Possible Reasons For Marks Health Results - Case Study Example

Diabetes Management of Case Study No: Lecturer: Presentation: Analysis of Consultation Taking this consultation forward requires an analysis and implications of the recent blood results. The patient’s initial assessment of his symptoms indicates that he is obese with a BMI of 30. This puts him at risk of other cardiovascular conditions such as stroke and heart disease compounding his current state of type 2 diabetes. An HbA1c of 86mmol/L indicates elevated levels of glucose that is stuck in his red blood cells far above the recommended HbA1c of 50-55 mmol/mol for diabetes patients. The HBA1c levels are a pointer that the patient’s diabetes is not being effectively controlled with his current therapy (SIGN 116 Guidelines, 2010). Two tablets of Metformin 500mgs twice per day have not been effective in maintaining blood sugar levels at the recommended range. Total cholesterol of 5.2mmol/l is within safe limits but for the risk of high blood pressure and diabetes mellitus that makes the patient vulnerable. A cholesterol level lower than 5 mmol/L would decrease the risk of heart disease (Marso & Hiatt, 2006). Triglycerides level of 1.8mmol/l is slightly below the level where they are considered to be high at 2.0 mmol/L. However, the risk is compounded by the patient’s condition of hypertension, obesity and low HDL. Normal HDL cholesterol level needs to be between 1.1-1.4 mmol/L. The patient’s HDL of 0.9mmol/l can be regarded as peculiarly low thereby posing the risk of heart disease. Blood pressure of 146/80mm/Hg is a little higher than normal and needs to be lowered (ADVANCE, 2007). Possible Reasons For Mark’s Results The physical factors of Mark are facilitating deterioration of his diabetes condition. Obesity is associated with inactivity and Mark’s work as a HGV driver is a major contributor to this condition. Truck driving is associated with an unhealthy lifestyle that does not require physical effort rather than walking short distances to purchase fast foods that are considered to be convenient and time saving. Lack of exercise and unhealthy diet poses a health risk to truck drivers. As long as he remains in this job and does not make extra effort for exercise, it is unlikely that he will lose weight or improve his total cholesterol, triglycerides and HDL levels. The patents psychosocial environment influences his condition as he is likely to remain alone for prolonged periods at work (Anderson et al. 2004). According to Torgerson et al. (2004), there is a high tendency for food to be used as a way of dealing with weight issues especially when obese individuals are lonely, anxious or stressed. There is a high correlation between obesity and successive of disturbance of mood, overindulgence and increase in weight. When feelings of anxiousness or distress arise, overweight individuals are likely to eat thereby dealing with their mood temporarily. This behavior leads to weight gain which in turn fronts a dysphoric mood owing to the individual’s incapacity to cope with stress. Such moods result in to feelings of guilt that again set off the cycle hence a constant pattern of resorting to food to deal with emotions. Mark’s work is pre-disposed to an environment with calorically rich rations and inadequate physical activity. HGV drivers are also at risk of eating disorders such as regular snacking and absentmindedness while eating high calories food stuff as well as night eating while on long journeys, which may be associated with Mark’s incessant weight gain. There is an 80% risk for people with diabetes mellitus to develop high blood pressure at a certain stage which Mark could be approaching. Obesity is also a significant contributor to high blood pressure. Ineffective diabetes control and excess body fat are the major reasons causing high triglycerides in Mark’s blood. High triglycerides in turn have led to a reduction in HDL-cholesterol thereby raising the risk of heart attack (Chokalingham, 2010). Microvascular Implications for Mark’s Long-Term Health Diabetic retinopathy is one of the microvascular implications that are likely to influence Mark’s long-term health. It is a condition that is associated with a significant number of blindness cases in the UK. Prolonged and severe high blood glucose levels increase the risk of developing the condition among diabetic patients, which in Mark’s case will be facilitated by high blood pressure. Diabetic retinopathy might emerge well before type 2 diabetes is diagnosed, which places Mark at a high risk as his was diagnosed 3 years ago. The high glucose levels for Mark may trigger the production of free radicals in the blood (Shah, 2008). Diabetic nephropathy is also an important condition that causes renal malfunction. In type 2 diabetes, the condition may develop before diagnosis but is highly prevalent 10 years after diagnosis (Ajikumar & Gerich, 2010). This also indicates the risk that Mark is exposed to with regards to the time that has passed after being diagnosed with the disease. The high blood glucose levels increase the risk of developing the malfunction. Diabetic neuropathy is the third implication that is associated with nerve malfunctioning. The condition is influenced by the intensity and length of high blood glucose level. Mark has a high susceptibility to diabetic neuropathy due to prolonged hyperglycemia and genetic characteristics that are evident by both his mother and sister having Type 2 diabetes. The condition is blamed for more