Diabetes: What do I need to know?
Objectives: Upon completion of the CE activity, learners will be able to:
- Describe statistical data regarding diabetes in the US.
- Identify the prevalence and significance of diabetes to the US population.
- Articulate the pathophysiology of the different types of diabetes.
- Discuss the types of diabetes and risk factors.
- Define patient care for management of types of diabetes.
- Recognize complications of diabetes and opportunities to decrease risk.
The purpose of this module is to provide an overview of the types of diabetes, current treatment and management, impact of diabetes on the individual, and the cost of healthcare in the US.
Each year in the U.S. about 1.4 million individuals are diagnosed with diabetes (Centers for Disease Control, 2017). In 2017, there were an estimated 30 million individuals in the United States with some form of diabetes; both diagnosed and undiagnosed (CDC, 2017; ADA, 2018c). In 2017, the overall cost was calculated to be in excess of $327 billion dollars and appears to be rising annually, with the average medical expenditure cost per person near $17,000 dollars. In addition, there is decreased quality of life, disability leading to inability to work, lost productivity, and premature deaths. Diabetic patients over 65 years of age contribute greatly to the growing economic impact of diabetes. There was a projected 40.3 million hospital days incurred by people with diabetes in 2017 and about one-fourth of all nursing/residential facility days are incurred by people with diabetes (ADA, 2018c).
Almost half of all physician office visits, emergency department visits, hospital outpatient visits, and medication prescriptions incurred by people with diabetes are attributed to their diabetic diagnosis (ADA, 2018c). It is easy to see the economic impact on the healthcare system as well as the personal impact to the individual diagnosed with diabetes. We will discuss diabetes in this lesson and explore the statistical data, diagnoses, complications, treatments and resources in the United States.
Statistical Data in U.S.
There is a tremendous amount of data gathered each year related to diabetes. It is important to understand individuals and populations at risk in order to provide targeted education and prevention information. Among ethnic groups and individuals aged 18 years or older in the U.S., American Indians and Alaska Natives had the highest diagnosed cases of diabetes between 2013 and 2015, totaling 15.1%. The next highest groups were African Americans at 12.7%, Hispanics at 12.1%, Asians at 8%; and White, non-Hispanics at 7.4%. Those 18 and over diagnosed between 2013 and 2015 were highest with less than a high school diploma at 12.6%; high school diploma at 9.5%; and more than high school at 7.2% (CDC, 2017).
While the national median is 9.1% of the adult population in each state that is diagnosed with diabetes, the state with the highest prevalence is Mississippi at 13.6%, and the lowest is Colorado at 6.4%. In 2015, approximately 193,000 of the diagnosed diabetics were children under the age of 20. Type 1 and type 2 diabetes is rising in children with an increase in type 2 of 4.8% versus a 1.8% increase in type 1. In contrast to overall diabetic ethnic populations, White, non-Hispanic children were at 27 per 100,000 versus American Indian children at 6.5 per 100,000 for type 1 diabetes diagnosis. Rates for these same groups when comparing type 2 diabetes showed the American Indian children were diagnosed at a rate of 46.5 per 100,000 and White, non-Hispanic children at a rate of 3.9 per 100,000. Black children and adolescents were diagnosed with type 2 diabetes at a rate of 32.6 per 100,000, just behind the American Indian group (CDC, 2017).
In addition to the high number diagnosed with some form of diabetes, the CDC estimates that over 84 million U.S. adults over age 18 have prediabetes. They further predict that while almost 34% of the U.S adult population has prediabetes, a significant number are not aware of their risk or condition, and remain undiagnosed (CDC, 2017; Zand, Ibrahim & Patham, 2018). This leaves much room for education, screening and prevention measures. Public service announcements put out by the CDC in 2016 focused on getting individuals to check their risk in a campaign called “Know Where you Stand, DoIHavePrediabetes.org”. It consists of a one-minute screening quiz that will identify prediabetes risk as well as local resources to find teaching and support to decrease the risk (CDC, 2017).
In addition to the monetary costs of diabetes are the intangible losses that are difficult to predict or quantify. These include reduced quality of life, pain, and suffering of the patient and their loved ones.
Cost of Diabetes
In 2017, the reported cost of diabetes overall was over $327 billion dollars, with $29.3 billion spent in medication and supplies to treat diabetes. An additional $37.3 billion was spent on cardiovascular-related illnesses associated with the individual’s diabetes. Studies have shown that all hospital stays are longer in general for the diabetic patient than the non-diabetic patient and there is greater use of all healthcare services with the diabetic patient (ADA, 2018c).
Diabetes mellitus (DM) is a chronic disease impacting multiple body systems due to abnormal insulin production, impaired insulin utilization by the body or a combination of the two. The complications of DM are overwhelming and make it a devastating disease to those impacted by it. DM is the leading cause of end-stage renal disease, blindness and non-traumatic lower limb amputations. DM is a major contributing factor in hypertension, heart disease and stroke, which can all lead to premature death (Lewis, Dirksen, Heitkemper & Bucher, 2014).
The causes of diabetes can be linked to genetics, autoimmune, and environmental factors including viruses and obesity (Lewis et al., 2014). Individual types of diabetes and linked causes will be discussed in the next section.
Normal insulin metabolism occurs through continuous release of insulin by the β (Beta) cells in the islets of Langerhans of the pancreas. Insulin secretion increases with food intake to maintain a stable blood glucose level of 70-120 mg/dL. The average amount of insulin secreted daily by an adult is 40-50 U or 0.6 U/kg of body weight (Lewis et al., 2014).
The secreted insulin promotes glucose transport into the cell. As blood glucose increases after a meal or food intake, glucose is stored as glycogen in the liver and muscle tissue. Concurrently, this secretion of insulin also inhibits gluconeogenesis, enhances fat deposition of adipose tissue, and increases protein synthesis. Due to these actions, insulin is considered an anabolic or storage hormone in the body. The reduced insulin during overnight fasting causes the liver to release glucose, the muscles to release proteins, and the adipose tissue to release fat during sleep (Lewis et al., 2014).
Insulin functions by unlocking receptor sites in the skeletal muscle and adipose tissue that allow the transport of glucose into the cells to be used for energy. Skeletal muscles and adipose tissue are considered insulin-dependent, while the brain, liver and blood cells do not depend on insulin and only require an adequate supply of glucose for normal functioning. While liver cells are not insulin-dependent tissue, the liver does have “insulin receptor sites that facilitate hepatic uptake of glucose and its conversion to glycogen” (Lewis et al., 2014, p. 1154).
Counter-regulatory hormones such as glucagon, epinephrine, growth hormone and cortisol work to oppose the effects of insulin and increase blood glucose by stimulating the production of glucose and liver output through a decrease in the movement of glucose into the cells. The normal range of blood glucose levels are typically maintained by regulating the release of glucose for energy during periods of fasting, food intake, and the production and release of insulin and the counter-regulatory hormones (Lewis et al., 2014).
Insulin synthesis begins with its precursor, proinsulin. Proinsulin is split by enzymes to make insulin and C-peptide in equal amounts. This byproduct is useful when assessing pancreatic β cell function as the C-peptide can be measured in the urine and blood (Lewis et al., 2014)
An individual is said to have pre-diabetes if they have impaired glucose tolerance, impaired fasting glucose, or both. Lewis et al., (2014) defines impaired glucose tolerance as “an intermediate stage between normal glucose homeostasis and diabetes where the blood glucose level is 140 mg/dL to 199 mg/dL 2 hours after a meal” and impaired fasting glucose as “an intermediate stage between normal glucose homeostasis and diabetes”. These individuals are at an increased risk of developing type 2 diabetes yet may not exhibit any symptoms, although damage to their vessels could already be occurring. This serves as a powerful rationale for individuals to have annual physicals with routine glucose screenings (Lewis et al., 2014).
Gestational diabetes is similar to type 2 diabetes, however this develops during pregnancy. Those at high risk for gestational diabetes include patients with obesity, advanced maternal age, and/or a family history of diabetes (Lewis et al., 2014).
Diabetes can occur due to other medical conditions or due to treatment for other diseases if the β cell function of the pancreas are damaged, injured or destroyed. Risk factors could include Cushing’s syndrome, hyperthyroidism, recurrent pancreatitis, cystic fibrosis, hemochromatosis and parenteral nutrition. Medications that can cause diabetes include corticosteroids, thiazides, phenytoin and atypical antipsychotics such as clozapine. Diabetes caused by any of the previous may resolve when the condition is treated or the medication is discontinued (Lewis et al., 2014).
Type 1 DM is caused by the autoimmune destruction of the pancreatic β cells leading to the total absence of insulin production. There is a genetic predisposition and exposure to a virus that contribute to this type of autoimmune-related condition (Lewis et al., 2014). Auto-antibodies to the islet cells cause a decrease in the normal function before other symptoms of type 1 DM appear. The genetic component to type 1 diabetes is related to the human leukocyte antigens (HLA’s). When an individual with the HLA’s is exposed to viral infections, the β cells of the pancreas can be destroyed directly and/or through an autoimmune process (Lewis et al., 2014).
Another form of type 1, idiopathic diabetes, is inherited and does not have an autoimmune component. There are only a small number of people with this type of diabetes; most commonly individuals of Hispanic, African or Asian descent. A third form of type 1 is latent autoimmune diabetes in adults (LADA). LADA is a slow-developing autoimmune form of type 1 diabetes that usually occurs in people over 35 years of age and presents without obesity (Lewis et al., 2014).
