Diabetic Patient Education

The patient is a 56-year-old male with type 2 diabetes; he was first diagnosed with the disease 12 years ago. He has come to see his primary care provider (PCP) because, for the past six weeks, he has had numbness and tingling in both feet, extending from the tips of the toes to just below the ankles. These sensations were intermittent for the first four weeks, but now they are constant. He states that he also has occasional episodes of substernal chest pain; these are brief and occur both at rest and when he is active.

The patient is 5 feet 6 inches, weighs 267 pounds, and has a BMI of 43.1, placing him in the obese category. He has currently prescribed metformin, 800 mg twice a day, HCTZ, 25 mg twice a day, and lisinopril, 5 mg once a day. He had been prescribed post-prandial insulin but stopped taking it eight months ago because he "felt fine without it." His blood pressure today is 168/92 mm Hg. The physical examination and health history are unremarkable, aside from the subjective complaints of numbness and tingling in both feet and chest pain. The patient smokes 10-15 cigarettes a day. He does not drink alcohol, and he has a desk job and a sedentary lifestyle.

When asked, the patient cannot identify any long-term complications of diabetes, and although he knows that high serum glucose is not good, he does not know why. He has not spoken in-depth about his disease with a healthcare professional for several years, and he last saw the PCP 14 months ago. The patient cannot remember when he last had an eye examination for several years. He confesses that he never examines his feet and does not take any special precautions to protect them. He occasionally skips his metformin doses and antihypertensives, never exercises, and measures his blood sugar two to three times a month. Although his primary care provider has offered the patient consultations with a dietician, a physical therapist for an exercise program, appointments with a smoking cessation program, and the name and address of a diabetes support group, the patient has not followed up with any of these as he considers them unnecessary and inconvenient.

The patient is married, and according to the patient, his wife "thinks he looks fine," and she does not understand why he needs to "take all those medications" if the patient is relatively happy with his current state of health.

The primary care provider does a 12-lead ECG and obtains a blood sample to measure A1C, blood glucose, serum cholesterol, BUN, creatinine, and estimated GFR. The office has laboratory capabilities, and the results are:

• A1C - 9.4%
• Blood glucose - 219 mg/dL
• Serum cholesterol - 199 mg/dL
• BUN - 24 mg/dL
• Creatinine - 1.9 mg/dL
• Estimated GFR – 50-54 mL/min/1.73 m2
• The 12-lead ECG shows evidence of a mild degree of left ventricular hypertrophy

Based on the patient's medical history, somatic complaints, laboratory tests, and the ECG results, the PCP informs the patient that he has atherosclerotic heart disease, kidney damage, and peripheral neuropathy. The PCP also informs the patient that he is at risk for diabetic retinopathy, an extension and worsening of heart disease and kidney disease, and foot ulcers, and only immediate changes in his lifestyle and health habits can prevent these complications.

There are many types of diabetes, and they can be usefully classified into four groups. The condition of prediabetes will also be discussed.

Type 1 diabetes: Type 1 diabetes is an autoimmune disease caused by genetic susceptibility and environmental triggers (Powers et al., 2020). It is characterized by pancreatic β cell destruction and lack of insulin production (Powers et al., 2020). The onset typically occurs during childhood or adolescence, and type 1 diabetes accounts for ~ 5-10% of all disease cases in the United States (ADA, 2020a). In a very small percentage of cases of type 1 diabetes, the patients do not secrete insulin, but there is no evidence of autoimmunity; these patients have what is called idiopathic type 1 diabetes (ADA, 2020a).

Type 2 diabetes: Type 2 diabetes is characterized by insulin resistance and a relative lack of insulin production (Powers et al., 2020). Type 2 diabetes is also caused by an interplay of genetics and environment, but in this form of the disease, the environmental factors that increase the risk of developing type 2 diabetes have been identified, and many of them are modifiable, e.g., diet, obesity, and a sedentary lifestyle (ADA, 2020a).

