1. Chapter 20
Diabetes Mellitus

2. Chapter 20
Lesson 20.1
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3. Key Concept
Diabetes mellitus is a metabolic disorder of glucose metabolism with many causes and forms.
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4. About Diabetes
20.8 million Americans have diabetes (7% of the population).
54 million Americans have prediabetes.
Diabetes is the seventh leading cause of death from disease in the United States.
How does the incidence of diabetes affect nursing care?
What is the role of patient education in prevention and management of this disorder?
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5. About Diabetes, cont’d
People with diabetes either do not produce insulin or cannot effectively use it.
Diabetes is characterized by hyperglycemia.
How long has insulin replacement therapy been available as a treatment?
How is hyperglycemia defined?
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6. Incidence of Diabetes Figure information:
From Centers for Disease Control and Prevention: National diabetes fact sheet, accessed April 2007.
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7. Word Origins Diabetes from Greek “to pass through”
Mellitus from Latin for “honey”
Insulin from Latin for “island”
Islets of Langerhans: clusters of pancreatic cells named for discoverer
What characteristics are noted in the urine of a diabetic patient?
How do those characteristics apply to the word origins?
What do the pancreatic cells produce in addition to insulin?
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8. Type 1 Diabetes Mellitus
Accounts for 5% to 10% of cases
Previously called insulin-dependent or juvenile-onset diabetes
Severe, unstable form
What are special considerations of type 1 diabetes mellitus (DM) that make it especially challenging to manage?
How do growth and development affect metabolism?
What are some psychosocial considerations involved in type 1 DM?
Why is exogenous insulin necessary?
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9. Type 1 Diabetes Mellitus, cont’d
Caused by autoimmune destruction of pancreatic cells
Can occur at any age
Requires exogenous insulin
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10. Type 2 Diabetes Mellitus
Accounts for 90% to 95% of cases
Previously called adult-onset or non–insulin-dependent diabetes
Initial onset usually after age 40 years
Now being diagnosed in children
What societal factors contribute to the increasing incidence of type 2 DM?
What are oral hypoglycemic agents and how do they work?
Name some examples of medications used to treat type 2 DM.
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11. Type 2 Diabetes Mellitus, cont’d
Strong genetic link
Prevalent in older, obese people
Caused by insulin resistance or defect
Usually treated with diet, exercise
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12. Risk Factors for Type 2 Diabetes Mellitus
Family history of diabetes
Age 45 years or older
Overweight
Not physically active
Race/ethnicity (African American, Hispanic American, Native American, Asian American, Pacific Islander)
Ask students to describe a typical person at risk for developing type 2 DM.
What are the risk factors that a person can control?
How can a community health nurse identify people at risk for this disease?
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13. Risk Factors for Type 2 Diabetes Mellitus, cont’d
History of gestational diabetes
Woman who has delivered infant weighing more than 9 pounds
Identified impaired glucose tolerance
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14. Gestational Diabetes Temporary form of disease occurring in pregnancy
Presents complications for mother and fetus/infant
Must be carefully monitored and controlled
What are the complications associated with gestational diabetes?
Who should be screened for it?
What tests are used to diagnose gestational diabetes?
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15. Other Types of Diabetes (Secondary)
Causes
Genetic defect
Pancreatic conditions or disease
Endocrinopathies: imbalance with other hormones in the body
Drug/toxin induced or chemical induced
List types of drugs and chemicals that cause secondary diabetes.
Is this type of diabetes more or less prevalent than the others presented previously?
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16. Impaired Glucose Tolerance
Above normal fasting blood glucose but not high enough to be diabetes
A risk factor for type 2 diabetes
Underlying conditions often present
What are some underlying conditions that are often present with impaired glucose tolerance? Hypercholesterolemia, obesity, hypertension
Given the increasing incidence of diabetes, why is identification of impaired glucose tolerance important?
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17. Symptoms of Diabetes Initial signs Increased thirst
Increased urination
Increased hunger
Unusual weight loss (type 1)
Unusual weight gain (type 2)
Why would you expect weight loss with type 1?
Why would you expect weight gain with type 2?
Explain how an accurate nursing assessment and health history assist in identifying patients at risk.
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18. Symptoms of Diabetes, cont’d
Laboratory test results
Glycosuria (sugar in urine)
Hyperglycemia (elevated blood sugar)
Abnormal glucose tolerance tests
Progressive results
Water, electrolyte imbalance
Ketoacidosis
Coma
Define the normal range for laboratory test results.
How is the urine tested?
What are ketones?
Why does coma result in untreated ketoacidosis?
How do early symptoms compare with progressive symptoms?
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19. Chapter 20
Lesson 20.2
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20. Key Concept
Diabetes mellitus is a metabolic disorder of glucose metabolism with many causes and forms.
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21. Metabolic Patterns of Diabetes
Diabetes is especially related to metabolism of carbohydrate and fat.
It is important to control blood glucose within normal levels of 70 to 110 mg/dl.
What is the primary nutrient affected in diabetes?
