Literature Review
From television news or special segment, from magazines to medical journals, from school thesis and newspaper articles, there is a common nursing topic that is the usual content of most journals – diabetes – to be specific, diabetic care and management. In the recent literature review done by the American Journal of Medical Library Association (2006), they made a compilation of studies/ articles/ journals regarding biomedical nursing. Out of 115 cited journals, one of the most searched and most studied journal is the topic of – Diabetic Care/ Management – it ranked number 22 and has garnered 13 studies and a total of 499 articles in the year 2002. This literature review aims to provide an overview, a review of different studies/ journals done, a comparison and contrast of the quality of the study and to discuss different diabetic management being done, the old and new, medical and non-medical management, and various alternative therapies. It aims to answer or cover the following questions: (a) what is diabetes? (b) What is the difference between type I and type II diabetes? (c) What are the various medical and non-medical management on diabetes, as cited by different journals? (d) What are special measures/ considerations to be done for a diabetic client? (e) How can diet affect the prognosis of diabetes?
Across the world, diabetes mellitus is one of the most prevalent and serious chronic diseases (2001). In the United States alone, almost 16 million people suffer from diabetes, which cost many of them from their eyesight, kidney function, lower limbs, or life itself. According to Centers for Disease Control and Prevention (CDC,1998), diabetes affects 15.7 million people in the United States alone, 10.3 million of who have been diagnosed and 5.4 million of who are unaware that they have this disease. Diabetes exacts an equally devastating toll; it is the disease, and it is the 7th leading cost of death in the US (CDC, 1998). As a topic of research, a review of social work literature identified 5 articles on diabetic management topics. To assist people with diabetes, it is important to understand the disease, how it challenges the patients and then ways to become involved
(2001). This literature review provides an analysis of the basic aspects of management of Diabetes, both type1 and type II.
Diabetes Mellitus is a cluster of endocrine diseases characterized by the body’s complete or partial inability to absorb glucose, the principal source of energy, from digested food into cells (Harris, 1995). Unabsorbed, glucose accumulates into the bloodstream, eventually exceeding physiologically tolerable levels, damaging blood vessels and capillaries. There are two types of diabetes: Type I Diabetes Mellitus and Type II Diabetes Mellitus. Diabetes Mellitus Type I or Insulin Dependent Diabetes Mellitus (IDDM) has a juvenile onset, it accounts for about 10% of diabetes cases and is caused by an absolute deficiency of insulin that results from autoimmune destruction of islets by anti-islets cell antibodies. It is a lifelong disease, it occur when autoimmune destruction beta cells cause a decrease in or absence of insulin production by the pancreatic islets of Langerhans. Each type 1 Diabetes Mellitus (DM), the islets is infiltrated by T-lymphocytes; in some patients anti-insulin antibodies are present in the blood. There is also a genetic component: some persons are more susceptible than others to the insult that infiltrates the disease. Type 1 DM tends to run in families, but familial tendency is much greater in type 2 DM. In type 2 DM or Non-Insulin Dependent Diabetes Mellitus (NIDDM), there is an insulin production but not sufficient enough. As was mentioned, the majority of patients with type 2 DM have a parent or sibling with the disease. The strong genetic influence toward diabetes is especially evident in ethnic groups that have very high rates of type 2 DM. The main problem of type 2 DM is the peripheral cell resistance to the effect of insulin. Patients who developed type 2 DM, peripheral tissues begin to resist the effect of insulin as much as 10 years before the diagnosis become apparent, unlike type 1 DM, type 2 DM has a late onset. As peripheral resistance increases, the pancreas secretes increased amounts of insulin to compensate, and blood glucose levels continue to remain normal or near normal. Type 2 DM could also be the result of gestational diabetes or a type of diabetes that usually occurs during pregnancy. Some may or may have not type 2 DM after delivery (Mc Connell, 2006) . Due to the prevalence of the disease, several treatment modalities have been researched/studied for their effectiveness in treating the disease. The succeeding paragraphs would mostly deal about the different diabetic care management, from pharmacological to non-pharmacological treatments being offered in clinics and hospitals. Since there are variety of non-pharmacological methods in treating diabetes, discussion of pharmacological methods will be the first.
