Introduction
In previous decades, epidemics were associated entirely with communicable diseases. However, a recent global phenomenon is the significant rise in incidence of chronic diseases linked to individual lifestyles. Unhealthy diet, inadequate physical activity, smoking, and alcohol intake all play a role in initiating the physiologic changes that lead to the development and progression of lifestyle-related conditions including cardiovascular disease, type 2 diabetes, and cancer (Strychar, Elisha & Schmitz, 2012). These are the top causes of death in populations as reported by many countries.
Because of the association with lifestyle factors, such illnesses are largely preventable but require complex management once acquired. The chronic nature of these conditions requires the active participation of patients in self-management, close collaboration with health care providers, and multidisciplinary teamwork among health professionals to maintain and further improve individual health outcomes (McGill & Felton, 2007). Hence, it is imperative for disciplines involved in direct care to gain sufficient understanding of chronic diseases. This paper will discuss type 2 diabetes, how lifestyle contributes to its development, and specific recommendations for management.
Background
Type 2 diabetes mellitus (DM) is a disorder involving insulin, the hormone responsible for the cellular absorption of blood glucose for use in processes that require energy (Tortora & Derrickson, 2010). It is produced by beta cells in the pancreas. Insulin levels increase during rapid metabolism such as during digestion or physical activity and decreases when the rate of metabolism falls (Verges, 2005).
In type 2 diabetes the pancreas either produces inadequate levels of insulin or body cells become less sensitive to the effects of the hormone (Kahn, Cooper & Del Prato, 2013). Either way, there is impaired utilization of glucose accumulates in the bloodstream. Besides lifestyle, recent studies show that genes, aging, and the built environment play roles in type 2 DM development, although to a lesser extent, while gestational diabetes is also linked with higher risks of type 2 DM in the offspring (Kahn, Cooper & Del Prato, 2013). Advancing age is thought to cause a decline in pancreatic functioning while the unavailability of safe areas for exercise as well as affordable healthy foods is a barrier to lifestyle change.
Glycated hemoglobin (HbA1c) presents the average blood glucose levels during the three months prior to the test. A result of 7% or more is equivalent to an average blood glucose level of 170 mg/dL or higher and a diagnosis of type 2 DM is made based on this test (ADA, 2007). If unmanaged or poorly managed, hyperglycemic hyperosmolar syndrome (HHS) may develop, especially when the metabolic needs of the body increase such as during an infection and other acute illnesses (Bacon, 2013). The resulting dehydration and the probability of seizures and coma make HHS a medical emergency with a high mortality rate.
Without optimal management, type 2 DM also leads to serious complications, namely kidney disease and failure, heart disease, stroke, nerve injury, vision problems including blindness, as well as delayed healing of wounds that can lead to gangrene and subsequent amputation (Li et al., 2013). Type 2 DM is irreversible. Thus, early diagnosis and optimal management are the keys to reducing the risk of complications and increasing the quality of life despite chronic illness.
Trends in Type 2 Diabetes
Epidemiological studies show that in 2010, an estimated 26 million Americans had diabetes with more than 90% with type 2 (CDC, 2013). About 13 million or 50% were female. A little below 19 million were diagnosed cases while about 7 million were undiagnosed. The highest prevalence of type 2 DM noted in 2008 was among individuals aged 65 years and older while in 2010, the number of newly diagnosed cases was highest in the 45-64 age bracket (CDC, 2013). This suggests a younger disease onset.
Though most statistics are not aggregated by age or ethnicity, trends show an alarming phenomenon of increasing type 2 DM incidence among children and adolescents similarly associated with lifestyle (Wilson, 2013). One projection states that at the present rate of incidence, the number of children with type 2 diabetes will likely increase by 49% come 2050 (Imperatore et al., 2012) unless interventions successfully reverse the trend.
On the other hand, ethnic minorities especially Hispanics and Asians are at a significantly higher risk for type 2 diabetes than the rest of the population. Among foreign-born Asian Americans, the highest rates are observed among those from India and the Philippines (Holland et al., 2013) probably owing to culturally-prescribed diets and lifestyles, socioeconomic status, and heredity (Abate & Chandalia, 2003; Huffman & Vaccaro, 2013). The lack of culturally competent care and culturally sensitive health information are further contributory factors to the disparity in type 2 diabetes rates (Carr, 2012).
Diabetes-related medical treatment throughout the lifetime of persons with type 2 DM comes at a significant cost. One study estimated the average cost to be from $54,700 to $124,700 among men and $56,600 to $130, 800 among women depending on the age bracket (Zhuo, Zhang & Hoerger, 2013). Costs were highest among Whites as compared to Hispanics, Black Americans, and Asians (Li et al., 2013). This is inconsistent with statistics showing a higher prevalence of type 2 DM among ethnic minorities. As such, this finding may be attributed to disparities in health care utilization wherein Whites access costly treatments such as dialysis and kidney transplantation more.
