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Terms in this set (137)
continuous glucose monitoring system
a device used to continuously monitor blood glucose levels
-useful in type 1
-cannot be used in making decisions about specific insulin doses
continuous subcutaneous insulin infusion, insulin pump
a small device that delivers insulin on a 24 hour basis as basal insulinw
> a group of metabolic diseases that are characterized as hyperglycemia
diabetes resulting from defects in...
1. insulin secretion
2. insulin action
3. or both
diabetic ketoacidosis (DKA)
metabolic derangement in type 1 diabetes that results from a deficiency of insulin; highly acidic ketone bodies are formed, resulting in metabolic acidosis
fasting plasma glucose (FPG)
blood glucose determination obtained in the lab after fasting for at least 8 hours.
any degree of glucose intolerance with its onset during pregnancy
glycated hemoglobin (Hgb A1C)
a measure of glucose control that is a result of glucose molecule attaching to hemoglobin for the life of the red blood cell.
-only shows elevated levels when blood glucose levels have been consistently high
-normal range is 4-6% (indicate near-normal blood glucose concentrations)
-target range for diabetics is <7%
the amount of which a given food increases the blood glucose level compared with an equivalent amount of glucose
elevated blood glucose level
fasting hyperglycemia: >110
postprandial or after meal: >140
This is blood sugar that's higher than 110 mg/dL (milligrams per deciliter) after not eating or drinking for at least 8 hours. Postprandial or
Postprandial or after meal hyperglycemia
This is blood sugar thats higher than 140 mg/dL 2 hours after you eat
hyperglycemic hyperosmolar syndrome
a metabolic disorder of type 2 diabetes resulting from a relative insulin deficiency initiated by an illness that raises the demand for insulin
low blood glucose level
usually less than 70mg/dL
impaired fasting glucose (IFG)
a metabolic stage intermediate between normal glucose homeostatsis and diabetes; referred to as prediabetes
hormone secreted by the beta cells of the islets of Langerhans of the pancreas that is necessary for the metabolism of carbohydrates, proteins, and fats; a deficiency of insulin results in diabetes
a highly acidic substance formed when the liver breaks down free fatty acids in the absence of insulin
medical nutrition therapy (MNT)
nutritional therapy prescribed for management of diabetes that usually is administered by a registered dietician
a long-term complication of diabetes resulting from damage to the glomerulus, which is a small convoluted mass of capillaries.. It is an integral part of the nephron which is the basic unit of the kidney.
a long-term complication of diabetes resulting from damage to the nerve cell.
impaired glucose metabolism in which blood glucose conentrations fall between normal and considered diagnostic for diabetes
>includes fasting glucose and impaired glucose tolerance, not clinical entities in their own right but risk factors for future diabetes and cardiovascular disease.
normal fasting blood glucose level
fasting blood glucose level: diabetes
126 or above mg/dL
fasting blood glucose lab value: prediabetes
6.5 or above
5.7 to 6.4
A1C%: normal range
Oral glucose tolerance test (OGTT): diabetes
200 or above
Oral glucose tolerance test (OGTT): prediabetes
Oral glucose tolerance test (OGTT): normal
139 or below
a complication of diabetes in which the small blood vessels that nourish the retina in the eye are damaged
self-monitoring of blood glucose (SMBG)
A MEHTOD OF CAPILLARY BLOOD glucose levels
a class of oral antidiabetic medication for treating type 2 diabetes
>stimulates insulin secretion and insulin action
a class of oral antidiabetic medications that reduces insulin resistance in target tissues, enhancing insulin action without directly stimulating insulin secretion
actions of insulin
1. transports glucose
2. metabolizes glucose into energy
3. stimulates liver and muscle to store glucose (glycogen)
4. enhances storage of dietary fat into adipose tissue
5. accelerates transport of amino acids into cells
6. inhibits the breakdown of stored glucose, protein, and fat.
hormone secreted by pancreas when: blood glucose levels are low
hormone secreted by pancreas when: blood glucose levels are high
renal threshold for glucose
usually 180-200 mg/dL
what happens when glucose exceeds 180-200 mg/dL in the bloodstream?
>the kidney cant reabsorb (return to blood) all the glucose
>glucose then appears in the urine (glycosuria)
>accompanied by loss of fluids electrolytes (osmotic diuresis)
why does insulin deficiency lead to further to hyperglycemia?
because insulin INHIBITS breakdown of glucose, which leads to unrestrained breakdown of glucose into the blood.
