Insulin

Introduction Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. Insulin is a hormone that regulates blood sugar. Hyperglycemia, or raised blood sugar, is a common effect of uncontrolled diabetes and over time leads to serious damage to many of the body’s systems. No cure has been found for this disease. However, an important part of managing diabetes is maintaining a healthy weight through a healthy diet and exercise plan. Olokoba, Obateru, Olokoba, 2012) Type 1 diabetes (previously known as insulin-dependent, juvenile or childhood-onset) is characterized by deficient insulin production and requires daily administration of insulin. The cause of type 1 diabetes is not known and it is not preventable with current knowledge. Symptoms include excessive excretion of urine (polyuria), thirst (polydipsia), constant hunger (polyphagia), weight loss, vision changes, and fatigue. These symptoms may occur rapidly. Mosorovic, Brkic, Nuhbegovic, Pranjic, 2012) Type 2 diabetes (formerly called non-insulin-dependent or adult-onset) results from the body’s ineffective use of insulin. Type 2 diabetes comprises 90% of people with diabetes, and is largely the result of excess body weight and physical inactivity. Symptoms may be similar to those of Type 1 diabetes, but are often less obvious. As a result, the disease may be diagnosed several years after onset, once complications have already arisen. (Mosorovic, Brkic, Nuhbegovic, Pranjic, 2012) Diabetes is the seventh leading cause of death in the United States, affecting 25. million people of all ages (8. 3 percent of the U. S. population). Of the 25. 8 million affected people, 7. 0 remain undiagnosed. Diabetes is the leading cause of heart disease, stroke, kidney failure, lower-limb amputations, and new cases of blindness among adults in the United States. (http://diabetes. niddk. nih. gov) Meet Mrs. M, who was diagnosed with type 2 diabetes at the age of 35. Mrs. M is now 57 years old. She has learned that although there is no cure for type 2 diabetes, it can be managed. She is aware that in order to better manage this disease she needs to eat well, exercise, and maintain a healthy weight.

Mrs. M has graciously agreed to be interviewed. We will learn more about her, how she copes with this disease, and her struggle in maintaining a healthy weight by incorporating healthy cooking in her lifestyle. I will use the five holistic variables within the Neuman Systems Model (NSM) to identify how Mrs. M’s internal and external environment are affected. I will also assess Mrs. M’s learning needs and provide a trustworthy and reliable resource from which she can benefit from. Physical Variable Mrs. M was diagnosed with type 2 diabetes at the age of 35 when she became pregnant with her last child.

During a routine doctor’s visit, it was noticed Mrs. M was gaining a significant amount of weight. Around her 24th week of pregnancy, the doctor ordered she have a glucose test. The test showed a high level of sugar in her blood. The test was repeated and once again, it showed that her glucose level was higher than normal and there was also sugar in her urine. At that point, the doctor diagnosed her with gestational diabetes. In 1990, the only thing that was prescribed was that she begin administering a daily injection of insulin. This came as a completely shock to Mrs. M. She had never even heard of this thing called “diabetes”.

Even more disturbing was the fact that she, and her unborn baby, was now carrying this disease. The doctor advised Mrs. M that although the glucose could reach and affect her baby, the insulin would not cross over to the baby. She was pleased with the news that once she delivered the baby, she would return to her normal diabetic state. The doctor informed Mrs. M the importance of checking her blood glucose and maintaining a healthy diet after the birth. This would help to reduce her chances of developing type 2 diabetes. Despite the recommendations, Mrs. M ended up developing type 2 diabetes.

For the past 22 years, Mrs. M has been living with this chronic disease. Her medication has been changed several times throughout the years. At the moment, she is taking Glucophage 500mg and 4 units of Humilin in the morning. From the last time Mrs. M was seen by her primary care physician, these were her results: she weighed 170 pounds, blood pressure was 122/78, average blood sugar was 125 mg/dL, average hemoglobin A1c test (HbA1c) average was 5. 98%, her cholesterol and triglyceride levels were within normal limits, her kidneys were working well, and no obvious sores or infections of her feet or skin.

Her last optometry visit showed no problems with her vision. She knows dental exams and cleaning are important and makes sure to visit the dentist every six months. In assessing Mrs. M’s physical variable, I determined that the lack of knowledge about diabetes as a major stressor. Mrs. M’s doctor visits have been a major resource. Socio-cultural Variable She is a traditional Mexican woman and her cooking or eating habits have never been a concern. She has always cooked traditional Mexican dishes, which are high in fat. She never learned to cook or eat healthy.

It is a belief of Mrs. M that anything that is “low fat”, “nonfat”, or essentially “healthy” must not taste good. Mrs. M was recently laid off and is unemployed, leaving her with no insurance. She does not want to visit the doctor’s office because she says that it is too expensive. Not only does she have to pay for her medication, but also the doctor’s visit and the laboratory bill. This has given her motivation to try to lose weight. She does realize that if she loses weight, she could possibly be able to get off the medications she is on.

At this point, she is walking on a daily basis but still finds it hard to start healthy eating habits. She would like to learn how to maintain a healthy diet that she and her family can benefit from. It is hard for her to break free from all the foods she has loved all her life. However, she realizes it is necessary to make this drastic change in order to help her lose the weight. In assessing Mrs. M’s social-cultural variable, I determined that the lack of insurance as a major stressor. Mrs. M’s motivation and willingness to lose weight are major resources. Psychological Variable

Just like everyone else, Mrs. M has good days and bad days. On most days, she feels motivated and hopeful that she will be able to better control her diabetes and get off her medicine. She goes on daily walks and really enjoys it when her daughter goes with her. She says that when her daughter goes on these walks with her, it makes the time go by fast and she really enjoys the time they spend together. These walks serve not only to lose weight but also as a distractor. Mrs. M uses this time to talk about her day and about life in general. However, there are days that are not so good for Mrs. M.

There are days where she feels defeated and burned out by her diabetes. She feels like she is “old” now and her health is slowly declining. She has had this disease for so long now and doesn’t see any improvement. It has been a stagnant process for her and that really frustrates her. There are days when she gets angry that she can’t eat certain foods and that she has to take medications to be able lead a semi normal life. Some days, she feels like just giving up and letting God decide her faith. In assessing Mrs. M’s psychological variable, I determined her feeling of defeat is a major stressor. Mrs.

M’s daily walks with her daughter are a major resource. Spiritual Variable Mrs. M is a devoted Catholic. She has complete faith in God, the Catholic Church, and the power of prayer. Mrs. M feels our whole universe isn’t controlled by human beings, but by God. Her life, past and future, lies solely in God’s hands. There is no question in her mind that there is an afterlife, where her soul and spirit will rise to and will go to a better place. She is not scared of death. She looks forward to the day when she will be at peace and free of worries and pain; a place where she will live eternally, full of happiness and joy.

She anticipates the day when she can reunite with her father and be able to see him, talk to him, and hold him again. Mrs. M feels she has lived a gratifying and good life. She says she has been blessed to have had the opportunity to live and experience this thing we call “life”. She knows her disease has many health consequences and feels that if something happens to her, God made it happen for a reason. He controls her life and she is willing to accept what he has decided for her. In assessing Mrs. M’s spiritual variable, I determined that there is no stressor involved. Mrs.

M’s faith in God is a major resource. Developmental Variable Stage of development Generativity vs. Stagnation is Erik Erikson’s second psychosocial development stage of adulthood and happens between the ages of 25-64. During this time, we establish our careers, settle down within a relationship, begin our own families and develop a sense of being a part of the bigger picture. We give back to society through raising our children, being productive at work, and becoming involved in community activities and organizations. By failing to achieve these objectives, we become stagnant nd feel unproductive. Mrs. M is in the Generativity stage. (Craven, Hirnle, 2009) Tasks of developmental stage Mrs. M is married with 4 grown children, and will celebrate her 36th wedding anniversary on December 14, 2012. Mrs. M was born in Jalisco, Mexico and moved to the United States when she was 21 years old. Her ideas and customs still remain traditional to the Mexican culture. Mrs. M was raised with the idea that family should come before everything, even herself. Mrs. M put her education on hold to be able to provide for her family, leaving her to work low paying jobs.

