rn type 1 diabetes mellitus case study test

Diabetes Mellitus Reviewer and NCLEX Questions (100 Items)

Welcome to your ultimate diabetes NCLEX questions and review! Please answer all the diabetes mellitus practice questions (100 items) from our nursing test bank and test your competence in the nursing management of diabetes.

Diabetes Mellitus Nursing Test Bank

In this section is the practice NCLEX quiz for diabetes mellitus . This 100-item quiz will test your knowledge and ability to differentiate the different types of diabetes mellitus, recognizing the clinical manifestations and signs and symptoms of complications, medical management, nursing management, and patient education .

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Review Notes for Diabetes Mellitus

If you need a quick review around the concepts of diabetes mellitus, please see the refresher below:

Description

• Diabetes mellitus is a disorder characterized by insufficient production of insulin in the pancreas or when there is a resistance or deficiency of available insulin resulting in hyperglycemia.
• It is characterized by disturbances in carbohydrate, protein, and fat metabolism.
• Sustained hyperglycemia has been shown to affect almost all tissues in the body and is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels.
• Type 1 diabetes mellitus or, formerly called insulin-dependent diabetes mellitus, typically occurs in younger people with the exact cause is unknown. Type 1 diabetes may result from an autoimmune process triggered by a virus 
• Type 2 diabetes mellitus , formerly called non-insulin dependent diabetes mellitus, is characterized by defects in insulin release and use, and insulin resistance. Commonly occurs in patients with obesity and those with genetic susceptibility to DM. 
• Gestational diabetes mellitus is characterized by glucose intolerance of any degree that occurs during pregnancy. 

Pathophysiology

• There is a destruction of the islet cells in the pancreas causing insufficient insulin and excess glucagon . 
• Glucose accumulates in the serum causing hyperglycemia. 
• Blood being delivered in the kidneys has high glucose concentration causing osmotic diuresis and glycosuria. 
• Osmotic diuresis causes water loss, resulting in polydipsia. 
• Lack of insulin makes the body unable to use carbohydrates primarily and instead uses fats and proteins for energy production, resulting in ketosis and weight loss. 
• Polyphagia and fatigue result from the break down of nutritional stores. 
• Insulin resistance occurs in diabetes mellitus, wherein there is a decrease in tissue sensitivity to insulin. 
• In normal conditions, insulin binds to special receptors on the cell surfaces and initiates reactions involved in glucose metabolism. However, in type 2 diabetes, these intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver. 
• If the beta cells cannot keep up with the increased demand for insulin, the glucose level rises and type 2 diabetes develops. 
• Hyperglycemia develops in pregnancy because of the secretion of placental hormones, which causes insulin resistance. 
• Gestational diabetes is related to the anti-insulin effects of progesterone , cortisol, and human placenta lactogen, which increase the amount of insulin needed to maintain glycemic control.

Complications

• Hypoglycemia is when the blood the glucose falls to less than 50 to 60 mg/dL and is linked to excessive use of hypoglycemic agents, decreased food intake, increased physical activity , excessive alcohol consumption, or renal failure . It often occurs before meals, especially if meals are delayed or snacks are omitted. It can occur on type 1 or type 2 diabetes. 
• Diabetic ketoacidosis (DKA) is caused by an absence or severe inadequacy of insulin. This deficit in available insulin results in disorders in the metabolism of carbohydrate, protein, and fat. DKA is usually associated with incorrect or failure to take insulin as prescribed and stress and is occurring in clients with type 1 diabetes. 
• Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) is the combination of severe hyperglycemia and hyperosmolarity with little or no acidosis. The insulin level in HHNS is too low to prevent hyperglycemia but is high enough to prevent fat breakdown. HHNS occurs in older clients (50 to 70 years old)  with type 2 diabetes and is associated with stress or ingestion of certain drugs. 
• Microangiopathy , or diabetic microvascular disease , is characterized by capillary basement membrane thickening most prominently in the retina and glomerulus. 
• Diabetic retinopathy is the deterioration of the small blood vessels that nourish the retina causing visual impairment. 
• Nephropathy is a renal dysfunction caused by microvascular changes in the kidney secondary to diabetes mellitus. 
• Diabetic neuropathy refers to a group of diseases that affect all types of nerves characterized by paresthesias or decreased sensation. Peripheral neuropathy and autonomic neuropathy are two of the most common types of neuropathy found in diabetes. 
• Increased susceptibility to infections results from an impaired ability of granulocytes to respond to infectious agents. 

Clinical Manifestations

• Polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased appetite) are the classic symptoms of diabetes mellitus, also known as the “3 P’s of DM” . 
• Fatigue and weakness
• Weight loss
• Sudden vision changes
• Tingling or numbness in hands or feet
• Skin lesions or wounds that are slow to heal
• Recurrent infections (urinary, skin, vulva)
• Dehydration
• Tachycardia
• Kussmaul’s respirations
• Nausea and vomiting
• Abdominal pain
• Acetone breath (fruity odor)
• Decreased level of consciousness
• Orthostatic hypotension
• Dehydration (dry mucous membranes, poor skin turgor)
• Decreased level of consciousness (altered sensorium, seizures , hemiparesis)
• Hypotension
• Cool, moist skin, or pallor
• Palpitation
• Nervousness
• Impaired CNS function
• Inability to concentrate
• Lightheadedness
• Memory lapses
• Double vision
• Disoriented behavior
• Difficulty arousing from sleep
• Loss of consciousness

Laboratory and Diagnostics

• Fasting blood glucose level above 140 mg/dL or postprandial (after meals) blood glucose levels above 200 mg/dl measured on more than one occasion is diagnostic. 
• Glycosylated hemoglobin (HgbA1C) shows an elevated blood glucose level. 
• Blood glucose levels between 300 and 8900 mg/dL
• Ketoacidosis is reflected in low serum bicarbonate (0 to 15 mEq/L) and low pH values. 
• Accumulation of ketone bodies is reflected in blood and urine ketone measurements. 
• Sodium and potassium concentrations may vary depending on the degree of dehydration . Increased levels of creatinine , blood urea nitrogen, and hematocrit go along with dehydration . 
• Arterial blood gas indicate metabolic acidosis
• Serum blood glucose higher than 700 mg/dL
• Serum blood osmolality is higher than 350 mOsm/kg
• Urine specimen reveals the absence of ketosis
• Serum electrolyte levels show hypernatremia and hypokalemia. 
• Serum blood glucose level is less than 70 mg/dL

Medical Management

• The main goal of treatment is to normalize insulin activity and blood glucose levels to reduce the development of complications. 
• There are five components of management for diabetes: nutrition , exercise, monitoring, pharmacologic therapy, and education. 
• Insulin is the primary treatment for type 1 diabetes. 
• Weight reduction is the primary treatment for type 2 diabetes. 
• Exercise enhances the effectiveness of insulin. 

Nursing Management

• Monitor blood glucose levels and provide teaching to the patient on how to do so. 
• Insulin for type 1 diabetes
• Hypoglycemic agents for type 2 diabetes ( sulfonylureas , thiazolidinediones , biguanides, alpha-glucosidase inhibitors)
• Provide information and teaching on how to self-administer insulin. 
• On storing insulin: vials of insulin, when not in use, should be refrigerated (extreme temperatures should also be avoided).  Insulin vial that is currently in use can be kept at room temperature (1 month). Cloudy insulins should be thoroughly mixed by gently inverting the vial or rolling it between the hands before drawing the solution. Intermediate-acting insulin showing a frosted, whitish coating inside the bottle, should be discarded. 
• On selecting syringes: syringes should match the insulin concentration. 
• On mixing insulins : patients should be warned not to inject one type of insulin into the bottle containing a different type of insulin. Patients with difficulty mixing insulins may use premixed insulin. 
• Selecting and rotating injection sites: the abdomen, upper arms, thighs, and hips are the four main sites for insulin injection. Rotation of injection sites is recommended to prevent lipodystrophy which may cause a decrease in the absorption of insulin. Encourage the patient to use all available injection sites within one area rather than randomly rotating sites from area to area. 
• Inserting the needle : insulin should be injected into the subcutaneous tissue, the incorrect technique may affect the rate of absorption. 
• Assess readiness to learn and include the patient’s family in developing a diabetic teaching plan. 
• Prevention of complications
• Dietary and lifestyle changes
• Proper self-care (especially foot care)
• Administration and management of insulin
• Use of hypoglycemic medications
• Treatment goal is to prevent dehydration , electrolyte loss, and acidosis. 
• Normal saline (0.9%) is infused at a high rate to replace fluid loss. Hypotonic solution (0.45% NS) may be used for hypertension or hypernatremia. 
• Administer regular insulin, as ordered.
• Monitor serum glucose levels as insulin is administered. 
• Monitor potassium levels, because potassium shifts affect the heart. 
• Monitor respirations as respiratory distress can occur. 
• Assess vital signs, intake and output , and monitor ketone levels. 
• Assess vital signs, fluid status, and laboratory values. Fluid status and urine output are closely monitored because of the risk for renal failure secondary to severe dehydration . 
• Because clients are usually older, monitor for heart failure and cardiac arrhythmias.
• Monitor blood glucose levels. 
• Administer glucose (oral glucose, I.V. glucose, or glucagon). 
• Advise client to carry simple sugar at all times to prevent case of hypoglycemia. 

Recommended Resources

Recommended books and resources for your NCLEX success:

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10 thoughts on “Diabetes Mellitus Reviewer and NCLEX Questions (100 Items)”

Thank you! Your content is amazing and the practice questions are a lifesaver.

It seems that question 8 and 9 have conflicting information.

Such a great service. Great job sir…

I admire your work of service and love for fellow RNs. Thank you Sir Matt. Your life is a blessing to many. God bless you more.

Thanks for your uninterrupted support. The exercise is very helpful. Keep it up.

I have learned from your article, and it is helpful. Thank you for your uninterrupted education

I thought only DM1 can cause ketoacidosis? If I’m assessing a pt with DM2, I wouldn’t expect to see ketonuria. . . .

Question 26: Nurse Robedee is teaching an underweight and emaciated client about the proper methods/techniques when giving insulin. Which one of the following shows a proper technique?

I believe the answer should be 45 degrees because they are underweight and emaciated but the quiz said it should be 90 degrees.

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Diabetes Practice Questions with Answers and NCLEX ® Review

Over the last few decades, diabetes mellitus has grown into a national health crisis affecting millions of Americans every year. When diabetes is uncontrolled, it can lead to many serious health consequences ranging from neuropathy (nerve pain), retinopathy (blindness), nephropathy (kidney failure), and high blood pressure, which further increases your risk of having a heart attack or stroke.

Diabetes Practice Questions with Answers and Practice Questions

Learning outcomes, test taking tips.

It’s critical to understand diabetes well as diabetes NCLEX ®  questions  will be a major part of the exam. Before getting into the types of diabetes, you need to learn the basic pathophysiology of the disease.

A protein that’s released from the pancreas when blood sugar levels start to rise after eating. When insulin binds to the cells in the body, it causes them to take in both sugar and potassium from the blood into the cell.

The result of this is lower blood sugar as the cells are free to utilize the sugar for various purposes, usually for storage as fat for future use. When insulin cannot do its job, a client will begin to exhibit high blood sugar. When blood sugar remains elevated for too long it causes blood vessels to shrink, leading to nerve and organ damage .

One other key protein to understand in diabetes is glucagon, which is also released by the pancreas but only when blood sugar gets too low.

Glucagon is released when clients are in a state of starvation or in situations where all the sugar in the blood is used up like during exercise. Glucagon acts on the liver to breakdown glycogen into glucose which is thereby sent to the blood to deliver sugar wherever the body needs it.

Now that the basic pathophysiology of diabetes has been addressed, it is important to recognize that there are two different kinds of diabetes, Type 1 and Type 2 , which are critical for understanding how we treat clients and when their symptoms begin to manifest.