1. glycogenolysis-breakdown of stored glucose
2. gluconeogenesis- production of new glucose from amino acids and other substances
breakdown of stored glucose
production of new glucose from amino acids and other substances.
the liver forms glucose from the breakdown of noncarbohydrate substances, including amino acids after how many hours without food?
ketone bodies are produced from the breakdown of?
what are ketone bodies?
highly acidic substance formed when the liver breakdown FREE FATTY ACIDS in the ABSENCE OF INSULIIN
The three major metabolic derangements?
1. hyperglycemia- high glucose level in the blood
2. ketosis- an abnormal increase in ketone bodies in the body
3. metabolic acidosis- acidosis resulting from excess acid due to abnormal metabolism, excessive acid intake, or renal retention or from excessive loss of bicarbonate (as in diarrhea)
Diabetic ketoacidosis (DKA) clinical manifestations
1. polyuria----large amount of dilute urine
2. polydipsia----great thirst as a symptom of disease
6. stupor and coma (if not treated)
7. fruity breath odor
what makes the fruity breath odor in DKA?
Type 1 diabetes is characterized by?-insulin?
-destruction of the pancreatic beta cells which PRODUCE insulin-->LEADING TO---> an insulin deficiency
Type 1 regardless of cause leads to?
1. decrease in insulin production
2. unchecked glucose production by the liver
3. unchecked fasting hyperglycemia
1. glucose accumulates in the blood and exceeds renal threshold
2. kidney places extra glucose in the urine, which leads to fluid and electrolyte loss
3. fat breakdown (because lack of insulin) occurs resulting to an increased production of ketone bodies
two main problems related to insulin in type 2 diabetes
1. insulin resistance
2. impaired insulin secretion
decreased tissue sensitivity to insulin
making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver.
how to maintain insulin resistance and prevent glucose buildup in the blood?
increased amounts of insulin must be secreted to maintain glucose levels or slightly elevated level.
what happens when if the beta cells cannot keep up iwth the increased demands for insulin?
glucose levels rise and type 2 diabetes occurs
insulin resistance may lead to metabolic syndrome which has a constellation of what symptoms?
3. abdominal obesity
why is type 2 diabetes undetected for a long time?
1. slow and progressive glucose intolerance
2. symptoms are mild
The classic clinical manifestations of diabetes:
"The three P's"
1. polyuria-increased urination
2. polydipsia- increased thirst as a result of the excess loss of fluid associated with osmotic diuresis
3. polyphagia- increased appetite due to the catabolic state induced by insulin deficiency and the breakdown of protein and fats
mild symptoms associated with high glucose levels that leads to type 2 diabetes?
5. poorly healing wounds
6. vaginal infections
7. blurred vision
Consequence of undetected diabetes
long-term diabetes complications
1. eye disease
2. peripheral neuropathy
3. peripheral vascular disease
type 1clincial characteristics
5-10% of all diabetes
1. onset any age; USUALLY YOUNG (<30yrs)
2.usually thin at diagnosis; recent weight loss
3. etiology includes: genetic, immunologic, and environmental factors (virus)
4. often have ISLET cell antibodies
5. often have antibodies to insulin even before insulin treatment
6. little or no endogenous insulin (insulin pancreas makes)
7. need exogenous insulin to perserve life (injections)
8. ketosis prone when insulin absent
9. acute complication of hyperglycemia; diabetic ketoacidosis
type 2 clinical characteristics
90-95% of all diabetes
obese--80% of type 2
1. onset any age, USUALLY >30yrs
2. usually obese at diagnosis
3. causes include: obesity, heredity, and environmental factors
4. no islet cell antibodies
5. decrease in endogenous insulin, or increased with insulin resistance (needs more insulin to produce the same effect)
6. most patients can control through weight loss
7. oral antidiabetic agents help if diet and exercise don't help
8. may need insulin on short or long-term basis to prevent hyperglycemia
If you have type 2 diabetes and your doctor says you need to start using insulin, it means you're failing to take care of your diabetes properly.
For most people, type 2 diabetes is a progressive disease. When first diagnosed, many people with type 2 diabetes can keep their blood glucose at a healthy level with oral medications. But over time, the body gradually produces less and less of its own insulin, and eventually oral medications may not be enough to keep blood glucose levels normal. Using insulin to get blood glucose levels to a healthy level is a good thing, not a bad one -
Myth: People with diabetes are more likely to get colds and other illnesses.
