Diabetes and Health Protection - Essay Example

Diabetes, Nursing, Health Promotion and Health Protection Diabetes is a rising epidemic; an estimated 800,000 adult New Yorkers - more than one in every eight - now have diabetes, and city health officials describe the problem as a bona fide epidemic1. Diabetes in New York is growing, affecting more number of people and killing more and more people than it ever did in the past. City health officials are alarmed as the disease and its complications threaten to swamp the hospital resources in the city. In 2002, the American Diabetes Association estimated that diabetes cost the United States $132 billion in direct and indirect costs. This figure is based on a study conducted by the Lewin Group for the American Diabetes Association and contains 2002 estimates of both the direct costs (cost of medical care and services) and indirect costs (costs of short-term and permanent disability and of premature death) attributable to diabetes2. With the rise in the incidence and prevalence of the illness and the rising expenditure incurred by the health care system in managing the illness as well as containing its complications, there is a rising awareness that early diagnosis and management of diabetes and its complications can afford some measure of control over its effects. For instance, if diabetes is diagnosed early and controlled from the very beginning, the individual who has the illness will have less microvascular and macrovascular complications of diabetes. The high blood sugar levels that are a part of diabetes may not cause any discomfort to the patient, except a slightly higher frequency of urination with attendant increased thirst. But a high and uncontrolled blood sugar over a long period of time causes changes in the tissues which leaves a mark and gives rise to its complications, which include renal failure, loss of vision, coronary artery disease, stroke, peripheral vascular disease, etc. Some of these lead to progressive problems which ultimately lead to dependence on expensive treatment. For instance, renal failure can progress to end-stage renal failure, with dependence on renal replacement therapy, such as dialysis. This is expensive treatment, not easily available and exacts a heavy toll in terms of time and money on the sufferer. In addition, it is not exactly perfect, in the sense that even though RRT can improve survival as well as quality of life, it cannot provide normal life, as the loss of renal function cannot be fully compensated by this artificial means. All the complications of diabetes can be prevented if adequately treated from the beginning; at the very least, they can be delayed and mitigated to a great extent. For the prevention of diabetes complications, the condition has to be diagnosed at an early stage and controlled appropriately for the rest of the life of the patient. Diabetes is a life-long illness and hence the patient has to adjust his life so that he never loses sight of the fact that he has the condition, and maintains a lifelong vigil not only on the illness but also on the strict maintenance of a lifestyle designed to control its effects. This involves intensive education of the patient. One worrisome problem is that diabetes is now increasingly affecting younger people. Type 2 diabetes, previously considered to be a disease of the aged, the elderly and the overweight, is increasingly being diagnosed in children below the age of 10. This has paralleled the change in lifestyle among these children, with a tendency to overeat and have a less active life. Another major problem in this age group is that they are not easily educable; it is difficult to convince them of the importance of control of diet and activity. This is especially true in the early stages when the disease does not produce any significant symptoms. Shorn of critical preventive measures, these unfortunate sufferers of the malady tend to develop the complications of long-term uncontrolled diabetes much earlier than usual, a situation which has been described as a "double whammy". From this account it is clear that there is an urgent need for increasing awareness of the disease among people and for providing preventive measures. There is an exigent need for measures of health promotion in this field that cannot be over-emphasized. In this essay, I shall discuss the role of health promotion in diabetes to stave off the long-term complications of this illness, not only at the individual level, but also at the community level3. THE US GOVT INITIATIVE IN DIABETES HEALTH PROMOTION Diabetes poses a significant public health challenge for the United States. Some 800,000 new cases are diagnosed each year, or 2,200 per day4,5. Diabetes is a chronic and