Diabetes Intro

3 Primary Disorders of Glucose Metabolism

Sustained hyperglycemia, abnormal insulin secretion, insulin resistance

What is Diabetes?

A chronic, multi-system disorder of abnormal insulin production, impaired use of insulin, or both; being in a constant state of hyperglycemia

What are the 2 major risks from developing Diabetes?

Heart disease and Stroke

Causes of Diabetes

Genetics (Human leukocyte antigens), autoimmune disorders, environmental (virus, obesity)

Normal Glucose Metabolism Pathophysiology

1. Glucose levels rise from eating, etc.

2. Pancreas responds by secreting “Bolus” of insulin

3. Insulin decreases glucose level

4. Feedback loop occurs where kidneys maintain glucose homeostasis

5. Pancreas reduces insulin secretion and returns to basal rate

6. Liver resumes function as a store

Fasting Glucose Metabolism Pathophysiology

1. Insulin continues to be released at basal rate

2. cells still demand glucose or energy of some source

3. Liver provides energy in form of glycogen

4. Other sources like adipose or muscle tissue are broken down for energy creating fatty acids

5. Fatty acids affect pH

6. Ketones are produced as byproducts of fatty acid metabolism

Type ___ Diabetes has a higher association with Human Leukocyte Antigens (HLA-DR3 and HLA-DR4)

1

How is T1D developed as an Autoimmune Disorder?

You already have a gene in your body that develops antibodies against insulin or specific pancreatic cells that make insulin, and some environmental factor triggers it at some point in your life

T or F: Insulin is continuously released into the bloodstream in small amounts

T

Insulin (hormone) is produced and secreted by the _________

Pancreas

Insulin must latch onto __________ in order for it to enter cells, leading to glucose breakdown for energy and lowered blood sugar

Glucose

What are the 3 main types of Cells that Insulin enters?

Adipose, Liver, Muscle

How does the Rise in blood insulin After a Meal work?

Gluconeogenesis is inhibited, dietary fat is deposited into adipose tissue, protein synthesis increases

How does the Fall in blood insulin Overnight work?

Glycogen from liver, protein from muscle, and fat from adipose tissue is released to maintain glucose homeostasis

T or F: If you don’t consume glucose, your body will get it from adipose, liver, and muscle tissue, which can lead to hyperglycemia and then DKA

T

What makes Liver Cells different from Adipose or Muscle Cells?

They are not insulin-dependent SO instead they have receptors that facilitate the uptake of glucose which converts to glycogen

What do Counter-Regulatory Hormones do to Blood Glucose?

They are released at night to work against insulin and therefore increase blood glucose

Counter-Regulatory Hormone Examples

Glucagon, Epinephrine, Growth Hormone, Cortisol

Glucagon stimulates the release of _________ that is stored

Glycogen

T or F: Counter-Regulatory Hormones increase blood glucose levels, even when they are already elevated, because of the expected drop in blood glucose at night

T

Diabetes Risk Factors

Family history, age, metabolic syndrome, obesity, physical inactivity, high blood pressure, Hispanic

What Labs are done for Diagnosing Diabetes?

HgB A1C > 6.5%, fasting glucose > 126, oral glucose tolerance test > 200 mg, random glucose level > 200 mg

Which lab is the best indicator for how a patient is managing/controlling their Diabetes?

HgB A1C

T or F: You must meet ALL Lab work criteria to be diagnosed with Diabetes

T

Type 1 Diabetes

A chronic, autoimmune condition where the pancreas produces little to no insulin from the destruction of insulin-producing beta cells; NOT reversible

Specific Characteristics of T1D

Onset is months to years, typically occurs in children, usually skinny, treatment is just insulin, only affected by pancreas

Type 2 Diabetes

A chronic condition where the body becomes resistant to insulin or doesn’t produce enough; reversible

Specific Characteristics of T2D

Onset is gradual over many years, typically occurs in older adults, usually obese, treatment is a combination, affected by pancreas / liver / muscle / and adipose tissue

4 main factors leading to T2D

Insulin resistance, decreased insulin production, abnormal glucose production, production of adipokines

What does the production of Adipokines lead to?