Gestational diabetes: Gestational diabetes is defined as insulin resistance and abnormal glucose tolerance that occurs during pregnancy (Rogers & Roberts, 2020). Approximately 9% of all pregnancies are complicated by gestational diabetes. Many women who have gestational diabetes will develop the disorder in subsequent pregnancies, and approximately 50% will eventually develop type 2 diabetes (Durnwald, 2020).

Diabetes due to other causes: Type 1 and type 2 diabetes account for approximately 95% of all disease cases. There are many other types of diabetes, including (but not limited to) drug or chemical-induced diabetes, monogenic diabetes syndromes, diabetes caused by an infection, and diabetes due to diseases such as cystic fibrosis, neonatal diabetes, and Wolfram syndrome, but these are uncommon (ADA, 2020a).

It should also be noted that the traditional separation of diabetes into type 1 and 2 is not absolute, and some patients cannot be definitively characterized as having type 1 or type 2 diabetes (ADA, 2020a).

Prediabetes: Prediabetes is not a disease itself, but it refers to patients with glucose levels below the criteria for diabetes mellitus but above normal (ADA, 2020a). A cluster of risk factors characterizes prediabetes and an abnormal and progressive impairment of glucose homeostasis that precedes the development of type 1 or type 2 diabetes (Powers et al., 2020). The diagnostic criteria for prediabetes are 1) A fasting plasma glucose of 100 to 120 mg/dL, or a two-hour plasma glucose during an oral glucose tolerance test of 140 to 199 mg/dL, or an A1C of 5.7-6.4% (ADA, 2020a).

The information in this section is from the American Diabetes Association's (ADA) Standards in the Medical Care of Diabetes – 2020 (ADA, 2020a).

• All adults should be tested for diabetes beginning at age 45.
• Adults of any age should be tested for diabetes or prediabetes if they are overweight or obese (BMI ≥ 25 kg/m2 or ≥ 23 kg/m2 in Asian Americans) or if they have one or more of the following additional risk factors for diabetes that are listed below. If the screening tests are normal, they should be repeated at three-year intervals, at a minimum (ADA, 2020a).
  • First-degree relative with diabetes.
  • HDL cholesterol level < 35 mg/dL (0.90 mmol/L) and/or a triglyceride level > 250 mg/dL (2.82 mmol/L).
  • High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander).
  • History of cardiovascular disease (CVD).
  • Hypertension: ≥140/90 mmHg or on therapy for hypertension.
  • Other clinical conditions associated with insulin resistance, e.g., severe obesity, acanthosis nigricans (A skin condition that occurs in people who have diabetes or who are obese).
  • Sedentary lifestyle.
  • Women who have polycystic ovary syndrome.
• For children and adolescents who are overweight (BMI ≥ 85th percentile) or obese (BMI ≥ 95th percentile, risk-based screening for prediabetes or type 2 diabetes should be considered after the onset of puberty or after ten years of age, whichever is first (ADA, 2020a) Risk factors for diabetes in this population are (ADA, 2020a):
  • A first-degree or second-degree relative who has/had type 2 diabetes.
  • Gestational diabetes during the child's gestation.
  • Native American, African American, Latino, Asian American, Pacific Islander ethnicity.
  • Conditions associated with insulin resistance (Acanthosis nigricans, dyslipidemia, hypertension, polycystic ovary disease, or small for gestational age birth weight) or signs of insulin resistance.
• Patients who have prediabetes should be tested every year (ADA, 2020a).
• Women who have had gestational diabetes should be tested at least every three years for life (ADA, 2020a).

A normal fasting glucose level is 70 to 100 mg/dL. Diagnostic criteria for diabetes mellitus are listed in Table 1.

To diagnose prediabetes, fasting plasma glucose, a two-hour plasma glucose done during an OGTT, or A1C can all be used (ADA, 2020a). The diagnostic criteria for prediabetes are a fasting plasma glucose of 100 to 120 mg/dL (5.6 to 6.9 mmol/L, or a two-hour plasma glucose during an oral glucose tolerance test of 140 to 199 mg/dL (7.8 to 11.0 mmol/L), or an A1C of 5.7-6.4% (39 to 47 mmol/L) (ADA, 2020a).

