Mild hypoglycemia - associated with adrenergic symptoms such as tachycardia, palpitation, pallor and shakiness or cholinergic symptoms such as diaphoresis or the effect on the nervous system such as hunger, dizziness or blurred vision. The patient remains totally alert.

Moderate hypoglycemia - associated with neuroglycopenia, the impairment of the central nervous system. Symptoms include confusion, inability to concentrate slurred speech or irrational behavior. The patient is able to seek help or administer self-treatment.

Severe hypoglycemia - associated with severe neuroglycopenia causing seizure or coma. The patient is unable to self-treat and needs the assistance of others for administration of glucagon or IV glucose.

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• 25x greater chance of developing blindness
• 17x greater chance of developing kidney disease
• 20x greater chance of developing gangrene
• 30-40x greater chance of having a major amputation
• 2x (males) to 4x (females) greater chance of developing coronary heart disease
• 2x as likely to suffer a stroke.

• 76% reduction in primary-prevention of retinopathy
• 54% reduction in the progression of established retinopathy
• 47% reduction in the progression of proliferative and severe nonproliferative retinopathy
• 39% reduction in the occurrence of microalbuminuria
• 60% reduction in clinical neuropathy

1. Nonproliferative
2. Preproliferative
3. Proliferative

1. Care of the eyes in a diabetic patient reflects a partnership between the primary care physician and the ophthalmologist.
2. The former has a fundamental role in the medical management, appropriate referrals, and coordination of care, and the latter determines the diagnosis and treatment of diabetic retinopathy.
3. It is the responsibility of the primary care physician to inform the patient of the potential for visual loss in diabetes and that early detection and treatment greatly reduced this risk and to refer the patient to a qualified ophthalmologist.
4. Patients with type 1 diabetes should be referred after 5 years of having diabetes.
5. Patients with type 2 diabetes should be referred at the time of diagnosis since many patients have already had diabetes for 10 years before finally being diagnosed and treated.
6. Persons at risk for developing retinopathy or who have retinopathy should avoid exercise that involves heavy lifting/straining or pounding/jumping since it will worsen the condition.

1. Washing feet with warm water and soap daily
2. Do not soak feet in hot water because of the risk of a burn
3. Wear proper fitting, comfortable shoes; inspect shoes for foreign objects
4. Do not walk barefoot outside or inside
5. Trim nails carefully if able; if not, see a Podiatrist
6. Do not perform "home surgery" on ingrown toenails or try to remove calluses
7. Don’t smoke

1. Puncture wounds
2. Cuts or scrapes that do not heal
3. Ingrown toenails
4. Corns and calluses
5. Sore feet from ill-fitting shoes
6. Discoloration, pain, redness, or swelling
7. Pain in the calves during walking or exercise

Almost half of the patients undergoing kidney dialysis have diabetic nephropathy. It is a disease process that involves albuminuria, hypertension, and progressive renal insufficiency. It is believed that the same process occurs in both type 1 and type 2 diabetes.

1. Stage I is characterized by a 30-40% increase in the glomerular filtration rate (GFR) above normal at the time of diagnosis. The hyperfiltration causes increased intraglomerular pressure and possibly albumin excretion.
2. Stage II reverts to normal albumin excretion (<30mg/24 hr) and GFR. Those with an improved glucose control, reflected by lower glycated hemoglobin levels, are more likely to have an improved GFR.
3. Stage III or incipient diabetic nephropathy is seen with microalbuminuria at rest. Albumin is excreted at rates of 30-300 mg/24 hr. A mild increase in blood pressure is noted along with a decrease in GFR. This is more likely in those with microalbuminuria at >100 mg/24 hr and poor glucose control. Control of glucose and blood pressure helps to normalize albumin excretion.
4. Stage IV, also known as overt diabetic nephropathy is characterized by positive urinary protein detectable using a dipstick method. Protein is excreted at 500mg/24 hr and albumin is excreted at 300 mg/24 hr. Typically, 30-40% of type 1 patients with diabetes develop diabetic nephropathy; however, in a study of tight control only 10% did. Hypertension, family history of renal disease, and smoking are independent risk factors for developing nephropathy. Once the serum creatinine concentration exceeds 2.3 mg/dl there is an inverse relationship to the GFR.
5. Stage V is end-stage renal disease (ESRD) and resembles overt kidney failure as in any other cause. Fifty percent of the patients initiating dialysis have diabetic nephropathy. Symptoms are weakness, lethargy, edema, anorexia, nausea, vomiting, diarrhea, hiccups, pruritis, anemia, uncontrolled hypertension, and electrolyte abnormalities. Patients with diabetes seem to be more symptomatic and receive dialysis at an earlier stage than others with ESRD. Transplant remains the most viable option for these patients at this point.

1. HMG-CoA reductase inhibitors
2. Bile acid resins
3. Nicotinic acid
4. Fibric acid derivatives

• One-step approach: Perform a diagnostic OGTT without prior plasma or serum glucose screening. The one-step approach may be cost-effective in high risk patients or populations (e.g. some Native-American groups)."
• Two-step approach: Perform an initial screening by measuring the plasma or serum glucose concentration 1 h after a 50-g oral glucose load (glucose challenge test [GCT]) and perform a diagnostic OGTT on that subset of women exceeding the glucose threshold value on the GCT. When the two-step approach is employed, a glucose threshold value >140 mg/dl (7.8 mmol/l) identifies approximately 80% of women with GDM, and the yield is further increased to 90% by using a cutoff of >130 mg/dl (7.2 mmol/l).

Method for diagnosis. In pregnancy, the oral glucose tolerance test should be performed as follows:

• Perform the test in the morning, after at least 3 days of unrestricted diet (more than 150 grams of carbohydrate per day) and unrestricted physical activity and after an overnight fast of at least 8 hours but not more than 14 hours.
• Ask the patient to remain seated. If she smokes, ask her not to do so during the test.
• Administer a 75 or 100-gram oral glucose load.
• Measure venous plasma glucose when the patient is fasting and at 1, 2, and 3 hours after administering the glucose load.
• Diagnose gestational diabetes when two or more of the following concentrations are met or exceeded.



(If the initial glucose tolerance test is normal but the patient is thought to be at high risk for gestational diabetes, or if one concentration is met or exceeded, consider repeating the glucose tolerance test at 32 weeks of gestation.)

Although blood glucose measurements using glucose-oxidase-impregnated test strips are useful for monitoring treatment, they are not sufficiently precise for diagnostic purposes. Glycosuria and glycosylated hemoglobin tests are also not sensitive enough to be used to diagnose gestational diabetes.

Treatment

Most women with gestational diabetes can be cared for as outpatients. The patient should be seen at 1- to 2-week intervals to assess glucose control, weight gain, and blood pressure. The patient may need to be hospitalized if she does not maintain acceptable glucose control or if she develops hypertension or an infectious complication such as pyelonephritis.

Diet. Dietary therapy is the mainstay of treatment for patients with gestational diabetes. The daily dietary plan should contain approximately 2000 to 2400 calories distributed among three meals and a bedtime snack.

