Post-Transplant Diabetes Mellitus (PTDM)

What is Post-Transplant Diabetes Mellitus (PTDM)?

PTDM is the new onset of diabetes in patients who previously received an organ transplant. Specific predisposing factors play a role in the development of PTDM like:

          Age

          Body Mass Index (BMI)

          Hepatitis C virus (HCV) infection

          Various immunosuppressive therapies

          Ethnicity

Post-transplant diabetes mellitus (PTDM) is a complication which takes place after a solid organ transplant, and its incidence is widely variable, ranging from 2% to 53%. Specific types of immunosuppressive regimens (steroids) are related to the highest risk of for developing PTDM like, tacrolimus and corticosteroid. One of the major effects of the transplant is hyperglycemia.

Non-Modifiable Risk Factors:

          Ethnicity

          Age

          Gender of Recipient

          Donor’s Gender

          Family History of Diabetes

 

Modifiable Risk Factors Include:

          Immunosuppressive Therapy

o   Tacrolimus

o   Cyclosporine

o   Corticosteroid

o   Sirolimus

          Obesity

          Metabolic Syndrome

 

Potentially Modifiable Risk Factors:

          Infections

o   HCV

o   CMV

          Impaired Glucose Tolerance: IGT (pre-transplantation)

Every patient in the pre-transplant period must be examined for glucose intolerance and diabetes. The clinical history of the patient will also be important for the identification of risk factors and co-morbidities. The clinical management of patients with PTDM is normally the same as recommended for patients with type 2 diabetes (T2DM).

American Diabetes Association Guidelines

          A1C: 7%

          A1C may also be reported as eAG: 154 mg/dl

          Before a meal (preprandial plasma glucose): 70–130 mg/dl

          1-2 hours after beginning of the meal (Postprandial plasma glucose): Less than 180 mg/dl

          LDL Cholesterol: Less than 100 mg/dl

          HDL Cholesterol: Higher than 40 mg/dl for men and 50 mg/dl for women is good, but an HDL 50 mg/dl or higher helps everyone lower their risk for heart disease.

          Triglycerides: Less than 150 mg/dl

          Blood Pressure: 120/80

          Body Weight Control

Patients with PTDM have a higher risk of cardiovascular disease and infections compared to the general population and these problems could compromise the survival period and transplant durability. PTDM is a significant cause of morbidity in transplant patients. The early identification of this condition in addition to a thorough treatment of diabetes and its co morbidities will definitely determine its development.

ADA Glucose

ADA Cholesterol

ADA Blood Pressure

PTDM Journal Article

ptdm

Diabetic Ketoacidosis (DKA)

As part of my Medical Nutrition Therapy (MNT) rotation, my preceptor has asked me to create a summary sheet of certain illnesses and complications associated with various disease states. One of which, is diabetic ketoacidosis (DKA).

What is DKA?

DKA is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones.
It develops when your body is unable to produce enough insulin. Insulin normally plays a key role in helping sugar (glucose) — a major source of energy for your muscles and other tissues — enter your cells. Without enough insulin, your body begins to break down fat as an alternate fuel. This process produces a buildup of toxic acids in the bloodstream called ketones, eventually leading to diabetic ketoacidosis if untreated.

What causes DKA?

1. Not enough insulin

2. Not enough food

3. Low blood glucose

When cells don’t get the glucose they need for energy, your body begins to burn fat for energy, which produces ketones. Ketones are acids that build up in the blood and appear in the urine when your body doesn’t have enough insulin. They are a warning sign that your diabetes is out of control or that you are getting sick. High levels of ketones can poison the body. When levels get too high, you can develop DKA. DKA may happen to anyone with diabetes, though it is rare in people with type 2. Treatment for DKA usually takes place in the hospital. But you can help prevent it by learning the warning signs and checking your urine and blood regularly. DKA usually develops slowly. But when vomiting occurs, this is life-threatening and can develop in a few hours.

