Quiz 3: Weeks 6-8 14% Flashcards
What is type II diabetes?
it’s a problem where the hormone insulin (secreted by the pancreas) does not work properly.
The pancreas is an organ sitting behind the stomach and it secretes many things for digestion and produces and secretes hormones, which are important metabolism.
Insulin is produced by the pancreas in response to high blood glucose,
for example, after you eat, glucose enters your blood, stimulates the pancreas and produces insulin.
Since there is high blood glucose, the pancreas is told to secrete more insulin
= persistent high blood glucose
How does insulin work normally?
On the liver, adipose tissue (fat), and muscles there are receptors for insulin.
High blood glucose stimulates insulin production and insulin release from the pancreas. Insulin starts different organs by binding onto their insulin receptors/insulin sensitive proteins, which decreases blood glucose levels.
This happens because the binding of insulin to the receptor/protein triggers a cascade of events within a cell = increased uptake of glucose from circulation, by producing more glucose channels/transporters on the surface of cells
= glucose moves from the blood to the cells of the organs.
What are the other roles of insulin?
- Insulin promotes glucose storage. In the liver, insulin stimulates glycolysis and glycogenesis to store glucose as glycogen.
- Insulin stimulates glucose to be stored as fat, which is transported to adipose tissue
What happens to insulin in T2DM?
Insulin resistance, the receptors that insulin usually binds to don’t work properly, therefore insulin doesn’t work properly on the liver, adipose tissue, and skeletal muscle.
This causes high blood glucose levels to remain for long periods of time.
Insulin resistance causes glucose to not be taken up by all the different organs
= high blood glucose
What are the different factors that cause insulin resistance?
- genetics
- family predisposition
- bad eating habits
- obesity
What is glucose urea?
Glucose travels to the kidneys to be secreted out. This results in osmotic diuresis (glucose drags water with it because it is a solute = frequent urination (polyuria))
Constant polyuria can lead to loss of water and loss of electrolytes
What 2 things can happen when there is a loss of water and electrolytes due to osmotic diuresis?
- Dehydration, from loss of water. Stimulates the brain to drink more water
= polydipsia (excessive thirst) - Hyperosmolar state, a medical emergency
What is polyphagia?
the feeling of hunger, an urge to eat more
If there is high blood glucose, and it doesn’t go into the tissues that need it, the organs will signal the body that it needs food
What happens with prolonged insulin resistance?
The beta cells produced by the pancreas will decrease in size because the body isn’t responding to insulin properly.
Individuals may eventually need to be on insulin injections to compensate
What are the 2 acute complications of T2DM?
- Diabetic ketoacidosis (DKA)
- Hyperosmolar hyperglycemic non-ketotic state (HHNS)
mortality rate of 8-20%
What is Hyperosmolar hyperglycemic non-ketotic state (HHNS)?
a dangerous condition resulting from very high blood glucose levels can affect both T1DM and T2DM but is more common in T2DM
HHNA is caused by diabetes (deficiency of insulin, the body can’t adequately respond to the insulin being produced by the pancreas)
Someone with HHNS has already been diagnosed with diabetes, and they will likely have hyperglycemia (one of the defining characteristics of diabetes mellitus).
Hyperglycemia drives the events that occur in HHNS
Symptoms of HHNS?
- fatigue
- weight loss
- extreme thirst
- frequent urination
- signs of dehydration
- high heart rate (tachycardia)
- low blood pressure (hypotension)
- mucus membranes in the mouth can be dry
- decreased skin turgor (skin sticks up when pinched)
in severe cases, - confusion
- altered mental status
Because of diabetes, glucose builds up in the blood, which results in hyperglycemia (high blood sugar). Since glucose can’t be used for energy, it can’t be taken up, this causes fatigue/decreased energy and weight loss with someone who has HNNS
Glucose is an osmotically active solute, what does this mean?
this means whenever it goes into the body, water likes to follow. Water is pulled out of the cells to keep the concentration of glucose in the blood at a relatively constant level.
As blood moves to the kidneys where it’s filtered, under normal situations, the kidneys filter out very little glucose and reabsorb almost all the glucose that’s in the blood.
When hyperglycemia becomes severe, what happens to the kidneys?
The kidneys are not able to reabsorb all the glucose and it spills out into the urine.