She has worked her whole life to give her children the most and best she can. This has included working 12 to 14 hour shifts and then rushing home to make sure her kids had dinner and did their homework. She has always strived to keep her family happy, safe, and united. Her children are grown now and she maintains a good relationship with them. Now that her children are grown, she feels a sense of emptiness. She admits to feeling an overwhelming amount of sadness when thinking of how her house was once filled with her children’s laughter and now is so “empty”.

There have been days when she feels she may be depressed. On these days she has to force herself to get out of bed and doesn’t feel like eating. She knows this is not good for her and affects her diabetes. She has noticed when she is feeling this way, her blood sugar drops. On the other hand, remembering all the precious times she has lived with her family brings a smile to her face. Mrs. M has always made her kids her number one priority and feels they have not let her down. Knowing that her kids are positive and productive members of society gives her a sense of accomplishment.

She has a glow on her face every time she speaks of her kids. It makes her feel proud, loved, and special to know she has a family she can depend on, regardless of the situation. In assessing Mrs. M’s developmental variable, I determined that the depression she deals with is a major stressor. Mrs. M’s family is a major resource. Health Learning Needs After speaking with Mrs. M, her main concern is incorporating healthy meals and eating habits into her lifestyle. She feels cooking healthy is something she has always struggled with and would like to get more information as to how to cook healthy meals.

Mrs. M has made it clear that she is a visual and hands on learner. She needs to ”first see it and then do it” in order to better understand a task. Due to this information, I believe Mrs. M would benefit from a website that plays videos and has live demonstrations. Learning resource My recommendation to Mrs. M is that she visits the American Diabetes Association website at www. diabetes. org. This website has a lot of information that is helpful to anyone with type 2 diabetes. Mrs. M would benefit from the “Food and Fitness” tab.

Under this tab she can find information on what type of foods she should be eating, healthy recipes, and helps in planning meals. There is also information about fitness and weight loss. There are great exercise ideas which will help Mrs. M get motivated to lose weight. This website offers live videos which will help with her visual learning need. Conclusion In summary, the NSM aims to promote a client’s optimal wellness. This model helps us see beyond just the objective clinical manifestations, which we are trained to observe. It helps us understand our clients on a whole new level, an interpersonal and holistic level.

By completing an accurate NSM assessment, we see how culture, economic resources, spirituality, and family affect a client’s disease process. With the help of the NSM, I was able learn more about Mrs. M, assess her learning need, and provide a trustworthy and reliable resource from which she can benefit from. The www. diabetes. org website will teach her how she can maintain a healthy weight by incorporating healthy cooking in her lifestyle. References Olokoba, A. B. , Obateru, O. A. , ; Olokoba, L. B. (2012). Diabetes Mellitus: A Review of Current Trends. Oman Medical Journal, 27(4), 269-273. oi:10. 5001/omj. 2012. 68 Mosorovic, N. , Brkic, S. , Nuhbegovic, S. , ; Pranjic, N. (2012). Quality of life of people with Diabetes Mellitus. Healthmed, 6(7), 1076-1080. Demirbag, B. (2012). Neuman system model as a conceptual framework for community-based nurses when working with patients. Healthmed, 6(7), 2438-2445. Craven, R. F. , Hirnle, C. J. (2009). Fundamentals of Nursing. Philadelphia: Lippincott Williams and Wilkins. National Diabetes Information Clearinghouse (NDIC) (February 2011). Fast fact on Diabetes. Retrieved from http://diabetes. niddk. nih. gov/dm/pubs/statistics/#fast

This is a personal health plan for a 50 year old woman who is diabetic, has had a heart attack and overweight by 30 pounds. More than seven million American women have diabetes, about the same number as men.

Diabetes is a disease that forces your body to starve when it is full of food. Normally, your body takes last night’s dinner or this morning’s breakfast and turns it into a sugar called glucose. Then it dumps the glucose into your blood, where it teams up with insulin secreted by your pancreas. The insulin carries glucose into you muscles and organs, where it provides the energy for everything you do.

A drop in available insulin or the body’s resistance to using that insulin can cause   metabolic mayhem. With diabetes, glucose builds up in the bloodstream because it is unable to gain admission to muscles and organs. It wears on the heart, kidneys and eyes and then it flows into the bladder and passes out of the body – leaving behind damaged organs starved for fuel.

Left too long, in this situation, the body powers down: Symptoms you may have attributed to stress or growing older, can, if unheeded escalate into the complications of diabetes—heart disease, stroke, blindness or kidney failure.

Physical

Prevention is important here. That is why, they physical part of the 12 month personal plan involves losing weight. “The higher your weight, the higher your risk of diabetes,” say Richard Hamman, M.D. professor of preventive medicine at the University if Colorado School of Medicine in Boulder. You especially need to lose weight if your body is shaped like an apple—thick in the middle. More glucose in the blood makes the pancreas dump in more insulin. Eventually the whole system breaks down, says Dr. Kohrt.

Women who are sedentary probably have a 25 to 40 percent increased risk of diabetes compared to women who are more active at the same weight,” Dr. Hamman says. You must be active physically. What do we mean by this? It is like taking a walk in the morning, going up three or four flights of steps rather than taking elevators. It is doing these things every day.

Psychological

You must visit a massage center and have a good massage, so that your body and nerves will become relaxed and full of energy. You must plan to do this the next time you find yourself edgy. You must get a Manual Lymph Drainage Massage.

This is a process done to the body in order to improve the flow of the lymph rhythmic strokes. This is used in conditions when the body is already developing edema. The process is used in several massage spas and is a great way to detoxify the body. The massage can be readjusted to a low pressure of the hands for those afflicted with some bone disease.

Type 2 diabetes mellitus is a condition that is characterized by a chronic rise in the glucose levels of the blood.  It can lead to changes of the blood vessels of the retina, nephron, heart, nerves, etc, causing a lot of complications.

Individuals, who suffer from type 2 diabetes, may or may not require insulin (as the condition primarily occurs due to insulin resistance or improper utilization of insulin by the blood cells).  In many cases, people who suffer from type 2 diabetes, are ultimately given insulin, even though the drug is not very effective in control the high blood sugar levels (Ligaray, 2008).

Studies conducted in the UK effectively demonstrate that 25 % of the patients who suffer from type II diabetes require insulin within 6 years of initiating therapy with oral hypoglycaemic agents (Edelman, 2005).

In clinical practice, type 2 diabetes mellitus is one of the commonest diseases that are seen.  The insulin levels may be low, defective in nature or the very utilisation of insulin by the fat, liver and the muscle cells may be hampered.  The individual may not for bringing back the blood glucose levels back to normal.  Ketosis seldom develops, but is common under stressful conditions (Inzucchi, 2007).

Today, in the US, the screening for diabetes is usually performed in elders or high-risk individuals, and as such there may be several members of the general population who may be silently suffering from the disorder.

The prevalence of diabetes mellitus in the US is about 7 %, but in individuals above the age of 50 years, the incidence may be about 15 %.  Certain minority groups including the Hipics, African-Americans, Native Americans, etc, are at a higher risk of developing the disorder.

  The mean age of incidence of the disorder in high-risk populations usually occur at a younger age compared to the White American populations.  If we look at the prevalence of diabetes mellitus type 2 throughout the world, the incidence is high in Indians, Polynesians, Micronesians, Latin Americans, etc.

