Essay: Type 2 Diabetes (T2DM)

American Diabetes Association (2015) describes “Diabetes as a group of metabolic diseases characterized by hyperglycaemia resulting from defects in insulin secretion, insulin action, or both. Type 2 Diabetes(T2DM), the most prevalent form of the disease is caused by a series of metabolic disorders which results from insulin resistance in muscles and tissues, unrestricted glucose secretion, reduced insulin secretion from the pancreas and or declining beta cell function. which lead to elevated levels of sugar in the blood (Talachai et al 2012).
Diabetes of all types can lead to complications in many parts of the body, increasing the overall risk of dying prematurely (Lind 2013). Complications include heart attack, stroke, kidney failure, leg amputation, vision loss and nerve damage. In pregnancy, poorly controlled diabetes increases the risk of fatal death and other complications (Diabetes UK 2015). Both Diabetes UK (2015) and WHO (2016) makes us aware of the substantial economic loss diabetes and its complication can bring to people with diabetes, their families, health systems and national economies through direct medical costs, loss of work and wages.
Because of the huge burden of mortality and morbidity attributed to diabetes through micro and macro vascular completion (Lind 2013), people with diabetes require access to systematic, ongoing, and structured care delivered by a team of competent healthcare professionals (NICE 2017).The U.K. prospective diabetes study group UKPDS (1998) had indicated that this was necessary in order to achieve strict glucose control, blood pressure and cholesterol which can reduce the risk of diabetes related complication.
Diabetic care in the primary care involves the use of medication, health education, counselling, consistent follow up and periodic referral for specialist services (Long 2011) in accordance with National Institute of Clinical Excellence (NICE) (2017) guidelines for managing diabetes. The initial recommendation is to follow a healthy diet and exercise regime and usually followed with one or more hypoglycaemic agents to prevent micro and macrovascular complication (American Diabetes Association 2015).
Despite the benefit of medication, numerous studies have indicated that that recommended glycaemic targets are not achieved by majority of patients. America Diabetic Association (2015) makes us aware that about 50% of patients with type 2 diabetes fail to achieve glycaemic control that is HBA1c less than 7%. As a result, two third of patients die prematurely of cardiovascular diseases (Bailey and Kodack 2011). Edege et al (2016) further believes that the problem is due to poor patient adherence to prescribed medication. Particularly In primary care population.
Anecdotal evidence from practice, gathered from HBA1c results suggest that even with the wide range of oral pharmacological available to patients, achieving recommended glycaemic control among adult patients’ groups on oral medication is a challenge. This results in a greater number of patients remaining at risk of long term complication, premature mortality, and increased healthcare cost.
It well documented that reasons for non-adherent may be difficult to modify, partly due to factors beyond patient control such as demographic and healthcare structures (Luis Emilio et al 2013). Never the less, Salker (2016) believes if primary care nurses understand the barriers to medicine adherence, they will be able to intervene to increase adherence and improve patient outcome.
Pathophysiology of Type 2 Diabetes
The characterises hyperglycaemia associated with Type two diabetes is caused by a series of metabolic disorders which results from insulin resistance in muscles and tissues, unrestricted glucose secretion, reduced insulin secretion from the pancreas and or declining beta cell function (Ruso et al 2014)
Talachi et al (2012) further explains that, although beta cell disfunction may be partly due to genetics, it can also be caused by inflammation, obesity, insulin resistance, overconsumption of saturated fats and free fatty acid. Beta cell disfunction is characterized by impairment in the first phase of insulin secretion during glucose stimulation followed by the inability of the pancreas to compensate for insulin resistance. This leads to hyperglycemia and the onset of diabetes with symptoms as tiredness, polyphagia, polyuria, polydipsia, blurred vision, slow healing wounds, loss of muscle mass and thrush (Barr, Myslinksi, & Scarborough, 2008). Russo et al (2014) further comments, it is the β-cell dysfunction along with glucotoxicity, lipid toxicity, and other inflammatory agents on pancreatic insulin production all play a contributing role in the development of type 2 diabetes mellitus.
Tissue resistance to glucose uptake is also recognized as a major cause of DMT2.Cerf (2013) explains that tissue resistance is linked to elevated levels of pro-inflammatory cytokines which trigger endothelial cell dysfunction leading to vascular abnormalities. These mechanisms may also lead to atherosclerosis and coagulation tendencies which can also be present with DMT2. Although these causes are not linked to diabetes alone, they are found in other chronic diseases such as dyslipidemia and hypertension which are known risk factors of diabetes. (Cerf 2013).