Glucose is still osmotically active, therefore water follows the glucose out of the blood and into the urine. The body starts to lose a lot of water and fluid very quickly, the concentration of the solutes in the blood (sodium, potassium, glucose) increases = hyperosmolarity (high concentration of osmotically active solutes)
What is osmotic diuresis?
increased urination due to the presence of certain substances in the fluid filtered by the kidneys.
it’s the reason for the intense thirst and frequent urination, severe dehydration and altered mental state in HHNS
What are the similarities between DKA and HNNA?
- In both DKA and HHNA, the body is in a state of starvation. Even though there is plenty of energy present in the blood in the form of glucose, the body is starving for energy because it can’t utilize this energy.
What is ketogenesis?
The body’s metabolism responds as though it is starving
= ketogenesis, a process where ketones/ketone bodies/ketoacids are produced. The ketones are produced from acetyl CoA (a by-product of fat metabolism).
The production of ketones results in metabolic acidosis (a serious electrolyte disorder by an imbalance in the body’s acid-base balance)
What is the difference between diabetic ketoacidosis and hyperosmolar hyperglycemic non-ketotic state?
People with HHNS most commonly have T2B, which means they are still able to produce insulin. The pancreas is still producing insulin, it’s just the cells throughout the body can’t adequately respond to it.
The insulin that is present acts to inhibit the ketogenesis pathway. Therefore, since insulin is present in HHNS, the creation of ketone bodies is minimized = non-ketotic state.
How can HHNS be treated?
Should be treated in the intensive care unit because of how severe HHNS is.
Two major treatments:
1. administration of IV (intravenous insulin)
this helps decrease insulin deficiency and drives glucose out of the bloodstream and into the cells through the body. Decreases hyperglycemia, which decreases osmotic diuresis and fluid loss. All this also decreases the hyperosmolarity of the blood
2. aggressive rehydration with intravenous fluids (normal saline). This replenishes the fluid loss caused by osmotic diuresis. Also decreases osmolality. Rehydration helps alleviate the signs of dehydration (tachycardia, hypertension, altered mental status)
What is Hemoglobin A1C & an A1C Test?
It’s a form of hemoglobin that is chemically linked to sugar.
An A1C test is a simple blood test that measures your average blood sugar levels over the past 3 months. It’s the main test to help manage diabetes.
What are the A1C targets?
Adults with T2DM to reduce the risk of CKD and retinopathy if at low risk of hypoglycemia should be at <6.5%
Most adults with T1DM or T2DM should be at an A1C level of <7.0%
- 1-8% functionally dependent
- 1-8.5% recurrent severe hypoglycemia and/or hypoglycemia unawareness
What are some acute symptoms of T2DM?
- unusual thirst
- frequent urination
when the person can’t utilize blood glucose that’s circulating in the blood from the food ingested, there’s excess glucose in the blood. The body usually converts glucose into fatty acids and then stores it.
Ppl with T2DM are insulin resistant, therefore glucose can’t be uptaken by the cells as it normally does. This causes glucose to be excreted in the urine. Glucose is an osmolar solute, which means water follows it, therefore there is a large excretion of fluids, which makes the person thirty and frequently urinate
- weight change (gain or loss)
- extreme fatigue or lack of energy (loss of fluid and electrolytes)
- blurred vision (the vessels within the retina and behind the eye. When you have high glucose levels for a long period the blood thickens and the arterial walls narrow = reduced blood flow. Hyperglycemia)
- frequent infections, cuts, bruises that are slow to heal
- tingling and numbness in hands and feet (reduced blood flow)
Once the patient starts treatment such as meds, diet to manage their blood glucose the acute symptoms start to go away
What are the silent symptoms of T2DM?
- elevated A1C (above 8%), high triglyceride
- could have complications later on, or other comorbidities that put them at a higher risk for diabetes (high cholesterol, hypertension, dyslipidemia (elevated LDL)
- started on 1-2 meds (Metformin: helps control high blood sugar) on insulin for a short period if their hyperglycemia is very bad
- lifestyle changes
What happens to someone with stage 4 kidney disease and diabetes?
When you have stage 4 kidney disease, the cells within the kidneys are damaged. If you have stage 1 or 2 kidney disease, the functioning kidney cells still do a good job at accommodating the cells that are damaged.
Stage 4 kidney disease causes a decrease in urination because the kidney isn’t functioning properly. It’s not able to filter out the blood. This can cause retinopathy since you’re not able to excrete that excess glucose through the urine.
A specialized diet for kidney disease is needed and the diet becomes limited if someone also has diabetes. Need to control carbs very strictly. More about survival, so difficult to stay within the client’s preferences
In stage 4 kidney disease the patient may or may not be on dialysis (filtering of the blood, helps to correct disturbances in the blood mechanically)
What is a diabetes education center?
focused on medical and nutritional care for the patient. Multidisciplinary team (endocrinologists (specialize in diabetes and hormones issues), nurses, dietetics) can run group or individual sessions.
