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Importance of diabetes to occupational health S heri Morris rn,bsn,cde

How you can help your patients. Importance of diabetes to occupational health S heri Morris rn,bsn,cde. Diabetes Mellitus. Official definition – …a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both

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Importance of diabetes to occupational health S heri Morris rn,bsn,cde

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  1. How you can help your patients Importance of diabetes to occupational healthSheri Morris rn,bsn,cde

  2. Diabetes Mellitus • Official definition – …a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both • The chronic hyperglycemia of diabetes is associated long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels. Diabetes Care 28:S37-S42,2005,ADA Clinical Practice Recommendations,2005

  3. Diabetes Mellitus • Patient Definition – Blood sugar is high because… - beta cell does not make enough insulin - cells do not take in insulin and glucose High blood sugar over a “long time” can lead to damage, dysfunction, and failure of the eyes, kidneys, nerves, and heart

  4. Diabetes in South CarolinaS.C. ranks 10th highest in the nation in the percent of population with diabetes • Approximately 1 in 8 African-Americans in South Carolina has diabetes – the 16th highest rate of diabetes among African-Americans in the nation. • The prevalence of diabetes increases with age – a dramatic increase can be seen among those 45 years of age and older. • Diabetes is the seventh leading cause of death in South Carolina after heart disease, cancer, accidents, stroke, chronic lower respiratory disease and Alzheimer’s. • In 2006, three to four people died each day from diabetes – that is one death from diabetes every 7 hours, 33 minutes. • About 70 percent of adults with diabetes have high blood pressure. • Uncontrolled diabetes can lead to many complications including blindness, kidney failure, heart attacks, strokes and amputations

  5. HealthcareCosts • In 2006, the total amount for hospital charges related to diabetes diagnosis in South Carolina was $199.5 million. • Medicare and Medicaid paid for more than two-thirds of this cost. • Diabetes hospital costs have increased by 50 percent in the past five years in South Carolina.

  6. The American Diabetes Association recommends that people with diabetesshould: • Have an eye exam every year • Have a foot exam every year, examine your feet daily • Have an A1C test at least twice a year • Have your blood pressure checked regularly • Get regular dental exams • Have your cholesterol checked at least once a year • Get a flu shot every year • Check your blood sugar regularly • Get a pneumonia shot at least once in a lifetime • Complete a diabetes self-management education course

  7. Important points to remember: • People with diabetes can live long, healthy lives when their diabetes is properly managed. • Diabetes can be prevented or delayed by eating healthily, being physically active, not smoking and losing 5 to 10 pounds. • The complications of diabetes can be prevented when the person with diabetes manages their diabetes. This includes eating healthily, being physically active, not smoking, taking medication as prescribed and managing stress. 2007 Behavior Risk Factor Surveillance Survey, 2007 American Diabetes Association (ADA), DHEC SCAN (South Carolina Community Assessment Network), ADA 2009 Clinical Recommendations (slides 1-5)

  8. Making the Business Case for Diabetes Education in the Workplace • Nearly 24 million Americans have diabetes. • Many people in their 20s and 30s were diagnosed with type 2 diabetes. • Adults with diabetes die of heart disease 2 to 4 times more than people without diabetes. • The risk for stroke is 2 to 4 times higher among people with diabetes. • Diabetes is the leading cause of new cases of blindness among adults aged 20 to 74 years old and is the leading cause of end-stage renal disease. • More than 60% of nontraumatic, lower-limb amputations in the United States occur among people with diabetes. • Type 2 diabetes is a growing epidemic among Native Americans, African Americans, and Hispanics, Asian Americans and Native Hawaiians or other Pacific Islanders. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes TranslationMarch 12, 2010

  9. Diabetes does affect corporate America and its bottom line. • In 2007, direct and indirect costs of diabetes total nearly $174 billion a year. • People with diagnosed diabetes, on average have medical expenditures that are 2.3 times higher than what the expenditures would be in the absence of diabetes. • In 2007, Indirect costs include increased absenteeism ($2.6 billion) and reduced productivity while at work ($20.0 billion for the employed population, reduced productivity for those not in the labor force ($0.8 billion), unemployment from disease- related disability ($7.9 billion) and lost productive capacity due to early mortality ($26.9 billion). • Diabetes accounts for 15 million work days absent, 120 million work days with reduced performance, 107 million work days lost due to unemployment disability attributed to diabetes. • People with diabetes have a health related absenteeism rate that is 0.8% higher than people without diabetes. • The population with the highest per capita productivity loss from absenteeism is males age 45-53. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes TranslationMarch 12, 2010

  10. Corporate America can help employees manage their diabetes or reduce their risks of developing it. • With employees spending more than one-third of their days on the job, corporate America is in a unique position to address this health issue. • It is in the employer’s best interest to try to work with their employees who have diabetes or are at risk for the disease to improve productivity • Control the ABCs (A1c, Blood Pressure, Cholesterol) • Current data from the American Diabetes Association : show that people with diabetes who control their disease by keeping their blood sugar down cost employers only $24 a month, compared with the $115 a month for people with diabetes who do not control their blood sugar. Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes TranslationMarch 12, 2010

  11. Diabetes At Work Launched in April 2002, Diabetesatwork.org is the first online resource specifically designed to address the management of diabetes in the workplace.

