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2014 Winter Lecture Series

2014 Winter Lecture Series. Choices Foundation for Health Education and Research. Management of the Diabetes Epidemic. Prevention , Early Recognition, and Treatment Options. Bonnie Elkhair, FNP. Choices Integrative Healthcare of Sedona. The Diabetes Epidemic.

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2014 Winter Lecture Series

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  1. 2014 Winter Lecture Series Choices Foundation for Health Education and Research

  2. Management ofthe Diabetes Epidemic Prevention, Early Recognition, and Treatment Options

  3. Bonnie Elkhair, FNP Choices Integrative Healthcare of Sedona

  4. The Diabetes Epidemic • Around the world, every 10 seconds, one person dies from complications of diabetes. • Around the world, every 10 seconds, two people develop diabetes. • According to the National Institutes of Health, more than 6 million Americans currently have Diabetes and don’t know it.

  5. In 2010: 25.8 million people 8.3% of the population 1.9 million new dx In 2012: 29.1 million people 9.3% of the population 1.7 million new dx *American Diabetes Association www.diabetes.org Prevalence of Diabetes in America*

  6. The Diabetes Epidemic* • Diabetes Mellitus is the 7th leading cause of death in the United States. • Diabetes Mellitus affects 25.9% of Americans age 65 or older,11.8 million seniors. • Type 2 Diabetes accounts for 95% of all cases of diabetes in the United States. *American Diabetes Association www.diabetes.org

  7. PREDIABETES • Reflects failing pancreas compensation for underlying insulin resistance • 86 million Americans affected • About 1 in 3 adults affected • 9 of 10 cases not diagnosed • 15-30% of Prediabetic patients will develop Type 2 Diabetes within 5 years

  8. Effects of Uncontrolled Diabetes* • Microvascular Complications • Target nerves, eyes, feet, kidneys • BLINDNESS • LIMB AMPUTATION • DIALYSIS • Macrovascular Complications • Target brain, heart • Heart Attack • Diabetic risk of heart attack 2-4X higher than general population • Diabetic patient just as likely to die from heart attack as person who has already had one heart attack • Stroke • Diabetic risk of stroke 2X higher than general popuation *American Diabetes Association www.diabetes.org

  9. Financial Cost of Diabetes* $245 Billion annually for medical costs, lost work and wages, for diabetic patient care Medical costs of people with diabetes are twice as high as medical costs for people without diabetes *Center for Disease Control

  10. Normal Carbohydrate Metabolism • Carbohydrate food is digested in the stomach. • Sugar from the stomach flows into the bloodstream, to the cells. • Cells use the sugar to produce energy to fuels our cells and our selves. • Insulin secreted by the pancreas keeps blood sugar at healthy balanced levels.

  11. Type 1 Diabetes Mellitus • Dysfunctional pancreas doesn’t produce insulin • Glucose accumulates in the blood stream causing damage to other organs • An auto-immune response • Can occur at any age • No known prevention • Accounts for 5% of all cases of diabetes

  12. Type 2 Diabetes Mellitus • Insufficient insulin is released by pancreas, AND/OR • Body develops resistance to the insulin made by the pancreas • Can develop at any age • Can be prevented

  13. Metabolic Syndrome RISK FACTOR for diabetes type 2, heart disease, stroke Diagnosis requires at least 3 of 5 factors: • Elevated blood glucose • Elevated triglycerides • Decreased HDL • Hypertension • Central Obesity (male WC>40 inches, female WC >35 inches)

  14. Risk Factors for Diabetes • Overweight • Family history of diabetes • African American, Latino, Native American, Asian American, Pacific Islander race • Having Gestational Diabetes

  15. Symptoms of Diabetes • Increased thirst • Frequent urination • Increased hunger • Weight loss • Fatigue • Blurred vision • Irritability

  16. Detecting and Diagnosing Diabetes June, 2009 International Committee: American Diabetes Association European Association for Study of Diabetes International Diabetes Federation

  17. Detecting and Diagnosing Diabetes • A1C (Glycated hemoglobin A1c test) • Measures % of blood sugar attached to hemoglobin, (the oxygen carrying protein found in red blood cells) • Average blood sugar over past 3 months • No fasting required for test • Score 6.5% or higher (twice) for Diabetes • Score 5.7-6.4% for Prediabetes • Score less than 5.7% is normal

