Diabetic Education | Harmony Restored

DIABETIC EDUCATION

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Type 1 diabetes (T1D) is an autoimmune disease that develops when the pancreas stops producing insulin. People can be diagnosed with T1D at any age, but it is the most common childhood endocrine disorder (Meadows-Oliver, 2019). An estimated 1.6 million Americans are living with T1D, including about 200,000 youth (people less than 20 years of age) and 1.4 million adults (people 20 years of age and older; JDRF, n.d.).

Statistics that indicate the probable future development of T1D and its significance include the following (JDRF, n.d.):

About 64,000 people in the US are diagnosed with T1D each year.
It is expected that five million people in the US will have T1D by 2050, including almost 6,000,000 youth.
In the US, there are $16 billion in T1D-associated healthcare costs and lost income annually.
Less than 33% of people with T1D in the US are consistently achieving target blood-glucose control levels.

Pathophysiology

In T1D, the beta cells of the pancreas are destroyed or suppressed. The disease is divided into two types: idiopathic and immune-mediated. Idiopathic T1D causes a permanent insulin deficiency with no evidence of autoimmunity. In immune-mediated T1D there is an autoimmune attack on beta cells. This type of attack causes an inflammatory response known as insulitis (Rebar et al., 2019).

Evidence-Based Practice: Research shows that by the time signs and symptoms are evident, 80% of beta cells have been destroyed (Rebar et al., 2019).

Although signs and symptoms occur rather abruptly, it can take months or even years for enough beta cells to be destroyed before these signs and symptoms appear. Signs and symptoms, once evident, can be severe (Centers for Disease Control and Prevention (CDC)), (2021c).

Nursing Consideration: Symptoms of T1D are similar to those of other health conditions. Nurses must encourage patients to immediately seek medical help if signs and symptoms develop. Untreated T1D can lead to severe, even fatal, health conditions (CDC, 2021c).

The development of T1D typically occurs in three stages (Lucier & Weinstock, 2021):

Stage 1: Stage 1 is characterized by a lack of symptoms and a normal fasting glucose, normal glucose tolerance, and the presence of greater than, or equal to, two pancreatic autoantibodies.
Stage 2: Stage 2 diagnostic criteria include the presence of greater than or equal to 2 pancreatic autoantibodies and dysglycemia (glucose of 100 to 125 mg/dl), impaired glucose tolerance (2-hour PG of 140 to 199 mg/dL), or a hemoglobin A1C between 5.7% to 6.4%. Patients remain asymptomatic.
Stage 3: In Stage 3 the patient has hyperglycemia with clinical symptoms and two or more pancreatic autoantibodies.

Etiology. The exact cause of T1D is unknown. However, several risk factors and possible trigger factors have been identified, including the following:

Genetics: Having a family history of T1D puts people at greater risk of developing the disease. However, the majority of diagnoses are found in people who have no family members with the disease (JDRF, n.d.).
Viral Infections: Viral infections may be triggers for T1D development (JDRF, n.d.).
Geography: The further away from the equator a person lives, the greater the incidence of T1D (Mayo Clinic, 2021c).
Age: Although T1D can occur at any age, it seems to peak at two specific age ranges. The first peak appears in children between the ages of 4 and 7 years old. The second peak is in children between the ages of 10 and 14 years old (Mayo Clinic, 2021c).

Nursing Consideration: Unlike type 2 diabetes, no dietary changes can be made to prevent the onset of T1D. Likewise, lifestyle factors such as exercise and weight do not contribute to T1D development (JDRF, n.d.). Some insulin regimens can be very expensive, so this should be discussed with patients to help them avoid skipping doses.

Complications. Maintaining a normal blood glucose level can significantly reduce the occurrence of complications. Such complications may be disabling or even fatal. Without insulin to facilitate the entry of glucose into the cells, blood glucose levels increase and complications may be likely (Mayo Clinic, 2021c).

Complications linked to T1D include the following (Mayo Clinic, 2021c):

Cardiac and vascular diseases: T1D radically increases the risk of cardiovascular diseases such as coronary artery disease (CAD), angina, heart attack, stroke, atherosclerosis, and hypertension.
Neuropathy: Excessive blood glucose levels may injure the capillaries that nourish the nerves. Symptoms of neuropathy include tingling, numbness, and burning or pain that typically starts at the tips of the toes or fingers and spreads gradually. If blood glucose levels are not controlled, all sensation may be lost in the affected limbs. If the nerves of the gastrointestinal tract are damaged, patients may suffer from nausea, vomiting, diarrhea, or constipation. In men, erectile dysfunction may occur.
Diabetic retinopathy: If the blood vessels of the retina are damaged, the patient may go blind. Other conditions linked to diabetic retinopathy include cataracts and glaucoma.
Damage to the feet: Nerve damage or reduced blood flow to the lower extremities increases the risk of complications to the feet. Without treatment, even minor cuts and blisters can become quite serious, leading to infections that may eventually require the amputation of toes, feet, or leg(s).
Skin and mouth issues: Patients may be more vulnerable to skin and mouth infections including those caused by bacteria and fungi. Disease of the gums and dry mouth are also likely.
Pregnancy issues: If the T1D is poorly controlled in pregnant females, the risk of miscarriage, stillbirth, and birth defects increases. The risk of diabetic ketoacidosis, retinopathy, pregnancy induced hypertension, and preeclampsia may also increase.

Diabetic ketoacidosis (DKA) is a serious, acute metabolic complication characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. DKA is most common in patients with T1D and occurs when insulin levels are inadequate to meet the body’s basic metabolic requirements. Hyperglycemia causes osmotic diuresis with severe fluid and electrolyte loss (Merck Manual, 2020b).

Signs and symptoms of DKA include nausea, vomiting, and (especially in children) abdominal pain. If untreated, significant decompensation can occur. Patients may display hypotension and tachycardia because of dehydration and acidosis. To compensate for acidemia, respirations increase in rate and depth (Kussmaul respirations). The patient’s breath may have a fruity odor because of exhaled acetone (Merck Manual, 2020b).

Treatment consists of rapid intravascular volume repletion with 0.9% saline given IV, correction of hyperglycemia and acidosis, and prevention of hypokalemia. Treatment should take place in critical care settings because of the need for hourly clinical and laboratory assessments with necessary adjustments indicated by assessment results (Merck Manual, 2020b).

Assessment and Diagnosis

Patients are assessed for common symptoms of T1D. These include the following (Mayo Clinic, 2021c; Rebar et al., 2019):

Increased thirst.
Extreme hunger.
Frequent urination.
Unintended weight los.s
Fatigue.
Weakness.
Blurred vision.
Irritability.
Mood changes.
In children, bed-wetting in those who did not previously wet the bed at night.

A thorough history and physical are conducted to help rule out other conditions. In addition to history, physical, and a review of signs and symptoms, several diagnostic tests are performed. These include the following (Mayo Clinic, 2021c; Rebar et al., 2019):

Glycated hemoglobin (A1C) test: The A1C is a blood test that reports average blood glucose levels for the past 2 to 3 months. The test measures the percentage of blood glucose that is attached to the body’s hemoglobin. The higher the glucose levels, the higher the percentage of hemoglobin with attached glucose. An A1C level of 6.5% or higher on two separate tests is an indicator of T1D.
Random blood glucose test: This test requires that a blood sample be obtained at a random time and confirmed by repeat testing. A random blood glucose level of 200 mg/dL or higher suggests T1D, particularly if the patient has signs and symptoms of T1D.
Fasting blood glucose test: The fasting blood glucose test requires that a blood sample be obtained following an overnight fast. A fasting blood glucose level of less than 100 mg/dL is normal. A level from 100-125 mg/dL is classified as prediabetes. A level of 126 mg/dL or higher on two separate tests is diagnostic for T1D.
Antibody test: If a diagnosis of diabetes is made, the healthcare provider may order blood tests to check for antibodies that are common in T1D. Presence of antibodies helps to differentiate between T1D and type 2 diabetes when the diagnosis is uncertain.

Nursing Consideration: Certain conditions such as pregnancy or having a hemoglobin variant may interfere with the accuracy of the A1C test. In these types of cases, the healthcare providers will rely on additional blood tests to determine an accurate diagnosis.

Treatment

T1D is managed with a variety of insulins. Patients, families, and the healthcare team must work together to find the best treatment regimen. Types of insulin may include the following (JDRF, n.d.):

Rapid acting: Starts working in about 15 minutes after injection. It peaks in about 1 hour and continues for about 2 to 4 hours after injection. Examples include aspart (Novolog), glulisine (Apidra), and lispro (Humalog).
Regular or short acting: Starts working 30 minutes after injection, peaks from 2 to 3 hours after injection, and continues to work for about 3 to 6 hours. An example is Humulin R.
Intermediate acting: Starts working 2 to 4 hours after injection. It peaks about to 12 hours later and lasts 12 to 18 hours. An example is Novolin N.
Long acting: Long acting is often combined with rapid or short acting insulin. It starts to work several hours after injection and tends to lower glucose levels up to 24 hours. An example is Lantus.
Ultra-long lasting: Starts to work in 6 hours, but it does not peak and lasts an estimated 36 hours. An example is Tresiba.

Insulin is administered in a variety of ways. Historically, insulin was administered via injection using a syringe. Today, other options are available including the following (CDC, 2021a; JDRF, n.d.):

Insulin pen: Some pens use cartridges that are inserted into the pen while others are pre-filled and discarded after all insulin is used. The dose of insulin is dialed on the pen and the insulin is injected through a needle.
Insulin pump: About the size of a small cell phone, insulin pumps provide a basal dose of short or rapid-acting insulin per hour. When blood sugar is high, the patient calculates the dose and the insulin in the pump delivers the bolus.
Artificial pancreas: The artificial pancreas is a hybrid closed-loop system that requires minimal patient intervention. It is a combination of the technology of a pump with that of a continuous glucose monitor.
Inhaled insulin: Inhaled insulin is taken by using an oral inhaler to deliver ultra-rapid-acting insulin at the start of meals. Inhaled insulin is used in conjunction with an injectable long-acting insulin.
Additional treatment interventions include having personalized meal plans designed to meet nutritional needs, control blood glucose levels, and help patients maintain ideal body weight. With the guidance of healthcare providers, patients should participate in regular exercise. Patients should be cautioned that physical activity lowers blood glucose levels. Thus, blood glucose levels should be monitored frequently. Patients may need to adjust their meal plans or insulin to compensate for increased physical activity (Mayo Clinic, 2021c; Rebar et al., 2019).

Nursing Interventions:Nursing interventions focus on education and emotional support. Patients and families need education pertaining to meal planning, exercise, and insulin administration. Emotional support is also critical to the success of any treatment regimen (Rebar et al., 2019).
Patients and families also need information about potential complications, how to recognize them, and what to do if they occur. It is recommended that families pay special attention to the issue of complications. Teachers should be informed that a child is diabetic and they must be aware of emergency procedures. In some cases, patients experiencing complications (such as DKA) may not be able to articulate the need for help or describe their symptoms at the time. It is, therefore, absolutely essential that family members and other caretakers be able to intervene correctly in the event that complications occur (Rebar et al., 2019). DKA is a medical emergency and must be treated immediately.

According to the National Diabetes Statics Report, 2020, 34.2 million Americans, just over 1 in 10, have diabetes. Of these 34.2 million people, 7.3 million, or 21.4%, are undiagnosed (Centers for Disease Control and Prevention (CDC), 2020c; 2020d). The World Health Organization (WHO) reports that in 2019 an estimated 1.5 million deaths were directly caused by diabetes (WHO, 2021). The numbers of people who have diabetes continue to increase at alarming rates. It is critical that healthcare professionals aggressively pursue identification of persons who have, and who are at risk for, developing diabetes, and intervene to facilitate not only treatment, but prevention efforts (CDC, 2020c; 2020d).

Incidence and Prevalence of Diabetes Mellitus

Diabetes mellitus (DM) is a chronic endocrine disease characterized by impaired glucose regulation that occurs when the pancreas fails to produce adequate amounts of insulin or when the patient’s body is unable to effectively utilize the insulin that is produced (Ignatavicius et al., 2018; WHO, 2021).

Approximately 34.2 million Americans have diabetes. Data indicate that (CDC, 2020c; 2020d):

An estimated 10.5% of the United States (US) population are dealing with diabetes.
About 26.9 million people have been diagnosed. This figure includes 26.8 million adults.
A significant number of these people, 7.3 million or 21.4%, are undiagnosed.
A total of 88 million people 18 years of age and older have prediabetes. This figure represents 34.5% of the adult US population.
For persons 65 years of age and older, 24.2 million people have prediabetes.

Healthcare Professionals Consideration: An estimated 1.5 million world-wide deaths were directly caused by diabetes in 2019 (WHO, 2021). Healthcare professionals must increase their efforts in the recognition, treatment, and prevention of diabetes mellitus.

Incidence and Prevalence of Diabetes Mellitus (cont.)

Diabetes is also a leading cause of death in the United States. According to the most recent data available on the CDC website (2021d), the following are the leading causes of death in the United States.

Heart disease: 659,041
Cancer: 599,601
Accidents (unintentional injuries): 173,040
Chronic lower respiratory diseases: 156,979
Stroke (cerebrovascular diseases): 150,005
Alzheimer’s disease: 121,499
Diabetes: 87,647
Nephritis, nephrotic syndrome, and nephrosis: 51,565
Influenza and pneumonia: 49,783
Intentional self-harm (suicide): 47,511

Key findings of the National Diabetes Statistics Report 2020 regarding incidence and prevalence include (CDC, 2020d ;2020e; 200f):

34.2 million Americans—just over 1 in 10—have diabetes.
88 million American adults—approximately 1 in 3—have prediabetes.
New diabetes cases were higher among non-Hispanic blacks and people of Hispanic origin than non-Hispanic Asians and non-Hispanic whites.
For adults diagnosed with diabetes:

New cases significantly decreased from 2008 through 2018.
The percentage of existing cases was highest among American Indians/Alaska Natives.
15% were smokers, 89% were overweight, and 38% were physically inactive.
37% had chronic kidney disease (stages 1 through 4); and fewer than 25% with moderate to severe chronic kidney disease (stage 3 or 4) were aware of their condition.

New diagnosed cases of type 1 and type 2 diabetes have significantly increased among US youth.
For ages 10 to 19 years, incidence of type 2 diabetes remained stable among non-Hispanic whites and increased for all others, especially non-Hispanic blacks.
The percentage of adults with prediabetes who were aware they had the condition doubled between 2005 and 2016, but most continue to be unaware.

More people are developing type 1 and type 2 diabetes during youth, and racial and ethnic minorities continue to develop type 2 diabetes at higher rates. Likewise, the proportion of older people in our nation is increasing, and older people are more likely to have a chronic disease like diabetes. By addressing diabetes, many other related health problems can be prevented or delayed.

