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Diabetes Type 1

Sara Martinez

Chamberlain College of Nursing

NR 507 Advanced Pathophysiology

2018

What is Diabetes

Body Does not make or properly use insulin: (ADA,2005)

No insulin production

Insufficient insulin production

Resistance to insulin’s effects

No insulin to move glucose from blood into cells

High blood glucose means:

Fuel loss, cells starve

Short and long term complications

Diabetes is a chronic disease in which the body does not make or properly

use insulin, a hormone that is needed to convert sugar, starches, and other

food into energy by moving glucose from blood into the cells ( American Diabetes Association, 2005).

People with diabetes have increased blood glucose (sugar) levels for one or

more of the following three reasons: Either

No insulin is being produced,

Insulin production is insufficient, and/or

The body is resistant to the effects of insulin.

As a result, high levels of glucose build up in the blood, and spill into the

urine and out of the body. The body loses its main source of fuel and cells

are deprived of glucose, a needed source of energy. High blood glucose

levels may result in short and long term complications over time ( Centers for Disease Control and Prevention, 2017).

Understanding Diabetes Type 1

Auto immune disorder

Insulin – producing cells destroyed

Daily insulin replacement necessary

Age of onset: usually childhood, young adults

Most prevalent type of diabetes in children and adolescent’s

(CDC,2017)

Diabetes mellitus (DM) is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both (CDC,2017).

The term diabetes mellitus describes a metabolic disorder of multiple aetiology characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.

The effects of diabetes mellitus include long–term damage, dysfunction and failure of various organs.

Diabetes is a condition where the body fails to utilize the ingested glucose properly. This could be due to lack of the hormone insulin or because the insulin that is available is not working effectively. Diabetes is the fastest growing long term disease that affects millions of people worldwide (CDC,2017). According to the charity Diabetes UK, more than two million people in the UK have the condition and up to 750,000 more are unaware of having the condition. In the United States 25.8 million people or 8.3% of the population have diabetes. Of these, 7.0 million have undiagnosed diabetes. In 2010, about 1.9 million new cases of diabetes were diagnosed in population over 20 years. It is said that if this trend continues, 1 in 3 Americans would be diabetic by 2050 (Mayo Clinic, 2017).

Type 1 diabetes is a disease of the immune system, which is the body’s system for fighting infection.

In people with type 1 diabetes, the immune system attacks the beta cells, the insulin-producing cells of the pancreas, and destroys them.

The pancreas can no longer produce insulin, so people with type 1 diabetes need to take insulin daily to live.

Type 1 diabetes can occur at any age, but the disease develops most often in children and young adults.

Type 1 diabetes accounts for about 5 to 10 percent of diagnosed diabetes in the United States (ADA,2005).

Risk factors and Etiology Diabetes Type 1

The exact cause of type 1 diabetes is unknown. Usually, the body's own immune system — which normally fights harmful bacteria and viruses mistakenly destroys the insulin-producing (islet, or islets of Langerhans) cells in the pancreas. Other possible causes include: (CDC,2017)

Genetics

Exposure to viruses and other environmental factors

Family history

Age

Family history. Anyone with a parent or sibling with type 1 diabetes has a slightly increased risk of developing the condition. Family history may be important in some cases of type 1 diabetes. If you have a family member with type 1 diabetes, your risk of developing increases (CDC,2017). However, not everyone who is at risk for type 1 diabetes develops the condition.

Genetics. The presence of certain genes indicates an increased risk of developing type 1 diabetes. Several genes have been tentatively linked to this condition,

Geography. The incidence of type 1 diabetes tends to increase as you travel away from the equator.

Age. Although type 1 diabetes can appear at any age, it appears at two noticeable peaks(CDC,2017). The first peak occurs in children between 4 and 7 years old, and the second is in children between 10 and 14 years old.

Though scientists have made much progress in predicting who is at risk for developing type 1 diabetes, they do not know exactly what triggers the immune system’s attack on beta cells.(autoimmunity) They believe that type 1 diabetes is due to a combination of genetic and environmental factors.