Type 2 DM differs from type 1 with a continued production of endogenous insulin by the pancreas. However, the insulin is either insufficient in amount or used poorly by the tissues, or both. The most common risk factor for type 2 DM is obesity, especially in the abdominal region. Genetic mutations that increase the risk for obesity and insulin resistance are found in individuals with type 2 DM. There are four major metabolic abnormalities connected to the development of type 2 diabetes:
- Insulin resistance, or the gradual decline in the normal reaction of skeletal muscle and adipose cells to insulin
- Decrease in the pancreas’s ability to produce insulin
- Inappropriate glucose production by the liver
- Altered production of hormones and cytokines by adipose tissue (Lewis et al., 2014)
Another risk factor for developing type 2 diabetes is metabolic syndrome. The individual diagnosed with metabolic syndrome has at least three of the following components:
- Elevated glucose levels
- Abdominal obesity
- Elevated blood pressure
- High triglycerides
- Decreased levels of high-density lipoproteins (HDLs) (Lewis et al, 2014)
Types of Diabetes
As previously mentioned, many individuals are unaware they are at risk for pre-diabetes. Educating the population on their risk and encouraging screenings can decrease not only their risk of DM, but also their risk of the complications of diabetes. Zand et al. (2018) note that individuals with pre-diabetes have an increased risk of cardiovascular disease and strokes. Healthcare providers can offer education and support to decrease the risk associated with pre-diabetes including lifestyle management. There are modifiable and non-modifiable risk factors for pre-diabetes.
Modifiable risk factors:
- Reduced physical activity
Non-Modifiable risk factors:
- Family history of DM
- Personal history of high blood glucose (Zand et al., 2018).
The American Diabetes Association (ADA, 2019a) recommends screening for pre-diabetes in the general population and any population at-risk, including those with a body mass index (BMI) of 25 or greater who also have one or more of the following: hypertension, physical inactivity, history of cardiovascular disease, HDL less than 35 and/or triglyceride level greater than 250 mg/dl, AIC of 5.7% or greater, women with history of gestational diabetes or polycystic ovarian syndrome, patient with a first degree relative with DM, or patients within a high-risk ethnic group (African Americans, Pacific islanders, Latinos, Native Americans) (ADA, 2019a; The Advertising Council, Inc., 2019).
Screening Tests for pre-diabetes:
- Fasting plasma glucose (defined as no caloric intake for at least 8 hours)
- Blood glucose is less than 126 mg/dL but greater than 100 mg/dL on fasting (ADA, 2019a).
- An A1C greater than 5.7% but less than 6.5%. The A1C indicates the percentage of the total hemoglobin that has glucose attached to it (ADA, 2019a).
- Two-hour glucose tolerance test
- Very sensitive in predicting patients with type 2 DM, but primarily used in screening pregnant women. The prediabetes range is 140 mg/dL to 200 mg/dL at two hours (ADA, 2019a).
- Urine glucose
- Minimally sensitive but can be used for screening prior to more invasive testing.
For any abnormal screenings, a second test should be performed on another day prior to initiating treatment. A second abnormal test confirms a diagnosis of pre-diabetes if continued results in the elevated ranges above. Intervals of screening are debated but the ADA recommends that a high-risk patient with normal testing be retested at least every three years (Abdallah, Ahmed, Stevens & Griebeler, 2019; ADA, 2019a).
Treatment/Management of Pre-diabetes
The goal of treatment and/or management of the individual diagnosed with pre-diabetes is to prevent or delay micro- and macro-vascular complications related to diabetes. Evidence has proven that lifestyle changes such as increased physical activity and dietary modifications are effective ways to decrease risk in pre-diabetes, as well as control glucose levels in type 2 diabetics (Abdallah et al., 2019). The ADA (2019a) suggests the Diabetes Prevention Program (DPP) as a guide for weight loss and physical activity goals. This program allows for flexibility in selecting dietary and exercise options. The program focuses on decreasing calories, increasing exercise and physical activity, and maintaining healthy lifestyle behaviors along with social and psychological challenges that motivate the individual (CDC, 2019b)
Typical goals for weight loss are 2-3 pounds per week. At least 150 minutes of physical activity (brisk walking or similar) per week is associated with the most benefits and reduced risk of developing DM (Abdallah, 2019; ADA, 2019a; CDC, 2019b). Further goals to prevent diabetes may be additional strength/resistance training and a sustained 7% weight loss in the first six months of intervention. These interventions increase the chance of avoiding the complications of pre-diabetes and subsequent type 2 diabetes (Abdallah et al., 2019).
Dietary management is a significant part of minimizing risk with pre-diabetes. A specific diet is not recommended but rather outlining a general theme of nutrition that includes whole grains, nuts, berries, yogurt, coffee and tea are associated with a reduced risk of diabetes. The Mediterranean Diet and Dietary Approaches to Stop Hypertension (DASH) Diet have been linked to reducing the incidence of DM regardless of weight loss. It is suggested that red meats and sugary beverages should be avoided as well as high-carbohydrate diets (Abdallah et al., 2019; ADA, 2019a; CDC, 2019b).
Type I Diabetes
Type I DM affects children and adults and is usually diagnosed by the age of 30. About 5% of all diabetics have type 1 (CDC, 2019). Peak incidence is between the ages of 10 and 15 years and is typically earlier in females than males. There has been a continued rise in DM type 1 amongst children under 5 years of age as compared to children over age 16. Males have the highest onset at 25-29 years of age. Genetic factors constitute a strong component in the development of type 1 diabetes with only a 0.4% risk in the population without a genetic history. There is a 4-6% chance that each child of a type 1 diabetic will develop the disease. Young adults considering having children should be educated on this risk (Hippich et al., 2019).
As previously discussed, there are other components to risk for type 1 DM including viral illnesses, autoimmune responses and unknown or simply poorly-understood factors. While diet and lifestyle do not cause type 1 diabetes, they are important components in management (CDC, 2019). There are current studies underway considering the potential impact of maternal viral infections during pregnancy and subsequent development of type 1 diabetes in the offspring (Allen, Kim, Rawlinson & Craig, 2018).
Risk factors for type 1 DM:
- Genetic predisposition
- Having a parent, brother or sister with type 1 diabetes.
- Whites are more likely to develop type 1 than African Americans or Hispanics (CDC, 2019).
- Viral illnesses
- Cytomegalovirus (CMV),
- Congenital rubella (Allen et al., 2017).
- Autoimmune factors
- May be associated with other organ-specific autoimmune diseases including autoimmune thyroid disease, pernicious anemia and idiopathic Addison’s disease (Kawasaki, 2014).
- Idiopathic factors
- Hereditary component with high incidence in Africa and Asia
- No evidence of autoimmunity (Kalyani, 2017).
Common signs and symptoms of type I DM include:
- Polydipsia (increased thirst)
- Polyphagia (increased hunger
- Polyuria (increased urination)
- Unintentional weight loss
- Blurry vision
- Excessive fatigue
- Nausea, vomiting or stomach pains
- Diabetic ketoacidosis, with or without kussmaul respirations
The initial presentation of type 1 diabetes may be diabetic ketoacidosis (DKA). This person may not realize they have diabetes until they have advanced symptoms that require them to seek medical care. In DKA, ketones develop due to the lack of glucose available for the cells. The liver breaks down body fat for energy, producing ketones as a byproduct (CDC, 2019). These ketones build up and cause a metabolic acidosis. A compensatory symptom of kussmaul respirations (deep and labored breathing) may occur in an attempt to decrease the acidity in the body by reducing carbon dioxide (Gallo de Moraes & Surani, 2019). If untreated, DKA will lead to coma or death (CDC, 2019b).
Diagnostic tests for type 1
According to the presentation of a type 1 DM patient, (e.g. emergency in DKA, or office visit due to symptoms such as polyuria, polyphagia, polydipsia and or weight loss), diagnostic tests may vary. Patients should have the following for a diagnosis of type 1:
- Random blood-glucose
- The quickest option for testing when a patient presents with symptoms. If this test is high, the healthcare provider will order the following tests for more precise diagnosis (JDRF, 2019b).
- Fasting plasma glucose
- Blood glucose is greater than 126 mg/dL on fasting (ADA, 2019a).
- Hemoglobin A1C
- An A1C greater than 6.5%. (ADA, 2019a).
- Two-hour glucose tolerance test
- Very sensitive in predicting patients with type 2 DM, but primarily used in screening pregnant women. The diabetic range is greater than 200 mg/dL at two hours (ADA, 2019a).
- Urine glucose
- Minimally sensitive but can be used for screening prior to more invasive testing (ADA, 2019a).
- Urine ketones
- The presence of ketones suggests type 1 versus type 2 diabetes (ADA, 2019a).
- This test measures how much C-peptide is in a person’s blood. Peptide levels typically mirror insulin levels in the body. Low levels of C-peptide and insulin can point to type 1 DM (JDRF, 2019b).
- Antibody testing
- Four autoantibodies are markers of beta cell autoimmunity in type 1 diabetes: Islet Cell Antibodies (ICA, against cytoplasmic proteins in the beta cell), antibodies to Glutamic Acid Decarboxylase (GAD-65), Insulin Autoantibodies (IAA), and IA-2A, to protein tyrosine phosphatase (Kawasaki, 2014).
For abnormal screenings of blood glucose or A1C, a second test should be performed on another day prior to administering a diagnosis of type 1 diabetes. Antibody testing and ketone presence are more precise diagnostic methods and a diagnosis can be made without subsequent revalidation of the tests (ADA, 2019a; Kawasaki, 2014).
