|
| A) | total an estimated $132 million per year. | ||
| B) | are about the same as the general population. | ||
| C) | are about 2.3 times that of people without diabetes. | ||
| D) | represent 5% of the nation's healthcare expenditures. |
Diabetes places a substantial burden on the individual, society, and the economy. In the United States, 15.9 million (29.2%) people older than 65 years of age have diabetes, and the numbers are growing [10]. It is projected that one in three Americans born in 2000 will have diabetes over the course of their lives [11]. National statistics indicate that with 37.3 million cases in the United States, 11.3% of the total population has this disease [10]. Approximately 8.5 million individuals with diabetes have not been diagnosed [1,10]. Another 96 million people are estimated to have prediabetes, a condition that significantly increases the risk for developing diabetes [10]. Diabetes accounts for substantial loss in overall worker productivity, costing approximately $90 billion in lost productivity in 2018 [10]. Reductions in productivity were associated with absenteeism, decreased efficiency at work, disability, and early death [3]. In addition to economic loss, chronic complications of diabetes can significantly diminish quality of life for the individual, accounting for more new cases of blindness, end-stage renal disease, and lower extremity amputation than any other medical diagnosis [1].
Healthcare utilization by people with diabetes is considerable. Researchers report that people with diagnosed type 1 diabetes incur an average of $14,856 in healthcare expenditures per year, while those with type 2 diabetes acquire approximately $9,677 in expenditures [3]. This equates to healthcare expenditures that are roughly 2.3 times higher than for people without diabetes [4]. Diabetes contributes to longer hospital length of stay and higher rates of physician office and emergency department visits. A substantial amount of healthcare utilization by people with diabetes is associated with the chronic complications of this condition, particularly cardiovascular disease, neurologic symptoms, and renal complications. As sobering as these statistics are, it is predicted that the toll of diabetes will increase, related to higher rates of obesity and increasing cases of type 2 diabetes in children [12].
| A) | Eastern Europeans | ||
| B) | Chinese Americans | ||
| C) | Hispanic Americans | ||
| D) | Native Americans and Alaska Natives |
The prevalence of diabetes is greater in some racial and ethnic populations. Estimated prevalence rates for diabetes among adults 20 years of age and older in the following racial/ethnic groups are [2,10]:
Non-Hispanic White Americans: 7.4%
Asian Americans: 9.5%
Hispanic/Latino Americans: 11.8%
Non-Hispanic Black Americans: 12.1%
Native Americans/Alaska Natives: 14.5%
| A) | pancreas, stomach, and skin. | ||
| B) | pancreas, liver, and stomach. | ||
| C) | pancreas, liver, and muscle tissue. | ||
| D) | pancreas, muscle tissue, and stomach. |
Three organ systems are involved in the regulation and utilization of glucose by the body. They are the liver, the pancreas, and the skeletal muscle tissue. The liver plays two roles in the regulation of blood glucose. One is the storage and release of glucose that has been ingested from the diet; the other is the synthesis of its own glucose supply. (The process of glucose production by the liver is called gluconeogenesis.) Normally, when blood glucose levels are low, the liver releases some of its stored or synthesized glucose and blood levels rise. Conversely, when blood glucose levels are high, the liver stops producing and releasing glucose and blood levels fall.
| A) | a secondary type of diabetes. | ||
| B) | a disordered release of glucose from the liver. | ||
| C) | insufficient insulin secretion by the pancreas. | ||
| D) | an impairment in the body's ability to utilize insulin. |
Insulin resistance is the second major pathologic process in diabetes. This refers to impairment in the body's ability to utilize insulin. With insulin resistance, blood levels of insulin may be high, but receptor sites for it are not available.
| A) | is most often seen in people who are obese. | ||
| B) | is by far the most common type of diabetes. | ||
| C) | usually has its onset in people younger than 30 years of age. | ||
| D) | develops during pregnancy with a return to normal blood glucose levels by six weeks postpartum. |
Although type 1 diabetes is the most common form of diabetes in youth, the traditional paradigms of type 1 diabetes occurring only in children and type 2 diabetes occurring only in adults are no longer accurate, as both diseases occur in both age groups [6,24]. Children with type 1 diabetes often present with the hallmark symptoms of polyuria/polydipsia; approximately one-half present with diabetic ketoacidosis (DKA). The onset of type 1 diabetes may be more variable in adults [6]. The features most useful in identifying type 1 diabetes include younger age at diagnosis (<35 years) with lower BMI (<25 kg/m2), unintentional weight loss, ketoacidosis, and glucose >360 mg/dL at presentation [6]. Difficulties in distinguishing diabetes type may occur in all age groups at onset; however, the diagnosis becomes more obvious over time in patients with beta cell deficiency [6]. Overweight and obesity are common in children with type 1 diabetes, and diabetes-associated autoantibodies may be present in pediatric patients. The presence of islet autoantibodies has been associated with a faster progression to insulin deficiency [24].
