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Diabetes mellitus is a group of diseases characterized by hyperglycemia (fasting plasma glucose level >100 mg/dL) and abnormalities in fat, carbohydrate, and protein metabolism that lead to microvascular, macrovascular, and neuropathic complications. Several pathologic processes are associated with the development of diabetes, and patients often have impairment of insulin secretion as well as defects in insulin action, resulting in hyperglycemia. It is now recognized that different pathologic mechanisms are involved that affect the development of the different types of diabetes.

Diabetes mellitus is occurring with increasing frequency in the United States as the population increases in weight and age. In the United States, the Centers for Disease Control and Prevention (CDC, 2011) estimates that the prevalence of diabetes in the general population is approximately 8.3% (25.8 million people, 7 million of whom are undiagnosed). Direct expenditures of medical care totaled $116 billion in 2007. An additional $58 billion was attributed to lost productivity at work, disability, and premature death. Diabetes is listed as the sixth leading cause of death in the United States. Most diabetes-related deaths are the result of cardiovascular disease because the risk of heart disease and stroke is two to four times greater in patients with diabetes compared with those without the disease.

Undiagnosed diabetic adults, with few or no symptoms, present a major challenge to the health profession. Because early symptoms of diabetes are minimal, many of these people do not seek medical advice. Indications of the disease are discovered only at the time of routine physical examination. Those with a predisposition to developing diabetes include people who have relatives with diabetes (they have a 2.5 times greater incidence of developing the disease), obese people (85% of all diabetic patients are overweight), and older people (four out of five diabetic patients are older than 45 years). The incidence of diabetes is higher in African Americans, Hispanics, American Indians, Native Alaskans, and women. There also appears to be a significant increase in diabetes among those younger than 20 years. The CDC has a major study underway to quantify this perception.

The National Diabetes Data Group of the National Institutes of Health and the World Health Organization Expert Committee on Diabetes (NDDG/WHO) classify diabetes by the underlying pathology causing hyperglycemia (Box 36-1).

Type 2 diabetes mellitus, formerly known as non–insulin-dependent diabetes mellitus (NIDDM), is present in 90% to 95% of the diabetic population. In contrast to type 1 diabetes mellitus, type 2 diabetes is characterized by a decrease in beta cell activity (insulin deficiency), insulin resistance (reduced uptake of insulin by peripheral muscle cells), or an increase in glucose production by the liver. Over time, the beta cells of the pancreas fail and exogenous insulin may be required. Most people with type 2 diabetes mellitus also have metabolic syndrome, also known as insulin resistance syndrome and syndrome X (see Chapter 21). Type 2 diabetes onset is usually more insidious than that of type 1 diabetes. The pancreas still maintains some capability to produce and secrete insulin. Consequently, symptoms (polyphagia, polydipsia, polyuria) are minimal or absent for a prolonged period. The patient may seek medical attention several years later only after symptoms of the disease are apparent (see later, “Complications of Diabetes Mellitus”). Fasting hyperglycemia can be controlled by diet in some patients, but most patients require the use of supplemental insulin or oral antidiabetic agents, such as metformin or glyburide. Although the onset is usually after the fourth decade of life, type 2 diabetes can occur in younger patients who do not require insulin for control. See Table 36-1 for a comparison of the characteristics of type 1 and type 2 diabetes mellitus.

A third subclass of diabetes mellitus (see Box 36-1) includes additional types of diabetes that have causes other than those that cause type 1 and type 2 diabetes mellitus. They are part of other diseases having features not generally associated with the diabetic state. Diseases that may have a diabetic component include pheochromocytoma, acromegaly, and Cushing’s syndrome. Other disorders included in this category are malnutrition, infection, drugs and chemicals that induce hyperglycemia, defects in insulin receptors, and certain genetic syndromes.

The fourth category of classification, known as gestational diabetes mellitus (GDM), is reserved for women who show abnormal glucose tolerance during pregnancy. Gestational diabetes is diagnosed in about 7% of all pregnancies in the United States, resulting in about 200,000 cases per year. (The range is 1% to 14%, depending on the population studied and the diagnostic criteria used). It does not include diabetic women who become pregnant. Most gestational diabetic women have a normal glucose tolerance postpartum. Gestational diabetic patients must be reclassified 6 weeks after delivery into one of the following categories: diabetes mellitus, impaired fasting glucose, impaired glucose tolerance, or normoglycemia. Gestational diabetic patients have been put into a separate category because of the special clinical features of diabetes that develop during pregnancy and the complications associated with fetal involvement. These women are also at a greater risk of developing diabetes 5 to 10 years after pregnancy.

