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What are the differences between Type I and Type II DM?
- Type I: 5-10% of cases, early onset (<30yo), insulin deficiency
- Sx: weight loss, Polydypsia, Polyphagia, Polyuria
- Tx: Insulin
- others: hypoglycemic, diabetic ketoacidosis
- Type II: 90% of cases, late onset (>40yo), insulin resistant, impaired glucose tolerance
- Sx: usually asymtomatic (except sweating)
- Tx: TLC, PO meds, eventually insulin
- others: metabolic syndrome, undiagnosed until Sx present
What are the Sx's, prevalence, and risk factors of Gestational Diabetes (GDM)?
- No previous history of DM before pregnancy
- Sx: hyperglycimic and Sxs of DM during pregnancy
- Prevalence: ~4% of pregnant women in the US annually
- Risk factors:
- Maternal Age >25yo
- Hx of GDM
- Hx of polyhydraminos (excess amniotic fluid)
- Prior infant born >9lbs (macrosomia) or with congenital anomolies
- Family Hx of DM
- Obesity (BMI >30)
- Previous unexplained miscarriage/stillbirth
- ethnicity: Hispanic American, Native American, Asian American, African American, Pacific Islander
What are the categories of Increased Risk for Diabetes? (ie: pre-diabetic)
Elevated blood glucose levels, but not high enough for DM diagnosis
- Impaired Fasting Glucose (IFG): 100-125 mg/dL
- Impaired Glucose Tolerance (IGT): 2hr post prandial 140-200 mg/dL
- A1C range: 5.7%-6.4%
Lifestyle changes MUST be made
How do you do an Impaired Fasting Glucose (IFG) test and an Impaired Glucose Tolerance (IGT) test?
- 1o test for dx
- fasting >8hrs
- help identify pt's with increased risk for DM
- DM diagnosed with 2 tests of elevated glucose at PCP's office
- 2o test- conformational tool
- fasting >8hrs, then consume 75g glucose, sample 2hrs later
What are the glucose levels for a normal, pre-diabetic, and diabetic pt?
Self test machines test whole blood, auto convert to PBG
*whole blood level x 1.12 = Plasma Blood Glucose
- Normal pt:
- Fasting Plasma Glucose (FPG): <100 mg/dL
- 2hr post prandial: <140 mg/dL
- Random glucose: <140 mg/dL
- A1C: <5.7%
- FPG: 100-125 mg/dL
- 2hr post prandial: 140-199 mg/dL
- A1C: 5.7-6.4%
- FPG: >= 126 mg/dL
- 2hr post prandial: >= 200 mg/dL
- A1C: >= 6.5%
What are the Sx of hyperglycemia?
- 3 P's: Polydypsia (drinking), Polyphagia (eating), Polyuria
- Blurred vision
- Dry Skin
- Slow healing wounds
What are the Sx and Tx of hypoglycemia?
- Sx: FPG <70 mg/dL
- Irritability and Anxiety
- Impaired Vision
- Tx: caused by skipped meals, excessive insulin/diabetic meds, dangerous condition
- 2-3 glucose tabs
- 1/2 cup juice
- 1/2 cup soda
- 5-6 pieces of candy
- 1-2 tsp sugar/honey
What are the Microvascular, Neuropathic, and Macrovascular complications of DM?
Microvascular: nephropathy (end stage renal disease), retinopathy (blindness)
Neuropathy: autonomic neuropathy (gastroparesis and ED), peripheral neuropathy (amputations)
Macrovascular: coronary heart disease (MI), peripheral vascular disease (amputations), cerebrovascular disease (stroke)
What are the therapeutic goal levels for diabetic patients?
- FPG: 70-130 mg/dL
- Post prandial glucose: <180 mg/dL
- A1C: <7%
- BP: <130/80 mmHg
- LDL <100 mg/dL
- Trigs: <150 mg/dL
- HDL: Male >40, female >50 mg/dL
What are the non-modifiable risk factors for DM?
- age >45 yo
- Family Hx (parent or sibling)
- Ethnic Background: Alaskan Native, African American, Hispanic/Latino, Asian American/Pacific Islander
- History of Gestational DM
What are the modifiable risk factors for DM?
- Weight BMI >25 kg/m2
- HTN: >140/90 mmHg
- dyslipidemia: HDL < 35 mg/dL, TG >250 mg/dL
- Inactivity (exercise less than 3x week)
- Cardiovascular disease
What are TLC points for a pt at risk for diabetes?
- eat regularly scheduled meals and snacks
- monitor portion sizes
- limit foods high in fat, salt, sugar
- exercise >30min of aerobic most days of the week
- smoking cessation
When do you start screening for dyslipidemia?
- adults >= 20yo should be tested every 5 years
- pt's with higher risk for CHD should be screened more frequently (ie: smoker, diabetic, obese, fam hx of CHD, >=65yo)
What are the lipid levels?
