World Diabetes Day 2023

• November 14th is World Diabetes Day, a time to reflect and deepen our understanding of a nurse’s role in patients’ diabetic care. 
• Review the types of diabetes, risk factors that increase the chance of diabetes, the diagnostic process for diabetes, and the common treatment/management strategies. 
• Learn the importance of patient education on foot care, diet, different medications, and other health concerns for diabetic patients of all ages. 

Diabetes mellitus is a global epidemic, with people with it exceeding 366 million. November 14 is world diabetes day. Let’s talk about it.

According to the WHO, 422 million people have diabetes worldwide, and 1.5 million deaths are attributed to it each year. Moreover, according to the CDC, and Centers for Disease Control and Prevention, 1 in 10 people in the US is living with diabetes, which is around 37.3 million Americans. In the US, 1 in 5 people have diabetes, and they don’t know about it. Moreover, of 96 million American adults, more than 1 in 3 have prediabetes.

Diabetes mellitus is a chronic metabolic disorder in which the blood glucose levels remain high. Left untreated for a long time, it can lead to serious damage to the heart, eyes, kidneys, blood vessels, and nerves, leading to complications such as coronary artery disease, peripheral vascular disease, hypertension, retinopathy, renal failure, and neuropathy that can affect the peripheral nerves, resulting in numbness and pain of the hands or feet.

If glycemic control is poor, there is a high risk of infections because the presence of elevated glucose levels in the blood encourages bacterial growth. The combination of peripheral neuropathies with numbness of the extremities, peripheral vascular disease leading to poor tissue perfusion, and the risk for infection makes the diabetic patient prone to feet and leg ulcers that can even lead to amputation. Therefore, preventing and controlling infections is a must in diabetic patients.

What Are The Types of Diabetes?

Broadly, diabetes can be classified into two categories, type I and type II diabetes. Other types include gestational diabetes, or diabetes secondary to other conditions such as pancreatic disease, hormonal disease, insulin resistance, or drug-induced.

Type I Diabetes Mellitus

In type I DM, the beta cells of the pancreas that secrete insulin get destroyed due to an autoimmune reaction, leading to no insulin secretion. Patients with type I diabetes mellitus are lifetime dependent on insulin from external sources to lower blood glucose levels or prevent ketosis.

Therefore, it is also referred to as insulin-dependent diabetes mellitus. Often, it occurs before 20 years and is common in young people. Type I DM can’t be prevented even with a healthy lifestyle. It happens when the beta cells of the pancreas have insulitis, a pancreatic inflammatory response accompanied by beta cell destruction.

Type II Diabetes Mellitus

Type II diabetes mellitus occurs because of relative insulin deficiency accompanied by resistance to the actions of insulin in muscle, fat, and liver cells. Insulin resistance is also accompanied by increased levels of free fatty acids in the blood, reduced glucose transport in muscle cells, elevated hepatic glucose production, and increased breakdown of fat.

Patients with type II DM are not completely dependent on insulin. But sometimes, they have to administer insulin to maintain glycemic control. Furthermore, they have to take medicines that help sensitize the cells resistant to the action of insulin.

What Causes Diabetes Mellitus?

The exact cause of diabetes mellitus is not known, but genetic, autoimmune, viral, environmental, and socioeconomic factors play a role in the development of the disease.

In type I diabetes mellitus, following the environmental stimulus, such as a virus or bacteria, antibodies attack the beta cells of the pancreas and cause insulitis- inflammation and destruction of the beta cells.

The risk factors leading to type II diabetes are:

• Obesity
• Exposure to environmental pollutants
• Low birth weight
• Consuming a diet rich in sugars
• Inactive lifestyle

What Are The Diagnostic Tools For Diabetes Mellitus?