Diabetes can also be managed at the family physician level, but individuals should consider going to a diabetes education center for more comprehensive care
What are some common medications/hypoglycemic agents? **redo this when rewatching lecture video
- Metformin (Glucophage): works at a cellular level help with the uptake of glucose
What’s involved in nutrition therapy?
- Individualized goal setting: blood glucose levels are different for everyone, cultural foods, eating habits
- Healthy dietary patterns: MediterraneanDASH diet, Canada’s Food Guide, the main tool we use to maintain blood glucose levels
- Nutrient targets
- Menu planning
- Basic carbohydrate counting: we try to focus on healthy dietary patterns first, for someone who’s motivated
- Glycemic index: for someone who’s motivated and can retain the info to make changes to their diets based on carbs. A more complicated topic for patients.
- Self-monitoring of blood glucose (SMBG)
What is Beyond the Basics?
- A tool used for meal planning for healthy eating and diabetes management. A good RD will adapt this tool to meet the needs of the patient
- help manage blood glucose and maintain a healthy weight
- helps choose the right food and portions
- 1 serving - 15g or 1 carb choice
- gives Canadian food choices, has a lot of empty boxes to fill in for patient preferences
- if you have a patient that is Southeast Asian, include food sources for that specific person, or Mediterranean diet then choose food sources that follow the Mediterranean diet
thechildren.com/sites/default/files/cda_poster_eng.pdf
What are some dietary management goals?
- manage blood glucose
- manage weight
- manage blood pressure and cholesterol to reduce the risk of any other comorbidities such as hypertension, dyslipidemia (elevated total or low-density lipoprotein LDL)
- reduce risk of diabetes complications like stroke or heart attack. Patients with hyperglycemia, or even diabetes (uncontrolled diabetes is worse), and also have high blood pressure and cholesterol are at a higher risk for stroke and heart attack. Might be due to small vessel disease that develops as a result of these comorbidities/comorbid states.
Small vessel disease: plaque builds up in small vessels within the body or striction due to plaque and damaged vessels. Not something that can really be detected, too hard to look at the small vessels within the body
What are the ABCDES of Diabetes Care?
a reminder of the importance of tracking your blood sugar numbers along with your blood pressure and cholesterol. High blood pressure and cholesterol are well-known risk factors for heart disease and stroke. Knowing your numbers, lifestyle changes are recommended to manage diabetes and sometimes meds.
A: A1X or HbA1C. a test that measures blood glucose control over the past two to three months. The A1C target for most people is under 7%
B: Blood pressure. Nearly 2 out of 3 people with diabetes have high blood pressure. For most people with high blood pressure and diabetes, blood pressure levels should be <120/80 mm Hg. Diets can help such as the Mediterranean diet, higher potassium, lower sodium type diets
C: Cholesterol. Total cholesterol, LDL, and triglycerides should be monitored. LDL-C should be <2.0 mmol/L or >50% reduction from baseline
D: Drugs. For CVD risk reduction
E: Exercise and healthy eating
S: Stop smoking. Smoking doubles the risk of heart disease in people with diabetes
S: Screening for complications.
S: Self-management. Stress and other barriers. Teach individuals how to manage their blood glucose levels
What is the glycemic index?
- looking at the carbs of food, macronutrient, and how it increases blood glucose levels
- more complex for the general T2DM patients
- there is a green light system to rank carb foods based on how much they increase blood glucose levels
Green (go): low GI (55 or less) choose most often
ex. grain bread, whole grain, steel-cut oats, quinoa, peas
Yellow (caution): medium GI (56 to 69) choose less often
ex. chapati white bread, rye bread, quick oats, brown rice
Red (stop): high GI (70+) choose least often
ex. white bread, cereals such as special K, white rice, soda crackers
It’s important to educate patients on how these foods might affect their blood glucose levels daily. Once they understand how foods affect them, they’re more inclined to make better choices
What are the recommendations for macronutrient distribution?
- carbs: 45-60%, 4 cals per g, 225-300 cals
- protein: 15-20%, 4 cals per g, 75-100 cals
- fat: 20-35%, 9 cals per g, 44-78 cals
How to choose “healthy” fats?
