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This program has been pre-approved by The Commission for Case Manager Certification to provide continuing education credit to CCM® board certified case managers. Nurse practitioners may apply these contact hours to pharmacy continuing education and prescriptive authorization. Summarize the causes of type 2 diabetes and underlying disorders of insulin resistance and beta cell abnormalities. Discuss prevention strategies for type 2 diabetes and characteristics of patients with prediabetes.
Describe the components of a comprehensive plan of care and long-term monitoring for patients with type 2 diabetes.
Identify the most serious complications associated with type 2 diabetes and their effective treatment interventions. Almost all forms of diabetes stem from problems in the body’s production and use of insulin, the hormone that is responsible for keeping blood glucose levels in check. Currently, diabetes is incurable, and it takes daily management to prevent or delay further damage to the body. Type 2 diabetes is one of the two main forms of diabetes mellitus, a disease that has been a problem during all of recorded human history. Even in early times, two different diabetes diseases were distinguished: diabetes insipidus and diabetes mellitus. In the less-common cases in which children, teenagers, or young adults developed diabetes, the disease worsened much more rapidly. By the early 1800s, pancreatic damage was recognized in autopsies of people who died of diabetes, and late in that century German scientists showed that removing the pancreas from a dog would cause diabetes in the animal.
Attempts to extract this substance failed because the pancreas also makes a number of destructive enzymes, the presence of which in the extracts would destroy the key anti-diabetes substance. At the beginning of the twentieth century, diabetes mellitus was considered one disease, although young people who developed the disease died much more quickly than people who first became ill in middle or old age.
People with insulin-sensitive diabetes (who tended to be young and prone to developing ketosis, a build-up of ketone bodies in body tissues and fluids, leading to nausea, vomiting, and stomach pain) easily disposed of an oral dose of glucose after receiving an injection of insulin. Insulin-insensitive diabetes, on the other hand, is generally categorized as type 2 diabetes.
More than 90% of people with diabetes have the type 2 form, previously called insulin-insensitive diabetes, non-insulin-dependent diabetes, type II diabetes, or adult-onset diabetes. The CDC reports that about 1.7 million Americans aged 20 years or older were newly diagnosed with diabetes in 2012.
The CDC estimates that 86 million adults living in the United States have prediabetes, including 51% of those aged 65 years or older (CDC, 2014). Diagnosed and undiagnosed diabetes among people aged 20 years or older, United States, 2012. In the past two decades, type 2 diabetes has been reported among children and adolescents in the United States with an increasing frequency. Children diagnosed with type 2 diabetes are usually between 10–19 years old, obese, and have a strong family history for type 2 diabetes.
Obesity and sedentary lifestyle are key factors driving the dramatic increase of type 2 diabetes in our society.
The increase in prevalence of type 2 diabetes among children and adolescents is a new challenge for healthcare providers and the health system to monitor and manage. People with diabetes have a shorter life expectancy and have twice the risk of dying on any given day as a person of similar age without diabetes (CDC, 2011c). Diabetes is a disease that unbalances the metabolism of carbohydrates, which are sugars and molecules built of sugars.
Glucose is central to a number of chemical reactions in the cells, and it is the most important of the carbohydrates for most mammals. Glucose is an essential molecule, but most tissues of the body can survive when there are low levels of blood glucose.
Excess blood glucose is stored in the liver and muscles as long chains (polysaccharides) called glycogens.
Blood sugar levels are kept low by the liver and muscle cells, which can absorb large amounts of glucose from the circulation. Insulin is a protein molecule made in beta cells that are clustered in islets within the pancreas. Glucose is the main stimulus for insulin secretion, but the pancreas also releases insulin in response to elevated blood levels of amino acids or when signaled by the parasympathetic (vagal) nervous system. After they have been secreted from the pancreas, insulin molecules remain outside cells, and they work by interacting with specific receptors on a cell’s membrane.
When a person has not eaten in many hours, the pancreas secretes about 2 units (0.09 mg) of insulin per hour. The direct causes for type 2 diabetes include insulin resistance and abnormal insulin secretion by pancreatic beta cells.
Some aspects of all these predisposing problems are inherited, and in this way, the propensity for developing type 2 diabetes is inherited.
As with many pathologic processes, insulin resistance develops most readily in people with a genetic predisposition for it. Intra-abdominal fat is strongly associated with insulin resistance—more so than is extra-abdominal (subcutaneous) fat.
Abdominal fat distribution in the body, showing subcutaneous and various types of visceral fat.
Signals within the sympathetic nervous system cause fat cells to break down and release their stored fat. If it had been subcutaneous fat cells that were releasing the excess fatty acids, the newly released insulin would turn off the tap by slowing or stopping the fatty acid release. This sequence can be triggered by anything that causes high blood levels of free fatty acids, glucose, or insulin. In addition to an inherited metabolic tendency to be overweight, eating patterns developed over time are key causes of excess weight gain. Additionally, recent research suggests that insulin resistance may also result from immune system abnormalities, whereby certain immune cells create antibodies that attack fat cells instead of foreign substances. People with type 2 diabetes have insulin resistance; therefore, they often have hyperinsulinemia.
