Introduction to Diabetes Mellitus
Presented by LMC Diabetes and Endocrinology
LMC Diabetes
Objectives
1.
2.
3.
4.
Overview of Diabetes Mellitus (DM)
Complications
Management of Diabetes Mellitus
Patient Management
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Overview of DM - What is Diabetes?
Diabetes is a condition where your body does
not produce or use insulin properly in the body,
resulting in high blood sugars
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Overview of DM - What is Diabetes?
In a person without
DM……
 Insulin, a hormone
produced by the
pancreas, is secreted in
response to
carbohydrate digestion
 Insulin acts like a key it allows sugar to enter
into the body’s cells to
create energy
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In a person with DM….
 The secretion and/or
the process of insulin
opening the cells to
allow sugar in is not
working properly 
high blood sugars
Overview of DM - Types of Diabetes
• Type 1 Diabetes - autoimmune disease where the
pancreas does not produce insulin
• Type 2 Diabetes – occurs when your body does not
produce and/or use the insulin in the body properly
• Gestational Diabetes-occurs during pregnancy
• Pre-Diabetes – the beginning stages of type 2
diabetes
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Type 1
Diabetes
• Occurs in approx.
10% of people
with DM
• Formerly known
as Juvenile
Diabetes
• Insulin therapy is
initiated
immediately
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• Occurs in approximately
90% of people with
Diabetes
• Used to be known as
“Adult Onset” but a
growing number of young
people are developing
Type 2 Diabetes due to
lifestyle factors
• Management: healthy
eating, exercise,
medication and/or insulin
injections
• Progressive disease
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Type 2
Diabetes
Overview of DM –
Risk Factors for Type 2 Diabetes
• Age >40
• Being overweight
• Having an “apple” shaped
body
• Family history (very strong)
• Gestational diabetes or
baby >9 lbs
• Ethnicity (African, Asian,
South Asian, Aboriginal
descent)
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Overview of DM –
Symptoms on presentation
Common symptoms :
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•
•
•
Fatigue
Increased thirst
Increased urination
Unexplained weight
loss
• Blurred vision
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Overview of DM - Diagnosis of Prediabetes*
Test
Result
Prediabetes Category
Fasting Plasma Glucose
(mmol/L)
6.1 - 6.9
Impaired fasting glucose
(IFG)
2-hr Plasma Glucose in a
75-g Oral Glucose
Tolerance Test (mmol/L)
7.8 – 11.0
Impaired glucose tolerance
(IGT)
6.0 - 6.4
Prediabetes
Glycated
Hemoglobin
(A1C) (%)
* Prediabetes = IFG, IGT or A1C 6.0 - 6.4%  high risk of developing T2DM
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Overview of DM – Diagnosis?
FPG ≥7.0 mmol/L
Fasting = no caloric intake for at least 8 hours
or
A1C ≥6.5% (in adults)
Using a standardized, validated assay, in the absence of factors that affect the
accuracy of the A1C and not for suspected type 1 diabetes
or
2hPG in a 75-g OGTT ≥11.1 mmol/L
or
Random PG ≥11.1 mmol/L
Random= any time of the day, without regard to the interval since the last meal
2hPG = 2-hour plasma glucose; FPG = fasting plasma glucose; OGTT = oral glucose tolerance test; PG = plasma glucose
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Diabetes Complications
Prolonged high blood sugars can
affect:
• Eyes - Retinopathy
• Heart and cardiovascular
system
• Kidney - nephropathy
• Nervous system - neuropathy
• Sexual organs - erectile
dysfunction
BEST WAY TO REDUCE
COMPLICATIONS IS WITH
GLYCEMIC CONTROL
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Complication Prevention (therapies that may
be used)
• Kidneys
– Control Blood Pressure
– ACE or ARB (i.e. Altace)
• Cardiovascular disease
– ECASA – 81 mg
– ACE or ARB (i.e. Altace)
– Cholesterol Lowering Medication
• Foot Care
– Patient should check feet daily, wear proper shoes and
socks
– Patient to see MD if a cut, blister or crack on the foot is not
healing
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Complication Prevention (therapies that may
be used)
Neuropathy – peripheral
• 10-g monofilament or assessment of loss of sensitivity to
vibration at the dorsum of the great toe
• Anticonvulsants, antidepressants, topical nitrate spray
Retinopathy
• Annual screening with ophthalmologist
• Fenofibrate may be added to a statin in some patients
Erectile Dysfunction
• A PDE5 inhibitor, if there are no contraindications
LMC Diabetes
Monitoring/Preventing Complications:
What are the ABC’s?
