The purpose of this module is to provide the learner with a review of basic information about diabetes mellitus and how to help patients perform self-care and manage the disease. (Note: The term diabetes mellitus is used to distinguish this disease from other types of diabetes. However, simply saying diabetes is common and universally accepted).
After completing this module, the learner will be able to:
Diabetes is a chronic, incurable disease and managing diabetes can be complex, requiring careful attention to diet, exercise, blood glucose levels, and the proper use of medications. Managing diabetes requires patients to make significant and lifelong changes in lifestyle, and it has been clearly established that the incidence and seriousness of diabetic complications and the incidence of type 2 diabetes can be decreased if the disease is properly managed.
These changes require a lifelong commitment from the patient. Healthcare professionals can provide information and guidance, but much of the burden for the day-to-day management of the disease must be on the patient and to successfully live with diabetes, patients need information. They must understand the disease of diabetes, they must understand the importance of the therapeutic interventions, and they must follow treatment recommendations. If they don’t have the proper information and adhere to the treatment plan, they will not control the disease, the disease will control them. The responsibility of nurses and other healthcare professionals is to ensure that patients who have diabetes receive the information they need to self-manage their disease and the support they need to apply this knowledge. The incidence of type 1 and type 2 diabetes is already very high, the incidence of both is rapidly increasing, and this trend is expected to continue. Nurses have traditionally taken a lead role in diabetes education and as the number of people with diabetes increases, this responsibility is sure to grow.
: The patient is a 56-year-old male who has 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. For the first four weeks these sensations were intermittent 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 and weighs 267; his BMI is 43.1, placing him in the category of obese. He is 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 8 months ago because he “felt fine without it.” His blood pressure today is 168/92 mm Hg. Aside from the subjective complaints of numbness and tingling in both feet and chest pain the physical examination and health history are unremarkable. The patient smokes 10-15 cigarettes a day. He does not drink alcohol and he has a desk job.
When asked, the patient is unable to name any long-term complication of diabetes, and although he knows that a 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 in the past 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; he never exercises, and; he 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 if the patient is relatively happy with his current state of health he needs to “take all those medications.”
The primary care provider does a 12-lead ECG and obtains a blood sample for measurement of 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 - 58 60 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, his somatic complaints, and the results of the laboratory tests and the ECG 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.
Diabetes is an enormous and rapidly growing public health problem. The most current data for the United States, The National Diabetes Statistics Report (CDC, 2014) noted that 29.1 million Americans/9.3% of the population have diabetes, and the number of people expected to develop type 2 diabetes is predicted to increase, affecting large segments of the population and many different age groups (WHO, 2016; CDC, 2014; Dabelea, Mayer-Davis, & Saydah, 2014). In addition, millions of Americans have pre-diabetes and many people who have diabetes have not been diagnosed.
There are many types of diabetes and they can be usefully classified into four groups. The condition of pre-diabetes will also be discussed.
Type 1 diabetes: Type 1 diabetes is an autoimmune disease caused by genetic susceptibility and environmental triggers. It is characterized by pancreatic β cell destruction and lack of insulin production. The onset is typically during childhood or adolescence, and type 1 diabetes accounts for 5%-10% of all cases of the disease.
Type 2 diabetes: Type 2 diabetes is characterized by insulin resistance and a relative lack of insulin production. 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 clearly identified and many of them are modifiable, e.g., obesity, hyperlipidemia, hypertension, and a sedentary lifestyle. Type 2 diabetes accounts for approximately 90%-95% of all cases of the disease. The onset is usually in late adulthood.
Gestational diabetes: Gestational diabetes occurs during pregnancy, and the incidence of this form of the disease has been estimated to be 9.2%. (Desisto, Kim, & Sharma, 2014). With good prenatal care and lifestyle adjustments the condition usually resolves but approximately 5%-10% of all women who have gestational diabetes develop type 2 diabetes after delivery.
Diabetes due to other causes: Type 1 and type 2 diabetes account for approximately 95% of all cases of the disease. There are many other types of diabetes, including (but not limited to) drug and/or chemical-induced diabetes, monogenic diabetes syndromes, diabetes due to diseases such as cystic fibrosis, neonatal diabetes, and Wolfram syndrome, but these are rare. It should also be noted that the traditional separation of diabetes into type 1 and 2 has been questioned as researchers have found that there can be a clinical overlap between the two (Schwartz et al., 2016).
Pre-diabetes: Pre-diabetes is not a disease. It is a condition characterized by a cluster of risk factors and identified by impaired fasting glucose and impaired glucose tolerance. Taken together these risk factors and the abnormal laboratory results identify individuals who are likely to develop type 2 diabetes.
The information in this section is from the American Diabetes Association’s (ADA) Standards in medical care of diabetes – 2016 (ADA, 2016).
All adults should be tested for diabetes beginning at age 45.
Adults of any age should be tested for diabetes 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 tests are normal they should be repeated at three year intervals, at a minimum.
Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 hours
A two-hour plasma glucose ≥200 mg/dL (11.1mmol/L) during an oral glucose tolerance test (OGTT)
A1C ≥ 6.5% (48 mmol/mol)
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dL (11.1 mmol/L)
To diagnosis pre-diabetes, fasting plasma glucose, a two-hour plasma glucose done during an OGTT, or A1C can all be used.
Chronic hyperglycemia initiates several pathologic processes that increase the production of reactive oxygen species and cause inflammation and cellular damage. Certain tissues such as the capillary cells of the retina, cells in the renal glomeruli, and neurons and Schwann cells in peripheral nerves cannot efficiently regulate the transport of glucose, making them vulnerable to persistently high levels of serum glucose and large amounts of free radicals. Diabetes, both type 1 and type 2, is a major cause of amputations, blindness and vision loss, and kidney disease and diabetic retinopathy, diabetic nephropathy, and diabetic neuropathies are common chronic complications of both type 1 and type 2 diabetes. In addition, diabetes is considered to be a risk factor for the development of atherosclerosis, heart disease, hypertension, and stroke.
Diabetes and its attendant complications is a devastating disease but there is convincing evidence that pre-diabetes, type 2 diabetes, and diabetic complications can be prevented and the number of diabetic complications can be reduced (ADA, 2016; Bonner, Foster, & Spears-Lanoix, 2016; Davies et al., 2016; Mainous, Tanner, & Baker, 2016; Mehravar et al., 2016; Modesti, Galanti, Cala’, & Calabrese, 2016; Prabhu, Kakhandaki, Chandra, & Dinesh, 2016; Knowler et al., 2002) If an at-risk patient can control her/his blood sugar and if he/she can exercise, lose weight, stop smoking, and attain blood pressure control, type 2 diabetes and diabetic complications can be avoided (Kueh, Morris, & Ismail, 2016; Rashed, Sabbah, Younis, Kisa & Parkash, 2016; Saundankar et al., 2016; Balk et al., 2015; Pronk & Remmington, 2015).
However, maintaining glycemic control and initiating and sustaining these lifestyle changes is very difficult for most people. It has been estimated that 33% - 49% of diabetic patients do not have adequate control of blood sugar, blood pressure, or blood cholesterol and that only 14% have adequate control of those three factors and are able to stop smoking as well (ADA, 2016).
But if patients at risk for diabetes and those who have the disease are able to modify their behaviors the rewards are huge: they will have a longer and healthier life (Kueh et al., 2016; Balk et al., 2015; Kueh, Morris, Borkoles, & Shee, 2015; Pronk & Remington, 2015; Haas et al., 2014). However, attaining these goals depends on self-care, and in the context of diabetes this is a complex and life-long commitment that requires patient education, education that is often lacking (Kueh et al., 2016; Balk et al., 2015; Haas et al., 2014). Many diabetic patients do not have the knowledge they need to prevent diabetes and/or manage the disease, and this significantly contributes to poor glycemic control and failure to stop smoking, exercise, lose weight, and control blood pressure in this patient population (ADA, 2016; Krishnan & Thirunavukkarasu, 2016; Mahon, Moore, Gaze, Chusid, & MacGilchrist, 2016; Ahola & Groop, 2013). Self-care is critical for diabetic patients and at-risk patients and it depends on education. Support is also a vital aspect of diabetic self-care and both of these concepts are discussed in the next section of the module.
The 2016 American Diabetes Association (ADA) Standards for Diabetes Self-Management and Education were developed by a task force of experts from the American Diabetes Association and the American Association of Diabetes Educators and these Standards strongly support the need for diabetes self-management education (DSME) and diabetes self-management support (DSMS).
According to the ADA (2016), DSME and DSMS are essential elements of diabetes care, and the current national standards for DSME and DSMS are based on the evidence of their benefits. High-quality diabetes self-management education (DSME) has been shown to improve patient self- management, satisfaction, and glucose control.
Diabetes self-management education (DSME), diabetes self-management support (DSMS), medical nutrition therapy (MNT), counseling on smoking cessation, education on physical activity, guidance on routine immunizations, and psychosocial care are the cornerstone of diabetes management
The Standards define DSME and DSMS, respectively, as:
The ongoing process of facilitating the knowledge, skill, and ability necessary for pre-diabetes and diabetes self-care. This process incorporates the needs, goals, and life experiences of the person with diabetes or pre-diabetes and is guided by evidence-based standards. The overall objectives of DSME are to support informed decision-making, self-care behaviors, problem-solving, and active collaboration with the health care team and to improve clinical outcomes, health status, and quality of life (Haas et al., 2014).
DSMS: Activities that assist the person with pre-diabetes or diabetes in implementing and sustaining the behaviors needed to manage his or her condition on an ongoing basis beyond or outside of formal self-management training. The type of support provided can be behavioral, educational, psychosocial, or clinical (Haas et al., 2014)
There are 10 Standards and they address vital parts of DSME and DSMS such as patient support, patient progress, and curriculum. This module will focus on the recommended curriculum for DSME and important aspects of DSMS. Standard 6, curriculum, notes that successful DSME programs include the following topics (Haas et al., 2014).
