Current Innovation in Diabetes Mellitus

Management and Stroke Prevention: Technology,

Therapy and Holistic Approach

Prof. Jesusa M. Magno

Faculty, VSU College of Nursing
FACTS ABOUT DIABETES
• In the past 3 decades the prevalence of type 2 diabetes
has risen dramatically in countries of all income levels.

• Urgent action needed as global diabetes cases increase

four-fold over past decades.

• For people living with diabetes, access to affordable

treatment, including insulin, is critical to their survival.
• About 830 million people worldwide have diabetes, the
majority living in low-and middle-income countries.

• More than half of people living with diabetes are not

receiving treatment.
• Both the number of people with diabetes and the
number of people with untreated diabetes have been
steadily increasing over the past decades.

• There is a globally agreed target to halt the rise in

diabetes and obesity by 2025.
Diabetes- a chronic, metabolic disease characterized by
elevated levels of blood glucose which leads over time to
serious damage to the heart, blood vessels, eyes,
kidneys and nerves.

Insulin - not produced, insufficient, not utilized properly;

therefore glucose stays in the blood and does reach the
cells.
Types of diabetes
Type 1 diabetes – IDDM

• Inability to produce little or no insulin at all.

• Autoimmune: (IgG) cell destruction before
hyperglycemia occurs
• Genetic mutations
• Children, young adults, or at any age.
• “Exist with insulin daily”
Type 2 diabetes-NIDDM
• Insulin resistance
• Risk factors : overweight/obesity, family history, more
sedentary lifestyle, gestational diabetes or prediabetes
• Develop at childhood or any age
• “Weight gain no more.”
Gestational diabetes
• Preexisting prediabetes, family history and Type 2 DM
diagnosed.
• Hormonal imbalance
• Higher chance of developing type 2 diabetes later in life.

Prediabetes
• Blood glucose levels that are higher than normal but not
high enough to be diagnosed with type 2 diabetes.
• Higher risk of developing type 2 diabetes and heart
disease
Other types of diabetes
• Monogenic diabetes, caused by a change in a
single gene, surgery to remove the pancreas, damage
to the pancreas due to cystic fibrosis, pancreatitis
CLINICAL MANIFESTATIONS:
Type 1 diabetes:

frequency of urination
thirst
constant hunger
weight loss
vision changes
 fatigue, drowsiness
Type II Diabetes:

Same with Type I

Some specific symptoms
• Pruritus
• Recurring infection, skin, vaginal
• Numbness or tingling of hands and feet
• Slow healing sores or wounds
• Acanthosis negricans
OTHER MANIFESTATIONS:
• Sexual dysfunction- damage of nerves blood vessels
erectile dysfunction, low arousal and poor lubrication in
female
• Irritability
• Fruity-smelling breath (ACETONE)- due to breakdown
of fats for glucose (DKA)
• Weight loss- fats and muscle mass utilization for energy
• Pain in limbs from nerve damage-diabetic neuropathy
• Dry mouth high blood sugar decreases saliva flow a
precursor for tooth decay, gun disease
• 12. Nausea from gastroparesis from nerve damage
DIAGNOSTIC TESTS:
• Fasting blood sugar (FBS) for baseline blood sugar
• Random blood glucose (RBS/PPT) test
• A1c or (HbA1C) or glycated hemoglobin test provides
average blood glucose level over the past two to three
months.
• Oral glucose tolerance test (OGTT) to screen for and
diagnose gestational diabetes
 In-range Prediabetes Diabetes
Type of test
(mg/dL) (mg/dL) (mg/L)
FBS Less than 100. 100 to 125. 126 or higher.
200 or higher
(with classic
symptoms of
RBS N/A. N/A. hyperglycemia
or
hyperglycemic
crisis).
Less than
A1c 5.7% to 6.4%. 6.5% or higher.
5.7%.
Aspects of Management
1. Involve client and family in monitoring and managing
blood glucose levels.
2. Prevent complications DKA and other macro
and micro blood vessels affectation.
3. Provide patient/support system teaching
covering:
Dietary and lifestyle changes
All aspects of self-care ( esp. foot care)
Administration and management of insulin
Use of oral hypoglycemic medications
4. Diet: Meal planning and choosing a healthy diet
5. Exercise
6. Weight reduction
6. To decrease risk of CAD maintain a healthy
• Weight
• BP
• Cholesterol level
INSULIN THERAPY
1. Type 1 / some Type II
• Given SQ, insulin pens, rapid acting inhaled insulin or
continuously with an insulin pump.
• Medication to manage cholesterol, high BP, or other
complications
• Dosing depends on changes in weight, diet, health status
(including pregnancy), activity level, and work as these
affect the amount of insulin needed to keep blood sugar
within normal limits.
• Check blood sugar level at pre-meals or through a
continuous glucose monitor (CGM).
• Regular check-up for advises in dosing.
Insulin regimens:
• Designed to imitate a nondiabetic pancreas.
• Intensive insulin treatment : to keep blood glucose in
near-normal or "tight" control.
• three or more insulin administration / day or via insulin
pump.
• Monitor blood glucose frequently to determine treatment
plan; to achieve blood glucose levels as close to the
nondiabetic range as safely possible, while minimizing
hypoglycemia (low blood sugar) events.
• Consider work or school schedules, eating times and
preferences, exercise schedule, and cost concerns.

