Over the last few decades diabetes mellitus has grown into a national health crisis affecting millions of Americans every year. When diabetes is uncontrolled it can lead to many serious health consequences ranging from neuropathy (nerve pain), retinopathy (blindness), nephropathy (kidney failure), and high blood pressure which further increases your risk of having a heart attack or stroke.
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It is critical to understand diabetes well as NCLEX™ diabetes questions will be a major part of the exam. Before getting into the types of diabetes it is important to understand the basic pathophysiology of the disease.
A protein that is released from the pancreas when blood sugar levels start to rise after eating. When insulin binds to the cells in the body it causes them to take in both sugar and potassium from the blood into the cell. The result of this is lower blood sugar as the cells are free to utilize the sugar for various purposes, usually for storage as fat for future use. When insulin cannot do its job, a patient will begin to exhibit high blood sugar. When blood sugar remains elevated for too long it causes blood vessels to shrink which ultimately leads to nerve and organ damage.
One other key protein to understand in diabetes is glucagon, which is also released by the pancreas but only when blood sugar gets too low. Glucagon is released when patients are in a state of starvation or in situations where all the sugar in the blood is used up like during exercise. Glucagon acts on the liver to breakdown glycogen into glucose which is thereby sent to the blood to deliver sugar wherever the body needs it.
Now that the basic pathophysiology of diabetes has been addressed, it is important to recognize that there are two different kinds of diabetes, Type 1 and Type 2, which are critical for understanding how we treat patients and when their symptoms begin to manifest.
Causes of Diabetes
Patients with T1DM (Type 1 Diabetes Mellitus) begin to show symptoms very early on in life, usually in adolescence to early adulthood. T1DM is strictly a result of unfortunate genetics, where the genes were obtained from one or both parents. It is an autoimmune disorder which leads to the destruction of pancreatic beta cells, the cells responsible for insulin production. Overtime a patient with T1DM will have absolutely no insulin produced in their body which therefore makes them insulin dependent. Without insulin substitution the patient would otherwise be unable live.
Patients with T2DM (Type 2 Diabetes Mellitus) on the contrary are insulin resistant and not insulin dependent. Insulin resistance is the result of lifestyle choices such as poor diet and lack of exercise. People who consume large amounts of carbs frequently (e.g. pizza, juice, soda, ice cream, bread, etc.) cause their insulin receptors to become less sensitive to the effects of insulin over time. Patients who develop T2DM usually do so over an extended period. This means that their symptoms began to manifest later in life.
One way to assess for a patient’s risk of developing T2DM is to understand what the Metabolic Syndrome is. You can use the acronym BBOL from metabolic syndrome to remember what metabolic syndrome is. The first B stands for blood pressure medications or high blood pressure (over 130 systolic). The second B stands for blood sugar medications or high blood sugar (over 100 mg/dL). The O stands for obesity which regards a waste size of 35+ inches for women and 45+ inches for men. And the L stands for lipids regarding cholesterol (total cholesterol > 100, triglycerides > 150, LDL > 100, and HDL < 40). If a patient fit under three or more of these criteria, they will find that they are at a high risk of developing T2DM at some point in their lifetime.
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Signs and Symptoms of Diabetes
The symptoms and clinical manifestations of T1DM all revolve around the fact that patients no longer produce any insulin whatsoever. Remember that without insulin the cells in the body do not retrieve any sugar which means they have no energy for use or storage. This means a very common symptom of T1DM is weight loss as well as symptoms of low blood sugar (blood glucose < 70 mg/dL). These manifestations are usually observed in younger populations as the disease is strictly genetic.
Patients with T2DM retain some insulin function which means the symptoms manifest more gradually as we age. Some common symptoms of T2DM includes polyuria (frequent urination), polydipsia (excess thirst) and polyphagia (excess hunger). Polyuria is a result of the body trying to excrete the excess sugar in the blood in order to protect the organs and blood vessels. This results in dehydration as water is excreted with the sugar as well. To compensate patients will feel thirstier and hungrier as the cells are not getting adequately supplied with sugar. Another symptom that can be observed in T2DM includes a brownish thickening of the skin particularly in around the neck or armpit.
