Management of Diabetes Mellitus Type 2
Argumentative essay
Management of Diabetes Mellitus Type 2
Introduction
Diabetes mellitus is one of the most common chronic conditions, affecting about 7% of the Australian population (Lamoureux et al., 2012). Many of the lifestyle habits and choices of people today – obesity, sedentary lifestyle, cigarette smoking, and hyperlipidemia, and low-fiber diet – are modifiable risk factors for diabetes (Australian Institute of Health and Welfare, 2013). Environmental and social determinants for diabetes include family history, ethnic background, highly stressful lifestyle, low socio-economic conditions, adverse childhood experiences, and malnutrition in early childhood (Raphael et al., 2010).
The management of diabetes includes, apart from the medications, lifestyle modifications countering the risk factors. This includes control of blood glucose levels, lipids and
blood pressure as these are the major risk factors (Lamoureux et al., 2012). The implementation of changes in long-term behavioral, social and lifestyle risk factors proves challenging for diabetes patients. Many patients continue to have poor glycemic control and develop complications. New strategies are therefore, continuously being devised to manage diabetes. These strategies are based on two basic models: a physician-centered model to enhance physicians’ vigilance in monitoring and managing patients, and a patient-centered model to improve patient adherence to the necessary lifestyle modifications.
This paper will compare the interdisciplinary strategies, frameworks and approaches for the management of diabetes type 2. It shall also reflect on the effectiveness, strengths, limitations, barriers, and enablers for these frameworks and strategies, particularly for the Australian population.
Discussion
Diabetes is a chronic, lifelong condition. Its management is fundamentally simple – to keep blood glucose levels in check. The basic long-term management involves regularly schedules visits to the physician. So why has it become a source of great controversy, debate, and research? This is because diabetes affects every aspect of the patient’s life, and enabling the patient to life successfully with the disease requires person-centered diabetes services (National Health Priority Action Council, 2006). Medications are not sufficient to treat diabetes – it requires annual surveillance of patients for complications, treatment of associated modifiable risk factors for adverse outcomes such as obesity and smoking, as well as agreeing on a care plan with the patient (International Diabetes Federation, 2012). Most countries follow a framework more or less similar to these guidelines.
Through regular clinic visits, tests are performed to monitor diabetes control, and detect complications at the earliest (International Diabetes Federation, 2012). At an initial look, this strategy seems adequate. However, a much more comprehensive involvement in the patient’s life is recommended by the international guidelines. The patient’s knowledge and beliefs regarding diabetes self-care, as well as psychological status and self-monitoring skills must first be assessed. What role can these play in managing diabetes? These are necessary to provide appropriate diabetes education to the patient, make an agreeable care and follow-up plan, and to find the best way to encourage the patient to adopt behaviors that would reduce their risk of diabetes complications. Patient body weight is to be checked, and advice to lose weight given. Improved nutrition, more physical activity, and reduction in smoking are to be advised (National Health Priority Action Council, 2006). Blood glucose is controlled by regular checks of glycated hemoglobin, about 3-monthly. The glycated hemoglobin level should be maintained below 7%. Until what point is this strategy to be used? When lifestyle modifications fail to normalize blood glucose levels, medication must be started.
Blood pressure is to be checked, at least annually, in diabetic patients to prevent cardiovascular complications. The patient is also monitored for heart disease, lipid levels, peripheral neuropathy, foot care, erectile dysfunction. Ophthalmoscopy for diabetic retinopathy and tests to screen for kidney damage should be done at least annually. The patient’s medications are regularly reviewed for any contraindications, and adjusted to maintain optimum glycemic control. If patients have adequate knowledge and skills, they must be encouraged to self-monitor blood glucose levels so that medications can be altered based on the readings.