Healthcare provider implications of prevention

Currently, there is no established means by which to prevent the onset of DM1, but research is ongoing (Schub & Parks, 2017).

There are some possible preventions are:

Vitamin Supplementation

Probiotic use in infancy

Identification of DM1

Vitamin D supplementation in early childhood might offer some degree of protection against DM1 Investigators who conducted a meta-analysis of four case-control studies including a total of 6,455 participants concluded that vitamin D supplementation in early childhood is associated with a 29% reduction in risk of DM1- However, researchers in Sweden found that maternal use of a multivitamin supplement containing vitamin D during pregnancy had no effect on risk of developing DM in their children–The American Diabetes Association (ADA,2005), makes no nutritional recommendations for preventing DM1

Probiotic use in infancy may be associated with reduced risk of DM1–Researchers in a study of 7,473 children who were genetically predisposed to DM1 (due to carriage of HLA-DR-DQ alleles) in Finland, Germany, Sweden, and the United States found that probiotic supplementation during the first27 days of life was associated with a 34% decreased risk of islet autoimmunity. This overall decrease was almost entirely accounted for by children with the DR3/4 genotype, in whom early probiotic exposure decreased risk of islet autoimmunity by 60%; children with other genotypes did not benefit from probiotic use(CDC,2017).

Identification of a DM1-causing virus and the autoantibodies associated with pancreatic beta cell destruction could make the development of a preventive vaccine possible(6)–Autoantibodies against the antigen glutamic acid decarboxylase-65 (GAD65), which are frequently found in patients withDM1 of recent onset, may be a target of specific immunotherapy using recombinant human GAD65; although this is a feasible and promising approach, it is in early stages of development (CDC,2017).

Health Care provider implications for prevention of Type 1 Diabetes

Become knowledgeable about Type 1 Diabetes

Educate parents/patients, Especially those with a family history of Type 1 Diabetes

Educate parents/patients about possible protective factors against Type 1 Diabetes

Encourage parents/patients to dee a diabetes specialist for risk evaluation

(CDC, 2017)

Become knowledgeable about DM1, including risk factors for the disease and potential prevention strategies, so you can accurately assess your patients’ personal characteristics and health education needs; share this information with your colleagues› Education is best provided with sensitivity to the age and developmental stage of the child, with regard to both the educational approach and the content of the material delivered. For the preschooler, education likely will be directed toward the parents and primary caregivers, whereas for most adolescents (after consideration of their emotional and cognitive development), education should be directed primarily toward the patient, with parents included. Since small, albeit often insignificant inconsistencies in information can be confusing to a distraught family, education should be provided to all caregivers simultaneously if possible.

Educate parents/patients, especially those with a family history of DM1, about factors that might increase the risk for DM1in children, including- enterovirus infection reduced exposure to UVB light and subsequent low vitamin D levels- consumption of nitrates (i.e., substances that are used as food additives in meat products and are also found in potatoes, cabbage, carrots, and beet root), nitrites (i.e., substances that are used as food additives in sausage), and N-nitroso compounds (i.e., substances that are found in bacon, smoked fish, and smoked sausage)• consumption of cow’s milk in infancy• increased weight for height› (CDC,2017).

Educate parents/patients about possible protective factors against DM1, including• breastfeeding for a longer period of time• vitamin D and/or probiotic supplementation in infancy and early childhood›

Encourage your patients and the parents of your pediatric patients to ask their primary clinician for a referral to a diabetes specialist to evaluate risk for DM1, if suspected

Complications of Diabetes Type 1

Heart and blood vessel disease (ADA, 2005)

Nerve damage (neuropathy)

Kidney damage (nephropathy)

Eye damage

Foot damage

Skin and mouth conditions

Pregnancy complications

Over time, type 1 diabetes complications can affect major organs in your body, including heart, blood vessels, nerves, eyes and kidneys. Maintaining a normal blood sugar level can dramatically reduce the risk of many complications.

Eventually, diabetes complications may be disabling or even life-threatening (ADA,2005).

Heart and blood vessel disease. Diabetes dramatically increases your risk of various cardiovascular problems, including coronary artery disease with chest pain (angina), heart attack, stroke, narrowing of the arteries (atherosclerosis) and high blood pressure.

