The Rising Tide of Diabetes - Essay Example

1. Demonstrate critical understanding of the need to develop, implement and monitor strategies for early detection, to reduce the risk of developing Type 2 diabetes in the population across the life span.(notes from tutor -overview regard to prevalence Type 2 DM who at risk of developing type 2 dm including impaired fasting glucose tolerance, obesity, metabolic syndrome, insulin resistance others at risk people with IHD, HTN and gestational diabetes, what has been written about screening. Reduce risk, lifestyle intervention reports from america and finland. Link lifestyle and what is happening) In a decade’s time (1991-2001), the diagnosis of self-reported diabetes increased 61% in the US (Mokdad et al, 2003) including a startling increase from 1990 to 1998 among people in their 30s (Mokdad et al, 2000). Accounting for roughly 95% of all diabetes, type 2 diabetes is associated with obesity and weight gain (Mokdad et al, 2001), which is also increased over the same time period. One projection is that the 11 million residents that have been diagnosed with diabetes will increase to 29 million in 2050 (Boyle et al, 2001). The escalating prevalence of type 2 diabetes portends serious consequences for the quality of life of those affected and their families and communities. To stem the rising tide of diabetes, public health policies need to move upstream toward prevention or at least delay in the onset of type 2 diabetes. A number of scientific studies offer scientific evidence and new hope for curtailing the epidemic of type 2 diabetes with support for intensive lifestyle modification and modest weight loss as effective interventions among adults at high risk for developing type 2 diabetes (Diabetes Program Research Group, n.d.; Pan et al, 1997; Tuomilchto et al, 2001). The transitional state in the natural history of diabetes when impaired glucose tolerance (IGT), impaired fasting glucose, or both are present has recently become known as “pre-diabetes” which affects 12 million overweight Americans between the aged 45-74 years (Benjamin et al, 2003), also raising their risk for cardiovascular disease (American Diabetes Association, 2002). Detection of pre-diabetes is not a goal for most diabetes screening programs (Rolka et al, 2001), but the lengthy development period diabetes, coupled with the potential to prevent or delay the onset of type 2 diabetes, offers an opportunity for multifaceted prevention efforts. Distinct preventive medicine strategies have been presented by Rose (1985) as follows: 1) the “high-risk” approach, which identifies and focuses exclusively on individuals at highest risk for developing disease; and 2) the “population” or “public” health approach which attempts to reduce risk factors for or causes of disease within communities, which are generally defined in terms of localities but can also represent groups who share a common cause or interest (Green, Daniel, & Novick, 2001). Rose identified advantages and disadvantages for both approaches. For example, the high risk approach is generally cost-effective with a high likelihood of benefit for motivated individuals. The population approach, frequently referred to as the community based approach, offers a smaller benefit to individuals but more potential to benefiting the larger population. Whereas the high risk approach is palliative, the community based approach aims to determine the underlying causes of ill-health (Rose, 1985); the latter is typically predicated on the community’s strengths including cultural practices and wisdom with meaningful participation of the community from the beginning. Both high risk and community based approaches are likely to be required for the challenging goals of preventing or delaying type 2 diabetes (Harris & Zinman, 2000). Participatory action research, which involves collaboration of those affected by the issue being studied (Green et al, 1995), with researchers in the position of co-learners (Minkler, 2000) may be particularly suited to strategies for primary prevention of diabetes in well-defined communities (Harris & Zinman, 2000). Such approaches tend to be valued by local communities because they can ensure the cultural relevance of these interventions (Macaulay et al, 1999; Simmons et al, 1997). Federal agencies, voluntary organizations, and others aim to reduce the burden of diabetes by translating research findings into practice at multiple levels, including providing assistance to states and territories to develop comprehensive, sustainable programs to prevent and treat diabetes among their constituents. 2. Have knowledge of those differing beliefs, attitudes and values, which may influence people’s lifestyles and cultural choices of practice. (notes -Population as a whole access health promotion literature Tanner Hill and Ewles +simnett alot around beliefs attitudes and values. Becker’s health belief model) The Health Belief Model (Janz & Becker, 1984) has been shown to useful for predicting preventive behavior for certain diseases, but the results regarding which HBM measures predict such prevention have been varied (Montgomery, Joseph & Becker, 1989). The HBM originally contained four health belief measures – perceived susceptibility to the health problem, perceived severity of the health problem, perceived efficacy of practicing preventive behavior, and perceived barriers to practicing preventive behavior (Janz & Becker, 1984). The HBM posits that health protective behavior is most likely to occur when perceived susceptibility, perceived severity, and perceived benefits are high and when perceived barriers are low. Modified versions of the HBM contain additional health belief measures – self-efficacy and knowledge about the disease (Hayes, 1991), social support (Wilson, Manual, & Lavelle, 1991), perceived access to healthcare and advice (Wilson, Lavelle, et al, 1991), and facilitating cues for health protection (Wilson, Manual, et al, 1991). All of which are expected to increase diabetes preventive behavior. 