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Diabetes Care and Education

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This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Athletic Trainer (AT/AL), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Nursing Assistant (CNA), Clinical Nurse Specialist (CNS), Home Health Aid (HHA), Licensed Nursing Assistant (LNA), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Medical Assistant (MA), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Friday, November 20, 2026

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

Outcomes

≥ 92% of participants will know the significance of diabetes, how to identify the correct type of diabetes, and how to plan and deliver evidence-based, patient-centered diabetes care and education to improve diabetes outcomes.

Objectives

After completing this module, the learner will be able to:

  1. Determine the incidence and prevalence of diabetes.
  2. Differentiate between the different types of diabetes.
  3. Explain why glycemic control is important to diabetes care.
  4. Identify the four critical times for diabetes education.
  5. Describe technology used in supporting diabetes management.
  6. Summarize common barriers that prevent adherence to and compliance with the diabetic treatment regimen.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.
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Author:    Sarah Beattie (DNP, APRN-CNP, CDCES)

Introduction

Diabetes is a chronic and complex disease that affects 537 million people worldwide between 21-79 years old. Though some countries have lower rates of diabetes, in low to middle-income countries, diabetes affects every three in four adults (International Diabetes Federation, 2021). The Centers for Disease Control and Prevention (CDC) National Diabetes Statistics Report (2024b) found that 38.1 million adults, or 14.7% of the U.S. adult population, have been diagnosed with diabetes. Unfortunately, another 8.4 million adults in the U.S. were undiagnosed, while a staggering 38% of the population has prediabetes. The incidence of diabetes is highest in non-Hispanic blacks and people of Hispanic origin. The highest prevalence of diabetes occurred among American Indians and Alaskan Natives. It was also noted that new cases of both type 1 and type 2 diabetes have increased in children (CDC, 2024b). These staggering statistics underscore the urgent need for nurses who are competent in the knowledge of diabetes as it relates to care, education, and self-management.

Diabetes Overview

Diabetes is a chronic disease of glucose regulation in which the body does not make insulin or cannot effectively use insulin to transport glucose into the body's cells, resulting in hyperglycemia. Common symptoms of hyperglycemia include polyuria, polydipsia, polyphagia, blurred vision, and fatigue. Severe hyperglycemia can cause shortness of breath, nausea, vomiting, or altered mental status. There is currently no cure for diabetes. If not identified and treated, hyperglycemia has a significant impact on all organs of the body, leading to increased morbidity and mortality. Nurses are vital leaders in healthcare, positioned to partner with patients to educate patients on pathophysiology, treatment, prevention of complications, and identification of barriers to successful self-management to improve diabetes outcomes.

Type 1 Diabetes Mellitus

Type 1 diabetes mellitus (T1DM) is an autoimmune disease in which antibodies attack the pancreatic β-cells, causing an insulinopenic state resulting in hyperglycemia. β-cell destruction occurs at variable rates, though it typically occurs faster in infants and children and slower in adults (American Diabetes Association [ADA], 2024a). Not all patients with autoimmune diabetes have positive autoantibodies, making diagnosis difficult at times. Antibodies identified in the pathogenesis of T1DM include:

  • Insulin autoantibody
  • Glutamic acid decarboxylase (GAD)
  • Protein tyrosine phosphatase (IA-2 or IA-2β)
  • Zinc transporter 8 (ZnT8)

Though no single cause has been identified, hypothesized links exist between genetic predisposition and environmental factors such as viruses, alterations in the gut microbiome, and environmental toxins that trigger the autoimmune process (Zajec et al., 2022). Cancer treatments with checkpoint inhibitor immunotherapy can also trigger T1DM by altering the immune system. These patients often do not have positive antibodies. 

Historically, T1DM was diagnosed when the patient was symptomatic with severe hyperglycemia, which often was at diagnosis of diabetic ketoacidosis (DKA). DKA is a life-threatening complication of T1DM. It has now been identified that T1DM progresses in three stages, described in Table 1. Understanding the stages of T1DM can result in earlier intervention and possible delay in transition to stage 3 T1DM and avoidance of DKA.

Table 1. Stages of T1DM
Stage 1This is the earliest stage of T1DM, in which two or more autoantibodies are present despite clinically normal blood sugar levels.
Stage 2This next stage of T1DM is defined as having multiple autoantibodies present but with the progression to abnormal blood sugar levels with or without symptoms of hyperglycemia. This is defined as a fasting blood glucose between 100-125 milligrams per deciliter (mg/dL), a 2-hour post-prandial glucose reading of 140-199 mg/dL, or a hemoglobin A1c (HbA1c) of 5.7-6.4%.
Stage 3This stage of T1DM is overt hyperglycemia, meeting diagnostic criteria for diabetes with fasting blood sugar > 126 mg/dL or HbA1c of > 6.5%. At this stage, the autoantibodies can become absent.
(Greenbaum et al., 2024)

Current research has shown that T1DM can be identified in earlier stages, which can improve the time to treatment, reduce the incidence of DKA, and offer an approved treatment with Teplizumab to delay progression to stage 3 T1DM.