Monitoring. Ideally, the efficacy of the diet is assessed by daily self-monitoring of blood glucose. Weekly measurements of fasting and postprandial glucose levels are also an acceptable method of monitoring.

Pharmacologic therapy. If the fasting plasma glucose level exceeds 105 mg/dL and/or the 2-hour postprandial value exceeds 120 mg/dL, treatment with human insulin should be initiated. Patients who require insulin should be instructed in glucose self-monitoring. Oral hypoglycemic agents should not be used during pregnancy.

Fetal assessment. Patients with insulin-treated gestational diabetes require a program of fetal surveillance identical to that recommended for patients with pregestational diabetes (see the earlier discussion). Begin fetal surveillance by 34 weeks of gestation for patients with non-insulin-treated gestational diabetes who develop preeclampsia or have a history of intrauterine death. Begin fetal surveillance at 40 weeks of gestation for patients with uncomplicated non-insulin-treated gestational diabetes who have not delivered.

Postpartum care. All patients with gestational diabetes should undergo a 75-gram oral glucose tolerance test at 6 to 8 weeks postpartum to determine whether abnormal carbohydrate metabolism has persisted.

The glucose tolerance test should be performed as follows:

• Perform the test in the morning, after at least 3 days of unrestricted diet (more than 150 grams of carbohydrate per day) and unrestricted physical activity and after an overnight fast of between 8 and 14 hours.
• Ask the patient to remain seated. If she smokes, ask her not to do so during the test.
• Administer a 75-gram oral glucose load.
• Measure the venous plasma glucose when the patient is fasting and 30, 60, 90, and 120 minutes after administering the glucose load.
• Diagnose abnormal glucose tolerance according to the following criteria:



Encourage patients to achieve their ideal body weight to decrease their likelihood of developing non-insulin-dependent diabetes mellitus. Patients with a history of gestational diabetes should be annually evaluated for onset of diabetes.

For contraception, patients may use low-dose oral contraceptive pills, progestin-only pills, or barrier methods.

Patient Education Principles

For patients with pregestational diabetes:

• Emphasize the importance of prepregnancy care.
• Work with the patient, her partner, her family, and other health care providers to improve the patient's nutrition, exercise program, and glucose control.
• Recommend that conception be delayed until the patient's blood glucose control is excellent and the glycosylated hemoglobin level is normal or near normal.
• Explain the risks of birth defects and adverse perinatal outcomes and the need for fetal surveillance.
• Recommend that the patient's vascular condition be thoroughly evaluated before she becomes pregnant. Explain that pregnancy may exacerbate advanced diabetic retinopathy but generally does not permanently worsen diabetic nephropathy.
• Explain that, overall, pregnancy does not shorten the life expectancy of a woman with diabetes but does increase her risk for hypoglycemia and ketoacidosis and for associated mortality.
• Inform patients with coronary atherosclerosis that their risks for morbidity or mortality may be greater during pregnancy.
• Discuss the emotional and financial demands of pregnancy with the patient, her partner, and her family.
• Inform patients about lifestyle elements--such as drinking alcoholic beverages and smoking--that increase the risk for a poor outcome of pregnancy. Emphasize that patients will need to modify such behaviors before becoming pregnant.

For patients with gestational diabetes:

• Work with the patient, her partner, her family, and other health care providers to improve the patient's nutrition, exercise program, and glucose control.
• Explain the risks of adverse perinatal outcomes and the need for fetal surveillance.
• Inform patients that they are at increased risk both for developing gestational diabetes during future pregnancies and for developing overt diabetes later in life.
• Encourage physical activity and postpartum weight loss to decrease the likelihood of developing diabetes later in life.
• Recommend an evaluation at 6 to 8 weeks postpartum, and annually thereafter, for detecting the development of diabetes.

For patients with a history of gestational diabetes:

• Recommend screening for overt diabetes before subsequent pregnancies.
• Recommend early screening for the onset of carbohydrate intolerance during subsequent pregnancies.

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Section X. Psychological Issues

Psychological Impact

Diabetes can be overwhelming to manage. Diabetes is a condition that affects all aspects of a person’s life. Many patients mourn after receiving the diagnosis of diabetes. Most people resolve their distress within the first year. Prochaska and colleagues outlined predictable stages of change that a client will work through when making alterations in behavior.¹⁰

Five stages of change:

1. Precontemplation: the period when the patient is not considering or recognizing a need for change
2. Contemplation: desires change, but is only thinking about it
3. Preparation: the client is actively making plans to change
4. Action: the client begins implementing the plan of change
5. Maintenance: if successful, the patient will continue the new behaviors and work to prevent relapse

It is possible for a patient to become "stuck" in any one of these phases or shift back and forth through these stages. If the counselor leads and perceives the relationship appropriately, the counseling process will align itself with these stages of change. A mismatch in this process occurs when a client is pushed to change before they are even considering change or only discussing changes when a client is ready for action. The first few stages require a shift in thought processes, while later stages require observable activity on the client’s part.

Self-Care Responsibilities

A person’s ability to cope is seen in the degree to which they assume the self-care responsibilities of diabetes. Those who cope well will monitor their glucose, seek medical advice, and follow most or all of the recommendations necessary to manage their glucose levels. Those who cope poorly are likely to resist monitoring glucose levels, miss doctor’s appointments, and ignore medical advice. Barriers to caring for one’s self include living alone, personal and financial stress, concomitant illness, lack of insurance, lack of education, and cultural issues. Simple, open-ended questions like "How do you feel about having diabetes? How do your family and friends react to you having diabetes? What concerns you about having diabetes?" may be helpful in assessing the patient’s ability to cope.

Family support is important in promoting adherence. The optimal atmosphere is encouraging, supportive, and non-judgmental. Maladaption is seen via family members who sabotage and do not support the diabetes regimen or by those who foster dependency and over-protection. Diabetes self-care responsibilities should be given to the child or teenager at an age-appropriate level. As the child matures, he/she can begin to be responsible for glucose monitoring and insulin administration.

Fear of hypoglycemia is one of the most immediate worries a person with diabetes has and this is heightened with hypoglycemia unawareness. Teaching prevention strategies is required to minimize this fear. Other prominent fears include loss of sight and amputation. As complications progress, a sense of hopelessness and depression may occur.

Warning signs of depression are behavior changes such as disturbed sleep patterns, altered eating habits, giving possessions away, resistance to medical treatment, frequently skipping medication dosages, frequent hospitalizations, inconsistent accounts of diabetes management, a lack of self-care activities, and a pattern of missed appointments.

Intervention strategies include: being alert to the above risky behaviors, establishing an atmosphere of trust and cooperation with the client, and seeing patients with and without family members for consistency in information they are sharing. Health care providers should be ready to make referrals to mental health practitioners as appropriate.

Diabetes, hypoglycemia and employment/licensure: In 1984, the American Diabetes Association established the following policy on employment taking into consideration the advancements that have been made with regard to treatment and daily management of diabetes:

"Any person with diabetes, whether insulin dependent or non-insulin dependent, should be eligible for any employment for which he/she is otherwise qualified."

