Conclusion to Diabetes and introduction to CVD

92% of all diabetes can be prevented- by life style changes- exercise and diet
                                      and smoking caseation..
99% of all diabetes can be prevented by diet , exercise and weight loss if
                                      patients  are overweight.
 
        In reality most diabetics are on OHA- oral hypoglycemic agents, out of
them small % of people will require later  insulin injections. Problem with
some of the medication is that it may cause weight gain, which will eventually
worsen the symptoms of diabetes. In controlling their blood sugar then  they
become more overweight, and their receptor sites become less sensitive to
insulin.

    Goals for NIDDM
    Goals are similar as in IDDM, because high serum of BG will cause the
same complications as in IDDM. No matter what the cause for your high
blood glucose; may it  be pancreatic tumor, car accident that destroys your
pancreas, IDDM , NIDDM,  if you have high BG, you will get the same
complications from it.
	
     Goals are then:
1)Control blood glucose
2)Loose weight -even with 10 lb weight loss, BG will come back to normal.
   If for example there       is somebody who needs to loose 50 lb or less, if this
   person loses anywhere between 10-20 lb,       his BS will normalize..Of course
   if there is someone who is 100-120 lb overweight, this 10- 20 lb weight
   loss will help, but it won’t have such a dramatic effect as in previous case.
   Here we have to look for more significant weight loss than that.
3) Control serum lipid because #1 cause of death  in NIDDM is hear disease.
   Elevated levels of      insulin and glucose in the blood will cause high level of
  triglyceride and LDL in the blood from excess of glucose. 

  Oral hypoglycemic agents  OHA
  Generally we recognize 5 classes of OHA
  1)Sulfonylureas- sulfodrugs
     - have been on market for the longest time
     - most people are started on them initially
     - especially older people will be on Diabinase, Orinase, Tolinase- these are
       the oldest ones-first generation sulfo OHA.
     - Problems-The main problem with them is due to their mechanism of action which 
                is to stimulate  release of more insulin = they cause  hypoglycemia.
                They also cause weight gain because of the insulin production 
                stimulation. 
     - You will se that older people will not want to change this medication.
     - modern version of these drugs are Glucotrol XL  and Micronase - these are the 
       most common in people around 40-45 years . They are currently  the most commonly 
       prescribed OHA
     - Theory behind their mechanism of action  is that if you put more insulin into 
       blood and thus overwhelm the cells with  insulin, some of it will get into cell. 
       This is  true, but it has also side effects such as those  mentioned above.


2) Biguanides
    - this class of drugs keep liver from releasing too much glucose- it prevents break 
      down of glycogen in the liver
    - Metformin
   
3) Combination of first and second class drugs - sulfur and Biguanide
    - They together control BG by stimulating insulin production and preventing of
      releasing too much glucose into blood.

4)  Alpha -glucosidase inhibitors
    -It slows down digestion of CHO - only small amount of CHO is released at a time, 
     and so only small amount of insulin is then needed to cover it. But the problem 
     is that people don’t change their eating habits, and then this drugs may not work 
     properly.
    - Precose, Glyset are drugs in this group. They both  work exactly the same
    -you need to take it with CHO

5) Thiazolidinediones
     - Makes muscles more sensitive to insulin so that glucose can be used for making
       glycogen
     - Actos is the drug used. 

6) Meglitinides
    - Stimulate pancreas to release more insulin- can cause hypoglycemia
    - Repaglinide is the drug used here.
       					

