Identification of the Problem
The PICOT question for this clinical case is stated as follows:
P-Individual with diabetes
I-Improved Lifestyle
C-Normal Lifestyle
O-Reduced Incidences of Diabetes Complications
T-With six months
In individual with diabetes, how can improved lifestyle as compared to normal lifestyle reduce the incidences of diabetes complications within six months?
In the clinical setting, diabetes is a condition that affects patients of all ages, genders and socioeconomic standing. As of 2014, the number of people with diabetes stood at 422million. In adults aged 18 years and above it affects over 8% of the population and the prevalence has been rapidly on the rise most notably in the middle and low-income countries. The WHO predicts that by 2030, the disease will be the seventh cause of mortality globally if the trends continue to hold (WHO, 2016). Despite these trends and the increasing knowledge base on diabetes, there is a large population that lives with undiagnosed diabetes. In the US alone, 7 million people are believed to fall in this category (Haas et al., 2013) the disease has an extreme multifactorial causation and in order to combat it, it must be faced from many different angles.
There are two major variants of diabetes: T1D (Type I Diabetes) and T2D (Type II Diabetes). In T1D, the onset is from childhood. It is a result of deficient production of i9nsulin. The treatment regimen therefore requires daily administration of insulin. T2D is a result of inefficiencies in the use of insulin by the body caused by resistance development over time. The symptoms may be similar to those of T1D, however, it is usually diagnosed late because the symptoms appear to be milder. This diagnosis is usually made after the complications have developed.
A third variant of diabetes is Gestational diabetes (GDM). This usually occurs in the third trimester of pregnancy. It is characterized by above normal blood glucose levels that are slightly below those required to diagnose typical diabetes. The condition increases the chances of complications during pregnancy and future development of T2D in the mother and the child.
An intermediate category of individuals has been found that exhibits above normal glucose concentrations. These levels are not high enough for a conclusive diabetes diagnosis. These Impaired Glucose Tolerance (IGT) or Impaired Fasting Glucose (IFG) individuals are said to have prediabetes. They have the indicators for an increased risk of developing diabetes. These two risk factors are usually associated obesity. Given that the prevalence of obesity is on the rise globally, there is a concomitant increase in the number of people at risk (TA, 2014). The most common consequences are increased risk of cardiovascular diseases such as heart attacks and strokes, limb amputation caused by neuropathy and inefficiency in peripheral blood supply, ulcers and infections in the feet, loss of sight and kidney failure.
Evidence based practice in diabetes insists on a multipronged approach in order to counter the multiple factors that cause and complicate diabetes in patients. It is crucial to acknowledge that the disease has genetic origins. This dictates that a family history should be probed to identify any chances of heredity. The outcome of these probes will enable the practitioner to designate the patients according to risk. This is important in the prevention and early diagnosis especially in T2D that remains undetected until the complications set in. In infants and children, the onset of T1D is rapid and debilitating. Family history of this condition should inform a prudential check of the child's blood glucose levels to enable early management and prevent complications (Haas et al., 2013).
In dealing with obese patients, the practitioner must take into account the prediabetic category. The aim of intervention at this point will be to inculcate lifestyle changes that will help the individual to preempt the development of full-blown diabetes. Target areas include increasing physical activity, improving the quality of the diet and changing the mindsets to enable effective health seeking behavior that will allow for early detection and management of any complications. As a bonus, an improvement in the BMI of the patient reduces the risk of diabetes (Blackberry et al., 2013).
In diabetic patients, the practitioner aims to improve the outcomes of clinical intervention, increase the comfort of the patients and prevent further complications. These goals dictate prompt treatment, lifestyle changes, physiotherapy and psychotherapy, and building of support structures within the individual's family and society to ease their lives (ADA, 2015a). Constant monitoring of GDM patients and their offspring will enable the practitioner to monitor for complications in pregnancy and any future risk of T2D development (Vera, 2013; Carpenter et al, 2015). In dealing with any disease, knowledge dissemination is the most crucial intervention at any stage.