• A = A1C (3 month blood sugar average) <7%
An AIC <7% reduces the risk of patients developing
complications of diabetes (type 1 &2), specifically, an AIC
of < 7% showed in people with type 2 DM:
• 76% reduction in eye disease
• 50% reduction in kidney disease
• 60% reduction in nerve disease
•B
•C
= Blood Pressure <130/80
= LDL “Bad” Cholesterol <2.0 mmol/L
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Management of DM Blood Sugar Targets
 FPG / pre meal : 4-7 mmol/L
 2 hours after eating: 5-10 mmol/L
 If HbAIC not at target: 5-8 mmol/L
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Management of DM - Medications
• For a full review of pharmacological approaches, please
review the 2013 CDA Clinical Practice Guidelines
• Medications are decided based on the person’s:
– Blood sugar level
– Individual characteristics
– Properties of the medication
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Class of Drug
Action & Target Organ
Dosage
What to Watch out for
Sulfonylurea
Targets the pancreas to
stimulate insulin secretion
glyburide: 2.5-20 mg/day
Diamicron: 80-160 mg twice daily Amaryl:
4-8 mg/day
Taken with meals
Can cause low blood sugars, weight
gain (glyburide); Rarely, rash if allergic
to sulfa
metformin (Glucophage)
(Glumetza)
Biguanide
Targets liver to restore insulin
sensitivity
Metformin: 250 -2000 mg/day
Taken with meals
Glumetza: 1000 -2000 mg once per day
with evening meal
GI upset: diarrhea, nausea, bloating
Should not be taken if decreased
kidney or liver function
Avandia (rosiglitazone)
Actos (pioglitazone)
Glitazone
(Thiazolidine-dione
Family)
Increases overall sensitivity
to insulin
Avandia: 2-8 mg / day
Actos: 15 - 45 mg / day
Weight gain (average of 1-3 Kg), fluid
retention
GlucoNorm
(repaglinide)
Meglitinide
Targets the pancreas to
stimulate insulin secretion
Approximately 0.5-4 mg
Taken with each meal
MUST be taken with food
Prandase
(acarbose)
Alpha-glucosidase
inhibitor
Targets digestive track to
delay absorption of starch
50-100 mg
Taken with each meal
Flatulence very common; rarely,
bloating
Januvia
(sitagliptin)
Onglyza
(saxagliptin)
Di-peptidyl peptidase-4
inhibitor
Januvia: 100 mg / day
Onglyza: 5 mg / day
May cause stomach discomfort
and diarrhea
Doses should be lowered if decreased
kidney function
Medication
glyburide (Diabeta)
Diamicron (gliclazide)
Amaryl (glimepiride)
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Triggers pancreas to secrete
more insulin
Management of DM – Self Monitoring Blood
Glucose (SMBG)
Allows patients to:
1. Understand the effect of food, exercise, medication and
stress
2. Assist in self management and empowering the patient
3. Keep on track with their blood sugar to reach target AIC of
<7%
4. Provide physician and diabetes educator with information to
adjust their therapy appropriately – can target pre meal
and/or post meal blood sugars
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Management of DM –
How often to test? The more, the better
Diet alone and/or Medication:
• Individualize to patients’ situation
• Difficult to assess patient if testing at
the same time each day
• Suggestion: test before and 2 hrs after
a different meal each day
Insulin Therapy:
• 4-7 x /day for MDI
• Before each insulin injection for safety
• 2 hrs pc are helpful if the patient is willing to increase
frequency of testing
LMC Diabetes
Management of DM - Smart Testing
• Smart testing empowers patients to analyze their values, not
just record them
• When the blood sugars are out of target empower the patient
to ask why?