To diagnose gestational diabetes, a one-step or a two-step process can be used (ADA, 2020a). With the one-step process, the diagnostic criteria for gestational diabetes are fasting glucose of ≥ 90 mg/dL (5.1 mmol/L), or a one-hour OGTT result of ≥ 180 mg/dL (10 mmol/L), or a two-hour OGTT result of ≥153 mg/dL (8.5 mmol/L).

For the two-step process, the diagnostic criteria are a fasting glucose of ≥95 mg/dL (5.3 mmol/L), or a one-hour OGTT result of ≥ 180 mg/dL (10.0 mmol/L), or a two-hour OGTT result of ≥ 155 mg/dL (8.6 mmol/L), or a three-hour OGTT result of ≥ 140 mg/dL (7.8 mmol) (ADA, 2020a).

Chronic hyperglycemia initiates pathologic processes that cause inflammation and free radical formation and initiate cellular damage to many organs and tissues. The complications of type 1 and type 2 diabetes include (but are not limited to) diabetic retinopathy, diabetic nephropathy, diabetic neuropathies, coronary heart disease, cerebrovascular disease, and peripheral arterial disease (Powers et al., 2018). Diabetes mellitus is a leading cause of blindness, lower limb amputation, chronic kidney disease (CKD), and renal failure (Powers et al., 2018).

A patient who has just been diagnosed with diabetes will be unlikely to know much, if anything, about the disease. Also, many diabetic patients do not have the information they need to self-manage diabetes, and nurses and physicians may not have an adequate knowledge base about diabetes (Lee et al., 2019). Research has shown that a lack of knowledge negatively affects a patient's self-management of diabetes (Chen et al., 2020).

Assessing a patient's knowledge level of diabetes can be accomplished using written material, classroom work, etc. There are many ways to perform this assessment. A useful assessment tool that can be used is the Diabetes Knowledge Test (DKT). The DKT has been in use for many years and is valid and reliable. Several questions from the DKT are listed in Table 3.

Patients do not need in-depth knowledge of the pathological process of diabetes, but they should have the information that is essential for successful self-management of the disease. The following points should be covered; the provided level of detail will be situationally dependent.

What is diabetes: Diabetes is a chronic disease that affects the body's ability to control blood sugar levels. If it is not properly treated, diabetes causes high blood sugar levels, and chronic high blood sugar - hyperglycemia - can cause serious complications.

The causes of diabetes: Type 1 diabetes is caused by the destruction of the pancreatic cells that produce insulin. Type 2 diabetes is caused by insufficient insulin production and an inability to use the available insulin. Type 1 diabetes is essentially genetic and inherited. Type 2 diabetes is caused by susceptibility to the disease and lifestyle factors.

What is insulin: Insulin is a naturally produced hormone that is used to carry glucose from the blood to the cells and tissues. Without insulin, glucose cannot be used by the body, accumulating in the blood.

Glucose: Glucose, commonly called blood sugar, is one of the primary sources of energy for the body.

The consequences of high blood glucose: Without insulin, blood glucose levels will become abnormally high, and chronic hyperglycemia causes progressive damage to the eyes, the kidneys, and the peripheral nerves. Chronic hyperglycemia also increases the risk of developing cardiovascular diseases such as atherosclerosis, hypertension, and stroke.

A cure for diabetes: Type 1 diabetes cannot be cured, and someone who has this disease must be on life-long insulin therapy. Type 2 diabetes can be controlled but not cured, and someone who has type 2 diabetes must be on a life-long program of diabetes self-management.

Careful attention to diet is one of the cornerstones of diabetes self-management (ADA, 2020f). A consultation with a dietician or education from a diabetes education professional is considered mandatory when someone is initially diagnosed with diabetes, and periodic follow-ups are especially important. The basic principles that patients should learn are listed below.

Diet and diabetes: Patients must be taught that food is converted to glucose, and diabetes is a disease characterized by an inability to regulate blood glucose, so attention to diet is the cornerstone of diabetic self-management. Medications, exercise, weight loss, and other lifestyle changes cannot change the course of diabetes if the patient does not eat a proper diet and has chronic hyperglycemia.