In spite of this statement and the advances made, discrimination in the work place continues, often due to lack of information or misinformation. Hypoglycemia is one of the greatest fears for both employees and employers. Hypoglycemia is typically detected by most persons with diabetes and is readily treatable. It is rarely associated with a lack of consciousness or seizure. Those who lack hypoglycemia awareness should be evaluated on an individual basis and may need modification of their employment position. Factors related to employment conditions should be made on an individual basis considering their current medical status, complexity of treatment regimen, medical history, and their ability to detect the onset of hypoglycemia. Referrals to agencies that can assist with job retraining may be needed. In 1996, the FAA (Federal Aviation Authority) reversed its long-standing position on restricting those taking insulin from flying a plane. The FAA will consider cases on an individual basis. The American with Disabilities Act (ADA) prohibits discrimination based on physical limitations.

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Section XI. Teaching Strategies

Patient Education Program

The design and content of a diabetes patient education program can have a significant impact on their interest in learning. There are many methods used to disseminate information. Historically, the compliance-based approach has been used to improve adherence to the treatment plan established by health care professionals. This model places the health care provider as the director of the client’s medical care and assumes the provider knows what is best for the patient. Clients are expected to conform to the practitioner’s directions. The ultimate goal is to optimize glucose control to prevent complications. This approach may be more suitable for newly diagnosed or poorly informed patients.

The empowerment model serves to guide patients in making informed decisions about their diabetes management. This approach assumes that patients have the right and the responsibility to be the primary decision-makers in their health care. The health care provider acts as technical resource in the decision making process. There is a sense of partnership between the client and health care provider. This model can work well with the client who is self-directed and motivated.

These approaches can be alternated or modified to individualize its use. Considerations may include the patient’s level of comprehension and experience in making complex, long-term decisions.

Readiness to Learn

A patient’s past experience can affect their readiness to learn. If they have a relative who managed their diabetes poorly with resultant complications, they may transfer that poor experience to their own situation. Also, if they feel no ill effects from hyperglycemia, they may be inclined to not treat their glucose management seriously. Their level of social support can affect their interest in learning. Those with greater support from family and friends are more likely to manage better. Other areas that can affect readiness to learn include: current ability to care for themselves, preferred style of learning (verbal, written, active participation), psychological stability, stress level, cultural influences, ability to read, language barriers, visual acuity, hearing loss, and dexterity.

Adult learners are usually self-directed and are more likely to participate in a process that is relevant. Adults focus on problem-solving rather than learning the information for fact gathering. Learning is maximized when the process is active rather than passive. A non-judgmental approach is recommended to gain the patient’s trust so that the health care providers and the patient may work as a team.

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Section XII. Diabetes Advocacy

Federal Legislation

The Balanced Budget Act of 1997, which was signed into law by President Clinton in August 1997, provided for Medicare outpatient coverage of equipment and diabetes self-management training. While Medicare traditionally covers blood glucose monitors and test strips for patients with diabetes who are insulin-users, this new legislation expands coverage to include monitors and test strips for all patients with diabetes, whether they need to take insulin or not. If the physician treating the patient’s diabetes feels that it is necessary and writes a prescription, the patient will be covered.

The Health Care Financing Administration (HCFA) has published instructions on coverage of blood glucose monitors and test strips, and information regarding implementation (partial) of the diabetes outpatient self-management training services. These benefits are effective as of July 1, 1998. As of this date, the education portion may be covered under Medicare only if the physician deems the service necessary. As for the providers of this service, physicians and certain non-physician providers may be eligible to perform this service, but they must meet the National Diabetes Advisory Board Standards. More information concerning the guidelines on other possible categories of certified providers of the self-management training services will be available in 1999.

State Legislation

Many States currently have legislation requiring health insurance coverage for diabetes outpatient self-management training and supplies for patients with diabetes. As of the end of 1997, 23 States

have passed such legislation: Arkansas, Connecticut, Florida, Indiana, Louisiana, Maine, Maryland, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Rhode Island, Tennessee, Texas, Vermont, Washington, West Virginia, and Wisconsin.. Many state have completed studies that have shown a cost savings with proper management of diabetes.

Since diabetes education and monitoring supplies are the keys to successful diabetes self-management; everyone with diabetes, no matter how old they are, no matter which State they live in, should have coverage and access to these services. To improve the quality of life of patients with diabetes, we encourage all health care providers to become Diabetes Advocates, and help your patients to secure health insurance coverage if your State do not already have it. For more information concerning diabetes legislative issues, go to: www.diabetes.org.

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Section XIII. Glossary

Developed by the Centers for Disease Control and Prevention. Take Charge of Your Diabetes. 2nd edition. Atlanta: U.S. Department of Health and Human Services, 1997.

Albumin A protein found in blood plasma and urine. The presence of albumin in the urine can be a sign of kidney disease.

Autoimmune process A process where the body's immune system attacks and destroys body tissue that it mistakes for foreign matter.

Beta cells Cells that make insulin. Beta cells are found in areas of the pancreas called the islets of Langerhans.

Bladder A hollow organ that urine drains into from the kidneys. From the bladder, urine leaves the body.

Blood glucose The main sugar that the body makes from the food we eat. Glucose is carried through the bloodstream to provide energy to all of the body's living cells. The cells cannot use glucose without the help of insulin.

Blood pressure The force of the blood against the artery walls. Two levels of blood pressure are measured: the highest, or systolic, occurs when the heart pumps blood into the blood vessels, and the lowest, or diastolic, occurs when the heart rests.

Blood sugar See Blood glucose.

Calluses Thick, hardened areas of the skin, generally on the foot, caused by friction or pressure. Calluses can lead to other problems, including serious infection and even gangrene.

Carbohydrates One of three major sources of calories in the diet. Carbohydrate comes primarily from sugar (simple carbohydrate) and starch (compex carbohydrate, found in bread, pasta, beans). Carbohydrate is broken down into glucose during digestion and is the main nutrient that raises blood glucose levels.

Cholesterol A substance similar to fat that is found in the blood, muscles, liver, brain, and other body tissues. The body produces and needs some cholesterol. However, too much cholesterol can make fats stick to the walls of the arteries and cause a disease that decreases or stops circulation.

Corns A thickening of the skin of the feet or hands, usually caused by pressure against the skin.

Diabetes The short name for the disease called diabetes mellitus. Diabetes results when the body cannot use blood glucose as energy because of having too little insulin or being unable to use insulin. See also Type 1 diabetes, Type 2 diabetes, and Gestational diabetes.

Diabetes pills Pills or capsules that are taken by mouth to lower the blood glucose level. These pills may may be combined with insulin treatment to provide maximum control.

Diabetic eye disease A disease of the small blood vessels of the retina of the eye in people with diabetes. In this disease, the vessels swell and leak liquid into the retina, blurring the vision and sometimes leading to blindness.

