Metabolic syndrome

____ million Americans (7.8%) have diabetes ____ million adults over 20 y/o have pre diabetes

23.6, 79

Assessing the Metabolic Syndrome Diagnosed when at least ___ of the following criteria met: ! 1. Abdominal Obesity ! • Visceral fat ! • Increased waist circumference ! 2. High TG ! 3. Low HDL ! 4. Hypertension ! 5. Impaired fasting plasma glucose • International Diabetes Federation Definition: central/ abdominal/visceral o besity (waist circumference or BMI > 30) plus at least 2 of the following criteria met ! 1. High triglycerides (>150) ! 2. Low HDL ! 3. High blood pressure ! 4. High fasting plasma glucose, FPG

3

Health Effects Diabetes (x___ chance mortality) ! Cardiovascular disease ! Atherosclerosis and hypercoagulability ! Hypercholesterolemia ! Hypertension ! Peripheral arterial disease ! Coronary Artery Disease and Heart attack (x2 chance mortality) ! Stroke (x__ chance mortality) ! High uric acid retention and increased CRP levels

5, 2

Used as a part of tertiary prevention Regular and complete physical exams Regular glucose monitoring Blood test Skin prick testing at home Urinalysis Albuminuria: protein in urine (sign of kidney disease) Glycosuria: glucose in urine (sign of hyperglycemia) Ketoaciduria: ketoacids in urine (sign of dangerous hyperglycemia) Annual eye checkups Fundoscopic exams to check for hemorrhages and aneurysms

Assessing Complications and Sequelae of T2DM

Hypoglycemia Low blood sugar levels Mainly due to diabetes medication or insulin therapy (patient education required) Hyperglycemia Dermatologic Skin conditions: from mild to severe Ophthalmologic Diabetic retinopathy: leading cause of sudden and permanent blindness in the U.S. Neuropathy Damage to nerves results in paresthesia (tingling and numbness) starting in fingers and toes, and resulting in pain Diabetic nerve pain is the body's way of warning the patient that their blood glucose is not being controlled ! ! ! ! Angiopathy Damage to blood vessels results in tissue damage and ischemia, starting in fingers and toes Neuropathy and angiopathy will result in tissue ischemia: ulcers, gangrene and autoamputation Diabetes is the leading cause of amputations in the U.S. Podiatric Foot infections, ulcers and gangrene Nephropathy Diabetic kidney disease is the leading cause of renal failure in the U.S. together with hypertension Gastroparesis Delayed emptying of the stomach contents due to impaired function of the stomach muscles (likely due to neuropathy and angiopathy) Coma: Non-ketotic hyperosmolar coma : mostly T2DM Ketoacidotic coma : mostly in T1DM H ypoglycemic coma Cardiovascular disease Dangerous as diabetes can mask signs of heart attack (patients do not feel pain due to neuropathy) Stroke Recurrent and severe infection s Mental health

Complications and Sequelae

linical diagnosis Signs and symptoms : increased urination, increased thirst, fatigue Fasting plasma glucose (FPG) Blood test taken after 8-12 hours of fasting Casual plasma glucose Blood test taken at any time Oral glucose tolerance test (OGTT) Patient is asked to fast for 8-12 hours Patient is then given a loading does of glucose (80-100 mg of glucose). Wait 2-3 hours Measure blood glucose to see body's response to glucose load ! ! Glycated hemoglobin (HbA1c) Blood test to measure amount of glycated hemoglobin: the percentage of hemoglobin in the red blood cells that has glucose bound to it Most reliable predictor of long term control of blood sugar as it estimates glucose control over a 3 month period of time (red blood cells survive up to 120 days in the body) Used as diagnostic tool, as well as method of monitoring glucose control and diabetic therapy

Diabetes Mellitus

A reversible form of diabetes mellitus that develops during pregnancy and resolves spontaneously after delivery , mainly due to hormonal changes during pregnancy Occurs in 2-10% of all pregnancies Onset: pregnancy Non-modifiable risk factors Race and ethnicity: African American, Hispanic/Latino American, American Indian Family history: diabetes ! Modifiable risk factors Obesity

Gestational Diabetes Mellitus (GDM)

When an individual is between meals, the blood sugar level drops. ______________ hormone is secreted by pancreatic alpha cells to help raise blood sugar levels back to normal ! Insulin and glucagon have opposite/ anatgonistic actions

Glucagon

What is Prediabetes? Also known as ____________________ (impaired oral glucose tolerance test, OGTT) Impaired Fasting Glucose (impaired fasting plasma glucose, FPG) Reversible condition where the body's control of glucose is becoming abnormal ,while still maintaining glucose levels below a diabetic level Variable symptomatology

Impaired Glucose Tolerance

Assessing the ____________ Additional diagnostic measurements ! Abnormal body fat distribution ! General body fat (DEXA) ! Central fat (CT/MRI) ! Adipose tissue biomarkers: leptin, adiponectin ! Liver fat (MRS) ! Atherogenic dyslipidemia ! ApoB lipoprotein increase ! Small LDL particle increase ! Elevated uric acid (protein metabolism byproduct) Additional diagnostic measurements ! OGTT (oral glucose tolerance test) ! Vascular dysregulation ! Endothelial dysfunction ! Microalbuminuria !

