Diabetes and Heart Disease - Assignment Example

Running head: Comparative analysis Comparative Analysis By ___________________ Diabetes Researches have shown that chronic illness in adolescence is not a rare occurrence (Inge, 2001:9). Apart from life threatening illness, the larger volume of research in more recent years has devoted more attention to illnesses that are less often fatal, more easily treated, and in principle, more readily managed by the patient. Lately this approach has included diabetes and some types of cancer, which nowadays are not necessarily fatal but rather chronic, very stressful illnesses (Inge, 2001:10). Coping with Diabetes Over here the focus would be on one illness in particular, namely, insulin-dependent diabetes mellitus (IDDM), which is also known as diabetes mellitus type I or juvenile-onset diabetes. Diabetes is a comparatively frequently occurring chronic disease in adolescence and exhibits the typical aspects of a chronic illness (Inge, 2001:25). Medical Characteristics Insulin-dependent diabetes mellitus is a complex metabolic disorder. It is characterized by an absolute or relative lack of circulating insulin. It develops as a consequence of an imbalance between insulin production and release on the one hand and hormonal or tissue factors modifying the insulin requirement on the other hand. Insulin, a hormone produced by beta cells of the pancreas and secreted into the blood, facilitates entry of glucose to body cells. Without insulin, excess glucose accumulates in the blood. The cells, deprived of their main source of energy, turn to the body's energy reserves, beginning with glycogen, and then proceeding to protein and ultimately fat, for sustenance. The burning of fat leads to the formation of highly acidic ketones, which also accumulate in the blood. The kidneys work overtime in an effort to clear the blood of both excess glucose and ketones, resulting in frequent urination. This leads to dehydration and concurrent losses of essential substances such as sodium. The diagnosis of diabetes is frequently suggested by a history of polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive food intake), associated with weight loss. A clinical suggestion of diabetes is confirmed by finding glucose in the urine and by detecting an abnormally elevated blood glucose level. Left untreated, insulin-dependent diabetes leads inevitably to death caused by the metabolic consequences of insulin insufficiency. In essence, the cells "starve" in the presence of sufficient foodstuffs (Hauser, Jacobson, Benes, & Anderson, 1997). Insulin-dependent diabetes mainly strikes children and adolescents and accounts for 10% of all known cases of diabetes. Medical treatment of diabetes primarily strives to maintain blood glucose levels within a range that avoids wide swings, which may lead to severe hyperglycemia or hypoglycemia. The status of a diabetic patient's metabolic adaptation may be assessed by monitoring certain physiological parameters at regular intervals, for example, by regularly testing blood and urine sugar levels. Most practitioners use glycosylated haemoglobin (HbA1 or HbA1c) values. The HbA1 or HbA1c value, that is, the fraction of glycosylated haemoglobin in the blood, provides information about the average state of the metabolism over the preceding 4 to 8 weeks (Inge, 2001:26-27). Patient Compliance and Practitioner Relationship The therapeutic demands on patients and their parents are complex and involve injecting insulin, monitoring glucose levels in the blood and urine, and attending to dietary regulations on a daily basis. Obviously, diabetes therapy can only be successful if both the adolescent and the parents understand the treatment. For the attending practitioner, the goals of diabetes therapy include reducing or eliminating clinical symptoms and helping the patient to achieve normal growth, correctly timed maturation, and physical efficiency. Certainly, the most important aim is to minimize the danger of long-term damage. Long-term optimization of metabolism can only be based on acceptance of the illness by the adolescents and on their readiness to act independently and responsibly. Accordingly, because adolescents must receive intensive and adequate medical treatment, the quality of the patient-practitioner relationship will also decisively influence their motivation to follow practitioner's instructions (Inge, 2001:42). Unlike the adult form of diabetes, the manifestation of juvenile diabetes is sudden, and the illness progresses rapidly. Within a few weeks, patients display excessive thirst (polydipsia), abnormally frequent urination (polyuria), weight loss, and overall deterioration in physical health and mental efficiency (Struwe, 1991). If these symptoms are not recognized and correctly diagnosed in the early stages of the disease, metabolic breakdown and diabetic coma may occur. Within our sample, the time