The Management & Prevention of Type 2 Diabetes

1. 0Introduction Working presently as Senior Assistant Medical Officer at the Department of Psychiatry and Mental Health, I had been in this profession since 1982. Global warnings over diabetes increase. Research carried out by the International Diabetes Federation (2009) reveals that around 314 million people, equating to 8. 2% of the global adult population, may have impaired glucose tolerance (IGT) which is a condition that often precedes the development of diabetes.

The incidence of diabetes in Malaysia is similar to other countries in the world (Malaysian Diabetes Association, 2009). Diabetes Mellitus is one of the commonest chronic illnesses seen at primary care facilities. A past study by the Malaysian National Health and Morbidity Survey (1996) showed that the prevalence of Diabetes is increasing from 6. 3% to 8. 3% for adults aged above 30 in 1996. However, there are nearly 1. million people in Malaysia who currently have diabetes as studies showed that the prevalence of obesity among Malaysian adults increased by a staggering 250% over a 10 year period from 1996 till 2006 while the number of overweight cases has increased by 70% as 43% of Malaysians aged above 30 suffer from diabetes (Malaysian Diabetes Association, 2010). The National Health and Morbidity Survey (2006) in a later study showed that two out of every five Malaysian adults or 43%, were either overweight or obese and a distressing situation where the number of obese adults had more than tripled over a decade, from 4% in 1996 to 14% in 2006.

In addition, about 38% of youngsters aged between 12 and 18 were classified as overweight. The major causes of morbidity and mortality in the diabetic patient are heart disease and stroke (Tzagournis & Falko, 1982). 2. 0Definitions Diabetes Mellitus is a chronic and progressive disorder that can have an impact upon almost every aspect of life. It can affect children, young people and adults of all ages, and is becoming more common. Diabetes is a disease which causes the body to either not produce insulin or to not properly make use of the insulin that it does make (American Diabetes Association, 2002).

When carbohydrates are consumed, the body must convert glucose into energy that can be used to do everyday tasks. Insulin is a hormone which facilitates this process and is therefore an important part of the body's normal functioning that helps to maintain an appropriate level of glucose in the blood. In the case of diabetic patient who do not produce or properly use insulin, blood glucose levels must be manually regulated or the patient may sufferer undesired consequences (Stratton et al. , 2000)

A high proportion of diabetes cases are not diagnosed or are diagnosed late, which contributes to a high prevalence of complications and thus to the high cost of their management (Eliasson et al. , 2005). Complications from diabetes can be reduced by better and more adapted follow-up such as blood glucose control, regular eye and kidney function examinations, lipid and blood pressure management. 2. 1Classification of Diabetes Mellitus Type-1 insulin dependence diabetes mellitus was formerly called juvenile-onset diabetes, because it mostly attacks young people.

This type of diabetes mellitus is characterized by the destruction of pancreatic beta cells. The destruction of BETA cells will decreased insulin production and caused uncontrolled glucose production by the liver. It symptoms include increased thirst and urination, constant hunger, weight loss, blurring of vision and extreme tiredness (Mayo Clinic, 2010). In type-2 diabetes, the body cells are resistant to the action of insulin and/or the pancreas produce decreasing amounts of insulin.

As a result, the blood glucose level becomes progressively higher over time and the body cells receive an inadequate supply of glucose – the body’s primary energy source. The symptoms of type-2 diabetes develop gradually and are not as noticeable as for type-1 diabetes. The symptoms include feeling tired or ill, frequent urination at night, unusual thirst, weight loss, blurring of vision, frequent infections and slow healing of sores (Mayo Clinic, 2010). Type 2 diabetes mellitus is a serious health problem affecting approximately 4. percent of adults aged 20 years and over in the world in 1995 (Harris et al. , 1998) and this prevalence is projected to rise from 4. 0 to 5. 4 percent (King et al. , 1998). The proportional increase in type 2 diabetes prevalence rates is greater in developing countries, especially those of Asia (King et al. , 1998; Cockram, 2000). In both types of diabetes, the symptoms are quickly relieved once the diabetes is treated. Early treatment will also reduce the chances of developing serious health problems. A third type of the diabetes is called gestational diabetes.

It develops or is discovered during pregnancy. It usually disappears when the pregnancy is over and women who have had gestational diabetes have a greater risk of developing type 2 diabetes later (Mayo Clinic, 2010). 2. 2Cause and Risk factors for Diabetes Mellitus. There are many risk factors that predispose an individual or population to developing glucose intolerance and finally to have diabetes (Ram, 2000). There is evidence that lifestyle related changes are the main factors influencing the explosion of diabetes in the modern times.