There is a group of patients found to have an impaired glucose tolerance (IGT) or impaired fasting glucose (IFG). These patients are often normally euglycemic, but develop hyperglycemia when challenged with an oral glucose tolerance test. In many of these patients, the glucose tolerance returns to normal or persists in the intermediate range for years. This intermediate stage between normal glucose homeostasis and diabetes is now known as prediabetes. It is now thought that patients with IGT or IFG are at a higher risk for developing type 1 or type 2 diabetes and cardiovascular disease in the future. The CDC has estimated that 79 million American adults over the age of 20 had prediabetes in 2010. Categories of fasting plasma glucose (FPG) levels are the following:

See Table 36-2 for criteria for the diagnosis of types 1 and 2 diabetes mellitus.

Complications of Diabetes Mellitus

Long-standing hyperglycemia and abnormalities in fat, carbohydrate, and protein metabolism lead to microvascular, macrovascular, and neuropathic complications. Microvascular complications are those that arise from destruction of capillaries in the eyes, kidneys, and peripheral tissues. Diabetes has become the leading cause of end-stage renal disease and adult blindness. Macrovascular complications are those associated with atherosclerosis of middle to large arteries, such as those in the heart and brain. Macrovascular complications, stroke, myocardial infarction, and peripheral vascular disease account for 75% to 80% of mortality in patients with diabetes. Complications of diabetes mellitus that often arise include the following (Figure 36-1):

• Hypertension

• Cardiovascular disease (atherosclerosis) leading to myocardial infarction and stroke

• Retinopathy leading to blindness

• Renal disease leading to end-stage renal disease and the need for dialysis

• Peripheral arterial disease leading to nonhealing ulcers, infections, and lower extremity amputations

• Neuropathies with sexual dysfunction, bladder incontinence, paresthesias, and gastroparesis

• Periodontal disease with loss of teeth

Symptoms associated with complications of diabetes may be the first indication of the presence of diabetes. Patients may complain of weight gain or loss. Blurred vision may indicate hyperglycemia or diabetic retinopathy. Neuropathies may first be observed as numbness or tingling of the extremities (paresthesia), loss of sensation, orthostatic hypotension, impotence or vaginal yeast (candidiasis) infections, and difficulty in controlling urination (neurogenic bladder). Nonhealing ulcers of the lower extremities may indicate chronic vascular disease. Diabetic complications can be delayed or prevented with continuous normoglycemia, accomplished by monitoring blood glucose levels; drug therapy; and treatment of comorbid conditions as they arise.

Drug Therapy for Diabetes Mellitus

The primary treatment goal of type 1 and type 2 diabetes is normalization of blood glucose levels. Insulin is required to control type 1 diabetes and other types of diabetes in patients whose blood glucose cannot be controlled by a MNT diet, exercise, weight reduction, or oral antidiabetic agents. Patients normally controlled with oral antidiabetic agents require insulin during situations of increased physiologic and psychological stress, such as pregnancy, surgery, and infections. The dosage of insulin is usually adjusted according to the blood glucose levels. The patient should test the blood glucose level before each meal and at bedtime while the insulin and food intake are being regulated.

The ADA now recommends that patients with prediabetes be treated to prevent or delay the onset of type 2 diabetes. Patients should be referred to an effective ongoing support program targeting weight loss of 7% of body weight and increasing physical activity to at least 150 minutes per week of moderate activity such as walking. Metformin therapy should be considered for treatment of prediabetes, especially in those patients whose body mass index (BMI) is greater than 35 kg/m², are older than 60 years, and women with prior GDM. Patients should be monitored at least annually for the development of diabetes mellitus.

Oral antidiabetic agents are used in the therapy of type 2 diabetes. They are recommended only for those patients whose diabetes cannot be controlled by MNT diet and exercise alone and who are not prone to develop ketosis, acidosis, or infections. Patients most likely to benefit from treatment are those who have developed diabetes after age 40 and who require less than 40 units of insulin daily.

A combination of oral antidiabetic agents working by different mechanisms is often required to control hyperglycemia successfully (Figure 36-2):

• Biguanide: The only biguanide available in the United States is metformin. Unless contraindicated, it is the initial drug of choice for treatment of type 2 diabetes. Metformin decreases hepatic glucose production by inhibiting glycogenolysis and gluconeogenesis, reducing absorption of glucose from the small intestine, and increasing insulin sensitivity, which improves glucose uptake in peripheral muscle and adipose cells. The net result is a significant decrease in fasting and postprandial blood glucose and A1C concentrations.

• Secretogogues: The sulfonylureas (glyburide, glipizide) and the meglitinides (repaglinide, nateglinide) stimulate the pancreas to secrete more insulin. The sulfonylureas also diminish hepatic glucose production and metabolism of insulin by the liver. The net effect is a normalization of insulin and glucose levels.

