What Is Diabetes?

Body does not make or properly use insulin:

 no insulin production
 insufficient insulin production
 resistance to insulin’s effect

No insulin to move glucose from blood into cells:

 high blood glucose means:
i. fuel loss, cells starve
ii. short and long-term complications
Body function without
Diabetes?
 Type 1 Diabetes Mellitus
ONSET: relatively quick

SYMPTOMS: increased urination

tiredness
weight loss
increased thirst
hunger
blurred vision

CAUSE: uncertain,
likely both genetic and environmental factors
 Type 2 Diabetes Mellitus
ONSET: in children
variable timeframe

SYMPTOMS: tired, thirsty, hunger,

increased urination

some children show no

symptoms at diagnosis
Type 1 vs Type 2 Diabetes
Mellitus

No insulin(Key) means sugar can’t

enter the cell

No insulin (key) means that sugar Insulin (key) cannot unlock the cell door.
cannot enter the cell. Insulin resistance or inability of body to
use insulin.
2045”

Rural-urban division among people with

diabetes
 ed
(over 212
million people)”
Undiagnosed percentage and undiagnosed cases of diabetes
(20-79 years) per region
Criteria for the Diagnosis of Diabetes
Fasting plasma glucose (FPG)
≥126 mg/dL (7.0 mmol/L)
OR
2-h plasma glucose ≥200 mg/dL
(11.1 mmol/L) during an OGTT
OR
A1C ≥6.5%
OR
Classic diabetes symptoms + random
plasma glucose
≥200 mg/dL (11.1 mmol/L)
 Diabetes is Managed,
But it Does Not Go Away.

GOAL:
To maintain target
blood glucose
 Diabetes Management 24/7

Constant Juggling:
Insulin/medication

with:
BG
BG Exercise
&
Food intake
BG
 Diabetes Management

Proactive 
keep juggling the balls

Reactive

a response is indicated

corrective actions for
highs or low

emergency intervention
 Goals of Nutrition Therapy

1.
o Achieve and maintain body weight goals
o Attain individualized glycemic, blood pressure, and lipid
goals
o Delay or prevent complications of diabetes

2. Address nutrition needs, make behavioral changes & barriers

to change.
 Recommendations:
Nutrition
Energy Balance:
•Modest weight loss achievable by the combination of
lifestyle modification and the reduction of calorie intake benefits
overweight or obese adults with type 2 diabetes and also those
with prediabetes.
 Recommendations:
Nutrition
Eating patterns & macronutrient distribution
• should avoid sugar-sweetened beverages

• Should minimize the consumption of foods with added

sugar
• A variety of eating patterns are acceptable
 Recommendations:
Nutrition
Eating patterns & macronutrient distribution:

•Macronutrient distribution should be individualized.

•Carbohydrate intake from whole grains, vegetables, fruits,
legumes, and dairy products with an emphasis on foods
higher in fiber and lower in glycemic load.
 Recommendations:
Nutrition
Protein:

•ingested protein appears to increase insulin response.

•carbohydrate sources high in protein

should not be used to treat or prevent hypoglycemia.
 Recommendations:
Nutrition
Dietary Fat:
•diet rich in monounsaturated fats
may improve glucose metabolism and lower CVD risk .

•Eating foods containing long-chain ω-3 fatty acids is

recommended to prevent or treat CVD
 Recommendations:
Nutrition
Alcohol:
•Adults with diabetes should drink alcohol only in
moderation.

•Alcohol consumption may place people with diabetes at an

increased risk for hypoglycemia, especially if taking insulin or
insulin secretagogues.
 Recommendations:
Nutrition
Nonnutritive sweeteners:
•The use of nonnutritive sweeteners has the potential to
reduce overall calorie and carbohydrate intake if substituted
for caloric sweeteners.

•Nonnutritive sweeteners are generally safe to use within the

defined acceptable daily intake levels. B
 Recommendations:
Physical Activity
• Children with diabetes/prediabetes: at least 60 min/day physical
activity.

• Most adults with type 1 and type 2 diabetes: 150+ min/wk of

moderate-to-vigorous activity over at least 3 days/week.

• Adults with type 1 and type 2 diabetes should perform resistance

training in 2-3 sessions/week on nonconsecutive days.
 Recommendations:
Smoking Cessation
• Advise all patients not to use cigarettes, other tobacco
products or e-cigarettes.

• Include smoking cessation counseling and other forms of

treatment as a routine component of diabetes care.
 Recommendations:
Psychosocial Care
• Psychosocial care should be provided to all people with
diabetes, with the goals of optimizing health outcomes and
QOL .
• Psychosocial screening and follow-up include:

● Attitudes ● Quality-of-life (QOL)

● Expectations for ● Resources- financial,
medical mgmt. & social & emotional
outcomes ● Psychiatric history
● Affect/mood
Glycemic Targets
 Assessment of Glycemic
Control
• Two primary techniques available for glycemic control
1. Patient self-monitoring of blood glucose (SMBG)
2. A1C

• CGM or interstitial glucose assesses the effectiveness and

safety of treatment.
 Recommendations:
Glucose Monitoring
• SMBG results:
i. helpful to guide treatment decisions and
ii. use less frequent insulin injections or noninsulin therapies.

