Ch 15, DIABETES MELLITUS

1. Ch 15, DIABETES MELLITUS DIABETES

2. Group 7; Section 302 • Bernard Boateng • Latoya Newby • Linda Lawrence • Nehemiah Dorce • Disease State: Diabetes • Lenz Ch. 12 • 11/15/11

3. DIABETES Overview • Diabetes was listed as Sixth leading cause of death in the United states in 2002 • An estimated 20.8 million people or 7.3% of the United States population currently has diabetes • About 90 to 95% of patients have type 2 diabetes (Non-insulin-dependant diabetes Mellitus) • Pharmacists are well positioned to assist patients at risk

4. Prevalence • In 2003,Prevalence of physician-diagnosed diabetes was more than 14 million new cases • In 2005 alone, over 1.5 million new cases in adults were diagnosed • American Indians or Alaska natives 15.3% • Non Hispanic Blacks 11.7% • Mexican Americans 9.6% • World wide prevalence was 2.8% in 2000

5. Prevalence Cont… • World wide prevalence projection 4.4% by 2030 • Individuals with pre-diabetes are at risk for • diabetes Mellitus, Heart disease and stroke • Many people with pre-diabetes do not know. • 73% of patients with diabetes have blood pressure of 130/80 mm of Hg or use prescription medication for Hypertension • Total direct and indirect cost associated with diabetes was approximately $132 billion annually

6. Type 1 and type 2 diabetes Type 1 Type 2 Insulin-dependant Juvenile-onset Associated with HLA types Family history of obesity not common Age at onset < 30yrs Treatment Physical activity MNT Non-insulin-dependant Adult-onset Defect in insulin Obesity Common (60-90%) Age at onset > 40yrs Treatment Physical activity MNT & Insulin

7. Normal and diabetic plasma glucose • A normal FPG is < 100mg/dl • An FPG of 100 to 125mg/dl is IFG • An FPG ≥ 126mg/dl indicates provisional diagnosis of diabetes that must be confirmed • Diabetes resulting from stress in pregnancy are classified as gestational diabetes • Impaired glucose tolerance diagnosed when FPG < 126g/dl

8. Risk Factors • Overweight (≥ 25 kg/m2) • Physical Inactivity • Hypertension • Dyslipidemia HDL-C < 35mg/dl Triglyceride > 250 mg/dl • Cardiovascular diseases • Family History of diabetes

9. Risk Factors / signs and symptoms • Age > 45 years • History of vascular disease • Rapid progression (days to weeks ) of • Polyuria • Polydipsia • Fatigue • Weight loss • ketoacidosis

10. Treatment • TYPE 1 • Proper eating habits • Exercise • Insulin • TYPE 2 • Weight loss • Proper eating plan • Exercise • Oral Antidiabetic agents • Possibly Insulin

11. Physical Activity recommendations Type 1 Goal Prevent the onset of disease and increase work capacity Types Large muscle activities Intensity moderate to vigorous Duration At least 30 minutes Frequency most days of the week Resistance training All major muscle groups Life style Activities Walking the dog taking stairs yard work house duties etc.

12. Physical Activity recommendations Type 2 Goals Improve insulin sensitivity Reduce risk of cardiovascular disease Reduce body weight Types Large muscle activities Intensity very low to moderate Duration 5-10 min initially, 20-60 min Frequency 2-4 times per week ( for initial 2 to 8 weeks ) Resistance training All major muscle groups 1 set 15-20 repetitions, 2 to 3 times per week rest at least 48 hrs between session.

13. Nutrition and diabetes Mellitus(MNT) Four Goals of American Diabetes Association (ADA) • Attain and maintain optimal metabolic outcomes including blood glucose, blood lipid and blood pressure • Prevent and treat chronic complications by modifying nutrient intake and treat obesity, dyslipidemia, cardiovascular , hypertension, and nephropathy • Improve health through healthy food choices and physical activities • Address individual nutritional needs taking into consideration the patient’s cultural life style needs while respecting the patient’s wishes and willingness to change.

