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
• 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.
Prevalence of Diabetes in America*
In 2010:
In 2012:
25.8 million people
8.3% of the population
1.9 million new dx
29.1 million people
9.3% of the population
1.7 million new dx
*American Diabetes Association
www.diabetes.org
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
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
Effects of Uncontrolled Diabetes*
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Microvascular Complications
– Target nerves, eyes, feet, kidneys
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BLINDNESS
LIMB AMPUTATION
DIALYSIS
Macrovascular Complications
– Target brain, heart
1. Heart Attack
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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
2. Stroke
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Diabetic risk of stroke 2X higher than general popuation
*American Diabetes Association www.diabetes.org
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
Normal Carbohydrate Metabolism
1. Carbohydrate food is digested in the
stomach.
2. Sugar from the stomach flows into the
bloodstream, to the cells.
3. Cells use the sugar to produce energy
to fuels our cells and our selves.
4. Insulin secreted by the pancreas
keeps blood sugar at healthy
balanced levels.
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
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
Metabolic Syndrome
RISK FACTOR for diabetes type 2, heart
disease, stroke
Diagnosis requires at least 3 of 5 factors:
1.
2.
3.
4.
5.
Elevated blood glucose
Elevated triglycerides
Decreased HDL
Hypertension
Central Obesity
(male WC>40 inches, female WC >35 inches)
Risk Factors for Diabetes
• Overweight
• Family history of diabetes
• African American, Latino, Native
American, Asian American, Pacific
Islander race
• Having Gestational Diabetes
Symptoms of Diabetes
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Increased thirst
Frequent urination
Increased hunger
Weight loss
Fatigue
Blurred vision
Irritability
Detecting and Diagnosing Diabetes
June, 2009
International Committee:
American Diabetes Association
European Association for Study of
Diabetes
International Diabetes Federation
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
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
Detecting and Diagnosing
Diabetes
• Random Plasma Glucose
– No fasting required
– Score 200 or higher suggests diabetes
American Association of Clinical Endocrinologists
AACE Consensus Statement:
Comprehensive Diabetes Management Algorithm 2013*
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9.
*AACE
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
Comprehensive Diabetes Management, Endocr Pract. 2013;19(Suppl 2)
Diabetes Management Options
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Work with your healthcare professional
Lose weight
Choose healthy foods
Exercise
Take medications
Take supplements
Diabetes Management Options
WORK WITH YOUR HEALTHCARE PROFESSIONAL
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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
Diabetes Management Options
LOOSE WEIGHT.
Excess body fat causes body cells to
become resistant to insulin.
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
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
Exercise for Diabetes Management
A SINGLE EXERCISE SESSION CAN…*
1. Increase bioavailability of nitric oxide, thus
decreasing post exercise stress
2. Increase oxygen consumption, thus
boosting fat metabolism
3. Increase metabolism of carbohydrates during
exercise
4. 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.
Medications for Diabetes Type 1
Management
Insulin.
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
Classes of Diabetes Type 2 Medication
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Increase insulin sensitivity of liver, fat and
muscle cells.
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Stimulate insulin production by the pancreas.
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Slow the digestion of carbohydrates.
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
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)
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Decrease blood glucose levels by making muscle, fat and
liver cells more sensitive to insulin
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On the market since 1999, in popular use since 2007
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Increased risk of bone fracture, CHF, bladder cancer
Medications that
Stimulate Insulin Production by the Pancreas
GOAL: Stimulate the pancreas to make produce more insulin.
1.
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.
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
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
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
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
Side Effects of Insulin Injections
HYPOGLYCEMIA
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7-15% of insulin treated patients with T2DM experience at
least one hypoglycemic episode per year
Frequency of hypoglycemia increases with
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Intensive insulin targets
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Comorbid use of sulfonylurea
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Decreased caloric intake
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Exercise
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Alcohol consumption
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Renal dysfunction
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Diabetes duration
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Cognitive impairment
Side Effects of Insulin Injections
WEIGHT GAIN
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3-5 pound weight gain compared to other diabetes agents
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Adding amylin analog (Symlin) injection at same time of bolus
insulin improves DMT2 may improve gycemia and weight
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Combining incretin therapy (DPP-4, GLP-1) with basal insulin may
improve glycemia and weight
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
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
1.
Glucose-tolerance factor (GTF) Chromium
Biologically active form
1.
Chromium Picolinate
No known side effects from supplement use.
Supplements for Diabetes Management
GTF CHROMIUM 800-1000 mcg daily for
patients with Metabolic Syndrome or
Diabetes Type 2.
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
Supplements for Diabetes Management
VANADYL SULFATE (VOSO4)*
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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.
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.
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.
Supplements for Diabetes Management
FENUGREEK*
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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.
Supplements for Diabetes Management
INSINASE
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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.
Supplements for Diabetes Management
AMERICAN GINSENG (Panax quinquefolius)
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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
Supplements for Diabetes Management
MYRTLE SENG
• Traditional Chinese Medicine formula
• Nutritionally reduces blood glucose
levels
• Improves insulin sensitivity
• May aid in weight loss
Supplements for Diabetes Management
TAURINE
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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
Supplements for Diabetes Management
TAURINE “anorexigenic” effect on hypothalamus of rats*
• Minimizes feelings of hunger
• Improves energy and metabolism
• Helps stall body fat gain
TAURINE Antioxidant effects
• Lowers chronic inflammation in hypothalamus**
• Neutralizes free radicals in pancreatic beta cells
• Increases exercise capacity in heart failure patients***
*Solon CS, Franci D, et al. Taurine Enhances the Anorexigenic Effects of Insulin in the Hypothalamus of Rats. Amino Acids. June 2012. 42(6):2403-10.
**Arruda A, Milanski M, et al. Low-Grade Hypothalamic Inflammation Leads to Defective Thermogenesis, Insulin Resistance and Impaired Insulin Secrection. Endocrinology. April
2011. 152(4), 1314-1320.
***Beyranvand M, Khalafi M, et al. Effect of Taurine Supplementation on Exercise Capacity of Patients with Heart Failure. Journal of Cardiology. May 2011. 57(3), 333-335.
Living with Type 2 Diabetes
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To guide and support Type 2 Diabetes patients
Free through American Diabetes Association
12 month program
Available in English and Spanish
Call 1-800-DIABETES
Text Type2 to 69866
Visit diabetes.org/type2program
2014 Winter Lecture Series
Choices Foundation for
Health Education and Research