Type 1 Treatment/Management
Exogenous insulin will be needed for the type 1 DM patient for life as there is no endogenous insulin available. Daily needs for insulin will vary based on illness, stressors or any of the previous mentioned concerns that led to uncontrolled glucose levels and potential DKA. The goal of any exogenous insulin regimen is to mimic how the body normally releases endogenous insulin. Unfortunately, insulin cannot be administered orally (University of California San Francisco [UCSF] Medical Center, 2019). See Table 1 below for examples of different types of insulins currently available.
Table 1: Insulins
Starts working (onset)
Works hardest (Peak)
Can be mixed with other insulins
Can be mixed in the syringe with other insulins
Can be mixed in the syringe with other insulins
Steady throughout day
CANNOT be mixed in the syringe with any other insulins
CANNOT be mixed in the syringe with other insulins
(Wood & Peters, 2018)
Insulins can be premixed in various combinations for individuals who have difficulty drawing insulin from two bottles and/or for convenience. This type of insulin can be helpful to elderly patients or those suffering from poor eyesight or manual dexterity (ADA, 2019b). Examples of premixed insulin include Humulin 70/30; Novolin 70/30; Humalog Mix 75/25. An inhalable insulin, Afrezza has been introduced as an alternative to injections. This insulin is absorbed via the lungs and introduced to the bloodstream within seconds. This insulin peaks within 30-90 minutes and lasts up to 5 hours (Diabetes Forecast, 2015).
Patient education for insulin administration should include information on the insulin regime including type of insulin, times of administration, methods of administration and adverse reactions to monitor for. Site rotation should be included to preserve subcutaneous tissue integrity (ADA, 2019b).
Basal/Bolus Dosing- A basal dose of insulin is one that will deliver a continuous dose of insulin. This can be attained via a long-acting insulin that has no peaks or via an insulin pump with rapid-acting insulin that is administered in continuous small doses. The basal dose is typically administered at the same time every day and does not change with increased blood glucose levels, as it is intended to mimic the normal pancreas which secretes a basal dose of insulin to manage blood glucose levels in a healthy individual. A bolus dose of insulin is then administered throughout the day with meals and will be used to bring the blood glucose down to normal range with intake of food or with elevated glucose levels (USCF Medical Center, 2019).
Other types of treatment in current literature include Pramlintide, an injection derived from amylin, a hormone that is released into the bloodstream much like insulin after a meal. Amylin has been found to be deficient in patients with diabetes. This drug delays gastric emptying, blunts pancreatic secretion of glucagon and promotes a feeling of fullness. The F.D.A. has approved this drug for treatment of type 1 diabetes. Further positive outcomes with Pramlintide include weight loss, decreased insulin dose, and decreased risk of hypoglycemia (ADA, 2018a).
The patient with type 1 diabetes should consume a balanced diet for good nutrition. A diet consisting of the four food groups with a low intake of empty carbohydrates is optimal. While all individuals should eat a healthy diet combined with an exercise regime, it is vital for the person with diabetes. Proper nutritional intake, control of glucose levels and maintaining a healthy weight can decrease the impact of diabetes on the body (Juvenile Diabetes Research Foundation [JDRF], 2019b). Nutrition, physical activity, and medication are major factors in determining the blood glucose level. Determining what to eat, how much to eat and when to eat all impact the blood glucose level, in addition to exercise and medication (NIH, 2016). The type 1 diabetic may feel as if they will not be able to eat the foods they like or enjoy after being diagnosed. It is important for the nurse to help educate the patient on eating smaller portions and a healthy diet that meets their nutritional needs and their personal taste. As previously mentioned, the DPP, DASH and Mediterranean diets can all be recommended. The food groups that should be included in any healthy eating plan are:
- Vegetables including non-starchy and starchy options. Suggested foods are carrots, greens, tomatoes, broccoli, carrots, squash, and peppers in the non-starchy group. Starchy options would include potatoes and corn.
- Fruits including bananas, grapes, oranges, apples, berries, and melons.
- Grains should be primarily whole grains including wheat, rice, oats quinoa, corn meal, or barley.
- Proteins should include lean meats, nuts, eggs, dried beans or tofu.
- Dairy products should be non-fat or low-fat. This includes yogurts, cheese, and milk.
- Heart-healthy foods are also encouraged including avocados, oils that are liquid at room temperature such as olive oil or canola oil; nuts and seeds; fish such as tuna or salmon.
(JDRF, 2019b; NIH, 2016)
Certain foods and drinks that should be avoided or severely limited by patients with diabetes include:
- Fried foods
- High-sodium foods
- High-sugar foods including ice cream and candy
- High-sugar beverages including juices, sweetened coffees, sports drinks, or soft drinks.
- Alcohol should be used in moderation since it is high in glucose. Women should drink no more than one drink per day and men no more than two drinks per day. Alcohol can cause your glucose level to drop if you use insulin or diabetes medications that increase the amount of insulin the body produces. When drinking even one drink, food should be ingested simultaneously to avoid hypoglycemia (NIH, 2016).
Diabetic patients should be taught to count carbohydrate intake of their meals and administer insulin based on the grams of carbohydrates being consumed (ADA, 2019b). This same process of counting carbohydrate intake and adjusting insulin bolus administration can be achieved with an insulin pump. The patient should calculate their intake and match it with an appropriate dose of insulin. For the patient who continues to have an elevated blood glucose even after their bolus of insulin, a correction bolus can be given. This dose takes into consideration how much the blood glucose drops with each unit of rapid-acting insulin. The patient will then administer the appropriate amount to bring their blood glucose within the desired range (USCF Medical Center, 2019). The Diabetes Control and Complications Trial (DCCT) provided evidence that three or more insulin injections per day provided the optimal glycemic control and improved outcomes for type 1 diabetic patients (ADA, 2016).
The term glycemic index (GI) is used throughout that American Diabetic Association’s education on diabetic nutrition as well as evidence-based practice related to managing diabetes (ADA, 2014a; Brighenti et al., 2018; de Mello Fontanelli, Sales, Carioca, Marchioni & Fisberg, 2018). The maintenance of blood glucose levels support the decrease in vascular damage and future complications associated with diabetes (Vascular Cures, 2019). The GI measures the manner in which carbohydrate-containing foods raise blood glucose. Food choices are ranked on how they compare to a specific reference food (i.e. white bread and glucose). Foods with high GIs will raise the individual’s blood glucose level more than a food with medium or low GIs. When meal plans are being developed, it is best to choose foods with low or medium GIs. Occasionally eating a food with a high GI can be offset by eating a food with a low GI, allowing the individual to eat foods that may be preferred due to taste without impacting their blood glucose level as significantly (ADA, 2014a).
Examples low GI foods would include:
- 100% stone-ground whole wheat or pumpernickel bread
- Oat bran, oatmeal that is steel cut/rolled or muesli
- Pasta, converted rice or barley
- Legumes and lentils, sweet potatoes, corn, lima or butter beans
- Non-starchy vegetables and carrots, and fruits other than melons or pineapples
Medium GI foods would include:
- Whole wheat, rye and pita bread
- Quick oats
- Couscous, basmati rice, wild rice, or brown rice
High GI foods would include:
- Bagels and white bread
- Instant oatmeal, bran or corn flakes, or puffed rice
- Short grain white rice, rice pasta, macaroni and cheese mix
- Pumpkin or russet potatoes
- Popcorn, pretzels, or saltine crackers
- Pineapples or melons
Glycemic index is impacted by certain factors of a food. Fat and fiber content typically lower the GI of a food. Other factors that impact the GI of a food are the cooking or processing method. Also, ripeness and storage of food may impact the GI. An example would be a banana. The riper, the higher the GI. The more cooked or processed a food is, the higher the GI, which is another rationale for eating more whole foods that are less processed (ADA, 2014a). The GI takes into consideration the type of carbohydrates in a food but not the impact from quantity of the carbohydrate. Portion sizes are important for both the GI as well as weight management. Nutrition (protein, vitamin, and mineral content) should be taken into consideration as well. Some foods high in nutrition may have high GIs, so a balance of all these aspects should be considered in order to have the optimal nutritional intake that also supports a steady blood glucose level (ADA, 2014a).
Since there are multiple ways to manage blood glucose levels, typically carbohydrate counting is the first tool of management. Considering the glycemic index of foods in addition to carbohydrate counting can provide improved blood glucose control for those individuals who are willing to put forth additional effort into managing their diabetes (ADA, 2014a). For further guidance on helping diabetic patients manage their nutrition, review the American Diabetic Associations’ website.
The health and wellness of everyone is impacted by physical activity. Exercise is particularly important for diabetic patients in order to reduce the risks and damage to the body. Patients with type 1 DM should have awareness of the effect of physical activity on their blood glucose levels, however. Even mild exercise and physical activity can cause drops in blood sugar, or hypoglycemia. Exercise can bring on hypoglycemia through an increased need for glucose related to the increase in metabolic activities. An individual’s blood glucose will respond based on the glucose level prior to starting the activity, the intensity of the activity, the length of time of the activity and any modifications to insulin intake. A pre-exercise snack and frequent blood glucose checks should be encouraged to prevent hypoglycemia. For individuals with an insulin pump, they may be able to lower their basal rate during the physical activity to avoid eating a snack as well as avoiding hypoglycemia. In the event the blood glucose level drops to a dangerously low-level during exercise, patients should have an emergency management plan in place for hypoglycemia (ADA, 2018b).