Risk factors for developing T1DM include a family history of T1DM and the presence of other autoimmune disorders. If there is a family history of T1DM in a first or second-degree relative, screening for T1DM should take place even if the person is asymptomatic.

Type 2 Diabetes Mellitus

The most prevalent diabetes diagnosis in the United States is type 2 diabetes mellitus (T2DM), accounting for up to 95% of cases (ADA, 2024a). Glycemic dysregulation in T2DM is related to insulin resistance and, at times, reduced insulin production. In T2DM, there is not a total lack of insulin production from the β-cells, like in T1DM, so the risk of DKA is lower.

As with T1DM, there is no one single cause of T2DM. A predominant factor in most people with T2DM is being overweight or obese. An excessive caloric intake coupled with a sedentary lifestyle leads to increased adipose tissue in the body, increasing insulin resistance; this insulin resistance results in hyperglycemia, thus perpetuating insulin production from the beta cells. Hyperinsulinemia disrupts the body's natural mechanisms to regulate insulin and glucagon, resulting in continued hyperglycemia. Over time, β-cells burn out, causing a decline in endogenous insulin production. Inflammation, oxidative stress, fatty liver, disruption in the gut microbiome, and other factors also contribute to the progression of hyperglycemia (Galicia-Garcia et al., 2020). These pathologic processes are slow and insidious. Many patients do not recognize hyperglycemic symptoms until the blood sugars have been elevated for some time. Without diligent screening, those diagnosed with T2DM have had elevated blood sugars typically for up to five years before diagnosis.

Diagnosing T2DM requires one of the following (Inzucchi & Lupsa, 2024):

  • HbA1c ≥ 6.5%
  • Fasting plasma glucose ≥ 126 mg/dL
  • 2-hour plasma glucose ≥ 200 mg/dL during oral glucose tolerance test (OGTT)
  • Random plasma glucose ≥ 200 mg/dL (defined as any time of the day without regard to time since the previous meal) 

The ADA identifies numerous risk factors for T2DM. Adults with identified risk factors should be screened every three years, though more frequent testing can be performed depending on the results and risk factors. If no risk factors are identified, screening starts at age 35(Inzucchi & Lupsa, 2024).  

Risk factors for T2DM include (ADA, 2024a):

  • First-degree relative with diabetes
  • High-risk race and ethnicity (African American, Latino, Native American, Asian American, Pacific Islander)
  • History of cardiovascular disease
  • Hypertension
  • High-density lipoprotein (HDL) cholesterol level < 35 mg/dL and/or a triglyceride level > 250 mg/dL
  • Polycystic ovary syndrome
  • Sedentary lifestyle
  • Other conditions associated with insulin resistance, such as severe obesity or the presence of acanthosis nigricans

Screening should occur yearly for those diagnosed with prediabetes. If other risk factors are not present, screening should occur at least every three years for those with a history of gestational diabetes mellitus (GDM). Certain medications carry a high risk of T2DM, and a screening plan should be individualized. Human immunodeficiency virus (HIV) and a history of pancreatitis also increase the risk of T2DM; thus, screening should be individualized based on the entire clinical picture.

Prediabetes

Prediabetes is the diagnosis given to those whose blood sugar is above normal levels but does not meet the criteria for T2DM. This diagnosis includes impaired fasting blood glucose (IFG) and impaired glucose tolerance (IGT). The multifactorial underlying mechanisms in prediabetes are the same as T2DM, though they derive from being overweight or obese and a sedentary lifestyle. The risk of transitioning to T2DM is high, but with intensive intervention, progression to T2DM can be delayed or prevented. Unfortunately, most people with prediabetes do not even know they have it.

Diagnostic criteria for prediabetes consist of one of the following (ADA, 2024a):

  • Fasting glucose = 100-125 mg/dL (IFG)
  • 2-hour 75-gram OGTT = 140-199 mg/dL (IGT)
  • HbA1c = 5.7-6.4%

Risk factors for prediabetes are the same as T2DM, thus making screening even in asymptomatic patients with risk factors imperative.