The ADA (2016) standards of medical care in diabetes also emphasize the need for education and self-care and recommend providing patients with the same information, e.g., healthy lifestyle choices, basics of disease self-management such as proper use of medications and self-monitoring of blood glucose and where appropriate, blood pressure, and prevention of and screening for ocular, podiatric, and renal complications, and immunizations.
Other key points of DSME and DSMS are:
Access: Some patients who need DSME and DSMS may not have access to them. Each patient should be evaluated for possible access issues and barriers to effective self-care such as cultural, geographical, economical, language, and monetary barriers (ADA, 2016; Haas et al., 2014).
Coordination: Coordination is essential for good diabetic care (Powers et al., 2015; Haas et al., 2014). The AADE/ADA standards note that coordination “. . . is essential to ensure that quality diabetes self-management education and support is delivered through an organized, systematic process,” and that a coordinator should be designated to oversee the process (Haas et al., 2014).
Educators: The ADA/AADE Standards stress the need for qualified diabetes education professionals.
At least one of the instructors responsible for designing and planning DSME and DSMS will be a registered nurse, registered dietitian, or pharmacist with training and experience pertinent to DSME, or another professional with certification in diabetes care and education, such as a CDE (Certified Diabetes Educator) or BC-ADM (Board Certification in Advanced Diabetes Management (Haas et al., 2014)
Evidence-based care and quality improvement: Diabetes education should use the latest evidence-based data and its effectiveness should be continually monitored and assessed (ADA, 2016; Hass et al., 2014)
Individual care: DSME and DSMS must be individualized to be effective so the patient’s characteristics and needs such as age, gender, language, level of education, ethnic and cultural background, income, and food insecurity must be considered (ADA, 2016). Patient-centered care that stresses individual responsibility is also very important. Theoretical models of empowerment indicate that people can successfully manage their illnesses when they are encouraged to develop the capacity for self-responsibility and self-care (Wong et al., 2016; Tol, Alhani, Shojaeazadeh, Sharifirad, & Moazam, 2015). Patients must be actively involved in the process of diabetic self-care (Powers et al., 2015).
Progress: Patients should be periodically assessed for progress and adherence to the self-care regimen and the goals must be behaviorally oriented (ADA, 2016; Haas et al., 2014).
Support: A support system of family, friends, community, or other resources has been associated with improved diabetes self-management (Black, Maitland, Hilbers, & Orinuela, 2016; Hempler, Joensen, & Willaing 2016; Vorderstrasse, Lewinski, Melkus & Johnson, 2016). The ADA/AADE Standards and the ADA medical standards both recognize the importance of support systems (ADA, 2016; Haas et al., 2014). The ADA/AADE Standards are quite specific on this issue. According to Hass et al. (2014) “While DSME is necessary and effective, it does not in itself guarantee a lifetime of effective diabetes self-care. To sustain the level of self-management needed to effectively manage pre-diabetes and diabetes over the long term, most participants need ongoing DSMS.”
Timing: DSEM and DSMS should be delivered at the time of diagnosis; annually, with an assessment of educational, nutritional, and emotional needs; when factors arise that complicate self-management, and; when transitions in care occur (ADA, 2016; Powers et al., 2015).
The National Certification Board for Diabetes Educators (www.ncbde.org) and the American Nurses Credentialing Center (www.nursecredentialing.org) both offer certification as a diabetes educator and the need for expertise in DSME has been discussed. Although patients should be educated by a healthcare professional with experience and/or certification in DSME, every nurse who is caring for a patient with diabetes should be familiar with the basic concepts and content taught in DSME programs. Patients will receive comprehensive education from diabetic specialists, but they often need frequent, on the spot reinforcement, review, and reminders of the information that was taught; providing this is very often the responsibility of the nurse at the bedside.
Educating patients about diabetes and supporting them is vitally important, and DSME and DSMS programs can only be effective if they are planned. The following outline of the DSME process is a suggestion, and it can be tailored to a patient’s needs and personal situation. Issues that are essential and that should be covered are:
A DSME program must be individualized to the patient’s needs and to be successful it must take into account the patient’s age, culture, family situation, finances, gender, literacy, personal coping mechanisms, pre-existing health problems, work demands, and the patient’s preferences (ADA, 2016; Attridge, Creamer, Ramsden, Cannings-John, & Hawthorne, 2014; Haas et al., 2014; Kim et al., 2009; Utz et al., 2008)
This module cannot discuss all of the information that would be included in a DSME program administered by a diabetes educator. There is too much to cover and as well, these programs are individualized, so this module will only provide the highlights. A convenient way to remember the key points of a DSME program is to think of them as the four Ms - Meals, Motions, Medications, and Monitoring (Darbishire, Plake, Nash, & Shepler, 2009). The information in the following sections would be considered the minimum for a DSME program.
A patient who has just been diagnosed with diabetes will be unlikely to know much, if anything, about the disease. Many diabetic patients do not have the information they need to self-manage diabetes (Krishnan & Thirunavukkarasu, 2016; Mahon et al., 2016; Hussain et al., 2016; Patiño-Fernandez, Eidson, Sanchez, & Delamater, 2010),and nurses and physicians may not have comprehensive knowledge about diabetes (Ahmed, Jabbar, Zuberi, Islam & Shamim, 2012; Trep, Wille, Wieland, & Reinhart, 2010).
