DIABETES MELLITUS

Diabetes mellitus is a group of metabolic diseases characterized by elevated levels of glucose in the blood
(hyperglycaemia) resulting from defects in insulin secretion, insulin action, or both.

(American Diabetes Association [ADA]

Insulin, a hormone produced by the pancreas, controls the level of glucose in the blood by regulating the production
and storage of glucose. In the diabetic state, the cells may stop responding to insulin or the pancreas may stop producing
insulin entirely. This leads to hyperglycemia.

Incidence
Diabetes mellitus affects about 17 million people, 5.9 million of whom are undiagnosed. In the United States,
approximately800,000 new cases of diabetes are diagnosed yearly. Diabetes is especially prevalent in the elderly, with up t
50% of people older than 65.

Risk Factors for Diabetes Mellitus

 Family history of diabetes (ie, parents or siblings with diabetes)
 Obesity (ie, ≥20% over desired body weight or BMI ≥27 kg/m2)
 Race/ethnicity (eg, African Americans, Hispanic Americans, Native Americans, Asian Americans, Pacific
Islanders)
 Age ≥45 years
 Previously identified impaired fasting glucose or impaired glucose tolerance
 Hypertension (≥140/90 mm Hg)
 HDL cholesterol level ≤35 mg/dL (0.90 mmol/L) and/or triglyceride level ≥250 mg/dL (2.8 mmol/L)
 History of gestational diabetes or delivery of babies over 9 lbs

Causes
 Our digestive system breaks down whatever food we eat into glucose. This glucose is absorbed by the blood
with the help of a hormone called insulin. Diabetes occurs when the body is not able to produce insulin or is
not able to use it effectively. Here are some of the reasons why this happens.
 Genes
 Genes can be responsible for causing both Type 1 and Type 2 diabetes. Having certain combination of
genes may increase or decrease the risk of diabetes. If your parents were diabetics, you should be extra
careful about your lifestyle.
 Autoimmune destruction of beta cells
 Sometimes, our own immune system may recognise the beta cells that produce insulin as antigens, and
create antibodies to destroy them. Often, diabetes is diagnosed after most of the cells are destroyed and the
patient then needs a daily dose of insulin to survive.
 Lack of physical activity, obesity
 Lack of exercise and obesity can be major causes of Type 2 diabetes. An imbalance between calories
consumed and calories burned renders our body incapable of absorbing insulin properly. Just 30 minutes of
physical activity reduces the chances of you having diabetes by 30 per cent. So, make sure you include
activities like walking and cycling in your daily timetable.
 Ageing
 As a person ages, several parts of his/her body stop functioning at their optimum best. This can lead to
diabetes, along with several other ailments.
 Certain drugs
Certain medicines like nicotinic acid, psychiatric drugs, diuretics, etc. can destroy the beta cells that
produce insulin or disrupt insulin absorption.
 Pancreatic disease or injury
 Since the beta cells are present in the pancreas – any injury or diseases like cancer, pancreatitis, etc. can
stop beta cells from functioning and ultimately lead to diabetes. (Read: How I reversed my diabetes in 3
months)

Classifications
There are several different types of diabetes mellitus; they may differ in cause, clinical course, and treatment. The
major classifications of diabetes are:
 Type 1 diabetes (previously referred to as insulin-dependent diabetes mellitus)
 Type 2 diabetes (previously referred to as non-insulindependent diabetes mellitus)
 Gestational diabetes mellitus
 Diabetes mellitus associated with other conditions or syndromes

PATHOPHYSIOLOGY OF DIABETES

Insulin is secreted by beta cells, which are one of four types of cells in the islets of Langerhans in the pancreas When
a person eats a meal, insulin secretion increases and moves glucose from the blood into muscle, liver, and fat cells.

During fasting periods (between meals and overnight), the pancreas continuously releases a small amount of insulin
(basal insulin); another pancreatic hormone called glucagon (secreted by the alpha cells of the islets of Langerhans) is
released when blood glucose levels decrease and stimulate the liver to release stored gluucose. The insulin and the glucagon
together maintain constant level of glucose in the blood by stimulating the release of glucose from the liver. Initially, the liver
produces glucose through the breakdown of
glycogen (glycogenolysis). After 8 to 12 hours without food, the liver forms glucose from the breakdown of noncarbohydrate
substances, including amino acids (gluconeogenesis).

destruction of the beta cells results in decreased insulin production

unchecked glucose
production by the liver, and fasting hyperglycemia.
+
glucose derived from food cannot be stored in the liver but instead
remains in the bloodstream and contributes to postprandial (after meals) hyperglycemia.