• ensure that patients:

i. SMBG technique and
ii. SMBG results.
 Recommendations:
Glucose Monitoring
• Most patients on multiple-dose insulin (MDI) or insulin pump
therapy should do SMBG
o Prior to meals and snacks
o At bedtime
o Prior to exercise
o When they suspect low blood glucose
o After treating low blood glucose until they are normoglycemic
o Prior to critical tasks such as driving
o Occasionally postprandially
 Recommendations: A1C
Testing
• Perform the A1C test at least 2x annually in patients
that meet treatment goals.

• Perform the A1C test quarterly in patients whose

therapy has changed or who are not meeting glycemic
goals.

• Use of point-of-care (POC) testing for A1C provides

the opportunity for more timely treatment changes.
 Mean Glucose Levels for
Specified A1C Levels
  Mean Glucose
Mean Plasma Glucose* Fasting Premeal Postmeal Bedtime
A1C% mg/dL mmol/L mg/dL mg/dL mg/dL mg/dL
6 126 7.0        
<6.5   122 118 144 136
6.5-6.99     142 139 164 153
7 154 8.6        
7.0-7.49     152 152 176 177
7.5-7.99     167 155 189 175
8 183 10.2        
8-8.5     178 179 206 222
9 212 11.8   professional.diabetes.org/eAG
     
10 240 13.4        
11 269 14.9        
12 298 16.5        
 Recommendations:
Glycemic Goals in Adults
• A reasonable A1C goal for many nonpregnant adults is <7%
(53 mmol/mol).

• Consider more stringent goals (e.g. <6.5%) for select patients

if achievable without significant hypos or other adverse
effects.

• Consider less stringent goals (e.g. <8%) for patients with a

history of severe hypoglycemia, limited life expectancy, or
other conditions that make <7% difficult to attain.
Obesity Management
for the
Treatment of Type 2
Diabetes
 Overweight/Obesity
Treatment
Body Mass Index Category (kg/m2)

Treatment 23.0* or 27.0-29.9 27.5* or 35.0-39.9 ≥40

25.0-26.9 30.0-34.9
Diet, ┼ ┼ ┼ ┼ ┼
physical activity &
behavioral therapy

Pharmacotherapy ┼ ┼ ┼ ┼

Metabolic surgery ┼ ┼ ┼
Recommendations: Diet, physical activity & behavioral

therapy
• Diet, physical activity & behavioral therapy designed to
achieve >5% weight loss.

• Interventions should be high-intensity (≥16 sessions in 6

months).
 Recommendations:
Pharmacotherapy
• Consider impact on weight when choosing glucose-lowering
meds for overweight or obese patients.

• Minimize the medications for comorbid conditions.

• adjuncts to diet, physical activity & behavioral counseling for

select patients.
 Metabolic Surgery
• Costly
• Some associated risks
• Outcomes vary
• Patients undergoing metabolic surgery
may be at higher risk for depression, substance abuse,
and other psychosocial issues
 Pharmacologic
Approaches
to
Glycemic Treatment
Recommendations: Pharmacologic Therapy For Type 1 Diabetes

• Most people with T1DM should be treated with multiple daily

injections(CSII).

• Individuals who have been successfully using CSII should

have continued access after they turn 65 years old.

CSII: continuous subcutaneous insulin infusion

Recommendations: Pharmacological Therapy For Type 1 Diabetes

• educating individuals on matching prandial insulin dose to

carbohydrate intake.

• Most individuals with T1DM should use insulin analogs to

reduce hypoglycemia risk.
 Pancreas and Islet Cell
Transplantation
• Can normalize glucose but require lifelong
immunosuppression.
• Reserve pancreas transplantation for T1D patients:
o Undergoing renal transplant
o Following renal transplant
o With recurrent ketoacidosis or severe hypos

• Islet cell transplant investigational

o Consider for patients requiring pancreatectomy who meet eligibility criteria.
 Recommendations: Pharmacologic Therapy For

T2DM
• Metformin, if not contraindicated and
if tolerated, is the preferred initial pharmacologic agent for
T2DM.