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 been shown to be valid and reliable. Several questions from the DKT are listed in Table 2. (Fitzgerald et al., 2016)
The best way to take care of your feet is to:
a. Look at and wash them each day. *
b. Massage them with alcohol each day.
c. Soak them for 1 hour each day.
d. Buy shoes a size larger than usual.
If you are beginning to have a low blood glucose reaction, you should:
b. Lie down and rest.
c. Drink some juice*
d. Take rapid-acting insulin.
Numbness and tingling may be symptoms of:
a. Kidney disease.
b. Nerve disease*
c. Eye disease.
d. Liver disease.
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 level of detail that is provided will be situation dependent.
What is diabetes: Diabetes is a chronic disease that affects the body’s ability to control blood sugar level. 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 insulin that is available. Type 1 diabetes is essentially genetic and inherited. Type 2 diabetes is caused by a 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 and it accumulates in the blood.
Glucose: Glucose, commonly called blood sugar, is the end product of the breakdown of many of the foods we eat. Glucose 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.
A consultation with a dietician and/or education from a diabetes education professional is considered mandatory when someone is initially diagnosed with diabetes, and periodic follow-ups are very 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 she/he has chronic hyperglycemia.
Weight management: Weight loss and weight control can slow down and prevent the progression of pre-diabetes to type 2 diabetes. 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, and when. The dietician or the diabetic educator will provide each patient with dietary details specific to him/her. But, it is reasonable for any healthcare professional to inform a patient of the following points.
Exercise prescriptions will be given to each patient, but every patient who has the disease should understand the following information about exercise and diabetes.
Exercise appears to increase the effectiveness of endogenous insulin and it may decrease insulin resistance (Colberg et al., 2010). Exercise and decreasing the amount of sedentary time has been shown to help control blood glucose and prevent diabetic complications (especially in patients who have type 2 diabetes) and it may prevent type 2 diabetes in high-risk people (Mendes, Noqueira, Reis, DE Meiners, & Dullius, 2016; Sakane et al., 2011). Adults who have diabetes should perform at least 150 minutes a week of moderate-intensity aerobic exercise; this should be done over at least three days a week. Resistance exercise should be done two or more days a week (ADA, 2016; Colberg et al., 2010).
Smoking increases the risk of developing diabetes and diabetic complications (Yeom, Lee, Kim, & Suh, 2016; Prasad & Cucullo, 2015; Chang, 2012), particularly diabetic neuropathy, and smoking cessation is a vital part of diabetic self-management.
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 ad type 2 diabetics. The following basic points should be covered with each diabetic patient.
There are many medications used to treat diabetes, and they work by: a) providing exogenous insulin, b) increasing the production and/or release of insulin, c) decreasing the absorption of glucose, d) increasing sensitivity to the effects of insulin, and e) 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 of the possible diabetic drug regimes. But every nurse who is caring for patients who have diabetes should be able to provide the 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 takes, 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 a 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 have an effect on the action of diabetic medications (May & Schindler, 2016): always ask a physician, pharmacist or other healthcare providers before taking a medication 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 and/or use their diabetic medications properly(Krishnan & Thirunavukkarasu, 2016; Sapkota, Brien, Greenfield, & Aslani, 2015).
The acute complications of diabetes are hypoglycemia, diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar syndrome. Patients should be advised that the latter two are acute but compared to hypoglycemia they develop over a longer period of time and they are characterized by a very high serum glucose. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome are primarily caused by poor compliance with diabetic medication regimen or an 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 the aforementioned signs/symptoms and a 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 it is quite important that patients are well educated about the causes, consequences, signs and symptoms, and treatment of hypoglycemia and about hypoglycemia unawareness. In addition, 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:
Treatment recommendations for hypoglycemia are listed in Table 3 (ADA, 2016).
Asymptomatic hypoglycemia: Repeat the blood sugar measurement, avoid tasks that require a high level of alertness and coordination, and ingest some carbohydrates
Symptomatic hypoglycemia: Ingest carbohydrates - 15-20 grams of glucose is preferred - and repeat the blood glucose measurement in 15 minutes. If the blood glucose is still low ingest more glucose until the level is normal and then have a meal or a snack.
Severe hypoglycemia: IM or SC glucagon and call 911. If glucagon is not available there is no proven benefit from trying to give the patient glucose in the space between the teeth and the buccal mucosa
The most common chronic complications of diabetes that are 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 great detail. However, diabetic patients should be educated so that they understand how serious these complications are and how they can be prevented. Periodic assessment of a patient’s knowledge of the topic should be scheduled, as well.
A DSME program should include the following facts about diabetic complications:
Diabetic foot ulcers deserve special mention because: 1) They are very common, and 2) There are many practical day-to-day things a patient can do to prevent diabetic for ulcers (Ahmin & Doupis, 2016). See Table 4 for details about diabetic foot care.
