DIABETES

Question 1

diabetes is mainly caused by _____

Answer 1

hyperglycemia

Question 2

3 causes of hyperglycemia (insulin related)

Answer 2

1. impairment of insulin secretion
2. defective insulin action (producing insulin but its not working)
3. both

Question 3

common complications related to diabetes

Answer 3

• loss of sensation
• poor blood circulation
• poor wound healing
• heart disease
• leads to blindess
• kidney diseases

Question 4

epidemiology of diabetes

Answer 4

5-10% of canadians have type 1 - most onset <25 years
90-95% of canadians have type 2 - most onset > 24
Prevalence increases with age
Higher prevalence in males than females

Question 5

where are alpha and beta cells secreted from and what do they secrete

Answer 5

from the pancreas

• beta = insulin
• alpha = glucagon

Question 6

what is c-peptide

Answer 6

• Insulin secreted as a pre hormone that needs to be activated (connected by c-peptide)
• When insulin is activated - c-peptide is released (1:1 ratio)
• Useful to differentiate between the two types of diabetes

Question 7

how to differentiate T1DM and T2DM with c-peptide

Answer 7

• Type 1: does not produce insulin - low/no c-peptide
• Type 2: usually have high secretion of insulin - high c-peptide levels

Question 8

what is normal blood glucose levels

Answer 8

3.9-6.1 mmol/L

Question 9

explain what happens to blood glucose levels and organs that are relevant after eating a meal

Answer 9

• After a meal, increase levels of blood glucose which will trigger insulin secretion from the pancreas and this will trigger the uptake of glucose in our tissues and muscles
• Return blood glucose back to normal
• Increase of insulin will also increase glycogenesis (synthesis of glycogen) and decreasing gluconeogenesis (synthesis of glucose from precursors that are not carbs)

Question 10

which organs have glycogen and which one contributes to the maintenance of blood glucose levels

Answer 10

liver and muscles
- liver contributes to maintenance of blood glucose levels

Question 10

explain what happens to blood glucose levels and organs that are relevant when fasting

Answer 10

• If normal blood glucose levels are dropping (fasting or overnight), trigger secretion from alpha pancreatic cells to secrete glucagon
• Inhibit glycogenesis (synthesis of glycogen) and increase gluconeogenesis (making carbs from non carb precursors)
• Sends glucose to our blood

Question 11

describe the molecular process of insulin

Answer 11

insulin binds to insulin receptor - triggers a chain of reactions
- finishes with translocation of GLUT4 to the membrane which lets glucose enter
- insulin itself DOES NOT directly uptake glucose into cells

Question 11

describe T1DM

Answer 11

• autoimmune response that destroys beta cells and then this impacts the ability to synthesize insulin
• autoimmune destruction of beta cells - caused by genetic + environmental + immune regulation
• patients will not produce insulin
• 90-95% of beta cells are destructed - some insulin produced but not nearly enough

Question 12

describe T2DM

Answer 12

• combination of abnormal insulin secretion + insulin resistance
• individuals with T2DM produce insulin but their tissues are insulin resistant –> increases the need for insulin –> pancreas increases production –> over time, the pancreas is not able to maintain such high production levels

Question 13

primary factors that “cause” T2DM

Answer 13

• obesity - central adiposity increases the degree of insulin resistance
• poor nutrition
• physical inactivity (activity seems to enhance whole-body insulin sensitivity

Question 14

what is A1C

Answer 14

glycated hemoglobin - 3 month average
- expect high levels of A1C for those who have poor glycemic control

Question 15

what is fasting glucose

Answer 15

blood sugar levels after fasting (8+ hours

Question 16

what is random glucose

Answer 16

blood sugar levels anytime, no fasting

Question 17

what is the A1C level to diagnose adults

Answer 17

A1C > or equal to 6.5

Question 18

how are hyperglycemia and hydration/hunger related

Answer 18

• threshold until the kidneys cannot filter glucose anymore so you start losing glucose in the urine (glucoseurea)
• glucose is an osmotic active - draws water - leads to an increase of water in urine and this will increase urinary output (polyuria)
• decrease uptake of glucose by cels will lead to intracellular glucose deficiency that leads to polyphagia (hunger)

Question 19

what are the three criteria of hypoglycemia and what mmol/L is the range

Answer 19

1. development of neurogenic or neuroglycopenic symptoms
2. low blood glucose (<4 mmol/L)
3. symptoms respond to the administration of carbohydrate

Question 20

what are some causes of hypoglycemia

Answer 20

• more physical activity than usual
• not eating on time
• eating less than planned
• taking too much medication
• alcohol (inhibits gluconeogenesis and inhibits glycogenolysis)

