Understanding Diabetes: Types and Risk Factors

• Diabetes is a group of metabolic diseases characterized by hyperglycemia

Definition

• Defects in insulin secretion, insulin action, or both cause hyperglycemia
• Insulin's main function is to allow glucose to enter cells
• The pancreas produces and regulates insulin

Hyperglycemia

• Hyperglycemia increases blood glucose levels
• The destruction of B and T cells can cause hyperglycemia
• Type 1 diabetes can cause hyperglycemia

Risk factors

• Age over 30 is a risk factor for type 2 diabetes
• Age less than 30 is a risk factor for type 1 diabetes
• Low HDL (High Density Lipoprotein) cholesterol is a risk factor
• High triglyceride levels (LDL - Bad Fats) is a risk factor
• Hypertension is a risk factor
• A history of gestational diabetes or delivery of a baby over 9 lbs is risk factor
• A family history of diabetes which include parents and siblings are a risk factor

How Insulin Works

• Carbohydrates provide energy and are broken down in the small intestine
• Cells in the intestinal wall absorb glucose into the bloodstream
• The pancreas detects sugar and releases insulin into the bloodstream
• Insulin then reduces sugar to a healthy level
• Cells move through the blood until they come into contact with other cells
• Insulin attaches to receptors that opens through lock and key attachment

Pathophysiology

• Etiological Factors
• Blood thinks there is no glucose due to resistance

Altered CHO Metabolism

• Destruction of B & T Cells occurs
• Glucose not transported into intracellular compartment
• Glucose can't be converted into stored forms
• Hyperglycemia ensues
• Initiation of compensatory mechanism is needed to meet energy requirements
• Altered CHO, protein, and fat metabolism occurs, CHO = Carbohydrates
• Glycogenolysis: Glycogen is when excess glucose is stored for later use
• Gluconeogenesis converts fats to glucose, using lactates and amino acids for glucose production
• Hyperglycemia occurs
• Cross Renal Threshold is (180-200 mg/dl)
• Glucose becomes present in urine
• Sweet, fruit smell in urine is another indicator

Altered Protein Metabolism (Loss of Muscle Mass)

• Increase in protein catabolism
• Increase in gluconeogenesis converts amino acids into glucose, resulting in weight loss, fatigue, and muscle loss

Altered Fat Metabolism

• Decreased Insulin causes resistance
• Increase in lipolysis, breaking down stored fat into fatty acids and glycerol
• Increase in free fatty acids + ketones results in metabolic acidosis
• Kidneys try to balance by activating, resulting in electrolyte imbalance
• Lungs try to balance by releasing an excess of CO2, resulting in Kussmaul's respiration

Type 1 DM --- Insulin-Dependent Diabetes

• Most common under 30 years old
• Genetic trait
• Appears in childhood
• Immunology: Often have Islet cell antibodies. Autoimmune disease
• Environmental Factors: Virus, Gut microbiolia, Climate
• Dietary: Gluten, Milk
• Chemical Exposure: Heavy Metals, Lead, Pesticides
• Vitamin D deficiency and stress plays are contributing factors
• Destruction of pancreatic beta cells B Cells & T Cells plays a major role
• Little/no endogenous insulin: Necessary to preserve life and needed from outside
• Ketosis is prone when insulin is absent, which is breakdown of fat for energy
• Acute complication of hyperglycemia: Diabetic Ketoacidosis Medical Consideration NEED INSULIN TO LIVE
• Diets doesn't need oral antidiabetic

Diets

• Diabetes Plate Method Consists of 50-60% Cal Which is made up of Carbs & Whole Grains, 20%-30%: Fats Olive Oil & Seeds 10%-20% Proteins Poultry, eggs, meat, & fish and Fiber Spinach Broccoli Brussel Sprouts
• There maybe improve A1C Level, Decrease Need Exogenous Insulin, Lower LDL levels and Total Cholesterol Level
• MYPLATE FOOD GUIDE is Commonly Used for pt with type 2 diabetes who have a hard time following a calorie controlled diet
• Exercise:
  • Educate in food portion control and identification of good carbs, protein, fats
  • Control fats and sugar
• Exercise Increases insulin sensitivity, Decreases resistance, and lowers A1C levels
• Prevent exercise induced hypoglycemia by have a Small carb snack q 30 min during exercise or exercising after Meals
• Plans should be individualized and must monitor Glucose before, during, and after
• Recommendations: Exercise should be done 3x a week with no more 2 day rest between, same day, time, duration each session using Proper footwear
• Stretching 10-15min before helps avoid Trauma to lower extremities for patients especially with numbness
• When in extreme climates it's best to avoid exercise or avoid if there is poor metabolic control