• Benefits : improved blood glucose management, good

sense of well-being and reduce risk of health
complications later in life.
• Smart insulin pens and caps – (additional
features)
receive glucose data from some continuous glucose
monitor (CGM) devices and blood glucose meters.
communicate with specific smartphone apps that
allow the client to track insulin doses
calculate insulin doses, provide reminders and alerts,
and generate reports for the diabetes care team
perusal

• Regular check-up for advises in dosing.

INSULIN PUMP WITH CGM:

• Sensor-augmented insulin pump with low glucose

suspend or predictive low glucose suspend features

• Partially automated insulin pump (hybrid system)

• Fully automated insulin pump system or bihormonal

insulin pump
Advantages:
• Increase flexibility in the timing of meals and other day-to-
day events.
• Injection (insulin infusion) site can be changed every 48 to
72 hours.
• There is less variation in the amount of insulin absorbed
compared with when insulin is given with a needle and
syringe or pen.
• Can deliver smaller amounts of insulin at a time than
injection therapy which can help reduce day-to-day
variations in blood sugar levels
• Help reduce hypoglycemia and increase time in the target
range.
Disadvantages
• Cost is greater than insulin syringes and needles or
pens.
• Skin irritation or infection at the infusion site or pump
malfunction.
• Monitor blood sugar levels carefully; stopping insulin,
even for a short time, can lead to a significant increase
in blood sugar.
• Bent, torn or kinked cannulas: block the flow of
insulin
• Insulin crystallization: crystallize or formation of
insulin fibrils in 2-3 days
• Infusion set disconnection from the tubing: leaks
• Inflammation or hematoma at infusion site
• Adhesive issues: premature/accidental peeling off
adhesive tape from skin, allergy issues
• Pump failure: break or malfunctioning, battery
charge
Challenges to intensive insulin treatment:
• Should coordinate with daily activities, food taken and
amount, exercise, and check blood glucose frequently
(4 or more times a day) or use a continuous glucose
monitoring (CGM) device.
• Risk of low blood sugar episodes may be present, the
client should learn how to prevent, recognize, and treat
hypoglycemia.
• Exercise to counteract weight gain
• Cost
Factors affecting insulin action:

• Dose of insulin injected

• Injection technique
• Site of injection
• Variations in absorption
• Subcutaneous blood flow
• Time since opening the insulin bottle or pen
• Individual factors
Types:
●Rapid acting:
Insulin lispro 10-15/1 hr/ 2-4 hrs
Insulin aspart 5-15 mins/ 40-50 mins/ 2-4 hrs.
Insulin glulisine 5-15 mins/ 30-60 mins/ 2-4 hrs.

