Diabetes

Diabetes is a chronic disorder characterized by either an absolute or relative absence of insulin. Insulin is secreted primarily by the beta cells located in the anterior head, body, and tail of the pancreas. Type 1 and type 2 are the primary categories of diabetes, but other types do exist (gestational diabetes, impaired glucose tolerance, and diabetes related to other conditions). Early detection and treatment of pre-diabetes and diabetes are essential to prevent the serious complications associated with this disease. The focus of this discussion is type 1 and type 2 diabetes.

Type 1 diabetes represents an absolute lack of insulin caused by a decrease in beta cell mass. It affects about 10% of the diabetic population and usually occurs before the age of 30. It is typically detected by an abrupt onset of symptoms of hyperglycemia. The affected patient is often prone to ketoacidosis, which occurs when accumulation of ketones (byproducts of fat metabolism) leads to acidosis, causing diuresis, dehydration, loss of electrolytes, and eventually renal failure, coma, and death.

Type 2 diabetes is related to insulin resistance and a defect in insulin secretion. Sustained hyperglycemia is diagnostic of type 2 diabetes and occurs over a long period of time. Symptoms usually occur after the age of 30 but can occur at any age. Obesity and a sedentary lifestyle are primary factors of occurrence. Type 2 diabetes usually is not prone to ketoacidosis because some insulin is still produced. Treatment is centered on diet, exercise, weight loss, oral medications, and/or insulin as indicated, with careful monitoring of blood glucose levels by the patient and physician.

Patient self-monitoring involves glucose testing four times per day for type 1 diabetes and as indicated for glucose control in type 2 diabetes. Glycosylated hemoglobin (HbA1c) levels are used to determine long-term (about 3 months) glucose control. HbA1c should be maintained at < 7%. Monitoring is aimed at preventing chronic complications, including eye disorders, kidney disease, peripheral neuropathies, and cardiovascular disease.

Treatment protocols involve a combination of diet, exercise, and medications to maintain blood glucose levels as close to normal as possible. Nutrition is no longer based on American Diabetes Association diets but is individualized to patient need and associated with exercise and lifestyle. When diet and exercise do not provide adequate control of blood glucose, medications may be added to the treatment plan. Medications can be oral agents, insulin, or a combination of both for type 2 diabetes. Type 1 diabetes will always require insulin.

For further information on diabetes, review Chapter 22 in the Core Curriculum for Medical-Surgical Nursing (3rd edition), then answer the following questions.

1. The nurse is teaching a patient with a new diagnosis of diabetes mellitus about disease management. Among the "survival skills" that the nurse should identify is:

a. Weight loss.

b. Eliminating sugar from the diet.

c. Self-monitoring of blood glucose.

d. Limited physical activity.

2. Which of the following is characteristic of type 2 diabetes?

a. Absolute lack of circulating insulin

b. Decreased mobilization of glucose by the liver

c. Resistance to insulin by cell receptors

d. Sustained hyperglycemia in both fasting and postprandial blood glucose levels

3. Which of the following is used to measure chronic glucose control?

a. Microalbuminuria

b. HbA1c

c. Fasting plasma glucose

d. Serum ketones

4. To decrease the risk for developing diabetic neuropathy, the nurse will encourage the patient to:

a. Drink 8 to 10 glasses of water daily.

b. Eliminate alcohol.

c. Decrease consumption of red meat.

d. Stop smoking.

1. c--Self-monitoring of blood glucose is the foundation of successful disease management for the patient with diabetes mellitus.

2. d--Insulin resistance is a cause of sustained hyperglycemia in fasting and postprandial blood glucose levels.

3. b--HbA1c provides a picture of glucose control over a period of approximately 3 months.

4. d--Risk factors for the development of diabetic neuropathies include hypertension, smoking, and chronic hyperglycemia.

Diabetes

What the clinical trials found: A phase III study suggested that exenatide LAR may offer improved blood glucose control over the currently marketed formulation, Byetta.