  18. Detecting and Diagnosing Diabetes • Fasting Plasma Glucose • Requires 8 hour fast (no intake but water) • Score 126 or higher is Diabetes (twice) • Score 100-126 is Prediabetes • Oral Glucose Tolerance Test • Requires 8 hour fast (no intake but water) • Requires lab draw for fasting plasma glucose, then • Requires repeat lab draw two hours after having special sweet drink • Score 200 or more on second lab draw is Diabetes • Score 140-199 on second lab draw is Prediabetes

  19. Detecting and Diagnosing Diabetes • Random Plasma Glucose • No fasting required • Score 200 or higher suggests diabetes

  20. American Association of Clinical Endocrinologists AACE Consensus Statement: Comprehensive Diabetes Management Algorithm 2013* • Optimize A1c, target <6.5 if patient tolerates • Obesity Treatment • Therapeutic Lifestyle Changes • Prescription monotherapy if A1c 6.5 to 7.5 • Add second agent if A1c >7.5 • Add third agent if A1c 8.0, also consider adding basal insulin • Add basal and some bolus insulin if A1c >9.0 • Use full basal plus bolus insulin management if A1c >10 • Minimize risk of hypoglycemia *AACE Comprehensive Diabetes Management, Endocr Pract. 2013;19(Suppl 2)

  21. Diabetes Management Options • Work with your healthcare professional • Lose weight • Choose healthy foods • Exercise • Take medications • Take supplements

  22. Diabetes Management Options WORK WITH YOUR HEALTHCARE PROFESSIONAL • Regularly scheduled clinic visits • Surveillance labs at least annually • EKG at diagnosis of diabetes, then periodically • Wellness exams annually • Lifestyle counseling • Eye exams • Foot exams

  23. Diabetes Management Options LOOSE WEIGHT. Excess body fat causes body cells to become resistant to insulin.

  24. Decrease Diabetes Risk WEIGHT LOSS of 7% of total body weight will decrease risk of diabetes by 58% even if you can’t get to your ideal body weight.* *American Diabetes Association

  25. Diabetes Management Options CHOOSE HEALTHY FOODS. dark leafy greens, cucumbers, bell peppers, zucchini, asparagus, broccoli, cabbage, Brussels sprouts, radishes, spinach, eggplant, yogurt, cherries, berries, grapefruit, apples, pears, tomatoes, sweet potatoes, winter squash, fish, monounsaturated fats, flaxseed, walnuts AVOID UNHEALTHY FOODS: processed and refined foods, snack foods, white bread, sweetened drinks, sugary deserts, trans-fats LOW GLYCEMIC INDEX CARBOHYDRATES http://www.health.harvard.edu/newsweek/Glycemic_index_and_glycemic_load_for_ 100_foods.htm

  26. Exercise for Diabetes Management A SINGLE EXERCISE SESSION CAN…* • Increase bioavailability of nitric oxide, thus decreasing post exercise stress • Increase oxygen consumption, thus boosting fat metabolism • Increase metabolism of carbohydrates during exercise • Improve glucose intolerance, improve insulin sensitivity, and reduce blood glucose * Asano RY, Sales MM, et al. Acute effects of physical exercise in type 2 diabetes: A review. World J Diabetes. 2014 Oct 15;5(5):659-65.

  27. Medications for Diabetes Type 1 Management Insulin.

  28. Medications for Diabetes Type 2 Management 1. Biguanides (Metformin) decreases amount of glucose produced by the liver, increases muscle sensitivity to insulin 2. Sulfonylureas (Diabinese, Glucatrol, Micronase, Glynase, Diabeta, Amaryl) stimulates beta cells of the pancreas to release more insulin 3. Meglitinides (Prandin, Starlix) stimulates beta cells of the pancreas to release more insulin 4. Thiazolidinediones (Avandia, Actos) decreases amount of glucose produced by the liver, increases muscle and fat sensitivity to insulin 5. DPP-4 Inhibitors (Januvia, Onglyza, Tradjenta, Nesina) Dipeptidyl peptidase-4 prevents breakdown of GLP-1 (a naturally occurring compound that reduces blood glucose) 6. GLP-1 Inhibitors (Vicotoza, Byetta, Bydureon) Glucagon-like-peptide-1 receptor agonist improves insulin sensitivity 6. SGLT2 Inhibitors (Invokana, Farxiga) Sodium-glucose transporter 2 blocks reabsorption of glucose in the kidneys, causing excess glucose to be eliminated in urine 7. Alpha-glucosidase inhibitors (Acarbose, Glyset) blocks breakdown of starches such as bread, potatoes, pasta, in the intestine 8. Bile Acid Sequestrants (Welchol) lowers blood sugar by removing cholesterol by binding with bile acids in the digestive system 9. Insulin, alone or in combination with one or more of the above medications