Sugar is a main source of energy for the cells that make up your muscles and other tissues. Normally, sugar enters your cells with the help of insulin. If you don’t have enough insulin in your body, your body won’t be able to use sugar properly for energy. This prompts the release of hormones that break down fat as an alternate fuel. In turn, this process produces toxic acids known as ketones. Excess ketones accumulate in the blood and eventually “spill over” into the urine.

Early symptoms include:

– Polydypsia (increase of thirst)

– Polyuria (frequent urination)

– Hyperglycemia (high blood glucose levels)

– High level of ketones in the urine

– Fatigue, dry skin, nausea, difficulty breathing, fruity odor on the breath (caused from the presence of ketones)

When diagnosing DKA, a healthcare provider should pay close attention to the following lab values:

Blood Glucose: If there isn’t enough insulin in your body to allow sugar to enter your cells, your blood sugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugar level will continue to rise.

Ketone level: When your body breaks down fat and protein for energy, toxic acids known as ketones enter your bloodstream.

Blood acidity: If you have excess ketones in your blood, your blood will become acidic (acidosis). This can alter the normal function of various organs throughout your body.

– Blood electrolyte tests, Urinalysis, Chest X-ray, and an Electrocardiogram (ECG)

The treatment for DKA involves a three-pronged approach:

1. Fluid Replacement: receive fluids, orally or intravenously, until rehydrated. These fluids will replace those that have been lost through excessive urination and dilute the excess sugar in the blood.

2. Electrolyte Replacement: Electrolytes are minerals in your blood that carry an electric charge, such as sodium, potassium and chloride. The absence of insulin can lower the level of several electrolytes in your blood. You’ll receive electrolytes through your veins to help keep your heart, muscles and nerve cells functioning normally.

3. Insulin Therapy: Insulin reverses the processes that cause diabetic ketoacidosis. Along with fluids and electrolytes, you’ll receive insulin therapy — usually through a vein. When your blood sugar level falls below 240 mg/dL (13.3 mmol/L) and your blood is no longer acidic, you may be able to stop intravenous insulin therapy and resume your normal subcutaneous insulin therapy.

Diabetic ketoacidosis is usually triggered by an illness or insulin therapy.

An infection or other illness can cause your body to produce higher levels of certain hormones, such as adrenaline or cortisol. Unfortunately, these hormones work against insulin — sometimes triggering an episode of diabetic ketoacidosis. Pneumonia and urinary tract infections are common culprits.

Missed insulin treatments or inadequate insulin therapy can leave you with too little insulin in your system, triggering an episode of diabetic ketoacidosis.

Other possible triggers of DKA could include:

– Stress

– Physical or emotional stress

– High fever

– Surgery

– Heart attack

– Alcohol or drug abuse, specifically cocaine

While DKA is being treated, there are complications that patients and healthcare providers need to be aware of as well. Complications could include:

Hypoglycemia: Insulin allows sugar to enter your cells. This causes your blood sugar level to drop. If your blood sugar level drops too quickly, you may develop low blood sugar.

Hypokalemia: Fluids and insulin used to treat diabetic ketoacidosis may cause your potassium level to drop too low. A low potassium level can impair the activities of your heart, muscles and nerves.

Cerebral Edema: Adjusting your blood sugar level too quickly can produce swelling in your brain. This complication appears to be more common in children, especially those with newly diagnosed diabetes.

American Diabetes Association- DKA

Mayo Clinic- DKA

DKA3

DKA2

DKA

Cystic Fibrosis-Related Diabetes (CFRD)

The most common types of diabetes are type 1 and type 2 diabetes. CFRD has some features that are common in both. Type 1 diabetes used to be called insulin-dependent or juvenile-onset diabetes. It occurs most often in childhood. People with type diabetes can’t make any insulin, so they must take insulin to stay alive. This is why type diabetes is often called “insulin-dependent diabetes.” People with type diabetes who miss insulin doses get very sick and can get ketoacidosis (a life-threatening change in blood acidity). Type 2 diabetes used to be called non–insulin dependent or adult-onset diabetes. It is caused by the lack of a normal response to insulin in addition to not making enough insulin. This type of diabetes occurs most often in overweight people over the age of 0. People with type 2 diabetes don’t often get ketoacidosis, but they can get very sick when their blood sugars are too high. People with type 2 diabetes do not always need insulin to manage their diabetes. Some use insulin. Some take pills. Most are told to lose weight. Some manage type 2 diabetes through diet and exercise alone.

