St.

Paul University Philippines

Tuguegarao City, Cagayan

AAN 203 : Advance Adult Nursing 3

Diabetes Nursing

By:

MA. CLARRISE ANN SD. CRUZ

LORA MAE O. MATUTE
FREDERICK ALLAN RANA

Graduate School Student

Submitted to:

Krishan Soriano, RN, MSN

Professor
Diabetes from a Greek verb diabetes meaning "to run through" Latin Mellitus meaning "honey" is a
chronic condition associated with abnormally high levels of sugar (glucose) in the blood. Insulin
produced by the pancreas lowers blood glucose. It is a disorder of altered carbohydrate, fat and protein
metabolism caused either by a relative or absolute lack of insulin Diabetes mellitus (DM) is a chronic,
non-communicable disease and also one of the major global public health issues. It produces many
complex changes in the lives of those affected. Diabetes mellitus is defined as a clinical syndrome
characterized by hyperglycemia due to absolute or relative deficiency of insulin. Diabetes mellitus is an
etiologically and clinically heterogeneous group of metabolic disorders that share the commonality of
hyperglycemia.

DIABETES NURSING EDUCATION AND DIABETES NURSING PRACTICE

Diabetes self-management education is a collaborative process through which people with diabetes gain
the knowledge and skills needed to modify their behavior and to self-manage successfully the disease
and its related conditions. Diabetes educators are health care professionals who apply in-depth
knowledge and skills in the biological and social sciences, communication, counseling, and pedagogy to
enable patients to manage daily and future challenges.

A primary role for nurses is that of a diabetes self-management educator who provides information to
patients with pre-diabetes and diabetes in an effort to help patients make informed decisions about
prevention and managing their condition. With a focus on helping people make lifestyle changes that
contribute to improved health, the duties of a diabetes educator include, Working with patients to
assess their needs and to develop a plan that includes educational interventions and self-management
support strategies appropriate for the patient, Providing education that helps the patient accomplish
self-management goals, Evaluating patients periodically to determine if they are meeting their goals or if
they need other interventions and future reassessments, Developing, with the cooperation of the
patient, a personalized follow-up plan for ongoing self-management support, Documenting the
assessment and education plan, as well as interventions and outcomes, Diabetes nurse educators
provide services in hospitals, physician offices, pharmacies, patients’ homes, and other settings.
Advanced practice registered nurses typically serve under a primary specialization in their patient
population focus, allowing them to further specialize as adult, gerontological, or pediatric diabetes
educators.

Emergency trend in nursing specialization

The primary role of a nurse is to advocate and care for individuals of all ethnic origins and religious
backgrounds and support them through health and illness. However, there are various other
responsibilities of a nurse that form a part of the role of a nurse, including to:

• Record medical history and symptoms

• Collaborate with team to plan for patient care

• Advocate for health and wellbeing of patient

• Monitor patient health and record signs

• Administer medications and treatments

• Operate medical equipment

• Perform diagnostic tests

• Educate patients about management of illnesses

• Provide support and advice to patients

In the event of a natural disaster there can be serious impacts on the ability to manage appropriate self-
care for those living with diabetes and other chronic conditions. Planning ahead reduces the risk of
diabetes-related infections and life-threatening situations. Stress in an emergency or a natural disaster
can raise or lower blood glucose to dangerous levels. There may be no medication or food available, and
no way of getting medical help. A Diabetes Emergency Plan helps you to self-manage your diabetes
before, during and after an emergency.

Nurses who specialize in diabetes educate their clients. Newly diagnosed diabetics often have many
misconceptions about what they can eat and how diabetes will affect their lives. Because diabetes is
largely a disease of self-management, clients have a great deal of power over their condition if they
learn techniques to lower blood glucose. Learning about early signs of potential complications can also
help diabetics ward off more serious consequences. A diabetes nurse educator generally has more time
to spend per patient than a physician and can address lifestyle issues in depth. Professionals in this field
concentrate on helping clients adjust behaviors relating to eating well, staying physically active,
monitoring their blood glucose levels, taking medication, coping with the stress of diabetes and reducing
risks. The nurse educator must be skilled in this teaching-learning process and have a good background
and understanding of diabetes, including diabetes complications and problems. Very importantly, the
educator must have the capability and the responsibility to evaluate the effectiveness of the teaching
and learning that are done. This evaluation provides proof that better education of the diabetic patient
does provide improvement in patient self-care through a better understanding of his illness. Proper care
and management reduce the frequency of office visits, telephone calls, and hospitalization. Finally, the
educator must interpret, for each diabetic patient, the research being done, and, when possible,
encourage diabetic patients to become involved themselves, for they are the ones who reap the
benefits from diabetes research.

ADVANCE PRACTICE NURSING IN DIABETES

Diabetes highlights a growing epidemic imposing serious social economic crisis to the countries around
the globe. Despite scientific breakthroughs, better healthcare facilities, and improved literacy rate, the
disease continues to burden several sections, especially middle and low income countries. The present
trends indicate the rise in premature death, posing a major threat to global development. Scientific and
technological advances have witnessed the development of newer generation of drugs like
sulphonylureas, biguanides, alpha glucosidase inhibitors, and thiazolidinediones with significant efficacy
in reducing hyperglycemia. Recent approaches in drug discovery have contributed to the development
of new class of therapeutics like Incretin mimetics, Amylin analogues, GIP analogs, Peroxisome
proliferator activated receptors, and dipeptidyl peptidase-4 inhibitor as targets for potential drugs in
diabetes treatment. Subsequently, the identification and clinical investigation of bioactive substances
from plants have revolutionized the research on drug discovery and lead identification for diabetes
management. With a focus on the emerging trends, the review article explores the current statistical
prevalence of the disease, discussing the benefits and limitations of the commercially available drugs.
Additionally, the critical areas in clinical diabetology are discussed, with respect to prospects of statins,
nanotechnology, and stem cell technology as next generation therapeutics and why the herbal
formulations are consistently popular choice for diabetes medication and management. Current trends
in the management of type 2 diabetes mellitus include intensive treatment to control the blood glucose
level and blood pressure in order to prevent or delay microvascular and cardiovascular complications. In
the new millennium, type 2 diabetes will become epidemic in developing countries. Laboratory tests are
useful for detecting risk factors before the onset of the disease and convincing the general public to take
preventive measures. Glucose tolerance testing is one of these tests. Educating the public about eating a
healthy diet and exercising may prevent the development of diabetes and thereby reduce the global
prevalence of type 2 diabetes.

PATHOPHYSIOLOGY
There is a direct link between hyperglycemia and physiological & behavioral responses. Whenever there
is hyperglycemia, the brain recognizes it and send a message through nerve impulses to pancreas and
other organs to decrease its effect [2].

Type 1 diabetes mellitus

Type 1 Diabetes is characterized by autoimmune destruction of insulin producing cells in the pancreas
by CD4+ and CD8+ T cells and macrophages infiltrating the islets. Several features characterize type 1
diabetes mellitus as an autoimmune disease:

1. Presence of immuno-competent and accessory cells in infiltrated pancreatic islets;

2. Association of susceptibility to disease with the class II (immune response) genes of the major
histocompatibility complex (MHC; human leucocyte antigens HLA);

3. Presence of islet cell specific autoantibodies;

4. Alterations of T cell mediated immune regulation, in particular in CD4+ T cell compartment;

5. The involvement of monokines and TH1 cells producing interleukins in the disease process;

6. Response to immunotherapy and;

7. Frequent occurrence of other organ specific auto- immune diseases in affected individuals or in their
family members.

Approximately 85% of patients have circulating islet cell antibodies, and the majorities also have
detectable anti-insulin antibodies before receiving insulin therapy. Most islet cell antibodies are directed
against glutamic acid decarboxylase (GAD) within pancreatic B cells.

The autoimmune destruction of pancreatic β-cells, leads to a deficiency of insulin secretion which results
in the metabolic derangements associated with T1DM. In addition to the loss of insulin secretion, the
function of pancreatic α-cells is also abnormal and there is excessive secretion of glucagon in T1DM
patients. Normally, hyperglycemia leads to reduced glucagon secretion, however, in patients with
T1DM, glucagon secretion is not suppressed by hyperglycemia. The resultant inappropriately elevated
glucagon levels exacerbate the metabolic defects due to insulin deficiency. Although insulin deficiency is
the primary defect in T1DM, there is also a defect in the administration of insulin. Deficiency in insulin
leads to uncontrolled lipolysis and elevated levels of free fatty acids in the plasma, which suppresses
glucose metabolism in peripheral tissues such as skeletal muscle. This impairs glucose utilization and
insulin deficiency also decreases the expression of a number of genes necessary for target tissues to
respond normally to insulin such as glucokinase in liver and the GLUT 4 class of glucose transporters in
adipose tissue [34] explained that the major metabolic derangements, which result from insulin
deficiency in T1DM are impaired glucose, lipid and protein metabolism.