     Diet
     Carbohydrates CHO
   Distribution of CHO needs to be evenly spread, unlike in IDDM when you have set 
amount in three meals a day. You want him to have little snacks between main meals.
Small amounts throughout the day . Smaller amount of CHO needs less insulin, and helps
to prevent the insensitiveness to insulin. 
     Teach people that sugar is very concentrated form of CHO, and you need to mix it
with other food substances. Sugar substitutes are made especially for this group of 
people . Meal containing only sugar gets digested very quickly. Protein and fat slows 
this process down. 
   Emphasize complex CHO. In this area we stress glycemix index- individual glycemix 
index however. Here you really have to watch for 2 foods - white potatoes and anything 
made from white flower such as pasta. Pasta is not a complex CHO, it is a starch- its 
polysaccharide, but it gets digested very quickly. It doesn’t mean you can’t have it.
You can, but smaller amounts, or in combination with whole grain pasta. Eat half white 
rice and half brown rice. 
      This population should have about 45% CHO in their diet


      Lipids
  -Will be about 30-35%
  - Fat should be mostly polyunsaturated or monounsaturated and less than 7% saturated.
  -They have to eat less red meat and more fish.
  -In cooking use more monounsaturated oils- Olive , Sesame, peanuts, flaxed, avocado
   and Canola oil. 
       There is a problem with polyunsaturated fats -vegetable oils- if they are not 
stored correctly. They have to be stored in refrigerator, otherwise they get quickly 
rancid. Monounsaturated oils should be stored in refrigerator as well. 
     Rancidity will produce free radicals . Polyunsaturated fats unlike saturated fats
are very reactive . They react with oxygen, which is very damaging to cell membrane. 
By damaging cell membrane, they are opening doors for any pathogens or carcinogen to 
enter the cell membrane and alter the cell structure. Polyunsaturated fats got for that 
reason bad reputation, and lots of people will rather use butter. In fact polyunsaturated
fats are great because they reduce cholesterol. Another thing you have to watch for is
that you can’t over- heat them, because they will again form free radicals. Generally,
however they are not bad, we just don’t treat them properly. 
       Monounsaturated fats have smaller opportunity to react with oxygen, because they
have only one double bound. Monounsaturated fatty acids don’t lower LDL, they just don’t 
raise serum cholesterol. We don’t have to worry about them. 
     Most important fats to talk about to the patients are trans fatty acids. They are 
produced by hydrogenation. This process is done by adding hydrogens to polyunsaturated 
fatty acids to make them solid in room temperature, and thus increase their shelf life.
Trans fatty acid is a chemical structure - transformation of regular cis formation to 
trans formation. Trans fatty acids will increase serum cholesterol like saturated fats, 
but they also reduce serum HDL. In this regard they are worst than saturated fats, 
because saturated fats only increase serum cholesterol and don’t have nothing to do with 
HDL. You can find trans fatty acids in all processed foods containing hydrogenated or 
partially hydrogenated oils.  Law has been passed to label products containing trans 
fatty acids, but as of now it hasn’t been instituted. 
    Margarine is a big issue in this discussion. Most margarines, except few, have
trans fatty acids. Benocol is one of them, but they are very expensive. In any other 
country, you probably will not find margarines with trans fatty acids. That may be one 
of the reasons why French don’t have such a high incidence of cardiovascular disease.
It is not just the drinking of vine, there are always other aspects of diet. 

      Gestational Diabetes
     This is another area of diabetes, that doesn’t get enough education. If you are 
pregnant, usually around 24th week you have to get glucose tolerance test according to 
the law in this country. And remember that 10 years later most of these patients  will 
develop NIDDM. 

     Diet 
     Diet  is the same as for NIDDM, except in the morning they should have less than
40 gm of CHO, because of the Dawn phenomenon- hyperglycemia - to wake you up. This is
more severe here, in gestational diabetes. It takes while for the sugar  to level off.
For that reason they should have only complex CHO - no juice for breakfast!!
     They are not put on OHA, because the medication  will go also to baby= they are 
mostly  diet controlled. 
     In the first pregnancy, it is easily controlled by diet. They have to monitor BG
with glucometer In second pregnancy, most women require insulin. It is usually one 
injection in the morning. The diet then becomes little bit different - CHO will be more 
related to the insulin. 
    If you are pregnant and have diabetes, you should really be either on insulin pump 
or intensive therapy, and test BS all the time. Hey  take regular and short acting 
insulin because with the change of hormones and having increase in blood flow, its very
hard to control blood sugar.