  12. Diagnosis of Pre-Diabetes and Diabetes

  13. Type 2 Diabetes • Characterized by chronic hyperglycemia • Associated with microvascular and macrovascular complications • Generally arises from a combination of insulin resistance and -cell dysfunction Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications. Department of Noncommunicable Disease Surveillance,World Health Organization, Geneva 1999. Available at: http://www.diabetes.org.uk/infocentre/carerec/diagnosi.doc

  14. IR What is insulin resistance? • Major defect in individuals with type 2 diabetes1 • Reduced biological response to insulin1–3 • Strong predictor of type 2 diabetes4 • Closely associated with obesity5 1American Diabetes Association. Diabetes Care 1998; 21:310–314. 2Beck-Nielsen H & Groop LC. J Clin Invest 1994; 94:1714–1721. 3Bloomgarden ZT. Clin Ther 1998; 20:216–231. 4Haffner SM, et al. Circulation 2000; 101:975–980. 5Boden G. Diabetes 1997; 46:3–10.

  15. IR Insulin resistance is closely linked to cardiovascular disease Present in> 80%of people with type 2 diabetes1 Approximatelydoublesthe risk of a cardiac event2 Implicated in almosthalfof CHD events in individuals with type 2 diabetes2 Insulin resistance 1Haffner SM, et al. Circulation 2000; 101:975–980. 2Strutton D, et al. Am J Man Care 2001; 7:765–773

  16. Hyperglycemia Dyslipidemia Hypertension Damage to blood vessels Clotting abnormalities Inflammation Insulin resistance IR Atherosclerosis Insulin resistance is linked to a range of cardiovascular risk factors Zimmet P. Trends Cardiovasc Med 2002; 12:354–362

  17.    What is -cell dysfunction? • Major defect in individuals with type 2 diabetes • Reduced ability of -cells to secrete insulin in response to hyperglycemia DeFronzo RA, et al. Diabetes Care 1992; 15:318–354.

  18. GGenetic susceptibility, obesity, Western lifestyle susceptibility, obesity, Western lifestyle Insulin resistance  b-cell dysfunction IR Type 2 diabetes Insulin resistance and -cell dysfunction are core defects of type 2 diabetes Rhodes CJ & White MF. Eur J Clin Invest 2002; 32 (Suppl. 3):3–13.

  19. Hyperglycemia • Gradual onset • Excessive glucose in the blood • Signs and symptoms Polyuria Polydipsia Polyphagia Weight loss • Visual Changes • Asymptomatic

  20. Common Causes of Hyperglycemia • Food Choices • Lack of activity/exercise • Inadequate medications of timing of meds • Other medications • Altered insulin absorption • Illness/stress

  21. Hypoglycemia • Most common complication possible wit sulfonylurea therapy • Sudden onset • “Types” Minor: quick recognition and self treatment Moderate: self care possible Major: requires assistance

  22. Common Causes of Hypoglycemia • Medication “errors” • Meal delayed or omitted • Poor timing of insulin and meal • Increased exercise • Other health conditions

  23. Treating Hypoglycemia • Mild: 15gm of simple carbohydrate Glucose tablets or gel 2 tsp honey or 3 tsp table sugar ½ cup orange or apple juice • Moderate: 20-30gm of simple carbohydrate • Severe: Glucose injection Glucose gel inside cheek IV dextrose 25% or 50% • Follow with meal or snack

  24. Preventing Hypoglycemia • Determine causes: Questions to ask Blood glucose testing patterns • Teach the patient to: Recognize “feelings of low blood glucose” Carry emergency sugar/food Adjust food/insulin if planning to exercise If eating out, take insulin at the restaurant Check blood glucose routinely Carry or wear medical identification

  25. Blood Glucose Monitors • One Touch Ultra 2 or mini • Bayer Ascensia • Accu Chek • FreeStyle Lite • True Track • Several different kinds issued by Medicare

  26. Nutrition Therapy and Diabetes

  27. Meal Planning Strategies • Carbohydrate counting • - Prescribed meal plan • - Exchange system • - Carbohydrate servings • - Label reading • -Glycemic index • - Insulin to carbohydrate ratio + correction factor (if applicable) • Timing of meals • Healthy choices and balanced meals • Variety including nutrient-rich foods and high-fiber foods • Moderation using portion control • Limit refined sugars