In Australians, Africans, Aborigines, Asians, etc, the incidence is relative lower when they live in the native countries.  However, when they migrate to the US, the prevalence of the disorder is relatively higher, owing to the change in lifestyle, poor control over risk factors, etc.

A great proportion of diabetic patients die from cardiac diseases such as heart attacks, stroke, etc.  Studies have effectively demonstrated that the risk for cardiac disease raises two-folds in men, and up to four folds in women (Ligaray, 2008).

The main pathophysiology of diabetes is the rise in the blood glucose levels (hyperglycaemia) due to the low insulin levels in the blood, improper utilisation of insulin by the cells, defective functioning of the insulin or resistance to insulin.  The pancreatic beta islet cells may not produce sufficient amounts of insulin required by the body or several groups of cells present in the body such as the fat, muscle, liver, etc, may be resistant to the action of insulin.

Studies conducted during autopsy have effectively demonstrated that the beta cell mass in type 2 diabetics are reduced to about half the normal size.  The body cells find it seemingly difficult to utilize glucose resulting in lower amount of glucose transportation to the muscles, greater production of glucose by the liver and greater breakdown of fat (Ligaray, 2008).

Other causes of diabetes type 2 include production of substance by the body that hamper the action of insulin, glucotoxicity and lipotoxicity.  When the individual consumes carbohydrates, there are chances that the blood glucose level would raise further, as insulin is not available to control (Inzucchi, 2007).

The ability of the body to use insulin immediately to control carbohydrate and sugar level following ingestion is difficult (Ligaray, 2008).  Studies may have shown that although the insulin deficiency may be mild, the ability of the insulin to stop an immediate rise in the blood glucose level would be absent.  When the individual suffers from mild type 2 diabetes during the initial stages, there are chances that the insulin secretion would respond to other secretogogues such as amino acids.

However, in severe type 2 diabetes, the condition does not respond to other secretogogues resulting in a severe deficiency of insulin.  In individuals suffering from type 2 diabetes, there may be deposition of an amyeloid-like substance in the beta-cells of the pancreatic islets.  The beta-cells begin to malfunction following the deposition of amyloid (Inzucchi, 2007).

In some of the type 2 diabetics the insulin secretion may be defective in nature.  The ability of the cells to respond to insulin is reduced and the normal response is less.

The cells may not be able to use the insulin effectively to ensure utilization of glucose by the cells.  In an environment of hyperglycaemia, the cells find it very difficult to utilize the insulin and the glucose.  The body finds it difficult to produce glycogen from glucose in the liver and breakdown of fats, as a result of the decreased sensitivity of the insulin.

The exact reason for the poor response of the cells to insulin is not understood clearly, but scientists suggest that it has to do with the defective mitochondrial functioning and the accumulation of free fatty acids in the cells that are usually supposed to respond to insulin.  The insulin receptors in such cells may be normal, but the insulin pathways that are related to the insulin receptors may go haywire.

The functioning of the glucose transporting agent GLUT may become abnormal.  Scientists also feel that the defects in insulin use and glucose transportation may be due to a genetic defect.  Obesity also increases the risk of the individual developing resistance to insulin.  The presence of free fatty acids in the body would suggest greater amount of lipid deposition in the liver and the muscles thus playing a major role in developing insulin resistance (Inzucchi, 2007).

When the blood glucose levels are high, the sensitivity of the cell to insulin and the ability of the cell to utilize glucose are seriously affected.  Besides, a rise in the lipids in the blood can affect glucose metabolism, causing a raise in hepatic gluconeogenesis, and raising the free fatty acid levels.  The pancreas functions abnormally and the muscles are unable to utilize glucose effectively (Inzucchi, 2007).

It may be difficult to assert whether the primary defect in type 2 diabetics is due to insulin insufficiency or insulin resistance.  Studies have demonstrated that in high-risk populations, the initial defect is primarily due to insulin resistance and a decrease in the insulin sensitivity.

However, diabetes would not occur only with insulin resistance alone.  Studies have shown that frequently due to the secretory defects, the beta cells seem to get exhausted.  It may also be that chronic stimulation of the beta-cells along with the genetic defects would result in insulin insufficiency (Inzucchi, 2007).

Evidence strongly supports that genetics and environmental factors both play a major role in the development of diabetes mellitus type 2 (some even suggest complex genetic factors).  Most of the forms of type 2 diabetes mellitus have been polygenic in nature, whereas maturity-onset diabetes of the young (MODY) has been monogenic in nature.  There is a clear familial linkage seen in diabetes mellitus type 2, but there seems to be no classical Mendelian inheritance (Inzucchi, 2007).

Diabetes mellitus patients are at the risk of high mortality in case their condition worsens and complications develop.  Hence, one the keys to ensure a longer lifep in diabetes patients is effective management using drugs and medications.

Studies have clearly demonstrated that diabetes patients require an aggressive, intensive and early intervention that would be able to identify a rise in the blood sugar level and ensure that it is brought within normal range.  One of the most difficult complications of diabetes patients would be developing is heart disease.

The mortality from heart disease is quite high (70 %) in diabetics.  Besides, the costs of managing a patient suffering from diabetes and heart disease are about three times higher (Unger, 2008).

Diabetes mellitus is mainly diagnosed on the basis of the plasma glucose levels.  The fasting blood glucose level should be more than 126 mg per dl of blood.  The post prandial blood glucose level should be greater than 200 mg per dl of blood (typically taken 2 hours after a meal).  The impaired glucose tolerance levels include 140 to 199 post-prandially.

In diabetes, a random blood glucose test should demonstrate reading above 200 mg per dl along with the presence of symptoms of diabetes.  For the individual to be classified as diabetic, the blood glucose tests should demonstrate consistent results.  Haemoglobin A-1c is also useful in demonstrating the retrospective glucose levels, but cannot be taken as standard as there are several potential errors that may be associated with this test (Buse, 2008).

DESCRIPTION

Diabetes pertains to a metabolic disorder that is associated with the lack or absence of insulin, a protein that transports glucose into the cells of the body.  Glucose, also simply known as sugars, is considered as the first source of energy for the daily activities performed by the human body, such as walking and standing.  In addition, glucose also serves as the main resource for the energy that is required to fuel cellular processes within the body, including that of growth and repair of cells and tissues.  The food items consumed by an individual generally contain glucose and thus the presence of insulin is important for the transport of this macromolecule to the appropriate regions of the body.

Insulin is mainly produced by the pancreas, which is a digestive organ that is strategically located next to the small intestines, where digestion commonly occurs.  Once the process of digestion has been completed in the intestines, the glucose molecules transported into cells through .  In normal individuals, the amount of insulin produced by the pancreas is enough to transport the glucose that is present in the meal consumed.  On the other hand, individuals with diabetes show a lack or absence of insulin secreted by the pancreas, thus preventing the transport of the glucose molecules into the cells.  Glucose is therefore left outside the cells and these remain circulating in the blood.  The continuous accumulation of glucose further extends from the blood to the urine, which in turn are samples employed for the diagnostics of diabetes.

CAUSES OF DIABETES

Diabetes is generally caused by a number of factors, depending on the type of diabetes that has been positively diagnosed in an individual.  Type 1 diabetes, also known as insulin-dependent diabetes mellitus (NIDDM), pertains to an autoimmune condition that involves the incapacity of the body to combat infections (NIH, 2010a).  In this case, the immune system of an individual causes the destruction of the cells of the pancreas, thus decreasing and possibly preventing the production of insulin for glucose transport.  The actual mechanism that triggers the destruction of the pancreatic cells by the immune system is still unknown and there are active efforts in the field of biomedical research that are attempting to elucidate this reaction.

Type 2 diabetes, also known as non-insulin dependent diabetes mellitus (NIDDM), pertains to an increase in the level of glucose in the body due to aging, obesity or genetic inheritance of the condition (NIH, 2010b).  Type 2 diabetes is therefore more commonly observed among elderly individuals, as their metabolic rate generally slows down as they age.  Obese individuals tend to develop diabetes because their food choices are often different from the recommended daily diet, thus increasing the likelihood that sugar-rich foods would be consumed on a regular basis.

