T1DM, GDM, & HYPOGLYCEMIA Flashcards
Accounts for 5% of all diagnosed cases of DM
T1DM
Commonly occurs in childhood and adolescence
T1DM
T or F: T1DM can develop at any age including older individuals
T
T or F: More cases of T1DM are diagnosed before 50
F; More cases of T1DM are diagnosed before 30
Another term for T1DM
Juvenile diabetes
Screening for other autoimmune diseases is highly recommended due to increased frequency in people with this type of diabetes
T1DM
Give examples of autoimmune diseases screened in people with T1DM
- Autoimmune thyroid disease
- Celiac disease
- Addison’s disease
- Autoimmune hepatitis
- Autoimmune gastritis
- Dermatomyositis
- Myasthenia gravis
Diabetes where body produces auto antibodies attacking organs
T1DM
Primary defect of T1DM
Pancreatic B-cell destruction
Describe the rate of destruction of pancreatic B-cell for infants & children and that of adults
Infants & children: rapid
Adults: slow
What are the markers of immune destruction of B-cells for T1DM
- Islet cells autoantibodies
- Autoantibodies to insulin
- Autoantibodies to glutamic acid decarboxylase (GAD65)
- Autoantibodies to the tyrosine phosphatases IA-2, IA-2B & ZnT8
How many markers if immune B-cell destruction are needed to define T1DM
Greater than or equal to 1
Pertains to a protein on the surface if beta-cells
GAD65
Genetic links of T1DM are associated with ___ with linkage to the ___, ___, ___ genes
Histocompatibility locus antigen (HLA);
DQA, DQB, DRB
Two types of HLA alleles based on function
- predisposing
- protective
Forms of T1DM
- Immune-mediated T1DM
- Idiopathic T1DM
This is due to autoimmune destruction of B-cells of the pancreas
Immune-mediated T1DM
This has no known etiology and only a minority of individuals fall in this category (mostly African or Asian)
Idiopathic T1DM
Also known as Type 1.5 diabetes
Latent Autoimmune Diabetes of the Adult (LADA)
Most prevalent form of adult-onset autoimmune diabetes
LADA
Possibly the most common form of autoimmune diabetes in general
LADA
Pertains to adult-onset diabetes w/ associated antibodies
LADA
This type of diabetes requires no insulin treatment for a certain period after diagnosis
LADA
This diabetes has genetic features of both T1DM & T2DM
LADA
Explain the flow of the onset of LADA
Genetic features (TCF7L2, HLA, INS VNTR, PTPN2S)
— specific trigger —> (GADA +)
—> insulin deficiency —> LADA onset
Visceral adiposity
—low grade inflammation —> INULITIS (IA2-A+)
—> impaired insulin secretion —> LADA onset
*Genetic features also cause Insulitis (IA2-A+)
Autoantibody that promotes insulin deficiency
GADA
What does GADA stand for?
Glutamic Acid Decarboxylase Antibodies
Antibody that impairs insulin secretion
IA2-A
What does IA2-A stand for?
Islet Antigen-2 Antibodies
Usual Clinical Presentation of T1DM
- onset: extensive asymptomatic period of months to years
- most are lean
- some diagnosed without any or subtle symptoms & may be at higher weight
- polydipsia
- polyuria
- significant unexpected weight loss
- dehydration
Early symptoms of T1DM
- polyuria (Excessive urination)
- polydipsia (Excessive thirst)
- feeling tired or weak
- yeast infection (vaginal discharge or itching)
- increase in appetite
- dry mouth or throat
- unexplained weight loss
Advanced symptoms of T1DM (appear if untreated or undiagnosed)
- stomach aches
- nausea and vomiting
- feeling drowsy
- Kussmaul breathing (heavy, rapid breathing)
Usual metabolic abnormalities of T1DM
- Hyperglycemia
- Electrolyte imbalance
- Diabetic Ketoacidosis
What does DKA stand for?
Diabetic Ketoacidosis
What characterizes DKA?
Extreme:
hyperglycemia,
ketonemia, and
ketonutria
This serious DM complication is a common presentation among infants & children
DKA
The honeymoon phase of T1DM occurs after __
after the diagnosis & the correction of
- hyperglycemia,
- metabolic acidosis &
- ketoacidosis
Pertains to recovery of endogenous insulin secretion
Honeymoon phase of T1DM
T or F: During the honeymoon phase of T1DM, the need for exogenous insulin decreases dramatically for up to >= 2 years
F; >= 1 year
Good metabolic control may be easily achieved during ___
Honeymoon phase of T1DM
T of F: During the honeymoon phase, the need for increasing exogenous insulin replacement is inevitable & should always be anticipated
T
What is the medical management of T1DM?