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22. Metabolic Patterns of Diabetes, cont’d
If diabetes is uncontrolled and insulin is lacking:
Glucose cannot enter the cells and builds up in the blood.
Fat tissue breaks down.
Protein breaks down, causing weight loss and nitrogen loss.
Are other nutrients also involved in the disease process?
Why do fat and protein get broken down?
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23. Metabolic Pattern of Diabetes, cont’d
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24. Metabolic Patterns of Diabetes, cont’d
Three basic stages of normal glucose metabolism:
Initial interchange with glycogen and reduction to smaller central compound
Joining with fat and protein
Common energy production
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25. Metabolic Patterns of Diabetes, cont’d
Normal blood glucose balance
Sources of glucose include glycogen, carbohydrate, fat, and protein
Uses:
Burned for energy needs
Changed to glycogen
Stimulate lipogenesis
Inhibit tissue fat breakdown
Promote amino acid uptake
Influence burning of glucose
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26. Metabolic Pattern of Diabetes, cont’d
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27. Pancreatic Hormonal Control: Three Key Hormones
Islets of Langerhans produce:
Insulin
Glucagon
Somatostatin
Where are the islets of Langerhans? Specialized cells located in the pancreas
Why are they referred to as “islands” or “islets”?
Why is diabetes considered an endocrinologic disorder?
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28. Pancreatic Hormonal Control
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29. Insulin Controls blood sugar Helps transport glucose into cells
Helps change glucose to glycogen and store it in liver, muscles
Stimulates changes of glucose to fat for storage as body fat
Inhibits breakdown of tissue fat and protein
Promotes uptake of amino acids
Influences burning of glucose for energy
Which pancreatic cells produce insulin?
What happens if insulin is not produced by the body?
Why does insulin resistance occur?
What are ketones?
What is acidosis?
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30. Glucagon Acts in a manner opposite to insulin
Breaks down stored glycogen and fat
Raises blood glucose as needed to protect brain during sleep or fasting
How does glucagon compare to insulin?
Which pancreatic cells produce glucagon?
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31. Somatostatin A “referee” for several other hormones
Inhibits secretion of insulin, glucagon, and other hormones
Also produced in other parts of the body (e.g., hypothalamus)
Why is somatostatin considered a referee?
Describe how all three hormones relate to one another.
Where in the pancreas is somatostatin produced?
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32. Abnormal Metabolism Glucose Fat Protein
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33. Abnormal Metabolism, cont’d
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34. Long-Term Complications of Diabetes
Retinopathy
Nephropathy
Neuropathy
Heart disease
Dyslipidemia: Elevated triglyceride, decreased high-density lipoprotein cholesterol
Hypertension: A major comorbid condition
Why does hyperglycemia contribute to the various complications?
What does comorbid mean?
What is the leading cause of death among patients with diabetes?
Why is skin care important?
Why are amputations associated with diabetes?
What is cellulitis?
Why do patients with a history of diabetes often require dialysis?
How often should patients be screened for retinopathy?
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35. Criteria for Diagnosis of Diabetes Mellitus
Symptoms of diabetes plus casual (any time) plasma glucose concentration ≥200 mg/dl
Fasting plasma glucose ≥126 mg/dl
Two-hour plasma glucose ≥200 mg/dl during an oral glucose tolerance test
How long should a patient fast before a fasting plasma glucose test?
What are the symptoms of diabetes that a patient should report?
How is an oral glucose tolerance test administered?
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36. Chapter 20
Lesson 20.3
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37. Key Concepts
A consistent, sound diet is the keystone of diabetes care and control.
Daily self-care skills enable a person with diabetes to remain healthy and reduce risks for complications.
What is the relation between diet, activity, and insulin production to metabolism and homeostasis?
Is diabetes a chronic or acute condition?
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38. Key Concepts, cont’d
Blood glucose monitoring is a critical practice for blood glucose control.
A personalized care plan balancing food intake, exercise, and insulin regulation is essential to successful diabetes management.
Describe how diabetes can affect patients across the lifespan.
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39. Management of Diabetes
Early detection
Glycemic control
Prevention of complications
Glucose tolerance test
Goals of care
Maintaining optimal nutrition
Avoiding symptoms
Preventing complications
Why is early detection important?
How can it be promoted in your community?
What is glycemic control?
List complications associated with uncontrolled diabetes.
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40. General Management
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41. Medical Nutrition Therapy
The Diabetes Control and Complications Trial
Compared the effects of intensive insulin therapy aimed at achieving blood glucose levels as close as possible to the normal nondiabetic range with the effects of conventional therapy on early microvascular complications of type 1 diabetes mellitus.