3. Consider the particular needs of clients with diabetes from ethnic minority groups. (notes What their needs are Diabetes UK centre around diet and some groups starve) Diabetes is one of the most common chronic diseases in Europe and the US (Kamel et al, 1999). Diabetes is subdivided into two etiologic subclasses, of which Type 1 and Type 2 are the most prevalent (American Diabetes Association, 2004). The prevalence of Type 1, and in particular, Type 2 diabetes is rising in all European countries (Passa, 2002). Type 2 diabetes is the major contributor to the epidemic rise in diabetes because it accounts for >90% of diabetes. In the US, the overall prevalence of diabetes increased from 4.9% in 1990 to 6.5% in 1998 (Mokdad et al, 2002). There is a parallel rise in the prevalence of complications related to diabetes. The prevalence of diabetes varies, among other factors by ethnicity. Several studies of ethnic differences in diabetes have reported higher prevalence and incidence rates among ethnic minorities (Skyler & Oddo, 2002). Furthermore, endstage complications of diabetes have been reported to be more common among ethnic minorities (Lavery et al, 1996), who also experience higher mortality (Tull & Barinas, 1996). However, research on ethnic differences in mortality and complications among diabetic patients is fragmented; a systematic overview is missing. Explanatory research of ethnic differences in general health has mainly focused on factors that are related to the ethnic minorities directly, such as genetic, sociocultural, and socioeconomic factors. Another possible determinant of ethnic health differences is healthcare itself, more specifically the accessibility and the quality of health care (Uniken et al, 1995). Although health care alone cannot be expected to eliminate ethnic inequalities in health outcomes, it can potentially play an important role, especially for chronic diseases for which prolonged and regular treatment is required. Only a few studies have examined the role of quality of care as a contributor to ethnic differences in health. For depression, another chronic disease requiring prolonged treatment, improving quality of care reduced ethnic disparities (Harris, 2001). Mortality. Five US studies reported higher mortality rates among ethnic minorities, after adjusting for confounders. In one study , the ethnic differences in black vs. white disappeared after adjustment for additional risk factors like income and cigarette smoking. In another study, the ethnic differences persisted for US-born Mexican Americans after adjusting for factors like smoking status and blood pressure. However, after additional adjustment for more risk factors like disease severity, the differences disappeared (Tull & Barinas, 1996). Two UK studies reported, on the contrary, lower mortality rates among blacks after adjusting for sex, age, and BMI, which was no longer significant when adjustment for additional risk factors was done. One UK study which was adjusted for age, sex, and duration of diabetes reported no differences in mortality rates between Asians and whites. A New Zealand study showed higher mortality rates for Maori people but no differences for inhabitants of the Pacific Islands (Tull & Barinas, 1996). After adjusting for confounders, higher mortality rates were found among blacks in the US but lower rates for blacks in the UK. After adjusting for other risk factors, besides age and sex, no ethnic differences in mortality were found in most studies. After adjusting for confounders, the literature shows that diabetic patients from ethnic minorities have higher mortality rates and a higher risk of diabetes complications. After additional adjustment for risk factors like smoking, socioeconomic status, income, years of education, and BMI, in most cases ethnic differences disappear. Nevertheless, among US blacks and Hispanics and among UK Asians, an increased risk for ESRD is seen, and blacks and Hispanics in the US have an increased risk for retinopathy. Intermediate outcomes of care are worse in blacks, and outcomes among Hispanics were also inclined to be worse. Likewise, ethnic differences in the quality of care in the US exist: process of care is worse among blacks (Lanting et al, 2005). 