Incidence of Type 2 diabetes
Global incidence of diabetes is on the rise (World Health Organization (WHO) (2016). Similarly, International Diabetes Federation (IDF) (2015) predict the cases of type 2 diabetes are set to double particularly in US, Australia, and Europe, by 2040 making type 2 diabetes the seventh-biggest cause of death worldwide (Long 2011, WHO 2016). Type 2 diabetes in United Kingdom is estimated to double by 2040, causing 16% of deaths (Diabetes UK 2011, Basu et al 2014, IDF 2015). As the UK’s fifth-biggest cause of death, it accounts for one tenth of NHS expenditure (Paulweber et al 2010, Hex et al 2012, WHO 2016).
The incidence of type 2 diabetes in a locality in outer London borough is not an isolated case. Of the 15000 active patients within the health facility 810 do suffer from type 2 diabetics. Type 2 diabetes affect more men than women and affect people from black and south Asian ethnic minority groups (PHE 2011). The increase in T2DM is associated with the increases in obesity, and an increasingly elderly population (PHE 2011)
Management of type two diabetes and Quality and outcome framework
NICE (2017) guideline NG28 provides evidence-based management system for the management of type 2 diabetes in primary care. This is based on the intervening to promote and support healthy lifestyle, pharmacological control of hyperglycaemia, hypertension, and hyperlipidaemia regular exam for early detection of cardiovascular risk and standard criteria for referral of patients to specialist care
The guideline is supported by Quality and Outcomes Framework (QOF) introduced in 2004 and provides financial incentives to general practices for the provision of high-quality care Diabetes UK (2018). Contrary to the limited evidence of improving healthcare quality (PRUComm 2016, NHS 2017), diabetic outcomes and care process under QOF has improved according to National Diabetic Audit Report (2017)
Poor Medicine adherence and Glycaemic control
The suggestion that people are achieving the recommended target for glycaemic control (NDA 2017) is debatable. Indeed, some practices may be achieving recommended targets according to QOF (NDA 2017), yet poor glycaemic control remains a problem among patient groups (Hendelsman et al 2015). Hendelsman et al (2015) further argue that, the present high morbidity and mortality associated with the disease and its associated high healthcare bill is attributed to poor glycaemic control which is a result of poor medicine adherence among patients ((DiBonaventura et al 2014)
Medicine adherence is crucial if the recommended glycaemic control, essential to prevent long term micro and macro vascular complication of the disease is to be achieved (American diabetic association 2013). Aside poor glycaemic control, Poor medicine adherence is also associated with increased healthcare costs (Nasseh et al 2012), and higher morbidity and mortality rates (Currie et al 2012).
Improved medication adherence has the potential to reduce healthcare related with care T2DM (Jha et al 2012) and improve patient outcomes (Egede et al 2014.) it is obvious that therefore that improving medicine adherence in patients with T2DM offers real opportunity for improving outcomes as well as reducing health care costs. Numerous studies have evidence non-adherence in patients on one or more to oral hypoglycaemic medications, all with wide variation the in actual occurrences.
An extensive study of electronic records on patients on oral hypoglycaemic agents revealed that only 39.6 % of patients filled their prescription after two years although 53% had HBA1C over 7 % (Karter et al 2009). A retrospective analysis of health records of patients who had recently initiated oral diabetic medication showed an overall adherence of 81% (Garzia-Perez et al 2013) Similarly, a recent meta-analysis of 40 studies in which patients taking oral antidiabetic drugs found that medication adherence rates were suboptimal, with only 67.9% of patients showing an overall adherence of about 80% (Iglay et 2105).all studies recognize the scope of the problems and its key contributors.
Factors influencing adherence to oral antiglycaemics
Studies have been conducted in attempt to identify the factors that influence patients’ adherence to prescribed medication (Houston et al 1997, Ho et al 2006 and Maningat et al 2013). Most of the factors identified. include relationship between patient and healthcare professional, healthcare systems and environment.
Hsu et al (2014) explains the factors as lack of education about treatment regimes, lack of support to help patients establish a routine for taking their medicine and poor communication between healthcare professionals as the major barriers to medication adherence. Experience from practice also reveals four major reasons of non-adherence among the patient groups. These include medication side effect, complexity of regime, beliefs about diabetic medication and communication between patients and healthcare professionals These are explored.