- LDL: <100 mg/dL optimal
- 100-129 near optimal
- 130-159 borderline high
- 160-189 high
- >= 190 very high
- TC: <200 mg/dL optimal
- 200-239 borderline high
- >=240 high
- HDL: >60 mg/dL high
- <40 low
- TG: <150 mg/dL
- 150-199 borderline high
- 200-499 high
- >=500 very high-> @risk for pancreatitis
What are the causes of dyslipidemia?
- sedentary lifestyle
- 2ndary causes: drugs, diseases
How do you calculate LDL?
LDL = TC - HDL - (TG/5)
if TG >400 mg/dL, cannot use calculation for LDL
What are risk equivalents of CHD?
- Established CHD
- abdominal aortic aneurysm
- peripheral arterial disease
- carotid artery stenosis
What are the risk factors for CHD?
- HTN ( bp >=140/90 mmHg or on HTN meds)
- low HDL (<40 mg/dL)
- family hx of premature CHD
- -----> male: <55 yo
- -----> female: <65 yo
- age: men >=45; women >=55 yo
What are the risk categories (treating risk equiv/risk factors) of CHD?
- High Risk (CHD or CHD risk equivalent):
- LDL Goal: <100, <70 optional
- Initiate TLC: >=100
- consider drug therapy: >=100
- Moderately High (2+ risk factors, 10-20% 10yr risk):
- LDL Goal: <130, <100 optional
- Initiate TLC: >=130
- consider drug therapy: >=130, 100-129 optional
- Moderate (2+ risk factors, <10% 10yr risk):
- LDL Goal: <130
- Initiate TLC: >=130
- consider drug therapy: >=160
- Lower (0-1 risk factors):
- LDL Goal: <160
- Initiate TLC: >=160
- consider drug therapy: >=190, 160-189 optional
What are the TLC points for CHD?
- TLC Diet
- increased fiber
- weight management
- smoking cessation
What are the symptoms of metabolic syndrome (3 or more, increases risk of CVD)?
- Waist circumference: >40" (men) >35" (women)
- TG >=150
- HDL <50
- BP >=130/85
- fasting glucose >=100
Lipid levels for children?
*although not recommended, screening high risk is performed*
- TC: <170 acceptable
- 170-199 borderline
- 200 high
- LDL: <110 acceptable
- 110-129 borderline
- 130 high
What are some health repercussions of obesity?
- TypeII Diabetes
- gallbladder disease
- respiratory problems (sleep apnea)
- risk of cancers (endometrium, breast, prostate)
- gynecological problems (abnormal menses, infertility)
What does weight loss benefit?
- reduces risk factors for:
- gallbladder disease
- decreases BP, LDL, TG, blood glucose, A1C
- increases HDL
What are the BMI ranges?
- underweight: <18.5 kg/m2
- Normal: 18.5-24.9
- overweight: 25-29.9
- obesity class 1: 30-34.9
- obesity class 2: 35-39.9
- extremely obese: >=40
What are the body fat ranges for males?
- essential fat: 2-4%
- athletes: 6-13%
- fitness: 14-17%
- acceptable: 18-25%
- at risk: +25%
What are the body fat ranges for females?
- essential fat: 10-12%
- athletes: 14-20%
- fitness: 21-24%
- acceptable: 25-31%
- at risk: +32%
How do you measure body fat?
- hydrodensity weighing
- dual energy x-ray absorptiometry (dexa)
- magnetic resonance imaging (MRI)
- bioelectric impedance device (BIA device)
Best time to measure body fat using a BIA device?
After waking up, 2hrs or more after a meal, or before going to bed
avoid: drinking large amount of water/meal (1-2hrs), after drinking alcohol, after vigorous exercise, after bath/sauna
What are the weight loss goals in overweight pt's?
- *3500 cal = 1 lbs*
- BMI 27-35:
- decrease caloric intake 300-500/day
- weight decrease of 0.5-1 lb/week
- BMI >35:
- decrease caloric intake 500-1000/day
- weight decrease of 1-2 lb/week
What are some dietary recommendations for overweight pt's?
- keep total fat intake 20-35% of calories
- ~35% calories from proteins
- ~45-65% calories from carbohydrates
- choose lean meats, fats from mono/poly unsaturated FA, whole grains, fibers
- 300mg/day of cholesterol, 200mg/day if pt has CVD or DM II
- Avoid trans fats
When should you opt for weight loss surgery?
(Gastric band, sleeve gastroectomy)
BMI >= 40 or >=30 with serious co-morbid conditions
still must maintain TLC (diet, physical activity, behavioral changes)
How do most people die from osteoperosis?
fractures, 10-40% increased risk of mortality after a fracture
What is osteoperosis?
weakening of the bones (loss of bone mass and structural loss)
sign of osteoperosis: kyphosis (stooped stature), bone pain, fractures
Risk factors for osteoperosis?
- Age: no specific age, but bone density decreases past 35 yo
- Gender: females, but males can still get the disease
- Family history
- Slender/low weight (BMI <19)
- post-menopausal/estrogen deficient
- history of fractures
What are some modifiable risk factors?