If the concentration of glucose in the blood exceeds the renal threshold for glucose, usually 180 to 200 mg/dL (9.9
to 11.1 mmol/L), the kidneys may not reabsorb all of the filtered glucose; the glucose then appears in the urine
(glucosuria)

When excess glucose is excreted in the urine, it is accompanied

by excessive loss of fluids and electrolytes. This is
called osmotic dieresis

Because insulin normally inhibits glycogenolysis (breakdown of stored glucose) and gluconeogenesis (production
of new glucose from amino acids and other substrates), in people with insulin deficiency, these processes occur in
an unrestrained fashion and contribute further to hyperglycemia.
+
fat breakdown occurs, resulting in an increased production of ketone bodies, which are the by-products of fat
breakdown.
TYPE 2 DIABETES
The two main problems related to insulin in type 2 diabetes are

1. Insulin resistance: Insulin resistance refers to decreased tissue sensitivity to insulin

2. Impaired insulin secretion.

Normally, insulin binds to special receptors on cell surfaces and initiates a

series of reactions involved in glucose metabolism.

In type 2 diabetes, due to resistance, insulin become less effective at stimulating glucose uptake by the tissues and there will
be glucose release by the liver

To overcome insulin resistance and to prevent the buildup of

glucose in the blood, increased amounts of insulin must be secreted
to maintain the glucose level at a normal

If the beta cells cannot keep up with the

increased demand for insulin, the glucose level rises, and type 2
diabetes develops

Despite the impaired insulin secretion that is characteristic of

type 2 diabetes, there is enough insulin present to prevent the
breakdown of fat and the accompanying production of ketone
bodies. Therefore, DKA does not typically occur in type 2 diabetes.

Uncontrolled type 2 diabetes may, however, lead to another acute problem, HHNS

GESTATIONAL DIABETES
Gestational diabetes is any degree of glucose intolerance with its onset during pregnancy.
• Hyperglycemia develops during pregnancy because of the secretion of placental hormones, which causes
insulin resistance.
• Selective screening for diabetes during pregnancy is now being recommended between the 24th and 28th
weeks of gestation: age 25 years or older; age 25 years or younger and obese; family history of diabetes in
first-degree relatives.
• Gestational diabetes occurs in up to 14% of pregnant women and increases their risk for hypertensive
disorders during pregnancy
• After delivery of the infant, blood glucose levels in the woman with gestational diabetes return to normal.
However, many women who have had gestational diabetes develop type 2 diabetes later in life.
CLINICAL MANIFESTATIONS
Clinical manifestations of all types of diabetes include the
• “three Ps”: polyuria, polydipsia, and polyphagia.
• Polyuria (increased urination) and polydipsia (increased thirst) occur as a result of the excess loss of
fluid associated with osmotic diuresis.
• The patient also experiences polyphagia (increased appetite) resulting from the catabolic state
induced by insulin deficiency and the breakdown of proteins and fats.
• fatigue and weakness,
• sudden vision changes,
• Tingling or numbness in hands or feet,
• dry skin, skin lesions
• Wounds that are slow to heal,
• Recurrent infections.
• The onset of type 1 diabetes may also be associated with
 sudden weight loss or nausea, vomiting, or abdominal pains, if DKA has developed.

DIAGNOSTIC EVALUATION

Diabetes is diagnosed using blood tests, and the three tests used for diagnosing diabetes are:
1. A1C test or glycohaemoglobin test
This test is used for diagnosing Type 2 diabetes. It measures a person’s average blood glucose levels over
the past three months.
If a person’s A1C level is below 5.7%, it means that he/she is normal. If it is between 5.7 to 6.4%, it
indicates prediabetes which may lead to diabetes if appropriate measures are not taken. A person is
diagnosed with diabetes if he/she has an A1C level of 5.7% or above.  
2. Fasting Plasma Glucose (FPG) test
The Fasting Plasma Glucose test is the most common test used for diagnosing diabetes. It is performed by
measuring a person’s blood sugar level, after he/she has fasted for at least 8 hours.
If a person has a fasting glucose level of 126 mg/dL or above, he or she has diabetes. It is advised to repeat
the test on another day for confirmation.
3. Oral glucose tolerance test (OGTT)
In an oral glucose tolerance test, a person has to fast for at least 8 hours. After that, he/she has to drink a
glass of water mixed with 75g of glucose.  
If a person’s 2-hour blood glucose-level is between 140 to 199 mg/dL, the person has prediabetes which
could lead to diabetes if appropriate measures are not taken. If the blood glucose-level is above 200 mg/dL,
then the person is diagnosed with diabetes.