Nerve damage (neuropathy). Excess sugar can injure the walls of the tiny blood vessels (capillaries) that nourish your nerves, especially in the legs. This can cause tingling, numbness, burning or pain that usually begins at the tips of the toes or fingers and gradually spreads upward. Poorly controlled blood sugar could cause you to eventually lose all sense of feeling in the affected limbs.

Damage to the nerves that affect the gastrointestinal tract can cause problems with nausea, vomiting, diarrhea or constipation. For men, erectile dysfunction may be an issue.

Kidney damage (nephropathy). The kidneys contain millions of tiny blood vessel clusters that filter waste from your blood. Diabetes can damage this delicate filtering system. Severe damage can lead to kidney failure or irreversible end-stage kidney disease, which requires dialysis or a kidney transplant.

Eye damage. Diabetes can damage the blood vessels of the retina (diabetic retinopathy), potentially causing blindness. Diabetes also increases the risk of other serious vision conditions, such as cataracts and glaucoma.

Foot damage. Nerve damage in the feet or poor blood flow to the feet increases the risk of various foot complications. Left untreated, cuts and blisters can become serious infections that may ultimately require toe, foot or leg amputation.

Skin and mouth conditions. Diabetes may leave you more susceptible to infections of the skin and mouth, including bacterial and fungal infections. Gum disease and dry mouth also are more likely.

Pregnancy complications. High blood sugar levels can be dangerous for both the mother and the baby. The risk of miscarriage, stillbirth and birth defects increases when diabetes isn't well-controlled. For the mother, diabetes increases the risk of diabetic ketoacidosis, diabetic eye problems (retinopathy), pregnancy-induced high blood pressure and preeclampsia.

Sexual Dysfunction - loss of libido and erectile dysfunction

In its most severe forms, ketoacidosis or a non–ketotic hyperosmolar state may develop and lead to stupor, coma and, in absence of effective treatment, death (CDC,2017).

(AMSL, 2017)

The symptoms of type 1 diabetes usually develop over a short period of time. They include increased thirst and urination, constant hunger, weight loss, and blurred vision ( AMSL,2017). Children may also feel very tired all the time. If not diagnosed and treated with insulin, the person with type 1 diabetes will eventually lapse into a life-threatening condition known as diabetic ketoacidosis or DKA

regardless of excreting some of the glucose through waste, the blood levels continue to be elevated. When this is occurring, fluids are pulled outside the intercellular space into general blood circulation causing frequent urination called polyuria. Due to large volumes of urine, the body becomes dehydrated and the natural sense of thirst occurs to coach the body into consuming more fluids, identified as polydipsia (AMSL,2017). Also, since glucose or sugar is unable to enter the cell and provide it the energy it needs the body triggers you to eat to consume sugars and provide it energy. Since the body doesn’t create insulin to allow the sugars in hyperglycemia continues. The state that triggers your body to see nutrition is called polyphagia (AMSL,2017).

Diagnosis of Diabetes Type 1

Glycated hemoglobin (A1C) test

Random blood sugar

Fasting blood sugar

Glucose Tolerance Test

Urine Test

(Mayo Clinic, 2017)

Glycated hemoglobin (A1C) test. This blood test indicates your average blood sugar level for the past two to three months. It measures the percentage of blood sugar attached to the oxygen-carrying protein in red blood cells (hemoglobin). The higher your blood sugar levels, the more hemoglobin you'll have with sugar attached. An A1C level of 6.5 percent or higher on two separate tests indicates diabetes.

If the A1C test isn't available, or if you have certain conditions that can make the A1C test inaccurate — such as pregnancy or an uncommon form of hemoglobin (hemoglobin variant)

Random blood sugar test. A blood sample will be taken at a random time and may be confirmed by repeat testing. Blood sugar values are expressed in milligrams per deciliter (mg/dL) or millimoles per liter (mmol/L). Regardless of when you last ate, a random blood sugar level of 200 mg/dL (11.1 mmol/L) or higher suggests diabetes, especially when coupled with any of the signs and symptoms of diabetes, such as frequent urination and extreme thirst.

