Complete Nurse's Guide to Diabetes Care

Chapter 1:

Nurse’s Roles Evolve in Diabetes Care and Education

Belinda P. Childs, ARNP, MN, CDE, BC-ADM,¹ Marjorie Cypress, PhD, MSN, RN, C-ANP, CDE,² Geralyn Spollett, MSN, C-ANP, CDE³

¹Great Plains Diabetes Center, Wichita, KS. ²Adult nurse practitioner and CDE, Albuquerque, NM. ³Yale Diabetes Center, New Haven, CT.

Nearly one-half of all Americans have or are at risk for developing diabetes.¹ Nurses have played an integral role in providing diabetes care and education to individuals with diabetes and their families for years. With the increasing prevalence of diabetes, the nurse’s role will be pivotal in providing individuals with diabetes with the knowledge, skills, and strategies required to prevent acute complications as well as reduce the risk of long-term complications. Nurses in all settings contribute to the care and education of individuals with diabetes. Equally important is the role of all nurses in all settings to promote healthy lifestyles to reduce the growing prevalence of diabetes.

This chapter not only discusses the evolving role of the diabetes nurse specialist but also considers the roles of the nurse in a variety of health-care settings.

EVOLUTION OF THE DIABETES NURSE

Nurses have been integral in providing diabetes care for more than 100 years. As early as 1914, even before the advent of insulin, nurses carried out Dr. Frederick Allen’s undernutrition therapy, also known as the starvation diet, to prolong a patient’s life by reducing glucosuria and acidosis. By 1915, the New England Deaconess Hospital (NEDH) opened the William Nast Broadbeck Cottage, dedicated to the care of patients with diabetes.² The nursing school affiliated with the NEDH was unusual for its time in that it had a sound education program, with dedicated nursing instructors, as well as several Harvard Medical School physicians who participated in classroom education. These nurses, well-trained in a rigorous program, were the first to conduct diabetes education programs for patients and their families, as well as educating other nurses and physicians who were interested in diabetes care.

Elliot Joslin, MD, originally a general internist, developed a specialty in the care of individuals with diabetes and saw a potential role for nursing in patient education. He believed that with the proper education, patients with diabetes would be able to care for themselves. In his book, The Treatment of Diabetes Mellitus, Dr. Joslin addressed the education of nurses in a section entitled Directions for Nurses in Charge of Diabetic Patients.³ He believed that educated nurses could be responsible for carrying out the treatments then associated with diabetes care, including measuring urinary glucose and albumin, helping patients with diet management and exercise, and reducing stress through diversions.

Joslin’s overall philosophy of diabetes management stressed the empowerment of patients to care for their own diabetes and for nurses to become the doctor’s associates in reaching this outcome. Joslin continued to stress the importance of this alliance with nursing in his second edition of The Treatment of Diabetes Mellitus (1917) and proposed extending the role of the nurses through diabetes education and treatment programs into the outpatient setting.⁴ He felt that developing a specialty area in diabetes offered a new career for nurses. In fact, he expressed utmost confidence in these nurses in his statement that a well-trained nurse was of more value than the patient’s doctors.⁴ As a strong advocate of this team approach to diabetic management, Joslin also wrote A Diabetic Manual for Mutual Use of Doctor and Patient in 1918.⁵

With the discovery of insulin came the need to further investigate its use in patients with diabetes. Joslin and the facilities associated with the William Nast Broadbeck Cottage, provided an ideal setting for research into the use of insulin. By that time, the Joslin-trained nurses had the basic diabetes skill set necessary to make them well suited to assist in the first of these clinical trials. Joslin developed training sessions for self-injecting insulin, and the nurses participated in this patient education. Nurses kept meticulous records of the trials, thus contributing to the initial research on insulin use.

The patient to receive the first commercially available injection of insulin in the U.S. was a nurse, Miss Mudge. She had been treated with the starvation diet for 5 years, wasting away to only 69 lb. After 9 months of insulin treatment, she gained back 31 lb.

Harriet McKay, NEDH class of 1922, after developing expertise in diabetes, including insulin management skills, became one of the earliest visiting diabetes nurses. McKay gave personal diabetes nursing care to a wealthy 14-year-old boy. During the 7 years that she cared for her patient, she learned how to regulate insulin for activity and meals and she was so successful in her care that the young man was able to engage in a healthy active life.²

Once insulin became commercially available, the need for educated nurses in diabetes care increased both for the self-care education of patients as well as for daily support and guidance. Nurses participated in the development of protocols for diabetic ketoacidosis, and other complicated medical and surgical problems related to diabetes. They worked on the foot care team changing bandages and applying antiseptics. Additionally, they continued to conduct patient education classes that addressed specific components of self-care management, such as testing urine for glucose, understanding dietary carbohydrate and how to use a scale for food measurements, adjusting insulin for food and activity, and learning how to avoid diabetic coma.

Lovilla Winterbottom, RN, and NEDH class of 1927, became what was called a wandering diabetic nurse for children with diabetes who could not afford a private-duty nurse. Her role was similar to a modern visiting nurse in that she not only made home visits shortly after hospital discharge to establish a routine for diabetes care, but also made periodic follow-up visits. In some instances, she made contact with the patients’ teachers and visited the schools. Winterbottom also saw diabetic children in five different residential summer camps. If she was not busy making home visits, Winterbottom instructed hospitalized patients both individually and in groups in diabetic self-care. She was available to help children with diabetes in any home, regardless of ability to pay, because Joslin’s friends supported this nursing position through a private fund.⁶

In 1929, the American Journal of Nursing published an informative article entitled The Care of the Diabetic: As Carried Out at the New England Deaconess Hospital.⁷ Many of the tenets espoused in this article for the treatment of diabetes are similar, if not identical, to 21st-century standards. The article outlines the predisposing factors to diabetes; hospital management of the disease; hygiene of the feet, skin, and teeth; precise dietary preparation and its relationship to the insulin ordered; and the content and teaching methods used in patient education classes. Additionally, boosting morale and keeping the patient optimistic are seen as part of diabetes care. The article also instructs the diabetes nurse to have a physiotherapist teach bed-bound patients necessary exercises. In every instance, the nurse plays a central and essential role in giving care and directing the patient toward diabetes self-management.

In 1936, an article entitled Teaching the Diabetic Patient also was published in the American Journal of Nursing. The author of this seminal article, Iris Langhart, RN, addressed the need for individualization in patient education. She wrote, when the teaching of such [hospitalized] patient is under consideration, it is more a question of what sort of person he is, what kind of work he does, and how he lives, than how severe his diabetes.⁸

Langhart then emphasized that a team approach is needed:

"In the formation of any unified teaching plan, all services must be drawn together in an effort to preserve the identity of the patient and his individual problem and at the same time conserve the time and energy of those who are to participate in the teaching program.⁸"

The team was coordinated by the head nurse who brought the various disciplines together—physician, dietitian, and nurse—to enact the teaching plan developed by the physician who was in charge of the diabetic clinic, as well as representatives from the dietary department and the medical teaching supervisor. The hospital placed the mantle of responsibility on the head nurse’s shoulders to oversee the unification of the teaching effort and ensure that the complete piece of teaching was done. In this way, the nurse became the coordinator of patient education and long-term care.

