Diabetes Transcript - Learn About Diabetes

Diabetes Transcript Part 1 Announcement Before the Diabetes Lecture I hope everyone is doing well. Before we dive into the diabetes lecture, I just want to make one quick announcement. As you know, the Eagles parade will be this Friday, which was also scheduled to be our test day. We're going to mo...

Diabetes Transcript Part 1 Announcement Before the Diabetes Lecture I hope everyone is doing well. Before we dive into the diabetes lecture, I just want to make one quick announcement. As you know, the Eagles parade will be this Friday, which was also scheduled to be our test day. We're going to move the test to Monday instead. As a result, you'll receive the full diabetes lecture today—both the lecture that was supposed to be covered on Thursday and the one for Monday. The test will be on Monday afternoon, starting promptly at 12:30 p.m. Following the test, Professor Schreger will begin her lecture on amputations. Now, let's get started on the diabetes lecture. Facts on Diabetes: ​ Prevalence: Diabetes affects 34.2 million Americans, which is 10.5% of the U.S. population. Of these, 26.8 million are diagnosed, and 7.3 million are undiagnosed.​ ​ CDC Statistics:​ ○​ Just over one in ten Americans have diabetes. ○​ Approximately one in three adults in the U.S. (88 million) have prediabetes. ○​ New cases of diabetes are higher among non-Hispanic Blacks and individuals of Hispanic origin than among non-Hispanic Asians and non-Hispanic Whites. ○​ The percentage of existing diabetes cases was highest among American Indians and Alaskan Natives. Among this group: ​ 15% were smokers ​ 89% were overweight ​ 38% were physically inactive ​ 37% had chronic kidney disease (stages 1-4) ​ Fewer than 25% with moderate to severe chronic kidney disease (stages 3 or 4) were aware of their condition. ​ Trends and Demographics:​ ○​ New cases of type 1 and type 2 diabetes have significantly increased among U.S. youth, particularly those aged 10 to 19. ○​ Incidence of type 2 diabetes remained stable among non-Hispanic Whites but increased for all other groups, especially non-Hispanic Blacks. ○​ Between 2005 and 2016, the percentage of adults with prediabetes who were aware of their condition doubled, but most continued to be unaware. Understanding Diabetes: Diabetes is a primary disorder of glucose metabolism, resulting from either an absence or insufficient supply of insulin or poor utilization of available insulin in the body. Those are the key facts for today’s lecture. Let’s continue. Lecture: Diabetes Learning Outcomes: 1.​ Relate the pathophysiology to the clinical manifestations of diabetes mellitus. 2.​ Compare and contrast the differences between Type 1 and Type 2 diabetes mellitus. 3.​ Determine the possible complications associated with diabetes mellitus. 4.​ Relate the role of nutrition, exercise, and acute medical interventions in the management of diabetes mellitus. 5.​ Describe the diagnostic studies used to diagnose and monitor diabetes. 6.​ Compare indications, administration, actions, and nursing considerations for insulin and oral hypoglycemic agents. 7.​ Differentiate information to be taught to patients receiving diabetes medication. 8.​ Organize a teaching plan for self-care strategies for patients with diabetes. 9.​ Organize and plan care based on interprofessional care recommendations and the nursing process for patients with diabetes mellitus. The Pancreas: Functions and Structure The pancreas has both digestive and endocrine functions. ​ Digestive Function: It secretes digestive enzymes. ​ Endocrine Function: It secretes hormones, including insulin and glucagon. The pancreas contains clusters of cells known as the Islets of Langerhans, which are located throughout the organ. These islets contain three types of cells: ​ Alpha Cells: These produce glucagon, a hormone that acts opposite to insulin. It stimulates the release of glucose from stored glycogen when blood glucose levels are low.​  ​ Beta Cells: These produce insulin and amylin. Insulin allows the body’s cells to use and store carbohydrates, fats, and proteins. Amylin is a glucose-regulating hormone that affects postprandial glucose levels by:​ ○​ Impairing glucagon secretion ○​ Slowing the rate at which glucose travels to the small intestine for absorption. ​ Delta Cells: These produce somatostatin, which acts within the Islets of Langerhans to inhibit the production of both glucagon and insulin. Somatostatin also slows gastrointestinal motility, allowing more time for food to be stored and absorbed.​ Small Intestines and Hormones The small intestines secrete glucagon-like peptide 1 (GLP-1), which you may have heard about recently, especially in relation to medications that help with weight loss. Another hormone secreted is glucose-dependent insulinotropic polypeptide (GIP). Both of these hormones increase insulin release after food ingestion. Medications and Hormonal Interactions Some newer medications enhance the action of GLP-1 or inhibit the enzyme that inactivates the incretin hormone. This enzyme inactivation is important because it affects the action of these hormones in regulating glucose metabolism. Glucagon: The Counterregulatory Hormone Here’s a look at the alpha cells in the pancreas, which produce glucagon. Glucagon is the counterregulatory hormone that has the opposite effect of insulin. It stimulates the release of glucose from storage sites when blood glucose levels are low. Specifically, glucagon: ​ Stimulates the breakdown of glycogen in the liver ​ Promotes the formation of carbohydrates in the liver ​ Stimulates the breakdown of lipids in both the liver and adipose tissue The primary function of glucagon is to decrease glucose oxidation and increase blood glucose levels. Insulin and Its Role Insulin allows body cells to use and store carbohydrates, fats, and proteins. It binds to insulin receptors on the cell membrane, causing a change in the membrane structure that allows glucose to enter the cell. Liver Functions: In the liver: ​ Glycogenesis (the formation of glycogen from glucose) is promoted. ​ Glycogenolysis (the breakdown of glycogen into glucose) is inhibited. ​ Ketogenesis (the formation of ketones) is also inhibited. Insulin's Effects on the Body ​ In Muscles: Insulin promotes protein and glycogen synthesis. ​ In Fat Cells: Insulin promotes triglyceride storage. Structure of Insulin Insulin is composed of two polypeptide chains: the A chain and the B chain, which are connected by the C chain. When the C chain is cleaved by enzymes, it is released. The presence of the C peptide chain in blood and urine can be tested to indicate beta cell function in terms of insulin production. Insulin's Journey After Production After insulin is produced, it travels to the liver and then into the systemic circulation. In the liver, insulin promotes the conversion of glucose into glycogen, which is then stored. Additionally, insulin: ​ Promotes glycogenesis, the formation of glycogen from glucose. ​ Inhibits glycogenolysis, the breakdown of glycogen into glucose in the liver. ​ Inhibits ketogenesis, the production of acetone and other ketones. ​ Inhibits gluconeogenesis, the formation of glucose from fats and proteins, including amino acids, fats, or other carbohydrate sources. Effects of Insulin in the Liver In the liver, insulin: ​ Promotes the production and storage of glycogen while inhibiting its breakdown into glucose. ​ Increases protein and lipid synthesis. ​ Inhibits the synthesis of glucose from fat and proteins. Insulin's Effects on Muscle and Fat Cells ​ In Muscles: Insulin promotes protein and glycogen synthesis. ​ In Fat Cells: Insulin promotes triglyceride storage. Insulin Structure and Function Insulin is composed of two polypeptide chains: chain A and chain B, which are connected by chain C. When the C chain is cleaved by enzymes, the C peptide chain is released. This C peptide can be tested in the blood and urine to assess beta cell function in relation to insulin production. Insulin's Role in Blood Glucose and Lipid Regulation Insulin helps maintain normal blood glucose and lipid levels. There are two primary phases of insulin secretion: 1.