Chronic inflammation and (maybe) insulin resistance

Metabolic Syndrome Criteria

Central obesity, hyperlipidemia, high BP, hyperglycemia

Metabolic Syndrome increases the Risk for….. ?

T2D and Cardiovascular events

4 Main Diabetes Treatments

Insulin, drugs, nutrition, exercise

Rapid Acting Insulin → Onset, Peak, Duration

O: 10-30mins

P: 30mins-3hrs

D: 3-5hrs

Intermediate Acting Insulin → Onset, Peak, Duration

O: 1.5-4hrs

P: 4-12hrs

D: 12-18hrs

Long Acting Insulin → Onset, Peak, Duration

O: 0.8-4hrs

P: no peak

D: 16-24hrs

Rapid Acting Insulin is given as a _______, often in smaller amounts and given before meals (compensates for rise in glucose after a meal)

Bolus

Long Acting Insulin is given as a _______, often in larger amounts and given once at night (mimics body’s constant release of insulin)

Basal

The highest risk for hypoglycemia is at the ______

Peak

4 Complications from Insulin Therapy

Morning hyperglycemia, allergic reactions, lipodystrophy, hypertrophy

What is Lipodystrophy?

Loss of SQ fatty tissue from not rotating injection sites

What is Hypertrophy?

Thickening of SQ fatty tissue

3 Causes of Morning Hyperglycemia

Insulin Waning, Dawn Phenomenon, Somogyi Effect

How do we treat Morning Hyperglycemia?

Check blood sugars throughout the night

Why should patients NOT take more insulin before going to sleep to combat Morning Hyperglycemia?

It can cause hypoglycemia

What Psychological problems arise from Diabetes?

Stigma of being “handicapped”/”disabled”, family burden, religious obstacles (pork products), language barriers, poor health literacy

How do Diabetes Drugs affect the Pancreas?

Increase insulin production

How do Diabetes Drugs affect Adipose and Muscle Tissue?

Increase use/uptake of glucose, decrease insulin resistance

How do Diabetes Drugs affect the Stomach and Small Intestine?

Delay starch absorption, increase incretin activity, decrease gastric emptying

How do Diabetes Drugs affect the Liver?

Decrease hepatic glucose production

How do Diabetes Drugs affect the Kidney?

Decrease glucose reabsorption

What is the Main risk when treating Diabetes with Drugs?

Hypoglycemia

Goal for T1D

Maintain insulin dosing based on eating and exercise habits

Goals for T2D

Achieving healthy glucose / lipid / BP levels AND weight loss

What food groups should Diabetic focus on?

Carbohydrates, proteins, fats, fiber, alcohol

What is the PRIMARY treatment for Hypoglycemia?

15 mg of Carbs

How does Exercise affect blood glucose levels?

Decreases insulin resistance → low BS and weight loss, increases risk for hypoglycemia

Interventions for Diabetics prior to Exercising

Check glucose before and after, eat 15mg carb snack before and every 30 mins during exercise

What is the most IDEAL way to monitor Glucose?

Continuous Glucose Monitor (CGM) that monitors Q5 minutes via interstitial fluid

Symptoms of Hypoglycemia

Less severe: Headache, fatigue, drowsiness Severe: pallor, diaphoresis, tachycardia, shakiness, confusion, slurred speech, unconsciousness

Symptoms of Hyperglycemia

Excessive thirst, frequent urination, fatigue, blurred vision, sudden weight loss, headaches

_____________ gives you time to be treated while _____________ DOES NOT (is an emergency)

Hyperglycemia, Hypoglycemia

Nursing Interventions for Unconscious Hypoglycemic patient

Check BS, administer Glucagon or Dextrose, repeat BS check in 15 mins

Nursing Interventions for Conscious Hypoglycemic patient

Check BS, give 15 mg of simple carbs, repeat BS check in 15 mins

Diabetic Considerations for Sick Days

Notify provider, continue basal insulin and oral meds, monitor BS every 2-4 hours, stay hydrated, maintain carbohydrate needs with solid foods or fluids containing sugar (if not tolerating solids)

What does the presence of Ketones in the urine mean?

Indicates that fat and protein are being used to maintain glucose needs which can lead to DKA

Normal Fasting BS

Under 100

Normal Random BS

70-115

HgB A1C indicating Diabetes

6.5+

T1D vs. T2D