Type 2 diabetes mellitus

In type 2 diabetes these mechanisms break down, with the consequence that the two main pathological
defects in type 2 diabetes are impaired insulin secretion through a dysfunction of the pancreatic β-cell,
and impaired insulin action through insulin resistance. In situations where resistance to insulin
predominates, the mass of β-cells undergoes a transformation capable of increasing the insulin supply
and compensating for the excessive and anomalous demand. In absolute terms, the plasma insulin
concentration (both fasting and meal stimulated) usually is increased, although “relative” to the severity
of insulin resistance, the plasma insulin concentration is insufficient to maintain normal glucose
homeostasis. Keeping in mind the intimate relationship between the secretion of insulin and the
sensitivity of hormone action in the complicated control of glucose homeostasis, it is practically
impossible to separate the contribution of each to the etiopathogenesis of DM2.

Insulin resistance and hyperinsulinemia eventually lead to impaired glucose tolerance. Except for
maturity onset diabetes of the young (MODY), the mode of inheritance for type 2 diabetes mellitus is
unclear. MODY, inherited as an autosomal dominant trait, may result from mutations in glucokinase
gene on chromosome 7p. MODY is defined as hyperglycemia diagnosed before the age of twenty-five
years and treatable for over five years without insulin in cases where islet cell antibodies (ICA) are
negative.

Insulin resistance

The primary events are believed to be an initial deficit in insulin secretion and in many patients relative
insulin deficiency in association with peripheral insulin resistance. Resistance to the action of insulin will
result in impaired insulin mediated glucose uptake in the periphery (by muscle and fat), incomplete
suppression of hepatic glucose output and impaired triglyceride uptake by fat. To overcome the insulin
resistance, islet cells will increase the amount of insulin secreted. Endogenous glucose production is
accelerated in patients with type 2 diabetes or impaired fasting glucose. Because this increase occurs in
the presence of hyper insulinemia, at least in the early and intermediate disease stages, hepatic insulin
resistance is the driving force of hyperglycemia of type 2 diabetes.

ETIOLOGY

I. Type 1 Diabetes (beta cell destruction, usually leading to absolute insulin deficiency)

 Immune-mediated

 Idiopathic
 II. Type 2 Diabetes (may range from predominantly insulin resistance with relative insulin
deficiency to a predominantly insulin secretory defect with insulin resistance)

III. Other specific types of diabetes

a) Genetic defects of beta cells development or function characterized by

mutation in:

 Hepatocyte nuclear transcription factor (HNF) 4ɑ (maturity-onset

diabetes of the young)

b) Genetic defects in insulin action

c) Disease of exocrine pancreas

d) Endocrinopathies

e) Drug- or chemical-induced

f) Infections

g) Uncommon forms of immune-mediated diabetes

h) Other genetic syndromes sometimes associated with diabetes

IV. Gestational Diabetes Mellitus

SIGNS AND SYMPTOMS

Symptoms vary depending on how much the blood sugar is elevated. Some people, especially those with
prediabetes or type 2 diabetes, may not experience symptoms initially. In type 1 diabetes, symptoms
tend to come on quickly and be more severe [1].

Some of the signs and symptoms of type 1 and type 2 diabetes

 Increased thirst

 Frequent urination

 Extreme hunger

 Unexplained weight loss

 Presence of ketones in the urine

 Fatigue

 Irritability

 Blurred vision

 Slow-healing sores
  Frequent infections, such as gums or skin infections and vaginal infections

The symptoms of diabetes may be pronounced, subdued, or even absent [1].

 In Type 1 diabetes, the classic symptoms are excessive secretion of urine (polyuria), thirst
(polydipsia), weight loss and tiredness.

 These symptoms may be less marked in Type 2 diabetes. In this form, it can also happen that no
early symptoms appear and the disease is only diagnosed several years after its onset, when
complications are already present.

TYPES OF DM
 Type 1 DM

- Also known as juvenile diabetes, is characterized by beta cell destruction caused by an autoimmune
process, usually leading to absolute insulin deficiency [20]. Type 1 is usually characterized by the
presence of anti–glutamic acid decarboxylase, islet cell or insulin antibodies which identify the
autoimmune processes that lead to beta cell destruction. Eventually, all type1 diabetic patients will
require insulin therapy to maintain normglycemia.

 Type 2 DM

- The relative importance of defects in insulin secretion or in the peripheral action of the hormone in
the occurrence of DM2 has been and will continue to be cause for discussion. DM2 comprises 80% to
90% of all cases of DM. Most individuals with Type 2 diabetes exhibit intra-abdominal (visceral) obesity,
which is closely related to the presence of insulin resistance. In addition, hypertension and dyslipidemia
(high triglyceride and low HDL-cholesterol levels; postprandial hyperlipidemia) often are present in
these individuals. This is the most common form of diabetes mellitus and is highly associated with a
family history of diabetes, older age, obesity and lack of exercise. It is more common in women,
especially women with a history of gestational diabetes, and in Blacks, Hispanics and Native Americans.

 Gestational DM

- is an operational classification (rather than a pathophysiologic condition) identifying women who

develop diabetes mellitus during gestation. Women who develop Type 1 diabetes mellitus during
pregnancy and women with undiagnosed asymptomatic Type 2 diabetes mellitus that is discovered
during pregnancy are classified with Gestational Diabetes Mellitus (GDM). In most women who develop
GDM; the disorder has its onset in the third trimester of pregnancy.

 Other specific type (Monogenic diabetes)

- Types of diabetes mellitus of various known etiologies are grouped together to form the classification
called “Other Specific Types”. This group includes persons with genetic defects of beta-cell function (this
type of diabetes was formerly called MODY or maturity-onset diabetes in youth) or with defects of
insulin action; persons with diseases of the exocrine pancreas, such as pancreatitis or cystic fibrosis;
persons with dysfunction associated with other endocrinopathies (e.g. acromegaly); and persons with
pancreatic dysfunction caused by drugs, chemicals or infections and they comprise less than 10% of DM
cases.
DIAGNOSTIC/ LAB EXAMS
RANDOM PLASMA TEST

• The simplest test and doesn’t require fasting before taking the test.

• If 200 or more than 200 mg/dl of blood glucose it probably indicates diabetes but has to be
reconfirmed. Fasting plasma glucose test:

• There should be eight hours fasting before taking this test. Blood glucose more than 126 mg/dl on two
or more tests conducted on different days confirms a diabetes diagnosis.

ORAL GLUCOSE TOLERANCE TEST

• When random plasma glucose test is 160-200 mg/dl and the fasting plasma test is 110-125 mg/dl, then
this test is conducted.

• This blood test evaluates body’s response to glucose. This test requires fasting at least eight but not
more than 16 hrs.

• Fasting glucose level is determined, and then gives 75 gm of glucose, 100 gm for pregnant women. The
blood is tested every 30 minutes to one hr for two or three hrs.

• This test is normal if your glucose level at two hrs is less than 140 mg/dl. A fasting level of 126 mg/dl or
greater and two hour glucose level of 200 mg/dl or higher confirms a diabetes diagnosis.

GLYCATED PROTEINS

Proteins react spontaneously in blood with glucose to form glycated derivatives. The extent of glycation
of proteins is controlled by the concentration of glucose in blood and by the number of reactive amino
groups present in the protein that are accessible to glucose for reaction. All proteins with reactive sites
can be glycated and the concentration of the glycated proteins that can be measured in blood is a
marker for the fluctuation of blood glucose concentrations during a certain period. From a clinical
diagnostic point glycated proteins with a longer life time in blood are of interest, since they reflect the
exposure of these proteins to glucose for longer periods.