Fact: You are no more likely to get a cold or another illness if you have diabetes. However, people with diabetes are advised to get flu shots. This is because any illness can make diabetes more difficult to control, and people with diabetes who do get the flu are more likely than others to go on to develop serious complications.
why is DKA uncommon in type 2 diabetes?
there is enough insulin present to prevent the breakdown of fat and the accompanying production of ketone bodies.
gestational diabetes clinical characterisitics and implications
>onset during pregnancy, USUALLY 2 OR 3RD trimester
> due to hormones secreted by the placenta, which inhibit the action of insulin
>above normal perinatal complications, esp. with babies greater or equal to 9lbs (macrosomia)
>treated with diet; insulin if needed
>30-40% will develop type 2 within 10 years
risk factors for gestational diabetes?
previous large babies(>9lbs)
family history of diabetes
ethnicity (african, asian, pacific islanders, Hispanic, and native Americans)
High or average risk pregnant women should be screened with the glucose challenge test for gestational diabetes between_____ and _____ weeks/months/years?
about 2 months
criteria for low risk individuals for gestational diabetes?
1. <25 years old
2. normal weight BEFORE pregnancy
3. member of low prevalence ethnic group
4. no history of abnormal glucose tolerance
5. no first degree relatives with diabetes
6. no history of poor obstetric (childbirth)outcomes
goal for blood glucose level during pregnancy?
before meals: 105 mg/dL or less
2hr after meals: 130 mg/dL or less
criteria for the DIAGNOSIS of diabetes?
1. symptoms of diabetes (classic: polyuria, polydispsia, unexplained weight loss) +
casual plasma glucose concentration of 200 mg/dL or greater
2. fasting plasma glucose: 126 mg/dL
3.two-hour postload glucose 200 mg/dL or greater during an oral glucose tolerance test.
what does "casual" mean (casual plasma glucose)
what does "fasting" mean (fasting plasma glucose)
anytime of day without regard to when the last meal was.
no caloric intake for atleast 8hrs
normal fasting glucose
after meals (70-140)
prediabetes glucose lab value
141-200 post meal
diabetes glucose lab value
125 mg/dL or more
For patients who are obese and have diabetes and DO NOT TAKE insulin or sulfonylurea, what is more important; consistent meal timing or decreasing the overall caloric intake
consistent meal timing is important but NOT AS CRITICAL as decreasing the overall caloric intake
Why should diabetic patients regardless if they take insulin or other meds NEVER skip meals
pacing food intake throughout the day places more manageable demands on the pancreas
What is essential with MEAL PLANNING in patients who require insulin to help control glucose levels
maintaining as much consistency as possible in the amount of calories and carbohydrates ingested at each meal
The main goal of diabetic treatment?
to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications
Intensive treatment is defined as?
3-4 insulin injections/day
continuous subcutaneous insulin infusion (insulin pump therapy) + frequent blood glucose monitoring
weekly contacts with diabetes educators
Therapeutic goal for diabetes management?
achieve normal blood glucose levels without hypoglycemia while maintaining a high quality of life.
What are the five components of diabetes management?
1. nutritional therapy
2. pharmacologic therapy
Foundations of diabetes management
nutrition, meal planning, weight control, and increased activity
nutritional management of diabetes includes the following goals
1. achieve and maintain: blood glucose levels, lipid and lipoprotien profile, blood pressure
2. to prevent/slow, the rate of development of chronic complications of diabetes by modifying nutrient intake and lifestyle
3. taking into account personal and cultural preferences and willingness to change when addressing nutritional needs
4. to maintain the pleasure of eating by ONLY limiting food choices when indicated by scientific evidence.
what is the
for patients who are
weight loss (its also a major factor in preventing diabetes)
-small as 5%-10% of total weight may significantly improve blood glucose levels.
education addressing nutrition with diabetic patients
addressing the importance of consistent eating habits, the relationship of food and insulin, and the provision of an individualized meal plan.
why do carbohydrates have the greatest effect on blood glucose levels?
they are more quickly digested than other foods and are converted into glucose rapidly.
what is the leading cause of death and disability among people with diabetes?
coronary heart disease
-keep dietary cholestrol <300mg/day
increased fibers? good or bad?
good may help reduce blood glucose levels, decrease the need for exogenous insulin, and lower total cholestrol and low-density lipoprotein levels in the blood.
-it increases satiety which is helpful for weightloss
foods such as legumes, oats, and some fruits.
-plays a slightly higher role in lowering blood glucose and lipid levels than does insoluble fiber.
-slows the stomach emptying and movement of food through the upper digestive tract.
whole-grain breads, cereal, and some veggies
what is one risk for suddenly increasing fiber?
may require adjusting the dosage of insulin or oral agents to prevent hyperglycemia.
-it make include abdominal fullness, nausea, diarrhea, increased flatulence, and constipation if fluid intake is inadequate.
why is reading food labels and counting carbohydrates an important nutritional tool?