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42. Applications in Clinical Practice: Recommendations
For individuals at risk for type 2 diabetes or with prediabetes:
Decrease risk of diabetes and cardiovascular disease
Promote healthy food choices and physical activity
Maintain moderate weight loss
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43. Applications in Clinical Practice: Recommendations, cont’d
Individuals with diabetes
Achieve and maintain:
Blood glucose levels as safely as possible
Lipid and lipoprotein profile
Blood pressure levels
Prevent, or at least slow, the rate of chronic complications
Address individual nutrition needs
Maintain the pleasure of eating
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44. Applications in Clinical Practice: Recommendations, cont’d
Goals of MNT that apply to specific situations
For youth with type 1 diabetes, youth with type 2 diabetes, pregnant and lactating women, and older adults with diabetes, to meet the nutrition needs of these unique times in the life cycle
For individuals treated with insulin or insulin secretagogues, to provide self-management training for safe conduct of exercise, including the prevention and treatment of hypoglycemia and diabetes treatment during acute illness
Define secretagogues.
How would nutrition needs for youth differ from nutrition needs of adults?
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45. Exercise
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46. Core Focus: Glycemic Control
Nutrition therapy
Total energy balance
Nutrient balance
Food distribution balance
Personal diet
Total kilocalories of energy balance
Ratio of carbohydrate, fat, protein
Daily food distribution pattern
What is glycemic control?
How does activity affect this balance?
Why is fiber important?
Why is the concept of dietary variety important in managing diabetes?
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47. Total Energy Balance Normal growth and weight maintenance
Energy intake
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48. Nutrient Balance Carbohydrate Protein Fat
Starch and sugar: Complex and simple carbohydrates
Glycemic index
Fiber
Sugar substitutes: Nutritive and nonnutritive
Protein
About 15% to 35% of total energy
Fat
No more than 25% to 30% of kilocalories
What is the difference between a simple and complex carbohydrate? Give examples.
Are sugar substitutes allowed if a patient has diabetes?
How does this energy balance compare to recommendations for the average person?
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49. Food Distribution Balance
Eat even amounts of food at regular intervals.
Maintain even blood glucose supply.
Snacks may be needed.
Adjust eating according to activity level and stress.
Regulate glycemic response according to physical activity and exercise.
Drug therapy.
Why are snacks important? What are examples of recommended snacks?
Is it possible for a child with type 1 diabetes to play sports?
How does stress affect metabolism?
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50. Diet Management General planning according to type of diabetes
Develop plan to meet individual needs
Why must individual preferences and cultural background be taken into consideration?
How does a clinical dietician fit in the plan of care?
What is the food exchange system?
Why should processed foods be limited?
How is alcohol metabolized?
What happens if a person skips a meal?
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51. Diet Management, cont’d
Food exchange system
Carbohydrate counting
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52. Diet Management, cont’d
Figure information:
From Peckenpaugh NJ: Nutrition essentials and diet therapy, ed 9, Philadelphia, 2003, Saunders.
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53. Diet Management, cont’d
Special concerns
Special diet food items
Alcohol
Hypoglycemia
Illness
Eating out
Stress
What concerns does eating out pose?
How does stress affect hormone levels?
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54. Special Concerns
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55. Person-Centered Self-Care
Persons with diabetes need essential skills and knowledge.
Understand nature of diabetes
Nutrition: Develop sound food plan
Insulin: Know type, duration of action, combinations
Monitor glucose levels
Control emergencies, illness
Identification bracelet
Why is assessing educational background helpful in planning patient teaching?
What is the role of a diabetes educator?
How can patient understanding be assessed or demonstrated?
What challenges exist throughout the lifespan in managing diabetes?
What is the role of support groups in facilitating adjustment and compliance?
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56. Insulin
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57. Oral Hypoglycemic Agents
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58. Tools for Self-care Figure information:
Courtesy DexCom, Inc., San Diego, Calif.
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59. Resources American Diabetes Association American Heart Association
“Light” cookbooks
Why are diabetes and heart disease related?
How do menu planning and cooking affect disease management?
What resources are offered by the American Diabetes Association?
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60. Summary
Diabetes mellitus is a syndrome of varying forms and degrees that have the common characteristic of hyperglycemia.
Underlying metabolic disorder involves all three of the energy nutrients (carbohydrate, fat, and protein) and influences energy balance.
The major controlling hormone involved is insulin from the pancreas; persons with diabetes have either a lack of insulin or a resistance to its action.
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61. Summary, cont’d
Type 1 diabetes affects approximately 5% to 10% of all persons with diabetes; it usually presents itself first during childhood and is more severe and unstable.
Treatment of type 1 diabetes involves regular meals and snacks balanced with insulin and exercise.
Self-monitoring of blood glucose levels is an important part of disease management.
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62. Summary, cont’d
Type 2 diabetes occurs mostly in adults, especially those who are overweight. Acidosis is rare.
Treatment of type 2 diabetes involves weight reduction and maintenance along with regular exercise. Medications may or may not be needed.
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63. Summary, cont’d
A significant keystone of care for all forms of diabetes is sound diet therapy.
The basic food plan should be rich in complex carbohydrates and dietary fiber; low in simple sugars, fats (especially saturated fats), and cholesterol; and moderate in protein.
Food should be distributed throughout the day in fairly regular amounts and at regular times and tailored to meet individual needs.
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