Gestational diabetes pertains to the increase in the blood glucose level of a female during pregnancy.  This occurrence is usually linked to the gain in the total body weight of a woman during pregnancy, as well as the decrease in the physical activity of the woman as she progresses through the entire gestational period of 36 weeks or 9 months.  Unlike types 1 and 2 diabetes, gestational diabetes often disappears once the woman has given birth.  The disappearance of the features of diabetes are possibly linked to the loss in the total body weight after birth, as well as the increase in the physical activity of the woman after delivery.

EPIDEMIOLOGY OF DIABETES

Type 1 diabetes generally affects both males and females, yet there are certain characteristics that strongly associated with this metabolic disease.  According to the World Health Organization, type 1 diabetes is more common among whites and is considered as a rare disease among non-white populations of Africa and Asia.  Type 2 diabetes, on the other hand, is commonly diagnosed in elderly individuals.

Moreover, elderly individuals who are overweight are more likely to develop type 2 diabetes because these individuals tend to be less active in physical activities.  Certain populations are thus associated with type 2 diabetes, including those of African and Asian ethnicities.  In the United States alone, there are 24 million individuals with the age of 20 years old and above that have been diagnosed with diabetes (NIDDK, 2007).  On the other hand, there are 12 million elderly individuals who have been diagnosed with diabetes in the United States.

TREATMENT OF DIABETES

Type 1 diabetes is generally treated with the administration of insulin on a daily basis.  Patient are therefore taught how to inject insulin everyday, in order to maintain a normal level of insulin in their blood.  Type 2 diabetes is usually treated with medications that assist in the digestion of glucose from the food items consumed.  This medication is given on a daily basis using a tablet or capsule format.  In addition to medications, a healthy diet is highly recommended to diabetic patients.  This includes food items that are low in sugar content, such as green, leafy vegetables and fiber-rich fruits and grains.

Exercise is also recommended for diabetic patients, as this assists in increasing the metabolic rate of the body.  Diabetic patients are also educated on the condition of hypoglycemia, which is the extreme lowering of the blood glucose level of the body, resulting in fainting and a decrease in the arterial blood pressure.  A dietician therefore plays an important role in the design of the dietary regimen of diabetic patients.  A regular check-up should also be performed every 3 to 6 months, wherein the fasting blood sugar levels are determined, in order to evaluate the progress of the patient with the current dietary regimen.

REFERENCES

National Institute of Diabetes and Digestive and Kidney Diseases.  (2007).  National Diabetes Statistics, 2007.  Downloaded from http://diabetes.niddk.nih.gov/dm/pubs/statistics/DM_Statistics.pdf on July 8, 2010.

National Institutes of Health.  (2010a).  Type 1 diabetes: Thirty years of progress.  Downloaded from http://www.nih.gov/about/researchresultsforthepublic/Type1Diabetes.pdf on July 8, 2010.

National Institutes of Health.  (2010b).  Type 2 diabetes: Thirty years of progress.  Downloaded from http://www.nih.gov/about/researchresultsforthepublic/Type2Diabetes.pdf on July 8, 2010.

Introduction

In recent times there has been a surge in non-communicable diseases, especially Type 2 diabetes mellitus (T2DM), in sub-Saharan Africa (SSA). This is an extra burden upon the healthcare systems, which already have to cope with the high prevalence of communicable diseases such as HIV/AIDS, tuberculosis and malaria. I chose to read up on this issue as it is a topic that is not really addressed in the field of diabetes.

Epidemiology

There were approximately around 200 million people with diabetes worldwide. This figure is on the rise and has the potential to reach around 380 million in the year 2025. This huge increase also is expected to be seen in Africa and Asia.

T2DM is the most common form of diabetes with around 90% of diabetic patients. The current prevalence of T2DM in SSA is only a third of the HIV prevalence, however it is estimated to reach the same as current HIV prevalence by 2025. The prevalence is around 1.4% or lower in most SSA countries, however it is raised to around 3% in South Africa. There is also a greater prevalence of the disease in urbanised areas, as apposed to the more rural locations. It has been. The prevalence of diabetes in Africa was around 3 million in 1994, rising to 7.1 million by the year 2000. In 2010 the figure was around 12 million and is set to rise up to around 24 million by the year 2030. This phenomenon may be due to the rapid urbanisation these countries are facing.

Risk factors

These factors can be split into modifiable (i.e. can be changed) and non-modifiable. Modifiable risk factors include the rise in obesity seen in SSA. This rise can be attributed to the rapid urbanisation of SSA countries. A study in 2002 showed the extent of clinically overweight/obese people in South Africa to be 56% for females and around 29% for males. Other studies have shown diabetic patients in SSA have a higher BMI than non-diabetic patients. However, one may argue that it is truncal obesity, which is more closely linked to T2DM than BMI. One study has shown the level of truncal obesity in Cameroon to be 18% in males and 67% in females. This may be due to the consensus that women who are larger are deemed healthier and richer, especially in countries where HIV is prevalent.

The diet of the people of SSA is becoming more westernised including the rise of saturated fats, sugars and lower levels of fibre. This paired with rapid urbanisation leading to a more inactive lifestyle is likely to contribute to the rise in T2DM seen.

Countries of SSA are also increasing their GDP and so are becoming more prosperous. This is linked with the urbanisation, which has been mentioned. This has lead to the rise in processed foods consumed, inactive lifestyle and inevitable increase in obesity.

Non-modifiable risk factors include age and ethnicity. The most common age group for T2DM was 45-65 year. Some studies showed that more women had T2DM than women in certain SSA countries. There is also an effect from ethnic origin, for example some countries have a higher population of Indian people, where the prevalence of T2DM is higher.

Other risk factors include TB or the use of antivirals, which may increase the likelihood of contracting T2DM.

Complications

Complications arising from T2DM can either be classified as macrovascular or microvascular. Macrovascular complications include cardiovascular disease and stroke. Microvascular complications include nephropathy, neuropathy and retinopathy. Patients from developed countries have greater macrovascular morbidity, whereas in SSA the opposite is true.

In developed countries T2DM mortality is due to CVD and renal complications, however in SSA the mortality is greatly due to infections and metabolic problems. Infections include sepsis and TB. Metabolic problems are usually keto-acidosis and hyperosmolar non-ketotic coma.

However there is still a lot of un-obtained data, which is due to the poor documentation of the cause of death. It is one of the challenges to increase the number of deaths reported, and also to report it accurately.

Treatment

The key to decreasing the morbidity and mortality associated with T2DM is to maintain good control over the blood glucose levels. This can be achieved using a diet management plan, exercise and, if needed, the use of appropriate medication.

Drugs, which can be administered, include sulphonylureas, which promote insulin secretion after a rise in glucose levels. Meglitinides, which are insulin secretagogues. Biguanides such as Metformin, decrease the rate of gluconeogenesis and thus lower blood glucose. Insulin can also be used as a last resort in T2DM to maintain good glucose control.

A study has highlighted the poor blood-glucose control for patients with T2DM in SSA. These were patients who were on various different treatment regimens ranging from sulphonylureas to insulin. This maybe due to lack of availability of drugs, high cost of drugs/lack of funds, lack of adherence, lack of patient education and late presentation. One paper showed that a few health care settings in Tanzania only had a couple of sulphonylureas and insulin in their drug stores.

Major challenges and solutions

To understand why there is poor care of patients with T2DM in SSA, one has to identify the problems that are faced in order to create a solution. The economy of these countries is already stretched and so have low healthcare budgets. This means that there is not enough money to purchase drugs and provide optimal healthcare to T2DM patients who require chronic care. This problem is exacerbated due to the fact that communicable diseases such as HIV take up more of the budget, leaving a decreasing amount of money to be spent on non-communicable chronic conditions.