Risk factors such as obesity, physical inactivity and high-fat diet are significant predictors of type 2 diabetes (Zimmet, 1992), which are the results of lifestyle choices determined by one’s culture. According to Mendosa (2001), the common risk factors are: i. Person who has a family history of diabetes is in risk of type-2 diabetes if a parent or siblings has type-2 diabetes. Being obese or overweight person may heighten the risk to have type-2 diabetes as excessive fatty tissue will make the cells to be insulin resistant.

Past studies indicate that a person’s race or ethnicity such as blacks, Hispanics, American Indians and Asian-American are more likely to develop type-2 diabetes. ii. The risk of type-2 diabetes increases as a person gets older, especially after age 45 as people tend to exercise less, lose muscle mass and gain weight as they age. However, current studies indicate that type-2 diabetes is also increasing dramatically among children, adolescents and younger adults. iii. Hypertension, or high blood pressure, has many serious consequences, especially for people with diabetes. Hypertension is twice as common in people with diabetes.

Older persons with diabetes have higher rates of death at a younger age, disability, hypertension, heart disease, and stroke. iv. Hyperlipidemia can be defined as a condition where there are too many fats, or lipids, in the circulating blood. Untreated or poorly treated diabetics do not metabolize fats properly, due to lack of enough insulin to do so. The increased risk of coronary artery disease in subjects with diabetes mellitus can be partially explained by the lipoprotein abnormalities associated with diabetes mellitus. Hypertriglyceridemia and low levels of high-density lipoprotein are the most common lipid abnormalities.

In type-1 diabetes mellitus, these abnormalities can usually be reversed with glycemic control. In contrast, in type-2 diabetes mellitus, although lipid values improve, abnormalities commonly persist even after optimal glycemic control has been achieved. v. If a woman developed gestational diabetes when they were pregnant, she has a higher risk of developing type-2 diabetes later. If a woman gave birth to a baby weighing more than 9 pounds (4. 1 kilograms), she also has a higher risk of having type-2 diabetes. 2. 3Managing Diabetes Mellitus Diabetes is a chronic disease with no cure.

As such, the main task of managing diabetes is to keep the blood glucose level within a specified range to avoid short-term emergency problems stemming from hypoglycemia (blood sugar too low) and possible long-term complications of hyperglycemia (blood sugar too high) (Plocher,1996). The American Diabetes Association (2002) recommends guideline levels of blood glucose during certain times of the day. The ADA recommends a blood glucose level of 90 milligrams per deciliter (mg/dl) during fasting, 105mg/dl prior to meals, 130mg/dl one hour after meals, and 120mg/dl two hours after meals (American Diabetes Association 2002).

It is associated with an impaired glucose cycle, altering metabolism. Management of this disease may include lifestyle modifications such as achieving and maintaining proper weight, diet, exercise and foot care. The attitude toward the management of Type 1 diabetes and Type 2 diabetes has been greatly changed by the Diabetes Control and Complications Trial (DCCT), which has shown conclusively that we need to obtain and maintain a high degree of control in order to prevent complications of diabetes (Diana & Richard, 2003). 2. 4Treating Diabetes Mellitus Although diabetes cannot be cured, it can be treated very successfully.

Type 1 diabetes is treated by insulin injections and a healthy diet, and regular exercise is recommended. Insulin cannot be taken by mouth because it is destroyed by the digestive juices in the stomach. People with this type of diabetes commonly take either two or four injections of insulin each day. Type-1 diabetes, insulin injections are vital to keep patient alive and must have them every day (Diana & Richard, 2003). Type-2 diabetes is treated with lifestyle changes such as a healthier diet, weight loss and increased physical activity. Tablets and/or insulin may also be required to achieve normal blood glucose levels.

There are several kinds of tablets for people with Type 2 diabetes. Some kinds help the pancreas to produce more insulin. Other kinds help the body to make better use of the insulin that the pancreas does produce. Another type of tablet slows down the speed at which the body absorbs glucose from the intestine. The doctor will decide which kinds of tablet are going to work best for the patient and may prescribe more than one kind. Type 2 diabetes is progressive. If the diabetes cannot be controlled through lifestyle changes and tablets the doctor may recommend that the patient take insulin injections (Diana & Richard, 2003).

The main aim of treatment of both types of diabetes is to achieve blood glucose, blood pressure and cholesterol levels as near to normal as possible. This, together with a healthy lifestyle, will help to improve wellbeing and protect against long-term damage to the eyes, kidneys, nerves, heart and major arteries (Diana & Richard, 2003) 2. 5Complication of Diabetes Mellitus Complications of diabetes include both short-term, acute problems, as well as long-term, chronic problems. Among the former group are problems such as diabetic ketoacidosis, nonketotic hyperosmolar coma, hypoglycemia, and diabetic coma.