- avoid trans fats
- recommendation to reduce saturated fatty acids to <9% of energy intake
- replace with polyunsaturated fatty acids (PUFAs) such as nuts, canola oil, soybean oil, flaxseed
- eat monounsaturated fatty acids (MUFAs) from plant sources such as extra virgin olive oil, high oleic oils, avocados
How to choose “healthy” fats?
- avoid trans fats
- recommendation to reduce saturated fatty acids to <9% of energy intake
- replace with polyunsaturated fatty acids (PUFAs) such as nuts, canola oil, soybean oil, flaxseed
- eat monounsaturated fatty acids (MUFAs) from plant sources such as extra virgin olive oil, high oleic oils, avocados
How to choose “healthy” carbs?
- soluble dietary fibre helps with managing the health of arteries and excreting LDL cholest from circulation, helps with plaque build-up. Helps manage comorbidities
- 30-50g of dietary fibre per day
- 10-20g per day from viscous soluble fibre such as steel-cut oats, barley soups, eggplant
How to calculate Estimated Energy Requirement (EER)?
EER male = 622 - (9.53 x age) + PA x (15.91 x kg) + (539.6 ht (m))
Need:
Age, physical activity level, weight, height
https://www.omnicalculator.com/health/eer-estimated-energy-requirement
How to calculate carb choices?
First, you need the patient’s EER
ex. 2200 kcal/day
Step 1. Use the EER and multiply by daily percent carb intake (ex. 45-50%)
2200 x 0.5 = 1210 kcal from carbs
Step 2. Take the number from step 1 and divide it by 4.
4 = 4kcal per 1g of carbs
1210/4 = 302g carb/day
Step 3: Determine the number of carb choices
302/15 = 20 carb choices/day
What are some questions you can ask a T2DM patient about their eating patterns?
- why are they skipping meals (if they skip), are they busy? Need quick and healthy recipes
- times he usually eats
- do they pack lunches from home
- how well do they sleep
- portion sizes
- types of bread, rice, fish (glycemic index)
- cooking methods for chicken and broccoli?
- who does the most cooking at home?
- fluids?
- likes and dislikes
How to write a PES statement?
P: The problem: The nutrition diagnosis
E: The etiology: the cause(s) of the nutrition problem (nutrition diagnosis)
S: The signs and symptoms: the evidence that the nutrition problem (nutrition diagnosis) exists
Ex. Nutrition diagnosis term (nutrition Problem) related to (RT) the Etiology (the cause(s) of the problem or nutrition diagnosis as evidenced by (AEB) the Signs and symptoms.
Diabetes PES Statement Example:
Excessive carbohydrate intake RT limited diet compliance and diagnosis of Type 2 Diabetes, AEB reported intake of 80% calories from carbohydrates, HbA1C 8.2%, and blood sugar 240.
Inadequate blood glucose management RT family history, diet, and sedentary lifestyle as evidenced by A1C 7.5% and FGB 8.9 mmol/L
What is diabetic ketoacidosis?
- a medical emergency
- especially in T1DM, but can also occur in T2DM
- there’s an increase in the acidity in the blood
- it’s a serious complication of diabetes that occurs when your body produced high levels of blood acids called ketones
- it develops when your body can’t produce enough insulin
What are the signs and symptoms of Diabetic Ketoacidosis?
- nausea
- vomiting
- polyuria (excessive urination)
- polydipsia (excessive thirst)
- weight loss
- hyperventilation (Kussmaul breathing, a type of hyperventilation that is the lung’s emergency response to acidosis) Acidosis is a condition in which there is too much acid in the body fluids
What are the 5 Is of triggers that cause Diabetic Ketoacidosis?
- Infection
- Intoxication
- Inappropriate withdrawal of insulin
- Infarction (tissue death or necrosis due to inadequate blood supply to the affected area)
- Intercurrent illness (a disease that intervenes during the course of another disease)
What happens to the pancreas in T1DM?
- the pancreas normally produces insulin, in T1DM there is an autoimmune attack on the B cells (they normally produce insulin). Therefore, insulin is not being produced anymore = decrease in insulin
What happens when insulin is not produced in T1DM?