The nurse also became the link between the patient and the registered dietitian, for although the major portion of the teaching about diet is to be done by the trained dietitian, the nurse is the constant interpreter of the diet as it is served.⁸ In this role, the nurse assisted the patient in applying education to the practical everyday setting. Furthermore, the nurse was keenly aware of the psychological problems facing the patient and was able to assist the patient in rearranging his life to make diabetes a dynamic problem and to refurnish him with the will to live his life as normally as possible as part of the teaching duty.⁷

To prepare the nurse for this task, a class for teaching patients with diabetes was added to the nursing curriculum. It included not only the rudiments of diabetes education, such as instruction about how to perform a urinalysis and how to prepare and administer insulin, but also actual patient case studies that illustrated difficult teaching scenarios.

In many ways, the methods for teaching diabetes self-management have not changed significantly from those espoused in 1936. The nurse educator presents material in small segments over a period of time, knowing that although a plan for education is in place, the individual needs of the patient take precedence. The teaching plan should be considered suggestive and can be modified as necessary.⁸ Patients learned about insulin injections and urinalysis through a written guide and hands-on demonstration. The nurse educator then observed and corrected unsafe techniques, as needed. In some cases, a well-informed, experienced patient assisted a newly diagnosed patient to learn about diabetes self-care, benefiting both patients through mutual support. In modern terms, this would be called peer-to-peer support, and it remains an important part of diabetes education. Family involvement in the care of the person with diabetes included participation in education sessions, such as nutrition therapy and meal preparation, administering insulin, and urine-testing methods, all of which are still taught or reinforced by nursing staff in the 21st century.

The early diabetes nurse educators, as well as pioneering nursing teams and clinicians, put down strong and enduring roots for the continued growth of nursing’s essential role in diabetes management and important developments in patient care.

For years, hospital staff nurses provided diabetes inpatient education, but staff nurses had to provide this support along with their many other responsibilities. Additionally, increasing technology required even more education in diabetes self-management. The role of the specialized diabetes nurse educator emerged, with an expanding role to coordinate and promote care by acting as a resource person for education materials, and as this role emerged, these nurse educators also served as role models for expert clinical practice.⁹

As diabetes care moved into the ambulatory setting, the role of the diabetes nurse became increasingly important. The diabetes educator was one of the first nursing specialties to develop and has served as a model for specialties ever since.¹⁰ Widespread implementation of the diabetes nurse educator as well as the diabetes educator, which included other health professionals (primarily registered dietitians) was occurring in the 1970s, and in 1973, the American Association of Diabetes Educators (AADE) was founded in Chicago. In 1982 The National Institutes of Health’s National Diabetes Advisory Board (NDAB) called for the establishment of quality standards for diabetes education to create consistency for diabetes education programs and to help diabetes educators meet payers’ need for quality assurance to facilitate reimbursement.¹¹–¹³ In 1983, the NDAB developed National Standards for Self-Management Education. These later became the foundation for the expanded National Standards for Diabetes Education (NSDE) and for the review criteria adopted by the American Diabetes Association Education Recognition Program, which has been administering a program to recognize quality education programs that meet National Standards for Diabetes Self-Management Education (NSDSME) since 1990.¹⁴ Years later, the AADE developed an accreditation process for quality education programs that meet the NSDSME, the Diabetes Education Accreditation Program (DEAP).¹⁵

As it became obvious and necessary for health-care professionals to have specialized skills to care for people with diabetes, the AADE appointed a committee to investigate developing a multidisciplinary certification program for diabetes educators.¹⁶ In 1986, the National Certification Board for Diabetes Educators, an independent organization, began offering the certified diabetes educator (CDE) credential. The first CDE examination was in October 1986 with 1,248 candidates successfully completing the examination to become CDEs. Although the majority were registered nurses, registered dietitians (RDs) made up the second-largest group, but other professionals were represented as well, including exercise physiologists, social workers, pharmacists, psychologists, podiatrists, physicians, and physical and occupational therapists.¹⁷ In the years since, this credential has become the gold standard for formal recognition of specialty practice and knowledge. As of 2016, 19,283 CDEs were registered in the U.S.¹⁸ CDEs have become recognized as experts in diabetes education, and their role continues to expand as educators enhance their position on the diabetes team, working with physicians and providing clinical management as well as patient self-management education.¹⁸ The Diabetes Control and Complications Trial (DCCT), conducted in the 1980s and early 1990s, helped to define this more advanced role and to establish the value of the multidisciplinary team for intensive diabetes management.¹⁹ The DCCT utilized a specialized health-care team to provide intensive management to the intervention group and offered standard care to the control group. Intensive management consisted of frequent telephone calls and in-person visits to review glucose values and make adjustments in treatment regimens, including insulin dose changes, nutrition therapy, and exercise modifications as needed. Nurses, dietitians, and behaviorists were recognized as key members of the team responsible for the success of the study.²⁰

In 1998 and in recognition of the expanded specialty of diabetes nursing and improvements in diabetes and technology, the American Nurses Association (ANA) in concert with the AADE developed the Scope and Standards of Diabetes Nursing Practice,²¹ which targeted the scope and standards of the diabetes nurse or diabetes educator and those of the advanced practice diabetes nurse. The standards are authoritative statements described by AADE for the profession of nursing; identify the responsibilities, values, and priorities of diabetes nurses; and provide a framework for the evaluation of practice. In 2005, the AADE published a multidisciplinary scope of practice, standards of practice, and standards of professional performance for diabetes educators.²² The increasing rates of diabetes and need for diabetes self-management education and management by advanced practice practitioners gave rise to the development of advanced nursing degree programs with a diabetes concentration at several universities and colleges of nursing. Advanced practice health professionals frequently working in teams (e.g., nurses, dietitians, pharmacists) have addressed an important need for expertise in diabetes management. Presently the AADE offers an Advanced Diabetes Management Certification (BC-ADM) to health-care professionals with a minimum master’s degree level of education in a relevant clinical, educational, or management field. This credential validates a health-care professional’s in-depth knowledge and expertise in the complex management of people with diabetes, including advanced clinical assessment, prioritization of complex data, problem solving, counseling, and clinical intervention and monitoring.²³ This certification, however, does not permit health-care professionals to practice outside their legal scope of practice. Despite this limitation, it is obvious that the care of the person with diabetes is complex, is challenging, and requires a specialized knowledge of the disease and its comorbidities. Continuing education is necessary as diabetes research uncovers a better understanding of the disease and as new treatments emerge. Nurse researchers can be leaders in helping to define best nursing practice in diabetes care.

With our evolving healthcare delivery systems, including patient-centered medical homes, increasing telehealth services, workplace health incentive programs, and insurance case managers, the role of the diabetes educator continues to evolve.²⁴–²⁷ The effectiveness of some of these delivery systems have not been well studied; however, diabetes educators are well positioned to be valuable partners in these evolving health-care modalities.