Prevalence and Incidence According to Age, Race, and Ethnicity

Age

According to the National Diabetes Statistics Report 2020, (CDC, 2020c; 2020d;2020e):

About 34.2 million people of all ages had diabetes mellitus.
The percentage of adults (18 years of age or older) with diabetes increased with age.
About 34.1 million adults 18 years of age or older) had diabetes.
The highest percentage was 26.8% among persons 65 years of age or older.
An estimated 4.9 million adults between the ages of 18 and 44 had diabetes.
An estimated 14.8 million people between the ages of 45 and 64 had diabetes.
An estimated 14.3 million people over the age of 65 had diabetes.

Incidence and Trends among Children and Adolescents. According to the National Diabetes Statistics Report 2020 (CDC, 2020c; 2020d; 2020e):

18,291 children and adolescents younger than age 20 years with type 1 diabetes.
5,758 children and adolescents age 10 to 19 years with type 2 diabetes.
During 2011–2015, non-Hispanic Asian and Pacific Islander children and youth had the largest significant increases in incidence of type 1 diabetes.
During 2011–2015, non-Hispanic Asian and Pacific Islander children and youth had the largest significant increases in incidence of type 1 diabetes.

Among US children and adolescents aged 10 to 19 years (CDC, 2020c; 2020d; 2020e):

For the entire period 2002–2015, overall incidence of type 2 diabetes significantly
During the 2002–2010 and 2011–2015 periods, changes in incidence of type 2 diabetes were consistent across race/ethnic groups. Specifically, incidence of type 2 diabetes remained stable among non-Hispanic whites and significantly increased for all others, especially non-Hispanic blacks.

Evidence-Based Practice: Research data shows that the number of younger people with diabetes is significant and continues to increase (CDC, 2020c; 2020d; 2020e). It is therefore essential that nurses identify those at risk and provide patient/family education regarding risk factors for the disease and how to modify these risk factors as appropriate.

Racial and Ethnic Differences (Prevalence of Diagnosed Diabetes)

Among the US population overall, crude estimates for 2018 were (CDC, 2020c; 2020d; 2020e):

26.9 million people of all ages—or 8.2% of the US population—had diagnosed diabetes.
210,000 children and adolescents younger than age 20 years—or 25 per 10,000 US youths— had diagnosed diabetes. This includes 187,000 with type 1 diabetes.
1.4 million adults aged 20 years or older—or 5.2% of all US adults with diagnosed diabetes—reported both having type 1 diabetes and using insulin.
2.9 million adults aged 20 years or older—or 10.9% of all US adults with diagnosed diabetes—started using insulin within a year of their diagnosis.

Among US adults aged 18 years or older, age-adjusted data for 2017–2018 indicated the following (CDC, 2020c; 2020d; 2020f):

Prevalence of diagnosed diabetes was highest among American Indians/Alaska Natives (14.7%), people of Hispanic origin (12.5%), and non-Hispanic blacks (11.7%), followed by non-Hispanic Asians (9.2%) and non-Hispanic whites (7.5%).
American Indians/Alaska Natives had the highest prevalence of diagnosed diabetes for women (14.8%).
American Indian/Alaska Native men had a significantly higher prevalence of diagnosed diabetes (14.5%) than non-Hispanic black (11.4%), non-Hispanic Asian (10.0%), and non-Hispanic white (8.6%) men.
Among adults of Hispanic origin, Mexicans (14.4%) and Puerto Ricans (12.4%) had the highest prevalence, followed by Central/South Americans (8.3%) and Cubans (6.5%).
Among non-Hispanic Asians, Asian Indians (12.6%) and Filipinos (10.4%) had the highest prevalence, followed by Chinese (5.6%). Other Asian groups had a prevalence of 9%.
Among adults, prevalence varied significantly by education level, which is an indicator of socioeconomic status. Specifically, 13.3% of adults with less than a high school education had diagnosed diabetes versus 9.7% of those with a high school education and 5% of those with more than a high school education.

Prevalence of Prediabetes in Adults

Data regarding prediabetes in adults show that (CDC, 2020c; 2020d; 2020e):

An estimated 88 million adults aged 18 years or older had prediabetes in 2018.
Among US adults aged 18 years or older, crude estimates for 2013–2016 were: 34.5% of all US adults had prediabetes, based on their fasting glucose or A1C level (Table 3).
10.5% of adults had prediabetes based on both elevated fasting plasma glucose and A1C levels.
15.3% of adults with prediabetes reported being told by a health professional that they had this condition.

Among US adults aged 18 years or older, age-adjusted data for 2013–2016 indicated:

A higher percentage of men (37.4%) than women (29.2%) had prediabetes.
Prevalence of prediabetes was similar among all racial/ethnic groups and education levels.

Incidence of Newly Diagnosed Diabetes in Adults

Among US adults aged 18 years or older, crude estimates for 2018 were (CDC, 2020c; 2020d; 2020e):

1.5 million new cases of diabetes—or 6.9 per 1,000 persons—were diagnosed.
Compared to adults aged 18 to 44 years, incidence rates of diagnosed diabetes were higher among adults aged 45 to 64 years and those aged 65 years and older.
Among US adults aged 18 years or older, age-adjusted data for 2017–2018 indicated that non-Hispanic blacks (8.2 per 1,000 persons) and people of Hispanic origin (9.7 per 1,000 persons) had a higher incidence compared to non-Hispanic whites (5.0 per 1,000 persons).

Evidence-Based Practice: The rate of new cases of diabetes in youths younger than 20 years of age increased in the US between 2002 and 2015, with a 4.8% increase per year for type 2 diabetes and a 1.9% increase per year for type 1 diabetes (CDC, 2020g). These findings indicate that education regarding prevention and recognition of diabetes in youth must be provided with increased effectiveness, as well as aggressive efforts to prevent development whenever possible.

Financial and Societal Impact of Diabetes Mellitus

The momentous financial and societal impact of diabetes continues to increase at an alarming rate. Federal, state, and local governments (and ultimately the US taxpayer) bear the brunt of costs related to diabetes. The American Diabetes Association (ADA) gives as an example that Medicare’s diabetes-related burden increased as the prevalence of diabetes increased (O’Connell & Manson, 2019).

According to the CDC, diabetes is the most expensive chronic condition in the US. A summary of these expenses includes (CDC, 2021c):

The total annual cost of diabetes is $327 billion. An additional $90 billion is spent on reduced productivity.
One dollar out of every four dollars in US healthcare costs is spent on caring for people with diabetes.
The total economic cost of diabetes rose 60% from 2007 to 2017.
Sixty-one percent of diabetes costs are for people 65 years of age or older. These costs are mainly paid by Medicare.
An estimated 48% to 64% of lifetime medical costs for a person with diabetes are for complications related to diabetes, such as heart disease and stroke.

Medical costs are not the only costs related to diabetes. The stress of chronic illness can impact interpersonal relationships. It can impact the person’s ability to work, which may have significant economic impact on the family income. Financial burdens are inter-related with psychological issues that impact persons dealing with diabetes. Medical bills, loss of work time, and inability to actively participate in work and social activities can all have significant adverse impact on patients, their families, and their employers. Dealing with a chronic illness can lead to significant stress, which can adversely impact ability to function effectively at work, home, and school and interfere with interpersonal relationships. Therefore, the costs of diabetes include monetary, societal, and interpersonal factors. The impact on society includes overextended health services, increased public assistance programs for financially stressed families, and the societal burden of mental health care and rehabilitation for those with complications resulting from diabetes (CDC, 2021c; O’Connell, 2019).

Financial and Societal Impact of Diabetes Mellitus

According to the CDC, diabetes is the most expensive chronic condition in the US. A summary of these expenses includes (CDC, 2021c):

The total annual cost of diabetes is $327 billion. An additional $90 billion is spent on reduced productivity.
One dollar out of every four dollars in US healthcare costs is spent on caring for people with diabetes.
The total economic cost of diabetes rose 60% from 2007 to 2017.
Sixty-one percent of diabetes costs are for people 65 years of age or older. These costs are mainly paid by Medicare.
An estimated 48% to 64% of lifetime medical costs for a person with diabetes are for complications related to diabetes, such as heart disease and stroke.

Financial and Societal Impact of Diabetes Mellitus (cont.)

The cost of medications used in the treatment of diabetes continues to increase at alarming rates. The price of insulin, for example, has increased 1,200% since 1996 (Kumok, 2021).

The estimated economic cost of glucose-lowering drugs is $57.6 billion per year in the U.S. in 2015–2017 (15–20% of the estimated annual cost for all prescription drugs in the U.S.). The cost of such drugs can cause a financial burden and have a devastating impact on people without health insurance and people whose insurance imposes high deductibles—the people least able to afford the high cost of diabetes drugs. This means that the high cost of diabetes drugs has important implications for both public policy and social justice (Taylor, 2020a).

Members of an Insulin Access and Affordability Working Group (Cefalu, (2018) made the following recommendations to help lower the cost of insulin. These recommendations may also be applied to other drugs used in the treatment of diabetes. Examples include (Cefalu, (2018):

Providers, pharmacies, and insurers should discuss the cost of insulin preparations (and other drugs) with patients to help them understand the advantages, disadvantages, and financial impact of potential insulin preparations and those of other diabetes medications.
Providers should prescribe the lowest-priced medications that effectively and safely achieve treatment goals.
Researchers should study the comparative effectiveness and cost-effectiveness of the various insulins.
Organizations such as the (ADA) should:

Advocate for access to affordable medications for all people who have diabetes.
Develop and regularly update clinical guidelines or standards of care based on scientific evidence for prescribing medications.
Make information about the advantages, disadvantages, and financial implications of medications easily available to people with diabetes.

Normal Anatomy and Physiology of the Pancreas

It is not possible to comprehend the pathophysiology of diabetes without an understanding of normal pancreatic functioning. The pancreas is a triangular shaped organ, about six to 10 inches long, located in the curve of the duodenum (the first portion of the small intestine from the stomach to the jejunum). The pancreas plays critical roles in both the digestive process and the process that regulates blood sugar (The Pancreas Center, n.d.; Willis, 2018).

The pancreas is surrounded by various other organs: the small intestine, liver, and spleen. It has three sections. The wide part, referred to as the head of the pancreas, is positioned toward the center of the abdomen. The middle section is called the neck and the body of the pancreas. The thin end of the organ is referred to as the tail and extends to the left side (Johns Hopkins Medicine, n.d.; The Pancreas Center, n.d.; Willis, 2018).

The pancreas is surrounded by several major blood vessels: the superior mesenteric artery, the superior mesenteric vein, the portal vein, and the celiac axis, which supply blood to the pancreas and many other abdominal organs (The Pancreas Center, n.d.).

Exocrine Function of the Pancreas

The pancreas contains exocrine glands, which produce enzymes that are essential to the process of digestion (The Pancreas Center, n.d.). Acinar cells make up most of the pancreas and are responsible for the regulation of the exocrine functions of the gland (Willis, 2018).

Below is a summary of the exocrine function of the pancreas (The Pancreas Center, n.d.):

Food enters the stomach.
Pancreatic juices flow into a system of ducts that terminate in the primary pancreatic duct.
The pancreatic duct joins with the common bile duct to form the ampulla of Vater located in the duodenum.
The common bile duct produces bile. Pancreatic juices and bile flow into the duodenum and facilitate the digestion of fats, carbohydrates, and proteins.

Endocrine Function of the Pancreas

The endocrine function of the pancreas focuses on hormone secretion. The endocrine cells of the pancreas are islet cells, or islets of Langerhans. These islet cells exist as clusters of cells that are scattered among the acinar cells. They consist of alpha, beta, and delta cells, which produce the following essential hormones (Johns Hopkins Medicine, n.d.a.; The Pancreas Center, n.d.; Willis, 2018):

Glucagon: Glucagon is produced by the alpha cells. It raises blood glucose levels by causing the breakdown of glycogen to glucose.
Insulin: Insulin is produced by beta cells. Insulin’s primary function is to reduce blood glucose levels by triggering the conversion of glucose to glycogen.
Somatostatin: Delta cells are responsible for the production of somatostatin. Somatostatin inhibits the release of growth hormone (GH), corticotrophin, and some other hormones.

Under normal conditions, a small amount of insulin is constantly secreted by the pancreas. Insulin secretion increases in response to increases in blood glucose levels. Insulin triggers the conversion of glucose to glycogen. Glycogen is stored primarily in the liver and in skeletal muscle (Johns Hopkins Medicine, n.d.; The Pancreas Center, n.d.; Willis, 2018).

When blood glucose levels are low such as between meals or during or immediately following exercise, alpha cells are stimulated to release glucagon. Glucagon causes the liver to release glycogen, which is then converted to glucose. Glucose travels through the blood stream to the cells of the body where it is converted to energy to maintain body functioning (Johns Hopkins Medicine, n.d.a.; The Pancreas Center, n.d.; Willis, 2018).

Endocrine Function of the Pancreas (cont.)

Maintaining normal blood glucose levels is essential to the ability of key organs—including the brain, liver, and kidneys—to function properly (Johns Hopkins Medicine, n.d; The Pancreas Center, n.d.; Willis, 2018). However, the normal blood glucose range is rather narrow. Blood glucose levels are regulated by an internal feedback mechanism that involves the pancreas and the liver (Willis, 2018).

The following blood glucose test results indicate normal findings (Pagana et al., 2019).

From the ages of two to adulthood:

Fasting (no caloric intake for at least eight hours): 70 to 110 mg/dL or <6.1 mmol/L.
Casual (any time of day regardless of food intake): <200 mg/dL (11.1 mmol/L).

Children <2 years of age:

60 to 100 mg/dL or 3.3 to 5.5 mmol/L.

When normal blood glucose levels are not maintained, the impact can be devastating on an individual’s health and wellness. To effectively provide healthcare services for persons who have diabetes, healthcare professionals must understand both normal pancreatic functioning and the pathophysiology associated with the disease. To do this, it is essential to differentiate among the different types of diabetes, all of which have different pathologies.

The Different Types of Diabetes Mellitus

Health care professionals and health care consumers are arguably most familiar with type 1 and type 2 diabetes. But there are other types of diabetes with which nurses must be familiar (Rebar et al., 2019).

Type 1: The body is unable to produce adequate amounts of insulin.
Type 2: There is resistance to insulin or abnormal insulin secretion.
Secondary diabetes: This form of diabetes develops because of, or secondary to, another disease or condition.
Gestational diabetes: This occurs in pregnant women who have never had diabetes.

