Student number: n4513282 Shu-Fang Wu

Chapter 3 Literature on diabetes and outcome variables

Chapter 3 Review of literature on diabetes, self-care, quality of life, and psychosocial issues

3.1 Introduction
Diabetes mellitus is the main focus of this research study. The literature review in this chapter examines the main issues related to diabetes mellitus. The first section presents general information about diabetes, including its diagnosis and definition, classification, and complications. The following sections relate to the outcome variables of this study: self-care of diabetes, such as blood glucose monitoring, nutrition, exercise, medication and foot care; the quality of life of people with diabetes; and psychosocial issues.

3.2 Diabetes Mellitus

3.2.1 Diagnosis and Definition Diabetes mellitus (diabetes) encompasses a heterogeneous group of diseases of various aetiologies. It is defined as a symptomatic or asymptomatic state of altered carbohydrate metabolism characterised by two or more fasting plasma glucose levels of 126 mg/dL (7.0 mmol/L) or greater, or a value of 200 mg/dL (11.1 mmol/L) or greater at 2 hr, on an oral glucose tolerance test. A diagnosis of diabetes can also be made with a random blood glucose value of 200 mg/dL (11.1 mmol/L) or greater if it is associated with symptoms (polydipsia, polyuria, polyphagia, unexplained weight loss) (Guthrie & Guthrie, 2002; Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 1997). However, some people may have even 46

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been given a warning by a doctor that their sugar was a bit high, which they mistakenly interpreted as a grace period before a diagnosis of diabetes. Impaired Fasting Glucose (IFG) or Impaired Glucose Tolerance (IGT) are now known as prediabetes, where the sugar levels are clearly no longer normal, but not yet at the level required for the actual diagnosis of diabetes. The diagnosis of impaired fasting glucose (IFG) as fasting plasma glucose between 110 mg/dL and 126mg/dL (6.17.0mmol/L); and impaired glucose tolerance (IGT) as 2-hr post plasma glucose from 140/dL to <200mg/dL (7.8 to <11.1mmol/L). Both these categories, IFG and IGT, are risk factors for future diabetes and cardiovascular disease (ADA, 2002b). Table 3.1 shows that diagnostic criteria for diabetes based on the fasting plasma glucose.

Table 3.1 Diagnostic criteria for diabetes based on the fasting plasma glucose (venous) Stage Normal Impaired Fasting Glycaemia (IFG) Diabetes Mellitus Fasting plasma glucose (venous) mmol/L < 6.1 6.1 and <7.0 7.0 (mg/dL) (<110) ( 110 and <126) ( 126)

Another definition briefly states that diabetes mellitus is a metabolic disorder in which the bodys capacity to utilise glucose, fat and protein is disturbed, due to insulin deficiency or insulin resistance, both of which lead to an elevated blood glucose concentration and glycosuria (Dunning, 2003). In addition, the American Diabetes Association and WHO define diabetes as a group of metabolic diseases characterised by hyperglycaemia resulting from defects in insulin secretion, insulin action, or both. Common to all types of diabetes mellitus is chronic hyperglycaemia, which is associated with long-term damage, dysfunction and failure of various organs,

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especially the eyes, kidneys, nerves, heart and vessels (Alberti & Zimmet, 1998). After defining diabetes, the American Diabetes Association (ADA) announced in 1997 a revised diabetes classification system and diagnostic criteria, described below.

3.2.2 Classifying diabetes Since 1995, the American Diabetes Associations expert group has convened to review the literature and determine what changes to the diabetes classification system and diagnostic criteria are necessary. New recommendations for the classification and diagnosis of diabetes mellitus include the preferred use of the terms type 1 and type 2 instead of IDDM (Insulin Dependent Diabetes Mellitus) and NIDDM (Non-Insulin Dependent Diabetes Mellitus) to designate the two major types. In June 1997, an international expert committee released a report with new recommendations for the classification and diagnosis of diabetes mellitus (Expert committee on the Diagnosis and Classification of Diabetes Mellitus, 1997). These revised data resulted from a joint activity between the American Diabetes Association (ADA) and the World Health Organisation (WHO). The new classification system identifies four types of diabetes mellitus: type 1, type 2, gestational diabetes and other specific types. Arabic numbers are specifically used in the new system to minimise the occasional confusion of type II as the number 11. Moreover, the diagnostic criteria do not require the oral glucose tolerance test (OGTT) (Guthrie & Guthrie, 2002).