| A) | is always treated with insulin injections. | ||
| B) | is by far the most common type of diabetes. | ||
| C) | only occurs in people older than 50 years of age. | ||
| D) | results when the person's pancreas completely stops producing its own insulin. |
As stated, the traditional paradigms of type 1 diabetes occurring only in children and type 2 diabetes occurring only in adults are no longer accurate, as both diseases occur in both age groups [6,24]. Type 2 diabetes is by far the most common type of diabetes, accounting for 90% to 95% of cases [6]. This type of diabetes usually begins in people older than 30 years of age and most commonly occurs in people older than 55 years of age. However, as mentioned earlier, it can occur at younger ages as well. Regardless of age of onset, type 2 diabetes is more likely to occur in those who are overweight.
In the person with type 2 diabetes, the pancreas is able to produce at least some of its own insulin for use by the body. However, the insulin that is produced is either insufficient for the needs of the body or poorly utilized by the tissues. When available insulin is not readily utilized by the tissues, the condition is called insulin resistance.
The need for an outside insulin source is variable in people with type 2 diabetes. Individual cases of type 2 diabetes may be treated with diet therapy, oral medications, insulin, or any combination of these. A patient with type 2 diabetes usually has a pancreas that is able to produce enough of its own insulin to prevent ketoacidosis from occurring. However, these patients may require insulin injections to keep blood glucose levels under control for the prevention of other acute and chronic complications.
| A) | give birth to low-birth-weight infants. | ||
| B) | develop type 1 diabetes within 15 years after delivery. | ||
| C) | develop type 2 diabetes within 10 to 20 years after delivery. | ||
| D) | have no return to normal blood glucose levels after childbirth. |
Gestational diabetes complicates approximately 10% of all pregnancies [6,26]. For many years, gestational diabetes has been defined as any degree of glucose intolerance first recognized during pregnancy, but this definition has limitations. Many cases of gestational diabetes represent pre-existing hyperglycemia that is first detected by routine screening in pregnancy (though routine screening is not widely performed in nonpregnant women of reproductive age) [6]. Ideally, women with risk factors who are planning pregnancy should be tested for undiagnosed diabetes prior to conception [6]. If not screened preconception, universal early screening before 15 weeks' gestation for undiagnosed diabetes may be considered, particularly in populations with a high prevalence of risk factors, including women of non-Hispanic Black, Hispanic/Latino, and Native American ethnicity, women who are obese, women with a personal history of gestational diabetes, and those with a family history of diabetes [6,27]. Otherwise, testing should be done at between 24 and 28 weeks' gestation, usually with a glucose tolerance test [1,6]. Women with gestational diabetes are at higher risk for hypertensive disorders and cesarean delivery. Fetal complications of gestational diabetes may include neural tube defects, perinatal death, large body size (macrosomia), lower Apgar scores, and childhood obesity [28]. Although most women with gestational diabetes will have normal glucose levels within six weeks postpartum, 35% to 60% will have developed diabetes in the next 10 to 20 years [29,30]. Women with gestational diabetes should be screened for prediabetes or diabetes at 4 to 12 weeks postpartum. Women with a history of gestational diabetes should have lifelong screening for the development of diabetes or prediabetes at least every three years [6]. Maintenance of a healthy body weight and regular physical activity may help prevent the onset of type 2 diabetes in this population [31].
| A) | anorexia. | ||
| B) | excessive thirst. | ||
| C) | peripheral edema. | ||
| D) | urinary retention. |
The primary symptoms of hyperglycemia are sometimes referred to as the "three polys" of diabetes. They are polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive hunger). Polydipsia is related to intracellular dehydration, initiated after high levels of glucose in the blood remove water from the cells. Polyuria results when large amounts of glucose in the urine are accompanied by large losses of water. Polyphagia, which is most likely to occur in type 1 diabetes, is due to cellular starvation as stores of carbohydrates, fats, and proteins become depleted. Other signs and symptoms of hyperglycemia in diabetes include blurred vision, weakness, lethargy, and malaise.
