Diabetes Mellitus Medium

• The main classifications of diabetes include type 1, type 2, gestational diabetes, latent autoimmune diabetes of adults (LADA), and diabetes associated with other conditions or syndromes
• The different types of diabetes vary in cause, clinical course, and treatment
• The diabetes classification system is dynamic
• Research suggests many differences among individuals within each category of diabetes
• Patients may move from one diabetes category to another, except for those with type 1
• Women with gestational diabetes may move into type 2 diabetes after delivery
• Prediabetes is classified as impaired glucose tolerance (IGT) or impaired fasting glucose (IFG)

Risk Factors for Diabetes

• Age >30 years for type 2 and gestational diabetes
• Obesity (≥20% over ideal body weight or BMI ≥30 kg/m2)
• Family history of diabetes
• Members of high-risk ethnic groups (Hispanic Americans, Native Americans, Asian Americans, African Americans, Pacific Islanders)
• Previous history of hyperglycemia
• Current normal glucose metabolism
• Impaired glucose tolerance or impaired fasting glucose
• Screening after age 40 with family history or symptoms
• Encourage ideal body weight, as 10–15 lb loss may improve glycemic control

Pathophysiology of Insulin

• Insulin is a hormone secreted by beta cells in the islets of Langerhans in the pancreas
• Insulin is an anabolic or storage hormone
• Insulin secretion increases after a meal and moves glucose from the blood into muscle, liver, and fat cells
• In cells, insulin transports and metabolizes glucose for energy
• Insulin stimulates glucose storage in the liver and muscle as glycogen
• Insulin signals the liver to stop releasing glucose
• Insulin enhances dietary fat storage in adipose tissue
• Insulin accelerates amino acid transport into cells
• Insulin inhibits the breakdown of stored glucose, protein, and fat
• During fasting, the pancreas releases a small amount of insulin (basal insulin)
• Glucagon (secreted by alpha cells in the islets of Langerhans) is released when glucose levels decrease, stimulating the liver to release stored glucose
• Insulin and glucagon maintain a constant blood glucose level by stimulating glucose release from the liver
• Initially, the liver produces glucose through glycogenolysis (glycogen breakdown)
• After 8-12 hours without food, the liver forms glucose from noncarbohydrate substances (amino acids) through gluconeogenesis

Type 1 Diabetes

• Type 1 diabetes is characterized by the destruction of pancreatic beta cells
• Genetic, immunologic, and environmental factors contribute to beta-cell destruction
• Genetic susceptibility is an underlying factor
• People inherit a genetic predisposition toward the development of type 1 diabetes, not the disease itself
• Autoimmune response: antibodies directed against normal tissues
• Autoantibodies against islet cells and endogenous insulin are detected before the development of clinical signs
• Beta-cell destruction results in decreased insulin production, increased glucose production by the liver, and fasting hyperglycemia
• Glucose from food cannot be stored in the liver, contributing to postprandial hyperglycemia
• Glycosuria occurs when blood glucose exceeds the renal threshold (180–200 mg/dL or 9.9–11.1 mmol/L)
• Excess glucose excretion in urine leads to loss of fluids and electrolytes (osmotic diuresis)
• Insulin deficiency leads to unrestrained glycogenolysis and gluconeogenesis, increasing hyperglycemia
• Fat breakdown leads to increased production of ketone bodies, causing DKA

Diabetic Ketoacidosis (DKA)

• DKA results from insulin deficiency, mostly in type 1 diabetes
• Major metabolic derangements are hyperglycemia, ketosis, and metabolic acidosis
• DKA is preceded by polyuria, polydipsia, nausea, vomiting, and fatigue
• Can lead to stupor and coma if untreated
• Breath has a fruity odor due to ketoacids

Type 2 Diabetes

• Type 2 diabetes is more common in people over 30 with obesity
• Incidence increases in younger people due to obesity epidemic
• Two main problems: insulin resistance and impaired insulin secretion
• Insulin resistance is decreased tissue sensitivity to insulin
• Intracellular reactions are diminished, making insulin less effective
• Exact mechanisms leading to insulin resistance and impaired insulin secretion are unknown; genetic factors play a role
• Increased insulin secretion is required to overcome insulin resistance
• If beta cells cannot meet the demand, glucose levels rise and type 2 diabetes develops
• Insulin resistance may lead to metabolic syndrome
• Enough insulin is present to prevent fat breakdown and ketone body production, DKA does not typically occur, but uncontrolled type 2 diabetes may lead to HHS
• Onset may go undetected for years due to slow, progressive glucose intolerance
• Symptoms may be mild: fatigue, irritability, polyuria, polydipsia, poorly healing skin wounds, vaginal infections, blurred vision
• Detected incidentally during routine tests
• Long-term complications may develop before diagnosis are eye disease, peripheral neuropathy, and peripheral vascular disease