The breakdown of costs used in the calculation included money spent in treating the condition itself and any of complications that arise of which about 57% are for managing the negative effects on the heart and major blood vessels (Zhuo, Zhang & Hoerger, 2013). However, cost estimates typically exclude non-medical expenses for health promotion, e.g. nutrition, foot care, physical activity, and other measures that improve health and prevent further physiological damage. At the national level, a cumulative estimation of both direct and indirect expenditures amounted to $174 billion (Torre et al., 2011).
In addition to costs not quantified are home health nursing services and the management of psychosocial issues. The disease also translates to lost or reduced productivity during acute illness and in the event of disability. Besides physiologic signs and symptoms, type 2 DM is clearly a financial burden and a source of economic losses. Health care reforms and federal programs currently focus on public health and primary care that involves prevention, early diagnosis, and prompt management with the aim of creating better outcomes that can potentially reduce the costs of care (CDC, 2012).
Relationship with Diet, Physical Activity, and Obesity
Type 2 diabetes is a complex disorder brought on by the interplay of multiple factors. High-calorie diets such as meals rich in fat and sugar coupled with a sedentary lifestyle contribute to obesity. Excessive weight gain results because of the imbalance in food intake and energy expenditure (Tortora & Derrickson, 2010). It is characterized by increased visceral or abdominal fat, a form of storage of excess lipids, and constantly elevated fatty acid levels in the blood (Day & Bailey, 2011). Insulin resistance and reduced insulin production that are hallmark features of type 2 diabetes are attributed to the effects of too much fatty acids.
Reduced cellular sensitivity is the outcome of the body’s utilization of fatty acids for energy instead of glucose. Greater fat mass in obese persons also raise the amount of pro-inflammatory cytokines that speed up the rate of fat breakdown, thereby keeping lipid levels always high (Torre et al., 2011). Abnormally high circulating lipids further find their way to muscles and the liver producing variants of protein kinase C that impair the cell’s ability to signal for insulin that is responsible for facilitating the entry of glucose into cells (Day & Bailey, 2011). In addition, sustained fatty acid levels diminish the function of beta cells in the pancreas, thus limiting the amount of insulin produced.
Disease-Specific Recommendations
A major management approach to type 2 diabetes is pharmacologic. In the acute stage of HHS, intravenous insulin is administered to immediately correct hyperglycemia or abnormally high blood sugar levels. However, oral anti-glycemics such as sulfonylureas, biguanides, and glinides, are the first-line drugs for establishing long-term blood glucose control through action on the pancreas, body fat, and muscle that reduce glucose levels and increase cellular sensitivity to insulin (Torre et al., 2011).
The choice of drug depends on its efficacy in lowering the glycated hemoglobin (HbA1c) level to less than 7% and glucose levels to less than 170 mg/dL after meals (ADA, 2007). Medications for type 2 DM have expanded to include injectable insulin developed specifically for this disorder and includes amylin analogues and GLP-1 receptor agonists (Khan, Cooper & Del Prato, 2013). Health care providers recommend medications in a step-wise manner in that the drug, dose, and combination may be modified according to the patient’s physiologic response until optimum control based on individualized glucose level targets is attained.
Decisions pertaining to medication or combination of medications also factor in the side effects and the level of risk for hypoglycemia or abnormally low blood sugar. The anti-glycemic drug must not exacerbate the client’s already excessive body weight and blood lipid levels. For example, sulfonylureas are known to induce weight gain (Torre et al., 2011). Further, any diabetes-induced complication and comorbidities are part of the assessment and must be considered. Thus, pharmacologic treatment typically results in polypharmacy. Last, cost is also an important consideration for many patients.
Patient adherence is an important component of successfully meeting blood glucose targets (Grandy et al., 2013). There are many barriers to adherence to medications and lifestyle recommendations that are either financial or behavioral in nature. Behaviors are influenced by the degree of social support experienced by the individual, understanding of the disease, beliefs in the efficacy of medications versus nonprescription alternatives, level of motivation, self-confidence, and self-efficacy in coping with the illness (McGill & Felton, 2007). As such, it is necessary to individualize the approach for each patient.
Medications are not enough in managing glucose levels and preventing complications. It must be supported by lifestyle changes in the areas of diet and exercise that make weigh loss possible for obese patients (Strychar, Elisha & Schmitz, 2012). Significant weight loss of around 10 pounds has been associated with better glucose control that is usually long-lasting. It is recommended that patients create meal plans to ensure adequate nutrition while meeting caloric goals.