| A) | Hypoxia | ||
| B) | Hypertension | ||
| C) | Profuse sweating | ||
| D) | Acute abdominal pain |
Hyperpnea (deep breathing) is usually present as a sign of DKA, reflecting the pulmonary system's response to acidosis. Acetone breath may occur. Signs of dehydration related to DKA include orthostatic hypotension and poor skin turgor. Acute abdominal pain, tenderness, and diminished or absent bowel sounds are commonly associated with DKA and frequently cause the patient to seek emergent treatment. Changes in mental status occur as the ketosis progresses.
| A) | the leading cause of end-stage renal disease. | ||
| B) | unrelated to the risk for cardiovascular disease. | ||
| C) | the second leading cause of adult-onset blindness. | ||
| D) | implicated in very few lower extremity amputations. |
The chronic complications of diabetes have a profound effect on the healthcare system as well as the individual. In the United States, the treatment of these complications cost an estimated $55 billion in 2017 [36]. While the economic costs of diabetic complications are enormous, their effect on quality of life for the individual and family can be equally devastating. The CDC reports the impact of chronic complications on Americans with diabetes as [37]:
Leading cause of adult-onset blindness
Leading cause of end-stage renal disease
Significant morbidity and disability due to foot ulcer and lower extremity amputation
Increased risk for cardiovascular disease (two to four times greater in diabetic patient)
Significantly increased risk for nerve disease, periodontal disease, and a host of other health problems
| A) | Instituting a high-protein diet | ||
| B) | Long-term use of loop diuretics | ||
| C) | Aggressive blood pressure management | ||
| D) | Converting from oral medications to insulin |
Hypertension significantly accelerates the progression of diabetic nephropathy. Therefore, aggressive blood pressure management is indicated for all patients with diabetes. Angiotensin-converting enzyme (ACE) inhibitor drugs are commonly prescribed to diabetic patients for hypertension because they are effective blood pressure-lowering drugs with few side effects. In addition, ACE inhibitors are often prescribed to patients with diabetes even when they are not hypertensive because the drugs in this class have an independently protective effect on the kidneys, which can prevent the onset or progression of diabetic nephropathy. This means that the renal benefits of ACE inhibitors are above and beyond an effect attributable to blood pressure control alone. In addition to renal benefits, ACE inhibitors have been shown to reduce the risk for heart attack, stroke, and cardiovascular-related death in people with diabetes. Examples of ACE inhibitors include enalapril, fosinopril, lisinopril, and captopril. Another similar class of medication, angiotensin receptor blockers (ARBs), may be used in place of ACE inhibitors for delaying the progression of diabetic nephropathy [6]. A commonly used ARB is losartan.
| A) | have better outcomes than those who do not. | ||
| B) | are at greater risk for long-term complications. | ||
| C) | do not usually require as much insulin as those who do not. | ||
| D) | should be discouraged from making decisions on their own. |
Diabetes self-management education and support (DSMES) is considered an essential element of diabetes care. Furthermore, individuals who actively manage their own diabetes care have better outcomes than those who do not. For these reasons, an educational approach that facilitates informed decision making on the part of the patient is widely advocated [5,6].
| A) | Ineffective coping strategies | ||
| B) | Unwillingness to make necessary behavior changes | ||
| C) | Feelings of inadequacy about one's own abilities | ||
| D) | All of the above |
Unfortunately, patients can encounter a variety of psychologic and emotional barriers when it comes to effectively managing their diabetes. These barriers include feelings of inadequacy about one's own abilities, unwillingness to make the necessary behavior changes, and ineffective coping strategies. The following sections of this course will discuss the empowerment approach to diabetes education and will cover methods for overcoming related barriers.