Given the indiscriminate reach of the disease, the stakeholders are drawn from all sectors of society. To begin with, the individuals and families of patients and those at risk are the core of any structured interventions. The governments also have a social responsibility to provide healthcare and information to all its citizens. The insurance companies must provide comprehensive cover to cater for the lifelong management and treatment. Additionally, this cover should include lifestyle support such as gym membership fees for prediabetic individuals. The health care professionals are at the front line in the fight against diabetes. Through research and patient centered interventions, they can roll back the effects of the debilitating conditions (Markhorst et al., 2012). Diabetes is a costly disease to deal with. This is due to the magnitudes of the complications that arise from it. In the US alone, the American Diabetes Association (2015b) gives a price tag of a whopping $245 billion to the economy. This large amount is meant to cover the cost of inpatient care in hospitals (43%), prescription medication (18%), physician's office Visits (9%), ant diabetic agents/ Supplies (12%) and nursing facility stays (8%). This cost is on the rise as more people are diagnosed with diabetes yearly. What is even more worrying is that this cost only caters to the diagnosed cases. To the patient the average yearly cost of treatment ranges from $7,900. The cost to the economy as a whole cannot be numerically calculated as it accounts for lost person-hours, diverted incomes, reduced or inability to work.
The largest percentage of treatment costs for diabetes is provided by the government at 63%. Private insurance companies pay for 35% and the rest is paid by the uninsured. The trends in the US are an indicator of global patterns. This is especially detrimental to the developing world as the bills are too expensive. In the UK, the cost of treating T2D is higher than T1D indicating the worrying trend that this preventable condition is taking due to changing socioeconomic paradigms( Hex et al., 2012).
The facets of prevention and management of diabetes interact with many legal and ethical principles. The Law prohibits discrimination of the individuals by inheritable genetic risk factors. The implications of these are that, this information should not be allowed to interfere with the individual's right to procreate despite the fact that there is risk to the offspring. Communication of risk is a challenge, as risk does not always translate to development of the disease. Various other factors still come into play. Behavioral change though needful, may go against a person's beliefs and values and this poses questions (Haga, 2009).
In conclusion, given the alarming statistics on diabetes it is crucial to tailor make the interventions to the needs of the client. This will necessitate understanding the risk factors and the personal lifestyle of the individual. This will reduce the cost of management and prevention as well as reduce ethico-legal conflicts.
References
American Diabetes Association (ADA). 2015a. Foundations of Care: Education, Nutrition, Physical Activity, Smoking Cessation, Psychosocial Care, and Immunization. Retrieved from http://care.diabetesjournals.org/content/38/Supplement_1/S20
American Diabetes Association (ADA). 2015b. The Cost of Diabetes. Retrieved from http://www.diabetes.org/advocacy/news-events/cost-of- diabetes.html?referrer=https://www.google.com/
Blackberry, I. D., Furler, J. S., Best, J. D., Chondros, P., Vale, M., Walker, C., & Liew, D. (2013). Effectiveness of general practice based, practice nurse led telephone coaching on glycaemic control of type 2 diabetes: the Patient Engagement And Coaching for Health (PEACH) pragmatic cluster randomised controlled trial.
Carpenter, B., Munro, N. & De Lusignan, S. (2015). Gestational diabetes in primary care. Nursing in Practice; 83
Haas, L., Maryniuk, M., Beck, J., Cox, C. E., Duker, P., Edwards, L., & McLaughlin, S. (2013). National standards for diabetes self-management education and support. Diabetes care, 36(Supplement 1), S100-S108.
Haga, S. B. (2009). Ethical issues of predictive genetic testing for diabetes. Journal of diabetes science and technology, 3(4), 781-788.
Hex, N., Bartlett, C., Wright, D., Taylor, M., & Varley, D. (2012). Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabetic Medicine, 29(7), 855-862.
Markhorst, J., Martirosyan, L., Calsbeek, H., & Braspenning, J. (2012). Stakeholders' perspectives on quality indicators for diabetes care: a qualitative study. Quality in primary care, 20(4), 253-261.
TA, S. (2014). Diagnosis and classification of diabetes mellitus. Diabetes care, 37, S81.
Vera, M. (2013). 13+ Diabetes Mellitus Nursing Care Plans. Retrieved from http://nurseslabs.com/6-diabetes-mellitus-nursing-care-plans/
WHO. (2016). Diabetes. Retrieved from http://www.who.int/mediacentre/factsheets/fs312/en/
