DM 1

Question 1

obsolete terms

Answer 1

-Insulin-dependent diabetes mellitus (IDDM)
-Noninsulin-dependent diabetes mellitus (NIDDM)
-not used anymore -> type 2 can become insulin dependent
-Adult-onset diabetes mellitus - not always children
-children can also get type 2 diabetes
-Non-ketotic diabetes mellitus -> implies there are no ketones but there is always ketones present (not as much as DKA)
-dx is based on the pathogenic process

Question 2

diabetes

Answer 2

-Metabolic disorder
-Hyperglycemia
-Disturbance of carbohydrate, fat, and protein too!
-Relative (2) or complete lack (1) of Insulin
-Common chronic disease
-Acute (1) or sub-clinical (2)
-Complications
-Increases risk of other diseases

Question 3

DKA

Answer 3

-lactic acidosis takes over
-not enough insulin to utilize glucose -> body starts to break down fats
-type 1 higher levels of ketones
-acidotic

Question 4

insulin

Answer 4

-Stimulates skeletal muscle fibers:
-Glucose to glycogen
-Amino acid to protein (does protein synthesis too!)

-Acts on liver cells -> inhibits gluconeogenesis & glycogenolysis
-Acts on adipose cells to synthesize fat
-Acts on hypothalamus to reduce appetite

Question 5

DM pathophysiology

Answer 5

-DM causes secondary pathophysiologic changes in multiple organ systems that impose a tremendous burden on the individual with diabetes and on the health care system
-In US, DM is the leading cause of end-stage renal disease (ESRD), non-traumatic lower extremity amputations, and adult blindness

Question 6

hyperglycemia

Answer 6

-excessive glucose production -> hyperglycemia
-impaired glucose clearance -> hyperglycemia
-hyperglycemia -> tissue injury

Question 7

type 1 epidemiology

Answer 7

-High-risk HLA alleles among ethnic groups in different geographic locations – increases the risk of type 1 DM
-Highest incidence: Scandinavia
-Insulin- 1A and 1B
-Autoimmune
-1/3 - genetic (HLA –DR3 & 4)
-2/3 – environment
-Age of onset- generally young but can be later

Question 8

type 2 epidemiology

Answer 8

-Highest in certain Pacific islands
-Intermediate in: India; US
-Variability is likely due to genetic, behavioral, and environmental factors
-Insulin present but resistant
-Genetic vs. environment
-Age of onset- can be young too

Question 9

diabetes triad

Answer 9

-polyuria
-polydipsia
-polyphagia

Question 10

type 1 symptoms

Answer 10

-acute
-polyuria, polydipsia, polyphagia- not really chronic -> acute
-Unexplained weight loss and easy fatigability
-Ketoacidosis- life threatening
-Irritability, drowsiness, and loss of consciousness
-Dehydration, electrolyte abnormalities (Na, K), osmolality*, and acid-base disturbances (pH <7.2)
-Honeymoon remission- After ketoacidosis, may briefly revert to normoglycemia without requiring therapy (temporary phase)
-dx is usually from DKA -> acute (not insidious)

Question 11

type 2 symptoms

Answer 11

-Often asymptomatic
-Weight loss initially- but overall BMI tends to be high
-acute presentation- Hyperosmolar nonketotic coma, severe dehydration -> Secondary to osmotic diuresis (peeing water and Na out)
-PMH: Frequent/recurrent infections, poor wound healing, blurring of vision, and numbness or tingling in the extremities

Question 12

risk factors for and complications of diabetes

Answer 12

-CAUSES
-over weight and obesity
-genetics
-HTN
-gestational diabetes- dont use A1c - past 3 months -> not accurate to the baby

-EFFECTS
-retinopathy
-neuropathy
-nephropathy
-cardiovascular disease
-amputation

Question 13

components of the comprehensive diabetes evaluation- medical hx

Answer 13

-Age and characteristics of onset of diabetes (e.g., DKA, asymptomatic lab finding)
-Eating patterns (nutritionist), physical activity habits, nutritional status, and wt hx; growth and development in children and adolescents
-Diabetes education hx
-Review of previous tx regimens and response to therapy (A1C records)
-Current tx of diabetes, including meds, meal plan, physical activity patterns, and results of glucose monitoring and patient’s use of data
-DKA frequency, severity, and cause
-PATIENT COMPLIANCE IS EVERYTHING!