Question 21

what is the treatment for mild-to-moderate hypoglycemia

Answer 21

1. recognize symptoms
2. confirm if possible (blood glucose < 4mmol/L)
3. treat with “fast acting sugar” (15g)
4. retest in 15 min to ensure BG >4mmol/L and retreat if needed
5. eat snack/meal at usual time of day

Question 22

what is the treatment for severe hypoglycemia (conscious person)

Answer 22

1. Treat with oral fast-acting sugar
2. Test after 15 min, if BG < 4mmol/L give them another 15g
3. Once the hypoglycemia has been reversed, usual meal or snack that is due at that time

Question 23

what is the treatment for severe hypoglycemia (unconscious person)

Answer 23

1. With no intravenous access: 1mg glucagon given subcutaneously or intramuscularly 2. Call 911 3. With intravenous access: 10-25g of glucose should be given intravenously over 1-3 min

Question 24

what is diabetes ketoacidosis and which DM is it more common in?

Answer 24

type 1 - When increase lypolysis (breakdown of fat) happens with no insulin present, this produces ketones that may lead to diabetes ketoacidosis - Type 1 - no insulin present - increase lipolysis which will lead to formation of ketone bodies - Formation of ketone bodies will decrease blood pH leading to acidosis - With the presence of minimal insulin - this does not produce ketones - therefore diabetes ketoacidosis is not as prevalent in type 2 diabetes unless you are in the very late stages

Question 25

what is hyperglycemic hyperosmolar syndrome and which DM is it more common in?

Answer 25

In type 2, hyperglycemia will lead to increase urinary output that will lead to electrolyte imbalance, dehydration, osmotic diuresis and this will lead to this syndrome

Question 26

what is the treatment for hyperglycemic emergencies

Answer 26

- insulin, IV fluids, electrolyte replacement, sodium bicarbonate

Question 27

what is the dawn phenomenon and what is the treatment

Answer 27

- Abnormal early morning increase in blood sugar (between 4-8am) - More common in type I DM than type 2 - Mechanism: increase in hepatic glucose production, which may be secondary to the midnight surge of growth hormone treatment: - adjust insulin dosages - adjustment of bedtime snack

Question 28

what is somogyi effect and what is the treatment

Answer 28

- Early morning hyperglycemia occurs due to a rebound effect from late-night hypoglycemia - Mechanism: counterregulatory hormones stimulate gluconeogenesis treatment: - adjust insulin levels - adjust bedtime snack

Question 29

how do you differentiate between dawn phenomenon and somogyi effect?

Answer 29

- wake up between 2-4am and monitor BGL - if blood sugar is low, somogyi effect - if blood sugar is normal, dawn

Question 30

what is gastroparesis and how is it related with diabetes

Answer 30

- delayed gastric emptying in the absence of mechanical obstruction - affects 30-50% of patients with diabetes - increases risk of hypoglycemia

Question 31

what is the biggest thing we are trying to optimize with diabetes management

Answer 31

optimize glycemic control

Question 32

what are the A1C targets for most adults

Answer 32

7% or less

Question 33

what are the A1C goals for individuals with type 2 diabetes (and no risk of hypoglycemia)

Answer 33

<6.5%

Question 34

what are the A1C targets for those who have recurrent severe hypoglycemia, limited life expectancy, or frail elderly?

Answer 34

7.1-8.5%

Question 35

what is the range preprandial (fasting) for most individuals?

Answer 35

4-7mmol/L

Question 36

what is the range postprandial for most individuals?

Answer 36

5-10mmol/L

Question 37

when and what medication to give individual with type 1 diabetes?

Answer 37

insulin right away

Question 38

what intervention when patient has A1C 1.5% above the target

Answer 38

start with lifestyle changes (nutrition therapy, weight management, and physical activity)

Question 39

what intervention when patient has A1C over 1.5% of target?

Answer 39

start metformin - if patient is diagnosed with symptomatic hyperglycemic and diabetes ketoacidosis - treat with metformin and insulin

Question 40

what are some nutritional recommendations for individuals with diabetes?

Answer 40

- meals do not have to be drastically different than what we usually have - combining dietary modification + increased physical activity - T2DM: regular timing and spacing of meals - CHO - low glycemic index foods - 30-50g of dietary fiber (10-20g soluble fiber) - snacking: include protein to slow digestion

Question 41

nutritional recommendations for individuals with diabetes consuming alcohol

Answer 41

- risk of hypoglycemia because gluconeogenesis is inhibited - always consume with food - avoid sweet alcohol, try sugar free

Question 42

how many g of carbs should individuals with diabetes aim to have at each meal? snack?

Answer 42

meal: 30-60g snack: 15g

Question 43

after a meal, blood glucose levels should not rise more than ____ mmol/L

Answer 43

3.0

Question 44

how to calculate "carb counting"

Answer 44

- grams of CHO minus g of fiber