Even before type 2 diabetes develops, beta cell problems can be detected in glucose tolerance tests, which give abnormal test results in prediabetic individuals. In another parallel with insulin resistance, treating type 2 diabetes can improve the functioning of the beta cells, but it cannot bring beta cell functioning up to normal. Metabolic syndrome is the name for a particular group of health problems that are frequently found together. As his medical and family history is taken, George mentions that his mother and uncle were both diagnosed with diabetes after age 50. After discussing the clinical picture with the primary care physician, a lipid panel is ordered. When George returns for his follow-up visit, he reports that he has been following his diet and exercise plan and feels that this has made a difference in how he is feeling.
George continues to be motivated to make changes in order to improve his health and states that he feels better than ever. In the absence of the above risk factors, testing for diabetes should begin at age 45 years. People whose bodies do not handle blood sugar optimally have a condition called prediabetes, which places them at high risk of developing type 2 diabetes (Burant & Young, 2012). In addition to signaling a person’s risk for developing type 2 diabetes, prediabetes warns that the person also has a higher risk for heart disease and stroke. A program of weight loss and increased physical activity can improve the problems underlying prediabetes, and many times, lifestyle changes alone can prevent people with prediabetes from going on to develop diabetes. Recently, a task force of experts issued a set of guidelines for people diagnosed with prediabetes.
Anti-diabetes drug therapy may be considered for patients with prediabetes who are unable to control their blood sugar with weight loss and exercise. The health problems of diabetes are caused directly from hyperglycemia, and the medical diagnosis of the disease is not based on its cause but rather on evidence of persistent high plasma glucose levels, regardless of the cause.
An initial diabetes examination screens for abnormalities and also establishes baseline values that are used to evaluate the treatment program and to follow the progress of the disease objectively. Among the various measurements of the body’s ability to produce and use glucose, the blood level of glucose after an 8-hour fast is the standard.
Measuring a fasting plasma glucose (FPG) is one of the preferred diagnostic tests for diabetes, except in pregnant women. A more complicated test, the oral glucose tolerance test, can also be used to diagnose diabetes and gestational diabetes. The A1C test is also called the A1c, hemoglobin A1c, HbA1c, glycohemoglobin, glycated hemoglobin, and glycosylated hemoglobin test. The overall average blood glucose level for the past two to three months as indicated by various A1C values.
To recognize hypoglycemic periods or short-term shifts in plasma glucose levels, patients should monitor their glucose levels regularly. It is important for healthcare providers to understand A1C values and be able to explain what this level means to a patient who is diagnosed with diabetes.
Sharon is a 46-year-old woman who presents to her primary care clinic complaining of excessive urination over the last two months. LDL particles that are smaller and denser than usual and contain more than the normal amounts of free cholesterol. Baseline liver function tests are important to monitor in the diabetic patient, as most of the medications used to lower blood glucose levels are deactivated in the liver. At one time, diabetes treatment was monitored by measuring the amount of glucose in the urine. In the kidneys, glucose that is initially filtered from the blood is almost fully reabsorbed before the urine is excreted.
By the time measurable sugar appears in the urine, hyperglycemia is already at an unhealthy level. Ketones are released into the blood when fatty acids are being used for energy instead of glucose.
Protein (albumin) leaking into the urine of a person with diabetes usually indicates kidney damage. A patient examination and assessment is a team effort and may include a medical examination, a nursing assessment, as well as input from specialty care providers to rule out and diagnose any comorbid conditions that are related to diabetes. As a basis for creating the patient’s plan of care, the nurse collects information about lifestyle and social history.
An educational needs assessment is also important to consider as healthcare professionals work with the patient on information and education needs.
The physical exam should include an assessment for signs and symptoms of diabetic complications and other problems, such as abdominal obesity or hypertension, that may compound the risks posed by diabetes. As a broad generalization, the excess fat on people with type 2 diabetes tends to be central (in the face, neck, chest, and abdomen) rather than in the arms or legs. Studies have shown that simply measuring a person’s waist circumference gives a good indication of the amount of visceral fat.
Autonomic neuropathy can cause reduced sweating, which may make the patient’s skin (especially on the hands and feet) dry and itchy. Patients with diabetes are at increased risk for coronary artery disease (CAD) and cardiovascular disease (CVD), including an increase in the incidence of myocardial infarction (MI) and stroke.
Diagnostic testing for CAD and CVD should be considered in patients with any atypical cardiac signs or symptoms or an abnormal ECG.
Macrovascular problems lead to poor peripheral vascular circulation in patients with diabetes.
In diabetes, the feet and ankles can suffer from reduced micro- and macrovascular circulation, poor healing, and peripheral neuropathy (damage to the nerves outside of the brain and spinal cord). One common complication after many years of hyperglycemia is autonomic neuropathy, which is damage to the nerves that supply the internal organs, including the heart, stomach, and intestines.
Patients who do not know that they have diabetes may come to an office, clinic, or emergency room with hyperglycemia. Moderate to severe hyperglycemia in a person not previously known to have diabetes may be triggered by another recent medical problem, such as an acute infection or acute cardiac or kidney problems. The nurse continues the assessment by asking the patient about any classic symptoms or complications, such as weakness, fatigue, blurred vision, headache, dizziness, or dehydration. Although the treatment plan for a patient with type 2 diabetes must be tailored to the individual, the usual progression begins with lifestyle interventions. Ideally, patients with diabetes are treated by a multidisciplinary team of healthcare professionals working together.