Gestational Diabetes

GDM is the development of hyperglycemia due to glucose intolerance during pregnancy, specifically around the 24th week of gestation in an individual without pre-existing diabetes or hyperglycemia. In early pregnancy, the mother's body becomes more insulin-sensitive. During later pregnancy, the placental hormones create an environment of insulin resistance, creating β-cell dysfunction, thus, hyperglycemia. It has been noted that in GDM, insulin resistance reduces glucose uptake by over 50%. Placental hormones and their effect on glycemic control include the following (Shamsad et al., 2023):

  • Estrogen reduces insulin activity.
  • Progesterone inhibits pathways signaling glucose uptake from the bloodstream.
  • Human placental lactogen improves glucose uptake and glycogen production, but this positive effect is not enough to overcome the other hormones, which have a negative glycemic effect.
  • Human placental growth hormone and pituitary growth hormone increase insulin production. However, they also decrease glucose uptake and glycogen synthesis and impair the ability of insulin to suppress the hepatic production of glucose.
  • Cortisol, tumor necrosis factor alpha (TNFα), and cytokines decrease insulin signaling and increase insulin resistance.

Diagnosis of GDM is a challenge as there are now many women in their reproductive years with undiagnosed hyperglycemia, contributing to missed diagnoses of pregestational T2DM. Due to this concern regarding the rising rates of T2DM in younger patients, screening for hyperglycemia earlier in pregnancy is advised. The ADA recommends preconception counseling and screening, though if this did not occur, screening under 15 weeks gestation can be considered if risk factors for T2DM are present. Individuals with early gestation altered glucose metabolism have a higher risk of developing GDM during pregnancy, a higher risk of needing insulin treatment, and higher pregnancy complication rates, making early diagnosis crucial. Of note, HbA1c is not a recommended test for diagnosis after 15 weeks of gestation. Early screening positive results include (ADA, 2024a):

  • Fasting blood glucose > 110 mg/dL
  • HbA1c > 5.9%

If early screening is negative or there are no concerns regarding hyperglycemia, routine GDM screening starts at 24-28 weeks gestation. Routine screening includes the one-step or two-step OGTT approach. There is currently controversy about which testing approach is best. The testing option is determined based on the clinical situation and shared decision-making between the patient and provider (ADA, 2024a).

One-Step  

75-gram OGTT (fasting, defined as at least eight hours of overnight fasting). A baseline fasting blood glucose level is completed. The patient then ingests 75 gm of glucose. Glucose level is again measured at one and two hours after the glucose load.

The diagnosis of GDM is made when any of the following plasma glucose values are met or exceeded:

  • Fasting: 92 mg/dL
  • One hour: 180 mg/dL
  • Two hours: 153 mg/dL 

Two-Step

Step 1, 50-gram OGTT: The patient consumes 50-gram glucose (non-fasting), with plasma glucose levels tested after 1 hour.

If the glucose level is ≥ 130, 135, or 140 mg/dL, proceed to a 100-gram OGTT.

Step 2, 100-gram OGTT: The patient consumes 100-gram OGTT (fasting) with plasma glucose levels tested after one, two, and three hours.

The diagnosis of GDM is made when at least two of the following four plasma glucose levels (measured fasting and at one, two, and three hours during OGTT) are met or exceeded:

  • Fasting: 95 mg/dL
  • One hour: 180 mg/dL
  • Two hours: 155 mg/dL
  • Three hours: 140 mg/dL

Risk factors for developing GDM include the same risk factors for developing T2DM. Additional risk factors include a previous pregnancy affected by GDM, having delivered a baby larger than nine pounds, or if the patient is over the age of 25 (CDC, 2024c).

Other Causes of Diabetes

Most cases of diabetes are T1DM or T2DM, though there are other cases of diabetes to consider (ADA, 2024a):

Pancreatic Diabetes

Conditions such as acute or chronic pancreatitis, pancreatic surgery, trauma, neoplasia, cystic fibrosis, hemochromatosis, and other rare genetic and idiopathic disorders cause the loss of the structural and functional capacity of the pancreas, resulting in hyperglycemia.

Post-Transplant Diabetes

This is the new onset of diabetes after an organ transplant. Stress, steroid use, and side effects of antirejection medication result in hyperglycemia that is ongoing after stabilization of the antirejection medication regimen and without an active infection. The gold standard for diagnosis is the OGTT performed one year after transplant.

Monogenic Diabetes

This term includes monogenic diabetes of the young (MODY) and neonatal diabetes. These are genetic deficits that cause β-cell dysfunction. Several specific genetic mutations can occur with each disease. MODY typically occurs in young patients under the age of 25, and there is typically a family history of diabetes that does not fit the classical T1DM or T2DM picture. Genetic testing and referral to a diabetes specialist are recommended if MODY is suspected. Neonatal diabetes rarely occurs after six months of age and can be transient or permanent. Correct diagnosis is critical in these circumstances, as treatment is specified based on the genetic mutation. However, these clinical pictures can be confused with T1DM or T2DM, leading to misdiagnosis and incorrect treatment plans.