Diabetes

T1DM: The body cannot make insulin

T2DM: The body lacks normal responses to insulin and does not make enough insulin

CFRD: The body cannot make or use insulin

Causes of CFRD

CFRD is unique, though it shares features with both type and type 2 diabetes. As in type diabetes, the pancreas does not make enough insulin. Thus, people with CF have insulin deficiency. This is likely due to scars in the pancreas because of thick mucus. Most people with CF make less insulin than normal, though not all with CF get diabetes. Some people with CF get diabetes because they may have insulin resistance. This means that the cells in the body do not use insulin the right way so more insulin is needed to change food into fuel and keep blood sugars in the normal range. Because many with CF have both insulin deficiency and insulin resistance, more people with CF get diabetes than do people without CF. Even when people with CF are not acutely ill, their chronic underlying infections can cause insulin resistance. A third cause of insulin resistance is higher than normal cortisol levels. The hormone cortisol is a steroid. It is made in the adrenal glands. Our bodies make higher than normal cortisol levels in response to stress. High cortisol levels get in the way of insulin’s action. Steroid-containing drugs (called corticosteroids) can also increase cortisol levels. These drugs are sometimes needed to treat lung disease. When taken, they can, for a little while, worsen blood sugar control. In people with CF who do not have diabetes, using corticosteroids can give them diabetes for a little while during and after corticosteroid treatment. People can have CFRD only sometimes (intermittent CFRD) or always (chronic CFRD). If you have intermittent CFRD, you may only need to take insulin when sick or during steroid treatment. If you have chronic CFRD, you need insulin treatment at all times to prevent high blood sugar levels. Although CFRD is unique from type or type 2 diabetes, the problems caused by diabetes are the same for all. These include eye, kidney, and nerve problems. These problems are caused by many years of blood sugar levels that are too high. Every person’s goal for diabetes treatment, no matter what kind they have, is to keep blood sugar levels as normal as they can. This helps to prevent diabetes-caused problems.

Complications with Hyperglycemia:

          Vision Problems

          Kidney Problems

          Neurological Problems (Nerve Damage)

Goal: To Keep Blood Sugar Levels Normal

              A1C: 7%

              A1C may also be reported as eAG: 154 mg/dl

              Before a meal (preprandial plasma glucose): 70–130 mg/dl

              1-2 hours after beginning of the meal (Postprandial plasma glucose)*: Less than 180 mg/dl

ADA Normal Blood Sugar Levels

Managing Cystic Fibrosis-Related Diabetes

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Managing Diabetes- It’s App-tastic!

Currently, a steadily increasing amount of people are using their phone as a source of knowledge and information. Honestly, it makes sense though. Your phone is always with you, it’s convenient, and it fits in your pocket. But, more specifically it’s helping people manage diseases like diabetes. Diabetes can be a mountain to manage, unless you have the right tools: knowledge and organization. According to the American Diabetes Association, nearly 19 million Americans, or more than 8% of the population, have diabetes. An estimated 7 million more are living with diabetes and have no idea they have it.

As discussed, with the rapid rising rates of diabetes, managing the condition is more important than ever! By incorporating the digital age of electronic devices, Smartphones, and more importantly phone applications, managing your diabetes can become second nature. So, here is an app that I recently came across that has been generating a substantial amount of “buzz”. Allow me to further investigate the characteristics of the diabetes app….

1.     Diabetes Companion by mySugr

This is the #1 diabetes app in 6 countries. The Companion is a charming, sometimes outspoken diabetes manager. The app is a new-twist on a diabetes logbook. It gives you immediate feedback in a fun package and helps you stay motivated for the long haul. You win points for every entry made which helps tame your diabetes “monster”. The goal is to tame your monster every day. Challenges are available to help you set and attain personal goals. It’s all the diabetes management you’re used to, with a side-order of context to make it meaningful.