A foot examination by a physician or other healthcare professional should be done at least once a year
Check your feet every day, and don’t forget to examine the bottom of your feet. Look for blisters, cuts, red spots, swelling, or any other abnormalities and call your physician or healthcare provider if there is a problem
Wash your feet every day and dry them gently. Put powder between the toes and apply a moisturizing lotion to the tops and soles.
Always wear clean, dry socks and shoes. Do not go barefoot
Trim the toenails straight across
Diabetes often causes peripheral nerve damage so cold and heat sensation can be blunted. Do not expose your feet to very cold or very hot conditions; you may suffer a thermal burn and not be aware of it.
Complying with a diabetic treatment regimen is a lifelong commitment. Unfortunately, many people find the lifestyle changes, consistent and safe use of diabetic medications, self-monitoring of blood glucose to be, at times, unattainable and poor compliance with diabetic treatment regimens is a significant problem (ADA, 2016; Osborn & Gonzalez, 2016; Shivashankar et al., 2016).
As mentioned earlier, it has been estimated that 33% - 49% of diabetic patients do not have adequate control of blood sugar, blood pressure, or blood cholesterol and that only 14% have adequate control of those three factors and are able to stop smoking as well (ADA, 2016).
There are many reasons why patients do not adhere or adhere inconsistently and incompletely with a diabetic treatment regimen (ADA, 2016; Brown et al, 2016; Han, Kim, Kim, Kim, & Lee, 2016; Horigan, Davies, Findlay-White, Chancey, & Coates, 2016; Baig, Benitez, Quinn, & Burnet, 2015; Schreiner & Ponder, 2015; Winkley et al., 2015; Mayberry & Osborn, 2014; Abu Hasaan et al., 2013; Broadbent, Donkin, & Stroh, 2011).
Assessment of compliance with the diabetic treatment regimen should be done annually and when, according to the ADA (2016), “new complicating factors arise that influence self-management (and) when transitions occur.” Barriers to compliance should be clearly 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 schedule for follow-up should be made. Professional resources, community resources, and family resource should be utilized as needed (Baig et al., 2015; Mayberry & Osborn, 2014; Ghorob et al., 2011; Kim et al., 2009) and the interventions and goals must be patient-centered (ADA, 2016; Attridge et al., 2014).
Managing diabetes requires patients to make significant and lifelong changes in lifestyle, and it has been clearly established that the incidence and seriousness of diabetic complications and the incidence of type 2 diabetes can be decreased if the disease is properly managed.
Day-to-day management of diabetes is the responsibility of the patient successful self-care of diabetes requires education. Nurses and other healthcare professionals are to ensure that patients who have diabetes receive the information they need to self-manage their disease and the support they need to apply this knowledge.
The American Diabetes Association and the American Association of Diabetes Educators strongly support the need for DSME. A successful DSME program:
The goals of a DSME should include:
The specifics of each program will vary depending on individual needs. However, the basic content should include the following topics, and every nurse who cares for diabetic patients would be able to discuss them with her/his patients.
Abu Hassan, H., Tohid, H., Mohd Amin, R., Long Bidin, M.B., Muthupalaniappen, L., & Omar, K. (2013). Factors influencing insulin acceptance among type 2 diabetes mellitus patients in a primary care clinic: a qualitative exploration. BMC Fam Pract. 2013 Oct 29;14:164. doi: 10.1186/1471-2296-14-164.
Ahmed, A, Jabbar, A., Zuberi, L., Islam, M., Shamim, K. (2012). Diabetes related knowledge among residents and nurses: a multicenter study in Karachi, Pakistan. BMC Endocr Disord. 2012 Sep 11;12:18. doi: 10.1186/1472-6823-12-18.
Ahmin, N., & Doupis, J. (2016). Diabetic foot disease: From the evaluation of the “foot at risk” to the novel diabetic ulcer treatments. World J Diabetes, 7(7), 153-164.
Ahola, A.J., & Groop, P.H. (2013). Barriers to self-management of diabetes. Diabet Med,(4),413-420.
American Diabetes Association. (2016).Standards of medical care in diabetes – 2016. Diab Care, 39 (Suppl 1), S1-S119.
Attridge, M., Creamer, J., Ramsden, M., Cannings-John, R., & Hawthorne, K. (2014). Culturally appropriate health education for people in ethnic minority groups with type 2 diabetes mellitus. Cochrane Database Syst Rev. 2014 Sep 4;9:CD006424. doi: 10.1002/14651858.CD006424.pub3.
Baig, A.A., Benitez, A., Quinn, M.T., & Burnet, D.L. (2015). Family interventions to improve diabetes outcomes for adults. Ann N Y Acad Sci. 2015 Sep;1353:89-112. doi: 10.1111/nyas.12844. Epub 2015 Aug 6.
Balk, E.M., Earley, A., Raman, G., Avendano, E.A., Pittas, A.G., & Remington, P.L. (2015). Combined diet and physical activity promotion programs to prevent type 2 diabetes among persons at increased risk: A systematic review for the community preventive services task force. Ann Intern Med,163(6),437-451.