Gestational Diabetes

• Gestational diabetes is glucose intolerance with onset during pregnancy
• Hyperglycemia develops during the second and third trimesters
• Placental hormones cause insulin resistance
• High-risk women should be screened at the first prenatal visit
• High-risk factors: marked obesity, previous gestational diabetes, glycosuria, strong family history
• High-risk ethnic groups: Hispanic Americans, Native Americans, Asian Americans, African Americans, Pacific Islanders
• Average-risk women should be tested at 24-28 weeks
• Low-risk criteria: age <25 years, normal pre-pregnancy weight, low-risk ethnic group, no history of abnormal glucose tolerance, no diabetes history in first-degree relatives, no history of poor obstetric outcomes
• High or average risk: oral glucose tolerance test or glucose challenge test followed by oral glucose tolerance test if glucose threshold exceeds 140 mg/dL (7.8 mmol/L)
• Initial management: dietary modification and blood glucose monitoring
• 70-85% controlled with lifestyle modifications
• Dietary recommendations: ≥175 g carbohydrates, 71g protein, 28g fiber, low saturated fats
• If hyperglycemia persists, insulin is prescribed
• Target blood glucose levels: 140-180 mg/dL (7.8-10 mmol/L)
• After delivery, blood glucose levels usually return to normal
• Increased risk of developing type 2 diabetes later in life for women with a history of gestational diabetes
• Women with a history of gestational diabetes should be screened for the development of diabetes or prediabetes every 3 years

Latent Autoimmune Diabetes of Adults (LADA)

• LADA is a subtype of diabetes where autoimmune beta cell destruction is slower than in types 1 and 2 diabetes
• Patients with LADA are at high risk of becoming insulin-dependent
• LADA characteristics: age of onset <50 years, BMI <25 kg/m2, history of autoimmune disease, acute symptoms prior to diagnosis, or positive family history of autoimmune disease

Prevention of Type 2 Diabetes

• Type 2 diabetes can be prevented with lifestyle changes
• High-risk participants (BMI >24 kg/m2, elevated glucose levels) received: standard lifestyle recommendations plus metformin, standard lifestyle recommendations plus placebo, intensive lifestyle modifications
• Intensive program: weight reduction >7% of initial body weight and moderate physical activity and behavior modification strategies
• Lifestyle intervention group had a 58% lower incidence of diabetes
• Metformin group had a 31% lower incidence of diabetes
• Findings were consistent across genders and racial/ethnic groups
• Type 2 diabetes can be prevented or delayed in high-risk individuals
• Lower rate of developing type 2 diabetes compared to controls in those who enrolled in the program
• Glucosamine users had a lower risk of developing type 2 diabetes than non-users

Clinical Manifestations of Diabetes

• Clinical manifestations depend on the level of hyperglycemia
• Classic symptoms: polyuria, polydipsia, and polyphagia
• Polyuria (increased urination) and polydipsia (increased thirst) result from fluid loss due to osmotic diuresis
• Polyphagia (increased appetite) results from catabolic state induced by insulin deficiency and the breakdown of proteins and fats
• Other symptoms: fatigue and weakness, sudden vision changes, tingling or numbness in hands or feet, dry skin, slow healing skin lesions/wounds, and recurrent infections
• Type 1 diabetes may be associated with sudden weight loss, nausea, vomiting, or abdominal pains (if DKA has developed)

Criteria for Diabetes Diagnosis

• Symptoms of diabetes plus casual plasma glucose ≥200 mg/dL (11.1 mmol/L)
• Classic symptoms are polyuria, polydipsia, and unexplained weight loss
• Fasting plasma glucose ≥126 mg/dL (7.0 mmol/L)
• Fasting is defined as no caloric intake for at least 8 hours
• Two-hour postload glucose ≥200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test
• Test uses 75-g anhydrous glucose dissolved in water
• Hemoglobin A1C ≥6.5% (48 mmol/mol)
• Criteria should be confirmed by repeat testing on a different day in the absence of unequivocal hyperglycemia
• A1C is not recommended for routine clinical use

