640.cardiac,diabetes,renal

• hyperglycemic hyperosmolar syndrome
• -clinical manifestation of T2DM

• -blood glucose > 600 mg/dL
• -serum osmolality >320 mOsm/kg
• -absence of ketoacidosis
• -infection
• -dehydration

• -pulyuria
• -polydipsia
• -polyphagia
• -weight loss

• -slow rehydration
• -treat underlying conditions

• central obesity
• insulin resistance
• dyslipidemia
• hypertension

• -MNT
• -physical activity
• -medications
• -urine & blood ketone monitoring
• -self-management

• -monitor glucose levels (FSBS)
• -maintain/achieve IBW (lower total kcals, total fat, sat. fat)
• -exercise regularly (ACSM, American College of Sports Medicine guidelines)
• -consistent timing of mixed high fiber meals
• -avoid concentrated sweets

• -monitor glucose levels
• -match insulin to intake
• -maintain weight
• -exercise
• -be prepared for hypoglycemia

• 1.alpha-glucosidase inhibitors (AGIs)
• 2.amylin analogs
• 3.biguanides
• 4.incretin mimetics
• 5.meglitinides
• 6.sulfonylurea agents
• 7.thiazolidinediones

• -help pancreas to make more insulin
• ex. 1st & 2nd generation sulfonylureas & meglitinide analogs

• -targets different organs to help insulin work better
• ex.biguanides, AGIs, thiazoldinedones

• ex. diabinese
• -oral hypoglycemic agents
• -targets pancreas to increase insulin secretion
• -SE=hyperinsulinemia, hypoglycemia, weight gain
• -avoid alcohol - reactions reported!
• + inexpensive , once a day

• ex. Glynase
• -oral hypoglycemic agents
• -targets pancreas to increase insulin secretion
• -SE=hyperinsulinemia, hypoglycemia, weight gain
• -avoid alcohol
• + inexpensive , once a day

• ex. Prandin
• -oral hypoglycemic agents
• -helps pancreas make more insulin in the presence of glucose
• -acts for only about 4 hours after taken (fast acting, short acting)
• -SE=hyperinsulinemia, hypoglycemia, athralgia (joint pain)
• -more doses, more expensive
• -avoid alcohol
• +less hypoglycemia at night

• -alpha-glucosidase inhibitors
• ex. Glyset
• -oral antihyperglycemic agent
• -inhibits enterocyte disaccharidases thereby delaying CH digestion & absorption
• SE=GI - cramps, flatulence, diarrhea
• -take w/ first bite of meals 3x day
• - less efficacy with frequency of dosing

• ex. Avandia
• -oral antihyperglycemic agent
• -reduces hepatic glucose production
• -stimulates insulin receptors thereby increasing insulin sensitivity in muscle & adipose cells
• -can use with renal insufficiency
• -dose 1x/d
• -least food & drug interactions
• SE: possible weight gain/edema, but none reported
• - very expensive
• -more effective with insulin deficiency

gestational diabetes mellitus

• -overweight
• -physically unfit
• > 25 years
• -family history
• -African American, Hispanic, Native American

• -HTN (preeclampsia)
• -polyhydramnios (excess amniotic fluid)
• -difficult birth
• -preterm delivery
• -increased rate of C section

• overproduction of insulin by fetus
• macrosomia (>4500 g)
• birth trauma
• neonatal respiratory distress
• neonatal hypoglycemia
• hypocalcemia
• hyperbilirubinemia
• polycethemia (increase in RBCs)

• done between 24-28 weeks
• 50 g oral glucose challenge test (GCT)
• plasma glucose > 140 mg/dL 1 hour after
• 100 g oral glucose tolerance test (OGTT)
• + if 2 or more result:
• fasting plasma glucose > 95 (prior to oral load)
• 1 hour plasma glucose >180
• 2 hour pm > 155
• 3 hr pg >140

glucose challenge test

oral glucose tolerance test

• to promote appropriate weight gain
• avoid maternal ketosis

• hypoglycemia
• nausea
• vomiting
• constipation
• heartburn

self monitoring of blood glucose

• (check glucose levels 1 hour after each meal with GDM)
• assess effectiveness of MNT
• guide adjustments to intake
• determine if insulin therapy is needed

• -amount & timing
• -avoid highs & lows
• -avoid nausea
• -CHO not well tolerated in a.m. - plan for < 45 g

• aka Jovanovic Diet
• reduce caloric intake to just above ketonuric threshold
• restrict CHO to <40% of total calories (>40% from fat & 20% from protein)
• breakfast small & low in CHO to counter effects of high cortisol levels in a.m.