Registered nurses: Work closely with the primary care provider, patient, family, and other team members to educate and support the patient and family as the plan of care and treatment are initiated. Dietitians: Work closely with the patient and family to assist in educating and supporting dietary recommendations, including any special diets for weight reduction and later maintenance. Ophthalmologists: Provide specialty examinations focused on eye health, including annual fundoscopic, dilated-eye assessment. Podiatrists: Provide regular support and specialty care with assessment, evaluation, and management of foot care, including prevention and treatment strategies. Dentists and registered dental hygienists: Work closely with patient to provide regular cleaning and hygiene, screening exams for gum and tissue changes, and treatment for dental caries.
Psychological counselors: Address and provide support for emotional and psychological impact of a diagnosis of diabetes, including an increased risk for depression and social isolation. Diabetes educators: Provide education, direct care, and self-management interventions for diabetes patients and their families.
Diabetic patients are more likely than most nondiabetic patients to present with a variety of comorbidities.
Diabetes self-management may be coordinated by one or more trained professionals with specialty certification in diabetes. The primary lifestyle changes used to treat type 2 diabetes are weight loss, increased physical activity, smoking cessation, and nutrition management.
The best weight loss results come from structured programs that include individualized counseling, meals with reduced calories and fats, regular physical activity, and frequent contacts with a professional advisor. Even a modest weight loss makes a difference for an overweight or obese person, and losing 5% to 7% of the original weight and keeping the weight off is a realistic goal. The ADA recommends that nutrition therapy for people with type 2 diabetes should be an ongoing process throughout the management of their condition. The ADA further recommends that, even for weight loss, a daily diet should be balanced and moderate. Low-fat, low-carbohydrate, Mediterranean-type, and plant-based diets have been shown to be successful for weight loss.
For overweight or obese patients with type 2 diabetes, dietary fat should be watched carefully.
New England Journal of Medicine found that those with type 1 diabetes can reduce the risk of diabetes eye-related surgeries by up to 50%. What's New: Learn all you need to know about Type 1 Diabetes in our brand new Type 1 Section. A new study found that tightly controlling your glucose levels can decrease the rate of diabetes eye-related complications. A study published in the New England Journal of Medicine found that those with type 1 diabetes can reduce the risk of diabetes eye-related surgeries by up to 50%. Diabetes International Foundation - Pancreatic Islet Transplantation Info  What are pancreatic islets? The pancreas, an organ about the size of a hand, is located behind  the lower  part of  thestomach.
You must score 70% or better on the test and complete the course evaluation to earn a certificate of completion for this CE activity. In the short term, extreme hyperglycemia can lead to life-threatening dehydration and coma. The typical patient with type 2 diabetes is an adult who has had the disease for many years before it worsens sufficiently to cause symptoms prompting healthcare intervention. There were no good treatments for diabetes, although a low-carbohydrate diet slowed the progression of the disease in some obese people who developed the disease late in life. However, diabetes could be prevented in these dogs if a piece of pancreas was sewn under the dog’s skin, and this suggested that the pancreas made a substance that prevented diabetes.
In the early 1920s, the Canadian surgeon Frederick Banting and his assistant Charles Best, a medical student, devised a way to rid the pancreas of most of its destructive enzymes. In contrast, people with insulin-insensitive diabetes (who were usually middle-aged and did not have ketotic episodes) did not significantly reduce their blood glucose levels after receiving the same amount of insulin. In type 1 diabetes, the pancreas produces little or no insulin because the beta cells (the insulin-making endocrine cells in the islets of Langerhans of the pancreas) are not functioning. In type 2 diabetes, the pancreas produces enough insulin to prevent ketone (a chemical produced in the liver when fat is used for energy) formation but, because of insulin resistance, not enough to prevent hyperglycemia.


Both hyperglycemia and higher-than-normal circulating insulin levels (hyperinsulinemia) increase the existing insulin resistance. The National Diabetes Statistics Report for 2014 also reveals higher rates of diabetes among several racial and ethnic minorities compared to the general population (CDC, 2014; CDC, 2011b). People with prediabetes have an increased risk for developing type 2 diabetes, heart disease, and stroke. The epidemic of obesity, the low level of physical activity among young people, and exposure to diabetes in utero may be contributing factors. The prevalence of type 2 diabetes is increasing in children of all ethnic groups, however it is more commonly seen in non-white groups. If this trend continues, 1 in 3 American children born in 2000 faces the probability of developing type 2 diabetes, with increased associated co-morbid conditions and early mortality (Burant & Young, 2012). New strategies for prevention, early detection, and treatment may need to be developed and implemented as this new generation of patients with type 2 diabetes matures.
Additionally, people living with diabetes are three times more likely to be hospitalized than people without the disease. Normally, one of the central sources of metabolic energy is the simple sugar glucose, which is carried throughout the body in the bloodstream and which is stored mainly in the liver and muscles. In addition to being used for energy, glucose molecules are the building blocks of certain structural molecules, glycoproteins and proteoglycans, and of the informational molecules, ribo- and deoxyribonucleic acids (Bender & Mayes, 2006). The brain, however, is quite sensitive to low blood glucose, and it suffers irreversible damage if hypoglycemia lasts more than about half an hour. In a typical American diet, 60% of our carbohydrates are consumed in the form of starches, 30% in the form of sucrose, and 10% in the form of lactose. After a meal, insulin in the bloodstream lowers the amount of circulating glucose by encouraging its storage in the form of glycogen molecules. Insulin is the main signal that tells the liver and the muscles when to remove glucose from the blood.