Diabetes Education

Glycemic control is the primary goal of diabetes management; this control is achieved through pharmacologic interventions in conjunction with lifestyle and behavior changes. Achieving glycemic control is necessary to reduce morbidity and mortality. Common diabetes-related chronic complications are nephropathy, retinopathy, neuropathy, and cardiovascular disease, which cause significant disability and reduced quality of life. Acute complications include hyperglycemia (DKA and hyperosmolar hyperglycemic state [HHS]) as well as hypoglycemia events, both with short and long-term ramifications.

Pharmacologic agents used to treat diabetes include oral agents, insulin injections, non-insulin injections, and continuous subcutaneous insulin infusions (CSII). The choice of agent depends on the type of diabetes, current glycemic control, presence of diabetes complications, co-morbid conditions, side effect profile, and patient preference.

Diabetes education is vital to the lifestyle changes and behavior modifications needed to improve glycemic control in diabetes management. Diabetes management aims to facilitate knowledge regarding diabetes, personalize treatment plans, and create goals that can be implemented to continually improve glycemic control and reduce diabetes complications while avoiding burnout and diabetes distress. This lofty aim in diabetes management can be achieved using a patient-centered and evidence-based approach to diabetes education.

Diabetes education should occur at four critical times during the diabetes journey (Powers et al., 2020):

  1. At diagnosis
  2. Annually or sooner if struggling to meet personalized diabetes targets
  3. When complicating factors develop, such as:
    • Pregnancy
    • Development of diabetes complications
    • Physical or cognitive change affecting diabetes management
  4. When transitions in life occur:
    • Change in living situation (hospitalization, nursing home, assisted living)
    • Significant change in diabetes management (new insulin/insulin pump)
    • Age-related changes in self-management (hearing, vision changes)

Assessment of the Learner

Before delivering diabetes education, the nurse will assess the patient to understand their learning needs. First, a physical and psychological assessment is completed, including a personal and family health history, including a history of diabetes complications. Assessing social determinants of health (SDOH) offers insights into the patient's economic and living situation, social support, and healthcare access. Assessment of current diabetes-related data, including body mass index (BMI), blood pressure, HbA1c, renal function, lipid profile, and blood glucose offers a starting point for future data comparison. Next, assess the patient's mental health status, including coping skills. Items such as the Patient Health Questionnaire-9 (PHQ-9) or Patient Health Questionnaire-2 (PHQ-2) can help assess for underlying depression in those with diabetes (ADA, 2024b). There are other valuable and validated tools to use in screening for mental health conditions related to diabetes, which can be found here (ADA, 2021).

The patient's assessment also includes current diabetes self-management behaviors and knowledge. Understanding their diet, physical activity, and glycemic monitoring patterns is helpful. Investigate the use of resources or technology to manage diabetes. Ask how they problem-solve regarding their diabetes care. Ask the patient about diabetes-related complications and their knowledge of their risk of future complications.

Also, evaluate the patient's personal diabetes goals and potential barriers to reaching those goals. It is vital to assess their literacy or numeracy level. Evaluate for their preferred learning style or any learning considerations such as developmental stage, language barrier, spiritual or cultural preferences, learning disabilities, or specific family/caregiver dynamics (ADA, 2024b). Assessing the patient's readiness to change is essential at this stage. Prochaska's Transtheoretical Model is often used to identify where patients are in their readiness to change (Yeshiva University, 2021).

  • Precontemplation: The patient has not yet recognized there is a problem.
  • Contemplation: The patient realizes there is a problem but has not thought about changing.
  • Preparation: The patient starts planning for change.
  • Action: The patient implements the change.
  • Maintenance: The patient maintains change.
  • Relapse: The patient stops maintaining change, and the problem returns.

Patients move up and down the model over time. The educator focuses on identifying where the patient is starting and how to guide them through the maintenance stage and achieve long-term maintenance while avoiding relapse (Yeshiva University, 2021).

Delivery of Diabetes Education

After the patient is assessed, a personalized diabetes education plan can be developed. Topics addressed in diabetes education will vary from patient to patient based on factors such as diabetes type, previous diabetes knowledge, physical and cognitive barriers, and preferred learning styles. Patients must understand their type of diabetes, etiology, and treatment expectations.

