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Diabetes Mellitus

Diabetes Mellitus. Diabetes Mellitus (Greek: a Flow-Through of Honey). w Disorder of carbohydrate metabolism characterized by high blood sugar levels and presence of sugar in the urine. w Affects approximately 16 million Americans.

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Diabetes Mellitus

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  1. Diabetes Mellitus

  2. Diabetes Mellitus (Greek: a Flow-Through of Honey) w Disorder of carbohydrate metabolism characterized by high blood sugar levels and presence of sugar in the urine w Affects approximately 16 million Americans w Develops when insulin production is inadequate or when insulin is ineffective in facilitating the transport of glucose from blood into cells w Most cases are classified as type 1 or type 2 w Prevalence increases with aging; affects 25% of adults over 85 years of age

  3. Type 1 Diabetes w Insulin-dependent (IDDM) w Onset occurs most often during childhood or young adulthood w Requires daily injections of insulin • Includes only 5% to 10% of all individuals with diabetes • Excessive hunger, thirst, urination and loss of weight

  4. Type 2 Diabetes w Non-insulin dependent in the early stages (NIDDM) w Onset occurs most often gradually during adulthood (now being seen in more and more children) w Includes 90% to 95% of all individuals with diabetes

  5. Type 1 w Heredity w Destruction of insulin-secreting beta cells in the pancreas w Destruction possibly linked to immune system dysfunction Type 2 w Heredity w Impaired insulin action (insulin resistance); later, impaired insulin release as beta cells “fatigue” w Excessive glucose output from the liver w Beta-cells become less responsive to increased blood glucose–obesity-related w Target cells undergo reduction in active insulin receptors–obesity-related Causes of Diabetes Mellitus

  6. Health Problems and Diabetes w Coronary artery and peripheral vascular disease (increased atherosclerosis; ulceration, gangrene) w Cerebrovascular disease and stroke (atherosclerosis) w Hypertension w Toxemia during pregnancy w Renal disorders (diabetic nephropathy) w Eye disorders (diabetic retinopathy)

  7. Public Awareness Survey on 2,000 People with Diabetes (Fall 2001) • Findings: • 68% do not consider cardiovascular disease to be complication of diabetes • 50%+ don’t feel risk for heart condition or stroke • 60% don’t feel at risk for high blood pressure or cholesterol • Awareness lowest among elderly, minorities 2

  8. Diabetes-CVD Facts • More than 65% of all deaths in people with diabetes are caused by cardiovascular disease. • Heart attacks occur at an earlier age in people with diabetes and often result in premature death. 3

  9. Diabetes-CVD Facts • Up to 60% of adults with diabetes have high blood pressure. • Nearly all adults with diabetes have one or more cholesterol problems, such as: • high triglycerides • low HDL (“good”) cholesterol • high LDL (“bad”) cholesterol 4

  10. Treating Diabetes w Individualized insulin administration and monitoring (if needed) for type 1 diabetes w Well-balanced diet w Regular exercise and physical training w Weight loss and maintenance of healthy weight

  11. Physical Activity and Diabetes w People with type 1 diabetes may or may not improve their glycemic control with exercise, but exercise will help lower their risk for coronary artery disease. w It is important to carefully monitor blood sugar levels of individuals with type 1 diabetes during exercise so that diet and insulin dosage can be altered as needed. w Attention to foot care is especially important for individuals with type 1 diabetes due to decreased sensation and peripheral blood flow in the feet. w Exercise increases muscle and fat cell uptake of glucose, which decreases insulin resistance and increases insulin sensitivity.