Diabetic ketoacidosis High blood glucose, often caused by illness or taking too little insulin. The body uses stored fat for energy, and ketones build up in the blood. Insulin and fluids must be given right away to avoid serious injury or even death.

Diabetic kidney disease Damage to the cells or blood vessels of the kidney.

Diabetic nerve damage Damage to the nerves of a person with diabetes. Nerve damage may affect the feet and hands, as well as major organs.

EKG exam A test that measures the heart's action. Also called an electrocardiogram.

Flu See Influenza.

Food exchanges A way to help people stay on special food plans by letting them replace items from one food group with items from another group.

Gestational diabetes A type of diabetes that can occur in pregnant women who have not been known to have diabetes before. Although gestational diabetes usually subsides after pregnancy, many women who've had gestational diabetes develop Type 2 diabetes later in life.

Gingivitis A swelling and soreness of the gums that, without treatment, can cause serious gum problems and disease.

Glucagon A hormone that raises the blood glucose level. When someone with diabetes has a very low blood glucose level, a glucagon injection can help raise the blood glucose quickly.

Glucose A sugar in our blood and a source of energy for our bodies.

HDL (or high-density lipoprotein) A combined protein and fatlike substance. Low in cholesterol, it usually passes freely through the arteries. Sometimes called "good cholesterol."

Hemoglobin A1c A test that sums up how much glucose has been sticking to part of the hemoglobin during the past 3-4 months. Hemoglobin is a substance in the red blood cells that supplies oxygen to the cells of the body.

Heart attack Damage to the heart muscle caused when the blood vessels supplying the muscle are blocked, such as when the blood vessels are clogged with fats (a condition sometimes called hardening of the arteries).

High blood glucose A condition that occurs in people with diabetes when their blood glucose levels are too high. Symptoms include having to urinate often, being very thirsty, and losing weight.

High blood pressure A condition where the blood circulates through the arteries with too much force. High blood pressure tires the heart, harms the arteries, and increases the risk of heart attack, stroke, and kidney problems.

Hormone A chemical that special cells in the body release to help other cells work. For example, insulin is a hormone made in the pancreas to help the body use glucose as energy.

Hyperglycemia See High blood glucose.

Hypertension See High blood pressure.

Hypoglycemia See Low blood glucose.

Immunization Sometimes called vaccination; a shot or injection that protects a person from getting an illness by making the person 'immune' to the illness.

Impotence A condition of being unable to keep an erect penis and ejaculate. Some men who have had diabetes a long time become impotent if their nerves have become damaged.

Influenza A contagious viral illness that strikes quickly and severely. Signs include high fever, chills, body aches, runny nose, sore throat, and headache.

Inject To force a liquid into the body with a needle and syringe.

Insulin A hormone that helps the body use blood glucose for energy. The beta cells of the pancreas make insulin. When people with diabetes can't make enough insulin, they may have to inject it from another source.

Insulin-dependent diabetes See Type 1 diabetes.

Ketones Chemical substances that the body makes when it doesn't have enough insulin in the blood. When ketones build up in the body for a long time, serious illness or coma can result.

Kidneys Twin organs found in the lower part of the back. The kidneys purify the blood of all waste and harmful material. They also control the level of some helpful chemical substances in the blood.

Laser surgery Surgery that uses a strong ray of special light, called a laser, to treat damaged parts of the body. Laser surgery can help treat some diabetic eye diseases.

Low blood glucose A condition that occurs in people with diabetes when their blood glucose levels are too low. Symptoms include feeling anxious or confused, feeling numb in the arms and hands, and shaking or feeling dizzy.

LDL (or low-density lipoprotein) A combined protein and fatlike substance. Rich in cholesterol, it tends to stick to the walls in the arteries. Sometimes called "bad cholesterol."

Meal plan A guide to help people get the proper amount of calories, carbohydrates, proteins, fats, vitamins, minerals, and fiber in their diet. See also Food exchanges.

Nephropathy See Diabetic kidney disease.

Neuropathy See Diabetic nerve damage.

Non-insulin-dependent diabetes See Type 2 diabetes.

Pancreas An organ in the body that makes insulin so that the body can use glucose for energy. The pancreas also makes enzymes that help the body digest food.

Periodontitis A gum disease in which the gums shrink away from the teeth. Without treatment, it can lead to tooth loss.

Plaque A film of mucus that traps bacteria on the surface of the teeth. Plaque can be removed with daily brushing and flossing of teeth.

Retinopathy See Diabetic eye disease.

Risk factors Traits that make it more likely that a person will get an illness. For example, a risk factor for getting Type 2 diabetes is having a family history of diabetes.

Self-monitoring blood glucose A way for people with diabetes to find out how much glucose is in their blood. A drop of blood from the fingertip is placed on a special coated strip of paper that "reads" (often through an electronic meter) the amount of glucose in the blood.

Stroke Damage to part of the brain that happens when the blood vessels supplying that part are blocked, such as when the blood vessels are clogged with fats (a condition sometimes called hardening of the arteries).

Support group A group of people who share a similar problem or concern. The people in the group help one another by sharing experiences, knowledge, and information.

Type 1 diabetes A condition in which the pancreas makes so little insulin that the body can't use blood glucose as energy. Type 1 diabetes most often occurs in people younger than age 30 and must be controlled with daily insulin injections.

Type 2 diabetes A condition in which the body either makes too little insulin or can't use the insulin it makes to use blood glucose as energy. Type 2 diabetes most often occurs in people older than age 40 and can often be controlled through meal plans and physical activity plans. Some people with Type 2 diabetes have to take diabetes pills or insulin.

Ulcer A break or deep sore in the skin. Germs can enter an ulcer and may be hard to heal.

Vitrectomy An operation to remove the blood that sometimes collects at the back of the eyes when a person has eye disease.

Yeast infection A vaginal infection that is usually caused by a fungus. Women who have this infection may feel itching, burning when urinating, and pain, and some women have a vaginal discharge. Yeast infections occur more frequently in women with diabetes.

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Section XIV. Case Studies

It is recommended that you spend a minimum of 20 minutes studying each of the following 3 case studies and answering the questions. The answers and a more detailed explanation follow each case study.

Case Study 1. Type 1 Diabetes- Diabetic Ketoacidosis

A.H., a slim, 18 year old female, is brought to the Emergency Room because her roommate is concerned about her friend's sudden episodes of confusion. She also has noted that her friend has been complaining of increasing fatigue for the past week, and she thought she smelled alcohol on her breath, although A.H. denies drinking. Laboratory studies reveal glucosuria; a random plasma glucose ordered subsequently was 550 mg/dL. Approximately four weeks before this visit, A.H. moved across the country to attend college, her first time away from home. In retrospect, she has noted polydipsia, nocturia (three times nightly), fatigue and a 14 pound weight loss over this period, which she has attributed to the anxiety associated with her move away from home and adjustment to her new environment. Her past medical history is remarkable for recurrent upper respiratory infections and several vaginal infections during the past six months. Her family history is negative for diabetes. The only medications she takes are birth control pills.

