Ways to Reduce the Risk of CVD Amongst Patients With Type 2 Diabetes Mellitus - Research Paper Example

Diabetes mellitus is considered one of the biggest public health concerns of countries worldwide. Today, lifestyle illnesses have become more rampant and uncontrollable as compared to epidemics or plagues which can now be contained. As a growing public issue, many physicians, doctors and even lay individuals are trying to come up with different means to improve the condition of a diabetic. More and more programs are being set up especially for people who are susceptible to acquiring this disease. In addition, since this disease usually brings about complications such as kidney disease or cardiovascular illnesses, studies are being made to avoid such occurrences and improve the quality of life of people inflicted with diabetes mellitus. One of the proposed techniques for avoiding complications such as cardiovascular diseases (CVD) in patients with diabetes is to stringently control and manage blood pressure of the patient. The author believes that this practice of keeping blood pressure in check could actually be efficient in preventing CVDs. This paper aims to discuss the mechanism of diabetes mellitus, focusing on type 2. At the same time, a discussion of why strict control and management of a type 2 diabetic patient’s blood pressure could prevent CVDs will also be presented. Pertinent and related information such as prevalence of diabetes particularly in the United Kingdom will be discussed, as well as the social and economic impact of this disease. The organization of this paper begins with a brief description of diabetes mellitus, type 1 and type 2. The author deems it necessary to also present statistics such as prevalence of diabetes in the United Kingdom and CVDs. After which the author will once again emphasize on the thesis statement, followed y a presentation of supporting journals and other studies. The social and economic bearing of all these will then be expanded on, ending with the recommendations of the author, applicability of the paper to actual practice and ultimately, the conclusion. Around the world, diabetes mellitus continues to e a concern for many. In fact, over the years its prevalence has grown in several countries. According to a 2004 study by Diabetes UK (2004), since 1996 the statistics of people who have been diagnosed with diabetes went up from only 1.4 million during that year to 1.8 million. By the year 2000, they believe that diabetes will further go up to 3 million (Diabetes UK, 2004). An estimate of the International Diabetes Foundation done in 2003 was that in 2007 the prevalence of diabetes would go up to 4% of the population (www.heartstat.org, 2008). Notably, Diabetes UK claims that most of these cases will be Type 2 because of the fast increase in the statistics of the obese and overweight individuals (Diabetes UK, 2004). In brief, Diabetes Mellitus is a condition wherein the glucose level in the blood is beyond normal range. The range considered normal is 70-90 mg/dL, but those with diabetes report that theirs goes up to 140 mg/dL (Champe and Harvey, 1994). Diabetes is characterized by an elevation of what is known as the fasting blood glucose levels due to a deficiency in insulin (Guyton and Hall, 2006). The secretion of hormones insulin and glucagon mainly come from the pancreas—an organ significant in digestion. These hormones function as the regulators of glucose levels in the blood and also play a significant role in protein and lipid metabolism (Guyton and Hall, 2006). Diabetes mellitus can be further categorized into two types. One involves an inability of the pancreas to produce insulin, making the individual insulin-dependent. On the other hand, type 2 is what is known as the non-insulin dependent diabetes mellitus (NIDDM) (Buchanan, et al, 1995). In this case, the pancreas is able to produce insulin. However, the problem arises when this organ fails to respond appropriately to the glucose present in the blood stream. As a result, insufficient insulin is secreted leading to a condition called hyperglycemia (Champe and Harvey, 1994). When tissues are not able to respond normally to the secreted insulin, on the other hand, resistance to insulin occur (Champe and Harvey, 1994). This disease may be caused by genetic abnormality in certain molecular structures of the body such as proinsulin or insulin itself (Berne, et al, 2004). Obesity may also be a significant contributing factor for the development of diabetes. According to recent study, obesity leads to an increase in insulin secretion or a condition called hyperinsulinemia (Berne, et al, 2004). Although highly dependent on the genetic trait associated with diabetes type 2 or NIDDM, one must manifest a drastic weight gain coupled with the other symptoms (Abbas, Fausto and Kumar, 