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1

Behavioral Risk Factors for Type II

Sedentary lifestyle

Overweight: also fat distribution

Smoking: increases with cigs per day and pack years

Sleep: increased if less than 5 hours or more than 9

Unhealthy Diet: red meat and sweets increase

Vitamin D deficiency

2

Diabetes Prevention Program

Three groups-
1. Lifestyle Intervention: achieve and sustain weight loss, increase exercise, education, and dietary goals
2. Metformin
3. Placebo

Done to overweight patients with high risk for type II

Lifestyle had biggest decrease of incidence relative to placebo, Metformin had lower decrease

Metformin helped more relative to lifestyle changes when fatter

Weight loss was the most effective lifestyle change (better hand diet change and exercise), 1 kg weight loss resulted in 16% reduction in type II incidence




3

Finnish Diabetes Prevention Study

Overweight people with impaired glucose tolerance (IGT)

Control: diet instruction at start of study

Experimental Group: personal advice given routinely, >5% weight loss, reduce fat intake to less than 30%, increase fiber, exercise 30 mins a day

Experimental diet intervention had less than half of diabetes incidents

4

Look AHEAD

Action for health in diabetes

Adults with type II, look at incidence of cardiovascular and cerebrovascular events

Control group with usual medical care (diabetes support and education)

Experimental group had usual medical care with intensive lifestyle intervention

Intensive Lifestyle Intervention: lose 7-10% of initial weight, physical activity requirement, calorie and fat restriction

There is an additive beneficial effect to combining pharmacotherapy with lifestyle modification, acts on internal and external environment

Intervention group had better BP, A1C, and lipid levels, also lost more weight

Limitations: unblinded, weight loss from meds, mess were not u inform across groups and some people stopped taking meds

Orlistat: gastric lipase inhibitor reduces fat uptake

5

Outcome of studying reduction of diabetes medications with lifestyle changes

Patients can reduce the number of diabetes medications or undergo diabetes remission with lifestyle changes

6

4 Components of Lifestyle Changes

Dietary Consultation (Medical Nutrition Therapy)

Behavioral Modification

Increased Physical Activity Level

Weight Loss

7

Dietary Consultation (Medical Nutrition Therapy) for Lifestyle Changes of Type II

Optimize A1C, BP, and LDL Cholesterol (ABCs)

No universal meal plan, needs to be individualized

Components-
1. Calorie Intake: balance between calories in/out, calories out measured by total energy expenditure

2. Weight Management: different amount of kcal to maintain weight due to differences in RMR, weight loss of 5-10% helps with Glu, HT, and dyslipidemia

3. Consistency in Carb Intake: avoid erratic blood sugars and hypoglycemia on fixed insulin doses

4. Nutritional Content: specific diet composition in glycemic reduction and CV risk reduction is uncertain, better to choose patient preference to have long term adherence

8

Macronutrients of Nutritional Content for Lifestyle Changes

High fiber has lower glycemic index

Little difference in A1C or CV risk with low/high carb diets independent of weight loss

Fat quality better than fat quantity, low fat diet had no effect on glycemic control, omega 3-FAs don't improve glycemic control but help with lipid levels

Protein-
Without kidney problems: high protein diet has conflicting A1C reports, lower lipid levels

With kidney probs: reducing protein in diet doesn't change glycemic control, CV risk, or decline in GFR

Little evidence that altering macronutrient composition has a significant effect on glycemic control independent of weight loss or effect on reducing CV risk (omega 3, high protein without kidney probs, and higher soy intake with kidney probs are possible exception)

9

Importance of Glucose Control on Management of Type II

Intensive blood glucose control with sulphonylureas or insulin resulted in better A1C levels, less microvascular problems but no effect on macrovascular problems

10

Diabetes Regimen

Varies depending on if need insulin

Involves taking meds (insulin or oral meds)

Monitor food intake and blood glucose levels

Checking for ketones

Physical activity

Planning/organizing to have supplies ready for different situations

Alerting others

11

Complications of no adherence to diabetes regimen

Short term:
High blood glucose, diabetic ketoacidosis, higher A1C, BP, and hospitalizations

Long term: retinopathy, neuropathy, renal disease, amputation, higher LDL, sterility, heetndisease, gastroparesis, peripheral artery disease, death

12

Compliance

Extent o which patient behavior matches medical advice

13

Factors related to nonadherence

Patient/family characteristics: adolescents, men, lower SES, minorities

Disease related characteristics: duration, course, severity(real or perceived)

Regimen related characteristics: costs outweigh benefits, side effects

Health care provider/system: need support from medical team, increased contact, and quality doctor-patient relationship

14

No adherence in youth

Teens more likely to be non-adherent than little kids cuz less parental influence, more peer influence, and seek independence while rebel

Parents see long term while teens are short term

Different levels of motivation and burnout to follow 💯 the whole time

15

Diabulimia

Involves intentional nonadherence

Skip meals or eat only "free" foods to avoid administering insulin

30% of Type I women omit insulin to lose weight by piss glucose

Not diagnosable condition

Look for increased eating but weight loss, Hyperglycemia, low energy, and frequent urination