- there is no known cure
- administration of exogenous insulin
- self-monitoring of glucose from early diagnosis
T or F: the MNT for T1DM is significantly different from MNT for pre-diabetes and T2DM
F: it is similar with the MNT of Pre-diabetes & T2DM
This form of diabetes consists of high blood glucose levels during pregnancy
Gestation diabetes (GDM)
T or F: Gestational diabetes affects 2-10% of pregnancies in the USA
T
T or F: GDM develops n 1 of 25 pregnancies worldwide
T
T or F: approx. 2 in 3 women w/ diabetes are of reproductive age
F; 1 in 3 women
This can reduce risk of adverse pregnancy outcomes in women w/ diabetes
Careful control and monitoring of body glucose levels during pregnancy w/ support of healthcare provider
Tor F: 21.3 million women had some form of high blood glucose in pregnancy (2017)
T
Increased risk for the mother in GDM:
Hypertension during pregnancy
Macrosomic baby —> requires C-section
Increased risk for the baby (mother w/ GDM):
- premature labor & ARDS
- low blood sugar
- developing diabetes later in life
Meaning of ARDS
Acute respiratory distress syndrome
Predisposing factors of GDM
Women of low socioeconomic status
Women of Hispanic, Native American, Asian & African American descent
High-risk factors for GDM
- previous history of GDM
- previously elevated blood glucose level
- maternal age >= 40 years
- family history of DM (1st degree relative w/ diabetes or sister w/ GDM)
- BMI > 35 kg/m2
- previous macrosomia (baby w/ bw > 4500 g or > 90th percentile)
- PCOS
- Medications: corticosteroids, antipsychotics
At which prenatal visit should women with risk factors be screened for T2DM? What criteria will be used?
1st prenatal visit; standard diagnostic criteria
Ideal time for screening of pregnant women
Between 24-48 weeks of gestation
Why is GDM most often diagnosed during 2nd or 3rd trimester?
- increase in insulin-antagonist hormone levels
- insulin resistance that normally occurs at this time
What should be the diagnosis of women with diabetes in the first trimester?
Overt diabetes
(NOT GDM)
How many weeks are women screened for diabetes postpartum?
4-12 weeks
Women who had undergone GDM should have lifelong screening development of diabetes or pre-diabetes in what year-interval?
At least every 3 years
Should HBA1C be used for GDM?
NO; ineffective
What laboratory tests should be done for GDM?
Glucose Tolerance Test (GTT)
- One-step: 75 g OGTT or
- Two-step: 50 g (non-fasting screen) followed by 100-g OGTT (2nd step: done if positive - 50 g result w/ abnormally high blood glucose)
T or F: for most affected women, blood sugar levels will revert back to normal after pregnancy w/ GDM
T
Percentage of women w/ prior GDM developing diabetes in __ years
15-25% develop T2DM within 1-2 years after pregnancy
35-70% develop T2DM 10-15 years after pregnancy
Complications of GDM
Fetal macrosomia
Neonatal hypoglycemia at birth
Congenital Malformations
Characteristics of Fetal Macrosomia
- Excess maternal glucose crosses the placenta
- Fetal pancreas releases more insulin that converts glucose to fat
- Converts normal delivery to a C-section
Characteristics of Neonatal Hyperglycemia at birth
- Due to the extra insulin produced prior birth
- Requires VI feedings for 1-2 days to maintain normoglycemia
Characteristics of Congenital Malformations
- Not caused by GDM
- Occurs during the first 6-8 weeks (period of organogenesis) of pregnancy in women with uncontroled diabetes
General medical management of GDM (5)
- Regular blood glucose monitoring
- Maintaining the blood glucose level within the normal range
- Recommending a balanced diet & regular, moderate physical activity
- Monitoring the babys’ growth and development
- Some will require oral hypoglycemic agents and/or insulin therapy
Pharmacological management of GDM: what is the preferred medication and why?