Meals must contain lower calories which means less fat and carbohydrates because these are higher in caloric content compared to proteins (ADA, 2007). If fats are to be consumed, these should be monounsaturated in order for it not to contribute to an elevation in lipid levels. Glucose control is easier to achieve when carbohydrate intake is predictable. Thus, eating similar amounts of carbohydrates per meal, such as 30-45 grams, is advised (Rennert, 2011). Using the Diabetes Food Pyramid and the USDA food plate guide will assist individuals in making healthier food choices in terms of type and amount.
On the average, a person with type 2 diabetes will need 6 servings of carbohydrates per day (Rennert, 2011). However, high-fiber and low fat foods are best such as whole-grain bread and pasta, beans, and rice. These have a high glycemic index, which means they are metabolized at a slower and steadier rate and thus do not cause excessive spikes in blood glucose levels after meals (Bibra et al., 2013). Milk and milk-based products should be 2-3 servings a day and likewise must be low in fat and sugar content.
Food guides for type 2 diabetics also recommend 3-5 vegetable servings and 2-4 fruit servings daily (Rennert, 2011). Fresh produce are best because these are highest in fiber and do not contain added sugars or fats as compared to canned juices, fruit slices, and soups or jams. Patients must know how to read food labels to see whether processed fruit and vegetable products contain added fats and sugars (ADA, 2007). Citrus or sour fruits are the best choice because of the lower fructose or fruit sugar content.
Two to three servings of meat and fish per day will suffice (Rennert, 2011). Fresh fish and poultry are the best selections because they are lean meats. Skin from poultry and fat in other meats must be removed to reduce the fat content or lean cuts should be chosen. The manner of preparing fish and meat is also an important consideration. It is recommended to broil, boil, bake, grill, or roast rather than fry, again to minimize the amount of fats consumed from these foods (ADA, 2007). Fats, sweets, and alcohol generally must be limited.
Meal plans also need to be individualized to take into account specific physiologic needs based on developmental stage (Carr, 2012). For example, the caloric need of growing children with type 2 diabetes is different from those of adults. Nutritional needs also change with age. Among older adults, for instance, osteoporosis is a significant concern that is addressed in part by diet. The presence of comorbidities and complications is another factor influencing the diet of a person with type 2 diabetes. For example, concurrent cardiovascular and renal problems require the control of sodium and potassium from food.
In addition, finances and the availability of healthy foods in the area where the patient lives and works must be discussed (Bibra et al., 2013). Individuals commonly cite limited access to fresh vegetables and fruits that are commonly available in large grocery stores but not in smaller ones. Low-fat and low-sugar foods may also be more expensive than their regular counterparts. Patients need to assistance in dealing with these practical concerns that spell adherence to dietary recommendations.
A healthy diet goes hand-in-hand with physical activity. Besides facilitating the expenditure of energy, thus preventing the further build-up of visceral fat mass and inducing weight loss, exercise also improves cellular sensitivity to insulin that increases the uptake of glucose from the blood (Fagour et al., 2012). As such, adequate physical activity enhances the effects of anti-diabetic medications. Additional benefits to the person with type 2 diabetes include improved strength and balance, stronger bones, better control of hypertension, reduced risk of health disease and cancer, alleviation of musculoskeletal problems brought on by obesity, and a better sense of wellbeing (Jennings et al., 2013).
As with medications and diet, physical activity plans need to be individualized as well. Persons who have been sedentary for long periods of time need to start increasing their activity levels gradually to ensure safety (Wisse et al., 2010). Once tolerated, activities may be increased in terms of intensity and duration. Current physical activity guidelines for people with type 2 diabetes recommend that for most days of each week, patients must engage in at least 30 minutes of moderate-intensity exercise daily (Jennings et al., 2013). Examples of moderate-intensity exercise are walking, jogging, cycling, and hiking.
Personal preferences and available resources must be explored with the patient. The ability to choose activities that are interesting helps individuals adhere to guidelines (Wisse et al., 2010). Open spaces, gyms and clubs, parks, trails, and sidewalks in the community represent resources that can be utilized by patients, young and old, to achieve their physical activity goals and outcomes. In addition, patients must be encouraged to be active as much as possible by walking up the stairs rather than taking the elevator, walking instead of driving if possible, or playing active games with children rather than watching television.
Last, an essential recommendation in relation to physical activity and mobility is foot care (Nyenwe et al., 2011). Type 2 diabetes reduces blood flow to the extremities that make wounds and ulcerations difficult to heal. Prevention entails choosing comfortable shoes with a proper fit; taking great care when cutting toenails to prevent injury, and maintaining good foot hygiene. Adequate foot care ensures the individual’s continued engagement in physical activity.
Conclusion
Type 2 diabetes is a significant lifestyle-related and chronic health concern that requires appropriate treatment and management. Because of the complexity of this condition, a holistic and individualized approach must be adopted. Pharmacologic therapy and lifestyle change are the pillars of management to prevent progression and further complications. Health care professionals from various disciplines play a role in ensuring that patients achieve optimal outcomes and a better quality of life.
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