• Thiazolidinediones (TZDs): The TZDs (pioglitazone, rosiglitazone) increase tissue sensitivity to insulin, causing greater glucose uptake in muscle, adipose, and liver tissue. They also diminish glucose production by the liver.

• Alpha-glucosidase inhibitors: Acarbose and miglitol inhibit enzymes in the small intestine that metabolize complex carbohydrates. This slows the absorption of carbohydrates, reducing postprandial hyperglycemia.

• Incretin-based therapy: It is thought that patients with type 2 diabetes have a suppressed incretin hormone system. The incretin hormones act in the gastrointestinal tract to control blood glucose levels by enhancing insulin secretion, suppressing glucagon secretion from the liver, suppressing glucose output from the liver, delaying gastric emptying (thus slowing carbohydrate and lipid absorption), reducing postprandial hyperglycemia, reducing appetite, and maintaining beta cell function. There are currently two classes of agents that increase incretin activity: (1) incretin mimetics (the glucagon-like peptide-1 [GLP-1] agonists exenatide and liraglutide) and (2) dipeptidyl peptidase-4 (DPP-4) inhibitors (sitagliptin, saxagliptin, and linagliptin).

Initial oral antidiabetic therapy for type 2 diabetes is highly dependent on the patient’s success with lifestyle modification and diet control. A consensus statement endorsed by the ADA recommends metformin in combination with MNT and exercise as initial treatment of type 2 diabetes mellitus. If the goal A1C level below 7% has not been achieved with this monotherapy within 3 to 6 months, add basal insulin (most effective) and/or a sulfonylurea (least expensive), a TZD, or an incretin-based DPP-4 inhibitor or GLP-1 agonist. If the A1C level is still higher than 7%, insulin doses should be intensified, and another member of a drug class not already being used in the initial therapy should be added. An alpha-glucosidase inhibitor may be added if postprandial hyperglycemia is a problem. See Table 36-4 for a comparison of oral antidiabetic agents and their effects on lowering blood glucose levels and A1C concentrations.

Table 36-4

Summary of Physiologic Effects of Antidiabetic Agents

DRUG	INSULIN SECRETION	DECREASE IN FASTING BLOOD GLUCOSE LEVEL	EFFECT ON HEMOGLOBIN A1C LEVEL	WEIGHT GAIN
Insulin	Decrease	Significant	Significant	Yes
Sulfonylureas	Increase	40-60 mg/dL	1%-2%	Yes
Meglitinides	Increase	30 mg/dL	1.1%	Yes
Biguanide	No change	53 mg/dL	1.4%	No; mild
Thiazolidinediones	No change	25-55 mg/dL	0.1%-0.7%	Yes
Alpha-glucosidase inhibitors	No change	20-30 mg/dL	0.5%-1%	No
Glucagon-like peptide-1 agonists	Increase	—	0.8%-1.1%	No
Dipeptidyl peptidase-4 inhibitor	Increase	—	0.5%-0.8%	No

Data from the American Association of Clinical Endocrinologists: Medical guidelines for the management of diabetes mellitus. The ACCE system of intensive diabetes self-management, 2002 update, Endocr Pract 8(Suppl 1):52, 2002; Department of Health and Human Services and Department of Agriculture: Dietary guidelines for Americans, 2005. Available at www.health.gov/dietaryguidelines.

Nursing Implications for Patients With Diabetes Mellitus

A major challenge in nursing is to teach the recently diagnosed diabetic patient all the necessary information to manage self-care and the disease process and to prevent complications. The patient must be taught the entire therapeutic regimen—diet, activity level, blood or urine testing, medication, self-injection techniques, prevention of complications, illness management, and effective management of hypoglycemia or hyperglycemia. Patient education may begin in the hospital and continue for several weeks in the outpatient setting. The dietician, nurse, and diabetic nurse educators are all actively involved in educating the patient and family. A referral to the ADA serves as an excellent resource in the community for the patient and family. Many diabetic patients have difficulty understanding the critical balance that must be maintained among the dietary prescription, prescribed medication, and maintenance of general health. All are important to the control and effective management of the disease process.

Assessment

The order of performing the assessment depends on the setting and the severity of the patient’s symptoms.

Description of Current Symptoms

• Ask the reasons for seeking the current appointment or admission.

• Review symptoms and procedures used to diagnose diabetes mellitus in a general medical-surgical textbook.

Patient’s Understanding of Diabetes Mellitus

• Assess the individual’s current knowledge of the treatment of diabetes mellitus. Gather additional data about the person’s current educational needs with regard to self-management of the disease process.

• Will other family members or significant others be providing part of the care or participating in the health education portion of the individual’s care?

• Is there a need to communicate with a child’s school regarding the disease process?

• Patients who are readmitted must be assessed for the understanding of the treatment regimen and for adherence with the prescribed diet, medications, and exercise.