Weight management: Weight loss and weight control can slow down and prevent the progression of prediabetes to type 2 diabetes(ADA, 2020f). If you have type 2 diabetes, weight loss and weight control can also help you attain control of blood sugar, reduce the need for medications, and prevent diabetic complications.

Diet specifics: Diet is perhaps the most challenging and confusing part of diabetic self-management, and patients will want to know what to eat, how much to eat, when to eat, and what foods they should avoid. The dietician or the diabetic educator will provide each patient with dietary details specific to him/her. However, it is reasonable for any healthcare professional to inform a patient of the following points.

1. A proper diet is the cornerstone of diabetic self-management.
2. A typical diet prescription for a patient who has diabetes is not radically different from a "normal" diet.
3. Weight loss/weight control is highly beneficial.
4. Knowing what to eat, how much, and when is an ongoing process, and a flexible approach is best.
5. The ideal amount of carbohydrates for diabetic patients is not known, but as carbohydrates are quickly converted to glucose, monitoring carbohydrate intake is especially important.
6. The ideal amount of fat for diabetic patients is not known. However, dyslipidemia is quite common in patients who have type 2 diabetes. Dyslipidemia is especially harmful to diabetics, so a diet that emphasizes monounsaturated fats and avoids trans-fats and saturated fats should be stressed, and frequent measurement of the lipid profile is desirable.
7. The ideal amount of protein for diabetic patients is not known.
8. Supplementation with vitamins or minerals is not needed if you are eating a balanced diet and there is no evidence for its benefits.
9. Alcohol can cause delayed hypoglycemia, especially if the patient takes insulin or an insulin secretagogue. Also, the symptoms of alcohol intoxication and hypoglycemia are, in many ways, identical. You should drink alcohol in moderation, two drinks a day for men, one drink a day for women.
10. Avoid sugar-sweetened beverages.

Exercise is another vital part of diabetes self-management(ADA, 2020f).

Exercise helps patients lose weight, improves glycemic control and insulin sensitivity, helps decrease the risk for and the severity of the cardiovascular disease, and can help prevent or delay the onset of type 2 diabetes (Chiang, 2019).

Exercise prescriptions will be given to each patient, but every patient with the disease should be informed of its benefits. Aerobic exercise and resistance exercise can be included in the exercise program as both have been shown, alone or in combination to be effective for patients who have prediabetes, type 1 diabetes, or type 2 diabetes (Reddy et al., 2019).

Unfortunately, many people who have diabetes smoke (Georges et al., 2019). Smoking increases the risk of developing type 2 diabetes and diabetic complications. It increases insulin needs, insulin resistance, and the risk of hypoglycemia (Georges et al., 2019). Smoking cessation is considered an essential part of diabetes care (ADA,2020b).

Blood glucose monitoring is a complex topic. There are many ways to do it, and blood glucose monitoring is a lifelong concern for type 1 and type 2 diabetics. The following basic points should be covered with each diabetic patient.

1. Blood glucose monitoring is done daily and periodically.
2. Periodic glucose monitoring is done by measuring A1C, and the goal for most (but not all) patients is an A1C < 7% (ADA, 2020g). Higher and lower A1C levels may be acceptable in certain situations, e.g., older adults (ADA, 2020g). The A1C should be measured at least twice a year if the patient follows the prescribed treatment regimen and the daily glucose levels are within the target range. More frequent testing may be necessary, e.g., four times a year (ADA, 2020g).
3. The A1C level is used to predict the risk of long-term diabetic complications and to determine the effectiveness of the diabetic treatment regimen.
4. Daily glucose monitoring is used to adjust food intake, exercise intensity, and frequency and determine the proper use of diabetic medications.
5. The desirable blood glucose level differs for each person, but low and high levels can cause acute and chronic complications.
6. Each patient should be given clear, goal-oriented instructions about what to do if the blood glucose level is too high or too low.
7. Infections, illness, and stress can affect blood glucose levels, and more frequent glucose monitoring will be needed during these situations.
8. Accurate self-monitoring of blood glucose depends on the proper use of the equipment.
9. For most people, a fasting blood glucose level should be between 80-130 mg/dL, and one-two hours after a meal, a blood glucose level should be < 180 mg/dL (ADA, 2020g).