These interventions, with or without patient education and support, have been shown to improve glycemic control, as well as diabetes complications (Norris et al., 2002). Yet, this basic framework by the International Diabetes Federation has proved to be hugely inadequate in managing the diabetes epidemic at the individual community level. This is because the guidelines are an extensive and expensive list of steps for the patient to follow, and many patients make a big mistake by ignoring these recommendations as they don’t understand their benefit. Thus, to maximize patient adherence to management guidelines, additional educational and support measures are necessary.
In Australia, the basic framework for diabetes management is the general practice component of the primary health care system. The national health insurance scheme, Medicare, as well as charity organizations fund the system through community health centers. Divisions combine collaboration, practice support and general practitioner education approaches to support optimal diabetes care (Moretti, Kalucy, Hordacre, & Howard, 2010). This system does not satisfy the overall healthcare need. Many people end up utilizing private general practitioners working on a fee-for-service basis (Bailie et al., 2007). This basic framework also did not take into account the difference in the needs of patients from different backgrounds, or the difference in infrastructure needed to manage acute versus chronic diseases. With an increase in understanding of the management of diabetes and the pre-emptive role that healthcare can play in preventing diabetes complications, modifications to the framework have been designed.
The National Diabetes Strategy (Commonwealth of Australia, 1999) first outlined a framework for diabetes care with a 5-year strategic plan. The crux of the plan was to develop guidelines for primary care physicians managing diabetes patients, and to ensure early detection of diabetes complications with appropriate referrals. In 2002, the National Integrated Diabetes Program was established to provide more appropriate infrastructure for diabetes chronic management, as well as improve the attitude of healthcare professionals towards diabetes control. The National Service Improvement Framework for Diabetes (National Health Priority Action Council, 2006) was released to address the shortfalls in diabetes management. It aimed to prevent and limit the progression of chronic illnesses, and also address the inequities in healthcare provision.
The national strategy described above made glaring omissions as well. It did not consider how indigenous communities would be given access to diabetes care. Also, diabetes is often found in association with other chronic illnesses like hypertension and heart disease. Any strategy that deals only with diabetes, therefore, will not adequately deal with most patients’ overall health needs or prevent overall diabetes complications. The government, upon realizing this, has taken further steps to devise a more comprehensive patient-centered framework.
Australia's First National Primary Health Care Strategy (Australian Government, 2010) defines the national policy on primary healthcare, and it emphasizes on the necessity of integrating primary health care with other health sectors, including care for indigenous and aged populations. The strategy has 5 building blocks: regional integration, information and technology, skilled workforce, infrastructure, and financing. It also outlined the areas of primary health care in Australia most in need of change, which included improving access and reducing inequity and providing better management of chronic conditions. In addition, the National Diabetes Service Scheme facilitates the access of patients to diabetes care products such as testing strips and needles, at subsidized prices (National Health Priority Action Council, 2006).
The SNAP (Smoking, Nutrition, Alcohol and Physical Activity) framework was further designed to provide diabetes care and assist in treating associated risk factors. It provides a system-wide approach to guide general practitioners on modifying behavioral risk factors in diabetes patients. The framework spawned into the Lifestyle Prescription Initiative, which instructs general practitioners to discuss healthy lifestyle choices with patients, advise good nutrition and exercise, discourage alcohol and smoking, and refer to other providers for assistance if needed (National Health Priority Action Council, 2006). Until proper implementation, however, this framework remains to emerge as a significant benefit.
Indigenous Australians have been found to be at higher risk of diabetes, as well as low socioeconomic status. These population groups require diabetes care that is tailored to their situation. Therefore Northern Territory Preventable Chronic Disease Strategy was developed as a model for an integrated approach to chronic diseases for Indigenous Australians (Weeramanthri et al., 2003). Its key message is to manage five chronic illnesses including diabetes and heart disease, by focusing on teaching patients to control the risk factors. It is a 10-year long project with results awaited.