MANAGEMENT
If your diabetes can’t be controlled with diet, exercise and weight control, your doctor may recommend anti-
diabetic medications or insulin. Most people who have type 2 diabetes start with an oral medicine. Here are some
of them:

1. MONITORING GLUCOSE LEVELS AND KETONES

Self-monitoring of blood glucose (SMBG)

Blood glucose monitoring is a cornerstone of diabetes management, and self-monitoring of blood glucose
(SMBG) levels by patients has dramatically altered diabetes care. This allows for detection and prevention of
hypoglycemia and hyperglycemia and plays a crucial role in normalizing blood glucose levels. Various SMBG
methods are available. Most involve obtaining a drop of blood from the fingertip, applying the blood to a special
reagent strip, and allowing the blood to stay on the strip for the amount of time specified by the manufacturer
(usually 5 to 30 seconds). The meter gives a digital readout of the blood glucose value.
Some common sources of error include:
• Improper application of blood (eg, drop too small)
• Improper meter cleaning and maintenance (eg.allowing dust or blood to accumulate on the optic window).
• Damage to the reagent strips by heat or humidity; use of outdated strips

For most patients who require insulin, SMBG is recommended two to four times daily (usually before
meals and at bedtime).

Glycosylated Hemoglobin

Glycosylated hemoglobin (referred to as HgbA1C or A1C) is a blood test that reflects average blood
glucose levels over a period of approximately 2 to 3 months (ADA, Tests of Glycemia in Diabetes, 2003). When
blood glucose levels are elevated, glucose molecules attach to hemoglobin in the red blood cell. The longer the
amount of glucose in the blood remains above normal, the more glucose binds to the red blood cell and the higher
the glycosylated hemoglobin level. This complex (the hemoglobin attached to the glucose) is permanent and lasts
for the life of the red blood cell, approximately 120 days. If near-normal blood glucose levels are maintained, with
only occasional increases in blood glucose, the overall value will not be greatly elevated.

Urine Testing for Glucose

Before SMBG methods were available, urine glucose testing was the only way to monitor diabetes on a
daily basis. Today its use is limited to patients who cannot or will not perform SMBG. The advantages of urine
glucose testing are that it is less expensive than SMBG and it is not invasive. The general procedure involves
applying urine to a reagent strip or tablet and matching colors on the strip with a color chart at the end of a
specified period.

Testing for Ketones

Most commonly, patients use a urine dipstick to detect ketonuria. The reagent pad on the strip turns
purplish when ketones are present. (One of the ketone bodies is called acetone, and this term is frequently used
interchangeablywith the term “ketones.”) Other strips are available for measuring both urine glucose and ketones
Large amounts of ketones may depress the color response of the glucose test area.
2. PHARMACOLOGIC THERAPY

Drugs that act on your pancreas 

 Sulfonylureas (acetohexamide,chlorpropamide,tolazamide,tolbutamide, glipizide) lower blood glucose

levels by increasing the release of insulin from the pancreas. These drugs decrease blood sugar rapidly but
may cause abnormally low and dangerous levels of blood sugar (hypoglycaemia) leading to mental
confusion and even coma. 
 Meglitinides (repaglinide, nateglinide) also work on the pancreas to increase insulin secretion. Their effects
depend on the level of glucose. 
 Victoza (lyraglutide), an injectable medicine, helps the pancreas make more insulin after eating a meal. It
improves blood sugar in people with type 2 diabetes when used with a diet and exercise programme. 

Drugs that decrease the amount of glucose released from the liver

 Biguanides (Metformin) decrease glucose production by the liver, decrease the absorption of glucose in the
intestines and improve the body’s resistance to insulin. It also suppresses hunger, which may be beneficial
in diabetics who are overweight.

Drugs that increase the sensitivity (response) of cells to insulin 

 
 Thiazolidinediones (Actos and Avandia) lower blood glucose by increasing the sensitivity of the muscle
and fat cells to insulin. These drugs may be taken with metformin and/or a sulfonylurea. They can cause
mild liver problems but are reversible with discontinuation of the drug.

Drugs that decrease the absorption of carbohydrates from the intestine

Alpha glucosidase is an enzyme in the small intestine which breaks down carbohydrates into
glucose. Acarbose is the drug that inhibits this enzyme. Carbohydrates are not broken down as efficiently and
glucose absorption is delayed, thus preventing high glucose levels after eating in people with diabetes.

Drugs that slow emptying of the stomach

 Exenatide (Byetta) is a substance like gut hormone (GLP-1) that cannot be easily broken down. It slows
stomach emptying, slows the release of glucose from the liver and controls hunger. Administered in the
form of an injection, Byetta also causes weight reduction, thus making it particularly suitable for patients
with type 2 diabetes who are also overweight. 
 DPP-IV inhibitors (Januvia, Onglyza, Tradjenta), inhibit DPP-IV enzyme from breaking down gut
hormone (GLP-1). This allows the hormone already in the blood to circulate longer. They also increase
insulin secretion when blood sugars are high and signal the liver to stop producing excess sugar.