​ Basal Insulin Secretion: This is the constant, low-level release of insulin during fasting. 2.​ Prandial Insulin Secretion: This increases after eating. Generally, insulin levels rise within minutes of food ingestion, peak around 3 to 5 minutes, and return to baseline within 2 to 3 hours. For example, in a hospital setting, when a patient knows that food carts are about to arrive on the floor, insulin levels will already begin to rise in anticipation of food. If a blood glucose test is taken during this time, it could be inaccurate because of the rising insulin levels. Best Practices for Blood Sugar Testing It is crucial not to take a blood sugar test while the person is eating or immediately after they have eaten, as the result will be skewed. This is especially important when using a sliding scale to administer insulin, as the timing of the test can affect the accuracy. Mimicking Natural Insulin Secretion In diabetes management, we try to mimic the natural secretion of insulin in the body. This is done through methods like ACHS (Before meals, at bedtime) and SSI (Sliding Scale Insulin) checks. While insulin levels in these methods can resemble natural secretion to some extent, they may vary depending on the patient’s individual insulin production. Absence of Insulin and the Effects on the Body In the absence of insulin, hyperglycemia (high blood glucose) occurs, leading to several symptoms and complications: 1.​ Polyuria: This is osmotic diuresis, where the kidneys try to eliminate excess glucose through urine, resulting in frequent urination. 2.​ Polydipsia: Excessive thirst, as the body becomes dehydrated from the loss of fluids due to polyuria. 3.​ Polyphagia: Decreased energy production since glucose cannot enter the cells. Despite eating more, the person may lose weight due to water loss and the breakdown of fats and proteins for energy. Metabolic Acidosis and Respiratory Compensation The body's response to these issues can lead to metabolic acidosis, a condition where the body becomes too acidic. To compensate, the body increases the rate and depth of breathing to expel carbon dioxide (CO2) and acetone, leading to Kussmaul respirations—a deep, rapid breathing pattern. This results in a fruity odor on the person's breath, caused by the acetones being exhaled. Complications from Hyperglycemia ​ Hemoconcentration: Increased blood concentration due to dehydration. ​ Hypovolemia: Decreased blood volume from fluid loss. ​ Hyperviscosity: Thick, concentrated blood. ​ Hypoperfusion: Decreased circulation to tissues. ​ Hypoxia: Poor oxygenation of tissues, especially in the brain. ​ Altered Potassium Levels: Imbalance in potassium, which can affect heart and muscle function. Glucose: The Body's Energy Source Glucose is a simple sugar that provides energy to all cells in the body. It enters cells from the bloodstream to be used as fuel. There are other simple sugars: ​ Fructose: Found in fruits, honey, and root vegetables. ​ Lactose: Found in dairy products like milk. Fat Metabolism and Ketone Production In the absence of insulin, glucose cannot enter cells, so the body resorts to fat metabolism for energy. When fat is broken down, fatty acids are produced as byproducts. These fatty acids convert into ketone bodies (ketones), which serve as an alternative energy source. However, the accumulation of ketones in the blood leads to metabolic acidosis in the absence of insulin. Normal Insulin Function and Blood Glucose Regulation Under normal conditions, when blood glucose levels rise, the pancreas releases insulin. Insulin helps cells take up glucose from the blood and also signals the liver to produce glycogen (stored glucose). As a result, blood glucose levels fall back to normal. Low Blood Glucose and the Role of Glycogen If a person has low blood glucose, the pancreas releases glucagon to signal the liver to break down glycogen into glucose, which then raises blood glucose levels. This process helps restore normal blood sugar levels. Definition of Diabetes Mellitus Diabetes mellitus is a chronic, multisystem disease related to abnormal insulin production and impaired insulin utilization. It often develops long before a person is aware that they have it. In its early stages, during the prediabetes phase, the person may feel fine and not realize anything is wrong. Routine yearly blood work can sometimes catch this condition early, helping to identify elevated glucose levels that are higher than normal but not yet high enough to be diagnosed as diabetes. Fasting blood sugar levels between 100 and 126 mg/dL are indicative of prediabetes. Risks and Complications of Prediabetes People with prediabetes are at a higher risk of developing type 2 diabetes, often within 10 years. At this stage, damage to the heart and blood vessels may already be occurring. If no action is taken to prevent or delay the onset of type 2 diabetes, the condition can progress. Lifestyle Changes to Prevent Diabetes To reduce the risk of developing type 2 diabetes, lifestyle changes are crucial, including: ​ Maintaining a healthy weight ​ Exercising regularly ​ Eating a healthy diet Impact of High Blood Sugar Levels As I’ve mentioned in previous lectures, high blood sugar levels can be damaging to organs over time. When left unchecked, this can lead to significant damage to various body systems. However, if caught early, changes in lifestyle can help manage blood sugar levels and prevent the condition from progressing into full-blown diabetes. Understanding Prediabetes and Type 2 Diabetes Prediabetes is used to identify individuals at risk of developing type 2 diabetes. It is characterized by increased levels of fasting blood glucose and HbA1c. HbA1c reflects the average blood sugar levels over the past 120 days by measuring sugar levels attached to red blood cells. People with impaired glucose tolerance have insulin present, but for some reason, their body isn’t utilizing it effectively. In these cases, the body doesn’t allow glucose to move from the bloodstream into cells via insulin. This can sometimes be managed with medications that