The development of T1D typically occurs in three stages (Lucier & Weinstock, 2021):

Stage 1: Stage 1 is characterized by a lack of symptoms and a normal fasting glucose, normal glucose tolerance, and the presence of greater than, or equal to, two pancreatic autoantibodies. 

• Stage 2: Stage 2 diagnostic criteria include the presence of greater than or equal to 2 pancreatic autoantibodies and dysglycemia (glucose of 100 to 125 mg/dl), impaired glucose tolerance (2-hour PG of 140 to 199 mg/dL), or a hemoglobin A1C between 5.7% to 6.4%. Patients remain asymptomatic. 

• Stage 3: In Stage 3 the patient has hyperglycemia with clinical symptoms and two or more pancreatic autoantibodies.

Etiology. The exact cause of T1D is unknown. However, several risk factors and possible trigger factors have been identified, including the following: 

Genetics: Having a family history of T1D puts people at greater risk of developing the disease. However, the majority of diagnoses are found in people who have no family members with the disease (JDRF, n.d.).

• Viral Infections: Viral infections may be triggers for T1D development (JDRF, n.d.). 

• Geography: The further away from the equator a person lives, the greater the incidence of T1D (Mayo Clinic, 2021c).

• Age: Although T1D can occur at any age, it seems to peak at two specific age ranges. The first peak appears in children between the ages of 4 and 7 years old. The second peak is in children between the ages of 10 and 14 years old (Mayo Clinic, 2021c).

Nursing Consideration: Unlike type 2 diabetes, no dietary changes can be made to prevent the onset of T1D. Likewise, lifestyle factors such as exercise and weight do not contribute to T1D development (JDRF, n.d.). Some insulin regimens can be very expensive, so this should be discussed with patients to help them avoid skipping doses.

Complications. Maintaining a normal blood glucose level can significantly reduce the occurrence of complications. Such complications may be disabling or even fatal. Without insulin to facilitate the entry of glucose into the cells, blood glucose levels increase and complications may be likely (Mayo Clinic, 2021c).

Complications linked to T1D include the following (Mayo Clinic, 2021c):

Cardiac and vascular diseases: T1D radically increases the risk of cardiovascular diseases such as coronary artery disease (CAD), angina, heart attack, stroke, atherosclerosis, and hypertension.

• Neuropathy: Excessive blood glucose levels may injure the capillaries that nourish the nerves. Symptoms of neuropathy include tingling, numbness, and burning or pain that typically starts at the tips of the toes or fingers and spreads gradually. If blood glucose levels are not controlled, all sensation may be lost in the affected limbs. If the nerves of the gastrointestinal tract are damaged, patients may suffer from nausea, vomiting, diarrhea, or constipation. In men, erectile dysfunction may occur.

• Diabetic retinopathy: If the blood vessels of the retina are damaged, the patient may go blind. Other conditions linked to diabetic retinopathy include cataracts and glaucoma.

• Damage to the feet: Nerve damage or reduced blood flow to the lower extremities increases the risk of complications to the feet. Without treatment, even minor cuts and blisters can become quite serious, leading to infections that may eventually require the amputation of toes, feet, or leg(s).

• Skin and mouth issues: Patients may be more vulnerable to skin and mouth infections including those caused by bacteria and fungi. Disease of the gums and dry mouth are also likely.

• Pregnancy issues: If the T1D is poorly controlled in pregnant females, the risk of miscarriage, stillbirth, and birth defects increases. The risk of diabetic ketoacidosis, retinopathy, pregnancy induced hypertension, and preeclampsia may also increase.

Diabetic ketoacidosis (DKA) is a serious, acute metabolic complication characterized by hyperglycemia, hyperketonemia, and metabolic acidosis. DKA is most common in patients with T1D and occurs when insulin levels are inadequate to meet the body’s basic metabolic requirements. Hyperglycemia causes osmotic diuresis with severe fluid and electrolyte loss (Merck Manual, 2020b).

Signs and symptoms of DKA include nausea, vomiting, and (especially in children) abdominal pain. If untreated, significant decompensation can occur. Patients may display hypotension and tachycardia because of dehydration and acidosis. To compensate for acidemia, respirations increase in rate and depth (Kussmaul respirations). The patient’s breath may have a fruity odor because of exhaled acetone (Merck Manual, 2020b).

Treatment consists of rapid intravascular volume repletion with 0.9% saline given IV, correction of hyperglycemia and acidosis, and prevention of hypokalemia. Treatment should take place in critical care settings because of the need for hourly clinical and laboratory assessments with necessary adjustments indicated by assessment results (Merck Manual, 2020b).