GLYCATED HEMOGLOBIN

The life span of hemoglobin in vivo is 90 to 120 days. During this time glycated hemoglobin A forms,
being the ketoamine compound formed by combination of hemoglobin A and glucose. Several
subfractions of glycated hemoglobin have been isolated. Of these, glycated hemoglobin A fraction
HbA1c is of most interest serving as a retrospective indicator of the average glucose Concentration.
HbA1c is recommended as an essential indicator for the monitoring of blood glucose control. The blood
HbA1c≥ 6.5% is considered as diabetes.

FRUCTOSAMINE TEST

Albumin is the main component of plasma proteins. As albumin also contains free amino groups, non-
enzymatic reaction with glucose in plasma occurs. Therefore glycated albumin can similarly serve as a
marker to monitor blood glucose. Glycated albumin is usually taken to provide a retrospective measure
of average blood glucose concentration over a period of 1 to 3 weeks. Reference interval: 205- 285
mmol/L.

COMPREHENSIVE APPROACHES TO DIABETES CARE AND COLLABORATIVE MANAGEMENT

INCLUDING MONITORING MARKERS OF DIABETES MELLITUS
Although treatment guidelines are in place for diabetes, many people do not achieve optimal glycemic
control. There are a number of barriers to optimal glycemic control, including poor adherence to
treatment, clinical inertia and misalignment of resources, resulting from a fragmented approach to care.

Diabetes care should be individualized and all aspects of care (glycemic control,
management/prevention of complications, and psychological, emotional and behavioral well-being)
should be included in the treatment plan. In addition, it is essential that people with diabetes are
educated about their condition and encouraged to play an active role in its management.

Drug delivery systems, treatment algorithms and self-monitoring blood glucose devices, as well as
innovations in medication, may provide the tools needed for a patient-centered multidisciplinary
integrated care system, and it is vital that all these tools are used in the best possible combination.
Furthermore, a more comprehensive, multidisciplinary approach to treatment might overcome the
misalignment of resources, enabling more people to attain and maintain optimal glycemic control. This
comprehensive approach, which allows the coordinated use of all available tools, has the potential to
revolutionize diabetes care, which is often delivered in a fragmented manner. Integrated diabetes care
models will need to be validated to assess their economic sustainability.

DRUGS (OHA) AND INSULIN TREATMENT AND MANAGEMENT

Oral antihyperglycemic agents (OHA)

Oral antihyperglycemic agents lower glucose levels in the blood. They are commonly used in the
treatment of diabetes mellitus.

Biguanides

Biguanides decrease hepatic glucose production, decrease gastrointestinal glucose absorption, and
increase target cell insulin sensitivity

Example: Metformin

Sulfonylureas

Sulfonylureas increase beta-cell insulin secretion, decrease hepatic glucose output, and increase insulin
receptor sensitivity at peripheral target tissues

Examples: Glyburide, glipizide, glimepiride, tolazamide, tolbutamide

Thiazolidinediones

Thiazolidinediones increase insulin receptor sensitivity and influence the production of gene products
involved in lipid and glucose metabolism; their mechanism of action depends on the presence of insulin
for activity
Examples: Pioglitazone, rosiglitazone

Alpha-glucosidase inhibitors

Inhibit the upper gastrointestinal enzymes that convert dietary starch and other complex carbohydrates
into simple sugars, which can be absorbed

Examples: Acarbose (Precose) & Miglitol (Glycet)

INSULIN
Various types of insulin are used to treat diabetes and include:

Rapid-acting insulin: It starts working approximately 15 minutes after injection and peaks at
approximately 1 hour but continues to work for two to four hours. This is usually taken before a meal
and in addition to a long-acting insulin.

Short-acting insulin: It starts working approximately 30 minutes after injection and peaks at
approximately 2 to 3 hours but will continue to work for three to six hours. It is usually given before a
meal and in addition to a long-acting insulin.

Intermediate-acting insulin: It starts working approximately 2 to 4 hours after injection and peaks
approximately 4 to 12 hours later and continues to work for 12-18 hours. It is usually taken twice a day
and in addition to a rapid- or short-acting insulin. 

Long-acting insulin: It starts working after several hours after injection and works for approximately 24
hours. If necessary, it is often used in combination with rapid- or short-acting insulin.

NUTRITION & DIET THERAPY, DIABETES MEAL PLANNING

A diabetes diet simply means eating the healthiest foods in moderate amounts and sticking to regular
mealtimes.

A diabetes diet is a healthy-eating plan that's naturally rich in nutrients and low in fat and calories. Key
elements are fruits, vegetables and whole grains. In fact, a diabetes diet is the best eating plan for most
everyone.

For most people with type 2 diabetes, weight loss also can make it easier to control blood glucose and
offers a host of other health benefits. If the patient need to lose weight, a diabetes diet provides a well-
organized, nutritious way to reach your goal safely.

Diet details
A diabetes diet is based on eating three meals a day at regular times. This helps the body better use the
insulin it produces or gets through a medication.

A registered dietitian can help to put together a diet based on health goals, tastes and lifestyle. He or
she can also talk with about how to improve eating habits, for example, by choosing portion sizes that
suit the needs forthe size and level of activity.

Recommended foods
Make the calories count with these nutritious foods:

Healthy carbohydrates. During digestion, sugars (simple carbohydrates) and starches (complex

carbohydrates) break down into blood glucose. Focus on the healthiest carbohydrates, such as fruits,
vegetables, whole grains, legumes (beans, peas and lentils) and low-fat dairy products.

Fiber-rich foods. Dietary fiber includes all parts of plant foods that your body can't digest or absorb.
Fiber moderates how your body digests and helps control blood sugar levels. Foods high in fiber include
vegetables, fruits, nuts, legumes (beans, peas and lentils), whole-wheat flour and wheat bran.

Heart-healthy fish. Eat heart-healthy fish at least twice a week. Fish can be a good alternative to high-
fat meats. For example, cod, tuna and halibut have less total fat, saturated fat and cholesterol than do
meat and poultry. Fish such as salmon, mackerel, tuna, sardines and bluefish are rich in omega-3 fatty
acids, which promote heart health by lowering blood fats called triglycerides.

Avoid fried fish and fish with high levels of mercury, such as tilefish, swordfish and king mackerel.

"Good" fats. Foods containing monounsaturated and polyunsaturated fats can help lower your
cholesterol levels. These include avocados, almonds, pecans, walnuts, olives, and canola, olive and
peanut oils. But don't overdo it, as all fats are high in calories.

Foods to avoid
Diabetes increases risk of heart disease and stroke by accelerating the development of clogged and
hardened arteries. Foods containing the following can work against the goal of a heart-healthy diet.

Saturated fats. High-fat dairy products and animal proteins such as beef, hot dogs, sausage and bacon
contain saturated fats.

Trans fats. These types of fats are found in processed snacks, baked goods, shortening and stick
margarines. Avoid these items.

Cholesterol. Sources of cholesterol include high-fat dairy products and high-fat animal proteins, egg
yolks, liver, and other organ meats. Aim for no more than 200 milligrams (mg) of cholesterol a day.

Sodium. Aim for less than 2,300 mg of sodium a day. However, if you also have hypertension, you
should aim for less than 1,500 mg of sodium a day.

Putting it all together: Creating a plan

A few different approaches to creating a diabetes diet are available to help to keep the blood glucose
level within a normal range. With a dietitian's help, patient may find one or a combination of the
following methods works for them:

The plate method. The American Diabetes Association offers a simple seven-step method of meal
planning. In essence, it focuses on eating more vegetables. When preparing the plate, fill one-half of it
with nonstarchy vegetables, such as spinach, carrots and tomatoes. Fill one-quarter with a protein, such
as tuna or lean pork. Fill the last quarter with a whole-grain item or starchy food. Add a serving of fruit
or dairy and a drink of water or unsweetened tea or coffee.
Counting carbohydrates. Because carbohydrates break down into glucose, they have the greatest
impact on your blood glucose level. To help control blood sugar, eat about the same amount of
carbohydrates each day, at regular intervals, especially if taking diabetes medications or insulin.

The exchange lists system. A dietitian may recommend using food exchange lists to help in planning
meals and snacks. The lists are organized by categories, such as carbohydrates, protein sources and fats.

One serving in a category is called a "choice." A food choice has about the same amount of
carbohydrates, protein, fat and calories — and the same effect on your blood glucose — as a serving of
every other food in that same category.

Glycemic index. Some people who have diabetes use the glycemic index to select foods, especially
carbohydrates. This method ranks carbohydrate-containing foods based on their effect on blood glucose
levels.