Fasting blood sugar test. A blood sample will be taken after an overnight fast. A fasting blood sugar level less than 100 mg/dL (5.6 mmol/L) is normal. A fasting blood sugar level from 100 to 125 mg/dL (5.6 to 6.9 mmol/L) is considered prediabetes. If it's 126 mg/dL (7 mmol/L) or higher on two separate tests, you have diabetes.

If you're diagnosed with diabetes, your doctor may also run blood tests to check for autoantibodies that are common in type 1 diabetes.

Glucose Tolerance Test- This measures your blood sugar before and after you drink a liquid that contains glucose. You’ll fast (not eat) overnight before the test and have your blood drawn to determine your fasting blood sugar level. Then you’ll drink the liquid and have your blood sugar level checked 1 hour, 2 hours, and possibly 3 hours afterward. At 2 hours, a blood sugar level of 140 mg/dL or lower is considered normal, 140 to 199 mg/dL indicates you have prediabetes, and 200 mg/dL or higher indicates you have diabetes.

Urine- random urine will be tested for the presence of ketones ( produced when your body burns fat for energy)

Managing and Treatment of Diabetes Type 1 NO cure at this time!

Treatment for type 1 diabetes includes:

Taking insulin

Carbohydrate, fat and protein counting

Frequent blood sugar monitoring

Eating healthy foods

Exercising regularly and maintaining a healthy weight. (Mayo Clinic, 2017)

The following principles are recommended as dietary guidelines for people with diabetes:

Dietary fat should provide 25-35% of total intake of calories but saturated fat intake should not exceed 10% of total energy. Cholesterol consumption should be restricted and limited to 300 mg or less daily(CDC,2017).

Protein intake can range between 10-15% total energy (0.8-1 g/kg of desirable body weight). Requirements increase for children and during pregnancy. Protein should be derived from both animal and vegetable sources.

Carbohydrates provide 50-60% of total caloric content of the diet. Carbohydrates should be complex and high in fibre.

Excessive salt intake is to be avoided. It should be particularly restricted in people with hypertension and those with nephropathy (CDC,2017).

Making diabetes a part of life, such as maintain blood glucose control is a juggling act, 24 hours a day , 7 days a week

The key to optimal diabetes control is a careful balance or balancing of food, physical activity, and insulin and/or oral medication.

As a general rule:

Insulin medication and physical activity makes blood glucose levels go down.

Food makes blood glucose levels go up.

Several other factors, such as stress, illness or injury, also can affect blood glucose levels

Pharmacological Interventions for Diabetes Type 1 Treatment and Management

Insulin

Short acting insulin

Rapid- acting Insulin

Intermediate- acting insulin (NPH)

Long-Acting insulin

(Mayo Clinic, 2017)

Examples of short-acting (regular) insulin include Humulin R and Novolin R.

Rapid-acting insulin examples are insulin glulisine (Apidra), insulin lispro (Humalog) and insulin aspart (Novolog).

Long-acting insulins include insulin glargine (Lantus, Toujeo Solostar), insulin detemir (Levemir) and insulin degludec (Tresiba).

Intermediate-acting insulins include insulin NPH (Novolin N, Humulin N) (Mayo Clinic, 2017).

The majority of patients will require more than one daily injection if good glycaemic control is to be achieved. However, a once-daily injection of an intermediate acting preparation may be effectively used in some patients.

Twice-daily mixtures of short- and intermediate-acting insulin is a commonly used regimen.

In some cases, a mixture of short- and intermediate-acting insulin may be given in the morning. Further doses of short-acting insulin are given before lunch and the evening meal and an evening dose of intermediate-acting insulin is given at bedtime.

Other regimens based on the same principles may be used.

A regimen of multiple injections of short-acting insulin before the main meals, with an appropriate dose of an intermediate-acting insulin given at bedtime, may be used, particularly when strict glycaemic control is mandatory (Mayo Clinic, 2017).