Causes of Diabetes

Clients with T1DM (Type 1 Diabetes Mellitus) begin to show symptoms very early on in life, usually in adolescence to early adulthood. T1DM is strictly a result of unfortunate genetics, where the genes were obtained from one or both parents.

It’s an autoimmune disorder that leads to the destruction of pancreatic beta cells, the cells responsible for insulin production. Over time, a client with T1DM will have absolutely no insulin produced in their body, making them insulin-dependent. Without insulin substitution, the client would otherwise be unable live.

Clients with T2DM (Type 2 Diabetes Mellitus) on the contrary, are insulin resistant and not insulin dependent . Insulin resistance is the result of lifestyle choices such as poor diet and lack of exercise.

People who consume large amounts of carbs frequently (e.g. pizza, juice, soda, ice cream, bread, etc.) cause their insulin receptors to become less sensitive to the effects of insulin over time. Clients who develop T2DM usually do so over an extended period. This means that their symptoms began to manifest later in life.

One way to assess for a client’s risk of developing T2DM is to understand what Metabolic Syndrome is. You can use the acronym BBOL from metabolic syndrome to remember what metabolic syndrome is.

• The first B stands for blood pressure medications or high blood pressure (over 130 systolic).
• The second B stands for blood sugar medications or high blood sugar (over 100 mg/dL).
• The O stands for obesity which regards a waste size of 35+ inches for women and 45+ inches for men.
• And the L stands for lipids regarding cholesterol (total cholesterol > 100, triglycerides > 150, LDL > 100, and HDL < 40).

If a client fit under three or more of these criteria, they will find that they are at a high risk of developing T2DM at some point in their lifetime.

Symptoms of Diabetes

The symptoms and clinical manifestations of T1DM all revolve around the fact that clients no longer produce any insulin whatsoever. Remember that without insulin the cells in the body do not retrieve any sugar which means they have no energy for use or storage.

This means a very common symptom of T1DM is weight loss as well as symptoms of low blood sugar (blood glucose < 70 mg/dL ). These manifestations are usually observed in younger populations as the disease is strictly genetic.

Clients with T2DM retain some insulin function which means the symptoms manifest more gradually as we age. Some common symptoms of T2DM includes polyuria (frequent urination), polydipsia (excess thirst) and polyphagia (excess hunger) .

Polyuria is a result of the body trying to excrete the excess sugar in the blood in order to protect the organs and blood vessels. This results in dehydration as water is excreted with the sugar as well. To compensate clients will feel thirstier and hungrier as the cells are not getting adequately supplied with sugar.

Another symptom that can be observed in T2DM includes a brownish thickening of the skin particularly in around the neck or armpit.

Once classic symptoms of T2DM are observed a diagnosis can be made by measuring blood glucose and A1c.

Key diagnostics include a random blood glucose of 70-115 mg/dL , a fasting blood glucose > 100 mg/dL , and an A1c > 6.5 . Fasting blood glucose should reveal the concentration of sugar in the blood when a client has not eaten for several hours, if it reads above 100 mg/dL it suggests a client may have significant insulin resistance.

A1c is a very important measurement that can demonstrate the average blood sugar levels in clients over the previous three months as it measures the amount of sugar molecules that have attached to hemoglobin, an important protein usually used to transport oxygen in the blood.

Pathophysiology of Diabetes

People with both type 1 and type 2 diabetes will find themselves at an increased risk of experiencing high blood sugar and low blood sugar which both have clinical significance. These manifestations are critical to understand as they can play a role in a client’s acute health leading to several complications that can become life-threatening.

Hyperglycemia:

High blood sugar can be described as blood glucose levels > 115 mg/dL. When a client has high blood sugar the symptoms associated with diabetics are present. This includes polyuria, polydipsia, and polyphagia.

If a client is getting treated for diabetes but still has high blood sugar it can often be caused by one of several factors which can be remembered as the four S’s . The first S to know is sepsis which relates to infection.

• Sepsis:  Since bacteria and other microbes also use sugar to spread and multiply, having high blood sugar can trigger serious infections which can be observed often on the client’s periphery such as the hands or feet, or a systemic infection where it has spread throughout the body infecting multiple organs and tissues.
• Stress:  When a client undergoes physically or mentally stressful situations, they may experience elevated blood sugars. Common situations include hospitalization or surgeries where the body essentially mobilizes its sugars in response to stress, not unlike the fight or flight response where a client exposed to danger may require more energy in their muscles or the affected tissues to resolve the situation. Glucagon release is a key protein involved in this process as the liver releases extra glucose to help the areas of the body that are needed to respond to stress (e.g. the surgical site).
• Skipped insulin:  This is the most obvious and common cause of high blood sugar as a client may simply forget to dose themselves with insulin. The consequence of this is that the sugars are not taken into the cell, therefore keeping the glucose in the blood.
• Steroid medications:  Steroids can be regarded much like how stress acts on blood sugars in the body. Steroids are common causes of high blood sugar because they stimulate the release of sugar into the bloodstream from the liver. Examples of steroids include prednisone, prednisolone, hydrocortisone, and methylprednisolone . Clients on acute and high doses of steroids should be aware of this side effect if they are diabetic.

Hypoglycemia:

Symptoms of low blood sugar are important to understand for both type 1 and 2 diabetics. Low blood sugar can be defined as BG < 70 mg/dL . When blood sugar drops below that threshold a client may be at risk of several complications depending on the severity and duration of hypoglycemia.

Common symptoms include sweating, irritability, hunger, lack of coordination, and sleepiness. An acronym that can be used to memorize this is HIWASH .

• I rritability
• A nxiousness or trembling
• S weating (diaphoresis)

Causes of hypoglycemia includes exercise, lack of eating, or overdosing on insulin. Other causes can include alcohol or insulin peak times (when insulin release is greatest in the body). When a client experiences hypoglycemia but is responsive (meaning they are awake and alert) they can be instructed snacks that are high in sugar.

Examples include juice, candy, crackers, or low-fat milk. If a client is asleep and not responsive, they can be injected with IV D50 (IV Dextrose) or in some cases glucagon to stimulate sugar release into the bloodstream. Clients going through a hypoglycemic episode should be instructed to check their blood sugars every 15 minutes until their blood sugars are restored to normal.

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Pharmacology of Diabetes

By far the most important treatment to understand for diabetes, insulin is the mainstay treatment for T1DM as well as a refractory treatment for clients with advanced T2DM. There are three general formulations of insulin to know about with different insulin peak properties as well as administration methods.

• Rapid-acting insulin:  Examples of rapid-acting insulin includes insulin aspart , insulin lispro , and insulin glulisine . These forms of insulin are by far the most dangerous formulations as they exhibit a quick 15-minute onset with a peak of 30-90 minutes. This quick onset suggests that clients can bolus with insulin and quickly reduce their blood sugars to dangerous hypoglycemic levels (BG < 70 mg/dL) . For this reason, rapid acting insulin should only be given 15 minutes prior to eating a meal to prevent a drop-in blood sugar.
• Regular insulin:  Examples of regular insulin include: Novolin R and Humulin R which have an onset of 30-60 minutes and a peak of 2-4 hours. Regular insulin shares a risk of hypoglycemia like rapid-acting formulations. Like rapid-acting, a client should consume a meal approximately 30 minutes before injection. Regular insulin is the only kind of insulin that should be injected intravenously. The duration of regular insulin should last 5-8 hours.
• NPH or intermediate insulin:  Examples of NPH include Novolin N and Humulin N . This kind of insulin is a mix between long-acting and short-acting formulations. They exhibit an onset within 2-4 hours and a peak in 4-8 hours. This formulation of insulin does not need to be taken with food. NPH should be given only twice daily and should never be administered in IV formulation.
• Long acting insulin:  Examples of long-acting insulin include: insulin detemir , insulin glargine , and insulin degludec . Like NPH, these formulations do not need to be taken with meals. The onset of these insulins vary based on the kind given but all of them last for several hours. These types of insulin can last up to a day and will have minimal peaks. Most long-acting insulins are injected once a day.

Clients who are insulin-dependent (T1DM) are generally put on a long-acting formulation in addition to a rapid-acting to bolus with meals. Type 1 diabetics or type 2 clients with advanced disease may be put on a CGM, a continuous glucose monitor, to help optimize insulin release in response to blood sugar levels. It’s essentially to understand which kinds of insulin are being used for a client and their onset to ensure stable blood sugar levels.

Oral Diabetic Medications:

Oral diabetic medications are reserved for clients with type 2 diabetes because they should still have some insulin function. When T2DM first gets diagnosed some clients may be able to utilize lifestyle changes such as increasing exercise while eating lower carb diets to avoid getting put on a medication. If lifestyle changes fail, oral diabetic medications will be recommended.

Metformin is the most common type of diabetic medication used today. Metformin increases insulin sensitivity and decreases the output of glucose from the liver. Most clients who have T2DM will be on metformin for a lifetime. Metformin comes in extended-release formulations as well as rapid formulations. The optimal dose of metformin is 2000mg per day which can be broken up into 1000mg in the morning and evening.

The common side effects of metformin include diarrhea, GI upset, and weight gain (usually minimal). Metformin can also increase the risk of hypoglycemia, especially when given with insulin. More serious side effects of metformin include kidney damage, potential liver damage, and lactic acidosis (rare but serious). It is critical to evaluate a client’s renal function before starting therapy. A CrCL of less than 30 ml/min is a contraindication for metformin.

Sulfonylureas are another common class of oral diabetic medications. Unlike metformin, these come with a higher risk of hypoglycemia especially when taken with insulin. This is because these medications stimulate insulin release as opposed to increasing insulin sensitivity. Examples of sulfonylureas include glipizide, glyburide, and glimepiride . Sulfonylureas are associated with weight gain and can cause GI upset.

Thiazolidinediones or TZD medications are another class of oral diabetic medications that decreases glucose output from the liver and increases insulin sensitivity. A common example of a medication in this class is pioglitazone which is commonly referred to as Actos.

These medications can cause weight gain and hypoglycemia like the other oral medications. Serious side effects of meds from this class includes water retention which can be serious for clients with heart failure. Signs of water retention includes edema and crackling in the lungs.

The last group of oral diabetic medications to discuss are alpha-glucosidase inhibitors . These medications are used much less commonly than the others and are among the least effective at treating T2DM. They work by inhibiting the breakdown of complex starches and sugar molecules in the digestive system leading to less sugar absorption. The key side effects of these medications relate to indigestion such as flatulence and diarrhea. These medications cannot cause hypoglycemia and do not influence insulin.

Nursing Interventions for Diabetes

Medical nutrition therapy (mnt).

Medical nutrition therapy plays an important role in preventing and managing diabetes. MNT can play a part in providing both clients and healthcare providers with nutritional interventions to optimally manage a client’s diabetes. These interventions should involve treatment goals, strategies to achieve these goals, and consider the changes a client is willing to make.

The American Diabetes Association recommends that a registered dietician takes the leading role for providing nutritional care.1 Optimal MNT is designed to both decrease the risks associated with diabetes as well as cardiovascular disease. Several goals should be established according to the American Diabetes Association for clients with diabetes with respect to MNT: 1

• Achieve and maintain adequate blood glucose levels, lipid and blood pressure. 1
• To prevent and slow the progression and chronic complications of diabetes by modifying nutrition intake and lifestyle. 1
• To address individual nutritional needs, such as cultural or personal preferences that may affect a client’s desire to implement a change. 1
• To maintain the pleasure of healthy eating and lifestyle while limiting food choices only when indicated by scientific evidence. 1

It’s important to note that clients may benefit from additional MNT interventions such as prevention and treatment of hypoglycemia in clients who use insulin. Special populations may also require unique interventions such as youth with T1DM or in pregnancy to achieve optimal nutritional care for the individual.