After a meal, the person’s blood insulin level rises quickly, and in an hour it reaches a peak about 5 times the fasting level. On average, an insulin molecule stays in the bloodstream for less than 10 minutes (Davis, 2008). Some of the problems associated with type 2 diabetes, such as obesity and hypertension, worsen insulin resistance and beta cell dysfunction. Polygenic type 2 diabetes usually occurs in older people, and it develops from a complex mix of genetic predispositions and outside factors. Insulin resistance is a molecular problem in which most tissues do not respond normally to insulin in the bloodstream, whether the insulin has been secreted by the pancreas or has been administered therapeutically. Insulin resistance exists in a person years before the diabetes is diagnosed, and the presence of insulin resistance in an asymptomatic person predicts the high probability of developing type 2 diabetes.
Insulin receptors (which are in the membranes of responding cells) are complex structures made of a number of separate subunits. In predisposed people, certain genes produce poorly functioning insulin receptor subunits or other molecules in the intracellular chain leading from the receptor to the actual glucose utilization machinery. Intra-abdominal fat is visceral fat, and an overabundance of visceral fat cells both triggers and worsens insulin resistance. Insulin gives the opposite message; insulin signals fat cells to slow or stop the release of fat. Visceral fat cells, however, are less sensitive to insulin signals, and the feedback circuit is not very effective.
Aspects of a person’s eating patterns are learned, but other parts are inborn and probably genetic. For example, a fetus who is undernourished in the first two trimesters of pregnancy will have a higher than normal chance of becoming an obese adult.
The action of the antibodies makes the fat cells insulin-resistant and hinders their ability to process fatty acids (Winer et al., 2011). To maintain healthy blood glucose levels, the pancreatic beta cells in a person with insulin resistance are forced to secrete more than the normal amount of insulin.
But even when they have hyperinsulinemia, the blood insulin levels are not high enough to prevent hyperglycemia. As with insulin resistance, beta cell dysfunction precedes the development of overt hyperglycemia by many years (Burant & Young, 2012). At present, both insulin resistance and beta cell dysfunction can be improved but not cured (Burant & Young, 2012). It is also called dysmetabolic syndrome, insulin resistance syndrome, obesity dyslipidemia syndrome, or syndrome X. Three additional problems are high blood pressure, high blood levels of triglycerides, and low blood levels of high-density lipoprotein cholesterol (HDL). A follow-up appointment is scheduled for three months later to assess how the patient is doing with initial management.
He adds that his wife has been very supportive—together they are following a Mediterranean diet for meals and exercising on a regular basis. If results are normal, testing should be repeated at least at three-year intervals; more frequent testing should be considered depending on initial results and risk status (ADA, 2011). The new guidelines prompted the ADA to recommend the same cardiovascular treatment goals for prediabetes as for diabetes.
Research shows that drugs such as metformin (Glucophage) or acarbose (Precose) can delay the onset of type 2 diabetes in people with prediabetes, but not nearly as effectively as lifestyle changes. Patients with diabetes may have frequent testing to assess the effectiveness of the treatment plan and measure changes in various lab values.
In an OGTT, the patient drinks a sugar-water solution (75 g glucose in 300 ml water), and the plasma glucose level is measured after two hours.
This test is used to monitor a patient’s blood glucose levels during treatment and has been adopted by the ADA as a recommended diagnostic test for diabetes (ADA, 2011). The true level of glycemic control (using lifestyle changes and medications to avoid hyper- and hypoglycemia) can be seen best through a combination of A1C tests and daily blood glucose readings (Giroaurd Mertig, 2012; ADA, 2011). Ideally, the same test should be repeated for confirmation, as this can provide a greater likelihood of concurrence.
Overall monitoring of A1C levels is also important as an indicator for patients who are at increased risk for chronic complications of diabetes. This means the cholesterol in type 2 diabetes is more easily added to atherosclerotic plaque. If the liver is not functioning properly or if it later develops problems, the dosages or types of medications may need to be adjusted.
Finger-stick blood glucose measurements are more sensitive and more accurate, and they have replaced urine tests for monitoring daily plasma glucose levels. Nonetheless, urine testing is an easy and quick warning of mild hyperglycemia, and urine tests are sometimes used for screening.
The goal of an initial evaluation is to understand the health of the patient from head to toe.
It is also important to collect baseline information about dietary habits; therefore, an important component is to have patients write down their typical daily diet.
Waist circumference is determined by measuring around the smallest (minimal) circumference anywhere in the waist region (below the ribs and above the top margins of the hip bones). BMI has been shown to be a good indirect indication of the percentage of body fat, and it is the most commonly used measure of total body fat.
Diabetes also can increase the patient’s risk for infections and cause delayed healing.
Regular dental exams and dental hygiene are important in the management of diabetic patients.
Medical management of cardiovascular risk factors is a key component for reducing risk in patients with type 2 diabetes.
Patients may need to undergo additional screening with stress tests or echocardiogram (Burant & Young, 2012).