14. ADA Dietary recommendations • Carbohydrate • 50-60% total calorie intake • Most should come from whole grain Protein • Most American Adults consume 50% more than required • 15-20% of total calorie intake • Dietary fats • Less than 10% of total calorie intake • Limit saturated fat and cholesterol intake • Individuals with low-density lipoprotein(LDL) greater than 100mg/dl should take less than 7% of calorie intake Fiber 20-30g/day

15. Safety considerations ADA recommendations • All patients must undergo extensive medical evaluation before undergoing any physical program • All patients with diabetes should have a comprehensive foot examination along with education regarding self examination • Persons with diabetes use footwear that cushions and distribute pressure evenly on the foot • Patients who exercise late in the evening may need to increase consumption of carbohydrate before going to bed

16. Osteoporosis Chapter 16 Group 10: Joseph Bishay, Chantel Grubbs, Meranda Maley, Shanae Perry, Jasmine Stanton

17. OSTEOPOROSIS – “Porous Bone” • Characterized by the thinning of bone tissue and a loss of bone density over time, which results in an increased risk of fractures of: • Hip • Spine • Wrist • Often called a “silent” disorder until • it causes one or more bone fractures DEFINITON

18. Affects 44 million Americans age 50 years and older • 80% of cases are from women • White/Asian women have a higher prevalence compared to • African American/Hispanic women. • Environmental Risk Factors: • Physical inactivity • Low calcium and vitamin D intake • Decreased mobility • Family history of osteoporosis • Female gender • Caucasian or Asian • Small stature PREVELANCE & HEALTH RISKS

19. The annual direct care expenses for osteoporotic fractures range from • $12.2 to $17.2 billion. • Men account for 18% of this amount (~ $3.2 billion) • Hip fractures alone account for 63% ($11.3 billion) of this annual cost • In 2002, the treatment for each hip fracture was roughly $30,100 to $43,400 • Hospital care and nursing home care account for a majority of the total direct • costs associated with osteoporotic fractures ECONOMIC COSTS

20. As we continue to age our bones continue the process of remodeling. • Remodeling is important because it helps to maintain our bone health and prevents us from having fractures. • In the remodeling process, older fatigued bone and damaged bone is replaced by new bone. • Two cells are involved in remodeling: • Osteoblast • Osteoclasts Pathophysiology of Osteoporosis

21. Osteoclasts- are the cells that break down or reabsorb the old bone. • This is done by erosion and cavity formation in the old bone. • Osteoblasts- are the cells that build up or generate new bone to replace the old bone that osteoclasts had previously broken down. • These cells fill the cavities made by the osteoclasts. • At the age of 30 is when most people reach their peak bone mass. After this time the remodeling process results in small deficits in bone formation which begin to increase with age. Pathophysiology

22. Become proactive! Osteoporosis is a PREVENTABLE disease! • Prevention strategies include: • Adequate calcium intake • Physical activity • Maintaining a healthy body weight • Smoking abstinence • Women who smoke have lower estrogen levels, often reaching menopause sooner. • Alcohol control Prevention and Treatment

23. Preventive Medications • Calcium products • Vitamin D • Estrogens • Calcitonin • Oral Bisphosphonates • Rx Treatment medications: • Boniva • Helps increase bone mass and reduce the chances of fracture • Fosamax • A bisphosphonate that acts as a specific inhibitor of osteoclast (break down bone).

24. Adherence Recommendations • Ensure the patient has a clear understanding of the risks for osteoporosis and the strategies to prevent the disease. • Recommend that multiple adherence strategies work better than a single approach. • Establish contact with patient to assess the patient’s progress. • Help set achievable goals • Obtain baseline assessment of calcium and vitamin D intake. • Institute a self monitoring program such as keeping a log of food intake and exercise participation. • Identify patient specific barriers to the lifestyle changes.