Must diabetes patients rely only on doctor’s appointments and tests for their care? The answer is no. Self-management is an essential part of diabetes management. The Global Guideline for Diabetes (International Diabetes Federation, 2012) instructs that self-management education of diabetes patients needs to be given and re-assessed regularly. The education must be tailored to the individual’s lifestyles, ethnic, and social background, and modern technologies should be used to provide patient education. Patients must be given lifestyle advice to modify eating habits and increase physical activity, in a way to match the patient’s preferences and culture.
A diabetes self-management program at the individual level for Aboriginal Australians was found to be effective in improving glycemic control in diabetics (Battersby et al., 2008). In contrast, recent evidence from a global systematic review compared group-based training to routine diabetes treatment, and has shown that group-based training for self-management strategies significantly helps improve diabetes control (Deakin, McShane, Cade, & Williams, 2005).
The strengths, limitations, potential gaps and barriers to the frameworks and strategies
Frameworks are aimed at common target audiences, which can be applied to most members of a population. However, these frameworks sideline individuals with low levels of health literacy, low socioeconomic status, and members of culturally and linguistically diverse communities (Glasgow et al., 2008). In the in the United Kingdom, the National Health System provides health care that is free at the point of care, but sometimes a limited supply of available services exist (Comino et al., 2012). In the United States, by contrast, high healthcare costs and the absence of universal health insurance are reflected in the predominance of interventions to improve affordability, availability and acceptability through establishment of systems of managed care and of reach to uninsured and marginalized groups (Comino et al., 2012). In Australia, although universal health coverage is available, it is not always accessible geographically or culturally. Providers may not be sensitive to the health literacy, cultural background or service needs of some groups of patients, and may have poor communication skills or discriminatory attitudes (Comino et al., 2012). The recommended approach to diabetes care is interdisciplinary. In reality, however, it can be unaffordable, uncomfortable or technically impossible for a diabetes patient to arrange timely appointments with many caregivers. The self-management program, being now encouraged by researchers, would likely become another fragment in this multi-fragmented system, further complicating the patient’s treatment plan (Glasgow et al., 2008). In Australia, Divisions have shown the success of using a range of strategies to deliver effective diabetes education (Moretti et al., 2010).
Globally and in Australia, the implementation of strategies to manage diabetes faces many limitations (National Health Priority Action Council, 2006). The management requires regular physician visits and tests, which the hospital or patient may not be able to conduct due to financial or logistic reasons. The community health centers that are run by charity and government funds, for example, are often overwhelmed by the number of patients to treat. Understaffing, inadequate funding, and infrequent visits by specialists are the challenges facing these primary care centers. The centers receive more patients with acute illnesses, and are inadequately oriented to tend to the needs of patients with chronic health problems. The patients at these centers do not always receive regular physician appointments and monitoring of disease control (Battersby et al., 2008). There is a lack of coordination between services provided in different settings such as community, general practice and hospitals. Psychosocial issues in diabetes are often not recognized, which hamper compliance (National Health Priority Action Council, 2006).
One major barrier to diabetes care strategies is the lack of patient compliance advised by the medical care team (Deakin et al., 2005). The traditional diabetes education is delivered in a didactic format; it is now recognized that patient education must be tailored to the individual’s social and socio-economic situation in order to secure patient compliance (Deakin et al., 2005). Nagelkerk et al. explored the barriers to implementation of diabetes care by asking the patients. They reported that lack of knowledge of the diet plan, as well as frustration with failing to improve glycemic control despite medical compliance, as the major barriers to continuing self – management (Nagelkerk, Reick, & Meengs, 2006).
Although the framework for diabetes care includes advising healthcare professionals to practice evidence-based medicine and prescribe treatment in accordance with local guidelines, in many cases the health centers fail to do so (National Health Priority Action Council, 2006). Also, it has been reported that after the development of the SNAP (Smoking, Nutrition, Alcohol and Physical Activity) framework, its recommendations were not well implemented by Australian general practitioners (Harris, Amoroso, & Laws, 2008). Therefore, the development of effective frameworks will not be sufficient in improving diabetes care, without overseeing the complete implementation of these frameworks at the primary care level. Therefore, further promotion of these frameworks is needed to enhance their implementation.