-Hypoglycemic episodes
-Hypoglycemia awareness- worse
-Any severe hypoglycemia: frequency and cause

-History of diabetes-related complications
-Microvascular: retinopathy, nephropathy, neuropathy (sensory, including history of foot lesions; autonomic, including sexual dysfunction and gastroparesis)
-Macrovascular: CHD, cerebrovascular disease, PAD
-Other: psychosocial problems, dental disease

Question 14

physical exam

Answer 14

-Height, weight, BMI
-Blood pressure determination, including orthostatic measurements when indicated
-Fundoscopic examination- 1st appt -> if normal f/u 1 year
-Thyroid palpation- other autoimmune problems
-Skin examination (for acanthosis nigricans and insulin injection sites)

-Comprehensive foot examination:
-Inspection
-Palpation of dorsalis pedis and posterior tibial pulses
-Presence/absence of patellar and Achilles reflexes
-Determination of proprioception, vibration, and monofilament sensation

Question 15

BMI

Answer 15

-Underweight = <18.5
-Normal weight = 18.5–24.9
-Overweight = 25–29.9
-Obesity = BMI of 30 or greater

Question 16

why do we screen?

Answer 16

-Screening test is recommended because:
-(1) a large number of individuals who meet the current criteria for DM are asymptomatic and unaware that they have the disorder
-(2) epidemiologic studies suggest that type 2 DM may be present for up to a decade before diagnosis
-(3) as many as 50% of individuals with type 2 DM have one or more diabetes-specific complications at the time of their diagnosis
-(4) treatment of type 2 DM may favorably alter the natural history of DM

Question 17

criteria for dx of prediabetes and diabetes

Answer 17

1. Glycated hemoglobin (A1C) ≥6.5%.
   The test should be performed in a laboratory using a method that is National Glycohemoglobin Standardization Program (NGSP) certified and standardized to the Diabetes Control and Complications Trial (DCCT) assay.
   OR
2. Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L) -> repeat it if high to confirm
   OR
3. 2-hour plasma glucose ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test (OGTT) -> 2 hours after eating you should have glucose and insulin go down
   OR
4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis (triad), a random plasma glucose ≥200 mg/dl (11.1 mmol/L)

Question 18

criteria for screening diabetes or prediabetes in asymptomatic adults

Answer 18

-1. testing considered in adults with overweight or obesity (BMI >= 25 or 23 in asians) who have 1 or more risk factors:
-1st degree relative with diabetes
-high risk race/ethnicity (african american, latino, native american, asian, pacific islander)
-hx of CVD
-women who delivered a baby weight >9 lbs or were dx with GDM
-hypertension (>130/80 or on med for HTN)- use ACE
-HDL cholesterol < 35 and/or triglyceride level >250
-pts with PCOS
-physical inactivity
-other clinical assoc with insulin resistance (severe obesity, acanthosis nigricans)
-2. people with prediabetes (A1C >= 5.7) -> should be tested yearly
-3. people dx with GDM should have lifelong testing at least every 3 years
-4. all others -> testing should begin at age 35
-5. if results are normal -> repeat at min of 3 years -> consider more frequent testing depending on initial results and risk status
-6. pts with HIV

Question 19

criteria for the dx diabetes mellitus

Answer 19

-Fasting is defined as no caloric intake for at least 8 h.
-test should be performed using a glucose load containing the equivalent of 75g (50 in pregnant) anhydrous glucose dissolved in water; not recommended for routine clinical use.
-Random is defined as without regard to time since the last meal
-Note: In the absence of unequivocal hyperglycemia and acute metabolic decompensation, these criteria should be confirmed by repeat testing on a different day.