Insulin Injections – Insulin is the backbone of treatment for patients with Type 1 diabetes. Insulin is also
important in Type 2 diabetes when blood glucose levels cannot be controlled by diet, weight loss, exercise and oral
medicines. Different types of insulin are:
1.  Rapid-acting insulin – starts working in about 15 minutes and lasts for 3 to 5 hours. There are 3 types of
rapid-acting insulin: Insulin lispro, Insulin aspart and Insulin glulisine
2.  Short-acting insulin (regular insulin) – starts working in 30 to 60 minutes and lasts 5 to 8 hours.
3.  Intermediate-acting insulin (insulin NPH) – starts working in 1 to 3 hours and lasts 12 to 16 hours.
4.  Long-acting insulin (insulin glargine and insulin detemir) – starts working in about 1 hour and lasts 20
to 26 hours.
5.  Premixed insulin- combination of 2 types of insulin (usually a rapid-acting or short-acting insulin and an
intermediate-acting insulin).

The various methods for administering insulin are:

Pre-filled Insulin Pens – This is similar to an ink cartridge in a fountain pen. An insulin cartridge is held by a
small pen-sized device. The amount of insulin to be injected is dispensed by turning the bottom of the pen until the
required number of units is seen in the dose-viewing window. The tip of the pen consists of a needle that is
disposed off with each injection.

Insulin pump – This is the most recently available advance in insulin delivery. It is composed of a pump reservoir
similar to that of an insulin cartridge, a battery-operated pump and a computer chip that allows the user to control
the exact amount of insulin being delivered. The pump is used for continuous insulin delivery. The amount of
insulin is programmed and is administered at a constant rate.

Inhalers – Inhaled form of insulin is not much in use these days. The insulin is packaged in dry packs which are
inserted into an inhalation device. This device allows the insulin to enter a chamber that has a mouth piece.
Through this mouth piece the user can inhale the insulin.

Newer injectable injections - Symlin (pramlintide) is an injectable medication for use in diabetes patients treated
with insulin but unable to achieve adequate sugar control. Amylin is a hormone synthesised by pancreas and helps
control glucose after meals. It is absent or deficient in patients with diabetes. Pramlintide, a synthetic form of
human amylin, when used with insulin, can improve sugar control. Symlin reduces blood sugar peaks after meal,
reduces glucose fluctuations throughout the day and increases the sensation of fullness (leading to weight loss).

3. DIETARY MANAGEMENT OF DIABETES MELLITUS

Diabetes is a major health problem being faced by modern society of today all over the world and India is
predicted to have the most number of people with diabetes mellitus by the year 2025. This disease is the most
common cause of blindness and is responsible for 25 per cent of all new end-stage renal diseases each year. Once
one has developed diabetes, it cannot be cured but fortunately enough, can be managed very well and quality of life
can be improved under 'Wellness program' involving diet, exercise and medicine.
Diabetes is a metabolic disorder characterised by the limited ability or complete inability of the tissue to utilise
carbohydrate (also known as CHO, since it is made up of carbon, hydrogen and oxygen), accompanied by changes
in metabolism of fat, protein, water and electrolytes.
Diabetes May Result From:
 Destruction of beta cells
 Defective synthesis of insulin
 Defective release of insulin by beta cells
 Autoimmune disease
 Cellular insensitivity to insulin

