Running head: DIABETES BIBLIOGRAPHIC ESSAY
Diabetes Bibliographic Essay
Tammy A. Garcia
Ferris State University
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Abstract
This bibliographic essay documents the various research tools used to access the most up to date
information available on Diabetes. Through the use of the Ferris Library for Information,
Technology and Education (FLITE) various databases are available to research professional
journals and articles. Utilization of the internet search engine Google provides links to the
American Diabetes Association (ADA), the National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK), and the Centers for Disease Control and Prevention (CDC). By using
the information and research methods in this essay, the health care professional will be able to
access current information on treatment, prevention and research for diabetes.
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Diabetes Bibliographic Essay
Diabetes is a chronic medical disorder that affects 25.8 million people, 18.8 million
diagnosed and 7 million undiagnosed. That translates into approximately 8.3% of the U.S.
population. It is the 7th highest cause of death in the U.S. (Centers for Disease Control, 2011).
In addition, the latest Centers for Disease Control (CDC) report states 1 in 3 people have prediabetes.
Diabetes is a disease that results from either a failure of the pancreases to produce enough
insulin or insulin resistance. It affects every organ in the body. Currently, diabetes costs $174
million in direct and indirect expenses (CDC, 2011).
As a registered nurse, diabetes is a health issue I see patients living with daily. I chose to
research diabetes because of its increasing prevalence in our population. Because of that
increase, the topic of the service learning project I chose do for the Ferris State RN to BSN
program is diabetic teaching in the geriatric population.
During the research for this paper I have utilized many sources. I started my research
through FLITE, The Ferris Library for Information, Technology and Education. FLITE allows
Ferris State students access to multiple databases for research. I chose to start my search by
searching journals. The category health sciences with a sub category of Diabetes and HTN
yielded a return of 58 e journals that could assist with my research. When searching through
FLITE under the subject of Diabetes journals 64 e journals were available with diabetes in the
journal name. I also utilized Google with a search term of diabetes. The search found
114,000,000 web sites that mentioned diabetes. I located excellent information from several
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websites including the American Diabetes Association, National Health Institute (NHI), and
Centers for Disease Control and Prevention (CDC).
The amount of information on diabetes available is staggering. Treatments and
recommendations change as research and technology advances. I wanted to make sure I had the
latest information on diagnosis, treatment and recommendations so the teaching I plan to provide
will be relevant and up to date. This paper will highlight information and research on the
following diabetes topics and subtopics, with the primary emphasis on type 2:

What is Diabetes?
o Type 1
o Type 2
o Gestational
o Prediabetes

Prevention or Delay of Onset
o Weight Loss
o Diet
o Physical Activity
o Medications

Preventing Complications

Research and Resources

Conclusion
Diabetes: What is it?
Diabetes is a chronic disease marked by high levels of blood glucose. The high blood
glucose levels can be caused by either ineffectual insulin production or insulin action or both.
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There are three types of diabetes; type 1, type 2, and gestational. There is also a condition called
prediabetes. In the American Diabetes Association Standards of Medical Care in Diabetes2011, the criterion for a diagnosis of diabetes is:

A1C greater than or equal to 6.5%
or

Fasting plasma glucose (FPG) greater than or equal to 126 mg/dl (7.0mmol/l)
or

Two-hour plasma glucose greater than or equal to 200 mg/dl (11.1 mmol/l) during
an OGTT
or

A random plasma glucose greater than or equal to 200 mg/dl (11.1 mmol/l)
(ADA, 2011)
Type 1
Type 1 diabetes is caused by immune system destruction of pancreatic beta cells (Bcells). Beta cells are the sole insulin producing cells in the body and without the hormone,
insulin; blood glucose levels are not regulated. The patient with type 1 diabetes must replace
insulin by injection or continuous infusion. There is no known way to prevent type 1 diabetes
and it is typically diagnosed in children or young adults. Risk factors for type 1 are autoimmune
and genetic.
Type 2
Type 2 diabetes is caused by ineffectual use of insulin and an eventual pancreatic loss of
ability to produce insulin. The National Diabetes Fact Sheet, 2011, states that “type 2 diabetes
accounts for about 90% to 95% of all diagnosed cases of diabetes” in adults (CDC, 2011, p.11).
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The National Institute of Diabetes and Digestive and Kidney Disease (NIDDK) list risk factors
for type 2 diabetes as:

“being overweight or obese”

“age 45 or older”

“physical inactivity”

“having a parent, brother, or sister with diabetes”

