Diabetes M Flashcards
Estimated population with DM
What about in 2018
7% US
1.5 million new cases each year
- 5%
- 2 million US
What is diabetes mellitus
A group of metabolic disease with elevated blood glucose levels (hyperglycemia) over a prolonged period
What complications may occur if DM is not treated
Acute
Acute:
Diabetic ketoacidosis
Nonketotic hyperosmolar coma
Death
What complications may occur if DM is not treated
Chronic
Heart disease Stroke Chronic kidney failure Neuropathies Retinopathy Nephropathy
What are the clinical symptoms of DM
Polyuria Polydipsia Polyphagia Blurred vision Weight loss
What is polyuria
Excessive urination
What is polydipsia
Excessive drinking/thirst
What is polyphagia
Excessive eating/hunger
What is type 1 DM
Insulin dependent DM
Autoimmune destruction of beta cells in pancreas
What is type 2 DM
Non insulin dependent DM
Insulin resistance in skeletal muscle,liver and adipose tissue
Insulin secretory defect
What are the other types of DM
Gestational diabetes
Specific genetic syndromes
Drugs
Surgery
Other illnesses
Levels for:HbA1C for:
Normal
Prediabetes
Diabetes
Normal:
< 5.7%
Prediabetes:
5.7 - 6.4%
Diabetes
>= 6.5%
Levels for fasting plasma glucose for:
Normal
Prediabetes
Diabetes
Normal:
< 100 mg/dl
Prediabetes:
100 - 125 mg/dl
Diabetes:
>= 126 mg/dl
Levels for oral glucose tolerance test for:
Normal
Prediabetes
Diabetes
Normal:
< 140 mg/dl
Prediabetes:
140 - 199 mg/dl
Diabetes:
>= 200 mg/dl
What is HbA1C
Glycosylated hemoglobic
Where there is an attachment of glucose to N terminal amino acid valine of the beta chain of hemoglobin
What are the advantages of finding HbA1C
Easy to measure
Relatively cheap
Predictive of vascular complications
Helps management decisions
What are the limitations of finding HbA1C
Only provides an approximate measure of glycemia
Unable to address GV or hypoglycemia
Unreliable in certain conditions such as RF, Hb abnormalilites
What are the pancreatic hormones
Insulin
Glucagon
Where are beta and alpha cells in the pancreas found
Pancreatic islet
Where is insulin produced
Beta cells
Where is glucagon produced
Alpha cells
What does insulin do
Promotes storage of glucose, amino acids and fats
What does glucagon do
Promotes the mobilisation of fatty acids and glucose
Type 1 DM is found in (population)
Characteristics of it
Around 10%
Loss of insulin producing beta cells of the islets of langerhans in the pancreas
Idiopathic
T cell mediated autoimmune attack leads to loss of beta cells
Ketoacidosis common
In type 1 DM what causes the loss of beta cells
T cell autoimmune attack
Type 2 DM is found in (population)
Characteristics of it
Around 90%
Insulin resistance
Insensitivity of receptors
Lifestyle factors and genetics
What is the evidence that someone has type 1 DM
Presence of anti insulin and anti islet cell antibodies
Presence of inflammatory cells around the islets
Activation of T lymphocytes
Association of diabetic genes with the incidence of development of diabetes
What are the symptoms that occur with destruction of 80-90% of beta cell mass
Lack of insulin
Excessive hepatic glucose production
Decreased muscle glucose uptake
Glucose intolerance
A lack of insulin causes several…
Intracellular abnormalities in both muscle and liver
Excessive hepatic glucose production leads to
Gluconeogenesis
Glucose is the main source for what organ
A lack of it causes
Brain
Fainting
What happens when no CHO (glucose) is available because of DM
Shift from CHO to fat metabolism
Ketoacidosis
A shift from CHO to fat metabolism is because
This causes…
No glucose into the cell results in body shifting to other fuel sources - fat and protein
Increased fat metabolism results in increase keto acid levels
Sodium is excreted in the urine with the excess keto acids
Sodium is replaced by hydrogen ions in the extracellular fluid
Thus increasing acidosis
Sodium is excreted into urine because of
Excess keto acids
Helps to neutralise the acid
Diebetic ketoacidosis is seen in
Severe cases of UNCONTROLLED diabetes
Usually seen in people who have not yet been diagnosed with diabetes
Those that have diabetic ketoacidosis will experience
Kussmaul respiration
Can develop into acidotic coma and death
What is kussmaul respiration
Rapid and deep breathing which is resulting in loss of the bicarbonate content in the extracellular fluid
(hydrogen that replaced sodium in extracellular fluid)
Indication of kussmaul respiration is