Adis R&D Insights Rating & Comment: 70. Exenatide LAR is expected to replace the existing, immediate-release formulation of exenatide (Byetta), also developed by Amylin and Lilly. Byetta requires twice daily subcutaneous administration, so a once-weekly formulation would be a more convenient option. An NDA for exenatide LAR is expected to be submitted in 2009, and if approved, the agent is predicted to supersede Byetta as an adjunctive therapy in patients with type-2 diabetes mellitus.

What the analysts had to say:

* In the GLP-1 class, interest will remain high, given the need for better post-prandial control, beta cell preservation and weight control. But competitors will have to demonstrate clear and meaningful benefits for acceptance by physicians, payers and patients.

-David Jacobson, SVP, GfK Market Measures

* We believe exenatide LAR has now demonstrated the most convincing clinical profile of all GLP-ls to date. Efficacy appears to be best in class. We forecast $2 billion in peak sales.

-ING Wholesale Banking's Tun Race

Liraglutide Novo Nordisk

Indication: Type-2 diabetes mellitus (Ph.III)

What the clinical trials found: Phase III clinical trials found oncedaily liraglutide + glimepiride gave superior glycemic control compared with a rosiglitazone-glimepiride combination and with glimepiride monotherapy. The triple combination of glimepiride, metformin and liraglutide was also superior to glimepiride, metformin and insulin glargine. Notably, three trials demonstrated that liraglutide promoted weight loss and had a good safety profile with no serious adverse events reported.

Adis R&D Insights Rating & Comment: 72. Liraglutide may face direct competition from exenatide LAR. A direct, head-to-head study of liraglutide vs. exenatide, initiated this year, may show which is the more effective agent in maintaining glycemic control and hence provide a better therapeutic option for patients with type 2 diabetes.

What the analysts had to say:

* Long-term we have reduced our 2013 sales for liraglutide form $1.3 billion to $1.1 billion reflecting the potential for exenatide LAR to dominate the market. If liraglutide reaches the market, Novo Nordisk is likely to have significant competition to its only major new compound.

-ING Wholesale Banking's Tun Race

Saxagliptin Bristol-Myers Squibb/AstraZeneca/Otsuka

Indication: Type-2 diabetes mellitus (Ph.III)

What the clinical trials found: Preliminary six-month data from a phase III study in patients with type 2 diabetes, which was poorly controlled with metformin, showed that add-on, once daily saxagliptin was safe and well tolerated. The compound significantly improved glycemic control compared with metformin alone. Saxagliptin is currently in phase III multi-center clinical trials worldwide. BMS and AZ plan to file an NDA with the FDA in the first-half of 2008. Studies are assessing the compounds as monotherapy, as an adjunct to diet and exercise, and as an add-on therapy in combination with metformin, sulfonylurea or thaizolizinediones.

Adis R&D Insights Rating & Comment: 74. It remains to be seen whether saxagliptin will have a successful run in the diabetes market. Its future depends on the results from pending clinical trials and its ability to outperform other gliptins already on the market.

What the analysts had to say:

* Saxagliptin is emerging as a serious competitor to Merck's Januvia.

-Rodman & Renshaw 's Michael King

* Saxagliptin could add $750 million to peak US sales by 2017.

-Lehman Brothers PharmaPipelines estimates,

cited by Adis R&D Insight

OTHER KEY PRODUCTS IN THE DIABETES PIPELINE

AJD 101 Ajinomoto/Sankyo

Diabetes (Ph.I)

Insulin inhalation Alkermes/Eli Lilly

Diabetes (Ph.III)

DiaPep277 Andromeda

Type 1 diabetes (Ph.III), Latent autoimmune diabetes in adults (Ph.II)

AZD AstraZeneca

Diabetes (Ph.I)

AZD 2207 AstraZeneca

Diabetes (Ph.I)

BAY 737977 Bayer

Diabetes (Ph.I)

Insulin inhalation Baxter

Diabetes (Ph.I)

Insulin inhalation Coremed

Diabetes (Ph.I)

Insulin oral Coremed

Diabetes (Ph.I)

Diabetes mellitus vaccine Diamyd Medical

Latent autoimmune diabetes in adults (Ph. I), Type 1 diabetes (Ph.II)