relentless disease manifesting itself in two forms: type 1 usually occurring in children and adolescents, a life-long disorder in which the total inability of the pancreas to produce insulin means that extraneous insulin administration is essential to sustain life; and type 2 which manifests itself in later life, and in which a relative lack of insulin and some degree of resistance to the effects of insulin manifested by the target tissues leads to diabetes and all its attendant complications. Since the illness starts at a relatively younger age in Type1 the patients are by and large well-habituated to the process of self-care and familiar with all the nuances of the illness. It is mainly in Type 2 that education plays an even greater role and motivation to continue with the diet and lifestyle modifications becomes all the more crucial. The changing demographic patterns in the United States are expected to increase the number of people who are at risk for diabetes and who eventually develop the disease. The incidence and prevalence of diabetes are on the increase6. There has been a steady rise of these numbers in the decade 1990-2000; currently 10.5 million cases have the disease, and a further 5.5 million have undiagnosed or latent diabetes. The rise in the number of new cases has been disproportionately high in certain ethnic groups7. Diabetes is the seventh leading cause of death in the United States, primarily from diabetes-associated cardiovascular disease, and has held that dubious post for several decades now. Diabetes contributes to a three- to four-fold increase in cardiovascular mortality in pre-menopausal women when compared to non-diabetic age-matched women8. In the United States, diabetes is the leading cause of non-traumatic amputations (approximately 57,000 per year or 150 per day); blindness among adults in the working age (approximately 20,000 per year or 60 per day); and end-stage renal disease (ESRD) (approximately 28,000 per year or 70 per day)9. Diabetes is a costly disease, and the total attributable cost of diabetes is around $ 100 billion, $43 billion direct and $45 billion indirect, of which hospitalization for cardio-vascular complications account for the lions share of the direct costs. Increasingly, however, diabetes is being managed in the out-patient departments and diabetics tend to prefer using nursing home facilities10. The incidence of new cases of diabetes in certain racial and ethnic groups is inordinately higher; the rate of case detection is likely to get higher before it begins to decline in certain vulnerable, high-risk groups- African Americans, Hispanics, American Indians or Alaska Natives, Asians or other Pacific Islanders, elderly persons, and economically disadvantaged persons11-19. Detection of diabetes and the treatment of its complications is a much greater challenge within these groups20. The frequent occurrence of diabetes in these groups, in epidemic proportions can be explained by many factors: among them are behavioral elements (improper nutrition, for example, increased fat consumption; decreased physical activity; obesity); demographic changes (aging, higher numbers of at-risk, vulnerable populations); improved case-ascertainment and state-of-the-art surveillance systems that more completely capture the actual burden of diabetes; and the relative lack of success of interventions to change individual, community, or organizational behaviors21. One of the distressing realities of modern life is that one is seeing more obesity, improper nutrition (including increased ingestion of fats and processed foods), and lack of physical activity along with excessive (addictive) television-viewing among persons under age 15 years. Due to this drastic change in the pattern of behavior in this age group, more and more cases of Type 2 diabetes are being diagnosed in this hitherto immune age group22-25. It has been shown in scientific studies and literature that measures for secondary and tertiary care for diabetes are highly successful in meeting the targets; primary prevention, however, continues to lag behind woefully. This is because changing the behavior of people who have diabetes or of individuals and organizations involved in the care of diabetic patients is a mammoth task not easily undertaken. While both Types 1 and 2 diabetes have a significant genetic component, it is the personal behavior of individuals which are influenced by cultural-religious factors, beliefs, and attitudes which matter the most. For instance, in certain ethnic groups, there is an over-reliance on traditional modes of treatment which prevent them from accessing modern medicine, and this can contribute to significant disease burden. BARRIERS TO DIABETES CARE AND SUPPORT: COST