A number of diabetes approaches and frameworks have been developed. The diversity in these diabetes care programs has been explored by a review of systematic reviews (Borgermans et al., 2008). It was concluded that there is no single conceptual framework that is linked to all quality indicators such at the structure, process and outcome level. The challenge facing public health authorities is now to synthesize a standardized framework on high quality care for diabetes (Borgermans et al., 2008).
Enablers to Frameworks and Strategies
The cornerstone of diabetes management – adequate nutritional intake and lifestyle changes – can only be undertaken if the patient has the motivation to do so (Deakin, McShane, Cade, & Williams, 2005). Patients will not be compliant with physician instructions without adequate education, as well as feasible plans to alter behaviors. Therefore, the strongest enabler to the framework for diabetes care is good patient education and support, either individually or group-based. Positive outcomes in diabetes care have already been shown to be associated with education programs that focus on self-management, and provide culturally relevant information (Whittemore, 2000).
It has been recognized that some communities have inadequate access to healthcare and do not receive regular diabetes follow-up management. To enable access of these communities to the diabetes care framework, some government measures have been taken. These include incentive payments to practitioners to relocate to areas of high need, and increased provision of allied health care services in rural areas (Comino et al., 2012).
Recent technology has provided assistance to holistic diabetes care, through cell-phone based pill reminders and educational applications. Internet-based home tele-monitoring systems, have also proved useful in helping diabetes patients measure, monitor, manage, and receive health care (Mazzi & Kidd, 2002).
After comparison of these local strategies and international frameworks, it is apparent that the system envisioned by the National Health Priority Action Council is the most likely to deliver adequate diabetes care to Australian communities at all levels, while the international guidelines fall short on practicality and consideration of patient education and local community concerns.
Conclusions
Diabetes is a lifelong condition which eventually leads to complications if not controlled, therefore its management requires more than mere guidelines on the medications to take and the lifestyle choices to make. Its management requires a healthcare system which includes adequate patient education, self-monitoring and self - management, regular check-ups and investigations to monitor the progress of disease, and surveillance that the treatment given adheres to national guidelines. Various frameworks and strategies are currently in place to provide adequate care, including the Global Guideline for Type 2 Diabetes by the International Diabetes Federation, the Australian National Diabetes Strategy, and others. The international guidelines fall short of addressing patient education and enabling diabetes care provision to isolated communities, which is why regional ongoing strategies need to be devised and used in parallel to international guidelines. However, there are many shortfalls in these strategies and further research and funding efforts are necessary to minimize the risk of complications in patients with diabetes.
References
Australian Institute of Health and Welfare. (2013). Diabetes risk factors. Retrieved 18 March 2013, from http://www.aihw.gov.au/diabetes/risk-factors/
AustralianGovernment. (2010). Building a 21st Century Primary Health Care System: Australia’s First National Primary Health Care Strategy. Department of Health and Aging. ACT.
Bailie, Ross, Si, Damin, Dowden, Michelle, O'Donoghue, Lynette, Connors, Christine, Robinson, Gary. (2007). Improving organisational systems for diabetes care in Australian Indigenous communities. BMC Health Services Research, 7(1), 67.
Battersby, M. W. , Kit, J. A., Prideaux, C., Harvey, P. W. , Collins, J. P., & Mills, P. D. (2008). Research Implementing the Flinders Model of Self-management Support with Aboriginal People who have Diabetes: Findings from a Pilot Study. Australian Journal of Primary Health, 14(1), 66-74. doi: http://dx.doi.org/10.1071/PY08009
Borgermans, Liesbeth A. D., Goderis, Geert, Ouwens, Marielle, Wens, Johan, Heyrman, Jan, & Grol, Richard P. T. M. (2008). Diversity in diabetes care programmes and views on high quality diabetes care: are we in need of a standardized framework? International journal of integrated care, 8.
