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Response 1Obesity is one of the significant causes of type 2 diabetes, and also it appears to be related to aging, sedentary lifestyle, and genetic influence. Type 2 diabetes develops when the receptor cells have become less sensitive to the insulin—this insulin resistance results in less sugar being removed from the blood because the beta-cells cannot secrete sufficient insulin to keep up with demand (Le Gresley et al., 2021). On the other hand, type 1 diabetes is primarily due to the autoimmune-mediated destruction of the pancreatic beta-cell leading to insulin deficiency (Mishra & Ndisang, 2014). Juvenile diabetes is also called type 1 diabetes or insulin-dependent diabetes. It is most commonly diagnosed in children, teens, and young adults, but it can develop at any age. Diet and lifestyle habits do not cause type 1 diabetes (Centers for Disease Control and Prevention, 2021). Type 1 diabetes means using insulin. Because the body no longer makes this hormone. One has to take insulin several times during the day, including with meals. However, type 2 diabetes and gestational diabetes can be managed by healthy eating and exercise first. If the blood sugar is not well controlled, they may also need to use oral medications and insulin injection treatment (National Institutes of Health, 2016).Gestational diabetes (GD) is a serious pregnancy complication and type of diabetes that occurs during pregnancy. In most circumstances, this hyperglycemia is the consequence of impaired glucose tolerance. Risk factors for GD include overweight and obesity, advanced maternal age, and family history of any form of diabetes. In addition, GD includes an increased risk of maternal cardiovascular disease, type 2 diabetes and macrosomia, and birth complications in the infant (Plows et al., 2018).Oral Medication of Type 2 DiabetesMost medications for type 2 diabetes are oral drugs. One good example of oral medication is a biguanide, and the most common is Metformin. Metformin helps control the amount of sugar in the blood by decreasing intestinal glucose absorption and how much glucose is made in the liver. Metformin comes as a liquid, a tablet, and an extended-release (long-acting) form. The diabetic pills are taken by mouth and should be every day around the same time (National Library of Medicine, 2020).Usual Adult Dose for Oral MetforminStart on a low dose of PO Metformin 500 mg twice a day or 850 mg once a day. Then, gradually increase in 500-850 mg does not more often than once every 1–2 weeks. The maintenance dose will be 2000 mg/day in divided doses, and the maximum dose is 2550 mg/day. The extended-release tablet usually takes 500-100 mg daily with the evening meal. An increase in 500 mg increments weekly as tolerated and with a maximum dose of 2000 mg/day. Swallow metformin extended-release tablets whole, not split, chew, or crush (Drug.com, 2020).Dietary ConsiderationsThe primary purpose in the management of diabetes is to achieve as near normal regulation of blood glucose (postprandial and fasting) as possible. The total amount of carbohydrates consumed have the most substantial influence on the glycemic response (American Diabetes Association, 2019). Carbohydrate intake should emphasize nutrient-dense carbohydrate sources high in fiber, including vegetables, fruits, legumes, whole grains, and dairy products. Less refined grains, red/processed meats, and sugar-sweetened beverages Short-term and Long Term Complications of Type 2 DiabetesShort-term complications of type 2 diabetes are hypoglycemia (very low blood glucose) and are one of the most common short-term effects. Hyperglycemia (high blood sugar) are consuming more carbohydrates or sugar than your body can handle can sometimes cause hyperglycemia. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is very high blood glucose and can lead to coma and death. More short-term complications include increased thirst and urination, blurred vision, fatigue, and headache (Inspira Health, 2019).Diabetic individuals have a mortality rate twice that of the general healthy individuals. Long-term complications include damage to large (macrovascular) and small (microvascular) blood vessels. In addition, many affected populations are at high risk of developing diabetes-related complications such as myocardial infarction (MI), stroke, retinopathy, nephropathy, arterial diseases, and neuropathy, leading to amputation (Laursen et al., 2017).Type 2 diabetes medication therapy sometimes stops working after months or years with an unknown cause. However, a single medication may be effective before, especially if someone developed diabetes just recently. On the other hand, one may need combination oral therapy when having diabetes for a long time and take more than 20 units of insulin each day (American Diabetes Association, n.d.). For example, a biguanide and a sulfonylurea may be taken together. Although multiple oral diabetic medications are costly and the risk of side effects increases, combination therapy can improve blood sugar, and taking only a single pill does not have the desired effects. Furthermore, in cases of severe infection or need surgery, insulin injections are taken with pills