Diabetes and Insulin Regulation Quiz

Diabetes Mellitus

• A group of diseases characterized by hyperglycemia.
• Defects in insulin secretion, insulin action, or both.
• Almost one-third of cases are undiagnosed.
• Prevalence is increasing.
• Minority populations and the elderly are disproportionately affected.

Hormones Regulating Blood Glucose

Insulin

• The chief glucose regulatory hormone.
• Synthesized by beta cells (β-cells) in the islets of Langerhans in the pancreas.
• Secretion is stimulated by hyperglycemia.
• Attaches to receptors on the body's cells, acting as a gatekeeper for glucose entry into the cells.

Insulin Function

• Decreases blood glucose levels.
• Inhibits glycogenolysis (breakdown of stored glucose) in the liver.
• Inhibits gluconeogenesis (production of glucose from amino acids and other substrates).
• Transports glucose into muscle, liver, and adipose tissue.
• Muscle, liver, and adipose cells require insulin activation at insulin receptors to facilitate glucose transport.
• Neural tissue and erythrocytes do not require insulin for glucose utilization.
• Once inside the cell, glucose can be oxidized.

Normal Physiologic Insulin Secretion

• Insulin peaks immediately after meals (prandial insulin).
• A constant supply of basal insulin is essential to maintain overall glycemic control.

Endogenous Basal and Prandial Insulin Secretion

• Basal Insulin Secretion*
• Occurs continuously.
• Suppresses hepatic glucose production between meals and overnight.
• Maintains a nearly constant level throughout the day.
• Not appropriate for handling post-meal glucose increases.
• Prandial Insulin Secretion*
• Occurs in response to food intake or a meal.
• Helps control hyperglycemia after meals.
• Provides the remaining 50% of daily insulin requirement.

Classification of Diabetes Mellitus (DM)

1. Type 1 (Insulin-dependent DM...IDDM):

• Beta cells in the pancreas are destroyed by an autoimmune process.
• Requires insulin; little to no insulin is produced.
• Onset is acute and usually before 30 years of age.
• 5-10% of people with diabetes.
• Genetic causes.

2. Type 2 (Non-Insulin-dependent DM...NIDDM)

• More common in people over 30 years old.
• Causes include insulin resistance due to obesity, impaired insulin secretion (still some secretion), and hereditary factors.
• Often treated initially with diet and exercise.
• Oral hypoglycemic agents or insulin may be used.
• Diabetic Ketoacidosis (DKA) is less common in type 2 diabetes because of sufficient insulin levels.

3. Gestational Diabetes Mellitus (GDM):

• Occurs in about 2-5% of pregnancies.
• Onset during pregnancy, usually in the second or third trimester.
• Caused by hormones secreted by the placenta inhibiting insulin action.
• Treated with diet and insulin (if needed) to strictly maintain normal blood glucose levels.

4. Pre-diabetes (Impaired Glucose Homeostasis):

• Risk factor for DM.
• Impaired glucose tolerance (IGT).
• Impaired fasting glycemia (IFG).

Pathogenesis of Type 2 Diabetes

• Impaired insulin secretion.
• Gastrointestinal absorption of glucose.
• Increased basal hepatic glucose production.
• Decreased insulin-stimulated glucose uptake in muscle.

Risk Factors for Diabetes Mellitus

• Type 1*
• Genetic predisposition combined with immunological and possibly environmental (viral) factors.
• Type 2*
• Family history of diabetes, obesity, race/ethnicity, age over 45 years.
• Previous impaired fasting glucose or impaired glucose tolerance, hypertension (≥ 140/90), HDL cholesterol ≤ 35, triglycerides ≥ 250, history of gestational diabetes or babies over 9 pounds.
• Metabolic syndrome (obesity, hypertension, hypercholesterolemia).

Type 1 vs. Type 2

Glucose Regulation

• Fasting: Lowers blood glucose concentration
• Eating: Raises blood glucose, Beta cells are stimulated to secrete insulin, blood glucose concentration decreases

Diagnostic Tests for Diabetes

• Fasting plasma glucose (FPG or FBS): ≥ 126 mg/dL (7.0 mmol/L)
• Random plasma glucose: > 200 mg/dL (11.1 mmol/L) plus symptoms of diabetes
• Oral Glucose Tolerance Test (OGTT): ≥ 200 mg/dL during an OGTT
• Glycosylated Hemoglobin Assays (HgA1C)

Fasting Blood Glucose

• Measures blood glucose levels after fasting.
• Normal: 70-100 mg/dL; Prediabetic: 100-126 mg/dL; Diabetic: > 126 mg/dL

Random Plasma Glucose

• Performed regardless of when the patient last ingested food.
• If symptoms (polydipsia, polyuria, and weight loss) are present, and blood glucose levels are ≥ 200 mg/dL, there's a possibility of having DM.