Medication side effects
The first line of treatment in type 2 diabetes are lifestyle modification and metformin Bartolomeo et al (2010). If glycaemic control is not achieved and or is contraindicated, a second drug such as sulphanylureas, meglitinide thiazolidines, alpha-glucosidase inhibitors incretin mimetics and incretin enhancer are used (Bartolomeo et al 2010)
However, patients’ knowledge of and or experience of side effects of medication can prevent them from adhering to medication especially when the side effect(s) is/are not communicated to healthcare professionals. Side effect associated with oral medication includes bloating or diarrhoea, weight loss or weight gain, feeling sick and swollen ankles (NHS 2017), erectly dysfunction and hypoglycaemia (Garcia-Pérez et al 2013).
For example, the link between obesity and type 2 diabetes is known (Russo et al 2014), so if patients who are overweight or obese are gaining weight because of side effects of medication, and do not report for medication review, they are likely not to adhere to the medication
Garcia-Pérez et al (2013) and Skyler et al (2009) evidence this, that obese or severely obese patients and patient who have experience symptoms hypoglycaemia are more likely to have low or moderate low compliance to medication as compared to non-obese individuals.
Also, contrary to the assertion that Intensive treatment of hyperglycaemia reduce HBA1C levels and reduce in cardiovascular events (Mannuci et al 2009), Terry et al (2012) makes us aware that, intensive glucose control does not reduce macrovascular diseases in older patients with long standing diabetes but may be associated with increased mortality. Which way, if patients have knowledge or have experience side effects of medication and do not report the side effects for appropriate intervention, they are more likely not to take their medication
Perceived complexity and inconvenience
Type 2 diabetes mellitus is a chronic complex disease which implies patients will not only have to be on medication for life but also faced the reality of doses and types of medication increasing over time. For example, the progressive nature of the disease may mean that at oral therapies may over time not be effective in achieving the recommended HbA1c levels, and most patients over time are eventually prescribed injectables which further reduce adherence (cook et al 2010)
Furthermore, Medication for T2DM and related complication can involve up to 10 tablets per day (Gaede et al 2003).This has a profound influence on adherence It has been observed in practice that non adherence to medication tend to be more prevalent when the number of prescribed doses per day increases and more so where patients indicates the treatment was complex and/or inconvenience .Hauber et al ( 2006 )put this in context; that, the number of prescribed dosed in a day is inversely associated with medication adherence with mean adherence decreasing sharply from 79% on once daily dose to 51% on four times daily dose. Adding to the effect of dose regime, de Vires et al (2014) further Comment that where treatment regime has been viewed as complex, adherence ifs further reduced.
Medication beliefs
The perceptions of patients’ effectiveness of medication and fear of the long-term risks associated with diabetic medication contributes to non-adherence to medication in patient groups. Mann et al (2009) indicates that when patients hold negative beliefs or hold sceptical beliefs about their prescribed medications, often fearing that the long-term risks outweigh any benefits. They are more likely not to adhere to prescribed medication and this will be indicated in HBAIc results
Although the general believe that when patients view medications as necessary, they are more likely to adhere to prescribed medication, it is equally valid too that patients’ concerns about their medications are more strongly linked to adherence than their beliefs in the necessity of those same medications (Foot et al 2016) .Particularly In patients with T2DM,Mann et al (2009) makes us aware that concerns, about the possible negative impact of medications are associated with poor adherence including reluctance to starting new medications
Communication between Healthcare Professionals and Patients
Communication between patients suffering from type 2 diabetes and their healthcare providers can have a profound impact on adherence. In practice, where a good rapport has been established and patients understand very well their diseases and the need for medication, adherence is good. Likewise, where effective communication has not been established adherence is poor.
Tiv et al (2012) evidence this; that good adherence is associated with good relationship between patients and health professionals whiles poor relationship between patient and healthcare professional is observed in patients with poor adherence to medication and glucose monitoring which is associated with higher HBA1C levels
Rubin et al (2006) goes further comment that where there is not only a good relationship between patient and healthcare provider but also have a diabetic specialist nurse at the premises, adherence to both medication and lifestyle is improved. Effective communication between patients and healthcare providers resolves patient distress, patients become aware of treatment options and decisions which leads to patients becoming empowered to self-care. this improves adherence and glycaemic control
Improving adherence
Nurses owe duty of care to their patient in accordance with the requirements of Nurse and Midwifery (NMC) 2015 code. General practice nurses remain crucial in screening, maintaining, and supporting people with diabetes (Royal College of Nursing 2017). This is because it they are privileged to meet patient at least on annual basis and hence best placed to identify incidences on non-adherence and positively influence the patients. General practice nurses provide the crucial supportive role by providing information (Hick 2010) and developing patients knowledge to be able to take ownership of their care process, through this process patients, can overcome barriers and modify their lifestyles to attain a better quality of life,
Evidence evaluating the long-term impact of interventions to improve adherence is limited and results from existing studies are inconsistence (Newman et al (2013), however where there is evidence, the suggestion is that interventions to improve adherence may be beneficial (Sapkota et al 2015). Which way, the case for nurse intervention in improving adherence to diabetic medication is firmly held (Farmer et al 2006). Farmer A et al (2012) recommend that interventions targeted at improving adherence in patients with chronic conditions such as Type 2 diabetes could help to reduce the burden of the disease.