Comino, Elizabeth, Davies, Gawaine, Krastev, Yordanka, Haas, Marion, Christl, Bettina, Furler, John. (2012). A systematic review of interventions to enhance access to best practice primary health care for chronic disease management, prevention and episodic care. BMC Health Services Research, 12(1), 415.
CommonwealthofAustralia. (1999). National Diabetes Strategy 2000 - 2004. Canberra: Commonwealth of Australia.
Deakin, T., McShane, C. E., Cade, J. E., & Williams, R. D. (2005). Group based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev, 2.
Glasgow, Nicholas J., Jeon, Yun-Hee, Kraus, Stefan G., & Pearce-Brown, Carmen L. (2008). Chronic disease self-management support: the way forward for Australia. Medical Journal of Australia, 189(10), S14.
Harris, Mark F., Amoroso, Cheryl L., & Laws, Rachel A. (2008). Moving Towards a More Integrated Approach to Chronic Disease Prevention in Australian General Practice. Australian Journal of Primary Health, 14(3), 112-119. doi: http://dx.doi.org/10.1071/PY08043
International Diabetes Federation. (2008). International Curriculum for Diabetes Health Professional Education. Brussels: International Diabetes Federation.
International Diabetes Federation. (2012). Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation.
Lamoureux, Ecosse Luc, Fenwick, Eva, Xie, Jing, McAuley, Annie, Nicolaou, Theona, Larizza, Melanie. (2012). Methodology and early findings of the Diabetes Management Project: a cohort study investigating the barriers to optimal diabetes care in diabetic patients with and without diabetic retinopathy. Clinical & Experimental Ophthalmology, 40(1), 73-82. doi: 10.1111/j.1442-9071.2011.02697.x
Mazzi, Christian P., & Kidd, Michael. (2002). A framework for the evaluation of Internet-based diabetes management. Journal of medical Internet research, 4(1).
Moretti, C., Kalucy, E., Hordacre, A., & Howard, S. (2010). South Australian Divisions of General Practice supporting diabetes care: insights from reporting data. Australian Journal of Primary Health, 16(1), 60-65. doi: http://dx.doi.org/10.1071/PY09057
Nagelkerk, Jean, Reick, Kay, & Meengs, Leona. (2006). Perceived barriers and effective strategies to diabetes self-management. Journal of Advanced Nursing, 54(2), 151-158. doi: 10.1111/j.1365-2648.2006.03799.x
National Health Priority Action Council. (2006). National service improvement framework for diabetes. http://www.health.gov.au/internet/main/publishing.nsf/content/252F134AC658C2BFCA2571410007C6E0/$File/diaball.pdf
Norris, Susan L., Nichols, Phyllis J., Caspersen, Carl J., Glasgow, Russell E., Engelgau, Michael M., Jack Jr, Leonard. (2002). The effectiveness of disease and case management for people with diabetes: A systematic review. American Journal of Preventive Medicine, 22(4, Supplement 1), 15-38. doi: http://dx.doi.org/10.1016/S0749-3797(02)00423-3
Raphael, D., Anstice, S., Raine, K., McGannon, K., Rizvi, S., & Yu, V. (2010). Type 2 Diabetes: Poverty, Priorities and Policy The Social Determinants of the Incidence and Management of Type 2 Diabetes. Social Science & Medicine, 47(9), 1189-1195.
Weeramanthri, Tarun, Hendy, Shirley, Connors, Christine, Ashbridge, David, Rae, Cheryl, Dunn, Maree. (2003). The Northern Territory Preventable Chronic Disease Strategy - promoting an integrated and life course approach to chronic disease in Australia. Australian Health Review, 26(3), 31-42. doi: http://dx.doi.org/10.1071/AH030031
Whittemore, Robin. (2000). Strategies to Facilitate Lifestyle Change Associated with Diabetes Mellitus. Journal of Nursing Scholarship, 32(3), 225-232. doi: 10.1111/j.1547-5069.2000.00225.x