• For pregnant women, risk assessment for GDM should be performed at the first prenatal visit. High-risk women who have an initial negative testing for diabetes should be retested between 24 and 28 weeks of gestation.

The FPG is the preferred test used to screen for diabetes in children and nonpregnant adults.

Psychosocial Assessment

• Mental status: Ask specific information to evaluate the patient’s current level of consciousness, alertness, comprehension, and appropriateness of responses. Evaluate the person’s judgment capabilities and ability to solve problems about the management of the diabetes.

• Adaptation to disease: Ask specifically about the person’s adjustment to the diagnosis of diabetes mellitus; or, in a recently diagnosed individual, identify prior coping mechanisms used successfully to deal with life events.

• Feelings: Assess for fears and the person’s perspective of the impact of the disease on his or her life.

• Support system: Obtain information regarding who can provide support for the patient. Does the individual live alone? What effect does the disease have on other members of the family structure (e.g., children who are diabetic, people with renal or visual complications)? Does the patient participate in a support group for patients with diabetes?

Nutrition

• Is the patient on a prescribed MNT diet? The recently diagnosed diabetic patient requires a thorough nutritional assessment. Information collected by the nurse or dietitian should include identification of the patient’s average daily diet, the ability and willingness to prepare foods, food budget, and level of daily activity and exercise.

• Ask about diet prescription—total daily calories and distribution pattern of carbohydrates, fats, and proteins.

• Have there been any problems encountered in purchasing or preparing the foods? Has it been difficult to comply with the diet? If so, what are the problems encountered?

• How much alcohol is consumed and how often?

• Has the individual experienced any weight loss or gain recently?

• If the patient is a child, obtain data relating to the individual’s growth and development patterns.

Activity and Exercise

• Does the individual experience weakness or fatigue with daily activities? Does the patient get regular exercise? What type, intensity, and duration is the exercise? Has there been any significant variation in the degree of exercise recently?

• Has the patient made any adjustments in the insulin, oral antidiabetic agents, or diet to offset an increase or decrease in exercise?

• Has there been a change in occupation that has affected the level of exercise?

Medications.

What medications have been prescribed, and what is the degree of adherence with the regimen? What over-the-counter medications (including herbal medicines) does the patient take, and how often? Does the patient consume alcohol? If so, how much and how often? Ask specifically about the type and amount of insulin being taken and the times of administration.

Monitoring.

Ask the patient to bring a record of self-monitoring of insulin or antidiabetic agents taken, as well as any blood glucose testing or A1C testing that was done. Has the patient done any testing for ketones? If so, what were the results? Other tests to be performed periodically include the fasting lipid profile, which includes measurement of levels of cholesterol (high-density lipoprotein [HDL], low-density lipoprotein [LDL] cholesterol, triglycerides]; serum creatinine; and microalbuminuria.

Physical Assessment.

Generally, data are collected about all body systems to serve as a baseline for subsequent evaluations throughout the course of treatment. Periodic focused assessments are completed to detect signs and symptoms of complications commonly associated with diabetes mellitus.

• Hyperglycemia and hypoglycemia: Have there been any episodes of hypoglycemia or hyperglycemia? If so, obtain details of the occurrences (e.g., has the patient eaten the prescribed diet, taken the prescribed medications, or altered the exercise level?). Record all prescription and over-the-counter medications being taken to assess whether any drug interactions may be causing the hyperglycemia or hypoglycemia.

• Illnesses, stress: Have there been any recent illnesses, infections, or stressful events? If so, what treatments have been initiated? Ask specifically about any sores on the skin and feet, periodontal disease, and occurrence of urinary tract or vaginal (candidiasis) infections.

• Vascular changes: Obtain baseline vital signs. Does the person have any symptoms of, or is the patient being treated for, cerebrovascular, peripheral vascular, or cardiovascular disease (including hypertension), or diabetic retinopathy or nephropathy? Obtain a current history of the patient’s blood pressure and details of any medications being taken to treat hypertension. When hypertension is present, perform a urinalysis and check for protein. If protein is negative, microalbumin testing should be performed to determine the presence of protein in the urine. Annual monitoring of LDL, triglyceride, and A1C levels is also recommended.

• Neuropathy: Ask about specific symptoms of paresthesias (numbness or tingling sensations), foot injuries and ulcerations, diarrhea, postural hypotension, impotence, or neurogenic bladder.

• Smoking: Obtain history of smoking and tobacco use from all patients with diabetes mellitus.

Implementation

• Answer questions that the patient has regarding any aspect of the care being provided, including the rationale.

• Encourage expression of the patient’s feelings and concerns; address the patient’s concerns first. Involve support personnel, as appropriate, in the delivery of care or planning for home management of the diabetes.