Vascular exams, including monitoring all the peripheral pulses, provide a baseline for the patient’s circulation (especially in the ankles and feet). The skin on the feet and toes should be assessed regularly for erosions, ulcers, and infections. Peripheral sensory and motor neuropathies injure the longest nerves first and show up in the feet before the hands. The nurse also asks the patient about her family history of diabetes and discovers that her mother has been diagnosed with type 2 diabetes. After discussing the patient’s case with the primary care physician, a full diabetic workup is initiated. A good up-to-date source is the information provided by the American Association of Clinical Endocrinologists (AACE). The many necessary interactions with a patient, especially at the beginning of therapy, should be coordinated based on each patient’s individual needs among the team. Patients with medical complications may be referred to specialty providers, such as ophthalmologists, cardiologists, renal specialists, podiatrists, psychiatrists, and prosthetists. Diabetes educators are specialty educated and licensed and may include registered nurses, registered dietitians, pharmacists, or other specialists.
During pregnancy, weight-loss programs should be terminated, oral hypoglycemic medications are contraindicated, and insulin therapy should be intensified. Weight loss, increased physical activity, and improved diet can all reduce hyperglycemia in a person with type 2 diabetes, while weight loss and exercise are the most effective ways to reduce the insulin resistance that causes type 2 diabetes. Losing weight takes encouragement, monitoring, and practical advice—even for people who are only mildly overweight.
If they succeed in producing A1C values <7%, the lifestyle changes are continued and the patient is seen (and A1C levels are measured) every 3 to 6 months. Patients should be counseled on the medical consequences of smoking and strongly encouraged to stop smoking. It is best to tailor the foods of any diet program to the patient, and it is ideal to have a nutritionist or dietitian as part of the diabetes care team. To achieve weight loss and prevent excess weight gain, a multifaceted approach is needed, including nutrition interventions, physical activity, lifestyle changes, and ongoing support (Warshaw, 2012). Meal replacement (liquid or pre-packaged) diets designed to assist weight loss may also be an option. Intensive or tight glucose management is difficult to obtain and maintain, but the good news even those that decreased their A1c levels by 10%, can reduce the risk of diabetes eye-related surgeries by 35%.
Wild Iris Medical Education, Inc., provides educational activities that are free from bias. Over the long term, hyperglycemia damages capillaries and larger blood vessels by thickening their walls and narrowing their inner diameters. Diabetes was the seventh leading cause of death in the United States in 2010, and studies further suggest that diabetes may be underreported as a cause of death.
Diabetes is thus characterized by polydipsia (prodigious drinking) and polyuria (prodigious urinating). This disease is now known to be caused most often by the insufficient secretion of ADH (anti-diuretic hormone) by the pituitary. The disease came on gradually, with increasing thirst and correspondingly voluminous urination. Muscles weakened, skin infections and pneumonias were common, and people developed gangrene of the lower limbs. From the remaining pancreatic tissue they extracted a hormone that would decrease the amount of sugar in the bloodstream and in the urine of diabetic dogs.
As early as the 1930s, clinicians found that people with diabetes could be divided into two classes according to the way they reacted to an injection of insulin.
Type 1 diabetes occurs most commonly in young people, although it can occur in any age group (ADA, 2014a). A distinguishing feature of type 2 diabetes is that, even when there is a normal amount of circulating insulin, body tissues do not take up glucose as readily as normal. Hyperglycemia also injures the beta cells (the insulin-manufacturing cells) in the pancreas, and this makes it increasingly difficult for the pancreas to lower high levels of blood glucose. Centers for Disease Control and Prevention (CDC, 2014) estimates that over 29 million Americans have diabetes. As these patients enter the adult years, they may have unique health challenges and may be at risk for developing early complications because of the early onset of disease. Glucose is the source of quick energy, and we always need a certain minimum amount of glucose in the bloodstream.
The dependence of the brain on continuous supplies of glucose makes it crucial that the body maintain sufficient blood glucose levels at all times. In the gastrointestinal tract, enzymes break these carbohydrates into monosaccharides (glucose, galactose, fructose), which are the only forms we can absorb. Between meals, liver glycogen is broken down to maintain sufficient glucose in the bloodstream, and the production of glucose from glycogen is encouraged by another pancreatic enzyme, glucagon. The sympathetic nervous system (the fight-or-flight system) is activated in stressful situations when higher blood glucose levels would be useful, such as in hypoglycemia, exercise, hypothermia, and trauma. The insulin receptors also set off a cascade of intracellular events that regulate oxidation of glucose and lipids, storage and release of glucose, transport and metabolism of amino acids, protein synthesis, cell growth, cell differentiation, and even cell death (Davis, 2008).
Likewise, the development of type 2 diabetes from these two underlying problems is hastened by the other disorders found in metabolic syndrome. These monogenic forms usually show up in young people, who then develop the disease no matter their lifestyle. Although diabetes is often thought of as a disease of the pancreas, insulin resistance is a problem in the cells throughout the body that respond to insulin. The malfunctioning or mutation of any of these subunits can make them work inefficiently or make them insensitive to insulin, leading to insulin resistance. Since visceral fat cells are less responsive to insulin, having too many visceral fat cells leads to too much free fatty acid in the bloodstream, and the high level of free fatty acid eventually leads to hyperglycemia.
When visceral fat is the source of excess free fatty acids, the natural balancing mechanisms do not work well, and the hyperinsulinemia persists.