improve glucose absorption. Prediabetes and Associated Risks People with prediabetes also have an increased risk for other conditions, such as heart disease and stroke, due to the buildup of excess sugar in the blood. Type 1 Diabetes Mellitus Type 1 diabetes is characterized by little to no insulin production by the pancreas. It was once referred to as childhood diabetes or juvenile diabetes because it often develops early in life. However, with changing eating habits and lifestyle, type 2 diabetes is now being diagnosed in younger people as well. Type 1 diabetes is still primarily diagnosed before age 30, with the peak onset between ages 11 and 13. Former Terminology and Onset ​ Former Names: Type 1 diabetes was previously known as juvenile-onset diabetes or insulin-dependent diabetes mellitus (IDDM). ​ Age of Onset: Although type 1 is most commonly diagnosed in individuals under age 30, the onset is typically between ages 11 and 13. Etiology and Pathophysiology of Type 1 Diabetes Type 1 diabetes is considered an autoimmune disorder, where the body's immune system attacks its own tissues. The autoimmune process leads to the destruction of the beta cells in the pancreas, which are responsible for insulin production. This results in an absolute loss of insulin. The development of type 1 diabetes is thought to involve: 1.​ Genetic predisposition: The condition is believed to be linked to human leukocyte antigens (HLAs). 2.​ Viral exposure: Exposure to a virus may trigger the immune system to attack the beta cells, either directly or through an autoimmune response. Destruction of Beta Cells ​ T Cells: In type 1 diabetes, T cells of the immune system progressively destroy the body’s beta cells in the pancreas. ​ Autoantibodies: These autoantibodies cause a reduction of 80-90% of normal beta cell function before symptoms manifest. Progressive Destruction The destruction of beta cells is progressive, meaning that significant loss of beta cell function occurs before any symptoms are apparent. Though it is primarily classified as an autoimmune disorder, some cases of type 1 diabetes are classified as idiopathic, meaning the cause is unknown. Type 1 Diabetes: Disease Onset and Clinical Manifestations One of the key manifestations of type 1 diabetes is weight loss. It is part of the classic triad of symptoms of hyperglycemia, which includes polyuria, polydipsia, and polyphagia. ​ Polyuria: Excessive urination ​ Polydipsia: Excessive thirst ​ Polyphagia: Excessive hunger These symptoms can sometimes develop rapidly when the body is no longer able to produce insulin. Type 1 diabetes is often discovered when a patient presents to the emergency department with these clinical manifestations. Mechanisms Behind Symptoms ​ Weight Loss: This occurs because the body cannot obtain glucose for energy, so it begins using fats and proteins as alternative energy sources. ​ Polyuria: Excessive urination happens as a result of high blood glucose levels. ​ Polydipsia: The body becomes dehydrated due to excessive urination, leading to extreme thirst. ​ Polyphagia: Despite the high blood sugar levels, the body is unable to use glucose, causing a constant feeling of hunger. Other Symptoms and Complications ​ Ketoacidosis: Patients with type 1 diabetes may develop ketoacidosis, a serious condition that will be discussed later. ​ Blurred Vision: This occurs due to osmotic effects, which cause swelling of the lenses in the eyes. ​ Glycosuria: This refers to the excretion of glucose in the urine when blood glucose levels exceed the renal threshold. Managing Type 1 Diabetes People with type 1 diabetes require insulin injections to manage their blood glucose levels. In modern times, many individuals consistently monitor their glucose levels, either using a wearable device on their arm or performing regular blood tests. Additionally, many have insulin pumps that automatically inject insulin. However, for very young children, careful monitoring is still necessary, and they may not be ready to manage insulin injections on their own just yet. Type 2 Diabetes Mellitus Type 2 diabetes, also known as non-insulin dependent diabetes mellitus (NIDDM) or adult-onset diabetes, accounts for over 90% of all diabetes cases. ​ Prevalence: 80-90% of patients with type 2 diabetes are overweight at the time of diagnosis. ​ Increasing Incidence in Children: Type 2 diabetes is increasingly being diagnosed in children due to rising childhood obesity rates, and it may also have a genetic predisposition. Risk Factors for Type 2 Diabetes Several factors increase the risk of developing type 2 diabetes: 1.​ Body Mass Index (BMI):​ ○​ A BMI greater than 26 kg/m² is considered overweight. ○​ The risk of developing type 2 diabetes significantly increases with a BMI greater than 30 kg/m², which is classified as obesity. 2.​ Physical Inactivity: Lack of exercise is a major risk factor.​ 3.​ HDL Cholesterol Levels: Low levels of HDL cholesterol (less than or equal to 35 mg/dL) increase the risk of diabetes.​ ○​ HDL cholesterol helps remove fat from the bloodstream, so low levels are undesirable. 4.​ Triglyceride Levels: High levels of triglycerides (greater than or equal to 250 mg/dL) are also a risk factor for type 2 diabetes.​ ○​ Elevated triglycerides contribute to increased fat accumulation and poor cardiovascular health. Non-Modifiable Risk Factors for Type 2 Diabetes Mellitus Several non-modifiable risk factors increase the likelihood of developing type 2 diabetes: 1.​ First-degree relative with diabetes mellitus: Having a parent or sibling with diabetes increases the risk. 2.​ Ethnic Groups at High Risk: ○​ African American ○​ Latino ○​ Native American ○​ Asian American ○​ Pacific Islander 3.​ Women diagnosed with gestational diabetes or those who have delivered a baby weighing 9 pounds or more. 4.​ Hypertension: Blood pressure greater than or equal to 140/90 mmHg or current therapy for hypertension. 5.​ Polycystic Ovary Syndrome (PCOS): Women with PCOS are at a higher risk. 6.​ Previous HbA1c levels greater than or equal to 7.5%: Indicates poor blood sugar control in the past. 7.