Assessment and Diagnosis

Patients are assessed for common symptoms of T1D. These include the following (Mayo Clinic, 2021c; Rebar et al., 2019):

• Increased thirst.

• Extreme hunger.

• Frequent urination.

• Unintended weight los.s

• Fatigue.

• Weakness.

• Blurred vision.

• Irritability.

• Mood changes.

• In children, bed-wetting in those who did not previously wet the bed at night.

A thorough history and physical are conducted to help rule out other conditions. In addition to history, physical, and a review of signs and symptoms, several diagnostic tests are performed. These include the following (Mayo Clinic, 2021c; Rebar et al., 2019):

• Glycated hemoglobin (A1C) test: The A1C is a blood test that reports average blood glucose levels for the past 2 to 3 months. The test measures the percentage of blood glucose that is attached to the body’s hemoglobin. The higher the glucose levels, the higher the percentage of hemoglobin with attached glucose. An A1C level of 6.5% or higher on two separate tests is an indicator of T1D.

• Random blood glucose test: This test requires that a blood sample be obtained at a random time and confirmed by repeat testing. A random blood glucose level of 200 mg/dL or higher suggests T1D, particularly if the patient has signs and symptoms of T1D.

• Fasting blood glucose test: The fasting blood glucose test requires that a blood sample be obtained following an overnight fast. A fasting blood glucose level of less than 100 mg/dL is normal. A level from 100-125 mg/dL is classified as prediabetes. A level of 126 mg/dL or higher on two separate tests is diagnostic for T1D.

• Antibody test: If a diagnosis of diabetes is made, the healthcare provider may order blood tests to check for antibodies that are common in T1D. Presence of antibodies helps to differentiate between T1D and type 2 diabetes when the diagnosis is uncertain.

Nursing Consideration: Certain conditions such as pregnancy or having a hemoglobin variant may interfere with the accuracy of the A1C test. In these types of cases, the healthcare providers will rely on additional blood tests to determine an accurate diagnosis.

Treatment

T1D is managed with a variety of insulins. Patients, families, and the healthcare team must work together to find the best treatment regimen. Types of insulin may include the following (JDRF, n.d.):

• Rapid acting: Starts working in about 15 minutes after injection. It peaks in about 1 hour and continues for about 2 to 4 hours after injection. Examples include aspart (Novolog), glulisine (Apidra), and lispro (Humalog). 

• Regular or short acting: Starts working 30 minutes after injection, peaks from 2 to 3 hours after injection, and continues to work for about 3 to 6 hours. An example is Humulin R.

• Intermediate acting: Starts working 2 to 4 hours after injection. It peaks about to 12 hours later and lasts 12 to 18 hours. An example is Novolin N.

• Long acting: Long acting is often combined with rapid or short acting insulin. It starts to work several hours after injection and tends to lower glucose levels up to 24 hours. An example is Lantus.

• Ultra-long lasting: Starts to work in 6 hours, but it does not peak and lasts an estimated 36 hours. An example is Tresiba.

Insulin is administered in a variety of ways. Historically, insulin was administered via injection using a syringe. Today, other options are available including the following (CDC, 2021a; JDRF, n.d.):

• Insulin pen: Some pens use cartridges that are inserted into the pen while others are pre-filled and discarded after all insulin is used. The dose of insulin is dialed on the pen and the insulin is injected through a needle.

• Insulin pump: About the size of a small cell phone, insulin pumps provide a basal dose of short or rapid-acting insulin per hour. When blood sugar is high, the patient calculates the dose and the insulin in the pump delivers the bolus.

• Artificial pancreas: The artificial pancreas is a hybrid closed-loop system that requires minimal patient intervention. It is a combination of the technology of a pump with that of a continuous glucose monitor.

• Inhaled insulin: Inhaled insulin is taken by using an oral inhaler to deliver ultra-rapid-acting insulin at the start of meals. Inhaled insulin is used in conjunction with an injectable long-acting insulin.

• Additional treatment interventions include having personalized meal plans designed to meet nutritional needs, control blood glucose levels, and help patients maintain ideal body weight. With the guidance of healthcare providers, patients should participate in regular exercise. Patients should be cautioned that physical activity lowers blood glucose levels. Thus, blood glucose levels should be monitored frequently. Patients may need to adjust their meal plans or insulin to compensate for increased physical activity (Mayo Clinic, 2021c; Rebar et al., 2019).

• Nursing Interventions:Nursing interventions focus on education and emotional support. Patients and families need education pertaining to meal planning, exercise, and insulin administration. Emotional support is also critical to the success of any treatment regimen (Rebar et al., 2019).