Although Farmer et al (2006) and Hick (2010) continues to make the case for improving medicine adherence, Gorter et al (2011) makes the case that healthcare professionals including general practice nurse often do not prepare patient well enough to take responsibility of their care. This leads to misunderstanding between the two parties. The lack of effective communication inhibits partnership building and results in limitation of patients sense of ownership in the care process and adhering to medication. There is therefore the need for general practice nurses to build effective partnership with patients diagnosed with type 2 diabetes right form the onset of the care process, to earn patients trust to empower patients to own the treatment process (Garcia-Perez et al 2013).
Patient empowerment is a predictor of self-care behaviours and HBAIc (Yang et al 2015). Therefore, intervening to enhance and promote empowerment must be key in diabetic education programs to improve self-behaviour including medicine adherence for glycaemic control. (Yang et al 2015). Yang et al (2015) even challenges the notion of medicine adherence as a dysfunctional concept in diabetes care which must replace by collaboration between patients and healthcare professional. In all, patients will only attain growth and personal maturity if healthcare professional not only tailor relationships but also help them to reflect on their lives and formulate new meaning in their modified lives.
The complex nature of T2DM and real possibility of increase in medication types and doses have been noted, (Bartolomeo et al 2013), this requires that patients are armed with coping skills to deal with the complexities of living with T2DM.Here practice nurse can make a difference by early referral for intervention when that challenge has been identified. Garter et al (2010) notes that although patients with higher education may have the capacity to cope with complexities associated with diabetes medication regime, those with lower education may not.
Referrals can be made to both commissioned services as well as voluntary services available within the practice locality. It requires adequate knowledge of commissioned services as well as a voluntary service that are available to patients. There is robust evidence that early referral and engagement with diabetic services result in significant decrease in HBA1c levels (Chrvala et al 2016), yet the experience is sometimes some patient may be seen for several times without referral to structured education program or when the referrals have been made, it had not been followed through
Also, Patients ability to cope can be adversely affected if they feel thay have little or no imput regarding decision about their care (Dutton et al 2012). The notion of patient centred care is further stressed in diabetes care (Inzucchi et al 2012). Primarily general practice nurse not only promote health but also facilitate the care of individuals within their practice population.it will therefore self-defeating for general practice nurse to accept or even to be inclined to think that they have no contribution to make to help people develop coping strategies and that a patient ability to cope is down to the person individual characteristics.
Schulman-Green et al (2012) point out that often healthcare professionals focus on management of illness through improved medication adherence rather than focussing on the emotional aspects of having the diseases and the impact the emotional aspects plays in the patient’s medicine adherence. Obviously, general practice nurses can positively influence adherence when they pay greater attention to patient’s emotions too rather than focusing on the illness alone in efforts to improve adherence.
General practice nurses (GPNs) provide knowledge and skill training, facilitate problem solving, motivate for lifestyle adaptation, developing coping skills to achieve goals. Patients including those suffering from T2DM relies on the services of general practice nurses for health and well-being of themselves and family (Madan 2016). General practice nurses, therefore, need to be confident and capable of providing evidence-based information that will instil confidence in patients and carers. This requires a personal commitment to improving practice for better patients’ outcomes thorough ongoing personal and professional development such as attending conferences supervision and regular updates.
It is an also worth noting that although GPNs are well placed to be health promotions champion in their communities, let us not forget the challenges they also face which could affect their ability to effect the much-needed changes in patients within their practice community. GPNs are faced with increased patients’ demand, an ageing population, increase in number of people suffering from long term conditions including T2DM, (Cumings 2017) against the backdrop of a shrinking workforce and this is likely to impact on care patients receive. This calls for a need for nurses including customary practices nurses involved in diabetic care to be well supported and recognized. (While 2004)
The need to develop and support GPN workforce is widely acknowledged (NHS 2016) Although it may be too early to realize its impact, it has provided an opportunity to develop the much-needed confidence, capability, and capacity to support general practice nurses to effect changes that will ensure that will ensure better outcomes for patients suffering fromT2DM