Once classic symptoms of T2DM are observed a diagnosis can be made by measuring blood glucose and A1c. Key diagnostics includes a random blood glucose of 70-115 mg/dL, a fasting blood glucose > 100 mg/dL, and an A1c > 6.5. Fasting blood glucose should reveal the concentration of sugar in the blood when a patient has not eaten for an several hours, if it reads above 100 mg/dL it suggests a patient may have significant insulin resistance. A1c is a very important measurement which can demonstrate the average blood sugar levels in patients over the previous three months as it measures the amount sugar molecules that have attached to hemoglobin, an important protein usually used to transport oxygen in the blood.
People with both type 1 and type 2 diabetes will find themselves at an increased risk of experiencing high blood sugar and low blood sugar which both have clinical significance. These manifestations are critical to understand as they can play a role a patient’s acute health leading to several complications that can become life threatening.
High blood sugar can be described as blood glucose levels > 115 mg/dL. When a patient has high blood sugar the symptoms associated with diabetics are present. This includes polyuria, polydipsia, and polyphagia. If a patient is getting treated for diabetes but still has high blood sugar it can often be caused by one of several factors which can be remembered as the 4 S’s. The first S to know is sepsis which relates to infection.
- Sepsis: Since bacteria and other microbes also use sugar to spread and multiply, having high blood sugar can trigger serious infections which can be observed often on the patient’s periphery such as the hands or feet, or a systemic infection where it has spread throughout the body infecting multiple organs and tissues.
- Stress: When a patient undergoes physically or mentally stressful situations, they may experience elevated blood sugars. Common situations includes hospitalization or surgeries where the body essentially mobilizes its sugars in response to stress, not unlike the fight or flight response where a patient exposed to danger may require more energy in their muscles or the affected tissues to resolve the situation. Glucagon release is a key protein involved in this process as the liver releases extra glucose to help the areas of the body that are needed to respond to the stress (e.g. the surgical site).
- Skipped insulin: This is the most obvious and common cause of high blood sugar as a patient may simply forget to dose themselves with insulin. The consequence of this is that the sugars are not taken into the cell therefore keeping the glucose in the blood.
- Steroid medications: Steroids can be regarded much like how stress acts on blood sugars in the body. Steroids are common causes of high blood sugar because they stimulate the release of sugar into the blood stream from the liver. Examples of steroids includes prednisone, prednisolone, hydrocortisone, and methylprednisolone. Patients on acute and high doses of steroids should be aware of this side effect if they are diabetic.
Symptoms of low blood sugar are important to understand for both type 1 and 2 diabetics. Low blood sugar can be defined as BG < 70 mg/dL. When blood sugar drops below that threshold a patient may be at risk of several complications depending on the severity and duration of hypoglycemia. Common symptoms include sweating, irritability, hunger, lack of coordination, and sleepiness. An acronym that can be used to memorize this is HIWASH.
- Anxiousness or trembling
- Sweating (diaphoresis)
Causes of hypoglycemia includes exercise, lack of eating, or overdosing on insulin. Other causes can include alcohol or insulin peak times (when insulin release is greatest in the body). When a patient experiences hypoglycemia but is responsive (meaning they are awake and alert) they can be instructed snacks that are high in sugar. Examples include juice, candy, crackers, or low-fat milk. If a patient is asleep and not responsive, they can be injected with IV D50 (IV Dextrose) or in some cases glucagon to stimulate sugar release into the bloodstream. Patients going through a hypoglycemic episode should be instructed to check their blood sugars every 15 minutes until their blood sugars are restored to normal.
Test Your Knowledge
1. A male patient with a history of T1DM is two days post-op following cholecystectomy. He has complained of nausea and can’t tolerate solid foods. The nurse finds the patient confused and shaky. Which of the following most likely explains the patient’s symptoms?