Among the latter group, usually associated with chronically high glucose levels, are diabetic retinopathy, diabetic neuropathy, diabetic nephropathy, coronary artery disease, stroke, peripheral vascular disease, diabetic myonecrosis, and carotid arterystenosis. Diabetic ketoacidosis is caused by the accumulation of ketones, the by-product of the breakdown of fat cells. Nonketotic hyperosmolar coma occurs during extreme hyperglycemia when water is scarce in the body. Whereas the excess glucose would normally leave the body via urination, the kidneys try to conserve water causing the glucose to remain in the body.

This leads to a cycle of dehydration leading to increased blood glucose levels which leads back to dehydration and so on. This condition may lead to shock, cerebral edema, blood clots, lactic acidosis and coma (Stratton et al. , 2000) Diabetic nephropathy is a condition in which the kidneys cease to function properly, resulting in increased protein levels in the urine. This condition may lead to high blood pressure, chronic kidney failure and end-stage kidney disease. Diabetic neuropathy is a diabetes complication in which nerve damage results from decreased blood flow and chronic hyperglycemia.

This condition affects approximately 50% of diabetic patients. Diabetic neuropathy may lead to constant, intense pain or total loss of sensation in the affected area. Diabetic retinopathy is a complication that affects the eye's retina. Nearly everyone who has diabetes for more than 30 years will exhibit symptoms of diabetic retinopathy. Most of the complications of diabetes mellitus may be avoided by maintaining normal blood glucose levels (Stratton et al. , 2000; The Diabetes Control and Complications Trial Research Group, 1993). 2. 6The Primary Prevention of Diabetes Mellitus in Malaysia

This population based approach is being set up by the Ministry of Health. In the Government Clinic, any individual who has symptoms of Diabetes (tiredness, lethargy, polyuria, polydipsia, polyphagia, weight loss, pruritis vulvae, balanitis) and any adult who are overweight (BMI) > 23kg/m2 or waist circumference ? 80cm for women and ? 90cm for men and having family members having diabetes must be screened. Pregnant women who is overweight (BMI) >27kg/m2 and has previous gestational diabetes will be screened annually. The onset of Type 2 diabetes can be prevented or delay through a healthy lifestyle.

Change your diet, increase your level of physical activity, maintain a healthy weight with these positive steps, you can stay healthier longer and reduce your risk of diabetes (American Diabetes Association, 2009). 3. 0Critical Evaluation Diabetes Mellitus education is not sufficient in Malaysia. There is no school-based obesity prevention and treatment program for overweight and obese adolescents. Healthy lifestyle must be taught at school level. The best and most effective ways to prevent Diabetes Mellitus is to educate the population to take care of their own health both in the urban and rural areas. 4. 0Clinical Case Scenario . 1Patient background Mr. S is a 52 years old Malay man and works as a male nurse. He is married and has three teenage children. He has a happy family life and other than his hypertension he has no medical history of note. He feels fit and well (with no symptoms of diabetes such as thirst, fatigue, blurred vision, frequency of micturition). He was somewhat alarmed when he was called back for a glucose tolerance test, as his FBS reading was 16. 1mmol/L during health awareness campaign week at age 49 years old. He was diagnosed with type 2 diabetes on blood test. On examination he was obese and has hypertension.

He had been on anti-hypertensive a low-dose of Atenolol for the past ten years. At that time his weight was 120 kg at 5 feet 6 inches height. He stopped smoking and consumes alcohol at age of 40 years old. His blood glucose when he was first diagnosed with type 2 diabetes was 10. 2 mmol/L, His oral glucose tolerance test (OGTT) was 16. 1 mmol/L Oral glucose tolerance testing (OGTT) is the most sensitive test for diagnosing diabetes and pre-diabetes. He was referred to Diabetic Clinic for diabetic management and assessment such as lifestyle modification, healthy diet and medication. The baseline examination done for Mr.

S was to assess the risk factors and complications of diabetes. His hemoglobin HbA1C test was 7. 5 %. The HbA1C blood test measured the average blood glucose level during the past two or three months. His fasting lipid profile, Cholestrol 7. 1 mmol/L,Triglycerides 2. 5 mmol/L,HDL 1. 0 mmol/L,LDL 4. 9 mmol/L,Serum Creatinine 96 mmol/L , Liver Function Test , Bilirubin. Total 15umol/L,Transaminase. G-O 5-23 u/L,Transaminase G-P 31 u/L,Proteins. Total 89 umol/L,Albumin 54g/L,Globulin 35g/L, Bilirubin, Conjugated 5umol/L and Phosphatase alkaline 77 u/L, Blood Urea Serum Electrolyte, Sodium 145mmol/L, Potassium 4. mmol/L, Blood Urea 5. 4 mmol/L, foot examination : No abnormality detected, eye examination: no abnormality detected. Electrocardiogram ( ECG ) : nor abnormality detected. His current medication is tablet metformin 1000mg twice a day and tablet aspirin 62. 5mg once a day, tablet Simvastatin 20mg on night and tablet Irbesartan 150mg daily. 3. 2Clinical monitoring protocol for Mr. S in the management of his diabetes. Blood pressure, body weight and blood glucose should be monitored at each visit. Feet for pulses to check for neuropathy, body weight, blood pressure, blood glucose and HbA1c to be monitored quarterly.

