Research Korner: Diabetes Type 2

Managing Type 2 Diabetes

Managing Type 2 Diabetes Introduction: Diabetes mellitus is a common disease affecting approximately 5 % of the population (1995).  Diabetes is a chronic life – long condition impacts upon almost every aspect of life. The two major forms of diabetes are type 1 (previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes) and type 2 (previously called noninsulin-dependent diabetes mellitus (NIDDM) or maturity-onset diabetes) occurs after age 40, often between the ages of 50 to 60, and the disease develops gradually. Type 2 diabetes mellitus is caused by decreased sensitivity of target tissues to the metabolic effect of insulin. This reduced sensitivity is often referred to as insulin resistance. Type 2 diabetes usually need to change their lifestyle, but this can be difficult to do if the individual does not feel ill or the impact of not doing so does not have immediate repercussions. This syndrome like type 1 diabetes is associated with multiple metabolic abnormalities, although high levels of keto acids are usually not present in type 2 ( 2000). The frequency of diabetes in England is higher in men than in women. However, women with diabetes are at relatively greater risk of dying then men. This may be because of gender compounds other aspects of inequality. The key interventions underpinning the standards in this NSF are based on research evidence. The views and the experiences of people with diabetes, the work of the Audit Commission and the report of the Health Services Ombudsman have informed the development of this NSF. The typology below has been developed to distinguish between the different levels of supporting evidence. Levels of Evidence: Level 1: Meta – analyses, systematic reviews of randomized controlled trials, or randomized controlled trials Level 2: systematic reviews of case – control or cohort studies, or case – control or cohort studies Level 3: non – analytical studies, e.g. case reports, case series Level 4: expert opinion (in the absence of any above) Figure 1: Levels of Evidence Source: Department of Health: Modern standards and services The Diagram below summarizes the prevention and the management of diabetes.      Diagram 1: summary of the prevention and the management of diabetes Source: Department of Health: Modern standards and services Empowering people with diabetes: Standard 3 Aim: to promote self-reliance in attaining the best quality of life in managing diabetes type 2 Key interventions: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Structured education can improve knowledge, blood glucose control, weight and dietary management, physical activity and psychological well – being, particularly when it is tailored to the needs of the individual and includes skills – based approached to education (level 1).</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Personal care plans can help empower people with diabetes (level 4)</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Patient held/accessed records can facilitate self – care (level 4)</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> Telephone or postal reminders (1998) prompting people with diabetes to attend clinics or appointments are an effective method in improving attendance (level 4) </li> </ul> Implications for service planning:             According to , A; level one evidence, patient’s satisfaction and knowledge improve when lifestyle interventions are delivered by primary care staff who have been trained to take a patient – centered approach (1998). The health care professional’s task is to develop a working alliance with the person with diabetes to enhance and support their capacity to self- care. The components of self- care include: adopting and maintaining a healthy lifestyle; self- monitoring; and concordance with medication (See Box 1). Box 1: components of diabetes Self - Care Lifestyle: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Eating a balanced diet and other changes in eating habits, such as the timing of meals</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Regular physical activity</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Maintaining a healthy weight</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Smoking cessation</li> </ul> Self – monitoring <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Blood glucose self – monitoring and / or monitoring urine for glucose</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Monitoring for symptoms of hypoglycemia and hyperglycemia</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Monitoring for signs of long – term complications e.g. undertaking regular foot checks</li> </ul> Concordance with medication <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Oral hypoglycemic agents</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Other medications, such as antihypertensive drugs and lipid lowering drugs</li> </ul>   Box 1: Components of Diabetes Self – Care Source: Department of Health: national service framework for diabetes Diabetes Education should: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> equip people with the confidence and competence to manage their day