Occasionally, high-intensity exercise can cause a high blood glucose level due to elevated stress hormones. Prior to exercise, diabetic patients should be counseled to check their blood glucose level. If the blood glucose is high, then check the urine for ketones. If the urine is positive for ketones, then intense exercise should be avoided. If there are no ketones in the urine, they can proceed with exercise. Efforts should be taken to develop consistent routines and understand the impact of insulin, food and exercise on the individual’s blood glucose levels. Through recognizing this impact and working with the healthcare team, the best outcomes for exercise can be achieved (ADA, 2018b). Devices such as a continuous glucose monitor can give even more precise information related to the impact of exercise on the body’s glucose level. This device measures interstitial glucose rather than blood glucose but gives direction to the ups and downs of glucose related to exercise (Wood & Peters, 2018).
The type 1 diabetic should proceed with caution for certain activities including scuba diving and sky diving. If they experience hypoglycemia while scuba diving, they may not be able to ascend quickly enough to manage their blood glucose. Vigilant monitoring should be part of the precautions that are considered. Skydiving increases adrenaline which can raise the blood glucose levels. Also, if an insulin pump is used, care must be used to secure it with either scuba or sky diving (Wood & Peters, 2018).
Hyperglycemia (elevated blood glucose level) occurs when the blood sugar is higher than target levels. Hyperglycemia can occur for a number of reasons including but not limited to:
- Ingestion of high GI foods.
- Missed doses of medication
- Decreased activity
The nurse should educate patients to call their healthcare provider if their blood glucose level remains above 240 mg/dl for more than two consecutive checks (CDC, 2019b; Mayo Clinic, 2019b).
- Hypoglycemia occurs when the blood sugar falls below 70 mg/dl. While it is more common with type 1 DM, hypoglycemia may occur with type 2 DM after taking insulin or certain medications that stimulate more insulin production, more physical activity than normal and/or upon skipping a meal. The individual suffering from hypoglycemia may exhibit the following signs and symptoms:
- Blurred vision
- Heart palpitations
- Slurred speech
- Confusion (CDC, 2019b; Mayo, 2019b; ADA, 2017a).
The nurse should educate patients to recognize hypoglycemia quickly, and that management should include:
- Eat or drink a simple sugar such as fruit juice, glucose tablets, hard candy, regular soda (should be 15 grams of sugar).
- Retest their blood glucose in 15 minutes to ensure it is above 70 mg/dl. If not, eat another 15 grams of simple sugar as above. Avoid foods high in fat as glucose absorption will be delayed in the presence of fat.
- Once the glucose level is above 70 mg/dl, the individual should eat a complex carbohydrate and protein such as cheese and whole grain crackers to avoid another episode of hypoglycemia.
- For the patient who loses consciousness during hypoglycemia, family members should be instructed to administer a glucagon injection or simple sugar inside the gums to regain consciousness, then offer a complex carbohydrate and protein as above (CDC, 2019b; Mayo, 2019b; ADA, 2017a).
Any individual who takes insulin, certain categories of the hypoglycemic medications that stimulate the pancreas to produce more insulin or does not eat enough food during the day may suffer from hypoglycemia. It is important for nurses to educate the patient and caregivers about the risk of this life-threatening condition. Hypoglycemia can be avoided through early recognition, intervention and prevention (CDC, 2019b).
Sick days and insulin
For the diabetic experiencing a sick day, the patient should continue to drink or eat carbohydrates and take their usual short-acting, intermediate and/or premixed insulin dose. If they are unable to eat or drink and their glucose levels are less than 250 mg/dL, they should reduce these insulin doses by 50%. For the patient that is unable to eat or drink for a longer than one day, the healthcare provider should be contacted for further directions (Wood & Peters, 2018).
The patient on a basal/bolus insulin regime should continue to take their regular basal dose of insulin during sick days, and their bolus dose(s) should match their carbohydrate intake. If the patient is unable to eat or drink, they should be instructed to take a correction factor dose every 3-4 hours. A correction factor dose is insulin that is given to decrease the blood glucose when it goes too high. Each patient should have an individualized correction dose determined by their healthcare provider and based on their current blood glucose reading. A typical correction dose may be 1 unit for each 50 mg/dL. This can be adjusted with various factors including age, weight or activity level (Wood & Peters, 2018).
When sick, diabetic patients should check their blood glucose level every 2-3 hours. They should further check their urine for ketones. It is important to stay hydrated during sick days to avoid the risk of dehydration (ADA, 2019b).
Diabetic Ketoacidosis (DKA) is a complication of type 1 diabetes that can lead to a diabetic coma or death. Due to a lack of insulin to transport glucose into the cells for energy, the body breaks down fat for energy which produces ketones. These ketones build up in the blood and make it more acidic. The rising ketones lead to DKA. The warning signs of DKA are:
- Thirst or dry mouth
- Frequent urination
- High blood glucose levels
- Elevated ketones in the urine
- Fruity breath smell
- Increased respirations (Kussmaul’s)
- Chronic fatigue
- (ADA, 2018a)
For any of these symptoms, the patient should be instructed to seek healthcare immediately.
The causes of DKA are:
- Not enough insulin taken or increased need due to illness causing a breakdown of fat.
- Not enough food leading to high ketone from breakdown of fat.
- Insulin reaction due to a low blood glucose during sleep causing a breakdown of fat.
Emergency management of DKA is based on the restoration of circulating volume and the reduction of blood glucose levels. DKA is a hyperglycemic crisis that occurs primarily with type 1 DM but can occur in some cases with type 2 DM. Increased mortality and morbidity occurs with DKA. It is a reversible condition that requires immediate attention by the healthcare team. DKA may be the first sign of type 1 diabetes in the patient who is unaware of their disease, or it may be brought on by a number of other causes including but not limited to infections, failure to use insulin, or acute medical conditions involving the cardiac, endocrine, or gastrointestinal systems. Stressors to the body from medical procedures such as surgery can also lead to DKA. Medications that impact carbohydrate metabolism or volume status may trigger an episode of DKA including diuretics, corticosteroids, antipsychotics, or beta blockers (Alshammari et al., 2017).
For treatment of DKA, the ADA recommends initiation of 0.9% normal saline, a crystalloid fluid to replace the volume loss caused by polyuria. The fluid replacement goal is 15-20 mL/kg of body weight within the first hour as early intervention is critical with reversing the risk associated with DKA (ADA, 2019b). An insulin drip will be initiated in the early phases of treatment and the greatest fall in blood glucose occurs in the first 1-2 hours. Regular (rapid-acting) and glulisine (rapid-acting) insulins are equally effective in the treatment of DKA. As glucose levels fall, the introduction of D5W should occur to prevent hypoglycemia. (Alshammari et al., 2017). Potassium levels should be monitored throughout the acute phases to assess for hypokalemia, and replacement potassium given as appropriate. Most acid-base imbalances are corrected with the initiation of fluid and insulin, however the patient’s electrolytes should be monitored throughout treatment and managed accordingly (Alshammari et al., 2017; Rouf, Rahim & Latif, 2018; Sindi et al., 2017).
Surgical Management of type I DM
A curative option for the type 1 diabetic is a pancreas transplant. Many patients have experienced positive results from a pancreas transplant, while others have not had the same success. This variation in results has prevented this procedure from being utilized more commonly. The primary benefit to a pancreas transplant is the ability to maintain euglycemia, which is a normal concentration of glucose in the blood, without taking exogenous insulin. The long-term damages caused by diabetes are prevented or delayed and nerve damage from diabetes is slowed or even reversed after a transplant. The primary risk of a pancreas transplant is the body’s rejection of the foreign organ and requisite immunosuppressant drugs that must be taken to avoid such a rejection. As mentioned above, immunosuppressants are necessary to lower the chance of rejection, yet increase the risk of infections, cancer or other opportunistic diseases (ADA, 2013; Mayo Clinic, 2019a).
Due to the high risk of rejection of the pancreas, there has been research and success with islet transplants. Islet cells produce insulin and in type 1 diabetes they are destroyed. Only 1-2% of the pancreas is made up of islet cells so there is a significantly reduced risk of rejection with the transplantation of islet cells than with the entire pancreas. Islet cells are taken from a donor pancreas and transplanted into the recipient’s pancreas. The new islet cells should start producing insulin and thus reduce or eliminate the need for exogenous insulin. This process can be gradual, so close monitoring of the blood glucose in the initial phase of transplantation is important to maintain euglycemia. Islet transplantation is much less invasive and costly than a pancreas transplant. At this time, immunosuppressant drugs are still needed to avoid rejection but research is ongoing to potentially eliminate that need (ADA, 2014b; Mayo Clinic, 2019a).
The nurse has many opportunities for promoting success in patients with pre-diabetes through education, promotion of self-care, screenings and encouraging continued monitoring by the healthcare team. Studies also identified the efficacy of technology to track exercise, diet and progress with personal goals (Abdallah et al., 2019; Beauvais, Wardian & Sauerwein, 2018; Grock, Ku, Kim & Tannaz, 2017).
Type 2 DM
While type 2 DM is typically found in those over 45 years of age, there has been an increase in the incidence of type 2 DM amongst children, teens and young adults in recent years due to obesity and poor lifestyle choices including inactivity. While type 1 DM is almost entirely outside the individual’s control, type 2 DM is largely determined by modifiable risk factors related to the individual’s lifestyle choices (CDC, 2019b; Wood & Peters, 2018). Type 2 DM can be prevented or delayed with modifications to lifestyle including exercising at least 3 times per week and a healthy diet based on complex, low GI carbohydrates (ADA, 2016).