Oral Glucose Tolerance Test (OGTT)

• 75 grams of glucose dissolved in water (100 grams for pregnant women) given after fasting.
• Blood samples taken at 30 minutes, 1 hour, 2 hours, and 3 hours.
• No medications or strenuous activities 8-12 hrs before the test.
• Diabetic level: 2hPG ≥ 200 mg/dL.

Glycosylated Hemoglobin Assays (HgbA1C)

• Measures the percentage of glycosylated hemoglobin, reflecting average blood glucose levels over 2-3 months.
• Non-diabetic: 4-6%; Diabetic (patient with diabetes): > 7%; Diabetic (patient without diabetes): > 6.4%

Type 1 & 2 Diabetes: Key Concepts

• Minimizing diabetes complications requires early diagnosis, treatment, and maintaining HbA1C levels < 7%.
• HbA1C < 7% requires control of post-prandial and fasting hyperglycemia.

Assessment of Diabetic Patients

• History: hypo/hyperglycemia, glucose levels, complications, adherence to dietary, exercise, and pharmacological management.
• Physical examination: BP, WT (BMI), check for complications (eye, foot, skin, renal, neurological, and oral).
• Laboratory examination:
• HbA1c (every 3 months), Microalbuminuria or 24-hour urine collection (annually), Fasting lipids (annually), serum creatinine level, and ECG.
• Referrals to ophthalmologist and podiatry.

Treatment Goal

• Normalize insulin activity and blood glucose levels.
• Intensive control decreases vascular and neuropathic complications.

Management

• Nutritional management, Exercise, Monitoring glucose and ketones, Pharmacologic therapy, Education

Dietary Management Goals

• Provide optimal nutrition.
• Maintain normal body weight, blood glucose levels, and lipid profile.
• Prevent complications.
• Address individual nutrition needs.
• Promote eating pleasure.
• Promote 1-2 pound weight loss per week (500-1000 calories less).

Role of the Nurse

• Be knowledgeable about dietary management.
• Communicate important information to the dietician or other management specialists.
• Reinforce patient understanding.
• Support dietary and lifestyle changes.

Meal Planning

• Consider food preferences, lifestyle, eating times, and cultural background.
• Review diet history (weight loss, gain, or maintenance).
• Consider caloric needs and distribution throughout the day.
• Emphasize whole grains, limiting 20%-30% of daily intake to fat, and less than 300mg of cholesterol.
• Use non-animal protein (legumes, grains) to reduce saturated fat and cholesterol intake.
• Increase fiber to lower cholesterol.

Glycemic Index

• Describes how much a given food increases blood glucose.
• Combining starchy food with protein and fat slows absorption and improves glycemic response.
• Raw or whole foods have a lower response than cooked or processed foods.
• Eating whole fruits decreases the glycemic response.
• Adding food with sugars to foods slowly absorbed may reduce the response.

Other Dietary Concerns

• Alcohol may inhibit gluconeogenesis, leading to hypoglycemia.
• Nutritive sweeteners (fructose, sorbitol, xylitol) provide calories similar to sucrose but cause less elevation in blood glucose.
• Non-nutritive sweeteners (saccharin) have minimal calories.
• Reading labels carefully, as "sugar-free" or "dietetic" foods may provide calories.

Exercise

• Lowers blood sugar by increasing glucose uptake.
• Aids in weight loss.
• Improves lipid Profile and raises HDL (high-density lipoprotein).
• Lowers cardiovascular risk.
• Decreases stress.

Exercise Precautions

• Avoid exercise when blood sugar is elevated (>250mg/dL) and ketones are present in urine.
• Insulin needs may decrease with exercise; patients taking exogenous insulin may need a carbohydrate snack before moderate exercise to prevent hypoglycemia.
• Adjust insulin if exercising to control or reduce weight.
• Monitor blood glucose levels.

Exercise Recommendations

• Encourage regular, gradual increase in daily exercise.
• Modify exercise regimens to patient's needs and presence of diabetic complications.
• Exercise at the same time of day.
• Assess feet daily, avoid trauma, and use proper footwear.
• Avoid extreme temperatures (heat or cold) during exercise.
• Consider exercise stress tests for patients older than 30 with two or more risk factors.

Monitoring

• Self-Monitoring of Blood Glucose (SMBG): Enables people with diabetes to adjust treatment and detect hypo- or hyperglycemia. Disadvantages include need for good vision, fine motor coordination, and comfort with technology, with cost being a factor.
• Candidates for SMBG include those with unstable diabetes, a tendency for severe ketosis or hypoglycemia, hypoglycemia without warning symptoms, and abnormal renal glucose threshold.
• Frequency: 2-4 times per day (before meals and bedtime recommended).
• Urine testing for glucose and ketones. Glucosylated hemoglobin (HgbA1c) should be assessed every 2-3 months.