Overview of Insulin and Action

(AMSL,2017)

Types of Insulin

(AMSL,2017)

Hypoglycemia (low blood sugar) can happen quickly and needs to be treated immediately. It’s most often caused by too much insulin, waiting too long for a meal or snack, not eating enough, or getting extra physical activity. Hypoglycemia symptoms are different from person to person; make sure you know your specific symptoms, which could include:

Shakiness

Nervousness or anxiety

Sweating, chills, or clamminess

Irritability or impatience

Dizziness and difficulty concentrating

Hunger or nausea

Blurred vision

Weakness or fatigue

Anger, stubbornness, or sadness

If you have hypoglycemia several times a week, talk to your doctor to see if your treatment needs to be adjusted.

Frequent blood sugar monitoring

Frequency of monitoring dependent on type of insulin therapy

Checking your blood sugar

Recording your blood sugar in a log

Latest way to monitor blood sugar continuously

(CDC,2017)

Depending on what type of insulin therapy you select or require, you may need to check and record your blood sugar level at least four times a day.

Blood glucose monitoring shows your current blood glucose (sugar) level. High bloodsugar over a long time may cause problems with your heart, eyes, kidneys, nerves, orfeet. When you don’t monitor blood sugar, it’s like driving down the street with yourwindshield covered up. You can’t see where you’re going, and you’re likely to have anaccident and get hurt.Monitoring shows how food, medicine, exercise, and stress affect your blood sugar. Askyour medical team how often to check your blood sugar level. They will also help youdecide the target range in which most of your blood sugar readings should fall.Your medical team will help you see patterns in your blood sugar levels. If a reading at acertain time of day is often out of the target range, you can figure out how to control it.

The American Diabetes Association recommends testing blood sugar levels before meals and snacks, before bed, before exercising or driving, and if you suspect you have low blood sugar. Careful monitoring is the only way to make sure that your blood sugar level remains within your target range — and more frequent monitoring can lower A1C levels (ADA,2005).

Even if you take insulin and eat on a rigid schedule, blood sugar levels can change unpredictably. You'll learn how your blood sugar level changes in response to food, activity, illness, medications, stress, hormonal changes and alcohol.

Continuous glucose monitoring (CGM) is the newest way to monitor blood sugar levels, and may be especially helpful for preventing hypoglycemia. When used by people older than 25, the devices have been shown to lower A1C.

Continuous glucose monitors attach to the body using a fine needle just under the skin that checks blood glucose level every few minutes. CGM isn't yet considered as accurate as standard blood sugar monitoring, so at this time it's still important to check your blood sugar levels manually.

Diet- Carbohydrate, fat and protein counting

Dietary treatment should aim at: (Gottlieb,2015)

Making healthily food choices

Ensuing weight control

Providing nutritional requirements

Diet is a basic part of management in every case. Treatment cannot be effective unless adequate attention is given to ensuring appropriate nutrition.

center your diet on nutritious, low-fat, high-fiber foods such as:

Fruits

Vegetables

Whole grains

Your dietitian will recommend that you eat fewer animal products and refined carbohydrates, such as white bread and sweets. This healthy-eating plan is recommended even for people without diabetes (Gottlieb,2015).

You'll need to learn how to count the amount of carbohydrates in the foods you eat so that you can give yourself enough insulin to properly metabolize those carbohydrates. A registered dietitian can help you create a meal plan that fits your needs.

Exercise

Physical activity

Minimum of 30 to 60 min of moderate physical exercise daily

Example- Walking, running, aerobic exercise

Any sort of physical activity

Before exercise it is suggested to intake 15 g of carbohydrate

Example- sports drink , juice or glucose tablet

Physical exercise should be encouraged and sedentary life style should be discouraged

(Mayo Clinic, 2017)

Physical activity promotes weight reduction and improves insulin sensitivity, thus lowering blood glucose levels.

Together with dietary treatment, a programme of regular physical activity and exercise should be considered for each person. Such a programme must be tailored to the individual’s health status and fitness (Mayo Clinic, 2017).

People should, however, be educated about the potential risk of hypoglycaemia and how to avoid it.