Educators are moving into community settings in which they are participating with providers in shared medical visits.²⁸ They are becoming embedded in primary care practices and are becoming key members of collaborative teams, including physicians, advanced practice nurses, pharmacists, behaviorists, and social workers. Strong teams are needed for this complex disease, with the person with diabetes as the center of the team. Diabetes educators are positioned to serve as community resources as the diabetes experts, providing professional education for less-experienced caregivers including nonspecialist nurses, licensed practical nurses, medical assistants, and community health workers.

All nurses, however, regardless of specialty or setting should recognize that they have an opportunity to enhance knowledge, support skill development, and sustain the individual by providing encouragement to obtain and maintain good diabetes control and guide healthy lifestyle behaviors. Incorporating the individual’s family and significant others is imperative.

Nurses in every setting, including the hospital, public health, case management, school health, long-term care and assisted living, home health, and college nursing, can support the individual with diabetes. A knowledgeable, skilled, and compassionate nurse can and should be a coach for the individual with diabetes. It is a complex, challenging, lifelong disease that is self-managed. If the individual has not completed a self-management education program, take the opportunity to refer the individual to a diabetes education program or diabetes educator. Identify your community resources (a list of education programs also can be obtained online).²⁹,³⁰

The nurse not only serves as an educator but also as an advocate. The nurse may advocate for the individual with diabetes by identifying covered medications and supplies, identifying resources for supplies and food, and providing ongoing support services and even clinical resources. Diabetes is an expensive disease. Many individuals struggle to take their medications or to obtain appropriate medical care because they lack resources.

SUMMARY

Our health-care system continues to evolve, as does the role of the nurse. Without a doubt, individuals with diabetes will be more successful living with diabetes if they have the support of well-educated nurses and diabetes educators in every setting. Nurses are essential in the prevention of diabetes. Helping to identify people at risk and providing education and counseling is a vital role in 21st-century health care.

REFERENCES

1. Menke A, Casagrande S, Geiss L. Prevalence of and trends in diabetes amoung adults in US-1988-2012. JAMA 2015;314:1021–1029. DOI: 10.1001/jama.2015.10029

2. Allen NA. The history of diabetes nursing, 1914–1936. Diabetes Educ 2003;29:976–989

3. Joslin EP. The Treatment of Diabetes Mellitus: With Observations upon the Disease Based upon One Thousand Cases. Philadelphia, Lea & Febiger, 1916

4. Joslin EP. The Treatment of Diabetes Mellitus: With Observations upon the Disease Based upon One Thousand Cases. 2nd ed. Philadelphia, Lea & Febiger, 1917

5. Joslin EP. A Diabetic Manual for the Mutual Use of Doctor and Patient. Philadelphia, Lea & Febiger, 1918

6. Anon LE, Winterbottom, RN. A wandering diabetic nurse. Am J Nurs 1931;31:957–958

7. Moores W. The care of the diabetic: as carried out at the New England Deaconess Hospital. Am J Nurs 1929;29:499–503

8. Langhart I. Teaching the diabetic patient. Am J Nurs 1936;26:319–324

9. Davis, E. Role of the diabetes nurse educator in improving patient education. Diabetes Educ 1990;16:36–38

10. Dunning, T. The complex and constantly evolving role of diabetes educators. Diabetes Voice 2007;52:9–11

11. National Diabetes Advisory Board. National standards for diabetes patient education programs. Diabetes Educ 1984;9:11–14

12. National Diabetes Advisory Board. National standards and review criteria for diabetes patient education programs. Diabetes Educ 1987;12:286–291

13. Berlin N, Sims D, Belloni J, et al. National standards for diabetes patient education programs: pilot study results and implementation plan. Diabetes Educ 1987;12:292–296

14. Maryniuk MD, Bronzini BM, Lorenzi GM. Quality diabetes self management education: achieving and maintaining American Diabetes Association Education Recognition Program. Diabetes Educ 2004;30:467–475

15. American Association of Diabetes Educators. AADE Diabetes Education Accreditation Program. Available from https://www.diabeteseducator.org/practice/diabetes-education-accreditation-program-(deap). Accessed 28 February 2016

16. Personal communication—Anonymous. Lovilla E. Winterbottom, RN: A Wandering Nurse, 2016

17. Anderson BJ, Ratner RE, Warren L, et al. CDE’s in 1988: A two-year progress report. Diabetes Educ 1988;14:483–486

18. National Certification Board for Diabetes Educators. 2016 Count of CDEs by state and other statistics. Available from http://www.ncbde.org/2016-count-of-cdes-by-state-and-other-statistics/. Accessed 27 February 2016

19. Valentine V, Kulkarni K, Hinnen DH. Evolving roles: from diabetes educator to advanced diabetes managers. Diabetes Spectr 2003;16:27–31

20. Bayless M, Martin C. The team approach to intensive diabetes management. Diabetes Spectr 1998;11:33–37

21. American Nurses Association and American Association of Diabetes Educators. Scope and Standards of Diabetes Nursing Practice. 2nd ed. Washington, DC, American Nurses Association, 2003

22. American Association of Diabetes Educators. The scope of practice, standards of practice and standards of professional performance for diabetes educators. Diabetes Educ 2005;31:287–512

23. English, T. New diabetes credential offers increased level of clinical recognition. Pharmacy Today 2001;7

24. Siminerio L, Ruppert K, Huber K, Fredrico GS. Telemedicine for reach, education, access and treatment (TREAT): linking telemedicine with diabetes self-management education to improve care in rural communities. Diabetes Educ 2014;40:797–805

25. Watts S, Sood A. Diabetes nurse case management: improving glucose control: 10 years of quality improvement follow up data. Appl Nursing Res 2016;29:202–205. DOI: http://dx.doi.org/10.1016/j.apnr.2015.03.011

26. Wolber T, Ward D. Implementation of a diabetes nurse case management program in primary care clinic: a process evaluation. J Nurs Health Chron Ill 2010;2:122–134

27. Fitzner K, Moss G. Telehealth: an effective delivery method for diabetes self-management education? Popul Health Manag 16:169-177, 2013.

28. Ridge T. Shared medical appointments in diabetes care: a literature review. Diabetes Spectr 2012;25:72–75. DOI: http://dx.doi.org/10.2337/diaspect.25.2.72

29. American Association of Diabetes Educators. Find a diabetes educator in your area. Available from https://www.diabeteseducator.org/patient-resources/find-a-diabetes-educator. Accessed 19 January 2017

30. American Diabetes Association. DiabetesPro, ERP listing. Available from http://professional.diabetes.org/erp_list_zip. Accessed 19 January 2017

Chapter 2:

Diagnosis and Classification

Marjorie Cypress, PhD, MSN, RN, C-ANP, CDE,¹ and Donna Tomky, MSN, RN, ANP-BC, CDE¹

¹Adult nurse practitioners and certified diabetes educators in Albuquerque, NM.

The prevalence of diabetes and prediabetes continues to increase at alarming rates. From 1980 to 2014, the number of individuals with diagnosed diabetes has increased fourfold to 22 million with continued estimates of 8.1 million people with undiagnosed diabetes.¹ Prediabetes rates also are increasing, and it is estimated that 86 million Americans ages 20 years or older have prediabetes.² These problems are not limited to the U.S.