- Modifiable Risk Factors
- Physical activity less than 3 times per week
- Non-Modifiable Risk Factors
- African American, Hispanic, American Indian or Alaska native
- Over 45 years old
- Have a close family member with type 2 (mother, father, brother, sister)
Due to its slow, insidious onset, type 2 DM is often silent and without symptoms for years prior to being diagnosed. Similar to patients with pre-diabetes, these individuals may be unaware there is a problem until they have been exposed to abnormally elevated blood glucose levels for extended periods of time. Type 2 DM is often discovered on a routine check-up, annual physical, pre-employment screening or when the patient develops a wound that won’t heal, repeated vaginal infections or other infections of increased frequency. Further presenting symptoms may be blurred vision, polyuria, polydipsia, polyphagia, numbness or tingling of hands or feet, or dry skin. Due to the silent nature of type 2, individuals who have increased risk factors should be screened at routine intervals for early intervention and recognition of the disease (ADA, 2018a; CDC, 2019b).
Diagnostic tests for type 2
According to the presentation of symptoms, the most common diagnostic tests are as follows:
- Random blood glucose
- Regardless of the last time food was eaten, a blood glucose higher than 200 mg/dL suggests diabetes. The presence of other diagnostic symptoms such as polyuria or polydipsia increase the likelihood of diabetes.
- Fasting plasma glucose
- Blood glucose is greater than 126 mg/dL on fasting (ADA, 2019a).
- Hemoglobin A1C
- An A1C greater than 6.5%. (ADA, 2019a).
- Two-hour glucose tolerance test
For abnormal screenings of blood glucose or A1C, a second test should be performed on another day prior to administering a diagnosis of type 2 diabetes. To diagnose as type 2, other historical data and symptoms will be considered. For the patient diagnoses with diabetes, further testing such as antibodies may be done to determine between type 1 and type 2 (ADA, 2019a).
Type 2 DM is primarily managed by the individual with the disease. While there is support from the healthcare team, the day to day control is managed by the patient. Management includes eating a healthy diet, physical activity at least three times per week, monitoring of blood glucose levels, and if needed the administration of medication as ordered by the healthcare provider. Even when medications are taken, the nurse should encourage the patient to consistently maintain a healthy diet. An appropriate diet for a patient with type 2 DM would be consistent with the dietary recommendations already discussed for the type 1 diabetic including lots of vegetables, complex, low GI carbohydrates, whole grains, nuts and fruits, lean proteins and dairy products and heart-healthy options whenever possible. Further opportunities to maintain glycemic control are limiting alcohol and sugary drinks, portion control, increased water intake and a consistent routine in both dietary plans and exercise (CDC, 2019b).
Initial diagnosis will result in the primary healthcare provider referring the new diabetic patient to other members of the healthcare team including a dietician, diabetes educator, and/or mental health providers as appropriate. Other referrals may include an ophthalmologist, dentist, podiatrist, and potential visit to a bariatric doctor if obesity is involved. The entire family may be involved in diabetic education. Long and short-term goals will be established with the primary healthcare provider, dietician and/or diabetic educator. Goals will be reviewed at each subsequent visit and updated as appropriate. Smoking cessation will be discussed if this is a factor and support will be provided alongside established goals by the healthcare team. It is very important for the patient with type 2 DM to be active in their treatment plan and voice preferences and concerns with their healthcare team (ADA, 2018a).
One option for diabetic education is a program called Diabetes Self-Management Education and Support (DSMES) which are services that will help the diabetic learn how to care for themselves with the new diagnosis (CDC, 2019b). There are other diabetic education programs across the country that can be found on the American Association of Diabetes Educators (AADE) website. These programs will help the patient to manage the day-to-day challenges of living with diabetes and support their management of long-term implications (AADE, 2019).
The first line of treatment for type 2 DM is diet and exercise. Many patients with type 2 DM are able to avoid oral and subcutaneous hypoglycemic medications and/or insulin with diet and exercise. In other patients, these measures are not enough and medications are added when needed to avoid complications related to consistently elevated blood glucose levels.
The type 2 diabetic has life-long implications related to their disease and management of the condition. Considerations for wellness including foot care, eye care, weight management, routine blood glucose checks, A1C monitoring, medication regime, pregnancy for the female, impotence for the male, other neuropathies, nephropathies, and dental care are just a start to the list. The type 2 should drink responsibly if at all and should work to stop smoking. Vaccinations should be kept up-to-date and include hepatitis B vaccines and flu vaccines since diabetes lowers the immune system (Mayo Clinic, 2019b).
- Hemoglobin A1C (or simply A1C) monitoring should be done with any type of diabetes and pre-diabetes. The A1C is a blood test that is performed in the lab or healthcare provider’s office. This test will give an average of the blood glucose level over the past 3 months. This is the most commonly used test to diagnose pre-diabetes and diabetes. The test can also determine effectiveness of the treatment plan and if modifications should be made. Increased A1C levels are linked to an increase in diabetic complications, thus highlighting why individual goals are so important to reach and maintain (CDC, 2019b; Mayo Clinic, 2019b; ADA, 2017a).
A1C results are reported as estimated averages rather than mg/dL that are displayed on blood glucose meters. Table 3 below indicates the A1C percentage as it correlates to the estimated average glucose (eAG) which the patient would see on the blood glucose monitor.
Table 3. A1C Correlation with Estimated Average Glucose
The A1C may be inaccurately high or low due to kidney failure, liver disease or severe anemia. Certain medications can interfere with A1C levels including opioids and some HIV medications. Blood loss or transfusions, early or late pregnancy or certain blood disorders such as sickle cell anemia or thalassemia may all interfere with accurate A1C results (CDC, 2019b; Mayo Clinic, 2019b).
A1C goals are typically 7% or lower. Personal goals may be adjusted due to age or medical conditions. Each patient’s A1C goal should be determined between the individual and their healthcare provider or healthcare team. For individuals who experience frequent hypoglycemia, a higher goal may be established to avoid the severe lows. Younger people tend to have lower A1C goals since they have many years to live with diabetes. Older individuals may have higher goals due to multiple health conditions or to avoid hypoglycemic episodes (CDC, 2019b).
- Blood glucose monitoring
In addition to the A1C goals, blood glucose monitoring should be done throughout each day. A blood sugar should be checked at the following times:
- Upon awaking
- Before a meal
- Two hours after a meal
- At bedtime
Individual targets for blood sugar will vary but a pre-prandial goal (before the meal) is typically 80-130 mg/dl. The postprandial goal (2 hours after eating a meal) should be less than 180 mg/dl. The individual along with their healthcare team will develop targets for the pre- and postprandial glucose levels as part of the treatment plan. Logging blood glucose levels will allow the patient to discuss trends with their healthcare provide and determine opportunities for further improvement and management of their overall blood glucose levels. A concern for many diabetics is the cost of testing supplies and medications. These can be very expensive and often insurances do not cover the cost. The healthcare team can help with resources that may offer low-cost or free supplies to the diabetic in need (CDC, 2019b).
Individuals with type 2 DM who are morbidly obese or have a body mass index (BMI) over 35 may be referred for weight loss (bariatric) surgery. Blood glucose levels are often drastically improved by the weight loss that occurs after bariatric surgery. The consideration of risk such as long-term nutritional deficiencies, osteoporosis and even death must be discussed with the patient by the healthcare team (ADA, 2017a).
Oral medications to lower blood glucose levels are typically the first step in pharmacologically controlling glucose levels, and they work best when combined with diet and exercise. Only individuals with type 2 DM are able to take oral medications. Not all individuals are able to control their blood glucose with oral medications. Examples of possible oral treatments for type 2 DM include:
- Biguanides work by lowering glucose production in the liver and improving the way the body uses insulin. One example is metformin (Glucophage, Glumetz), which is typically the first medication prescribed for type 2 DM and sometimes for weight loss in prediabetes. When metformin, diet and exercise are not successful in controlling blood glucose levels another oral or injectable medication will be added (Mayo Clinic, 2019b).
- Sulfonylureas help the body to secrete more insulin (Mayo Clinic, 2019b).
- Meglitinides work like sulfonylureas and help the pancreas to make more insulin, but they have a faster onset of action and a shorter duration than sulfonylureas (Mayo Clinic, 2019b).
- Thiazolidinediones makes tissues more sensitive to insulin. Examples include rosiglitazone (Avandia) and pioglitazone (Actos). Thethiazolidinediones are typically not first-choice treatments due to these adverse effects and are used only in unique cases where glucose control is not attained with other drug categories (Mayo Clinic, 2019b).
- Dipeptidyl-peptidase 4 (DPP-4) inhibitors assist in reducing blood glucose levels but at a minimal effect (Mayo Clinic, 2019b).
- Sodium-glucose transporter 2 (SGLT2) inhibitors prevent the kidneys from reabsorbing sugar back into the blood, but rather excrete it via the urine (Mayo Clinic, 2019b).
Table 2. Antidiabetic Medications
Potential Side Effects
Effective; may cause minor weight loss; low cost
Nausea, diarrhea; rare buildup of lactic acid if used in patients with kidney or liver failure.
Effective; low cost
Hypoglycemia, weight gain and/or skin rash
Hypoglycemia, weight gain, interact with alcohol with N/V
May increase the HDL cholesterol (good cholesterol)
Possible increased risk of bladder cancer with pioglitazone; increased risk of fractures, MI, HF, weight gain
Dipeptidyl-peptidase 4 (DPP-4) inhibitors
Do not cause hypoglycemia; do not cause weight gain
Headache, sore throat, URI’s
Sodium-glucose transporter 2 (SGLT2) inhibitors
May lower BP; Could promote weight loss
UTI, Yeast infections, rare genital infections
- GLP-1 receptor agonists are non-insulin injectable medications that slow down digestion and thus decrease blood glucose levels. They may promote weight loss, but have potential adverse effects such as nausea and increased risk of pancreatitis. These drugs may be taken twice daily, daily or weekly. Examples are exenatide (Byetta, Bydureon), dulaglutide (Trulicity) and liraglutide (Victoza). Liraglutide (Victoza) and semaglutide (Ozempic) have been associated with a decreased risk of heart attack and stroke often associated with type 2 DM (Mayo Clinic, 2019b; ADA, 2017b).