  29. Classes of Diabetes Type 2 Medication • Increase insulin sensitivity of liver, fat and muscle cells. • Stimulate insulin production by the pancreas. • Slow the digestion of carbohydrates.

  30. Medications that Increase Insulin Sensitivity GOAL: sensitize liver, fat and muscle cells to insulin, making cells less resistant to insulin Biguanide (Metformin) Decreases amount of glucose produced by the liver. Increases muscle and fat cell sensitivity to insulin. In use since the 1920s. Most widely used prescription in the world for Type 2 Diabetes. Can cause diarrhea. Increased risk of lactic acidosis in patients with excess alcohol use Must be discontinued prior to radiological procedures involving injection of dye, major medical procedures, and dental procedures, waiting 48 hours before resuming treatment

  31. Medications that Increase Insulin Sensitivity GOAL: sensitize liver, fat and muscle cells to insulin, making cells less resistant to insulin Thiazolidindediones (TZD) Actos (pioglitazone), Avandia (rosiglitazone) • Decrease blood glucose levels by making muscle, fat and liver cells more sensitive to insulin • On the market since 1999, in popular use since 2007 • Increased risk of bone fracture, CHF, bladder cancer

  32. Medications that Stimulate Insulin Production by the Pancreas GOAL: Stimulate the pancreas to make produce more insulin. • Sulfonylureas (Diabinese, Glucatrol, Micronase, Glynase, Diabeta, Amaryl) stimulates beta cells of the pancreas to release more insulin 2. Meglitinides (Prandin, Starlix) stimulates beta cells of the pancreas to release more insulin Can cause weight gain. Has highest risk for serious hypoglycemia of any non-insulin therapy.

  33. Medications that Slow Digestion of Carbohydrates GOAL: Slow the digestive process of ingested starches and sugars. Alpha-glucosidase inhibitor (Acarbose, Glyset) Blocks breakdown of starches such as bread, potatoes, pasta, in the intestine Can cause nausea and flatulence Bile Acid Sequestrant (Welchol) May lower blood sugar by removing cholesterol by binding with bile acids during digestion Second line therapy commonly combined with metformin, sulfonyureas, or insulin Has not been studies with all anti-diabetes medications Not for patients with history of intestinal blockage or history of pancreatitis

  34. Peptide Analogs DPP-4 Inhibitor (Januvia, Onglyza, Tradjenta, Nesina) Dipeptidyl Peptidase-4 enzyme Prevents breakdown of hormone incretin Slows digestion Simulates insulin production GLP-1 Inhibitor (Vicotoza, Byetta, Bydureon) Glucagon-like peptide-1 Incretin Mimetic Increases insulin secretion in response to eating Decreases gastric emptying Decreases liver fat content Cause decrease appetite and cause weight loss Amylin Agonist (Symlin, pramlintide) Anti-hyperglycemic Synthethic Analog Used in addition to insulin Increases risk of hypoglycemia Increases risk of pancreatitis

  35. Newest Medication for Diabetes Type 2 Management SGLT2 Inhibitors (Invokana, Farxiga) New drug class since 2014 Sodium-glucose transporter 2 Blocks reabsorption of glucose in the kidneys Causes glucose to be eliminated in urine Increases risk of urinary tract infections Increases risk of genital fungal infections Can cause kidney damage Increases risk of bladder cancer