| A) | is an unpopular approach to diabetes education. | ||
| B) | emphasizes the patient's role in decision making. | ||
| C) | assumes that patients will rely on others to make most decisions. | ||
| D) | involves having patients obtain all they need to know about diabetes self-management without assistance. |
Patient empowerment is a widely supported approach to diabetes education. This model assumes that the patient is the person who will experience the consequences of diabetes and, therefore, is the one with primary rights and responsibilities regarding its management. Because the empowerment approach emphasizes the patient's role in decision making, education is aimed at providing information that the patient will need in order to manage his or her own care effectively. Healthcare providers who use the empowerment approach recognize that the ultimate responsibility for making changes that will affect health outcomes is with the patient. Therefore, the role of the healthcare provider is to assess patients' willingness to make changes and to help them set realistic goals.
| A) | Providing the patient with a list of goals set by the healthcare provider | ||
| B) | Emphasizing the role of the healthcare provider as the expert on diabetes care | ||
| C) | Giving the patient an agenda of items to be covered in the teaching session | ||
| D) | Providing information the patient can use in order to manage his or her own care effectively |
According to the empowerment model, educators are most effective when they are able to recognize that they cannot and should not try to solve patients' problems for them. Instead, the role of the educator is to facilitate the patients' problem-solving skills and to support a decision-making process that is likely to benefit patients' health status. These skills can be supported by exploring, with the individual, the range of self-care options available and the consequences of each. Educators will discover that some patients are resistant to this type of exploration and should be prepared to accept their own limitations in their ability to effect change [44].
| A) | How would you describe or define diabetes? | ||
| B) | Do you have family and friends who help and encourage you? | ||
| C) | Do you have any cultural or religious preferences about what you eat? | ||
| D) | How confident do you feel about your ability to manage your diabetes on a day-to-day basis? |
Assessment of diabetes self-efficacy can be useful in targeting areas where the patient lacks confidence in the ability to carry out a self-care behavior. Specific self-efficacy questionnaires are sometimes used to make this assessment. One such questionnaire asks respondents how sure they are that they can perform specific diabetes-related behaviors. Sample statements from this type of questionnaire are presented in Table 5. The use of a specific questionnaire for self-efficacy is not always feasible. In that case, asking a few related questions as part of the general assessment can still make an expedient self-efficacy assessment. For example, patients can be asked how confident they feel (on a scale of 1 to 10) about their ability to manage diabetes on a day-to-day basis [45].
| A) | people who lead unhealthy lifestyles are not ready to change. | ||
| B) | healthcare providers should make decisions for patients who are not ready to change. | ||
| C) | people are more likely to initiate change after a healthcare provider recommends it. | ||
| D) | people move through a series of stages as they adopt new, health-enhancing behaviors. |
Readiness to change refers to the hypothesis that people move through a series of stages as they give up unhealthy behaviors and adopt health-enhancing behaviors. The Stages of Change Model has been widely used in smoking cessation as well as in DSMES. The researchers identified six stages that people go through as they attempt lifestyle changes. These stages range from precontemplation, during which the patient does not intend to change within the next six months, to maintenance, when healthy behaviors have been practiced for greater than six months. For each stage of change, certain interventions on the part of the healthcare provider are recommended. By employing these interventions, the healthcare provider is able to "meet" the patient within his or her own particular stage of change at a given time [46].
| A) | teaching the patient how to accomplish as much as possible in one day. | ||
| B) | helping the patient identify the thoughts and beliefs that motivate behavior. | ||
| C) | helping the patient set goals that are based upon specific outcomes recommended by the physician. | ||
| D) | providing the patient with a set of goals based upon the national standards of care for diabetes management. |
Helping the patient identify his or her own beliefs about having diabetes is an important step toward facilitating the development of coping skills. Because beliefs are usually reflected in the thoughts that a person has, healthcare providers can help the patient identify the thoughts that motivate self-care behavior. For example, negative thoughts tend to trigger behavior that is not constructive. The patient may think, and therefore believe, that "Checking blood sugar is useless." This negative thought process can result in failure to monitor blood glucose levels adequately. On the other hand, a positive thought, such as "Checking my blood sugar helps me stay well," would be more likely to result in constructive health-enhancing behavior. Providing the patient with reflective feedback about his or her beliefs may help convert self-limiting thoughts into constructive thoughts. When the patient with diabetes is able to reflect upon his or her beliefs about having the disease, he or she may be able to identify how those thoughts affect health-related behaviors and, ultimately, health status.
| A) | utilize physicians as the primary educators. | ||
| B) | focus solely upon the didactic elements of care. | ||
| C) | are always led by people who have diabetes themselves. | ||
| D) | enable the patient to become the most active participant in his or her own care. |
In general, the goal of diabetes self-management skills training programs is to enable the patient to become the most active participant in his or her own care.
