What does diabetes stand for?
- named for the sweet taste of urine
- diabetes = flow through a siphon
- mellitus = honeyed
What is diabetes?
a systemic disorder of carbohydrate, fat and protein metabolism
What are characterisitcs of Type I diabetes?
- IDDM, juvenile
- severe insulin deficiency due to beta cell destruction
- diagnosed before age 30
What are characteristics of Type II diabetes?
- NIDDM, adult onset
- begins with reduced sensitivity to insulin
- overtime inadequate secretion of insulin due to beta cell exhaustion
- usually diagnosed after age 40
WHat are characteristics of Gestational diabetes?
- develops during pregnancy (4%)
- higher prevalence in overweight moms
- babies > 9lbs
- if BG remains high >6 wks after delivery then type II
What are characterisitics of prediabetes?
- decreased insulin sensitivity, increased insulin resistance
- higher than normal levels of insulin required for glucose transport into body cells
What are characteristics of secondary diabetes?
- chronic pancreatic
- cushings syndrome (hormonal disorder with high levels of cortisol which inhibits use of glucose as fuel and promotes storage of glucose)
- myotonic dystrophy ( delayed relaxation of muscles after contraction)
- prolonged immobilization
What is the prevelance of diabetes?
- 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
What is the rate of type 2 diabetes in children?
What is the cost of medical care for people with diabetes?
3-4x higher than a healthy individual
Diabetes is the ___ leading cause of death in the US.
What does diabetes put you at a greater risk for?
2-4x greater risk of CV disesase, stroke, PVD, and kidney disease
What is the difference in effect of diabetes on small and large arteries?
- small arteries: relate to sensory
- large arteries: relate to CV disease
What are some complications of diabetes?
- impaired metabolism
- diabetic retinopathy
- diabetic nephropathy
- diabetic neuropathy
- PAD (4x greater risk for LE amputation)
- impaired wound healing
- joint stiffness
What do microangiopathy and macroangiopathy lead to?
- microangiopathy: lead to "opathy"
- macroangiopathy: lead to CVD, CAD, PAD
What do diabetic retinopathy, nephropathy, and neuropathy cause?
- retinopathy: cause blindness
- nephropathy: end stage renal disease
- neuropathy: autonomic, sensory, or muscular
What are risk factors for type II diabetes?
- obesity (BMI >27, BW 20% > normal)
- family history (doubles likelihood)
- sedentary lifestyle
- AA, hispanics, & american indians have highest rates
How does glucose impact the body?
food --> glucose --> body cells for energy
What is glucose regulated by and where is it formed?
regulated by hormone insulin which is formed by beta cells in the pancreas
What does high glucose mean?
release more insulin to push glucose into cells
What does low glucose mean?
body signals you to eat and release glucose stores from liver
What tissues in the body require insulin?
What tissues in the body do not require insulin?
- nerve cells
- blood vessels
In people with diabetes lack of or ineffective action of insulin leads to what?
- 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
What is the difference between fat metabolism in healthy muscle and in insulin resistant muscle?
- healthy: FA uptake --> lipid intermediates --> FA oxidation
- insulin resistant: FA uptake--> increase lipid intermediates --> FA oxidation
What does insulin do?
promotes uptake and storage of amino acids resulting in protein synthesis in the muscle and liver
What are the 3 P's of diabetes and what do they mean?
- polydipsia: excessive thirst
- polyuria: excessive urine
- polyphagia: excessive hunger
What are sysmptoms of diabetes?
- 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
- sweet smelling breath
What are normal BG levels?
- < 180 after meals
- lowest BG levels around 2 am
- BG fluctuates throughout day but within normal range
What is a fasting glucose test?
- measures glucose after 12 hour fast (usually more accurate)
- >126=diabetes, 100-126= prediabetes, <100=normal
What is a oral glucose tolerance test?
- measures glucose 2 hours after drinking concentrated glucose solution
- delayed removal of glucose indicates diabetes
- >200=diabetes, 140-200=prediabetes, <140=normal
How can you diagnose diabetes?
- glycated hemoglobin- HbA1c <6.5-7%
- symptoms plus + fasting glucose test or + oral glucose test
Who do you test for diabetes and when?
- 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
What characteristics are associated with increased risk for CVD and type 2?
- waist circumference
- HDL <40/50
- elevated fasting BG
- (3 of 5)
How do you treat hyperglycemia (>220) and ketosis?
- have too little insulin- in a diabetic coma so give insulin
- if still over 250 call MD
What are signs/symptoms of hyperglycemia?
- frequent urination
- general weakness
- nausea and vomitting
- loss of appettie
- ill appearance
- dry skin and mouth
- decreased BP and increased HR
How do you treat hypoglycemia (<60)
- 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
What are signs/symptoms of hypoglycemia?
- increased tiredness and hunger
- excessive sweating
- dizzy or fainting spells
- nervous and increased HR
- confusion and lack of coordination
- changes in behavior/irritable
- blurred vision
- slurred speech
What are the different types of insulin and when are they effective?
- 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)
When are adverse effects of insulin usually a problem?
- 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
What are some of the different medications and how can they effect exercise?
- 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
Exercise with ECG is recommended when?
- prior to vigorous exercise
- type II DM > 10yrs
- type I DM > 15 yrs
- presence of additional CAD risk factors
- presence of retinopathy or nephropathy
- autonomic neuropathy
What are aerobic exercise guidelines for diabetics?
- 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
What are resistance exercises for diabetics?
- 2-3 days/wk, all major muscle groups (8-20 exercises)
- 8-12 RM
- progress from 1 to 3 sets, rest 30 seconds between
What do diabetics want to avoid when exercising?
skipping exercise for more than 2 days
What are flexibility exercises for diabetics?
- all major muscle groups
- hold 15-30 seconds
- repeat 4-6 times
What are balance exercises for diabetics?
static and dynamic balance
What do you do if BG is <70?
- give 15 gm CHO snack, recheck in 15 min
- if >70 proceed with exercise
What do you do if BG is 70-100?
give 15 gm CHO snack per hour of moderate intensity of exercise
What do you do if BG is 100-300
proceed with exercise
What do you do if BG is >300 & on oral meds?
- do 10-15 min exercises and check sugar
- if rises then stop
- if drops then proceed
What do you do if BG is >300 & on insulin?
- check for ketones
- if + then NO exercise
- if - then proceed and monitor BG
What happens when BG and ketones aren't ocntrolled during exercise?
ketone bodies increase because not enough sugar and trying to break down fat
Which is exercise more important for Type I or Type II?
- Type II
- more important in Type I to prevent CVD
What are some complications with retinopathy with exercise?
- 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
What are some complications with autonomic neuropathies with exercise?
- 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
What are some complications with peripheral neuropathies with exercise?
What are some complications with nephropatheis with exercise?
- maintain SBP <180
- avoid high intensity aerobic or resistance training and valsalva
What are absolute contraindications to exercise for diabetetics?
- 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
What is the role of PT in prolonged bedrest?
- IRS evident within 3 days
- decrements in BG tolerance decrease in pts that are active in bed
What is the role of PT in immobilization?
one wk of immobilization reduces glucose uptake in the immobilized limb, isometric exercises minimize the reduction in glucose transport to the limb
How do you avoid hypoglycemia and hyperglycemia when exercising?
- 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