between onset of first symptoms and diagnosis of diabetes varied in length; in some cases even the most obvious manifestations of the disease had been denied for some time (Inge, 2001:44-45). Aside from the social support system, the ill adolescent has the opportunity to utilize the support offered by the medical system. The relationship between practitioner and patient is recognized as essential for the patient's compliance and ability to deal with the illness. Patients consider the investment of trust in their practitioners as being particularly helpful in dealing with their health problems (Freund & McGuire, 1991). However, findings from studies on adult populations cannot be generalized to adolescents, who can be unmotivated patients owing to their strong wish for independence (Seiffge-Krenke, 1998a). Further barriers to using health care lie in developmental changes in self-disclosure behavior and dealing with nudity. Privacy is very important to adolescents, who are extremely concerned about issues of confidentiality. In a study conducted by Ginsburg et al. (1995), adolescents considered a practitioner's honesty, confidentiality, competence, knowledge, and carefulness to be the most important personal characteristics necessary for ensuring a positive patient-practitioner relationship. Impact on Patient and Family The management of diabetes places a variety of complex demands on both the patient and the family. For example, insulin injections must be performed at specified times, blood and urine glucose levels must be tested, and dietary regulations must be followed. Successful therapy will first depend on how well the patient and the patient's family have been instructed about and understood the treatment. Obviously, successful therapy requires that the patient be conscientious about following instructions. In this regard, the burden of illness management is largely placed on the adolescents themselves. The adolescent has to live by the clock and to administer insulin at predetermined times during the day. Adhering to diet and checking blood and urine glucose levels are also important daily activities. Yet, these are not necessarily matters that concern the adolescent alone. Although it is essentially up to the diabetic adolescent patient to carry out the procedures belonging to the treatment regimen and to maintain adequate blood glucose levels, the parents still need to monitor their adolescent on a continual basis. In addition, numerous family activities are interrupted or impaired by diabetes management, including mealtimes and leisure time activities. Thus, it is obvious that the onset of diabetes leads to quite radical changes in the adolescent's and the family's life-styles. Finally, the chronicity of the stressor has a major impact on the adolescent's ongoing life and future, and in part, on those of the family as well. The threat of long-term physical damage poses additional burdens on adolescents with diabetes and their families (Inge, 2001:27-28). Moreover, diagnosis and management of the illness present major long-term stressors for the parents as well (Eiser, 1985). Although some families are able to adjust to the illness by experimenting with new behaviors, other families are incapable of devising new strategies. They continue along familiar paths and rely on former methods of solving problems in order to meet the adolescent's new needs. Often one parent devotes the bulk of his or her time and energy to caring for the ill adolescent, thereby withdrawing from the other members of the family, a pattern seen most commonly in mothers of chronically ill children and adolescents (Cook, 1984). The onset of a child's chronic illness is a source of stress, which spurs the family to develop coping strategies. These strategies may lead to a restructuring of family life that extends far beyond illness management and the family's coping style. The form of coping depends on the type of family and its history before the onset of the illness (Cole & Reiss, 1993). Some families develop functional coping processes that reduce the emotional stress and allow the family to deal effectively with the adolescent's needs. Other families are more preoccupied with the stress caused by the illness and its management. Although temporarily functional, the latter situation can be dysfunctional in the long term (Inge, 2001:118-119). Friendships Peer relationships and close friendships are of great importance to adolescents. One of the adolescent's central developmental tasks, highlighted in the literature on developmental psychology, is to create new, more mature relationships with peers of both genders (Havighurst, 1972). However, studies of chronically ill adolescents have long neglected peer relationships and, above all, the important experience of close friendships (Inge, 2001:167). Researches shown that for chronically ill adolescents the friend's supportive