There is also a lack of qualified healthcare providers and so insufficient manpower. This maybe due to the lack of training and courses in order to create these qualified healthcare providers. There are also poor healthcare referral systems. This inevitably shows the lack of organisation within the healthcare systems in SSA. This needs to be tackled by reorganising the healthcare infrastructure and create/improve training programmes for the staff. Greater drug supply is also essential. One study showed that there was a lack of insulin in some SSA countries such as Mali. There also needs to be improved access to care, as many patients can’t reach the required level of care in order to manage their T2DM well.

There is also poor patient education in SSA, and so this leads to poor adherence of treatments as well as poor glycaemic control. T2DM is a chronic disease and so patient education is key in good management of the disease in order to decrease complications arising. Greater primary and secondary prevention strategies need to be established, as this will be economically beneficial. Interventions need to be cost effective as there are limited resources and funds.

A lot of the data collected regarding T2DM care is inaccurate or just simply not collected. In order to assess the characteristics of the disease in SSA, better data collection methods need to be initiated. Poor record keeping is detrimental to the care of the T2DM patient, where glucose monitoring ensures stable control.

An example to follow is the National Diabetes and Hypertension Program in Cameroon. This initiative saw the coming together of health-care providers, policy-makers and people from the community in order to tackle the growing epidemic of T2DM in SSA. Strategies are shown in figure 2. This program ensured greater monitoring, documentation as well as better interventions which all lead to better care for T2DM patients.

Conclusions

With the rapid urbanisation and greater prosperity seen in sub-Saharan Africa, T2DM is becoming an underestimated epidemic. With the focus on communicable diseases, the care of T2DM is not improving, as seen by the multitude of problems faced in SSA. Strained healthcare budgets mean that it is necessary, more than ever, to produce cost-effective initiatives. Governments need to understand the dangers of communicable diseases as well as non-communicable diseases. Better primary and secondary prevention strategies need to be created to target issues such as the rising levels of obesity. Governments need to issue better guidelines, training and promote policymaking. Initiatives such as National Diabetes and Hypertension Program in Cameroon have had very positive feedback and have set the standard for other governments within SSA.

If this problem is not addressed, there will be a negative impact on T2DM morbidity and mortality. This will inevitably reduce the socioeconomic growth in SSA countries, which is vital for the prosperity of the country.

Introduction

Diabetes mellitus is a group of metabolic diseases characterised by chronic hyperglycaemia. Its causation is due to an insulin deficiency resulting from the body’s inability to produce enough insulin, or an inability at a cellular level to respond to insulin that is produced. These two pathological mechanisms are used to distinguish between the two major classifications of the condition.

In the first case (Type 1), insulin-producing cells in the pancreas have been destroyed, usually as a result of an auto-immune process, whereby the body mistakenly identifies the insulin-producing cells (or beta cells) as foreign, and ultimately destroys them. By the point of diagnosis, whereby the body’s inability to produce enough insulin leads to clinically significant blood sugar levels, it is estimated that 60 – 80% of the body’s beta cells have been destroyed (Notkins & Lernmark, 2001). The subsequent lack of insulin leads to a typical triad of clinical symptoms; polydipsia (increased thirst), polyuria (frequent urination) and polyphagia (increased hunger).

As insulin is necessary for survival, Type 1 diabetes is fatal unless treated. Missing insulin must be replaced indefinitely in all patients, and is typically administered via injection or insulin pump. Although such treatment can be burdensome for patients, with appropriate clinical care, teamed with patient awareness and training in self-management, it should not significantly impair daily life.

In the case of Type 2 diabetes, the body responds to either a relative reduction in insulin, a resistance to the insulin the body does produce, or a combination of both. Initially the pancreas may begin to over-produce insulin to offset insulin resistance but this mechanism, over time, may fail. Type 2 diabetes is typically associated with obesity and age, usually appearing in people over forty. Although a chronic condition, Type 2 diabetes can be successfully managed by addressing certain lifestyle factors, with a healthy diet and regular exercise forming the basis of Type 2 diabetic care (Vijan, 2010). With even modest weight loss, insulin sensitivity can be restored (Barnard et al 2009) eliminating the need for medication. Where medication is used, orally administered insulin is usually sufficient to restore normal levels of blood sugar (Ripsin, Kang & Urban, 2009).

Global estimates in 2010 put the total number of people worldwide with a diabetic diagnosis at 285 million, or 6% of the total population. People with Type 2 diabetes comprise 90% of this statistic, with the remaining 10% being comprised of patients with Type 1 and gestational diabetes (Meetoo, McGovern & Safadi, 2007). In the UK alone, 2.9 million people live with diabetes and a further 850,000 people have diabetes but are unaware of it (Diabetes UK, 2012). The implications of diabetes are serious; complications include cardiovascular disease, retinopathy (eye disease), neuropathy (damage to the nerves), nephropathy (kidney disease) stroke and possibly death. Additionally, the costs incurred by the NHS are vast; every year the NHS spends ?14 billion treating diabetes and its complications, with the vast majority of this cost (66%) being attributable to inpatient treatment (Kavanos, van den Aardweg & Schurer 2012). Treatment for diabetes-related complications is economically troubling due to the increased prevalence of inpatient treatment, and the cost per patient increases proportionally with each complication. By comparison, the cost of glucose reducing medications are relatively low, comprising only 8% of the total annual spend (Kavanos, van den Aardweg & Schurer 2012). This highlights the need for ongoing diabetes policies to address management of the condition in its early stages.

The incidence and prevalence of diabetes, particularly Type 2, is rising to epidemic proportions and represents a grave and growing global health problem, due to the population numbers affected, its associated complications and the costs of controlling the condition (Torres et al. 2009). Health care providers however struggle to manage a chronic condition which requires self-management; the responsibility for non-acute daily care for diabetes lies with the patient. These factors together reinforce the need for effective programs of education that can be successfully incorporated into health systems. Several studies however have indicated that the incidence or severity of diabetes can be successfully managed with lifestyle interventions. Knowler et al. (2004) for example in a large-scale randomised controlled trial assigned patients at a high risk of developing Type 2 diabetes to a placebo, metformin or lifestyle-intervention programme. The lifestyle-intervention programme concentrated on introducing 150 minutes of physical activity per week, plus an overall weight loss of 7 percent. After a three year follow-up, lifestyle changes were significantly more effective at reducing the incidence of Type 2 diabetes than metformin. Lifestyle factors reduced incidence by 58%, whilst metformin reduced incidence by 31%, as compared to placebo. Wing et al. (1987) explored whether modest weight loss could provide long-term benefits for patients with Type 2 diabetes. They studied 114 patients who had enrolled in a weight control programme, and followed them up for one year. They found that those who had lost at least 5% of their body weight demonstrated significant improvements in blood sugar levels at one year follow-up. Those who had maintained their body weight showed no improvement, and those who had gained weight showed a significant worsening of blood sugar levels. Self-management also plays an important role in the management of Type 1 diabetes. In an integrative review of 18 longitudinal studies Guo and Whittemoor (2011) found a strong positive relationship between diabetes self-management and metabolic control.

Given that self-management plays such a vital role in management of diabetes, it follows that programmes of education that are designed to provide information to patients regarding the condition, and to encourage self-management programme adherence could be of critical importance. In the UK there are currently a number of patient education programmes that are designed to aid people to manage their condition on a daily basis. All aim to increase patient knowledge of their condition and how to manage it including the effect of their lifestyle, and the use of insulin when appropriate. In 2003 the National Institute for Clinical Excellence (NICE) published guidance on the use of patient-education models in the management of diabetes, recommending that:

“…all individuals with diabetes should be offered structured patient education at the time of initial diagnosis and ongoing patient education as required, based on a formal, regular assessment of need, recognising that needs change over time. In this context, structured patient education is defined as being a planned and graded programme that is comprehensive in scope, flexible in content, responsive to an individual’s clinical and psychological needs, and adaptable to his or her educational and cultural background. “

(NICE, 2003: 14)

In the UK, there is a large number of diabetes education programmes offered to patients, and these range widely in length, content and educational style (NICE, 2003). However, for the purposes of this essay a focus on three of the most widely used structured patient education programmes in the UK will be taken. These include DAFNE, DESMOND and X-Pert.

