelines

27. Calorie distribution Carbohydrate 50%-60% of total calorie/day Protein 15% - 20% of total calorie/day Fats 15% - 35% of total calorie/day

28. Calorie counting For a dietary prescription of 1800kcal: Carbohydrate 50 × 2000 = 1200kcal 900 = 225g 100 4 Protein 20 × 1800 = 360kcal 360 = 90g 100 4 Fat 25 × 1800 = 540kcal 540 = 60g 100 9

29. INSULIN DISTRIBUTION Total daily insulin dose Basal Insulin replacement Bolus Insulin replacement (40% - 50%) (50% - 60%) 1 unit of insulin 10 – 15grams of carbohydrate 1 unit of insulin 50mg/dl of blood glucose 1/10 th unit of insulin 15grams of carbohydrate (in children) N.B.: Depending on activity level, I unit of insulin 4-30g of carbohydrate

30. Total daily INSULIN requirement ( tdir ) Total daily insulin requirement can be calculated using the formula below : TDIR = Weight in pounds ÷ 4 OR Weight in Kg × 0.55 For a reference man of 70kg OR 160pounds; 160 = 40 units OR 70 × 0.55 = 38.5 units 4 For 40 units; Basal insulin = 40 × 40 = 16 units 100 Bolus insulin = 40 – 16 = 24units Breakfast, Lunch, Dinner = 24units = 8 units per meal 3

31. For 300g of carbohydrate, the amount of insulin required: 1 unit of Insulin 15g of CHO X 300g of CHO X = 300 = 20 units of insulin 15 insulin calculation

32. High blood sugar correction To calculate insulin need for HBS correction: Insulin need = Actual blood sugar level – Target blood sugar level For example: If a patient’s blood sugar is 220mg/dl and the target blood sugar is 120mg/dl Insulin need for correction = 220 – 120 = 100mg/dl Since 1 unit of insulin 50mg/dl blood sugar Therefore; 100mg/dl ÷ 50mg/dl = 2units of insulin

33. Meal Food Items Qty (g) Handy measure Energy value (kcal) Pro (g) Fat (g) CHO (g) Breakfast Bread 90 3 slices 199.6 6.38 - 47.6 63.69 Margarine 10 1 leveled Tbsp 73 0.02 8.07 0.07 Boiled egg 60 1 medium size 71 7 5.85 0.8 Tea 2 1 tea bag 2.16 0.39 0.04 0.06 Whole powder milk 40 4 Tbsp 198 10.36 10.64 15.16 Snack Apple 150 1 medium size 79.5 0.45 0.3 17.1 Lunch Boiled yam 220 2 thin slices 242 1.32 - 59.4 65.94 vegetables 100 25 2 - 5.1 Stew 40 1 serving spoon 47.6 3.84 3 1.44 Beef 60 2 pieces 120 14 1 Snack Watermelon 250 #50 worth 72.5 1.25 0.5 15.5 Dinner Pap 300 2 bowls 91.95 2.55 - 18.9 62.15 Moi-moi 300 2 small wraps 243.5 16.75 16.75 43.25 Boiled chicken 90 2 pieces 241.2 19.8 18 - TOTAL 1706.8 86.1 64.2 224.4

34. FOODS ALLOWED FREELY All leafy vegetables, Tea, Lettuce , Garden eggs, Cucumbers, cabbage, onions, tomatoes FOODS ALLOWED IN LIMITED AMOUNT Milk, butter, margarine, egg, potatoes, rice, yam, bread, plantain, orange, grapefruits, carrots, apples, beans, moin-moin , akara , agidi , amala , pounded yam, plain biscuit FOODS TO BE AVOIDED Beverages, sweets, chocolate,

35. Physical activity in type 1 dm Adjust food intake and insulin therapy to prevent hypoglycemia during physical activity Checked blood glucose levels both before and after an activity Insulin doses that precede exercise often need to be reduced substantially FBS below 100mg/ dL before an activity; consume carbohydrate FBS levels are 250 mg/ dL or higher; No strenuous exercise FBS levels are 300mg/ dL or higher or ketosis is present; No physical activity

36. Physical activity in type 2 dm Regular physical activity can improve the metabolic outcomes associated with type 2 diabetes: Before an exercise program is planned, a medical evaluation should be done Types of activity recommended should depend on complications present. Only mild or moderate exercise may be prescribed at first Persons with retinopathy should avoid heavy lifting or straining Discourage strenuous exercise in persons with nephropathy In persons with peripheral neuropathy, be cautious repetitive weight-bearing exercises. proper hydration should be encouraged before and during exercise

37. CASE STUDY Bio-Data Name: K.X . Address: 4, Ayo Fanimokun Street, Agege , Lagos Sex: Male Age: 64years Social Hx : A retiree, married with children, who relocated from the north to Lagos. Family Hx : Positive of diabetes (parents) Past Medical Hx : Patient has been diagnosed of DM about 5 years ago. Surgery , Hypertension , Asthma

38. CASE STUDY Drug Hx : Nil Clinical assessment A middle-age man, conscious, not underweight, not pale, not dehydrated, with bilateral pedal oedema Biochemical assessment K + : 3.3mmol/L (3.5-5.1) FBS: 145 mg/ dL Na + : 132mmol/L (136-145) HbA1c: 8.9% Cl - : 93mmol/L (98-107) Creatinine : 96 (57-113umol/L) Urea: 11.5mmol/L (1.9-9.1) Medical Diagnosis A case of biventricular failure 2 to dilated cardio- myopathy and electrolyte imbalance

39. CASE STUDY Medical treatment Sc clexane 40mg daily Tab slow K 600mg t.d.s . Tab betaloc-201 25mg daily IV torsemide 20mg daily Diet Hx : Meal skipping Meal Frequency/day: Twice (Breakfast and Lunch) Food dislikes: Rice, yam, eba Food preferences: beans, vegetables, tea, lime, organ meats (Food likes and dislikes are based on dietary misconceptions) No alcohol, no tobacco, drinks herbs occasionally Nutrition Diagnosis Hyperglycemic crisis as a result of poor management control as evidenced by blood glucose profile

40. CASE STUDY PLAN: Place on 1800kcal diet/day Commence 0.8g of protein/ KgIBW /day Give dietary allowance for in-between meals (fruits and vegetables) Counsel patient on foods allowed, those to avoid and importance of proper portioning to suit drug regimen Provide substitutes for foods to avoid Correct patient’s dietary misconception about DM Encourage patient to discontinue meal skipping Educate patient about dietary prescription and the need for adherence Request for serum albumin, protein and lipid profile for further dietary management

41. Prognosis: Compliance to dietary advice by patient FBS Range: 85 – 115mg/ dL RBS Range: 145-190mg/ dL Leg sore healed after a week

42. Selected REFERENCES Columbia University Medical Center. (2017). The Pancreas and Its Functions http://columbiasurgery.org/pancreas/pancreas-and-its-functions (retrieved 13/03/17) Diabetes Quebec (2015). Antidiabetic Drugs. www.diabete.qc.ca Mahan, L. K. and Escott -Stump, S. (2008). Krause’s Food and Nutrition Therapy. Elsevier; Philadephia Mathers , C.D., and Loncar , D. (2006) Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med, 3(11):e442 National Institute of Diabetes and Digestive and Kidney Diseases (2016) Diabetes https://www.niddk.nih.gov/health-information/diabetes/overview/symptoms-causes (Retrieved 14/02/2017) Roth, R. A. (2011). Nutrition and Diet therapy. 10 th ed. Indiana/Purdue university; Fort Wayne

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