Pharmacological Therapy (Insulin)

• Insulin Therapy: Taken one or more times per day to control blood glucose levels.
• Insulin Sources: Beef, pork, and human insulin, including different types based on onset, peak, and duration of action. Rapid-acting, short-acting, intermediate-acting, and long-acting insulins (Lispro, Humalog, Regular, NPH, Lente, Ultralente, Glargine [Lantus], 70/30).
• Insulin types are important in managing fluctuating blood glucose.

Pharmacological Therapy (Oral Antidiabetic Agents)

• Used for patients with type 2 diabetes not responding well to diet and exercise alone.
• Includes numerous medications, each with potential side effects (e.g., hypoglycemia).
• Nursing interventions include monitoring blood glucose, assessing for hypoglycemia, and patient teaching.

Sites of Action of Oral Antidiabetic Agents

• Diagram illustrating how oral agents impact blood glucose levels, targeting different sites and mechanisms.

Education for Diabetic Patients

• Patients should understand their condition and its associated complications well; learning about prevention strategies and monitoring techniques is essential.
• Nutritional information is crucial, including medication effects and adjustments, exercise considerations, disease progression, and monitoring techniques.

Complications of Diabetes Mellitus

• Acute: Hypoglycemia, Diabetic Ketoacidosis (DKA), Hyperglycemic Hyperosmolar Syndrome (HHS).
• Chronic: Macrovascular (coronary artery disease, cerebrovascular disease, peripheral vascular disease), Microvascular (retinopathy, nephropathy, neuropathy).

Hypoglycemia

• Blood glucose falls below 70 mg/dL.
• Causes: Too much medication (insulin or hypoglycemic agents), too little food, or excessive exercise.
• Often occurs before meals, when meals are delayed, or during the insulin peak.
• Symptoms: range from mild (sweating, tremor, hunger) to severe (confusion, seizures, loss of consciousness).

Diabetic Ketoacidosis (DKA)

• Absence of or markedly inadequate amount of insulin that results in disorders in CHO, protein, and fat metabolism.
• Mostly associated with type 1 diabetes.
• Main clinical features: Hyperglycemia, dehydration (polyuria), and electrolyte loss; metabolic acidosis.
• Causes: Decreased or missed insulin doses, illness or infection.
• Management: Rehydration, insulin infusion, and electrolyte correction.

Hyperglycemic Hyperosmolar Syndrome (HHS)

• Hyperglycemia, high blood osmolarity, and alteration of awareness/consciousness with minimal or absent ketonemia or ketoacidosis.
• Primarily associated with type 2 diabetes.
• Causes / Risk Factors: lack of effective insulin, elderly patients (50+ years old or older) with mild type 2 DM, recent illness (pneumonia, CVA, etc), medications exacerbating hyperglycemia; hypokalemia.
• Pathophysiology: Persistent hyperglycemia, dehydration, hypernatremia, and increased serum osmolarity.
• Management: Rehydration, potassium correction (be mindful of serum potassium levels and timing of administration), and insulin treatment.

Retinopathy

• Deterioration of the small blood vessels nourishing the retina, potentially leading to vision loss.
• Stages: background, preproliferative, proliferative.
• Symptoms: Painless vision changes (e.g., blurry vision, floaters, complete loss of vision).
• Prevention/treatment: Management of hyperglycemia, argon laser photocoagulation.

Nephropathy

• Renal disease resulting from diabetic microvascular changes in the kidneys.
• Pathophysiology: Elevated blood glucose levels stress the kidneys, causing blood proteins to leak into the urine, increasing pressure within kidney blood vessels, eventually leading to nephropathy.
• Diagnosis: Microalbuminuria (protein in the urine).
• Prevention/treatment: Control of blood glucose levels.

Neuropathy

• Group of diseases affecting all types of nerves (peripheral, autonomic, and spinal).
• Pathophysiology: Associated with blood vessel damage (thickening of capillary basement membranes plus inflammation and demyelination); associated with hyperglycemia.
• Types: Peripheral and autonomic.
• Symptoms: Paresthesia, burning sensations, decreased pain or temperature perception, impaired reflexes, muscle problems, GI and/or bladder dysfunction, etc.
• Management: Control blood glucose levels, specific treatments for specific symptoms.

Diabetic Foot

• Complication resulting from interplay of neuropathy, vascular disease, and immunocompromise.
• Risk Factors: Duration of diabetes (>10 years), age (>40 years), smoking, decreased peripheral pulses, decreased sensation, anatomical deformities, history of foot ulcers or amputations.
• Prevention/treatment: Proper foot care (inspecting feet for sores, blisters, etc., wearing appropriate footwear, maintaining good circulation, managing hyperglycemia); managing any complications if they appear; consult physician.

Nursing Diagnosis of Newly Diagnosed DM

• Risk for fluid volume deficit related to polyuria and dehydration.
• Altered nutrition related to imbalance of insulin, food, and physical activity.
• Knowledge deficit about diabetes self-care skills.
• Potential self-care deficit related to physical impairment or social factors.
• Anxiety related to loss of control and fear of inability to manage diabetes.