​ History of cardiovascular disease: Increases the likelihood of developing type 2 diabetes. Insulin Production in Type 2 Diabetes In type 2 diabetes, the pancreas continues to produce some insulin. However, it is either produced in insufficient quantities or is poorly used by the tissues due to insulin resistance. This is a major distinction from type 1 diabetes, where there is virtually no endogenous insulin produced by the body. Type 2 Diabetes: Etiology and Pathophysiology Insulin Resistance: In type 2 diabetes, the body does not respond properly to endogenous insulin, leading to hyperglycemia. This occurs in both glucose and lipid metabolism. The tissues of the body, including those in the skeletal muscle, fat, and liver, either fail to respond to insulin or have insufficient insulin receptors. If insulin is not effectively used, glucose is not brought into the cells to be used for energy, causing high blood sugar levels. Remember the "Three P's": ​ Polyuria (excessive urination) ​ Polydipsia (excessive thirst) ​ Polyphagia (excessive hunger) Decreased Insulin Production In type 2 diabetes, there is also decreased production of insulin by the pancreas. The beta cells in the pancreas fail, meaning insulin is either insufficiently produced or ineffective at controlling blood glucose. Inappropriate Glucose Production by the Liver In addition to insulin resistance, glucose production by the liver becomes dysregulated. Normally, the liver releases glucose based on the body’s glucose needs. However, in type 2 diabetes, the liver no longer responds appropriately to glucose levels and continues to release glucose into the bloodstream, contributing to hyperglycemia. Type 2 Diabetes Mellitus: Etiology and Pathophysiology (Continued) Alterations in Hormones and Cytokines by Adipose Tissue Adipose tissue plays a significant role in glucose and fat metabolism. It is considered an active endocrine organ that, in addition to regulating fat mass and nutrient balance, releases a wide range of bioactive mediators (adipokines). These adipokines signal to organs that are important for metabolic functions, including the brain, liver, skeletal muscle, and the immune system. This signaling helps regulate: ​ Homeostasis ​ Blood pressure ​ Lipid metabolism ​ Glucose metabolism ​ Inflammation ​ Atherosclerosis In the presence of atherosclerosis, these disruptions can further contribute to metabolic dysfunction. Comparison of Type 1 and Type 2 Diabetes ​ Type 1 Diabetes:​ ○​ Genetic susceptibility plays a role, with individuals developing autoantibodies months to years before a diagnosis of type 1 diabetes.  ○​ This condition usually develops at a young age, with a progressive autoimmune destruction of beta cells in the pancreas. ○​ As much as 80-90% of beta cell function is lost before hyperglycemia is detected and the diagnosis of type 1 diabetes is made. ​ Type 2 Diabetes:​ ○​ Insulin resistance is the hallmark of type 2 diabetes, caused by an inherited defect in insulin receptors. This defect is found in all patients with type 2 diabetes. ○​ Insulin resistance can precede the development of impaired glucose tolerance and type 2 diabetes by as much as 3 to 4 decades. ○​ This resistance stimulates the pancreas to produce more insulin, but eventually, the beta cells lose their ability to produce enough insulin to overcome the resistance, leading to hyperglycemia and the diagnosis of diabetes. Excessive Hepatic Glucose Production In type 2 diabetes, excessive glucose production by the liver contributes to hyperglycemia both during fasting and after eating (postprandial). Metabolic Syndrome Metabolic syndrome is a group of abnormal conditions that act together to increase the risk for cardiovascular disease and type 2 diabetes. These include: 1.​ Obesity 2.​ Hyperglycemia 3.​ Hypertension 4.​ Dyslipidemia (abnormal cholesterol levels) 5.​ Increased risk of atherosclerosis 6.​ Increased risk of stroke, cardiac disease, and early death Syndrome X and Risk Factors Also known as Syndrome X, this condition includes the following risk factors for type 2 diabetes and cardiovascular disease: ​ Elevated insulin levels ​ Hypertension ​ Elevated triglycerides  ​ Decreased HDL cholesterol ​ Visceral obesity (fat around internal organs) ​ Fasting blood glucose greater than 110 mg/dL It is important to note that this fasting blood glucose level is from a standard blood draw, not an HbA1c test. Type 2 Diabetes Mellitus: Etiology, Pathophysiology, and Risk Factors Metabolic Syndrome Risk Factors: ​ Central Obesity: This is often referred to as an "apple-shaped" body, where excess fat is stored around the abdomen. ​ Sedentary Lifestyle: Lack of regular physical activity increases the risk. ​ Urbanization/Westernization: Lifestyle changes associated with urbanization and Western diets contribute to the development of type 2 diabetes. Prevention and Management: Type 2 diabetes can often be prevented or delayed through: ​ Weight loss ​ Regular exercise Understanding Central Obesity and Its Effects: ​ Central obesity, high blood pressure, elevated triglycerides, low HDL cholesterol, and high LDL cholesterol contribute to insulin resistance. These factors are all part of metabolic syndrome, which increases the risk for type 2 diabetes. Onset of Type 2 Diabetes Mellitus: The onset of type 2 diabetes is usually gradual, as the condition has been developing over time without noticeable symptoms. ​ High blood sugar levels are toxic to the body and can cause damage even before symptoms are recognized. ​ People with undetected hyperglycemia may go for years without realizing they have the condition.  ​ Eventually, they may present with the classic symptoms of hyperglycemia, including the three P's (polyuria, polydipsia, and polyphagia). Important Note: Just because a person is not experiencing symptoms does not mean that damage to the body is not occurring. High blood sugar levels can cause ongoing harm, even in the absence of noticeable symptoms. Type 2 Diabetes: Clinical Manifestations The classic triad of hyperglycemia includes: ​ Polyuria (excessive urination) ​ Polydipsia (excessive thirst) ​ Polyphagia (excessive hunger) However, these symptoms are not always present in type 2 diabetes. ​ Weight loss is uncommon in type 2 diabetes. ​ Recurrent infections and poor wound healing are common, particularly when diabetes is combined with coronary artery disease (CAD), which can lead to wounds on the lower legs. ​ Visual changes may also occur, which are often seen in peripheral vascular disease (PVD). ​ Renal insufficiency and paresthesia (numbness or tingling) are other common manifestations. Comparing Type 1 and Type 2 Diabetes Mellitus You should be able to compare the similarities and differences between type 1 and type 2 diabetes. Here's a brief comparison: ​ Cause:​ ○​ Type 1: Destruction of beta cells leading to a lack of insulin. ○​ Type 2: Insulin resistance or insulin deficiency. ​ Incidence:​ ○​ Type 1: Accounts for 5-10% of diabetes cases.  ○​ Type 2: Accounts for 90-95% of diabetes cases. ​ Onset:​ ○​ Type 1: Typically occurs in children and young adults, usually under 35 years old. ○​ Type 2: Typically develops in individuals older than 35 years old. ​ Onset Speed:​ ○​ Type 1: Rapid onset. ○​ Type 2: Gradual onset. ​ Body Weight:​ ○​ Type 1: Often associated with weight loss. ○​ Type 2: Often associated with weight gain or obesity. Symptoms of Type 1 and Type 2 Diabetes ​ Type 1 Diabetes: ○​ Classic Symptoms: Polyuria (excessive urination), polydipsia (excessive thirst), polyphagia (excessive hunger), and weight loss. ​ Type 2 Diabetes: ○​ Classic Symptoms: The same as type 1, including polyuria, polydipsia, and polyphagia, but also includes: ​ Recurrent infections ​ Fatigue ​ Blurred vision ○​ Ketosis: Often present in type 1 with poor control, but infrequent in type 2. Treatment for Type 1 and Type 2 Diabetes ​ Type 1 Diabetes:​ ○​ Insulin Replacement: Insulin shots are required daily. ○​ Diet and Exercise: Important for overall health, but weight gain, rather than weight loss, is the goal. ○​ Lipid and Blood Pressure Control: Monitoring fats and blood pressure is essential to prevent complications. ​ Type 2 Diabetes:​ ○​ Initial Treatment: ​ Start with diet and exercise, aiming for weight loss and lipid control. ​ If these measures are insufficient, oral medications may be added.  ○​ If Oral Medications Don’t Work: Insulin therapy may be needed. ○​ Lipid and Blood Pressure Control: Just like in type 1, managing lipids and blood pressure is crucial for type 2. Gestational Diabetes Gestational diabetes develops during pregnancy and is typically detected between 24 to 28 weeks of gestation. It increases the risk for: ​ Cesarean delivery ​ Prenatal death ​ Neonatal complications (often due to the baby being very large) Risk for Future Type 2 Diabetes Gestational diabetes also increases the risk of developing type 2 diabetes later in life. According to the CDC, reported rates range from 2 to 10% of women who develop gestational diabetes and will experience it again as they age. Postpartum Considerations ​ Blood sugar levels: Most women return to normal blood sugar levels after delivery. ​ However, 5 to 10% of women are found to have type 2 diabetes after giving birth. Treatment ​ Nutritional therapy is the first-line treatment for managing gestational diabetes. ​ If nutritional therapy is not effective, medications may be added. Cause of Post-Pregnancy Diabetes It is thought that the persistence of diabetes after pregnancy is related to the placenta, but this often resolves over time. Secondary Diabetes Secondary diabetes occurs due to other conditions that cause high blood glucose. For example, patients may experience elevated blood sugars when taking corticosteroids. Managing High Blood Sugar in the Hospital When you receive a patient in the hospital and draw their labs, if you notice a blood sugar of 200 mg/dL or higher, it's important to investigate the medications they are on. Ideally, this should have been checked before, but now you need to know the medications they are taking, as some can cause elevated blood sugar levels. Medications and Conditions Causing Secondary Diabetes Certain medications and conditions can lead to secondary diabetes. Be aware of these potential causes: ​ Cushing's syndrome ​ Hyperthyroidism ​ Recurrent pancreatitis ​ Parenteral nutrition (TPN) Medications that can cause elevated blood glucose include: ​ Corticosteroids (such as prednisone) ​ Phenytoin (Dilantin) ​ Antipsychotic medications It is well-known that secondary diabetes often resolves once the underlying condition is treated or the exacerbation passes. Understanding these factors will help you manage the patient’s care more effectively. Important Considerations for Diagnosis When treating a patient, it's crucial to gather all relevant information. For example, if you're preparing to give insulin and don't know why the patient’s blood sugar is high, they might express confusion, saying they've never been diabetic. This could be due to medications like steroids or conditions like Cushing's syndrome. In this case, you can inform the patient that the high blood sugar is due to these factors, especially if their doctor hasn't yet explained it. Diagnostic Criteria for Diabetes 1.​ Fasting Plasma Glucose:​ ○​ A level greater than or equal to 126 mg/dL is diagnostic for diabetes. 2.​ Random Plasma Glucose:​ ○​ A level greater than 200 mg/dL combined with symptoms of hyperglycemia (such as the three P's) can also indicate diabetes. However, a random test alone, without fasting, is not sufficient for diagnosis. 3.​ Oral Glucose Tolerance Test:​ ○​ A two-hour test with a glucose load of 75 grams resulting in a level greater than or equal to 200 mg/dL confirms diabetes. 4.​ Hemoglobin A1c:​ ○​ A value greater than or equal to 6.5% is considered diabetic. However, the threshold has recently been changed to 7.0% for diagnosing diabetes. ○​ Pre-diabetes is classified as an A1c between 5.7% and 6.4%. Pre-diabetes and Normal Blood Sugar Levels ​ Pre-diabetes: Blood sugar levels fall between 100 and 125 mg/dL. ​ Normal Levels: Blood sugar levels are less than 100 mg/dL. ​ Diabetes: A fasting blood glucose level of 126 mg/dL or higher is considered diagnostic for diabetes. For the Oral Glucose Tolerance Test (OGTT): ​ Greater than or equal to 200 mg/dL after two hours indicates diabetes. ​ 140 mg/dL or below is considered normal. You can find more information on these criteria from the American Diabetes Association. Diagnostic Studies: Hemoglobin A1c The Hemoglobin A1c (HbA1c) test measures the amount of glucose that has attached to hemoglobin molecules over their lifespan, which is about 120 days. ​ Ideal A1c for diabetics: Less than 7%. What Does the A1c Test Measure? The A1c test reflects your average blood glucose levels over the past 2 to 3 months (or 90 to 120 days). Since red blood cells have a lifespan of about 120 days, the A1c test provides a good indication of your overall glucose control during that time. The A1c test is often compared to a baseball player's season batting average. While a single day’s test result is like one game’s batting record, the A1c gives a much clearer picture of how well your glucose is being controlled over several months. Why is the A1c Test Important for Diabetes Management? The A1c test helps: ​ Confirm self-testing results: You can compare home blood sugar tests with A1c results. ​ Assess treatment effectiveness: It shows whether your current diabetes treatment plan is working. ​ Track the impact of lifestyle changes: Healthy choices, like diet and exercise, can be monitored through changes in A1c. How Does the A1c Test Work? Hemoglobin is a protein found in red blood cells that carries oxygen from the lungs to the body’s tissues. Glucose enters red blood cells and attaches to the hemoglobin molecules, a process known as glycation. The more glucose in the bloodstream, the more glucose binds to hemoglobin. By measuring the percentage of glycated hemoglobin (A1c) in the blood, the test provides an overview of your average blood glucose control for the past few months. How Often Should A1c Levels Be Measured? Your doctor should measure your A1c levels at least twice a year to track your long-term glucose control. Other Diagnostic Tests and Monitoring Urine Testing:​ Urine testing was once the mainstay for diabetes testing but is now considered less reliable. It is still used to assess ketones in type 1 diabetes during hyperglycemia, illness, or pregnancy, and as part of the evaluation for ketoacidosis. ​ Ketones should not be present in a healthy person’s urine. They are a byproduct of altered metabolism that occurs when the body uses fat as a replacement for glucose (fuel). ​ When the body is deprived of carbohydrates, as in the case of the keto diet, it begins to break down fat stores for energy, which results in ketones in the urine. ​ Over time, if this process continues, the body may also break down muscle tissue for fuel, which is why ketones appear in the urine. Serum Cholesterol and Triglycerides:​ These tests are used to identify the risk for cardiovascular disease. Elevated levels of cholesterol and triglycerides are associated with an increased risk of heart disease, particularly in individuals with