These factors ultimately lead to insulin insufficiency within the cells resulting in inability to utilise glucose as a
source of energy.
Long term effect of metabolic derangement may lead to permanent and irreversible functional and structural
changes in the vascular system of the body characteristically affecting the eye, kidney and nervous system.
Diabetes mellitus is categorised mainly into type I and type II diabetes. Type I diabetes may be due to autoimmune
destruction of pancreatic beta cells in genetically susceptible persons. Environmental factors including viruses,
faulty diet, bacteria and chemicals may be responsible for the cellular destruction. They are insulin dependent,
usually appears in youth or young adults and therefore also known as juvenile diabetes. The symptoms appear
suddenly and the patient needs insulin for control. Type II diabetes is often diagnosed in adults and is known as
maturity onset diabetes (common in Indian population). It is characterised by insulin resistance at the cellular level
as the number of insulin receptors of the cell membrane decreases in both hepatic and muscle tissue, along with the
increase in basal insulin level. There is also gestational diabetes which is transitional but definitely indicates that
the subject is unable to maintain the sugar level under stress of pregnancy and therefore prone to develop diabetes
in later stages of life.
Different types of diabetes may have different etiology and pathophysiology, but whatever the underlying
cause, the resultant effect is high blood sugar level (hyperglycemia) and associated problems. Therefore, dietary
guidelines are similar for all the conditions with specific emphasis on Type I and gestational diabetes where growth
of the young or foetus has to be considered.
The Basic Objective of Meal Planning Is-
 To achieve and maintain healthy and productive life
 To maintain optimal nutrition for adequate growth, development and maintenance.
 To maintain near normal blood sugar level
 To achieve and maintain a desirable body weight
 To provide relief from symptoms
 To prevent, delay or minimise the onset of chronic degenerative complications.
Dietary Management
 Energy requirement should be assessed according to the subject's ideal body weight, current physiological
conditions like pregnancy or growing age etc and degree of physical activity. Special care has to be taken
for growth and for weight control dietary regime. Accordingly, required calorie should be distributed as
CHO - 60 per cent, fat less than 20 per cent and protein can be 15 - 20 per cent of the total energy.
Normally 10 per cent of energy comes from protein. Total fat intake is lowered to 20 per cent as diabetic
patient have higher risk of atherosclerosis.
 If the diabetic person is overweight, shedding those extra kilos by reducing calorie intake can help lower
blood glucose levels.
 Due to lack of insulin, glucose can not enter the cell and therefore, cells are starved of energy. It makes the
person hungry, weak and develop a craving for sugar. Small frequent meals, five- six times will help them
to manage their sugar level. High fiber diet will give satiety as well as work as energy diluents. One can
limit the number of calories per day, without eliminating the favorite foods and therefore easy to continue
for long time.
 Often it is said that a diabetic person should not have sweet fruits with free sugar in it. Fruits are rich in
antioxidants which have therapeutic value for diabetes and if we compare the CHO content of fruits versus
CHO content of bread, we will see that CHO content is much higher in bread than in an equal quantity of
any fruit that are restricted for diabetics. Bread or any such starchy product may not be sweet but they are
digested and absorbed as sugar only. We must remember that diabetics may not have functional insulin but
they do not have any problem with their digestive system which breaks starch to glucose only. Fruit should
be given to diabetics but definitely not in large quantities in one serving or along with other starchy
products so that the total glycemic load is controlled.
 It is often suggested that food with high glycemic index should not be given to the diabetic patient. As
mentioned before, glycemic load is more important than Glycemic Index itself for this diabetic population.
Half a spoon of sugar in tea will increase postprandial sugar level to a much lower level than a bowl of rice.
But definitely if one takes rice instead of equal calorific quantity of sugar, their stomach will be fuller.
 Amounts less than 100g of CHO is not advised as it will lead to ketosis. Beside total amount of CHO, type
of CHO and its distribution between meals is extremely important.
 It is also very common that excessive control of diet, higher dose of hypoglycemic medicine or insulin,
excessive exercise to facilitate blood sugar control, irregular insulin secretion or uncoordinated drug and
food intake may result in more dangerous effect of occasional hypoglycemia (low blood sugar level) in
hyperglycemic diabetic patients. In type I diabetes, dose of insulin is the main reason for hypoglycemic
reaction. When this hypoglycemic effect is taking place at night (nocturnal hypoglycemia) it may get
unnoticed with severe consequences. The patient has to identify the signs and symptoms of this
hypoglycemic phase to be able to handle the blood sugar level. Bedtime snacking is the suggested approach
to prevent nocturnal hypoglycemia.
 Any time when there is a hypoglycemic attack one must immediately give glucose/ sugar water as drink for
faster absorption. If the patient is unable to drink, then one can put sugar powder in the mouth before one
gets medical help. Here one point to remember is that symptoms are similar for both acute hypo and
hyperglycemic patient. If the patient is hyperglycemic, little more sugar will not affect much and can be
controlled later by medicine. But if severely hypoglycemic, little sugar can save the life. Therefore, one
must treat with glucose water to a collapsing diabetic person even though one has a doubt about the specific
condition.
 The patient and the care giver should also be aware of two of the most common types of hyperglycemic
attack as Somoyogi Phenomenon and Dawn Phenomenon.
 Somoyogi Phenomenon: Rebound hyperglycemia after a period of hypoglycemia before meals or during the
night is called Somoyogi Phenomenon. Body adjusts hypoglycemia by releasing Epinephrine,
 Norepinephrine, Cortisol, glucagons etc resulting in Hyperglycemia in the morning. One needs to modify
the insulin dose.
 Dawn Phenomenon: normal nocturnal glycemia, but hyperglycemia is due to increased GH, in the morning.
No modification of dose of the insulin is needed. In such case, snacks may be taken little late to cover the
night period.
 Chromium and Zinc are the two most important elements for the diabetic person. Sufficient Chromium is
present in raw onion, broccoli, tomato, and lettuce. Many foods contain some amounts of zinc and whole
grains are a better source of zinc than refined grains. On the other hand, the zinc from meat is four times
more bio-available than in grain foods.