Individuals and families with diabetes incur certain direct expenses, which include the cost of medical care, certain drugs, insulin and other supplies. Persons with diabetes also have to spend considerably more on the premiums for health insurance as well as life and automobile insurance, compared to non-diabetic individuals. Though this may at first seem unfair, the insurance companies justify this by pointing to the additional costs incurred by them due to the presence of diabetes which they have to face. To the healthcare sector, direct costs include hospital services, physician services, lab tests and the daily management of diabetes. The last one (daily management) includes availability of products such as insulin, syringes, oral hypoglycemic agents and blood-testing equipment, without which the basic treatment of a large number of diabetics cannot be managed. While some diabetics may be managed in the out-patient department without leading to excessive cost, a much larger number of patients require long hospital inpatient stays for the treatment of complications. The average annual health care costs for a person with diabetes has been found by the CDC Coordinating Center for Health Promotion (May 2005) to be $13,243 (compared to $2,560 for the health care costs for a person without diabetes)26. A growing number of people with diabetes do not have health insurance or have health insurance that does not cover insulin, other medications, or diabetes supplies like self-monitoring of blood glucose monitoring (SMBG) equipment; they are often forced to pay out of their pockets for these items which are unavoidable in the day-to-day management of diabetes. Individuals who are on a fixed income cannot afford to pay for medication or SMBG equipment; they run the risk of being labeled "non-compliant" by their healthcare providers and when so labeled, little effort is made to follow up. While resources for low-income people with diabetes are limited, there are some available; these include programs that provide low-cost, sliding scale or free diabetes care and support services. Sliding scale services, also involve frequent measurement of blood glucose, which entails unavoidable cost. There are two major barriers facing such services: navigability and the stigma attached to welfare. Such programs, which include Medicaid, are not able to provide continuous care and services; the application procedures are often complex and tedious, requiring extensive documentation and form-filling that many elders have difficulty fulfilling (providing proof of permanent address, income records, proof of disability, etc.). Low-income, immigrant, or homeless elders may experience much more difficulty in providing adequate documentation. Many healthcare and social service organizations face financial crunch and shortfall in the funds required to provide basic services for all those in need, including low-income elders with diabetes. Charitable large-scale free camps with provision for free blood glucose screening, though tempting, are short-term measures not designed to meet the long-term needs of these low-income diabetics, for which system-wide changes are the need of the hour. Older adults among poorer sections can be reached better through partnerships between community health centers and community-based organizations serving low-income and immigrant elders, and between local health departments and area agencies on aging; greater co-operation is required among these various agencies which otherwise tend to work in isolation without co-ordination. Some communities have reduced the stigma of "welfare" type services by creating public-private partnerships to address the problem of diabetes in the whole community, and adapting existing diabetes care guidelines to their community. Out of that process, partnerships have emerged that provide more services to poorer, low-income people by pooling together community resources. Many professionals in the field of healthcare and aging have been trying to determine how to make home and community-based services (sometimes called personal assistance services) more affordable to all older adults. These individuals and agencies, who have been working in this field for a long time, have been utilizing home and community-based services (including home care, home delivered meals and adult day care) as an integral part of the chronic care continuum, bridging community resources with healthcare. A good 60% of older adults aged 65 and above with diabetes have a disability and many of these people are hospitalized each year, and would prefer to return home after hospitalization27. Tragically, many of those elders are discharged to nursing homes instead of their own homes due to various