• Patients and families also need information about potential complications, how to recognize them, and what to do if they occur. It is recommended that families pay special attention to the issue of complications. Teachers should be informed that a child is diabetic and they must be aware of emergency procedures. In some cases, patients experiencing complications (such as DKA) may not be able to articulate the need for help or describe their symptoms at the time. It is, therefore, absolutely essential that family members and other caretakers be able to intervene correctly in the event that complications occur (Rebar et al., 2019). DKA is a medical emergency and must be treated immediately.

According to the National Diabetes Statics Report, 2020, 34.2 million Americans, just over 1 in 10, have diabetes. Of these 34.2 million people, 7.3 million, or 21.4%, are undiagnosed (Centers for Disease Control and Prevention (CDC), 2020c; 2020d). The World Health Organization (WHO) reports that in 2019 an estimated 1.5 million deaths were directly caused by diabetes (WHO, 2021). The numbers of people who have diabetes continue to increase at alarming rates. It is critical that healthcare professionals aggressively pursue identification of persons who have, and who are at risk for, developing diabetes, and intervene to facilitate not only treatment, but prevention efforts (CDC, 2020c; 2020d).

Incidence and Prevalence of Diabetes Mellitus

Diabetes mellitus (DM) is a chronic endocrine disease characterized by impaired glucose regulation that occurs when the pancreas fails to produce adequate amounts of insulin or when the patient’s body is unable to effectively utilize the insulin that is produced (Ignatavicius et al., 2018; WHO, 2021).

Approximately 34.2 million Americans have diabetes. Data indicate that (CDC, 2020c; 2020d):

• An estimated 10.5% of the United States (US) population are dealing with diabetes.

• About 26.9 million people have been diagnosed. This figure includes 26.8 million adults.

• A significant number of these people, 7.3 million or 21.4%, are undiagnosed.

• A total of 88 million people 18 years of age and older have prediabetes. This figure represents 34.5% of the adult US population.

• For persons 65 years of age and older, 24.2 million people have prediabetes.

Healthcare Professionals Consideration: An estimated 1.5 million world-wide deaths were directly caused by diabetes in 2019 (WHO, 2021). Healthcare professionals must increase their efforts in the recognition, treatment, and prevention of diabetes mellitus.

Incidence and Prevalence of Diabetes Mellitus (cont.)

Diabetes is also a leading cause of death in the United States. According to the most recent data available on the CDC website (2021d), the following are the leading causes of death in the United States.

1. Heart disease: 659,041

2. Cancer: 599,601

3. Accidents (unintentional injuries): 173,040

4. Chronic lower respiratory diseases: 156,979

5. Stroke (cerebrovascular diseases): 150,005

6. Alzheimer’s disease: 121,499

7. Diabetes: 87,647

8. Nephritis, nephrotic syndrome, and nephrosis: 51,565

9. Influenza and pneumonia: 49,783

10. Intentional self-harm (suicide): 47,511

Key findings of the National Diabetes Statistics Report 2020 regarding incidence and prevalence include (CDC, 2020d ;2020e; 200f):

• 34.2 million Americans—just over 1 in 10—have diabetes.

• 88 million American adults—approximately 1 in 3—have prediabetes.

• New diabetes cases were higher among non-Hispanic blacks and people of Hispanic origin than non-Hispanic Asians and non-Hispanic whites.

• For adults diagnosed with diabetes:

• New cases significantly decreased from 2008 through 2018.

• The percentage of existing cases was highest among American Indians/Alaska Natives.

• 15% were smokers, 89% were overweight, and 38% were physically inactive.

• 37% had chronic kidney disease (stages 1 through 4); and fewer than 25% with moderate to severe chronic kidney disease (stage 3 or 4) were aware of their condition.

• New diagnosed cases of type 1 and type 2 diabetes have significantly increased among US youth.

• For ages 10 to 19 years, incidence of type 2 diabetes remained stable among non-Hispanic whites and increased for all others, especially non-Hispanic blacks.

• The percentage of adults with prediabetes who were aware they had the condition doubled between 2005 and 2016, but most continue to be unaware.

More people are developing type 1 and type 2 diabetes during youth, and racial and ethnic minorities continue to develop type 2 diabetes at higher rates. Likewise, the proportion of older people in our nation is increasing, and older people are more likely to have a chronic disease like diabetes. By addressing diabetes, many other related health problems can be prevented or delayed.

Prevalence and Incidence According to Age, Race, and Ethnicity

Age

According to the National Diabetes Statistics Report 2020, (CDC, 2020c; 2020d;2020e):

• About 34.2 million people of all ages had diabetes mellitus.

• The percentage of adults (18 years of age or older) with diabetes increased with age.