  28. Breakdown of Macronutrients • Total carbohydrate: 45-65% of total calories • Total Protein: 10-35% of total calories • Total fat: 20-35% of total calories

  29. Basic Nutrition Advice • Timing of meals and snacks (no more than 4 hours without eating) • Get a variety of healthy, high-fiber foods • Limiting refined carbs and added sugars • Watch portion sizes and read labels • Keep a food journal • Learn to make lifestyle changes and not diet for a short period of time

  30. My Pyramid http://www.mypyramid.gov

  31. Portion Control http://www.ncescatalog.com

  32. Portion Control http://www.snacksense.com/files/u1/portions_v4.jpg

  33. The Plate Method http://www.tops.org/images/plate.gif

  34. Eat starchy foods regularly • Bread • Potatoes • Rice • Pasta • Cereals • Plantain • Chapatis

  35. Eat more fruit and vegetables • Fresh • Frozen • Tinned • Dried • Juice

  36. Choose more high fiber foods • Helps to maintain a healthy gut • Wholegrain cereals • Wholemeal bread • Whole wheat pasta • Brown rice To help maintain blood glucose levels and cholesterol levels • Fruit • Vegetables • Pulses • Oats

  37. Use less fat in cooking • Grill • Dry-roast • Microwave • Steam • Bake

  38. Cut down on sugary foods • Not a sugar free diet • Cut out sweets • Cut out sugary drinks

  39. Slimming tips • Be realistic about your target weight • Aim to lose weight gradually • Eat regular meals • Make small changes you can stick to

  40. Lifestyle Interventions = ↓Risk 58% • Healthy food choices: low calorie, low saturated fat • Modest weight loss: 5% to 10% of starting weight • Physical activity: 150 min per week • Education and support Lindström et al. Diabetes Care 2003;26:3230; DPP. N Engl J Med 2002;346:393

  41. What is Known About WeightManagement? •At ~6 months individuals can lose 5% to 10% of their starting weight •Regardless of the intervention, plateaus and regain of weight loss are expected; compensatory mechanisms protect against weight loss •If treatment is discontinued, weight gain occurs •With support, modest weight loss can be maintained

  42. Comparison of Popular Weight Loss Diets • Subjects (n=160) utilized one of the following diets - Atkins (carbohydrate restricted) - Zone (macronutrient balanced) - Weight Watchers (calorie restriction) - Ornish (fat restriction) • Weight loss and completers at 1 year

  43. Comparison of Popular Weight Loss Diets - Atkins 2.1 kg (4.6 lb) [53%] - Zone 3.2 kg (7.0 lb) [65%] - Weight Watchers 3.0 kg (6.6 lb) [65%] - Ornish 3.3 kg (7.3 lb) [50%] • Amount of weight lost was not associated with diet type but with self-reported adherence to diet Dansinger M et al. JAMA 2005;293:43

  44. Predictors of Successful Weight Loss and Maintenance (Most had childhood onset obesity) • Continuing to eat lower energy diets (average energy intake ~1400 kcal/day) and a low-fat diet (24% of energy from fat) • Frequent self-monitoring • Participating in a minimum of 60 minutes of physical activity nearly every day of the week (2800 kcal/week; 28 miles of walking/week) • Eating breakfast every day (contrary to the typical eating pattern for dieters) Wing & Hill. Ann Rev Nutr 2001;21:323; Wyatt et al. Obes Res 2002;10:78; Shick et al. J Am Diet Assoc 1998;98:408

  45. Conclusions • Calories count—not macronutrients!! • Multiple encounters are needed (59 group and 13 individual counseling sessions offered)Attendance at group sessions predicted weight loss at 2-y • Attendance at 2/3 of the sessions = 9 kg weight loss • “Any type of weight loss diet taught with enthusiasm and persistence can be effective.” • “Thus, even these highly motivated, intelligent participants who were coached by expert professionals could not achieve the weight losses needed to reverse the obesity epidemic.” Katan MB. N Engl J Med 2009;360:923

  46. Oral Medications • Secretagogues (Hypoglycemia Agents)—Stimulates the pancreas to produce more insulin

  47. Oral Medications – con’t • Biguanides—Decrease hepatic glucose production

  48. Oral Medications – con’t • Alpha-glucosidase Inhibitors—Slows carbohydrate absorption in intestines • Thiazolidinediones (Insulin Sensitizer)—Improves peripheral insulin sensitivity

  49. Oral Medications – con’t • DPP – 4 Inhibitor – Inhibits the breakdown of GLP1. Increases insulin release and reduces hepatic glucose release.

  50. Combination Pills

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