2005). Usually, this type of diabetes becomes evident at the age of 40, although for Asians and African Caribbean descent, studies have shown that these races have the tendency to develop the disease earlier in life (Diabetes UK, 2004). Nevertheless, physical activities, proper diet and exercise plus medication have been proven to be important factors that prevent development of complications (Diabetes UK, 2004). It is quite obvious in the text that keeping diabetes in control to prevent complications have received significant attention. This is because diabetes is a life long disease without cure. As a result, advances and researches are made to at least improve the quality of life of those who are inflicted. In the United Kingdom, diabetes is considered a major problem. Diabetes UK (2004) reports that for this disease to become manageable there is a need to identify those who are at risk and those who have the disease earlier and a better treatment plan should be employed. In 2004, about 3% of the UK population was projected to have the disease (Watkins, 2003). This is equivalent to about 1.8 million, 250,000 of which have type 1 diabetes, and the rest, type 2. AS for the undiagnosed population, it is estimated that the figures lie between 765,000 to one million individuals (Diabetes UK, 2004). Since 1945, the number of people with type 1 diabetes has doubled. Half of the type 1 diabetics are also found to be below the age of 15 (Williams and Pickup, 2004). In 2004, Diabetes UK (2004) reported that 20,000 children and patients below the age of 14 have type 1 diabetes. On the other hand, type 2 seems to inflict more people across the globe. As a matter of fact, 100,000 cases of type 2 diabetes are reported every year in the United Kingdom (Diabetes UK, 2004). It was also reported that this type of diabetes is diagnosed mostly in people who are over the age of 40. Nonetheless, an increasing prevalence seen in younger people is being noted mainly because of the lifestyle of the youth today. This disease is seriously associated with numerous chronic illnesses and complications such as stroke, limb amputations (foot ulcer, etc.), kidney diseases and cardiovascular diseases. In this paper, focus will be more on CVDs. According to Barnet and O’Gara (2003), 80% of individuals with diabetes will die of complications of a cardiovascular nature. The author believes that in order to avoid deaths by CVD, or CVD per se in patients with NIIDM, a close watch on and strict management of blood pressure is needed. In a study by Vijan and Hayward (2003), they proposed that treatment of hypertension in type 2 diabetes mellitus patients may lead to a drastic outcome. The main focus on their study was to evaluate the goals and treatment programs already available for type 2 diabetes. They did this by gathering previous studies using the Cochrane Library and MEDLINE in 2000 and the data was qualified based on a first and second reviewer. The researches that were included were all randomized trial aiming to study the pharmacological aspect of treating hypertension and its impact on microvascular and macrovascular effects (Vijan and Hayward, 2003). According to the review they did, thiazide diuretics, angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers are effective drugs to prevent hypertension. Although, positive significant outcome does not always happen even with the use of these agents. What they concluded was that maintaining the blood pressure of the patient at 135/80 mmHg could prove more important and effective. Adverse outcomes may be better prevented if the patient’s blood pressure is maintained at this level (Vijan and Hayward, 2003). Similarly, a study by Estacio et al (2000) studied the effect of blood pressure control on the microvascular complications associated with type 2 diabetes. Compared to the previous study discussed above, the study of Estacio and his colleagues was more clinical and experimental in nature. They enlisted 470 patients with type 2 diabetes and enrolled them in a clinical trial involving intensive to moderate control of their blood pressure by usage of a drug nisoldipine, and for another group enalapril for antihypertensive emergencies to prevent neuropathy, retinopathy and nephropathy (Estacio, et al, 2000). Estacio and his colleagues (2000) noted that there is a significant correlation between blood pressure and vascular complications. To be more specific, Mehler et al (1997) showed that an independent association between hypertension and complications of diabetes such as retinopathy, neuropathy and nephropathy exists. He and his co-researchers were able to come up with such results by employing the Appropriate Blood Central in Diabetes (ABCD) Trial (Mehler, et al, 1997). Target blood pressure levels for non diabetics was pegged at 140/90 mmHg by the Joint