Diabetes and Treatment
Diabetes is a group of diseases that result from a defect in the body’s ability to maintain a homeostatic glucose level. The defect may be in insulin secretion, insulin action or both. Diabetes can be classified as Juvenile, Type 1, Type 2, or Gestational. Distinction between the different classifications is based on the circumstances present at time of the diagnosis.
Defect in insulin secretion
Type 1 diabetes is an absolute deficiency in insulin secretion in the pancreatic islets. Type 1 diabetes can be confirmed by serological evidence of an autoimmune process and genetic markers. Type 1 is the results from a cellular-mediated autoimmune destruction of the β-cells of the pancreas. These patients are dependent on insulin to survive and have a high risk of being ketoacidosis when first diagnosed.
Type 2 diabetes or noninsulin dependent diabetes has a gradual onset and patients may take years to identify common symptoms. Autoimmune destruction of β-cells does not occur. Insulin secretion is defective in these patients and insufficient to compensate for insulin resistance. These patients are usually obese or carry extra fat in the midsection of the body.
Gestational diabetes (GDM) is recognized as any glucose intolerance that is diagnosed initially during pregnancy. “The definition applies regardless of whether insulin or only diet modification is used for treatment or whether the condition persists after pregnancy.”(“ADA,” 2004, para. 26) If a patient is diagnosed with GDM the patient may not continue to be diabetic after delivery or may develop Type 2 diabetes immediately after delivery or later in life. Women who have had GDM have a 35% to 60% of developing diabetes in the next 10 to 20 years according to the National Diabetes Fact Sheet of 2011.
Treatment for Gestational Diabetes
The first line treatment for GDM is nutritional therapy and education. It is not recommended for pregnant females to lose weight. The current recommendations of restricting carbohydrate intake to 35 to 40% of dietary calories, there is debate about restricting calorie intake, due to the effects of reduce calories on the fetus. The recommendation by the American Diabetes Association for patient’s that have a body mass index greater than 30 kg per m2 is to decrease the calorie intake by 30 to 33% of daily intake. If the patient is unable to maintain blood glucoses 105 mg per dL in the fasting state and 120 mg per dL two hours after meals then either insulin or oral medications are recommended.
There has been no documented evidence that either form is better at maintaining normal plasma glucose. Patients must be educated on taking her blood glucose often, usually at least four to five times per day. Initial treatment for GDM with insulin maybe either via multiple daily injections or continuous subcutaneous insulin infusion. Regular and neutral protamine hagedorn (NPH) insulin, both of which are classified as pregnancy category B, have been the classic initial therapy. Recently, rapid-acting insulin aspart has been approved for use in pregnancy, and lispro is considered a treatment option for patients, 70/30 aspart mix and 75/25 lispro mix are pregnancy category B. For basal insulin, detemir is recommended during pregnancy but remains a pregnancy category C.(Jodon, 2011)
Short term effects of GDM
The short term effects of GDM are usually seen in the fetus. In the early weeks of pregnancy it is thought that uncontrolled hyperglycemia may cause birth defects that include neural tube defects, cardiac malformations, and early loss of pregnancy. In later weeks there is evidence that the maternal hyperglycemia crosses the placenta and causes “fetal hyperglycemia, compensatory fetal hyperinsulinemia, and consequently increased adipose deposition of nutrients, resulting in macrosomia.”(Jodon, 2011, para. 7) The effects on the infant can last beyond the womb. The infant may have to be delivered by c-section due to macrosomia. An infant that has been exposed to hyperglycemia levels in utero may need support after delivery for hypoglycemia due to the infant’s pancreas secreting large amounts of insulin.
Long term effects of GDM
The long term effects of GDM are currently being studied. In recent years there have been correlation studies between GDM and Type 2 diabetes diagnoses later in life. The long term effects of GDM on the infant include an increase in obesity and type 2 diabetes later in life. If a patient does not make modifications to lifestyle and diet choices then she may continue to need insulin to keep her blood glucose at a healthy level. The most recent recommendation from the American College of Obstetrics and Gynecology is to retest GDM patients six to twelve weeks after delivery for hyperglycemia; the recommendation was made to catch early indications of Type 2 diabetes.
Diabetes can affect any person, whether a fetus or an older adult. The long term effects of gestational diabetes are not just on the mother but can have long term effects on the child also. The diabetic mother needs to understand the changes she makes during her pregnancy can help her after pregnancy from becoming an insulin dependent diabetic and also lower the chances of her child developing diabetes. Educating the patient includes modifications to diet, exercise, glucose monitoring, and appropriate medication regimen. Education is the key to helping patients maintain good glucose control and decrease their future risk.
Arcangelo, V. P., & Peterson, A. M. (Eds.). (2013). Pharmacotherapeutics for Advanced Practice: A practical approach (3 ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Diagnosis and Classification of Diabetes Mellitus. (2004). Retrieved from dio:10.2337/diacare.27.2007.S5 Jodon, H. (2011). New Standards of Care for Gestational Diabetes. Retrieved from Clinicians Review: http://www.clinicianreviews.com/home/article/new-standards-of-care-for-gestational-diabetes/43f9e46f915c950c0d48257fbbe7bb52.html McCance, K. L., & Huether, S. E. (2012). Understanding Pathophysiology (5th Custom Edition