Black, S., Maitland, C., Hilbers, J., Orinuela, K. (2016). Diabetes literacy and informal social support: A qualitative study of patients at a diabetes centre. J Clin Nurs. 2016 May 18. doi: 10.1111/jocn.13383. [Epub ahead of print]
Bonner, T., Foster M., & Spears-Lanoix, E. (2016). Type 2 diabetes-related foot care knowledge and foot self-care practice interventions in the United States: a systematic review of the literature. Diabet Foot Ankle. 2016 Feb 17;7:29758. doi: 10.3402/dfa.v7.29758. eCollection 2016.
Broadbent, E., Donkin, L., & Stroh, J.C. (2011). Illness and treatment perceptions are associated with adherence to medications, diet, and exercise in diabetic patients. Diabetes Care, 34(2), 38-40.
Brown, S.A., García, A.A., Brown, A., Backer, B.J., Conn, V.S., Ramírez, G.,…Cuevas, H.E. (2016). Biobehavioral determinants of glycemic control in type 2 diabetes: A systematic review and meta-analysis. Patient Educ Couns. 2016 Mar 19. pii: S0738-3991(16)30142-2. doi: 10.1016/j.pec.2016.03.020. [Epub ahead of print]
Centers for Disease Prevention and Control. (2014). National Diabetes Statistics Report. Accessed May 8, 2016 (Visit Source).
Centers for Disease Control and Prevention. (2014) Diabetes 2014 Report Card. Accessed may 8, 2016 (Visit Source).
Chang, S.A. (2012). Smoking and type 2 diabetes mellitus. Diabetes Metab J, 36(6), 399-403.
Colberg, S.R., Sigal, R.J., Fernhall, B. Regensteirner, J.G., Blissmer, B J., Rubin, R.R.,…Braun, B. (2010). Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement. Diabetes Care, 33(12), e147-e167.
Cryer, P.E. (2016). Management of hypoglycemia during treatment of diabetes mellitus. UpToDate, February 22, 2016. Accessed May 30, 2016 (Visit Source).
Dabelea, D., Mayer-Davis, E.J., & Saydah, S., (2014). Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA, 311(17),1778-1786.
Darbishire, P.L., Plake, K.S., Nash, C.L., & Shepler, B.M. (2009). Active-learning laboratory session to teach the four M's of diabetes care. Am J Pharm Educ, 73(2), Article 22, 1-9.
Davies, M.J., Gray, L.J., Troughton, J., Gray, A., Tuomilehto, J., Faroogi, A.,…Yates, T. (2016). A community based primary prevention programme for type 2 diabetes integrating identification and lifestyle intervention for prevention: the Let's Prevent Diabetes cluster randomised controlled trial. Prev Med, 84,48-56.
DeSisto, C.L., Kim, S.Y., & Sharma, A.J. (2014). Prevalence estimates of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System (PRAMS), 2007-2010. Prev Chronic Dis. 2014 Jun 19;11:E104. doi: 10.5888/pcd11.130415.
Ghorob, A., Vivas, M.M., De Vore, D., Ngo, V., Bodenheimer, T., Chen, E., & Thom, D. (2011). The effectiveness of peer health coaching in improving glycemic control among low-income patients with diabetes: protocol for a randomized controlled trial. BMC Public Health, 11, 208-213.
Fitzgerald, J.T., Funnell, M.M., Anderson, R.M., Nwankwo, R., Stansfield, R.B., & Piatt, G.A. (2016). Validation of the revised brief diabetes knowledge test (DKT2). Diabetes Educ. 2016 Apr;42(2):178-87. doi: 10.1177/0145721715624968. Epub 2016 Jan 14.
Haas, L., Maryniuk, M., Beck. J., Cox, C.E., Duker, P., Edwards, L.,…Youssef, G. (2014) National standards for diabetes self-management education and support. Diab Care, 37(Suppl. 1), S144 - S153
Han, J., Kim, S., Kim, G., Kim, E., & Lee, S.Y. (2016). Factors affecting a screening for diabetic complication in community: A multi-level analysis. Epidemiol Health. 2016 May 3. doi: 10.4178/epih.e2016017. [Epub ahead of print]
Hempler, N.F., Joensen, L.E., & Willaing, I. (2016). Relationship between social network, social support and health behaviour in people with type 1 and type 2 diabetes: cross-sectional studies. BMC Public Health. 2016 Feb 29;16(1):198. doi: 10.1186/s12889-016-2819-1.
Horigan, G., Davies, M., Findlay-White, F., Chaney, D., & Coates, V. (2016). Reasons why patients referred to diabetes education programmes choose not to attend: a systematic review. Diabet Med. 2016 Mar 21. doi: 10.1111/dme.13120. [Epub ahead of print]
Hussain, R., Rajesh, B., Giridhar, A., Gopalakrishnan, M., Sadasivan, S., James, J.,…John, N. (2016). Knowledge and awareness about diabetes mellitus and diabetic retinopathy in suburban population of a South Indian state and its practice among the patients with diabetes mellitus: A population-based study. Indian J Ophthalmol, 64, (4),272-276.