In 2014, the World Health Organization estimated that more than 422 million people worldwide had diabetes, and that number is expected to double by the year 2030.³ Almost 40% of the population over the age of 65 years suffers from diabetes.⁴ Diabetes is listed as the seventh leading cause of death and is linked with heart disease, hypertension, blindness, kidney disease, nervous system disease, amputations, and dental disease.² Although historically type 2 diabetes (T2D) has been an adult disease, more children are being diagnosed with T2D and risk earlier and more serious complications. As the U.S. and the world continue to see rising rates of diabetes, it stands as one of the most common diseases that nurses will encounter in their professional lives. It is essential that nurses appreciate the tremendous growth of diabetes in the population and be knowledgeable about the classification and diagnostic criteria for diabetes and prediabetes so that early and appropriate interventions can be instituted. Diagnosing diabetes or prediabetes early decreases the risks for complications and improves outcomes to lessen the burden on individuals, families, communities, and society.

Diabetes is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of different organs, especially the eyes, kidneys, nerves, heart, and blood vessels. Importantly, patients with diabetes are at much higher risk for cardiovascular events, including myocardial infarctions and cerebrovascular accidents.

Diabetes is classified into four distinct categories: type 1 diabetes (T1D), T2D, other specific types of diabetes that may be due to other causes, and gestational diabetes mellitus (GDM). T1D accounts for 5–10% of people with diabetes, while T2D accounts for ~90% of all people with diagnosed diabetes. Another classification category is increased risk of diabetes, also known as prediabetes. Many of the people who meet the criteria for prediabetes are obese and have abnormal glucose levels but do not meet the criteria for a diagnosis of diabetes.

DIAGNOSING DIABETES

The clinical presentation and disease progression vary in T1D and T2D.⁵ Although the categories appear straightforward, it may be difficult to correctly diagnose some children, teens, and adults, and the true diagnosis may become evident over time.

Classic symptoms of diabetes, all caused by elevated blood glucose, include polyuria, polydipsia, weight loss, fatigue, blurred vision, and dry mouth. Many people, usually those with milder elevations in blood glucose, have no symptoms at all or may not recognize them as problems. The diagnosis therefore first may be suspected on routine measurement of blood glucose or on an incidental finding of glucose in the urine. Sometimes, diagnosis occurs when evidence already exists of chronic diabetes complications, such as retinopathy, other vascular disease, or neuropathy. The onset of diabetes is generally insidious. Many patients with T2D are often free of classic symptoms and, thereby, may remain undiagnosed for a prolonged period.

The diagnosis of diabetes can be made based on one or more plasma glucose criteria: hemoglobin A1c (A1C), or fasting blood glucose (FBG), or a 2-h plasma glucose during an oral glucose tolerance test (OGTT), or in a patient with classic symptoms of hyperglycemia or hyperglycemic crisis and random plasma glucose ≥200 mg/dL (see Table 2.1).⁵

Table 2.1—Criteria for the Diagnosis of Diabetes

FPG, fasting plasma glucose; PG, plasma glucose.

Source: From American Diabetes Association.⁵

The A1C test should be performed using a method that is certified by the National Glycohemoglobin Standardization Program. Interpreting A1C levels in patients with certain anemias and hemoglobinopathies may be problematic. For those with abnormal hemoglobin such as sickle cell trait, an A1C assay without interference from certain abnormal hemoglobins should be used. In those with increased red blood cell turnover such as in pregnancy, hemodialysis, recent blood cell losss or transfusion, or erythropoietin therapy, only blood glucose criteria should be used to diagnose diabetes.

Diagnosing GDM

GDM is defined as diabetes diagnosed in the second or third trimester of pregnancy that was not clearly overt diabetes prior to gestation. GDM carries risks for the mother and neonate. With the ongoing epidemic of overweight and obesity and higher rates of T2D among women of childbearing age, the number of pregnant women with undiagnosed T2D has increased. If possible, a patient’s risk for GDM should be determined before conception to detect undiagnosed T2D in high-risk women, but certainly, if not before, at the onset of the diagnosis of pregnancy. It is reasonable to screen women with risk factors for T2D at the initial prenatal visit using standard diagnostic criteria (Table 2.2). The Hyperglycemia and Adverse Pregnancy Outcomes Study of ~25,000 pregnant women demonstrated that risk of adverse maternal, fetal, and neonatal outcomes continuously increases as a function of maternal glycemia at ~24–28 weeks’ gestation, even within ranges previously considered normal for pregnancy.⁶ As a result of this study, two groups met to establish the most appropriate criteria for diagnosing GDM, but they developed different criteria. The International Association of Diabetes and Pregnancy Study recommends GDM screening as a two-step method,⁷ and the National Institutes of Health (NIH) consensus statement recommends a one-step method for GDM screening.⁸ GDM screening can be accomplished with either of these two strategies: 1) the one-step 2-h 75 g OGTT, or 2) the two-step approach with a 1-h 50 g (nonfasting) screen followed by a 3-h 100 g OGTT for those who screen positive (see Table 2.3). Abnormal blood glucose levels in the first trimester of pregnancy suggest a diagnosis of T2D or prediabetes as opposed to typical GDM. Regardless of the diagnosis, because GDM is a risk factor for the development of T2D, women with abnormal blood glucose levels should be screened for diabetes 4–12 weeks postpartum, using OGTT diagnostic criteria for individuals who are not pregnant.⁵ Women with a history of GDM should have lifelong screening for the development of T2D or prediabetes at least every 3 years. Women with a history of GDM found to have prediabetes should receive intensive lifestyle interventions or metformin to prevent diabetes.⁵

Table 2.2—Criteria for Testing for Diabetes or Prediabetes in Asymptomatic Adults and Children

1. Testing should be considered in overweight or obese (BMI ≥25 kg/m² or ≥23 kg/m² in Asian Americans) adults who have one or more of the following risk factors:

• A1C ≥5.7% (39 mmol/mol), IGT, or IFG on previous testing

• first-degree relative with diabetes

• high-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)

• women who were diagnosed with GDM

• history of CVD

• hypertension (≥140/90 mmHg or on therapy for hypertension)

• HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL (2.82 mmol/L)

• women with polycystic ovary syndrome

• physical inactivity

• other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans).

2. For all patients, testing should begin at age 45 years.

3. If results are normal, testing should be repeated at a minimum of 3-year intervals, with consideration of more frequent testing depending on initial results (e.g., those with prediabetes should be tested yearly) and risk status.

Source: From American Diabetes Association.⁵

Table 2.3—Screening for and Diagnosis of GDM

NDDG, National Diabetes Data Group.

*The ACOG recommends either 135 mg/dL (7.5 mmol/L) or 140 mg/dL (7.8 mmol/L). A systematic review determined that a cutoff of 130 mg/dL (7.2 mmol/L) was more sensitive but less specific than 140 mg/dL (7.8 mmol/L).

