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DIABETES AND ITS MOST COMMON COMPLICATIONS By Manon Picard CONFLICT OF INTEREST I have no actual or potential conflict of interest in relation to the contents of this presentation. TODAY’S OBJECTIVES Review blood sugar and hypoglycemia List and provide a general overview of the main chronic complications Explain how smoking can worsen certain complications Reiterate the importance of properly controlling blood sugar to avoid complications Give a reminder about vaccination QUICK REMINDER BLOOD SUGAR: Controlling blood sugar is key in managing diabetes. Target values: 4–7 mmol/L FPG and 5–10 mmol/L 2hPG. According to epidemiological analyses, A1C values above 7.0% are associated with a higher risk of both microvascular and macrovascular complications, regardless of the underlying treatment.(1,2) COMPLICATIONS BY CATEGORY ACUTE METABOLIC COMPLICATIONS MACROVASCULAR COMPLICATIONS Diabetic ketoacidosis Hypoglycemia Heart disease Stroke Peripheral arterial disease MICROVASCULAR COMPLICATIONS Retinopathy Nephropathy Neuropathy HYPOGLYCEMIA 1. 2. 3. Is characterized by the following: When blood sugar drops below 4 mmol/L. Symptoms responding to the administration of carbohydrate. Depending on whether hypoglycemia comes on quickly or slowly, the signs will not be the same. A person may sometimes not show any visible symptoms. HYPOGLYCEMIA The severity of hypoglycemia is defined by clinical manifestations (mild, moderate, severe). Can lead to: - Confusion - Coma - Convulsions - Death HYPOGLYCEMIA Treat hypoglycemia by recognizing the signs as quickly as possible and bring blood sugar to a safe level as quickly as possible to avoid any risk of injury and relieve symptoms. Patients at high risk for severe hypoglycemia should be informed of their risk and counselled, along with their significant others, on preventing and treating hypoglycemia (including use of glucagon). HYPOGLYCEMIA To protect the brain and heart, it is important to correct hypoglycemia, regardless of the severity, by following the recommended approaches. There is no such thing as “minor hypoglycemia.” THE MOST COMMON COMPLICATIONS OF DIABETES The risk of complications is increased when blood sugar is poorly controlled. http://tpe-diabete-ilm-2015.weebly.com/ BLOOD VESSEL / MACROVASCULAR DAMAGE Diabetes Affects the heart and blood vessels by accelerating premature aging of the arteries (hardening of arteries) and the process of atherosclerosis, i.e., the thickening of the artery walls and the buildup of plaque inside them. Damage to the blood vessels of the heart is the leading cause of morbidity and mortality in persons with diabetes. BLOOD VESSEL / MACROVASCULAR DAMAGE Diabetes facilitates the development of cardiovascular risk factors (e.g., high blood pressure, dyslipidemia) and the associated effects, which accelerate cardiovascular aging. There are often no symptoms before an myocardial infarction (fatal or nonfatal). That is why it is important to recognize patients who present a high risk of vascular events. The majority (65% to 80%) of people with diabetes will die of cardiopathy. BLOOD VESSEL / MACROVASCULAR DAMAGE A global multifaceted approach to reducing risk: Healthy weight Healthy diet Regular physical activity Quitting smoking Moderate alcohol consumption Optimizing control of blood sugar (A1C level of 7%) Optimizing control of blood pressure (<130/80 mmHg) Medication for vascular protection NEPHROPATHY Elevated blood sugar levels Thickening and hardening of the blood vessels that irrigate the kidneys Ineffective function of the vessels and breakdown of the small vessels that filter the blood and purify blood waste DIABETIC NEPHROPATHY NEPHROPATHY Diabetic nephropathy (DN) corresponds to a gradual increase in proteinuria in a long-term diabetic, followed by kidney dysfunction that can ultimately lead to kidney failure at the terminal stage. The main risk factors of DN are: Long-standing diabetes Poor control of blood sugar High blood pressure Male sex Obesity Smoking NEPHROPATHY 50% of people with diabetes will show signs of nephropathy at some point in their lives. In Canada, diabetes is the leading cause of nephropathy, which is a particularly devastating complication because it is associated with a reduced lifespan and quality of life. NEPHROPATHY, SCREENING/FOLLOW-UP Type 1 Type 2 First examination Follow-up 5 years after diagnosis Annually At the time of diagnosis Annually depending on the physician’s recommendations Urine and blood tests will be used to assess the quality of kidney function while assessing and measuring the presence