IMPORTANCE OF EXERCISE

People with diabetes are encouraged to exercise regularly for better blood sugar control and to reduce
the risk of cardiovascular diseases. The reason for this is that muscles which are working use more
glucose than those that are resting. Muscle movement leads to greater sugar uptake by muscle cells and
lower blood sugar levels.

Aerobic activity at moderate intensity basically means exercising at a level that raises your heart rate
and makes you sweat. This includes a multitude of sports For example;

Fast paced walking

Light jogging

Bike riding 

Rowing

Playing doubles tennis or badminton

Water aerobics

Cutting the grass, cleaning your home and other daily chores such as shopping don't count towards your
150 minutes of weekly exercise as advances in technology have made these activities far less demanding
on the body than for previous generations, who were active naturally more active through work and
manual labor. 

However, the less time you spend sitting down, the better it will be for your health. Sedentary behavior,
such as sitting or lying down for long periods, increases your risk of weight gain and obesity, which in
turn, may also up your risk of chronic diseases such as heart disease and diabetes.

IMPORTANCE OF FOOT CARE

Foot problems are a common complication in people with diabetes. Fortunately, most of these
complications can be prevented with careful foot care. If complications do occur, daily attention will
ensure that they are detected before they become serious. It may take time and effort to build good
foot care habits, but self-care is essential. In fact, when it comes to foot care, the patient is a vital
member of the medical team.

Diabetes And Foot Complications

Diabetes can lead to many different types of foot complications, including athlete's foot (a fungal
infection), calluses, bunions and other foot deformities, or ulcers that can range from a surface wound
to a deep infection.

Poor circulation — Longstanding high blood sugar can damage blood vessels, decreasing blood flow to
the foot. This poor circulation can weaken the skin, contribute to the formation of ulcers, and impair
wound healing. Some bacteria and fungi thrive on high levels of sugar in the bloodstream, and bacterial
and fungal infections can break down the skin and complicate ulcers.

Nerve damage (neuropathy) — Elevated blood glucose levels over time can damage the nerves of the
foot, decreasing a person's ability to notice pain and pressure. Without these sensations, it is easy to
develop callused pressure spots and accidentally injure the skin, soft tissue, bones, and joints. Over time,
bone and joint damage can dramatically alter the shape of the foot. Nerve damage, also called
neuropathy, can also weaken certain foot muscles, further contributing to foot deformities.

Foot Examination

People with type 1 diabetes for at least five years should have their feet examined at least once a year.
People with type 2 diabetes should have their feet examined once per year.

During a foot exam, a health care provider checks for poor circulation, nerve damage, skin changes, and
deformities. Patients should mention any problems they have noticed in their feet. An exam may reveal
decreased or absent reflexes or decreased ability to sense pressure, vibration, pin pricks, and changes in
temperature.

Special devices, including a monofilament or tuning fork, can help determine the extent of nerve
damage. A monofilament is a very thin, flexible thread that is used to determine if a patient can sense
pressure in various areas of the foot. A tuning fork is used to determine if a patient can sense vibration
in various areas, especially the foot and toe joints.

Possible foot problems

Poor circulation — Some simple clues can point to circulatory problems. Poor pulses, cold feet, thin or
blue skin, and lack of hair signal that the feet are not getting enough blood.

Nerve damage — Nerve damage may lead to unusual sensations in the feet and legs, including pain,
burning, numbness, tingling, and fatigue. Patients should describe these symptoms if they occur,
including the timing, if the feet, ankles, or calves are affected, and what measures relieve the symptoms.

Nerve damage may cause no symptoms as the foot and leg slowly lose sensation and become numb.
This can be very dangerous because the person may be unaware that they have improperly fit shoes, a
rock or other irritant in a shoe, or other problems that could cause damage.
Skin changes — Excessive skin dryness, scaling, and cracking may indicate that circulation to the skin is
compromised. Other skin changes may include healed or new ulcers, calluses, and broken skin between
the toes.

Deformities — The structure and appearance of the feet and foot joints can indicate diabetic
complications. Nerve damage can lead to joint and other foot deformities. The toes may have a peculiar
"claw toe" appearance, and the foot arch and other bones may appear collapsed. This destruction of the
bones and joints is called Charcot arthropathy.

WHAT TO DO IF CLIENT IS FOR SURGERY?

Diabetes is associated with increased requirement for surgical procedures and increased postoperative
morbidity and mortality. The stress response to surgery and the resultant hyperglycemia, osmotic
diuresis, and hypoinsulinemia can lead to perioperative ketoacidosis or hyperosmolar syndrome.
Hyperglycemia impairs leukocyte function and wound healing. The management goal is to optimize
metabolic control through close monitoring, adequate fluid and caloric repletion, and judicious use of
insulin.

Patients with diabetes undergo surgical procedures at a higher rate than do nondiabetic people. Major
surgical operations require a period of fasting during which oral antidiabetic medications cannot be
used. The stress of surgery itself results in metabolic perturbations that alter glucose homeostasis, and
persistent hyperglycemia is a risk factor for endothelial dysfunction, postoperative sepsis, impaired
wound healing, and cerebral ischemia. The stress response itself may precipitate diabetic crises (diabetic
ketoacidosis [DKA], hyperglycemic hyperosmolar syndrome [HHS]) during surgery or postoperatively,
with negative prognostic consequences. HHS is a well known postoperative complication following
certain procedures, including cardiac bypass surgery, where it is associated with 42% mortality.

It is therefore imperative that careful attention be paid to the metabolic status of people with diabetes
undergoing surgical procedures. Elective surgery in people with uncontrolled diabetes should preferably
be scheduled after acceptable glycemic control has been achieved. Admission to the hospital 1–2 days
before a scheduled surgery is advisable for such patients. Even emergency surgery should be delayed,
whenever feasible, to allow stabilization of patients in diabetic crises.

The actual treatment recommendations for a given patient should be individualized, based on diabetes
classification, usual diabetes regimen, state of glycemic control, nature and extent of surgical procedure,
and available expertise. Some general rules can be applied, however. Whenever possible, ketoacidosis,
hyperosmolar state, and electrolyte derangements should be searched for and corrected preoperatively,
and the surgery itself should be scheduled early in the day, to avoid protracted fasting.

WHAT TO DO WHEN SICK?

In response to illness, the body boosts levels of stress hormones to help fight infection, but these
hormones can drive up blood glucose levels. Vomiting and diarrhea disrupt normal digestion, which can
slow the absorption of foods and drive down blood glucose levels, sometimes too low if you're using
certain medications. To handle these diabetes control challenges, experts recommend following "sick-
day rules" to ensure blood glucose levels stay safe and put on the road to recovery.
Each person is different, especially when it comes to how the body responds to illness. Some patients
are completely unaffected by sickness, while others are sensitive to a wide variety of illnesses, says
Rachelle Gandica, MD, a pediatric endocrinologist at the Columbia University Medical Center. Plus, each
type of illness can affect a person's blood glucose differently. It's important for insulin users to check
blood glucose every two to three hours when sick. Even non-insulin users should check more often than
usual, says Gandica.

Keep taking medications while sick, though perhaps with some dose adjustments to compensate for
high blood glucose levels or to avoid low blood glucose if can't eat. For insulin users, the "rule of thumb
is to continue taking basal and bolus insulin," says David Dugdale, MD, FACP, professor of medicine at
the University of Washington. For ill people with type 2 diabetes, the insulin recommendations are the
same as for type 1, but figuring out what to do about oral medications may actually be harder, says
Dugdale. "They may take pills that are designed to offset what they eat. There is no formula for that," he
says. "Some of the pills should be adjusted if [people] are sick enough that they can't eat." For example,
sulfonylurea use may need to be reduced because the medication can increase the risk of hypoglycemia.
People with type 2 diabetes using metformin may need to switch to insulin during a serious illness, such
as gastrointestinal flu, because dehydration and the decreased kidney function that may result increase
the risk for a rare complication, lactic acidosis, associated with metformin use.

One of the most serious risks of sickness in people with diabetes is Diabetic Ketoacidosis (DKA), a life-
threatening condition caused by too little insulin in the body in combination with the stress hormones
associated with illness. 

Dehydration is a risk factor for DKA, so it's critical to stay well hydrated while ill. A cup of fluid every
hour should be enough, but keep in mind that vomiting and diarrhea increase the risk for dehydration.
Dugdale recommends carbohydrate-free fluids, such as water, to help keep blood glucose levels from
rising too high.

