quiz #3- diabetes

• named for the sweet taste of urine
• diabetes = flow through a siphon
• mellitus = honeyed

a systemic disorder of carbohydrate, fat and protein metabolism

• IDDM, juvenile
• 10-15%
• severe insulin deficiency due to beta cell destruction
• diagnosed before age 30

• NIDDM, adult onset
• 85-90%
• begins with reduced sensitivity to insulin
• overtime inadequate secretion of insulin due to beta cell exhaustion
• usually diagnosed after age 40

• develops during pregnancy (4%)
• higher prevalence in overweight moms
• babies > 9lbs
• if BG remains high >6 wks after delivery then type II

• decreased insulin sensitivity, increased insulin resistance
• higher than normal levels of insulin required for glucose transport into body cells

• chronic pancreatic
• cushings syndrome (hormonal disorder with high levels of cortisol which inhibits use of glucose as fuel and promotes storage of glucose)
• prednisone
• myotonic dystrophy ( delayed relaxation of muscles after contraction)
• denervation
• prolonged immobilization

• 40% of adults have diabetes or prediabetes
• 23.5 million= diabetes
• 41 million= prediabetes
• 80% of PT pts have diabetes, prediabetes, or risk factors for diabetes

10-20%

3-4x higher than a healthy individual

3rd

2-4x greater risk of CV disesase, stroke, PVD, and kidney disease

• small arteries: relate to sensory
• large arteries: relate to CV disease

• impaired metabolism
• CVD
• diabetic retinopathy
• diabetic nephropathy
• diabetic neuropathy
• PAD (4x greater risk for LE amputation)
• impaired wound healing
• joint stiffness
• microangiopathy
• macroangiopathy

• microangiopathy: lead to "opathy"
• macroangiopathy: lead to CVD, CAD, PAD

• retinopathy: cause blindness
• nephropathy: end stage renal disease
• neuropathy: autonomic, sensory, or muscular

• obesity (BMI >27, BW 20% > normal)
• family history (doubles likelihood)
• sedentary lifestyle
• aging
• AA, hispanics, & american indians have highest rates

food --> glucose --> body cells for energy

regulated by hormone insulin which is formed by beta cells in the pancreas

release more insulin to push glucose into cells

body signals you to eat and release glucose stores from liver

• muscle cells
• fat cells
• WBC

• nerve cells
• CNS
• lens/retina
• RBC
• blood vessels
• kidney

• inability to use carbohydrates as fuel source
• for energy metabolism of fat as a fuel source is increased above normal
• decreased uptake of triglycerides by cells which leads to elevated blood triglyceride levels by 5x's, and excess formation of ketones and increased CHO levels

• healthy: FA uptake --> lipid intermediates --> FA oxidation
• insulin resistant: FA uptake--> increase lipid intermediates --> FA oxidation

promotes uptake and storage of amino acids resulting in protein synthesis in the muscle and liver

• polydipsia: excessive thirst
• polyuria: excessive urine
• polyphagia: excessive hunger

• the 3 P's (polydipsia, polyuria, polyphagia)
• increased fatigue
• weight in people with type I
• dry mouth
• blurred vision
• labored breathing
• numbness in hands or feet
• impotence
• sweet smelling breath

• 80-120
• < 180 after meals
• lowest BG levels around 2 am
• BG fluctuates throughout day but within normal range

• measures glucose after 12 hour fast (usually more accurate)
• >126=diabetes, 100-126= prediabetes, <100=normal

• measures glucose 2 hours after drinking concentrated glucose solution
• delayed removal of glucose indicates diabetes
• >200=diabetes, 140-200=prediabetes, <140=normal

• glycated hemoglobin- HbA1c <6.5-7%
• symptoms plus + fasting glucose test or + oral glucose test

• adults >45 repeat every 3 years
• adults <45 with one of the following- BMI >27, triglycerides >250, family hx, hx of gestational diabetes, member of risk ethnic group, on previous testing had IFG or IGT
• children >10 who are overweight plus two of the following- family hx, member of risk race, signs of insulin resistance- administer fasting glucose every 2 years