Several studies have demonstrated that self-management training improves self-care behavior, clinical outcomes, and the quality of life for patients with diabetes. Diabetes education and support is also associated with better use of primary and preventive services and lower rates of hospitalization [6]. Further, it has been found that patients who have diabetes education have lower average healthcare costs than those who do not [48]. Although experts and research findings agree that DSMES is essential, the U.S. Department of Health and Human Services reported that in 2019 only 55.1% of people with diabetes have ever received any formal education on how to manage their condition. This was indicated as "little or no detectable change" according to Healthy People 2030 objectives [49]. In 2020, a total of 2,158 sites were delivering DSMES services across the United States, with approximately 1 million people participating in the programs [50]. One barrier to diabetes education is access. Although DSMES are offered in 56% of counties across the United States, 62% of rural counties have limited access to these services [50]. Providers of DSMES can help address the lack of access by [5]:
Clarifying the specific population to be served by understanding the community, service area, or regional demographics
Determining that population's DSME needs and identifying resources outside the provider's practice that can assist in ongoing support
Identifying access issues (e.g., socioeconomic or cultural factors, lack of encouragement from other healthcare providers to seek education) and working to overcome them
National standards have been developed for the establishment and maintenance of quality diabetes self-management programs [5,6]. This curriculum includes, but is not limited to, the following components (specific components to be delivered should be based upon an individual needs assessment):
Diabetes disease process and treatment options
Nutrition
Exercise and activity
Medications
Monitoring of blood glucose and use of results
Prevention and treatment of acute complications
Prevention and treatment of chronic complications
Psychosocial adjustment
Developing personal strategies to promote health and behavior change
| A) | Focus on the past experiences of the educator | ||
| B) | Focus on the main problems perceived by the educator | ||
| C) | Find out what the patient already knows prior to beginning a session | ||
| D) | Always have the educator select the mode of learning best suited to the patient |
An effective approach to teaching diabetes self-care in adult settings is to employ various principles of adult learning theory. An important principle of adult learning theory is that adults tend to be self-directed learners who feel a need to learn. Asking the patient what he or she feels addresses this principle of adult learning and is the most important issue during the needs assessment.
Determine what the patient feels he or she needs to know and what the perceived problems are. The adult learner will be more likely to acquire new knowledge and skills when teaching is directed toward specific problems rather than toward a comprehensive set of material.
Adults tend to learn better when teaching incorporates prior knowledge and past experiences. When teaching a problem-solving process, for example, ask the patient how he or she has dealt with a similar situation in the past. Build upon this experience to teach new material.
Provide opportunities for interaction, questions, and sharing. Teaching is apt to be more effective when the patient's own life experiences can be incorporated into the lesson.
Enhance the learner's sense of autonomy by letting him or her make choices about what is being taught. For example, you can allow the patient to choose the mode of learning or the amount of time spent on a particular topic.
Adult learners generally must perceive the benefits of what is being taught. Address this by giving the patient a brief rationale for the content that you are presenting, focusing on the benefits that can result from learning.
| A) | Replacing the need for regular HbA1c testing | ||
| B) | Decreasing costs associated with blood glucose monitoring | ||
| C) | Helping patients determine a target blood glucose range | ||
| D) | Providing feedback on how well treatment goals are being met |
A major benefit of SMBG is that it provides feedback about how well treatment goals are being met. By keeping blood glucose levels as near normal as possible over time, people with diabetes can reduce their risk for acute and chronic complications. SMBG can help prevent hypoglycemia and provide information relevant to adjusting food intake, activity level, and medication [6]. Several studies have shown that SMBG is associated with decreased morbidity and mortality in individuals with type 2 diabetes [52,53,54].
