Page 900 - Cardiac Nursing

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D D D D Diabetes Mellitus and Metabolic Syndrome
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Beverly Dyck Thomassian
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OVERVIEW OF DIABETES ci circuulating glucose. Inn thee preesence of diabetes, there is a dimin-
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Thee global epide ic fof diabetess will challenge our generationn to
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Th gl ob al e pi de mi d ia be te wi ll c ha ll en ge o ur g en er at io to Thesee deffects, coupled withh a deficiency of other glucose lowering
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develop novel strategies to prevent and treat this life long condi- hormones, resuult inn higher fasting a dnd postmeal gluucose llevels.
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tion. Every 10 secondds, two peoplle dev lelop diabbetes and one per- To diagnose diabetes, either fasting plasma glucose, random
son dies from diabetes-related causes. In 2007, 246 million peo- glucose, or a post 75 g glucose challenge glucose level can be used.
ple worldwide had diabetes. That number is expected to climb to Currently, there is international consensus that a fasting blood
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380 million by 2030. In most developed countries, diabetes is glucose level of 126 mg/dL (7 mmol), or a random or post meal
the fourth or fifth leading cause of death and there is concern that glucose tolerance level of 200 mg/dL (11.1 mmol) in the pres-
it will become an epidemic in many developing and newly indus- ence of symptoms of hyperglycemia confers a diagnosis of diabetes
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trialized nations. City dwellers are at especially high risk since they (Table 39-1). Blood glucose levels that are higher than normal
tend to be less physically active and are more likely to be obese as but do not reach the criteria for diabetes indicate future risk of di-
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compared to their rural counterparts. Heart disease is the leading abetes and heart disease. This category of blood glucose is referred
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cause of death for all people with diabetes. Heart disease, coupled to as prediabetes and includes impaired fasting glucose and im-
with the other long-term complications including kidney, eye, and paired glucose tolerance. Impaired fasting glucose is defined as
nerve disease, results in disability, reduced life expectancy, and enor- fasting blood glucose of 100 to 125 mg/dL (5.6 to 6.9 mmol/L)
2
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mous hearth burdens for virtually every society. In 2007, the United by the ADA and 110 to 125 mg/dL (6.0 to 6.9 mmol/L) by the
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Nations General Assembly recognized that diabetes “poses a severe EASD. There is international consensus that impaired glucose
risk for the families, Member States and the entire world” and passed tolerance is defined as blood glucose of 140 to 199 mg/dL (7.8 to
a resolution declaring November 14 World Diabetes Day. 3 11.1 mmol/L) 2 hours after a 75 g glucose challenge. Uncon-
In spite of this emerging epidemic, there is abundant evidence trolled, chronically elevated glucose, often termed “glucose toxic-
that diabetes can be prevented and its complications avoided. The ity,” can lead to a multiplicity of vascular complications that start
challenge faced by health care providers is to increase awareness re- long before the diagnosis of diabetes is made. Identifying and
garding diabetes risk factors, promote early identification, and pro- treating hyperglycemia in its earliest stages is critical to prevent
vide treatment aimed at preventing complications and improving complications. Unfortunately, as many as 50% of people with di-
quality of life. The purpose of this chapter is to discuss (1) the abetes worldwide remain undiagnosed and untreated. 1
natural history and pathophysiology of types 1 and 2 diabetes,
(2) the relationship between insulin resistance and cardiovascular
disease (CVD), (3) prevention of type 2 diabetes, (4) metabolic Prevalence and Consequence
syndrome and cardiovascular complications, and (5) the goals of of Diabetes
care and interventions aimed at complication prevention and
The global prevalence of diabetes will double in the next 30 years
mitigation.
due to population growth, urbanization, increasing prevalence of
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obesity, aging, and physical inactivity. Table 39-2 illustrates the
Definition and Diagnosis 10 countries with the highest prevalence estimates for diabetes in
2000 and 2030. The countries with the highest rates of diabetes
Diabetes can be caused by a variety of hormonal and cellular de- include India, China, and the United States. In India, the crude
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fects, which result in elevated blood glucose levels. A normal fast- prevalence rate is 9% in urban areas and in the United States, 7%
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ing glucose level is less than 110 mg/dL (6.1 mmol) according to of the population is affected by diabetes. In developing countries,
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the World Health Organization (WHO) and the European As- the highest prevalence of diabetes is the middle productive years
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sociation for the Study of Diabetes (EASD). According to the of 45 to 64 years of age range. In contrast, the majority of people
American Diabetes Association (ADA), normal fasting blood glu- with diabetes in developed countries are greater than 64 years
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cose is less than 100 mg/dL (5.7 mmol). This level of fasting of age. 7
glucose is maintained in the body by an intricate balance of hor- In the United States and globally, 90% to 95% of people with
mones, which work to maintain glucose levels at a steady state. diabetes have type 2 and the majority of those are overweight. 9
Normally, insulin and other hormones are released in response to Over 50% of the U.S. population is overweight and more than
rising blood glucose levels. These powerful hormones activate cel- one billion people in the world are overweight, of which at least
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lular storage of glucose, amino acids, and triglycerides in target 300 million are obese. The United States and other developing
cells, including the liver, muscle, and fat, with the end result of countries are experiencing an epidemic of type 2 diabetes in
normoglycemia. To keep glucose levels from falling too low, other youth. This increase in type 2 diabetes in youth strongly correlates
hormones, such as glucagon, corticosteroids, growth hormone, with increasing prevalence of childhood obesity. 10
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