The major goal in treating diabetes is to minimize any elevation of blood sugar (glucose) without causing abnormally low levels of blood sugar. Type 1 and type 2 are both treated differently. Type 1 DM is treated with insulin, exercise and diet. In type 1 DM, insulin is needed for life (Gwen, 2007). Should insulin treatment not be available, ketoacidosis, coma and death are inevitable. People with type 1 DM are often managed within specialist acre unless staff has additional knowledge and skills in this area (Gwen, 2007). Before the availability of insulin, treatments for people with Type 1 DM were unpleasant and often ineffective (Lewis, 2002). A low-carbohydrate, semi-starvation diet and exercise were all doctors have to offer. Like many scientific advances, the discovery of replacement insulin in the 1920s was nothing short of a miracle (Lewis, 2002). Insulin injections are given under the skin (subcutaneously) into the fat layer, usually in the arm, thigh, or abdomen. In recent years, several external insulin pumps, which deliver insulin continuously through a thin, flexible tube placed under the skin have been developed. There are more than 20 types of insulin available in four basic forms, each at different tome of onset and duration of action. The decision as to which insulin to choose is based on an individual’s lifestyle, a physician’s preference and experience, and the person’s blood sugar levels. According to a recent nationwide diabetes management survey, 82% of endocrinologist believes that patients using the standard insulin injections do not control glucose levels well enough (Warren, 2006). The survey, conducted by GFK Roper Public Affairs and commissioned by Medtronic (2006), showed that endocrinologist and patients believe that insulin pump therapy is a more effective way to control glucose levels and avoid hypoglycemic events. Nearly 90 percent of endocrinologists surveyed agreed with the statement that insulin pump therapy reduces the risk of hypoglycemic events. When asked to choose a therapy for themselves or their family members, two-thirds of endocrinologists said they would choose an insulin pump over insulin injections, citing that insulin pump therapy provides greater flexibility and control of glucose levels. One in 10 adult patients surveyed admitted to calling 911 within the past three months for a serious hypoglycemic event. “Even with the advent of newer, long-acting insulin, hypoglycemia remains a significant barrier to achieving excellent diabetes control,” said Dr. Buckingham, director of Pediatric Endocrinology at Lucille Packard (2006) Children’s Hospital, Stanford University. “Insulin pump therapy delivers insulin in patterns similar to how the human body delivers insulin. This decreases the risk of severe hypoglycemic events, and allowing patients the flexibility to lead more active, normal lives.” (Buckingham, 2006). The findings presented in this report are based on telephone interviews among 201 primary care physicians and 200 endocrinologists treating patients with type 1 DM. All primary care physicians are treating at least five patients with type 1 DM. 106 adult type 1 patients were seeing an endocrinologist and 133 parents of juvenile type 1 DM patients are treated by endocrinologist, the clients used three or more daily insulin injections to manage their diabetes during the said survey. Pancreas transplants and kidney transplants are options for people with type 1 DM (Lewis, 2002). Since the 1970s, doctors have performed pancreas transplants along with kidney transplants in hopes of halting or reversing the complications of diabetes.
In Type 2 DM, treatment is usually focused on weight-reduction, then to diet and drugs. It is aimed at alleviating symptoms, reducing blood glucose levels, and, where possible, preventing complications. Hypoglycemic or anti-diabetic agents are used only in type 2 DM treatment. Four general classes of drugs work in different ways to lower blood sugar (Lewis, 2002). Oral medications must be taken regularly every day for best results. Dosages may vary if blood sugar (BS) is running too high or too low. Many of these drugs can be used in combination with one another, but any change in their use should be done only at the direction of a health professional. Extreme caution is required when treating elderly people with oral hypoglycemic agents (sulphonylureas and insulin therapy) in order to avoid any complication of hypoglycemia (Gwen, 2007). People with type 2 DM may require insulin in the short term in times of illness or during surgical intervention.
These pharmacological methods are proven beneficial to patients in treating their diabetes, however, it is important to note that diabetes is a life-long disease , it is not enough to take certain medications to halt the progression of different complications.
Non-medical management may be of help in treating both type 1 and type 2 DM. Weight-reduction by means of diet and exercise is one of the means to control blood sugar levels. For individuals with diabetes, the type and duration of exercise can have a big effect on blood sugar responses during the activity (Colberg, 2002). Activities lasting less than two minutes (e.g., sprinting, power-lifting) are anaerobic in nature and fueled primarily by phosphagens stored in skeletal muscle (ATP and creatinine phosphate) and by carbohydrates (mainly stored muscle glycogen). The intensity of exercise and the training level of the individual also affect the combination and proportions of fuels used for an activity (Colberg, 2000).