Sweet smell from breath
Acidotic coma and death can occur when
The pH of the blood falls below 7.0
Normal range is 7.35 - 7.45
What is the pathophysiology of type 2 DM
Stomach converts food into glucose which enters the blood stream
Pancrease produces sufficient insulin
Insulin is resistant
Liver resistant to effects of insulin
Glucose cant get into the body’s cells, causes glucose to build in the blood stream
Causes serious dangerous complications
What does type 2 DM cause in the MUSCLE
Insulin resistance
What does type 2 DM cause in the LIVER
Insulin resistance
Increase hepatic glucose output
What does type 2 DM cause in the GUT
Impaired incretin effect
What does type 2 DM cause in the PANCREAS
Decrease insulin secretion
Increase BETA cell apoptosis
Decrease BETA cell mass
Hyperglucagonemia
What does type 2 DM cause in the ADIPOCYTES
Increase circulating fatty acids
Hyperlipidemia
What are the glucose level after eating for:
Normal people
Type 2 diabetics
Normal people is a small increase in blood glucose concentration - after a couple of hours blood glucose concentration goes lower than to begin with
Type 2 diabetes shows a huge increase in blood glucose concentration - takes significantly longer to go back down to resting
Sources of blood glucose include
Intestinal absorption of food
Glycogenolysis from liver
Gluconeogenesis from liver
Insulin causes a inhibition of
Stimulation of
Inhibition:
Glycogenolysis
Gluconeogenesis
Stimulation:
Transport of glucose into muscle and adipose tissue
Storage of glucose as glycogen
What causes glycosuria
When blood glucose level is high over time
The kidney reaches threshold of reabsorption
Glucose excreted into urine
Increase osmotic pressure of urine
Inhibits reabsorption of water
Increase urine production - excess fluid loss
How do we manage DM
Diet
Exercise
Medication
Intensive treatment to control blood glucose reduces the risk of progression of diabetic complications
Exercise testing may not be necessary for….
Individuals with DM or Prediabetes who are ASYMPTOMATIC for cardiovascular disease and LOW RISK (< 10% risk)
Medical supervised graded exercise test with ECG monitoring is needed for…
Individuals with DM or Prediabetes with a > 10% risk of cardiac event who want to begin VIGOROUS intensity exercise program
What are the FITT recommendation for individuals with DIABETES with AEROBIC
(Time involves differences for type 1 and type 2)
3 - 7 days a week
Moderate (40 - 60%) to vigorous (60 - 90%)
For type 1:
150 min a week at moderate
or
75 min a week at vigorous
For type 2:
150 min a week at moderate/vigorous
Prolonged, using large muscle groups
What are the FITT recommendation for individuals with DIABETES with RESISTANCE
Minimum of 2 nonconsecutive days per week - prefer 3 days
Moderate (50 - 70% 1RM) to vigorous (70 - 85% 1RM)
8 - 10 exercises
1 - 3 sets
10 - 15 reps to near fatigue
Gradually progress to
1 - 3 sets
8 - 10 reps of heavier weights
Resistance machines/ free weights
What are the FITT recommendation for individuals with DIABETES with FLEXIBILITY
> = 2-3 days a week
Stretch to the point of discomfort
Hold stretch 10-30 secs
2 - 4 reps
Static/dynamic/PNF
What is the special consideration with exercise for individuals with DM
Hypoglycemia - most serious problem for people with DM when they exercise
What is hypoglycemia
When does it occur
Blood glucose level < 70mg/dl
During exercise
Delayed up to 12 hr post exercise
Hypoglycemia is a concern for
People with DM
People who are taking insulin or oral hypoglycemic agents that increase insulin secretion
What are the common symptoms of hypoglycemia
Shakiness Weakness Abnormal sweating Nervousness Anxiety
Neuroglycopenic symptoms of hypoglycemia
Headache Visual disturbance Mental dullness Seizures Coma
How do we prevent hypoglycemia both during and after exercise
Blood glucose monitoring before and for several hours following exercise
Timing of exercise should be considered in individuals taking insulin or other medicine
Exercise with a partner or under supervision to reduce the risk of problems associated with hypoglycemia
People with DM who exercise are also at risk of
Retinopathy
Autonomic Neuropathy
What is retinopathy and how do we avoid it
Rentinal detachment and vitreous hemorrhage associated with vigorous intensity aerobic and resistance exercise
Avoid activities that dramatically elevate BP
How do we avoid autonomic neuropathy