reasons including lack or resources at home to provide for care. Medicaid Funding of Home and Community-based Services is an example of how consumers and consumer advocates obtained additional funding support through the courts for home and community-based services for all people with disabilities, including elders with diabetes. Community Health Centers and the Diabetes Collaborative Initiative is another example of how community health centers, which traditionally reach out to lower income groups, have been able to significantly improve the care and health of people with diabetes in their communities. MARGARET NEWMAN'S THEORY OF EXPANDING CONSCIOUSNESS IN THE PRACTICE OF NURSING Margaret Newman propounded the theory of expanding consciousness as it applies to nursing practice; she considered health and illness to be unitary processes moving through variations in order and disorder. From this standpoint, health and illness can no longer be considered as two distinct opposing entities as in the more orthodox medical science; that is, health cannot and should not be considered as mere absence of disease nor should one believe that life flows passively as a continuum from wellness to illness or vice versa. Consciousness refers to the capacity of a system (in this case a human being) to interact with the environment. This consciousness refers not only to cognition, affection and other similar physical attributes of the mind, but to the interconnectedness to the entire living system. By this an individual becomes part of an ever-expanding universe. In this situation, health and the evolving pattern of consciousness are the same; that is to say, the living system evolves within the consciousness, from one state to another, from health to illness and so on. In this view consciousness is a manifestation of an evolving pattern of person-environment interaction. David Bohm is another proponent of this theory. Bohm considers reality as an undivided wholeness; health and illness are unitary process within this wholeness (Bohm, 1980). Bohm postulates the existence of an unseen, underlying pattern (called the implicate order), which is the primary order of reality, and all tangible things of the world are external manifestations of this implicate order. Disease is therefore one such manifestation. Health and illness are integral unitary parts of the summate wholeness of the universe, and to see it in this perspective, the individual needs to have a non-fragmentary view of the universe. Disease and non-disease from this standpoint are simply different points of view of a much larger reality so that they cannot be separated from the whole, except in a fragmentary way of viewing them. DOROTHEA E OREM'S CONCEPTUAL FRAMEWORK OF SELF-CARE DEFICIT NURSING THEORY Among the many models of scientific and theoretical knowledge on which nursing practice has been developed, Orem's conceptual framework depends on the identification of the patient as an individual as someone who needs self-care28; the function of nursing is formulated around this basic concept. There are some universal self-care practices affected by illness and its management; health deviations have their effects and need their own management. There is a need for promotion of health and well being through self/dependent care. Thereafter, a patient has to be helped to get into the health care system, to adapt, and to manage as effectively as possible given his level of knowledge, his abilities and resources. The conceptual framework is, therefore, dynamic, and provides guidelines to adapt to individual needs, to the specific medical condition as well as to other circumstances. In the Johns Hopkins, a diabetic management clinic was among the first to be started in 1968, based on these concepts, and the aims were to give better care to more patients at a lesser cost and at a saving to physicians' time. The Diabetic Nurse Management Clinic and its subsidiary the Diabetic Foot Clinic were started as subclinics to the Endocrine department. Over time, the nurses 'manning' the clinics became such experts in managing complex problems for diabetic patients that they were getting referrals only for the more difficult-to-manage diabetic patients. Gradually, the DMC as it was called became an exemplar, providing not only quality care to diabetic patients, but also serving as an educational institution for medical students, physician fellows in endocrinology, nurse practitioners, nursing students, etc. APPLICATION OF THESE THEORIES FOR HEALTH PROMOTION & HEALTH PROTECTION IN DIABETICS: These theories would remain just what they were if they had no practical utility. The authors were acutely aware of this reality and always sought exemplars of its practical