Section 7

### LEARNING OBJECTIVES

LEARNING OBJECTIVES

Upon completion of the chapter, the reader will be able to:

1. Discuss the incidence and economic impact of diabetes.

2. Distinguish clinical differences in type 1, type 2, and gestational diabetes.

3. List screening and diagnostic criteria for diabetes.

4. Discuss therapeutic goals for blood glucose and blood pressure for a patient with diabetes.

5. Recommend nonpharmacologic therapies, including meal planning and physical activity, for patients with diabetes.

6. Compare oral agents used in treating diabetes by their mechanisms of action, time of action, side effects, contraindications, and effectiveness.

7. Select appropriate insulin therapy based on onset, peak, and duration of action.

8. Discuss the signs, symptoms, and treatment of hypoglycemia.

9. Define diabetic ketoacidosis and discuss treatment goals.

10. Develop a comprehensive therapeutic monitoring plan for a patient with diabetes based on patient-specific factors.

### INTRODUCTION

KEY CONCEPT Diabetes mellitus (DM) describes a group of chronic metabolic disorders characterized by hyperglycemia that may result in long-term microvascular and neuropathic complications. These complications contribute to diabetes being the leading cause of (a) new cases of blindness among adults, (b) end-stage renal disease, and (c) nontraumatic lower limb amputations. Macrovascular complications (coronary artery disease, peripheral vascular disease, and stroke) are also associated with DM.

### EPIDEMIOLOGY AND ETIOLOGY

DM affects an estimated 29.1 million persons in the United States, or 9.3% of the population.1 Although an estimated 21 million persons have been diagnosed, another 8.1 million have DM but are unaware they have the disease. The total financial impact of DM in 2012 was approximately $245 billion, with direct medical costs equaling$176 billion (2.3 times higher than what expenditures would be in the absence of diabetes) and indirect costs secondary to disability, work loss, and premature mortality equaling \$69 billion.

DM is characterized by a complete lack of insulin, a relative lack of insulin, or insulin resistance as well as disorders of other hormones. These defects result in an inability to use glucose for energy. The increasing prevalence of DM is partly caused by three influences: lifestyle, ethnicity, and age.

#### Lifestyle

A sedentary lifestyle coupled with greater consumption of high-fat, high-carbohydrate foods, and larger portion sizes have resulted in increasing rates of persons being obese. Current estimates indicate that 34.9% of the US population is obese when obesity is defined as a body mass index (BMI) of greater than 30 kg/m2.2 In a 2008 survey, the Centers for Disease Control and Prevention (CDC) found that 25.4% of American adults spent none of their free time being physically active.3

#### Ethnicity

In addition to current lifestyle trends and increased body weight, certain ethnic ...

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