• if 1 hour postprandial glucose level is >120 mg/dL more than twice in 2 weeks
• if FBS is >90 mg/dL

• NPH - intermediate-acting before breakfast & at bedtime
• Lispro (Humalog) at lunch and dinner

Don't forget to exercise! This may cure GDM!

diabetic ketoacidosis

build up of scar tissue surrounding adipose can affect/inhibit absorption (atrophy/hypertrophy)

hypoglycemia

hyperglycemia

intensive insulin therapy

multiple daily injections

• MD, RD and patient work together
• MD adjusts basal insulin to blood sugar (BS) pattern
• Patient must keep records of BS, insulin, & intake
• Bolus insulin bases on FSBS 4 or more times/day

continueous subcutaneous insulin infusion

• kcals to maintain optimal body weight
• CHO = 55-60% but don't increase if they consume less (as long as they have at least 130 g/d)
• protein = 10-20% (usually 15-20, but can be 10% if they have nephropathy)
• fat = 25-30% of total kcalories
• cholesterol <300 mg/d
• Na < 3000 mg/d
• eat carbs with alcohol & be careful
• Be careful about sugar alcohols.
• Sugarfree candy is not carb-free

• reduce risk of micro & macrovascular disease by addressing lipoprotein profile
• reduce risk associated with HTN
• address individual nutritional needs accounting for cultur & lifestyle
• enhance health

• What's a carb?
• Where is it in your diet?
• Eat at regular intervals.

• alcohol
• exercise
• being sick
• menstrual cycle
• eating & exercise pattern
• morning
• fiber
• sugar alcohol

1 unit/10-15 g CHO

• total available glucose
• or
• triacylglycerol

• will decrease blood glucose unless BG > 250-300 (there is insulin deficiency)
• exercise can speed the absorption of insulin in the active limb
• blood lipid control
• blood pressure control
• depression

• add 15 g CHO if exercising moderately for 1 hour
• add 30-45 g CHO if 100-180 exercising for 1-2 hours

if >5 g, subtract half from total carbs

• HbA1c fraction
• reflects average glucose level over last 4 mo.
• 6-7% are normal values for someone with DM
• 8-9% acceptable
• 11-13% poor

• eyes
• kidneys
• nerves
• macrovascular

• retinopathy
• cataract
• glaucoma
• ...blindness

• nephropathy
• microalbuminuria
• gross albuminuria
• ...kidney failure

• neuropathy
• peripheral
• autonomic
• ...amputation

• coexistence of HTN & dyslipidemia
• underlying metabolic syndrome

before

• before meals
• antecibum

twice a day

with

approximately

chief complaint

complains of

chest X-ray

discontinue

emergency department

family medical history

follow up

head, eyes, ears, nose, throat

history of present illness

hour of sleep

history of

intake and output

no know allergies

• after eating
• post cibum

past history

past orally

prior to admission

• each
• every

respirations

without

symptoms

social history

temperature

three times a day

temperature, pulse, respirations

within normal limits

• renin released from kidney
• angiotensinogen converted to angiotensin I
• angiotensin I converted to angiotensin II
• -decrease of Na+ & H2O excretion
• -vasoconstriction
• -increase in aldosterone...increased blood volume

• ejection fraction
• end of diastole
• amount of blood ejected

140/90

• dizziness
• faintness
• headaches
• vision changes

• 90% of cases are idiopathic - primary or essential
• secondary - result of another chronic condition
• lifestyle - smoking, exercise, diet, obesity
• sodium intake
• inflammatory response

• adult treatment panel III
• guidelines used for cholesterol management

weight reduction, PA, nutrition therapy, pharmacological

• "loop" diuretics
• thiazides
• carbonic anhydrase inhibitors
• potassium sparing diuretics

• used for HTN
• ex. furosemide
• effective in patients with impaired kidney function
• inhibit sodium & chloride reabsorption in the ascending loope of henle
• potassium depleting