- Insulin may be added to the treatment plan when a type 2 diabetic is unable to adequately control their blood glucose level with oral medications and/or non-insulin injectable medications along with diet and exercise. Initially a single injection of long-acting insulin such as glargine (Lantus) or insulin detemir (Levemir) may be used in combination with other oral or subcutaneous medications (Mayo Clinic, 2019b; ADA, 2017b). Please review the aforementioned information related to insulin in the section on type 1 DM.
- Other medications that may be added to the regime of type 2 diabetics may be anti-hypertensives to control blood pressure, a low-dose aspirin to reduce cardiovascular risk and/or cholesterol-lowering medications to manage hypercholesterolemia (ADA, 2017b).
Secondary diabetes is elevated blood glucose levels cause by an illness, toxin or medication. This type of diabetes occurs due to reduced tissue sensitivity to insulin or a reduction in pancreatic insulin secretion. This type of diabetes makes up approximately 1-2% of all diagnosed cases of diabetes (Parks-Chapman & Schub, 2018).
While there are several individual disease processes that can cause secondary diabetes, examples are:
- Cushing’s Syndrome
- Autoimmune disorders including Lupus
- Liver disease
- Muscle disorders such as myotonic dystrophy
Medications that can trigger secondary diabetes are:
- Thyroid hormone
- Second-generation antipsychotics (e.g. clozapine [Clozaril] or olanzapine [Zyprexa]) (Parks-Chapman & Schub, 2018).
The signs and symptoms of secondary diabetes are consistent with type 1 and type 2 diabetes depending on the severity of the insulin insensitivity and hyperglycemia. If the cause is not obvious, this type of diabetes can be difficult to diagnose. This patient may present with DKA (similar to type 1 DM) or HHNS (similar to type 2 DM) or more minor symptoms including polydipsia, polyphagia and/or polyuria (Parks-Chapman & Schub, 2018).
Diagnostic tests for secondary diabetes
According to the cause of secondary diabetes, the diagnostic tests may vary. Most will be diagnosed in a similar fashion to type 1 and type 2. Starting with the random blood glucose level, further tests up to antibody testing may be needed to determine the optimal treatment plan for the patient with secondary diabetes (Parks-Chapman & Schub, 2018).
- Random blood-glucose
- The quickest option for testing when a patient presents with symptoms. If this test is high, the healthcare provider will order the fasting plasma glucose, A1C and check for ketones (JDRF, 2019b).
- Fasting plasma glucose
- Blood glucose is greater than 126 mg/dL on fasting (ADA, 2019a).
- An A1C greater than 6.5%. (ADA, 2019a).
- Urine ketones
- The presence of ketones suggests type 1 versus type 2 diabetes (ADA, 2019a).
For abnormal screenings of blood glucose or A1C, a second test should be performed on another day prior to administering a diagnosis of type 1 diabetes. Antibody testing and ketone presence are more precise diagnostic methods and a diagnosis can be made without subsequent revalidation of the tests (ADA, 2019a).
Laboratory and diagnostic tests will be consistent with type 1 and type 2 DM. A fasting blood glucose above 126 mg/dL or a random blood glucose above 180 mg/dL or an elevated A1C above 6 could indicate secondary diabetes. A thorough history and physical would be indicated to determine any pharmacological or physical history that could indicate secondary diabetes.
Immediate treatment to lower the blood glucose level should be initiated with either oral antidiabetic drugs and/or insulin. Basic diabetic education should be given, as well as education regarding nutrition, medication regimen and lifestyle modifications needed for the newly diagnosed diabetic. For secondary diabetes caused by medications, a change in the medication regime should be considered where possible to eliminate the need for insulin or other antidiabetics. For medical conditions, treatment focuses on the underlying cause. For other patients with secondary diabetes, lifelong treatment will be needed (Parks-Chapman & Schub, 2018).
Gestational diabetes is diabetes that develops during pregnancy in women who do not have a previous diagnosis of diabetes. Approximately 2-10% of all pregnancies in the U.S. are affected by gestational diabetes. The pregnant woman’s body is unable to make enough insulin due to the hormonal changes and weight gain associated with pregnancy. Insulin resistance may develop due to these changes and the body’s need for insulin increases. All women have increased need for insulin during late pregnancy, but women with gestational diabetes need more insulin throughout their entire pregnancy, requiring treatment. All pregnant women are screened between 24-28 weeks for gestational diabetes (CDC, 2019a). Risk factors include:
- Previous pregnancy with gestational diabetes
- Previous birth with baby over 9 pounds
- Over 25 years of age
- Family history of type 2 DM
- Polycystic ovary syndrome (PCOS)
- Ethnic backgrounds including American Indian, African American, Hispanic American, Alaska Native, Native Hawaiian, or Pacific Islander (CDC, 2019a)
Often, there are no symptoms associated with gestational diabetes. Typically, it is diagnosed during routine checks or based on risk factors leading to screening.
To reduce the risk of developing gestational diabetes in future pregnancies, the nurse should encourage the patient to lose weight and engage in regular physical activity prior to trying to conceive again. Women should not try to lose weight during pregnancy without their healthcare provider’s orders. In addition, early blood glucose screening should take place with future pregnancies. For a patient who was diagnosed with gestational diabetes with a previous pregnancy, screening should take place at their first prenatal visit with further testing at 24-28 weeks pregnancy if the initial testing was negative (CDC, 2019a).
Screening/diagnostic tests for gestational diabetes
For the woman at risk of gestational diabetes subsequent screening tests will be implemented.
- Initial glucose challenge test. (screening)
- The patient drinks a glucose solution and one hour later will have a blood test to determine the blood sugar level. If the blood glucose is higher than 140 mg/dL at one hour, it indicates a higher risk that normal for gestational diabetes (Mayo Clinic, 2019b).
- Follow-up glucose tolerance test
- After fasting overnight, the blood glucose is drawn for a fasting level. A glucose solution with a very high concentration of glucose is ingested and then blood glucose is checked every three hours. If two of the three blood glucose levels are higher than 140 mg/dL, the patient is diagnosed with gestational diabetes (Mayo Clinic, 2019b).
- Check blood sugars routinely
- Take medications as ordered and on schedule, which may include metformin, insulin, or other antidiabetic medications
- Dietary consult
- Eat a healthy diet; measure food; eat on schedule, at appropriate times
- Regular physical activity
- Close monitoring of fetus for optimal growth and development (CDC, 2019a)
Complications of DM
The patient with pre-diabetes has an increased risk of cardiovascular disease and other micro- and macro-vascular complications, even prior to developing a diagnosis of type 2 diabetes. They are often unaware of having the disease and thus routine screening is needed to identify those at risk and start early interventions that are low cost and extremely effective. Dietary modifications and increased physical activity can likely reverse the risk of developing diabetes and the need for future costly interventions such as oral/subcutaneous hypoglycemic medications and/or insulins (ADA, 2019a; CDC, 2019b).
Type 1 DM complications
The patient with type 1 diabetes may be diagnosed in infancy through young adulthood, but will be impacted by the disease for their entire lifespan. Therefore, it is vital that steps are taken to avoid the long-term complications associated with diabetes. Complications can be prevented or delayed by consistently maintaining blood glucose levels within acceptable ranges. The poorly controlled diabetic is at heightened risk for micro and macro-vascular damage to vessels throughout the body (ADA, 2018a). Complications of uncontrolled diabetes may include:
- Foot complications:
- Poor circulation can make the patient vulnerable to infections on the feet and endure decreased healing.
- Foot ulcers can develop from poor circulation and poorly fitting shoes.
- Skin changes can cause the feet to become dry and cracked.
- Amputations due to peripheral arterial disease that decreases blood flow to the feet. Even small wounds can lead to future amputations.
- Nephropathy: The kidneys are very vascular with tiny vessels that filter out the waste products from the blood. Due to microvascular damage, the kidneys may gradually lose the ability to filter out waste, thus eventually necessitating dialysis. However, not all diabetics have kidney damage. Factors that contribute to kidney disease include hypertension, poor glycemic control, and genetics. By maintaining therapeutic blood glucose levels and controlling hypertension, patients are able to decrease their risk of kidney damage. A low-protein diet is also recommended for some patients with macroalbuminuria (elevated protein in the urine), as protein can increase the workload on the kidneys. This should be discussed with the healthcare provider (ADA, 2018a).
- Stroke: Patients with diabetes have a 1.5 times greater risk of stroke than individuals without diabetes (ADA, 2018a). Further risk factors for stroke include both modifiable and non-modifiable risks:
- High LDL cholesterol or low HDL cholesterol
- Lack of exercise/activity
- Tobacco use
- Alcohol use
- Age over 55
- Race, particularly African American
- Previous history of TIA or stroke
- Family history of TIA or stroke
- History of heart disease or hypertension (ADA, 2018a)
Similar to above, the patient’s overall risk can be lowered by maintaining therapeutic blood glucose levels, physical activity, smoking cessation, maintaining a healthy weight, and managing any existing hypercholesterolemia (ADA, 2018a).