It has been found that increasing intake of vitamins such as Vitamin C, E and B6 and minerals such as
magnesium can increase zinc absorption in the body.

4. EXERCISE

People with diabetes should exercise at the same time (preferably when blood glucose levels are at their
peak) and in the same amount each day. Regular daily exercise, rather than sporadic exercise, should be
encouraged. Exercise recommendations must be altered as necessary for patients with diabetic complications such
as retinopathy, autonomic neuropathy, sensorimotor neuropathy, and cardiovascular disease. Increased blood
pressure associated with exercise may aggravate diabetic retinopathy and increase the risk of a hemorrhage into the
vitreous or retina. Patients with ischemic heart disease risk triggering angina or a myocardial infarction, which may
be silent. Avoiding trauma to the lower extremities is especially important in the patient with numbness related to
neuropathy. In general, a slow, gradual increase in the exercise period is encouraged. For many patients, walking is
a safe and beneficial form of exercise that requires no special equipment and can be performed anywhere.

Benefits of Exercise
Exercise is extremely important in managing diabetes because of its effects on lowering blood glucose and
reducing cardiovascular risk factors. Exercise lowers the blood glucose level by increasing the uptake of glucose by
body muscles and by improving insulin utilization. It also improves circulation and muscle tone.

5. EDUCATION

1. Tell patient what diabetes is and what it will do in the body and its complications
2. Educate about Risk factors for type 2 diabetes/prediabetes include:
 High Body Mass Index (BMI)
 Little or no physical activity
 Family history of diabetes
 Race/ethnicity (African American, Hispanic/Latino, American Indian, Asian, Pacific Islander)
3. Prediabetes

Prediabetes means your blood glucose is higher than normal but lower than the diabetes range. It
also means you’re at risk for type 2 diabetes; however, you can reduce your risk of getting diabetes and even return
to normal blood glucose levels with modest weight loss and moderate physical activity.
4. Diagnosing DM
Some signs of diabetes include being very thirsty or hungry, feeling very tired, blurry vision,
tingling in the hands or feet, and sores that are slow to heal.
5. How to prevent diabetes?
 Maintain a healthy weight. Lose weight if your BMI is greater than 25.
 Exercise regularly. Go with friends, take a dance class, relax with yoga… Find something
you like so you’ll stick with it. Recent studies show that upping your lean muscle mass may
lower your odds of developing prediabetes.
 Choose lean and low-fat foods.
o Eat unprocessed, high-fiber foods like whole grains, fruits and veggies.
o Bake, broil or grill lean meats.
o Use fat-free or low-fat milk and yogurt.
o Eat as little added sugar as possible each day.
 o Use less fat and/or oil when cooking and baking.
 Eat healthy, moderate amounts.
o Watch your portion sizes, especially when eating out.
o Make your meals last at least 20 minutes.
o Add satisfying, protein-rich foods to all meals and snacks.
o Divide your plate in half and fill one side with veggies.

PROGNOSIS/COMPLICATIONS

Diabetes, if uncontrolled can lead to deadly complications.  

1. Effect on fat and metabolism (Diabetic ketoacidosis): Since the hormone insulin which breaks down glucose is
lacking, in uncontrolled cases, the body starts using fat as the fuel source. While you might think it’s not such a bad
idea to lose some fat, what this leads to is build up of by-products of fat digestion called ‘ketones’. If you’re not
taking your insulin doses regularly, have fever/diarrhoea/vomiting and/or going through a lot of stress or are an
alcoholic, you need to be extra careful about developing this condition called ‘ketoacidosis’.  If you develop
symptoms like deep gasping breathing, acute pain in the abdomen, bad dehydration leading to weakness and
fainting, vomiting, it’s time you take it seriously and contact your doctor. 

2. Effect on the eyes (Diabetic retinopathy): Retina (the innermost layer of your eye) is affected by ineffective
blood glucose control. The small blood vessels in the retina are damaged and weakened. The early symptom of eye
problems related to diabetes is blurred vision and double vision. It can also cause a severe, permanent loss of
vision. Diabetes increases the risk of developing cataracts and glaucoma. (Read: Diabetic Retinopathy: All you
need to know)

3.  Effect on kidneys (Diabetic nephropathy): If you notice swelling in your feet and legs or around your eyes,
your kidneys might get affected because of the uncontrolled blood sugar levels. If you have hypertension (or high
BP), your chances of developing this is even higher.