25. Nutrition & Osteoporosis • DASH Eating Plan: • Emphasizes eating fruits, vegetables, low-fat or fat-free dairy foods, whole grains, poultry, and nuts. • Minimize intake of fat, cholesterol, and sodium • Important nutrients for bone growth include: • Calcium • Vitamin D • Phosphorus • Magnesium • Zinc • Iron

26. Calcium • Important nutrient for strong bones. • Low calcium intake is associated with low bone mass, rapid bone loss, and high fracture rates. • Adequate calcium intake differs by age • Ages 1-3yrs old: 500mg/day • Ages 4-8yrs old: 800mg/day • Ages 9-18yrs old: 1300mg/day • Ages 19-50yrs old: 1000mg/day • Ages 51+: 1200mg/day

27. Nutrition • Most Americans obtain a majority of their calcium from dairy products. • Dairy products that are low-fat or non-fat are good choices because they allow for the full amount of calcium but avoid high fat and calorie intake. • Other options include: • Dark leafy greens • Broccoli, collard greens, and spinach • Salmon • Tofu • Almonds • Orange Juice • Cereals • Surveys show that Americans consume less than half the amount of calcium needed to build and maintain healthy bones.

28. Nutrition • It’s important for healthcare practitioners to teach patients to read food labels to estimate the amount of calcium that a particular food may have. • The amount of calcium listed on food labels is stated in a percentage of the daily value of recommended calcium intake. • For example: A cup of yogurt contains 30% of the recommended daily value of calcium. • Foods that contain 20% or more are considered high in calcium and those that contain 5% or less are considered low in calcium content.

29. General physical activity for adults is 30 minutes daily and for children 60 minutes daily. • Primary Goal: Maintain bone mass through the use of bone loading activities (e.g., playing games, running, turning, and jumping) • PHYSICAL ACTIVITY is the only intervention that can potentially increase both bone mass and bone strength and decrease the risk of falling in elderly individuals. • Studies have reported that individuals who are physically active can lower their age-related decline and the risk for fractures. Physical Activity and Osteoporosis

30. Doing activities that impose an increased load to the bones of the upper body will only affect the bones of the lower body. • The adaptive response that occurs as a result of increased bone load occurs only when the loading stimulus exceeds that of the individuals usual loading conditions. • Jogging opposed to walking • Rope jumping opposed to standing • In adults, the benefits of physical activity on the bone health may not persist, if the physical activity is significantly reduced. • Stopping physical activity loses bone mineral density that was previously gained. Principles about the Osteogenic Effect

31. A successful, “extreme” training can have positive and negative outcomes. • Women tend to exercise to the extreme, that cause problems on their health (e.g., amenorrhoic and miss menstrual period) • Amenorrhea is the absence of a menstrual period in a woman of reproductive age. Its also a sign of decrease estrogen levels, which can lead to low bone density and predispose women to osteoporosis. • Reports have shown that women in their 20’s who have became amenorrhoic secondary to high levels of physical activity, have bone mineral densities that are similar to those for women in their 80s. Bone Health & Overtraining in Women

32. Warnings/Signs of Overtraining • Missed or Irregular menstrual periods • Extreme or “unhealthy looking” thinness • Extreme or rapid weight loss • Behaviors that reflect frequent dieting (eating very little, not eating in front of others, trips to the bathroom after meals) • Anxiety about missing and exercise session • Problems sleeping • Increase chewing of gums • Unusual amount of self-criticism • Inability to concentrate • Feeling cold all the time • Constantly talking about their body weight

33. Problems: • Not a significant forefront of many pharmacists because of other diseases such as cardiovascular disease and cancer. • Patients may not appear unhealthy or at risk. • The U.S Surgeon General has named osteoporosis a significant public health concern. • Pharmacists should be aware of the risk factors and talk with patients about osteoporosis prevention. • Pharmacists have used risk assessment questionnaires and patient-appropriate health information to increase awareness of the disease. Pharmacy Practice Application

34. What is Project ImPACT? • A study sponsored by the American Pharmacists Association • An example of community-based pharmacists operating a successful osteoporosis screening and treatment program in conjunction with physicians. • Interventions with patients took place with an initial visit to screen patients and provide health promotion information. Pharmacists referred those patients who required physician follow-up. • The project demonstrated that patients were willing to pay for these services offered by pharmacists. Project ImPACT: Osteoporosis