to day diabetes care</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> provide people with diabetes with the necessary knowledge and skills to enable them to improve their blood glucose control and make the lifestyle changes necessary to reduce their likelihood of developing the complications of diabetes</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%"> be tailored to the beliefs, attitudes and social environment of the individual, their capacity to learn, and their changing life circumstances, knowledge and treatment goals</li> <li class="MsoNormal" style="text-align: justify; line-height: 200%">  allow and enable people with diabetes to practice the skills required for effective self- care. See Box 2 for topics to be covered in education programmes for people with diabetes.</li> </ul> Box 2: Topics to be covered in education programmes for people with diabetes Nature of diabetes <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Significance and implications of a diagnosis of diabetes; the impact of diabetes</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Aims and different types of treatment</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Relationship between blood glucose levels, dietary intake and physical activity</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Short and long- term consequences of poorly controlled diabetes</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Nature and prevention of long – term complications</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Importance of annual surveillance for complications</li> </ul> Day – to – day management of diabetes ·         Importance of healthy lifestyle, especially physical activity, a balanced diet and smoking cessation ·         Importance of self – management ·         Self – monitoring – glucose monitoring or urine testing ·         Interpreting the results of self- monitoring and tests  of long – term blood glucose control ·         Importance of regular foot care, choice of footwear, foot hygiene, the role or podiatry ·         Importance of oral hygiene and regular dental check – ups Specific Issues: <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Other illness and diabetes – ‘sick day’ rules must be given to al people with diabetes; immunizations.</li> </ul> Living with diabetes <ul style="margin-top: 0in; margin-bottom: 0in" type="disc"> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Importance of carrying personal identification, such as Medic – Alert, and a warning card including the name, contact address and telephone number of a person who can help them</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Driving: notification of the DVLA and insurance company and the importance of avoiding hypoglycemia while driving</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Holidays</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Implications of diabetes for employment, life insurance and travel insurance</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Making best use of health care services: what care to expect; when to contact local services for what; how to get more information (NB people with diabetes are entitles to receive an annual free eye examination by an optometrist/ophthalmic medical practitioner; those receiving treatment with either tablets or insulin are exempt from paying prescription charges)</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Contacting other people with diabetes</li> <li class="MsoNormal" style="text-align: justify; line-height: 150%"> Information about Diabetes UK and other local support groups </li> </ul>   Box 2: Topics to be covered in education programmes for people with diabetes Source:  national service framework for diabetes Care of people with foot ulcers: 1. For a new foot ulcer, urgent (within 24 hours) assessment by an appropriately trained health professional should be arranged (level 4) 2. ongoing care of an individual with an ulcerated foot should be undertaken without delay by a multidisciplinary foot care team (level4). 3. The multidisciplinary foot care team should compromise highly trained specialist podiatrists and orthotists, nurses with training in dressing of diabetic foot wounds and diabetologist with expertise in lower limb complications. They should have unhindered access to suites for managing major wounds, urgent inpatient facilities, antibiotic administration, community nursing, microbiology diagnostic and advisory services, orthopedic / podiatic surgery, vascular surgery, radiology and orthotics (level D). 4. Patients who may benefit from revascularization should be referred promptly. 5. Patients with non-healing or progressive ulcers with clinical signs of active infection (redness, pain, swelling or discharge) should receive intensive, systemic antibiotic therapy (level 3). 6. In the absence of strong evidence of clinical or cost – effectiveness, healthcare professionals should use wound dressings that best match clinical experience, patient preference, and the site of the wound, an consider the cost of the dressing (level 4). 7. Wound should be closely monitored and dressings change regularly (level 4). 