  36. Insulin Injections Basal insulin Preferred over NPH insulin due to flat serum insulin concentrations over 24 hours starting dose 0.1-0.2 units/kg for A1c <8.0 starting dose 0.2-0.3 units/kg for A1c 8-10 SMBG twice daily Patients self-increase insulin doses by 2-unit steps Basal-Bolus insulin regimens Flexibility for patients with variable mealtimes and/or variable meal carbohydrate content starting dose about 5 units SQ 10-15 minutes prior to meal Patients self increase doses by 2-3 units every 2-3 days based on two hour post prandial glucose readings

  37. Side Effects of Insulin Injections HYPOGLYCEMIA • 7-15% of insulin treated patients with T2DM experience at least one hypoglycemic episode per year Frequency of hypoglycemia increases with • Intensive insulin targets • Comorbid use of sulfonylurea • Decreased caloric intake • Exercise • Alcohol consumption • Renal dysfunction • Diabetes duration • Cognitive impairment

  38. Side Effects of Insulin Injections WEIGHT GAIN • 3-5 pound weight gain compared to other diabetes agents • Adding amylin analog (Symlin) injection at same time of bolus insulin improves DMT2 may improve gycemia and weight • Combining incretin therapy (DPP-4, GLP-1) with basal insulin may improve glycemia and weight

  39. Supplements for Diabetes Management CHROMIUM • Trace mineral, enhances action of insulin* • Involved in metabolism of carbohydrate, protein, fat* • Deficiency impairs body’s ability to use glucose for energy, increases insulin requirements** • Three hospitalized patients who were fed intravenously showed signs of diabetes (weight loss, neuropathy, impaired glucose tolerance). Adding chromium to their feeding solutions corrected their diabetes symptoms.** • Common ingredient in infant formulas and total parental nutrition (TPN) • Deficiency uncommon; additional research needed to determine if clinically relevant chromium deficiency state exists in humans due to inadequate dietary intake*** • Goal 200 mcg per day • Older adults may be more vulnerable to Chromium depletions *Mertz W. Chromium occurrence and function in biological systems.Physiol Rev 1969;49:163-239 **Jeejeebhoy KN, Chu RC, et al. Chromium deficiency, glucose intolerance, and neuropathy reversed by chromium supplementation in a patient receiving long-term total parenteral nutrition. Am J Clin Nutr 1977; 30:531-8. ***Chromium Dietary Supplement Fact Sheet, National Institutes of Health, Office of Dietary Supplements,11/4/2013

  40. Supplements for Diabetes Management CHROMIUM Food sources: Brewer’s yeast, broccoli, grape juice, meats, red wine, whole grains, romaine lettuce, raw onions, ripe tomatoes, oranges, black pepper, molasses, oysters, liver, egg yolks, peanuts, beer Dietary supplement forms Different carrier (transporter) molecules attached to chromium ion • Glucose-tolerance factor (GTF) Chromium Biologically active form • Chromium Picolinate No known side effects from supplement use.

  41. Supplements for Diabetes Management GTF CHROMIUM 800-1000 mcg daily for patients with Metabolic Syndrome or Diabetes Type 2.

  42. Supplements for Diabetes Management Alpha-Lipoic Acid* • Helps lower blood sugar • Antioxidant effect relieves peripheral neuropathy burning tingling numbness pain • General antioxidant support: 20-50 mg/day • Diabetes, Diabetic neuropathy: 800 mg per day in divided doses *Ziegler D, Reljanovic M, et al. Alpha-lipoic acid in the treatment of diabetic polyneuropathy in Germany: current evidence from clinical trials. Exp Clin Endocrinol Diabetes. 1999: 107-421-430. *Melhem MF, Craven PA, et al. Alpha-lipoic acid attenuates hyperglycemia and prevents mesangial matrix expansion in diabetes. J Am Soc Nephrol. 2002;13:108-116. *Ziegler D, Gries FA. Alpha-lipoic acid in the treatment of diabetic peripheral and cardiac autonomic neuropathy: The SYDNEY 2 trial. Diabetes Care. 2006;29:2356-70

  43. Supplements for Diabetes Management VANADYL SULFATE (VOSO4)* • Oxidative form of vanadium salts • Improves glucose metabolism • Decreases fasting glucose • Decreases A1c • Improves hepatic and muscle insulin sensitivity in Diabetes Mellitus Type 2** *Goldfine AB, Patti ME, et al. Metabolic effects of vanadyl sulfate in humans with non-insulin-dependent diabetes mellitus: in vivo and in vitro studies. Metabolism. 2000 mar;49(3):400-10. **Cusi K, Cukier S, et al. Vanadyl sulfate improves hepatic and mscle insulin sensitivity in type 2 diabetes. J Clin Endocrinol Metab. 2001 Mar;86(3)14:1410-17.