35. Project results showed: • Of the patients screened, there was a significant increase in investigators being able to contact these patients for follow-up interviews 3 to 6 months later. • Of the patients screened, 37% were at a high risk for osteoporosis. • A total of 78% of the patients indicated that they had no prior knowledge of their risk for future fractures Project ImPACT: Results

36. Ch 17 Osteoarthritis Section 301 Chapter 17 November 28, 2011 Group 11: Amber Brown Kirollos Hanna Mini Mathai MeenaRagheb Erica Starke

37. arthritis • Arthritis is the inflammation of a joint, often accompanied by pain and structural changes. • Joint inflammation may result from: • An autoimmune disease • A broken bone • General "wear and tear" on joints • An infection, usually by bacteria or virus • There are over 100 different types of arthritis.

38. OA vs. RA • Osteoarthritis (OA) is the progressive breakdown of the joints' natural shock absorbers (cartilage). • Also called "wear and tear" arthritis or degenerative joint disease, • Rheumatoid arthritis (RA) is an autoimmune disease, where the immune system attacks normal tissues in the body, causing inflammation.

39. OA vs. ra • http://www.healthline.com/hlvideo-5min/osteoarthritis-vs-rheumatoid-arthritis-326724706

40. OA • Osteoarthritis tends to occur in men and women over the age of 40 and becomes more common with increasing age. Women are more severely affected then men. • It can also be found in persons who put exceptional stress on joints. For example: gymnasts, long distance runners, basketball players, soccer players, etc. These individuals are more likely to develop osteoarthritis at earlier ages.

41. Prevalence of OA in the United States is estimated to be at 21 million Americans or 12% of the population. • Disability from arthritis results in 750,000 hospitalizations and 36 million outpatient visits each year.

42. Osteoarthritis can occur in any joint, but it is most commonly diagnosed in the knees, hips, hands, and spine.

43. Pathophysiology • Osteoarthritis is characterized by narrow joint spacing, absence of articular cartilage, increased bone density, and stiffness of the subchondral bone and bone spur formation along the joint margins.

44. Pathophysiology • Joint cartilage degradation leads to pain, which usually results in decreased physical activity, which causes loss in muscular strength, loss of physical functioning and disability. This results in loss of independence and decreased quality of life.

45. Pathophysiology • Weight-bearing joints, such as the knees and hips, can be compromised by structural factors, such as obesity or neuromuscular abnormalities. • Inflammatory cytokine interleukin-1β is present in the joints of patients with osteoarthritis (it plays a role in mediating joint inflammation and cartilage degradation). • The inflammatory markers interleukin-6, tumor necrosis factor α, and C-reactive protein have been shown to be higher in patients with hip or knee osteoarthritis.

46. Pathophysiology

47. Risk Factors • Increased age • Overweight and obesity • Joint injury • Joint overuse from certain vocational or sport activities • Quadriceps muscle weakness • Genetic predisposition • Developmental abnormalities

48. Medical conditions that can lead to OA • Bleeding disorders that cause bleeding in the joint, such as hemophilia • Disorders that block the blood supply near a joint can lead to avascular necrosis • Other types of arthritis, such as chronic gout, pseudogout, or rheumatoid arthritis

49. Symptoms • Major symptoms are pain and stiffness. • “Morning stiffness”-  pain and stiffness felt upon waking up in the morning. It usually lasts for 30 minutes or less. It is improved by mild activity that "warms up" the joint. • During the day, the pain may get worse with activity and feel better when resting. After a while, the pain may be present even while resting. • A rubbing, grating, or crackling sound when the joint is moved. • Some people might not have symptoms

50. Signs & tests • A physical exam can show: • Joint movement may cause a cracking (grating) sound, called crepitation • Joint swelling (bones around the joints may feel larger than normal) • Limited range of motion • Tenderness when the joint is pressed • Normal movement is often painful • X-ray of affected joints will show a loss of the joint space. In advanced cases, there will be a wearing down of the ends of the bone and bone spurs.