Kim, M.T., Han, H.R., Song, H.J., Lee, J.E., Kim, J., Ryu, J.P., & Kim, K.B. (2009). A community-based, culturally tailored behavioral intervention for Korean Americans with type 2 diabetes. Diabetes Education, 35(6), 986-994.
Knowler, W.C., Barrett-Connor, E., Fowler, S.E., Hamman, R.F., Lachin, J.M., Walker, E.A., & Nathan, D.M.; Diabetes Prevention Program Research Group. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med, 346(6), 393-403.
Krishnan, V., & Thirunavukkarasu, J. (2016). Assessment of knowledge of self blood glucose monitoring and extent of self titration of anti-diabetic drugs among diabetes mellitus patients - A cross sectional, community based study. J Clin Diagn Res. 2016 Mar;10(3):FC09-11. doi: 10.7860/JCDR/2016/18387.7396. Epub 2016 Mar 1.
Kueh, Y.C., Morris, T., Borkoles, E., Shee, H. (2015). Modelling of diabetes knowledge, attitudes, self-management, and quality of life: a cross-sectional study with an Australian sample. Health Qual Life Outcomes. 2015 Aug 19;13:129. doi: 10.1186/s12955-015-0303-8.
Kueh, Y.C., Morris, T., Ismail, A.A.(2016). The effect of diabetes knowledge and attitudes on self-management and quality of life among people with type 2 diabetes. Psychol Health Med. 2016 Feb 5:1-7. [Epub ahead of print]
Mahon, A.M., Moore, G.D., Gazes, M.I., Chusid, E., & MacGilchrist, C. (2016). An investigation of diabetes knowledge levels between newly diagnosed type 2 diabetes patients in Galway, Ireland and New York, USA: A cross-sectional study. Int J Low Extrem Wounds. 2016 Mar 23. pii: 1534734616638775. [Epub ahead of print]
Mainous, A.G. III, Tanner, R.J., Baker, R. (2016). Prediabetes diagnosis and treatment in primary care. J Am Board Fam Med, 29(2):283-285
May, M., & Schindler, C. (2016). Clinically and pharmacologically relevant interactions of antidiabetic drugs. Ther Adv Endocrinol Metab. 2016,7(2),69-83.
Mayberry, L.S., & Osborn, C.Y. (2014). Family involvement is helpful and harmful to patients' self-care and glycemic control. Patient Educ Couns, 97, (3),418-425.
Mehravar, F., Mansournia, M.A., Holakouie-Naieni, K., Nasli-Esfahani, E,, Mansournia, N., & Almasi-Hashiani, A. (2016). Associations between diabetes self-management and microvascular complications in patients with type 2 diabetes. Epidemiol Health. 2016 Jan 25;38:e2016004. doi: 10.4178/epih/e2016004. eCollection 2016.
Mendes, G.F., Nogueira, J.A., Reis, C.E., DE Meiners, M.M., & Dullius, J. (2016). Diabetes education program with emphasis on physical exercise promotes significant reduction in blood glucose, HbA1c and triglycerides in subjects with type 2 diabetes: a community-based quasi-experimental study. J Sports Med Phys Fitness. 2016 May 24. [Epub ahead of print]
Modesti, P.A., Galanti, G., Cala', P., & Calabrese, M. (2016). Lifestyle interventions in preventing new type 2 diabetes in Asian populations. Intern Emerg Med, 11(3), 375-384.
Osborn, C.Y., & Gonzalez, J.S. (2016). Measuring insulin adherence among adults with type 2 diabetes. J Behav Med. 2016 Apr 9. [Epub ahead of print]
Patiño-Fernandez, A.M., Eidson, M., Sanchez, J., & Delamater, A.M. (2010). What do youth with type 1 diabetes know about the HbA1c test? Child Health Care. 38(2), 157-167.
Powers, M.A., Bardsley, J., Cypress, M., Duker, P., Funnell, M.M., Fischl, A.H.,…Vivian, E. (2015). Diabetes self-management education and support in type 2 diabetes: a joint position statement of the American Diabetes Association, the American Association of Diabetes Educators, and the Academy of Nutrition and Dietetics. Diabetes Educ,41(4),417-430.
Prabhu, M., Kakhandaki, A., Chandra, K.R., & Dinesh, M.B. (2016). A hospital based study regarding awareness of association between glycosylated haemoglobin and severity of diabetic retinopathy in type 2 diabetic individuals. J Clin Diagn Res. 2016 Jan;10(1):NC01-4. doi: 10.7860/JCDR/2016/15834.7014. Epub 2016 Jan 1.
Prasad, S., & Cucullo, L. (2015). Impact of tobacco smoking and type-2 diabetes mellitus on public health: A cerebrovascular persepective. J Pharmacovigil. 2015 Nov;Suppl 2. pii: e003. Epub 2015 Nov 12.