The American Diabetes Care and Education Specialists (ADCES) developed the ADCES7, previously called the AADE7, which consists of seven topics to ensure comprehensive diabetes education (American Association of Diabetes Educators [AADE], 2020):

  • Healthy coping
  • Healthy eating
  • Being active
  • Taking medications
  • Monitoring
  • Reducing risk
  • Problem solving

Healthy Coping

During diabetes education, it is crucial not only to evaluate for any mental health conditions that may affect diabetes self-management but also to educate patients that self-management can be daunting. Diabetes distress and burnout can result in patients experiencing tension, fatigue, or a sense of being overwhelmed (ADCES, 2021). Assist the patient in recognizing these symptoms and how they impact their glycemic control. Referral to a mental health specialist is recommended if the patient has any positive screening tests or is demonstrating signs of distress or burnout.

Healthy Eating

Education regarding a healthy eating plan should be individualized based on access to foods and willingness to change eating habits while meeting the spiritual and cultural needs of the patient. There is no one specific diet recommendation for diabetes. Each patient should be educated on how to read a nutrition label. A healthy diet is recommended to include non-starchy vegetables, whole fruits, legumes, whole grains, nuts/seeds, and low-fat dairy products while minimizing meat, sugar-sweetened beverages, sweets, and highly processed foods (ADA, 2024b). For those on insulin therapy or sulfonylurea medications, education includes the need for consistent carbohydrates at each meal to avoid hypoglycemia. Carbohydrate counting education is often needed for those on intensive insulin therapy. The focus is on balancing the diet to achieve a healthy weight, attain glycemic, blood pressure, and lipid goals, and prevent or delay diabetes-related complications. A referral to a registered dietician is recommended to implement medical nutrition therapy (ADA, 2024b).

Being Active

Physical activity is another key component of diabetes education for optimal glycemic and cardiovascular outcomes. Evaluate the patient's current physical activity status and barriers to physical activity. Table 2 lists the ADA recommendations for physical activity.

Table 2. Physical Activity Recommendations
Children and YouthAttain 60 minutes daily moderate to vigorous exercise with muscle/bone strengthening activities three days per week.
Adults with T1DM and T2DMAchieve 150 minutes or more of moderate to vigorous-intensity aerobic activity per week. This includes at least three activity days with no more than two consecutive days without activity. A minimum of 75 minutes per week of vigorous-intensity or interval training may be sufficient for younger and more physically fit individuals. Patients should engage in resistance exercise two to three days per week on non-aerobic activity days.
Older AdultsFocus on flexibility and balance training 2-3 days per week.
For all Patients with DiabetesInterrupt sitting every 30 minutes with some form of movement.
(ADA, 2024b)

Taking Medications

Patient education includes ensuring that patients know what medications they are taking and why. Keeping an accurate medication list in the medical record, including any over-the-counter supplements, is crucial. Patients must also be aware of how to properly take the medication, potential side effects, and the risk of hypoglycemia with medications. For those taking injectable medications, such as insulin or other non-insulin injectable medications, education must include choosing the correct dose, using the syringe or pen, and appropriate injection sites and techniques (AADE, 2020). Both insulin and non-insulin injectable medications are given as a subcutaneous injection.

How to give a subcutaneous injection:

  1. Choose an injection site. Appropriate injection sites are the abdomen (two inches away from the belly button), outer thighs, back of the arms, and upper buttock.
  2. Make sure the skin is clean.
  3. Pull up and pinch a fold of skin.
  4. Insert the needle at a 90° angle.
  5. Push the plunger and hold the syringe and needle in place for 5-10 seconds.
  6. Remove the needle.
  7. Do not rub the injection site (Weinstock, 2024).

There are many reasons why patients may not adhere to their medical therapy. Cost, fear of side effects, fear of hypoglycemia, or other SDOH are just a few very common barriers to taking medication. Asking open-ended questions nonjudgmentally can help understand barriers and create a plan to address them.

Technology can assist in improving medication adherence (AADE, 2020). There are phone apps that can set reminders that will alarm when it is time to take medications. There are also apps available for those on multiple insulin doses a day or with difficulty calculating insulin doses to help with reminders and calculating doses. CSII uses an insulin infusion pump to deliver a continuous basal insulin rate and boluses for carbohydrates and correction boluses. Many of these devices are now hybrid closed-loop pumps. These hybrid closed-loop insulin pumps communicate with a continuous glucose monitor (CGM) to create personalized insulin delivery systems based on patient glucose patterns. Smart insulin pens can link to apps that can assist patients with calculating insulin doses, help remind patients when to take insulin, and show the last dose given and the amount of insulin still on board. Several apps can log glucose data and aid in patient motivation to improve compliance with treatment regimens. A list of available options can be found here.