“having a family background that is African American, Alaska Native, American
Indian, Asian American, Hispanic/Latino, or Pacific Islander”

“giving birth to a baby weighing more than 9 pounds or being diagnosed with
gestational diabetes”

“having high blood pressure-140/90 mmHg or above-or being treated for high
blood pressure”

“having HDL cholesterol below 35mg/dL, or a triglyceride level above 250
mg/dL”

“having polycystic ovary syndrome (PCOS)”

“having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) on
previous testing”

“having other conditions associated with insulin resistance, such as severed
obesity or a condition called acanthosis nigricans, characterized by a dark, velvety
rash around the neck or armpits”

“having a history of cardiovascular disease” (NIDDK, 2008, DPP, section Who
Should be Tested for Prediabetes and Diabetes).
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Several of the risk factors for type 2 diabetes are modifiable by lifestyle changes and/or
medication.
Gestational Diabetes
Hormones in pregnancy can impair insulin’s action. This results in increased glucose
levels in the pregnant woman’s blood. A woman is at increased risk for developing gestational
diabetes if:

She is over the age of 25

She has a family history of diabetes

She previously gave birth to a baby with a birth defect or a baby that weighed
more than 9 pounds

She has a history of HTN or has HTN during pregnancy

She has a routine urinalysis and has glucose in her urine

She has a large amount of amniotic fluid

She previously had a stillbirth or unexplained miscarriage

She is overweight prior to pregnancy
Usually there are no symptoms, however if present, they may include: increased urination,
frequent infections, increased thirst, blurred vision, fatigue, nausea and vomiting, and weight
loss. An oral glucose tolerance test is typically done between the 24th and 28th week of
pregnancy if no risk factors are present. In women with risk factors, testing is usually done
earlier. (U.S. National Library of Medicine National Institutes of Health, 2010)
Prediabetes
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Prediabetes is a condition of higher than normal blood glucose levels but not high enough
to be diagnosed as diabetes. The ADA Standards of Medical Care in Diabetes-2011 list criteria
for a prediabetes diagnosis as:

“FPG 100-125 mg/dl (5.6-6.9 mmol/l): IFG”
or

“2-h plasma glucose in the 75-g OGTT 140-199 mg/dl (7.8-11.0 mmol/l): IGT”
or

“A1C 5.7-6.4%” (ADA, 2011, p.S13)
Risk factors for prediabetes are the same as those for type 2 diabetes.
Prevention or Delay of Onset
Many of the risk factors for diabetes or prediabetes are modifiable. Life style changes
include: weight loss, physical activity, and diet. In the Diabetes Prevention Program (DPP)
study, losing weight and increasing physical activity reduced the development of type 2 diabetes
by 58% in a 3 year period that studied people at high risk (NIDDK, 2008).
Weight Loss
Achieving and maintaining an ideal body mass index (BMI) has helped to reduce the
weight related risk factor. Franz (2010) noted that clinical improvements have been noticed in
individuals who have had even small amounts of weight loss (approximately 5-7%). According
to the Standards of Medicare Care in Diabetes-2011, “bariatric surgery may be considered for
adults with a BMI greater than 35 and type 2 diabetes, especially if the diabetes or associated
comorbidities are difficult to control with lifestyle and pharmacological therapy” (ADA, 2011,
p.S26). There have only been a few studies on the benefit of bariatric surgery on patients with
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type 2 diabetes with a BMI in the range of 30-35. Those studies have shown limited benefit,
however, more studies are need before any recommendations can be made.
Diet
Nield, Summerbell, Hooper, Whittaker, Moore, (2008) noted that dietary counseling can
reduce the risk of type 2 diabetes by 33%. In the Nutrition and Health: Nutrition Guide for
Physicians, Franz (2010) states “the primary diet intervention in the diabetes prevention trials
was a lower energy, lower fat diet” (p. 293). There isn’t one specific diabetes diet. Diets need to
be adjusted to each person’s metabolic goals. This includes “the best mix of carbohydrate,
protein, and fat. Monitoring carbohydrate, whether by carbohydrate count, choices, or
experience-based estimation, remains a key strategy in achieving glycemic control” (ADA, 2011,
p. S23). General dietary recommendations include:

45-65% of total daily calories should be carbohydrates. The best carbohydrate
choices are vegetables, fruit, beans, and whole grains.

25-35% of daily calories should be fats. Saturated fats should be limited to less
than 7% of daily calories; trans fats should be less than 1% of total daily calories

12-20% of daily calories should come from protein. These requirements vary
with different co morbidities and individual health requirements.