In rare cases, a single gene can cause obesity; in most cases, however, obese people have more than one contributory gene. Normally, a number of proteins, hormones, and neural signals communicate with the hunger and satiety centers in the brain. Together, insulin resistance and poorly functioning beta cells lead to the continual hyperglycemia that characterizes type 2 diabetes. In other words, even when secreting high levels of insulin, their pancreas does not keep up with the demand. Nurses and diabetes educators may be the primary point of contact for discussing the results of laboratory tests as a patient’s progress is tracked. It is important to confirm high FPG values on a second day, because the FPG varies from day to day (ADA, 2011). Red blood cells (and their hemoglobin) are replaced after about four months, and the amount of glycosylated hemoglobin at any one time reflects the average plasma glucose level over the last two to three months. The following graph shows the average plasma glucose levels that are indicated by various A1C values. This has been shown to be a realistic goal and one that will improve the health of a wide variety of people with type 2 diabetes. Also, A1C values will not reflect short swings in plasma glucose levels, as often happens with brittle diabetes (a diabetic condition in which the blood glucose level easily swings from too low to too high and back again).
The nurse reviews the importance of monitoring A1C levels and explains to Sharon that this test gives the best idea of overall glucose control. Patients on insulin therapy who have not taken sufficient insulin have measurable ketones in the urine (Giroaurd Mertig, 2012).
This early sign of diabetic kidney damage can be qualitatively recognized using specialized reagent strips (Micral-Test) or tablets (Micro-Bumintest) (Unger, 2013). A periodic record should be kept of serum creatinine and blood urea nitrogen (BUN) levels, and a glomerular filtration rate (GFR) should be calculated with each blood test. A complete skin assessment should be completed with regular skin exams, paying close attention to the legs and feet for new injuries and any changes.
To check for diabetic autonomic neuropathy, it is necessary to assess for miotic or constricted pupils with sluggish light reflexes.
This includes assessment, management, and ongoing monitoring of hypertension, hyperlipidemia, and obesity (Burant & Young, 2012). Additionally, assessment should include checking for capillary refill under the nails of the toes and whether the patient’s feet are cool and pale. On the other hand, these patients may have symptoms of diabetes, such as polydipsia, polyuria, weakness, fatigue, blurred vision, headache, dizziness, or dehydration. She is also complaining of recurrent urinary tract infections (previous infections twice in the past four months). The team of health professionals caring for a person with diabetes should take a holistic approach to caring for their patient’s health.


Diabetes educators have the opportunity to earn two different credentials – Certified Diabetes Educator (CDE) or Board Certified-Advanced Diabetes Management (BC-ADM). Congenital malformations are more common in diabetic pregnancies when the diabetes is not well controlled, and infants are often of larger than normal birth weight. These lifestyle changes will also improve many of the health problems that often accompany type 2 diabetes, notably obesity, hypertension, and dyslipidemia. Moving from a sedentary pattern to a program of physical activity is also extremely challenging for patients with newly diagnosed diabetes. If lifestyle changes are not effective or become insufficient to keep A1C values low, medication may be added to the management program. Since it is often difficult for smokers to quit on their own, patients may find that formal programs that include support, counseling, and the availability of smoking cessation medications are helpful. In addition to nutrition planning, these professionals can suggest patterns of eating that help in weight loss.
Instead, low-carbohydrate or low-fat calorie-restricted diets may be effective in the short term (up to one year). This reduces the blood flow to many areas of the body and causes permanent tissue damage, notably to the retinas and the kidneys.
In contrast, people with diabetes mellitus produce urine that is denser than normal and that leaves crystals of sugar when the water in the urine is evaporated. The patient’s mouth and skin were always dry, and the breath often had a sweetish odor. This is called insulin resistance, a condition in which normal concentrations of insulin in the blood produce less than the normal effects in the body (ADA, 2014a). Aging, a sedentary lifestyle, or excess intra-abdominal fat can activate or enhance a person’s predisposition to develop type 2 diabetes (ADA, 2014a). As these processes continue and interact with each other, the patient has more frequent and higher episodes of hyperglycemia, which over time damage the eyes, kidneys, nerves, and blood vessels (ADA, 2014a).
This group may also have an increase in frequency of diabetes during the reproductive years, which may increase diabetes in the next generation (Dabelea et al., 2014).
C-peptide is an unnecessary protein, and it is released into the bloodstream along with insulin. More than seventy variants of monogenic diabetes have been identified that are caused by different mutations of the insulin receptor—a problem that then leads to insulin resistance. Usually, it is a problem in the molecular mechanisms by which cells recognize the insulin molecule and then produce the intracellular effects of this recognition. Insulin resistance can also be caused by the malfunctioning of any of the components of the intracellular cascade that connects the insulin receptors in the cell membrane to the glucose-processing machinery inside the cell (Burant & Young, 2012). This persistent hyperinsulinemia is a direct cause of insulin resistance (Burant & Young, 2012). These biochemical cues are triggered by fullness of the stomach, the presence of food in the small intestine, and the levels of fat and glucose in the blood. Depression, especially when part of bipolar disorder, can lead to excess eating and weight gain. On the other hand, if two different tests produce discordant results in an individual, the test whose result is above the diagnostic threshold should be repeated, and the diagnosis is made on the basis of the confirmed test (ADA, 2011).