Everyone needs regular aerobic exercise, and people who have type 1 diabetes are no exception. First, get your doctor's OK to exercise. Then choose activities you enjoy, such as walking or swimming, and make them part of your daily routine. Aim for at least 150 minutes of aerobic exercise a week, with no more than two days without any exercise (Mayo Clinic, 2017). The goal for children is at least an hour of activity a day.

Remember that physical activity lowers blood sugar. If you begin a new activity, check your blood sugar level more often than usual until you know how that activity affects your blood sugar levels. You might need to adjust your meal plan or insulin doses to compensate for the increased activity.

Self-Care of Diabetes

Patients should be educated to practice self-care. This allows the patient to assume responsibility and control of his / her own diabetes management. Self-care should include: (ADA, 2005)

Blood glucose monitoring

Body weight monitoring

Foot-care

Personal hygiene

Healthy lifestyle/diet or physical activity

Identify targets for control

Stopping smoking

Blood glucose monitoring - Your doctor will advise you how often you should check your blood sugar level.

Body Weight Monitoring - Many factors affect how well diabetes is controlled. Many of these factors are controlled by the person with diabetes, including how much and what is eaten, how frequently the blood sugar is monitored, physical activity levels, and accuracy and consistency of medication dosing. Even small changes can affect blood sugar control.

Eating a consistent amount of food every day and taking medications as directed can greatly improve blood sugar control and decrease the risk of diabetes-related complications, such as coronary artery disease, kidney disease, and nerve damage. In addition, these measures impact weight control. A dietitian can help to create a food plan that is tailored to your medical needs, lifestyle, and personal preferences( ADA, 2005).

Foot Care- inspect your feet every day, and seek care early if you do get a foot injury. Make sure your health care provider checks your feet at least once a year - more often if you have foot problems.

Personal Hygiene- in the diabetic patient refers primarily to cleanliness. Careful and frequent cleansing of the skin should be emphasized. Immediate attention to all skin abrasions will often prevent serious problems.

Healthy lifestyle/Physical Activity -Exercising regularly can help to lose weight and keep it off. The recommended amount of exercise is 30 minutes per day most days of the week. People who take insulin should check their blood sugar level before and after exercising. If exercise is vigorous and prolonged (more than thirty minutes), check your blood sugar every 15 minutes (if the exercise regimen is new and will be used again). Frequent monitoring can help to get a sense of what effect exercise has on your blood sugar level.

Identify targets for control- Your doctor will advise you what your targets for control are

Stop smoking - Smokers also have a harder time controlling their blood glucose levels, because insulin resistance is increased by smoking. Plus its bad for you.

Conclusion of Diabetes Type 1

What is diabetes type 1

Cause of Type 1 Diabetes

Symptoms of Type 1 Diabetes

Possible long term complications

Treatment and Management of Type 1 Diabetes

(Gottieb, 2015)

What is diabetes and what causes Type 1 diabetes?

Diabetes occurs when the level of glucose (sugar) in the blood becomes too high. Normally, after we eat, various foods are broken down in the gut into sugars which are then absorbed into the body. The main sugar is called glucose. To remain healthy, your blood glucose level should not go too high or too low. A hormone called insulin helps to take glucose from the bloodstream into various cells of the body. This helps to keep the blood sugar normal. Insulin is made by special cells in the pancreas. In Type 1 diabetes the pancreas stops making insulin, and so the blood glucose remains high. This occurs because the immune system makes antibodies which destroy the insulin-making cells in the pancreas. It is not known why the immune system does this. Type 1 diabetes usually first develops in children or young adults (Gottieb, 2015).

What are the symptoms of Type 1 diabetes?

Symptoms tend to develop quite quickly, over a few days or weeks. They include: excess thirst, passing large amounts of urine, tiredness, weight loss, and feeling generally unwell. After treatment is started these symptoms soon go. But, without treatment, the blood glucose level will go very high which can cause you to become very ill, lapse into a coma, and die.

Possible long term complications which may develop?

Even a mildly raised glucose level which does not cause any symptoms in the short-term can affect the blood vessels in the long-term. This may lead to some complications (often years after diabetes is first diagnosed). These include: an increased risk of heart disease, stroke and poor circulation; eye and vision problems; kidney damage; nerve damage; serious foot problems; impotence. In general, the risk of developing complications is reduced if the blood glucose level is well controlled, and other risk factors such as high blood pressure are dealt with.