DAFNE is an acronym for Dose Adjustment For Normal Eating and is a structured education programme designed for patients with Type 1 diabetes. It aims to empower people to lead an as normal a life as possible whilst controlling blood sugar levels and therefore protecting against the long-term complications of the condition. Over the course of a five-day intensive training course (with post-course follow-up after eight weeks plus half-yearly refresher courses), participants learn the necessary skills to adjust their daily insulin doses to their carbohydrate intake. Delivered as group training to small groups of 6-8 participants, it offers information on carbohydrate counting, insulin regimens, exercise and blood glucose monitoring (NICE, 2003). It is recommended only to patients aged 17 and over, who have been diagnosed with Type 1 diabetes for at least six months, and who demonstrate a commitment to improve their diabetes control. Additionally, participants must be willing to administer insulin up to five times a day, as the regimen that accompanies the course requires two daily injections of long-acting insulin, plus quick-acting insulin after meals and snacks containing carbohydrates.

DAFNE has a strong evidence base; it was the only structured patient education programme to be named in the NICE guidance published in 2003, following the publication of several UK-specific studies into the effectiveness of DAFNE. In 2002, the DAFNE Study Group presented the findings of its UK Feasibility Study. The study used a randomised controlled design, with 169 patients with Type 1 diabetes showing moderate or poor insulin control. Participants either engaged in a DAFNE course immediately as the research began (immediate DAFNE), or acted as waiting list controls, and received the training 6 months later (delayed DAFNE), and continued to receive usual care. The differences between the two groups were measured using a battery of outcome measures. These included laboratory measured levels of glycated haemoglobin, patient reported episodes of hypoglycaemia, and the audit of diabetes-dependent quality of life (ADDQoL) questionnaire, a survey measuring the impact of diabetes on the patient’s quality of life. Additionally, treatment satisfaction was measured using the diabetes treatment satisfaction questionnaire (DTSQ), overall psychological wellbeing was measured with the 12-item wellbeing questionnaire (W-BQ12) and a number of health-related outcomes such as weight, blood pressure and cholesterol level were also measured. Overall, the authors concluded that DAFNE was successful; those patients receiving the training immediately showed significantly improved blood sugar levels, without episodes of hypoglycaemia. Additionally, patients who received treatment scored significantly better on indices of satisfaction with treatment, psychological wellbeing and quality of life compared to those whose treatment was delayed. This was despite an increase in insulin injections and blood glucose monitoring demands.

It must be noted, that despite the positive findings of this study, it did not meet the rigorous methodological criteria for inclusion in NICE’s review of patient education programmes (NICE, 2003), as the concurrent control group ran only for 6 months (after which they received the ‘delayed’ training). However, its results were still quoted in the guidance, and formed part of NICE’s rationale for recommending the programme.

An additional component of the NICE review included the cost-effectiveness of DAFNE. In 2003 it was estimated that the cost per person to attend a DAFNE education course was ?545, but the resultant saving per patient (as compared to normal treatment) over a 10 year period would be ?536. Extrapolating across the population, in 2003 the DAFNE study group estimated that the maximum cumulative cost to provide DAFNE would peak in 2006/07 at ?19 million, but would be self-financing by 2009, suggesting the potential for self-financing in future years (NICE, 2003). Shearer et al. (2004) also provided support for the cost-effectiveness of DAFNE. Drawing on effectiveness data from three randomised controlled trials conducted in Germany, Austria and the UK. They concluded that DAFNE was effective at a lower cost than usual treatment models for Type 1 diabetes, saving approximately ?2200 per patient over a ten year period. They considered this result compelling enough to suggest that DAFNE should be introduced as the standard treatment for people with Type 1 diabetes in the UK.

The second programme for discussion is Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND). It is a programme targeted at those with Type 2 diabetes to help them manage the necessary changes to their lives brought about by diabetes. Crucially, it was developed post-2003, after the publication of the NICE review, and was designed specifically to meet the standards outlined in the resultant national policy. The programme itself has three variations; a newly diagnosed programme, a foundation programme and a version specifically designed for black and minority ethnic patients. It is delivered across six hours of group work by specially trained healthcare professionals, using a written programme to ensure consistency of delivery (DESMOND project, 2012). Its core philosophy is one of patient empowerment; those on the course are encouraged to learn by discovering knowledge for themselves (DESMOND project, 2012).

The programme was originally piloted across 17 primary care trusts in England, and 13 of these sites were included in a randomised controlled trial, including over 800 participants, making it the largest study of educational programmes for Type 2 diabetes conducted to date. The intervention group attended DESMOND within twelve weeks of diagnosis. The control group received an equivalent amount of contact time with healthcare professionals. After 12 months, there were no significant differences in levels of blood sugar between the groups, but the intervention group showed a significantly higher degree of weight loss, increase in physical activity and reduction in smoking. Additionally, they had significantly more positive views about behaviour change impacting on their illness, and significantly lower levels of depression than the control group (Davies et al. 2008). In 2012, the results of this study were followed up (Khunti et al. 2012) to measure whether the benefits were sustained over three years. The authors managed to contact 731 of the original 824 study participants, and found that none of the biomedical or lifestyle advantages had been maintained over the period. However, the intervention group continued to hold more positive illness-related beliefs. However, the authors concluded that these results did not necessarily indicate a failure of DESMOND. The programme is very much in its infancy, and the authors point out the importance of the psychosocial benefits of the programme. Over time, an association between psychosocial factors and a more effective management of blood sugar levels may emerge (Khunti et al. 2012).

A recent meta-analysis yielded more positive outcomes. Minet et al. (2010) looked at all studies conducted up until late 2007 that used a randomised controlled design to assess the impact of DESMOND-like self-management programmes on adults with Type 2 diabetes. 47 studies including 7677 participants were suitable for inclusion, and showed a small but significant positive effect of such programmes on blood sugar levels. Although closer analysis revealed that studies utilising smaller samples with shorter follow-up periods were more likely to yield positive effects, they also found that programmes incorporating educational elements (like DESMOND) were also more likely to return significant effects (Minet et al. 2010).

The final programme to be discussed is X-PERT. It is similar to DESMOND in that it is a structured education programme devised for people with Type 2 diabetes; however it has been delivered across the UK and Republic of Ireland to people with both Type 1 and Type 2 diabetes. The two and a half hour group work sessions are delivered weekly over a six week period and aims to empower patients to identify and manage their own diabetes-related problems, and create their own possible lifestyle management solutions. It aims to improve clinical outcomes and quality of life for patients whilst reducing the need for diabetes medication and diabetes-related complications (Diabetes UK, 2012). The work to develop the programme began in 2000, and this included a randomised controlled trial (Deakin, Cade, Williams and Greenwood 2006). 314 patients with Type 2 diabetes were randomly assigned to an intervention (X-PERT) or control (treatment as normal) group, and lifestyle, clinical and psychosocial measures were taken at the outset, and repeated at 4 and 14 month intervals. At 14 months post-evaluation, those in the intervention group ate a healthier diet than controlled, and reported a greater sense of freedom over their diet. The intervention group also took more exercise and demonstrated greater foot care at both follow-up periods. Crucially, those in the intervention group also demonstrated significantly improved glycaemic control, lower BMI, reduced cholesterol reduced waist circumference measurements, and a reduced need for diabetes medication at 14 months post-intervention (Deakin et al. 2006).