• The patient can then self manage themselves to assist in
meeting the target AIC!
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Management of DM - Activity
• Newly diagnosed patient comes in for glucometer teaching
• Doctor suggested patient to test once/day
• What do you suggest?
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Management of DM - Activity Answer
• Very subjective answer
Possible answers:
1. First ask the patient what he/she feels comfortable with
2. Explain the benefit of testing blood sugars
3. Explain the use of a logbook/downloading the meter
4. Test before and after one meal/day – rotate the meal from
day to day to get a clear picture of what is happening
throughout the day without having to test 7 times/day
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Management of DM -Hypoglycemia
Mild to Moderate = blood sugar <4.0 mmol/L
Severe = blood sugar < 2.8 mmol/L
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Management of DM - Hypoglycemia
• Causes of hypoglycemia include:
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Increased physical activity
Not eating on time
Eating less than normal
Taking too much medication/insulin
The effects of drinking alcohol
• Ask your patient to self-reflect: why did my blood sugars go
low? – How can I prevent this in the future?
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Management of DM –
Hypoglycemia Treatment
• Check blood glucose right away.
present, patient should treat!
If no meter but symptoms are
• If blood sugar is < 4 mmol/L patient to eat
fast acting carbohydrate such as:
or drink 15 g of a
– 3 glucose tablets, 1/2 cup of juice , 3 packets of sugar dissolved in
water, 6 Life Savers™ (chewed up)
• Patient should wait 15 minutes, then check blood sugar again.
If blood sugar is still < 4mmol/L, treat again.
• If the next meal is more than one hour a way patient should eat a
snack (15g of carbohydrates and a protein source ex: 1 oz of cheese
and 7 soda crackers).
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Management of DM - Nutrition
• Nutrition therapy can reduce AIC by 1.0 to 2.0% and may be
even more beneficial when combined with other aspects of
diabetes care
• Weight loss and exercise increases insulin sensitivity
• Patients should aim for a BMI of 18.5-24.9 and/or a 5-10%
weight loss of current weight
• Patients should aim for a waist circumference of <102 cm
for men and < 80 cm for women
• Types and portions of food can assist to control blood sugars
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Management of DM –
Healthy Living with Diabetes
• Healthy living includes:
• Regular Meals
• Balanced Meals
• Portion Control
• Physical Activity
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Management of DM - Regular Meals
• 3 meals/day spaced 4-6 hours apart
– Why? Skipped or delayed meals can cause low blood sugars (if on certain
diabetes meds) or higher blood sugars (sugar is released by the liver with
prolonged fasting).
• If the next meal > 5 hours away– suggest a healthy snack to
prevent overeating and to keep blood sugars balanced
(snack:<100-150 calories, <3-5 g fat).
breakfast
breakfast
lunch
vs.
lunch
dinner
dinner
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Management of DM –
How To Approach Food
Canada’s Food Guide To Health Eating – The Food Groups:
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•
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Grains
Fruits and Vegetables
Meat and Alternatives
Dairy
(other)
*Healthy Eating Goal: 3 out of the 4 food groups/meal
*Problem: Doesn’t account for the carbohydrates
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Management of DM –
How To Approach Food
• When managing diabetes with food, it is important to look at
food in these food groups:
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•
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Carbs
Protein
Vegetables
Fat
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Management of DM – Balance and Portion
Control: Space on Your Plate
vs.
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Management of DM –
What is a carb?
Carbohydrates = Sugar/Glucose
• Sources of Carbohydrates :
1. Grains and Starch (rice, legumes, bread, corn, potato,
pasta, bread, chipati)
2. Fruit, fruit juice, and dried fruit
3. Milk and Yogurt
4. Sugars (syrup, pop, candy, baked goods)
Are all carbs considered equal?
No!
