The complications of this disease are costly to the healthcare system. The total cost (direct and indirect) of diabetes in 2007 was $174 billion.2 These estimated costs include medical care, disability, and premature death. As the incidence of diabetes continues, there's growing concern about the morbidity and mortality of this disease. Literature indicates a concern for an increase in diabetes-related complications, which may devastate the healthcare delivery system.2 About a third of people with diabetes are age 65 or older, and diabetes-attributable healthcare expenditures for this age group reached $65 billion in 2007.3 This age group generally uses Medicare as their primary insurance.
Diabetes decreases a person's life expectancy by up to 15 years. Literature reveals that diabetes increases cardiovascular heart disease risk and is the leading cause of kidney failure, lower limb amputations, and adult-onset blindness. It's clear that diabetes is on the rise in the United States. In 2050, it's predicted that the number of people with diabetes will increase to 48.3 million.4 With the tripling of the number of diabetes cases comes an increase in the medical expense of the disease and its comorbidities.
Nurses are educators and, therefore, we must come to the forefront in teaching and stressing weight reduction through diet and exercise, along with smoking cessation and adherence to the medication regime. It's imperative that nurse leaders make a conscious effort to educate patients, family members, and the community as a whole about lifestyle changes to prevent diabetes and its complications. Good glycemic control is an important factor in reducing the burden on the healthcare system.
According to the CDC, diabetes is an endocrine disease in which the body has either a shortage of insulin or a decreased ability to use insulin, or both.2 Insulin is a hormone that allows glucose to enter cells and be converted to energy. Diabetes is a chronic metabolic disease associated with major morbidity and mortality characterized by the body's elevated blood glucose levels.5 When diabetes isn't controlled, glucose and fats remain in the blood and, over time, damage vital organs.
Diabetes can be categorized as type 1, type 2, gestational diabetes, or pre-diabetes. Type 1 diabetes accounts for 5% to 10% of all diagnosed cases; type 2 accounts for 90% to 95%.3 Additionally, there are other types of diabetes that result from specific genetic conditions (such as maturity-onset diabetes of youth), surgery, medications, infections, pancreatic disease, and other illnesses. Other types of diabetes account for less than 5% of all diagnosed cases.4
The pathophysiology of type 1 diabetes results from a lack of insulin production, causing the autoimmune destruction of pancreatic beta cells. These patients rely on insulin supplementation for survival.5 On the other hand, in type 2 diabetes, insulin is either produced, but not in sufficient quantities, or the body isn't able to process the insulin that's produced and use it properly.
Gestational diabetes only applies to women in whom glucose intolerance develops or is first discovered during pregnancy. Hyperglycemia during pregnancy can be harmful to the fetus.6 Gestational diabetes develops in 2% to 5% of all pregnant women, but disappears after delivery. It's found to be more prevalent in women with a family history of diabetes. Obesity is also a risk factor, which makes these women prone to developing diabetes later in life if proper treatment isn't received.7
Data indicate that approximately one half of persons diagnosed with diabetes already have complications when diagnosed. This means that it's imperative for people who may develop diabetes to be identified as early as possible. Pre-diabetes includes persons with an impaired fasting blood glucose level of 100 to 125 mg/dL, an elevated HbA1c of 5.7 to 6.4, or a 2-hour impaired glucose tolerance of 140 to 199 mg/dL.8 Prediabetes is defined when the blood glucose level is higher than normal, but not increased enough to be classified as type 2 diabetes. It's estimated that in 2010, 79 million adults in the United States were diagnosed with prediabetes. However, if interventions don't occur, prediabetes will result in type 2 diabetes in 10 years or less. Damage to the heart and circulatory system may begin in the prediabetes phase. Healthy lifestyle changes, such as physical activity, maintenance of a healthy weight, and eating healthy foods may result in a return to normal blood glucose levels.9
The clinical presentation of a patient with diabetes is easily recognizable. These patients present with a history of increased thirst (polydipsia), frequent urination (polyuria), weight loss, extreme fatigue, blurred vision, slow healing of wounds, and increased infections.10
Diabetes is diagnosed using a fasting blood glucose sample if the patient presents with the common signs and symptoms; otherwise, two separate glucose readings are needed for diagnosis.5,10
The risk factors
There are a number of risk factors that increase a person's tendency toward developing diabetes. Genetic or family history, age, gender, and race are considered to be nonmodifiable risk factors. Modifiable risk factors include obesity, physical inactivity, poor dietary habits, hypertension, smoking, and alcohol use. Lower socioeconomic levels, depression, and increased stress are also considered risk factors.5,10
The mortality and morbidity from this condition is astounding. Those with diabetes have twice as much risk of death as people of the same age who don't have diabetes.5 Patients who are diagnosed at a younger age have an increased risk of premature death than those of the same age without the disease.
The treatment plan
Managing diabetes can be challenging, despite the research and clinical trials that continue in the United States. The major goal of the treatment plan is to reduce elevation of blood glucose levels. Type 2 diabetes is treated first through lifestyle changes, such as weight reduction, a change in dietary intake, and exercise.11 If adhering to the recommended diet and exercise fails to reduce blood glucose levels, then medications may be prescribed.