Although no study has exclusively analysed the potential cost savings offered by X-PERT, Jacobs-van de Bruggen et al. (2009) performed a review of randomised controlled trials assessing the impact of seven self-management programmes for diabetes, including X-PERT. The results found large differences in health outcomes across the seven trials included, but X-PERT was found to be one of the most effective whilst simultaneously delivering potentially the largest cost savings.

All three programmes therefore have returned some positive results. DAFNE remains the only NICE supported intervention addressing Type 1 diabetes in the UK, and both interventions discussed here to manage Type 2 diabetes demonstrated clinical, psychosocial and lifestyle benefits, with X-PERT in particular delivering sustained improvements to patient health whilst simultaneously being cost-effective. What is clear however is that more research regarding the effectiveness of DAFNE needs to be conducted, involving large populations, randomised controlled trials and adequate follow-up periods. DESMOND and X-PERT which were specifically designed with rigorous assessment in mind are still in their relative infancy; research regarding longer term outcomes will be necessary as the impact of diabetes continues to grow.

References

Barnard, N.D., Katcher, H.I., Jenkins, D.J., Cohen, J. & Turner-McGrievy, G. (2009). Vegetarian and vegan diets in type 2 diabetes management. Nutrition Reviews 67 (5).

Davies, M.J., Heller, S., Skinner, T.C., Campbell, M.J., Carey, M., Cradock, S., Dallosso, M.D. & Daly, H., Doherty, Y., Eaton, S., Fox, C., Oliver, L., Rantell, K., Rayman, G. & Khunti, K. (2008) Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. British Medical Journal 336: 491 – 495.

Deakin, T.A., Cade, J.E., Williams, R & Greenwood, D.C. (2006). Structured patient education : the Diabetes X-PERT Programme makes a difference. Diabetic Medicine 23 (9): 944 – 954.

Diabetes in the UK 2012. Key statistics on diabetes. Availiable at: http://www.diabetes.org.uk/Documents/Reports/Diabetes-in-the-UK-2012.pdf (accessed 18.07.2012).

Funnell, M.M. & Anderson, R.M. (2004). Empowerment and Self-Management of Diabetes. Clinical Diabetes 22 (3): 123 – 127.

Guo, J. & Whittemore, R. (2011).The relationship between diabetes self-management and metabolic control in youth with type 1 diabetes: an integrative review. Journal of Advanced Nursing 67(11): 2294-310.

Jacobs-van de Bruggen, M.A.M, vaan Baal, P.H., Hoogenveen, R.T., Feenstra, T.L., Briggs, A.H., Lawson, K., Feskens, E.J.M. & Baan, C.A. (2009). Cost-Effectiveness of Lifestyle Modification in Diabetic Patients. Diabetes Care 32 (8): 1453 – 1458.

Kamlesh Khunti, K., Gray, L.J., Skinner, T., Carey, M.T., Realf, K., Dallosso, H., Fisher, H., Campbell, M., Heller, S., Davies, M.J. (2012). Effectiveness of a diabetes education and self-management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. British Medical Journal 344: e2333

Knowler, W.C., Barrett-Connor, E., Fowler, S.E., Hamman, R.F., Lachin, J.M. & Walker, E.A. (2002). Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393-403.

Minet, L., Moller, S., Vach, W., Wagner, L. & Henriksen, J.E. (2010). Mediating the effect of self-care management intervention in type 2 diabetes: a meta-analysis of 47 randomised controlled trials. Patient Educ Couns. 80(1): 29-41.

NICE (2003). Guidance on the use of patient-education models for diabetes. Nice Technology Appraisal 60. Availiable at: http://www.nice.org.uk/nicemedia/live/11496/32610/32610.pdf (accessed 23.07.2012).

Ripsin CM, Kang H, Urban RJ (2009). Management of blood glucose in type 2 diabetes mellitus. American Family Physician 79 (1): 29–36.

Shearer A (2004). Cost-effectiveness of flexible intensive insulin management to enable dietary freedom in people with Type 1 diabetes in the UK. Diabet Med 21: 460-7.

Torres, H., Franco, J.L., Alves, M., Stradioto, V., Hortale, A. & Torres-Schall, V. (2009). Evaluation of a diabetes education program Rev Saude Publica 43(2): 1 – 8.

Vijan, S. (2010). Type 2 diabetes. Annals of internal medicine 152 (5):

Wing, R., Koeske,R.,. Epstein, L.H., Nowalk, M.P., Gooding, W. & Becker, D (1987). Long-term Effects of Modest Weight Loss in Type II Diabetic Patients

Accepted for publication June 23, 1987.

Reprint requests to Western Psychiatric Institute and Clinic, 3811O’Hara St, Pittsburgh, PA 15213 (Dr Wing).

From the University of Pittsburgh School of Medicine.

Arch Intern Med. 1987;147(10):1749-1753.

Type 1 Diabetes, which can be used to be called juvenile oncoming or Insulin-Dependent Diabetess Mellitus ( IDDM ) and normally appears during childhood, teenage old ages, or early maturity. It is an autoimmune disease, intending that the immune system has mistaken its ain pancreas for foreign tissue and destroys the pancreatic cells that produce insulin, which is a endocrine. As a consequence, people with Type 1 Diabetes produce about no insulin ( 1 ) . Furthermore, IDDM is largely inherited by the parent cell as the research said if you have a household member with Type 1 Diabetes, your hazard is approximately five to six per centum, compared to the hazard in general population which is 0.4 % ( 2 ) . Diabetes was the 7th prima cause of decease listed on U.S. decease certifications in 2006. This ranking is based on the 72,507 decease certifications in 2006 in which diabetes was listed as the underlying cause of decease ( 3 ) . Therefore, are at that place any possible solutions to get the better of this job?

Neuropathic ulcer may show on the pess of diabetic people.

A POSSIBLE Solution

Insulin pump therapy

Alpha cell secrete glucagon Raises glucose degree

Islet cell

of the pancreas

Beta cell secrete glucagon Lowers glucose degree

In the Islet cell of pancreas, Beta cell makes insulin. When immune system destroys beta cell, insulin can non be produced. As a consequence the cells in our organic structures will non be able to treat the glucose and hence have no energy for motion ( 6 ) . Furthermore, the glucose is unable to be transferred from blood stream to the cells and the glucose degrees in the blood will be higher than normal. Hence, insulin pump therapy is needed to get the better of this job.

Insulin pump is a little mechanical device, a small larger than a beeper that is worn outside the organic structure, frequently on a belt or in a pocket. It delivers insulin into the organic structure via an extract set which is injected beneath the tegument at the extract site ( 7 ) .

Nipro Diabetes Systems Amigo OmniPod Insulin Management System

Nipro Diabetes Systems Amigo OmniPod Insulin Management System

Examples of insulin pump. Beginning: hypertext transfer protocol: //www.childrenwithdiabetes.com/pumps/index.htm

Graph 1 shows the age distribution at the clip of diagnosing for members of the Insulin Pumpers.

From graph 1, we can see that most of the users of pumpers are kids and adolescents. About 1119 insulin pumpers have been recorded until 25th of December 2009, which shows a great figure of populations that had been infected with this disease.

Over the old ages, a figure of different types and trade names of insulin have been developed to run into different demands.