●Short acting insulin

Regular (Humulin R) 30-60 mins/ 2-3 hrs./ 4-6 hrs.
●Intermediate acting
Insulin NPH (Humulin N) 2-4 hrs./ 4-12 hrs./ 16-
20hrs.

Insulin lispro protamine (mixed with rapid-acting

insulin lispro- Humalog Mix)
Insulin aspart protamine (mixed with rapid-acting
insulin aspart [Novolog Mix]) 3-4 hrs./ 4-12hrs./ 16-
20 hrs.
●Long acting
Insulin glargine- Types I & II
Insulin detemir intermediate to long acting; may be
needed twice daily

●Very long acting 1-6 hrs. / continuous (no peak)/ 24-

36 hrs.
Insulin degludec
Insulin glargine 300 units/ml
• Rapid acting inhaled insulin

Afreeza <15 mins/ -50 mins/ 2-3 hrs.

ORAL HYPOGLYCEMIC
• Help manage blood sugar levels in Type 2 diabetes
and prediabetes, gestational diabetes.
Types:
Sulfonylureas and meglitinides: stimulate release of
insulin from the beta cells only in the pancreas
(glipizide, glimiperide, etc.)

Biguanides: decreases the over production of glucose

by the liver, make insulin more effective at peripheral
tissues (metformin)
Metformin
• Lowers hepatic glucose production
• Reduces intestinal glucose absorption
• Improves insulin sensitivity by increasing peripheral
glucose uptake and utilization

Given with:
losartan to Manage BP and atorvastatin for cholesterol.
Alpha-glucoside inhibitors- slows CHO digestion and
absorption at the small intestine. Post prandial glucose
and glycosylated hemoglobin are better controlled
reducing the risk of long term complication. ( acarbose,
miglitol etc.)

Thiazolidinediones- lowers glucose level by improving

insulin sensitivity. Potent and highly selective agonists
for receptors found in insulin-sensitive areas like
adipose, skeletal muscles and liver. (rosiglitazone,
proglitazone)
DPP-4 inhibitors- increase insulin release by inhibiting
the enzyme DPP-4. (linagliptin, sitagliptin)

Sodium-glucose cotransporter 2 inhibitors-reduce

reabsorption pf filtered glucose and lower plasma
glucose concentration by increasing urinary excretion of
glucose. (dapagliflozin, empagliflozin etc. )
Glucagonlike peptide I receptor agonists- increase
insulin secretion from pancreatic beta cells, suppress
glucagon secretion and slow gastric emptying
(albiglutide, dulaglutide, etc.)
Complications:
Acute onset:
1. HHNK – hyperglycemic hyperosmolar non ketotic coma
severe hyperglycemia and hypertonic DHN
without significant ketoacidosis; results from
reactive insulin deficiency

Causes:
inadequate insulin secretion or reaction
Increase insulin requirements associated with stress
2. DKA- acute insulin deficiency resulting in metabolic
acidosis from ketone bodies (acid-end products of fat
metabolism)
Causes:
Inadequate secretion of endogenous insulin
insufficient exogenous insulin
increased insulin requirement due to physical and
emotional stress

3.Severe hypoglycemia
Complications:
Long term:
• Vascular changes : HTN, stroke, CAD, atherosclerosis, MI
• Irreversible nerve damage
Retinopathy
Neuropathy
Nephropathy
• Amputations due to neuropathy or vessel disease
• Type 2 diabetes: risk of developing Alzheimer’s disease (if
blood glucose is not well managed).
• Infection or skin conditions
• Death
Complications in pregnancy:

• High BP
• Preeclampsia
• Stillbirth
• Birth defects
Stroke/CVA in DM: Ischemic-thrombotic/embolic CVA sec. to
atherosclerotic disease or embolic events.
HTN
Atherosclerosis of cerebral vessels -develop extensively in
DM
• Blurred vision, Slurred speech, Weakness, Dizziness