8. Dead tissues should be carefully removed from foot ulcers to facilitate healing, unless revascularization is required (level 2). 9. Total contact casting may be considered for people with foot ulcers unless there is ischemia (level 2). 10. For patients with foot ulcers or prevention amputation, healthcare professionals could consider offering graphic visualizations of the sequelae of disease, and providing clear, repeated reminders about foot care (level 2).     Dietary management: There is no one diet prescription for people with diabetes. Four possible alternative methods for planning diets use: 1) the Plate Model, 2) the Diabetic Exchange Lists, 3) Carbohydrate Counting, and 4) the Food Guide Pyramid. The Plate Method is a simple method for teaching meal planning. A 9-inch dinner plate serves as a pie chart to show proportions of the plate that should be covered by various food groups. This meal planning approach is simple and versatile. Vegetables should cover 50 percent of the plate for lunch and dinner. The remainder of the plate should be divided between starchy foods, such as bread, grains, or potatoes, and a choice from the meat group. A serving of fruit and milk are represented outside the plate.                 Figure 2: the plate method Source: Diet and Diabetes   The Diabetic Exchange Diets, in this food system the food is separated into six categories based on macro nutrient content (i.e., starch [cereals, grains, pasta, bread, beans, and starchy vegetables], meat and meat-substitutes, non-starchy vegetables, fruits, milk and fats). Individuals, with the help of a physician or dietitian, design a daily meal plan based on a set amount of servings from each category. The Food Exchange method allows a person to measure rather than weigh food. This saves time and encourages compliance. Any food may be substituted for another within the same food exchange list. As with other methods, all meals and snacks should be eaten at about the same time each day and be consistent in the amount of food consumed. The Carbohydrate Counting; some people choose to count the grams of carbohydrate in various foods, and adjust the amount of carbohydrate consumed during the day as a reflection of blood glucose levels. One choice from the starch, fruits, milk, or sweets and dessert list supplies about 15 grams of carbohydrate. Each selection is considered one carbohydrate choice. A meal plan outlines the number of carbohydrate choices a person may select for meals and snacks. This method requires great diligence with diet and blood glucose monitoring. The Dietary Guidelines/Food Guide Pyramid this provides a conceptual framework for selecting the kinds and amounts of various foods, which together provide a nutritious diet. The Pyramid focuses on variety and on reducing the amount of added fat and sugar in the diet. The bread/cereal, vegetable and fruit groups make up the base of the diet.                   Figure 3: The Food Pyramid Source: A guide for daily food choices   Psychological Interventions:             Depression is more common on people with diabetes than in the general population. The presences of microvascular and macrovascular complications are associated with a higher prevalence of depression and lower quality of life (1998). Remission of depression is often associated with an improvement glycaemic control (2000).             Antidepressant therapy with a selective serotonin reuptake inhibitor (SSRI) is a useful treatment in depressed patients with diabetes and may improve glycaemic control (2000); however tricyclic antidepressant may adversely affect metabolic control (1997).             Cognitive behavioural therapy (CBT) is a psychological treatment which attempts to find links between the person’s feelings and the patterns of thinking which underpins their distress. CBT, psychotherapy programmes and coping skills training are useful in treating depression in patients with diabetes (1995). However, CBT is less effective in patients with complications ( 1998).   Pharmacologic Management: New oral medications make these targets easier to achieve, especially in patients with recently diagnosed diabetes. Acarbose, metformin, miglitol, pioglitazone, rosiglitazone and troglitazone help the patient's own insulin control glucose levels and allow early treatment with little risk of hypoglycemia. Two new long- acting sulfonylureas (glimepiride and extended-release glipizide) and a short-acting sulfonylurea-like agent (repaglinide) simply and reliably augment the patient's insulin supply. Combinations of agents have additive therapeutic effects and can restore glucose control when a single agent is no longer successful. Oral therapy for early type 2 diabetes can be relatively inexpensive, and evidence of its cost- effectiveness is accumulating. (1999)             In particular, we may conclude that Diabetes per se is of need of long term rehabilitation since its incurable and has to be managed day to day through out the patient’s life in order to prevent further complications. Different strategies must be implemented with the use of multidisciplinary health care teams in order to manage it effectively since, there is proper referrals for a specific type of management.