Labels include how many grams of carbs are in that food which is needed to determine the amount of medication needed.
-carb counting is essential because they are the main nutrients in food that influence blood glucose levels.
what is the percent converted into glucose of carbohyrdates and proteins ?
100% of carbs are converted
50% of protein
food recommendations for lowering the glycemic index?
1. combining starchy foods with protein and fats
2. eating foods raw and whole instead of eating them chopped, pureed, or cooked. (except meat)
3. eating a whole fruit instead of drinking juice
4. adding foods with sugars to the diet may lower glycemic index IF they are eaten with foods that are more slowly absorbed.
What recommendations should you advise your diabetic patient with about alcohol?
1. moderation (1 drink for women, 2 for men)
2. lower-calorie/less sweet drinks (light beer, dry wine)
3. food intake along with alcohol consumption.
4. type 2 and wish to control weight--->incorporate calories in meal plan.
what is a concern regarding alcohol consumption in diabetic pt?
>alcohol is absorbed before other nutrients and does not require insulin for absorption, increasing the risk for DKA because large amounts can be converted into fat
>alcohol decreases normal physiologic reactions in the body that produce glucose, which increases the liklihood for pts drinking on an empty stomach of
Sweeteners advised for diabetic patients?
artificial sweeteners is acceptable especially if it assists in overall dietary adherence.
Why is exercise important in diabetic management?
-lowers glucose levels-increasing the uptake of glucose by body muscles
-improves circulation and muscle tone
-increases metabolic rate (useful in weight loss)
-increases HDL levels (good cholesterol)
-decreases total cholesterol and lipoprotein levels.
risk factors for heart disease
high cholesterol levels
family history of heart disease
general considerations for exercise in people with diabetes?
>exercise 3x/week with no more than 2 consecutive days without
>resistance training twice a week
>exercise same time and duration
>use proper footwear
>avoid trauma to the lower extremities (esp. in patients with peripheral neuropathy)
>inspect feet after exercise
>avoid exercise in extreme hot/cold
>avoid exercise in periods of poor metabolic control
when should you not advise your patients to exercise?
blood glucose levels exceed 250 AND have ketones in their urine
Why is it recommended to lower blood glucose level to more normal ranges BEFORE beginning an exercise regime?
because exercising with elevated blood glucose levels
the secretion of glucagon, growht hormone, and catecholamines, which stimulates the liver to release more glucose, increasing the blood glucose level further.
what is recommended for a patient treated with insulin engaging in moderate exercise?
a normal person experiences a decrease in insulin with exercise that pts with insulin do not.
> so they should eat a 15g
snack of carbs
BEFORE so they dont experience hypoglycemia.
>eat a snack at the END of a strenuous or prolonged exercise to avoid post-exercise hypoglycemia.
Can insulin sensitivity be reversed?
What is important to know about the monitor and strips when using a self-monitoring glucose device?
to know whether the monitor and strips are showing whole blood or plasma blood levels.
>plasma glucose levels are 10-15% higher than whole blood levels
how often should patients conduct a comparison of their self-monitoring glucose device results with a simultaneous lab?
every 6-12 months
common sources of error of SMBG testing?
1. improper application of blood (eg., drop too small)
2. damage to the reagent strips from heat or humitiy
3. outdated strips
4. improper cleaning and maintenance
candidates for SMGB (self monitoring glucose system)
>everyone with diabetes
>critical component for any intensive insulin therapy regimen (2-4 injection/day)
>diabetic management during pregnancy
>tendency to develop severe ketosis or hypoglycemia
>hypoglycemia w/o warning signs
frequency of SMGB
--> whenever hypo/hypergylcemia is suspected; changes in medications, activity, diet; and with stress and illness
pt requiring insulin
pt take insulin before meals (a.c.)
-->at least 3x/day before meals to determine each dose
pt not receiving insulin
-->2-3x/week; including 2hr posprandial test.
A continuous glucose monitoring system (CGMS) is most useful in which type of diabetes?
The data from the device are downloaded after 72 hours, which isnt helpful in knowing specific insulin doses, yet is useful in determining whether treatment is adequate over a 24hr period.