LABI Flamel/BristoWAyers Squibb

Diabetes (Ph.II)

Metformin XL Flamel

Diabetes (Ph.II)

KRP 101 Kyorin

Diabetes (Ph.II)

MK 0533 Merck

Diabetes (Ph.II)

MK 0893 Merck

Diabetes (Ph.I)

MK 0941 Merck

Diabetes (Ph.I)

MK 3887 Merck

Diabetes (Ph.I)

MP 513 Mitsubishi/Mitsubishi Tanabe

Diabetes (Ph.II)

Aliskiren Novartis Hypertension in diabetes (Ph.III),

Diabetic nephropathies (Ph.II)

Insulin inhalation QDose

Diabetes (Ph.I)

Diabetes - The 6 Points That Will Explain it to You

Diabetes mellitus is a chronic disease in which patients present with absolute or relative insulin deficiency. It affects about 6% of western populations and is a major contributing factor for heart attacks, strokes, kidney failure and peripheral vascular disease. Diabetes mellitus is also the leading cause of new blindness without a cure.

1. Types of Diabetes
There are four forms of the disease, classified as: types 1 and 2, gestational and other specific types.

a. Type 1 Diabetes
In people with type 1 diabetes the pancreas is not producing insulin, so blood glucose levels are higher than normal. People with this form of diabetes require daily insulin therapy to survive. This form is further split into idiopathic diabetes and immune mediated diabetes.

Type 1 accounts for around 10% to 15% of all people with diabetes. It is one of the most serious and common chronic diseases of childhood, with about half of the people with this form of diabetes developing the disease before age 18. It is also known as insulin dependent diabetes mellitus (IDDM) or juvenile-onset diabetes.

b. Type 2 Diabetes
Type 2 diabetes is marked by reduced levels of insulin (insulin deficiency) and/or the inability of the body to use insulin properly (insulin resistance). This form of the disease is most common among people aged 40 years and over and accounts for 85% to 90% of all people with diabetes. Most people with type 2 diabetes are obese.

c. Gestational Diabetes
Gestational diabetes occurs during pregnancy in about 3% to 8% of females not previously diagnosed with diabetes. It is a temporary form of diabetes and usually disappears after the baby is born. However, it is a marker of much greater risk of developing Type 2 diabetes later in life. Screening tests for gestational diabetes are usually performed around the 24th-28th week of pregnancy.

d. Other Specific Diabetes Types
This includes people who have diabetes as a result of a genetic defect, or exposure to certain drugs or chemicals.

2. Causes of Diabetes Mellitus
Diabetes is caused by resistance to, or deficient production of, the hormone insulin, which helps glucose move from the blood into the cells.

In type 1 immune mediated diabetes, pancreatic beta cell destruction results in failure to release insulin and ineffective transport of glucose. There is no known cause for idiopathic diabetes.

In type 2 diabetes, the beta cells release insulin but, receptors are insulin resistant and glucose transport is variable and inefficient. Some people may have conditions that can cause diabetes, such as Cushing's syndrome, pancreatitis or liver disease.

Risk factors for type 2 diabetes include;

a. Obesity
b. History of Gestational diabetes
c. Lack of physical activity
d. Hypertension
e. Age 45+
f. Ethnic groupings other than anglo-saxon
g. Low HDL cholesterol levels
h. Impaired glucose tolerance
i. Family history

3. Signs and Symptoms of Diabetes
Symptoms of diabetes include; dehydration, unexplained weight loss, excessive thirst, frequent need to urinate, fatigue, lethargy, severe irritation and itching, excessive hunger, blurred vision, skin and urinary infections and vaginitis.

4. Diagnosis
Diabetes or impaired glucose tolerance may be detected on routine blood tests as part of a general health check up or investigation for other symptoms or diseases. Diabetes tests check blood glucose levels. Someone with a random non fasting blood glucose level greater than 200mg/dl accompanied by other symptoms, or someone with a fasting blood glucose level greater than 126mg/dl can be diagnosed with diabetes.