Source: From the American Diabetes Association.⁵

Categories of Increased Risk for Diabetes (Prediabetes)

This section reviews recommendations for individuals at increased risk for diabetes and prediabetes.⁵ Testing to assess risk for future diabetes in asymptomatic people should be considered in adults of any age who are overweight or obese (BMI ≥25 kg/m² or ≥23 kg/m² in Asian Americans) and who have one or more additional risk factors for diabetes. The American Diabetes Association T2D risk test is helpful as a general screen and to refer those with high risk to have diagnostic tests (Figure 2.1).

Figure 2.1—American Diabetes Association Risk Test for T2D.

Source: From the American Diabetes Association.⁵

Table 2.2 outlines the criteria for testing for diabetes and prediabetes in asymptomatic adults and children. For all patients, particularly those who are overweight or obese, testing should begin at age 45 years.

To test for prediabetes, A1C, fasting plasma glucose (FPG), and 2-h plasma glucose (PG) after 75 g OGTT are appropriate. In patients with prediabetes, identify and, if appropriate, treat other cardiovascular risk factors.

Testing to detect prediabetes should be considered in children and adolescents who are overweight or obese and who have two or more additional risk factors (see Table 2.2).

PATHOGENESIS OF DIABETES

Several pathogenic processes are involved in the development of diabetes. These range from autoimmune destruction of the pancreatic β-cells with consequent insulin deficiency to abnormalities that result in resistance to insulin action. Both type 1 and type 2 diabetes may result from various genetic and environmental factors that result in progressive loss of β-cell mass and/or function that manifests as hyperglycemia. The basis of the abnormalities in carbohydrate, fat, and protein metabolism in diabetes is deficient insulin action on target tissues. Deficient insulin action results from inadequate insulin secretion or diminished tissue responses to insulin at one or more points along the complex pathways of hormone action. Impairment of insulin secretion and deficient insulin action frequently coexist in the same patient, and it often is unclear which abnormality, if either alone, is the primary cause of the hyperglycemia.

Type 1 Diabetes

TID is due to β-cell destruction leading to absolute deficiency of insulin secretion resulting from an autoimmune destruction of the β-cells of the pancreas (see Figure 2.2). Diabetic ketoacidosis can be present at diagnosis or may develop if insulin replacement therapy is not started immediately upon diagnosis or later, into the course of the disease, if insulin delivery is halted or inadequate for some reason (i.e., insulin pump failure, infusion site problems, poor absorption, damaged or expired insulin, omission by the patient, etc.).

Figure 2.2—Natural History of T1DM.

Source: Reprinted with permission from Lancet. 2014;383:69–82.

The pathogenesis of T1D is divided into autoimmune-mediated diabetes and idiopathic diabetes. In autoimmune-mediated diabetes, insulin-producing β-cells are destroyed by an autoimmune-mediated process. Typically, β-cells are totally destroyed, but in some patients, destruction is incomplete, resulting in residual insulin production. The rate of β-cell destruction is variable, can be very rapid in infants and children and slower in adults. Some will present with ketoacidosis and others will have increasing hyperglycemia but this can occur at any age, even adults in their 80s and 90s. Antibody markers usually are seen. Autoimmune markers include islet cell antibodies and autoantibodies to glutamic acid decarboxylase (GAD65), insulin, the tyrosine phosphates IA-2 and 1A2β and ZnT8.⁵ T1D is defined by the presence of one or more of these markers. There are well-recognized associations with several genes in the human leukocyte antigen (HLA) loci, including both predisposing and protective genes (DQA and DQB). Patients with T1D have increased incidences of other autoimmune diseases, including Hashimoto’s thyroiditis, Graves’ disease, pernicious anemia, vitiligo, celiac disease, and Addison’s disease.

Three distinct stages of T1D can be identified (see Table 2.4) dependent upon presence and number of autoantibodies and are a predictor of hyperglycemia and diabetes. Increasing glucose and A1c levels often rise before clinical symptoms, and staging is useful to make a diagnosis of T1D before the onset of DKA.

Table 2.4—Staging of Type 1 Diabetes

A less common form of T1D, known as idiopathic diabetes, reveals no evidence of autoimmune disease and immune markers are absent. This form of T1D appears to be inherited, but the cause is unknown. They do not have any evidence of β-cell autoimmunity but do have permanent insulinopenia. Idiopathic diabetes is more common in those of African or Asian ethnic origin and is characterized by episodic ketoacidosis and varying degrees of insulin deficiency. The need for insulin replacement is intermittent—and may change over time.

Type 2 Diabetes

T2D accounts for ~90–95% of those with diabetes (previously referred to as noninsulin-dependent diabetes or adult-onset diabetes). T2D is due to a progressive loss of insulin secretion, frequently with a background of insulin resistance. Most people with T2D (or prediabetes) are obese, with obesity itself causing some degree of insulin resistance. Ketoacidosis is rare (although not unheard of ) and usually seen in association with the stress of another illness, infection, or trauma. T2D may remain undiagnosed for many years because the hyperglycemia develops gradually and, at earlier stages, often is not severe enough for the patient to notice any of the classic symptoms of diabetes.

The pathogenesis of T2D is complex (see Figure 2.3). T2D develops progressively, with the pathogenic abnormalities already present in the prediabetes phase. Virtually all individuals with T2D have peripheral insulin resistance combined with a relative, not absolute, insulin deficiency and throughout their lifetime they may not need insulin treatment to survive.

Figure 2.3—Pathophysiology of Type 2 Diabetes.

Source: Reprinted with permission from DeFronzo.⁹

The progressive decline in β-cell function over several years, regardless of type of therapy, was demonstrated in the U.K. Prospective Diabetes Study (UKPDS),¹⁰ wherein the ability to maintain A1C levels continued to decrease markedly throughout the 9 years of follow-up, even when the researchers controlled for lifestyle issues, such as diet, physical activity, and medication. Notably, in the UKPDS, insulin resistance did not change, suggesting that decreasing β-cell function is responsible for diabetes progression. This progression of insulin deficiency is reflected in the treatment required by those with T2D. Many individuals with T2D require multiple anti-hyperglycemic medications and later will require insulin therapy either in combination with anti-hyperglycemic agents or as monotherapy. T2D is associated with insulin secretory defects related to inflammation and metabolic stress including genetic factors. Other defects in T2D include increased hepatic glucose production, decreased peripheral muscle uptake, defects in the gut or incretin hormones (g>lucagon-like peptide-1 [GLP1] and gastric inhibitory polypeptide [GIP]),¹¹,¹² increased kidney reabsorption of glucose, and increased lipolysis of adipose tissue (See Figure 2.3).

Obesity and sedentary lifestyle are risk factors for the development of T2D. Obesity, particularly abdominal or visceral obesity, increases insulin resistance and the risk for T2D. Genetic factors (i.e., those unrelated to obesity) also contribute to insulin resistance. Clearly, however, many obese individuals do not develop T2D. These individuals presumably have adequate β-cell function to produce sufficient insulin to overcome the insulin resistance. Even with insulin resistance, diabetes usually will not develop unless a concomitant defect in β-cell function results in a deficiency of insulin secretion. Weight loss in overweight individuals with diabetes improves insulin resistance but usually does not fully restore insulin sensitivity.