Clients who have pre-diabetes may also benefit from MNT as it can play a role in disease prevention and discourage pharmacological interventions. According to the ADA studies on MNT, clients have demonstrated reductions in A1c of ~ 1% and LDL decreases where improvements are apparent in 3-6 months. 1

Other interventions involving MNT includes weight loss in clients who are overweight and obese insulin-resistant individuals. The ADA recommends ~ 5-7% weight loss from baseline which should be implemented gradually.

Certain clients may benefit from pharmacological weight loss interventions as well as surgical (e.g. bariatric surgery) when indicated based on BMI. They do not recommend low carb diets (carbs < 130 grams/day) as the long-term effects of carb restrictions are not well studied. 1

Carbohydrate Management for Diabetics

Carbohydrate management is a core intervention to consider for clients with diabetes as it can have the most direct impact on A1c and diabetic complications. Clients should be advised to obtain carbohydrates from sources such as fruit, vegetables, whole grains, legumes, and low-fat milk. Severe carb restriction is not advised for clients with diabetes especially for clients on insulin and other medications that increases the risk of hypoglycemia.

Clients should be advised to monitor their carbohydrate intake to optimize blood sugar control. It is important to consider the quantity and type of carbohydrates as they can influence postprandial glucose levels. Carbohydrate types that can influence post-meal blood sugar levels includes starches, the style of preparation (e.g. cooking time and method), and degree of sugar processing.

Additionally, factors such as fasting and macronutrient distribution (e.g. vegetables, protein, dairy) can influence the amount of sugar absorbed into the blood.

Fiber intake should also be taken into consideration when evaluating a client’s diet. Fiber rich sources (> 5 g fiber/serving) can contribute to good health. Additionally, current data suggests that a high-fiber diet (~ 50 g fiber/day) can help reduce glycemic events. 1

Sugar substitution may be advised for clients to reduce starch and sucrose consumption. Clients may want to consider fructose which results in lower postprandial glucose response compared to sucrose or starch.

Low or zero calorie sweeteners (alcohol sugars) such as erythritol, isomalt, and mannitol have demonstrated lower glucose response and reduced energy consumption. Use of alcohol sugars is appears to be safe but can contribute to diarrhea, particularly in children.

Dietary Fat, Protein Management, and Alcohol Use in Diabetes

To reduce CVD risk in clients with diabetes it is recommended that clients restrict saturated fat intake to < 7 % total energy, trans fats should be reduced if not outright omitted from their diet, and dietary cholesterol should be < 200mg/day.

Consuming fish may help provide beneficial lipid intake while minimizing fat from bad sources. Metabolic studies have demonstrated LDL reductions when saturated fats are limited. By establishing optimal dietary fat and cholesterol intake a client can further reduce their risk of cardiovascular events.

Clients are recommended to consume 15-20% of their energy in the source of protein. 1  Some data has demonstrated that protein can improve insulin sensitivity in clients with T2DM but will not increase plasma glucose concentrations. Protein should not be used to prevent nighttime hypoglycemia as a result. Protein sources can include meat, fish, eggs, milk, cheese, poultry, and soy.

Alcohol is another area where interventions may be essential for clients to consider as alcohol in combination with mixtures, soda, or juice can lead to elevated blood sugar. Clients should be advised to consume one drink or less per day if female and two drinks per day if male.

Although moderate alcohol use has not been shown to increase acute plasma glucose levels it can increase the risk of nocturnal and fasting hypoglycemia especially in type 1 diabetics. Additionally, limiting alcohol to 1-2 drinks a day can contribute to reduces CVD risks.

Nursing Interventions for Hypoglycemia and Acute Illness

Hypoglycemia management and risk assessment is critical to evaluate for clients especially with type 1 diabetes and clients on insulin. Understanding how to treat hypoglycemia can prevent serious complications such as diabetic ketoacidosis. Current recommendations for hypoglycemia management includes ingestion of 15-20 grams of glucose in any form.

Glucose tablets are generally available in most pharmacies and can be a staple product to have on any client with high hypoglycemic risk. Blood sugar should be tested in approximately 15 minutes to reevaluate the need for further glucose consumption. Clients should also be advised that adding fat to their sugar source can decrease the glycemic response sugar sources high in fat should be avoided.

For clients experiencing acute illness they should be advised to continue their oral diabetic medications. Depending on hypoglycemic risk they may be advised to consider ketone tests as well as more frequent glucose monitoring.

Diabetics with acute illness are recommended to consume adequate levels of fluids which is a staple treatment for all illness. For clients with T1DM insulin and oral diabetic medications may need to be increased. Adults should be advised to consume between 150-200 grams of carbohydrates (45-50 grams every 3-4 hours) to prevent ketosis risk.1

Diabetes Mellitus Conclusion

Diabetes is a complex and chronic disease affecting millions of people in the United States today. The more prevalent type of diabetes is T2DM which has been rising substantially over the last few decades.

There’s no doubt that diabetes is a health crisis and among one of the most important diseases contributing towards mortality in populations throughout the world. As our understanding of diabetes continues to grow it will continue to be an area of great importance for generations to come. For this reason, diabetes NCLEX ®  questions are and will continue to be a part of the exam.

• Nutrition Recommendations and Interventions for Diabetes: A position statement of the American Diabetes Association. Diabetes Care. 2007;31(Supplement 1). doi:10.2337/dc08-s061.

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Diabetes Mellitus Lecture NCLEX Review Notes

Below are review notes for Diabetes Mellitus  to help you study for the NCLEX exam or your nursing lecture exams.

As the nurse taking care of the diabetic patient, you must know how to properly care for them, especially newly diagnosed diabetics. The nurses role include educating, assessing, planning, administering medications, and evaluating treatment. These NCLEX review notes will cover:

• Key players in Diabetes Mellitus Causes of Diabetes Mellitus Complications of Diabetes Mellitus Nursing Assessment

After reviewing these notes, don’t forget to take the Diabetes NCLEX quiz .

Lecture on Diabetes Mellitus

Diabetes Mellitus Lecture Notes for NCLEX Review

Key players:.

• “Sugar” (body needs it to survive) fuels the cells of your body so they can work properly, BUT IT CAN NOT ENTER THE CELL WITHOUT THE HELP OF INSULIN
• It is stored mainly in the liver in the form of glycogen
• “deals with high blood sugar levels”
• A hormone that helps regulate the amount of glucose in the blood (too much glucose is very toxic to the body).
• It allows your body to use glucose by allowing it to enter the cells (without insulin glucose would just float around in your body)
• Secreted by the BETA cells of the pancreas from the islets of Langerhans
• “deals with low blood sugar levels”
• A peptide hormone that causes the liver to turn glycogen into glucose …does the opposite as insulin.
• Also secreted by the pancreas
• Releases insulin and glucagon
• Sensitive to insulin levels and stores and turns glycogen into glucose when the pancreas secretes glucagon. Example : (if the body has increased blood glucose/increased insulin in the blood the liver with absorb and store the extra glucose for later….if there is low blood sugar/low insulin levels the liver will release glycogen which turns into glucose to help increase the blood sugar level)

Glucagon and Insulin Feedback Loop

• Increased blood sugar -> pancreas releases insulin -> causes glucose to enter into the cells to be used or be saved as glycogen for later (stored mainly in the liver)
• Decrease blood sugar -> pancreas release glucagon -> causes the liver to release glycogen which turns into glucose to increase the low blood sugar level

What happens in diabetes mellitus?

The body is unable to use glucose due to either the absence of insulin or the body’s resistance to use insulin . Therefore, the patient becomes HYPERGLYCEMIA  (the glucose just hangs out in the blood stream which affects major organs of the body)

The body starts to metabolize FATS for energy (since it can’t get to the glucose…remember glucose can NOT enter the cell without the help of INSULIN)….which happens in Type 1 diabetics OR there is a moderate amount of insulin to deal with fats and proteins BUT carbs cannot be used (Type 2).

Causes of Diabetes Mellitus

Divided into types:

Type 1 : the beta cells located in the islet of Langerhans don’t work (been destroyed) therefore the body doesn’t release anymore insulin. For treatment, the patient MUST USE INSULIN.

Risk factors : Genetic, auto-immune (virus) NOT RELATED TO LIFESTYLE (like type 2)

What do patients look like clinically? Patients are young and thin….happens suddenly; ketones will be present in the urine

Type 2 : cells quit responding to insulin (won’t let insulin do its job by taking the glucose into the cell). Therefore, the patient has INSULIN RESISTANCE . This leaves all the glucose floating around in the blood and the pancreas senses there’s a lot of glucose present in the blood so it releases even more insulin. Due to this the patient starts to experience hyperinsulinemia which caused metabolic syndrome

Treatment : diet and exercise (first line treatment)…when that doesn’t work oral medications are started Note : The type 2 diabetic may NEED INSULIN DURING STRESS, SURGERY, OR INFECTION

Risk Factors : Lifestyle- being obese, sedentary, poor diet (sugary drinks), stress AND genetic

What do patients look like clinically? Patients are overweight, it happens overtime, rare to have ketones (remember issues with carb metabolism) adult aged

Gestational : similar to type 2 diabetes where the cells are not receptive to insulin…typically goes away after birth

Complications of Diabetes Mellitus

Hypoglycemia:.

• Blood glucose less than 60 mg/dL or drops rapidly from an elevated level.
• Remember the mnemonic: “I’m sweaty, cold, and clammy….give me some candy”
• Signs and Symptoms: Sweating, clammy, confusion, light headedness, double vision, tremors
• Treatment: Need simple carbs if they can eat, or if unconscious IV D50
• Simple carbs include: hard candies, fruit juice, graham crackers, honey

Organ Problems:

Hardens the vessel (atherosclerotic….makes vessels hard from all the glucose that sticks on the proteins of the vessels and it forms plaques). So the patient can develop heart disease, strokes, hypertension, neuropathy, poor wound healing (FROM DECREASE circulation), eye trouble, infection.

DKA (Diabetic Ketoacidosis):

• Happens in Type 1 diabetics (rare to happen in type 2)
• There is no insulin in the body and the body starts to burn fats for energy since it can’t get to the glucose
• Due to this the ketones, which are acids, start to enter into the body and this causes life-threatening situation, such as acid/base imbalances
• Signs and Symptoms of DKA: N&V, excessive thirst, hyperglycemia, Kussmaul breathing

HHNS Hyperglycemic hyperosmolar nonketotic syndrome:

• Happens mainly in Type 2 diabetics
• This presents with hyperglycemia without the breakdown of ketones…so there isn’t acidosis/ketosis because there is just enough insulin present in the body to prevent the breakdown of fats
• Signs and Symptoms of HHNS: very dehydrated, thirsty, hyperglycemic, mental status changes

Assessment Findings of DM

3 of Hyperglycemia P’s & SUGAR

Hyperglycemia: Three P’s

P olyuria: (frequent urination)

Why? elevated levels of glucose in the body causes the body to remove the water from inside the cell (remember in the hypertonic, hypotonic video about OSMOSIS). The water will move to an area of higher concentration which will be the blood stream and this causes more fluid to enter the blood stream. The kidneys will secrete the extra water. HOWEVER, normally your kidneys could handle all of the glucose by reabsorption but there is too much so it leaks into the urine…. GLYCOSURIA

P olydipsia: very thirsty

Why? the blood is trying to prevent the body from becoming dehydrated from the excessive urination so it signals to the patient to drink more water…but it doesn’t work because the kidneys will remove the excess water

P olyphagia: very hunger

Why? the body is burning FAT for energy since it doesn’t have any glucose to use so the body signals to the person to keep eating so there will be food to use for energy. The patient will have WEIGHTLOSS!