Monitoring

Monitoring glycemic control assists the patient and healthcare provider in determining the effectiveness of treatment plans and customized goals. Improving glycemic control with patient involvement can reduce microvascular and macrovascular complications, such as cardiovascular disease and diabetes-related retinopathy, nephropathy, and neuropathy. Blood glucose monitoring does not have a one-size-fits-all approach. The glucose monitoring needs must be individualized to each patient's unique situation. The frequency of monitoring will depend on the type of diabetes, diabetes medications, and patient preferences and lifestyle. It is recommended for those on multidose insulin therapy to check blood sugar before each meal and at bedtime. Those with GDM often check blood sugar fasting, before meals, and two hours after meals. Patient education includes a personalized approach to instructing on the frequency of testing blood glucose and by what method.

Traditionally, blood glucose monitoring is done with a fingerstick reading using a handheld glucometer. In recent years, the use of CGM technology has improved the ease and frequency of monitoring and shows a reduction in HbA1c levels (Nemlekar et al., 2023). CGMs are wearable diabetes technology devices showing real-time or intermittent glucose readings. The devices stay on the body for 7-14 days, depending on the device used. Many of these devices also have alarms to alert patients of hyperglycemia or hypoglycemia. These devices allow patients to make real-time treatment or meal-based decisions based on blood glucose readings and patterns (ADA, 2024c).

Blood glucose goals should also be discussed with the patient. Like any other part of diabetes education, glycemic goals depend on modifiable and non-modifiable patient factors. For most non-pregnant adults with diabetes, glycemic goals include (ADA, 2024c):

  • HbA1c: < 7%
  • Pre-meal glucose: 80-130 mg/dL
  • Post-meal glucose (1-2 hours after meal): under 180 mg/dL
  • Time in range (if using CGM): > 70% while achieving < 4% time below range

Many patient factors influence how strict or loose glucose control should be. Non-modifiable factors include hypoglycemia or medication side effect risk, duration of diabetes, life expectancy, co-morbid conditions, and established cardiovascular disease. Modifiable factors include patient preferences and support systems. In situations where patients are elderly, frail, have had diabetes for many decades, live alone without a support system, and have a high risk for medication-related adverse events, the glycemic goals will be less stringent. In contrast, a young, active, and healthy adult with a robust support system and newly diagnosed with diabetes will have glycemic goals that are more stringent.

Reducing Risks

Optimal glycemic control will help reduce the risks of diabetes-related complications. Diabetes education focused on risk reduction involves the patient clearly understanding how to prevent and identify acute complications. Chronic complications of diabetes include microvascular and macrovascular complications, retinopathy, nephropathy, and neuropathy. Inform patients on the frequency of screening.

  • Eye exam: Annual comprehensive dilated eye exam starting at diagnosis for T2DM and five years after diagnosis for T1DM.
  • Neuropathy: Annually complete a comprehensive foot exam assessing for deformity, neurological assessment including vibratory and monofilament sensation, and vascular assessment. Patient education includes the daily visual inspection of the feet, as foot ulcers are common in those with neuropathy.
  • Nephropathy: Annual measurements of glomerular filtration rate (GFR) and urinary albumin-to-creatinine ratio starting at diagnosis for T2DM and five years after diagnosis for T1DM (ADA, 2024d).

How to instruct patients on daily foot checks:

  • Check the feet every day, and do not forget to examine the bottom of the feet. Look for blisters, calluses, cuts, red spots, swelling, or any other abnormalities, and call your physician or healthcare provider if there is a problem.
  • Wash the feet every day. Dry them gently, and then apply a moisturizing lotion or cream.
  • Always wear comfortable shoes – they should not be tight – and wear clean, dry socks.
  • Trim the toenails straight across. Do not cut them too short, and do not cut them down the sides.
  • Diabetes often causes peripheral nerve damage, so cold and heat sensations can be blunted. Do not expose the feet to very cold or hot conditions. Do not go barefoot.

Acute complications of diabetes include DKA, HHS, and hypoglycemia. DKA is an acute condition related to hyperglycemia in which the body has insufficient endogenous or exogenous insulin to maintain adequate glycemic control. This insulin deficiency causes the body to break down fat and muscle for fuel, resulting in ketosis. If not identified and corrected, DKA can be life-threatening. DKA typically occurs in those with T1DM but has been seen in other ketosis-prone individuals and those taking sodium-glucose cotransporter 2 (SGLT2) inhibitors. DKA presents with blood glucose levels over 250 mg/dL, though those taking SGLT2 inhibitors can have euglycemic DKA with mildly elevated or normal glucose levels. Symptoms of DKA include fatigue, polydipsia, abdominal pain, nausea or vomiting, acetone breath, hypotension, tachycardia, confusion, and, ultimately, coma (Hassan et al., 2022).