Diabetes mellitus is diagnosed through blood tests, such as:

• FPG or fasting plasma glucose in which the person fasts for 8 hours before measurement. The normal result for fasting plasma glucose is 70 to 105 mg/dL. If the results are greater than 126 mg/dL, it indicates some abnormality.
• Oral glucose tolerance test or OGTT- blood glucose levels are measured after 2 hours of 75g glucose ingestion following fasting of 12 hours. The normal result for OGTT is glucose less than 140 mg/dL. Levels greater than 200 mg/dL indicate abnormality.
• Hemoglobin A1c or HBA1c- is done for diabetics to know about glycated hemoglobin. It gives an insight into plasma glucose levels over 3 to 4 months. A1c is formed when glucose in the blood binds irreversibly to hemoglobin. Since the normal lifespan of red blood cells is 90–120 days, A1c is only eliminated when the red cells are replaced by the new ones. The normal result for HBA1c is 4 to 6%. Results greater than 8% indicate poorly controlled diabetes, less than 7% indicate well-controlled diabetes and an initial diagnosis of diabetes is made when it reaches 6.5%.
• Urinalysis- to check if glucose is present in urine.

The diagnosis of diabetes mellitus is confirmed when fasting plasma glucose is greater than or equal to 126 mg/dL on two occasions or random glucose is greater than or equal to 200 mg/dL along with the classic symptoms of diabetes mellitus such as polyuria, polydipsia, polyphagia, weight loss.

The goal of treatment is to lower and maintain blood glucose levels into the well-controlled range, such as preprandial blood glucose levels of 90– 130 mg/ dL and HbA1c levels of less than 7%.

How Is Diabetes Managed?

To manage diabetes the goal is to keep plasma glucose level under control to prevent the delay of complications. Patients having type I diabetes mellitus need subcutaneous insulin. However, in patients with type II diabetes, oral hypoglycemics may be enough. But sometimes, they also need insulin to keep their blood glucose levels under control.

Moreover, with strict dietary adherence to control blood glucose, obese patients with type 2 DM also need weight reduction. The dietitian selects an appropriate calorie allotment depending on the patient’s age, body size, and activity level. Physical activity can also help play a role in reducing blood glucose levels by increasing cellular sensitivity to insulin, improving tolerance to glucose, and encouraging weight loss.

Pharmacological treatments for diabetes include insulin and oral hypoglycemic drugs. They can be described as:

Insulin– is a protein hormone, and its dose varies for each patient as it is titrated to keep the blood glucose levels up to 80 to 140 mg/dL.

The duration of action of insulin varies according to the type.

• Rapid-acting insulin, such as lispro, glulisine, and aspart, have a duration of action of 3 to 8 hours.
• Short-acting insulin, such as regular insulin, has a duration of action of 6 to 10 hours.
• Intermediate-acting insulin, such as NPH, has a duration of action of 16 to 24 hours.
• Long-acting insulin, such as glargine, detemir, and degludec, have a duration of action of 12 to 42 hours.

Oral hypoglycemic agents include sulfonylureas, alpha-glucosidase inhibitors, biguanides, thiazolidinediones, and incretin mimetics.

The dose for antidiabetic drugs varies from patient to patient, depending on their blood glucose level.

• Sulfonylureas work by stimulating the release of insulin from beta cells of the pancreas.
• Alpha-glucosidase inhibitors- slow carbohydrate breakdown in the small intestine.
• Biguanides decrease hepatic glucose output and enhance peripheral glucose uptake.
• Thiazolidinediones- work by reducing insulin resistance.
• Incretin mimetic agent, Exenatide, mimics glucose-dependent insulin secretion, suppresses elevated glucagon secretion, and delays gastric emptying. It is used to improve glycemic control for type 2 diabetics. The dose for Exenatide is 5 mcg SC bid within 1 hour before meals in the morning and evening.

Role of Nurses in Diabetes Management

As a nurse, your key role is to keep the patient informed about their health status and what’s happening inside their body. Make sure to guide them on what’s good and bad for their health, especially when they have diabetes.

As a nurse, explain to the patient the disease process, the goals of management, and strategies to limit complications. Use simple explanations, answer questions, and provide written information for the patient to refer to between teaching sessions.