• waist circumference
• triglycerides
• HDL <40/50
• HTN
• elevated fasting BG
• (3 of 5)

• have too little insulin- in a diabetic coma so give insulin
• if still over 250 call MD

• thirsty
• frequent urination
• general weakness
• nausea and vomitting
• loss of appettie
• confusion
• ill appearance
• dry skin and mouth
• decreased BP and increased HR

• they are in insulin shock and have too much insulin so give them sugar, OJ, cola, (15 gram snack)
• check it again in 15 min and give another if necessary
• if still low call MD

• increased tiredness and hunger
• trembling
• excessive sweating
• dizzy or fainting spells
• nervous and increased HR
• confusion and lack of coordination
• changes in behavior/irritable
• headache
• convulsions
• blurred vision
• paleness
• slurred speech

• ultra short acting- before meal --> 3.5 hours after (1 hr pk)
• regular- 30 min before meal --> 6-8 hr after (2 hr peak)
• intermediate- 1-4 hr before -->14-24 hours (6-12 hr peak)
• long- 4-6 hr before --> 36 hours after (8-20 hr peak)

• waiting too long to take meds
• your BG is already low when you take it
• missed meals
• taking too much insulin
• exercising when sugar is low

• insulin: increase risk for hypoglycemia so avoid vigorous exercise during peak times
• sulfonylureas: increased risk of hypoglycemia
• metformin: increased risk of lactic acidosis so want to avoid high intensity anaerobic training
• ACE inhibitors: control BP by blocking vasodialation so may cause dizziness
• DON'T GIVE GRAPEFRUIT JUICE IF TAKING STATINS

• prior to vigorous exercise
• type II DM > 10yrs
• type I DM > 15 yrs
• presence of additional CAD risk factors
• presence of retinopathy or nephropathy
• PVD
• autonomic neuropathy

• 3-5 days/wk (150 min/wk)
• moderate intensity, PRE 10-12
• increase duration before intensity
• nonWB may be more appropriate if have peripheral neuropathy

• 2-3 days/wk, all major muscle groups (8-20 exercises)
• 8-12 RM
• progress from 1 to 3 sets, rest 30 seconds between

skipping exercise for more than 2 days

• all major muscle groups
• hold 15-30 seconds
• repeat 4-6 times

static and dynamic balance

• give 15 gm CHO snack, recheck in 15 min
• if >70 proceed with exercise

give 15 gm CHO snack per hour of moderate intensity of exercise

proceed with exercise

• do 10-15 min exercises and check sugar
• if rises then stop
• if drops then proceed

• check for ketones
• if + then NO exercise
• if - then proceed and monitor BG

ketone bodies increase because not enough sugar and trying to break down fat

• Type II
• more important in Type I to prevent CVD

• contraindicated if have retinal hemorrhage or recent surgical procedure
• avoid valsalva, head jarring activities, and head below waist
• SBP should not rise >20-30 RBP

• may not develop warning signs of hypoglycemia until it is severe, monitor BG
• may have blunted HR and BP responses to exercise
• monitor signs for silent ischema

impaired balance

• maintain SBP <180
• avoid high intensity aerobic or resistance training and valsalva

• ingesting alcohol 3 hours prior
• hypoglycemia symptoms (shakiness, dizziness, sweating, hunger, headache, pale skin, behavior changes, clumsy, seizure, tingling sensation)
• hyperglycemia symptoms (ketones with 1 or more of these symptoms- SOA, fruity breath smell, N/V, dry mouth

• IRS evident within 3 days
• decrements in BG tolerance decrease in pts that are active in bed

one wk of immobilization reduces glucose uptake in the immobilized limb, isometric exercises minimize the reduction in glucose transport to the limb

• check BG levels prior to exercise
• don't exercise at time of peak insulin action (generally take 1 hr prior to exercise)
• exercise after meals helps improve glycemic control
• late in the evening may increase risk of nocturnal hypoglycemia