Insulin
- does not cross the placenta
- oral hypoglycemic agents are insufficient to overcome insulin resistance in T2DM & ineffective in T1DM
Plasma glucose goals during pregnancy for GDM and pregnancy w/ preexisting T1DM or T2DM
Fasting: <95 mg/dL (5.3 mmol/L) and EITHER
- 1-h postmeal: <140 mg/dL (7.8mmol/L)
OR - 2-h postmeal: <120 mg/dL (6.7 mmol/L)
A1C: 6-6.5% (42-48 mmol/mol)
MNT goals of GDM
- To assist ni achieving & maintaining optimal blood glucose control
- To provide adequate maternal & fetal nutrition throughout pregnancy, energy intake for appropriate maternal weight gain, & necessary vitamins and minerals
MNT Recommendations (14) for GDM
- Pre-conception counseling focused on achieving near-normal blood glucose levels before pregnancy
- effective in reducing incidence of anomalies in infants born to women w/ pre-existing diabetes - MNT should be given at the time of GDM diagnosis
- Adjust eating plan to accommodate additional calories (CHO-controlled meal plan) to support fetal growth based on the woman’s food intake, eating habits, blood glucose responses
- Regular weight monitoring
- CHO should be distributed throughout the day into 3 small-to-moderate sized meals & 2-4 snacks
- minimum CHO: 175 g/day
- 30 g CHO for breakfast for better tolerance due to increased levels of cortisol and growth hormone - Protein foods can be added to satisfy hunger pangs since they do not generally affect blood glucose
- Match the food intake with the insulin regimen.
- Maintain consistent-eating times & food intake
- Smaller meals & more frequent snacks
- Late-evening snack: often necessary to decrease likelihood of overnight hypoglycemia & fasting ketosis - Regular monitoring of food intake & blood glucose values
- Regular follow-up visits during pregnancy to monitor:
- caloric & nutrient intake
- blood glucose control
- presence of starvation ketosis due to:
—-> inadequate energy or CHO intake
—-> omission of meals/snacks
—-> prolonged interval between meals (ex: >10 hrs between bedtime snack and breakfast) - Recommend regular exercise
- benefirs:
—-> improves peripheral resistance to insulin
—-> controls fasting & postprandial hyperglycemia
—-> improves maternal glycemia
- ideal form of exercise is unknown
—> brisk walk after meals often recommended - Women w/ preexisting diabetes should be encouraged to breastfeed because breastfeeding is associated with/ a reduced incidence of future T2DM
- Women w/ GDM who are overweight/obese or w/ above-recommended weight gain during pregnancy: weight loss is advised after delivery
- may aid in reducing risk of recurrent GDM or future development of T2DM
This MNT recommendation for GDM is effective in reducing the incidence of anomalies in infants born to women w pre-existing diabetes
Pre-conception counseling focused on achieving near-normal blood glucose levels before pregnancy
This is often necessary to decrease the likelihood of overnight hypoglycemia & fasting ketosis
Late-evening snack
This MNT recommendation for GDM improves peripheral resistance to insulin
Recommend regular exercise
This MNT recommendation for GDM controls fasting & postprandial hyperglycemia
Recommend regular exercise
This MNT recommendation for GDM improves maternal glycemia
Recommend regular exercise
This MNT recommendation for GDM may aid in reducing the risk of recurrent GDM or future development of T2DM
Weight loss after delivery (for obese or overweight or above normal weight gain during pregnancy)
Hypoglycemia is a clinical syndrome w/ diverse causes in w/c low levels of plasma glucose leads to ___
Neuroglycopenia
Normoglycemia range
Between 60-10 mg/dL (3.3-5.6 mmol/L)
Symptoms when blood glucose < 65mg/dL (3.6 mmol/L)
• Sweating
• Shaking
• Weakness
- Hunger
• Headaches
- Irritability
What happens at 50 mg/dL of blood glucose
Impairment of brain function
A hypoglycemia alert value of ___ can help determine therapeutic dose adjustment of glucose-lowering drugs & is often
related to symptomatic hypoglycemia
> = 70 mg/dL (3.9 mmol/L)
Whipple’s Triad is defined by:
- Low plasma or blood glucose level
- Symptoms of hypoglycemia at the same time
- Resolution of the symptoms once the blood glucose returns to normal
Types of hypoglycemia
- Postprandial or Reactive Hypoglycemia
- Fasting Hypoglycemia or Postabsorptive Hypoglycemia
