Diabetes Flashcards
Treatment of T 1 diabetes
Fluids and electrolytes - to balance dehydration and acidosis (ketosis)
Insulin - to maintain normoglycaemia / establish dosage regimen
Acute complications of diabetes
Hypoglycaemia (T1 and 2)
Diabetic ketoacidosis (T1)
Hyperosmolar hyperglycaemic state (T2)
Chronic complications of diabetes
Long term / secondary complications
What are the blood glucose levels for hypoglycaemia
Blood glucose <4 mmol/L
Symptoms present = 3mmol/L
Hypoglycaemia in T1
Insulin overdose
Excessive exercise or inadequate CHO intake relative to insulin dose
Hypoglycaemia in T2
Sulphonylureas (elderly) -
Hepatic or renal disease, some drugs
Signs and symptoms of hypoglycaemia
Palpitations, tremors, sweating, anxiety - counter regulatory activity of SNS
Dizziness Hunger Irritability Headache Tingly lips
As progresses:
Loss of concentration, slurred speech, behaviour / mood changes, seizures, loss of consciousness
- glucose deficiency in brain
Hypoglycaemia treatment
Conscious
- sugary drink / food
Glucogel (40% dextrose gel) recommended by NICE
10-15 minr recovery then a snack for sustained carbohydrates
Unconscious treatment for hypoglycaemia
Glucose iv 20% or 10% or glucagon IM, IV or SC
But not after alcohol (because it is metabolised in the liver)
Diabetic ketoacidosis
(Diabetic coma) Omission or reduction in insulin dose Illness / infection Emotional upset particularly in adolescence Menstruation / pregnancy ketosis
Treatment for diabetic ketoacidosis
Insulin (iv infusion)
Replacement of fluids, electrolytes (NaCl 0.9%) may need KCl, glucose 10%
Suppress ketogensis, reduce blood glucose and correct electrolyte balance
What is hyperosmolar non ketotic coma
Severe hyperglycaemia without ketosis (T2 DM)
Managed as DKA (less insulin)
What is the HbA1c test
Indicator of glycaemic control during the last 2-3 months
Recommended 48-59mmol/mol
(6.5-7.5%)
Micro vascular long term complications of DM
Retinopathy (eye disease)
Nephropathy (kidney disease)
Neuropathy (nerve damage)
Macro vascular long term complications of DM
Cardiovascular disease (ischaemic heart disease)
Cerebral vascular disease (stroke)
Peripheral vascular disease
Effects the medium - large vessels in the body
Define insulin resistance
Reduced ability of the hormone insulin to stimulate whole body glucose metabolism in obesity, T2D and even offspring of T2D
What is metabolic syndrome
A cluster of risk factors for cardiovascular disease and type 2 diabetes mellitus eg
Central obesity Triglycerides >1.7mmol/L HDL cholesterol <1 mmol/L (M) <1.3 mmol/L (F) Blood pressure >130/85 mmHg Fasting glucose >5.6 mmol /L
What is poor glycaemic control / excessive hyperglycaemia associated with
Long term microvascular complications (eyes, kidneys and PNS) and macrovascular disease (increased risk for stroke and myocardial infarction) that increase morbidity and mortality
Nutritional therapies for T1 diabetes
Integrate insulin regime into lifestyle
Adjust insulin regimen to match CHO intake
Consistent day-to-day carbohydrate intake
Adopt a balanced diet
Nutritional therapies for T2 diabetes
Lifestyle changes to improve glycaemia, insulin sensitivity’s dyslipidaemia, and blood pressure
Reduce energy intake/ weight loss (at least 5%)
Weight loss is highly effective in preventing from prediabetes to T2D and in managing cardio metabolic health in T2D
600 kcal/day for 8 weeks resolves T2 diabetes
How does a very low calorie diet help T2
Normalises beta cell function which is associated with a decrease in pancreatic lipid content
Dietary carbohydrate recommendations
Consistent day to day - 50% of energy requirements
Low glycaemia index
Low CHO diets may confer short term benefits but restrict essential nutrients incl fibre from fruits and vegetables
Diets containing >30g of fibre per day improve glycaemic control
Knowing basic information on CHO content of meals
Dietary protein recommendations
0.8 to 1g/kg/ day
Can increase acute insulin responses
Satiating - minimise appetite
High protein intake may promote weight loss and preservation of lean body mass but it may impair renal function in individuals with chronic kidney disease
Dietary fat recommendations
Limit fat to <35% of energy requirements
Saturated fats <7% of total energy, dietary cholesterol <200mg/day
Replace with mono or poly unsaturated fast to improve glycaemia, lipaemia and insulin sensitivity
Role of exercise in management of diabetes
Reduces blood glucose conc and controls glycaemia and reduce cardiovascular risk factors
Aim for at least 150min per week of moderate to vigorous physical activity over at least 3 days
Aerobic and resistance exercise exert similar benefits but combining the 2 forms of exercise may confer greater benefits
Combining hypocarolic diets with exercise increases body weight and fat loss and better preserve lean body mass
Who is screened for diabetes
1) white people ages >40 and people from BAME groups ages >25 with one or more risk factors:
- first degree family history of diabetes
- BMI of 25-30
- waist measurement of >37 inches for white and black men and >31.5 inches for white black and Asian women and >35 inches for Asian men
2) people with atherosclerosis or hypertension