application. One such application is in the field of diabetes. The Diabetes Nurse Management Clinic at the Johns Hopkins developed way back in 1968, described above is a practical and living example of the application of Orem's theoretical framework of Self-Care Deficit Nursing. In its Healthy People 2010 initiative the US Government has identified diabetes as one of the many diseases in which a lot needs to be done. According to its statistics, there are many barriers to the effective implementation of the various programs. Among these barriers are lack of awareness of the problem, inadequate infrastructural facilities for the less privileged sections of society, such as ethnic minorities, the elderly and the economically backward. In these vulnerable groups, diabetes is diagnosed late, treated inadequately, and allowed to wring its awful toll. One of the reasons is that diabetes has traditionally been considered a rich man's disease, and the under-privileged classes have been mistakenly considered to be safe from this disease. It is only now being recognized that all those people who have access to a largely westernized diet, who are ignorant of the consequences and who have begun to lead far more sedentary lives than their forefathers have suddenly become susceptible to this dangerous illness. It is this very unfortunate group who tend to be overlooked by the health care system; there is higher rate of unemployment among them, health insurance is beyond their reach, or the insurance that they can afford does not cover the cost of treatment of diabetes. They get lesser attention from the medical system, and physicians tend not to spend much time with such patients. Not only is the rate of Type 2 diabetes rising among these people, but they are also disadvantaged due to the failure of the health system to address their needs. It is in the context of these problems that the nursing practitioner has a bigger role to play. There is need for more Diabetes Nurse Management Clinics of the kind started in the Johns Hopkins, which address theses needs. Here the patients can be educated and motivated, their blood sugar can be periodically checked, their diets regulated, their complications attended to and the family motivated to participate in the management of the health of the patient. The nurse practitioner has a major role to play in the lives of such patients. Here the role is not so much the treatment of diabetes and related problems, as it is of preventing complications of the illness and promoting health and well-being. CONCLUSION: As is increasingly being recognized, diabetes is a major disease of mankind, and is at present looming large over the horizon and acquiring epidemic proportions. To an individual, the knowledge that he has diabetes sounds a deathly warning. There are many more practical adjustments to be made once this information is provided to the sufferer, some physical, some mental, and a lot of it psychological. The presence of a significant other carer who knows and understands the problems and stands like a pillar of support during his hour of crisis is like a God-send to the patient. The role of the nursing practitioner here goes beyond the mere call of duty, for here she has to provide psychological and moral support which requires major shifts in focus. Diabetes is the quintessential example of the paradigm shift in seeking the innate wholeness of the universe; health and illness are unitary parts of this whole, and diabetes is the epitome of such an illness. In reality, a patient suffering from diabetes never realizes when he has drifted from one end (health) to the other (illness). It is this silent shift in the condition of the patient which contains within it the seeds of crises. The initial panicky reaction on learning that he has diabetes is quickly replaced by a complacency that things cannot go wrong if he takes care of diet and lifestyle; during these early years, diabetes is not harsh and constantly entices the sufferer to a state of lulled consciousness of the situation. But the years take their toll, and he may suddenly find himself in the midst of a crisis. To be prepared for this crisis, yet to enjoy good health while it lasts, is the essence of life for a diabetic. The nursing practitioner must impart this wisdom to the diabetic, for it is in this ability to withstand the crises of life, and yet not become bitter in the struggle, that grace and elegance are manifested. REFERENCES: 1. [The New York Times May 9, 2006, HEALTH: Diabetes and Its Awful Toll Quietly Emerge as a Crisis By N. R. KLEINFIELD Published: January 9, 2006 http://query.nytimes.com/gst/fullpage.htmlsec=health&res=9907E2DA1F30F93AA35752C0A9609C8B63] 2. [CDC. (2004) "National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2003," rev. ed. Atlanta, GA: U.S. Department of Health and Human Services. Available at CDC on the World Wide Web: http://www.asaging.org/cdc/module7/phase3/phase3_1.cfm 3. CDC. (2004) "National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2003," rev. ed. Atlanta, GA: U.S. Department of Health and Human Services. Available at CDC on the World Wide Web: http://www.asaging.org/cdc/module7/phase3/phase3_3.cfm 4. Clark, C. How should we respond to the worldwide diabetes epidemic Diabetes Care 21:475-476, 1998. 