The primary focus of this educational program is on type 1 and type 2 diabetes, but the issue of other types of diabetes is also quite important. Therefore, it will be discussed before delving into type 1 and type 2 diabetes.

The term secondary diabetes refers to specific types of diabetes because of other causes (ADA, 2021b). Some of the most common causes of secondary diabetes include (Khardori, 2021c; Rebar et al., 2019):

Physical or emotional stress, which may cause prolonged increases in levels of the stress hormone cortisol, epinephrine, glucagon, and growth hormone (GH). These increases, in turn, raise the blood glucose level and place more demands on the pancreas.
Use of adrenal corticosteroids, hormonal contraceptives, and other types of drugs that antagonize the effects of insulin.
Diseases of the pancreas that destroy pancreatic beta cells, such as pancreatic cancer, pancreatitis, and cystic fibrosis.
Hormonal syndromes that interfere with the secretion of insulin, such as pheochromocytoma.
Hormonal syndromes that cause peripheral insulin resistance, such as Cushing syndrome.
Some medications, such as estrogens, phenytoin, and glucocorticoids.

Gestational Diabetes

Gestational diabetes occurs in women who have never had diabetes mellitus but have high blood glucose levels during pregnancy (Mayo Clinic, 2020c). This condition develops in a fairly high number of women. In the US, an estimated 10% of women who are pregnant develop gestational diabetes (Dansinger, 2019a). Healthcare professionals are becoming increasingly concerned about the occurrence of gestational diabetes. Thus, the following more detailed information is provided.

Etiology of Gestational Diabetes

As a result of hormonal changes associated with pregnancy, nearly all women experience some amount of impaired glucose intolerance. Although blood sugar may be higher than normal, it is not high enough to be diagnosed as diabetes mellitus. During the third trimester of pregnancy, these hormonal changes put women at higher risk for gestational diabetes. Hormonal changes can interfere with the appropriate action of insulin, which leads to insulin resistance (American Diabetes Association, 2021d; Dansinger, 2019a).

During pregnancy, certain placental hormones help to shift nutrients from the mother to the fetus. Other placental hormones help prevent hypoglycemia in the pregnant woman. As pregnancy advances, such hormones can lead to progressive impaired glucose intolerance (elevated blood glucose levels). Usually, the woman’s pancreas is able to compensate for these elevated levels by producing about three times the normal amount of insulin. If the pancreas is not able to produce adequate amounts of insulin, blood glucose levels rise, and gestational diabetes occurs (Dansinger, 2019a).

Risk Factors for Development of Gestational Diabetes

Several factors increase the risk for the development of gestational diabetes (Dansinger, 2019a; Mayo Clinic, 2020c):

Being overweight or obese
Being a member of a high-risk ethnic group such as Hispanic, Black, Native American, African American, Pacific Islander, Alaska native, Native American, or Asian
Being older than 25 years of age
Having impaired glucose tolerance or impaired fasting blood glucose levels. This means that blood glucose levels are high but not high enough to be diagnosed as diabetes mellitus.
Having gestational diabetes during a previous pregnancy
Having a family history of gestational diabetes
Having polycystic ovary syndrome or other condition that is associated with insulin abnormalities
Previously giving birth to a baby that weighed over 9 pounds
Previously giving birth to a stillborn baby or one that had birth defects
Having had a miscarriage
Having hypertension, elevated cholesterol, or heart disease

Complications

Gestational diabetes may increase the risk of (Mayo Clinic, 2020c):

Hypertension
Preeclampsia
Development of diabetes in the future
Need for a surgical delivery (C-section)

Diagnosis of Gestational Diabetes

The ADA (2021b) has published the following recommendations for gestational diabetes mellitus screening.

Test for undiagnosed prediabetes and diabetes at the first prenatal visit in those with risk factors using standard diagnostic criteria.
Test for gestational diabetes mellitus at 24-28 weeks of gestation in pregnant women not previously found to have diabetes.
Test women with gestational diabetes mellitus for prediabetes or diabetes at 4-12 weeks postpartum, using the 75-g oral glucose tolerance test and clinically appropriate nonpregnancy diagnostic criteria.
Women with a history of gestational diabetes mellitus should have lifelong screening for the development of diabetes or prediabetes at least every three years.
Women with a history of gestational diabetes mellitus found to have prediabetes should receive intensive lifestyle interventions and/or metformin to prevent diabetes.

Diagnosis of Gestational Diabetes (cont.)

The steps of an oral glucose tolerance include (Pagana et al., 2018):

Obtain fasting blood and urine specimens. The patient should fast for 12 hours before the test.
Administer a prescribed oral glucose solution of 75-100 g for pregnant women. Note that the ADA recommends using 75 g solution.
Instruct patient to drink the entire glucose solution.
Instruct patient not to eat or drink anything except water during the testing period.
Obtain a venous blood sample at 30 and 60 minutes and then hourly.
Collect urine specimens hourly.
Monitor the patient for dizziness, sweating, and weakness.

Screening tests may vary slightly depending on the patient’s healthcare provider. General results include (Mayo Clinic, 2020c; Pagana et al., 2019):

Initial glucose challenge test: This challenge test is done first. It is a one-hour test that involves drinking a glucose solution and having blood glucose levels assessed. A blood sugar level of 10 mg per deciliter (mg/dL) or 10.6 millimoles per liter indicates gestational diabetes. A blood glucose level below 140 mg/dL is usually considered normal. A higher-than-normal blood glucose level means that the glucose tolerance test should be performed.
Follow-up glucose tolerance testing: If at least two of the blood glucose readings are higher than normal, a diagnosis of gestational diabetes is made.

Management of Gestational Diabetes

The goal of treatment for gestational diabetes is to keep blood glucose levels equal to those of pregnant women who do not have gestational diabetes (ADA, 2021d).

Management of gestational diabetes includes the following initiatives (ADA,2021d; Dansinger, 2019a; Mayo Clinic, 2020c; WebMD, 2017a):

Teach patients and family members (as appropriate) how to monitor blood glucose levels. Monitoring should be done four times per day, before breakfast and two hours after meals. Some patients require checking glucose levels before meals as well.
Teach patients and family members (as appropriate) how to monitor urine for ketones.
Initiate a dietary consultation for the development of an appropriate diet. Explain to patients and family members the importance of following prescribed dietary plans. A healthy diet focuses on fruits, vegetables, whole grains, and lean proteins.
Help patients to develop medically approved exercise regimens.
Teach patients to monitor their weight.
If needed, teach patients about any hypoglycemic medications, including insulin, that are prescribed.
Monitor blood pressure and initiate prescribed actions such as exercise and reduction of salt intake. As appropriate, teach patient and family members how to monitor blood pressure.
Teach patients to keep a careful written record of their blood glucose levels and results of urine monitoring—including the time readings were obtained and how readings relate to dietary intake, exercise, and stress—and blood pressure readings if monitoring blood pressure at home. Instruct patients to bring a copy of these written records with them to all health care appointments.
Teach patients stress reduction techniques such as meditation and deep breathing exercise as appropriate.

Management of Gestational Diabetes (cont.)

Most pregnant women are concerned about the possible effects of gestational diabetes on their unborn children. Fortunately, gestational diabetes affects the mother relatively late in her pregnancy, when the majority of the baby’s organs have been formed, but while the baby is still growing. Gestational diabetes is not associated with the types of birth defects in infants whose mothers had diabetes mellitus before pregnancy (Dansinger, 2019a; Mayo Clinic, 2020c).

Unfortunately, untreated, or inadequately controlled gestational diabetes can harm the fetus. The pancreas works “overtime” to produce insulin in the presence of gestational diabetes, but the insulin does not reduce blood glucose levels. Insulin does not cross the placenta, but glucose does. Thus, the unborn child is exposed to high blood glucose levels. In response to these elevated levels, the unborn baby produces additional insulin, receives more energy, and stores the “extra” energy as fat. Additional stores of fat can lead to macrosomia, a condition in which the baby is abnormally large before birth. Adverse effects of macrosomia include damage to the baby’s shoulders during birth, low blood glucose levels because of the extra insulin production, respiratory distress, and jaundice. These infants are also at higher risk for obesity as children and at risk for type 2 diabetes as adults. Thus, it is essential that all pregnant women be screened for gestational diabetes and, if a diagnosis of diabetes is found, treated appropriately and promptly (Dansinger, 2019a; Mayo Clinic, 2020c).

Management of Gestational Diabetes (cont.)

About six weeks after delivery, the mother’s blood glucose levels usually return to normal because the placenta, which was responsible for producing the hormones that led to insulin resistance, is no longer in the body. Blood glucose levels will be monitored to ensure that they have returned to normal. Some health care providers recommend an oral glucose tolerance test 6 to 12 weeks after delivery to screen for diabetes mellitus (Dansinger, 2019a; Mayo Clinic, 2020c).

Evidence-Based Practice: Women who have had gestational diabetes have a 50% chance of developing type 2 diabetes within 10 to 20 years of delivery (Dansinger, 2019a). Therefore, they should work to reduce this risk by maintaining an ideal body weight, following a healthy diet, and exercising regularly.

Type 1 Diabetes: Etiology and Pathophysiology

Type 1 diabetes occurs when the beta cells of the pancreas are destroyed or suppressed. This results in failure of the pancreas to release insulin and inadequate transport of glucose (Rebar et al., 2019). The prevalence of diagnosed type 1 diabetes in 2016 was 0.55%, or 1.3 million adults. This is significantly less than the prevalence of diagnosed type 2 diabetes, which was 8.6%, or 21.0 million adults (Morr, 2018).

Healthcare Professional Consideration: Type 1 diabetes is divided into idiopathic and immune-mediated types. In idiopathic diabetes (referred to as type 1b diabetes) there is nearly complete insulin deficiency. There is no evidence of autoimmunity (Kalyani, 2017; Rebar et al., 2019). Healthcare professionals must be aware of the various types of diabetes to recognize them and to provide safe and appropriate care. Screening and patient education are critical elements of care. Clinical Practice Guidelines are constantly being updated and should be followed for effective care. The Centers for Medicare & Medicaid Services (CMS) sets reimbursement rates for Medicare providers and generally pays them according to approved guidelines.

Immune mediated types of type 1 diabetes, an autoimmune attack on beta cells occurs. This results in an inflammatory response in the pancreas (insulitis). Antibodies may be present for considerable time before the development of symptoms. In fact, by the time the disease is symptomatic, 80% of the beta cells are deactivated. Some experts believe that the beta cells are not destroyed, but instead they are disabled and may be able to be reactivated (Rebar et al., 2019).

Latent Autoimmune Diabetes (LADA)

Latent autoimmune diabetes in adults (LADA) is characterized by a slow progression of autoimmune reaction against the pancreas. Some experts recognize LADA as a form of type 1 diabetes, while others do not. LADA occurs because of an inadequate production of insulin. However, LADA does not require insulin administration for several months up to years after diagnosis is made (Castro, 2021).

Following are characteristics of LADA (Castro, 2021):

People are usually over the age of 30 when the disease is diagnosed.
The pancreas produces some insulin initially
LADA is often misdiagnosed with type 2 diabetes because the patients are older at diagnosis and some insulin production is still evident.
Initially, LADA is managed with diet, weight reduction as needed, exercise, and oral medications as needed. But insulin is eventually needed because the pancreas gradually loses its ability to produce insulin.

Research is underway regarding LADA and the best way to manage treatment. Health care providers with expertise in all forms of diabetes should direct treatment initiatives (Castro, 2021).

Type 2 Diabetes: Pathophysiology and Etiology

Type 2 diabetes is an impairment of the way the glucose is regulated and used by the body. A chronic condition, type 2 diabetes can lead to disorders of the circulatory, nervous, and immune system (Mayo Clinic, 2021g). The following are general characteristics of type 2 diabetes (Mayo Clinic, 2021g Santos-Longhurst, 2020):

The disease is caused by a combination of insulin resistance and insulin deficiency. Some people develop the disease predominantly because of insulin resistance, whereas others are affected predominantly by deficient insulin secretion but have little insulin resistance.
About 90% to 95% of people with diabetes have type 2 diabetes.
Type 2 diabetes has a strong hereditary component.
Its onset is typically slow and insidious
Type 2 diabetes is significantly less common in children and young adults than in older adults. But the number of children with type 2 diabetes is increasing because of the prevalence of overweight children.
Although some people with this type of diabetes may need insulin, they are still categorized as having type 2 diabetes.

Under normal conditions, insulin molecules bind to body cell preceptors. Insulin activates cell portals to open allowing glucose to enter the cells where it is then converted to energy. Insulin decreases the amount of glucose in the blood. As the blood glucose level decreases, so does the amount of insulin secreted by the pancreas (Mayo Clinic, 2021g).
In type 2 diabetes, the cells develop a resistance to insulin. This inhibits the ability of glucose to enter the cells. If glucose cannot enter the cells, the cells fail to receive enough energy. Blood glucose levels increase, and organs are damaged throughout the body (Mayo Clinic, 2021g).

Etiology

Type 2 diabetes is mainly the result of two interrelated issues (Mayo Clinic, 2021g):

Muscle, fat, and hepatic cells become insulin-resistant and are unable to function efficiently.
The pancreas is not able to manufacture adequate amounts of insulin to appropriately manage blood glucose levels.

Several environmental and lifestyle factors play a role in the development of type 2 diabetes. The aging process, alcohol consumption, smoking, lack of exercise, and obesity have all been found to be related to the development of diabetes (Mayo Clinic, 2021g). Obesity seems to have an impact on disease development. Obesity, especially visceral fat obesity, leads to a decrease in muscle mass and an increase in insulin resistance (Mayo Clinic, 2021g; Taylor, 2020b).

Research has shown that a number of factors contribute to an increase in the amount of visceral fat in the body (Mayo Clinic, 2021g; Taylor, 2020b):

Disorders of the nervous or endocrine systems that lead to an increase in cortisol and abnormalities in the secretion of sex hormones.
Smoking
Increased intake of alcohol
Overeating, particularly an excessive intake of simple sugars
Decreased energy consumption because of insufficient exercise
Genetic influences
The aging process

Prediabetes

Prediabetes is sometimes referred to as a “wake-up call” that the development of diabetes may be imminent. About 84 million Americans over the age of 20 have prediabetes, but 90% of these people do not know that they have it. (Dansinger, 2019b; Mayo Clinic, 2020d). Lifestyle modifications—including weight loss, implementing an exercise regimen, and following a healthy diet—are strongly recommended to prevent prediabetes from progressing to type 2 diabetes (Dansinger, 2019b; Mayo Clinic, 2020d).

With a diagnosis of prediabetes, patients must be counseled regarding diet, exercise, and weight loss. Patients may also need antidiabetic agents (Mayo Clinic, 2020d).