Socioecological and other environmental issues also contribute to diabetes and prediabetes. These include the prevalent rates of obesity in adults and youth, increased consumption of high-caloric fast food and soft drinks, larger portion sizes, and a sedentary population (only 19% of adults are meeting physical activity guidelines). In addition, low socioeconomic status, decreased access to health care, communities that do not have safe areas conducive to walking or exercising, and food deserts where access to fresh produce is limited all can increase risk for diabetes and prediabetes.¹³ Food insecurity also has been associated with higher rates of diabetes.¹⁴

GDM

GDM is initially diagnosed during the second or third trimester of pregnancy. The diagnosis can be made in either of two strategies, a one step 75-g OGTT, or a two-step with a 50-g (nonfasting) screen followed by a 100-g OGTT for those who screen positive (Table 2.3). The one-step strategy has been anticipated to increase the incidence of GDM (from 5–6% to 15–20%) in order to optimize gestational outcomes. However, either of these strategies can be used. GDM occurs more frequently in African American, Hispanic/Latino, and Native American populations. Although GDM is glucose intolerance during pregnancy, 5–10% of women with GDM are discovered to have T2D, and women with a history of GDM have a 40–60% chance of developing diabetes over the next 5–10 years.

GDM shares pathogenic features in common with T2D. The insulin resistance experienced during pregnancy leads to hyperglycemia in susceptible women, which often resolves after delivery but may recur in subsequent pregnancies. Screening on the first prenatal visit should include assessment for high-risk ethnic group, personal history of impaired glucose tolerance or fasting glucose, family history of diabetes, previous history of GDM, and obesity.⁵ Consistent with this pathogenesis, women who have had GDM are at increased risk of developing diabetes later in life and should be screened at least every 3 years for the subsequent development of diabetes or prediabetes throughout their lives.

Other Causes of Diabetes

Other specific types of diabetes may be caused by genetic abnormalities causing defects in β-cell function, abnormalities in insulin action, injury to or surgical excision of the pancreas, and excess secretion of hormones that work against insulin or may result from taking a drug toxic to the pancreas or β-cells.

Diabetes may be seen in diseases of the exocrine pancreas, such as cystic fibrosis. Various endocrine diseases, such as Cushing’s syndrome, acromegaly, and pheochromocytoma, can cause diabetes. Drug-induced diabetes is an important clinical problem. Corticosteroid drugs are the most frequent cause of hyperglycemia in clinical practice, but numerous other drugs can impair insulin action and precipitate diabetes. Most likely, these drugs are not the sole cause of diabetes but unmask hyperglycemia in individuals already at risk.⁵

Monogenic Diabetes Syndromes

Monogenic defects that cause β-cell dysfunction, such as neonatal diabetes and maturity-onset diabetes of the young (MODY), represent a small fraction of patients with diabetes (<5%). Neonatal diabetes is diagnosed in the first 6 months of life, whereas MODY may be diagnosed up until early adulthood. These monogenic defects cause impaired insulin secretion without insulin resistance. Monogenic diabetes, however, should not be applied to T2D, which, unfortunately, is being diagnosed more frequently in children and adolescents and should be diagnosed in appropriate individuals with genetic testing.

EPIDEMIOLOGY

Type 1 Diabetes

The incidence of T1D has been increasing 2–5% worldwide and prevalence is estimated to be 1 in 300 people in the U.S. under age 18 years.¹⁵ The Search for Diabetes in Youth, a Centers for Disease Control and Prevention (CDC) and National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)–supported study, found a general increase in T1D and T2D among those <20 years of age but noted that it primarily was driven by an increase in T1D and was among all race and ethnic groups.¹⁶ This increase was most significant among non-Hispanic white youth from 2002 to 2009 in the U.S. and was 2.72% per year (2.84% among males and 2.57% among females).¹⁷

Clinical Features of Type 1 Diabetes

Most often, T1D occurs in children and young adults, but it may occur in individuals of any age. The rate of β-cell destruction varies; it is typically more rapid in younger individuals, who present frequently with severe symptomatic hyperglycemia and sometimes with DKA. This suggests severe insulin deficiency. Insulin therapy is required for survival. Those with a slower progression of β-cell destruction may retain some insulin secretion for many years and may present with only modest asymptomatic hyperglycemia. As the disease progresses, they require insulin for survival and are at risk for ketoacidosis. Patients with T1D are not typically obese at diagnosis; however, obesity at the time of diagnosis does not exclude a diagnosis of T1D and sometimes confuses the diagnosis.

Type 2 Diabetes

It is estimated that 29.1 million people in the U.S. have diabetes (9.3%), with 8.1 million of them undiagnosed, and 86 million (37%) Americans >20 years old with prediabetes. 1.4 million Americans aged 20 years or older are newly diagnosed with diabetes each year. For those aged 65 years or older, 11.2 million, or 25.9% of all people in this age group, have T2D. This prevalence is believed to be related to the increasing rates of obesity and higher frequency of sedentary lifestyle among Americans and the rapidly growing high-risk populations of Native Americans, Hispanics/Latinos, African Americans, Asians, and Pacific Islanders. In those under 20 years of age, 1 in 400 has diabetes. Although, historically, diagnoses of diabetes in children have been almost exclusively of T1D, the incidence of the development of T2D in children has increased significantly as a result of increasing obesity. Worldwide there is a significant increase in the prevalence of T2D in children and adolescents, particularly among those ethnic groups with high susceptibility to T2D.

In the U.S., T2D is more common in minority populations. From an international perspective, however, an increased risk for T2D is seen in many diverse ethnic groups. Typically, T2D increases when susceptible populations adopt an industrialized lifestyle with increased caloric intake and reduced physical activity.

Clinical Features of Type 2 Diabetes

The clinical presentation of T2D is even more variable than that of T1D. Because the insulin deficiency is only relative, many of these patients can be treated without insulin, at least initially. Most patients with T2D are obese or overweight with increased abdominal adiposity. Adiposity is seen most commonly in adults, but also increasingly is being seen in adolescents and children, usually in association with obesity. The development of T2D in children and adolescents is a rapidly increasing clinical problem. These individuals are usually obese and most often belong to ethnic groups with a high incidence of T2D. No longer is age of onset a reliable indicator of the type of diabetes present.

Symptoms may be mild or nonexistent in many patients with T2D. Although DKA characteristically is associated with T1D, it may be seen in some cases in which patients with T2D are under severe physical stress, such as major infection, pneumonia, or even cardiac event. It is more likely that those with T2D under severe stress may develop hyperglycemic hyperosmolar syndrome (HHS). HHS is a syndrome characterized by severe hyperglycemia, hyperosmolality, and dehydration in the absence of ketoacidosis. Typically patients are elderly and most present with stupor or coma.¹⁸ This is different from the situation in T1D, in which patients are ketosis prone and may develop ketoacidosis rapidly by simply omitting insulin.

