Annotated Bibliography on Diabetes

This assignment consists of an annotated bibliography focusing on the topic of diabetes. The student has selected seven peer-reviewed journal articles that delve into different facets of diabetes, such as classification, the link between adiposity and insulin resistance, the role of metformin, diabetic retinopathy, cardiovascular diseases associated with type 2 diabetes, and HbA1c diagnostics in adolescents. Each article is accompanied by a concise annotation explaining its relevance to the overall understanding of diabetes.

Running head: BACHELOR OF NURSING
Case Study- Type 2 Diabetes
Name of the Student
Name of the University
Author Note

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Question 1
Insulin is a peptide hormone, produced by β-cells of the islets of langerhans, and
regulates the carbohydrates, proteins and fats metabolism by promoting the glucose absorption
from blood. Its effects are initiated by binding to a receptor containing α- and β subunits. This
binding triggers tyrosine kinase activity that promotes β subunits autophosphorylation. This
activates a signal transduction cascade that aids in glucose absorption. In the patient with type 2
diabetes, there is insufficient insulin production from the β-cells (American Diabetes
Association, 2014). This leads to insulin resistance. There occurs inappropriate release of
glucose from the liver cells into the bloodstream. The signal pathway gets inactivated which
leads to this resistance. Thus, the cells are unable to use insulin effectively, leading to increased
blood sugar.
Question 2
There is a high risk for angina pectoris in the patient because high blood glucose affects
the artery walls and increase the likelihood to degenerate the walls. Moreover, type 2 diabetes
increases risk of hypertension, high triglyceride levels and low levels of HDL cholesterol. Thus,
the risk of atheroma will increase (Shah et al., 2015). The heart muscles will become less
efficient to pump blood. Family history of diabetes, smoking and obesity will also make the
patient vulnerable to angina pectoris.
The patient is also at a risk of diabetic retinopathy due to chronically high blood glucose
levels. Light rays are detected by the retina and converted to signals, which are sent to the CNS
through the optic nerve. Type 2 diabetes will damage the blood vessels in the retina, and may

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lead to diabetic retinopathy. The blood vessels may bleed (hemorrhage) or leak fluid, thereby
distorting the vision (Ruta et al., 2013). In advanced stage, there may be abnormal proliferation
of the blood vessels on the retina surface, which in turn can lead to cell loss and scarring.
Question 3
Metformin can be considered as an effective drug for the patient. It works principally by
reducing or lowering the amount of glucose production from the liver. Metformin plays a role in
influencing peripheral glucose uptake and insulin sensitivity in the cells. It decreases elevated
blood sugar by the process of hepatic gluconeogenesis. Gluconeogenesis occurs three times the
normal rate in an average patient suffering from type 2 diabetes. Administration of metformin
reduces this amount by more than one-third. The potential action mechanisms include: AMP-
activated protein kinase (AMPK) activation, inhibition or suppression of mitochondrial
respiratory chain complex I and elevated cyclic adenosine monophosphate (cAMP) induced by
glucose, reduction of protein kinase A (PKA) and on gut microbiota effects (Pernicova &
Korbonits, 2014). Inhibition of liver glucose production primarily depends on AMPK activation.
The enzyme plays an essential role in maintaining energy balance, glucose metabolism and
insulin signaling. The drug also increases peripheral glucose uptake by GLUT4 phosphorylation
and enhances insulin sensitivity. However, it can lead to some gastrointestinal side effects in the
patient.
Question 4 (a)
Insulin resistance often is among patients with visceral adiposity. These people have an
increased amount of fatty tissue within their abdomen. This is distinct from any subcutaneous
adiposity. There are several evidences that suggest correlation between insulin resistance and

