Diabetes Mellitus

NUR 155

Part 1
Diabetes Definition
“… is a group of disorders
characterized by
high blood glucose levels
that result from
defects in the body's ability to
produce
and/or use insulin.”
Diabetes Prevalence
 Pre-Diabetes
■ Research shows that you can
lower your risk for type 2 diabetes
by 58% by:
– Losing 7% of your body weight
(or 15 pounds if you weigh 200
pounds)
– Exercising moderately (such as
brisk walking) 30 minutes a
day, five days a week
 Impact on Health
■ Major risk factor for CVD
■ Leading cause of lower limb amputations
■ Leading cause of kidney disease
■ ⅔ have HTN /↑ cholesterol/neuropathy
■ ⅓ have vision problems/blindness

Centers for Disease Control and Prevention, 2020

Diabetes and Mortality

■ In 2019, diabetes was the seventh

leading cause of death in the United
States.
■ Shortens the life span for adults by
8.5 years

Centers for Disease Control and Prevention, 2019

 Diabetes and Mortality

■ Among the elderly, it is associated with:

• Higher mortality
• Higher rate of institutionalization
• More cognitive impairment/dementia/Alzheimer’s
(2x more likely than non-diabetics)
• Decreased functional status (neuropathy – limits
physical mobility and increases fall risk; vision)

National Academy on an Aging Society, 2010

 Impact on Healthcare System

■ 2-4x increase in hospitalization rates

■ Increased LOS by 1-3 days
■ 1½-2x more likely to admit thru ED
■ Economic cost: $237 billion is spent each year
on direct medical costs and another $90
billion on reduced productivity.

Agency for Healthcare Research and Quality (AHRQ), 2008

American Diabetes Association (ADA), 2017
Centers for Disease Control and Prevention, 2020
 Glucose
Homeostasis
Glucose Homeostasis*
1. Glucose arrives in blood stream from 1 of 3 sources: carbs eaten by mouth, glucose
released from muscles and/or liver, or glucose created in liver and/or kidneys
2. Glucose is then transported to the TARGET cells
3. In response to increased blood glucose, insulin is released from the pancreatic BETA
cells
4. At the TARGET cells, insulin facilitates transport of glucose across cell membrane to cell
interior. Insulin is KEY to allowing glucose in the cell
5. Inside the cell, glucose is metabolized as fuel, releasing energy for cell function
6. If blood glucose levels are high, more insulin is secreted by the pancreas
7. When blood glucose is driven into the cell and metabolized, glucose levels in the
blood FALL
8. If blood glucose levels fall too LOW, insulin release is STOPPED and glucose remains in
the blood stream
9. Also if blood glucose falls TOO LOW, glucagon is released from pancreatic ALPHA cells
 Pancreas

Islets of Langerhans
■ Alpha Cells: produce glucagon
■ Beta Cells: produce insulin
 Insulin Physiology
– Released in response to high blood glucose
– Necessary for the transport of glucose from
bloodstream across the cell membrane into cell
 Insulin Physiology

– NORMAL FUNCTION:
➢ Basal – consistent release
(NEVER ZERO!)
➢ Bolus – released in response
to meal
 Diagnosis
■ Hemoglobin A1c (glycosylated hemoglobin) value (HbgA1c)
– >6.5%
– Measures average amount of glucose that binds to red blood cells over prior 3
months.
■ Fasting blood glucose
– >126 mg/dL
– 100-125 pre-diabetes
■ Oral glucose tolerance test (OGTT or 2 hour post-prandial test)
– >200 mg/dL
– Patient consumes beverage containing high dose of glucose with blood sampling
fasting, 1st hour, and 2nd hour
■ Random blood glucose
– >200 mg/dL, along with polyuria, polydipsia, polyphagia, and weight loss

American Diabetes Association (ADA). (2020)

 Classifications of DM
3 Classifications of Diabetes Mellitus
▪ Type 1
▪ Type 2
▪ Gestational
▪ Other less common types

Commonality: Hyperglycemia
Difference: Cause of hyperglycemia
 Type 1 Diabetes

■ Destruction of beta cells

– Immunological
– Genetics
– Environmental
■ No insulin production
 Type 1 Onset:

■ Commonly diagnosed during childhood

– peaks age 14
■ Fairly abrupt onset of symptoms
■ Unpreventable
 Type 1: The 3 “Ps”
■ Chronic hyperglycemia osmotic diuresis, resulting
in polyuria.
■ Diuresis dehydration, triggering thirst center,
causing polydipsia.
■ Polyphagia results from cellular starvation.