*The 3 P’s present mainly in Type 1 Diabetics

Other Assessment findings of the Diabetic Patient

Remember “Sugar”

S low wound healing

bl U rry vision (damaged from glucose on eyes)

G lycosuria (kidneys can’t reabsorb all the extra glucose)

A cetone smell of breath (from burning ketones) *type 1

R ashes on skin DRY and itchy, repeated vaginal infections (yeast….loves glucose)

More Diabetes NCLEX Review Videos

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• Indian J Endocrinol Metab
• v.19(Suppl 1); 2015 Apr

Type 1 diabetes mellitus-common cases

Surender kumar.

Department of Endocrinology, Sir Ganga Ram Hospital, New Delhi, India

Tight glycemic control in type 1 diabetes mellitus patients is associated with the risk of hypoglycemia. Diabetic patients are forced to change their lifestyle to adjust to the disease condition and survive it. The best way to manage diabetes would be to develop a therapy, which could adjust to the patient's conditions. Here, I present few cases wherein switching to a long-acting basal insulin analog helped combat recurrent hypoglycemic episodes experienced by the patients.

I NTRODUCTION

Tight glycemic control in type 1 diabetes mellitus (T1DM) patients is not possible because of hypoglycemia. Diabetic patients are forced to change their lifestyle to adjust to the disease condition and survive it. The best way to manage diabetes would be to develop a therapy, which could adjust to the patient's conditions.[ 1 ]

A 6-year-old boy presented with classic features of diabetic ketoacidosis, that is, weight loss and extreme weakness and osmotic features. The fasting blood sugar level was 300 mg/dL, postprandial glucose level was 467 mg/dL and hemoglobin A1c (HbA1c) was 7.2%. He was administered with standard intravenous insulin and fluid, which finally brought down the fasting blood glucose level to around 120 mg/dL. He was administered basal-bolus therapy and was discharged. Patient had two episodes of severe hypoglycemia. His parents were worried due to frequent checking of blood glucose levels many times in a day. The challenge was also to avoid urination in bed at night by the child. Otherwise he would get a common cold. The patient remained unconscious in the middle of the night and was fed up with the frequent monitoring of blood sugar. The patient and the parents had severe anxiety, depression, frustration, and disgust. The parents considered diabetes as a curse on their family. He was informed about degludec/injection tresiba, which is not yet approved in children because of lack of experience. The physician explained to them that there was nothing wrong in administering it and is not contra-indicated in T1DM.[ 2 ] The parents were also explained that insulin degludec may even help the child to convert from four injections to one injection a day, and from very frequent monitoring to once in a day. After reviewing the literature about insulin degludec, the parents were finally convinced about it. The patient was then put from basal-bolus to 2 bolus plus 1 basal and finally degludec at 16 U. Over the period of time, blood sugar level came to normal at around 110 mg/dL-pre meal. The patient was trained very well that if he wanted to reduce the frequency of monitoring of blood sugar level, then he had to follow small frequent meals. This made him felt happy because once the sugar was controlled then small amount of sweets was also given. The techniques resulted in good compliance from the patient. The patient did not report any hypoglycemic event over a period of 3 months. This was a big relief for the patient and his parents. Later parents were told that the child may require basal-bolus therapy. The outcomes of this case study were that in case of T1DM the physician should not be very aggressive except during the first 2 weeks of admission. The physician should also try to convince the parents about line of treatment, and educate both the patients and the child. The dose may be gradually stabilized without being aggressive, and this also prevents frequent episodes of hypoglycemia. Hence, gradual tightening of glycemic control is very important. The doctor should analyze the psyche of the patient and his parents.

A 57-year-old female presented with a 13 year history of diabetes. Due to the failure of oral hypoglycemic agents (OHAs) in controlling her sugar levels, for the last 3 years, she was treated with biphasic insulin aspart 30/70. She was a very frequent flier, a regular swimmer and socially very active, and this led her to have irregular meals. Hence, she often go into frequent hypoglycemia and during the last 6 months the patient's average blood glucose level during fasting were 170 mg/dL and postprandial glucose levels varied from 230 to 280 mg/dL. Even after high sugar levels, she fortunately had normal kidney functions. Patient was able to afford an insulin pump, so she was put on one. With the pump, her blood glucose was in control and patient was happy. However she soon realized the limitation of carrying it everywhere she went. These were the true feelings of a patient who was very active while she was on an insulin pump. The physician, after discussing with the patient, started her on insulin degludec and lifestyle modification, especially the diet component. Patient understood these problems and followed the diet. She followed the dietary modification and over 2 months of time, fasting blood glucose was 110 mg/dL, post meals values were around 180 mg/dL. She had only one episode of minor hypoglycemia which was due to delayed meal. The doctor later reduced degludec from 44 U to 40 U and blood glucose was still improving without any episode of hypoglycemia in the last 3 months. The outcome of this case is that with this therapy and dietary modification, a desired level of blood glucose can be achieved, without hypoglycemic risk.

An 80-year-old retired army officer, staying alone, has type 2 diabetes for the last 12 years and renal function test was normal and patient was on insulin along with other OHAs. Despite this, the patient was getting attacks of hypoglycemia, which scared the patient of unconsciousness and even death. The limiting factors were that the patient was staying alone and was dependent upon an attendant to get injections. During the weekends or holidays, the attendant was not on a regular time, and this led to irregular insulin injections, causing hypoglycemic episode to patient. This patient as well was put on insulin degludec and over a period the dose of degludec was also increased. His HbA1c and fasting blood glucose level improved without any episode of hypoglycemia. The outcomes of this case are that degludec along with dietary modifications gave desired diabetes control without any hypoglycemia.

The main barrier to tight glycemic control is hypoglycemia. This can be adjusted with slight dietary modification without changing the therapy.[ 3 ]

Source of Support: Nil

Conflict of Interest: None declared.

R EFERENCES

• Open access
• Published: 01 April 2024

Evaluation of cardiac autonomic dysfunctions in children with type 1 diabetes mellitus

• Davut Gözüküçük   ORCID: orcid.org/0000-0001-5918-3161 1 ,
• Berkut A. İleri   ORCID: orcid.org/0000-0002-3918-4455 2 ,
• Serra Karaca Başkan   ORCID: orcid.org/0000-0001-5421-0191 3 ,
• Ece Öztarhan   ORCID: orcid.org/0000-0001-9359-9005 4 ,
• Dilek Güller   ORCID: orcid.org/0000-0002-8306-5445 5 ,
• Hasan Önal   ORCID: orcid.org/0000-0001-9676-7086 6 &
• Kazım Öztarhan   ORCID: orcid.org/0000-0001-9919-1414 3  

BMC Pediatrics volume  24 , Article number:  229 ( 2024 ) Cite this article

35 Accesses

Metrics details

Cardiovascular autonomic neuropathy (CAN) is a serious complication of diabetes, impacting the autonomic nerves that regulate the heart and blood vessels. Timely recognition and treatment of CAN are crucial in averting the onset of cardiovascular complications. Both clinically apparent autonomic neuropathy and subclinical autonomic neuropathy, particularly CAN pose a significant risk of morbidity and mortality in children with type 1 diabetes mellitus (T1DM). Notably, CAN can progress silently before manifesting clinically. In our study, we assessed patients with poor metabolic control, without symptoms, following the ISPAD 2022 guideline. The objective is is to determine which parameters we can use to diagnose CAN in the subclinical period.

Our study is a cross-sectional case–control study that includes 30 children diagnosed with T1DM exhibiting poor metabolic control (average HbA1c > 8.5% for at least 1 year) according to the ISPAD 2022 Consensus Guide. These patients, who are under the care of the pediatric diabetes clinic, underwent evaluation through four noninvasive autonomic tests: echocardiography, 24-h Holter ECG for heart rate variability (HRV), cardiopulmonary exercise test, and tilt table test.

The average age of the patients was 13.73 ± 1.96 years, the average diabetes duration was 8 ± 3.66 years, and the 1-year average HbA1c value was 11.34 ± 21%. In our asymptomatic and poorly metabolically controlled patient group, we found a decrease in HRV values, the presence of postural hypotension with the tilt table test, and a decrease in ventricular diastolic functions that are consistent with the presence of CAN. Despite CAN, the systolic functions of the ventricles were preserved, and the dimensions of the cardiac chambers and cardiopulmonary exercise test were normal.

Conclusions

CAN is a common complication of T1DM, often associated with the patient’s age and poor glycemic control. HRV, active orthostatic tests, and the evaluation of diastolic dysfunctions play significant roles in the comprehensive assessment of CAN. These diagnostic measures are valuable tools in identifying autonomic dysfunction at an early stage, allowing for timely intervention and management to mitigate the impact of cardiovascular complications associated with T1DM.

Peer Review reports

Type 1 Diabetes Mellitus (T1DM) is a prevalent chronic disorder affecting children and adolescents. Clinical symptoms typically peak between 5 and 7 years old and during early puberty. These peaks are attributed to increased infection rates during school ages, elevated sex steroids, growth hormone levels, and heightened psychological stress in adolescents [ 1 , 2 ].

Complications of T1DM can be broadly categorized as microvascular (e.g., peripheral neuropathies, autonomic neuropathies, retinopathy, nephropathy) and macrovascular (e.g., coronary heart disease, cerebrovascular disease, peripheral vascular disease) [ 3 ].

Autonomic neuropathies in adult patients have been identified as significant contributors to diabetes-related mortality, leading to dysregulations in cardiovascular, gastrointestinal, and genitourinary functions, pupillary responses, sweat gland activity, and regulatory responses against hypoglycemia. Cardiovascular autonomic neuropathy, an important yet lesser-known complication of diabetes mellitus, is associated with nearly doubling mortality rates [ 4 ]. Studies have established a correlation between autonomic function disorders and factors such as age, prolonged diabetes duration, and poorly maintained metabolic control, with increased prevalence in patients exhibiting poor glycemic control [ 5 ].

Recognizing disruption in baroreceptor susceptibility is crucial for identifying autonomic function disorders in T1DM patients [ 6 ]. A decrease in baroreceptor susceptibility heightens sympathetic nervous system excitability, potentially leading to tachycardia by affecting the sinoatrial node [ 7 , 8 ]. The presence of cardiac autonomic neuropathy (CAN) is linked with arterial stiffness in both adult and young diabetes patients. Factors contributing to decreased baroreceptor susceptibility include endothelial dysfunction [ 9 , 10 ], oxidative stress [ 11 , 12 ], the Rho/Rho Kinase pathway [ 13 ], arginase mechanism, and adhesion molecules involved in initiating sympatho-sympathetic feedback reflexes [ 14 , 15 ].

Controversy exists regarding the early detection of subclinical signs of autonomic dysfunction in children with diabetes [ 16 , 17 , 18 ]. However, not only clinically apparent autonomic neuropathy but also subclinical autonomic neuropathy, particularly cardiac autonomic neuropathy (CAN), pose a significant risk of morbidity and mortality in children with T1DM. Some suggest that CAN may progress silently over time before becoming clinically manifest [ 1 , 19 ]. It has been estimated that diabetic patients with CAN have a 3.4 times higher risk of mortality than those without CAN.Recognition and treatment of autonomic cardiac functions not only decrease cardiovascular damage but may also decrease the disease’s mortality and morbidity rates with proper breathing and exercise education [ 13 , 20 ].

Our study aimed to recognize CAN early in the subclinical period in patients with poor metabolic control. As per the ISPAD 2022 consensus guideline, the categorization of metabolic control is defined as follows: good metabolic control (%HbA1c < 7.5%), moderate metabolic control (%HbA1c 7.5–8.5%), and poor metabolic control (HbA1c% > 8.5%) [ 21 ]. who are without clinical symptoms of CAN. We examined the parameters necessary for the early diagnosis of cardiovascular dysfunctions that may develop due to cardiac autonomic dysfunctions in pediatric patients with T1DM.