National Committee on Prevention, Detection, Education and Treatment of High Blood Pressure. On the other hand, for patients with Type 2 diabetes, standard was set 135/90 mmHg (Estacio, et al, 2000). A study by Hansson et al (1998) supported this standard. In their study, also involving diabetes, blood pressure central and microvascular and macrovascular complication, they found out that CVD was seen less in patients who maintained a diastolic pressure of less than 80 mmHg, as compared to those whose diastolic pressure was below 90 mmHg. Two groups with one having a mean blood pressure of 144/82 mmHg, and another at a mean of 154/87 mmHg were compared in the UK Prospective Diabetes Study. They found out that significantly lesser people experienced Cardiovascular related complications and deaths in the first group as compared to the second group (Estacio, et al, 2000). Because Estacio and his colleagues believed that an even lower blood pressure level would be more beneficial, they launched to the ABCD Trial (Estacio, et al, 2000). For their study, they randomly divided their patients into 2 groups. One was referred to as moderate blood pressure group. This involved patients whose goals of blood pressure level was put at 80-89 mmHg. A more intensive group had a goal of blood pressure level pegged at 75 mmHg (Estacio, et al, 2000). In addition to this, the study also received the long lasting calcium channel antagonist, nisoldipine against the effects of the ACE inhibitor, enalapril. Creatinine clearance was said to be the primary end point. Nonetheless, effects of blood pressure levels on CVD, retinopathy and neuropathy were also questioned. From the same cohort of 470, the researchers previously reported that the ACE inhibitor drugs had a better impact on preventing CVDs rather than the nisoldipine which is the calcium channel antagonist. The current study being discussed was done 5 years after, as a follow up to find out if there is an effect in developing CVDs if blood pressure is moderately or intensively controlled by the use of either drug. The study design, as mentioned, involved 470 patients randomized into 2 groups—moderate and intensive blood control, with moderate diastolic blood pressure goal of 80-89 mmHg, and a target of 75 mmHg for the latter. A second randomization was done to identify which parents would receive nisoldipine or enalapril as their hypertensive medication. Effect of blood pressure control will be identified and measured by the change in creatinine clearance (Estacio, et al, 2000). Participants of this study were between the ages of 40-74 years during the time they were identified as type 2 diabetes by the billing lists in the health care system that participated in the research (Estacio, et al, 2000). To qualify, patients should have a diastolic blood pressure of greater or equal to 90 mmHg without hypertensive medication. They should also be diagnosed to have diabetes type 2 based on the criteria set by the World Health Organization report of 1985 (Estacio, et al, 2000). However, researchers disqualified patients who reported or showed that they are allergic to ACE inhibitors or have a history of myocardial infarction or cerebral vascular accidents in the past 6 months. Exclusion was also applied to those who had a ceremony artery bypass surgery in the past 3 months, had a history of unstable angina pectoris in the past 6 months had a case of congestive heart failure classified as class III or IV in the New York Heart Association. Lastly, disqualification was given for those who were required to take ACE inhibitors, those who were receiving hemo or peritoneal dialysis, or a history of serum creatinine level greater than 3 mg/dL. (Estacio, et al, 2000). Creatinine clearance findings showed that there is no significant difference between moderate and intensive blood pressure control. However, a noted intense mean decline for creatinine clearance was seen on the first year of taking the required medication (Estacio, et al, 2000). For the cardiovascular events and deaths, the follow up period reflected that the intensive blood pressure control group had a lower incidence of mortality as compared to moderate therapy. In conclusion Estacio et al (2000) claimed that there is no significant difference between intensive or moderate diastolic blood pressure central. Nevertheless, in the 5 years follow up period, it was seen that creatinine clearance remained stable indicating that management and control of blood pressure significantly reduces the risks of CVD complications and the probability of having retinopathy and/or neuropathy. Finally, Estacio et al (2000) added that between the use of calcium channel blocker and an ACE inhibitor , the latter is preferred in the initial antihypertensive medication because of its advantageous effect on macrovascular complication (Estacio, et al, 2000). From here alone, the author’s argument regarding the efficiency of maintaining and controlling the blood pressure of type 2 diabetes patients can be supported. This article is highly valid because of the reliability of measure used and because the researchers themselves gave a competent review. Furthermore, statistics were used to back up their claims and from the 5 year follow up study, more information was gathered that ultimately led to the conclusions about how CVDs can be prevented by such practice of blood pressure control. To reiterate the importance of blood pressure control in preventing cardiovascular diseases in diabetes type 2, another clinical research will be presented. This is the study by Goede, et al with regard to multifactorial intervention to prevent CVDs in diabetes type 2. In this research, they viewed a patient’s blood pressure as one of the primary risk factors contributing to the development of microvascular and macrovascular dysfunction. According to their study, patients who have type 2 diabetes have about 2-6% more risk of dying from a CVD than a normal person who is not sick with diabetes (Goede, 2003). Moreover, hypertension was viewed as one of the biggest risk factors for a very poor outcome, and that when coupled with other factors may result to untimely death (Goede, 2003). Again, in this study, follow up was made after a number of years. In this case, it was 8 years. For selection of participants, a qualification guideline was set. Patients had to be diagnosed to have microalbuminuria because this condition has already been proven to increase the likelihood of acquiring CVDs (Goede, 2003). The primary end point that was used as measurement for this study was cardiovascular diseases. The authors also included secondary end points in the form of retinopathy, neuropathy and nephropathy. One hundred sixty patients were randomly divided between two groups—one receiving conventional treatment and the other the multifactorial treatment that stresses on hypertension control (Goede, 2003). All patients receiving the multifactorial treatment received ACE inhibitors twice a day, and those who cannot take the drug received angiotensin II-receptor antagonist also set at twice a day. This prescription was given to the patients regardless of their reported mean blood pressure. Combination was also given to those who reported that they actually have hypertension (Goede, 2003). The researchers collected their data through testing on the 4.7 year and the 8th year which was the end of the study. The results were very interesting as 118 patients from the total 160 patients developed diseases of a cardiovascular nature. Eight five events that are cardiovascular related were reported in the conventional treatment group. As for the intensive therapy, only 33 events were reported. In the conventional treatment group, 35 patients demonstrated cardiovascular diseases and ailments. Seven deaths were recorded and a total of 17 events of myorcardial infarction that was not fatal were observed. In addition to this, some patients underwent surgery. There were 10 events of coronary-artery bypass grafts and 5 percutaneous coronary interventions. To complete the 85, 20 nonfatal strokes, 12 surgeries for atherosclerotic lesions and 14 amputations were reported. The intensive therapy group however had significantly lower events non fatal myocardial infarction at only 5 occurrences. Although, the same number of deaths was observed. The results showed much promise because only 5 coronary bypass artery grafts happened, 7 amputations—50% less than the first group and 6 interventions for atherosclerosis. As a conclusion, the authors claimed that with intensive therapy focusing on controlling blood pressure levels of patients, patients with diabetes type 2 can avoid cardiovascular diseases by about 50%. To be more specific they said that the intensive treatment of hypertension in patients with diabetes type 2 over the course of 8 years significantly reduced the risk of stroke and death from a cardiovascular cause. They also found out during the time they gathered data at 4.7 years that reduction of absolute risk for cardiovascular diseases was 8% (Goede, 2003). The authors said that there was actually no significant difference between the results they gathered during the 4.7 year data collection period and the 8th year which was the end year of the study. But, they emphasized that the significant findings were on the fact that intensive therapy and paying so much attention to the contributing factors such as blood pressure could actually reduce the likelihood of a patient developing CVDs (Goede, 2003). Lastly, the long-term effect of the therapy was found very promising. It improves the quality of life of those who are sick and enables them to function almost