Because symptoms can be mild, diabetes is often detected when a person suffers a problem that is caused by diabetes, such as a heart attack, stroke, neuropathy, poor wound healing or a foot ulcer, certain eye problems, certain fungal infections, or delivering a baby with macrosomia or hypoglycemia.

5. Diabetes Treatment
Effective treatment endeavors to normalize blood glucose and reduce complications using insulin replacement, diet and exercise. For those with very mild diabetes, diet plus weight loss plus exercise may be enough to keep blood glucose within reasonable levels.
Dietary changes should focus on the ideas of weight loss and blood sugar regulation by keeping the blood sugar levels relatively stable throughout the day, avoiding big peaks or troughs.

The principal treatment of type 1 diabetes, even from its earliest stages, is replacement of insulin combined with careful monitoring of blood glucose levels using blood testing monitors.

Type 2 diabetes may require oral anti-diabetic drugs to stimulate the body's insulin production and increase insulin sensitivity. Various forms of natural supplements for diabetes treatment have also been postulated as effective.

People with unstable diabetes, or those requiring many injections a day, may benefit from an insulin pump which is worn on the body and delivers a continuous infusion of insulin via a needle implanted into the body.

Gestational diabetes is fully treatable but requires careful medical supervision throughout the pregnancy. Even though it may be transient, untreated gestational diabetes can damage the health of the fetus or the mother.

Treatment for all forms of diabetes need not significantly impair normal activities, if sufficient patient training, awareness, appropriate care, discipline in testing and dosing of insulin is taken

6. Complications
Diabetes mellitus is the most common cause of adult kidney failure worldwide in the developed world. If undetected or poorly controlled, diabetes can lead to blindness, kidney failure, lower limb amputation, heart attack, stroke and impotence.

Diabetes - A Good Diet Helps

Patients who are diagnosed with diabetes often ask if a good diet can help the disease in check. Most doctors agree - patients can keep diabetes in check with a good diet, one that's is low in sugars and carbohydrates. Such a diet may not necessarily help patients totally get rid of the disease, but it helps them avoid complications that are associated with diabetes.

Diabetics have problems breaking down and converting foods like starches and sugars into compounds that are needed by body cells. Instead they remain in the blood and increases sugar levels in the bloodstream. Too much sugar, or glucose, in the blood is an abnormality called glycemia. There are two types of diabetes, namely Type 1 and Type 2. Diabetics of either type suffer from very high blood sugar conditions. Problems in breaking down sugar also take their toll on other vital organs of the body, and often cause dysfunctions of the heart, eyesight, liver, kidneys and blood circulation.

When doctors treat diabetics, they usually apply medication, or insulin, depending on what stage their disease maybe at. The purpose of medication or insulin is to help body systems process blood sugars and break them down, allowing patients to expel excess sugar. But medication and insulin can only do so much; they cannot substitute for a good, healthy diet. Taking insulin or medication does not give patients license to eat as much sugar and carbohydrates as they can. Keeping diabetes in check requires patients not only to take insulin or medication per doctor's prescription; adhering to healthy diabetic diet is equally important. It is necessary therefore for diabetics to familiarize themselves with foods they must avoid or which foods they may eat sparingly.

This makes the Glycemic Index very useful. Established and adopted in 1981, the Glycemic Index identifies and rates carbohydrates in terms of how they adversely affect diabetics. Foods that top the list, like white bread, are hard to digest and must be avoided. Carbohydrates with low scores, on the other hand, like brown rice, may be eaten sparingly. Since it is almost impossible to do away with carbohydrates completely, it is important for diabetics to familiarize themselves with the Glycemic Index and adopt a diet on the basis of what the Index suggests.

The Glycemic Index also identifies and rates carbohydrates in the middle of the pack. People may find it surprising, for example, that chocolate bars rate in the middle group of the Glycemic Index list. But by no means this would suggest that diabetics may freely consume chocolate everytime they have opportunities to do so. The Glycemic Index tells people what foods need to be avoided at all cost and which foods can be taken in with moderation.