Eating healthy is critical in controlling elevated blood glucose levels in patients with diabetes. Guidelines for appropriate dietary intake have been provided by the American Diabetes Association, which consist of a balanced, nutritious diet that's low in cholesterol, simple sugar, and fat. Daily calories are divided into three meals. It's important that patients with diabetes eat three meals a day and also include snacks between meals, especially if they're taking medications to control their blood glucose levels.7,12 Patients should be taught to avoid drinks with sugar, such as colas, but may consume diet soft drinks. Fruit juices should be limited because they can cause blood glucose to rise quickly.
It's very important for patients diagnosed with diabetes to exercise regularly to reduce weight. This is a critical treatment for diabetes because exercise increases the body's sensitivity to insulin, resulting in better control of blood glucose elevation. Patients with type 2 diabetes should be encouraged to maintain or regain an acceptable body mass index.8,13
The first medication recommended for type 2 diabetes is metformin because its action decreases glucose production by the liver and increases the body's sensitivity to insulin.8 If metformin fails, another recommendation is to add a sulfonylurea such as glipizide. These medications increase the amount of insulin that's produced by the beta cells of the pancreas. When patients are prescribed a sulfonylurea, it's important that they're instructed about potential adverse reactions, including hypoglycemia, weight gain, and nausea. The next medication recommended if blood glucose remains uncontrolled is adding a thiazolidinedione, such as pioglitazone, which works to increase insulin production.14
Newer therapies such as dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 analogs may also be prescribed. These classes of drugs assist in the natural production of insulin when blood glucose levels are elevated, while at the same time reducing blood glucose without the risk of hypoglycemia.15 As clinical researchers continue to study medications and their effects on blood glucose levels, newer drugs may be implemented in clinical trials.
Patients with diabetes are at high risk for developing cardiovascular disease. (See Complications of diabetes.) In fact, they have up to a five-fold increase in the development of heart disease as those without diabetes.10 Stroke and ischemic heart disease have the greatest morbidity from diabetes. Increased glucose levels help contribute to atherosclerosis and increase the likelihood of macro cardiovascular events in these patients.16 Controlling hypertension, proper diet and exercise, and smoking cessation play a modifiable role in the prevention of cardiovascular disease.
Another complication of diabetes is diabetic neuropathy, which occurs when there's an increased glucose level resulting in nerve damage. Patients with diabetic neuropathy are prone to leg ulcers, which may lead to subsequent lower leg amputations.3,16 This complication is frequently asymptomatic; patients should be screened at every visit for any loss of sensation in their hands and feet.16
Retinopathy is a very common microvascular complication associated with diabetes, and is the cause of 10,000 new cases of blindness annually.4,5 It develops slowly over time with elevated glucose levels. When the blood vessels of the eye are exposed to prolonged elevated blood glucose levels, obstruction of blood flow results, which causes ischemic areas in the eye. These ischemic areas induce proliferation of new capillaries that are fragile and can hemorrhage. This entire process can cause vision loss and other eye complications.4,16 Patients with diabetes should have yearly eye exams to detect retinopathy and prevent any further complications.
Over time, prolonged exposure to elevated blood glucose levels in the body causes proteinuria, hypertension, and renal failure.4,16 The regulation of blood flow through the glomerulus of the kidney is lost, causing excessive perfusion and filtration, which results in microalbuminuria. Evidence-based guidelines suggest that patients with diabetes should be placed on an angiotensin-converting enzyme inhibitor for kidney protection, suggesting that perhaps angiotensin II plays into this complication of diabetes.3,4
Peripheral arterial disease
Peripheral arterial disease (PAD) is another complication of diabetes that occurs because of narrowing of the blood vessels. PAD manifests itself by presenting with intermittent pain, aches, or discomfort when walking or exercising, but disappears with rest. Because of the decreased blood flow with PAD, the risk of lower leg amputations increases.3,4
Lower leg amputations
Lower leg amputations are one of the most devastating complications of diabetes, affecting about 15% of patients with diabetes. These amputations tend to occur in patients of increasing age and those with peripheral neuropathy or chronic leg ulcers.4,5 It's the responsibility of healthcare professionals who care for patients with diabetes to help them reduce the most significant risk factors.
Nurse educators, as one of the many gatekeepers of care coordination, must continue to infiltrate the nursing curriculum with patient/family teaching. Teaching shouldn't only take place in the classroom and at the bedside. Nurse educators and nurse leaders must also take an active role by educating communities using a variety of mechanisms, such as mobile clinics, standing clinics, health fairs, schools, and places of worship. Nursing has a large community influence and can unite forces to educate the public, as well as businesses. This can result in knowledge of preventive strategies and early treatment of diabetes to decrease type II diabetes and recidivism. (See Table 2.)
Education = prevention
Affecting all age groups and all aspects of a person's life, diabetes is a major public health issue worldwide, requiring lifelong behavioral and lifestyle changes and support. In the United States, diabetes is the leading cause of new cases of blindness, end-stage renal disease requiring dialysis or transplantation, and foot and leg amputations. If current trends continue, one out of three American adults will have diabetes by 2050. Thus, it's critical that patients receive appropriate education about diabetes and its management using a multidisciplinary approach. With proper lifestyle changes, type 2 diabetes can be prevented.
Complications of diabetes
* Cardiovascular disease
* Renal disease
* Peripheral neuropathy
* Lower leg amputations
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15. National Institute for Clinical Excellence. Diagnosis and management of type 1 diabetes in children, young people and adults. http://www.nice.org.uk/CG15
© 2012 by Lippincott Williams & Wilkins, Inc.
16. Casey G. The glucose disease—understanding type 2 diabetes mellitus. Nurs NZ