Research involving individuals with type 1 DM (Mitchell, et al, 1998) has shown that very intense exercise such as weight training or near-maximal aerobic exercise can actually cause a rise in blood sugar levels, contrary to the usual glucose-lowering effect of prolonged exercise. Exercise training improves fat utilization for a given exercise intensity, sparing muscle glycogen and blood glucose. Type 1 DM exercisers are also encouraged to consume additional carbohydrates as needed in order to avoid hypoglycemia before, during, and following exercise, foods of choice to correct and prevent hypoglycemia during exercise are sports drinks, juice, regular soda, fresh and dried fruit, hard candy, and other items with rapidly absorbed carbohydrates (Colberg, 2000). In a research done by American Diabetic Association (2006), about the significance of exercise training and acarbose (a hypoglycemic drug) improves metabolic control and reduce the risk of cardiovascular disease (CVD), considering the fact that type 2 DM and hyperglycemia can lead to cardiovascular problems. This study was done to see of an exercise plan, either with or without acarbose would help the patients. Sixty-two patients with type 2 DM from Sweden were studied. It was divided into three groups: exercise training with acarbose treatment, exercise without acarbose and acarbose treatment alone. After 12 weeks, researchers found that patients who exercised and took acarbose had better blood glucose control. This implies that a combination of drug and diet is effective in managing diabetes.
Despite the improvements of blood sugar level when exercising, it is also important to watch what you eat. As the old saying goes, you are what you eat. Diet is extremely crucial in clients with diabetes, one of the causes of a type 2 DM is obesity, whereas, to prevent further complications, weight reduction is essential to control DM. In 2000, the prevalence of obesity in Americans increased from 18.9% to 19.8% and the prevalence of diabetes increased from 6.9% to 7.3% (Chappell, 2002). Contrary to popular belief that having diabetes means that you are stuck with a variety of diets recommended for diabetes. However, due to the prevalence of the disease, there are already food companies that are upgrading their product to make diabetes-friendly. Meal management for those with diabetes has also undergone dramatic changes recently (Chappell, 2002). No longer are starchy foods off-limits. No longer are sweets a no-no. While sugar used to have a bad name in the diabetes world, now it is considered to be no worse than milk and bread. Nutritionist pointed out that people with diabetes can enjoy their favorite foods, as long as the consumption is done in moderation. The diet recommended for people with DM is one that is high in dietary fiber, especially soluble fiber, but low in fat (especially saturated fat). Diet with high soluble fibers is especially important for diabetics because soluble fiber increases the time it takes for food to digest and for glucose to get into the blood (International Journal of Humanities and Peace, 2001). The American Diabetes Association (1994) recommended that 60-70% of caloric intake should be in the form of carbohydrates, 20-30% should be in form of fat, and 10-20% in protein. It is not enough for diabetics to eat thrice a day, healthy eating is not simply ‘what one eats’ but also when one eats. The question of how long before a meal one should inject insulin is one that is asked in Sonsken et al (1998). The answer is that it depends upon the type of insulin one takes, and whether it is long, medium, or quick-acting insulin. If patients check their blood glucose at bedtime and find out that it is low, it is advisable that they take some long-acting carbohydrate before retiring to bed to prevent night-time hypoglycemia. A good diet and exercise is helpful for problems in obesity, especially to kids who are suffering from type 1 DM. In a research conducted by American Diabetic Association (ADA, 2006), the researchers studied the short-term effects of increased physical activity and a healthy diet on diabetes-related problems and the likelihood that a person will get a cardiovascular disease. The study included kids between the ages 10-16 years old. Each participant was fed with a low fat, high fiber diet for two weeks with a supervised program of 2-2.5 hours of exercise a day. Each participant has a physical exam and blood samples taken for lab tests at the beginning and end of the study. The research revealed that diet and exercise program improved the body’s ability to handle glucose and insulin, lowered blood pressure, improved body mass index (BMI) and lowered levels of fat in the blood. This means that a careful, short-term program of physical activity and good dietary habits can improve the health of those who overweight, kids and adults. In the advent of the alternative therapy, several researches have also been made to evaluate the effectiveness of certain medicinal herbs for prevention and treatment of diabetes which could be incorporated in a diet. In a 1991 study, six type 2 diabetics were given 100ml of bitter melon, momordica charantia (also known as bitter gourd, bitter cucumber or la-kwa) solution each day. In 3 weeks, blood glucose levels dropped an average of 54%, in seven weeks , blood glucose levels of all six diabetics were close to normal and sugar was no longer detectable in their urine (International Journal of Humanities and Peace,2001). This research suggests that consumption of these products is also beneficial in treatment of diabetes, as long as there is an approval by your physician. Diabetic management is three-way: medication, diet and exercise should be considered for the management to be effective. Aside from these three, due to the complications associated with the disease, the American Diabetics Association (ADA) has released guidelines regarding the different considerations