role is very important. For adolescents, a friend offers emotional support and comfort at a stage of confrontation with developmental tasks and role transitions. Such adolescents increasingly avoid disclosing information to their parents, they confide in peers and friends more and more (Norell, 1984). Adolescent Development Some researches on adolescent development have been done but failed to produce more realistic conclusions. Many questions remain unanswered. Do adolescents see themselves as "producers of their own development," as Lerner (1987, p. 29) suggested How important are certain developmental tasks for them during certain periods in adolescence Do adolescents exercise their own competencies and pursue their own aspirations in accordance with society's expectations Despite the key role of developmental tasks, literature on this topic is quite limited. Most of the ill adolescents approached the dilemma between adhering to the therapeutic regimen and tackling developmental tasks by postponing development. Although these adolescents failed to achieve many important developmental tasks, they mostly adjusted well to the illness in a medical sense; that is, they maintained satisfactory to good metabolic control and showed good compliance (Inge, 2001:233). Although denial and trivialization can be important ways of coping, Lazarus (1985) has already suggested that their efficacy is short-lived. Continuous denial and trivialization can become dangerous when applied over a long time. The most problematical aspect is that because of these defence processes, the illness cannot be integrated into the life of the family and even more importantly, into the life of the adolescent. Clearly, the consequence of this failure will be the inhibition of the adolescent's development. Practitioner diabetes care management and intervention It is the duty of the practitioner to properly teach the children, young people and their families in order to enhance their self care skills and knowledge during the course of planned treatment. Proper counseling and support should be available at all times. Information should be provided about diabetes, sick day rules, life style changes and long-term implications to the patient and his family (NHS, 2006). The National Service Framework for Diabetes proposes a 'supported self care service model' for diabetes and recognises the importance of education in facilitating self-management as the cornerstone of diabetes care. The expert patient programme initiative, which is now being piloted in over 50 primary care trusts and as yet has not been evaluated, involves the introduction and evaluation of self management training programmes for people living with long-term medical conditions, including diabetes. The programmes are lay-led and focus on areas such as developing individuals' confidence to access services, and are therefore complementary to and not an alternative to diabetes education. Dose Adjustment for Normal Eating (DAFNE) is a structured educational programme for people with type 1 diabetes that teaches individuals to adjust their insulin to match carbohydrate intake and lifestyle on a meal-by-meal basis, thereby allowing enhanced dietary freedom. It is currently available in a number of diabetes centres across England as part of a national evaluation project. The programme consists of 5 days of intensive training delivered to groups of six to eight individuals on an outpatient basis. In the context of this appraisal, DAFNE was recognised as being both a treatment and an educational package (NICE, 2006). Heart Disease Coronary disease is frequently viewed as a disease only of men. Other diseases such as breast and cervical cancers have received much more attention as important illnesses of women. However, coronary disease is the primary cause of death in both men and women. The most obvious difference between men and women is the presentation of coronary disease in women in the older, postmenopausal years. Other important gender differences include the less specific clinical manifestations of coronary disease in women, the greater difficulty of diagnosis, and the more severe consequences of myocardial infarction when it occurs in women (Susan, 2002:53). Once coronary artery disease develops, women do not have a survival advantage over men. In fact, in every age group, women with coronary disease have a higher risk of death from a coronary event than men. Older women are twice as likely as older men to die within weeks after a heart attack (Susan, 2002:53-54). Risk factors The risk factors include diabetes, hyperlipidemia, hypertension, smoking, family history, obesity, and aging. However, the role of estrogen is unique to women. Cholesterol profiles of women and men differ with age. Levels of low-density lipoproteins (LDL) are lower in women than in men until the age of 50, when LDL levels increase in women. In women of all