• About 34.1 million adults 18 years of age or older) had diabetes.

• The highest percentage was 26.8% among persons 65 years of age or older.

• An estimated 4.9 million adults between the ages of 18 and 44 had diabetes.

• An estimated 14.8 million people between the ages of 45 and 64 had diabetes.

• An estimated 14.3 million people over the age of 65 had diabetes.

Incidence and Trends among Children and Adolescents. According to the National Diabetes Statistics Report 2020 (CDC, 2020c; 2020d; 2020e):

• 18,291 children and adolescents younger than age 20 years with type 1 diabetes.

• 5,758 children and adolescents age 10 to 19 years with type 2 diabetes.

• During 2011–2015, non-Hispanic Asian and Pacific Islander children and youth had the largest significant increases in incidence of type 1 diabetes.

• During 2011–2015, non-Hispanic Asian and Pacific Islander children and youth had the largest significant increases in incidence of type 1 diabetes.

Among US children and adolescents aged 10 to 19 years (CDC, 2020c; 2020d; 2020e):

• For the entire period 2002–2015, overall incidence of type 2 diabetes significantly

• During the 2002–2010 and 2011–2015 periods, changes in incidence of type 2 diabetes were consistent across race/ethnic groups. Specifically, incidence of type 2 diabetes remained stable among non-Hispanic whites and significantly increased for all others, especially non-Hispanic blacks.

Evidence-Based Practice: Research data shows that the number of younger people with diabetes is significant and continues to increase (CDC, 2020c; 2020d; 2020e). It is therefore essential that nurses identify those at risk and provide patient/family education regarding risk factors for the disease and how to modify these risk factors as appropriate.

Racial and Ethnic Differences (Prevalence of Diagnosed Diabetes)

Among the US population overall, crude estimates for 2018 were (CDC, 2020c; 2020d; 2020e):

• 26.9 million people of all ages—or 8.2% of the US population—had diagnosed diabetes.

• 210,000 children and adolescents younger than age 20 years—or 25 per 10,000 US youths— had diagnosed diabetes. This includes 187,000 with type 1 diabetes.

• 1.4 million adults aged 20 years or older—or 5.2% of all US adults with diagnosed diabetes—reported both having type 1 diabetes and using insulin.

• 2.9 million adults aged 20 years or older—or 10.9% of all US adults with diagnosed diabetes—started using insulin within a year of their diagnosis.

Among US adults aged 18 years or older, age-adjusted data for 2017–2018 indicated the following (CDC, 2020c; 2020d; 2020f):

• Prevalence of diagnosed diabetes was highest among American Indians/Alaska Natives (14.7%), people of Hispanic origin (12.5%), and non-Hispanic blacks (11.7%), followed by non-Hispanic Asians (9.2%) and non-Hispanic whites (7.5%).

• American Indians/Alaska Natives had the highest prevalence of diagnosed diabetes for women (14.8%).

• American Indian/Alaska Native men had a significantly higher prevalence of diagnosed diabetes (14.5%) than non-Hispanic black (11.4%), non-Hispanic Asian (10.0%), and non-Hispanic white (8.6%) men.

• Among adults of Hispanic origin, Mexicans (14.4%) and Puerto Ricans (12.4%) had the highest prevalence, followed by Central/South Americans (8.3%) and Cubans (6.5%).

• Among non-Hispanic Asians, Asian Indians (12.6%) and Filipinos (10.4%) had the highest prevalence, followed by Chinese (5.6%). Other Asian groups had a prevalence of 9%.

• Among adults, prevalence varied significantly by education level, which is an indicator of socioeconomic status. Specifically, 13.3% of adults with less than a high school education had diagnosed diabetes versus 9.7% of those with a high school education and 5% of those with more than a high school education.

Prevalence of Prediabetes in Adults

Data regarding prediabetes in adults show that (CDC, 2020c; 2020d; 2020e):

• An estimated 88 million adults aged 18 years or older had prediabetes in 2018.

• Among US adults aged 18 years or older, crude estimates for 2013–2016 were: 34.5% of all US adults had prediabetes, based on their fasting glucose or A1C level (Table 3).

• 10.5% of adults had prediabetes based on both elevated fasting plasma glucose and A1C levels.

• 15.3% of adults with prediabetes reported being told by a health professional that they had this condition.

Among US adults aged 18 years or older, age-adjusted data for 2013–2016 indicated:

• A higher percentage of men (37.4%) than women (29.2%) had prediabetes.

• Prevalence of prediabetes was similar among all racial/ethnic groups and education levels.