Healthcare Professional Consideration: Prediabetes is a significant risk factor for developing type 2 diabetes and cardiovascular disease (Dansinger, 2019b; Mayo Clinic, 2020d). Risk factors for the risk of developing prediabetes are the same as for type 2 diabetes, which will be discussed later in this education program.

Screening Guidelines

Type 1 Diabetes

At this time, there is a deficit of accepted and clinically validated screening programs outside of research settings. The ADA recommends considering referring relatives of those with type 1 diabetes for islet autoantibody testing for risk assessment in the setting of a clinical research study. (ADA, 2021b).

Current ADA (2021b) recommendations include:

Screening for type 1 diabetes risk with a panel of islet autoantibodies is currently recommended in the setting of a research trial or can be offered as an option for firs-degree family members of a proband with type 1 diabetes. The proband is the first individual to be studied in a family.
Persistence of autoantibodies is a risk factor for clinical diabetes and may serve as an indication for intervention in the setting of a clinical trial.

Prediabetes and Type 2 Diabetes

The 2021 ADA screening guidelines list the same recommendations for both prediabetes and type 2 diabetes. These include (ADA, 2021b):

Screening for prediabetes and type 2 diabetes with an informal assessment of risk factors or validated tools should be considered in asymptomatic adults.
Testing for prediabetes and/or type 2 diabetes in asymptomatic people should be considered in adults of any age with overweight or obesity (BMI ≥25 kg/m²or ≥23 kg/m² in Asian Americans) and who have one or more additional risk factors for diabetes
Testing for prediabetes and/or type 2 diabetes should be considered in women with overweight or obesity planning pregnancy and/or who have one or more additional risk factor for diabetes.
For all people, testing should begin at age 45 years.
If tests are normal, repeat testing carried out at a minimum of 3-year intervals is reasonable, sooner with symptoms.
To test for prediabetes and type 2 diabetes, fasting plasma glucose, 2-h plasma glucose during 75-g oral glucose tolerance test, and A1C are equally appropriate.
In patients with prediabetes and type 2 diabetes, identify and treat other cardiovascular disease risk factors.
Risk-based screening for prediabetes and/or type 2 diabetes should be considered after the onset of puberty or after 10 years of age, whichever occurs earlier, in children and adolescents with overweight (BMI ≥85th percentile) or obesity (BMI ≥95th percentile) and who have one or more risk factor for diabetes.
Patients with HIV should be screened for diabetes and prediabetes with a fasting glucose test before starting antiretroviral therapy, at the time of switching antiretroviral therapy, and three to six months after starting or switching antiretroviral therapy. If initial screening results are normal, fasting glucose should be checked annually.

Risk Factors

Risk Factors for the Development of Type 1 Diabetes

A number of risk factors are associated with the development of type 1 diabetes (American Heart Association, 2021; Mayo Clinic, 2020a):

Family history
Exposure to a viral illness
Presence of autoantibodies
Geography (Some countries, including Finland and Sweden, have higher rates of type 1 diabetes)

Risk Factors for the Development of Type 2 Diabetes

There are several risk factors related to the development of type 2 diabetes mellitus. These risk factors are classified as nonmodifiable and modifiable.

The following risk factors are nonmodifiable; in other words, they cannot be changed (American Heart Association, 2021; CDC, 2021b; Mayo Clinic, 2020a):

Age: Risk increases with age. This increase seems to begin at the age of 40
Race and ethnicity: Some racial and ethnic groups have a higher incidence of type 2 diabetes than others. These include:
African Americans
Asian-Americans
Latino/Hispanic-Americans
Native Americans
Pacific Islander descent
Family history: A person’s chances of developing type 2 diabetes increases if immediate or even extended family members have the disease.
History of gestational diabetes: Women who have gestational diabetes have a greater risk of developing prediabetes and type 2 diabetes. Having given birth to a baby that weighs more than 9 pounds also increases risk.

Healthcare Professional Consideration: Although research has shown that certain risk factors cannot be modified, healthcare professionals must still include them in patient/family education and be aware of such factors that increase the risk for development of diabetes.

Modifiable Risk Factors

The following risk factors are those that can be modified or changed to decrease risk of developing type 2 diabetes.

Overweight/Obesity. Being obese or overweight is one of the greatest risk factors for type 2 diabetes. Because obesity is increasing among children and adolescents, type 2 diabetes is affecting more and more young people (American Heart Association, 2021; Taylor, 2020b).

The body mass index, or BMI, is the standard to determine overweight and obesity. BMI is a person’s weight in kilograms divided by the square of height in meters. According to CDC, the following BMI measures indicate underweight, normal, overweight, and obesity (CDC, 2021a):

Underweight: BMI is < 18.5
Normal: BMI is 18.5 to <25
Overweight: BMI is 25.0 to <30
Obese: BMI is 30.0 or higher

Fortunately, even a small loss of weight can have a significant impact on health and longevity. Lifestyle modifications to achieve weight loss include the following:

Reduction in caloric intake:Patients should work with their health care providers, including a clinical dietician as necessary, to implement a well-balanced diet that will facilitate weight loss (Ignatavicius et al., 2018).
Increase in physical activity:The American Heart Association (2021) and CDC, 2020a) publishes the following physical activity guidelines for adult Americans:

Two hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity every week and muscle strengthening activities that work all major muscle groups two or more days a week OR
Seventy-five minutes of vigorous-intensity aerobic activity every week and muscle strengthening activities that work all major muscle groups two or more days a week.

39 – Modifiable Risk Factors (cont.)

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Modifiable Risk Factors (cont.)

Moderate-intensity aerobic activity is defined as exercising hard enough to increase heart rate and break a sweat. Examples include walking fast, water aerobics, riding a bicycle on level ground, and pushing a lawn mower. Vigorous-intensity aerobic activity is defined as exercising hard enough to breathe hard and fast and increase heart rate significantly. Examples include jogging, running, swimming laps, riding a bicycle rapidly or on hills, and playing basketball. Physical activity can be spread out so that it is not done all at once. However, physical activity should be sustained for at least 10 minutes at a time (American Heart Association, 2021; CDC, 2021b).

Elevated Blood Glucose. An elevated blood glucose level significantly increases the risk of diabetes as well as for cardiovascular disease and stroke. The American Diabetes Association recommends using one of three testing methods (American Diabetes Association, 2021b; National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), 2018e):

A1C test
Fasting plasma glucose (FPG)
Oral glucose tolerance test (OGTT)

Hypertension. Hypertension is a modifiable risk factor for diabetes as well as for cardiovascular disease and stroke. Hypertension is defined as a consistent systolic pressure of 130 mmHg or higher or diastolic pressure of 80 mmHg or higher. For persons who do not have diabetes, blood pressure should be evaluated at each regular health care provider visit or at least once every two years if it is less than 120/80 mmHg. For patients who have diabetes, blood pressure should be measured at each regular health care provider visit or as often as needed (CDC, 2020b; Ignatavicius et al., 2018).

Modifiable Risk Factors (cont.)

Abnormal Lipid Metabolism. Abnormalities in cholesterol levels can contribute not only to cardiovascular disease but also to the development of diabetes mellitus. The desired goals of cholesterol levels for adults are as follows (Mayo Clinic, 2021a):

LDL: below 70 mg/dL for people who have heart disease or diabetes; below 100 mg/dL for people at risk of heart disease; and 100 to 129 mg/dL near optimal if there is no heart disease but high if there is heart disease.
HDL: greater than 60 mg/dL
Triglycerides: less than 150 mg/dL
Total cholesterol: less than 200 mg/dL

Physical Inactivity. Physical inactivity contributes to overweight and obesity, cardiovascular disease, malignancies, diabetes, and many other adverse medical conditions. Participating in a regular physical exercise routine can increase insulin sensitivity, improve lipid levels, reduce blood pressure, reduce weight, lower the risk of cardiovascular disease, and improve blood glucose management in type 2 diabetes (Ignatavicius et al., 2018).

Smoking. Smoking is a significant risk factor for the development of type 2 diabetes and makes the disease harder to control after its development. Smokers are 30% to 40% more likely to develop type 2 diabetes than nonsmokers. People who smoke are more likely than nonsmokers to have trouble managing the disease (CDC, 2021e).

Medications. Such medications as glucocorticoids, thiazide diuretics, and atypical antipsychotics increase the risk of diabetes (American Diabetes Association, 2021b).

Healthcare Professional Consideration: Healthcare professionals need to be aware of the significance of metabolic syndrome. Metabolic syndrome is a group of conditions (hypertension, elevated blood glucose levels, excess amounts of body fat around the waist, and abnormal cholesterol level) that exist in conjunction with one another and increase the risk of cardiac disease, stroke, and diabetes. Taking steps to alter the impact of modifiable risk factors for diabetes can delay or possibly prevent the occurrence of serious health conditions (Mayo Clinic, 2020a). Assessing diabetic patients should include indicators for metabolic syndrome. Cholesterol level and blood pressure should be monitored at least yearly for obese patients at risk of diabetes.

Presenting Clinical Signs and Symptoms of Diabetes Mellitus

Many of the signs and symptoms of type 1 and type 2 diabetes are the same. There are, however, some differences. It is important for healthcare professionals to recognize all clinical manifestations of the disease and to know which of those signs and symptoms are more prevalent in one of the two types.

Clinical Manifestations of Type 1 Diabetes Mellitus

Type 1 diabetes is found most often in children. But the disease can also develop in adults. Patients with type 1 diabetes generally report an abrupt onset of symptoms. Following are the classic symptoms of type 1 diabetes (Khardori, 2021a; 2021b):

Polyuria: production of abnormally large amounts of urine that is dilute
Polydipsia: abnormally great thirst
Polyphagia: excessive appetite or excessive feelings of hunger
Unexplained weight loss

Polyuria is caused by osmotic diuresis secondary to hyperglycemia. Severe nocturnal enuresis (bedwetting) secondary to polyuria suggests type 1 diabetes in young children. Polyphagia develops to dehydration and hyperosmolar status (Khardori, 2021a; 2021b).

Following are other clinical manifestations of type 1 diabetes mellitus (Khardori, 2021a; 2021b):

Weight loss occurs despite experiencing excessive appetite and hunger. This is caused by water depletion and a catabolic state with reduction in glycogen, proteins, and triglycerides.
Fatigue and weakness may occur secondary to muscle wasting caused by a catabolic state of insulin deficiency, hypovolemia, and hypokalemia.
Muscle cramping is caused by electrolyte imbalance.
Blurred vision is a result of osmotic swelling of the lens, which alters its normal focal length.

Type 1 diabetes may also cause gastrointestinal (GI) disturbances (Khardori, 2021a; 2021b):

Nausea, abdominal pain, and changes in bowel movements: these signs and symptoms may accompany acute diabetic ketoacidosis.
Right upper quadrant pain because of acute fatty liver.
Persistent GI disturbances, which may be caused by abdominal causes of diabetic ketoacidosis.

The onset of symptomatic type 1 diabetes may be abrupt. The first evidence of the disease may be the occurrence of ketoacidosis (Khardori, 2021a; 2021b).

Diabetic Ketoacidosis (DKA)

DKA occurs most often in patients with type 1 diabetes and/or those less than 65 years of age, although it can occur with type 2 diabetes as well. DKA is an acute complication of hyperglycemic crisis. DKA is precipitated by acute insulin deficiency. Such deficiency can be caused by illness; stress; infection; and, in insulin-dependent patients, failure to take insulin (Ignatavicius et al., 2018; Mayo Clinic, 2020b; Rebar et al., 2019).

Without adequate amounts of insulin, which allow the cells to take in glucose to convert it to energy, glucose accumulates in the blood. The body begins to break down fat as an alternative fuel. When this happens, toxic acids known as ketones build up in the blood. Without treatment, DKA can result in coma or death (Ignatavicius et al, 2018; Mayo Clinic, 2020b).

The signs and symptoms of DKA usually develop rapidly, often within 24 hours. Patients experience polyuria, polydipsia, nausea, vomiting, abdominal pain, weakness or unusual fatigue, shortness of breath, fruity-scented breath, and confusion. Blood testing shows hyperglycemia and high levels of ketones in the urine (Mayo Clinic, 2020b; Rebar et al., 2019).

Because untreated DKA can be fatal, patients experiencing the signs and symptoms should seek emergency medical help. Emergency treatment usually includes insulin therapy, electrolyte replacement because inadequate amounts of insulin can reduce various electrolyte levels, and fluid replacement to correct dehydration (Mayo Clinic, 2020b).

Diabetic Ketoacidosis (DKA) (cont.)

Risk factors for DKA include having type 1 diabetes and frequently missing insulin doses. (Mayo Clinic, 2018g).

Persons with diabetes mellitus, especially those with type 1 diabetes, should work with their health care providers to manage conditions that trigger DKA. Following are examples of such conditions (Mayo Clinic, 2020b):

Infections and illnesses: Infections and illnesses can cause the body to produce higher levels of adrenaline or cortisol, both of which are antagonistic to insulin. Common conditions that trigger DKA are pneumonia and urinary tract infections.
Inadequate insulin therapy: Missing insulin treatments or taking inadequate amounts of insulin can trigger DKA.
Miscellaneous problems: High fever, surgery, physical or emotional trauma, or alcohol or drug abuse, especially cocaine, can trigger DKA.

Healthcare Professional Consideration: It is imperative that healthcare professionals assess the knowledge of patients and families regarding the signs and symptoms of DKA, what causes it, and what to do about it. Parents may want to discuss the symptoms of DKA with their diabetic child’s teachers, especially if the child participates in sports.

Clinical Manifestations of Type 2 Diabetes Mellitus

Until recently, it was believed that if diabetes occurred in childhood, it was type 1 diabetes. Now it is known that children also develop type 2 diabetes. As obesity in children increases, so does the incidence of type 2 diabetes in that population (Dansinger, 2021a). Therefore, it is important to identify risk factors and work with patients of all ages to reduce the risk of developing type 2 diabetes. It is also important to be alert to the clinical manifestations of the disease realizing that it can affect all age groups.

Clinical Manifestations of Type 2 Diabetes Mellitus (cont.)