TRAVELLING
People with both Type 1 and Type 2 diabetes can travel all over the world – diabetes is no
barrier. Make the right preparations and you should be able to minimise any potential problems.

The diet for people with diabetes is the same healthy diet recommended for everyone so you
should be able to choose items from the usual menu while away from home.

Things to check before travelling

Carry diabetes ID and a letter from the doctor, which says you have diabetes and the medication
you need to treat it if you are carrying insulin or an injectable medication.

Take twice the quantity of medical supplies you would normally use for your diabetes. 

Find out where you can get supplies of insulin at your destination, in case of emergency. Contact
your insulin manufacturer before the trip to see if your insulin is supplied in the country you are
travelling to. It's also worth checking that it is sold under the same name. You can get your
prescription sent to your destination by courier. 
Flights often cross time zones. If you treat your diabetes with medication or insulin, it’s
important you check with your diabetes care team. If you need to make any changes to your
regime be mindful that a hot or cold climate may affect how your insulin and blood glucose
monitor work.

Packing for the trip

Split diabetes supplies in separate bags.

If flying make sure have some diabetes supplies in hand lugguage in case bags get lost.

Pack extra snacks in case of delay with journey.

Make sure have all the diabetes medication and equipment packed.

If carrying syringes and insulin on flight take a letter from the doctor.

EXERCISING (TYPES OF EXCERCISES)

Two types of physical activity are most important for managing diabetes: aerobic exercise and strength
training.

Aerobic Exercise

Aerobic exercise helps body use insulin better. It makes the heart and bones strong, relieves stress,
improves blood circulation, and reduces the risk for heart disease by lowering blood glucose and blood
pressure and improving cholesterol levels.

Aiming for 30 minutes of moderate-to-vigorous intensity aerobic exercise at least 5 days a week or a
total of 150 minutes per week. Spread the activity out over at least 3 days during the week and try not
to go more than 2 days in a row without exercising.

If haven't been very active recently, start out with 5 or 10 minutes a day. Then, increase activity sessions
by a few minutes each week.

Some examples of aerobic activities:

Brisk walking (outside or inside on a treadmill)

Bicycling/Stationary cycling indoors

Dancing

Low-impact aerobics

Swimming or water aerobics

Playing tennis

Stair climbing

Jogging/Running

Hiking
Moderate-to-heavy gardening

Strength Training
Strength training (also called resistance training) makes the body more sensitive to insulin and can lower
blood glucose. It helps to maintain and build strong muscles and bones, reducing risk for osteoporosis
and bone fractures.

The more muscle, the more calories are burn – even when the body is at rest.

Preventing muscle loss by strength training is also the key to maintaining an independent lifestyle as you
age.

Below are examples of strength training activities:

Weight machines or free weights at the gym

Using resistance bands

Lifting light weights or objects like canned goods or water bottles at home

Calisthenics or exercises that use your own body weight to work your muscles (examples are pushups,
sit ups, squats, lunges, wall-sits and planks)

Classes that involve strength training

Other activities that build and keep muscle like heavy gardening

ADVISING ON HOW TO QUIT SMOKING AND DRINKING ALCOHOL

Smoking is bad for everyone especially if the patient has diabetes. The nicotine in cigarettes makes the
blood vessels harden and narrow, curbing blood flow around your body.

14 Quit-Smoking Tips

1. Set a quit date. You don't have to quit immediately. If you know it's more realistic for you to kick the
habit after a big event or deadline, make that your quit date.

2. Tell your doctor the date. You'll have built-in support.

3. Make smoking inconvenient. Don't have anything you need to smoke on hand, like ash trays, lighters,
or matches.

4. Breathe deeply when you crave a cigarette. Hold your breath for 10 seconds, and then exhale slowly.

5. Spend time in places where you can't smoke because it's banned, such as a library, theater, or
museum.

6. Hang out with friends who are also working on kicking the habit. Go to places that don't allow smoking.
7. Reach for low-calorie, good-for-you foods instead of smoking. Choose fresh fruit and crisp, crunchy
vegetables.

8. Exercise to ease your stress instead of lighting up.

9. Go decaf. Pass up coffee, soft drinks that have caffeine, and alcohol, as they all can increase the urge to
smoke.

10. Keep your hands too busy for cigarettes. Draw, text, type, or knit, for examples.

11. Hack your habits. If you always had a cigarette on your work break, take a walk, talk to a friend, or do
something else instead.

12. Wrap a cigarette in a sheet of paper and put a rubber band around it. It will be harder to get one. You'll
have time to notice what you're doing and stop.

13. Let your family and friends know you're quitting smoking. Ask for their support. If they smoke, tell them
not to do so around you. If they do, leave.

14. Be good to yourself. Do things that you enjoy. You'll notice that you don't need a cigarette to have fun.

Diabetes and Alcohol Consumption Dos and Don'ts

People with diabetes who drink should follow these alcohol consumption guidelines:

Do not drink more than two drinks of alcohol in a one-day period if you are a man, or one drink if you are a
woman. (Example: one alcoholic drink = 5-ounce glass of wine, 1 1/2-ounce "shot" of liquor or 12-ounce
beer).

Drink alcohol only with food.

Drink slowly.

Avoid "sugary" mixed drinks, sweet wines, or cordials.

Mix liquor with water, club soda, or diet soft drinks.

Always wear a medical alert piece of jewelry that says you have diabetes.

MICROVASCULAR AND MACROVASCULAR COMPLICATIONS OF DIABETES MELLITUS

1. Microvascular complications of diabetes are those long-term complications that affect small blood
vessels. These typically include retinopathy, nephropathy, and neuropathy.

Retinopathy is divided into two main categories: Nonproliferative retinopathy and proliferative
retinopathy.

Nonproliferative retinopathy is the development of microaneurysms, venous loops, retinal

hemorrhages, hard exudates, and soft exudates.

Proliferative retinopathy is the presence of new blood vessels, with or without vitreous hemorrhage. It is
a progression of nonproliferative retinopathy.
Diabetic nephropathy is defined as persistent proteinuria. It can progress to overt nephropathy, which is
characterized by progressive decline in renal function resulting in end-stage renal disease.

Neuropathy is a heterogeneous condition associated with nerve pathology. The condition is classified
according to the nerves affected and includes focal, diffuse, sensory, motor, and autonomic neuropathy.

Macrovascular complications of diabetes are primarily diseases of the coronary arteries, peripheral

arteries, and cerebrovasculature. Early macrovascular disease is associated with atherosclerotic plaque
in the vasculature supplying blood to the heart, brain, limbs, and other organs. Late stages of
macrovascular disease involve complete obstruction of these vessels, which can increase the risks of
myocardial infarction (MI), stroke, claudication, and gangrene. Cardiovascular disease (CVD) is the major
cause of morbidity and mortality in patients with diabetes.

MANAGEMENT OF COMPLICATIONS

A. Management: Microvascular

Retinopathy - Patients with type 1 DM should have an initial dilated and comprehensive eye exam within
5 years of the onset of diabetes. Patients with type 2 DM should have an eye exam shortly after
diagnosis. Patient with either type 1 or type 2 DM should have subsequent eye exams annually,
performed by an ophthalmologist or optometrist knowledgeable and experienced in diagnosing
retinopathy.

Visual loss in nonproliferative diabetic retinopathy occurs primarily through development of macular
edema. When clinically significant macular edema is present, intraviteral anti vascular endothelial
growth factor (VGEF) or focal laser photocoagulation are initial treatment options.

Once retinopathy is established, the best treatment to prevent blindness in those with high-risk and
severe proliferative retinopathy is laser photocoagulation. The Diabetic Retinopathy Study found that a
50% reduction in severe visual loss could be achieved by using photocoagulation to treat eyes with
neovascularization associated with vitreous hemorrhage or neovascularization on or near the optic disc,
and for eyes with proliferative retinopathy or very severe nonproliferative retinopathy. Anti-VGEF
inhibitors can be used as adjunct therapy to prevent photocoagulation for selected cases of diabetic
retinopathy. The Diabetic Retinopathy Clinical Research Network found that 0.5 mg intravitreous
ranibizumab was noninferior to panretinal photocoagulation at 2 years in regards to visual acuity
outcomes. Long-term data, however, are not available. If vitreous hemorrhage occurs and does not
resolve, vitrectomy may restore vision.