■ Primary acute complication:

– Diabetic Ketoacidosis
Type 2 Diabetes: Ineffective Insulin

■ Insulin level varies

■ Insulin production by pancreas is decreased, but
makes enough to prevent ketosis
■ Liver produces more glucose than normal
■ Carbohydrate metabolism impaired
■ Glucose builds up in blood
Type 2 Diabetes: Onset
■ Hyperglycemia occurs despite the
availability of insulin
– Insufficient amount of insulin
– Insulin resistance, due to
■ receptor deficits
■ tissue resistance

■ B-cells are not destroyed

■ Middle-age – Older adults*
■ Gradual onset
 Type 2 Diabetes: Risk Factors
Modifiable Non-modifiable
■ BMI greater than 26, even higher risk ■ First-degree relative
once above 30 ■ High-risk ethnic population
■ Physical inactivity ■ Gestational diabetes, polycystic ovary
■ HDL level less than or equal to 35 syndrome
mg/dL ■ HgbA1c greater than or equal to 5.7%
■ Triglyceride level greater than or equal on previous testing
to 250 mg/dL ■ History of cardiovascular disease
■ Metabolic syndrome* – Hypertension damage?
 Type 2 Diabetes: Risk Factors
■ Metabolic syndrome- cluster of risk factors for both cardiovascular disease and type 2
diabetes. Risk factors include resistance to the action of insulin, hypertension, high
cholesterol or low high-density lipoprotein, and hypercoagulability.
■ Address modifiable risk factors
■ A patient is considered to have metabolic syndrome if three of the following traits are
present. These traits include:
– Abdominal or central obesity
– Increased serum triglycerides greater than or equal to 150 mg/dL
– Decreased high-density lipoprotein less than or equal to 40 mg/dL in men; less
than 50 mg/dL in women
– Hypertension greater than or equal to 130/85 mm Hg
– Fasting blood glucose greater than 100 mg/dL
 Diabetes Management

■ Monitoring
■ Education
■ Nutritional therapy
■ Exercise
■ Pharmacologic therapy
Glucose Monitoring

▪ Self-monitoring
▪ Proper use the glucometer
▪ Technique for obtaining blood sample
▪ When to check their blood glucose levels
Patient Education
■ Outpatient Diabetes and Education Centers
– Assist the patient with developing a diabetes plan
■ Treatments
■ Recognition, treatment & prevention of acute
symptoms
■ Pragmatic information
Nutrition
■ Monitoring and limiting carbs/sugar intake is key to maintaining
glycemic control
■ Meal plan should focus on the percentage of calories that come from:
– Carbohydrates = whole grains
– Fats = mayo, salad dressing, olive oil
– Proteins = lean meats/fish, legumes
– Fiber = fruits, vegetables
■ Exchange list
■ 15/15 Rule for hypoglycemia
■ Limit alcohol consumption
■ Artificial sweeteners
Pharmacologic Treatment
■ Insulin
– Used for all Type 1
– Sometimes Type 2
■ Oral antidiabetic agents
Exercise

■ Controls weight
■ Decreases blood glucose
■ Increases circulation
■ Increases lean muscle mass
■ Increased resting metabolic rate
■ Decreases blood lipid concentration
Gestational Diabetes

■ Results from hormonal changes during pregnancy

■ Detected at 24-28 weeks
■ Higher risk for C-section, neonatal complications
■ Increased risk for Type 2