Assessment and Diagnostic Findings

• Abnormally high blood glucose level is the basic diagnostic criterion
• Fasting plasma glucose (FPG)
• Random plasma glucose
• Glucose level 2 hours after glucose load (2-hour postprandial) may be used to assess diabetes

Gerontologic Considerations

• Diabetes is prevalent in older adults
• Type 2 diabetes is the seventh leading cause of death
• Affects approximately 20% of older adults
• High prevalence among African Americans and those aged 65-74
• Early detection is important but challenging due to absent or nonspecific symptoms
• Glucose tolerance test is more effective than urine testing for glucose due to higher renal threshold

Medical Management

• Main goal: normalize insulin activity and blood glucose to reduce complications
• Intensive glucose control dramatically reduced the development and progression of complications such as retinopathy, nephropathy, and neuropathy
• Intensive treatment: 3-4 insulin injections per day or an insulin pump, frequent blood glucose monitoring, and weekly contacts with diabetes educators
• Strive for glucose control (HgbA1C <7%) to reduce the risk of complications

Assessing the Patient with Diabetes

• Symptoms related to the diagnosis of diabetes:
• Symptoms of hyperglycemia
• Symptoms of hypoglycemia
• Frequency, timing, severity, and resolution of diabetes
• Results of blood glucose monitoring
• Status, symptoms, and management of chronic complications such as eye, kidney, nerve, genitourinary and sexual, bladder
• Cardiac; peripheral vascular; foot complications associated with diabetes
• Adherence to/ability to follow prescribed dietary management plan
• Adherence to prescribed exercise regimen
• Adherence to/ability to follow prescribed pharmacologic treatment
• Use of tobacco, alcohol, and prescribed and over-the-counter medications/drugs
• Lifestyle, cultural, psychosocial, and economic factors that may affect diabetes treatment
• Effects of diabetes or its complications on functional status
• Blood pressure (sitting and standing to detect orthostatic changes)
• Body mass index (height and weight)
• Funduscopic examination and visual acuity
• Foot examination (lesions, signs of infection, pulses)
• Skin examination (lesions and insulin injection sites)
• Neurologic examination
• Vibratory and sensory examination using monofilament
• Deep tendon reflexes
• Oral examination
• Laboratory Examination: HgbA1C (A1C)
• Fasting lipid profile
• Test for microalbuminuria
• Serum creatinine level
• Urinalysis
• Electrocardiogram
• Need for Referrals: Ophthalmologist, Podiatrist, Dietitian, Diabetes educator, and others if indicated

Therapeutic Goal for Diabetes Management

• Achieve euglycemia (normal blood glucose levels) without hypoglycemia while maintaining a high quality of life
• Nutritional therapy, exercise, monitoring, pharmacologic therapy, and education
• Requires constant assessment and modification of the treatment plan by health professionals and daily adjustments by the patient
• Patient and family education is essential

Nutritional Therapy

• Nutrition, meal planning, weight control, and increased activity are the foundation of diabetes management
• Objectives: control total caloric intake to maintain reasonable body weight, control blood glucose levels, and normalize lipids and blood pressure to prevent heart disease
• MNT is complex; a registered dietitian has the major responsibility
• Prevention or slowing the development of chronic complications
• Individual nutrition needs, preferences, and willingness to change is important
• Maintain the pleasure of eating by only limiting food choices when indicated by scientific evidence
• Overweight is considered to be a BMI of 25 kg/m2 to 29 kg/m2
• Obesity is defined as 20% above ideal body weight or a BMI ≥30 kg/m2
• Weight loss of 5-10% may significantly improve blood glucose levels
• Decreasing overall caloric intake is of greater importance
• Meals should not be skipped
• Pacing food intake throughout the day decreases demands on the pancreas
• GLP-1 agonists: delayed gastric emptying and weight loss
• DPP4 and SGLT2 inhibitors improve glucose control while assisting with weight loss
• Restrict calories only moderately
• Diet education, behavioral therapy, group support, and ongoing nutrition counseling are encouraged to maintain weight loss

Meal Planning and Related Education

• The meal plan must consider the patient’s food preferences, lifestyle, usual eating times, and ethnic and cultural background
• Maintaining consistency in calories and carbohydrates ingested at each meal
• Consistency in time intervals between meals, with snacks if necessary
• Mastering insulin-to-carbohydrate calculations can provide more lifestyle flexibility
• Intensive insulin therapy may allow adjustments in insulin dosage based on eating and exercise habits
• First step: thorough review of diet history in order to identify eating habits and lifestyle and cultural eating patterns the goal is to assess weight loss, gain, or maintenance