Nephropathy - Early nephropathy is associated with microalbuminuria, hypertension, and, possibly,

elevated creatinine. First-line therapy is directed toward controlling hypertension. Generally, ACE
inhibitors are first-line agents. Patients who develop a severe cough, a common side effect of ACE
inhibitors, can be switched to an angiotensin II-receptor blocker. These agents have shown similar
efficacy at decreasing microalbuminuria, lowering blood pressure, and preventing worsening renal
function. Some calcium channel blockers (diltiazem and verapamil) have been shown to decrease
microalbuminuria and may be added to the medications, if necessary. If creatinine increases above 2 or
3 mg/dL, ACE inhibitors should be avoided because overt renal failure can result, which can lead to a
need for dialysis or kidney transplant.
Neuropathy - the Diabetes Control and Complications trial found some improvement in neuropathy with
intensive diabetes control. If this is not successful, further treatment should focus on analgesia. The
most common neuropathy is bilateral distal polyneuropathy. Increasing doses of tricyclic
antidepressants, gabapentin, phenytoin, carbamazepine, and benzodiazepines have been used with
varying degrees of success. Several agents have shown promise for restoring the structural nerve
damage that can cause neuropathy including laminin B2, immunoglobulin FI and FII, nerve growth
factor, insulin, and neurotrophin-3. Gastroparesis is treated with metoclopramide.

B. Management: Macrovascular

Patients with diabetes are at increased risk for the macrovascular complications of CVD. Compared with
a nondiabetic population, patients with diabetes have a two- to four-fold increased risk of CVD, and
more than half of patients with diabetes die from CVD complications. The increased CVD risks include
coronary ischemia, stroke, MI, and angina pectoris. Guidelines from the United States and Europe
consider type 2 DM to be a CVD equivalent, thereby elevating it to the highest category.

Table 3 lists the common CVD risk factors associated with diabetes and recommended therapeutic goals.
Practitioners should note that not all patients with diabetes have an elevated risk of a cardiac event, so
some discretion may be used with the guidelines.

Table 3. Goals for managing CVD risk factors in patients with diabetes.

Risk Factor Goal of Therapy

Hyperlipidemia

  LDL cholesterol, pts with CVD+DM LDL <70 mg/dL

  LDL cholesterol level elevated LDL <70 mg/dL

  Triglyceride level 200-499 mg/dL Non-HDL cholesterol level <130 mg/dL

  HDL cholesterol level <40 mg/dL Raise HDL (no specific goal)

Hypertension BP <140/90 mmHg (ADA, JNC 8)

Prothrombotic state (elevated plasminogen Low-dose aspirin therapy (patients with CVD and
activator inhibitor) other risk factors)

Hyperglycemia  HbA1c <7%

Overweight (BMI 25-29.9 kg/m2) Decrease BMI to healthy weight

Obese (BMI ≥30 kg/m2)

Physical inactivity Exercise prescription depending on patient's

status
 Cigarette smoking Complete cessation

Adverse nutrition Achieve, maintain goals for plasma glucose, lipids,

BP

NURSING CARE MANAGEMENT

The nurse should assess the following for patients with Diabetes Mellitus:

Assess the patient’s history. To determine if there is presence of diabetes, assessment of history of
symptoms related to the diagnosis of diabetes, results of blood glucose monitoring, adherence to
prescribed dietary, pharmacologic, and exercise regimen, the patient’s lifestyle, cultural, psychosocial,
and economic factors, and effects of diabetes on functional status should be performed.

Assess physical condition. Assess the patient’s blood pressure while sitting and standing to detect
orthostatic changes.

Assess the body mass index and visual acuity of the patient.

Perform examination of foot, skin, nervous system and mouth.

Laboratory examinations. HgbA1C, fasting blood glucose, lipid profile, microalbuminuria test, serum
creatinine level, urinalysis, and ECG must be requested and performed.

Nursing Diagnoses

The following are diagnoses observed from a patient with diabetes mellitus.

Risk for unstable blood glucose level related to insulin resistance, impaired insulin secretion, and
destruction of beta cells.

Risk for infection related to delayed healing of open wounds.

Deficient knowledge related to unfamiliarity with information, lack of recall, or misinterpretation.

Risk for disturbed sensory perception related to endogenous chemical alterations.

Impaired skin integrity related to delayed wound healing.

Ineffective peripheral tissue perfusion related to too much glucose in the bloodstream

Planning and Goals

Achievement of goals is necessary to evaluate the effectiveness of the therapy.

Acknowledge factors that lead to unstable blood glucose.

Maintain glucose in satisfactory range.

Verbalize plan for modifying factors to prevent or minimize shifts in glucose levels.
Achieve timely wound healing.

Identify interventions to prevent or reduce Risk for Infection.

Regain or maintain the usual level of cognition.

Homeostasis achieved.

Causative/precipitating factors corrected/controlled.

Complications prevented/minimized.

Disease process/prognosis, self-care needs, and therapeutic regimen understood.

Plan in place to meet needs after discharge.

Nursing Priorities

Restore fluid/electrolyte and acid-base balance.

Correct/reverse metabolic abnormalities.

Identify/assist with management of underlying cause/disease process.

Prevent complications.

Provide information about disease process/prognosis, self-care, and treatment needs.

NURSING INTERVENTIONS

The healthcare team must establish cooperation in implementing the following interventions.

 Educate about home glucose monitoring. Discuss glucose monitoring at home with the patient
according to individual parameters to identify and manage glucose variations.
 Review factors in glucose instability. Review client’s common situations that contribute to
glucose instability because there are multiple factors that can play a role at any time like missing
meals, infection, or other illnesses.
 Encourage client to read labels. The client must choose foods described as having a low
glycemic index, higher fiber, and low-fat content.
 Discuss how client’s antidiabetic medications work. Educate client on the functions of his or
her medications because there are combinations of drugs that work in different ways with different
blood glucose control and side effects.
 Check viability of insulin. Emphasize the importance of checking expiration dates of
medications, inspecting insulin for cloudiness if it is normally clear, and monitoring proper storage
and preparation because these affect insulin absorbability.
 Review type of insulin used. Note the type of insulin to be administered together with the
method of delivery and time of administration. This affects timing of effects and provides clues to
potential timing of glucose instability.
 Check injection sites periodically. Insulin absorption can vary day to day in healthy sites and is
less absorbable in lipohypertrophic tissues.

DRUGS AND INSULIN MANAGEMENT

• Exogenous insulin. In type 1 diabetes, exogenous insulin must be administered for life because the
body loses the ability to produce insulin.
• Insulin in type 2 diabetes. In type 2 diabetes, insulin may be necessary on a long-term basis to control
glucose levels if meal planning and oral agents are ineffective.
• Self-Monitoring Blood Glucose (SMBG). This is the cornerstone of insulin therapy because accurate
monitoring is essential.
• Human insulin. Human insulin preparations have a shorter duration of action because the presence
of animal proteins triggers an immune response that results in the binding of animal insulin.

• Rapid-acting insulin. Rapid-acting insulins produce a more rapid effect that is of shorter duration than
regular insulin.
• Short-acting insulin. Short-acting insulins or regular insulin should be administered 20-30 minutes
before a meal, either alone or in combination with a longer-acting insulin.
• Intermediate-acting insulin. Intermediate-acting insulins or NPH or Lente insulin appear white and
cloudy and should be administered with food around the time of the onset and peak of these
insulins.
• Oral antidiabetic agents may be effective for patients who have type 2 diabetes that cannot be
treated by MNT and exercise alone.
• Oral antidiabetic agents. Oral antidiabetic agents include sulfonylureas, biguanides, alpha-glucosidase
inhibitors, thiazolidinediones, and dipeptidyl-peptidase-4.
ISSUES IN DIABETES CARE AND MANAGEMENT:
Cardiovascular disease and diabetes
• At least 68 percent of people age 65 or older with diabetes die from some form of heart disease; and
16% die of stroke.
• Adults with diabetes are two to four times more likely to die from heart disease than adults without
diabetes.
• The American Heart Association considers diabetes to be one of the seven major controllable risk
factors for cardiovascular disease.
• Individuals with insulin resistance or diabetes in combination with one or more of these risk factors
are at even greater risk of heart disease or stroke. However, by managing their risk factors, patients with
diabetes may avoid or delay the development of heart and blood vessel disease. Your health care
provider will do periodic testing to assess whether you have developed any of these risk factors
associated with cardiovascular disease.