of a protein called albumin. RETINOPATHY Elevated blood sugar levels Thickening and hardening of the blood vessels that irrigate the eye Ineffective function of the vessels and breakdown of the small vessels in the area of the retina in particular RETINOPATHY RETINOPATHY Certain risk factors Poor control of blood sugar Long-standing diabetes Elevated glycated hemoglobin (A1C) levels High blood pressure Dyslipidemia Low hemoglobin levels RETINOPATHY Screening is important for early detection of this treatable disease. Blood sugar control can delay the onset and slow down the progression of diabetic retinopathy (DR) that threatens vision. DR is the most frequent cause of new cases of blindness in people of working age. RETINOPATHY Declining eyesight is associated with significant morbidity, including an increase in falls and hip fractures, and a mortality rate at four times the normal rate. The importance of screening—how often and by whom? RETINOPATHY, SCREENING/FOLLOW-UP First examination Type 1 Type 2 Pregnant woman with type 1 or type 2 diabetes Follow-up Starting at age 15 or 5 years Annually or according to the after diagnosis professional’s recommendations At the time of diagnosis Before conception During the first three months of pregnancy, then as needed during pregnancy and the years that follow The frequency of follow-ups for retinopathy varies according to the severity of the disease. Recommendations adapted from the 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada from the Canadian Diabetes Association NEUROPATHY Elevated blood sugar levels Nerve damage, especially in the extremities, but also in organs such as the intestines, stomach, bladder, heart and genitals. NEUROPATHY NEUROPATHY Some risk factors Poorly controlled blood sugar Hypertriglyceridemia High body mass index Smoking High blood pressure There are many symptoms, which vary according to the area of the body where they develop: Loss or decrease in sensation (pain, heat, cold) Numbness Burning sensation Gastroparesis Overactive bladder Erectile dysfunction NEUROPATHY Tight blood sugar control is effective for the primary prevention of neuropathy or as a secondary intervention when neuropathy has been established. Screening tests: such as using a monofilament and measuring response to vibration, are effective in detecting neuropathy and preventing it from occurring in the future. NEUROPATHY, SCREENING/FOLLOW-UP First examination Follow-up Type 1 5 years after diagnosis Annually Type 2 At the time of diagnosis Annually TYPE 2 DIABETES IN ABORIGINAL PERSONS In Canada, Aboriginal persons are among the populations with the highest risk of diabetes and its associated complications. Diabetes prevention should focus on risk factors. Regular screening is important. CONTROLLING BLOOD SUGAR To reduce the risks of these complications coming on quickly, emphasis should be placed on the importance of controlling blood sugar in managing diabetes. As you may have noticed throughout this presentation, this element is key. CONTROLLING BLOOD SUGAR / STRESS It is important to recognize that stress has an impact on blood sugar control, because many diabetes complications can also be brought on by excessive stress. Stress hormones are reduced by endorphins (produced during rest, laughter, exercise, etc.). COMMON PREVENTION MEASURES Keep blood sugar as close to normal as possible Manage blood pressure Quit smoking (vasoconstriction, etc.) Consume alcohol in moderation (neuropathy, hypoglycemia) Manage stress FLU/PNEUMONIA IMMUNIZATION The flu vaccine can reduce the rate of hospitalization by approximately 40% in persons deemed to be at high risk. Repeat the pneumococcal vaccine in certain cases. OTHER COMPLICATIONS Diabetes is also associated with other complications: Sleep apnea Capsulitis Erectile dysfunction Yeast infections Urinary infections Periodontitis EDUCATION People living with diabetes must fully understand their condition in order to make healthy choices and manage their illness, which requires their continued engagement. Effective management of diabetes can delay and even prevent diabetes complications from occurring. Education is the key to fully understanding and properly managing diabetes. REFERENCES Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2013;37: S367-S598 http://www.diabete.qc.ca/en/understand-diabetes/all-aboutdiabetes/complications/diabetes-complications Training program for community workers in diabetes prevention, Le diabète en bref. Yellowquill College 2010–2011 Metabolic Medicine Unit of the CHUM Hôtel-Dieu, Connaître son diabète pour mieux vivre. 2013. 317pages.