- Diabetic ketoacidosis
- Respiratory acidosis
2. The pediatric nurse is instructing the parents of a 10-year old boy who is newly diagnosed with type 1 diabetes. When teaching about hypoglycemia, which instruction should the nurse provide?
- Contact the health care provider if the child becomes drowsy
- Always have glucose tablets and subcutaneous glucagon available
- Check the child’s urine four times a day for acetone
- If the child is active in a sport, the evening dose of NPH insulin can be withheld
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Pharmacology of Diabetes
By far the most important treatment to understand for diabetes, insulin is the mainstay treatment for T1DM as well as a refractory treatment for patients with advanced T2DM. There are three general formulations of insulin to know about with different insulin peak properties as well as administration methods.
- Rapid-acting insulin: Examples of rapid acting insulin includes insulin aspart, insulin lispro, and insulin glulisine. These forms of insulin are by far the most dangerous formulations as they exhibit a quick 15-minute onset with a peak of 30-90 minutes. This quick onset suggests that patients can bolus with insulin and quickly reduce their blood sugars to dangerous hypoglycemic levels (BG < 70 mg/dL). For this reason, rapid acting insulin should only be given 15 minutes prior to eating a meal to prevent a drop-in blood sugar.
- Regular insulin: Examples of regular insulin includes Novolin R and Humulin R which have an onset of 30-60 minutes and a peak of 2-4 hours. Regular insulin shares a risk of hypoglycemia like rapid-acting formulations. Like rapid-acting, a patient should consume a meal approximately 30 minutes prior to an injection. Regular insulin is the only kind of insulin that should be injected intravenously. The duration of regular insulin should last 5-8 hours.
- NPH or intermediate insulin: Examples of NPH includes Novolin N and Humulin N. This kind of insulin is a mix between long-acting and short-acting formulations. They exhibit an onset within 2-4 hours and a peak in 4-8 hours. This formulation of insulin does not need to be taken with food. NPH should be given only twice daily and should never be administered in IV formulation.
- Long acting insulin: Examples of long acting insulin includes insulin detemir, insulin glargine, and insulin degludec. Like NPH these formulations do not need to be taken with meals. The onset of these insulins vary based on the kind given but all of them last for several hours. These types of insulin can last up to a day and will have minimal peaks. Most long-acting insulins are injected once a day.
Patients who are insulin dependent (T1DM) are generally put on a long acting formulation in addition to rapid-acting to bolus with meals. Type 1 diabetics or type 2 patients with advanced disease may be put on a CGM, a continuous glucose monitor, to help optimize insulin release in response to blood sugar levels. It is essentially to understand which kinds of insulin are being used for a patient and their onset to ensure stable blood sugar levels.
Oral diabetic medications:
Oral diabetic medications are reserved for patients who have type 2 diabetes because they still should have some insulin function. When T2DM first gets diagnosed some patients may be able to utilize lifestyle changes such as increasing exercise while eating lower carb diets to avoid getting put on a medication. If lifestyle changes fail, oral diabetic medications will be recommended.
Metformin is the most common type of diabetic medication used today. Metformin increases insulin sensitivity and decreases the output of glucose from the liver. Most patients who have T2DM will be on metformin for a lifetime. Metformin comes in extended release formulations as well as rapid formulations. The optimal dose of metformin is 2000mg per day which can be broken up into 1000mg in the morning and evening. The common side effects of metformin includes diarrhea, GI upset, and weight gain (usually minimal). Metformin can also increase the risk of hypoglycemia especially when given with insulin. More serious side effects of metformin includes kidney damage, potential liver damage, and lactic acidosis (rare but serious). It is critical to evaluate a patient’s renal function prior to starting therapy. A CrCL of less than 30 ml/min is a contraindication for metformin.