Depression and Diabetes: There is reported prevalence of depression in patients with diabetes mellitus
varies from 8 to 27%, with the severity of mood state correlating with the level of hyperglycemia and the
presence of diabetes complication. Treatment of depression may be complicated by effects of
antidepressive agents on glycemic control. MAOIs can induced hypoglycemia and weight gain, whereas
TCAs can produce hyperglycemia and carbohydrate craving. SSRIs and SNRIs, like MAOIs, may reduce
fasting plasma glucose, but they are easier to use and may also improve dietary and medication
compliance [6].

Barriers to diabetes self-care management: Socio-demographic and cultural barriers such as poor
access to drugs, high cost, patient satisfaction with their medical care, patient provider relationship,
degree of symptoms, unequal distribution of health providers between urban and rural areas have
restricted self-care activities in developing countries. In a study to identify the barriers from the
provider’s perspective in regard to diabetes care factors like affordability by the patient, belief by
providers that medications cannot cure patient condition, no confidence in their own ability to alter
patient behavior were identified. Another study stressed on both patient factors (adherence, attitude,
beliefs, knowledge about diabetes, culture and language capabilities, health literacy, financial resources,
co-morbidities and social support) and clinician related factors (attitude, beliefs and knowledge about
diabetes, effective communication).
Though multiple demographic, socio-economic and social support factors can be considered as positive
contributors in facilitating self-care activities in diabetic patients, role of clinicians in promoting self-care
is vital and has to be emphasized.
Diabetes self-care management and training
Educate in successful self-management of diabetes: self-monitoring of blood glucose; overall diet
concepts and exercise guidelines/techniques; medications; complication prevention, problem-solving,
coping, & motivation. Behavior change goals are individualized to fit lifestyle and clinical
targets/measures. The dynamic nature of diabetes and its impact on multiple aspects of one’s life
requires individuals to make frequent and ongoing self-management decisions.

Knowing your diabetes ABCs will help you manage your blood glucose, blood pressure, and cholesterol.
Stopping smoking if you smoke will also help you manage your diabetes. Working toward your ABC goals
can help lower your chances of having a heart attack, stroke, or other 
A is also for albuminuria. Albuminuria means protein in the urine. A test that measures your urine
microalbumin-to-creatinine ratio can detect kidney disease very early, when it can usually be stopped.
This can prevent dialysis or kidney transplantation later on.

A is for aspirin. Taking low-dose aspirin every day can help prevent heart attacks and strokes. Children
and young adults with no history of heart disease should not take aspirin without a doctor’s order, nor
should some older adults. Check with your doctor before starting daily aspirin.

B is for blood pressure. High blood pressure makes your heart work too hard and can cause damage to
your kidneys and eyes.

C is for cholesterol. Bad cholesterol, or LDL, builds up and clogs your arteries, leading to heart attacks
and strokes.

D is for diabetes education.

Help your doctor help you. The more you know about how food, exercise, and medicines affect your
diabetes control, the better you and your doctor can work together to make any needed changes.

E is for eye exam. Regular eye exams can catch diabetic eye disease early enough to prevent eventual
blindness.

F is for foot care Keep an eye on your feet. If you have nerve disease and can’t feel your feet, your feet
can’t tell you when something is wrong.

G is for glucose (sugar) monitoring. If you know when your blood sugar level is too high or too low, you’ll
know better how to treat it.

H is for staying healthy. For people with diabetes, getting the flu or pneumonia can lead to serious
complications. Avoid them by getting vaccinated.

I is for identifying special medical needs. Complications are complicated. As they occur, your doctor may
need to send you to various specialists. Voicing your health concerns at every visit can help your doctor
spot trouble and get any extra help you need quickly.

21 century drugs in diabetes

There are two different types of diabetes: type 1 diabetes and type 2 diabetes. People with both types
of diabetes need medications to help keep their blood sugar levels normal. The types of drugs that can
treat you depend on the type of diabetes you have. This article gives you information about drugs that
treat both types of diabetes to help give you an idea of the treatment options available to you.

for type 1 diabetes

Insulin Insulin is the most common type of medication used in type 1 diabetes treatment. It’s also used
in type 2 diabetes treatment. It’s given by injection and comes in different types. The type of insulin you
need depends on how severe your insulin depletion is. Options include:

Short-acting insulin

• regular insulin (Humulin and Novolin)

Rapid-acting insulins

• insulin aspart(NovoLog, FlexPen)

• insulin glulisine (Apidra)

• insulin lispro (Humalog)

Intermediate-acting insulin

• insulin isophane (Humulin N, Novolin N)

Long-acting insulins

• insulin degludec (Tresiba)

• insulin detemir (Levemir)

• insulin glargine (Lantus)

• insulin glargine (Toujeo)

Combination insulins

 NovoLog Mix 70/30 (insulin aspart protamine-insulin aspart)

 Humalog Mix 75/25 (insulin lispro protamine-insulin lispro)

 Humalog Mix 50/50 (insulin lispro protamine-insulin lispro)

 Humulin 70/30 (human insulin NPH-human insulin regular)

 Novolin 70/30 (human insulin NPH-human insulin regular)

 Ryzodeg (insulin degludec-insulin aspart)

Amylinomimetic drug Pramlintide (SymlinPen 120, SymlinPen 60) is an amylinomimetic drug. It’s an

injectable drug used before meals. It works by delaying the time your stomach takes to empty itself. It
reduces glucagon secretion after meals. This lowers your blood sugar. It also reduces appetite through a
central mechanism.

for type 2 diabetes

Most medications for type 2 diabetes are oral drugs. However, a few come as injections. Some people
with type 2 diabetes may also need to take insulin.

Alpha-glucosidase inhibitors

These medications help your body break down starchy foods and table sugar. This effect lowers your
blood sugar levels. For the best results, you should take these drugs before meals. These drugs include:

• acarbose (Precose)

• miglitol (Glyset)
Biguanides- Biguanides decrease how much sugar your liver makes. They decrease how much sugar
your intestines absorb, make your body more sensitive to insulin, and help your muscles absorb glucose.
The most common biguanide is metformin (Glucophage, Metformin Hydrochloride ER, Glumetza,
Riomet, Fortamet). Metformin can also be combined with other drugs for type 2 diabetes. It’s an
ingredient in the following medications:

 metformin-alogliptin (Kazano)

 metformin-canagliflozin (Invokamet)

 metformin-dapagliflozin (Xigduo XR)

 metformin-empagliflozin (Synjardy)

 metformin-glipizide

 metformin-glyburide (Glucovance)

 metformin-linagliptin (Jentadueto)

 metformin-pioglitazone (Actoplus)

 metformin-repaglinide (PrandiMet)

 metformin-rosiglitazone (Avandamet)

 metformin-saxagliptin (Kombiglyze XR)

 metformin-sitagliptin (Janumet)

Dopamine agonist

Bromocriptine (Parlodel) is a dopamine agonist. It’s not known exactly how this drug works to treat type
2 diabetes. It may affect rhythms in your body and prevent insulin resistance.

DPP-4 inhibitors DPP-4 inhibitors help the body continue to make insulin. They work by reducing blood
sugar without causing hypoglycemia (low blood sugar). These drugs can also help the pancreas make
more insulin. These drugs include:

• alogliptin (Nesina)

• alogliptin-metformin (Kazano)

• alogliptin-pioglitazone (Oseni)

• linagliptin (Tradjenta)

• linagliptin-empagliflozin (Glyxambi)

• linagliptin-metformin (Jentadueto)

• saxagliptin (Onglyza)

• saxagliptin-metformin (Kombiglyze XR)

• sitagliptin (Januvia)

• sitagliptin-metformin (Janumet and Janumet XR)

• sitagliptin and simvastatin (Juvisync)

Glucagon-like peptides (incretin mimetics) These drugs are similar to the natural hormone called
incretin. They increase B-cell growth and how much insulin your body uses. They decrease your appetite
and how much glucagon your body uses. They also slow stomach emptying. These are all important
actions for people with diabetes. These drugs include:

• albiglutide (Tanzeum)

• dulaglutide (Trulicity)

• exenatide (Byetta)

• exenatide extended-release (Bydureon)

• liraglutide (Victoza)

Meglitinides These medications help your body release insulin. However, in some cases, they may lower
your blood sugar too much. These drugs aren’t for everyone. They include:

• nateglinide (Starlix)

• repaglinide (Prandin)

• repaglinide-metformin (Prandimet)