diabetes. Diagnostic Monitoring of Glucose Levels Monitoring blood glucose levels is a cornerstone of diabetes management. One of the most common tools used for this is the One Touch meter, also known as an acute check. Self-monitoring of blood glucose (SMBG) allows patients to achieve better glucose control and manage their disease more closely. ​ Pre-meal checks: Done to guide insulin delivery. ​ Post-meal checks: Done to assess postprandial glucose levels and monitor disease control. This regular monitoring enables patients to make informed decisions about self-management regarding diet, exercise, and medications. Continuous Glucose Monitoring Some of the newer technologies today offer continuous blood glucose monitoring with a sensor inserted under the skin. This device provides glucose readings every few minutes, which patients can access through their phones, giving them real-time data to track their glucose levels. However, patients must follow specific instructions for each device to ensure accurate operation and reliable results. Collaborative Care Goals The goal of collaborative care is to: ​ Reduce symptoms ​ Promote overall well-being ​ Prevent acute complications ​ Delay the onset and progression of long-term complications These goals can be achieved when the patient is able to maintain their glucose levels as close to normal as possible. Consistency in following their treatment plan is essential for success. Patient Education and Treatment Success Teaching patients about their condition is essential for their active participation in managing their care. When patients understand their disease, they are more likely to adhere to their treatment plan, which is crucial for the success of the treatment. Treatment Modalities Nutritional Management:​ It’s important to teach patients about: ​ A plant-based exercise program that fits their lifestyle. ​ Blood glucose monitoring: They should understand how and when to check their levels. ​ Pharmacological interventions: Ensure they understand the medications they are taking, why they’re taking them, and the best times to take them, especially if they need to take multiple doses throughout the day. Emphasize the importance of sticking to a regular schedule. The goal is to maintain normal blood glucose levels with either oral medications or insulin, along with proper nutrient intake. This can help reduce the risk of cardiovascular disease. Managing Lipids and Blood Pressure​ Additionally, it’s crucial to maintain normal levels of lipids and blood pressure to reduce the risk of: ​ Cardiovascular disease ​ Cerebrovascular disease ​ Strokes or other cardiovascular accidents Lifestyle Modifications​ Lifestyle changes play a significant role in the prevention and treatment of: ​ Obesity ​ Dyslipidemia (abnormal cholesterol levels) ​ Cardiovascular disease ​ Neuropathies and kidney damage These modifications can also prevent or slow the progression of chronic complications. Goals of Therapy ​ Respect cultural differences when making nutritional recommendations and respect the patient’s willingness to change. ​ Limit food choices only when scientifically indicated. For example, reducing fast food like McDonald's and encouraging more fresh fruits and vegetables. Weight Loss and Physical Activity​ If the patient is overweight, aim for weight loss through regular physical activity. The target should be about 7% of their current body weight, combined with 150 minutes of exercise per week. ​ Incorporate whole grains to make up half of total grain intake. ​ Ensure that dietary fiber reaches the recommended level of 14 grams per 1,000 calories. Most people don’t meet the recommended fiber levels. Low Glycemic Foods​ Encourage low glycemic foods that are rich in fiber to help reduce glucose spikes in the blood. These foods also help meet dietary fiber recommendations. Examples of high-fiber, low-glycemic foods include:  ​ Whole grains like wheat, rye, and quinoa ​ Sprouts and other high-fiber grains These recommendations apply to type 2 diabetes prevention, not type 1 diabetes. Carbohydrate Recommendations​ The best sources of carbohydrates come from: ​ Fruits and vegetables ​ Whole grains ​ Legumes ​ Low-fat dairy products Carb monitoring can be done using carb counting, exchanges, or experience-based estimation. For people who are familiar with managing their glucose, sucrose (table sugar) can be substituted for carbohydrates in the meal plan or covered by insulin or medication. These individuals are often able to manage their blood glucose by adjusting insulin doses to match the carbohydrate intake. Careful Consideration of Energy Intake​ Be cautious not to increase the amount of energy (calories) in the diet too much. Fructose-containing foods can cause a rise in blood glucose levels but are often less nutritious. ​ The minimum carbohydrate intake recommended by the FDA is 130 grams per day. Nutritional Recommendations Meal Planning:​ Meal planning for diabetes does not prohibit any specific foods but emphasizes moderation and balance. Here are the key guidelines for nutrient intake: ​ Protein: Should be low in fat, including saturated fats and cholesterol.​ ​ Fats: Should be low in saturated fats, trans fats, and cholesterol.​ ○​ Saturated Fats: Found in animal meats, butter, lard, bacon, cocoa butter, coconut oil, and hydrogenated oils. ○​ Polyunsaturated Fats: Found in oils such as corn, sunflower, soybean, sesame seed, and cottonseed.  ○​ Trans Fats: Found in partially hydrogenated vegetable oils (e.g., shortening) and animal fats. These fats lower HDL (good cholesterol) and increase LDL (bad cholesterol), leading to an increased risk of coronary heart disease. ○​ Monounsaturated Fats: Healthier fats found in oils like peanut oil, olive oil, and canola oil. Carbohydrates: ​ Focus on whole grains, fresh vegetables, and fresh fruits. ​ Limit simple sugars and processed foods. Alcohol: ​ Alcohol has no nutritional value, is high in calories, and can be detrimental to the liver. ​ Alcohol also has adverse effects when combined with oral diabetic medications and can potentiate hypoglycemia (low blood sugar). ​ The American Diabetes Association (ADA) recommends up to two drinks per day for men and one drink per day for women. Fiber Intake: ​ Recommended fiber intake: 14 grams per 1,000 calories or about 25 grams per day. ​ Sugar alcohols like fructose, sorbitol, and xylitol have calorie contents similar to table sugar (sucrose) but cause less elevation in blood glucose levels. These are often used in sugar-free foods. Daily Nutrient Recommendations: ​ Protein: Should account for 15-20% of total daily calories. ​ Fat: Should be less than 10% of total daily calories. ​ Carbohydrates: Should make up 45-65% of total daily calories, which equates to 130 grams per day. ​ Fiber: 14 grams per 1,000 calories. Other Considerations: ​ The 2000 milligram per day sodium limit should not be exceeded in the diet. ​ Refined sugars should be restricted, and nonnutritive sweeteners that are FDA-approved can be used.  ​ Again, alcohol may potentiate the hypoglycemic effects of medications, so moderation is key. Type 1 Diabetes: Nutritional Therapies Nutritional therapy for type 1 diabetes involves creating a meal plan that aligns with an individual’s usual food intake, exercise habits, and insulin regimen. The insulin plan should be developed based on the person’s eating habits and activity schedule. ​ Self-monitoring of blood glucose allows patients to make adjustments to insulin based on planned or unplanned dietary changes. ​ Rapid-acting insulin users can adjust their insulin before meals based on their blood sugar readings. ​ Intensified insulin therapy or an insulin pump may be considered for greater flexibility in food choices and deviations in usual eating or exercise routines. Type 2 Diabetes: Nutritional Goals For type 2 diabetes, the goal is to achieve normal glucose, lipid, and blood pressure levels. Patients using rapid-acting insulin can also make adjustments before meals based on blood glucose readings. ​ Obesity is a significant risk factor, and caloric reduction is crucial for weight management. ​ Reduce total fat intake and space meals throughout the day. ​ Insulin pumps can be used along with glucose level readers for flexibility in managing food and exercise patterns. Weight Loss and Glycemic Control ​ Weight loss of 5 to 10% can significantly improve glycemic control. ​ Exercise is essential for overall health, as it helps the body improve insulin sensitivity and glucose management. ​ It is important for patients to monitor their blood glucose levels, A1c, blood pressure, and lipid levels to track progress and maintain control over their condition. Meal Planning and Food Choices For meal planning, balance is key. Here is a basic breakdown:  ​ Breakfast: Aim for half starch, a quarter protein, low-fat milk, and a piece of fruit.​ ​ The plate method helps guide portion sizes, with:​ ○​ Grains (upper left corner) ○​ Meats (purple section) ○​ Fruits and vegetables (remainder of the plate) This is similar to the old food pyramid, but now it’s simpler to visualize and follow. The Diabetes Plate The Diabetes Plate is a simple way to guide meal planning. It breaks down the types of food you should focus on: ​ Green: Low-carbohydrate vegetables ​ Grains/Starchy Vegetables: This includes grains and starchy vegetables, such as potatoes or corn, and also fruits. ​ Protein: Lean meats or meat substitutes While the plate doesn't require you to eat fruit at every meal, it gives you flexibility in how you balance the food groups. Dietary Teaching and Exchange System ​ The Exchange System categorizes foods based on carbohydrates, meats and meat substitutes, and fats. This system helps predict the effects on blood glucose levels, allowing patients to anticipate how their glucose will respond and adjust insulin accordingly. ​ Patients are instructed on how much to eat from each group at each meal, with the flexibility to interchange fruits and vegetables as desired. Carb Counting Carb counting is critical for managing postprandial (after meal) glucose levels, as it has the greatest impact on blood sugar. The amount of carbohydrates consumed at each meal determines insulin dosage. ​ 15 grams of carbohydrates is equivalent to one carb exchange.  ​ Insulin doses can be adjusted based on the grams of carbohydrates consumed and activity levels. Meal Planning ​ Carbohydrates should be distributed consistently throughout the day in small meals and snacks. ​ If the patient is unable or unwilling to count carbs, fixed doses of insulin can be used. ​ A dietitian should be involved in meal planning, especially in a hospital setting, to ensure proper guidance and consistency with hospital policies. Involving the Family ​ Involve the patient’s family in meal planning, as they may also be responsible for cooking. It's essential that everyone in the household understands the dietary requirements and supports the patient’s treatment plan. Cultural and Nutritional Beliefs ​ Cultural beliefs and nutritional preferences play a significant role in adherence to dietary plans. If the patient or the person preparing meals does not align with the prescribed diet, adjustments need to be considered to ensure both health and cultural acceptance. Exercise Exercise is an essential part of diabetes management. Here are the benefits: ​ Check glucose levels before exercising to ensure safety. ​ Increases insulin sensitivity in muscle cells. ​ Lowers blood glucose levels and helps with weight loss. ​ Reduces triglycerides and LDL (bad cholesterol) while increasing HDL (good cholesterol). ​ Decreases blood pressure and improves circulation. Exercise, such as walking or other physical activities, plays a crucial role in managing blood sugar levels and overall health. Exercise and Diabetes Management ​ If medications cause hypoglycemia, it's important to exercise one hour after a meal or have a 10 to 15-gram carb snack 30 minutes prior to exercising. ​ Moderate, not strenuous exercise can trigger a counterregulatory mechanism in the body that starts to raise blood sugar levels on its own. The glucose-lowering benefits of exercise can last up to 48 hours after physical activity. Starting a New Exercise Program ​ Before beginning a new exercise program, especially if you have diabetes, medical clearance is essential. ​ Initially, you may need to check your glucose levels before, during, and after exercise to understand how your body reacts to it. ​ Always discuss your exercise plans with your doctor before starting, as glucose levels need to be monitored and considered alongside medications and diet. Exercise for Type 1 Diabetes ​ Type 1 diabetics must monitor their blood sugar before exercising and should not exercise if blood sugar levels are outside the normal range. ​ Ketones indicate that there is not enough insulin for glucose transport, and exercise could worsen the situation. Therefore, monitoring ketones is important to prevent complications. Exercise for Type 2 Diabetes ​ Exercise can help type 2 diabetics with weight loss, which may reduce medication and insulin requirements. Since most type 2 patients are overweight, returning to an optimal weight can significantly reduce the size and symptoms of diabetes. ​ In some cases, weight loss may result in patients being able to discontinue medications altogether. Monitoring Glucose Levels ​ Type 1 diabetes: Patients typically monitor glucose levels once a day (QD), or more frequently if they use an insulin pump.  ​ Type 2 diabetes: Monitoring is more variable, and patients should document their results alongside food intake and medication dosages. Many type 1 and type 2 patients now use self-monitoring blood glucose devices that are connected to their phones, allowing for more frequent monitoring. These devices are commonly worn on the back of the arm, and are easily visible through clothing. Teaching Patients to Monitor Blood Glucose Levels 1.​ Wash your hands with warm, soapy water before testing. 2.​ Avoid cleaning the site with alcohol. You should clean the site with alcohol to prevent contamination, but alcohol should not be used to clean the puncture site directly. 3.