Care of People with Diabetes

A Manual for Healthcare Practice

Trisha Dunning, Alan J. Sinclair

• Publisher: Wiley-Blackwell
• Year: 2020
• ISBN:
  9781119520870
• Edition: 5
• Topic: Medicine
• Subtopic: Nursing

Now in its fifth edition, Care of People with Diabetes is a comprehensive clinical manual for nurses, healthcare professionals and students alike, providing an extensive summary of the most up-to-date knowledge in a rapidly developing field, as well as the role of education and self-care in achieving desirable outcomes. Covering both the theory and evidence-based practice of diabetes care, this authoritative volume integrates traditional thinking and innovative concepts to challenge readers to 'think outside the box' when rendering care.

• New and updated content on the pathophysiology of diabetes and the implications for management, how to apply guideline recommendations in practice, and contemporary evidence for best practice diabetes care
• Highlights personalised care and shared, evidence-based decision-making, emphasising the need for effective communication to reduce judgmental language and the negative effect it has on wellbeing and outcomes
• Written by internationally recognised experts in diabetes care, research and education
• Includes a range of learning features, such as practice questions, key learning points, diagrams, and further reading suggestions

Care of People with Diabetes is an essential companion to clinical practice for both trainee and experienced nurses and healthcare professionals, particularly those in acute care settings, and students undertaking diabetes courses or preparing for qualification exams.

Chapter 1
Diagnosing and Classifying Diabetes

Cancer, diabetes, and heart disease are no longer diseases of the wealthy. Today they hamper the people and economies of the poorest populations … this represents a health emergency in slow motion.

(Ban Ki Moon, Secretary General of the United Nations)

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Key points

• Diabetes is the modern pandemic. It represents a considerable global economic and social burden for the person with diabetes, families, and for health services.
• The prevalence of the metabolic syndrome, type 1, type 2 and gestational diabetes (GDM) is increasing.
• The greatest increase in diabetes prevalence is occurring in Africa, the Middle East, and South East Asia.
• The overlapping mechanisms by which obesity leads to the metabolic syndrome and type 2 diabetes are complex and still evolving.
• Not everybody who is obese has insulin resistance or diabetes.
• Central obesity plays a key role in the progression to insulin resistance and type 2 diabetes.
• Lean people may be at higher risk of morbidity and mortality than obese people.
• Primary prevention and early detection are essential to reduce the personal and community burden associated with the metabolic syndrome and diabetes and their complications.
• Type 2 diabetes is a progressive disease, and complications are often present at diagnosis. Thus, early diagnosis is essential. Insulin will eventually be necessary in most people with type 2 diabetes.
• The prevalence of obesity, the metabolic syndrome, and type 2 diabetes in children are increasing.

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What is diabetes mellitus?

Diabetes mellitus is a metabolic disorder in which the body's capacity to utilise glucose, fat, and protein is disturbed due to insulin deficiency or insulin resistance or both. Both states lead to hyperglycaemia, lipid abnormalities, and glycosuria.

The body is unable to utilise glucose in the absence of insulin and mobilises fat and protein stores in an effort to supply fuel for energy. Insulin is necessary for the complete metabolism of fats, however, and when carbohydrate metabolism is disordered fat metabolism is incomplete and intermediate products (ketone bodies) can accumulate in the blood leading to ketosis, especially in type 1 diabetes. Protein breakdown also occurs and leads to weight loss and weakness and contributes to the development of hyperglycaemia and lethargy.

The different types of diabetes have different underlying causal mechanisms and clinical presentation: in general, young people are insulin‐deficient (type 1 diabetes), whilst older people usually secrete sufficient insulin in the early stages but demonstrate resistance to insulin action (type 2 diabetes). In the early stages of type 2, hyperinsulinaemia might be present. Type 2 is a progressive disease with slow destruction of the insulin‐producing beta cells and, consequently, insulin deficiency.

There appear to be differences in insulin sensitivity and beta cell function between young people and adults with prediabetes and type 2 diabetes (Rise Consortium 2018). Clamp studies show young people are more resistant to insulin and have hyper‐responsive beta cells. The TEDDY study suggests beta cell function declines at a faster rate with early onset type 2 diabetes and the beta cells do not respond well to glucose lowering medicines (GLMs) (Rewers et al. 2018). Complications appear at an early age, which leads to higher rates of morbidity and mortality. Potential contributing factors are puberty‐related insulin resistance and obesity.

Some people diagnosed with type 2 diabetes have evidence of transient autoimmunity before they are diagnosed (Turner et al. 1997; ADA 2019). They are usually younger than people with negative autoantibodies and have evidence of reduced beta cell function such as lower fasting C‐peptide, worse metabolic control and are more symptomatic (Sørgjerd et al. 2018). This group of people could represent a heterogeneous phenotype of type 2 diabetes distinct from Latent Autoimmune Diabetes in Adults (LADA). Thus, diabetes is a complex disease of evolving aetiology and increasing prevalence. Type 2 diabetes is the most common, accounting for about 90% of diagnosed cases and type 1 accounts for about 10% of diagnosed cases.

Prevalence of diabetes

Diabetes is a global health problem affecting about 451 million people aged 18–99 years worldwide in 2017 (International Diabetes Federation [IDF] 2018) and an estimated 49.7% or people with diabetes are undiagnosed and an estimated 374 million have impaired glucose tolerance (prediabetes) (IDF 2017). More than 187 million are unaware they have diabetes. The prevalence is expected to increase to 693 million by 2045 unless the epidemic can be halted. In addition, almost 21.3 million live births were to women affected by some form of hyperglycaemia. Significantly, 5 million deaths in people aged 20–99 were attributable to diabetes worldwide.

The Australian Institute of Health and Welfare (AIHW 2005) shows that diabetes prevalence is escalating and rates are higher amongst males, Indigenous Australians, and socioeconomically disadvantaged people. This accounts for about 1.2 million people, about 6%, and 16 400 deaths in 2015. Most have type 2 diabetes (AIHW 2005). In the United Kingdom, an estimated 3.7 million people have diabetes, and up to another 12.3 million are at increased risk of type 2 diabetes: thus, 4.6 million people in the United Kingdom are living with diabetes (Diabetes UK 2014). The US Centers for Disease Control (CDC) estimated that 30.3 million Americans had diabetes and 84.1 million had prediabetes (CDC 2017).

The reason for the increasing global prevalence of type 2 diabetes is due to ...