Science of Diabetes and Diabetes Management as it
Science of Diabetes and Diabetes Management as it Relates to Legal Issues and the Need for Accommodations Daniel Lorber, MD, FACP, CDE Linda Siminerio, RN, Ph. D John Griffin, JD FIGHTING FOR FAIRNESS
Session Outline u. CAUSE/CLASSIFICATIONS u. COMPLICATIONS u. CARE u. CHALLENGES
The prevalence of diabetes current estimates - world* u. Number of people with diabetes: » 177 million (154 million projected) u. Top 10 countries (number of people with diabetes): » India, China, USA, Indonesia, Russia, Japan, UAE, Pakistan, Brazil, Italy *Source: WHO Global Burden of Disease
U. S. Diabetes Facts u 20% increase in past 20 years u 70% increase in diabetes in 30 -39 yr. age range from 1990 -1998 u 1 in 3 children born in 2003 will get diabetes u 125, 000 in U. S. under the age of 19 u. Type 2 in children is increasing u 14 million lost work days u. Annual costs -- $132 billion
What is Diabetes? u. Ancient Greek: “Diabetes Mellitus” » Diabetes: Copious Urine » Mellitus: Sweet u. Lay Definition: » Abnormally High Blood Sugar u. American Diabetes Association: » Fasting Blood Glucose above 126 mg/dl » Fasting Blood Glucose above 7 m. M
CLASSIFICATIONS/ CAUSE
What is the Cause of High Glucose in Diabetes? u. Type 1: Failure of the pancreas to make Insulin: cause = autoimmune u. Type 2: Resistance of the body to Insulin: cause unknown u. Both of these areas of active research in the U. S. and internationally
What Kinds of Diabetes are There? u. Type 1 (Juvenile, Insulin-Deficient) » 10% » Under 40 y. o. » Hereditary u. Type 2 (Adult Onset, Insulin-Resistant) » 90% » Strongly Hereditary » Associated with Overweight u. Secondary Diabetes » E. g. , medications like cortisone; pancreatitis
What is the Cause of High Glucose in Diabetes? How is Glucose Regulated?
Meet the Cast: Blood Glucose Brain Fat 100 mg/dl Muscle Intestine Pancreas Liver
Effects of Eating Food Blood Glucose Brain Fat 100 mg/dl Muscle Intestine Pancreas Liver
Effects of Eating Food Blood Glucose Intestine Brain Fat 100 mg/dl 140 mg/dl Pancreas Muscle Liver
Effects of Eating Food Blood Glucose Intestine Brain Fat 100 mg/dl 140 mg/dl Pancreas (makes Insulin) Muscle Liver
Effects of Eating Food Blood Glucose Intestine Brain Fat 100 mg/dl 140 mg/dl Pancreas (makes Insulin) Muscle Liver
Type 1 Diabetes: Food Blood Glucose Intestine Brain Fat 100 mg/dl 500 mg/dl Pancreas No Islets, No Insulin Muscle Liver
BALANCING ACT u. Insulin and food must stay in balance » The insulin you inject will work whether you eat or not » Timing and amounts of food are important » If you do not eat enough, your blood sugar (glucose) could go LOW » If you eat too much, your blood sugar could go too HIGH » Physical activity will effect your blood sugar level
Hb. A 1 c and Glucose 5% 6% GOAL Take Action 7% 8% 9% 10% 11% 12% - - - 90 120 150 180 210 240 270 300
CARE
How Do You Treat Diabetes? u. Type 1: » Glucose Monitoring (fingersticks) » Insulin Injections or infusion pump therapy (replacement doses) » Meal Plans » Physical Activity
How Do You Monitor Blood Glucose Control? u. Frequent Blood Sugar Measurements » Fingersticks, multiple times each day u. Hemoglobin A 1 c (Hb. A 1 c) » Quarterly
MONITORING u. Blood Glucose Meters » Small, lightweight and user friendly » Many varieties available » One size does not fit all » No danger to others
MONITORING u. How often? » Some suggestions: • • • Before each meal and at bedtime Fasting and two hours after you eat Before and after each meal Once daily before breakfast Fasting and once more during different times of the day • More often if you are ill, exercising, having a low blood sugar, driving. Always individualized for each person with diabetes!