Although it may be easy to distinguish the classic presentation of T1D seen in a lean child with weight loss and ketoacidosis and that of T2D seen in an obese older adult with no symptoms and mildly elevated glucose levels, other individuals may be difficult to classify in the initial stages of the disease process. Overlap between the two common forms of diabetes does exist. It may not be clear whether a middle-age adult with onset of fasting hyperglycemia has T2D or a slowly evolving form of T1D. In addition, an individual with a clear history of T1D subsequently may become obese and develop additional features associated with insulin resistance that are common in patients with T2D. Some patients who develop diabetes in adulthood and who initially may appear to have T2D may have a form of autoimmune diabetes. These individuals are usually leaner than the typical patient with T2D. Insulin deficiency may develop more rapidly than in a typical T2D patient but more slowly than in a child with T1D.

Practical Point

Assess clinical characteristics in new-onset hyperglycemia to help determine the safest and most effective treatment.

High-Risk Ethnicities and Type 2 Diabetes

The following ethnicities are at the highest risk for developing diabetes:

• Non-Hispanic blacks/African Americans. A total of 13.3% of all non-Hispanic blacks ≥20 years of age have diabetes. The risk of T2D is 1.8 times that for non-Hispanic whites.³

• Hispanic/Latino Americans. An estimated 12.8% of Hispanics ≥20 years of age have T2D. Hispanic/Latino Americans are 1.7 times more likely to have diabetes than non-Hispanic whites. Mexican Americans and Puerto Ricans have a risk for diabetes more than twice that of non-Hispanics whites.¹

• Native Americans/Alaska Natives. Native Americans/Alaska Natives have the highest risk of developing T2D (2.3 times that of non-Hispanic whites), and it is estimated that 15.9% of this population ≥20 years of age has T2D. Among all Native Americans, Alaska Natives have the least risk (6.0%), whereas Native Americans in the southeastern U.S. (24.1%) and in southern Arizona (27.8%) have the highest risk of developing diabetes.⁴

• Asians/Native Hawaiians/Pacific Islanders. An estimated 9.0% of Asian Americans ≥20 years of age have T2D, with highest risk among Filipinos at 11.3% and Asian Indians at 13.0%.⁴

Clues to Determining Type of Diabetes

*Idiopathic diabetes with features of T2D may present with ketosis²⁰

SUMMARY

The diagnosis of diabetes is made strictly by FPG, A1C, random blood glucose with symptomatology, or 75-g OGTT. Therapy is initiated based on the level of blood glucose and the type of diabetes diagnosed. Nurses in all settings have the opportunity to identify patients who are at risk for diabetes, have prediabetes, or have diabetes. Studies indicate that early diagnosis and aggressive therapy will delay and possibly prevent the complications of diabetes. Nurses have the opportunity to counsel, refer, and promote healthy behaviors among individuals with diabetes and prediabetes and those who are at high risk for diabetes. Identifying high-risk individuals and providing education about preventive strategies is of utmost importance to slow the seemingly epidemic increase in diabetes.

REFERENCES

1. American Diabetes Association. Fast facts: data and statistics about diabetes, revised 12/2015. Available from http://professional.diabetes.org/sites/professional.diabetes.org/files/media/fast_facts_12-2015a.pdf. Accessed 3 February 20

2. Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA, U.S. Department of Health and Human Services, 2014

3. World Health Organization. Global report on diabetes, 2016. Available from http://www.who.int/diabetes/global-report. Accessed 21 June 2016

4. Selvin E, Parrinello M, Sacks DB, Coresh J. Trends in prevalence and control of diabetes in the United States 1988–1994 and 1999–2010. Ann Intern Med 2014;160:517–525

5. American Diabetes Association. Diagnosis and classification of diabetes. Sec 2. Standards of medical care in diabetes—2017. Diabetes Care 2017; 40(Suppl. 1):S11–S24

6. Metzger BE, Lowe LP, Dyer AR, et al. HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. Diabetes Care 2008;31:899–904

7. International Association of Diabetes and Pregnancy Study Groups Consensus Panel. IADPSG recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676–682

8. Vandorsten JP, Dodson WC, Espeland MA, et al. NIH consensus development conference: diagnosing gestational diabetes mellitus. NIH Consens State Sci Statements 2013;29:1–31

9. DeFronzo, R. Banting Lecture. From the triumvirate to the ominous octet: a new paradigm for the treatment of type 2 diabetes mellitus. Diabetes 2009;58:773–795

10. U.K. Prospective Diabetes Study Group. Overview of 6 years’ therapy of type II diabetes: a progressive disease. Diabetes 1995;44:1249–1258

11. Maranthe CS, Rayner CK, Jones KL, Horowitz M. Relationships between gastric emptying, post prandial glycemia and incretin hormones. Diabetes Care 2013;36:1396–1405

12. Schwartz SS, Epstein S, Corkey B, et al. The time is right for a new classification system for diabetes: rationale and implications of the B-C-Centric classification schema. Diabetes Care 2016;39:179–186

13. Hill JO, Galloway JM, Goley A, et al. Scientific statement: socioecological determinants of type 2 diabetes and prediabetes. Diabetes Care 2013;36:2430–2439

14. Seligman HK, Schillinger D. Hunger and socioeconomic disparities in chronic disease. N Engl J Med 2010;363:6–9

15. Maahs, DM, et al. Chapter 1: Epidemiology of type 1 diabetes. Endocrinol Metabol Clin North Am 2010;39:481–497

16. Pettitt DJ, Talton J, Dabelea D, et al. Prevalence of diabetes in U.S. youth in 2009: the SEARCH for Diabetes in Youth study. Diabetes Care 2014;37: 402–408

17. Lawrence JM, Imperatore G, Dabelea D, et al. Trends in incidence of type 1 diabetes among non-hispanic white youth in the U.S., 2002–2009. Diabetes  2014;63:3938–3945. https://doi.org/10.2337/db13-1891

18. Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care 2014;37:3124–3131. doi: 10.2337/dc14-0984

19. Minges KE, Whitteore R, Grey M. Overweight and obesity in youth with type 1 diabetes. Annu Rev Nurs Res 2013;31:47–69. doi: 10.1891/ 0739-6686.31.47

20. Umpierrez GE. Ketosis prone type 2 diabetes. Diabetes Care 2006;29: 2755–2757. https://doi.org/ 10.2337/dc06-1870

Chapter 3:

Prevention and Risk Reduction

Marjorie Cypress, PhD, MSN, ANP-BC, CDE,¹ and Donna Tomky, MSN, ANP-BC, CDE, FAADE¹

¹Adult nurse practitioners and certified diabetes educators in Albuquerque, NM.

The importance of reducing risks of developing type 2 diabetes (T2D) cannot be overemphasized. The cost of diabetes and comorbidities continues to grow, with 2012 data indicating a cost of $245 billion, up from $174 billion in 2007.¹ The most current estimates of the economic burden associated with diagnosed diabetes, undiagnosed diabetes, gestational diabetes, and prediabetes were in excess of $322 billion in 2012. This estimate included $244 billion in excess medical cost and $78 billion in reduced productivity.²

As the prevalence of diabetes continues to grow, some 86 million people in the U.S. over the age of 21 years have prediabetes.³ One in three people are forecasted to have diabetes by 2030.⁴ Prevention and risk reduction include not only reducing the risk for developing diabetes, but also preventing the vascular diseases associated with diabetes. Primary and secondary prevention of diabetes and its complications should be a focus of all health-care professionals. Interventions to recognize high-risk individuals and strategies to decrease risk should be considered an essential part of medical and nursing care.