What is the treatment for Type 1 diabetes?

Treatment to keep your blood glucose level as near normal as possible. You will need insulin injections for the rest of your life. Most people take 2-4 injections each day. There are various types of insulin and the one advised will be tailored to your needs. You should aim to eat a low fat, high fiber diet with plenty of starchy foods, fruit and vegetables. But, you will need to know how to balance the right amount of insulin for the amount of food that you eat. So, you will normally be given a lot of instruction and advice from a dietician and diabetes nurse (Gottieb, 2015). To reduce your risk of future complications your blood pressure should be well controlled. Medication may be needed for this. In addition you are strongly advised: not to smoke, to exercise regularly, and to lose weight if you are overweight. Some of these lifestyle issues may not seem to be relevant at first to young children with diabetes. But, as children grow, a healthy lifestyle should be greatly encouraged to reduce the risk of developing complications in the long-term. Most people with Type 1 diabetes attend a diabetes clinic where doctors, nurses, dieticians, podiatrists, etc., advise on treatment, and aim to detect any complications as early as possible.

Implication for Nurse Practitioner

Begins with Trust

Relationship Building for Behavioral Change

Communication and Teamwork

Begins with Trust -Perhaps our most important skill is the ability to build a trust-based relationship with the patient and the patient’s defined support system. Once we understand the importance of trust, it shifts how we think about intervening. Sensitive, nonjudgmental empathy is crucial, because the patient’s process is often fraught with self-judgment as he or she struggles to achieve desired glucose, weight loss, exercise and other goals. There is often the sense among patients that they could be doing better. Sometimes this self-judgment manifests as defensive behavior; sometimes it borders on self-loathing; but there is often shame and blame in trying to manage their illness.

Relationship Building for Behavioral Change - What does all this mean, specifically, in practice? From the outset, not only must we take a good medical, family and social history and discern the current treatment plan (including current medications and frequency of glucose monitoring), but it is also of utmost importance to know:

How the patient and family have coped with other major stressors in their lives

Their experience with diabetes before they or their child was diagnosed with it (e.g., did they have a family member who died secondary to diabetes complications)

Their level of confidence in their ability to manage diabetes

Their greatest current challenge with diabetes

Communication and Team Work - Last but not least, communication extends to working effectively at the center of team-based care. Sometimes this can mean ensuring that everyone involved is clear on the patient’s status and next steps, but it can also mean understanding when we need – and how best – to consult with a physician on difficult medical cases, such as when a child requires excess insulin, which may indicate other metabolic disorders or something esoteric on the medical side. How often to consult with a physician depends on experience, but a beginning NP will likely ask for consultation frequently.

The point is that each role is important – from the medical assistant triaging a child, to the RN or dietitian trying to teach a family about diabetes, to the endocrinologist or NP fine-tuning the insulin regimen. It is our responsibility to use our intimate understanding of all these roles to maximize the efficacy of the entire team so that we help patients and families live the full and rewarding lives they deserve.

References

American Diabetes Association. ( 2005). Diabetes Care. Retrieved from: http://care.diabetesjournals.org/content/diacare/28/1/186.full.pdf

AMSL. (2017). Diabetes. Retrieved from: http://amsldiabetes.com.au/

Centers for Disease Control and Prevention. (2017). Type 1 Diabetes. Retrieved from: https://www.cdc.gov/diabetes/basics/type1.html

Gottlieb, P. A. (2015). What defines disease in an age of genetics and biomarkers?. Current Opinion in Endocrinology, Diabetes and Obesity, 22(4), 296-299.

Mayo Clinic. (2017). Type 1 Diabetes. Retrieved from https://www.mayoclinic.org/diseases-conditions/type-1-diabetes/symptoms-causes/syc-20353011

Schub, T. B.,& Parks, J. B. (2017). Diabetes Mellitus, Type 1: Risk Factors and Prevention. CINAHL Nursing Guide,