BACK
MONITORING u. How to test? » Wash hands with warm soap and water » Dangle fingers » Prick side of finger » Milk your finger to get a good drop of blood » Do not use the same finger over and over for testing
URINE TESTING u. Done to detect ketones » » » Ketones are BAD!! Ketones happen mostly in Type 1 diabetes Type 1: test in the presence of persistent hyperglycemia Should test if consistently high or anytime during illness Moderate or large ketones should be reported to physician immediately Urine testing is NOT used to detect glucose levels or as a measure of diabetes control
RAPID-ACTING INSULINS u. HUMALOG AND NOVOLOG » Work very quickly » Starts working in 15 minutes » Peak 1 -1 1/2 hours » Clear
SHORT-ACTING INSULIN u. REGULAR » Works quickly » Starts to work in 1/2 hour » Peaks in 2 -4 hours » Should be taken 15 -30 minutes before a meal » Clear
INTERMEDIATE-ACTING INSULINS u. NPH and LENTE » Work more slowly » Most often taken with oral medicine » Starts to work 1 -2 hours after it is given » Peaks in 6 -12 hours » Cloudy » Can be mixed with Humalog, Novolog and Regular
LONG-ACTING INSULIN u. ULTRALENTE and LANTUS » Lasts for 24 hours with little or no peak » Usually taken at bed » Ultralente is cloudy » Lantus(Glargine) is clear » Lantus CANNOT be mixed with any other insulin
Insulin Delivery Systems u. Injectors u. Injection Aids u. Pen delivery u. Insulin Pump u. Other technology
Other Delivery Systems Being Explored u. Closed-loop insulin pumps u. Lectin-and polymer-bound systems u. New routes: inhalation, oral, and transdermal u. Microencapsulation of islet cells u. Biohybrid artificial pancreas u. Pump cannula at portal vein (Disetronic)
How Do You Treat Diabetes? u. Type 2: » Careful Diet; Weight Reduction; Glucose Monitoring » Reduce glucose absorption from gut: (alphaglucosidase inhibitors) » Increase Sensitivity of Liver, Muscle to Insulin: (Thiazoladinediones, Metformin) » Stimulate Insulin Secretion: (Sulfonylureas, Repaglinide) » Insulin: large doses » Physical Activity
INSULIN u. INSULIN » Needed to lower blood sugar levels. » Diet alone or diet and oral medicine did not control your blood sugar levels (type 2) » Does NOT mean your diabetes is worse » What your body needs to keep blood sugar in control
Kinds of Oral Medicines u. Sulfonylureas u. Biguanides u. Alpha-glucosidase Inhibitors u. Insulin-sensitizing agents u. Meglitinides
Type 2 Diabetes: Food Blood Glucose Intestine Brain Fat 100 mg/dl 500 mg/dl Pancreas Liver, Fat, Muscle Resist Insulin Muscle Liver
Oral Medicines u. Medicines can be used alone, with each other or with insulin. u. Sulfonylureas and meglitinide. Help the pancreas make more insulin. u. Biguanides and insulin sensitizers Help the insulin to work better
Oral Medicines u. Sulfonylureas Lower pre-meal blood sugar levels u. Carbohydrate Inhibitors and Meglitinides Lower after meal blood sugar levels
SULFONYLUREAS u. Help pancreas make more insulin u. Several different types u. Do not exchange one for another u. Side effects » Low blood sugar » Weight gain » Upset stomach
BIGUANIDES u. GLUGOPHAGE » Help keep the liver from putting out too much sugar » Help insulin to work better » Lower cholesterol » Do not cause weight gain » Side effects: diarrhea, nausea and loss of appetite » Do NOT take is liver, kidney problems or heart failure