• Encourage adequate nutrition by implementing the dietary regimen prescribed. Promote adequate fluid intake to maintain hydration. Support dietary teaching by the health team, and be constantly alert for misperceptions or misunderstanding of the diet.

• Encourage activity and exercise at the prescribed level. Discuss the benefits while providing care.

• Administer prescribed medications (e.g., insulin, oral antidiabetic agents). Monitor for common and serious adverse effects, and document associated monitoring parameters on the records (e.g., blood glucose, ketone testing). If the patient is taking insulin, assess the ability and accuracy to self-administer injections. If a family member gives the insulin, assess his or her ability and accuracy in giving injections.

• If a hypoglycemic reaction occurs, notify the team leader or primary nurse, who will then contact the physician. The underlying cause of the hypoglycemia must be identified to prevent further occurrences. If in doubt about whether the patient is hypoglycemic or hyperglycemic, the nurse should always proceed to treat the individual for hypoglycemia to prevent neurologic damage from prolonged reduction in glucose to the nerve cells (e.g., brain cells).

• With any hyperglycemic reaction, notify the team leader or primary nurse, who will then contact the prescriber. The goals of treatment include maintaining normal fluid and electrolyte balance and restoring a normal serum glucose level.

• Perform routine physical assessments every shift as required by the clinical site. Perform focused assessments of areas where complications are anticipated, based on the admission data and subsequent data collected.

Patient Education and Health Promotion

Knowledge.

The ADA has developed areas of diabetic education. Not all aspects of the care outlined in these recommendations are presented in the sample teaching plan for diabetics (Chapter 5, p. 51, Box 5-2). The recommendations must be adapted to the individual’s needs. It may not be possible to teach the entire program during the hospitalization period. Teach the individual specifics regarding the type of diabetes that has been diagnosed.

• Type 1 diabetes mellitus results from damage to the beta cells of the pancreas, where insulin is normally produced. Insulin is needed to transport the glucose required by the body cells from the bloodstream to the individual cells to be used as an energy source. Without beta cells, no insulin is produced and the glucose accumulates in the blood (hyperglycemia).

• Type 1 diabetes mellitus requires the administration of insulin injections to replace the insulin that the body is no longer able to make. The patient must follow a prescribed diet and exercise program, perform glucose testing, and, when hyperglycemia is present, test for ketones in the urine.

• Type 2 diabetes mellitus is an illness characterized by abnormal beta cell function, resistance to insulin action, and increased hepatic glucose production. Type 2 diabetes mellitus requires a prescribed diet and exercise program, weight loss to a near-ideal body level, glucose testing, and an oral antidiabetic agent or antihyperglycemic agent if the diabetes cannot be managed with diet and exercise alone. During times of illness, or if the oral treatment stops being effective, insulin may be required. Special needs may be required for patients who are pregnant or nursing.

Psychological Adjustment

• When first diagnosed, the patient may experience varying degrees of grief, anger, denial, or acceptance. Let the patient express these concerns, and address those items that are considered to be of greatest importance first.

• Encourage the idea that the patient can control most aspects of diabetes by careful management of diet, medications, and activities. Having a sense of control is important to everyone. Stress that learning to manage the disease process is the best long-term approach.

• Discuss the individual’s lifestyle, travel, work, school schedules, and activities, and individualize the care needs.

• Discuss the need for continued regular monitoring of the diabetes to minimize the effect that the disease may have on the patient and family.

Smoking.

Health care providers should emphasize the need for smoking cessation as a priority of care for all patients with diabetes.

Nutrition

• Diet is used alone or in combination with insulin or oral antidiabetic agents to control diabetes mellitus. The patient with diabetes, whether type 1 or 2, must follow a prescribed diet to achieve optimal control of the disease.

• The dietary prescription is based on the nutritional and energy requirements necessary to maintain an appropriate weight, lifestyle, and normal growth and development. Diabetic patients are encouraged to maintain a reasonable body weight based on height, gender, and frame size.

• MNT is now being recommended for patients with diabetes. Standardized calorie-level meal patterns based on exchange lists have traditionally been used to plan meals for hospitalized patients. Other meal planning systems include menus based on Dietary Guidelines for Americans (USDHHS, 2005), regular hospital menus, individualized meal plans, or menus using carbohydrate counting. A new system, called the “consistent-carbohydrate diabetes meal plan,” is being developed that uses meal plans without a specific calorie level; instead, it incorporates a consistent carbohydrate content for each meal and snack. The meal plan also includes appropriate fat and protein modifications and emphasizes consistent timing of meals and snacks. A typical day’s meals and snacks provide 1500 to 2000 calories with 45% to 65% of the calories from carbohydrate, 10% to 35% from protein, and 20% to 35% from fat. If a patient’s nutritional needs are more or less than provided by these meal plans, individualized adjustments may be required. Patients who often require adjustments include children, adolescents, metabolically stressed patients, pregnant women, and older adult patients.