ages, high-density lipoproteins (HDL) are about 10 mg/dl higher than in men. In perimenopausal women, levels of lipoprotein (a) increase with age. This change in lipid levels may help explain the increased incidence of coronary artery disease in older women. Epidemiologic studies have confirmed that high cholesterol is a risk factor for coronary disease in women, but women have been excluded or included only in small numbers in primary and secondary prevention trials, which have usually included middle-aged men. Women have been enrolled in large numbers in only two secondary prevention studies. In the Scandinavian Simvastatin Survival Study Group, lowering cholesterol levels had a beneficial effect on nonfatal cardiovascular events but did not prevent death in women. The Upjohn Primary Prevention Study, in which 52% of the 2278 participants were women, showed that the use of colestipol was beneficial only in men; however, the statistical power of the study may have been insufficient to detect the effects in women. Thus, the effect of treating hypercholesterolemia on coronary disease risk in women requires further study (Susan, 2002:55). In women of childbearing age, oral contraceptive pills have been associated with an increased risk of stroke, myocardial infarction, and thromboembolism. Estrogens in these pills enhance both factor VII and fibrinogen in order to create a procoagulant effect. Progestins in contraceptive pills can decrease HDL levels, increase LDL levels, increase blood pressure, and exacerbate glucose intolerance. Estrogens have a favorable effect on lipid profiles; they increase HDL and decrease LDL levels. However, estrogen also increases triglyceride levels. The cardiovascular risk associated with oral contraceptive pills is dose related and is greatest in women smokers older than 40 years of age. Because these studies were done, the formulation of oral contraceptive pills has changed so that minimally effective doses of estrogen and progestin are used. At present, these pills are considered safe in young, nonsmoking women; caution is recommended in women older than 40 years of age and in women who smoke (Susan, 2002:55). Recognition and Diagnosis of Coronary Artery Disease Angina pectoris is the clinical term used to describe chest pain resulting from a relative oxygen deficiency in heart muscle. The coronary heart disease syndromes are stable angina pectoris, unstable angina pectoris, variant angina, acute myocardial infarction, non-Q- wave infarction, and Q-wave infarction. Most individuals with angina have underlying atherosclerotic coronary artery disease (CAD). This angina occurs because even normal coronary arteries may not adequately supply oxygen to hypertrophied, dilated, or failing heart muscle. Often coronary vasodilator reserve may explain angina, especially in some patients with ventricular hypertrophy associated with LV outflow obstruction, including valvular aortic stenosis and hypertrophic obstructive cardiomyopathy, and in patients with poorly controlled systemic arterial hypertension. Coronary artery vasoconstriction occurring with exercise or stress may also be a contributing factor. Role of Hormone replacement After menopause, when estrogen levels fall, the incidence of atherosclerotic disease is equal to or greater than that in men. This linkage between atherosclerotic disease and estrogen levels is reinforced by the observation that women who undergo surgical or chemical oophorectomy early in life have an accelerated rate of atherosclerosis. The cardiovascular benefits of estrogens may be partially or even completely preserved after menopause by exogenous hormone replacement (HRT), which refers to the use of estrogens with or without the concomitant use of progestins. However, many issues of HRT are controversial and unresolved (Susan, 2002:119). Risks associated with Hormone replacement Estrogens can have a number of deleterious effects. One significant effect is stimulation of hyperplasia in breast and uterine tissues, which may lead to cancer in these organs. In addition, estrogen use increases the risk of thrombosis, especially peripheral deep venous thrombosis or pulmonary embolism. This risk is further increased in women who smoke. Nevertheless, the question remains whether or not the additional risk of breast or uterine cancer is outweighed by the benefit of reducing deaths from CHD (Susan, 2002:121). Behavioural Barriers The most common one is smoking; researches have shown that the number of women addicted to this habit is increasing rapidly. Compared to men, this habit of smoking does not appear to be a risk factor for women as they have the benefit of estrogen levels during their ages of menopause. But after menopause, smoking risk factor becomes prominent as it accelerates the process of atherosclerosis. Rehabilitation Depending on the nature of complexity, the practitioner used to give varying therapies