You can use photos of your food along with smart searches to help make educated decisions on the go, use tags, notes, and locations to describe the situations and circumstances around your data, and choose from a variety of ever changing challenges to push yourself and your therapy to the next level of diabetes management nirvana.

Cost: FREE

Key Features include:

          Quick and easy logging

          Smart search

          Convenient data analysis

          Neat and clear graphs

          Handy photo functions (multiple pictures per entry)

          Exciting challenges

          Snappy reports (PDF, Excel)

          Smile-inducing feedback

          Secure data backup

           Social sharing functions

          Fast multi-device sync

          Practical glucose reminders

          Registered medical device (which is very important when looking into apps that help manage/regulate health-related diseases/illnesses)

mySugr Diabetes Manager App: The Companion

MySugrdm appdm

Qatar Outdoes America in Obesity Rates?

Well, America isn’t the Only Heavy Hitter Anymore…

The obesity epidemic in America has obviously generated a lot of publicity, in recent years. And more specifically, West Virginia has been in that spotlight with its towering obesity rates, let alone its childhood obesity rates.

But, now Qatar has been given that title of being the most obese country in the world.  According to new data release by the Supreme Council of Health, about 70% of people in Qatar are overweight and some 41% are obese.

If you’ve read my blogs before, I have posted about the Middle East and its urbanization, associated with fast food chains and obesity rates. The rapid urbanization in Qatar, and many other states in the Arab Peninsula, following the discovery of oil has contributed to a sedentary lifestyle. Coupled with a lack of exercise culture and diets high in fats, salts and sugar, obesity has rapidly increased in the Middle East.

The rapid increase in obesity has led to an increase in several non-communicable diseases in the small Gulf country, such as diabetes, cardiovascular diseases and some cancers. According to the International Diabetes Federation (IDF), the rate of diabetes in Qatar has climbed to 20.2% of the population.

Often people think that they need to do a lot to prevent illnesses. That is not the case. Often simply making minimal changes will help. The incidence of these diseases can be significantly reduced by simple lifestyle changes, such as increased regular exercise and integrating healthier foods into your diet.

Just alone is 2012, studies showed that 45% of adult Qataris were obese and up to 40% of school children were obese as well. Many Qataris, especially dietitians, are worried that in the next 5 years that 73% of Qatari women and 69% of Qatari men will be obese. Combined with high rates of diabetes, often triggered by excess weight, this has become a national… Wait, now a global concern for the country. In 2012, 15.4% of adult had diabetes, with rates in children below the age of 5 ay 28.8%.

Qatar surpasses US in obesity

Qatar is World’s Wealthiest and Obese

qatar fatty

qatar fat

Qatar sign

Happy RD Day!

Happy Registered Dietitian (RD) Day!!

March 13th celebrates Registered Dietitian Day! This celebration occurs every year during National Nutrition Month, which is March. RDs are the public’s go-to healthcare professionals when they need reliable nutrition information, in this field. RDs pull from their experience to create a personalized nutrition plan for people of every age. These are the professionals that are able to separate facts from fads and translate nutritional science into information you, the consumer/client/patient, can use!

Dietitians can improve the health of Americans and save money through healthcare costs. Medical nutrition therapy (MNT) provided by RDs is critical in preventing the top 3 chronic illnesses. It is well documented that MNT is associated with a decrease in utilization of hospital services of 9.5% for patients with diabetes and 8.6% for patients with cardiovascular disease. Also noteworthy is that participation in community-based programs that focused on improving nutrition and increasing physical activity had a 58% decrease in incidence of Type 2 Diabetes.

Registered Dietitians assist to promote a net decrease in healthcare utilization and costs for most people. The Robert Wood Johnson Foundation estimates that in Idaho, for every $1 spent in wellness programs, companies could save $3.27 in medical costs and $2.73 in absenteeism costs. Some interventions have been shown to help improve nutrition and activity habits in just 1 year and had a return of $1.17 for every $1 spent. Reducing the average BMI in the state of Idaho by 5% could lead to health care savings of more than $1 billion in 10 years and $3 billion in 20 years.