​ Warm your hands if needed. If it's difficult to get blood, soak your hands in warm water for a few minutes to bring the blood to the surface. 4.​ Use the side of the finger, not the center, for the puncture. 5.​ Puncture depth: The puncture should be deep enough to obtain drops of blood for testing. Important Points to Remember ​ Do not share glucose monitoring instruments. Hepatitis B can be transmitted through shared needles, and the virus can live in a dried state for up to a week on a needle. Continuous Glucose Monitoring ​ Continuous glucose monitoring (CGM) uses a sensor inserted under the skin to monitor interstitial fluid glucose levels.​ ​ The technology today is highly accurate, similar to acute checks, so there's no need to worry about differences in accuracy. (This note will be removed from the lecture content.)​ ​ Note: CGM does not replace fingerstick blood glucose tests, but it provides continuous monitoring and can be a helpful tool for tracking glucose trends.​ Acute Interventions and Sick Day Rules  ​ Never stop taking insulin or oral anti-diabetic agents, even if you do not feel well or cannot eat.​ ○​ Especially for type 1 diabetes, it is important to continue your medications as prescribed. ​ Monitor blood glucose levels more frequently—every 3 to 4 hours—and make insulin adjustments if necessary.​ ​ Test urine for ketones and glucose. This will help you detect any issues, such as a lack of insulin or inadequate carbohydrate intake. Ketones in the urine indicate that your body is not getting enough insulin, and early detection can help you manage the situation before it worsens.​ Acute Intervention and Sick Day Rules Alternatives to Solid Foods:​ When you are unable to eat solid foods, consider consuming the following alternatives to replace your carbohydrate allowance: ​ Milk ​ Soup ​ Cereal ​ Ice cream ​ Pudding ​ Fruit juice or fizzy drinks Hydration:​ It's essential to drink plenty of liquids, such as water or sugar-free beverages. Aim for: ​ 4 ounces of sugar-free, non-caffeinated liquids every half hour to prevent dehydration, or ​ At least 8 to 12 ounces every hour to ensure you’re staying hydrated. Sick Day Rules ​ Unable to eat for more than 24 hours: Contact your primary care physician or healthcare provider. ​ Vomiting or diarrhea lasting more than 6 hours: Contact your healthcare provider immediately. ​ Urine ketones: If ketones are moderate or large for more than 4 hours, you should contact your healthcare provider.  ​ Blood glucose levels remain high or low after two doses of insulin for treatment: Contact your healthcare provider. ​ Fever greater than 102°F lasting more than 12 hours or unresponsive to medication (e.g., Tylenol): Seek medical advice. ​ Rapid breathing, diarrhea more than 5 times, or lasting longer than 24 hours: Contact your healthcare provider immediately. Remember, diabetic patients have greater needs and are more fragile, so when experiencing illness or stress, it is crucial to stay vigilant and monitor closely. Impact of Acute Illness or Stress on Blood Glucose ​ Stress from surgery, illness, or emotional factors can raise blood glucose levels. ​ Hyperglycemia may occur due to the increase in catecholamines, cortisol, glycogen, growth hormones, and insulin resistance. ​ During stress, it is important to maintain and monitor blood glucose levels more frequently to avoid complications. Hyperglycemia in Stress:​ Hyperglycemia can increase the risk of: ​ Post-operative complications, including infection and delayed wound healing. ​ Fluid and electrolyte imbalances. ​ DKA (Diabetic Ketoacidosis), which we will cover in more detail later. Acute Illness and Its Effects on Blood Glucose ​ Illnesses such as upper respiratory infections and colds can cause blood glucose levels to become unstable. ​ It's essential to monitor your glucose levels closely during these times to keep them under control. When to Check for Ketones:​ If your blood glucose is greater than 240 mg/dL, perform a ketone check to ensure your body is not entering into a state of diabetic ketoacidosis (DKA). Type 1 and Type 2 Diabetes Management Before Surgery  ​ Type 1 Diabetes: Insulin should be administered before and after surgery. Even if the patient is NPO (nothing by mouth), insulin is still required.​ ​ Type 2 Diabetes: Discontinue oral agents 1 to 2 days prior to surgery. Cover with insulin, but it’s important to teach the patient that this change is temporary and due to the stress the body undergoes during surgery.​ ​ Monitoring for Hypoglycemia: Continue to monitor for low blood sugar levels, as the stress of surgery can affect glucose control.​ Patient Hygiene and Acute Interventions ​ Personal Hygiene: Good personal hygiene is essential, particularly in diabetic patients, due to the risk of microvascular complications and infections. Patients should follow these practices:​ ○​ Dental Hygiene: Brush and floss teeth daily and visit the dentist regularly. If dental work is required, inform the dentist that the patient has diabetes.​ ○​ Skin Care: Patients should bathe regularly and pay special attention to foot care.​ ○​ Wound Care: For any cuts, scrapes, or burns, they should be washed with non-abrasive antiseptic and covered with a dry sterile dressing. If signs of infection occur, the patient should immediately contact their healthcare provider.​ Medical Identification and Travel ​ Medical Identification: Patients should always carry medical information, including their diabetic status, and wear an identification bracelet or necklace to indicate they have diabetes. This should include:​ ○​ A medical information card listing their healthcare provider and the type of insulin or medication they are taking. ​ Travel Supplies: A full set of supplies should be carried, including:​ ○​ Medications with professionally printed pharmacy labels. ○​ A blood glucose monitoring kit. ○​ Lancets for blood sugar testing.  ○​ Low blood sugar treatment, such as glucose tablets or juice. ​ Having a letter from the primary care provider (PCP) outlining the need for these supplies may help prevent delays, especially when traveling.​ ​ Insulin Pump: If the patient has an insulin pump, they should inform security screeners before going through screening. The insulin pump should be inspected on the body rather than removed.​ Medical Bracelet Example A diabetic medical bracelet contains important information about the patient’s condition. The bracelet may have a message such as: ​ “If I am unconscious or behaving abnormally, I may be having a reaction related to diabetes or its treatment. If I can swallow, give me a sweet drink (e.g., orange juice, Life Savers, or low-fat milk). If I do not recover promptly, call a physician or send me to the hospital. If I am unconscious or unable to swallow, do not give me anything by mouth—please call 911 or send me to the hospital immediately.” That’s it for day one. I will follow up with a second video for day two, which you'll likely receive tomorrow, along with this one. So you’ll probably get them at the same time. Anyway, thanks, everyone, and enjoy Friday! I hope you have a great time if you decide to go down there. Stay safe, okay? Just be safe.