Question 20

criteria for prediabetes

Answer 20

-FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) (IFG)
OR

-2-h PG during 75-g OGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0 mmol/L) (IGT)
OR

-A1C 5.7–6.4% (39–47 mmol/mol)

-FPG, fasting plasma glucose; IFG, impaired fasting glucose; IGT, impaired glucose tolerance; OGTT, oral glucose tolerance test; 2-h PG, 2-h plasma glucose. *For all three tests, risk is continuous, extending below the lower limit of the range and becoming disproportionately greater at the higher end of the range

Question 21

IFG

Answer 21

-Impaired fasting glucose
-Defined by a fasting plasma glucose of 100-125mg/dL (prediabetic)
-this group is at higher likelihood of developing type 2 diabetes -> may be already at increased risk for macrovascular (cardiovascular) complications
-you want to start implementing diet and lifestyle modifications here !! -> check BP and lipids -> start statins if needed etc.

Question 22

IGT

Answer 22

-Impaired glucose tolerance
-2h after a glucose load of 75g it is 140-199mg/dL
-Associated with increased risk of developing DM & ischemic heart disease
-Annual screening recommended
-CHD risk factors treated aggressively
-qualitative detection of ketone bodies -> using acetest or ketostix -> tests ketones in urine

Question 23

OGTT

Answer 23

-pt should be on balanced diet, containing normal daily requirement of carbs, at least 2-3 days prior to test
-Pts should avoid drugs likely to influence blood glucose levels, at least 2 days prior to test.
-Pt should report to lab after FASTING for 12-16 hours
-He/She can drink water
-All samples should be venous preferably
-If capillary blood from ‘finger-prick’ is used, all samples should be capillary
-Pts should be in a position to wait at the lab for at least 2-3 hours, since 5 or more blood samples are collected at the interval of 30 minutes.

-Conduction of OGTT
-fasting sample of venous blood is collected in a fluoride vial.
-bladder is emptied completely and urine is collected for qualitative test for glucose and ketone bodies
-pt given 75g of glucose dissolved in water
-Note the time of oral glucose administration.
-total of 5 specimens of venous blood and urine are collected every 30 min
-Glucose content of all 5 samples of blood are estimated by the specific methods used in laboratory
-Corresponding urine samples are tested qualitatively for the presence of glucose and ketone bodies.
-curve is plotted by plotting time on X-axis and plasma glucose level on Y-axis, which is called Glucose Tolerance Curve (GTC)
->200 at 2 hrs - DM
-140-199- prediabetes

Question 24

OGTT results

Answer 24

-NO DIABETES
-fasting- <= 100
-2 hours- <140
-no excess micro- nor macro-vascular risk

-PREDIABETES
-fasting- 100-125
-2 hours- 140-199
-excess macro- but not micro-vascular risk

-DIABETES
-fasting- >= 126
-2 hours- >=200
-excess macro- and micro vascular risk

Question 25

testing for type 2 diabetes or prediabetes in asymptomatic children criteria

Answer 25

-Overweight (BMI .85th percentile for age and sex, weight for height .85th percentile, or weight .120% of ideal for height)

-Plus any 2 of the following risk factors:
-Family history of type 2 diabetes in first- or second-degree relative
-Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander)
-Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational age birth weight)
-Maternal history of diabetes or GDM during the child’s gestation
-Age of initiation: age 10 years or at onset of puberty, if puberty occurs at a younger age

-Frequency: every 3 years
*Persons aged ≤ 18 years

Question 26

improving care and promoting health in populations

Answer 26

-Care teams
-Telehealth
-Behaviors and well being
-Tailoring Treatment for Social Context** -> if pt is not on board nothing will get done
-Social Determinants of Health [SDOH]

Question 27

decision cycle for person-centered glycemic management in type 2 diabetes picture

Answer 27

-comorbidities
-mental health
-motivation
-negotiation, sharing
-access to education and support
-needle vs no needle
-review information
-side effects
-agree on management
-fasting
-hypoglycemia #- threshold is diff for everyone -> pt requires assistance to prevent neurological changes that present- coma

Question 28

SMART goals

Answer 28

-specific goals- walk around the block
-measurable- 3x a week
-achievable- negotiate
-realistic
-time- in a given period of time, FU