4.Critically explore the psychosocial effects of living with chronic disease upon individuals families and careers throughout the life span. (notes- psychosocial effects, 40% have depression, wellbeing. People who are depressed are less likely to adhere to advice, more complications) A growing literature on the relationship between chronic illness as stressor and psychological well-being yields provocative results. Chronic illness has been shown to constitute a source of stress, even as this concept is defined differently by different researchers. Stress has been conceptualized as "change and readjustment" (Brown & Harris, 1978), as "uncontrolled change" (Kleinman, 1988), or as "loss" (Mead, 1934). Chronic illness can be all of these. As Lichtman, Taylor, and Wood (1985) suggest, chronic illness often has a profound impact on "avocational and vocational" activity and on personal relationships. These authors focus specifically on the marital role and the way that illness can result in the loss of equity for the patient partner. The effects of chronic illness on work patterns have been noted by several authors. Work dysfunction is common, as chronically ill patients may need to cut down on work outside the home or retire altogether (Link et al, 1990). The effect of illness on the husband-wife role has also been studied by several researchers. A common aspect of the change produced by chronic illness is that social networks contract, resulting in fewer non-family social contacts and leading the ill person to depend even more on burdened family members. This contraction of the social network has been linked directly to depression (Dohrenwend, Shrout, Egri, & Mendelsohn, 1980).). A less dramatic source of distress than these outright losses, but one that is perhaps even more pervasive, is the way that diabetes can threaten the daily performance of social roles and role-related tasks. Pain, fatigue, and poor concentration can affect an individual’s competence in fulfilling such tasks, thus wounding self-esteem. A recent review of the literature on diabetes and psychiatric disturbance (Pearlin & Schooler, 1978).) suggests that it affects the psychological health of its victims in a variety of ways, one of which they term the "chronic exacerbation" of difficulties in carrying out the normal activities of daily life. Diabetes and Role Strain Pearlin has elaborated a concept of stress as "role strain or role loss" (Pearlin, 1989; Pearlin & Schooler, 1978) that provides a valuable key to understanding the painful experiences of people with diabetes reported in the literature. Pearlin has criticized the approach to stress research which focuses on discrete life events, preferring to regard stressful events as inextricably embedded in their social contexts. In this view, the source of much of the stress in peoples lives derives not from isolated stressful events but from chronic strains which cause stress insofar as they impact on valued role performance. Several types of role strain are elaborated: role overload, in which the demands entailed in a particular role become too great; role-captivity, in which people are stuck in roles when they prefer to occupy other roles; and interpersonal conflict in roles, in which the performance of the role entails stressful interpersonal conflict. Chronic illness itself is described as an "ambient strain." Ambient strains include environmental, or in the case of illness, biological conditions which do not occur within social roles; rather, they "cut across roles and envelop people" (Pearlin, 1989, p. 246). A number of studies of the psychological sequelae of diabetes indicate that the illness is often accompanied by depression and/or anxiety (Wachtel, 1987; Yelin, 1980). The rate of psychiatric disturbance among diabetes patients varies widely from study to study, ranging from 5-85% (Yelin, 1980), and it is not clear whether this variability results from different populations or different diagnostic techniques. Though some researchers have argued for a more rigorous disease approach to defining psychiatric outcomes of diabetes, many researchers prefer to conceptualize outcomes in terms of psychological distress as opposed to psychiatric disease (for a discussion of the distinction, see Holmes & Masuda, 1974)). In this study, psychological outcomes are conceptualized in terms of level of depressive symptoms and level of demoralization (a broader concept than depression that focuses on sense of inadequacy and low self-esteem, pain, loss, and anxiety). 5.Critically evaluate the provision of health care to ensure smooth transition between paediatric and adult services for children and young people. (notes-from paed to adult more poorly controlled, NSF lots written and standards within, What happens within my area, Portsmouth, Hampshire. Normally Type 1DM) 6. Critically analyse and evaluate the evidence relating to different types of treatment and management of diabetes across the life span. (notes-Make an overall aim of diabetes in short paragraph then do Type 1 i.e. insulin therapy, use of insulin and rationale as to why using that therapy. Diabetes control and complications trial American DCCT. Type 2 Macrovascular disease, use of oral meds the UKPDS hypertension and cholesterol, NICE guidelines) The following represents a summary of the main results and conclusions of the UKPDS which presents evidence relating to the different types of treatment of diabetes across the lifespan: The UKPDS results present that retinopathy, nephropathy, and possibly neuropathy, are benefited by lowering blood glucose levels in Type 2 diabetes with intensive therapy, which received a median HbA of 7% compared with conventional therapy with a median HbA of 7.9%. The overall microvascular complication rate was decreased by 25%. These results materially increase the evidence that hyperglycemia causes, or is the major contributor, to these complications. Epidemiological analysis of the UKPDS data showed a continuous relationship between the risks of microvascular complications and gylcemia, such that for each percentage point decrease in HbA (e.g. 9 to 8%), there was a 35% reduction in the risk of complications. The results demonstrate that the risks of complications can be significantly lowered even in the range of hyperglycemia where HbA levels are 6.2%). These results confirm previous conclusions that lowering blood glucose would be beneficial based on observational studies, pathological studies and on three randomized clinical trials: the DCCT, the Stockholm Diabetes Intervention Study, and the Japanese Study. No significant effect of lowering blood glucose on cardiovascular complications was observed. A 16% reduction (which was not statistically significant, p=.052) in the risk of combined fatal or nonfatal myocardial infarction. Again, no glycemic threshold for these complications above normal glucose levels was evident. The highest average annual incidence of major hypergylcemic events was 2.3% of patients per year in those receiving insulin therapy. The study showed that lowering blood pressure to a mean of 144/82 mmHg significantly reduced strokes, diabetes-related deaths, heart failure, microvascular complications, and visual loss. Epidemiological analysis showed that there is continuous relationship between the risk of all of the above outcomes and systolic blood pressure of 130 mmHg. The UKPDS results confirm and extend previous evidence supporting the hypothesis that hyperglycemia and its sequelae are a major cause of microvascular complications of diabetes. The risk gradient in the UKPDS for late microvascular cardiac events was very similar to that seen in the DCCT for early microvascular events. This indicates that the presence of hyperglycemia is a toxic state whether it occurs early or late in life and regardless of its underlying cause. The UKPDS also demonstrated by epidemiological analysis that cardiovascular outcomes were consistently associated with hyperglycemia in a manner similar to the relationship between microvascular complications and hyperglycemia. Nonetheless, the UKPDS did not prove definitely that intensive therapy that lowered blood glucose levels reduced the risk of cardiovascular complications compared with conventional therapy. Thus, the role of hyperglycemia is still unclear (American Diabetes Association, 2003). 7. Have knowledge of national and local policies/protocols and systems of care for the management of acute and long-term complications of diabetes. (notes-Why do we need policies/protocols i.e. DKA, clinical governance, Audits, NICE, and DRIVE guidelines Portsmouth. What do we have in our area i.e. retinal screening, feet) 8. Critically examine the local multi-agency support available to ensure the provision of integrated health and social care.(notes- who we work with secondary and primary care. Pharmacy, Diabetes specialist nurse, Dietician, best quality care) Research on multi-agency support for the provision of integrated health and social care has focused on community-based prevention of diabetes. Among the studies that have been published, most have been conducted among populations disproportionately affected by diabetes, with their communities either initiating or collaborating with researchers. This finding, in itself, is important and likely reflects the concern of leaders about diabetes from these communities. Many researchers and collaborative communities, including secondary and primary care givers, are breaking ground by implementing culturally relevant prevention programs in settings where economic and environmental challenges exist. This inclusion of community health workers, traditional practices (e.g. bush food), and the use of metaphors and stories in a number of these studies provide examples of genuine community involvement and application of cultural knowledge. Most of these studies have been lauded for using participatory research, which is said to be the new golden standard for federally funded research (Lindholm & Rosen, 2000). However, majority of them had certain constraints. Only one of the interventions found used an experimental design (Narayan et al, 1998), likely because of the cultural unacceptability of this approach (Mau et al, 2001). Some comparison groups find this design discomfiting enough to mount their own interventions, even when promised a delayed intervention (Holcolm et al, 1998). The successful Pride group (Narayan et al, 1998) was essentially meant to be a comparison group that chose to incorporate traditional ways (Greg & Narayan, 1998). Interventions that show the most promise were associated with well-designed research combined with participatory approaches. Other common study limitations included the shortness of intervention duration, large numbers of nonrespondents, and the inability to match pre and post test data or to link self-reported lifestyle changes to health outcomes or indicators (e.g. BMI, prevalence of IGT). Thus, given these limitations, the effectiveness of multi-agency support in community based approaches is not as accurately assessed as possible. References American Diabetes Association (2002). The prevention or delay of type 2 diabetes. Diabetes Care, 25, 742-749. American Diabetes Association. (2003). Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care, 26, S28. American Diabetes Association. (2004). Diagnosis and classification of diabetes milletus. Diabetes Care, 27, S5-S10. Bell, R., Camacho, F., Goonan, K., Duren-Winfield, V., Anderson, R., Konen, J., et al (2001). 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