• Weight loss is recommended for all adults who are overweight (BMI = 25 to 29.9 kg/m²) or obese (BMI ≥30 kg/m²) or who have or are at risk for developing type 2 diabetes. The primary approach for achieving weight loss is therapeutic lifestyle change, which includes a reduction in energy intake and/or an increase in physical activity. A moderate decrease in caloric balance (500 to 1000 kcal/day) will result in slow but progressive weight loss (1 to 2 lb/wk). For most patients, weight loss diets should supply at least 1000 to 1200 kcal/day for women and 1200 to 1600 kcal/day for men.

• Additional goals for medical nutrition therapy include maintaining a blood glucose level in the normal range to reduce the risk of complications of diabetes, a normal lipid profile to reduce the risk for microvascular disease, and normal blood pressure levels to reduce the risk for vascular disease.

• The ADA no longer endorses any single meal plan or specified percentages of macronutrients as it has in the past. The Institute of Medicine and the ADA recommend, in general, that the diet be composed of 45% to 65% carbohydrates, 15% to 20% protein (0.8 to 1 g protein/kg of body weight), and no more than 30% fat. Monounsaturated and polyunsaturated fats should be the primary fat sources; saturated fats should be limited to no more than 10% of the diet and cholesterol intake to 300 mg or less daily. Trans fatty acids should be avoided when possible. Including high-fiber foods (e.g., legumes, oats, barley) assists in lowering both blood glucose and blood cholesterol levels. Reduced sodium, alcohol, and caffeine consumption is also advisable (see also Chapter 47). The ADA has several cookbooks and pamphlets on nutrition available for the diabetic person.

• Patients with diabetes, as well as all individuals, need to be encouraged to consume an adequate intake of vitamins and minerals from natural food sources.

• Inclusion of sucrose is now permitted in limited amounts in the diabetic diet; however, the amount eaten must be calculated as part of the carbohydrate intake for the day. Meal plans such as “no concentrated sweets,” “no added sugar,” “low sugar,” and “liberal diabetic diets” are no longer appropriate. These diets do not reflect the diabetes nutrition recommendations and unnecessarily restrict sucrose. Such meal plans may perpetuate the false notion that simply restricting sucrose-sweetened foods will improve blood glucose control.

• The U.S. Food and Drug Administration (FDA) has approved the use of four artificial sweeteners as sugar substitutes: saccharin, aspartame (NutraSweet), sucralose (Splenda), and acesulfame potassium.

• Patients with diabetes should adhere to the same guidelines for ingestion of alcohol as for all Americans—no more than two drinks daily for men and one drink daily for women. People with good control of their diabetes may ingest alcohol in moderation. However, drinking can result in hypoglycemia or hyperglycemia in diabetics. The effects of alcohol are influenced by the amount ingested, if ingested on an empty stomach, or if used chronically or excessively. Many alcoholic beverages are high in sugar and should be used with caution; light beer or dry wines are alternatives. One drink is defined as 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of distilled spirits, each of which contains 15 grams of alcohol. Because alcohol affects the blood sugar, it may be prudent to test the blood glucose level before and after drinking to identify how the alcohol reacts in a particular patient. Abstinence is recommended for pregnant patients, those with known medical problems aggravated by its use, and those with a history of alcohol abuse.

• Dietary considerations for children and adolescents with type 1 or 2 diabetes are similar to the needs for all other children. They need to maintain a steady intake of a balanced diet aimed at maintaining normal growth and development. It is important to obtain height and weight values and to compare these to the normal growth curve found on charts to ascertain whether the dietary intake is adequate, deficient, or excessive. The individual’s meal planning must be done in such a way as to accommodate irregular meal times and schedules and the varying activity levels of the child or adolescent.

• All women have similar nutritional needs during pregnancy and lactation whether they have diabetes or not. A woman with gestational diabetes is given education on food choices that are appropriate for normal weight gain, normoglycemia, and absence of ketones. Some with gestational diabetes may require a modest restriction in carbohydrates.

• In older adults, a change in body weight of more than 10 pounds or 10% of the body weight in less than 6 months is considered sufficient reason to investigate for nutrition-related causes. In general, older people with diabetes in long-term care settings tend to be underweight rather than overweight. Administering a daily vitamin supplement to older adults, especially those with decreased energy intake, may be advisable. Specialized diets do not appear to be beneficial to the older adult in a long-term care setting, where food choices are decidedly limited. It is preferable to make medication adjustments to control blood glucose rather than implement food restrictions in the long-term care setting. Physical activity should be encouraged.