4. Effect on nerves: Some of the nerves, especially around your peripheries like legs might get affected first
leading to a loss of sensation. You might not be able to figure out if you’ve had an injury and it may end up getting
infected. Diabetic gangrene (infection of the leg, leading to decay of flesh) can occur and the leg may have to be
amputated. Uncontrolled diabetes can also affect nerves that control your heartbeat, blood pressure, digestion,
blood flow to organs etc leading to diarrhoea, erectile dysfunction, loss of bladder control, vision changes, and
dizziness.

5. Effect on heart: If you are a smoker, have high blood pressure, are grossly overweight and/or have a family
history of diabetes and are diagnosed with diabetes, you have a greater risk of developing heart disease, strokes.
 NURSING MANAGEMENT
Nursing Priorities
1. Restore fluid/electrolyte and acid-base balance.
2. Correct/reverse metabolic abnormalities.
3. Identify/assist with management of underlying cause/disease process.
4. Prevent complications.
5. Provide information about disease process/prognosis, self-care, and treatment needs.

Risk for Infection

Nursing Diagnosis:  Risk for Infection
Risk factors may include:
 High glucose levels, decreased leukocyte function, alterations in circulation
 Preexisting respiratory infection, or UTI
Desired Outcomes:
 Identify interventions to prevent/reduce risk of infection.
 Demonstrate techniques, lifestyle changes to prevent development of infection.
Nursing Interventions

1. Observe for signs of infection and inflammation, e.g., fever, flushed appearance, wound drainage, purulent
sputum, cloudy urine.

2. Promote good handwashing by staff and patient.

3. Maintain aseptic technique for IV insertion procedure, administration of medications, and providing
maintenance/site care. Rotate IV sites as indicated.

4. Provide catheter/perineal care. Teach the female patient to clean from front to back after elimination

5. Provide conscientious skin care; gently massage bony areas. Keep the skin dry, linens dry and wrinkle-free.

6. Auscultate breath sounds.

7. Place in semi-Fowler’s position.

8. Reposition and encourage coughing/deep breathing if patient is alert and cooperative. Otherwise, suction
airway, using sterile technique, as needed.

9. Provide tissues and trash bag in a convenient location for sputum and other secretions. Instruct patient in
proper handling of secretions.

10. Encourage/assist with oral hygiene.

11. Encourage adequate dietary and fluid intake (approximately3000 mL/day if not contraindicated by cardiac or
renal dysfunction), including 8 oz of cranberry juice per day as appropriate.

12. Administer antibiotics as appropriate.

Risk for Disturbed Sensory Perception

Nursing Diagnosis: Sensory Perception, risk for disturbed (specify)
Risk factors may include
 Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance
Desired Outcomes
 Maintain usual level of mentation.
 Recognize and compensate for existing sensory impairments.
Nursing Interventions

1. Monitor vital signs and mental status.

2. Address patient by name; reorient as needed to place, person, and time. Give short explanations, speaking
slowly and enunciating clearly.

3. Schedule nursing time to provide for uninterrupted rest periods.

4. Keep patient’s routine as consistent as possible. Encourage participation in activities of daily living (ADLs)
as able.

5. Protect patient from injury (avoid/limit use of restraints as able) when level of consciousness is impaired.
Place bed in low position. Pad bed rails and provide soft airway if patient is prone to seizures.

6. Evaluate visual acuity as indicated.

7. Investigate reports of hyperesthesia, pain, or sensory loss in the feet/legs. Look for ulcers, reddened areas,
pressure points, loss of pedal pulses.

8. Provide bed cradle. Keep hands/feet warm, avoiding exposure to cool drafts/hot water or use of heating pad.

9. Assist with ambulation/position changes.

10. Monitor laboratory values, e.g., blood glucose, serum osmolality, Hb/Hct, BUN/Cr.

11. Carry out prescribed regimen for correcting DKA as indicated.

Powerlessness
Nursing Diagnosis: Powerlessness
May be related to
 Long-term/progressive illness that is not curable
 Dependence on others
Possibly evidenced by
 Reluctance to express true feelings; expressions of having no control/influence over situation
 Apathy, withdrawal, anger
 Does not monitor progress, nonparticipation in care/decision making
 Depression over physical deterioration/complications despite patient cooperation with regimen
Desired Outcomes: 
 Acknowledge feelings of helplessness.
 Identify healthy ways to deal with feelings.
 Assist in planning own care and independently take responsibility for self-care activities.
Nursing Interventions