A good diet is therefore important to keep diabetes in check. A good diet cannot cure diabetes, but it can help diabetics live a healthier and longer life. Diabetics need to familiarize themselves with the Glycemic Index so that they can be guided on what foods to take and thereby help control their affliction.

Diabetes - Good Diet

Diabetes has become an alarming disease. It has reached epidemic proportions in the United States. It is time for the general public to be conscious about it. For people with diabetes, extra care in picking their diet will not only let them control the disease, it can also help them do away with insulin. Doctors often prescribe pills or tablets for most diabetics in an effort to stabilize their condition before resorting to any use of insulin. Choosing a diet specially programmed for people with diabetes can help them prolong the treatment of their ailment with medication and thereby postpone the use of insulin.
People who suffer from diabetes have problems breaking down and assimilating carbohydrates into their system. Carbohydrates are a fairly big group or cluster of foods that people need for a balanced diet. Sugar, which many people think diabetics must stay away from, is only one example or component of carbohydrates. Aside from white sugar, other elements of carbohydrates can be found in pasta, white bread, some vegetables, potatoes, fruits, and any food with high content of white flour.
Carbohydrates constitute a complex assemblage of foods. Different groups give rise to different conditions in the blood stream. Although people with diabetes have problems breaking down carbohydrates in general, the most difficult process happens with carbohydrates that rate high in the Glycemic Index. Foods with the highest Glycemic Index rating also pose the greatest harm for diabetics.
A diet for people with diabetes allows them to limit their intake of harmful carbohydrates as indicated in the Glycemic Index. Those who have been diagnosed with Type 2 diabetes, and given medication as well as diet suggestions by their doctors, would do very well to heed the doctors' advice. Studies show that people with diabetes tend to be more in denial and non-compliant compared to other categories of patients. This should not be the case. By electing to follow rigorously a diet for people with diabetes and taking the prescribed medication, diabetics can still live to the fullest.
A diet for people with diabetes is low in carbohydrates and high in protein. Sugars and white flour must be discarded. Rice, pasta and any food that is rich in carbohydrates, should be avoided. The low carbohydrate diet that was fashionable years ago can be helpful for diabetics. Such a diet had at varying degrees very limited content of carbohydrates. Also helpful are diabetic cookbooks which diabetics can use to prepare a diet that effectively responds to their needs.
The bad news is many people continue to be found having diabetes. The good news is there is now a growing body of information about cookbooks and diets for people with diabetes that is available in the market or through the internet. Diabetes puts a heavy strain on the human body. Having a healthy diet can reduce the ill-effects of the disease on the body and allow diabetics to live a fruitful and longer lives.
It is important for diabetics to get themselves familiar with the Glycemic Index, rigorously follow a diet prescribed for people with diabetes, get their blood sugar levels regularly monitored and take their medication per doctor's prescription. This is the only way they can keep their disease in check and prevent many of its dreaded complications from arising.

Diabetes - What Pregnant Women Need to Know

Statistics coming from the American Diabetes Association indicate that more or less four percent of expectant mothers gets to experience gestational diabetes. Gestational diabetes occurs when pregnant women who never have had diabetes before experience high blood sugar levels during their pregnancy, particularly at the latter period. Estimates put around 135,000 cases of pregnant women having gestational diabetes in the US every year.

Women who experience gestational diabetes are not likely to develop Type 2 diabetes. Gestational diabetes is occasioned by the inability of pregnant women to put into their system insulin which their bodies produce naturally. The pregnancy-related hormones they produce make them insulin resistant. It is under this condition that expectant mothers get to develop high levels of blood sugar, which is also known as hyperglycemia.

It is normal for women with gestational diabetes to be treated even while they are pregnant. Birth defects linked to gestational diabetes, or to diabetes contracted prior to pregnancy, are not usual. Thus there may no need for much concern for babies going through this condition. The problem, however, can arise when gestational diabetes is allowed to go on untreated. The mother has excess blood sugar, which means the unborn child is receiving more than her or his share of fat and energy. This condition can lead to macrosomia, or fat baby.