It can take years for the signs and symptoms of type 2 diabetes to become evident. Following are clinical manifestations of untreated diabetes (Ignatavicius et al., 2021; Mayo Clinic, 2021g):

Polyuria and polydipsia: Excessive buildup of glucose in the blood stream causes fluid to move from the cells into the bloodstream to maintain homeostasis. This increases thirst and fluid intake casing an increase in dilute urine production.
Polyphagia: When cells fail to receive adequate amounts of glucose for energy production, muscles, and organs experience energy depletion. This triggers intense hunger as the body attempts to obtain nourishment and energy.
Weight loss: Even though patients may be eating more because of intense hunger, weight loss can occur. This is because the body is using alternative fuel sources in muscle and fat because it cannot metabolize glucose. Calories are lost as glucose is excreted in urine.
Blurred vision: As glucose levels increase in the blood stream, fluid may be pulled from the lenses of the eyes to restore homeostasis. This can interfere with the ability of the eyes to focus, thus causing blurred vision.
Fatigue: When cells are deprived of glucose and the ability to create energy, weakness, fatigue, and irritability can occur.
Slow-healing cuts, lacerations or wounds, or frequent infections: Type 2 diabetes interferes with the body’s ability to heal and to resist infections.
Areas of darkened skin: Areas of darkened skin, called acanthosis nigricans, are dark velvety patches of skin in the folds and creases of the body. They are usually noted in the neck and axilla.

Healthcare Professional Consideration: Thirst mechanisms function less efficiently in elderly persons. So older adults may not report polydipsia when relaying signs and symptoms (Ignatavicius et al., 2018).

Clinical Manifestations of Type 2 Diabetes Mellitus (cont.)

Diabetic hyperglycemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes. HHS is characterized by extremely high blood glucose levels without the presence of ketones, extreme dehydration, and decreased levels of consciousness. The kidneys attempt to rid the body of excess amounts of glucose in the blood by increasing urinary output. Without adequate fluid replacement, dehydration occurs. Additionally, dehydration makes the blood more concentrated with sodium, glucose, and other substances. This condition is known as hyperosmolarity and causes the body to withdraw fluid from other body organs (including the brain) to restore balance. Electrolyte balances are disturbed as well. If blood glucose levels are not returned to normal, an ongoing cycle of hyperglycemia and dehydration occurs that can lead to coma and even death (Ignatavicius et al. 2018; MedlinePlus, 2021a).

The goals of treatment are to correct dehydration, restore fluid and electrolyte balance, and control blood glucose levels. Intravenous fluids containing appropriate amounts of various electrolytes are administered as well as insulin via the venous route. Untreated, HHS may lead to shock, thrombosis formation, cerebral edema, and lactic acidosis (Ignatavicius, Workman, & Rebar, 2018; MedlinePlus, 2021a).

Diagnosis of Diabetes Mellitus

Diabetes may be diagnosed based on plasma glucose criteria, either the fasting plasma glucose (FPG) value or the 2-hour plasma glucose (2-hour PG) value during a 75-g oral glucose tolerance test (OGTT), or A1C criteria (ADA, 2021b).

The ADA (2021b) diagnostic criteria include:

A fasting plasma glucose (FPG) level >126 ng.dL (7.0 mmol/L), or
A 2-hour plasma glucose level >200 mg/dL (11.1 mmol/L) during a 75-g oral glucose tolerance test (OGTT) or
A random plasma glucose >200 mg/dL (11.1 mmol/L) in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis.

Details about the various tests used in the diagnostic process follow.

Random (Casual) Plasma Glucose Test

This test can be performed at any time of day when severe diabetic symptoms develop. Diabetes is diagnosed when the blood glucose is >200 mg/dL (ADA,2021n).

Fasting Plasma Glucose (FPG)

FPG assesses fasting blood glucose levels. Fasting is defined as not have anything to eat or drink except water for at least eight hours before the test. The test is typically performed first thing in the morning before breakfast. (ADA, 2021n).

FPG results are (ADA, 2021n):

Normal: Less than 100 mg/dL
Prediabetes: 100 mg/dL to 125 mg/dL
Diabetes: 126 mg/dL or higher

Oral Glucose Tolerance Test (OGTT)

An OGTT is performed to assess insulin response to glucose loading. A fasting blood sugar is obtained before the ingestion of an oral glucose solution, and blood samples are drawn at specifically timed intervals. The oral glucose solution should contain the equivalent of 75 g anhydrous glucose dissolved in water (ADA, 2021a; Pagana et al., 2019).

Results from the OGTT are (ADA, 2021a):

Normal: less than 140 mg/dL.
Prediabetes: 140 mg/dL to 199 mg/dL
Diabetes: 200 mg/dL or higher

Patient care considerations and patient teaching include the following important factors (Pagana et al., 2019; Rebar et al, 2019):

The patient should follow their usual diet and exercise regimen for three days before the test.
The patient must be instructed to fast for 12 hours before the OGTT.
Certain drugs may be withheld before testing based on the recommendations of the patient’s health care provider. Examples of drugs that can interfere with test results are hormonal contraceptives, salicylates, diuretics, phenytoin, and nicotinic acid.
Fasting blood and urine specimens are obtained.
An oral glucose solution is administered that consists of 75 g of glucose or dextrose for patients who are not pregnant or 100 g for pregnant patients. The patient must drink the entire glucose solution. The amount of glucose in solution is based on body weight for pediatric patients.
During the OGTT, the patient must not use tobacco or ingest coffee or tea because these substances cause physiological stimulation. They must be told not to eat or drink anything during the testing period except for the oral glucose solution provided by the test administrator—except for water, which the patient is encouraged to drink.
A venous blood sample is collected at 30- and 60-minutes post-ingestion of the glucose solution and at hourly intervals thereafter.
Urine samples are collected at hourly intervals.
During the period of testing, the patient should be monitored for dizziness, sweating, weakness, and giddiness, which are usually transient and self-limiting.

A1C Test

The A1C test is a blood test used to obtain information about a patient’s average blood glucose over the past three months. The A1C is used in the diagnosis of type 2 diabetes and prediabetes and is the primary test used for diabetes management (NIDDK, 2018e).

The A1C test does not require fasting. Blood can be drawn at any time of day, thus making it more convenient than some other testing options. The test may also be used during the first health care pregnancy visit to determine if the woman had undiagnosed diabetes before becoming pregnant. After that, the oral glucose tolerance test (OGTT) or the glucose challenge test is used to test for gestational diabetes (NIDDK, 2018e; Pagana et al., 2019).

The A1C test is based on attachment of glucose to hemoglobin in red blood cells. Although red blood cells are continually forming and dying, they typically live for approximately three months. The A1C can reflect blood glucose levels over the previous three months. Reported as a percentage, the higher the percentage, the higher the blood glucose levels have been (NIDDK, 2018e).

Results of the A1C are (2021n):

Normal: Less than 5.7%
Prediabetes: 5.7 to 6.4%
Diabetes: 6.5% or higher

Recommendations from the ADA include (2021n):

Assess glycemic status (A1C or other glycemic measurement) at least two times a year in patients who are meeting treatment goals (and who have stable glycemic control).
Assess glycemic status at least quarterly, and as needed, in patients whose therapy has recently changed and/or who are not meeting glycemic goals.

Healthcare Professional Consideration: Because A1C reflects average glucose status over several months, it has significant predictive value for diabetes complications. A1C testing should be performed routinely in all patients who have diabetes (ADA, 2021e).

A1C Test (cont.)

Following are the A1C-range recommended goals (ADA, 2021e):

An A1C goal for many nonpregnant adults of <7% (53 mmol/mol) without significant hypoglycemia is appropriate.
If using ambulatory glucose profile/glucose management indicator to assess glycemia, a parallel goal is a time in range of >70% with time below range <4%.
Based on provider judgment and patient preference, achievement of lower A1C levels than the goal of 7% may be acceptable, and even beneficial, if it can be achieved safely without significant hypoglycemia or other adverse effects of treatment.
Less stringent A1C goals (such as <8% [64 mmol/mol]) may be appropriate for patients with limited life expectancy, or where the harms of treatment are greater than the benefits.
Reassess glycemic targets over time based on the criteria specific to various age groups.

Management of Diabetes Mellitus

Management of diabetes mellitus focuses on glycemic control and prevention and reduction of complications. Successful management depends on a team approach that involves physicians, nurse practitioners, nurses, dieticians, pharmacists, and mental health professionals who have expertise in diabetes mellitus management. The most critical members of the team are patients and families who are ultimately responsible for adhering, or helping loved ones to adhere to, the treatment regimen (ADA, 2021l).

Glycemic Control

Glycemic control is assessed by the A1C measurement, continuous glucose monitoring (CGM), and self-monitoring of blood glucose (SMBG). Rationale for these tests includes (ADA, 2021e; 2021m):

A1C reflects average glycemia over about a period of three months. This test is the primary test for the assessment of glycemic control and has strong predictive value for diabetic complications.
CGM: CGM plays an important role in the assessment of the effectiveness and safety of treatment in many patients with type1 diabetes, including the prevention of hypoglycemia and in selected patients with type 2 diabetes.
SMBG: SMBG can be used with self-management and medication adjustment, especially in persons who are taking insulin.

Recommendations for glycemic assessment are (ADA, 2021e):

Assess glycemic status (A1C or other glycemic measurement) at leasttwo times a year in patients who are meeting treatment goals (and who have stable glycemic control).
Assess glycemic status at least quarterly, and as needed, in patients whose therapy has recently changed and/or who are not meeting glycemic goals.

Self-Monitoring Blood Glucose (SMBG)

SMBG is essential to effective diabetes management. Individual patients’ needs and goals guide SMBG frequency and timing. Research findings have shown that in patients who have type 1 diabetes, there is a correlation between greater SMBG frequency and lower A1C (American Diabetes Association, 2021e).

Continuous Glucose Monitoring (CGM)

Most of the people who use CGM have type1 diabetes. Research is now underway to learn how CGM might help people who have type 2 diabetes. A healthcare provider’s prescription is needed to obtain CGM systems (NIDDK, 2021f).

CGMs are approved for use by adults and children. Some models may be used for children as young as two years of age. CGM may be recommended if the patient (NIDDK, 2021f):

Is on intensive insulin therapy (also referred to as tight blood sugar control)
Has hypoglycemia unawareness (Hypoglycemia unawareness occurs when the patient does not feel or recognize the signs or symptoms of hypoglycemia; patients who have frequent episodes of hypoglycemia may no longer experience hypoglycemia’s usual warning symptoms).
Often experiences episodes of elevated or low blood glucose

CGM has evolved swiftly in terms of both accuracy and affordability. This means that many patients have data available to assist with both self-management and assessment by healthcare providers (ADA, 2021e).

The ADA (2021e) makes the following recommendations for glucose assessment by continuous glucose monitoring.

Standardized, single-page glucose reports from continuous glucose monitoring (CGM) devices with visual cues, such as the ambulatory glucose profile (AGP), should be considered as a standard printout for all CGM devices.
Time in range (TIR) is associated with the risk of microvascular complications, should be an acceptable end point for clinical trials moving forward, and can be used for assessment of glycemic control. Additionally, time below target (,70 and ,54 mg/dL [3.9 and 3.0 mmol/L]) and time above target (.180 mg/dL [10.0 mmol/L]) are useful parameters for reevaluation of the treatment regimen.

Continuous Glucose Monitoring (CGM) (cont.)

CGM systems use a tiny sensor that is inserted under the skin to check glucose levels in tissue fluid. The sensor remains in place for several days to a week and then is replaced. A transmitter relays information about glucose levels via radio waves from the sensor to a wireless monitor (NIDDK, 2021f).

Advantages of a CGM system include (NIDDK, 2021f):

An alarm can sound when glucose levels are too high or too low
Meals, physical activity, and medicines can be noted in a CGM device, as well as glucose levels
Data can be downloaded to a computer or smart device to improve visibility of glucose trends
CGM systems offer better management of daily glucose levels
There are fewer hypoglycemic emergencies with the use of a CGM
With a CGM, fewer finger sticks are needed

CGM has limitations, as well as advantages. These limitations include (NIDDK, 2021f):

Most CGM models cannot be used to make treatment decisions unless the CGM reading is confirmed by doing a finger-stick glucose test.
A CGM is more expensive than using a standard glucose meter. Patients should check their insurance plans or Medicare to see what costs are covered.

Insulin Pumps

Most people with type 1 diabetes should be treated with multiple daily injections of prandial insulin and basal insulin or continuous subcutaneous insulin infusion. Most people with type 1 diabetes should use rapid-acting insulin analogs to reduce hypoglycemia risk (ADA 2021k).

Patient/family education regarding pharmacological management with insulin should include matching prandial insulin doses to carbohydrate intake, premeal blood glucose levels, and anticipated physical activity. Individuals with type 1 diabetes who have been successfully using continuous subcutaneous insulin infusion should have continued access to this therapy after they turn 65 years of age (ADA, 2021k).

Hundreds of thousands of people of all ages throughout the world are using an insulin pump for diabetes mellitus management. First used by patients with type 1 diabetes, some persons with type 2 diabetes use them as well. (Stoppler, 2018).

Insulin pumps are about the size of a small cell phone and are computerized. Insulin pumps provide a constant stream of insulin so that fewer needle sticks are required. Pumps are a good option for children or anyone else who has trouble remembering to administer their insulin injections (Cleveland Clinic, 2021).

Insulin pumps may be especially useful for people who (Cleveland Clinic, 2021):

Experience delays in the absorption of food
Are active and may want to pause insulin doses when exercising
Have severe reactions to hypoglycemia
Have diabetes and are planning a pregnancy

Insulin Pumps (cont.)

Traditional insulin pumps transport insulin from a chamber within the pump via tubing to a site on the skin that is connected to a smaller flexible plastic cannula. The cannula is a few millimeters long and delivers the insulin underneath the skin (Cleveland Clinic, 2021).

Insulin patch pumps also use a cannula beneath the skin. However, the insulin delivery chamber and the cannula are part of one pod that “sits” in the skin with an adhesive patch. The patch can be directly placed on the stomach or arm. There is no external tubing, and it is controlled wirelessly via a handheld controller (Cleveland, Clinic, 2021).

There are both advantages and disadvantages of insulin pumps. Advantages include:

Consistent, adjustable insulin delivery
Fewer insulin injections
Flexibility and privacy
Improved blood glucose levels
Improved lifestyle freedom and flexibility

Risks or complications of insulin pumps include (Cleveland Clinic, 20210:

Setting up the pump incorrectly
Costing more than injections
Problems hiding the tubing or pump with non-patch styles (Cleveland, Clinic, 2021)

Artificial Pancreas Device System

The Artificial Pancreas Device System is a system of devises that closely mimics the functioning of a healthy pancreas. Most of these systems consist of a continuous glucose monitoring system, and an insulin infusion pump. A blood glucose device is used to calibrate CGM. A computer-controlled algorithm connects the CGM and insulin pump to facilitate ongoing communication between the two devices (Food and Drug Administration (FDA), 2018).

An artificial pancreas device system replaces manual blood glucose testing and the use of insulin injections. The system monitors blood glucose levels 24-hours a day. The system can be monitored remotely (e.g., by parents or healthcare professionals) (NIDDK, 2021f).