Physical examination reveals thin, anxious young female with acetone odor to her breath. She is 5'6" tall and weighs 112 pounds. Laboratory results are as follows: fasting plasma glucose 580 mg/dL (<110 mg/dL) with ketonemia; HbA1c 14% (4%-6%); urine glucose and ketones as measured by Keto-Diastix 2% and 1+ respectively. On the basis of the above history and laboratory findings, a diagnosis of Diabetic Ketoacidosis is made, with the presumption that A.H. has Type 1 Diabetes.

Practice Questions:

1.    What findings would be consistent with the diagnosis of DKA in A.H.?
            a. Cold, clammy skin and shaking chills
            b. Acetone odor to breath, dry skin, confusion
            c. Frequent vaginal infections and upper respiratory infections

2.    Why does A.H.  probably have Type 1 Diabetes?
	a. Type 1 diabetes is usually inherited
	b. Type 1 diabetes often occurs when there is a history of birth control use
	c. Type 1 diabetes most often occurs in the young adult population

3.    A.H. will be started on insulin therapy.  What are the goals of insulin therapy?
	a. To achieve daily fasting blood glucose levels between 140 and 150
	b. To prevent long term complications of diabetes
	c. To keep clients as dependent upon the care provider as possible to achieve control

4.  A.H. is started on NPH insulin.  It is important for A.H. to know that NPH insulin peaks between:
	a. 2 - 4 hours after administration
	b. 8 - 14 hours after administration
	c. 14 - 20 hours after administration

5.  What is the difference between intermediate-acting NPH and long acting Ultralente?
	a. Ultralente insulin is slower to peak and lasts somewhat longer than NPH
	b. Ultralente insulin is made from pork, and NPH is a human insulin
	c. Ultralente insulin peaks in 4 - 6 hours, while NPH peaks in 6 - 8 hours

6.    You are asked to assess A.H. for glucosuria.  You would obtain a specimen of :
	a. blood
	b. urine
	c. stool

7.  Some of the possible risk factors associated with Type 1 diabetes are:
	a. early onset of arteriosclerosis
	b. early onset of background retinopathy
	c. early onset of kidney failure
	d. all of the above

8. A.H. can be told that she may expect all of the following except:
	a. She may have episodes of low blood sugar
	b. She can expect to be changed to oral medications after the crisis is over
	c. A localized response to insulin sometimes occurs at an injection site

9. What would the most significant laboratory value in determining Type 1 diabetes for A.H.?
	a. Ketones in the blood and urine
	b. Random glucose above 200
	c. Hemoglobin A1C of 14%

10. Treatment for DKA immediately focuses on:
	a. acidosis
	b. dehydration
	c. loss of electrolytes
	d. all of the above

 

Answers to Case Study 1:

1.    What findings would be consistent with the diagnosis of DKA in A.H.?
	a. Cold, clammy skin and shaking chills
	b. Acetone odor to breath, dry skin, confusion
	c. Frequent vaginal infections and upper respiratory infections

Correct answer "b":

Section VII. Diabetic Ketocidosis (DKA), "the patients Patients experiencing DKA could also present themselves with a collection of signs such as fever, deep respirations, acetone breath, orthostatic hypotension, poor skin turgor, acute abdomen, various mental states (alertness, stupor, or coma), decreased reflexes and/or hypotonia."

2.    Why does A.H.  probably have Type 1 Diabetes?
	a. Type 1 diabetes is usually inherited
	b. Type 1 diabetes often occurs when there is a history of birth control use
	c. Type 1 diabetes most often occurs in the young adult population

Correct answer "c":

Section VII. Diabetic Ketocidosis (DKA), "Diabetic Ketoacidosis is a serious form of complication that usually happens to persons with type 1 diabetes."

Section II: Pathophysiology, Types of Diabetes, "usually occurs at an early age (under age 30) in thin or normal weight individuals."

3.    A.H. will be started on insulin therapy.  What are the goals of insulin therapy?
	a. To achieve daily fasting blood glucose levels between 140 and 150
	b. To prevent long term complications of diabetes
	c. To keep clients as dependent upon the care provider as possible to achieve control

Correct answer "b":

Section VI. Treatment- Medications, Insulin. "Insulin is an anabolic hormone promoting protein synthesis, fat storage, entry of glucose into cells for energy use, and glycogen storage in muscle and liver cells. Insulin is an absolute requirement for type 1 diabetes and is used to prevent long term complications of diabetes. It may be required in those with type 2 diabetes if other forms of therapy do not adequately control glucose levels."

4. A.H. is started on NPH insulin.  It is important for A.H. to know that NPH insulin peaks between:
	a. 2 - 4 hours after administration
	b. 8 - 14 hours after administration
	c. 14 - 20 hours after administration

Correct answer "b":

Section VI. Treatment- Medications, Insulin, Table 14: Summary of Insulin Types and Dosage, shows the different types of insulin onset of action, peak activity and duration of action. NPH has a peak activity of 8-14 hours.

5. What is the difference between intermediate-acting NPH and long acting Ultralente?
	a. Ultralente insulin is slower to peak and lasts somewhat longer than NPH
	b. Ultralente insulin is made from pork, and NPH is a human insulin
	c. Ultralente insulin peaks in 4 - 6 hours, while NPH peaks in 6 - 8 hours

Correct answer "a":

Section VI. Treatment- Medications, Insulin, Table 14: Summary of Insulin Types and Dosage, shows the different types of insulin regarding the onset of action, peak activity and duration of action. The long-acting Ultralente peaks in 6-8 hours versus 3-4 for NPH and its duration is >32 hours versus 20-24 for NPH.

6. You are asked to assess A.H. for glucosuria.  You would obtain a specimen of:
	a. blood
	b. urine
	c. stool

Correct answer is "b":

Section VII. Acute Complications. "The test for Glucosuria measures the amount of glucose in the urine and is measured in the urine as a gradient of 1+ to 4+ by dipstick."

7. Some of the possible risk factors associated with Type 1 diabetes are:
	a. early onset of arteriosclerosis
	b. early onset of background retinopathy
	c. early onset of kidney failure
	d. all of the above

Correct answer is "d":

Review Section V. Chronic Complications which goes into detail on each of these possible risk factore, "Long term complications are retinopathy, diabetic neuropathy, kidney disease (nephropathy), macrovascular disease, and amputation. These complications can occur in both type 1 and type 2 diabetes." Macrovascular disease involves "arteriosclerosis and atherosclerosis. This includes coronary, cerebral vascular and peripheral vascular disease. Diabetes is an independent risk factor for developing atherosclerosis. Smoking doubles this risk. Macrovascular disease occurs earlier in diabetes."

8. A.H. can be told that she may expect all of the following except:
	a. She may have episodes of low blood sugar
	b. She can expect to be changed to oral medications after the crisis is over
	c. A localized response to insulin sometimes occurs at an injection site

Correct answer is "b":

Section II. Pathophysiology description of Type 1 diabetes states that, "These individuals need exogenous insulin (daily insulin injections) to live."