| A) | provide the patient with a talking meter. | ||
| B) | recommend testing fewer times each day. | ||
| C) | recommend a meter that is fast and easy to use. | ||
| D) | recommend regular HbA1c testing in lieu of self-monitoring. |
Individuals may not want to check their blood glucose on a regular basis because they perceive it to be an inconvenience that encroaches on their lifestyle. Healthcare providers might be able to help such patients overcome this barrier by providing information about how improved blood glucose control can result in feeling better on a day-to-day basis. Further information may be provided regarding how glycemic control reduces the risk for long-term complications, making patients more able to lead productive lives. The perception that SMBG is inconvenient may also be offset if patients are shown how this procedure can allow for greater flexibility in meal planning. By monitoring the effects of various foods and the timing of meals on blood glucose, patients can have more choices with regard to eating [6,51]. Patients who find regular blood glucose monitoring bothersome may be interested in meters that are smaller, faster, and require fewer steps during testing. Some meters allow for "alternate site" testing, in which the patient can collect a blood sample from the forearm or the thenar aspect of the palm, where fewer nerve endings make the procedure less painful. Additionally, the IDF/SMBG Working Group has suggested possible regimens that may be individualized to address the specific needs of each person with diabetes [51].
| A) | is a self-performed blood glucose test. | ||
| B) | has minimal implications for diabetes educators. | ||
| C) | reflects the blood glucose level on one specific day. | ||
| D) | reflects the average amount of glucose that has been in the blood over a two- to three-month period. |
Although SMBG using a capillary blood sample is indispensable in the day-to-day management of diabetes, results from these tests have some limitations. One such limitation is that results of SMBG reflect the blood glucose for a specific moment in time without giving an indication of overall blood glucose control. The glycated hemoglobin test, more commonly known as the HbA1c, is a laboratory test that uses a venous blood sample to show the average blood glucose over the previous two to three months.
| A) | is not a useful method of meal planning for people with diabetes. | ||
| B) | allows for very little flexibility or choice in the timing and content of meals. | ||
| C) | is a method for keeping track of the amount of carbohydrate in each meal or snack. | ||
| D) | can be thought of as a food budget, giving a certain number of food choices from each food group at each meal or snack. |
Carbohydrate counting is a method for keeping track of the amount of carbohydrate in each meal or snack. Emphasis is placed on the total amount of carbohydrate in a meal or snack rather than on the source. Limits are set for the maximum amount of carbohydrate that should be consumed for each meal or snack. Foods counted as carbohydrates are starches (including starchy vegetables), sugars, milk, and fruit. Nonstarchy vegetables are so low in carbohydrates that they are generally not included in carbohydrate counting. According to the ADA, evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with or at risk for diabetes; therefore, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and metabolic goals [77].
| A) | Use a five-inch dinner plate. | ||
| B) | Include a low-calorie drink, like water. | ||
| C) | Fill one-fourth of the plate with lower fat protein foods. | ||
| D) | Fill approximately one-half of the plate with nonstarchy vegetables. |
The teaching tenets of the Plate Method are [75,84]:
Use a nine-inch dinner plate.
Fill approximately one-half of the plate with nonstarchy vegetables, such as leafy greens, onions, peppers, tomatoes, cucumbers, green beans, broccoli, carrots, cauliflower, and others.
Fill one-fourth of the plate with lower fat protein foods, such as lean cuts of meat, fish, poultry with skin removed, egg whites and egg substitutes, two ounces of reduced-fat cheese, plant-based proteins (e.g., beans, lentils, edamame, tofu, hummus, tempeh), nuts, or spreads (e.g., peanut or almond butter).
Fill one-fourth of the plate with grains and starchy food, such as whole grain breads, brown rice, whole grain pasta, potatoes, pumpkin, corn, or peas.
Add a small piece of fruit, one-half cup fresh frozen or canned fruit, or two tablespoons of dried fruit.
Add a low-calorie drink, such as water, unsweetened tea, or coffee.
| A) | reducing glucose production from the liver. | ||
| B) | improving the body's ability to utilize insulin. | ||
| C) | improving the body's ability to utilize glucose. | ||
| D) | increasing insulin production from the pancreas. |
Sulfonylureas act primarily by increasing insulin production from the pancreas. They can be further classified as first- or second-generation hypoglycemic agents. The first-generation agent previously used in the United States is chlorpropamide; however, chlorpropamide and acetohexamide have been discontinued, and tolbutamide and tolazamide are no longer recommended treatment options for type 2 diabetes [18]. Although no first-generation sulfonylurea agents are currently used in the United States, it is important to have an understanding of all medications within this category in the rare case a patient presents with a history of having taken one of these agents. Second-generation sulfonylureas include glipizide, glyburide, and glimepiride, among others [6]. They have largely supplanted the use of first-generation sulfonylureas because they have the convenience of once or twice a day dosing and the potential for fewer adverse effects.