Chronotropic incompetence - blunted BP response
Monitor potential silent ischemia - unusual shortness of breath or back pain
Monitor BP before and after exercise to manage hypotension and hypertension
Monitor HR and BP response to exercise - may be blunted
Use RPE to assess exercise intensity
What is overall acute response to exercise in DM dependent on
Use and type of medication
Timing of medication
Blood glucose level prior to exercise
Timing, amount, and type of previous food intake
Presence and severity of diabetic complications
Intensity, duration and type of exercise
How does exercise lower blood glucose
Has an insulin like effect (muscle contraction)
Stimulates glucose transport and metabolism
Increases blood flow to exercising muscles
More glucose to enter the muscle to be utilised for energy production
What are the chronic adaptations of exercise
What do these adaptation inversely result in
Increase vasodilator signaling
Increase capillary density
Increase insulin/P13K signaling
Decreases HbA1c
Leads to decrease insulin secretion
Leads to micro complications
What is the overall effect of exercise training in DM
Improvement in blood glucose control
= improves glucose tolerance
Increase insulin sensitivity on skeletal muscle cells
= reduces insulin requirements in individuals with type 1 DM
Vascular adaptation
Individuals taking lipid lowering medications (e.g., Statins) may experience myalgia
True
Majority of obesity is caused by abnormal prevalence of gut bacteria
False
If your male client’s waist circumference is 105cm, and fasting glucose level is 130mg/dL, and HDL level is 45mg/dL. He has metabolic syndrome
False
Excessive amount of adipose tissue in the body can increase inflammation; thus, more pro-inflammatory markers (e.g., TNF-alpha) are found in the bloodstream
True
Following examples are potential causes of abnormal vascular remodeling
High sympathetic nerve activity
Insulin resistance
_______ higher than 48mmol/mol is considered to be diabetic
HbA1C
Ketoaciidosis is common in type 1 diabetes
True
Skeletal muscles and liver tend to build insulin resistance over a long period of time which develops type 1 diabetes
False
What is “not” the action of insulin
It stimulates glycogenolysis
When blood glucose level is high over time, kidney reaches a threshold of reabsorption. Thus, glucose is excreted in the urine. This phenomenon is called _____
Glycosuria
Acidotic coma or death can occur if the pH of the blood is higher than 7.3 in diabetic patients
False
If diabetic patients want to begin a vigorous intensity exercise program, they should undergo a medically supervised graded exercise test with electrographic monitoring
True
The most serious problem with diabetes who exercise is _____ because it can cause neuroglycopenic symptoms such as seizures and coma during and after exercise
Hypoglycemia
Muscle contraction causes translocation of AMPK to sarcolemma; this action opens up the pathway for glucose uptake
False
Muscle contractions from exercise can stimulate and transport _____ from cytosol to cell membrane; thus, glucose can enter the muscle cell to be utilized for energy production. Muscle contraction can also stimulate ____ to produce ___ in order to cause vasodilation and to increase microvascular surface area
Glut 4
Endothelial cells
Nitric oxide
___ are all clinical symptoms for diagnosis of diabetes mellitus
Poly dipsia
Polyuria
Polyphagia
Exercise testing may not be necessary for individuals with diabetes who are asymptomatic for cardiovascular disease and low risk
True
To prevent hypoglycemia both during and after exercise, timing of exercise should be considered in individuals taking insulin or other medicine
True
HR reserve or VO2 reserve can be used to identify exercise intensity for individuals with diabetes and with other complications, such as autonomic neuropathy
False
According to journal club article #1, at the point where speech first became difficult, exercise intensity was almost exactly equivalent to lactate threshold
False
According to journal club article #2, eight weeks of cycle training in people with metabolic syndrome increased insulin receptors and GLUT4 expression in vastus lateralis muscle
True
According to article #3, exercise training improved endothelial function in adolescents with type 2 diabetes depicted by flow mediated dilation and improvement on action of nitric oxide
True