There are three categories of artificial pancreas device systems. These include:

Threshold suspend device systems (also called low glucose suspend systems): This type of system temporarily suspends insulin delivery when the glucose level falls to or approaches a low glucose threshold. Its purpose is to reduce the severity of or reverse hypoglycemia.
Insulin-only system: This system “achieves a target glucose level by automatically increasing or decreasing the amount of insulin infused based on the CGM values.
Bi-hormonal control system: This device “achieves a target glucose level by using two algorithms to instruct an infusion pump to deliver two different hormones—one hormone (insulin) to lower glucose levels and another (such as glucagon) to increase blood glucose levels. The bi-hormonal system mimics the glucose-regulating function of a healthy pancreas more closely than an insulin-only system (FDA, 2017).

Research continues regarding the development of artificial pancreas device systems. To date, the FDA has approved two systems. These are (Tenderich, 2020).

Medtronic MiniMed 670G: This is a hybrid closed-loop system.
Control-IQ from Tandem Diabetes Care: This system combines Tandem’s touchscreen insulin pump with the Dexcom CGM and a smart algorithm for the purpose of auto-adjusts for high and low blood glucose levels and automatic corrections for unexpected highs.

Insulin

Typical blood glucose levels targets are to keep daytime blood glucose levels before meals between 80 and 130 mg/dL (4.44 to 7.2 mmol/L) and after meal results to no higher than 180 mg/dL (10 mmol/L), two hours after eating (Mayo Clinic, 2021f).

Persons with type 1 diabetes typically need lifelong insulin therapy. There are many types of insulin therapy and include:

Short-acting (regular) insulin
Rapid acting insulin
Intermediate-acting (NPH) insulin.
Long-acting insulin (Mayo Clinic, 2021f)

Examples of the various types of insulin include (Mayo Clinic, 2021f):

Short-acting: Humulin R and Novolin R
Rapid-acting: Glulisine (Apidra), insulin lispro (Humanlog), and insulin aspart (Novolog)
Intermediate-acting: Insulin NPH (Novolin N, Humulin N0
Long-acting: Insulin glargine (Lantus, Toujeo Solostar), insulin detemir (Levemir), and insulin degludec (Tresiba)

Inhaled insulin is available as a rapid-acting insulin. Inhaled insulin is contraindicated in patients with chronic lung disease and is not recommended in patients who smoke or who recently stopped smoking. All patients require spirometry evaluation to identify potential lung disease before and after starting inhaled insulin therapy (ADA, 2021k).

Pharmacologic Therapy for Type 2 Diabetes

The FDA (2021k) makes the following recommendations for pharmacologic therapy for type 2 diabetes.

Metformin is the preferred initial pharmacologic agent for the treatment of type 2 diabetes.
Once initiated, metformin should be continued as long as it is tolerated and not contraindicated; other agents, including insulin, should be added to metformin.
Early combination therapy can be considered in some patients at treatment initiation to extend the time to treatment failure.
The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high.
A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include effect on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences.
Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease or indicators of high risk, established kidney disease, or heart failure, a sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit is recommended as part of the glucose-lowering regimen independent of A1C and in consideration of patient-specific factors.
In patients with type 2 diabetes, a glucagon-like peptide 1 receptor agonist is preferred to insulin when possible.
Recommendation for treatment intensification for patients not meeting treatment goals should not be delayed.
The medication regimen and medication-taking behavior should be reevaluated at regular intervals (every 3–6 months) and adjusted as needed to incorporate specific factors that impact choice of treatment.
Clinicians should be aware of the potential for over-basalization with insulin therapy. Over-basalization is titration of basal insulin beyond an appropriate dose to achieve glycemic targets. Clinical signals that may prompt evaluation of over-basalization include basal dose more than ∼5 IU/kg, high bedtime-morning or post-preprandial glucose differential, hypoglycemia (aware or unaware), and high variability. Indication of over-basalization should prompt reevaluation to further individualize therapy.

Non-Pharmacologic Diabetes Management

Nutrition

Nutrition therapy is recommended for all patients with type 1 and type 2 diabetes. For those patients who are overweight or obese, modest weight loss may provide significant clinical benefits such as improved glucose control and lipid levels and reduction in blood pressure, especially early in the course of the disease (ADA, 2021h).

Evidence-Based Practice: Research suggests that there is a benefit to eating protein or protein and vegetables before eating the carbohydrate portion of a meal (ADA, 2021h). healthcare professionals should collaborate to ensure patients and families have access to planning the best meal options for persons with diabetes.

Non-Pharmacologic Diabetes Management (cont.)

The goal of a good nutrition plan is to get the nutrients needed while keeping blood glucose levels within target range. The patient’s goals, tastes, preferences, lifestyle, and medications should be considered when meal planning (CDC, 2021f).

According to the CDC (2021f) a good meal plan will:

Include more non-starchy vegetables, such as broccoli, spinach, and green beans.
Include fewer added sugars and refined grains such as white bread, rice, and pasta with less than two grams of fiber per serving.
Focus on whole foods instead of highly processed foods as much as possible.

The CDC (2021f) recommends using a plate method as part of the meal planning process. Patients should consider a nine-inch dinner plate and:

Fill half of the plate with non-starchy vegetables, such as salad, green beans, broccoli, cauliflower, cabbage, and carrots.
Fill one-quarter of the plate with a lean protein, such as chicken, turkey, beans, tofu, or eggs.
Fill one-quarter of the plate with carb foods such as grains, starchy vegetables (peas, potatoes), rice, pasta, fruit, and yogurt. A cup of milk counts as a carb food.
Choose water or a low-calorie drink such as unsweetened tea to go with a meal.

Many people appreciate having a guide as to what constitutes a “portion” of a particular nutrient. The CDC (2021f) offers the following suggestions for estimating portion size.

Three ounces of meat, fish, or poultry: Palm of hand (no fingers)
One ounce of meat or cheese: Thumb tip to base
One cup or one medium fruit: Fist
One to two ounces of nuts or pretzels: Cupped hand
One Tablespoon: Thumb tip (tip to first joint)
One teaspoon: Fingertip (tip to first joint)

Physical Activity

Being overweight or obese is linked to a vast number of medical problems, including heart disease and cancer. Proper nutritional intake and physical activity not only help patients to achieve weight goals but also have a positive impact on diabetes. Exercise may also have a positive effect for depression associated with the consequences of the need for diabetes management.

As previously noted, the American Heart Association (2021) recommends:

At least 150 minutes per week of moderate-intensity aerobic physical activity;
Or 75 minutes per week of vigorous-intensity aerobic physical activity (or a combination of the two);
And muscle-strengthening exercises at least two days per week.

People who have diabetes must monitor their physical activity in relation to their glycemic levels. For example, exercise can lead to hyperglycemia or hypoglycemia depending on its intensity, timing, duration, and type of physical activity (ADA 2021h).

People who take insulin or oral pharmacological agents are at risk for hypoglycemia if insulin dose or carbohydrate intake is not adjusted with exercise. Exercise regimens should be planned with the healthcare team. The ADA (n.d.) recommends following the 15-15 rule:

Check blood sugar
If the reading is 100mg/dL or lower have 15-20 grams of carbohydrate. Examples include four glucose tablets, one glucose gel tube, four ounces of juice ore regular soda, or one tablespoon of sugar or honey.
Check blood sugar again after 15 minutes. If it is still below 100 mg/dL another servicing of 15 grams of carbohydrate is needed.
Repeat these steps every 15 minutes until blood sugar is at least 100 mg/dL.

Smoking Cessation

All patients should be advised not to use any tobacco products or e-cigarettes. Nonsmokers should be advised not to use e-cigarettes. Smoking cessation should be a routine part of diabetes management (American Heart Association, 2021).

Psychosocial Care

Mental health and well-being are important to general health and wellness and can impact the patient’s or family’s ability to implement diabetes treatment. The physical and emotional stress that can accompany a chronic health problem can put the patient and her family at risk for mental health problems (ADA, 2021o; Grygotis, 2016).

Psychosocial screening and follow-up treatment include attitudes about illness; expectations for management and outcomes; affect/mood; quality of life experiences and expectations; financial, social, and emotional resources; and psychiatric history. Patients should also be routinely screened for such issues as depression and diabetes-related distress, anxiety, eating disorders, and impairment of cognitive functioning (ADA, 2021o; Grygotis, 2016).

Support groups for diabetics may offer some therapeutic value. In addition, group exercise such as yoga, workout groups, or swimming exercise classes can provide both psychosocial support and a physical benefit for weight loss and improved cardiovascular condition. Meditation, pet therapy, behavioral therapy, and religious support may be of interest to some patients. Antidepressant medication may be considered if needed (ADA, 2021o; Grygotis, 2016).

Hypoglycemia Prevention

Hypoglycemia is the primary factor limiting the glycemic management of type 1 and insulin-treated type 2 diabetes. It is imperative that nurses and other members of the health care team instruct patients and families how to recognize signs and symptoms of hypoglycemia, identify situations that increase their risk for hypoglycemia such as fasting, during or after intense exercise, and during sleep. They must be taught to balance insulin use, carbohydrate intake, and exercise to prevent and reduce hypoglycemic episodes (ADA, 2021e).

Immunizations

There are several recommendations for adults who have diabetes mellitus (ADA, 2021c).

Provide routinely recommended vaccinations for adults with diabetes by age. Children should also receive routine vaccinations by age.
Administer Hepatitis B vaccine for persons less than 60 years of age. For persons over 60 healthcare providers should be consulted.
Administer HPV vaccine to persons 26 years old and under. Persons between the ages of 27-45 years may also be vaccinated after consulting with their healthcare providers.
Administer influenza vaccine to all patients annually. All patients should be advised not to receive live attenuated influenza vaccine.
Administer pneumonia PPSV23 pneumovax to persons 19-64 years of age. Persons 65 and older should receive a second dose at least five years from prior pneumovax vaccine.
There are no recommendations for the administration of pneumonia (PCV13 Prevnar) to persons 19-64 years of age. For persons 65 and older who are not immunocompromised, have a cochlear implant, or cerebrospinal fluid leak, decisions must made in conjunction with their healthcare providers.
Administer tetanus, diphtheria, pertussis (TDAP) to all adults with a booster every 10 years. All adult pregnant women should have an extra dose of this vaccine.
Administer Zoster vaccine to all persons 50 years of age or older (two-dose Shingrix even if previously vaccinated).
COVID vaccinations for all patients, as permitted by age.

Obesity Management

Overweight and obesity contribute to a myriad of health problems. There is significant evidence that managing obesity can delay the progression from prediabetes to type 2 diabetes and may contribute to successful management of type 2 diabetes (ADA, 2021j).

The ADA (2021j) recommends that BMI be calculated and documented at all patient visits. Additional recommendations state that overweight and obese patients should participate in a regimen of diet, physical activity, and behavioral therapy to achieve >5% weight loss. Furthermore, such interventions should be individualized to the patient. After weight loss goals have been achieved, diet, physical activity, and behavioral therapy should be continued to maintain weight loss and achieve treatment goals.

Healthcare Professional Consideration: It is important that patients’ medication regimens be evaluated for their impact on weight. This evaluation should include all the medications the patient takes: prescription drugs, over-the-counter supplements, and herbal preparations. If necessary, weight loss medications may be prescribed to help lose weight. Potential benefits of these medications should be weighed against potential risks and side effects (ADA, 2021j). Patients should be cautioned not to take any weight loss products without prior consultation with their health care providers.

Metabolic Surgery

Metabolic surgery is the phrase used to describe surgery and procedures that treat metabolic diseases, especially type 2 diabetes (ADA, 2021j). Bariatric surgery that aims to treat comorbid conditions, such as diabetes mellitus associated with obesity, is called as metabolic surgery. Metabolic surgery is usually limited to patients with a body mass index (BMI) >35. The surgeon typically connects one end of the stomach to an opening in the new stomach pouch. After this surgery, when you eat, food bypasses most of the stomach and the first part of the small intestines. That makes this surgery both restrictive and malabsorptive.

Following are recommendations and suggestions for metabolic surgery (ADA, 2021j).

Recommend metabolic surgery as an option for the treatment of type 2 diabetes in appropriate surgical candidates with BMI >40 kg/m2⁽BMI >37.5 kg/m2 in Asian Americans and in adults with BMI 35.0-39.9 kg/m2 (32.5-37.4 kg/m2 in Asian Americans.
Suggest metabolic surgery as an option for adults with type 2 diabetes and BMI 30.0 to 34.9 kg/m2, (27.5 to 32.4 kg/m2 in Asian Americans, if hyperglycemia is inadequately controlled despite appropriate medical intervention.
Metabolic surgery should be done in health care facilities that perform high-volume numbers of such surgeries and where multidisciplinary teams experienced in metabolic surgery work.
Provide long-term support and monitoring of patients who have undergone metabolic surgery according to national and international standards.
Perform a comprehensive mental health evaluation before surgery.
Postpone surgery in patients with histories of alcohol abuse, substance abuse, depression, suicidal ideation, and other mental health concerns until these issues have been adequately addressed.
Evaluate the need for ongoing mental health services to help with medical and psychosocial changes post-surgery.

Research has shown that metabolic surgery leads to “superior glycemic control and reduction of cardiovascular risk factors in obese patients with type 2 diabetes compared with various lifestyle/medical interventions” (ADA, 2021j).

Pancreas Transplant

A pancreas transplant is performed to implant a healthy pancreas from a deceased donor into a patient with diabetes. Almost all pancreas transplants are done to treat cases of type 1 diabetes and are usually reserved for those patients with serious diabetes complications because side effects of transplantation are significant. The pancreas must be meticulously matched to the recipient and is transported in a cooled solution that preserves the organ for up to approximately 15 to 20 hours. Once a pancreas becomes available, it must be transplanted into a recipient within 18-24 hours. Pancreas transplant is often done in conjunction with a kidney transplant or after successful kidney transplantation in persons whose kidneys have been damaged by diabetes. The average waiting time for a pancreas transplant is about 23 months. The average wait for a simultaneous kidney-pancreas transplant is about 13 months (Mayo Clinic, 2019; MedlinePlus, 20121b).

Candidates for a pancreas transplant typically have type 1 diabetes, along with kidney damage, nerve damage, or eye problems, or other complications. Transplant candidates usually have diabetes that is out of control despite medical treatment. Some people who have type 2 diabetes may be candidates for transplant if they have both low insulin resistance and low insulin production (Johns Hopkins Medicine, 2021).

About 10% of all pancreas transplants are performed in people with type 2 diabetes. This is generally because of the patients’ having both low insulin resistance and low insulin production (Mayo Clinic, 2019).

Pancreas Transplant (cont.)