When is insulin therapy used
bc body loses ability to produce insulin
2. type 2:
-->when insulin deficiency occurs or when meal-planning and oral agents are ineffective
-->during illness, infection, pregnancy, surgery, or some other stressful event.
only insulin approved for IV use?
short-acting insulins or
(marked wiht R on bottle)
rapid-acting insulin agents
rapid acting insulin time course of actions
--> around 5-10 min
--> around 40-60 min
short acting insulin:
(course of actions)
--> 30-60 min
--> 2-3 hours
--> 4-6 hours
(course of actions)
very long-acting insulin:
(course of actions)
-->continuous (no peak)
short-acting insulin: indications
usually administered 20-30 min before a meal; can be taken alone or in combination with longer-acting insulin
short-acting insulin agents
regular (Humulin R, Novolin R, Iletin ll Regular)
long-acting insulin (intermediate): indications
usually taken after food
intermediate-acting insulin agents
NPH (neutral protamine Hagedorn)
(Humulin N, Iletin ll Lente, Iletin ll NPH, Novolin N [NPH])
long-acting insulin agents
long-acting insulin indications
used for basal dose
-given once a day at any time of day BUT MUST be the
everytime to prevent overlaps
-recommended to take in morning to ensure the pt takes dose.
rapid reduction of glucose level, to treat postprandial hyperglycemia, and to prevent nocturnal hypoglycemia
What meals-and-snacks- are being "covered" by which insulin doses?
>the increase in glucose levels a.c.
>the increase immediately after the injection
>covers subsequent meals
>act as basal insulin by providing a relatively constant level of insulin
>vary from 1-4 injections/day
>usually a combination of a short+long-acting insulin
>goal of all but the single dose injection is to mimic pancreas secretion
advantages/disadvantages of insulin regimen: ONE INJECTION
(before breakfast: NPH; NPH w/ rapid-acting insulin)
: simple regime
1.difficult to control fasting blood glucose if effects of NPH do not last
2. afternoon hypoglycemia may result from attempts to control fasting glucose level by increasing NPH dose
advantages/disadvantages of insulin regimen: TWO INJECTIONS-MIXED
[Before Breakfast and Dinner: (NPH or NPH with fast-acting insulin, or premixed rapid-acting insulin)]
: simplest regime that attempts to mimic the pancreas
1. need relatively fixed schedule of meals and exercise
2. cannot independently adjust NPH or regular if premixed insulin is used
advantages/disadvantages of insulin regimen: THREE OR FOUR INJECTIONS
[rapid-acting insulin before each meal with; NPH at dinner, NPH at bedtime or Glargine 1/2 times/day]
1. more closely mimics the pancreas than 3-injection regimen
2. each premeal dose of regular insulin is decided independently
3. more flexibility with meals and exercise
1. requires more injections than other regimens
2. requires multiple blood glucose tests on a daily basis
3. requires intentsive education and follow-up
advantages/disadvantages of insulin regimen: INSULIN PUMP-BASAL RATE
[uses only rapid-acting insulin infused at continuous, low rate called BASAL RATE and premeal BOLUS DOSES activated by pump wearer]
1.most closely mimics normal pancreas
2. increases meal and exercise flexibility
1. requires intensive training and frequent follow-up
2. potiental for mechanical problems
3. requires multiple blood glucose level tests on a daily basis
4. potential increase in expenses depending on insurance
conventional insulin regime
1. simplified regimen (1 or more injections involving a mixture of short and intermediate-acting insulins per day)
vary meal and exercise patterns
3. good for terminally ill, older adult who is frail and limited self-care abilities, pt who are unwilling or unable to engage in self-management activities of more intensive regimen
complex insulin regimen to achieve as much conrol over blood glucose levels as is safe and practical. (
3-4 injections a day
>allows pt for more flexibility to change insulin doses to meet their daily needs
>the risk for severe hypoglycemia increases threefold
GOOD FOR PATIENTS
1. patients who received kidney transplant and need to preserve the function of new kidney
NOT GOOD FOR PATIENTS
1. nervous system disorders
2. recurring severe hypoglycemia
3. irreversibble diabetic complications--blindness or ESKD
4. cerebrovascular or heart disease
5. ineffective self-care skills
complications of insulin therapy
1. systemic or local
: loss of subcutaneous fat caused by repeated use of an injection site
resistance to injected insulin
: daily insulin requirement of 200 units or more.
(insulin waning, dawn phenomenon, somogyi Effect)
all insulins cause some antibody production in humans
progressive rise in blood glucose from bedtime to morning
--> increase dose in the evening of intermediate-or-long-acting
relatively normal blood glucose until around 3am, when the levels begin to rise
-->change time of injection of evening intermediate-acting insulin from dinnertime to bedtime
normal or elevated blood glucose at bedtime, a decrease around 2-3am to hypoglyemic levels, and subsequent increase due to the production of counter-regulatory hormones
-->decrease evening of intermediate-acting insulin or INCREASE bedtime snack
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