   Hypoglycemia
   For the most part it is caused by tumor. We are not talking here about hypoglycemia
in diabetes. 
 We distinguish:  
a) Reactive hypoglycemia- an hour after you eat
                        - It can be what’s known as syndrome X.
                        - could be also pre diabetic condition.

     Syndrom X
     Syndrom X is one of those things we don’t know what it is, so we wont give it a 
name. It is not diabetes or cardiovascular disease, but people who has it eventually
will get NIDDM and eventually CVD disease. It is generally when you have irregular 
abnormal glucose tolerance 116-125. High serum insulin level is present. In response to
CHO too much insulin is produced, and their BS drop. They have also high level of 
triglycerides. First they will test you on high level of BG and then you get tested on 
high level of circulating insulin. 
     
b) Fasting hypoglycemia is basically any time.
    - It is usually tumor of pancreas, pituitary gland  and  adrenal glands.
    - Treated by removing the tumor

    
                                 CVD

#1 type of cardiovascular disease is ATHEROSCLEROSIS .
     Ather/-gruel/o/ sclero/ - hardening/ sis- condition = condition of hardening caused 
                                                           by gruel.
This is what the Greeks thought - cereal in the blood vessels. 

     Do not mix this up with arteriosclerosis.- this is type of atherosclerosis
affecting  arteries. Atherosclerosis includes all blood vessels- venules, capillaries, arteries.

    We have to look at what leads to Atherosclerosis. One condition always leading to 
it is Hypertension-as long as your blood pressure is elevated, you will develop 
atherosclerosis. 

     We distinguish - Primary hypertension or Malignant hypertention.
                    - Secondary hypertention
  
Primary HTN - means you are born with it. We don’t really know what causes  it.
              There are hypothesis that it can be genetic or within certain populations,
              but we don’t know exactly what causes it. 
            - This primary HTN will lead to Secondary HTN. 

Secondary HTN -  is caused by something else. In this case by atherosclerosis. 
    
     Primary and secondary hypertentio are treated differently, but the diet will be
the same.

     When there is any type of irritation of cell membrane, such as by smoke, blood 
vessel is damaged . (The heat of the cigaret that is over 1000 degrees destroys your
cells itself, and we are not anywhere near all the carbon monoxide or tar that causes
damage to the cell membrane)  The smoke or any other pathogen  will make a little 
irritation in the blood vessels that  will cause the blood vessel to start bleeding.
Platelets will surround this place and it will form plague on it.

See the picture of plaque development here

 Any lipid that floats 
by will attach to this plaque. Whenever you have Platelets attached to tissue, calcium 
will also deposit. This combination is known as plaque. It hardens very quickly. So now
you have a vessel with plaque on it. When there is plaque on cell membrane, your immune
system will think there is something wrong, because it doesn’t belong there, and it will
send white blood cells. This will cause the plaque to become bigger and bigger. This will
cause this sclerosis of blood vessel - hardening. It will also cause the blood vessel 
to  become inflexible.
     Because the blood coming out of your heart is coming under tremendous pressure, if
your aorta contains plaque, and is not able to expand, this high  pressure will cause
another additional irritation. It is not then the hardening that is dangerous, but the 
inflexibility that result from that plaque.
     The blood cloth, the Platelets,and  the calcium is also known as a thrombus. This 
vessel has then thrombosis. If piece of this thrombus breaks off, it  becomes 
emboli- moving thrombus. This piece can get stacked. If it happens in a place where
there is another plaque on blood vessels it can block blood supply to the area behind 
this block and cause stenosis. Stenosis is a condition of narrowing. It will cause
ischemia- lack of oxygen in the blood. If embolism happens above heart, it is 
called TIA transient ischemic attack - stroke  If it happens below heart, you will
have chest pain or angina- chest pain caused by ischemia. You feel like choking, because 
you don’t have oxygen.
      One of the more severe condition is aneurism. It is condition when the 
blood vessel loses all of its flexibility and gets stretched out. This patient is 
usually at complete bed rest- no movement is allowed. 