HHS is a non-ketotic state of severe hyperglycemia that occurs typically in those with T2DM and can also be life-threatening. HHS typically presents with glucose levels over 600 mg/dL. Since there is endogenous insulin production in HHS, hyperglycemia is multifactorial and includes decreased insulin action, increased counterregulatory hormones, and profound dehydration. Both DKA and HHS require intensive glycose-lowering treatment with insulin and rehydration, requiring hospitalization. Symptoms of HHS include ongoing polyuria, dehydration, tachycardia, stupor, unconsciousness, and ultimately coma (Hassan et al., 2022).

Hypoglycemia is more common than DKA or HHS, though it can also be life-threatening. The occurrence of hypoglycemia increases with the duration of diabetes, in those with T1DM, and in those with recurrent hypoglycemic events (Lin et al., 2020). Symptoms of hypoglycemia include diaphoresis, hunger, shakiness, irritability, and confusion. Hypoglycemia unawareness is when patients with hypoglycemia have no symptoms during a hypoglycemic event; this can be particularly dangerous. Hypoglycemia increases the risk of not only death but also is associated with higher rates of dementia, microvascular and macrovascular complications, falls, and fractures, particularly in older adults (Mattishent & Loke, 2021).

Treatment plans need to be altered to avoid hypoglycemia in these patients. The use of CGM technology can be beneficial for those who have hypoglycemia unawareness or recurrent hypoglycemia to improve recognition and treatment (Macon et al., 2023). Hypoglycemia, in those with diabetes, is a blood glucose reading below 70 mg/dL. The levels of hypoglycemia are (ADA, 2024c):

  • Level 1: Glucose < 70 mg/dL but ≥ 54 mg/dL
  • Level 2: Glucose < 54 mg/dL
  • Level 3: A severe event that requires assistance for treatment due to altered mental status, irrespective of glucose level 

Hypoglycemia should be discussed at each visit to monitor the frequency of hypoglycemic events and ensure a plan for identifying and treating hypoglycemia is in place.

Some common risk factors for hypoglycemia include (ADA, 2024c):

  • Recurrent hypoglycemia
  • Recent hypoglycemic event (within the past 3-6 months)
  • Chronic kidney disease
  • Fasting – often done for lab work, medical procedures, for health or religious reasons
  • Use of insulin or other high-risk hypoglycemia medications
  • Cardiovascular disease
  • Female sex
  • Polypharmacy
  • Alcohol use
  • SDOH – food insecurity, homelessness, low literacy, low-income status 

Treatment of hypoglycemia for patients who are awake and alert:

Ingest 15 grams of carbohydrates and check the blood sugar in 15 minutes. Repeat if needed. Avoid carbohydrate sources that include fat and protein, as this will slow the absorption of the carbohydrate. 

For those unable or unwilling to ingest carbohydrates by mouth, glucagon can treat hypoglycemia. Glucagon, previously only available in a formulation that required reconstitution, now comes in various forms, including a nasal powder spray and prefilled injectable pens or syringes. The Endocrine Society recommends using the newer forms of glucagon for ease of administration and efficacy (McCall et al., 2023).

Problem Solving

Diabetes education supports the patient in the constantly changing landscape of diabetes self-management by assisting with problem-solving. Problem-solving in diabetes education uses a patient-centered approach to do the following (AADE, 2020):

  1. Identify the problem
  2. Develop specific, measurable, achievable, relevant, and time-bound (SMART) goals
  3. Implement and evaluate the goals

Patients can often identify barriers but may not see any clear solutions to overcoming them. During diabetes education, asking open-ended questions and encouraging the patient to explore multiple options will aid the patient in discovering why barriers are occurring and what to do about them. Barriers to successful diabetes management often include financial barriers such as the cost of medications and diabetes supplies and being uninsured or underinsured. SDOH barriers include food insecurity, homelessness, lack of access to healthcare, and lack of access to healthy foods, all impacting diabetes self-management (Ji et al., 2021; Powers et al., 2020). Other barriers include the lack of time to implement self-care practices, lack of knowledge on the best approach to self-management, poor literacy and numeracy, depression, fatigue, diabetes stigma, and lack of support (ADA, 2024e).

Once barriers are recognized, work with patients to create personalized SMART goals that are specific, measurable, achievable, relevant, and time-bound (CDC, 2024c). Table 3 describes the difference between a basic goal and a SMART goal.

Table 3. Comparing Simple and SMART Goals
Examples of simple goals:

  "I will exercise more."

  "I will eat less carbohydrates with dinner."

  "I will take my weekly non-insulin medication injection every Sunday."
 		Examples of SMART goals:

  "I will walk for 10 minutes three times per week on Mondays, Wednesdays, and Fridays."

  "I will limit my carbohydrates to no more than 45 grams at dinner on Saturdays when we eat at a restaurant."

  "I will use my phone alarm to remind me to take my weekly non-insulin injection every Sunday at 9 am."  