• diuretic treatment for HTN
• ex. hydrochlorothiazide, hydrodiuril
• inhibits sodium-chloride-potassium reabsorption in distal convoluted tubule leading to a retention of water in the urine
• decreases calcium lost
• potassium depleting except for hydrochlorothiazide

• diuretic treatment for hypertension
• ex. acetazolamide
• prevents exchange of hydrogen, sodium, and water by blocking sodium anhydrase
• inhibit the transport of bicarbonate out of the proximal convoluted tubule, which leads to less sodium reabsorption and therefore greater sodium, bicarbonate and water loss in the urine
• the weakest of the diuretics and seldom used in CVD
• main use is in the treatment of glaucoma
• potassium depleting

Amiloride (Midamor®) Amiloride and Hydrochlorothiazide (Moduretic®) Spironolactone (Aldactone®) Spironolactone and Hydrochlorothiazide (Aldactazide®) Triamterene (Dyrenium®)Triamterene and Hydrochlorothiazide (Dyazide®, Maxzide®)

• Release of growth hormone, cortisol, glucagon and epinephrine in the early morning causes an increase in blood glucose
• NOT the same as the Samogyi Effect,thought to be a reaction to earlier hypoglycemia (if it occurs at all)
• Can distinguish between the Dawn Phenomenon and the Samogyi Effect by checking 2 am sugar.

• Peak onset age 4-6 and 10-14 (bimodal)
• Weight loss
• Polydipsia and polyuria
• Polyphagia, fatigue and weight loss
• Often with ketoacidosis

• Fasting blood glucose >126 mg/dL
• Random blood glucose >200mg/dL
• 2 hour oral glucose tolerance test > 200 mg/dL
• HbA1c 6.5% or higher

impaired glucose tolerance

inhibits secretion of both insulin & glucagon

• Presence of serum islet-specific pancreatic autoantibodies
• Note: About 10% are idiopathic (antibodies negative), and some patients with Type 2 diabetes DO have antibodies

• Continue usual dose of insulin when sick
• Monitor blood sugar and urine ketones closely to prevent DKA
• Ingest 45-50 g CHO every 3-4 hours to prevent DKA
• Drink more fluids than normal
• Follow insulin adjustments as per MD's recommendations

Consume CHO when consuming alcohol

• Alcohol -> AcetylCoA(not glucose)
• Alcohol metabolism requires glucose
• Insulin and alchohol both lower blood glucose

• ace inhibitors - angiotensin converting enzyme, restricts body's production of the chemical that makes vessels constrict ex. lotensin, vasotec, accupril, altase, prinivil, zestril
• beta blockers - reduces HR / lower force with heart s pressure,
• sympathetic nerve inhibitors - prevent certain nerves from constricting blood vessels
• vasodilators - relax muscles in walls of arteries allowing blood vessels to widen
• calcium antagonists - (calcium channel blockers) reduce HR & relax blood vessels, ex. norvasc, vacor, plendil

used for CHF to increase strength of contraction

percutaneous transluminal coronar angioplasty

coronary artery bypass graft

• C reactive protein
• indicator of inflammation
• good predictor of IHD (ischemic heart disease)

fainting

return to clinic

2 g

• 4:0-12:0 - SCFA & MCFA
• 14:0 - myristic acid (milk fat)
• 16:0 - palmitic acid (animal fats / palm oil)
• 18:0 - stearic acid (beef tallow, shortening, coconut oil)

• 16:1 - palmitoleic acid (macadamia nuts)
• 18:1 - oleic acid (oo, canola oil, avocado, almonds, dark chocolate, most common source in American diet - fr. fries, pizza...)

-does not raise LDL

• 18:2 - linoleic acid - oils in seeds & nuts
• shoudn't exceed 10% or more of total calories
• 11-17 g/day
• polyunsaturated

• a 18:3 - a linonlenic acid (veggies, flax seed)
• 20:5 - eicosapentaeic acid / EPA (fish oil, salmon, sardines)
• lower cholesterol & TAGs, inhibit platelet aggregation & reduce risk of sudden death
• 1.1-1.6 g/d meet needs
• oxidize easily

• LA, linoleic acid, can be desaturated & elongated
• conversion of 18:2 to 20:4 omega 6

substrate for eicosanoids, some being proinflammatory (ex. prostaglandin E2 & thromboxane A2) and some being antiinflammatory (ex. prostacyclin)

• soluble
• ex. oat bran, dried beans
• lowers blood lipids