than 80% amputations in the UK (VADT 2008). Macrovascular Implications for Mark’s Long-Term Health Type 2 diabetes is associated to atherosclerosis, which is a condition that is an upshot of persistent inflammation and damage to the arterial wall in the secondary vascular structure. The damage results in to the oxidization of lipids originating from LDL elements eventually building up along the internal arterial walls (Donnelly et al. 2000). Acute arterial infarction may result from the eventual breakage of the atherosclerotic lacerations formed on the arterial walls. Type 2 diabetes is also associated with sticking together of platelets and hyper-coagulation. Mark is at a high risk of developing cardiovascular disease, which is a common phenomenon among diabetic patients. It is widely considered to be the major cause of death among such individuals. Many diabetic patients have been found to die from coronary heart disease. The metabolic syndrome affecting Mark including obesity and hypertension will reduce the manageability of type 2 diabetes. The disease is a major risk factor for the occurrence of ischemic condition and stroke leading to death. Nevertheless, studies have shown a higher preference for coronary heart disease in women than men (ADVANCE Collaborative Group, 2007). Management Plan for Mark It is necessary for Mark to undergo microalbuminuria and creatinine tests annually. If Mark will be diagnosed for microalbuminuria or macroalbuminuria, he ought to be put on treatment with an ACE reducer or ARB except if his body responds negatively to the treatment. However, it is highly unlikely that he will be unable to tolerate both medications and hence one must be used (ADVANCE, 2007). He should be involved in setting HbA1c of 50-55 mmol/mol as his target from the current 86mmol/L. The advantages of this reduction should be effectively communicated to him so that he can participate proactively in managing his HbA1c. The HbA1c should be measured within 2 to 6 monthly breaks depending on Mark’s needs until the blood glucose level becomes stable. Self monitoring of HbA1c levels should be encouraged to help in early detection of postprandial hyperglycaemia. Clinical biochemistry experts or diabetes specialists need to be involved to offer suggestions and explanations with regards to inexplicable inconsistencies involving (ACCORD, 2008). Distal symmetric polyneuropathy and lipid tests need to be conducted annually while blood pressure measurements should be routine. At the time of diagnosis, Mark should have undergone through a broad eye inspection and dilation and so if this was not done, he should be examined. Despite treatment with Metformin, Mark’s sugar levels remain high and therefore there is need to scrutinize the manner in which he takes the medication. Twice a day with the morning and evening meals should be emphasized to deal with high sugar levels when they occur. Sulfonylurea which is a glucose-lowering prescription should also be given in addition to Metformin since the glucose control seems to be insufficient. A GLP-1 agonist is also necessary for Mark if Metformin and Sulfonylurea if the targeted glycaemia is not accomplished (SIGN 116 Guidelines, 2010). Metformin therapy needs to be increased progressively over a number of weeks to lessen risk of gastro-intestinal contraindications. The dosage of metformin should be reviewed upon the discovery that the creatinine goes beyond 130mmol/l or when the glomerular filtration rate is projected to be lower than 45 ml/minute/1.73-m2. On the other hand, the metformin dosage should be discontinued when creatinine goes above 150 mmol/l or when the glomerular filtration rate is lower than 30 ml/minute/1.73-m2 (Lau & Nau, 2004). Mark should also be given aspirin treatment of 75mg/day as a secondary deterrence measure for cardiovascular disease, which is necessary for diabetic adults above 40 years. 80 grams of fruits and vegetables need to be part of his daily diet to boost his immunity and also reduce appetite for high glycemic index foods. Fruits reduce appetite by ensuring an individual feels full. Mark should avoid saturated fats, trans-fats and foods with cholesterol as well as high amounts of salts that can raise his blood pressure (Gruppetta et al. 2010). Self care is vital in management of type 2 diabetes and therefore Mark needs to be trained with regards to diabetes pathophysiology and control, circulatory wellbeing, remedial nutritional therapy, and eye fitness as an individual, patient cluster lessons or discussion groups. The trainings need to be customized to fit his needs and program (NICE Guidelines, 2009). A training needs assessment needs to be conducted during this consultation to establish what Mark knows and what should be included in the training. He needs to make efforts to maintain optimal blood glucose and pressure regulation to lessen the possibility of diabetic retinopathy or its further progression (SIGN 116 Guidelines, 2010). A change in diet can be significant in helping him to lower blood sugar levels and reduce weight. A dietitian should be included in the diabetes management team to help Mark adjust his eating habits through developing a tailored nutrition plan. It should help the patient to modify his lifestyle on the basis of individual preferences (Tuomilehto et al. 2001). It is necessary for the patient to avoid carbohydrates in foods such as white bread, white rice and popcorns as they are known to increase blood glucose. Foods with a low glycemic index such as