16

Interventions to improve adherence

Educational: help initially but need other interventions for chronic diseases

Organizational: improve doctor-patient relationship, increase access, simplify regimen

Behavioral: assess barriers and encourage incentives, use technology to monitor, changes in behavior

17

Low flow oxygen delivery

Low flow oxygen cannula: 2 pronged tube that fits in nose, flow rate is 1-6 LPM and generates FiO2 of 24-45%, need humidification if above 4 LPM

Oxygen Mask: flow rates above 5 LPM, for mouth breathers only, uncomfortable and hard to talk

Oxygen Catheter: deliver same rate as oxygen cannula, inserted through nose to above uvula, uncomfortable but would use if one nare is closed

18

High flow oxygen delivery

High flow oxygen cannula: oxygen flow up to 15 LPM, FiO2 from 57-81%, for severe hypoxemia

High Flow Venturi Mask: FiO2 of 24-50% and depended on the size of the entrapment port, mixes oxygen with room air, when concerned with CO2 retention

19

Hazards of Oxygen Therapy

1. Oxygen toxicity: when given for long enough, free radicals accumulate and damage alveoli which will appear as patchy things in X-ray, damage to CNS and eyes also

2. Atelectasis: nitrogen normally used to expand alveoli but gets washed out from high oxygen, alveoli collapse since reduced ability to expand

3. O2 Induced Hypoventilation: patients normally rely on CO2 to tell when to breath, COPD people have reduced stimulus to breath since have high CO2 levels built up

4. Combustible

20

Oxygen Tanks

Don't roll or lean on wall since fire hazard

For transporting patients on oxygen

If PSI is below 300 then get new tank

21

Pulse Oximetry

Non-invasive monitor for estimate of arterial blood oxyhemoglobin saturation levels, SpO2 is oxygen saturation level

For vital signs, can be used on finger, toes, or earlobe

Uses 2 different wavelength of light

Accuracy check: compare SpO2 on pulse oximeter with patient's arterial blood levels, check pulse rate with actual pulse

SpO2 of 90% is at least 60 PaO2, 70% SpO2 is close to 40 PaO2

22

Factors that affect Pulse Oximetry

Presence of HbCO, high levels of metHb, anemia, vascular dyes, dark skin pigmentation, ambient light, poor perfusion, motion artifacts, elevated bilirubin levels, nail polish

23

Fertilization

1. Penetration of the corona radiata

2. Penetration of the zona pellucida: sperm that penetrate this extracellular matrix make this layer impermeable to other sperm

3. Fusion of the sperm and oocyte cell membranes: the pronuclei of each can fuse to form a zygote

24

Zygote Journey to Uterus

Start in Fallopian tube

30 hours after fertilization undergo cleavage to make blastomeres that are confined within the zona pellucida in a process called compaction

When enter uterus: 3 or 4 days after fertilization, zygote is a morula with 12-32 cells, blastomeres organize into inner cell mass for the embryo and outer cell mass for placenta

25

Blastocyst Formation

Morula absorbs fluid after 4 days and gets a blastocyst cavity, now called blastocyst

Inner cells form the stacked embryoblast cells (at the embryonic pole) and the outer cells form the single layered epithelium called the trophoblast (at the abembryonic pole)

26

Attachment and Differentiation of the Trophoblast

Blastocyst implants into the uterine lining

Syncytiotrophoblast: cells that are directly embedded in the endometrium

Cytotrophoblast: cells that line the wall of the blastocyst

27

Ectopic Pregnancy

Blastocyst implants in wrong spot

Threaten mom's life cuz blood vessels rupture at site of embryo growth, often identified by vaginal bleeding or abdominal pain, need drugs or surgery to treat

Common locations-
Within uterine tubes: most common (tubular ampullar)
Within abdomen
Abnormal site within uterus like cervix

28

Development of Amniotic Cavity

Occurs at day 8

Embryoblast forms 2 layers: the epiblast and the hypoblast (primitive endoderm), now forms bilaminar embryonic disc

Amniotic cavity forms between epiblast and overlying trophoblast

29

Development of the Chorionic Cavity

Days 10-11

Chorionic Cavity forms by the extraembryonic mesoderm splitting into two layers

30

Development of the yolk sac

Days 12-13

Primary yolk sac is behind hypoblast

Hypoblast cells have division and split primary yolk in half to form definitive yolk sac and the remnants of the primary yolk sac away from the uterine wall

Use primary yolk sac for nutrient transfer , the extraembryonic mesoderm forming the outer layer of the yolk sac is for hematopoiesis

At 4 weeks the yolk sac is replaced by the embryonic disc

31

Gastrulation

Formative process by which the 3 embryonic germ layers are formed from the epiblast

Ectoderm, mesoderm, and endoderm

Occurs at day 15-16

First sign is the presence of the primitive streak, defines all major body axes

32

Major Germ Layers

All derived from epiblast

Ectoderm: nervous system, epidermis, mammary glands

Mesoderm: connective tissue, bones, muscle, heart, kidneys, gonads

Endoderm:epithelial linings, liver, pancreas

33

Most common cause of spontaneous abortions

Chromosomal abnormalities