Type

Brand Name

Onset

Extremum

Duration

Remarks

Fast playing

Humalog

Novolog

5 – 15

proceedingss

45 – 90 proceedingss

3 – 4 hours

Human

The fastest-acting insulin available

Intermediate

moving

Humulin L

Humulin N

Novolin L

Novolin N

1 – 3

hours

6 – 12 hours

20 – 24 hours

Human

Long moving

Humulin U

4-6 hours

18-28 hours

28 hours

Human

Normally used in combination with a faster-acting insulin to supply proper control at mealtimes

Ultra-long

moving

Lantus

1.1 hours

No extremum

Changeless concentration over 24 hours

Human

Injected one time day-to-day at bedtime

Mixtures

Humulin 50/50

Humulin 70/30

Novolin 70/30

Humalog Mix 75/25

Varies

Varies

Varies

Varies

Varies

Varies

The Numberss refer to per centum of NPH ( 1st figure ) and regular ( 2nd figure )

Available in phials, pen-fill cartridges, and prefilled panpipes

75 % NPL ( a new NPH preparation ) and 25 % lispro ; available in disposable pen.

Beginning: hypertext transfer protocol: //www.lifeclinic.com/focus/diabetes/supply_insulin.asp

The end of insulin pump therapy is to copy the insulin secernment form which can be seen in people without diabetes. Normally there are two form of insulin release:

Basal insulin or background insulin which is continuously released from the beta cells and regulates the glucose production from liver.

Bolus insulin, which is insulin released in response to nutrient and controls the glucose alterations after repasts ( 2 ) .

There are four types of bolus form which can assist the pumpers to find what is best for any given nutrient and by accommodating the bolus form to their demands, it will better control of blood sugar.

Standard bolus.JPGExtended bolus.JPG

Combo bolus.JPGSuper bolus.JPGSource: hypertext transfer protocol: //en.wikipedia.org/wiki/Insulin_pump

All the graphs show the bolus form in order to find what the best nutrient is should be taken in order to better control of blood sugar. The standard bolus people should take low protein and low fat repasts while extended bolus diabetic covering high fat high protein repasts such as steak, which will be raising blood sugar for many hours past the oncoming of the bolus. Furthermore, those who have combination bolus is appropriate for high fat repasts such as pizza and cocoa bar but the ace bolus people must take certain nutrients ( like sugary breakfast cereals ) which cause a big post-prandial extremum of blood sugar. It attacks the blood sugar extremum with the fastest bringing of insulin that can be practically achieved by pumping.

SOCIAL AND ECONOMIC IMPLICATION

First and first, after being diagnosed as diabetic, some of them can non accept the fact and take some clip to mourn their loss. Some of them might fell depressed for illustration Katherine G who was diagnosed with diabetes and maintain inquiring what had I done incorrect? And wanted to thwack every overweight individual she saw ( 1 ) . They besides worried about the following coevals as Type 1 Diabetes is inherited and acquire stress believing about the complication of diabetes which cause them to utilize wheelchair because has no pess and besides being wheeled in order to utilize the dialysis machine. They may lose their ego regard to confront the universe. Some might be under force per unit area as they have to be strict on their nutrient consumption as they have to follow the diet for diabetic and they need to take a batch of medical specialty and besides injection.

In order to acquire the intervention for diabetes, more money has to be disbursement as the pumpers are high in cost. Diabetes impacting the earning or active member of the household affects non merely that single but might frequently hold important consequence on the household. The economic load of diabetes is increasing as the epidemic grows. As per WHO estimates, diabetes drains a important per centum of the wellness budget by cost towards direct diabetes attention and diabetes related disablements. Diabetess associated complications account for 60 % of diabetes related direct wellness attention costs and about 80-90 % of indirect costs. In India, for illustration, the poorest people with diabetes spend an norm of 25 % of their income on private attention. The most that they can pay for are interventions that keep them alive by blunting the highest, rapidly fatal degrees of blood sugar. In 2007, the universe is estimated to pass at least USD 232 billion to handle and forestall diabetes and its complications. By 2025, this lower-bound estimation will transcend USD 302.5 billion ( 11 ) .

BENEFIT AND RISK

Advantages

BEST hbA1c ‘s before the pumpBEST hbA1c ‘s utilizing the pump

The graph shows the hbA1C degree before and after utilizing insulin pump.

The degree of hbA1C lessenings with an norm of 6.3 after utilizing the insulin pump. So, it can take down the hazard of developing long-run complications for case shot, bosom disease, sightlessness, kidney failure and besides amputation.

Pumpers have been shown to see lesser episodes of terrible hypoglycemia than those who take injections, including during the dark. Clinical surveies shown that utilizing fast moving insulin, the glucose control can be improved with less hazard of hypoglycemia. Furthermore, the pumper can maintain up-to-date with their day-to-day agenda. They are flexible to travel and free to make what they want for illustration they can maintain on the pump during exerting in the eventide. Insulin pumpers require an extract set alteration merely approximately three times a hebdomad, or 156 interpolations a twelvemonth but the injection can accomplish mean more than 1,400 injection per twelvemonth.

Disadvantages

An episode of diabetic diabetic acidosis aa‚¬ ” province of unequal insulin degrees ensuing in high blood force per unit area and accretion of organic acids and ketones in the blood may take topographic point if the pumpers do non have sufficient sum of fast acting insulin for many hours. There is high hazard of infection if the catheter site of cannula has non been changed every three yearss and besides skin reactions such as roseolas may look at the site of cannula. This therapy is really expensive as pumps are high monetary values. By utilizing insulin therapy, the society might cognize that you have diabetes since this is one of the popular ways to bring around it ( 12 ) . Some of diabetic might develop film overing vision shortly after get downing insulin due to a alteration of lens refraction and it will rectify itself within two to three hebdomads ( 13 ) .

ALTERNATIVE SOLUTIONS

Diet for diabetics

If diabetes people eat excessively much, diabetic control will deteriorate but if they eat excessively small, leads to hypoglycaemia. Carbohydrate must be taken in little sums for aged and sedentary but in big sum for active people like adolescents. This must be taken at chief repasts illustration breakfast, tiffin and dinner ( 13 ) . When taking on empty tummy, intoxicant can take down down the glucose degree. Diabetics should restrict saccharide in liquid signifier as they are quickly absorbed. Furthermore, they should extinguish all refined sugars and starches and must intake a batch of fibre-rich veggies and fruits in their diet. This is because fibers slow down glucose soaking up and prevent high glucose degrees after repasts. They must take protein and restricted ruddy meats and besides trans-fats. Saturated fats must be reduced and take a batch of bosom healthy mono-saturated fats and omega 3.

Exerting

Peoples, who exercise on a regular basis, when compared to those who do non exert, diminish their opportunity of developing diabetes by 30 to 50 % . Exercise aid by bettering the bodyaa‚¬a„?s to utilize insulin and causes cholesterin degree and blood force per unit area to drop ( 14 ) . Aerobic exercising Burnss Calories to assist in pull offing the weight, beef up the bosom and lungs and gives endurance. In other word, it improves the bodyaa‚¬a„?s ability to utilize insulin and prevent diabetes. We must make warm up and chill down earlier and after exerting. Take at least 20 proceedingss and three times a hebdomad to exercising. Furthermore exercising can increase the consumption of glucose by musculuss therefore increase in carbohydrate consumption. We must take adequate saccharide before exerting but overdose of saccharide will consequences in hyperglycemia. As diabetes, insulin must be sufficient before and after exercising because strenuous exercising and deficient insulin will decline diabetic control ( 15 ) .

Supplement vitamin and herbs

Vitamin E helps fade out fresh coagulum in venas and cut down the O demand of tissue and cell. Furthermore, it besides helps to from new tegument ( in mending the ulcer and Burnss ) and increases the blood supply to weave, therefore reduces diabetes sphacelus and amputations. Vitamin E reduces the demand for insulin in 30 % of diabetes ( 16 ) .

Biotin is B vitamin that maps in industry and usage of saccharide, fat and amino acids. It enhances insulin sensitiveness and increase the activity of enzyme glucokinase, enzyme responsible for the first measure in the usage of glucose in liver as this enzyme is low in diabetic. It besides helps in the intervention of diabetic neuropathy ( 17 ) .

Evaluation