like those who are not sick. The author finds support and solid back up for the thesis statement earlier mentioned. Indeed, treatment of hypertension, specifically by lowering the blood pressure to almost normal could have a significant impact on the development of cardiovascular diseases in the people who have diabetes mellitus type 2. What is more interesting is that in the course of this paper, one can also derive that not only has this intervention have an impact on development of complications, but it also say a lot about long-term effect on the overall quality of life of the patients concerned. It is quite costly to have this disease. That is why in United Kingdom, addressing Diabetes is one of the country’s biggest health challenges (Diabetes UK, 2004). The occurrence of Diabetes has been observed as simultaneously growing with the doubling of country’s population. In this light, much effort has been placed on research towards the best practices for the prevention of this crippling disease, practically made a life partner to the obesity epidemic and sedentary lifestyles of its people. The increasing number of diabetics in the United Kingdom has been considered so alarming that the government has stepped up it initiatives to combat its widespread. The good news is that the government has acknowledged that the situation does not only impact the afflicted individual and its immediate family, but more so the government (Diabetes UK, 2004). The NHS (National health Services) is constantly reviewing present initiatives geared towards overall care and prevention of Diabetes. The government has also allocated budget for short-term investment on public healthcare which is envisioned to reap long term benefits for the entirety of the nation (Diabetes UK, 2004). In a recent Wanless report delving in part on the issue on various chronic disease management such as for Diabetes, it emphasized the pressing urgency for the Government to face head-on, with tangible and realistic strategies, the issues related to Diabetes, and implement these strategies in a systematic fashion to ensure long term positive results (Diabetes UK, 2004). While admittedly, the costs will be substantial, the Department of Health has considered the challenge to be significantly exciting, considering that Diabetes healthcare and prevention had been taking the sidelights for a long time. The NHS in a drafted policy, has now placed it as a priority, realizing the implications across primary and secondary care (Diabetes UK, 2004). The author believes that the effort exerted by the government in solving the problem of diabetes in these countries is truly crucial. This, along with the numerous researches such as this paper, aiming to identify better treatment plans and programs that can be implemented for diabetes mellitus patients would soon improve the situation in the UK. The author recommends that in the future, the programs and the actual facts like the effect of lowering blood pressure should be studied. There is a need for the medical world to integrate their findings such as what the author has proven here, with actual programs and plans of the government. By doing such, actual improvements in the condition of those patients with diabetes mellitus will be improved, and hopefully, prevalence will dramatically go down. References Barnet, A.H. and O’Gara, G. (2003). Diabetes and the heart. Oxford: Churchill Livingstone Barnett, T. (1998). The insulin treatment of diabetes: A practical guide. EMAP Healthcare Champe, P.C. and Harvey, R.A. (1994). Biochemistry, 2nd Ed. Philadelphia: Lippincott Williams and Wilkins Diabetes UK (2004). A report from Diabetes UK 2004. Diabetes UK The Charity for People with Diabetes Estacio, R.O., et al (2000). Data, results and consequences of major trials with focus on type 2 diabetes: Proceedings from a symposium. Diabetes Care, 23(2) Goede, P. et al (2003). Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. The New England Journal of Medicine, 348(5), 383-393 Guyton, A.C. and Hall, J.E. (2006). Textbook of medical physiology, 11th Ed. Philadelphia: Elsevier Saunders Hansson, L., et al (1998). Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial: HOT Study Group. Lancet, 351(1998), 1755-1762 Mehler, P.S., et al (1997). Associations of hypertension and complications in non-insulin-dependent diabetes mellitus. American Journal of Hypertension 10(1997), 152-161 UKPDS (1998). U.K. prospective diabetes study group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. BMJ, 317(1998), 703-713 Vijan, S and Hayward, R.A. (2003). Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Annals of Internal Medicine, 138(7), 593-602 Watkins, P. J. (2003). ABC of diabetes 2003. London: BMJ Publishing Williams, G. and Pickup, J. (2004). Handbook of diabetes. Massachusetts: Blackwell Publishing Read More