Activity and Exercise

• Maintenance of a normal lifestyle is to be encouraged. This includes exercise and activities enjoyed by the individual. The normal daily energy level is used in determining the dietary and medication requirements for the patient. The ADA recommends that initial therapy be modest, based on the patient’s willingness and ability, gradually increasing the duration and frequency to 30 to 45 minutes of moderate aerobic activity 3 to 5 days per week (150 minutes per week), when possible. Greater activity levels of at least 1 hour daily of moderate (walking) or 30 minutes daily of vigorous (jogging) activity may be needed to achieve successful long-term weight loss.

• As with all individuals who are about to undertake exercise, a proper period of warm-up and cool-down consisting of 5 to 10 minutes of aerobic activity at a low intensity should be done. It is very important to maintain proper foot care in a diabetic patient who is to start exercising. Use silica gel or air midsoles, as well as polyester or cotton blend socks, to prevent blisters and keep the feet as dry as possible. Visible inspection of the feet surfaces before and after exercise is an important component of an exercise regimen and is especially important for diabetic patients who already have peripheral neuropathy. Persons with loss of protective sensation should not use step exercises, jogging, prolonged walking, or treadmills as an exercise regimen. Rather, they should substitute swimming, bicycling, rowing, chair exercises, arm exercises, or other non–weight-bearing exercises.

• Just as it is important for the patient to maintain a certain diet, it is equally important to maintain a certain activity level. Patients who suddenly increase or decrease their activity level are susceptible to developing episodes of hyperglycemia or hypoglycemia. Both dietary and medication prescriptions may require adjustment if patients do not plan to resume the previous exercise level. Patients should consult with the prescriber before initiating an exercise program.

• Additional self-monitoring of the blood glucose level may be advisable before, during, and approximately 30 minutes after exercise to provide the prescriber with data to analyze regarding the effects of exercise on the individual’s blood glucose level. The ADA recommends that the diabetic not exercise if his or her glucose level is above 250 mg/dL. Conversely, exercising with hypoglycemia is not advisable. A snack high in carbohydrates (10 to 20 g) should be taken before exercising if the blood sugar is less than 100 mg/dL.

• Exercise helps the cells use glucose; therefore, exercise lowers the glucose level.

• Drink sufficient fluids without caffeine when exercising to prevent dehydration.

• Stop exercising if feeling weak, sick, dizzy, or if experiencing any type of pain.

Medication

• Insulin or oral antidiabetic agent therapy may be required to control diabetes mellitus. No changes in therapy should be made without medical supervision.

• A variety of combinations of insulin or insulin and oral antidiabetic agents may be used to provide control of the blood glucose level. The goal of therapy is to consistently maintain the blood glucose level within normal range. Administration schedules have evolved over the years to accomplish this goal. The schedules commonly used are as follows:

1 Divided doses of intermediate-acting insulin (two thirds in the morning, one third in the evening before dinner)

2 A combination of rapid- or short-acting and intermediate-acting insulin in the morning, followed by rapid- or short-acting insulin at dinner and intermediate-acting insulin before bedtime

3 Rapid- or short-acting insulin before each meal and intermediate-acting or long-acting insulin at bedtime

4 Rapid-acting or short-acting and long-acting insulin before breakfast, rapid-acting or short-acting insulin before lunch, and rapid-acting or short-acting and long-acting insulin again before dinner

5 Continuous infusion of rapid- or short-acting insulin using a small, portable insulin infusion pump

• The regimen chosen depends on each person’s response to medications, schedule of daily activities, and compliance with blood glucose monitoring, insulin injections, and diet.

• Medication preparation, dosage, frequency, storage, and refilling should be discussed and taught in detail. See Chapter 11, Figure 11-3, p. 159 for administration of subcutaneous injections and Chapter 10, Figure 10-26, p. 154 for mixing of insulins. Also, discuss proper disposal of used syringes and needles in the home setting.

• Be certain that the patient understands how to refill prescriptions for insulin or oral antidiabetic agents. When purchasing insulin, ask the patient to double-check the type, concentration (usually U-100), and expiration date. Insulin types should not be changed without the approval of the prescribing health care provider. The insulin should be stored in the refrigerator (not the freezer) before use. Once it is opened and being used, it can be stored at room temperature for up to 1 month. The patient or nurse should date the bottle when first opened and used. The patient should always have a spare bottle of each type of insulin prescribed available for use.