If BMI is between 25-29 or higher, lose weight (MD Consult, 2010).
Physical Activity
The American Diabetes Association (ADA) and the American College of Sports
Medicine (ACSM) recommend a regimen of moderate to vigorous activity for patients with type
2 diabetes. Moderate activity is defined as 40%-60% of maximal aerobic capacity (Colberg,
2010). Recommendations in the Standards of Medical Care in Diabetes-2011, call for at least
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150 minutes per week of moderate-intensity aerobic physical activity (ADA, 2011). The 150
minutes of recommended aerobic activity should be spread out over at least 3 days with a break
of no more than 2 days in between sessions. Recommendations also include resistance training
three times per week in patients without contraindications to the activity. In those patient’s
where resistance training is not contraindicated, it should be completed at lease 2 times per week,
preferably 3 times per week, on nonconsecutive days.
Medications
There are several different medications that are used to treat diabetes. Insulin is used to
treat type 1 diabetes and for type 2 diabetes that is not controlled by diet and/or oral
hypoglycemic medication. There are several types of insulin used: Lispro, is a rapid acting
insulin; Regular, a short acting insulin; NPH, an intermediate acting insulin; Ultralente, a long
acting insulin. Insulin is replacement for what the patient’s body is either not producing or not
producing enough of. Medications like Glucotrol, increase insulin secretion and are in the
sulfonylurea medication class. Insulin enhancers also help promote insulin secretion. Two
insulin enhancing medications are Prandin and Starlix. Glucophage belongs to a class of
medications called the Biguanides. Biguanides help decrease glucose production. The
medications Precose and Glyset are in the Alpha-glucosidase inhibitor family. They help
decrease glucose levels by prolonging carbohydrate digestion and by blocking intestinal
enzymes. The medications Avandia and Actos belong to a class of medications called
Thiazolidinediones. Medications in that class help to decrease the body’s resistance to the
insulin it produces. Januvia and Onglyza are dipeptidyl peptidase-4 (DPP-4) enzyme inhibitors.
They work to inhibit the DPP-4 enzyme which inactivates incretin hormones. Incretin hormones
are involved with glucose regulation. (Nursing 2011 Drug Handbook, 2011)
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Currently there are 2 diabetes treatment algorithms based on recommendations by the
ADA and the American Association of Clinical Endocrinologists. At this time there is not a
consensus on which algorithm should be adopted across the board. Both algorithms are attached
as Appendix A-AACE algorithm and Appendix B-ADA algorithm. Both algorithms were found
on the Cleveland Clinic Website. The AACE algorithm is the one that the Cleveland Clinic uses
and is the most detailed one (Babar & Skugor, 2010).
Preventing Complications
Diabetes affects every organ of the body. “Nationally, 6 in 10 people with diabetes have
one or more diabetes-related complications” (State of Michigan, 2010, p.1). Patients who suffer
from diabetes have an increased risk of heart disease, stroke, hypertension, kidney disease,
diabetic nerve disease, blindness, dental diseases, limb amputations, acute electrolyte
imbalances, decreased immune system, and depression.
Typically home monitoring of blood sugars is not routinely performed unless the patient
is on some form of insulin. In the article Self-Monitoring of blood glucose in patients with type 2
diabetes mellitus who are not using insulin, Welschen et al. (2009) suggest that “self-monitoring
of blood glucose might be effective in improving glucose control” (Summary section). Perhaps
if diabetic patients who do not use insulin were to start monitoring their blood sugars on a
regular basis, there would be more compliance with treatments.
In the article Health Literacy, Health Numeracy, and Diabetes Care, Cypress (2010)
discusses health literacy and “its effect on health care and health outcomes” (para. 6). The article
is a reminder to health care professionals that in order for patient’s to be able to use health care
information, they need to understand the information that has been presented to them. The
article also talks about the National Action Plan released by the U.S. Department of Health and
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Human Services to improve health literacy. “The plan is based on the principles that everyone
has the right to health information that can help them make informed decisions and that health
services should be delivered in ways that can be understandable, and beneficial to the health,
longevity, and quality of life” (Cypress, 2010, para.6). Teaching patient’s to self manage their
diabetes is critical to preventing further health complications. In the articles Group-based
training for self-management strategies in people with type 2 diabetes mellitus ( Deakin,
McShane, Cade, & Williams, 2009) and Individual patient education for people with type 2
diabetes mellitus (Duke, Colagiuri & Colagiuri, 2009) research appears to indicate that group
diabetes education can be as effective as individual education. Those results give me
encouragement that my service learning project of diabetic teaching to a geriatric population will
have the potential to make a difference in some patient’s lives.
Research and Resources
Given the prevalence of diabetes in our society and the health care costs associated with
its treatment, there is a wealth of information available for health care providers as well as for
patients. Currently at clinicaltrials.gov, there are ongoing studies related to diabetes in the
following areas:

Diabetes complications-657 studies

Diabetes Insipidus (type 1)-26 studies

Diabetes Mellitus (type 2)-8794 studies

Gestational diabetes-82 studies

Diabetic angiopathies-319 studies

Diabetic foot-144 studies

Diabetic Ketoacidosis-7 studies
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Diabetic Nephropathies-136 studies

Diabetic Neuropathies-320 studies

Diabetic Retinopathy-200 studies
The National Institute of Diabetes and Digestive and Kidney Diseases has a directory of diabetes
organizations available for download at
http://diabetes.niddk.nih.gov/resources/organizations.htm, the directory has information on
organizations that provide education, support, referrals, and clinical trials. There is information
for health care professionals as well as patients.
Conclusion
As the prevalence of diabetes in our population increases, the need for research and
evidence based treatments take on critical importance. Health care professionals need to stay
informed of current treatment trends and clinical recommendations. A healthy lifestyle that
includes physical activity, a healthy diet, and weight management will not only help prevent or
delay the onset of diabetes, it will help prevent or delay other chronic diseases as well. Teaching
patients the essentials of a healthy life style is as important as teaching a patient’s selfmanagement of the disease if it develops. A patient’s ability to self-manage their diabetes will
help prevent some of the many debilitating complications that result from uncontrolled or under
controlled diabetes. As a nurse I need to know how and where to access the most updated
information and treatment recommendations. I feel that the information, resources, and links in
this bibliographic essay are good examples of how and where to find what is needed to stay
informed on diabetes.
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References
American Diabetes Association. (January 2011). Standards of medical care in diabetes-2011.
Diabetes Care, 34(1), pp. S11-S88. doi: 10.2337/dc11-S011
Babar, T., Skugor, M. (August 1, 2010). Diabetes mellitus treatment. Retrieved from
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement
Centers for Disease Control and Prevention. (n.d.). Diabetes Public Heatlh Resource. Retrieved
from http://www.cdc.gov/diabetes/
Centers for Disease Control and Prevention. (2011). National diabetes fact sheet: national
estimates and general information on diabetes and prediabetes in the United States,
2011. Retrieved from http://www.cdc.gov/diabetes/pubs/references11.htm
Clinical Trials.gov. (n.d.). Diabetes. Retrieved from http://www.clinicaltrials.gov/ct2/home
Colberg, S.R. (2010). Exercise and type 2 diabetes American college of sports medicine and the
american diabetes association: joint position statement. Medicine & Science in Sports &
Exercise, 42(12), pp. 2282-2303. doi: 10.1249/mss.obo13e318/ee61c
Cypress, M. (October 2, 2010). From research to practice/health literacy, health numeracy, and
diabetes care. Diabetes Spectrum, 23(4), pp.216-218. doi: 10.23371/diaspect.23.4.216
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Deakin, T.A., McShane, C.E., Cade, J.E., Williams, R. (2009). Group based training for selfmanagement strategies in people with type 2 diabetes mellitus. Cochrane Database of
Systematic Reviews, 2(CD003417). doi: 10.1002/14651858.CD003417.pub2.
Diabetes.org. (n.d.). Prediabetes faqs. Retrieved from http://www.diabetes.org/diabetes-basics/
prevention/pre-diabetes/pre-diabetes-faqs
Duke, SAS., Colagiuri, S., Colagiuri, R. (2009). Individual patient education for people with
Type 2 diabetes mellitus. Cochrane Database of Systematic Reviews,1(CD005268).
doi: 10.1002/14651858.CD005268.pub2.
Franz, M.J. (2010). Lifestyle interventions to stem the tide of type 2 diabetes. Nutrition and
Health: Nutrition Guide for Physicians, 24, pp. 289-300. doi: 10.1007/978-1-60327431-9_ 24
National Institute of Diabetes and Digestive and Kidney Diseases. (n.d.). Diabetes prevention
program. Retrieved from
http://www.diabetes.niddk.nih.gov/dm/pubs/preventionprogram/
National Institute of Diabetes and Digestive and Kidney Diseases. (n.d.). Directory of diabetes
organizations. Retrieved from http://diabetes.niddk.nih.gov/resources/organizations.htm
Nield, L., Summerbell, C.D., Hooper, L., Whittaker, V., Moore, H. (2008). Dietary advice for the
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Prevention of type 2 diabetes mellitus in adults. Cochrane Database of Systematic
Reviews, 3(CD005102). doi: 10.1002/14651858.CD005102.pub2
Nursing 2011 Drug Handbook (31st ed.). (2011). Ambler, PA: Lippincott Williams & Wilkins.
Pub Med Health. (n.d.). U.S. National Library of Medicine National Health Institute. Retrieved
from http://www.ncbi.nlm.nih.gov/pubmedhealth/
State of Michigan, (2010). Diabetes in Michigan 2010-The Facts. Retrieved from
http://www.michigan.gov/documents/mdch/Diabetes_in_Michigan2010_331597_7.pdf
U.S. National Library of Medicine National Institutes of Health. (September 11, 2010).
Gestational diabetes. Retrieved from http://www.ncbi.nlm.nih.gov/pubmedhealth/
Welschen,L.M.C., Bloemendal, E., Nijpels, G., Dekker, J.M., Heine, R.J., Stalman, W.A.B.,
Bouter, L.M. (2009). Self-monitoring of blood glucose in patients with type 2 diabetes
mellitus who are not using insulin.
Cochrane Database of Systematic Reviews, 2(CD
005060). doi: 10.1002/14651858.CD005060.pub2
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Appendix A
Type 2 Diabetes
The ADA and the AACE have different algorithms for initiation and maintenance of therapy. No
studies are available comparing the efficacy of either method or comparing the two.
Box 1: Examples of Pharmacologic Regimens for Treating Type 2 Diabetes Mellitus*>
Patients Naive to Pharmacologic Therapy
Monotherapy
Initiate monotherapy when HbA1c levels are 6% to 7%
Options include:





Metformin
Thiazolidinediones
Secretagogues
Dipeptidyl-peptidase 4 inhibitors
α-Glucosidase inhibitors
Monitor and titrate medication for 2 to 3 months
Consider combination therapy if glycemic goals are not met at the end of 2 to 3 months
Combination Therapy
Initiate combination therapy when levels are 7% to 8%
Options include:








Secretagogue + metformin
Secretagogue + thiazolidinedione
Secretagogue + α-glucosidase inhibitor
Thiazolidinedione + metformin
Dipeptidyl-peptidase 4 inhibitor + metformin
Dipeptidyl-peptidase 4 inhibitor + thiazolidinedione
Secretagogue + metformin + thiazolidinedione
Fixed-dose (single pill) therapy
o Thiazolidinedione (pioglitazone) + metformin
o Thiazolidinedione (rosiglitazone) + metformin
o Thiazolidinedione (rosiglitazone) + secretagogue (glimepiride)
o Thiazolidinedione (pioglitazone) + secretagogue (glimepiride)
o Secretagogue (glyburide) + metformin
Rapid-acting insulin analogues or premixed insulin analogues may be used in special situations
Inhaled insulin may be used as monotherapy or in combination with oral agents and long-acting
insulin analogues
All oral medications may be used in combination with insulin; therapy combinations should be
selected based on the patient's profiles of self-monitoring of blood glucose
Initiating or Intensifying Therapy
 Initiate or intensify combination therapy using options listed above when HbA1c levels
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







are 8% to 10% to address fasting and postprandial levels
Initiate or intensify insulin therapy when HbA1c levels are >10%
Rapid-acting insulin analogue or inhaled insulin with long-acting insulin analogue or
NPH
Premixed insulin analogues
Patients Currently Treated Pharmacologically
The therapeutic options for combination therapy listed for patients naive to therapy are
appropriate for patients being treated pharmacologically
Exenatide may be combined with oral therapy in patients who have not achieved
glycemic goals
Approved exenatide + oral combinations:
o Exenatide + secretagogue (sulfonylurea)
o Exenatide + metformin
o Exenatide + secretagogue (sulfonylurea) + metformin
o Exenatide + thiazolidinedione
Pramlinitide may be used in combination with prandial insulin
Add insulin therapy in patients on maximum combination therapy (oral-oral, oralexenatide) whose HbA1c levels are 6.5% to 8.5%
Consider initiating basal–bolus insulin therapy for patients with HbA1c levels >8.5%
*
The options listed are in no order of preference.
HbA1c, glycated hemoglobin; NPH, neutral protamine Hagedorn.
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Appendix B
ADA algorithm for initiation and maintenance of therapy.