Well, unfortunately Wild and Wonderful West Virginia isn’t as lucky as ole Idaho. West Virginia still leads the nation in obesity, and was recently named the state with the highest number of overweight residents in the union. According to the 2012 Gallup-Healthways Well-being Index released last week, 33.5% of West Virginia’s population is considered obese.

Mississippi is the closest with an obesity rate of 32.2%. Arkansas has a rate of 31.4%, Louisiana is 30.9% and Alabama is listed at 30.4%, to round out the top five.

Residents of the Mountain State believe that a reason for the high obesity rate is the change in physical jobs and increase in availability of fast food. The combination of lack of physical activity and the ready access of fast food and junk food in homes has really contributed to the epidemic. On the flip side of our state, nutrition-related efforts seem to be working as West Virginia is no longer in the top five for childhood obesity!

With the help from schools and communities, West Virginia is increasing physical activity and need for healthier foods. As a unit we are advocating and promoting activity and nutrition. I think it seems to be helping! All thanks to those RDs out there!!!

Job outlook: According to the Bureau of Labor Statistics, Nutrition and Dietetics careers are expected to increase much faster (by 20%) than other jobs by 2020 and faster than many other industries within health care. In 2010, the median annual salary for RDs was $53,250, at $23.60 an hour. And the number of jobs available in the nutrition and dietetics field was 64,400.

Money Bags

Bureau of Labor Statistics

Academy of Nutrition and Dietetics

Fat West Virginia

Nutrition in the Community

RD Day 2013

RD Day

Southern Grocery Shopping

Southern Grocery Cart

It’s easy to throw healthy eating habits out the window when you’re away from home and your regular routine. Andrea D’Ambrosio, RD talks about ways to create a healthy winter routine while staying on a budget.

Plan ahead and stick to a list
Being prepared before you grab your grocery cart will help you avoid impulse purchases. It also gives you time to look at flyers, find sales and clip coupons. Try taking advantage of no-name products and avoiding shopping while you’re hungry.

Shop in season and avoid being wasteful
Buy in-season foods from local farmer’s markets, which is cheaper, and be resourceful with leftovers, using up excess food before it goes to waste, she says.

Consider vegetarian alternatives
If you study your grocery bill, meat products are often among the most expensive items. Consider planning meals with vegetarian alternatives like lentils, beans and soy. Check out vegetarian websites for heart- and budget-healthy meal ideas, she suggests.

Here are 5 friendly foods and the reasons you should add them to your grocery list:

  1. Fresh, seasonal fruit: A favorite snack to boost energy levels between meals if you feel a little hungry (power of carbs) and allows you to benefit from vitamins, minerals and antioxidants.
  1. Low-fat (1 percent) or non-fat milk: In order to maintain our bone density, we need to consume adequate dairy to receive calcium, phosphorous, magnesium and protein, which are all essential for bone growth and development.
  1. Whole grains: According to the Journal of Nutrition (2011), oats, barley, rice and quinoa all lower risk of chronic diseases such as coronary heart disease, diabetes and cancer, as well contribute to body-weight management and gastrointestinal health. Try buying whole-grain pasta and remember to look for the words “whole grain” on the label.
  1. Almonds: But just a handful a day, and make them unsalted! A portion-controlled (quarter cup) serving of almonds is excellent for lowering cholesterol because of the unsaturated fats, making them a heart-healthy choice. Almonds are high in vitamin E, a powerful antioxidant, and are naturally high in fiber and a good source of protein!
  1. Edamame: Green soybeans, made popular in Japanese cuisine but available in grocery stores, add a nice nutritional punch. These tasty soybeans can be added as a side dish, steamed in the pod or consumed as a snack or appetizer. Nutritionally speaking, they are another heart-healthy source of protein, fiber and vitamins.

http://www.thestar.com/specialsections/snowbirds/article/1301135–fill-your-southern-grocery-cart-with-healthy-foods

http://www.dieteticdirections.com/

groc shopp