Surgical pancreatic transplant takes about three hours. If done in conjunction with a kidney transplant, the combined surgery takes about six hours. The patient’s diseased pancreas is not removed during the surgery. The donor pancreas is usually placed in the right lower part of the abdomen, and blood vessels from the new pancreas are attached to the patient’s blood vessels. The donor duodenum is attached to the patient’s intestine or bladder (MedlinePlus, 2019).

The following are complications associated with the transplant surgery (Mayo Clinic, 2019).

Hemorrhage
Blood clots
Infection
Hyperglycemia
Urinary tract infections
Failure of the donated pancreas
Rejection of the donated pancreas

Following a pancreas transplant the patient must take medications for the rest of his life to help prevent rejection of the donor pancreas. Such medications have several side effects (Mayo Clinic, 2019):

Thinning of bones
Elevated cholesterol
Hypertension
Skin sensitivity
Fluid retention
Weight gain
Swollen gums
Acne
Excessive hair growth

Before transplantation, patients are evaluated both physically and mentally. Patients must be able to cope with and adhere to lifelong medical follow-up, the need to take medications to help prevent organ rejection for the rest of their lives, and the ability to cope with side effects of medications needed after transplantation (Mayo Clinic, 2019; MedlinePlus, 2021b18b).

Case Study: Jeremy Wilson

Jeremy is a 16-year-old high-school student who has a history of hard-to-control type1 diabetes. Jeremy is struggling to live what he calls “a normal life like my friends.” Because of the seriousness of his condition he, his parents, and his healthcare providers agree that he is a candidate for pancreas transplant.

Question 1: How long will it take to obtain a pancreas for transplantation?

Discussion:

The average wait time for a pancreas transplant is about 23 months. The pancreas must be meticulously matched to the recipient and is transported in a cooled solution that preserves the organ for up to approximately 15 to 20 hours. Once a pancreas becomes available, it must be transplanted into a recipient within 18-24 hours. Jeremy needs to know about the waiting period for a pancreas. It may be a difficult waiting period as he is anxious to live “a normal life.” Jeremy, and his family, may benefit from counseling as they wait and in preparation for undergoing, and living with, transplantation.

Question 2: What happens during the transplant procedure?

Discussion:

Question 3: Why is a mental health examination needed before transplant surgery?

Discussion:

Prevention and Management of Complications of Diabetes

The possibility of complications must be addressed with patients and families. Healthcare professionals must not only monitor patients but also teach patients and families to recognize signs and symptoms of complications and how to adhere to treatment regimens for complications if they occur.

The CDC identifies the following risk factors for diabetes-related complications (CDC, 2020c):

Smoking

21.6% were tobacco users based on self-report or levels of serum cotinine.
15.0% reported current cigarette smoking.
36.4% had quit smoking but had a history of smoking at least 100 cigarettes in their lifetime.

Overweight and Obesity

89.0% were overweight or had obesity, defined as a body mass index (BMI) of 25 kg/m2 or higher.

Specifically:

27.6% were overweight (BMI of 25.0 to 29.9 kg/m2 )
45.8% had obesity (BMI of 30.0 to 39.9 kg/m2 )
15.5% had extreme obesity (BMI of 40.0 kg/m2 or higher)

Prevention and Management of Complications of Diabetes (cont.)

Physical Inactivity

38.0% were physically inactive, defined as getting less than 10 minutes a week of moderate or vigorous activity in each physical activity category of work, leisure time, and transportation.

A1C

50.0% had an A1C value of 7.0% or higher

Specifically:

22.3% had an A1C value of 7.0% to 7.9%
13.2% had an A1C value of 8.0% to 9.0%
14.6% had an A1C value higher than 9.0%
16.3% of adults aged 18–44 years had A1C levels of 10% or higher, compared to 12.7% of those aged 45–64 years and 4.3% of those aged 65 years or older.

High Blood Pressure

68.4% had a systolic blood pressure of 140 mmHg or higher or diastolic blood pressure of 90 mmHg or higher or were on prescription medication for their high blood pressure.

High Cholesterol

43.5% had a non-HDL level of 130 mg/dL or higher

Specifically:

22.4% had a non-HDL level of 130 to 159 mg/dL
11.2% had a non-HDL level of 160 to 189 mg/dL
9.9% had a non-HDL level of 190 mg/dL or higher

Cardiovascular Disease

Prevention and management of complications of diabetes are important strategies for the promotion of health and wellness among those persons with diabetes mellitus. Cardiovascular disease (CVD) is the major cause of morbidity and mortality for persons who have diabetes as well as the largest contributor to both direct and indirect costs of diabetes. Research has shown that controlling individual cardiovascular risk factors helps prevent or slow CVD development in people with diabetes (ADA, 2021a).

Hypertension

Hypertension is a significant problem among people with diabetes and is a major risk factor for cardiovascular disease. There are generally three categories of blood pressure (CDC, 2020b):

Normal: systolic is less than 120 mmHg; diastolic is less than 80 mmHg.
Prehypertension: systolic is 120 to 139 mmHg; diastolic is 80 to 89 mmHg.
Hypertension: systolic is 140 mmHg or higher; diastolic is 90 mmHg or higher.

Persons who have elevated blood pressure should have blood pressure confirmed by using multiple readings and on separate days to diagnose hypertension. Additionally, all patients with hypertension and diabetes should monitor their blood pressure at home (American Diabetes Association, 2021a).

Hypertension (cont.)

In pregnant patients with diabetes and pre-existing hypertension, blood pressure targets of 110-135/85 mmHg are suggested (ADA, 2021a).

The ADA (2021a) Standards of Medical Care in Diabetes recommends the following treatment initiatives for blood pressure control in persons with diabetes (American Diabetes Association, 2021a):

Blood pressure should be measured at every routine clinical visit. Patients found to have elevated blood pressure (≥140/90 mmHg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension.
All hypertensive patients with diabetes should monitor their blood pressure at home.
For patients with diabetes and hypertension, blood pressure targets should be individualized through a shared decision-making process that addresses cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences.
For individuals with diabetes and hypertension at higher cardiovascular risk (existing atherosclerotic cardiovascular disease [ASCVD] or 10-year ASCVD risk ≥15%), a blood pressure target of <130/80 mmHg may be appropriate if it can be safely attained.
For individuals with diabetes and hypertension at lower risk for cardiovascular disease (10-year atherosclerotic cardiovascular disease risk <15%), treat to a blood pressure target of <140/90 mmHg.
In pregnant patients with diabetes and preexisting hypertension, a blood pressure target of 110–135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension and minimizing impaired fetal growth.
For patients with blood pressure >120/80 mmHg, lifestyle intervention consists of weight loss when indicated, a Dietary Approaches to Stop Hypertension (DASH)-style eating pattern including reducing sodium and increasing potassium intake, moderation of alcohol intake, and increased physical activity.

List continues on the next page.

Hypertension (cont.)

Patients with confirmed office-based blood pressure ≥140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals.
Patients with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes.
Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes. ACE inhibitors or angiotensin receptor blockers are recommended first-line therapy for hypertension in people with diabetes and coronary artery disease.
Combination drug therapy is generally required to achieve blood pressure targets. However, combinations of ACE inhibitors and angiotensin receptor blockers and combinations of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors should not be used. These combinations increase the risk of hypotension, hyperkalemia, and renal impairment.
An ACE inhibitor or angiotensin receptor blocker, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g creatinine. If one class is not tolerated, the other should be substituted.
For patients treated with an ACE inhibitor, angiotensin receptor blocker, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually.
Patients with hypertension who are not meeting blood pressure targets on three classes of antihypertensive medications (including a diuretic) should be considered for mineralocorticoid receptor antagonist therapy.

Hypertension (cont.)

The DASH (Dietary Approaches to Stop Hypertension) diet focuses on fruits, vegetables, whole grains, and other foods that are deemed to be heart healthy and low in fat, cholesterol, and sodium. DASH also emphasizes intake of fat-free or low-fat dairy products, fish, poultry, and nuts. The intake of red meats, sweets, added sugars, and sugar-containing beverages is reduced. DASH is rich in nutrients, protein, and fiber (Mayo Clinic, 2020e; 2021c). This diet has been shown to help diabetic patients lose weight and maintain a more stable blood sugar.

Salt should be limited. Foods that are low in sodium and contain no added salt should be chosen. Salt should not be on the table during meals. No more than one teaspoon of salt per day should be consumed (Mayo Clinic, 2020e; 2021c).

Patients who smoke should be referred to smoking cessation programs. Smoking constricts and damages blood vessels and increases hypertension risk (Mayo Clinic, 2021c).

Finally, patients must be instructed in stress management techniques. Relaxation training, deep breathing exercises, guided imagery, and exercise all have been shown to facilitate stress reduction. Equally important is to help patients identify stressors in their lives and how to deal with them. For example, financial issues may prove to be significant stressors. The costs of a chronic illness, even with insurance coverage, can place a financial burden on patients and families. Relaxation techniques may be helpful, but patients may also need referral to financial counseling or resources that may be able to help defray the cost of medications and other treatments (Mayo Clinic, 2021c).

Lipid Management

Lifestyle modifications that focus on weight loss if needed, dietary changes as needed (reduce intake of saturated fat, trans fat, and cholesterol; increase intake of n-3 fatty acids, fiber, and plant stanols/sterols), and glycemic control are central to lipid management (American Diabetes Association, 2021a).

The American Diabetes Association (2021a) offers the following recommendations for lipid management:

For adults not taking lipid-lowering therapy, obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every 5 years thereafter if younger than 40 years of age. Testing may be done more frequently as needed.
A lipid profile should be obtained at the start of lipid-lowering therapy 4 to 12 weeks after starting therapy or when there is a change in dosage and annually thereafter.
In adults not taking statins or other lipid-lowering therapy, it is reasonable to obtain a lipid profile at the time of diabetes diagnosis, at an initial medical evaluation, and every five years thereafter if under the age of 40 years, or more frequently if indicated.
For patients with diabetes aged 40–75 years without atherosclerotic cardiovascular disease, use moderate-intensity statin therapy in addition to lifestyle therapy.
For patients with diabetes aged 20–39 years with additional atherosclerotic cardiovascular disease risk factors, it may be reasonable to initiate statin therapy in addition to lifestyle therapy.
In patients with diabetes at higher risk, especially those with multiple atherosclerotic cardiovascular disease risk factors or aged 50–70 years, it is reasonable to use high-intensity statin therapy.
In adults with diabetes and 10-year atherosclerotic cardiovascular disease risk of 20% or higher, it may be reasonable to add ezetimibe to maximally tolerated statin therapy to reduce LDL cholesterol levels by 50% or more.

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Lipid Management (cont.)

For patients of all ages with diabetes and atherosclerotic cardiovascular disease, high-intensity statin therapy should be added to lifestyle therapy.
For patients with diabetes and atherosclerotic cardiovascular disease considered very high risk using specific criteria, if LDL cholesterol is ≥70 mg/dL on maximally tolerated statin dose, consider adding additional LDL-lowering therapy (such as ezetimibe or PCSK9 inhibitor). Ezetimibe may be preferred because of lower cost.
For patients who do not tolerate the intended intensity, the maximally tolerated statin dose should be used.
In adults with diabetes aged >75 years already on statin therapy, it is reasonable to continue statin treatment.
In adults with diabetes aged >75 years, it may be reasonable to initiate statin therapy after discussion of potential benefits and risks.
Statin therapy is contraindicated in pregnancy.
For patients with fasting triglyceride levels ≥500 mg/dL, evaluate for secondary causes of hypertriglyceridemia and consider medical therapy to reduce the risk of pancreatitis.
In adults with moderate hyper-triglyceridemia (fasting or non-fasting triglycerides 175–499 mg/dL), clinicians should address and treat lifestyle factors (obesity and metabolic syndrome), secondary factors (diabetes, chronic liver or kidney disease and/or nephrotic syndrome, hypothyroidism), and medications that raise triglycerides.
In patients with atherosclerotic cardiovascular disease or other cardiovascular risk factors on a statin with controlled LDL cholesterol but elevated triglycerides (135–499 mg/dL), the addition of icosapent ethyl can be considered to reduce cardiovascular risk.
Statin plus fibrate combination therapy has not been shown to improve atherosclerotic cardiovascular disease outcomes and is generally not recommended.
Statin plus niacin combination therapy has not been shown to provide additional cardiovascular benefit above statin therapy alone, may increase the risk of stroke with additional side effects, and is generally not recommended.

Antiplatelet Agents for the Management of CVD

Research findings indicate that aspirin has been shown to help reduce cardiovascular morbidity and mortality in patients who are high risk and who have had previous heart attack or stroke. However, its overall benefit in primary prevention among adults with no previous cardiovascular events (heart attack or stroke) is controversial for patients with or without a history of diabetes. Aspirin is not recommended for persons at low risk of ASCVD (men and women younger than 50 years of age with no other major ASCVD risk factors). This is because the low potential benefit is outweighed by the risks for bleeding (American Diabetes Association, 2021a).

Following are recommendations regarding aspirin therapy (American Diabetes Association, 2018j):

Use aspirin therapy (75 to 162 mg/day) as a secondary prevention strategy for persons with diabetes and a history of ASCVD.
Use clopidogrel (75 mg/day) for those patients with ASCVD and documented aspirin allergy.
The use of dual antiplatelet therapy (low-dose aspirin and a P2Y12 inhibitor) is deemed reasonable for a year after an acute coronary syndrome and may have benefits beyond one year.
Long-term treatment with dual antiplatelet therapy should be considered for patients with prior coronary intervention, high ischemic risk, and low bleeding risk to prevent major adverse cardiovascular events.
Combination therapy with aspirin plus low-dose rivaroxaban should be considered for patients with stable coronary and/or peripheral artery disease and low bleeding risk to prevent major adverse limb and cardiovascular events.
Aspirin therapy (75 to 162 mg/day) may be considered as a primary prevention strategy for those patients with type 1 or type 2 diabetes who have increased cardiovascular risk.

Screening and Treatment Recommendations for Cardiovascular Disease

The American Diabetes Association (2021a) does not recommend routine screening for coronary artery disease in asymptomatic patients if ASCVD risk factors are treated. Investigations for coronary artery disease should be considered if any of the following is present:

Unexplained dyspnea
Chest discomfort
Carotid bruits
Transient ischemic attack
Stroke
Claudication
Peripheral arterial disease
Electrocardiogram abnormalities

Screening and Treatment Recommendations for Cardiovascular Disease (cont.)