ALPHA-GLUCOSIDASE INHIBITORS u. PRECOSE AND GLYCET » Work in digestive tract » Block enzymes that break down carbohydrates to sugar » Prevent blood sugar from going up after meal » Side Effects: Bloating, gas, diarrhea » Side effects usually go away after a few months
INSULIN SENSITIZERS ACTOS AND AVANDIA » Help your body to use insulin better » May take 2 -12 weeks to work » Give medicine a fair trial » Monitor liver functions
MEGLITINIDES u. PRANDIN AND STARLIX » Help pancreas make more insulin » Work in response to blood sugar levels » Take before each meal and snack
Oral Medicine u. Most pills should be taken at mealtime u. Glucotrol (Glipizide) works best if taken 1/2 hour before a meal u. Prandin should be taken 15 minutes before a meal u. Precose and Glycet should only be taken with the first bite of food
Benefits of Oral Medicine u. Lower blood sugar will mean you will feel better u. Remember not a cure for diabetes The Person with Diabetes must u. Take medicine every day, eat at planned times, eat meals per appropriate diet. u. Stay in touch with his/her health team u. Test blood sugar level to see if the medicine is working
COMPLICATIONS u. Acute u. Chronic
Hypoglycemia u Sudden Onset u Staggering, Poor Coordination u Anger, Bad Temper u Pale Color u Confusion, Disorientation u Sudden Hunger u Sweating u Eventual Stupor or Unconsciousness Hyperglycemia u Gradual Onset u Drowsiness u Extreme Thirst u Very Frequent Urination u Flushed Skin u Vomiting u Fruity or Wine-Like Breath Odor u Heavy Breathing u Eventual Stupor or Unconsciousness
Why Do We Care? Chronic Complications: (Years, Decades) u. Diabetic Nephropathy: Kidney Failure, Dialysis, Kidney Transplant u. Diabetic Retinopathy: Blindness u. Diabetic Neuropathy: Numbness, Impotence, GI Probs, and more u. Accelerated Cardiovascular Disease: Stroke, Heart Attack, Impotence, Peripheral Vascular Disease (Amputations)
Are These Chronic Complications Preventable? u. Absolutely! » Tight Glucose Control Prevents or Delays Complications.
Proven Studies “benefits of intensified control” DCCT (type 1) Hb. A 1 c = 1. 9% u Complications in the DCCT Trial showed profound reduction » Retinopathy » Nephropathy » Neuropathy 76% 56% 60% UKPDS (type 2) Hb. A 1 c = 0. 9% u Intensive therapy… reduced overall microvascular complications by 25% and decreased risk of » retinopathy 21% » microalbuminuria 33% u Reduction in microvascular complications seen regardless of primary treatment modality for intensive therapy » insulin, sulfonylureas, or metformin
Hb. A 1 c and Glucose 5% 6% GOAL Take Action 7% 8% 9% 10% 11% 12% - - - 90 120 150 180 210 240 270 300
Decision Support ADA Standards of Medical Care u. A 1 C u. Blood pressure u. Lipids » LDL » Triglycerides » HDL <7% <130/80 mm. Hg <100 mg/dl <150 mg/dl >40 mg/dl u. Dilated eye exams u. Foot exam (Monofilament) u. Microalbumin
CHALLENGES
CHALLENGES at SCHOOL • Meet both the student’s health and educational needs one at the expense of the other • Blood glucose testing: assistance as appropriate, right to carry equipment • Eating: meals, snacks, treat low blood sugar • Medication: assistance as needed per individual child, right to carry, • Field trips • Extra-curricular activities • Treatment of severe low blood sugar • Testing accommodations
at WORK • Right to a job for which the person with diabetes is qualified • Individual assessments not blanket bans • Reasonable accommodation for testing, eating other care needs • Access to supplies and equipment • Modified work schedule
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