beans, non-starch vegetables and whole grains. Mark also needs to reduce the daily rations to avoid overeating (Brown, 1990). He needs to avoid junk as well as processed foods that contain sugar additives that raise blood glucose levels. Mark also needs to engage in regular exercises to supplement a healthy diet. Mark’s handlers can also be encouraged to attend training sessions so that they can help him to adjust effectively. They together with mark need to be given an opportunity to participate in the design and delivery of home-grown programmes (NICE Guidelines, 2009). Sedentary behavior that is associated with his work may not help in the management of his condition. He needs to spare 30 minutes per day, five days per week for aerobic exercises and also engage in walking and bicycle riding among other activities that require him to apply energy thereby reducing blood glucose. He should regularly monitor his weight to ensure a downward trend, which is necessary to deal with his obese status. Such adjustments should be learnt through client centered nutrition education by dietitians either individually or as a group. The education needs to address matters such as identifying carbohydrates, interpretation of diet labels, determining the right proportions of food, developing feeding schedules as well as managing body weight (Adams & Cook, 1994). A team of experts in diabetes management, nutrition and fitness will play a significant role in educating Mark with regards to the basics of a healthy lifestyle and also establish appropriate tools to enable him attain health goals. He will also be advised on effective management of sick days as well as on proper strategies to deal with stress, caring for his skin and feet to avoid injuries. Coaching is also necessary to enable him adjust to the lifestyle changes with ease. They should be well versed with the local programs (NICE Guidelines, 2009). Pharmacists attending to Mark’s prescriptions also need to be engaged in the team as they can take extra responsibility apart from administering the drugs prescribed by the physician. They can make the first move by recommending a change in medication when need arises and also organize laboratory examinations to determine the outcome of prescribed medication. Evaluating the level of medication knowledge as well as counseling the patient with regards to the use of drugs is an important role that pharmacists can play to help manage the condition (Jarvis et al. 2010). Reference List ACCORD, 2008. “The Action to Control Cardiovascular risk in Diabetes Study Group. Effects of Intensive Glucose Lowering in Type 2 Diabetes”. The New England Journal of Medicine. 358: 2545-2559. Adams, C. E. & Cook, D. L. 1994. “The impact of a diabetes nurse educator on nurses’ knowledge of diabetes and nursing interventions in a home care setting”. Diabetes Educator 20: 49-53. ADVANCE, 2007. “Advance Collaborative Group. Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes”. The New England Journal of Medicine. 358:2560-2572. ADVANCE Collaborative Group, 2007. “Effects of a fixed combination of perindopril and Indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial”. Lancet. 370: 829-40. Ajikumar, V. A. & Gerich, J. E. 2010. “Type 2 diabetes: postprandial hyperglycemia and increased cardiovascular risk”. Vascular Health Risk Management. 6: 145-55. Anderson, J., Freedland, E., Clouse, E., & Lustman, J. 2004. “The prevalence of comorbid depression in adults with diabetes: a meta-analysis”. Diabetes Care. 24(6): 1069-78. Brown, S. A. 1990. “Studies of educational interventions and outcomes in diabetic adults: a meta-analysis revisited”. Patient Education Counsel 16: 189-215. Chokalingham A, 2010. “Healthy weight – healthy blood pressure”. Canadian Journal of Cardiology 2, (5): 259-60. Donnelly, R., Emslie-Smith, A. M., Gardner I. D., & Morris, A. D. 2000. “Vascular complications of diabetes”. British Medical Journal. 320: 1062-6. Gruppetta, M., Calleja, N. & Fava, S. 2010. “Long-term survival after acute myocardial infarction and relation to type 2 diabetes and other risk factors”. Clinical Cardiology. 33(7): 424-9. Jarvis, J., Skinner, T.C., Carey, M.E. & Davies, M. J. 2010. “How can structured self-management patient education improve outcomes in people with type 2 diabetes”. Diabetes Obes Metab. 2: 12 19. Lau, T. & Nau, P. 2004. “Oral antihyperglycaemic medication nonadherence and subsequent hospitalization among individuals with type 2 diabetes”. Diabetes Care 27: 2149-53. Marso, S. P. & Hiatt, W. R. 2006. “Peripheral Arterial Disease in Patients with Diabetes”. Journal of the American College of Cardiology. 47: 921-929 NICE Guidelines, 2009. Type 2 diabetes: Managing type 2 diabetes, retrieved 14th May 2015 from Shah, C. A. 2008. “Diabetic Retinopathy: A comprehensive review”. Indian Journal of Medical Science. 62(12): 500-19. SIGN 116 Guidelines, 2010. Management of diabetes: A national clinical guideline, Scottish Intercollegiate Guidelines Network, retrieved 14th May 2015 from < http://www.sign.ac.uk/pdf/sign116.pdf> Torgerson, J.S., Hauptman, M. D., Boldrin, M. N. & Sjostrom, L. 2004. “Xenical in the prevention of Diabetes in Obese Subjects (XENDOS) study”. Diabetes Care 27: 155-61 Tuomilehto, J. Lindstrom, J. & Eriksson J. G. 2001. “Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance”. New England Journal of Medicine 344: 1343-50. VADT (2008). “Glucose Control and Vascular Complications in Veterans with Type 2 Diabetes”. The New England Journal of Medicine 10: 1056. Read More