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Management of DM –Fibre
Fibre is a form of carbohydrates that cannot be digested
Benefits:
• Helps to slow down digestion of sugar
• Helps to lower cholesterol
• Increases satiety
• Improves bowel function
Sources:
• whole grains, legumes, fruits and vegetables
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Management of DM –
Glycemic Index (GI)
GI = scale that ranks carbohydrate according
to their effect on blood glucose levels
• High GI foods will raise blood sugars
quickly - examples: white bread, fruit
juice
• Low GI foods are digested more slowly
and sugar is released more gradually into
the bloodstream. This is more desirable.
For example: whole grain bread, legumes
*** Higher fibre foods tend to be lower GI
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What does a recommended portion of
carbohydrate look like?
• To assist with estimating
portions: patients can
compare their first to a 1
cup portion or a medium
size fruit
• Patients should aim for 1 to
1.5 fists of total carbs per
meal
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Management of DM - What is a protein?
• Protein's main function is to build, maintain and repair the
body's tissue, such as muscles, organs, skin and hair.
• Protein does not raise blood sugars unless eaten in excess.
• Sources: Meat, poultry, fish, eggs, cheese, nuts
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What does a recommended
portion of
protein look like?
The goal is 3 oz. (the size of the palm of your hand or a deck of cards) per meal
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What does a recommended
portion of vegetables look like?
• Vegetables add bulk, fibre and important vitamins and
minerals
• Goals: to consume as much vegetables that is able to fit into
two handfuls.
• Sweeter vegetables to consider: carrots, peas, beets, squash,
turnips - > 2 cups – count as a carb
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Management of DM –
What about fat?
• Fat does not raise blood sugars unless eaten in excess.
• Fat, specifically total fat, saturated fat, and trans fat will
negatively affect blood cholesterol levels
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What does a recommended
portion of fat look like?
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Management of DM
Portions Review
Each meal aim for:
• 1 – 1.5 fist of carb
• 2 handfuls of vegetables
• 1 palm of protein
• 1 thumb of added fat
• All should fit nicely on a
balanced plate!
LMC Diabetes
Management of DM –
Summary of factors that slow down sugar
absorption into the bloodstream
1.
2.
3.
4.
5.
Low GI foods
Fibre
Protein
Fat
Appropriate portions of carbs
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Management of DM The importance of slowing down blood sugar
absorption
1. Increases satiety
2. Reduces spike in blood sugar  less stress on the pancreas –
can contribute to slowing down progression of diabetes
3. Food can becomes a better match to rapid acting insulin
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Management of DM –
Activity
Breakfast example
• 2 slices whole wheat toast
• 2 tsp butter
• ½ cup orange juice
How could this breakfast be improved?
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Management of DM –
Activity Answer
Breakfast example
• 2 slices whole wheat toast
• 2 tsp butter
• ½ cup orange juice
To Improve:
1. Use peanut butter instead
of butter for protein
• peanut butter will slow down
the absorption of the
carbohydrate
2. Switch orange juice to an
orange
• perhaps move orange to am
snack to reduce total carb
intake
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Management of DM - Alcohol
• If your patient doesn’t drink, they shouldn’t start!