to control glucose levels (American Diabetes Association, n.d.)3APA refResponse 2The American Diabetes Association (ADA) guides clinical care for each classification of diabetes. ­­ADA practice recommendations cover general treatment goals, pharmacologic interventions, and guidelines. The recommendations for type 1 diabetes, type 2 diabetes, and gestational diabetes differ because of variable underlying pathophysiology (American Diabetes Association [ADA], 2017). The following paper briefly compares diabetes and offers a detailed description of gestational diabetes.Type 1 diabetes is characterized by the destruction of pancreatic beta cells, resulting in absolute insulin deficiency. The destruction of pancreatic beta cells is primarily the result of an autoimmune disorder. This subtype is Type 1A diabetes. Patients with absolute insulin deficiency with no evidence of autoimmunity and no other cause of beta-cell destruction are Type 1B diabetics or idiopathic diabetics (Balasubramanyam, 2021). Type 1 diabetes is formerly known as juvenile diabetes because it is primarily diagnosed in childhood and adolescence; however, it can develop at any age. Insulin is the pharmacotherapy for Type 1 diabetes (CDC, 2021). The only FDA-approved adjunct therapy for Type 1 is pramlintide, an amylin analog (ADA, 2017).Type 2 diabetes is characterized by variable insulin resistance and deficiency. Type 2 diabetes is the most prevalent type and results from multifactorial genetic and environmental influences. The most significant environmental risk factors for Type 2 are obesity and decreased physical activity (Robertson & Udler, 2021). Treatment options include metformin, SGLT-2 inhibitors, GLP-1 RAs, DPP-4 inhibitors, thiazolidinediones, sulfonylureas, and insulin (ADA, 2017).Gestational diabetes results from insufficient insulin secretory capacity: the placenta secretes anti-insulin hormones, and the growing mother and fetus demand more energy (Balasubramanyam, 2021). Gestational pharmacotherapy is initiated when 30% of blood glucose levels are above the target range in a week. Pharmacologic options for pregnant patients are insulin, metformin, and glyburide (Durnwald, 2021).Short-term effects of gestational diabetes include lifestyle changes because they can effectively achieve glycemic targets. These measures include nutritional therapy, weight management, glucose monitoring, and physical activity. Meal plans for gestational diabetes include three meals and two to four snacks per day. Meal plans are continuously adjusted based on glucose reading, weight gain, and appetite. The patient will work with a registered dietitian to calculate precise goals. If lifestyle changes are ineffective, insulin is preferred because glyburide and metformin cross the placental barrier. Goals of therapy are fasting glucose < 95, one-hour post-prandial < 140, and two hour post-prandial < 120. Total insulin dosage ranges from 0.7 to 2 units/kg, and titrations are based on frequent monitoring, which should be conducted at least four times per day: fasting, post-prandial, before lunch, and before dinner (Durnwald, 2021).An insulin regimen requires frequent adjustments, and the patient should keep a glucose log. The following is a general approach to insulin management for patients diagnosed with gestational diabetes at 24 – 28 weeks (following glucose tolerance testing). An injection of 10-20 units of intermediate-acting basal insulin and 6 - 10 units of rapid-acting insulin are prescribed subcutaneously, immediately before breakfast. The exact dose would be determined by the individual results and their degree above the target. If post-prandial readings remain high, rapid-acting insulin is increased. If only the post-dinner glucose reading remains elevated, rapid-acting insulin 6 – 10 units subcutaneously will also be given immediately before dinner. If only the post-lunch glucose reading remains elevated, a dose of rapid-acting insulin 6 – 10 units subcutaneously is also given immediately before lunch. Intermediate-acting basal insulin is added in the evening if fasting glucose levels are elevated after post-prandial control is achieved. This dose is 0.2 units/kg subcutaneously given at dinner or bedtime (Durnwald, 2021).Lispro and Aspart are rapid-acting insulins considered safe during pregnancy. These agents have minimal transfer across the placenta and have no evidence of teratogenesis. Based on available data, NPH is the recommended intermediate insulin. Patients are educated on drawing up insulin with a syringe, pinching subcutaneous tissue, injecting at a 90-degree angle, and holding the needle in place for five seconds after injection. Patients will be educated that needles will be used once and thrown away. Patients will rotate injection sites to minimize tissue irritation and be taught that insulin is best absorbed in abdominal tissue. Hyperglycemia commonly occurs with illness, and sick day rules will also be taught (Wexler, 2021). Most patients with gestational diabetes are normoglycemic after birth, although the long-term risk for developing diabetes increases, and patients should be screened 4 to 12 weeks postpartum (Durnwald, 2021). 3APA ref

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