- Hypertension: While statistics show that 1 in 3 Americans have hypertension (HTN), the prevalence goes up to 2 in 3 among diabetics who have hypertension or are currently being medicated to lower their blood pressure. For all individuals with HTN, there is an increased risk of stroke, cardiac disease, and kidney disease. By lowering the blood pressure, the risk of these complications declines or is delayed. The ADA identifies the ideal blood pressure as 120/80 or less. Blood pressure should be checked at each healthcare visit to help patients to know their numbers (ADA, 2018a). The nurse should educate patients regarding the following tips to reduce their blood pressure:
- Determine the ideal treatment plan with their healthcare provider.
- Eat more whole grain breads and cereals.
- Avoid high sodium foods.
- Maintain a healthy weight.
- Limit or avoid alcohol intake (ADA, 2018a).
- Gastroparesis, or delayed emptying of the stomach, can occur due to vagus nerve damage. The vagus nerve controls the muscular activity of the stomach and intestines leading to food movement. Slower movement of food through the digestive tract may lead to heartburn, nausea, vomiting of undigested food, abdominal bloating, gastroesophageal reflux, decreased appetite, erratic blood glucose levels or early satiety when eating (ADA, 2018a). With gastroparesis, food stays in the stomach longer and leads to elevated blood glucose and increased difficulty maintaining euglycemia (ADA, 2018a). Further, food that stays in the stomach a longer period of time can lead to bacterial overgrowth from fermented food. The food can also harden into solid masses called bezoars that can lead to nausea, vomiting and obstruction, blocking the passage of food into the small intestines (ADA, 2018a; Mayo Clinic, 2017).
- Eye complications: Individuals with diabetes are at a 40% increased risk of developing glaucoma. This risk is further increased as the diabetic ages and is typically higher in patients with type 1 diabetes as compared to those with type 2 diabetes due to the lifelong nature of the disease. Cataracts are 60% more common in the diabetic patient. The age of onset is often younger, and the progression of cataracts is often faster in patients with diabetes. While cataract removal can correct the issue, there are further complications that can occur after cataract removal including glaucoma and retinopathy. Retinopathy is a general term for all the disorders of the retina caused by diabetes (ADA, 2018a). The types of retinopathy are nonproliferative and proliferative.
- Nonproliferative retinopathy is most common and involves the blocking of capillary blood flow to the back of the eye, which leads to capillaries swelling and forming pouches. This type of retinopathy goes through stages as more blood vessels are damaged.
- Proliferative retinopathy progresses over years as more blood vessels are completely blocked off from damage. New blood vessels start growing in the retina, but these tend to be weak and leak blood, leading to a vitreous hemorrhage. Proliferative retinopathy can also cause scar tissue to form and as it shrinks the retina is pulled out of place causing a retinal detachment (ADA, 2018a).
Both types of retinopathy can be corrected with precision laser treatment. Medications can be injected into the eye to slow the growth of new blood vessels and reduce the leakage of fluid. Surgical intervention with a vitrectomy may also be considered. This procedure is done by removing the vitreous humor gel that fills the eye cavity to gain better access to the retina. This allows the removal of scar tissue, laser repair of retinal detachments and treatment of macular holes. Despite the availability of medical and surgical procedures to correct retinopathy, prevention via vigilant blood glucose and blood pressure control should be the first line of treatment (ADA, 2018a).
- Skin complications: Since diabetes can impact every part of an individual’s body, the skin has its own concerns. Most skin conditions can be prevented or easily managed with proper treatment. The most common skin problems amongst patients with diabetes are bacterial or fungal infections. Itching may occur or other more serious conditions such as dermopathy, diabetic blisters or eruptive xanthomatosis (ADA, 2018a).
- Bacterial infections are typically caused by Staphylococcus bacteria and may cause styes, boils, folliculitis, carbuncles or nail infections. Good skin care and blood sugar control can decrease this risk (ADA, 2018a).
- Fungal infections in the diabetic patient are most often caused by Candida albicans. Common types of infection include jock itch (groin region), ringworm, athlete’s foot or vaginal infections.
- Itching is common in diabetics due to dry skin, poor circulation or yeast infections. Most itching can be controlled by limiting the number of baths, using a mild soap, and/or moisturizing the skin after bathing. When applying a moisturizing lotion, the nurse should be careful to educate the patient to avoid applying lotion between the toes as this can increase the moisture and cause further problems with infections (ADA, 2018a).
- Neuropathy: Peripheral neuropathy causes pain, tingling, numbness or weakness in the feet and hands. The pain may be described as pins and needles sticking into the feet or hands. There may be burning or stabbing pain in the feet or hypersensitivity to touch even with socks, shoes, gloves or bed covers. The individual with peripheral neuropathy may say their feet hurt all night or that they get extremely hot or cold. Numbness and weakness may be part of the descriptions of neuropathy as well. Often as the neuropathy progresses the burning and pain may stop but is replaced with a feeling of cold or numbness in the extremities (ADA, 2018a). Neuropathy cannot be reversed once established and the focus should be on managing symptoms and keeping the extremities healthy. Medications may be used to treat the uncomfortable symptoms. The healthcare team will determine the best course of action to decrease the discomfort or potential damage from neuropathy (ADA, 2018a; Wood & Peters, 2018).
With each of the aforementioned complications, the nurse should help focus the patient’s efforts on preventing damage through careful regulation of blood glucose levels. This is accomplished through eating a healthy, balanced diet focused on foods with a low GI and proper administration of insulin to meet the demands of dietary consumption. In addition, the type 1 diabetic patient should work with their healthcare team to individualize a treatment plan that works for their lifestyle, resources, and preferences (Wood & Peters, 2018).
Type 2 DM complications
Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS) is a life-threatening condition type 2 diabetics are at risk for if their blood glucose level rises above 600 mg/dL. They may present with a dry mouth, extreme thirst, confusion, dark urine and potential for convulsions. Lab values show there is no acidosis present, as they are still making enough insulin to avoid ketogenesis. The lack of ketones and metabolic acidosis is the primary difference between HHNS and DKA. This condition is found in patients with type 2 DM and may be preceded by illness or infection. A home glucose monitor may simply indicate “high” upon check of the blood glucose. The nurse should instruct patients to seek immediate care with any signs or symptoms of HHNS (ADA, 2018a).
Gestational Diabetes Complications
Women with gestational diabetes have a 50% chance of developing type 2 DM at some point in their life. Their risk can be lowered by maintaining a healthy weight, eating a healthy diet and routine exercise. The mother is also at an increased risk for a cesarean delivery due to the potential for macrosomia, or excessive birth weight (CDC, 2019a). Complications for the baby born to a mother with gestational diabetes includes:
- Macrosomia, over 9 pounds at birth
- Hypoglycemia at birth
- Prematurity leading to respiratory issues
- Development of type 2 DM later in life (CDC, 2019a).
Patients with type 2 DM should be counseled on the potential complications during pregnancy with the disease. Insulin may be required to control blood glucose levels and babies may be born with increased birth weight and hypoglycemia requiring interventions in the neonatal intensive care unit (NICU). Diabetic retinopathy may worsen during pregnancy and drugs such as aspirin, anti-hypertensive and cholesterol lowering drugs cannot be taken (ADA, 2018a). More information on diabetes during pregnancy can be found under the Gestational Diabetes section.
Previous mention of multi-system organ damage from elevated blood glucose has taken place throughout this module, however a focus on foot and wound care, renal complications and mental health care will be discussed in this section.
The nurse should educate patients on the implications of elevated glucose levels on the patient’s feet and legs. The patient with diabetes is at risk for nerve damage or neuropathies as has been previously discussed and this nerve damage can lead to deformed or misshaped feet. These misshaped areas can cause friction from shoes or surfaces that lead to blisters, sores or even ulcerations. Since the individual with diabetes already has poor circulation, the healing process will be delayed and can eventually lead to amputation or debridement of the toe, foot or even an entire extremity (CDC, 2019b). To avoid this type of outcome, the diabetic should do the following daily:
- Inspect the feet daily for cuts, cracks, redness, edema, blisters, calluses, splinters, or dark spots. The primary healthcare provider should be notified if foot lesions do not heal within one day.
- Discuss care of corns and calluses with a podiatrist or primary healthcare provider if needed.
- Wash feet daily in warm water and dry completely. Avoid hot water as burns can occur more easily due to neuropathy and reduced temperature sensation.
- Toenails should be filed or cut straight across. The edges should be filed to avoid sharp edges. Soak feet first to soften toenails. Avoid cutting toenails too short or rounded which may lead to ingrown toenails.
- Avoid lotion between the toes as this can lead to skin breakdown or fungal infections. However, the heels and top of feet should be moisturized to prevent cracking or dry skin which can cause break down.
- Cotton socks should be worn daily to avoid blisters or sores from shoes. Socks should be clean and dry without seams if possible.
- Good-fitting shoes should be worn to avoid friction and pressure sores. New shoes should be broken in slowly by wearing them 1-2 hours daily for 2 weeks.
- Do not go barefoot in or out of the house. Slippers or shoes should be worn to avoid injury to the feet.
- Protect feet from extreme hot or cold.
- Elevate the feet when sitting to promote blood flow. Avoid crossing legs and wiggle toes and move ankles up and down for 5 minutes 3-4 times per day.
- Stop smoking as this causes damage to the circulatory system that can lead to poor circulation to the feet and legs.
- Manage blood glucose levels, blood pressure and cholesterol levels to promote circulation and decrease vascular damage.
- Routine exercise is vital to promote circulation to the lower extremities and decrease damage from diabetes.
- Schedule an annual podiatrist evaluation (CDC, 2019b).