Incidence of Newly Diagnosed Diabetes in Adults

Among US adults aged 18 years or older, crude estimates for 2018 were (CDC, 2020c; 2020d; 2020e):

• 1.5 million new cases of diabetes—or 6.9 per 1,000 persons—were diagnosed.

• Compared to adults aged 18 to 44 years, incidence rates of diagnosed diabetes were higher among adults aged 45 to 64 years and those aged 65 years and older.

• Among US adults aged 18 years or older, age-adjusted data for 2017–2018 indicated that non-Hispanic blacks (8.2 per 1,000 persons) and people of Hispanic origin (9.7 per 1,000 persons) had a higher incidence compared to non-Hispanic whites (5.0 per 1,000 persons).

Evidence-Based Practice: The rate of new cases of diabetes in youths younger than 20 years of age increased in the US between 2002 and 2015, with a 4.8% increase per year for type 2 diabetes and a 1.9% increase per year for type 1 diabetes (CDC, 2020g). These findings indicate that education regarding prevention and recognition of diabetes in youth must be provided with increased effectiveness, as well as aggressive efforts to prevent development whenever possible.

Financial and Societal Impact of Diabetes Mellitus

The momentous financial and societal impact of diabetes continues to increase at an alarming rate. Federal, state, and local governments (and ultimately the US taxpayer) bear the brunt of costs related to diabetes. The American Diabetes Association (ADA) gives as an example that Medicare’s diabetes-related burden increased as the prevalence of diabetes increased (O’Connell & Manson, 2019).

According to the CDC, diabetes is the most expensive chronic condition in the US. A summary of these expenses includes (CDC, 2021c):

• The total annual cost of diabetes is $327 billion. An additional $90 billion is spent on reduced productivity.

• One dollar out of every four dollars in US healthcare costs is spent on caring for people with diabetes.

• The total economic cost of diabetes rose 60% from 2007 to 2017.

• Sixty-one percent of diabetes costs are for people 65 years of age or older. These costs are mainly paid by Medicare.

• An estimated 48% to 64% of lifetime medical costs for a person with diabetes are for complications related to diabetes, such as heart disease and stroke.

Medical costs are not the only costs related to diabetes. The stress of chronic illness can impact interpersonal relationships. It can impact the person’s ability to work, which may have significant economic impact on the family income. Financial burdens are inter-related with psychological issues that impact persons dealing with diabetes. Medical bills, loss of work time, and inability to actively participate in work and social activities can all have significant adverse impact on patients, their families, and their employers. Dealing with a chronic illness can lead to significant stress, which can adversely impact ability to function effectively at work, home, and school and interfere with interpersonal relationships. Therefore, the costs of diabetes include monetary, societal, and interpersonal factors. The impact on society includes overextended health services, increased public assistance programs for financially stressed families, and the societal burden of mental health care and rehabilitation for those with complications resulting from diabetes (CDC, 2021c; O’Connell, 2019).

Financial and Societal Impact of Diabetes Mellitus

The momentous financial and societal impact of diabetes continues to increase at an alarming rate. Federal, state, and local governments (and ultimately the US taxpayer) bear the brunt of costs related to diabetes. The American Diabetes Association (ADA) gives as an example that Medicare’s diabetes-related burden increased as the prevalence of diabetes increased (O’Connell & Manson, 2019).

According to the CDC, diabetes is the most expensive chronic condition in the US. A summary of these expenses includes (CDC, 2021c):

• The total annual cost of diabetes is $327 billion. An additional $90 billion is spent on reduced productivity.

• One dollar out of every four dollars in US healthcare costs is spent on caring for people with diabetes.

• The total economic cost of diabetes rose 60% from 2007 to 2017.

• Sixty-one percent of diabetes costs are for people 65 years of age or older. These costs are mainly paid by Medicare.

• An estimated 48% to 64% of lifetime medical costs for a person with diabetes are for complications related to diabetes, such as heart disease and stroke.

Medical costs are not the only costs related to diabetes. The stress of chronic illness can impact interpersonal relationships. It can impact the person’s ability to work, which may have significant economic impact on the family income. Financial burdens are inter-related with psychological issues that impact persons dealing with diabetes. Medical bills, loss of work time, and inability to actively participate in work and social activities can all have significant adverse impact on patients, their families, and their employers. Dealing with a chronic illness can lead to significant stress, which can adversely impact ability to function effectively at work, home, and school and interfere with interpersonal relationships. Therefore, the costs of diabetes include monetary, societal, and interpersonal factors. The impact on society includes overextended health services, increased public assistance programs for financially stressed families, and the societal burden of mental health care and rehabilitation for those with complications resulting from diabetes (CDC, 2021c; O’Connell, 2019).