Our study is a cross-sectional case–control investigation involving 30 children diagnosed with Type 1 Diabetes Mellitus (T1DM) exhibiting poor metabolic control (HbA1c% > 8.5%), as per the ISPAD 2022 Consensus Guide, at the pediatric endocrinology clinic of the University of Health Sciences. Comprehensive medical, endocrinological, cardiological, and neurological histories were obtained, examined, and meticulously recorded for all participants.

Relevant diabetes-related factors, including the duration of diabetes, insulin dosage, glycemic control, and instances of hypoglycemic events, were extracted from medical records. Adhering to the ISPAD 2022 guideline [ 21 ], well-controlled T1DM was defined by an HbA1c < 7%, whereas poor metabolic control was indicated by HbA1c > 8.5%. To ensure a representative measure of poor glycemic control, HbA1c values over a 1-year period were averaged.

In our study, the inclusion criteria for the study group are as follows: a minimum 1-year average HbA1c level > 8.5, patients aged between 5–18, and the ability to comply with and complete all the tests. For the control group, we selected healthy children with similar demographic characteristics to the study group, devoid of any additional diseases, and capable of adapting to and completing all the tests.

Excluded from the study were children with associated issues known to influence the outcomes of cardiac autonomic function, such as medical diseases (e.g., heart failure), medications impacting heart rate or rhythm (e.g., beta-blockers, digitalis, theophylline, thyroid hormones, tricyclic antidepressants, anti-arrhythmic drugs, atropine, and its derivatives), symptoms suggesting cardiac arrhythmia documented by electrocardiography (ECG) recording, history of febrile illness in the past week, conditions with symptoms mimicking autonomic neuropathy but not true autonomic neuropathy (e.g., syncope), presence of ketoacidosis or hypoglycemia during the study period, clinically manifest autonomic neuropathy, and children with test results that have suboptimal precision.

All children in both control and study groups underwent evaluation by the same cardiologist physician, who had no prior information about the patients. Traditional echocardiographic measurements were conducted using a 3.5–5 MHz transducer device (General ElectricTM Vivid-5S model), incorporating M mode, CW Doppler, PW Doppler, and Doppler Tissue Imaging mods. Video-recorded samples were analyzed, and to mitigate the impact of heart rate on diastolic functions, 7 cycle samples were collected, and the arithmetic mean was calculated. Systolic and diastolic functions of the ventricles were assessed through cardiac measurements using M mode, PW Doppler, and Doppler Tissue Imaging. Myocardial Performance Index (MPI) was calculated for both ventricles separately, obtained by dividing the sum of isovolumetric contraction time (IVCT) and isovolumetric relaxation time (IVRT) by ventricular contraction time ejection time (VCT) [ 22 ]. Conventional echocardiographic methods included measuring E wave, A wave, E/A wave ratio, and deceleration time with mitral valve PW Doppler. Tissue Doppler was employed to measure ejection time, relaxation time, contraction time from the septum, and myocardial systolic and diastolic waves from the apical four chambers and the lateral wall.

Left Ventricular Mass Index (LVMI), expressed in grams per square meter (g/m 2 ), was used to normalize left ventricular mass to body surface area. LVMI values greater than 115 g/m 2 in men and greater than 95 g/m 2 in women were indicative of Left Ventricular Hypertrophy (LVH). Relative Wall Thickness (RWT) was calculated by dividing the sum of septal and posterior wall thicknesses by the left ventricular internal diameter at end-diastole (LVIDd). The formula for calculating RWT is: RWT = (Septal wall thickness + Posterior wall thickness) / LVIDd. Relative Wall Thickness (RWT) assesses left ventricular remodeling, with a normal RWT typically considered to be less than 0,42 [ 23 , 24 , 25 ].

MPI, unaffected by heart rate, ventricular structure, and afterload, is a Doppler index evaluating systolic and diastolic functions together. This index, previously demonstrated to increase in diabetic patients and be effective in revealing diastolic dysfunction, was calculated by dividing the sum of isovolumetric relaxation time (ICZ) and isovolumetric relaxation time (IVRT) by ejection time (ET), as suggested by Tei et al. [ 26 ].

24-h rhythm Holter ECG recordings were obtained from all patients using a DMS-300 Holter recording device (DMS, Nevada, USA). Recordings were analyzed by the same cardiologist physician utilizing the DMS Cardioscan model 10 analyzer system (DMS, Nevada, USA). Various heart rate parameters, including 24-h mean heart rate, ectopic beats, presence of block, Standard Deviations of all NN intervals (SDNN), mean of the standard deviations of all NN intervals for all 5-min segments of the entire recording (SDNNI), the standard deviation of the averages of NN intervals in all 5-min segments of the entire recording (SDANNI), the square root of the mean of the sum of the squares of differences between adjacent NN intervals (rMSSD), the number of pairs of adjacent NN intervals differing by more than 50 ms divided by the total number of all NN intervals (pNN50), total power (TPow), very low-frequency range power (VLF power), high-frequency range power (HF power), and low-frequency range power (LF power), were recorded. This analysis aimed to determine the relationship between heart rate changes (using time parameters) and poor glycemic index and durations of diabetes [ 27 ].

All patients underwent evaluation through a cardiopulmonary exercise test (CPET) using a treadmill device model Mortara. The cardiopulmonary exercise tests were conducted following the Bruce protocols. Twelve-lead electrocardiographs were recorded both at the initiation and during the procedures. Blood pressure levels were monitored during exercise at 3-min intervals and at the 0th, 5th, 10th, and 30th minutes of the resting period. The duration of exercise, maximum systolic blood pressure (SBP), diastolic blood pressure (DBP) during exercise, and maximum apex beat were recorded. Test termination criteria were established, including ST depressions equal to or more than 2 mm compared to the starting electrocardiography, ST segment elevations equal to or more than 2 mm compared to the starting electrocardiography, systolic blood pressure lowering by more than 10%, onset of bradycardia, systolic blood pressure elevation to more than 210 mmHg in males and 180 mmHg in females, onset of class 3–4 angina, onset of severe arrhythmias, reaching the targeted heart rate, and feeling overwhelmed to the extent of being unable to continue testing. This part of our study aims to determine the relationship between effort capacity, effort duration, poor glycemic index, and the duration of diabetes.

All patients were evaluated by a tilt table test. Patients fasted for 4 to 6 h before the test. The procedure was conducted with a tilt-adjustable table. Patients lay down on the table when it was in a horizontal state, and they remained in this position for 5 min before starting the test. Vascular access was established, and patients were monitored to track heart rate and blood pressure values. After the test started, patients waited for 20 to 45 min on a 60 to 70-degree angled table; this phase of the test is referred to as the passive phase. If no syncope developed, patients proceeded to the second phase. In the second phase, 300 μg sublingual nitroglycerine was applied, and patients waited at the table, under the same conditions as the passive phase, for 15 to 20 min. The entire process lasted about 45 to 85 min (5 min for lying down, 20 to 45 min for the passive phase, and 15 to 20 min for the second phase). Test termination criteria were established as the onset of syncope (accompanied by arrhythmias and/or hypotension) or the patient not wanting to continue testing. Rates of developing orthostatic hypotension, syncope, and presyncope in patients were recorded. The definition of postural hypotension was determined as SBP decreasing by equal to or more than 20 mmHg or DBP decreasing equal to or more than 10 mmHg during the test compared to the start of the test. This part of our study aims to determine the relationship between sympathetic vasoreflexes, poor glycemic index, and the duration of diabetes.

The recorded data were analyzed using the program “IBM Corp. Released 2016. IBM SPSS Statistics for Macintosh, Version 24.0. Armonk, NY: IBM Corp.” The normal distribution of the data was tested through both visual (Q-Q, Box Plot, Stem, and Leaf, and histogram graphs) and analytical (Shapiro–Wilk and Kolmogorov–Smirnov tests) methods. Descriptive statistics were presented using Mean ± standard deviation (SD) for data showing normal distribution graphs (parametric), and median (lowest-highest value) for data not showing normal distribution graphs (non-parametric). Non-parametric data between groups were evaluated using Mann Whitney U and Kruskal Wallis tests, while parametric data between groups were assessed using the student’s T test. Categorical data were compared using Chi-square and Fisher Exact tests. Spearman and Pearson correlation analysis tests were employed to evaluate the relationship between metric data. The confidence interval was set at 95%, and cases where the p-value was below 0.05 were considered statistically significant.

Patients diagnosed with T1DM in the pediatric cardiology outpatient clinic and individuals in the healthy control group underwent comprehensive assessments based on height, weight, and BMI. No statistically significant differences were identified between the patient and control groups concerning age, weight, height, and body surface area, as indicated in Table  1 .

Thirty patients (female/male: 18/12) were followed up with a diagnosis of type 1 diabetes mellitus, with an average age of 13.73 ± 1.96 (10–17) for the patient group. For the control group, data from a total of 60 healthy individuals with an average age of 11.46 ± 3.04 (8–12) (girls/boys: 16/14) were evaluated. The average duration of diabetes in the patient group was 8 ± 3.66 (1 to 16) years. The 1-year average of HbA1C values for our patients was 11.34% ± 2.14% (8.5% to 16.4%).

In our investigation, echocardiographic M-mode examinations disclosed an increase in left ventricular end-systolic diameter (LVDs), left ventricular diastolic diameter (LVDd), left ventricular mass (LVM), and left ventricular mass index (LVMI). Nevertheless, this increase did not achieve statistical significance. Notably, BMI was significantly higher in the patient group, and echocardiographic findings aligned with the elevation in BMI. In Group A, there were noteworthy increments in pulmonary artery late diastolic flow velocity (PA) and pulmonary artery late diastolic flow time (PAT), indicative of right ventricular diastolic dysfunction. This increase was statistically significant when compared to the control group, as depicted in Table  2 .

When assessing right ventricular systolic and diastolic functions using tissue Doppler, a reduction in E RV , E/A RV , VCT RV , and TD RV , indicative of diastolic dysfunction, was observed. Additionally, an elevation in A RV was noted, and these changes were statistically significant. However, no statistically significant differences were found in the evaluation of E/E’ RV , VC RV , IVCT RV , IVRT RV , ET RV , AT RV , VC RV , IVCT RV , IVRT RV , DECT RV , and PHT RV . The study revealed a statistically significant difference in the average right ventricular myocardial performance index (MPI-RV) values between the patient group (0.27, range: 0.21–0.65) and the healthy group (0.23, range: 0.16–0.28) ( p  < 0.001). Details are provided in Table  3 .

When assessing left ventricular systolic and diastolic functions using Tissue Doppler, no statistically significant difference was observed in E LV , E/A LV , E/E’ LV , VCT LV , TD LV , A LV , VC LV , ET LV , AT LV , IVCT LV , and IVRT LV . However, there was an increase in IVCT LV values and a decrease in VCT LV , IVRT LV , TD LV , DECT LV , and PHT LV , and these changes were found to be statistically significant. The study revealed a statistically significant difference in the average left ventricular myocardial performance index (MPI-LV) values between the patient group (0.26, range: 0.18–0.55) and the healthy group (0.2, range: 0.16–0.3) ( p  < 0.001). Please refer to Table  3 for comprehensive details.

In the study, 24-h Holter electrocardiography measurements exhibited statistically significant differences between groups in variables such as 24-h mean heart rate (MHR), standard deviations of all NN intervals (SDNN), mean of the standard deviations of all NN intervals for all 5-min segments of the entire recording (SDNNI), the standard deviation of the averages of NN intervals in all 5-min segments of the entire recording (SDANNI), rMSSD, pNN50, total power (TPow), very low-frequency range power (VLF power), high-frequency range power (HF power), and low-frequency range power (LF power). Refer to Table  4 for comprehensive data.Upon evaluating data from cardiopulmonary exercise test (CPET) measurements, it was determined that the maximum systolic blood pressure was significantly higher during exercise, and this increase achieved statistical significance compared to the control group. However, no significant differences were found between the groups concerning maximum exercise capacity, maximum heart rate, and maximum systolic blood pressure values, as detailed in Table  5 .