Question 29

social determinants of health

Answer 29

-education access and quality
-health care access and quality
-neighborhood and built environment- safe, expensive, food security**
-social and community context- resources
-economic stability- employed, supportive system

Question 30

risk based screening for type 2 diabetes or prediabetes in asymptomatic children and adolescants in a clinical setting

Answer 30

-Screening should be considered in youth* who have overweight (≥ 85th percentile) or obesity (≥ 95th percentile) and who have one or more additional risk factors based on the strength of their association with diabetes:
-Maternal history of diabetes or GDM during the child’s gestation
-Family history of type 2 diabetes in first- or second-degree relative
-Race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander)
-Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans (flexors, hands), hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight)

*After the onset of puberty or after 10 years of age, whichever occurs earlier. If tests are normal, repeat testing at a minimum of 3-year intervals (or more frequently if BMI is increasing or risk factor profile deteriorating) is recommended. Reports of type 2 diabetes before age 10 years exist, and this can be considered with numerous risk factors

Question 31

prevention or delay of type 2 diabetes and associated combidities

Answer 31

-monitor pre-diabetes at least annually for development of type 2 -> modify based on risk/ benefit assessment.
-if overweight/obesity and high risk of type 2 -> achieve and maintain a weight reduction of at least 7% by diet and ≥ 150 minutes/week of moderate-intensity physical activity
-Pharmacologic interventions
-Person-centered care goals

Question 32

treatment goals

Answer 32

-alleviated symptoms
-minimize development of long term complications
-enhance quality of life
-reduce mortality
-Good glycemic control
-Good control of blood pressure
-Lipid lowering
-Monitoring for and treatment of diabetic nephropathy
-Monitoring for and treatment of diabetic retinopathy
-Foot care
-Prevention and treatment of other complications
-Lifestyle management, e.g. smoking cessation, weight control, and dietary measures
-Care of pregnant women with diabetes and pre-pregnancy counseling

Question 33

targets and goals of tx: nutrition

Answer 33

-refer to nutritionist
-Effectiveness of nutrition therapy
-Energy balance
-Eating patterns
-Dietary Fat - monounsaturated
-Protein
-Micronutrients, supplements
-Alcohol
-Men vs. Women
-Delayed hypoglycemia with Insulin

-Sodium
-Non-nutritive sweeteners

-DASH- vegetables, fruits, whole grains
-including fat free or low fat dairy products, fish, poultry, beans, nuts, and vegetable oils
-limiting foods that are high in saturated fat, such as fatty meats, full fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils
-limiting sugar sweetened beverages and sweets

Question 34

diabetes self management support (DSMS) and diabetes self management education (DSME)

Answer 34

-4 critical times when these have to be evaluated:
-1. At diagnosis
-2. Annually for assessment of education, nutrition, and emotional needs
-3. When new complicating factors (health conditions, physical limitations, emotional factors, or basic living needs) arise that influence self-management
-4. When transitions in care occur

-Appropriate referrals should be made as needed
-medical nutrition therapy- MNT

Question 35

key concepts in setting glycemic goals

Answer 35

-A1C is the primary target for glycemic control.
-Goals should be individualized based on:
-Duration of diabetes.
-Age/Life expectancy.
-Co-morbid conditions.
-Known ASCVD or advanced microvascular complications.
-Hypoglycemia unawareness.
-Individual patient considerations.
-More or less stringent glycemic goals may be appropriate for individual patients.
-Postprandial glucose may be targeted if A1C goals are not met despite reaching pre-prandial glucose goals

Question 36

referrals

Answer 36

-Annual dilated eye exam
-Family planning for women of reproductive age – ideally preconception
-Registered dietitian for MNT
-DSME (Delivery of diabetes self-management education )
-DSMS (Diabetes self-management support)
-Dental examination
-Mental health professional, if needed

Question 37

ADA recommendations

Answer 37

-Patient education – injections, monitoring Blood Sugar
-Dietary & life style changes (smoking cessation; regular exercise)
-Surgical interventions
-Tight BP control : ≤130/80
-Use of ACEI/ARBS