A repeat A1C test comes in at 6.6%, confirming a diagnosis of hyperglycemia and type 2 diabetes.
The GFR can be estimated using a formula that requires the serum creatinine level and the age, weight, and sex of the patient (Oh, 2006).
A patient may have symptoms of hypotension when going from a lying or sitting to a standing position. Diabetic patients may have ulcers and skin erosions, especially in places on the peripheral extremities that are bumped frequently, such as the pretibial regions and the feet. Sensory problems include paresthesias, numbness, and pain; motor problems include reduced deep tendon reflexes and muscle weakness. In the case of severe hyperglycemia, the patient may need to be treated with insulin and IV fluids. These and other potential complications make it important for women of reproductive age with diabetes to understand the risks of a pregnancy, and their diabetes care teams should include nurse-midwives or obstetricians specializing in diabetes.
Patients on low-carbohydrate diets should have their lipid profiles, renal function, and protein intake (for those with nephropathy) monitored and have their hypoglycemic therapy adjusted as needed (ADA, 2014b).
However, this approach needs medical supervision along with vitamin and mineral supplementation (Burant & Young, 2012).
Islets are made up of several types of cells, including beta cells that make insulin.  The pancreas is located in the abdomen behind the stomach. People with diabetes have higher rates of death due to cardiovascular disease and higher rates of hospitalization for heart attacks and stroke.
Death was usually from what was then called diabetic coma (now called diabetic ketoacidosis), which came on suddenly and was always fatal within a few days.
Insulin is the hormone that keeps blood glucose levels from getting too high, but diabetes disrupts the body’s ability to use insulin effectively. Therefore, by themselves, the kidneys cannot keep blood sugar levels low enough to prevent diabetes. By measuring the amount of C-peptide in the blood, it is possible to calculate how much insulin has been produced by the pancreas (Davis, 2008). In many obese people, the food signals do not work properly, and these people’s brains do not recognize when they have eaten a sufficient meal. In addition, the existing beta cells in type 2 diabetics do not secrete insulin as quickly and in as large amounts as normal.
A diabetic person with intra-abdominal obesity also has a high risk of developing atherosclerotic cardiovascular disease. Autonomic neuropathy can also produce resting tachycardia, which can be detected when checking the patient’s heart rate.
In patients using insulin, skin areas that are used as injection sites should be assessed regularly. For people with type 2 diabetes, spacing meals roughly every 4 hours during the day is optimal (Giroaurd Mertig, 2012).
Islets within the pancreas contain beta cells, which produce insulin. Insulin is a hormone that helps the body use glucose for energy.
Diabetes is a leading cause of kidney failure, retinopathy, and nontraumatic lower limb amputations (CDC, 2014). Diabetes develops when the body doesn't make enough insulin, cannot use insulin properly, or both, causing glucose to build up in the blood. We know that a structured lifestyle program that includes losing weight and increasing physical activity can prevent or delay type 2 diabetes” (CDC, 2011b). In type 1 diabetes-an autoimmune disease-the beta cells of the pancreas no longer make insulin because the body's immune system has attacked and destroyed them. Type 2 diabetes usually begins with a condition called insulin resistance, in which the body has difficulty using insulin effectively.
Over time, insulin production declines as well, so many people with type 2 diabetes eventually need to take insulin.  What is an islet cell transplant?An islet cell transplant is a treatment for people with type 1 diabetes who have trouble controlling their glucose (blood sugar). There is a limited supply of islet transplants available, so transplant centers are careful to select only those patients who really need the procedure and will be most likely to benefit. Islet transplants are done alone or after a kidney transplant (islet alone, or islet after kidney). This means that it has not been proven to be the best way to treat type 1 diabetes.  How does a person get an islet cell transplant?Most centers require patients to enter a clinical trial, also called a study. A clinical trial is a research study where doctors try experimental drugs or medical treatments to learn more about diseases and their cures.
During your clinical trial, transplant doctors will watch how your body reacts to different tests and treatments. You have to visit the clinic a lot and have extra blood work done. When you sign up for the clinical trial, you will be given an application package. The tests and exams are different at each center. Blood testsThe blood tests are done on the first day of your assessment. The total amount of blood that is taken is less than the amount given during a regular blood donation.
After you are done, you will go back home and wait while the doctors look at your test results. Once all tests are done, the islet transplant team will look at the results and decide what to do next. In 3 or 4 days, the transplant coordinator will let you know your test results and what will happen next.  What happens if I am a good match for a clinical trial?If you are a good match for a study, you will meet the doctors who are running that study.
After you sign the consent form you will meet with a coordinator to go over the plan for your transplant. When you get the call, you will need to go to the hospital quickly (within a few hours at most). Keep this list with you at all times.Make sure you know ahead of time what you need to pay for and have the money with you. If you have any questions about this, talk to your transplant nurse coordinator or the social worker at the program.Have a bag packed and ready to go.
You will need to monitor your blood sugar regularly, even while in the hospital.   Being on the list does not mean you will get an islet transplant. Know which friends and family members can help at any time. If your health changes, see your regular doctor soon. Your center might have a glucose meter with memory, which would allow them to download your readings and compare your glucose control before and after the islet transplant.  THE  TRANSPLANT  PROCEDURE It is your responsibility to be ready when the center calls. This way, if the transplant is cancelled, you can be reached while you are on your way to the hospital. Even if the center calls you, you may not get the transplant.