• When a patient is experiencing an acute illness, injury, or surgery, hyperglycemia may result. When ill, the patient should continue with the regular diet plan and increase noncaloric fluids such as broth, water, and other decaffeinated drinks. The patient should continue to take the oral agents and/or insulin as prescribed, and monitor the blood glucose level at least every 4 hours. If the glucose level is higher than 240 mg/dL, urine should be tested for ketones (see Urine Testing for Ketones on p. 572). If the patient is unable to eat the normal caloric intake, he or she should continue to take the same dose of oral agents and/or insulin prescribed, but supplement food intake with carbohydrate-containing fluids such as soups, regular juices, and decaffeinated soft drinks. The health care provider should be notified immediately if the patient is unable to “keep anything down.” Patients should understand that medication for diabetes, including insulin, should not be withheld during times of illness because counterregulatory mechanisms in the body often increase the blood glucose level dramatically. Food intake is also necessary because the body requires extra energy to deal with the stress of illness. Extra insulin may also be necessary to meet the demand of illness.

• If pregnancy is suspected, consult an obstetrician as soon as possible about continuing and adjusting medication therapy during pregnancy.

• Patients with diabetes should receive an annual influenza vaccination and at least one lifetime pneumococcal vaccination before the age of 65. The vaccination should be repeated at least 5 years later and after the patient turns 65 years of age.

Hypoglycemia.

Hypoglycemia, or low blood sugar, can occur from too much insulin, a sulfonylurea, insufficient food intake to cover the insulin given, imbalances caused by vomiting and diarrhea, and excessive exercise without additional carbohydrate intake.

Symptoms.

Recognize and assess early symptoms of hypoglycemia; these include nervousness, tremors, headache, apprehension, sweating, cold and clammy skin, and hunger. If uncorrected, hypoglycemia progresses to blurring of vision, lack of coordination, incoherence, coma, and death. Children younger than 6 to 7 years may not have the cognitive abilities to recognize and initiate self-treatment of hypoglycemia.

Treatment.

If the patient is conscious and able to swallow, give 2 to 4 ounces of fruit juice, 1 cup of skim milk, or 4 ounces of a nondiet soft drink, or give a piece of candy such as a gumdrop. An alternative is to carry a glucose-containing product (e.g., Glutose gel, Dex4 Glucose tablets) and take as recommended when hypoglycemic. Repeat in 10 to 15 minutes if relief of symptoms is not evident. Do not use hard candy if there is a danger of aspiration. If the patient is unconscious, having a seizure, or unable to swallow, administer glucagon or 20 to 50 mL of glucose 50% IV. (People taking insulin should have a family member, significant other, or coworker who is able to administer glucagon.) Obtain a blood glucose level at the time of hypoglycemia, if possible.

Hyperglycemia.

Hyperglycemia (elevated blood sugar) occurs when the glucose available in the body cannot be transported into the cells for use because of a lack of insulin necessary for the transport mechanism. Hyperglycemia can be caused by nonadherence, overeating, acute illness, or acute infection.

Symptoms.

Symptoms of hyperglycemia are headache, nausea and vomiting, abdominal pain, dizziness, rapid pulse, rapid shallow respirations, and a fruity odor to the breath from acetone. If untreated, hyperglycemia may also cause coma and death. Glucose levels higher than 240 mg/dL and ketones present in the urine are early indications of diabetic ketoacidosis.

Treatment.

Treatment of hyperglycemia often requires hospitalization with close monitoring of hydration status; administration of IV fluids and insulin; and blood glucose, urine ketone, and potassium levels. Hyperglycemia usually occurs because of another cause; therefore, the problem, often an infection, must also be identified and treated.

Prevention.

The risk of hyperglycemia can be minimized by taking the prescribed dose of insulin or oral antidiabetic agent; adhering to the prescribed diet and exercise; reporting fevers, infection, or prolonged vomiting or diarrhea to the physician; and maintaining an accurate written record for the physician to analyze to determine the individual patient’s needs. Self-monitoring of blood glucose results and evaluation of urine ketones can provide the prescriber with valuable information to manage the treatment of the individual effectively.

Self-Monitoring of Blood Glucose

• Home blood glucose monitoring (self-monitoring) is an accepted practice for managing diabetes mellitus. It is used to evaluate the degree of control of the blood glucose. It can also be used to evaluate when additional insulin must be taken or to determine the effect of exercise on insulin needs.

• Educate the individual using the equipment for self-monitoring that will be used at home. Teach the person all details of the operation, including calibration, care, handling, and cleansing of the glucose monitor.

• The best time to check blood glucose levels is just before meals, 1 to 2 hours after meals, before bed, and between 2 and 3 A.M. The prescriber will give specific instructions regarding how often and when glucose testing should be done. When the person is ill, it is important to increase the frequency of glucose monitoring.

• A small sample of capillary blood is obtained, generally using an automatic finger-sticking lancet. The blood sample is applied to a reagent strip, which is then placed into an electronic device that reads the amount of color change and converts this into a numeric value representing the blood glucose level. There also are meters and sensors that do not use reagent strips for delivering the glucose results. “Talking” glucometers are on the market for those who are visually impaired. Written records of the blood glucose results should be maintained and taken to all follow-up visits with the physician for analysis.

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