Following are recommendations for treatment of coronary heart disease for patients with diabetes (American Diabetes Association, 2021a):

Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease or established kidney disease, a sodium–glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit is recommended as part of the comprehensive cardiovascular risk reduction and/or glucose-lowering regimens.
In patients with type 2 diabetes and established atherosclerotic cardiovascular disease, multiple atherosclerotic cardiovascular disease risk factors, or diabetic kidney disease, a sodium–glucose cotransporter 2 inhibitor with demonstrated cardiovascular benefit is recommended to reduce the risk of major adverse cardiovascular events and/or heart failure hospitalization.
In patients with type 2 diabetes and established atherosclerotic cardiovascular disease or multiple risk factors for atherosclerotic cardiovascular disease, a glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular benefit is recommended to reduce the risk of major adverse cardiovascular events.
In patients with type 2 diabetes and established heart failure with reduced ejection fraction, a sodium–glucose cotransporter 2 inhibitor with proven benefit in this patient population is recommended to reduce risk of worsening heart failure and cardiovascular death.
In patients with known atherosclerotic cardiovascular disease, particularly coronary artery disease, ACE inhibitor or angiotensin receptor blocker therapy is recommended to reduce the risk of cardiovascular events.
In patients with prior myocardial infarction, β-blockers should be continued for 3 years after the event.
Treatment of patients with heart failure with reduced ejection fraction should include a β-blocker with proven cardiovascular outcomes benefit, unless otherwise contraindicated.
In patients with type 2 diabetes with stable heart failure, metformin may be continued for glucose lowering if estimated glomerular filtration rate remains >30 mL/min/1.73 m²but should be avoided in unstable or hospitalized patients with heart failure.

Diabetic Neuropathy

Diabetic neuropathy is a group of nerve disorders caused by diabetes mellitus. Over the course of time, nerve damage can occur throughout the body. Some persons have no symptoms of nerve damage, but others may feel pain, tingling, or numbness in the hands, arms, feet, and legs. Neuropathy can occur in every organ system throughout the body (NIDDK, n.d).

The following persons are at highest risk for diabetic neuropathy (Mayo Clinic, 2021b):

Those who are overweight
Those who are hypertensive
Those who have elevated cholesterol
Those who have advanced renal disease
Those who drink large amounts of alcohol
Those who smoke

The American Diabetes Association (2021i) advocates the following screenings and treatments:

Assess all patients for diabetic peripheral neuropathy beginning at diagnosis of type 2 diabetes and five years after the diagnosis of type 1 diabetes. After these initial assessments, patients should be evaluated at least annually.
Include a careful history and assessment of either temperature or pinprick sensation as part of the assessment for distal symmetric polyneuropathy.
Assess for signs and symptoms of autonomic neuropathy in patients who have microvascular complications.
Optimize glucose control to prevent or delay the development of neuropathy or to slow its progression.
Assess and treat patients to reduce pain related to diabetic peripheral neuropathy and symptoms of autonomic neuropathy.
Prescribe either pregabalin or duloxetine as initial pharmacologic treatments for neuropathic pain in diabetes.

There are four types of diabetic neuropathy (NIDDK, n.d.):

Peripheral
Autonomic
Proximal
Foca

Peripheral Diabetic Neuropathy

Peripheral neuropathy is the most common type of diabetic neuropathy. The areas of the body most affected are the feet and legs. Rarely, other areas of the body—the arms, abdomen, and back—may be affected by peripheral neuropathy. Nerve damage can lead to a loss of sensation in the feet and legs placing the patient at significant risk for foot problems. Injuries, lesions, blisters, and sores on the feet may go unnoticed because of a lack of sensation. Infection can easily occur, and if not treated promptly, the infection can spread to the bone. Such infections may lead to amputation of toes, feet, and lower limbs. Many amputations can be prevented with meticulous skin care and swift recognition and treatment of infections (Dansinger, 2021b; Mayo Clinic, 2021e; NIDDK, 2018).

Common symptoms of diabetic peripheral neuropathy are tingling (resembling a “pins and needles” sensation), numbness (which can become permanent), burning (especially in the evening), and pain. Discomfort related to these symptoms may be reduced or controlled when blood glucose levels are under control (NIDDK, 2018c).

Painful diabetic neuropathy may be treated with oral medications (NIDDK, 2018c):

Tricyclic antidepressants and other types of antidepressants as appropriate
Anticonvulsants
Skin creams, patches, or sprays (e.g., lidocaine)

Peripheral Diabetic Neuropathy (cont.)

Healthcare professionals must instruct patients and families in skin care, especially the care of the feet, because the nerves to the feet are the longest in the body and are the nerves most often impacted by neuropathy. Education should include the following instructions (Dansinger, 2021b; Mayo Clinic, 2021e):

Clean the feet daily using warm, not hot, water and a mild soap. Do not soak the feet. Dry the feet gently but thoroughly with a soft towel, paying special attention to the skin between the toes.
Apply gentle, non-perfumed lotion to the feet if they are dry. Do not put lotion between the toes.
Inspect the feet and toes every day for cuts, blisters, redness, sores, calluses, or other problems. Use a mirror to check the bottom of the feet. If any abnormalities are noted, notify a health care provider immediately. Rigorous attention to leg and foot ulcers may include debridement, hyperbaric oxygen therapy, or intensive would care.
Go to a podiatrist, if possible, to avoid injuring the toes when toenails need to be trimmed.
Never go barefoot. Wear properly fitting shoes or slippers at all times to protect the feet from injuries. Shoes should not be tight; the toes should be able to move when wearing them. New shoes should be broken in gradually by wearing them for only an hour at a time initially.
Examine shoes and slippers before putting them on, including feeling the insides. This is done to be sure that shoes and slippers are free from tears, sharp edges, or objects that might damage the feet.
Participate in regular, gentle exercise. Routines such as yoga and tai chi might be of benefit.
Stop smoking.
Eat healthy meals.
Avoid excessive amounts of alcohol.
Monitor blood glucose levels per health care provider instructions.

Autonomic Diabetic Neuropathy

Autonomic neuropathy is damage to the nerves that are responsible for the control of the internal organs. Autonomic neuropathy can lead to problems in the cardiovascular, digestive, and renal systems. It can also cause sexual dysfunction, vision problems, and alterations in the function of the sweat glands (NIDDK, 2018a).

Heart and Blood Vessel Impact of Autonomic Neuropathy. Damage to the nerves of the cardiovascular system adversely affects the body’s ability to adjust blood pressure and heart rate. This can lead to orthostatic hypotension, dizziness, lightheadedness, or fainting. Damage to the nerves that control heart rate can lead to tachycardia instead of normal increases and decreases in heart rate in response to body functions, stress, and physical activity (NIDDK, 2018a).

Patients must be taught to avoid changing position too quickly, especially from a lying to a sitting or standing position. Wearing elastic stockings may be helpful, and physical therapy can be useful when dealing with muscle weakness or loss of coordination. Heart healthy interventions such as smoking cessation, lipid management, blood pressure control, exercise, and diet may help to decrease the development or progression of heart and blood vessel autonomic neuropathy (NIDDK, 2018a).

Digestive System Autonomic Neuropathy. Following are common symptoms of digestive autonomic neuropathy (NIDDK, 2018a):

Bloating
Diarrhea
Constipation
Difficulty swallowing
Feeling full after eating only a small amount of food
Loss of appetite
Nausea
Vomiting
Fecal incontinence

Treatments include dietary changes and medications to treat symptoms of constipation, diarrhea, fecal incontinence, and gastroesophageal reflux (NIDDK, 2018a).

Autonomic Diabetic Neuropathy (cont.)

Urinary Tract Involvement. Nerve damage can cause incomplete emptying of the bladder and increase the likelihood of urinary tract infections. Patients may also experience incontinence and increased urination at night (NIDDK, 2018a).

Patients are encouraged to drink plenty of fluids to help prevent infections. Because they may not be able to sense when their bladders are full, patients may implement a regular schedule of voiding such as every four hours (NIDDK, 2018a).

Sexual Organs Involvement. Autonomic neuropathy can gradually decrease sexual response in men and women even though sex drive may be unchanged. Men may be unable to have or unable to maintain an erection or have dry or reduced ejaculations. Women may have difficulty becoming aroused or achieving orgasm or experience a decrease in vaginal lubrication that can lead to painful intercourse (NIDDK, 2018a).

Treatment of erectile dysfunction in men begins with testing to rule out hormonal causes. To treat erectile dysfunction caused by neuropathy, medications that increase blood flow to the penis may be prescribed. Some medications are oral; others are injected into the penis or inserted into the urethra at the tip of the penis. Other interventions include the use of mechanical vacuum devices to increase blood flow to the penis or surgical implantation of an inflatable or semirigid device in the penis (Dansinger, 2021b; Ignatavicius et al., 2018; NIDDK, 2018a).

For women, the use of vaginal lubricants, estrogen creams, suppositories, and rings or medications to help reduce symptoms and facilitate arousal may be prescribed (Dansinger, 2021b; Ignatavicius et al., 2018; NIDDK, 2018a).

Focal Diabetic Neuropathy

Focal diabetic neuropathy can appear suddenly. It affects specific nerves most often in the head, torso, or leg (NIDDK, 2018b).

Focal diabetic neuropathy may cause the following problems (NIDDK, 2018b):

Double vision
Aching behind one eye
Bell’s palsy (paralysis on one side of the face)
Difficulty focusing the eyes

Focal diabetic neuropathy is unpredictable as well as being painful and is seen most often in older patients with focal neuropathy who tend to develop nerve compressions, also called entrapment syndromes. Carpal tunnel syndrome, which causes numbness and tingling of the hand and sometimes muscle weakness and pain, is a common example of such compression. Other nerves that are vulnerable to entrapment may cause pain on the outside of the shin or the inside of the foot (NIDDK, 2018b).

Diabetic Retinopathy

Diabetic retinopathy is the most common diabetic eye disease and a leading cause of blindness in American adults. Initially, diabetic retinopathy may not cause any symptoms or only mild vision disturbances. However, the complication can eventually result in blindness (Mayo Clinic, 2021b; National Eye Institute, 2019).

The American Diabetes Association (2021i) recommends that to slow progression of diabetic retinopathy, patients should optimize glycemic control, blood pressure, and serum lipid control.

Diabetic retinopathy has four stages (Dansinger, 2021c):

Mild non-proliferative retinopathy: Microaneurysms occur, which are small areas of balloon-like swelling in the blood vessels of the retina.
Moderate non-proliferative retinopathy: Some blood vessels that provide nourishment to the retina are blocked.
Severe non-proliferative retinopathy: More and more blood vessels are blocked. Several areas of the retina are deprived of their blood supply, and they transmit messages to the body to grow new, additional blood vessels to supply nourishment.
Proliferative retinopathy: New blood vessels grow in an attempt to nourish the retina. This condition is referred to as proliferative retinopathy. These new blood vessels are fragile and abnormal and grow along the retina and along the surface of the clear vitreous gel that fills the inside of the eye. Because the walls of the abnormal vessels are so thin and fragile, they leak blood causing severe vision loss and even blindness.

Diabetic Retinopathy (cont.)

It is rare to have signs and symptoms of the disease during early stages of diabetic retinopathy. However, as the disease progresses, symptoms may include the following Mayo Clinic, 2021b; National Eye Institute, 2019):

Spots or dark strings floating in the visual field (commonly referred to as floaters)
Blurred vision
Dark or empty areas in vision
Vision loss
Problems with color perception

The American Diabetes Association (2021i) recommends that adults with type 1 diabetes have their first eye exam within five years of diagnosis. Persons with type 2 diabetes should get the initial eye exam soon after receiving a diagnosis. After the initial exam. The ADA recommends that all people with diabetes get an annual eye exam. Patients who have no evidence of retinopathy for one or more annual eye exams and glycemia is well controlled, then screening every one to two years may be considered.

The early stage of diabetic retinopathy may not require treatment. However, as the disease progresses, treatment is generally needed. Proliferative diabetic retinopathy requires prompt treatment (Mayo Clinic, 2021b).

Focal Laser Treatment

Also known as photocoagulation, focal laser treatment can stop or slow the leakage of blood or fluid in the eye. This procedure is performed in the office setting or at an eye clinic and is generally done in a single session. Vision may be blurry for a day after the procedure, and the patients may see small spots in their visual field for several weeks (University of Michigan Health, 2020).

Scatter Laser Treatment

Also known as pan retinal photocoagulation, this treatment can shrink abnormal blood vessels. Also performed in an office or eye clinic setting, this procedure involves treating affected areas with scattered laser burns. The burns cause the abnormal blood vessels to shrink and scar. Scatter laser treatment is usually done in two or more sessions and causes blurred vision for about a day after the procedure. Some loss of peripheral vision or night vision after undergoing the procedure is possible (University of Michigan Health, 2020).

Vitrectomy

A vitrectomy is performed to remove blood from the middle of the eye (vitreous) as well as any scar tissue that is pulling on the retina. A vitrectomy is performed in a surgical center or hospital using local or general anesthesia. A tiny incision is made in the eye through which scar tissue and blood are removed and replaced with a saline solution to maintain the normal shape of the eye. A gas bubble may be placed in the cavity of the eye to help reattach the retina. If so, the patient may need to remain prone (face down) for several days until the gas bubble dissipates. An eye patch is worn, and medicated eye drops instilled for a few days or weeks. Vitrectomy may be followed or accompanied by laser treatment (Johns Hopkins Medicine, n.d.b).

Nursing Considerations: Patients treated with Scatter Laser procedures or vitrectomy may be extremely anxious for the fear of both pain and the possible complete loss of vision. Coaching, information about the procedures, and possible pre-mediation for anxiety should be considered. Patients required to remain prone for extended periods may also present nursing care challenges for eating and elimination.

Diabetic Nephropathy

Diabetic nephropathy refers to damage to the kidneys caused by diabetes. Not all diabetics develop diabetic nephropathy. Diabetics who are at higher risk for its development include persons with hypertension, elevated cholesterol, smoking history, and uncontrolled blood glucose (ADA, 2021i).

Diabetic nephropathy does not produce symptoms in its early stages. Therefore, testing urine for the presence of albumin is very important so that kidney damage can be detected as soon as possible. Early kidney damage may be reversed (ADA, 2021g; 2021i).

Symptoms, when they appear, are not particularly specific. Fluid retention and edema, loss of sleep, loss of appetite, nausea and vomiting, weakness, and trouble concentrating are reported (ADA, 2020g; 2021i).

The primary treatment for diabetic nephropathy is to lower blood pressure. ACE inhibitors are recommended for most people who have hypertension, diabetes, and renal disease. Cholesterol and triglyceride levels must also be controlled; statins are generally prescribed (ADA, 2021g; 2021i).

As with most complications, the best way to prevent diabetic nephropathy is to control blood glucose levels. Blood pressure management, a healthy diet, regular physical exercise, and adhering to prescribed medication schedules are all extremely important. A low protein diet may be recommended (ADA, 2021g; 2021i).