Sodium glucose transporter (SGLT) 2 inhibitors These drugs work by preventing the kidneys from
holding on to glucose. Instead, your body gets rid of the glucose through your urine. These drugs
include:

• dapagliflozin (Farxiga)

• dapagliflozin-metformin (Xigduo XR)

• canagliflozin (Invokana)

• canagliflozin-metformin (Invokamet)

• empagliflozin (Jardiance)

• empagliflozin-linagliptin (Glyxambi)

• empagliflozin-metformin (Synjardy)

Sulfonylureas These are among the oldest diabetes drugs still used today. They work by stimulating the
pancreas with the help of beta cells. This causes your body to make more insulin. These drugs include:

• glimepiride (Amaryl)

• glimepiride-pioglitazone (Duetact)
• glimeperide-rosiglitazone (Avandaryl)

• gliclazide

• glipizide (Glucotrol)

• glipizide-metformin (Metaglip)

• glyburide (DiaBeta, Glynase, Micronase)

• glyburide-metformin (Glucovance)

• chlorpropamide (Diabinese)

• tolazamide (Tolinase)

• tolbutamide (Orinase, Tol-Tab)

Thiazolidinediones These medications work by decreasing glucose in your liver. They also help your fat
cells use insulin better. These drugs come with an increased risk of heart disease. If your doctor gives
you one of these drugs, they will watch your heart function during treatment. These drugs include:

• rosiglitazone (Avandia)

• rosiglitazone-glimepiride (Avandaryl)

• rosiglitizone-metformin (Amaryl M)

• pioglitazone (Actos)

• pioglitazone-alogliptin (Oseni)

• pioglitazone-glimepiride (Duetact)

• pioglitazone-metformin (Actoplus Met, Actoplus Met XR)

People with type 1 and type 2 diabetes often need to take other medications to treat conditions that are
common with diabetes. These drugs can include:

• aspirin for heart health

• drugs for high cholesterol

• high blood pressure medications

Herbal medicines to treat DM

Cinnamon- Chinese medicine has been using cinnamon for medicinal purposes for hundreds of years. It
has been the subject of numerous studies to determine its effect on blood glucose levels. A 2011 study
has shown that cinnamon, in whole form or extract, helps lower fasting blood glucose levels. More
studies are being done, but cinnamon is showing promise for helping to treat diabetes.
Bitter Melon- Bitter melon is used to treat diabetes-related conditions in countries like Asia, South
America, and others. There is a lot of data on its effectiveness as a treatment for diabetes in animal and
lab studies.

However, there is limited human data on bitter melon. There are not enough clinical studies on human.
The human studies currently available are not of high quality.

Green Tea Green tea contains polyphenols, which are antioxidants.

The main antioxidant in green tea is known as epigallocatechin gallate (EGCG). Laboratory studies have
suggested that EGCG may have numerous health benefits including:

• lower cardiovascular disease risk

• prevention of type 2 diabetes

• improved glucose control

• better insulin activity

Studies on diabetic patients have not shown health benefits. However, green tea is generally considered
safe.

Basil Leaves Nutritionists suggest that incorporating natural source such as basil leaves can alleviate
high blood sugar levels without hurting your health. The leaves of basil are a powerhouse of antioxidants
and various compounds that promote the adequate functioning of cells that release and intact insulin.

Mango Leaves It may seem unbelievable but consuming a tea made with fresh mango leaves can do
wonders for people with diabetes. All you need is 15 mango leaves, boil it for at least 15 minutes and
drink it after straining on an empty stomach. You should drink it at least once in a day to balance sugar
levels the bloodstream.

Bitter Gourd Bitter gourd is a powerhouse of charanthin – a chemical. When you consume it regularly,
bitter gourd helps lower blood glucose. The former increases secretion of pancreatic insulin to combat
its imbalances. Nutritionists recommend bitter gourd to people with any type of diabetes to control
their condition.

Fenugreek Fenugreek is one of the most useful spices that can help maintain type 1 and two diabetes.
Studies have shown that the nutrients found in it such as dietary fiber function to control high levels of
glucose. Moreover, it will allow your blood to absorb sugar properly preventing its buildup in your body
organs.

Indian Gooseberry You can obtain plenty of vitamin C from Indian gooseberry that is an antioxidant. The
fruit possesses numerous health benefits including balancing sugar levels in your bloodstream.
Consuming gooseberry supports pancreas activity and aids in the production of insulin. It could also
become a safe source to lower excess glucose in your body.

Black Plum Nutritionists highly recommend diabetic to incorporate the adequate servings of black plum
into their diet. The fruit contains antioxidants such as ellagic acid, hydrolyzable tannins, and
anthocyanins. Regular consumption of the black plum can benefit people with type 1 and two diabetes
alike.
Curry Leaves Once you learn that curry leaves are potent enough to maintain glucose levels in your
bloodstream, you will add them to your meals regularly. The leaves are said to reduce sugar quantity
obtained from the starch.

Aloe Vera Enriched with phytosterols, aloe vera can have an anti-hyperglycemic effect on the people
with type 2 diabetics. Nutritionists suggest that it is a safe and natural source to alleviate fasting sugar
levels in your blood. Also, you can prepare a mixture of turmeric, bay leaves, and aloe vera, this herbal
medicine is said to control glucose in the blood.

Guava Guava is a powerhouse of fiber, and vitamin C. Studies have proved that both nutrients are
essential when it comes to maintaining sugar levels in the diabetics. The high content of fiber in the fruit
supports metabolism that ultimately leads to better sugar absorption. And the antioxidants will ward off
further factors that contribute to type 1diabetes.

Flax Seeds Munching on some flex seeds can change the condition of your overall well-being. They are
highly beneficial for the diabetics as well. Enriched with antioxidants, regular consumption of the seeds
will reduce insulin sensitivity, due to oxidative stress alleviation in your body. Also, the fiber in the flax
seeds helps absorb fats and sugars alike.

Indian Lilac (Neem) Bitter in taste, neem is beneficial in treating diabetes. Studies have proved that
incorporating Indian lilac can maintain blood sugar levels stimulating insulin activity without hindrance.
Although natural sources do not contain adverse effects, it is still suggested to consult with your
endocrinologist in case constant high glucose content in the bloodstream.

Cloves Cloves are said to be effective in treating insulin resistance. Studies revealed that the spice is a
powerhouse of numerous antioxidants such as quercetin, anthocyanins, and phenol.

Rosemary People with diabetes will be delighted to learn that rosemary doesn’t only add flavors to their
meals but it could help neutralize high glucose levels as well. Regular consumption of the herb is highly
beneficial for gestational and type 1 and two diabetes.

Oregano It may be an essential ingredient for Italian cuisine, but it benefits regarding diabetes are
famous across the world. Oregano could reduce glucose levels in your bloodstream if regularly
consumed in moderation.

Sage Nutritionists suggest that consuming sage along with prescribed medicines for diabetes can
maintain the irregular sugar levels adequately. That is why it remained a part of traditional medicine for
centuries.

Technology advancement
Treatment of diabetes, like most areas of medicine, has changed considerably over the years as a result
of technological advances. From the discovery, purification, and mass production of insulin to the
development of less painful ways to deliver it, the lives of people with diabetes have been improved and
sometimes greatly extended by both diabetes-focused research and broader improvements in medical
care. The management of type 1 diabetes is being advanced by innovations in glucose measurement,
development of an artificial pancreas, and in alternate routes of insulin delivery. Emerging technologies
will allow insulin to be delivered more effectively. In the future, patients with type 1 diabetes will
 receive insulin in optimal quantities (because of more information about blood glucose values) at
optimal times (because of better integration of blood glucose values with appropriate insulin dosages)
by way of optimal routes into the body (because of needle-free routes of administration) in order to
achieve optimal blood glucose control.

Technologies for diabetes management, such as continuous subcutaneous insulin infusion and
continuous glucose monitoring systems, have improved remarkably over the last decades. These
developments are impacting the capacity to achieve recommended hemoglobin levels and assisting in
preventing the development and progression of micro- and macro vascular complications. While
improvements in metabolic control and decreases in risk of severe and moderate hypoglycemia have
been described with use of these technologies, large epidemiological international studies show that
many patients are still unable to meet their glycemic goals, even when these technologies are used. This
editorial will review the impact of technology on glycemic control, hypoglycemia and quality of life in
children and youth with type 1 diabetes. In addition, we need to continue our patient/family education
efforts.

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