• Health Canada’s Recommendation for consumption:
• 2 servings/ day max for men
• 1 serving/day max for women
• One serving =
• 1.5 fl z of hard liquor
• 5 fl oz. of wine
• 12 fl oz of beer
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Management of DM
Alcohol – Issues to Consider…
1. Alcohol may cause hypoglycemia – may need patient to
check blood sugars frequently and throughout the night to
monitor
2. Alcohol should always be consumed on a full stomach
3. Alcohol raises triglyceride levels – limit/avoid if triglycerides
are elevated
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Management of DM Benefits of Physical Activity
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Improved blood sugars
Increased insulin sensitivity
Increased glucose uptake
Decreased risk of heart disease
Increased metabolism
Important for bone strength
Weight loss/maintenance
Improved sleep patterns
Increased energy
Etc…
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Management of DM - Exercise Safe
Patients should be encouraged to:
1. Discuss exercise with their physician prior to beginning an
exercise routine - discuss having an ECG, if one has not been
done recently
2. Measure blood glucose pre and post activity
3. Reduce medication/have a snack prior to exercise to avoid
hypoglycemia, if necessary
4. Carry ID, Medic Alert bracelet and some form of simple carbs
to treat a low blood sugar (if on orals or insulin)
5. Drink water
6. Check feet and wear proper shoes
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Management of DM –
Balance of Activity: 3 different types
Cardio (walking, hiking, biking, swimming)
• 150 minutes/week on at least 3X/wk
• Anything more than a walk should be
discussed with the patients’ physician
Strength Training
• 2x/week, 1-3 sets of 10-15 reps
Stretching (yoga, pilates)
Patient is encouraged to include all 3 types
into their lifestyle
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Management of DM - Activity
• Patient walks for 20 minutes 3X/day
• Please assess and make suggestions
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Management of DM – Activity Answer
• Patient walks for 20 minutes 3X/day
1. Commend patient for getting active
2. Make sure that it is safe for the patient to exercise –
according to his/her physician
3. Ask patient what he/she likes to do
4. Discuss increasing different options:
a. Increasing cardio by time and frequency
b. Adding in different exercises – resistance and stretching
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Patient Management –
Setting your patient up for success...
1.
2.
3.
4.
5.
Connect with your patient
Identify patient’s Stage of Change
Set SMART Goals
Empower your patient – encourage self management
Go that extra mile – make your patient feel special
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Patient Management –
Connecting with your patient
• Make a good first impression
• Make eye contact
• Just because you talk about diabetes all day, it doesn’t mean
your patient does
• Be empathetic
• Be clear in your communication
• Offer support
• Do a mental health assessment and integrate psychosocial
goals into the care plan
• Allow the patient to discuss feelings, experiences, but don’t
let them lead the session
LMC Diabetes
Patient Management – Stage of Change
1.
2.
3.
4.
5.
Pre-contemplation – not ready to make change
Contemplation – thinking about making change
Preparation - getting ready to make change soon
Maintenance – maintaining the change
Action – making change and positive outcomes have
occurred
Goal Setting Should Always Occur Based on Patient’s Stage of
Change
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Patient Management –
Goal Setting = SMART Goals
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Specific
Measurable
Attainable
Realistic
Time
• Ex: I will run 3 times per week for 30 minutes in the morning
before my shift for the next 3 months VS. I will start to
exercise
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Patient Management – Activity
Make these goals into a SMART goals:
1. I will lose 25 lbs.
2. I will start to more fruits and vegetables
3. I will test my blood sugars
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Patient Management – Activity Answer
SMART goals:
1. I will lose 25 lbs.
– I will have a weight loss goal of 1-2 lbs. per week
2. I will start to more fruits and vegetables
– I will have a fruit for my morning and afternoon snack
– I will have 1 cup of vegetables at lunch and 1 cup of
vegetables at dinner
3. I will test my blood sugars
– I will start to test by blood sugars before and after one
meal/day and write my numbers in a logbook.
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Patient Management –
Counselling through a session....
1.
2.
3.
4.
5.
6.
7.
8.
9.
Gather your information
Prioritize your goals – top 3
Ask the patient for their goals – top 3
Set SMART Goals – 3 goals/session – based on both yours and their
goals
Negotiate with the patient – let the patient talk and think through
how to achieve the goal
Let the patient discuss barriers
Don’t feel the need to do too much – you always have a follow up!
Make sure you’ve answered all their questions
Provide your contact information
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Patient Management –
Empowering Self Management
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•
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Provide the tools for the patient to make decisions
Explain how and why your making suggestions
Provide an example of how to use the new information to
assist patient in making their own changes at home
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Conclusion
• Diabetes is a multifaceted condition
• The diabetes educator play a crucial role in the management
of the patient
• From explaining the physiology to the management and
counselling of the patient
• Work together to make diabetes more manageable for the
patient!
LMC Diabetes