  44. Supplements for Diabetes Management CINNAMON* • Lowers fasting plasma glucose • No significant effect on A1c • No adverse affects with taking supplement *Allen RW, Schwartzman E, et al. Cinnamon use in type 2 diabetes: an updated systematic review and meta-analysis. Ann Fam Med. 2013 Sep-Oct;11(5)452-9. *Mang B, Wolters M, et al. Effects of a cinnamon extract on plasma glucose, HbA, and serum lipids in diabetes mellitus type 2. Eur J Clin Invest. 2006 May;36(5):340-4.

  45. Supplements for Diabetes Management Biotin (Vitamin H)* • One of the B Complex vitamins • Converts carbohydrates to glucose • Combines with chromium to improve blood sugar control • Food sources include brewer’s yeast, whole grains, cauliflower, bananas, mushrooms, soybeans, blackeyed peas, cooked eggs, sardines, almonds, peanuts, pecans, walnuts. *Singer GM, Geohas J. The effect of chromium picolinate and biotin supplementation on glycemic control in poorly controlled patients with type 2 diabetes mellitus: a placebo-controlled, double-blinded, randomized trial. Diabetes Technol Ther. 2006 Dec;8(6):636-43.

  46. Supplements for Diabetes Management FENUGREEK* • Traditional Asian medicine to stabilize blood sugar • Seed extracts slow down carbohydrate digestion • Lowers post prandial glucose • Daily use lowers A1c • Not for use in pregnancy *Blumenthal M, Goldberg A, eds. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Lippincott Williams & Wilkins: 2000:130-133.

  47. Supplements for Diabetes Management INSINASE • Reduced iso-alpha acid (RIAA) and Acacia • Selective Kinase Response Modulators • Inhibits IL-6 cytokines to improve insulin signaling • Decreases insulin resistance • Usual dose is three tablets daily • Not for patients taking anticoagulants.

  48. Supplements for Diabetes Management AMERICAN GINSENG (Panax quinquefolius) • Light tan, gnarled root with stringy shoots • Yellowish green umbrella shaped flowers produce red berries • Used by early Native Americans to treat headaches, fever, indigestion, infertility • Studied in Diabetes Mellitus Type 2 patients* • Lowers fasting glucose levels • Lowers postprandial glucose levels • May lower or raise blood pressure • Has multiple possible drug interactions • Not for use by BiPolar diabetics due to risk of mania • Not for use by pregnant or breast feeding women • Not for use in history of breast cancer or other hormone sensitive conditions • Must be discontinued seven days prior to surgery due to blood thinner side effect *Vladimir V, Sievenpiper JL, Koo VY, et al. American ginseng (Panax quinquifolius L) reduces postprandial glycemia in nondiabetic subjects and subjects with type 2 diabetes mellitus. Arch Intern Med. 2000; 160(7):1009-1013. *Vuksan V, Stavro MP, Sievenpiper JL, et al. Similar postprandial glycemic reactions with escalation of dose and administration time of American ginseng in type 2 diabetes. Diabetes Care. 2000;23:1221-1226

  49. Supplements for Diabetes Management MYRTLE SENG • Traditional Chinese Medicine formula • Nutritionally reduces blood glucose levels • Improves insulin sensitivity • May aid in weight loss

  50. Supplements for Diabetes Management TAURINE • Organic acid derived from the amino acid cysteine • Available in seafood, meat, milk, eggs • Commonly added to infant formulas • Ingredient in many energy drinks • Stored in the gallbladder in bile, works during initial phase of fat metabolism • Synthesized in the pancreas, increases fat burning capacity during rest • Vegetarians with low taurine levels may feel anxiety as main symptom • No known negative side effects with use of dietary supplement • Begin at 2-3 grams daily, increasing to 6 grams daily

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