- gluconeogenesis is not inhibited, therefore we get more production of glucose
- increased glycogenolysis (a process where glycogen is broken down into glucose to provide immediate energy to maintain blood glucose levels during fasting)
- decrease in glycolysis (the metabolic pathway that converts glucose into pyruvic acid)
This all causes more glucose in the blood
= hyperglycemia causes: - glucose urea (glucose is peed out)
- polyuria (pee more than usual because glucose is an osmotic solute and draws water)
- polydipsia (excessive thirst from losing so much fluid)
- the decrease in insulin means that fat breaks down occur because the body is not receiving enough energy. During an infection or feeling ill, the body will break down fat because glucose (energy) is not present and is not being taken up
Fats are broken down from adipose tissue to form free fatty acids, which go to the liver and undergo ketogenesis to make more ketone bodies because the body needs some kind of energy since glucose is not present
What is Ketonemia?
occurs when there are high levels of ketone bodies in the blood
In T1DM,
the decrease in insulin means that fat breaks down occur because the body is not receiving enough energy. During an infection or feeling ill, the body will break down fat because glucose (energy) is not present and is not being taken up
Fats are broken down from adipose tissue to form free fatty acids, which go to the liver and undergo ketogenesis to make more ketone bodies because the body needs some kind of energy since glucose is not present
From high levels of ketone bodies (Ketonemia), this results in Ketonuria where ketones are being peed out
Ketones are acidic, they are acids. They reduce the pH in the blood and urine, this is the main path of DKA
What happens if a patient shows signs and symptoms of DKA?
- need a thorough history and examination
- need to check airways, breathing circulation: IV access is important to get blood for investigation, get base serum potassium level (K+)
- admin IV fluids (saline)
- admin insulin slowly (helps cells in the body take up the glucose that is in the blood)
- monitor pH using arterial blood gas (ABG) regularly
- full blood count, EUC for infections and electrolyte abnormalities, dehydration
- urine analysis to check and monitor if there’s glucose, ketones, and infections
- ECG performed to check for arrhythmias in case of potassium hyperkalemia/hypo
Monitoring K+ levels is important since insulin is being administered because insulin will cause hypokalemia (which can trigger an arrhythmia)
What are the main differences between T1DM and T2DM?
T1DM:
- is an autoimmune condition
- there’s damage to the beta cells in the pancreas that prevents the individual from producing insulin, which is why they have to inject it
- prone to diabetic ketoacidosis (DKA): medical emergency, your sugars get so high your body goes into a state of acidosis. Your blood gases, pH, and electrolytes levels are not normal
T2DM:
- ranges from insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance
- DKA is not common because you can still make a little bit of insulin
What is Gestational Diabetes Mellitus (GDM)?
- in pregnancy, a glucose intolerance
- they do an oral glucose tolerance test during week 26 of pregnancy, they drink 50-75g of sugar and then test their sugars to see how their body was able to process it
- once the woman gives birth diabetes goes away, but now she is at risk for T2DM later in life
What is Latent Autoimmune Diabetes in Adults (LADA)?
- someone who gets diagnosed with T1DM later in life
- can be difficult to diagnose, because of the individual’s age they might get diagnosed as a T2DM. As the disease progresses, it is realized that it is actually an autoimmune deficiency where they need insulin
- <50 years of age (could be in their 70s)
- BMI <25kg/m2
- history of autoimmune disease (thyroid disorder)
- family history of autoimmune disease
What is the physiology of a normal metabolism?
- pancreatic beta cells regulate the storage and metabolism of glucose through the secretion of insulin
- insulin is anabolic (muscle building), it is produced when sugars go up, the pancreas releases insulin to help the sugars come down =
biphasic pattern:
Phase 1: the insulin will release a ton of little bits of inulin when you start to eat and it notices the sugars are going up. a large burst produced in the first 3 mins after a meal
Phase 2: then there’s a smaller production of insulin over the next couple of hours
What are the roles of insulin in the body?
- insulin allows blood sugar to enter cells of the body to be used as fuel
- helps circulating free fatty acids to be stored as triglycerides in fat cells
- converts glucose to glycerol, the basis of stored triglycerides in far cells
- stimulates the storage of amino acids as protein in muscles
- helps the liver and muscle tissue store glycogen for future use
What is glucose homeostasis?
- it’s the balance of insulin and glucagon to maintain blood glucose
Steps:
1. When you eat something, your pancreas is triggered to release insulin
2. insulin triggers the fat cells in your muscles to take up glucose/sugar, which brings sugars down
Your liver starts to store sugar, which decreases the process of gluconeogenesis (production of carbs)
3. these processes bring sugars down to normal levels (4-6mM)
4. the opposite happens when you’re sleeping/fasting and not eating. When your sugars go down overnight, the pancreas releases the hormone glucagon (controls blood sugar/glucose levels)
5. Glucagon tells the liver it needs glucose, this increases glycogenolysis (glycogen breaks down into glucose) and increases gluconeogenesis (transform non-carbs into glucose), therefore glucose increases to balance to a normal blood glucose level (4-6 mM)