Diabetic medications work by:

• Providing exogenous insulin
• Increasing the production or release of insulin
• Decreasing the absorption of glucose
• Increasing sensitivity to the effects of insulin, and
• Decreasing/inhibiting the release/synthesis of glucagon

Teaching patients with diabetes about their medications is usually the responsibility of the diabetes educator, and it is beyond the scope of this module to discuss all the possible diabetic drug regimens. However, every nurse caring for patients who have diabetes should be able to provide patients with the basic information they need to use their medications safely and effectively.

A patient who has diabetes must know what medications she/he take, e.g., the name and dose, when and how to take them, and the side effects of each drug. The patient should be advised that he/she should never stop taking diabetic medication, skip doses, or take more or less than what has been prescribed. It should be stressed to patients who have type 1 diabetes that they can never stop using insulin, and patients who have type 2 diabetes should be informed that as they age, lifestyle changes and oral medications may not be sufficient to attain glycemic control and they may need insulin. Finally, there are many commonly used prescription medications, over-the-counter drugs, and supplements that can affect the action of diabetic medications (May & Schindler, 2016). Patients should be advised to ask a physician, pharmacist, or another healthcare provider before taking a prescription medication, over-the-counter medications, herbal product, or dietary supplement for the first time.

The previous points may seem very obvious, but it has been well documented that many patients do not have adequate knowledge of their medications, and patients who have diabetes often do not adhere to their medication regimen or do not use their diabetic medications properly (Huang et al., 2019).

The acute complications of diabetes are hypoglycemia, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar syndrome (HHS). Patients should be advised that the latter two are acute, but compared to hypoglycemia, they develop over a longer period, characterized by extremely high serum glucose. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome are caused by poor compliance with the diabetic medication regimen or acute infection or illness. The signs and symptoms of these complications are non-specific, but mental status changes, polydipsia, polyuria, and weakness are often seen. Patients who have diabetes should be informed that if they develop any of these signs/symptoms and high serum glucose, they may have DKA or hyperglycemic hyperosmolar syndrome and that these are serious, life-threatening complications.

Hypoglycemia is much more common than DKA or hyperglycemic hyperosmolar syndrome, so patients should be educated about the causes, consequences, signs and symptoms, treatment of hypoglycemia, and hypoglycemia unawareness. Also, every time patients have contact with a healthcare professional; they should be asked when and how often they have hypoglycemia.

Patient teaching points about hypoglycemia should include the following:

1. Hypoglycemia is more common in people who have type 1 diabetes, but many people who have type 2 diabetes have hypoglycemic episodes (Cryer, 2020a).
2. Level 1 hypoglycemia is defined as a blood glucose level < 70 mg/dL (ADA, 2020g).
3. Level 2 hypoglycemia is defined as a blood glucose level < 54 mg/dL, the patient is symptomatic, and treatment is needed (ADA, 2020g).
4. Level 3 hypoglycemia is a low blood glucose level that the patient has profound signs and symptoms of hypoglycemia, and he/she cannot self-treat (ADA, 2020g).
5. Hypoglycemia can occur without signs and symptoms (ADA, 2020g).
6. The basic causes of hypoglycemia in a patient who has diabetes are too much insulin and a lack of blood sugar.
7. An individual hypoglycemic episode may not be dangerous. However, frequent, multiple hypoglycemic events may negatively affect cognitive function over time. They can increase the risk of the development of cardiovascular disease, a severe hypoglycemic event can cause death, and hypoglycemic events increase the risk of mortality (Cryer, 2020a).
8. Typical signs and symptoms of hypoglycemia include (but are not limited to) agitation, confusion, dizziness, drowsiness, irritability, palpitations, sweating, and weakness (Johnson et al., 2019).
9. Some people can have significant hypoglycemia, but the body's response mechanisms fail to provide warning signs and symptoms, a condition called hypoglycemia unawareness (ADA, 2020g).
10. Hypoglycemia unawareness is not an unusual occurrence, and it is very common in type 1 diabetics, affecting as many as 35% of patients who have the disease (Lin et al., 2020).