Regardless of how most people may think that being fat is indicative of the baby being healthy, a child who is too fat has problems when the time for his birth comes. He might be too big to fit through his mother's birth canal. Such a condition will almost always require delivery by cesarean section. Moreover, overweight babies often experience breathing problems and may eventually, if they stay obese, develop Type 2 diabetes themselves.

It is good, however, that treatment for gestational diabetes is readily available. Doctors normally prescribe doses of insulin for the mother to restore her blood sugar to normal levels. Women who want pregnancy can prevent having gestational diabetes by preparing for it physically. The physical regimen includes regular exercise, weight loss, and taking a healthy diet. Women who are planning for pregnancy should also find the Glycemic Index useful. The Glycemic Index helps people identify which foods to avoid to prevent diabetes or for diabetics to help them contain the disease.

Pregnant women need, and should follow, doctor's advice with respect to exercise and diet, particularly with regards to carbohydrate intake. Even before they get pregnant, women would always do well to consult their doctors on matters concerning their weight and on ways of preventing diabetes. Professional advice is important for women to avoid complications during their pregnancy.

A pregnant woman who gets a diagnosis for gestational diabetes, as well as her child, has little risks of developing Type 2 diabetes. Gestational diabetes can be treated easily and is not alarming. Pregnant women can access plenty of medical care for their condition. What they need to do is follow what their doctors say.

Diabetes - A Metabolic Disease

Diabetes is a metabolic disease that affects the way our bodies use digested food for growth and energy. The food that we eat is broken down into a form of sugar called glucose, which is the main source of energy for the human body. This disease does not allow the body to create enough or properly process insulin, a hormone produced by the pancreas allowing glucose to enter all the cells of the body and be used as energy. For those that are diabetic, sugar builds up in the blood instead of moving into the cells. Some of the surplus sugar is carried through the urine, out of the body, wasting the energy, and resulting in the body losing its main fuel source.

Type 1, Type 2, and Gestational diabetes are three main forms of diabetes mellitus, which is the medical term for this sickness.

Type 1 diabetes is categorized as an autoimmune disease, in this case, one that attacks and devastates the beta-cells in the pancreas that produce insulin. These types of diabetics are dependent upon insulin. This form of the syndrome is commonly known as "Juvenile" diabetes, but is not the most common form, only attesting for about 10 - 15% of those suffering from the illness. Type 1 is more frequent among children. Some common symptoms of type 1 diabetes mellitus are excessive thirst and urination, distorted vision, sudden weight loss, and severe exhaustion. The symptoms of type 1 usually develop over a short period of time.

Type 2 diabetes, the most common form, is often related to obesity, old-age, a sedentary lifestyle, genetic history of the disease, ethnicity, and a history of gestational diabetes. Those with type 2 usually have a pancreas that produces enough insulin, but the body, for an unidentified reason, does not use it properly. This improper use of insulin is commonly referred to as insulin resistance. Throughout time the pancreas will begin to fail in producing insulin and sugar will build up in the body, making this main fuel source unattainable. Being the most common form of the debility, type 2 accounts for 90 - 95% of the diabetic population, and is on the increase. Though this ailment is mostly widespread among obese adults it is also being diagnosed in children and adolescents. Some of the most common symptoms of type 2 diabetes mellitus are severe exhaustion, excessive urination, distorted vision, and enhanced hunger. Compared to type 1, these symptoms develop at a more gradual pace.

Gestational diabetes is a form of the epidemic that can be acquired by women who are pregnant. This form of the condition usually disappears after the pregnancy is over, but leaves the mother with a 20 - 50% possibility of developing type 2 diabetes. Women who have a family history of developing the disease are, of course, the more likely candidates for diabetes. The disorder is primarily caused by hormones that are generated by the placenta and amplify the mothers' resistance to insulin. The percentage of pregnant women in the U.S. who will develop gestational diabetes is 3 - 8%.

There are a plethora of ways to help people who have diabetes stay as healthy as possible. Eating a healthy diet, exercising, maintaining a healthy weight, controlling your blood sugar, and taking any required medicine are all ways to tame the disease and keep living your life.