Type 2 Diabetes --- Non-insulin Dependent Diabetes

• Population: Age 30 + and throughout life
• Onset Any age but mostly due to Obesity which can most pt can control blood glucose through weight loss if they have obesity
• Hereditary contributing factor as well Environmental Factor: unhealthy Diet, Sedentary Life & Smoking
• Decrease in endogenous insulin but Body Still Producing Insulin
• Medication Considerations: Oral antidiabetics agents which is Only given if lifestyle changes are not made but one may Need insulin on a short or long term basis to prevent hyperglycemia
• Ketosis is uncommon unless in stress or infection in terms of Complications
• Acute Complication presents as Hyperglycemic & Hyperosmolar Syndrome

Collaborative Care

• Severe complications of diabetes is characterized by extremely high blood sugar levels w/o significant ketone production
• 1st line of Intervention includes Nutritional Therapy
• Goals are to Maintain normal A1C levels as well as Normal or close to normal lipid Levels helps Prevent Vascul, Disease, to Prevent/slow rate of chronic comp and to Address individual nutritional by understanding Personal & Cultural Preference to ensure Willingness to change

Diets and Exercise

• Diabetes Plate Method Consists of 50-60% Cal Which is made up of Carbs & Whole Grains, 20%-30%: Fats Olive Oil & Seeds 10%-20% Proteins Poultry, eggs, meat, & fish and Fiber Spinach Broccoli Brussel Sprouts
• There maybe improve A1C Level, Decrease Need Exogenous Insulin, Lower LDL levels and Total Cholesterol Level
• MYPLATE FOOD GUIDE is Commonly Used for pt with type 2 diabetes who have a hard time following a calorie controlled diet through Educating in food portion control and identification of good carbs, protein, fats while in Control fats and sugar
• Exercise:
  • Increases insulin sensitivity & Decreases resistance which Lowers A1C levels
  • Helps prevent hypoglycemia during exercise and after meals and Plans should be individualized where Glucose should Monitor before, during, and after
  • Recommendation: Exercise 3x a week with no more 2 day rest session and Resistance training 2x where Exercise the same day, time, and duration using Proper footwear
  • Avoiding:
    • Trauma to lower extremities especially due to numbness due to peripheral neuropathy
    • Extreme climates & Avoid exercise during poor metabolic control
    • Always Stretch 10-15 min before
• 2nd in Line of treatment is Drug Therapy and through Self-Monitoring and Patient Teaching

Secondary Diabetes / Associated with other conditions or syndrome

• Accompanied by certain diseases: Pancreatic Disease & Hormonal Abnormalities
• Caused by Medications Corticosteroids & Estrogen-containing preparations
• Due to Pancreas Depends on the ability of insulin production which then May require treatment with oral antidiabetic agents/insulin

Gestational Diabetes

• Occurs during the Second or Third Trimester
• Is caused by Hormones secreted by the placenta: Estrogen Progesterone Lactate Acid due to Resistance of Insulin where It Inhibit the action of insulin
• Can result in Risk of Perinatal Complications: Macrosomia - baby significantly larger than average at gestational age

Treatment and Statistics

• Includes Diet Modifications and If Needed: Insulin where Strictly to maintain glucose levels
• Statistic: 35-60% will develop diabetes (Usually type 2 due to Especially if obese) within 10-20 years
• Diagnostic/Testing: Glucose challenge test between 24-28 weeks of gestation & Diabetes screening every 3 years

Morning Hyperglycemia

• Dawn Phenomenon occurs when there is normal A1C levels and around 3Am the the blood level begins to rise which need Treatment of infection of evening intermediate-acting insulin from dinner time to bedtime
• Somogyi Effect occurs only Nocturnal hypoglycemia followed by rebound hyperglycemia and requires Treatment of Decreasing evening (Pre dinner/bedtime) dose of intermediate-acting insulin or increasing bedtime snack
• Insulin Waning: Progressive increase of A1C from bedtime to morning which need NPH Dose closer to bed time

Clinical Manifestations

• 3 P's (Clinical Manifestations)
  • Polyuria: Excessive urine
  • Polydipsia: Excessive thirst
  • Polyphagia: Excessive Hunger
• Other Manifestations:
  • Fatigue and Weakness
  • Sudden Vision Changes that maybe Blurred or Change if lens
  • Tingling or numbness in hands or feet -Dry Skin, Skin Lesions or wounds that are slow to heal and Recurrent infections

Diagnostics Testing & Normal Ranges

• Fasting Plasma glucose (FPG) Normal Levels 70-100 mg/dL (NPO @ least 8 hours)
• Random Plasma Glucose Normal Level 200 mg/dL
• 2-Hour Postprandial Load Glucose level 2 Hours after receiving glucose Normal Levels 140 mg/dL for Non Diabetics and 180 mg/dL for Diabetics
• Ketones are by-products of lipolysis, and they accumulate in blood and urine signals deficiency of insulin
  • Blood Normal Level in terms of mmols: where Normal levels are 0.6 - 1.5, 1.5 is considered slightly High and 1.6 - 3 mmols is at risk of DKA
  • Urine Normal Levels are to be Below 0.6 mmol/L