• Consider insulin therapy in patients with newly diagnosed

T2DM.
 New Recommendation: Pharmacologic Therapy

For T2DM
• Long-term use of metformin may be associated with
biochemical vitamin B12 deficiency, and periodic
measurement of vitamin B12 levels should be considered in
metformin-treated patients.
Recommendations: Pharmacological Therapy For T2DM

• If noninsulin monotherapy does not achieve or maintain the

A1C target, add a second oral agent.
• Use a patient-centered approach to guide choice of
pharmacologic agents.
• Don’t delay insulin initiation in patients not achieving
glycemic goals.
Cardiovascular Disease
and Risk Management
 Hypertension
• Common DM comorbidity
• Prevalence depends on diabetes type, age, BMI, ethnicity
• Major risk factor for ASCVD & microvascular complications
• In T1DM, HTN often results from underlying kidney disease.
• In T2DM, HTN coexists with other cardiometabolic risk
factors.
Recommendations: Hypertension/ Blood Pressure Control
Systolic Targets:
•People with diabetes and hypertension should be treated to a
systolic blood pressure goal of <140 mmHg.

• Lower systolic targets, such as <130 mmHg, may be

appropriate for certain individuals.
Recommendations: Hypertension/ Blood Pressure Control

Diastolic Targets:
•Patients with diabetes should be treated to a
diastolic blood pressure <90 mmHg.
• Lower diastolic targets, such as <80 mmHg, may be
appropriate for certain individuals at high risk for CVD if
they can be achieved without undue treatment burden.
Microvascular
Complications
and
Foot Care
 Recommendations:
Diabetic Kidney Disease
Screening
•At least once a year, assess urinary albumin
and estimated glomerular filtration rate
(eGFR):
o In patients with type 1 diabetes duration of ≥5 years
o In all patients with type 2 diabetes
o In all patients with comorbid hypertension
 Recommendations:
Diabetic Kidney Disease
Treatment:
• Optimize glucose control to reduce risk or slow progression
of diabetic kidney disease.
• Optimize blood pressure control to reduce risk or slow
progression of diabetic kidney disease.
 Recommendations:
Diabetic Kidney Disease
Treatment:
•For people with non-dialysis dependent diabetic kidney disease,
dietary protein intake should be ~0.8 g/kg body weight per day.
For patients on dialysis, higher levels of dietary protein intake
should be considered.
 Management of CKD in Diabetes
eGFR Recommended
All Yearly measurement of creatinine, urinary albumin excretion,
patients potassium

45-60 Referral to a nephrologist if possibility for nondiabetic kidney

disease exists
Consider dose adjustment of medications
Monitor eGFR every 6 months
Monitor electrolytes, bicarbonate, hemoglobin, calcium,
phosphorus, parathyroid hormone at least yearly

Assure vitamin D sufficiency

Consider bone density testing
Referral for dietary counselling
 Management of CKD in Diabetes (2)
eGFR Recommended

30-44 Monitor eGFR every 3 months

Monitor electrolytes, bicarbonate, calcium, phosphorus,

parathyroid hormone, hemoglobin, albumin
weight every 3–6 months

Consider need for dose adjustment of medications

<30 Referral to a nephrologist

 Recommendations:
Diabetic Retinopathy
Screening:
•Initial dilated and comprehensive eye
examination by an ophthalmologist or optometrist:
o Adults with type 1 diabetes, within 5 years of diabetes onset.
o Patients with type 2 diabetes at the time of diabetes diagnosis.
 Recommendations: Neuropathy
Treatment:
•Optimize glucose control to prevent or delay the
development of neuropathy in patients with T1DM & to slow
progression in patients with T2DM.
•Assess & treat patients to reduce pain related to
DPN and symptoms of autonomic neuropathy
and to improve quality of life.
 Recommendations: Foot
Care
• Perform a comprehensive foot evaluation annually.
• All patients with diabetes should have their feet inspected at
every visit.
• History should contain prior history of ulceration, amputation,
Charcot foot, angioplasty or vascular surgery, cigarette
smoking, retinopathy & renal disease.
• Exam should include total inspection.
 Glycemic Targets in
Pregnancy
For women with gestational diabetes or preexisting type 1 or type
2 diabetes in pregnancy, the following targets are recommended:
o Fasting ≤95 mg/dL (5.3 mmol/L)
and either
o One-hour postprandial ≤140 mg/dL (7.8 mmol/L) or
o Two-hour postprandial ≤120 mg/dL (6.7 mmol/L)
 Diabetes Care
in the Hospital
 Recommendations: Diabetes Care in the Hospital
• Perform an A1C for all patients with diabetes or hyperglycemia.

• Insulin therapy for should be initiated for treatment of persistent

hyperglycemia starting at a threshold ≥180 mg/dL.
 Recommendations: Diabetes Care in the Hospital

• Basal insulin or basal + bolus correction regimen is the preferred

treatment for noncritically ill patients with poor oral intake or
those who are taking nothing by mouth.

• A hypoglycemia management protocol should be adopted and

implemented by each hospital or hospital system..
.
control. burden.

Extend health
promotion to
reduce diabetes
and its
complications.