| A) | one to two hours after eating. | ||
| B) | one to two hours before eating. | ||
| C) | 15 to 30 minutes prior to eating. | ||
| D) | once a day, prior to the largest meal of the day. |
Patients taking this agent should be instructed to take their pills 15 to 30 minutes prior to each meal. The number of doses taken is determined by the number of meals eaten. For example, if a meal is missed, the corresponding dose of medication is skipped. Conversely, a dose is added when an extra meal or large snack is taken.
| A) | reducing glucose production from the liver. | ||
| B) | improving the body's ability to utilize insulin. | ||
| C) | increasing insulin production from the pancreas. | ||
| D) | slowing the digestion of carbohydrate in the small intestine. |
Medications in this class improve the body's ability to use insulin. Insulin action is enhanced by "opening up" the insulin receptors in the liver and skeletal tissues. When this occurs, insulin resistance is reversed and the body is able to utilize circulating insulin more effectively. A secondary action of the insulin sensitizers is that they decrease the production and release of glucose from the liver. Because these agents are not hypoglycemic agents, they will not generally lower blood glucose to levels below normal. When used in combination with insulin or sulfonylureas, the potential for hypoglycemia exists [18].
| A) | reducing glucose production from the liver. | ||
| B) | improving the body's ability to utilize insulin. | ||
| C) | increasing insulin production from the pancreas. | ||
| D) | slowing the digestion of carbohydrate in the small intestine. |
Alpha-glucosidase inhibitors (AGIs) work by slowing the digestion of carbohydrate in the small intestine [18]. This results in decreased postprandial blood glucose levels due to delayed absorption of sugars and starches into the bloodstream.
| A) | is a cloudy insulin. | ||
| B) | has an onset of action from two to three hours. | ||
| C) | should be injected 30 to 45 minutes prior to the meal. | ||
| D) | All of the above |
Also known as "regular" insulin, this is a clear insulin that is generally used to cover increases in blood glucose associated with the main meals. Onset of action is from 30 minutes to one hour after injection, with peak levels occurring in two to three hours. Persons using regular insulin are instructed to administer a dose between 30 to 45 minutes prior to the meal.
| A) | is strongly discouraged by the ADA. | ||
| B) | has no practical benefits for patients. | ||
| C) | is recommended by all manufacturers. | ||
| D) | should only be considered by people who self- inject and who are capable of safely capping a needle after use. |
| A) | is always 45 degrees. | ||
| B) | is always 90 degrees. | ||
| C) | should be individualized to ensure subcutaneous medication delivery. | ||
| D) | should be individualized to ensure intramuscular medication delivery. |
| A) | must be used within 24 hours of being filled. | ||
| B) | are not recommended for use by the visually impaired. | ||
| C) | are stable for up to 30 days when stored in the refrigerator. | ||
| D) | are stable for up to 30 days when stored at room temperature. |
| A) | decreases appetite. | ||
| B) | increases glucose utilization by the tissue. | ||
| C) | decreases the need to monitor blood glucose. | ||
| D) | decreases the need for carbohydrate in the diet. |
| A) | diet. | ||
| B) | insulin. | ||
| C) | thiazolidinediones. | ||
| D) | alpha-glucosidase inhibitors. |
| A) | includes proper footwear. | ||
| B) | includes weekly self-foot exam. | ||
| C) | includes soaking the feet in warm water daily. | ||
| D) | does not involve exams by healthcare providers. |
| A) | a need to stop exercising. | ||
| B) | an underlying infectious process. | ||
| C) | an increased risk for future amputation. | ||
| D) | the need for an annual clinical foot exam. |
| A) | help maintain glycemic control. | ||
| B) | include dopamine and serotonin. | ||
| C) | are likely to cause a hypoglycemic reaction. | ||
| D) | can make diabetes more difficult to control. |
| A) | Difficulty breathing | ||
| B) | Absence of ketones in the urine | ||
| C) | Vomiting or diarrhea for more than six hours | ||
| D) | Blood glucose of 300 mg/dL for 24 hours or more |
| A) | Developing a thorough understanding of every culture encountered | ||
| B) | Politely ignoring cultural characteristics during the diabetes needs assessment | ||
| C) | Recognizing that cultural healthcare practices may differ from one's own beliefs | ||
| D) | Making assumptions about the individual's beliefs based solely upon cultural identification |