In our study, data collected from tilt table tests revealed statistically significant differences ( p  = 0.024) in the rates of developing orthostatic hypotension, syncope, and presyncope between groups, as presented in Table  6 .

Diabetic autonomic neuropathy (DAN) is a significant complication of T1DM. Until the last two decades, DAN was often overlooked, and its prevalence was underestimated. It was commonly perceived as a rare and/or late complication of diabetes [ 1 ]. DAN is characterized by dysfunction or damage to the parasympathetic and/or sympathetic branches of the autonomic nervous system (ANS) in individuals with diabetes, following the exclusion of other potential causes of autonomic neuropathy [ 28 ]. Clinical manifestations of DAN vary depending on the affected organ and can include symptoms related to the cardiovascular, gastrointestinal, genitourinary, respiratory, neurovascular, neuroendocrine, and pupillomotor systems. Studies have reported a wide range of prevalence estimates for DAN in individuals with T1DM, ranging from 1 to 90%. While clinically manifest DAN is rare, subclinical DAN has been observed to develop within 2 years in patients with T1DM [ 29 ].

Certain researchers have proposed that CAN might advance silently before becoming clinically evident. Nevertheless, both clinically manifest autonomic neuropathy and subclinical forms, particularly CAN, pose a significant risk of morbidity and mortality in children with T1DM [ 1 ].

Symptoms indicative of cardiac autonomic neuropathy (CAN) encompass palpitations at rest, exercise intolerance, and signs suggestive of orthostatic hypotension (e.g., poor posture, fainting, dizziness, visual impairment, and syncope) [ 30 ].

Indeed, studies have demonstrated a relationship between poor metabolic control, older age, and longer duration of diabetes with autonomic dysfunction. There is evidence to suggest that increased autonomic dysfunction is often observed in patients with poor glycemic control.

In individuals with CAN, there is often a decrease in cardiac vagal regulation, which refers to the influence of the vagus nerve on the heart, and an increase in sympathetic cardiovascular markers. With a decrease in baroreflex sensitivity, the sympathetic system is stimulated, and tachycardia develops with its effect on the sinoatrial node. The duration of T1DM and impaired glycemic control (HbA1c > 8.5) over time have been associated with arterial stiffness and postural hypotension. In one study, we observed that compared to children without CAN, children with CAN had a longer duration of diabetes (more than 5 years), a significant number of diabetic complications, and worse glycemic control compared to those without CAN, but no differences were observed in age, gender, BMI, or blood pressure [ 30 ].

In our study, we enrolled asymptomatic patients with a mean age of 13.73 ± 1.96 years and a mean duration of diabetes of 8 ± 3.66 years. The one-year average HbA1c value was 11.34 ± 2.14%, ranging from 8.5 to 16.4%, indicating poor metabolic control according to the ISPAD 2022 consensus guidelines [ 21 ]. The patients enrolled in our study did not exhibit comorbidities and complications commonly associated with T1DM, such as hypertension, dyslipidemia, retinopathy, nephropathy, and neuropathy. In our study, we included patients who shared similar age, height, weight, and BMI. The specific focus of the study was on individuals at a high risk of developing CAN with poor metabolic control.

Our objective was to identify diagnostic tests capable of detecting CAN in asymptomatic patients within this cohort. All patients in the study underwent a comprehensive set of diagnostic assessments, including echocardiography, a 24-h rhythm Holter examination to assess HRV, a CPET, and a tilt table test.

In healthy individuals, the constant variation in intervals between heartbeats is a normal physiological occurrence. These periodic fluctuations in heart rate result from respiratory, thermoregulation, and baroreflex mechanisms. Vagal indices of heart rate variability tend to increase at night, while sympathetic indices show an increase during the day. Heart rate monitoring is a non-invasive technique used to illustrate autonomic neural dysfunction of the heart. A reduction in heart rate variability serves as a crucial indicator of the risk of sudden death and overall mortality. Parasympathetic and sympathetic autonomic dysfunctions have been reported at significantly higher frequencies in children with moderate and poor glycemic control. Increased adrenergic activity or decreased protective parasympathetic activity have been proved to cause diastolic dysfunction and fatal dysrhythmias, eventually increasing the mortality of T1DM as a complication. The findings from various studies indicate that the duration of diabetes exceeding 5 years, the presence of diabetes complications, and poor glycemic control are significantly associated with CAN in children with T1DM. However, no significant associations were observed with age, gender, or BMI [ 31 , 32 ].

During the 24-h Holter examination of patients in our study group, it was observed that the average heart rate exceeded the average heart rate calculated based on age (Table  4 ). Subclinical CAN is prevalent in children and adolescents with T1DM. Parasympathetic and sympathetic autonomic dysfunctions have been reported at significantly higher frequencies in children with moderate and poor glycemic control [ 30 ]. Notably, there is a marked impact on parasympathetic nervous system dysfunction in comparison to sympathetic dysfunction.Chessa et al. [ 17 ] conducted a 24-h analysis of heart rate variability (HRV) in 50 asymptomatic patients with T1DM. Their findings revealed significant alterations in the square root of the mean square differences of successive RR intervals (r-MSSD), the percentage of differences between adjacent normal RR intervals > 50 ms (pNN50), and the abnormal high-frequency (HF) band of spectral analysis of HRV. Young et al. [ 33 ] observed a significant correlation between poor glycemic control and the duration of diabetes with nerve dysfunction. The authors also noted significant abnormalities in HRV among individuals with poor metabolic control.

In our study, HRV was assessed through 24-h rhythm Holter monitoring in our patient group. The findings revealed that the average heart rate in the patient group was significantly higher than that in the control group. Additionally, there was a decrease in SDNN, SDANNI, SDNNI, RMSSD, pNN50, Total Power, LF, HF, and VLF values. In our study, we observed a decrease in total power, a reduction in heart rate variability, a decline in both low-frequency (LF) and high-frequency (HF) components, and no change in the LF/HF ratio. These findings are indicative of tachycardia associated with heightened sympathetic activity. These parameters are of particular significance for the early detection of diabetic autonomic neuropathy. Once diabetic autonomic neuropathy findings manifest, the 5-year mortality rate reaches 50%. Hence, it becomes crucial to detect it during the subclinical period. Observing changes in heart rate provides us with an opportunity for early detection and intervention.

Tachycardia resulting from sympathetic activation is typically accompanied by a notable decrease in total power. The reduction in time domain parameters of heart rate variability (HRV) not only holds negative prognostic significance but also facilitates the identification of autonomic neuropathy before the manifestation of clinical signs. Under controlled conditions, a decrease in the absolute power of low-frequency (LF) and high-frequency (HF) components has been observed in diabetic patients without apparent autonomic neuropathy. In diabetic neuropathy, LF and HF decrease, but the LF/HF ratio remains unchanged. The inability to increase LF during standing suggests decreased baroreceptor sensitivity or impaired sympathetic response [ 6 ].

Children with T1DM exhibited significantly higher heart rate frequencies in response to the standing position (POTs), active standing (30:15 ratio), and Valsalva maneuver, indicating parasympathetic ANS dysfunction. Additionally, there were abnormalities in blood pressure responses to cold, pointing towards sympathetic ANS dysfunction in these individuals.Postural hypotension (PH) is characterized by a decrease in systolic blood pressure (SBP) ≤ 20 mmHg and/or a decrease in diastolic blood pressure (DBP) ≤ 10 mmHg on the Tilt table test. The tilt table test is one of the assessments that reveal sympathetic autonomic dysfunction in T1DM [ 34 , 35 ]. The occurrence of postural hypotension associated with the duration of diabetes and poor glycemic control varies between 3–35% in adult patients. In contrast to adults, there are limited studies on postural hypotension in children with T1DM. In our study, postural hypotension was identified in 6 patients (20%) during the assessment of tilt table test analyses.

Tachycardia is considered the earliest sign of myocardial performance impairment or autonomic dysfunction. Given that the heart rate in our patient group is higher than in the control group, it is anticipated that there may be alterations in diastolic filling patterns. Ventricular functions were assessed using Doppler Tissue Imaging (DTI), a diagnostic method unaffected by heart rate variations, volume, and age [ 25 ]. It was observed that both systolic and diastolic periods were shortened due to the elevated heart rate. Findings consistent with diastolic dysfunction of the ventricles were identified, including increased A, DECT, PHT, and MPI values, as well as decreased E/A and E values. In our study, diastolic dysfunction with preserved systolic functions (EF) was noted in patients with poor metabolic control. Myocardial Performance Index (MPI) tends to increase in diabetic patients. This elevation in MPI is considered indicative of diastolic dysfunction, suggesting that MPI can be an effective tool in revealing early signs of impaired cardiac function in individuals with diabetes. Monitoring MPI can contribute to the assessment and management of diastolic dysfunction, offering insights into the cardiovascular impact of diabetes [ 36 , 37 , 38 , 39 ]. In addition to right ventricular tissue Doppler examinations, Pulmonary Valve (PW) Doppler examination was conducted. When right ventricular compliance decreases, the right ventricle operates as a passive conduit, leading to an anticipated increase in antegrade flow in the pulmonary artery during atrial systole. In our study, there is an observed increase in antegrade flow velocity (PA) and duration (PAT) in the pulmonary artery, consistent with right ventricular diastolic dysfunction.

In M-mode echocardiography examination, no significant differences were observed in heart dimensions and left ventricular systolic functions (EF, SF) measurements based on age. Given that our patients were asymptomatic, it is an expected finding that there was no change in the size of the heart chambers and that systolic functions were preserved.

In our study, we conducted exercise testing on our patients to assess the cardiopulmonary exercise response of individuals with type 1 diabetes and to evaluate the impact of glycemic control on these responses. In healthy children, it is typical for systolic blood pressure to increase with exercise. However, diastolic blood pressure tends to remain relatively unchanged, primarily due to vasodilation in the working skeletal muscles. This response is a normal physiological adaptation to the increased demand for oxygen and nutrients during physical activity. In the diabetic patient group, there is a lower cardiac output during exercise, and higher diastolic blood pressure is observed compared to the control group. Studies have reported an increase in both systolic and diastolic blood pressure during exercise in individuals with diabetes. Moreover, the rise in diastolic blood pressure has been associated with the duration of diabetes and poor diabetic control. Maximal exercise capacity, often measured in metabolic equivalents (METs), is considered one of the most crucial prognostic parameters obtained in exercise testing. It serves as a strong indicator of maximal oxygen consumption. In terms of the blood pressure response to exercise, it is generally expected that blood pressure will increase with the escalating treadmill workload. However, diastolic blood pressure typically remains relatively stable during exercise [ 40 ].

In our study, no significant differences were observed in T1DM patients who underwent exercise testing compared to the healthy group in terms of exercise duration, maximum exercise capacity (MET), maximum heart rate, or maximum systolic and diastolic pressure. These findings suggest that, based on the parameters assessed, there were no significant disparities in exercise performance and cardiovascular response between the two groups.

We acknowledge certain limitations in our study, firstly, the small sample size. To address this, longitudinal and prospective studies are essential for a more comprehensive understanding. Secondly, due to the cross-sectional design of our study, the temporal relationship between the appearance of signs of CAN and the onset of the disease remains unknown.

Cardiovascular autonomic neuropathy is a common complication of T1DM, often associated with the patient’s age and inadequate glycemic control. Autonomic dysfunction, marked by reduced baroreceptor sensitivity, is linked to various impairments such as decreased ventricular diastolic functions, compromised respiratory functions, and diminished exercise capacity. Early detection of this autonomic disorder is crucial, and methods such as assessing heart rate variability and conducting active orthostatic tests play a significant role in its early diagnosis.