Diabetic patients are at a higher risk of developing wounds or other skin conditions that lead to wounds, and their wound healing time is prolonged due to the complications of diabetes. Foot wounds are a particular concern. Elevated glucose levels delay healing and bacteria thrives in the high-glucose environment of the diabetic. Poor circulation further impedes healing in the diabetic patient and thus a reason many have amputations for even minor wounds to their lower extremities (CDC, 2019b).
Maintaining euglycemia is vital to improve the chances of wound healing in a diabetic patient. More aggressive wound treatments including negative pressure wound therapy, hyperbaric oxygen therapy, silver cream, extracorporal shockwave therapy or higher-cost dressing treatments including biological skin equivalent may be needed to ensure healing and avoid further complications (Ahangar, Woodward & Cowin, 2018). For more on wound care refer to the NursingCE module on Interdisciplinary Wound Care (2019).
Renal complications are one of the costliest aspects of long-term diabetes. In 2016, the cost of treating chronic kidney disease (CKD) by Medicare beneficiaries alone was over $79 billion dollars. The kidney cells and blood vessels are damaged inside the kidneys and cause decreased filtering of waste products. The waste products build up in the blood and can lead to serious health conditions including metabolic acidosis. The damage caused by diabetes can lead to total kidney failure requiring dialysis (CDC, 2018a).
The diabetic is also at risk for urinary tract infections (UTI) and should report any symptoms to the primary healthcare provider immediately. Signs and symptoms of a UTI include:
- Cloudy or bloody urine
- Back pain (called flank pain)
- Chills or a temperature
- Frequent urination
- Pain or burning with urination (CDC, 2018a).
Emergency preparedness for diabetics
Diabetics should always be prepared with sufficient amounts of medication and supplies for the maintenance of their care. During natural disasters, emergencies or other hazards the diabetic must be prepared to manage their care for at least a week. The CDC (2018a) has extensive Emergency Preparedness resources with specific advice to:
- Have at least one week’s supply of water, food, medications and syringes
- Have at least one week’s supply of test strips and extra batteries for blood glucose monitor and equipment
- Identify yourself as a diabetic upon arrival to a shelter or emergency facility
- Know your rights related to the Americans with Disabilities Act and Section 504 of the Rehabilitation Act that requires shelters to accommodate you with a service dog, use of sharps, or anything related to diabetes care
- Maintain fluid intake to avoid dehydration
- Monitor for hypoglycemia
- If limited on food, adjust medications
- Monitor for infection (ADA, 2017a).
Mental health and diabetes
Diabetes is a lifelong chronic illness that will require daily monitoring, treatment and acceptance. There is little chance that mental health will not be impacted and that an adjustment period will not be needed as part of the process by anyone being diagnosed with a life-altering disease. Mental health issues can lead to depression and non-compliance with treatment for diabetes or other conditions related to the disease. “Untreated mental health issues can make diabetes worse and problems with diabetes can make mental health issues worse” (CDC, 2018b). Due to this mind-body connection it is very important for the nurse to educate the patient regarding signs or symptoms of depression or stress. Symptoms of depression are:
- Loss of interest in activities of interest previously
- Over or under-eating
- Inability to sleep or sleeping continuously
- Difficulty making decisions
- Extreme tiredness
- Hopelessness, irritability, anxiety or guilt
- Aches, pains, digestive problems not associated with other conditions
- Having thoughts of suicide or death (CDC, 2018b).
A condition known as diabetes distress, which is overwhelming feelings of frustration, worry, fatigue, or discouragement related to the demands of having diabetes, effects a large number of diabetics throughout the course of their life due to management of their disease. It is very similar in characteristics to anxiety or depression but medication does not seem to improve the symptoms. Interventions that have been linked to improvement include:
- See a mental health counselor familiar with chronic health conditions and the unique needs.
- See a diabetic educator to problem solve concerns.
- Focus on small steps such as 1 to 2 small diabetic management goals.
- Join a support group for diabetes patients.
- See an endocrinologist for your diabetes care (CDC,2018b)
Sexual and bladder Implications
The diabetic patient can develop neuropathies pertaining to sexual dysfunction. The change to blood vessels, nerves and hormones in addition to mental health issues can cause the individual with diabetes to have a decreased ability or desire to have sex. Erectile dysfunction (ED) is one aspect of sexual dysfunction that can occur for the male diabetic patient. The patient may be unable to get or keep an erection due to vascular and nerve damage. Men with diabetes are three times more likely to develop ED than those without diabetes. Good control of blood glucose is a way to prevent ED. ED can also be treated with medication so it is important for nurses to discuss sexual concerns with patients to encourage open communication. Men may also develop a condition known as Peyronie’s disease or penile curvature. This curvature is caused from scar tissue called “plaque” in the penis making it curve when erect. Curves in the penis can cause pain and discomfort during intercourse. ED can co-exist with Peyronie’s disease making sex even more difficult for the patient. Low testosterone can also occur with diabetic men, which can increase sexual problems. The low testosterone can be a source of ED and decreased sex drive. Men with diabetes are often overweight and less active which can further contribute to the low testosterone levels. Testosterone therapy can improve the patient’s sex drive and energy levels (NIH, 2018).
Women’s sexual problems are related to low sexual desire, vaginal dryness and painful sex related to decreased blood flow to the genitals and hormonal changes from diabetes. This decreased blood flow can lead to reduced or no sensation in the genital area, inability to have an orgasm and inability to become aroused or stay aroused. Dryness can be very uncomfortable and lead to further pain and discomfort with intercourse. Mental health implications of having diabetes can also be involved in the decreased sexual desire and response by female patients. Furthermore, women may have increased vaginal infections including yeast infections due to elevated blood glucose and a decreased immunity. Yeast infections can lead to painful intercourse. The nurse should inquire about these issues, and encourage patients to discuss changes in their sex life and/or concerns related to their reproductive health with their primary healthcare provider or gynecologist (NIH, 2018).
Bladder concerns for both the male and female can interfere with sexual functioning, self-esteem and daily life. Leakage from the bladder can be embarrassing and troublesome for patients. Due to vascular and nerve damage to the urinary tract, frequency and urgency may occur. Leakage or difficulty emptying the bladder may be complaints as well. Obesity contributes further to incontinence (leakage) and elevated blood glucose levels contributes to more frequent UTIs. The healthcare team should encourage weight loss to decrease some of these symptoms, along with diligent blood glucose control to decrease the risk of infections (NIH, 2018).
Both sexual and bladder health can be improved by:
- Maintaining therapeutic blood glucose levels as determined by goals set with healthcare providers
- Routine physical activity
- Maintaining a healthy weight as determined by goals set with healthcare providers
- Quitting smoking
- Seeking mental health interventions for any emotional or psychological symptoms (NIH, 2018)
The diabetic’s significant other should also be part of the conversation and an active member of the healthcare team to offer the greatest amount of support and understanding possible. Such personal concerns as sexual and bladder health can be embarrassing and cause anxiety in many patients and a support system that involves their partner can be helpful in dealing with the issues of concern (NIH, 2018).
Future opportunities for the diabetic
Cell therapy is an emerging hope toward a cure for diabetes, particularly in the type 1 diabetic. The replacement of missing or damaged insulin-producing cells could potentially recover normal insulin production to cure patients (Fernandez, 2019). The Diabetes Research Institute is working toward a bioengineered “mini-organ where insulin cells are encapsulated within a protective barrier” (Diabetes Research, 2016; JDRF, 2019a). The first trials were completed in 2016 in Europe with a 41 year old male with type 1 diabetes since the age of 11. Insulin therapy was discontinued after the procedure and successful at one year upon publication of the study. Currently, Several US drug companies are developing their own cell therapy approaches for diabetes (Fernandez, 2019; JDRF, 2019a).
Another opportunity to cure diabetes includes immunotherapy. With type 1 DM, insulin producing cells are progressively destroyed by the immune system. If this process could be stopped early, enough cells could be saved and potentially provide a cure through prevention. A Belgium company is currently working on a clinical trial that uses immunotherapy targeted toward the immune cells that attack and destroy pancreatic cells. It is noted that even after diagnosis as much as 10% of the insulin producing cells are still producing insulin. If the immune process could be interrupted, the remaining beta cells could potentially be saved and continue to produce insulin (Fernandez, 2019; JDRF, 2019a).
Finally, an artificial pancreas is being researched that would replace the body’s pancreatic function. This treatment is a fully automated system that measures blood glucose levels and injects the right amount of insulin mimicking the healthy pancreas. This option replaces the human components of measuring blood glucose and would, in theory maintain a steadier glycemic control. Challenges with this treatment option are faster forms of insulin that would be needed to make swift changes in the blood glucose level. Also, algorithms must be developed that consider all aspects of the normal pancreas function to regulate blood glucose levels (Fernandez, 2019; JDRF, 2019a).
Just as the information related to diabetes can be overwhelming to a nurse or member of the healthcare team, it is even more overwhelming for the patient newly diagnosed with this life-changing disease. Resources abound, but the patient must become an active participant in their treatment and utilize the resources at their disposal and the nurse must actively assist in that process. For those who have fewer financial resources, the challenge may be in finding opportunities to obtain the necessary supplies. With such a multifactorial condition as diabetes, an entire team is needed to coordinate the care to meet the patient’s nutritional, medical, and mental health needs. However, the effort required is worthwhile to decrease or diminish the long-term implications of living with diabetes. A patient who is actively involved in the management of their diabetes will avoid many complications during their life. The entire healthcare team, friends and family can offer encouragement for persistence in the lifestyle modifications needed for success.
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