3) women who have gestational diabetes
4) PCOS + BMI >30
5) people who have IGT or IFG
6) people with severe metabolic health porblems (antipsychotics)
7) people with high triglycerides
Type 1 vs type 2 symptoms
More acute onset in T1
T2 progesrrive and symptoms gradual
T2 takes 10 years on average to present
Classifications of diabetes
T1 T2 Gestational Secondary Drug induced Pancreatic disease Insulin resistance syndrome
What is gestational diabetes
Risk assessment at first PN visit
Screen those at very high risk immediately
Otherwise check at 24-28 weeks
Glucose tolerance test
What is MODY
Maturity onset diabetes of the young
Early onset diabetes Not insulin dependent Autosomal dominant inheritance Caused by a single gene defect altering beta cell function Obesity is unusual
Diagnostic criteria for MODY
Early onset diabetes - before 25 in at least 1 and ideally 2 family members
Not insulin dependent diabetes - off insulin treatment or measurable C peptide at least 3 (ideally 5) years after diagnosis
Autosomal dominant inheritance - must be diabetes in 1 parent and ideally grandparent or child
Caused by a single gene defect altering beta cell function, obesity unusual
Major causes of insulin resistance
Obesity
Lipodystrophy - cannot store fat under skin result in ectopic fat - fat goes straight into pancreas or liver
Insulin receptor mutation
Very rare other genetic causes
Treatment goals
To keep blood sugar as normal as possible without serious high or low blood sugars (HbA1c)
To prevent tissue damage caused by too much sugar in the blood stream
- lipids
- blood pressure
- screening for complications (eyes, feet, kidneys)
Dietary recommendations for diabetes
Dietary fat should provide 25-35% of total intake of calories but saturdated fat intake should not exceed 10% of total energy
Protein intake can range between 10-15% total energy
Requirement increase for children and during pregnancy. From both animal and vegetable sources
Carbs 50-60% - complex and high in fibre
Excessive salt intake avoided especially in those with hypertension and nephropathy
Exercise guidelines
Physical activity promotes weight reduction and improves insulin sensitivity thus lowering blood glucose levels
30 mins of moderate intensity exercise per day
People should be educated about risk of hypoglycaemia and how to avoid it
Oral anti diabetic agents
Biguanides- metformin
Insulin secretagogues - sulphonylureas
Insulin secretagogues - non sulphonylureas
A-glucosidase inhibitors
Thiazolidinediones
Dipeptidylpeptidase inhibitors
Sodium glucose co transporter 2 inhibitor
Describe the pelvic floor
Consists mostly of flat muscles that line a cup shaped space. It is therefore flexible and can buffer the significant variations in pressure in the abdominopelvic cavity
What are the main contributing risk factors for diabetic foot disease
Peripheral arterial disease and loss of sensation
What is diabetic foot disease
A complication of DM
2 main risk factors: neuropathy (loss of protective sensation)
Peripheral arterial disease
Presents with loss of sensation, absent foot pulses, reduced ankle brachial pressure
How does metformin work
Increases insulin sensitivity and decreases hepatic gluconeogenesis
What is the main focus of diabetic management
Reducing the incidence of macrovascular (ischaemic heart disease, stroke) and microvascular (eye, nerve and kidney damage)
What is T1 diabetes mellitus
Autoimmune disorder where the insulin producing beta cells of the iselts of langerhans in the pancreas are destroyed by the immune system
Results in an absolute deficiency of insulin resulting in raised glucose levels
Tends to develop in child / early adult life and typically present unwell possibly in diabetic ketoacidosis
What is diabetic ketoacidosis
Serious complication of diabetes that can be life threatening
Excessive thirst, frequent urinaiton, nausea and vomiting, stomach pain, weakness or fatigue, shortness of breath
What is type 2 diabetes mellitus
Caused by a relative deficiency of insulin due to an excess of adipose tissue
Not enough insulin to go around all the excess fatty tissue, leading to blood glucose increasing
What is diabetes inspipidus
A condition characterised by either a decreased secretion of ADH from the pituitary (cranial DI) or an insensitivity to ADH (nephrogenic DI)
Causes of cranial diabetes insipidus
Idiopathic Post head injury Pituitary surgery Craniopharyngiomas Infiltrative
Causes of nephrogenic diabetes insipidus
Genetic: mutation in the gene that encodes the aquaporin 2 channel
Electrolytes: hypercalcaemia, hypokalaemia
Lithium: desensitised the kidneys ability to respond to ADH in the collecting ducts
Dee clock line
What is fetal macrosomia
Newborn baby larger than average
Weighs more than 8lbs 13 oz
Mode of action of novo rapid
Rapid acting insulin that helps to normalise the glucose level by moving glucose into cells
Menmonic for causes of hypercalcaemia (chimpanzees)
Calcium supplementation Hyperparathyroidism Iatrogenic drugs (thiazides) Milk alkali syndrome Paget disease of the bone Acromegaly and Addison’s disease Neoplasia Zolinger-Ellison syndrome Excessive vit D Excessive vit A Sarcoidosis