Metabolic Syndrome

For healthy patients with no known risk factors that would put them at higher risk than the general population ! Preventing and treating the metabolic syndrome reduces the chances of T2DM by more than 58% ! LIFESTYLE: main preventive intervention ! DASH diet ! ACSM physical activity recommendations ! Avoid smoking ! Prevent insulin resistance ! Maintain healthy weight ! Maintain healthy physical activity ! ADA meal plan guidelines recommended

Primary Prevention

Patient is healthy, with no risk factors Increase education and awareness T2DM risk test: http://www.diabetes.org/are-you-at- risk/diabetes-risk-test/ Set goals to maintain healthy status : Keep time limit for reaching goals short Keep it realistic Be specific about your goals Set 1-3 goals at a time and write them down Maintain health through diet and physical activity

Primary Prevention of T2DM

Patient appears healthy, but has risk factors, or has already been diagnosed with pre diabetes Lower risk of T2DM by 58% with: 7% body weight loss: 15 lbs of 200 lbs Moderate exercise 30 min/ day for 5 days/week Weight loss Get out of overweight or obese range: not necessary to reach ideal body weight ! ! ! Healthy eating ADA meal plan Lean meats: chicken, turkey, lean cuts of beef or pork Low fat or skim dairy products Whole grain breads and cereals Abundant fruits and vegetables Regular assessment and screening Individuals at risk: overweight, obesity, metabolic syndrome, prediabetes

Secondary Prevention of T2DM

1. Individual eats and blood sugar becomes elevated ! 2. Insulin hormone is produced and released by pancreatic beta cells in response to elevated blood sugar levels ! 3. Insulin travels to body tissue cells and binds insulin receptors on cells ! 4. The insulin-insulin receptor binding allows glucose to enter body tissue cells (glucose uptake by cells) from the blood ! 5. Glucose uptake increases glucose in cell (used for energy) and reduces glucose left in blood, bringing blood sugar levels back to normal

Steps for normal glucose control

Formerly known as juvenile diabetes or insulin dependent diabetes mellitus (IDDM) Mechanism Insulin deficiency caused by irreversible destruction of pancreatic beta cells Severe insulin deficiency results in excess lipolysis, with consequent increase in ketoacid formation 5% of all diagnosed DM Onset Mostly children and young adults Idiopathic disorder: cause is unknown Non-modifiable risk factors Autoimmunity: past viral infection activated patient's immune system and is now attacking own cells HLA-DR3 and HLA-DR4 Modifiable risk factors Environmental

diabetes type 1

Formerly known as adult onset diabetes or non-insulin dependent diabetes mellitus (NIDDM) Irreversible disorder Cannot be cured! Can be managed through lifestyle modification and medical therapy Mechanism Insulin resistance: defective response of tissue receptors to insulin resulting in abnormal glucose uptake Eventually, irreversible pancreatic beta cell damage does occur leading to insulin deficiency 90-95% of all diagnosed DM Onset Variable age , increasing incidence in children

diabetes type 2

> 1 in 4 people around the world ! > 1 in 3 Americans are diagnosed with the metabolic syndrome ! Metabolic syndrome ahead of HIV/AIDS in morbidity and mortality

metabolic syndrome

! For patients that appear healthy, but have risk factors or already have the metabolic syndrome ! LIFESTYLE modification ! DASH and ADA diets ! ACSM physical activity recommendations ! Stop smoking ! Correct insulin resistance ! Reduce weight ! Increase physical activity ! ADA meal plan guidelines recommended Correct atherogenic dyslipidemia ! Reduce triglycerides ! Increase HDL ! Reduce small, dense LDL ! Pharmacological: fibrates (increase HDL), statins (reduce LDL and ApoB lipoproteins) ! Correct prehypertension and hypertension ! Primarily lifestyle ! ACE inhibitors, ARBs ! Reduce coagulation: daily aspirin

secondary prevention

Non-modifiable risk factors Age (>30 y/o) Race, ethnicity: African American, Hispanic/Latino American, American Indian, Asian American, Pacific Islanders Family history: diabetes (hereditary) Personal history: gestational diabetes ! Modifiable risk factors Personal history: prediabetes, metabolic syndrome Overweight, obesity Low physical activity or sedentariness Hypertension, dyslipidemia Smoking, alcohol

type 2