for a diabetic client. This involves foot care, eye care and skin care. Foot health is very important with type 2 DM, because the condition is often linked to poor circulation and peripheral neuropathy (disease of the nerves). If proper care is not given, their feet can get skin ulcers. Foot sores take a long time to heal and can lead to complications like amputation and death. Proper foot care along with wearing proper foot wear is essential to prevent foot sores. Out of 1500 patients, a total of 151 patients or 9.1% of the overall study group , has 199 foot infections (ADA, 2006). Researchers thought this was a very high amount, having a foot wound is a precursor to a foot infection. This implies that proper education on foot care can prevent many harmful complications from occurring. In cases of eye infections, where diabetic retinopathy is the common complication of uncontrolled diabetes, researchers found that of the 28 patients examined, 75% were referred to a specialist, seven of these patients have diabetic retinopathy. This implies that patients with diabetes should be examined by an eye specialist. With regards to skin care, a client with diabetes is more prone to invasion of pathogen, since there are pathogens that thrive in a sugar-rich environment. Conditions that diabetics might face include: bacterial invasions, fungal (Candida albicans), itching, diabetic blisters, blisters, acanthosis nigricans and disseminated granuloma annulare. Several preventive measures are necessary such as keeping the skin clean and dry, moisturizing the skin, treating cuts and wounds immediately. This simple curative measures may be helpful in alleviating the progression of diabetes complications.
In this analysis, a total of six research based-journal were discussed briefly, research are related to diabetic care and management. Most of which are from the American Diabetics Association (ADA) Journal. Research were about the effectiveness of insulin injections versus the usage of insulin pumps, the effects of exercise in controlling blood sugar and a combination of exercise and drug (acarbose) in managing blood glucose, dietary guidelines essential for the nutritional well-being of the patient, studies about medicinal herb-charantia and how it is helpful for diabetes, foot care to prevent foot sores and eye care to prevent diabetic retinopathy. In these studies, it is important to note that despite the promising results, there is a variety of limitations that could be considered as its weaknesses. In the case of exercise and acarbose research study (ADA,2006), the number of patients in each group was rather small and the group on exercise training did not receive placebo. Also, in the study of overweight kids and exercise, the study is again, rather small, with only 16 people and was only followed for two weeks. A larger group for a longer period of time may lead to different results. Also, this was an intense program that was monitored closely by professionals, it will be hard for people to follow this sort of program alone (ADA, 2006). In the foot care research which was done in a foot clinic in Nottingham, UK, one of the research limitations was the fact that it is only done in one foot clinic and that the care of foot sores may be different to other clinics or hospitals (ADA, 2006). In the eye disease study, the physicians had only one month of practice with new methods and equipments. The study group was also small and that physicians all volunteered to be in the study. Future studies could include a larger group of physicians chosen at random (ADA, 2006). In the case of the usage of charantia (International Journal of Humanities and Peace, 2001), the study group is also small, with only six participants, and they don’t have a placebo to be compared with. Moreover, it was not stated what other measures did the participants undertook such as, whether they combined it with insulin or a hypoglycemic agent or what type of diet they followed while consuming charantia. Future studies could include a larger number of participants and other measures to undertake in order to evaluate the effectiveness of medicinal herbs in managing diabetes.
Research studies are a core component of the diabetes nurse educator role (Dunning, 2004). Research presents challenges for many nurse educator and few are actively involved in research activities. Doing a nursing research is integral to the delivery of effective, efficient nursing care. Patients who received evidence-based care have better outcomes ( Heater et al, 1988). The importance of using research evidence as the basis for diabetes education, is increasing in line with the general trend towards evidenced-based care. It is a propitious time to be undertaking research in diabetes care and management, not only because of the general focus on nursing research, but also the high priority given to diabetes in the health system and increasing media attention to diabetes, especially prevention, largely because of its increasing incidence and prevalence. In addition, recent research successes have visibly changed the way diabetic care and education is delivered, and treatments are not focus on diabetes alone but to its possible complications as well. These studies not only increased the focus of a good metabolic control, but made it important for nursing educators to be able to interpret findings in order to incorporate them in their practices, present them to colleagues, explain them to people with diabetes and help them develop appropriate health plans informed by evidence ( Dunning, 2004). Diabetic management is one of the topics that deserve to be reviewed, studied, implemented and further improved to serve patients better and for them to be more self-reliant in managing their disease. Research on newer and more improved diabetic management would soon efface to adapt to a one’s ever-changing lifestyle.
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