Glycemic Index, Alcohols, & Drug Therapy

• The glycemic index measures how much a food raises blood sugar levels
• Raw and whole foods have a lower glycemic index than processed foods
• This helps patients manage their blood sugar levels
• Alcohol should be Drank in Moderation without out needing to cut alcohol may lead to excessive weight gain
• Drug Therapy Includes Oral Anti-diabetic Medications: Alpha-Glucosidase, Biguanides, Dipeptidyl Peptidase-4 Sulfonylureas, Sodium-glucose Thiazolidinediones, & Injection Anti-Diabetic Meds
• Alpha-Glucosidase Inhibitor Trade Name: Acarbose & Miglitol has a Pharmacological Effect of delaying complex carbs from entering into blood stream and entry of glucose into system circulation: one that is Must be taken with first bite of as well as can lead to Monitor GI effects and Monitor Liver Function Panel and if one with preexisting GI issues you Can't be excreted
• Biguanides(Ex: Metformin, Glucophage) helps Inhibit production of glucose by the liver and Decrease hepatic synthesis of cholesterol: Diagnostic Studies required to ensure Metformin should be stopped 48 hours prior and up to 48 after depending on kidney and liver function
• Dipeptidyl Peptidase-4 (DPP-4) Inhibitors (Alogliptin, Linagliptin, Saxagliptin, Sitagliptin) has a Pharmacologic Effect of Hormones increasing insulin release and decrease Glucagon levels
• Second-Generation Sulfonylureas (Glimepiride, Glipizide, Glyburide), increase insulin, instruct pt to cut out alcohol as is sulfa based
• Sodium-glucose cotransporter 2 (SGL-2) (Anagliflozin, Dapagliflozin, empagliflozin), monitor genital and urinary tract infections and to pee after as frequently
• Thiazolidinediones (Rosiglitazone, Pioglitazone), counsel on risk to pregnancy if taking oral contraceptives
• Injetable Glucagon Like peptide-1 (Dulaglutide, Liraglutide, Trizepitide Semiglutide), once a week and trade names Zepbound, Monjauro, Wegovey, Ozempic
• Non-Sulfonylurea act fast, and take right before meal even

Insulins

• Subq Injections of: Rapid Acting (Lispro which has an Onset w/in 15-30 min, a Peak b/w 30-90 min and a Duration that is than 5 hours)
• Aspart has an Onset w/in 15 min, a Peak b/w 1-3 hrs, a Duration that is b/w 3-4 hrs and Glulisine has an Onset w/in 5-15 min, a Peak at 1 hr and a Duration to 5 hrs has Nursing action for Rapid reduction of AlC and to treat Postprandial Hyperglycemia/Prevent
• Short Acting (Ex: Regular) has an Onset b/w 30-60 min, a Peak b/w 2-3 hour the Duration is 4-6 hours This can be taken 15mins before meal given alone

Nursing Indications:

• Can be used in combination with longer acting insulin
• Intermediate-acting (Ex; NPH)Onset 1-1.hr,Peak 4-12 hrs, Duration 24 hrs, Food one must eat when starting this and food around peak to eat! NPh is Basal and Long Acting the same.
• Intermediate-acting (Ex; Determir)Onset 1-1.hr, Peak continuous, Duration 24 hrs, Food one doesn't need food around peak/basal
• Powdered Rapid act inhalation is last option but great onset 15 min , give 15 mins before food administer in the beginning of meal and give Subq Education and avoid temps extreme, and inject clear to cloudy! sites abdomen(1 in from umbelicus)
  • rotate injeciton causes lipodrystophy - 6-12 sites rotate and not same spot 30 days
• 90 degrees regular 45 degrees for lean and no rubbing and site can have red skin with 4 cm with 4 months allergies
• Complications of Diabetes Hypoglycemia where AlC falls to less than 70 and cause because of too much and too little food.
  • Check glucose level and too much insulin will have tachycardia ad diaphoresis .
• Give dextrose if not concious and need 15-30 min and go to ER as well to treat The most dangeous! Diabetes Ketoicidosis

Hypersmolar Hyperglycemic

• If high sugar and peeing the mangemnt is too correct first and last!
• Micro and macro vasculature , the small blood vessel in the retina micro vasulature is micro aneurism from Hemmoraghing

Preop considerations

• Micro alniumuria is progress end and manage HTH to control enzymes!
• Neuropathy macro vacscualr is MI and Cardio and give anti hypertensives
• Diminish peripherally and have foot issues with infections

Sick Day rules

• Never stop insulin,and drink fluids!
• Eat all same stuff just easier to eat Hyperosmolar is no ketone
• Diabetiv retinophaty - leakage focal closure
• 20-30 % diabetic nephropathy progresses!
• Prevent with vaccines and kidney healthy! 1/3 progresses
• Ace and caps can cause death to kidney - dialysis and transplant
• Micro and macro!
• Disclaimer:* These notes are intended for study purposes only and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment of diabetes.