to give relief from the pain. Whether the patient has undergone Pharmacological therapy for stable or unstable angina, Thrombolytic therapy, Percutaneous transluminal coronary angioplasty therapy or surgical therapy, proper rehabilitation is most important part afterwards, so that none of the complications can occur again. Cardiac rehabilitation has evolved into a multidisciplinary effort that involves baseline patient assessment, nutritional counselling, risk factor modification (lipids, hypertension, weight, diabetes, and smoking), psychosocial management, physical activity counselling, and exercise training. The goals of rehabilitation are to limit the impact of heart disease, minimize mortality, prevent further cardiac events, and enhance the patient's quality of life. Specifically, rehabilitation lowers the cardiovascular death rate, improves exercise tolerance (by 30%), reduces ischemia, decreases stress, improves blood lipid levels, decreases cigarette smoking, and slows the progress of CAD. Rehabilitation also reduces depression, promotes emotional well-being, and enhances psychosocial function. These benefits may be at least as great in women as in men. Most patients are referred for cardiac rehabilitation because they have undergone MI, CABG, or PTCA. Other indications are heart transplantation, valve surgery, angina, heart failure, and conduction disturbances. Of the patients who could benefit from a rehabilitation program, as few as 11% actually enrol in such a program. The traditional cardiac rehabilitation program is initiated 3 to 6 weeks after a cardiac event and lasts for 12 weeks. The program is usually held on the hospital premises but may also take place in a university, a community center, or some other private facility. Program personnel include cardiologists, physiotherapists, nurses, occupational therapists, psychologists, social workers, and dieticians. Traditional cardiac rehabilitation programs have been criticized because of sub optimal participation, poor facilitation of independent exercise, use of expensive ECG monitoring, and lack of insurance reimbursement. As a result, some centers have adopted a home-based exercise protocol for low- to moderate-risk patients. This protocol is implemented with the aid of educational support meetings, telephone follow-up, and transtelephonic monitoring if necessary. Compared with traditional programs, the home-based protocol is equally effective at improving physiologic outcomes while costing considerably less and being more attractive to patients (Susan, 2002:227). Appendix Type 1, Diabetic Patient James was 14 years old. He had suffered from diabetes for 8 years. His metabolic adjustment was good. His appearance in the first interview was not striking: He had short hair and wore jeans and a sweatshirt. He was generally quite open and sometimes a little precocious. Only his mother took part in the family discussion, explaining that the father's work and health were so strained that he could not take part in the study on this or future occasions. James' mother was very nervous and frequently laughed with embarrassment. During the family discussion, James' relationship with his mother came across as fraught with conflict, although the specific issues could not be named. James had barely changed by the second interview. He seemed a little inhibited about talking openly about many topics; for example, his answers to questions about girlfriends or girls in general were evasive and unclear. His mother confirmed that he had no contact with girls. James had no problems with managing the illness. His sole concerns involved his career plans. Above all, he was afraid of unreasonable employers. The interviewer had the impression that James was not a typical adolescent, especially since he described neither escapades nor daydreams. He had almost no friends, had no contact with peers, and was very withdrawn. In contrast, his parents seemed much more socially active; they especially liked to meet their friends at a camping ground on the weekend. In the interview, the mother and son agreed on almost every topic. The mother expressed many fears about her son's illness. Long periods of separation from James caused her great concern, and she also worried about the little contact her son had with peers. The third interview took place in 2002. James was 16 years old and had grown up considerably. He had a slight moustache and appeared stronger than in the previous year. He behaved a little precociously in the interview. He was proud to be the first member of his family to have attended Gymnasium and was already talking about obtaining a doctorate degree in some field of natural science. However, he also seemed lonely. He said that he dealt with his problems alone, since the only people he could talk to were much too busy. James believed he managed his diabetes very well, and he claimed to know more than the