For answer "a", review the definition of Blood Glucose in the Glossary also Section III. Monitoring & Self Management, Table 4: Target Blood Glucose levels to review the comparrsion of blood glucose in people without diabetes and people with diabetes.

Answer "c" is important. Section VI. Treatment- Medications, Insulin notes that, "Rotation of insulin injection sites is important to prevent lipodystrophy., which is an abnormal subcutaneous fat accumulation. Making an anatomical "map" for an injection rotation schedule has been helpful for patients."

9. What would the most significant laboratory value in determining Type 1 diabetes for A.H.?
	a. Ketones in the blood and urine
	b. Random glucose above 200
	c. Hemoglobin A1C of 14%

Correct answer "a":

The Glossary describes Ketones as a "Chemical substances that the body makes when it doesn't have enough insulin in the blood. When ketones build up in the body for a long time, serious illness or coma can result."

10. Treatment for DKA immediately focuses on:
	a. acidosis
	b. dehydration
	c. loss of electrolytes
	d. all of the above

Correct answer is "d":

Review Section VII. Acute Complications Diabetic Ketoacidosis (DKA) "Diabetic Ketoacidosis is a serious form of complication that usually happens to persons with type 1 diabetes. It is characterized by hyperglycemia, dehydration, ketosis and electrolyte imbalance."

 

Case Study 2. Diabetes

J.L., a 32 year old Hispanic female, presented to the ER of the University Medical Center complaining of nausea, vomiting, weakness and high readings on her urine glucose strips. J.L. has had Type 2 diabetes diagnosed two years ago, and has never had any problems associated with her diabetes. She has no other medical history, and states that she has been taking her medication (Glyburide) of five mg. a day as prescribed, and denies missing any doses.

J.L.'s mother has Type 1 diabetes; her father has coronary artery disease. Both are alive and in their fifties. J.L. denies smoking or recreational drug use, but does occasionally drink beer. She usually gets nauseated after drinking, and therefore seldom does.

Physical examination was unremarkable. Labs were drawn, revealing the following:

-Glucose: 650 mg/dL. BUN: 24 mg/dL. Serum Creatinine: 1 mg/dL

-CO2: 9 mEq/L Acetone: Moderate Beta-HCG: (+)

-Sodium: 135 mEq/L Potassium: 5.4 mEq/L Chloride: 97 mEq/L

-ABG: pH: 7.18 pCO₂: 24 mm Hg HCO3: 9

J.L. was admitted and treated with an insulin infusion, and later with regular insulin on a sliding scale. She was discharged on a total of 30 units of NPH insulin in the morning and 40 units of NPH insulin at bedtime to maintain her blood sugars between 126 and 180.

Practice Questions:

1. J.L. has the following type of diabetes:
	a. Type 1
	b. Type 2
	c. Gestational

2. What other oral diabetes medications can now be prescribed for J.L.?
	a. Glucatrol
	b. Glucophage
	c. None

3. J.L. needs to have the following information to best treat her diabetes at this time:
	a. She needs to lose weight
	b. She needs to follow a prudent diet and exercise in moderation
	c. She can continue to follow the same diet as prior to admission, including occasionally 
		having a beer.

4. Lack of diabetes control in pregnancy may lead to the following:
	a. Large babies (macrosomia)
	b. Congenital abnormalities
	c. Risk of maternal mortality
	d. All of the above

5. Pre-conception care of the patient with diabetes is important because:
	a. To achieve good outcomes, the health of the mother needs to be optimal
	b. Obstetricians do not like to deliver babies born to obese mothers
	c. It is difficult to detect fetal movements in obese mothers

 

Answers to Case Study 2:

1. J.L. has the following type of diabetes:
	a. Type 1
	b. Type 2
	c. Gestational

Correct answer "b":

The clue is in the physical examination which reveals that J.L. is pregnant: Beta-HCG: (+)

Section IX. Pregnancy , Introduction. "When a woman who is known to have diabetes becomes pregnant, she is said to have pregestational diabetes. When a woman develops diabetes during pregnancy or is first recognized as having this condition during pregnancy, she is said to have gestational diabetes."

Glossary defines Gestational diabetes as "a type of diabetes that can occur in pregnant women who have not been known to have diabetes before. Although gestational diabetes usually subsides after pregnancy, many women who've had gestational diabetes develop Type 2 diabetes later in life."

2. What other oral diabetes medications can now be prescribed for J.L.?
	a. Glucatrol
	b. Glucophage
	c. None

Correct answer "c":

Section IV. Treatments- Medications, Medication Choices discusses Sulfonylureas have been the mainstay of type 2 diabetes since the 1950’s, "Hypoglycemia is one of the more common side effects of these agents, particularly with the longer acting products." Glucotrol and Glucotrol XL are second generation hypoglycemic agents. Biguanides were approved for use in the US in 1995 and marketed under the name Glucophage. They are hypoglycemic agents that promote insulin secretion in the pancreas. Glucophage and "Its role is to enhance insulin mediated glucose transport in muscle and reduce hepatic glucose production in the liver although its exact mechanisms are unclear. It is not a hypoglycemic medication."

3. J.L. needs to have the following information to best treat her diabetes at this time:
	a. She needs to lose weight
	b. She needs to follow a prudent diet and exercise in moderation
	c. She can continue to follow the same diet as prior to admission, including occasionally 	having a beer.

Correct answer "b":

Review Section V: Treadment- Exercise, for additional information on the benefits of exercise but remember that "before beginning an exercise program a medical exam should be done in persons over 35 years of age or those having diabetes for more than 15 years." In Section II: Pathophysiology.

4. Lack of diabetes control in pregnancy may lead to the following:
	a. Large babies (macrosomia)
	b. Congenital abnormalities
	c. Risk of maternal mortality
	d. All of the above

Correct answer "d":

Section IX. Pregnancy , Pregestational & Gestational Diabetes: Background. Effect on the fetus. "Because glucose crosses the placenta by facilitated diffusion, maternal hyperglycemia produces fetal hyperglycemia. Fetal hyperinsulinemia occurs in response to this abnormal metabolic environment. Hyperinsulinemia, combined with hyperglycemia, leads to excessive fetal growth. It may also contribute to intrauterine fetal death, delayed fetal pulmonary maturation, and neonatal hypoglycemia.

The incidence of major congenital malformations is increased approximately fourfold among infants of women with pregestational diabetes." Effect on the mother. "Pregnancy may be associated with exacerbation of diabetic eye disease, especially in women with unrecognized or untreated proliferative diabetic retinopathy. Diabetic women with nephropathy and hypertension are at greater risk for preeclampsia and fetal growth retardation than are women without nephropathy. Death has been reported among pregnant women with diabetes and coronary artery disease."