Sulfonylureas are another common class of oral diabetic medications. Unlike metformin, these come with a higher risk of hypoglycemia especially when taken with insulin. This is because these medications stimulate insulin release as opposite to increasing insulin sensitivity. Examples of sulfonylureas includes glipizide, glyburide, and glimepiride. Sulfonylureas are associated with weight gain and can cause GI upset.
Thiazolidinediones or TZD medications are another class of oral diabetic medications that decreases glucose output from the liver and increases insulin sensitivity. A common example of a medication in this class is pioglitazone which is commonly referred to as Actos. These medications can cause weight gain and hypoglycemia like the other oral medications. Serious side effects of meds from this class includes water retention which can be serious for patients with heart failure. Signs of water retention includes edema and crackling in the lungs.
The last group of oral diabetic medications to discuss are alpha-glucosidase inhibitors. These medications are used much less commonly than the others and are among the least effective at treating T2DM. They work by inhibiting the breakdown of complex starches and sugar molecules in the digestive system leading to less sugar absorption. The key side effects of these medications relate to indigestion such as flatulence and diarrhea. These medications cannot cause hypoglycemia and do not influence insulin.
Test Your Knowledge
3. The healthcare provider administers NPH insulin at 6:00 AM to a patient with diabetes. How soon will the patient show any signs of hypoglycemia?
- 10:00 AM
- 8:00 AM
- 9:00 AM
- 7:00 AM
Medical nutrition therapy (MNT)
Medical nutrition therapy plays an important role in preventing and managing diabetes. MNT can play a part in providing both patients and healthcare providers with nutritional interventions to optimally manage a patient’s diabetes. These interventions should involve treatment goals, strategies to achieve these goals, and consider the changes a patient is willing to make. The American Diabetes Association recommends that a registered dietician takes the leading role for providing nutritional care.1 Optimal MNT is designed to both decrease the risks associated with diabetes as well as cardiovascular disease. Several goals should be established according to the American Diabetes Association for patients with diabetes with respect to MNT.1
- Achieve and maintain adequate blood glucose levels, lipid and blood pressure.1
- To prevent and slow the progression and chronic complications of diabetes by modifying nutrition intake and lifestyle.1
- To address individual nutritional needs, such as cultural or personal preferences that may affect a patient’s desire to implement a change.1
- To maintain the pleasure of healthy eating and lifestyle while limiting food choices only when indicated by scientific evidence.1
It is important to note that patients may benefit from additional MNT interventions such as prevention and treatment of hypoglycemia in patients who use insulin. Special populations may also require unique interventions such as youth with T1DM or in pregnancy to achieve optimal nutritional care for the individual. Patients who have pre-diabetes may also benefit from MNT as it can play a role in disease prevention and discourage pharmacological interventions. According to the ADA studies on MNT have demonstrated reductions in A1c of ~ 1% and LDL decreases where improvements are apparent in 3-6 months.1
Other interventions involving MNT includes weight loss in patients who are overweight and obese insulin-resistant individuals. The ADA recommends ~ 5-7% weight loss from baseline which should be implemented gradually. Certain patients may benefit from pharmacological weight loss interventions as well as surgical (e.g. bariatric surgery) when indicated based on BMI. They do not recommend low carb diets (carbs < 130 grams/day) as the long-term effects of carb restrictions are not well studied.1
Carbohydrate Management for Diabetics
Carbohydrate management is a core intervention to consider for patients with diabetes as it can have the most direct impact on A1c and diabetic complications. Patients should be advised to obtain carbohydrates from sources such as fruit, vegetables, whole grains, legumes, and low-fat milk. Severe carb restriction is not advised for patients with diabetes especially for patients on insulin and other medications that increases the risk of hypoglycemia.
Patients should be advised to monitor their carbohydrate intake to optimize blood sugar control. It is important to consider the quantity and type of carbohydrates as they can influence postprandial glucose levels. Carbohydrate types that can influence post-meal blood sugar levels includes starches, the style of preparation (e.g. cooking time and method), and degree of sugar processing. Additionally, factors such as fasting and macronutrient distribution (e.g. vegetables, protein, dairy) can influence the amount of sugar absorbed into the blood.