     So CVD is caused by atherosclerosis. Atherosclerosis may be caused by HTN.
usually when you are diagnosed with HTN you are given two numbers:
-For man it is   120/80
 For woman it is 110/70

      If BP for woman is over 120/80, it is not normal. But very often doctors won’t do 
much because there were not much studies done on women. Women, however do have naturally 
lower BP, because they have less blood. 

      HTN is generally 130/85. Systolic is the higher number
                               Diastolic is the lower number - when heart is at rest
   
     Generally doctor will tell you, that the systolic number can be 100+ your age, but
it doesn’t necessarily  mean that it is healthy. The diastolic doesn’t change. Lots of 
doctors however don’t accept it any more especially Nephrologist due to the danger of
kidney disease.
      The most dangerous about HTN is that it is known as the silent killer. You have
no symptoms. If you have any symptoms, it is not from the high blood pressure but from
something else. It has done so much damage to your body that you have symptoms from 
heart disease,neurological problems, kidney problems. 
     There are many types of antihypertensives, truth is that if you follow the dash 
diet you can lower dosage of antihypertensives and prevent becoming impendent which 
the medication causes. The diet can reduce the amount of medication or eliminate it all
together
 
    Treatment
1) weight loss
2) increase exercise
3) fats - less than 7%
        - cholesterol < 200mg
        - monounsaturated fats higher in diet
        - low trans fatty acids
        - fiber 20-35 gm - soluble fiber it binds cholesterol and forces thus liver to 
          produce more bile for which cholesterol from blood serum is needed.= reduction 
          of LDL
4) complex CHO with low glycemix load
5) ten fruits and vegetables a day
6) Antioxidants vit A,C,E, Selenium
7) NA 2400 mg but according to the new guidelines which are more realistic it is around
   3000mg

  It is basically as in diabetes and in HTN. 
  We are not looking at total fat. Based on nursing study, there  were not found any
relationships between total fat and heart disease. There was, however found relationship
between Cholesterol and heart disease.
  
  For man the risk is high level of  LDL
  for women it is low level of HDL. 

     It was found that in the mediterian diet, that is high monounsaturated fat - about 
35%  total fat there was no increase in  incidence of CVD. If the diet was high in total 
fat and cholesterol there was increased risk. High fat diet also causes wt gain. 

     The reason why there was recommendation to reduce total fat ion your diet was that 
the medical community thought that it would be too difficult for the general public to
understand the concept of different types of fats and that’s why they recommended 
reduction of al fat in diet. While it was found they you can have 50% of monounsaturated 
fats in your diet and have normal level of serum cholesterol.  But this is difficult for 
people in this country where people eat lots of read meat . In mediterian people rely
lot on eating fish and poultry. 
      The American heart association newest guidelines have been changed and say that
if you don’t have to loose weight, you can have 35% of fat coming from your total energy
intake. American cancer society still recommends 20% or less of fat because of concern 
that high fat diet was associated with some cancers . They look at the fact that lean 
people don’t get certain types of cancer.
     So you have to decide which one of those fits better with your way of life and your
clients way of life. 

  Dash diet 
     It emphasizes eating fruits and vegetables because it was found that the two most 
important things for lowering blood pressure are adequate calcium and potassium in the 
diet. Precessed food has potassium taking out and salt added.
     The dash diet was another study that was ended prematurely, because it was found 
that it reduces blood pressure so dramatically that they could not have the controlled 
group on the regular diet and not being thought this diet. 

      Some believe that 80% of CVD could be prevented by lifestyle changes and 70% of 
colon cancer could be prevented - second most common type of cancer.
        
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