Pronk, N.P., & Remington. P.L.; Community Preventive Services Task Force. (2015). Combined diet and physical activity promotion programs for prevention of diabetes: Community preventive services task force recommendation statement. Ann Intern Med,163(6):465-468.
Rashed, O.A., Sabbah,H.A., Younis, M.Z., Kisa, A., & Parkash, J. (2016). Diabetes education program for people with type 2 diabetes: An international perspective. Eval Program Plann. 2016, 56:64-68.
Sakane N., Sato J., Tsushita K., Tsujii, S., Kotani, K., Tominaga, M.,…Kuzuya, H; Japan Diabetes Prevention Program Research Group. (2011). Prevention of type 2 diabetes in a primary health care setting: three- year results of lifestyle intervention in Japanese subjects with impaired glucose tolerance. BMC Public Health, 11(1), 40-49.
Samson, W.K., Stein, L.M., Elrick, M., Salvatori, A., Kolar, G., Corbett, J.A., & Yosten, G.L.C. (2016). Hypoglycemia unawareness prevention: Targeting glucagon production. Physiol Behav. 2016 Apr 11. pii: S0031-9384(16)30147-0. doi: 10.1016/j.physbeh.2016.04.012. [Epub ahead of print]
Sapkota, S., Brien, J.A., Greenfield, J.,& Aslani, P. (2015). A systematic review of interventions addressing adherence to anti-diabetic medications in patients with type 2 diabetes--impact on adherence. PLoS One. 2015 Feb 24;10(2):e0118296. doi: 10.1371/journal.pone.0118296. eCollection 2015.
Saundankar, V., Peng, X., Fu, H., Ascher-Svanum, H., Rodriguez, A., Ali, A.,…Louder, A.(2016). Predictors of change in adherence status from 1 Year to the next among patients with type 2 diabetes mellitus on oral antidiabetes drugs. J Manag Care Spec Pharm, 22 (5),467-482.
Schreiner, B., & Ponder, S. (2015). Self-management education for the child with diabetes mellitus. (2015. UpToDate, September 16, 2015. Accessed May 28, 2016 (Visit Source).
Schwartz, S.S., Epstein, S., Corkey, B.E., Grant, S.F.A., Gavin III, J.R., & Aguilar, R.B. (2016). Rationale and implications of the beta-cell-centric classification schema. Diab Care, 39(2), 179-186.
Shivashankar, R., Bhalla, S., Kondal, D., Ali, M.K., Prabhakaran, D., Narayan, K,M., & Tandon, N. (2016).Adherence to diabetes care processes at general practices in the National Capital Region-Delhi, India. Indian J Endocrinol Metab, 20,(3),329-336.
Tol, A., Alhani, F., Shojaeazadeh, D., Sharifirad, G., & Moazam, N. (2015). An empowering approach to promote the quality of life and self-management among type 2 diabetic patients. J Educ Health Promot. 2015 Mar 26;4:13. doi: 10.4103/2277-9531.154022. eCollection 2015.
Trep, R., Wille, T., Wieland, T., & Reinhart, W.H. (2010). Diabetes-related knowledge among medical and nursing house staff. Swiss Medical Weekly, 140(25-26), 370-375.
Utz, S.W., Williams, I.C., Jones, R., Hinton, I., Alexander, G., Yan, G.,…Oliver, M.N. (2008). Culturally tailored intervention for rural African Americans with type 2 diabetes. Diabetes Education, 3(5), 854-865.
Vorderstrasse, A., Lewinski, A., Melkus, G.D., & Johnson, C. (2016). Social Support for Diabetes Self-Management via eHealth Interventions. Curr Diab Rep. 2016 Jul;16(7):56. doi: 10.1007/s11892-016-0756-0.
Weinstock, R.S., DuBose, S.N., Bergenstal, R.M., Chaytor, N.S., Peterson, C., Olson, B.A.,…Hirsch, I.B. (2016). Risk factors associated with severe hypoglycemia in older adults with type 1 diabetes. Diabetes Care, 39(4), 603-610.
Winkley, K., Evwierhoma, C., Amiel, S.A., Lempp, H.K., Ismail, K., & Forbes, A. (2015). Patient explanations for non-attendance at structured diabetes education sessions for newly diagnosed Type 2 diabetes: a qualitative study. Diabet Med, 2(1),120-128.
Wong, C.K., Wong, W.C., Wan, E.Y., Chan, A.K., Chan, F.W., & Lam, C.L. (2016). Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP). Endocrine. 2016 Jan 19. [Epub ahead of print]
World Health Organization. (2016). Global report on Diabetes. Accessed May 8, 2016 from (Visit Source).
Yeom, H., Lee, J.H., Kim, H.C., & Suh. I. (2016). The association between smoking tobacco after a diagnosis of diabetes and the prevalence of diabetic nephropathy in the Korean male population. J Prev Med Public Health, 49(2), 108-117.
This course is applicable for the following professions:
Advanced Registered Nurse Practitioner (ARNP), Athletic Trainer (AT/AL), Clinical Nurse Specialist (CNS), Dietitian/Nutritionalist (RDN), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN)
CPD: Practice Effectively, Diabetes, Medical Surgical