Using SMART goals allows patients and educators to track their success. Diabetes education aims to assist patients in continually evaluating these goals and creating solutions to barriers that keep them from their goals. Using a supportive and nonjudgmental approach to goal setting and goal evaluation increases trust and collaboration with patients. Goals will change over time, and new barriers to self-management will occur as diabetes education is an ever-evolving process.

Summary

Diabetes education is a necessary part of successful diabetes self-management. The intensive amount of knowledge needed to understand this chronic illness can overwhelm and burden patients. Due to the overwhelming prevalence of this chronic disease, nurses and other healthcare professionals are vital to implementing this critical education. From explaining the diabetes diagnosis to exploring treatment options and healthy coping, effective diabetes education is patient-centered and evidence-based. Using the ADCES7 topics and the current ADA Standards of Care as evidence-based guides, diabetes education can improve glycemic control, reduce diabetes-related complications, and improve quality of life.

Case Study

Mrs. K. is a 75-year-old female who was diagnosed with T2DM 15 years ago. She is newly widowed, as her husband of 50 years passed away just four months ago. She has a medical history including a myocardial infarction at age 70 when she underwent coronary artery bypass grafting, chronic kidney disease stage 3a with a GFR of 59, hyperlipidemia, obesity, diabetic neuropathy, osteoarthritis, and hypertension. Her medications include metformin extended-release 500 milligrams (mg) twice a day, dapagliflozin 10 mg daily, semaglutide 1 mg injection once a week, and insulin glargine 70 units once a day at bedtime. Her insulin glargine dose was increased last month due to elevated fasting blood sugars.

She is five foot 4 inches tall and weighs 198 pounds with a BMI of 34, which is in the obese category. Her blood pressure is 150/72 millimeters of mercury (mmHg). She has gained 8 pounds since her husband passed away. She no longer cooks because it is too hard to cook for one person, so she relies on fast food for most of her meals. She drinks one soda pop per day but enjoys 2-3 glasses of sweet tea per day. She does not exercise due to arthritis in her knees and hips.

Today, she is being seen by her primary care provider to review her recent lab work. Her only complaint today is that she cannot sleep because she wakes up every night with low blood sugar symptoms, which causes her to get up and eat in the middle of the night. She is also frustrated with her high morning blood sugar readings. She reports that this started last month when her insulin dose was increased.

You start diabetes education with Mrs. K. after evaluating her medical record. You assess her baseline knowledge of diabetes, her specific diabetes-related complications, and her current treatment regimen. She admits she has checked her blood sugar during the nighttime low blood episodes, which has been as low as 60 mg/dL. She treats low blood sugar symptoms with a brownie and 8 ounces of orange juice. She does not recheck the blood sugar but goes back to bed. She rarely checks her blood sugar any other time as she does not feel she needs to check it unless she has unusual symptoms.

She has not gone to church since her husband died, and she notes that her kids do not visit as much, which makes her feel isolated. She states she has no thoughts of harming herself. You administered a mental health screening test, and it did not suggest an underlying mental health disorder.

After the initial assessment of Mrs. K., you share your concerns with her about her recurrent nocturnal hypoglycemia and risk of adverse health outcomes. You write an order to lower the insulin glargine back to the previous dose of 50 units once a day at bedtime. You educate Mrs. K. on the symptoms of hypoglycemia and how to treat hypoglycemia using the 15/15 rule appropriately. You also educate her on the use of glucagon, which she already has at home but admits she never knew how to use it.

The education also focuses on her sugary drink use, and she is willing to start cutting that down. However, she has many questions about changing her diet as she realizes that fast food is causing her to gain weight.

Education also includes the recommendations for blood glucose monitoring, and you mention using a CGM with alarms to help alert her of early hypoglycemia. She is very interested in this and thinks she will sleep better knowing the alarm can alert her at night before she drops so low. You discuss her feelings of isolation, and she remarks that her church friends have offered to take her to church next week, and she is planning on going. You encourage her to continue to go to church and give her a schedule of the diabetes support group meetings in hopes that she will attend.

This diabetes education session covered many topics, including healthy eating, reducing risks, monitoring, taking medications, healthy coping, and problem-solving. You also recommended a referral to the dietician for medical nutrition therapy, to which she agreed. Mrs. K. develops two SMART goals today:

  1. By the next visit, I will decrease my sugary drinks to one 8-oz glass per day. I will either have one pop or one sweet tea per day.
  2. I will treat hypoglycemia with 4 oz of orange juice and wait 15 minutes to retest the blood sugar before treating it with additional carbohydrates to avoid overcorrecting hypoglycemia.

You plan to meet with Mrs. K. again in three months at her next visit to evaluate her SMART goals and determine if any adjustments need to be made.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

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