Managing Type 2 Diabetes

Managing Type 2 Diabetes Introduction: Diabetes mellitus is a common disease affecting approximately 5 % of the population (1995). D...

The Evolution of the Biopsychosocial Model: Type II Diabetes

The Evolution of the Biopsychosocial Model: Type II Diabetes   Type II Diabetes             Diabetes is a deficiency, wherein the internal chemistry of an individual is changed, resulting for the blood to contain too much glucose, caused by the inefficiency of the hormone ‘insulin’. The hormone insulin is the only hormone responsible for reducing the amount of glucose in the blood through the increase of glycogen in the liver, preventing the release of too much glucose from the liver, and by the increase of the take up of glucose by the other cells of the body. However, if this fails then the amount of glucose will be increased in the blood. There are two types of diabetes, namely, Type 1 or the Insulin-dependent diabetes mellitus, and the Type 2 or the Non-insulin-dependent diabetes mellitus. The Type-2 diabetes is more commonly regarded as age-related diabetes, being common to middle aged or older individuals and can be controlled by medications or dietary modification. The supply of insulin is low in this type of diabetes, thus, exhibiting inefficiency in controlling the levels of glucose in the blood. Several causes are determined in relation to this type of diabetes mellitus, namely, genetic factors, infection or other diseases, stress, and the environment. It has been perceived that genetic factors and heredity play an important role in the acquisition of diabetes, especially with identical twins. However, it does not always follow that if the parent has type 2 diabetes, then the offspring would also have it. Infections or diseases that may cause Type 2 diabetes may be related to diseases that may damage the pancreas, such as mumps and Coxsackie. Damage to the pancreas may also be brought about by excessive drinking, thus, relating alcoholism to this type of diabetes mellitus. Environmental factors pertain to the lifestyle of individuals, such as having an unhealthy diet and being overweight. This is also related to stress, as stress nowadays has become the major factor contributing to the change in the lifestyle of many individuals in all types of societies (2004). The recognition of the upsurge in cases of Type 2 diabetes mellitus leads many medical practitioners to adapt a number of models and approaches in terms of diagnosis and treatment. In fact, 85 to 90% of patients with diabetes exhibits the type 2 diabetes symptoms (1998), thus, becoming much more alarming. As such, this paper aims to discuss the evolution of the biopsychosocial model and its effects in the practice of medicine, specifically in Type 2 diabetes mellitus. This will be done with reference to a number of articles and journals regarding the subject matter.   Biopsychosocial and Biomedical Model             In the treatment of any disease, it is essential for any medical practitioner to diagnose the disease based on its symptoms and manifestations. However, due to the drastic changes that happen in the environment and the lifestyle of the many individuals, the diagnosis done based only on the symptoms of the disease may not be enough. As such, this relates to two models used in medicine, namely, the biopsychosocial and the biomedical models. The biomedical model refers to the model of illness that is being predominantly used for the past centuries, and emphasizes on biological factors in understanding the causes of any disease, without giving consideration on the psychological and social factors that may caused the disease or disorder ( 2004;2003). The use of this model of illness somehow contributes to the reduction of healthcare given to patients, as this is based on a number of beliefs that may hinder one to fully understand the disease. Beliefs of the biomedical model of illness emphasize that the illness and its symptoms come from an abnormality in the body of the patient, mental disorders are different from bodily dysfunction, thus, must be treated separately, and the patient is only a passive recipient of the treatment, thus, cooperation is expected (2004). In this regard, it can be understood that medical practitioners exhibit reductionism or becoming the detached observer in terms of treating and diagnosing patients, thus, becoming cold and impersonal towards patients and making them feel that they are not valued and ignored (2004). As such,  proposed and challenged the existing biomedical model of illness, and offered a model that aims to further understand the determinants of diseases to be able to arrive at balanced patterns of treatment in terms of healthcare ( 2003). This led to the recognition of many medical practitioners of the biopsychosocial model of illness, which, on the contrary to the biomedical model, integrates the psychological, social and biological factors in the diagnosis and treatment of any disease. In addition, this model of illness recognizes the fact that both the mind and the body interact with one another, thus, contradicting the biomedical model of emphasizing that a separate approach must be done in order to diagnose and treat mental and bodily illnesses. In relation to the treatment of Type 2 diabetes mellitus, it can be perceived that instead of using the biomedical model of illness alone, the use of biopsychosocial model would be more appropriate. This is because understanding the acquisition of Type 2 diabetes mellitus and the disease itself is not only based on the symptoms and manifestations of the disease, but of its various causes, which stem from biological, psychological, and social factors.     Evolution of the Biopsychosocial Model             As mentioned earlier, the evolution of the biopsychosocial model began with the recognition of Engel of the limited healthcare provided to patients, due to the reductionism approach and of being a detached observer of the medical practitioner. With such a new model of illness, the scope of the gaze of medical practitioners has been broaden, thus, presenting new ways and approaches in understanding the diseases of the patient through expansion of the domain of the knowledge involved in medicine. In addition, the foundation of the biopsychoscial model of illness is the content of emotions that is built upon the relationship of the patient and the medical practitioner. Integrated in such emotions is the fact that to be able observe the biopsychosocial model, the medical practitioner must be effective in influencing the behavior of the patient, thus, developing a good relationship. This leads to building trust between the medical practitioner and the patient, through extending empathy, basing decisions on race, sex, and gender, making intelligent decisions based on knowledge and learning, using informed intuition, and the use of effective communication between the patient and the medical practitioner (2004). As such, these practices would help enable the medical practitioners, including the doctors, clinicians, psychologists, and general physiologists to determine the causes of the diseases of a certain patient not only based on its symptoms and manifestations, but on social and psychological factors in the environment.             