Caloric Requirements

• Calorie-controlled diets are planned based on age, gender, height, and weight
• Activity level is factored in to determine calories needed for weight maintenance
• To promote a 1-2 lb weight loss per week, 500-1000 calories are subtracted
• Calories are distributed into carbohydrates, proteins, and fats
• A meal plan is developed based on lifestyle and food preferences
• Patients may be underweight at type 1 diabetes onset
• The initial goal may be to provide a higher-calorie diet to regain weight and control blood glucose

Caloric Distribution

• ADA and the Academy of Nutrition and Dietetics recommend 50-60% of calories from carbohydrates, 20-30% from fat, and 10-20% from protein
• Majority of carbohydrate selections should come from whole grains
• Carbohydrates consist of sugars and starches
• Low glycemic index diets may reduce postprandial glucose levels
• Sucrose should be eaten in moderation (up to 10% of total calories)
• Recommendations regarding fat content: reduce to <30% of total calories and limit saturated fats to 10% of total calories
• Limit dietary cholesterol to <300 mg/day
• Include nonanimal protein sources
• Reduce protein intake in patients with early kidney disease
• Increased fiber may improve blood glucose levels, decrease the need for exogenous insulin, and lower total cholesterol and LDL levels
• Soluble fiber has a greater role in lowering blood glucose and lipid levels than insoluble fiber

General Considerations for Exercise

• Exercise three times each week with no more than 2 consecutive days without exercise
• Perform resistance training twice a week if you have type 2 diabetes
• Exercise at the same time of day and for the same duration each session
• Use proper footwear and protective equipment
• Avoid trauma to the lower extremities, especially if you have numbness due to peripheral neuropathy
• Inspect feet daily after exercise
• Avoid exercise in extreme heat or cold
• Avoid exercise during periods of poor metabolic control
• Stretch for 10 to 15 minutes before exercising

Monitoring Glucose Levels and Ketones

• Self-monitoring of blood glucose (SMBG) levels is a method of capillary blood glucose testing
• Recommended SMBG occurs for many patients taking insulin during important circumstances
• Enable people with diabetes to individualize their treatment regimen for optimal control
• Allows for detection and prevention of hypoglycemia and hyperglycemia
• Plays a crucial role in normalizing blood glucose levels
• Obtain a drop of blood from the fingertip, apply it to a reagent strip, and read with a meter
• Meters offer features such as monthly averages, tracking events, and downloading capacity
• Calibrate blood glucose readings to plasma values
• Patient should know whether their monitor and strips provide whole blood or plasma results
• Must match the skill level and physical capabilities of patients
• Factors affecting SMBG performance: visual acuity, fine motor coordination, cognitive ability, comfort with technology, and cost
• Meters available for patients with visual impairments and for checking both blood glucose and blood ketone levels
• Most insurance companies cover costs of meters and strips
• SMBG carries the risk of erroneous values due to incorrect techniques
• The drop of blood is too small
• Damaged reagent strips are caused by heat or humidity
• The use of outdated strips
• Improper meter cleaning and maintenance is important
• Nurses provide initial education about SMBG techniques
• Evaluate techniques of experienced patients
• Patients should compare their meter result with a laboratory-measured blood glucose level every 6-12 months and have their technique observed
• The accuracy of the meter and strips can be assessed with control solutions

Managing Glucose Control in the Hospital Setting

• Hyperglycemia prolongs lengths of stay and increases infection rates and mortality
• Nurses need to address glucose management in all hospital patients
• Hyperglycemia occurs most often in patients with known diabetes and in those newly diagnosed with diabetes or stress hyperglycemia
• Blood glucose targets are 140 to 180 mg/dL
• Insulin (subcutaneous or IV) is preferred to oral antidiabetic agents to manage hyperglycemia
• Hospital insulin protocols or order sets should minimize complexity, ensure adequate staff training, include standardized hypoglycemic treatment, and make guidelines available for glycemic goals and insulin dosing
• Appropriate timing of blood glucose checks, meal consumption, and insulin dose are all crucial for glucose control and to avoid hypoglycemia
• Providing Patient Education: a lifetime of self-management skills
• MNT, physical activity, medication, and physical and emotional stress affect diabetic control
• Developing a Diabetes Education Plan: reinforcements of self-management skills, regardless of the setting
• Certified Diabetes Educators (CDEs) specialize in diabetes education and management
• All nurses play a vital role in identifying patients with diabetes, assessing self-care skills, providing basic education, reinforcing the education