Cholesterol, triglycerides, albiminuria and creatinine to be monitored if found abnormal at first visit. As for annually the whole investigation has to be monitored plus fundoscopy for visual acuity, body mass index, electrocardiogram and urine for microscopy. If cardiovascular or renal complications are present or patients are on lipid-lowering and or on anti-hypertensive therapy, lipids and renal function may need to be checked more often. This, together with a healthy lifestyle, will help to improve wellbeing and protect against long-term damage to the eyes, kidneys, nerves, heart and major arteries. 3. Nursing management Mr. S was advised to have a balanced diet, managing his weight and following a healthy lifestyle, together with taking any prescribed medication and monitoring where appropriate will benefit his health and losing his weight will help him to control his diabetes and will also reduce him risk of heart disease, and stroke. Being active is good for all of us but is especially important for people with diabetes. Physical activity, combined with healthy eating and any diabetes medication that Mr. S might be taking, will help him to manage his diabetes and prevent long-term diabetes complications. Mr.

S was also advised not to smoke again because giving up smoking is one of the most positive things him has done to both improve his health and reduce his risks of the long-term complications associated with the condition. Everyone risks of damaging their health through smoking a cigarette but for people with diabetes the risk may be even greater. Patient who has diabetes already have an increased chance of developing cardiovascular disease, such as a heart attack, stroke or circulatory problems in the legs. When combined with smoking this can also double his risk of complications and make the chances of developing these diseases even higher. . 0Conclusion There is no cure for Diabetes Mellitus but with close monitoring of blood glucose level and blood pressure it can be managed and this can avoid or minimized complications. Diabetes mellitus is a condition, which requires careful management in which the patient has to be the one who takes control. Although professionals in health and nutrition participate in the treatment, it is patient who is mostly responsible for the outcome. The diabetic person can learn how to manage his conditions in the best possible way. If anyone in the family like parent, brother, or sister with diabetes, he or she is at risk of developing diabetes.

She or he must get screened for it annually from the age of 30 years old onwards even though if they have no symptoms of diabetes, they must learn how to prevent it. References: American Diabetes Association, editor (2002) American Diabetes Association Complete Guide to Diabetes. 3rd edn. New York : Bantam Books. Cockram, C. S. (2000) The epidemiology of diabetes mellitus in the Asia-Pacific region, HongKong Medical Journal, Vol. 6, pp. 43-52. Diabetes Daily (2010) Available at https://www. diabetesdaily. com. (Accessed: 12 April 2010). Diana, W. G. & Richard, A. G. (2003) The Diabetes Sourcebook. th edn, New York: McGraw Hill. Eliasson, B. , Cederholm, J. , Nilsson, P. and Gudbjo? rnsdottir, S. (2005), “The gap between guidelines and reality: Type 2 diabetes in a national diabetes register 1996-2003”, Diabetic Medicine, Vol. 22 No. 10, pp. 1420-1426. Harris, M. I. , Flegal, K. M. , Cowie, C. C. , Eberhardt, M. S. , Goldstein, D. E. , Little, R. R. , Wiedmyer, H. M. and Byrd-Holt, D. D. (1998) “Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in US adults: The Third National Health and Nutrition Examination Survey ( 1988-1994 ) Diabetes Care, Vol. 1 No. 4, pp. 518-524. Health CareHandbook, Aspen Publishers, Inc. , Gaithersburg,MD, pp. 318-329. Health in Aging (2010) Available at https://www. healthinaging. org (Accessed: 25 April 2010). International Diabetes Federation (2009) Available at https://www. idf. org (Accessed: 22 May 2010). King, H. , Aubert, R. E. and Herman, W. H. (1998) “Global burden of diabetes, 1995-2025. Prevalence, numerical estimates, and projections”, Diabetes Care, Vol. 21 No. 9, pp. 1414-1431. Florence, T. et. al. (2009) Management of Type 2 Diabetes Mellitus 4th edn. Malaysia : CPG Ministry Of Health.

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