-Lipid level goals:
-LDL <70mg/dL (<2.6mmol/L)
-Triglycerides <150mg/dL (<1.7mmol/L)
-HDL >40mg/dL (>1.1mmol/L) ; Rx: statin

-Increased risk of infections - Vaccines
-Regular ophthalmic, foot care;
-Other specialty referrals (cardiology; nephrology)
-Dental exam

Question 38

follow up management

Answer 38

-HbA1c
-Measured quarterly if treatment is changed or if the patient is not meeting management goals
-Every 6-12 months if stable
-Microalbuminuria (albumin/creatinine ratio)- At diagnosis and then every year
-Blood lipids tested on initial visit and then annually, or as needed

Question 39

other labs to evaluate

Answer 39

-A1C, if results not available within past 2–3 months
-If not performed/available within past year:
-Fasting lipid profile, including total, LDL, and HDL cholesterol and triglycerides
-Liver function tests
-Test for urine albumin excretion with spot urine albumin-to-creatinine ratio
-Serum creatinine and calculated GFR
-TSH in type 1 diabetes, dyslipidemia or women over age 50
-*C-peptide level: indicates production of insulin
*Low level/ no insulin C-peptide) indicates that your pancreas is producing little or no insulin

Question 40

DSME

Answer 40

-increase adherence to standard of care and educating pts on glycemic targets and improves the percentage of pts who reach goal A1c

Question 41

self management training

Answer 41

-Management Principles and Complications:
-Initially and yearly
-Assess knowledge of diabetes, medications, self-monitoring, acute/chronic complications, and problem-solving skills
-Ongoing: Screen for problems with and barriers to self-care
-Sequential therapies, including insulin, likely to be necessary
-Lifestyle issues including nutrition, physical activity, and smoking cessation
-Assist patient to identify achievable self-care goals
-For children: As appropriate for developmental stage
-Resources available in the community

Question 42

self monitoring blood glucose (SMBG)

Answer 42

-Type 1: Typically test 3-4 times a day
-Type 2 and others: As needed to meet treatment goals
-Medical Nutrition Therapy (by trained expert):
-Initially: Assess needs/condition; assist patient in setting nutrition goals
-Ongoing: Assess progress toward goals; identify problem areas

Question 43

self management training: physical activity and weight management

Answer 43

-Physical Activity- Initially and ongoing: Assess and prescribe physical activity based on patient’s needs/condition.
-Weight Management- Initially and ongoing: Must be individualized for patient

Question 44

interventions

Answer 44

-Preconception, Pregnancy, and Postpartum Counseling and Management: Consult with high-risk, multidisciplinary perinatal/neonatal programs and providers where available (e.g., California Diabetes and Pregnancy Program “Sweet Success”).
-For adolescents: Age appropriate counseling advisable, beginning with puberty.
-Aspirin Therapy: 81 to 325 mg/day or 325 mg every other day in adults as primary and secondary prevention of cardiovascular disease, unless contraindicated
-Smoking Cessation: Screen, advise, access readiness to quit, and assist at every diabetes care visit, adjusting the frequency as appropriate to the patient’s response -> Refer to Helpline
-Immunizations- Influenza and pneumococcal, per CDC recommendations
-Psychosocial assessment- Barriers to self-care: common environmental obstacles, cultural issues, beliefs and feelings about diabetes, disorders of eating and mood, life stresses, and substance use

Question 45

dawn phenomena

Answer 45

-Pathophysiology:
-Waning-off ofInsulinaction in AM hours
-Secondary to increased nocturnal GH output
-Results in high AMBlood Sugars

-Diagnosis- Checking 3 amBlood Sugar
-Management- increase evening long-actingInsulin(NPH) dose

Question 46

somogyi phenomena

Answer 46

-Rebound Hyperglycemia
-Pathophysiology
-Rebound Hyperglycemia inDiabetes Mellitus
-Follows a hypoglycemic reaction during the night
-Diagnosis- Checking 3 amBlood Sugar
-Management- Decrease evening long-actingInsulin(NPH) dose

Question 47

hypoglycemia chart

Answer 47

Question 48

KNOW THIS

Answer 48

glycemic control= less symptoms

Question 49

KNOW THIS 2

Answer 49