5. Pre-conception care of the patient with diabetes is important because:
	a. To achieve good outcomes, the health of the mother needs to be optimal
	b. Obstetricians do not like to deliver babies born to obese mothers
	c. It is difficult to detect fetal movements in obese mothers

Correct answer "a":

Section IX. Pregnancy , Introduction. "The factor most important to the outcome of pregnancy is how well the mother's glucose level is controlled before and during pregnancy. When women with diabetes receive optimal care, the perinatal mortality rate for their offspring approaches the corresponding rate for the general population. However, when pregnant women with diabetes do not receive expert treatment, the perinatal mortality rate for their offspring more than doubles."

 

Case Study 3. Type 2 Diabetes

P.O., a 50 year old Black male is seen by his physician complaining of numbness and tingling of both feet, causing him to stay awake at night. When taking his nursing history, he also states that he has noticed some increasing thirst and urination, as well as blurred vision.

He has been well, except for a past history of hypertension which he has controlled on a salt-free diet, and takes no medications. He is employed full time as a prosthetist, and some of his patients with diabetes have mentioned that they have had similar symptoms.

Physical examination reveals well-developed male in NAD. He is 6' tall, and weighs 240 pounds. Blood pressure is 170/88, pulse 86.

The physician indicates that he has noted some blot dot hemorrhages when examining his eyes. The examination of the heart and lungs is normal. Pulses are equal and strong throughout. The examination of his extremities indicates that there is a decrease in sensation to a microfilament test, and decreased vibratory sensation. He also has hammer toes of his right foot.

Laboratory results reveal a random (non-fasting) glucose of 268, Hemoglobin A1C of 11.0. His urinalysis is significant for protein, but no glucose or ketones. His triglycerides were 672, and total cholesterol was 245.

Practice Questions:

1. Signs of Type 2 diabetes are:
	a. blurry or deteriorating vision
	b. fatigue
	c. frequent urinary tract infections
	d. all of the above

2. With non-proliferative retinopathy, examination of the retina may show:
	a. microaneurysm formation
	b. weakened capillary wall
	c. leakage of fluid
	d. all of the above

3. When a patient has peripheral neuropathy, there may be decreased sensivity to:
	a. heat
	b. foreign bodies
	c. cold
	d. all of the above

4. When patients are diagnosed with Type 2 diabetes, they often present with:
	a. kidney disease
	b. peripheral neuropathy
	c. macrovascular disease
	d. all of the above

5. What types of medications might P.O. be given today?
	a. Thiazide diuretic
	b. ACE inhibitor
	c. Oral diabetes agent
	d. No medications; diet and exercise should be tried first

 

Correct answers for Case Study 3:

1. Signs of Type 2 diabetes are:
	a. blurry or deteriorating vision
	b. fatigue
	c. frequent urinary tract infections
	d. all of the above

Correct answer is "d":

Section II. Pathophysiology, Types of Diabetes. "Signs of Type 2 diabetes are blurry or deteriorating vision, fatigue and frequent urinary tract infections."

2. With non-proliferative retinopathy, examination of the retina may show:
	a. microaneurysm formation
	b. weakened capillary wall
	c. leakage of fluid
	d. all of the above

Correct answer is "a":

Section VIII. Chronic Complications discusses microaneurysm formation in the section on Diabetic Retinopathy. "Microaneurysms appear as small red dots in the retina, while lipid molecules are seen as yellowish deposits, and intraretinal hemorrhages are seen as red smudges in the nonproliferative stage. The final stage, known as proliferative retinopathy is characterized by tangled-appearing veins, which looked like a string of sausages. Alternative pathways for blood flow develop near the area of capillary closure. These vessels are weak and leak fluid into the macula which lowers visual acuity."

3. When a patient has peripheral neuropathy, there may be decreased sensivity to:
	a. heat
	b. foreign bodies
	c. cold
	d. all of the above

Correct answer is "d":

Section VIII. Chronic Complications, Diabetic Neuropathy. "As many as 20% of patients presenting with newly diagnosed diabetes already have peripheral neuropathy…It usually appears first in the feet, then the legs, and may progress to the hands. As it progresses, pain sensation is lost via nerve damage, then muscle fibers begin to atrophy. This leads to deformities in the feet, which shifts pressure points and promotes callous formation. Patients may develop Charcot’s arthropathy, which is destruction in the joints of the feet. This causes a flattening of the arch, increased ulceration, and an increased risk for infection. Because sensation to pain is diminished, the patient may not be alert to the progression of the infection until it reaches the bone. This problem may be compounded by reduced circulation. This situation requires intravenous antibiotic therapy. If this therapy is ineffective, an amputation may be necessary to prevent the spread of gangrene."

4. When patients are diagnosed with Type 2 diabetes, they often present with:
	a. kidney disease
	b. peripheral neuropathy
	c. macrovascular disease
	d. all of the above

Correct answer is "d":

Section VIII. Chronic Complications, Long-Term Complications. "Long term complications are retinopathy, diabetic neuropathy, kidney disease (nephropathy), macrovascular disease, and amputation. These complications can occur in both type 1 and type 2 diabetes. Complications are linked to duration of diabetes and/or degree of glucose control. Almost half of the patients undergoing kidney dialysis have diabetic nephropathy."

5. What types of medications might P.O. be given today?
	a. Thiazide diuretic
	b. ACE inhibitor
	c. Oral diabetes agent
	d. No medications; diet and exercise should be tried first

Correct answer is "b":

Section VIII. Chronic Complications , Kidney Disease (Nephropathy). "Treatment revolves around prevention, especially in controlling glucose and hypertension. The medication of choice for most with diabetes is the angiotensin-converting enzyme (ACE) inhibitors. This class of medication reduced urinary excretion of protein, enhanced insulin sensitivity, and has no adverse effects on lipids. Beta blockers may also be useful in the treatment of hypertension. These medications should be used with caution in diabetic patients since they can adversely affect glucose and lipid levels, promote hypoglycemia unawareness, and reduce peripheral blood flow."

Exercise is not the correct answer because this question asks for the types of medication that might be given.

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Section XV. Bibliography and Additional Resources

For additional reading visit our web site, for the following books: www.vantageproed.com

The Uncomplicated Guide to Diabetes Complications by Marvin E. Levin (Editor) and the American Diabetes Association. Batam Books 1998.

American Diabetes Association Complete Guide to Diabetes: The Ultimate Home Diabetes Reference by the American Diabetes Association, 1997.

The Complete Quick & Hearty Diabetic Cookbook: More Than 250 Fast, Low-Fat Recipes With Old-Fashioned Good Taste by the American Diabetes Association. Contemporary Books 1998.