Pertains to blood glucose falling below normal limits within 2-5 hours after eating
Postprandial or reactive hypoglycemia
food-deprived hypoglycemia that occur in response to having gone w/o food for >= 8 hours
Fasting Hypoglycemia or Postabsorptive Hypoglycemia
Causes of Postprandial or reactive hypoglycemia
- Exaggerated or late insulin response caused by either insulin resistance or elevated GLP-I
- Renal glycosuria
- Defects in glucagon response
- High insulin sensitivity
- Rare syndromes: hereditary fructose intolerance, galactosemia, leucine sensitivity or a rare B-cel pancreatic tumor (insulinoma)
- Ingestion of alcohol after a prolonged fast or the ingestion of large amounts of alcohol & CHO on an empty stomach (“gin-and-tonic” syndrome) may cause hypoglycemia within 3-4 hours ni some healthy persons
- Alimentary Hyperinsulinemia:
—> Common after gastric surgery
—> Associated with rapid delivery of food to the small intestine, rapid absorption of glucose & exaggerated insulin response
—> Respond best to multiple, frequent feedings
Characterized by normal insulin secretion but increased insulin sensitivity & reduced response of glucagon to acute hypoglycemia symptoms
Idiopathic Reactive Hypoglycemia
Leads to a late postprandial hypoglycemia
Idiopathic Reactive Hypoglycemia
Documented only ni persons with hypoglycemia that occurs spontaneously & in persons who meet the criteria of Whipple’s triad
Idiopathic Reactive Hypoglycemia
Causes of Fasting Hypoglycemia / Post-Absorptive Hypoglycemia
- Eating disorders
- Hormone deficiency states (Ex: hypopituitarism, adrenal insufficiency, catecholamine or glucagon deficiency)
- Acquired liver disease
- Renal disease
- Certain drugs (Ex. alcohol, propranolol, salicylate)
- Insulinoma of which most are benign, but 6-10% can be malignant & other nonpancreatic tumors
- Taking high doses of aspirin
- Factitious hypoglycemia or self administration of insulin or sulfonylurea in people who do not have diabetes
Symptoms of Fasting Hypoglycemia / Post-Absorptive Hypoglycemia
- Tend to be severe
- Loss of mental acuity
- Seizures
- Unconsciousness
Diagnostic criteria of hypoglycemia of nondiabetic origin
- Blood glucose level of <70 mg/dL (3.9 mmol/L)
- Clinically significant hypoglycemia: 54 mg/dL (3.0 mmolL)
- To confirm the diagnosis:
—> Recording finger stick blood glucose measurements during spontaneous, symptomatic episodes at home
—> Perform a glucose test ni a medical office setting, ni which case the patient si given a typical meal that has ben documented ni the past ot lead to symptomatic episodes
—> Confirm the presence of the Whipple’s triad
Goals of Management of Hypoglycemia of Nondiabetic Origin
- Relief of neuroglycopenic symptoms by restoring blood glucose concentrations to the normal range
- Correction of the underlying cause
- Adoption of eating habits that wil keep blood glucose levels as stable as possible
- give simple carbs
- do not skip meals
- inject insulin after eating fi diagnosed with DM
- bring to ER to give IV dextrose
Management of Hypoglycemia of Nondiabetic Origin
- Immediate Treatment: Eat foods or beverages containing CHOs
- Eat small meals, with snacks interspersed between meals & at bedtime
—> Eating 5-6 smal meals rather than 2-3 large meals ot steady the release of glucose into the bloodstream - Spread the intake of CHO foods throughout the day
—> Have 2-4 servings (15 gCHO/serving) of CHO foods at each meal & 1-2 servings at each snack - Avoid or limit foods high in sugar & CHO, especially on an empty stomach.
—> Ex: regular soft drinks, syrups, candy, fruit juices, regular fruited yogurts, pies &cakes - Avoid beverages & foods containing caffeine
—> Caffeine can cause the same symptoms as hypoglycemia &make the individual feel worse. - Limit or avoid alcoholic beverages
—> Drinking alcohol on an empty stomach & without food can lower blood glucose levels by interfering with the liver’s ability to release stored glucose (gluconeogenesis)
—> If an individual chooses to drink alcohol, it should be done ni moderation (1-2 drinks no more than 2x a week) &food always should be eaten along with the alcoholic beverage - Consider teaching the patient to do CHO counting
8 . Moderate CHON intake at meals or with snacks
—> Adds satiety and calories
—> But excessive CHON intake may stimulate insulin release