Recognizing and addressing cardiac autonomic dysfunction in its initial stages can be crucial in preventing the development of cardiovascular events and improving overall patient outcomes. Regular monitoring and proactive management of glycemic control are essential components of a comprehensive approach to mitigate the impact of cardiovascular autonomic neuropathy in individuals with type 1 diabetes.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

We thank Sağlık Bilimleri University, Kanuni Sultan Süleyman Training and Research Hospital for providing us the environment to apply echocardiographic measurements, respiratory function tests, cardiopulmonary exercise tests, and tilt table tests. We thank Arda Deniz ERYİĞİT for statistical calculations.

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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Davut Gözüküçük

Department of Medicine, T.C. Demiroğlu Bilim University İstanbul Florence Nightingale Hospital, İzzetpaşa Mah, Abide-I Hürriyet Cd No:166, Şişli, 34381, Istanbul, Turkey

Berkut A. İleri

Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Cardiology, Istanbul University, Istanbul Faculty of Medicine Training and Research Hospital, Turgut Özal Millet St., Istanbul, Fatih, Topkapı, 34093, Turkey

Serra Karaca Başkan & Kazım Öztarhan

Department of Medicine, Yeditepe University, Yeditepe Faculty of Medicine Training and Research Hospital, Koşuyolu, Koşuyolu Cd. No: 168, Kadıköy, 34718, Istanbul, Turkey

Ece Öztarhan

Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Gastroenterology, T.C. Demiroğlu Bilim University, İstanbul Florence Nightingale Hospital, İzzetpaşa Mah, Abide-I Hürriyet Cd No:166, Şişli, 34381, Istanbul, Turkey

Dilek Güller

Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Endocrinology and Metabolism, Sağlık Bilimleri University, Başakşehir Çam ve Sakura City Hosptial, Başakşehir Mahallesi G-434 Caddesi No: 2L, Başakşehir, Istanbul, Turkey

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The authors confirm contribution to the paper as follows: Medical practices: Davut GÖZÜKÜÇÜK, Serra KARACA BAŞKAN, Kazım ÖZTARHAN; study conception and design: Davut GÖZÜKÜÇÜK, Dilek GÜLLER, Hasan ÖNAL, Kazım ÖZTARHAN data collection: Berkut A. İLERİ, Serra KARACA BAŞKAN, Ece ÖZTARHAN; analysis and interpretation of results: Davut GÖZÜKÜÇÜK, Dilek GÜLLER, Hasan ÖNAL, Kazım ÖZTARHAN; literature search: Berkut A. İLERİ, Serra KARACA BAŞKAN, Ece ÖZTARHAN, Dilek GÜLLER Hasan ÖNAL, Kazım ÖZTARHAN; writing of the manuscript: Berkut A. İLERİ, Serra KARACA BAŞKAN, Ece ÖZTARHAN. All authors reviewed the results and approved the final version of the manuscript.

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All methods were performed in accordance with the Declaration of Helsinki. informed consent was obtained from parent and/or legal guardian in all experiments involving human children and was written, the study was submitted and approved by Istanbul S.B.Ü Kanuni Sultan Süleyman Training and Research Hospital Ethics Committee. The reference number of the committee is 2020.06.84 dated 24/06/2020.

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Gözüküçük, D., İleri, B.A., Başkan, S.K. et al. Evaluation of cardiac autonomic dysfunctions in children with type 1 diabetes mellitus. BMC Pediatr 24 , 229 (2024). https://doi.org/10.1186/s12887-024-04644-y

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Geralyn Spollett; Case Study: A Patient With Uncontrolled Type 2 Diabetes and Complex Comorbidities Whose Diabetes Care Is Managed by an Advanced Practice Nurse. Diabetes Spectr 1 January 2003; 16 (1): 32–36. https://doi.org/10.2337/diaspect.16.1.32

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The specialized role of nursing in the care and education of people with diabetes has been in existence for more than 30 years. Diabetes education carried out by nurses has moved beyond the hospital bedside into a variety of health care settings. Among the disciplines involved in diabetes education, nursing has played a pivotal role in the diabetes team management concept. This was well illustrated in the Diabetes Control and Complications Trial (DCCT) by the effectiveness of nurse managers in coordinating and delivering diabetes self-management education. These nurse managers not only performed administrative tasks crucial to the outcomes of the DCCT, but also participated directly in patient care. 1  

The emergence and subsequent growth of advanced practice in nursing during the past 20 years has expanded the direct care component, incorporating aspects of both nursing and medical care while maintaining the teaching and counseling roles. Both the clinical nurse specialist (CNS) and nurse practitioner (NP) models, when applied to chronic disease management, create enhanced patient-provider relationships in which self-care education and counseling is provided within the context of disease state management. Clement 2 commented in a review of diabetes self-management education issues that unless ongoing management is part of an education program, knowledge may increase but most clinical outcomes only minimally improve. Advanced practice nurses by the very nature of their scope of practice effectively combine both education and management into their delivery of care.

Operating beyond the role of educator, advanced practice nurses holistically assess patients’ needs with the understanding of patients’ primary role in the improvement and maintenance of their own health and wellness. In conducting assessments, advanced practice nurses carefully explore patients’ medical history and perform focused physical exams. At the completion of assessments, advanced practice nurses, in conjunction with patients, identify management goals and determine appropriate plans of care. A review of patients’ self-care management skills and application/adaptation to lifestyle is incorporated in initial histories, physical exams, and plans of care.

Many advanced practice nurses (NPs, CNSs, nurse midwives, and nurse anesthetists) may prescribe and adjust medication through prescriptive authority granted to them by their state nursing regulatory body. Currently, all 50 states have some form of prescriptive authority for advanced practice nurses. 3 The ability to prescribe and adjust medication is a valuable asset in caring for individuals with diabetes. It is a crucial component in the care of people with type 1 diabetes, and it becomes increasingly important in the care of patients with type 2 diabetes who have a constellation of comorbidities, all of which must be managed for successful disease outcomes.

Many studies have documented the effectiveness of advanced practice nurses in managing common primary care issues. 4 NP care has been associated with a high level of satisfaction among health services consumers. In diabetes, the role of advanced practice nurses has significantly contributed to improved outcomes in the management of type 2 diabetes, 5 in specialized diabetes foot care programs, 6 in the management of diabetes in pregnancy, 7 and in the care of pediatric type 1 diabetic patients and their parents. 8 , 9 Furthermore, NPs have also been effective providers of diabetes care among disadvantaged urban African-American patients. 10 Primary management of these patients by NPs led to improved metabolic control regardless of whether weight loss was achieved.

The following case study illustrates the clinical role of advanced practice nurses in the management of a patient with type 2 diabetes.

A.B. is a retired 69-year-old man with a 5-year history of type 2 diabetes. Although he was diagnosed in 1997, he had symptoms indicating hyperglycemia for 2 years before diagnosis. He had fasting blood glucose records indicating values of 118–127 mg/dl, which were described to him as indicative of “borderline diabetes.” He also remembered past episodes of nocturia associated with large pasta meals and Italian pastries. At the time of initial diagnosis, he was advised to lose weight (“at least 10 lb.”), but no further action was taken.

Referred by his family physician to the diabetes specialty clinic, A.B. presents with recent weight gain, suboptimal diabetes control, and foot pain. He has been trying to lose weight and increase his exercise for the past 6 months without success. He had been started on glyburide (Diabeta), 2.5 mg every morning, but had stopped taking it because of dizziness, often accompanied by sweating and a feeling of mild agitation, in the late afternoon.

A.B. also takes atorvastatin (Lipitor), 10 mg daily, for hypercholesterolemia (elevated LDL cholesterol, low HDL cholesterol, and elevated triglycerides). He has tolerated this medication and adheres to the daily schedule. During the past 6 months, he has also taken chromium picolinate, gymnema sylvestre, and a “pancreas elixir” in an attempt to improve his diabetes control. He stopped these supplements when he did not see any positive results.

He does not test his blood glucose levels at home and expresses doubt that this procedure would help him improve his diabetes control. “What would knowing the numbers do for me?,” he asks. “The doctor already knows the sugars are high.”

A.B. states that he has “never been sick a day in my life.” He recently sold his business and has become very active in a variety of volunteer organizations. He lives with his wife of 48 years and has two married children. Although both his mother and father had type 2 diabetes, A.B. has limited knowledge regarding diabetes self-care management and states that he does not understand why he has diabetes since he never eats sugar. In the past, his wife has encouraged him to treat his diabetes with herbal remedies and weight-loss supplements, and she frequently scans the Internet for the latest diabetes remedies.

During the past year, A.B. has gained 22 lb. Since retiring, he has been more physically active, playing golf once a week and gardening, but he has been unable to lose more than 2–3 lb. He has never seen a dietitian and has not been instructed in self-monitoring of blood glucose (SMBG).

A.B.’s diet history reveals excessive carbohydrate intake in the form of bread and pasta. His normal dinners consist of 2 cups of cooked pasta with homemade sauce and three to four slices of Italian bread. During the day, he often has “a slice or two” of bread with butter or olive oil. He also eats eight to ten pieces of fresh fruit per day at meals and as snacks. He prefers chicken and fish, but it is usually served with a tomato or cream sauce accompanied by pasta. His wife has offered to make him plain grilled meats, but he finds them “tasteless.” He drinks 8 oz. of red wine with dinner each evening. He stopped smoking more than 10 years ago, he reports, “when the cost of cigarettes topped a buck-fifty.”

The medical documents that A.B. brings to this appointment indicate that his hemoglobin A 1c (A1C) has never been <8%. His blood pressure has been measured at 150/70, 148/92, and 166/88 mmHg on separate occasions during the past year at the local senior center screening clinic. Although he was told that his blood pressure was “up a little,” he was not aware of the need to keep his blood pressure ≤130/80 mmHg for both cardiovascular and renal health. 11  

A.B. has never had a foot exam as part of his primary care exams, nor has he been instructed in preventive foot care. However, his medical records also indicate that he has had no surgeries or hospitalizations, his immunizations are up to date, and, in general, he has been remarkably healthy for many years.

Physical Exam

A physical examination reveals the following:

Weight: 178 lb; height: 5′2″; body mass index (BMI): 32.6 kg/m 2

Fasting capillary glucose: 166 mg/dl

Blood pressure: lying, right arm 154/96 mmHg; sitting, right arm 140/90 mmHg

Pulse: 88 bpm; respirations 20 per minute

Eyes: corrective lenses, pupils equal and reactive to light and accommodation, Fundi-clear, no arteriolovenous nicking, no retinopathy

Thyroid: nonpalpable

Lungs: clear to auscultation

Heart: Rate and rhythm regular, no murmurs or gallops

Vascular assessment: no carotid bruits; femoral, popliteal, and dorsalis pedis pulses 2+ bilaterally

Neurological assessment: diminished vibratory sense to the forefoot, absent ankle reflexes, monofilament (5.07 Semmes-Weinstein) felt only above the ankle

Lab Results

Results of laboratory tests (drawn 5 days before the office visit) are as follows:

Glucose (fasting): 178 mg/dl (normal range: 65–109 mg/dl)

Creatinine: 1.0 mg/dl (normal range: 0.5–1.4 mg/dl)

Blood urea nitrogen: 18 mg/dl (normal range: 7–30 mg/dl)

Sodium: 141 mg/dl (normal range: 135–146 mg/dl)

Potassium: 4.3 mg/dl (normal range: 3.5–5.3 mg/dl)

Lipid panel

    • Total cholesterol: 162 mg/dl (normal: <200 mg/dl)

    • HDL cholesterol: 43 mg/dl (normal: ≥40 mg/dl)

    • LDL cholesterol (calculated): 84 mg/dl (normal: <100 mg/dl)

    • Triglycerides: 177 mg/dl (normal: <150 mg/dl)

    • Cholesterol-to-HDL ratio: 3.8 (normal: <5.0)

AST: 14 IU/l (normal: 0–40 IU/l)

ALT: 19 IU/l (normal: 5–40 IU/l)

Alkaline phosphotase: 56 IU/l (normal: 35–125 IU/l)

A1C: 8.1% (normal: 4–6%)

Urine microalbumin: 45 mg (normal: <30 mg)

Based on A.B.’s medical history, records, physical exam, and lab results, he is assessed as follows:

Uncontrolled type 2 diabetes (A1C >7%)

Obesity (BMI 32.4 kg/m 2 )

Hyperlipidemia (controlled with atorvastatin)

Peripheral neuropathy (distal and symmetrical by exam)

Hypertension (by previous chart data and exam)

Elevated urine microalbumin level

Self-care management/lifestyle deficits

    • Limited exercise

    • High carbohydrate intake

    • No SMBG program

Poor understanding of diabetes

A.B. presented with uncontrolled type 2 diabetes and a complex set of comorbidities, all of which needed treatment. The first task of the NP who provided his care was to select the most pressing health care issues and prioritize his medical care to address them. Although A.B. stated that his need to lose weight was his chief reason for seeking diabetes specialty care, his elevated glucose levels and his hypertension also needed to be addressed at the initial visit.