practitioners did. He confessed that he did not strictly follow his practitioner's advice. At the end of the interview, James gave the interviewer a few suggestions on how he would run the kind of research study we were conducting. James' mother had grown more relaxed since the last meeting. She was generally eager and willing to talk. Although she told what she knew about James, it was very little. As an explanation, she said that her son had become very closed. As soon as the fourth interview began in 2004, James exclaimed that everything was going wonderfully at school. Although he reported occasional conflicts with his father, he got along well with his mother. His career plans had changed; now he hoped to study another subject with more career opportunities. He admitted that he did not have a large circle of friends at the moment. It turned out that the boy he had called his best friend for the past 3 years was a neighbour whom he only saw at school. In contrast to the previous year, he openly acknowledged having no contact with girls, saying he had no time for them anyway. When asked about his current hobbies, he named weekend camping trips with his parents. He ("naturally") had no problems at all with the illness. James' mother described him as being a completely easy and agreeable boy. She reported that he complied perfectly with his diabetes regimen and kept his distance from peers who smoked and drank. There were no problems with school. However, she did remark that James liked to show off his academic superiority in the family, especially in front of his brother. Heart Patient Ms. Joana, a 52-year-old female, with no history of hypertension or diabetes was admitted with an evolving inferior myocardial. She used to smoke 15 cigarettes daily from the past 15 years. She had perfect body mass index and used to exercise daily. As far as the family history was concerned, her mother had undergone angioplasty at the age of 65. Doctor immediately suggested coronary angiography for more specific details, so she agreed. The report showed one coronary artery blockage due to plaque. The practitioner counselled her, while informing her about the hazards of smoking, that how it is decreasing HDL and increasing LDL there by forming plaque in the heart arteries and creating blockage within them. The practitioner also convinced her for the angioplasty and the precautions she has to take afterwards for the rest of her life. So she underwent angioplasty with the stent technique being used by the practitioner. After recovery she was discharged with the following medications: No Smoking Clopidogrel 75mg Simvastatin 40mg Ramipril 2.5mg Folic Acid 1mg Aspirin She was also advised to have lipid profile test after 15 days. References Cole, R. E., & Reiss, D. (1993). How do families cope with chronic illness. Hillsdale, NJ: Lawrence Erlbaum Associates. Cook, J. A. (1984). Influence of gender on the problems of parents of fatally ill children. Journal of Psychosocial Oncology, 2, 71-91. Eiser, C. (1985). The psychology of childhood illness. New York: Springer. Freund, E. E. S., & McGuire, M. B. (1991). Health, illness and the social body. Englewood Cliffs, NJ: Prentice-Hall. Ginsburg, K. R., Slap, G. B., Cnaan, A., Forke, C. M., Balsley, C.-M., & Ronselle, D. M. (1995). Adolescents' perceptions of factors affecting their decisions to seek health care. Journal of the American Medical Association, 273, 1913-1918. Hauser, S. T., Jacobson, A. M., Benes, K. A., & Anderson, B. J. (1997), Psychological aspects of diabetes mellitus in children and adolescents: Implications and interventions. In N. E. Alessi (Ed. ), Handbook of child and adolescent psychiatry (Vol. 4, pp. 340-354). New York: Wiley. Havighurst, R. J. (1972). Developmental tasks and education. New York: McKay. Inge Seiffge-Krenke (2001), Diabetic Adolescents and Their Families: Stress, Coping, and Adaptation, Cambridge University Press, 2001. Lazarus, R. S. (1985). The trivialization of distress. In P. Ahmed & N. Ahmed (Eds. ), Coping with juvenile diabetes (pp. 33-60). Springfield, IL: Charles C Thomas. Lerner, R. M., & Foch, T. T. (Eds. ) (1987). Biological-psychosocial interactions in early adolescence:A life-span perspective. Hillsdale, NJ: Lawrence Erlbaum Associates. NHS (2006) accessed from NICE (2006) accessed from Norell, J. E. (1984). Self-disclosure: Implications for the study of parentadolescent interaction. Journal of Youth and Adolescence, 13, 163-177. Seiffge-Krenke, I. (1998a). Adolescents' health:A developmental perspective. Mahwah, NJ: Lawrence Erlbaum Associates. Susan Wilansky, James T. Willerson; Churchill Livingstone (2002), Heart Disease in Women. Struwe, E. (1991). Diabetes mellitus [Diabetes mellitus]. In K. Betke, W. Knzer, & J. Schaub (Eds. ), Lehrbuch der Kinderheilkunde, 6. neubearb. Aufl. [Textbook of pediatric medicine, 6th ed., rev. ]. (pp.276-288). Stuttgart: Georg Thieme. Read More