Treatment recommendations for hypoglycemia are listed in Table 4.

The most common chronic complications of diabetes-specific to the disease and chronic hyperglycemia are diabetic nephropathy, diabetic neuropathy, diabetic retinopathy, and diabetic foot ulcers (Note: Diabetic neuropathy predisposes patients to the development of foot ulcers). Patients should not be expected to understand these complications in detail. However, diabetic patients should be educated to understand how serious these complications are and how they can be prevented. A periodic assessment of a patient's knowledge of the topic should also be scheduled.

A DSME program should include the following facts about diabetic complications:

1. Good glycemic control can prevent diabetic complications, and good glycemic control is a personal responsibility
2. Chronic diabetic complications develop very slowly, and they often do not cause obvious signs or symptoms until the pathologies are very advanced
3. In consideration of point number 2, it should be stressed that prevention of chronic diabetic complications also depends on periodic assessments by a physician or other health care provider
4. Patients should be given a schedule that clearly outlines when and how often they should have eye examinations, an assessment of their renal function and for the presence of peripheral neuropathy, and an examination for the presence of and risk of foot ulcers
5. Compliance with the preventive assessment schedule is crucial

Diabetic foot ulcers deserve special mention because:

1. They are quite common, and
2. There are many measures a patient can take to prevent diabetic foot ulcers (ADA, 2020h).

Educating about the proper use of medications is essential for diabetic education.

Insulin injection: Insulin should be injected into the subcutaneous tissue, aka fat (ADA, 2020i). Injection into muscle tissue can cause erratic and unpredictable absorption of insulin and can cause hypoglycemia (ADA, 2020i). Intramuscular injection is more likely to happen if the patient is young, lean, or is using a long needle (ADA, 2020i).

The recommended injection sites are the abdomen, the buttocks, the thighs, and the upper arms, and these sites should be rotated (ADA, 2020i). Constant use of the same site will cause fat to accumulate at the injection site. A condition called lipodystrophy can cause erratic, unpredictable absorption of the drug and hypoglycemia (ADA, 2020i).

The basic insulin injection technique that should be taught is:

• Choose a site.
• Unless the skin is dirty, there is no need to clean the site.
• Pull up and pinch a fold of skin.
• Insert the needle at a 90° angle.
• Push the plunger and hold the syringe and needle in place for 5-10 seconds. 6) Remove the needle.
• Do not rub the injection site (Weinstock, 2019).

It is not recommended that insulin be injected through clothing, but it does not appear to cause harm (Weinstock, 2019).

Insulin needles and syringes should be considered infectious; they should be disposed of in a hazardous waste container, not into a simple wastebasket (Weinstock, 2019).

Insulin needles and syringes are for one-time use only (Weinstock, 2019).

Insulin bottles should be stored correctly, and directions for storage will be provided with each prescription. If the patient suspects or knows that insulin has not been stored correctly, she/he should contact the dispensing pharmacy.

Oral medications: Oral diabetic drugs must be taken according to schedule. Doses should not be skipped unless the patient has been advised to do so by a clinician, and extra doses should not be taken. Patients should be educated about adverse drug effects, particularly adverse effects that can affect glycemic control, e.g., hypoglycemia, diarrhea, nausea, and vomiting.

Barriers to compliance should be identified, and the patient's active participation should be used to address these barriers using specific treatments. The goals should be clear and behavior-oriented, and a follow-up schedule should be made. There is a considerable amount of information and activity required of diabetic patients to effectively self-manage the disease. The lifelong need to self-manage diabetes compounds this challenge, and patients may develop a syndrome called diabetic distress (ADA, 2020d). Diabetic distress "refers to significant negative psychological reactions related to emotional burdens and worries specific to an individual's experience in having to manage a severe, complicated, and demanding chronic disease such as diabetes (ADA, 2020d). Diabetic distress is a common problem, and it can harm many aspects of self-management, e.g., adherence to the medication regimen, higher A1C levels, and poor diet and exercise habits (ADA, 2020d). All healthcare professionals that care for diabetic patients should be aware of this syndrome, and periodic evaluation for its presence is recommended (ADA, 2020d).