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abdominal adiposity. Unlike subcutaneous adipose tissue, the visceral adipose cells produce
increased amount of pro-inflammatory cytokines (Interleukins-1 and 6 and tumor necrosis factor-
alpha/TNF-α). Normal insulin function gets disrupted by these pro-inflammatory cytokines in
muscle and fat cells. This acts as the major contributor of development of insulin resistance in
patients with visceral adiposity. The NF-kappa-B/IKK-β pathway is a protein network, which
enhances transcription of inflammatory mediators and marker that are responsible for insulin
resistance (Hocking et al., 2013). Moreover, abdominal adiposity is associated with an
accumulation of fat in liver cells. This leads to a condition called non-alcoholic fatty liver disease
(NAFLD). Thus, free fatty acids get released into the bloodstream in excess amounts due to
increased lipolysis, followed by hepatic glycogenolysis increase. This exacerbates peripheral
insulin resistance and increases the likelihood of developing type 2 diabetes mellitus (Nolan et
al., 2015).
Question 4 (b)
HbA1c refers to glycated haemoglobin. It develops when haemoglobin joins with blood
glucose. The amount of glycated hemoglobin is directly proportional to total amount of blood
sugar level. Owing to the property of RBCs surviving for 8-12 weeks before they get renewed, a
measurement of HbA1c will reflect the average blood glucose level for the timespan (Sjaarda et
al., 2012).
This measurement will provide a long-term gauge of the patient’s blood glucose control.
If her HbA1c levels are found to be more than 6.5%, it will indicate that her blood sugar levels
have been elevated in the past few weeks. This will prove effective in administering medications.

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Annotated bibliography
American Diabetes Association. (2014). Diagnosis and classification of diabetes
mellitus. Diabetes care, 37(Supplement 1), S81-S90.
I used this journal to understand the basic classification of diabetes and the changes in insulin
hormone production associated with it. It is a reliable source as it is peer-reviewed.
Hocking, S., Samocha-Bonet, D., Milner, K. L., Greenfield, J. R., & Chisholm, D. J. (2013).
Adiposity and insulin resistance in humans: the role of the different tissue and cellular
lipid depots. Endocrine reviews, 34(4), 463-500.
I used this journal to examine the relative link between abdominal adiposity, hyperglycemia and
insulin resistance. It is a reliable source as it is peer-reviewed.
Nolan, C. J., Ruderman, N. B., Kahn, S. E., Pedersen, O., & Prentki, M. (2015). Insulin
resistance as a physiological defense against metabolic stress: implications for the
management of subsets of type 2 diabetes. Diabetes, 64(3), 673-686.
I used this journal to examine the effects of insulin resistance on obese patients with type 2
diabetes. It is a reliable source as it is peer-reviewed.
Pernicova, I., & Korbonits, M. (2014). Metformin [mdash] mode of action and clinical
implications for diabetes and cancer. Nature Reviews Endocrinology, 10(3), 143-156.
I used this article to understand the action of metformin in liver and its implications in
discovering metformin targets for diabetes mellitus and cancer treatment. It is a reliable source as
it is peer-reviewed.

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Ruta, L. M., Magliano, D. J., Lemesurier, R., Taylor, H. R., Zimmet, P. Z., & Shaw, J. E. (2013).
Prevalence of diabetic retinopathy in Type 2 diabetes in developing and developed
countries. Diabetic medicine, 30(4), 387-398.
I used this journal to study the association between type 2 diabetes and prevalence of diabetic
retinopathy among people belonging to developing and developed countries. It is a reliable
source as it is peer-reviewed.
Shah, A. D., Langenberg, C., Rapsomaniki, E., Denaxas, S., Pujades-Rodriguez, M., Gale, C.
P., ... & Hemingway, H. (2015). Type 2 diabetes and incidence of cardiovascular
diseases: a cohort study in 1· 9 million people. The lancet Diabetes &
endocrinology, 3(2), 105-113.
I used this journal to study the association between type 2 diabetes and cardiovascular diseases.
It is a reliable source as it is peer-reviewed.
Sjaarda, L. A., Michaliszyn, S. F., Lee, S., Tfayli, H., Bacha, F., Farchoukh, L., & Arslanian, S.
A. (2012). HbA1c diagnostic categories and β-cell function relative to insulin sensitivity
in overweight/obese adolescents. Diabetes Care, 35(12), 2559-2563.
I used this article to understand the relationship between HbA1c diagnosis and the
pathophysiologic mechanism of type 2 diabetes. It is a reliable source as it is peer-reviewed.

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