The patient and his wife agreed that a referral to a dietitian was their first priority. A.B. acknowledged that he had little dietary information to help him achieve weight loss and that his current weight was unhealthy and “embarrassing.” He recognized that his glucose control was affected by large portions of bread and pasta and agreed to start improving dietary control by reducing his portion size by one-third during the week before his dietary consultation. Weight loss would also be an important first step in reducing his blood pressure.

The NP contacted the registered dietitian (RD) by telephone and referred the patient for a medical nutrition therapy assessment with a focus on weight loss and improved diabetes control. A.B.’s appointment was scheduled for the following week. The RD requested that during the intervening week, the patient keep a food journal recording his food intake at meals and snacks. She asked that the patient also try to estimate portion sizes.

Although his physical activity had increased since his retirement, it was fairly sporadic and weather-dependent. After further discussion, he realized that a week or more would often pass without any significant form of exercise and that most of his exercise was seasonal. Whatever weight he had lost during the summer was regained in the winter, when he was again quite sedentary.

A.B.’s wife suggested that the two of them could walk each morning after breakfast. She also felt that a treadmill at home would be the best solution for getting sufficient exercise in inclement weather. After a short discussion about the positive effect exercise can have on glucose control, the patient and his wife agreed to walk 15–20 minutes each day between 9:00 and 10:00 a.m.

A first-line medication for this patient had to be targeted to improving glucose control without contributing to weight gain. Thiazolidinediones (i.e., rosiglitizone [Avandia] or pioglitizone [Actos]) effectively address insulin resistance but have been associated with weight gain. 12 A sulfonylurea or meglitinide (i.e., repaglinide [Prandin]) can reduce postprandial elevations caused by increased carbohydrate intake, but they are also associated with some weight gain. 12 When glyburide was previously prescribed, the patient exhibited signs and symptoms of hypoglycemia (unconfirmed by SMBG). α-Glucosidase inhibitors (i.e., acarbose [Precose]) can help with postprandial hyperglycemia rise by blunting the effect of the entry of carbohydrate-related glucose into the system. However, acarbose requires slow titration, has multiple gastrointestinal (GI) side effects, and reduces A1C by only 0.5–0.9%. 13 Acarbose may be considered as a second-line therapy for A.B. but would not fully address his elevated A1C results. Metformin (Glucophage), which reduces hepatic glucose production and improves insulin resistance, is not associated with hypoglycemia and can lower A1C results by 1%. Although GI side effects can occur, they are usually self-limiting and can be further reduced by slow titration to dose efficacy. 14  

After reviewing these options and discussing the need for improved glycemic control, the NP prescribed metformin, 500 mg twice a day. Possible GI side effects and the need to avoid alcohol were of concern to A.B., but he agreed that medication was necessary and that metformin was his best option. The NP advised him to take the medication with food to reduce GI side effects.

The NP also discussed with the patient a titration schedule that increased the dosage to 1,000 mg twice a day over a 4-week period. She wrote out this plan, including a date and time for telephone contact and medication evaluation, and gave it to the patient.

During the visit, A.B. and his wife learned to use a glucose meter that features a simple two-step procedure. The patient agreed to use the meter twice a day, at breakfast and dinner, while the metformin dose was being titrated. He understood the need for glucose readings to guide the choice of medication and to evaluate the effects of his dietary changes, but he felt that it would not be “a forever thing.”

The NP reviewed glycemic goals with the patient and his wife and assisted them in deciding on initial short-term goals for weight loss, exercise, and medication. Glucose monitoring would serve as a guide and assist the patient in modifying his lifestyle.

A.B. drew the line at starting an antihypertensive medication—the angiotensin-converting enzyme (ACE) inhibitor enalapril (Vasotec), 5 mg daily. He stated that one new medication at a time was enough and that “too many medications would make a sick man out of me.” His perception of the state of his health as being represented by the number of medications prescribed for him gave the advanced practice nurse an important insight into the patient’s health belief system. The patient’s wife also believed that a “natural solution” was better than medication for treating blood pressure.

Although the use of an ACE inhibitor was indicated both by the level of hypertension and by the presence of microalbuminuria, the decision to wait until the next office visit to further evaluate the need for antihypertensive medication afforded the patient and his wife time to consider the importance of adding this pharmacotherapy. They were quite willing to read any materials that addressed the prevention of diabetes complications. However, both the patient and his wife voiced a strong desire to focus their energies on changes in food and physical activity. The NP expressed support for their decision. Because A.B. was obese, weight loss would be beneficial for many of his health issues.

Because he has a sedentary lifestyle, is >35 years old, has hypertension and peripheral neuropathy, and is being treated for hypercholestrolemia, the NP performed an electrocardiogram in the office and referred the patient for an exercise tolerance test. 11 In doing this, the NP acknowledged and respected the mutually set goals, but also provided appropriate pre-exercise screening for the patient’s protection and safety.

In her role as diabetes educator, the NP taught A.B. and his wife the importance of foot care, demonstrating to the patient his inability to feel the light touch of the monofilament. She explained that the loss of protective sensation from peripheral neuropathy means that he will need to be more vigilant in checking his feet for any skin lesions caused by poorly fitting footwear worn during exercise.

At the conclusion of the visit, the NP assured A.B. that she would share the plan of care they had developed with his primary care physician, collaborating with him and discussing the findings of any diagnostic tests and procedures. She would also work in partnership with the RD to reinforce medical nutrition therapies and improve his glucose control. In this way, the NP would facilitate the continuity of care and keep vital pathways of communication open.

Advanced practice nurses are ideally suited to play an integral role in the education and medical management of people with diabetes. 15 The combination of clinical skills and expertise in teaching and counseling enhances the delivery of care in a manner that is both cost-reducing and effective. Inherent in the role of advanced practice nurses is the understanding of shared responsibility for health care outcomes. This partnering of nurse with patient not only improves care but strengthens the patient’s role as self-manager.

Geralyn Spollett, MSN, C-ANP, CDE, is associate director and an adult nurse practitioner at the Yale Diabetes Center, Department of Endocrinology and Metabolism, at Yale University in New Haven, Conn. She is an associate editor of Diabetes Spectrum.

Note of disclosure: Ms. Spollett has received honoraria for speaking engagements from Novo Nordisk Pharmaceuticals, Inc., and Aventis and has been a paid consultant for Aventis. Both companies produce products and devices for the treatment of diabetes.

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Evaluation of cardiac autonomic dysfunctions in children with type 1 diabetes mellitus

Affiliations.

• 1 Department of Medicine, Division of Pediatrics, Sağlık Bilimleri University, Kanuni Sultan Süleyman Training and Research Hospital, Atakent Mh, Turgut Özal Bulvari No:46/1, Küçükçekmece, 34303, Istanbul, Turkey.
• 2 Department of Medicine, T.C. Demiroğlu Bilim University İstanbul Florence Nightingale Hospital, İzzetpaşa Mah, Abide-I Hürriyet Cd No:166, Şişli, 34381, Istanbul, Turkey.
• 3 Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Cardiology, Istanbul University, Istanbul Faculty of Medicine Training and Research Hospital, Turgut Özal Millet St., Istanbul, Fatih, Topkapı, 34093, Turkey.
• 4 Department of Medicine, Yeditepe University, Yeditepe Faculty of Medicine Training and Research Hospital, Koşuyolu, Koşuyolu Cd. No: 168, Kadıköy, 34718, Istanbul, Turkey.
• 5 Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Gastroenterology, T.C. Demiroğlu Bilim University, İstanbul Florence Nightingale Hospital, İzzetpaşa Mah, Abide-I Hürriyet Cd No:166, Şişli, 34381, Istanbul, Turkey.
• 6 Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Endocrinology and Metabolism, Sağlık Bilimleri University, Başakşehir Çam ve Sakura City Hosptial, Başakşehir Mahallesi G-434 Caddesi No: 2L, Başakşehir, Istanbul, Turkey.
• 7 Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Cardiology, Istanbul University, Istanbul Faculty of Medicine Training and Research Hospital, Turgut Özal Millet St., Istanbul, Fatih, Topkapı, 34093, Turkey. [email protected].
• PMID: 38561716
• PMCID: PMC10986024
• DOI: 10.1186/s12887-024-04644-y

Background: Cardiovascular autonomic neuropathy (CAN) is a serious complication of diabetes, impacting the autonomic nerves that regulate the heart and blood vessels. Timely recognition and treatment of CAN are crucial in averting the onset of cardiovascular complications. Both clinically apparent autonomic neuropathy and subclinical autonomic neuropathy, particularly CAN pose a significant risk of morbidity and mortality in children with type 1 diabetes mellitus (T1DM). Notably, CAN can progress silently before manifesting clinically. In our study, we assessed patients with poor metabolic control, without symptoms, following the ISPAD 2022 guideline. The objective is is to determine which parameters we can use to diagnose CAN in the subclinical period.

Methods: Our study is a cross-sectional case-control study that includes 30 children diagnosed with T1DM exhibiting poor metabolic control (average HbA1c > 8.5% for at least 1 year) according to the ISPAD 2022 Consensus Guide. These patients, who are under the care of the pediatric diabetes clinic, underwent evaluation through four noninvasive autonomic tests: echocardiography, 24-h Holter ECG for heart rate variability (HRV), cardiopulmonary exercise test, and tilt table test.

Results: The average age of the patients was 13.73 ± 1.96 years, the average diabetes duration was 8 ± 3.66 years, and the 1-year average HbA1c value was 11.34 ± 21%. In our asymptomatic and poorly metabolically controlled patient group, we found a decrease in HRV values, the presence of postural hypotension with the tilt table test, and a decrease in ventricular diastolic functions that are consistent with the presence of CAN. Despite CAN, the systolic functions of the ventricles were preserved, and the dimensions of the cardiac chambers and cardiopulmonary exercise test were normal.

Conclusions: CAN is a common complication of T1DM, often associated with the patient's age and poor glycemic control. HRV, active orthostatic tests, and the evaluation of diastolic dysfunctions play significant roles in the comprehensive assessment of CAN. These diagnostic measures are valuable tools in identifying autonomic dysfunction at an early stage, allowing for timely intervention and management to mitigate the impact of cardiovascular complications associated with T1DM.

Keywords: Cardiac autonomic dysfunction; Heart rate variability; Tilt table test; Tissue Doppler; Type 1 diabetes mellitus.

© 2024. The Author(s).

• Autonomic Nervous System Diseases* / diagnosis
• Autonomic Nervous System Diseases* / etiology
• Case-Control Studies
• Cross-Sectional Studies
• Diabetes Mellitus, Type 1* / complications
• Diabetic Neuropathies* / diagnosis
• Diabetic Neuropathies* / etiology
• Glycated Hemoglobin
• Heart Rate / physiology