Along with general information on the disease process, don’t forget to reinforce collaborative teaching about medications and nutrition. The patient also needs specific information about foot care.

In diabetes, foot care remains an important topic as neuropathies lead to loss of sensation in the foot, and the patient can’t sense the blisters or cuts. Being more prone to infections, diabetic patients need to take a lot of foot care as the infection can become life-threatening.

If left untreated, amputation may be needed. Therefore, emphasize to the patient about taking efficient care of their foot health.

Tell the patient that all cuts, abrasions, and blisters should be washed with an antiseptic solution promptly. If they notice a blister that shows signs of infection, such as warmth, pain, and redness, tell them to inform the healthcare provider readily.

Delaying that can complicate the condition. Teach them to avoid wearing constricting clothing, such as constricting stockings, garters, girdles, or elastic slippers.

If the patient needs to be on bed rest, encourage them to keep bed linens loose over the feet and legs. Furthermore, instruct them to avoid having very hot baths as peripheral neuropathy causes decreased temperature sensation.

They might not recognize if their feet get burnt due to hot water. Therefore, it is good to take a bath with mild warm water, not too hot or cold.

If the patient diagnosed with diabetes is a teenager or a child, their family may be in shock and disbelief. Make sure to talk to them and explain things.

For patients with diabetes, their whole life and outlook is changed. Therefore, they need support and counseling.

School-age children may be impressed with the new “condition” and may be challenged by the new skills it involves. In comparison, adolescents may feel unfairly victimized and respond by becoming depressed, resistant, uncooperative, or insecure. Therefore, you have to spend time healing them mentally.

Introduce the family to other families with the same problem and encourage them to talk. However, if you feel the need, refer them to a professional counselor who can look after their mental health well.

Patients dependent on lifelong insulin therapy need to understand its dosage, route of administration, the purpose of administration, and possible side effects. If the patient is to self-administer insulin, demonstrate to them the appropriate preparation and administration techniques. Make sure they are comfortable and have learned the insulin administration properly.

Inform the patient about the complications of diabetes. To prevent them, they should keep their blood glucose levels well under control.

Otherwise, if plasma glucose levels remain elevated for a long time, it can result in serious consequences, leading to heart attack, vision loss, amputation, and life-threatening infections. Inform them they are at increased risk of infections. Moreover, explain to the patients and their caregivers how the complications of diabetes can be prevented.

The following tips can help:

• Diet- has to be altered according to the plasma glucose levels. Explain calculating the American Diabetic Association exchange list to develop a satisfactory diet within the prescribed calories. Diabetic patients need to adjust their diet during illness, growth periods, stress, and pregnancy. Encourage the patients to avoid intake of alcohol and refined sugars and to distribute nutrients to maintain balanced blood sugar throughout the 24-hour period.
• Insulin– dose needs to be managed according to diet intake. Teach them properly about the type of insulin they receive. Explain its onset of action, duration of action, and peak so they can manage dietary intake according to it. Tell them not to skip or delay meals after insulin administration as it can lead to hypoglycemia. Teaching regarding the proper preparation of insulin, its administration, and the importance of rotating sites is necessary.
• Skin care- routine is an essential thing for diabetic people. Stress over keeping their feet clean, dried, and wearing non-constricting socks. Emphasize wearing shoes all the time. Tell them to inspect their skin and feet, especially for cuts and abrasions, particularly the area between the toes. Encourage them to consult the podiatrist if needed. Loss of sensory abilities in the extremities can put the diabetic patient at risk of injuries. Therefore, direct them to check the water temperature first and then go for a bath.

The Bottom Line

Diabetes is a lifelong condition that needs to be managed well. The patient can continue their daily li­fe activities with medications and insulin. But you have to take more care of the patient as they are at increased risk of infections because of hyperglycemia.

As a nurse, educate the patient about their condition and compel them to attend follow-up visits as diabetes has to be managed lifelong. It can’t be left unattended. Tell them to get their fasting plasma glucose and HBA1c done routinely and get checked by the physician.

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