Prevention:
1. Weight reduction
2. Diet
3. Exercise
4. Medications
Prevention of DM:
• No known prevention for type 1 diabetes.
• Lower the risk of type 2 diabetes and gestational diabetes
Achieve a healthy weight and focus on a nutrient-dense
diet
Exercise regularly: 30 mins 5X a week
Avoid smoking, high triglycerides, and low HDL
cholesterol levels, limit alcohol intake
Adequate sleep (7-9 hrs.)
Manage stress
Take medications as prescribed
PROGNOSIS:
- varies greatly depending on several factors
- Type of diabetes
• Management over time and access to diabetes care.
• Age at diagnosis/how long a person had diabetes.
• Co morbidities
• Presence complications.
• Lifestyle changes
• Regular exercise
• Dietary changes
• Regular blood sugar monitoring.
• Consistently keeping their A1c levels below 7%
 WHO’s commitment to global diabetes response

“We have seen an alarming rise in diabetes over

the past three decades, which reflects the increase
in obesity, compounded by the impacts of the
marketing of unhealthy food, a lack of physical
activity and economic hardship,”
“To bring the global diabetes epidemic under
control, countries must urgently take action. This
starts with enacting policies that support healthy
diets and physical activity, and, most importantly,
health systems that provide prevention, early
detection and treatment.”

-WHO Director-General Dr. Tedros Adhanom Ghebreyesus

1. Effective approaches to prevent type 2 diabetes and to
prevent the complications and premature death that
can result from all types of diabetes.

policies and practices across whole populations and

within specific settings (school, home, workplace) that
contribute to good health for everyone, regardless of
whether they have diabetes such as exercising regularly,
eating healthily, avoiding smoking, controlling BP and
lipids.
2. The starting point for living well with diabetes is an
early diagnosis – the longer a person lives with
undiagnosed and untreated diabetes, the worse their
health outcomes.
Easy access to basic diagnostics such as blood
glucose testing should therefore be available in primary
health care settings.
Patients will need periodic specialist assessment or
treatment for complications.
Providing comprehensive guidance in measuring and
evaluating diabetes prevention, care, outcomes and
impacts.
3. A series of cost-effective interventions can improve
patient outcomes, regardless of what type of diabetes
they may have, these include:
Blood glucose control through a combination of diet,
physical activity and, if necessary, medication.
Control of BP and lipids to reduce cardiovascular risk
and other complications.
Regular screening for damage to the eyes, kidneys and
feet to facilitate early treatment.
4. Ensuring that all people who are diagnosed with
diabetes have access to equitable, comprehensive,
affordable and quality treatment and care.
to ensure that 80% of people with diagnosed diabetes
achieve good glycemic control by 2030.
the scale and urgency of action needed to advance
efforts to close the gap and halt diabetes epidemic.
to raise the priority given to the prevention, diagnosis
and control of diabetes as well as prevention and
management of risk factors.
 Chronic high blood sugar can cause severe
complications, which are usually irreversible. Untreated
chronic high blood glucose shortens a lifespan and
worsens the quality of life.
References:
• Brunner and Suddarth’s Medical-Surgical Nursing
• Williams Linda S, Hooper Paula D. Understanding Medical Surgical Nursing
• Nettina, S; Lippincott Manual of Nursing Practice
• Diabetes - World Health Organization (WHO) https://www.who.int/health-topics/diab…
• Beyond Type 1. Forms of Diabetes (https://beyondtype1.org/other-forms-of-diabetes/).
Accessed 2/17/2023.
• Centers for Disease Control and Prevention.
Diabetes (https://www.cdc.gov/diabetes/index.html). Accessed 2/17/2023
• Zaccardi F, et al. (2020). First-line treatment for type 2 diabetes: Is it too early to abandon
metformin?
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32523-X/fulltext
• National diabetes statistics report. (2022).
https://www.cdc.gov/diabetes/data/statistics/statistics-report.html
• Sapra A, Bhandari P. Diabetes Mellitus
(https://www.ncbi.nlm.nih.gov/books/NBK551501/). 2022 Jun 26. In: StatPearls [Internet].
Treasure Island, FL: StatPearls Publishing; 2022 Jan-. Accessed 2/17/2023.
Thank you.