5. Burke, J.; Williams, K.; Gaskill, S.; et al. Rapid rise in the incidence of type 2 diabetes from 1987 to 1996: Results from the San Antonio Heart Study. Archives of Internal Medicine 159:1450-1457, 1999. 6. King, H.; Aubert, R.; and Herman, H. Global burden of diabetes, 1995-2025: Prevalence, numerical estimates and projections. Diabetes Care 21:1414-1431, 1997 7. Flegal, K.; Ezzati, T.; Harris, M.; et al. Prevalence of diabetes in Mexican Americans, Cubans and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey, 1982-1984. Diabetes Care 14:628-638, 1991 8. American Diabetes Association (ADA). Diabetes 1996: Vital Statistics. Alexandria, VA: ADA, 1996 9. Centers for Disease Control and Prevention (CDC). National Diabetes Fact Sheet: NationalEstimates and General Information on Diabetes in the United States. Atlanta, GA:U.S. Department of Health and Human Services (HHS), CDC, 1999. 10. ADA. Economic consequences of diabetes mellitus in the U.S. in 1997. Diabetes Care 21:296-306, 1998. 9 Hodgson, T., and Cohen, A. Medical care expenditures for diabetes, its chronic complications and its comorbidities. Preventive Medicine 29:173-186, 1999.] 11. Diabetes Control and Complications Trial Research Group. The effects of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine 329:977-986, 1993. 12. Gotto, A. Cholesterol management in theory and practice. Circulation 96:4424-4430, 1997. 13. American College of Physicians, ADA, and Academy of Ophthalmology. Screening guidelines for diabetic retinopathy. Annals of Internal Medicine 116:683-685, 1992. 14. Levin, M. Diabetes and peripheral neuropathy. Diabetes Care 21:1, 1998. 15. Steffes, M. Diabetic nephropathy: Incidence, prevalence, and treatment. Diabetes Care 20:1059-1060, 1997. 16. Diabetes Control and Complications Trial Research Group. Lifetime benefits and costs of intensive therapy as practiced in the Diabetes Control and Complications Trial. Journal of the American Medical Association 276:1409-1415, 1996. 17. Eastman, R.; Javitt, J.; Herman, W.; et al. Prevention strategies for non-insulin dependent diabetes mellitus: An economic perspective. In: LeRoith, D.; Taylor, S.; and Olefsky, J.; eds. Diabetes Mellitus. Philadelphia, PA: Lippincott-Raven Publishers, 1996, 621-630. 18. Vinicor, F. Challenges to the translation of the Diabetes Control and Complications Trial. Diabetes Review 2:371-383, 1994. 19. Brechner, R.; Cowie, C.; Howie, L.; et al. Ophthalmic examination among adults with diagnosed diabetes mellitus. Journal of the American Medical Association 270:1714-1718, 1993. 20. Vinicor, F. Is diabetes a public health disorder Diabetes Care 17(S1):22-27, 1994.] 21. [Kuckzmarski, R. Increasing prevalence of overweight among U.S. adults: National Health and Nutrition Examination Survey 1960-1994. Journal of the American Medical Association 272:205-211, 1994. 22. Fagot-Campagna, A.; Rios Burrows, N.; and Williamson, D. The public health epidemiology of type 2 diabetes in children and adolescents: A case study of American Indian adolescents in the Southwestern United States. Clinica Chimica Acta 286:81-95, 1999. 23. Rosenbloom, A.; Joe, J.; Young, R.; et al. Emerging epidemic of type 2 diabetes in youth. Diabetes Care 22:345-354, 1999. 24. HHS. Physical Activity and Health: A Report of the Surgeon General. Atlanta, GA:HHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, 1996. 25. Dietz, W. Critical periods in childhood for the development of obesity. American Journal of Clinical Nutrition 59:955-959, 1994.] 26. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion. (May 2005) "Diabetes: Disabling, Deadly, and on the Rise." Available at CDC on the World Wide Web: www.cdc.gov/nccdphp. 27. National Institute of Diabetes, Digestive, and Kidney diseases. (1995) Diabetes in America, 2nd edition. Chapter 12: Disability in Diabetes. 28. From the article: "Development of a center for nursing at the Johns Hopkins based on the Self-Care Deficit Theory: a historical record" by Sarah E. Allison, Self-Care Deficit Nursing Theory -SCDNT-International Orem Society for Nursing Science and Scholarship IOS Newsletters, Volume 9, Edition 1, 2001 (PDF 392 KB) http://www.scdnt.com/download/NL-Vol9Ed1-2001.pdf Read More