This is because sometimes doctors cannot get enough cells from the pancreas to make the transplant work. The transplant might be cancelled at any step, and you will be sent home.  Islets extracted from a donor pancreas are infused into the liver. Once implanted, the beta cells in the islets begin to make and release insulin. Islets begin to release insulin soon after transplantation. However, full islet function and new blood vessel growth associated with the islets take time. The doctor will order many tests to check blood glucose levels after the transplant, and insulin is usually given until the islets are fully functional. Where does the pancreas come from?The pancreas comes from the same deceased donors that give hearts, lungs, livers, and kidneys.
These people tell their family and friends that they want to give their organs to someone else after they die. By donating, these people are giving you a chance to have your islet transplant. Transplant centers need one, two, or sometimes three pancreas organs for every islet transplant patient.
Because one transplant needs one whole pancreas, a friend or family member  cannot donate a section of their pancreas.
This is different from a kidney transplant, where people can donate one kidney and still be healthy with the one they have left.  What happens when I get to the hospital?When you arrive at the hospital, you will be registered and given a room. Your nurse will ask some questions about your medical history, then start an intravenous line (IV) for your medicines. Your care team will draw blood, perform an EKG and take a chest x-ray. Islet cell transplant is done in the Radiology Department or in the Operating Room. You will also be asked to monitor your glucose and tell the nurse what your level is each time. In the Radiology Unit, you will get a local anesthetic.
This is a drug that will be injected into the right side of your abdomen where the liver is located. The radiologist will then place a needle and a tube into the main vein (portal vein) of the liver. Using a special x-ray machine (fluoroscopy) and dye, doctors will inject the solution containing the islet tissue. Then they will remove the tube and take you back to the Nursing Unit where you will remain for several hours. If you do not take the anti-rejection drugs, your body will destroy the islet cells. You need to monitor your blood sugar levels very carefully. The transplant team will help you adjust the amount of insulin you need. Remember that the islet cells will take some time to settle into their new home in your liver.
We do not want to put stress on the islet cells, so it is important to keep your glucose at a good level. You do not want to make the new islets work too hard in the beginning. Taking care of your islet cells is like planting seeds in your garden. If you take good care of the cells right after your transplant, you have a better chance of good islet cell function. You can do this by sticking to a healthy diet and taking your medications.  What is rejection?Rejection is the body's natural defense against foreign cells or particles like bacteria and viruses. Your immune system knows that your new islet cells are not part of your own body, so it may reject and destroy them.  What can be done to keep my body from destroying my new islet cells? The doctors will use medicines that slow down your immune system enough to keep it from rejecting your islet cells. Some immunosuppressants are taken by mouth every day and others are given by vein less often.
Because islet transplantation is experimental, it is not yet known what the best immunosuppressive drugs are to prevent rejection. The center will monitor your blood levels closely to make sure you do not reject your islet cells, or have too much of these drugs in your system.
Over time, you will need less monitoring.  What can I do to prevent infections?You need to be careful about infections. Here are some things you should do: Use sunscreen (SPF 15) to avoid burning or even tanning. Not every center gives the same drugs, so ask your center to tell you which ones they prefer to use. Before having your blood drawn, ask your center what time you should stop eating before blood tests and how you should take your medicines.As your islet cells begin to work and your drug levels stabilize, you will need fewer blood tests. After a while, you may be able to get your blood work done in a lab closer to your home. You will also have your lipids (fat levels) tested. You are more open to getting infections and cancer due to suppression of your immune system. This can make it harder for you to get another transplant because the immune system will respond much quicker the next time your immune system sees these antigens. This can affect the success rate of a kidney or other organ transplant.  Weight gainBecause patients can eat a more normal diet after a successful islet transplant, some patients will gain weight. Researchers need to collect more safety data before these transplants are considered standard care in the United States. We also need to increase our supply of islet cells. We need to do more research so we can learn more about these medicines and develop medicines with fewer side effects. What an islet cell transplant patient gets to do is exchange insulin shots for immunosuppressive drugs and glucose monitoring. Patients who used to have irregular glucose levels now take immunosuppressive drugs so they have stable glucose levels. This is a possible long-term treatment for people who suffer from type 1 diabetes.  Can I buy an islet transplant?No.
Patients cannot buy a transplant or pay to have their name put on a transplant list.  Are there risks involved?Yes.
As more patients are having transplants, more risks are being observed  How much time does it take to be in a study?The first assessment takes about 10 days.
Some centers have patients who have combined kidney and islet transplants, either at the same time or one after the other. They can also be made ready at a later time, from a different donor, once the new kidney is stable.  What does an islet cell transplant cost?The costs for a transplant are different at each center.
The patient usually pays for transportation, housing, and medicines after leaving the hospital. If you need financial help, ask your transplant team if there are other programs that can help you pay for some of your costs. Sometimes the drug companies or clinical trial sponsors pay for the drugs, at least for a while. Diabetes develops when the body doesn't make enough insulin, cannot use insulin properly, or both, causing glucose to build up in the blood.
In type 1 diabetes-an autoimmune disease-the beta cells of the pancreas no longer make insulin because the body's immune system has attacked and destroyed them.



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