A number of models of illness have been based from the biopsychosocial model of illness with its introduction in the medical field. One of these models is the new model proposed by  (2004), which is also based or similar to the approach of the biopsychosocial model. It recognizes the fact that illness is both a physical and social dysfunction, and in this regard, illness must be both a dysfunction of the self and the organs, must be influenced by personal beliefs, values and attitudes, and free will, must be physical and cultural or social, and serves to hinder from social and physical activities. However, from its context, it can be perceived that this model is quite primitive or basic compared to other models developed for it is still incomplete with regards to the elements of providing substantial and effective healthcare to patients. Although this model presents a good basis and definition of illness, it does not provide concrete suggestions on how to address the illness itself. Nevertheless, its approach would still be helpful and beneficial in the medical field, with which it can be used as a basis for the consideration of what is illness and what it is not. In relation to the treatment and diagnosis of Type 2 diabetes, it can be perceived that from the definition of illness in this model, Type 2 diabetes mellitus is not much of an illness, as nowadays, more and more medications and preventive measures have already been dissipated in the public. In addition, nowadays, becoming a Type 2 diabetic is not anymore a hindrance in terms of social and physical functions, except for individuals who are suffering from extreme obesity and other complications such as visual impairment.               From this model, another model was developed from the biopsychosocial model proposed by in 1977, and is the IBM or the Interactive Biopsychosocial Model, which offers a dynamic framework that aims to build scientific hypotheses regarding health and disease, thus, even useful as a teaching tool in the aim of many individuals to share information and knowledge regarding health and disease. This model was used by (2003), being essential in aging and human sexuality. In relation to Type 2 diabetes, the IBM was also used to hypothesize that sexual dysfunction of individuals may be the effect of having diabetes due to physical manifestations, such as obesity, lack of energy, and visual impairments. In this regard, the authors relates sexuality with the severity of Type 2 diabetes, as their hypothesis suggest that sexual health helps prevent or helps reduce the development of Type 2 diabetes, in relation to aging. In addition to this is the conclusion of the authors, suggesting that many Type 2 diabetics have their conditions worsened due to compromised or poor sexuality, physical and mental health, and social activities ( 2003). From this, it can be understood that one way in understanding Type 2 diabetes is through the help of the Interactive Biopsychosocial Model, which emphasizes the importance of having social, mental, physical, and sexual activities in order to help preserve and maintain the health and well-being of a Type 2 diabetic.             In support of such claims that the determination of biopsychosocial factors being much more useful in terms of providing effective and efficient treatment to patients, physicians have done a certain study, which emphasizes the importance of the roles their attitudes play in the diagnosis and treatment of their patients using psychosocial factors. This particular study done by (2006) suggests that although many physicians recognize the significant role of psychosocial factors in the diagnosis and treatment of a particular disease, not all physicians would opt to use “mind-body methods”, such as therapies and focus groups. This is because the findings suggested that many physicians, who do not opt for alternative method states that they either lack the time, they lack the expertise, or there is the lack for available methods. This study also suggested the difference between male and female physicians in terms of adopting mind-body methods, as more female physicians might consider the role of psychosocial factors in the diagnosis and treatment of diseases more than men physicians do. Thus, in this regard, it can be understood that female more often recognize the importance of emotions and the factors that contribute to it than men. From this study, it can be understood that due to the lack of time and the lack of expertise of many physicians, it must be suggested that physicians must be provided with more knowledge and exposure to such alternative methods to provide them the information of its uses and implications to their patients. In this regard, these physicians would be able to realize the importance of psychosocial factors in the development of a particular disease. In relation to Type 2 diabetes mellitus, it can be perceived that the diagnosis and the treatment of this illness would be more effective if psychosocial factors would be given importance and significance. This is because its development is caused by a variety of factors, not only confined to the organic or functional dysfunction of an individual. With the changes in the environment and the lifestyle of individuals in today’s generation, the role of the society and the person’s environment could be contributory to the development of Type 2 diabetes mellitus. As mentioned earlier, one of the causes of Type 2 diabetes mellitus is the environment, including infections and stress.             From the discussion, it can be deduced that the introduction of the biopsychosocial model in the medical field has produced a number of positive effects, especially in the diagnosis and treatment of diseases, such as Type 2 diabetes mellitus. The evolution of this model from the biomedical model has provided many medical practitioners the opportunity to further and better understand their patients through the use of integrative and rational approaches that include the recognition of the significant role of the interaction of biological, social, and psychological factors in the development of a particular disease. As such, many changes have been observed and gone through by medicine practice, such as providing many medical practitioners with alternative approaches in treatment, including therapies and focus groups in order to cater to the social and psychological needs of their patients.

The Evolution of the Biopsychosocial Model: Type II Diabetes

The Evolution of the Biopsychosocial Model: Type II Diabetes Type II Diabetes Diabetes is a deficiency, wherein the ...

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