1. Encourage patient/SO to express feelings about hospitalization and disease in general.

2. Acknowledge normality of feelings.

3. Assess how patient has handled problems in the past. Identify locus of control.

4. Provide opportunity for SO to express concerns and discuss ways in which he or she can be helpful
to patient.

5. Ascertain expectations/goals of patient and SO.

6. Determine whether a change in relationship with SO has occurred.

7. Encourage patient to make decisions related to care, e.g., ambulation, time for activities, and so
forth.

8. Support participation in self-care and give positive feedback for efforts.

Imbalanced Nutrition Less Than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements
May be related to:
 Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased
protein/fat metabolism)
 Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness
 Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone),
infectious process
Possibly evidenced by:
 Increased urinary output, dilute urine
 Reported inadequate food intake, lack of interest in food
 Recent weight loss; weakness, fatigue, poor muscle tone
 Diarrhea
 Increased ketones (end product of fat metabolism)
Desired Outcomes: 
 Ingest appropriate amounts of calories/nutrients.
 Display usual energy level.
 Demonstrate stabilized weight or gain toward usual/desired range with normal laboratory values.
Nursing Interventions

1. Weigh daily or as indicated.

2. Ascertain patient’s dietary program and usual pattern; compare with recent intake.

3. Auscultate bowel sounds. Note reports of abdominal pain/bloating, nausea, vomiting of undigested food.
Maintain nothing by mouth (NPO) status as indicated.

4. Provide liquids containing nutrients and electrolytes as soon as patient can tolerate oral fluids; progress to
more solid food as tolerated.

5. Identify food preferences, including ethnic/cultural needs.

6. Include SO in meal planning as indicated.

7. Observe for signs of hypoglycemia, e.g., changes in level of consciousness, cool/clammy skin, rapid pulse,
hunger, irritability, anxiety, headache, lightheadedness, shakiness.

8. Perform fingerstick glucose testing.

9. Administer regular insulin by intermittent or continuous IV method, e.g., IV bolus followed by a

continuous drip via pump of approximately 5–10 U/hr so that glucose is reduced by 50 mg/dL/hr.

10. Administer glucose solutions, e.g., dextrose and half-normal saline.

11. Provide diet of approximately 60% carbohydrates, 20% proteins, 20% fats in designated number of
meals/snacks.

12. Administer other medications as indicated, e.g., metoclopramide (Reglan); tetracycline.

Deficient Fluid Volume

Nursing Diagnosis: Deficient Fluid Volume
May be related to
 Osmotic diuresis (from hyperglycemia)
 Excessive gastric losses: diarrhea, vomiting
 Restricted intake: nausea, confusion
Possibly evidenced by:
 Increased urinary output, dilute urine
 Weakness; thirst; sudden weight loss
 Dry skin/mucous membranes, poor skin turgor
 Hypotension, tachycardia, delayed capillary refill
Desired Outcomes:
 Demonstrate adequate hydration as evidenced by stable vital signs, palpable peripheral pulses, good
skin turgor and capillary refill, individually appropriate urinary output, and electrolyte levels within normal
range.
Nursing Interventions

1. Obtain history from patient/SO related to duration/intensity of symptoms such as vomiting, excessive
urination.

2. Monitor vital signs:

3. Note orthostatic BP changes;
4. Respiratory pattern, e.g., Kussmaul’s respirations, acetone breath;
5. Respiratory rate and quality; use of accessory muscles, periods of apnea, and appearance of cyanosis;
6. Temperature, skin color/moisture.

7. Assess peripheral pulses, capillary refill, skin turgor, and mucous membranes.

8. Monitor I&O; note urine specific gravity.

9. Weigh daily.

10. Maintain fluid intake of at least 2500 mL/day within cardiac tolerance when oral intake is resumed.

11. Promote comfortable environment. Cover patient with light sheets.

12. Investigate changes in mentation/sensorium.

13. Insert/maintain indwelling urinary catheter.

Fatigue
Nursing Diagnosis:  Fatigue
May be related to
 Decreased metabolic energy production
 Altered body chemistry: insufficient insulin
 Increased energy demands: hypermetabolic state/infection
Possibly evidenced by
 Overwhelming lack of energy, inability to maintain usual routines, decreased performance, accident-
prone
 Impaired ability to concentrate, listlessness, disinterest in surroundings
Desired Outcomes
 Verbalize increase in energy level.
 Display improved ability to participate in desired activities.
Nursing Interventions
1. Discuss with patient the need for activity. Plan schedule with patient and identify activities that lead
to fatigue.

2. Alternate activity with periods of rest/uninterrupted sleep.

3. Monitor pulse, respiratory rate, and BP before/after activity.

4. Discuss ways of conserving energy while bathing, transferring, and so on.

5. Increase patient participation in ADLs as tolerated.