This tutorial covers the aetiology of diabetes Types 1 and 2 as well as gestational diabetes. Symptoms, treatment and management are discussed in detail along with the complications of diabetes. The ANMF diabetes tutorial is relevant to all levels of nurses and midwives.

Diabetes affects an estimated 800,000 Australians, and many of these are not aware they have the disease. If undetected or poorly controlled, diabetes can lead to vision impairment, renal failure, lower limb amputation, MI, CVA and impotence.
The process of insulin releasing blood glucose into the body’s cells is known as glucose metabolism. In diabetes, the pancreas cannot make insulin or the insulin it does make is insufficient. Without insulin the glucose channels are closed. Glucose builds up in the blood leading to high blood glucose levels (hyperglycaemia) which cause the health problems linked to diabetes.

World-wide, diabetes is becoming epidemic. In collaboration with the World Health Organization (WHO) in Geneva, the International Diabetes Institute produced new global predictions for the number of people with diabetes in various countries. It was estimated that in 2000 there were approximately 160 million people with diabetes in the world. This will climb to over 280 million by the year 2025, the majority of them with Type 2 diabetes.

Changes in society over recent decades have impacted on lifestyle leading to lower levels of physical activity and unfavourable changes in our diet with consequent increase in obesity. These factors, and the ageing of the Australian population, have led to high levels of morbidity from a number of chronic diseases which contribute greatly to national health costs. Diabetes and cardiovascular disease are two of these conditions. As a result they have been included by the federal, state and territory governments in the six National Health Priority Areas which also include cancer, trauma, asthma and mental health.

Diabetes is recognised as:
• The second most common cause for commencing renal dialysis.
• The most common cause of blindness in people under the age of 60 years.
• The most common cause of non-traumatic lower limb amputation.
• One of the most common chronic diseases in children.

IDDM (Insulin Dependent Diabetes Mellitus) is one of the most common childhood diseases in developed nations and constitutes about 10% of all persons with diabetes in Australia. It is believed to be caused by an auto-immune process which results in a slow destruction of pancreatic islet beta-cells by the body’s own immune system. There is a strong family link with Type 1 diabetes however it appears to require a trigger such as a viral infection. While Type 1 diabetes can and does occur at any age, it usually affects children and young adults. It is the less common form of diabetes with just 10-15% of all people with diabetes having Type 1 diabetes.

In Type 1 diabetes, the pancreas cannot produce enough insulin due to the relevant cells having been destroyed by the body’s immune system. This insulin must be replaced. People with Type 1 diabetes must have insulin every day to live. While insulin can only be injected at the time, other ways of administering it may be possible in the future.

While the cause of Type 1 diabetes has nothing to do with lifestyle, a healthy lifestyle is important in its management. There is no known prevention or cure for Type 1 diabetes at this time. Current treatment includes closely monitoring blood glucose (sugar) levels, modifying the diet and daily insulin injections.

Symptoms of Type 1 diabetes include: polyuria – frequent urination; polydipsia – excessive thirst (increase in fluid intake and consequent increase in output); polyphagia – increased hunger; weight loss; fatigue; visual disturbances, such as blurred vision; pruritis, particularly around the genitals; nausea and vomiting. Symptoms may develop quite rapidly (weeks or months), particularly in children.

NIDDM (Non-Insulin Dependent Diabetes Mellitus) is sometimes described as a ‘lifestyle disease’ because it is more common in people who do insufficient physical activity and are overweight or obese. It is strongly associated with high blood pressure, high cholesterol and an ‘apple’ body shape, where excess weight is carried around the waist.

Type 2 diabetes is the most common form of diabetes. It affects 85-90% of all people with diabetes. It usually affects mature adults although younger people are also now being diagnosed in greater numbers as rates of overweight and obesity increase. The causes of Type 2 diabetes are known and in some cases can be prevented. However there is no cure.

Type 2 diabetes is characterised differently due to insulin resistance of reduced insulin sensitivity combined with reduced insulin secretion. In the early stage the predominant abnormality is reduced insulin sensitivity characterised by elevated levels of glucose in the blood. At this stage hyperglycaemia can be reversed by a variety of measures such as dietary management and oral hypoglycaemic medications that improve insulin sensitivity or reduce glucose production by the liver.

There are numerous theories as to the exact cause of Type 2 diabetes. Central obesity (fat concentrated around the waist in relation to abdominal organs, but not subcutaneous fat) is known to predispose individuals for insulin resistance. Abdominal fat is especially active hormonally, secreting a group of hormones called adipokines that may possibly impair glucose tolerance. Obesity is found in approximately 55% of people diagnosed in with Type 2 diabetes. Other factors include ageing and family history.

Risk factors for type 2 diabetes include: People with pre-diabetes; Aboriginal and Torres Strait Islander people aged 35 and over, Pacific Islanders, those from the Indian subcontinent or of Chinese origin aged over 35 years; people aged 45 and over who are obese or overweight, have high blood pressure or have a first-degree relative with Type 2 diabetes; people aged 55 and over; people with cardiovascular disease such as myocardial infarction (MI), angina, cerebrovascular accident (CVA) or atherosclerosis (narrowed blood vessels); women with polycystic ovarian syndrome who are overweight; women who have had gestational diabetes; people aged 55 and over.
Lifestyle factors that increase the risk of developing Type 2 diabetes include: being overweight or obese, especially around the waist; low levels of physical activity; unhealthy eating habits, such as regularly choosing high fat, high sugar, high salt or low fibre foods; high blood pressure; high blood cholesterol; cigarette smoking.

The symptoms of Type 2 diabetes develop much more slowly than with Type 1 and may be quite subtle or completely absent, they include: polydipsia – being more thirsty than usual; polyuria – passing more urine; feeling tired or lethargic; slow-healing wounds; pruritis and skin infections; blurred vision; mood swings.

Management options of Type 2 diabetes: It is usually first treated by increasing physical activity, decreasing carbohydrate intake and losing weight. These can restore insulin sensitivity even when the weight loss is moderate e.g. 5kg, most especially when it is in abdominal fat deposits. It is sometimes possible to achieve long-term, satisfactory glucose control with these measures alone, however, the underlying tendency to insulin resistance is not lost, and so attention to diet, exercise and weight loss must continue. The aim of diabetes treatment is to maintain blood glucose levels within the normal range, which is between 4 and 6mmol/L before meals and 4 and 8mmol/L two hours after meals. Keeping blood pressure and cholesterol within the recommended range is important (cholesterol <5.5mmol, BP 140/90 mmHg). Healthy eating, achieving and maintaining a healthy weight and doing regular physical activity are also important. Sometimes oral hypoglycaemic medication and then insulin may be required.

The information presented here is just the tip of the iceberg in relation to the content in the tutorial. To learn more about, or just refresh your knowledge on diabetes, go to http://anmf.org.au/pages/cpe. For further information, contact the education team on: 02 6232 6533 or education@anmf.org.au

This article was published with permission of the Australian Nursing and Midwifery Federation