  12. The Diabetes Prevention ProgramA Randomized Clinical Trial to Prevent Type 2 Diabetes in Persons at High RiskThe DPP Research Group

  13. Feasibility of Preventing Type 2 Diabetes • There is a long period of glucose intolerance that precedes the development of diabetes • Screening tests can identify persons at high risk • There are safe, potentially effective interventions that can address modifiable risk factors

  14. Modifiable Risk Factors for Type 2 Diabetes • Obesity • Body fat distribution • Physical inactivity • Elevatedfasting and 2 hr glucose levels

  15. DPP Primary Goal • To prevent or delay the development of type 2 diabetes in persons with impaired glucose tolerance (IGT)

  16. DPP Secondary Goals • Reduce cardiovascular disease (CVD) events • Reduce CVD risk factors • Reduce atherosclerosis

  17. Study Interventions Eligible participants Randomized Standard lifestyle recommendations Intensive Metformin Placebo Lifestyle (n = 1079) (n = 1073) (n = 1082)

  18. Primary Outcome: Diabetes • Annual fasting plasma glucose (FPG) and 75 gm Oral Glucose Tolerance Test • FPG > 126 mg/dL (7.0 mmol/L) or • 2-hr > 200 mg/dL (11.0 mmol/L), • Either confirmed with repeat test • Semi-annual FPG • > 126 mg/dL, confirmed

  19. Lifestyle Intervention An intensive program with the following specific goals: • > 7% loss of body weight and maintenance of weight loss • Dietary fat goal -- <25% of calories from fat • Calorie intake goal -- 1200-1800 kcal/day • > 150 minutes per week of physical activity

  20. Lifestyle Intervention Structure • 16 session core curriculum (over 24 weeks) • Long-term maintenance program • Supervised by a case manager • Access to lifestyle support staff • Dietitian • Behavior counselor • Exercise specialist

  21. The Core Curriculum • 16 session course conducted over 24 weeks • Education and training in diet and exercise methods and behavior modification skills • Emphasis on: • Self monitoring techniques • Problem solving • Individualizing programs • Self esteem, empowerment, and social support • Frequent contact with case manager and DPP support staff

  22. Post Core Program • Self-monitoring and other behavioral strategies • Monthly visits • Must be seen in person at least every two months • Supervised exercise sessions offered • Periodic group classes and motivational campaigns • Tool box strategies • Provide exercise videotapes, pedometers • Enroll in health club or cooking class

  23. Lifestyle Intervention: Physical Activity Results • 74% of volunteers assigned to intensive lifestyle achieved the study goal of > 150 minutes of activity per week at 24 weeks The DPP Research Group, NEJM 346:393-403, 2002

  24. Mean Change in Leisure Physical Activity Lifestyle Metformin Placebo The DPP Research Group, NEJM 346:393-403, 2002

  25. Mean Weight Change Placebo Metformin Lifestyle The DPP Research Group, NEJM 346:393-403, 2002

  26. Incidence of Diabetes Placebo (n=1082) Metformin (n=1073, p<0.001 vs. Placebo) Lifestyle (n=1079, p<0.001 vs. Metformin , p<0.001 vs. Placebo) Risk reduction 31% by metformin 58% by lifestyle The DPP Research Group, NEJM 346:393-403, 2002

  27. Mean Change in Fasting Plasma Glucose Placebo Lifestyle Metformin The DPP Research Group, NEJM 346:393-403, 2002

  28. Mean Change in HbA1c Placebo Metformin Lifestyle The DPP Research Group, NEJM 346:393-403, 2002

  29. Diabetes Incidence Rates by Sex The DPP Research Group, NEJM 346:393-403, 2002

  30. Diabetes Incidence Rates by Age Age (years) The DPP Research Group, NEJM 346:393-403, 2002

  31. Diabetes Incidence Rates by BMI (n=1045) (n=995) (n=1194) Body Mass Index (kg/m2) The DPP Research Group, NEJM 346:393-403, 2002

  32. Diabetes Incidence Rates by Fasting Glucose Fasting Plasma Glucose: mg/dl (mmol/l) The DPP Research Group, NEJM 346:393-403, 2002

  33. Diabetes Incidence Rates by 2-hr Glucose 2-Hour Plasma Glucose (mg/dl) The DPP Research Group, NEJM 346:393-403, 2002

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