- low diet of vit D or calcium
- excessive caffeine consumption
- >2 alcoholic drinks per day
- inactive lifestyle
- lack of weight bearing exercise
- lack of sun exposure (vit D)
Other ways to get osteoporosis? (2o osteoporosis)
disease related: paget's disease, chronic kidney disease, liver disease, etc
medication related: coritosteroids, anticonvulsants, aluminum containing antacids (prevents Ca absorption), furosemide, etc
Who should be tested for osteoporosis?
- all women >=65yo
- younger, post menopausal women w/ risk factors
- women during menopausal transition w/ clinical risk factors
- men >70
- men <70 with clinical risk factors
- anybody w/ disease/medication associated with osteoporosis
- women discontinuing estrogen
How do you test for osteoporosis?
Look at bone mineral density (BMD) either through a DEXA or heel bone densitometer
What is Z score and what are the values for osteoporosis?
- Z score: comparing patients to other people of the same age, sex, and ethnicity (young compared to young)
- for men <50 and women prior to menopause
- > -2 normal
- < -2 below normal range
What is T score and what are the values for osteoporosis?
T score: comparing patients to 30 year olds of the same sex and ethnicity as the patient (old pt's compared to young people) for men >50 and postmenopausal women
- > -1 normal bone density
- -1 to -2.5 low bone mass (osteopenia)
- < -2.5 presence of osteoporosis
What are the recommended calcium and vit D levels?
- 19-49 yo:
- Ca2+: 1000 mg/day
- vit D: 400-800 IU/day
- >=50 yo:
- Ca2+: 1200 mg/day
- vit D: 800-1000 IU/day
What are different types of Ca2+ supplements?
- Calcium Carbonate:
- greatest amount of elemental Ca2+ (40%)
- take with food, do not exceed 500-600 mg/dose
- Calcium Citrate:
- 21% elemental Ca2+
- best absorbed form, less constipating
- more expensive
- doesn't require food
What are some lifestyle recommendations for osteoporosis?
- start weight bearing exercise (walking, dancing, stair-climbing, jumping, etc)
- fall risk reduction
- smoking cessation
- adequate nutrition
What are some medication classes for osteoporosis?
- intermittent parathyroid hormone
- selective estrogen receptor modulators (SERMs)
- estrogen replacement therapy
What 2 factors are needed to make a HTN diagnosis?
> 140 SBP OR > 90 DBP
diagnosed after 3 consecutive high readings over 3 different visits @ PCP's office
Which organs are affected in Target Organ Damage in HTN?
- Heart: MI or heart failure
- Brain: stroke, paralysis, or death
- Kidneys: kidney damage requiring dialysis
- Eyes: impared vision and blindness
What is the difference between hypertensive urgency and hypertensive emergency?
Urgency: DBP >120mmHg, no signs of target organ damage; not life threatening
Emergency: DBP >120mmHg, signs/sx of target organ damage, life threatening
What are the uncontrollable risk factors of HTN?
- Age: >60
- Gender: males and postmenopausal women
- Ethnicity: african americans and hispanics
- Family Hx of CVD (women <65, men <55)
What are the controllable risk factors of HTN?
- Obesity (BMI >=30)
- lack of physical activity
- excess sodium intake
- excess alcohol intake
- Metabolic syndrome
What is the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure? (JNC VII)
guidelines for HTN for reducing risk, classification of BP measurements, diets, and BP technique
What are the blood pressure levels?
written in SBP and DBP
Normal: <120 AND <80 (recheck in 2 yrs)
PreHTN: 120-139 OR 80-89 (recheck in 1 yr)
HTN stage I: 140-159 OR 90-99 (confirm w/in 2mo)
HTN stage II: >=160 OR >=100 (evaluate immediately)
What are some various drugs that can help lower BP?
Loop diuretics, thiazide diuretics, beta blockers, ACE inhibitors, angiotensin receptor blockers, Ca2+ channel blockers, alpha blockers, alpha-2 agonists
What are Korotkoff sounds?
the "lub" "dub" sounds heard through the stethoscope
1st sound is systolic, last sound is diastolic
What is the normal HR?
calculated by counting for 15 seconds and multiplying by 4; if irregular, count for 60seconds
What is the normal respiratory rate?
10-14 breaths per minute
What are some reasons for error in taking BP?
- Arm below heart (high reading)
- Arm above heart (low reading)
- Legs dangling (high reading)
- unsupported back (high reading)
inappropriate wrapping also gives inaccurate readings
What events can alter BP?
Physical activity, emotional state, pain, noise, temperature, caffeine, smoking, "white coat"
What are some TLC points for HTN?
- weight reduction
- dash diet
- sodium restriction
- moderation of alcohol
- caffeine and smoking
- good sleeping habits
- stress reduction
What are DASH diet, sodium reductions, alcohol moderation counseling points?
DASH diet (reduces SBP 8-14mmHg): Diet rich in nutrients, fiber, and electrolytes
Sodium restriction (reduces SBP 2-8): reduce to 2.4gm of sodium a day (1/4 tsp of salt is 1.5gm)
Alcohol reduction (reduces SBP 2-4): men 2drinks/day, women 1drink/day