Fiber intake should also be taken into consideration when evaluating a patient’s diet. Fiber rich sources (> 5 g fiber/serving) can contribute to good health. Additionally, current data suggests that a high-fiber diet (~ 50 g fiber/day) can help reduce glycemic events.1
Sugar substitution may be advised for patients to reduce starch and sucrose consumption. Patients may want to consider fructose which results in lower postprandial glucose response compared to sucrose or starch. Low or zero calorie sweeteners (alcohol sugars) such as erythritol, isomalt, and mannitol have demonstrated lower glucose response and reduced energy consumption. Use of alcohol sugars is appears to be safe but can contribute to diarrhea, particularly in children.
Dietary Fat, Protein Management, and Alcohol use in Diabetes
To reduce CVD risk in patients with diabetes it is recommended that patients restrict saturated fat intake to < 7 % total energy, trans fats should be reduced if not outright omitted from their diet, and dietary cholesterol should be < 200mg/day. Consuming fish may help provide beneficial lipid intake while minimizing fat from bad sources. Metabolic studies have demonstrated LDL reductions when saturated fats are limited. By establishing optimal dietary fat and cholesterol intake a patient can further reduce their risk of cardiovascular events.
Patients are recommended to consume 15-20% of their energy in the source of protein.1 Some data has demonstrated that protein can improve insulin sensitivity in patients with T2DM but will not increase plasma glucose concentrations. Protein should not be used to prevent nighttime hypoglycemia as a result. Protein sources can include meat, fish, eggs, milk, cheese, poultry, and soy.
Alcohol is another area where interventions may be essential for patients to consider as alcohol in combination with mixtures, soda, or juice can lead to elevated blood sugar. Patients should be advised to consume one drink or less per day if female and two drinks per day if male. Although moderate alcohol use has not been shown to increase acute plasma glucose levels it can increase the risk of nocturnal and fasting hypoglycemia especially in type 1 diabetics. Additionally, limiting alcohol to 1-2 drinks a day can contribute to reduces CVD risks.
Hypoglycemia Interventions and Acute Illness
Hypoglycemia management and risk assessment is critical to evaluate for patients especially with type 1 diabetes and patients on insulin. Understanding how to treat hypoglycemia can prevent serious complications such as diabetic ketoacidosis. Current recommendations for hypoglycemia management includes ingestion of 15-20 grams of glucose in any form. Glucose tablets are generally available in most pharmacies and can be a staple product to have on any patient with high hypoglycemic risk. Blood sugar should be tested in approximately 15 minutes to reevaluate the need for further glucose consumption. Patients should also be advised that adding fat to their sugar source can decrease the glycemic response sugar sources high in fat should be avoided.
For patients experiencing acute illness they should be advised to continue their oral diabetic medications. Depending on hypoglycemic risk they may be advised to consider ketone tests as well as more frequent glucose monitoring. Diabetics with acute illness are recommended to consume adequate levels of fluids which is a staple treatment for all illness. For patients with T1DM insulin and oral diabetic medications may need to be increased. Adults should be advised to consume between 150-200 grams of carbohydrates (45-50 grams every 3-4 hours) to prevent ketosis risk.1
Diabetes is a complex and chronic disease affecting millions of people in the United States today. The more prevalent type of diabetes is T2DM which has been rising substantially over the last few decades. There is no doubt that diabetes is a health crisis and among one of the most important diseases contributing towards mortality in populations throughout the world. As our understanding of diabetes continues to grow it will continue to be an area of great importance for generations to come. For this reason, NCLEX™ diabetes questions are and will continue to be a part of the exam.
- Nutrition Recommendations and Interventions for Diabetes: A position statement of the American Diabetes Association. Diabetes Care. 2007;31(Supplement 1). doi:10.2337/dc08-s061.