 

Additional information about Diabetes is available at the following Internet web sites:

American Association of Diabetes Educators (AADE) 444 N. Michigan Ave., Suite 1240, Chicago, IL 60611, (800) 832-6874, website: www.AADEnet.org

American Diabetes Association (ADA) - ADA National Service Center 1660 Duke St., Alexandria, VA, 22314, (800) 232-3472, website: www.diabetes.org

American Dietetic Association (ADA) 216 W. Jackson Blvd., Chicago, IL, 60606-6995, (800) 366-1655, website: www.eatright.org

Centers for Disease Control and Prevention (CDC) 1600 Clifton Rd., NE, Atlanta, GA 30333,(404) 639-3311 (CDC Operator); (800) 311-3534 (CDC Public Inquiries), website: http://www.cdc.gov/

Juvenile Diabetes Foundation International (JDFI) 432 Park Ave S., New York, NY, 10016-8013, (800) 223-1138, website: www.jdfcure.org

National Diabetes Information Clearinghouse, 1 Information Way, Bethesda, MD, 20892-3560, website: www.aerie.com/niddk

Joslin Diabetes Center 1 Joslin Place, Boston, MA, 02215, (617) 732-2400, website: www.joslin.harvard.edu

Additional Internet Sites Referenced in the text:

Health Care Financing AdministratioN  www.hcfa.gov

Advocate- Health Care Issues contact  Advocate@diabetes.org

National Institute of Neurological Disorders and Stroke PO Box 5801, Bethesada, MD, 20824,  http://www.ninds.nih.gov/  

The Neuropathy Association- public, nonprofit organization which was established by people with neuropathy and their families or friends to help those who suffer from disorders that affect the peripheral nerves.   http://www.neuropathy.org/

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Section XVI: Footnotes

1. American Diabetes Association . Economic consequences
of diabetes mellitus in the U.S. in 1997. Diabetes Care
21(2):296-309, 1998. American Diabetes Association website: publication date 2002-07-30
http://ada.yellowbrix.com.
2. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.
Diabetes Care, 21: S5-S19, 1998.
3. American Diabetes Association position statement. Screening for type 2 Diabetes. Diabetes Care, 21: S20-22, 1998.
4. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care, 21:S7, 1998.
5. American Health Consultants: Diabetes: The Disease State Management Resource. Atlanta, GA:  
6. American Health Consultants; 1997.
7. American Diabetes Association position statement. Screening for type 2 Diabetes. Diabetes Care, 21: S20-
    22, 1998.
8. American Diabetes Association position statement. Screening for type 2 Diabetes. Diabetes Care, 21: S20-
    22, 1998.
9. Report of the Expert Committee on the Diagnosis and
Classification of Diabetes Mellitus. Diabetes Care,     21: S5-S19, 1998.
10. State of Florida, Diabetes Medical Practice Guidelines, 1997.
11. Position Statement of the American Diabetes Association: Standards of Medical Care for Patients with Diabetes Mellitus.  Diabetes Care, Volume 25, Supplement 1, January 2002. S33-49.
12. The Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of
diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. NEJM; 329: 977-986, 1993.
13. Babione, L: SMBG: The underused nutrition counseling tool in diabetes management. Diabetes Spectrum. 1994; 3:196-197.
14. American Diabetes Association: Nutrition recommendations and principles for people with diabetes    
     mellitus. Diabetes Care, 21:S32-S35, 1998.
15. A Core Curriculum for Diabetes Education. 2nd ed. Chicago, Ill: American Association of Diabetes 
    Educators; 1993:128-177.
  National Institute of Health; Modified Diets for Diabetes Management; 1998.
16. The National Cholesterol Education Program's Lipid Classifications: ATP III; Page 30.)
17. Exchange Lists for Meal Planning.  The American Diabetes Association, American Dietetic Association. 1995.
18. Exercise. In: A Core Curriculum for Diabetes Education, 3rd Edition. A Publication of the American Association of Diabetes Educators. Chicago, IL. 1998
19. Davidson, MB: Diabetes Mellitus: Diagnosis and Treatment. 4th ed. Philadelphia, PA: W.B. Saunders 
    Company; 1997.
20. Davidson, MB: Diabetes Mellitus: Diagnosis and Treatment. 4th ed. Philadelphia, PA: W.B. Saunders 
    Company; 1997.
21. Powers, MA: Handbook of Diabetes Medical Nutrition Therapy. 2nd ed. Gaithersburg, MD: Aspen 
    Publishers, Inc.; 1996.
22. Davidson, MB: Diabetes Mellitus: Diagnosis and Treatment. 4th ed. Philadelphia, PA: W.B. Saunders 
    Company; 1997.
23. Reference RXList: http://www.rxlist.com/cgi/generic2/nateglinide_wcp.htm
  Davidson, MB: Diabetes Mellitus: Diagnosis and Treatment. 4th ed. Philadelphia, PA: W.B. Saunders 
    Company; 1997.
24. Davidson, MB: Diabetes Mellitus: Diagnosis and Treatment. 4th ed. Philadelphia, PA: W.B. Saunders 
    Company; 1997. 
25.  Genuth S. Diabetic ketoacidosis and hyerosmolar hyperglycemic nonketotic syndrome in adults. In: 
    Therapy for diabetes mellitus and related disorders.  2nd ed. Alexandria, Va: American Diabetes 
    Association, Inc.; 1994:65-76 
26. Jaspan J. A practical guide to managing diabetes. Minneapolis, Mn: McGraw-Hill Company; 1997
27. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38.  UK  Prospective Diabetes Study Group.  British Medical Journal, 12 Sept. 1998, Vol. 7160, p 703-713.
28. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).  UK Prospective Diabbetes Study (UKPDS) Group. The Lancet. 12 Sept 1998, vol. 352, No. 9131, p 837-853.
29. Diabetic Neuropathy. In: A Core Curriculum for Diabetes Education, 3rd Edition. A Publication of the American Association of Diabetes Educators. Chicago, IL. 1998
30. The Third Report of the Expert Panel on the Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (ATP III Adult Treatment Recommendations):
http://www.nhlbi.nih.gov/guidelines/cholesterol/profmats.htm
31. Position Statement of the American Diabetes Association: Standards of Medical Care for Patients with Diabetes Mellitus.  Diabetes Care, Volume 25, Supplement 1, January 2002. S33-49.
32. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus.  Diabetes Care. Vol 25, Supplement 1, January 2002. pp S5-19.
33. Position Statement of the American Diabetes Association: Standards of Medical Care for Patients with Diabetes Mellitus.  Diabetes Care, Volume 25, Supplement 1, January 2002. S33-49.
34. Edwards, V.: Violence, suicide, and diabetes: Considerations for health-care providers.  Diabetes 
    Professional, Summer 1991, 26-27.
35.  Mazur, M.: Come fly with me.  Diabetes Forecast. April 1998, 34-38; Hypoglycemia and Employment/Licensure.  Position Statement of the American Diabetes Association.  Diabetes Care.  Volume 25, Supplement 1, Jan 2002.  p 132
36.  Powers, MA: Handbook of Diabetes Medical Nutrition Therapy. 2nd ed. Gaithersburg, MD: Aspen 
    Publishers, Inc.; 1996.
37. A Core Curriculum for Diabetes Education. 2nd ed. Chicago, Ill: American Association of Diabetes 
    Educators; 1993:128-177.
38. Third-party reimbursement for diabetes care, self-management education, and supplies.  Position Statement of the American Diabetes Association.  Diabetes Care. Vol 25, Supplement 1, January 2002.