PRIMARY PREVENTION OF DIABETES

Type 1 Diabetes

Many of the studies to prevent or delay type 1 diabetes (T1D) have focused on preserving β-cell function. These studies have used a number of immune intervention strategies, have been largely unsuccessful, and are not ready for routine clinical use. These active trials, however, are recruiting relatives of individuals with T1D and should be directed to TrialNet (http://www.diabetestrialnet.org) so they can be screened.

Type 2 Diabetes

Large-scale prospective randomized trials focused on the prevention of T2D have demonstrated that T2D can be either prevented or delayed in a population of people identified to have increased risk of diabetes because of impaired glucose tolerance. These prevention interventions are centered on lifestyle interventions that included diet and exercise. The six major trials—U.S. Diabetes Prevention Program (USDPP), Finnish Diabetes Prevention Study, Da Qing China, Swedish Malmö, Indian Diabetes Prevention Program, and Japan Prevention Trials—all have shown that lifestyle was more effective than controls in reducing the risk of developing diabetes (ranges from 42% to 58%).⁵–¹⁰ The largest of these was the 27 sites in the U.S. and Canada. The USDPP randomly assigned 3,234 participants ages 25–85 years to an intensive lifestyle intervention consisting of a weight-loss diet and 150 min of exercise a week, a medication intervention group (metformin), or a control group. The goal was to lose 5–7% body weight and to maintain at least 150 min of exercise a week. The results showed that individuals in the lifestyle intervention group, whose sustained average weight loss was ~5% of body weight and exercised averaged >150 min/week, had a 58% decrease in the risk for developing T2D. Individuals in the metformin group experienced a 31% decrease in the risk for developing T2D. The lifestyle group was most successful in decreasing the risk of developing diabetes in the population >60 years of age. Of note, 45% of the study population was from high-risk minority groups. This and other studies have provided the evidence for preventing T2D.

Since the USDPP, considerable research has translated the USDPP protocol to different settings, including hospitals, primary care, YMCAs, and work or church groups for at-risk adults for T2D, with promising results. Health coaches have been trained to deliver the 16-week curriculum and have produced positive results.¹¹,¹² The 16-week curriculum for the DPP is readily available online.¹³ The Centers for Disease Prevention and Control has instituted the National Diabetes Prevention Program (NDPP), which offers a recognition program known as the Diabetes Prevention Recognition Program (DPRP). The purpose of the DPRP is to recognize programs that have demonstrated effective delivery of a lifestyle change program (lifestyle program) to prevent T2D. The key objectives are to ensure the quality, consistency, and broad dissemination of the lifestyle intervention; develop and maintain a registry of organizations recognized for their ability to deliver an effective lifestyle program to people at high risk for T2D; and provide technical assistance to organizations that have applied for recognition to help them deliver an effective lifestyle program and achieve and maintain recognition status.¹³

All individuals with prediabetes should be referred to a diabetes prevention program (preferably the NDPP) and, equally important, to an ongoing effective support program. Nurses should be familiar with available community resources for diabetes prevention programs and refer at-risk patients to those interventions. At this time, not all health insurance plans cover these programs; however, some programs have received grant funding and are able to offer participants curriculum for free or at a reduced price. At $1,600 per quality-of-life years, the American Diabetes Association (the Association) has reviewed these intensive lifestyle interventions for diabetes prevention and has deemed them to be very cost effective.¹⁴ In 2016, the Centers for Medicare and Medicaid Services (CMS) proposed expanded Medicare reimbursement coverage for USDPP programs to expand preventive services using a cost-effective model.

Numerous studies have focused on diabetes medications (i.e., metformin, thiazolidediones, α-gluocosidase inhibitors, insulin secretagogues) to prevent T2D and have shown some effectiveness. Currently, however, no medications for diabetes prevention have approval from the U.S. Food and Drug Administration (FDA).

Other contributing risk factors for T2D and prediabetes are believed to be socioecological factors. The increased consumption of high-caloric fast food and soft drinks, larger food portion sizes, and a sedentary population (only 19% of adults are meeting physical activity guidelines) are cited for the increasing prevalence of obesity in adults and youth. In addition, low socioeconomic status, decreased access to health care, the lack of safe areas conducive to walking or exercising, and food deserts with very limited access to fresh produce all increase risk for diabetes and prediabetes.¹⁵

Identifying High-Risk Individuals

Adults and children of any age who are overweight or obese and have additional risk factors should be tested for diabetes or prediabetes (for diagnostic criteria, see Chapter 2, Diagnosis and Classification).¹¹,¹⁶

People with obstructive sleep apnea have been found to be 2.5 times more likely to develop T2D than people without sleep apnea.¹⁷ Evidence shows that the intermittent shortage of oxygen in the body from sleep apnea may cause a stress response that can alter glucose metabolism and may play a role in insulin resistance. In addition, sleep apnea has been associated with hypertension and heart failure and may be an independent risk factor for the development of hypertension. The International Diabetes Federation (IDF) has suggested further testing on people who have symptoms of sleep apnea (witnessed apnea, heavy snoring, or daytime sleepiness).¹⁸ The treatment includes weight reduction (if overweight), decreased alcohol intake, and use of continuous positive airway pressure (CPAP). In addition, because metabolic diseases, including T2D, are common in patients with sleep apnea, the IDF recommends that these individuals be screened for other metabolic abnormalities.

Community blood glucose screening often is offered at health fairs and shopping malls, but it is difficult to evaluate and is subject to wide variability and inaccuracies. Its cost effectiveness, sensitivity, and specificity have been challenged,¹⁹,²⁰ and this type of screening is not recommended. However, community screening in the form of risk factor assessment to identify individuals who have multiple risk factors for developing T2D and cardiovascular disease (CVD) may be beneficial. Community risk factor screening also can provide opportunities to heighten awareness of diabetes, identify high-risk individuals and refer them for appropriate testing, and promote early intervention or prevention strategies. It is therefore important that screening be conducted by a health professional with specific plans and referrals for people with and without regular medical care who have clear risk factors. The diabetes risk test is an online risk assessment program that anyone can access. It also directs the user to additional resources.²¹

Lifestyle Interventions

One of the most important lifestyle interventions for diabetes prevention focuses on healthful eating, maintenance of a desirable body weight, and regular, routine physical activity. Medical nutrition therapy and physical activity are effective in helping people lower their risks for developing diabetes, hypertension, dyslipidemia, and heart disease. Although high-risk adults with lifestyle interventions have shown a decreased risk of developing T2D, studies of adolescents have been problematic, with high dropout rates and difficulties with medication adherence.²²

Medical nutrition therapy should focus on decreasing total calories as well as the intake of fat, particularly trans fat and saturated fat, and increasing the intake of whole grains and dietary fiber (see Chapter 4, Nutrition Therapy). It is important to incorporate