Type 1 diabetes mellitus (formerly called type I, IDDM or juvenile diabetes) is characterised by beta cell destruction caused by an autoimmune process, usually leading to absolute insulin deficiency (Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 1997). Over 95% of persons with type 1 diabetes

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mellitus develop the disease before the age of 25. There are two forms of type 1 diabetes: immune-mediated diabetes mellitus, which results from autoimmune destruction of the pancreatic beta cell; and idiopathic diabetes mellitus, referring to a form of the disease that has no known aetiologies (Dunning, 2003).

Type 2 diabetes mellitus (formerly called type II, NIDDM or adult-onset) is characterised by insulin resistance in peripheral tissue and an insulin-secretory defect of the beta cell (Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 1997). This disease was formerly called adult or maturity-onset diabetes, but with the increasing prevalence of the disease in children, age related terminology can no longer be used. The term NIDDM (Non-Insulin Dependent Diabetes Mellitus) was also changed because many of these individuals require insulin for control. With these problems in mind, in 1997 the Committee decided to simplify the terminology to type 2 diabetes. This form of disease occurs predominantly in adults (basically persons older than 30), but may occur at any age (Guthrie & Guthrie, 2002) and is strongly associated with a family history of diabetes in women, especially women with a history of gestational diabetes, with old age (especially over 40 years of age), and with obesity and lack of exercise; however, the prevalence of eating disorders is similar in type 1 and type 2 diabetes (Herpertz, Albus & Wagener, 1998; Dunning, 2003). Previous research has shown that diabetes is a genetic disease, the gene or genes being prevalent in all societies, but that the disease becomes manifest primarily as societies industrialise, and as calorie intake increases and calorie expenditure decreases (Guthrie & Guthrie, 2002). The majority of people with type 2 diabetes require multiple therapies to maintain acceptable blood glucose goals, for example 50 to 70% require insulin, often in combination with oral medicine regimes. This means that diabetes management is more complicated for people with type 2 diabetes, which 49

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increases their likelihood of non-compliance, and the cost of managing the disease for both the patient and the health system (Dunning, 2003).

Gestational diabetes mellitus is an operational classification (rather than a pathophysiologic condition) referring to diabetes mellitus developed by women during gestation. This definition of gestational diabetes mellitus and its diagnosis was not altered in the new recommendations (Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 1997).

Other specific types of diabetes mellitus include diabetes caused by other identifiable disease processes: genetic defects of beta cell function such as Maturity Onset Diabetes in the Young (MODY); genetic defects of insulin action; disease of the exocrine pancreas, such as cancer and pancreatitis; endocrine diseases such as Cushings disease and acromegaly; and drug or chemically induced diabetes (Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, 1997).

3.2.3 Complications Diabetic complications contribute to the overall cost of health care for those with diabetes and for health care providers; many people are admitted to hospital because they have active diabetes. Complications can be classified as acute or long term; acute complications may occur during temporary changes in blood glucose levels, while long term complications usually accompany long duration of diabetes and persistent hyperglycaemia (Dunning, 2003). Acute complications include hypoglycaemia; hyperglycaemia; infection; fat atrophy or hypertrophy; and insulin allergy. In recent years, vascular disease and neuropathy, long term complications of diabetes, have

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become the leading cause of death among persons with diabetes (Guthrie & Guthrie, 2002).

Long term complications can be divided into macrovascular complications, including increased atherosclerosis and cardiovascular disease, myocardial infarction and stroke (Dunning, 2003; Guthrie & Guthrie, 2002) and microvascular complications, including retinopathy, neuropathy, and nephropathy (Wandell, 1998; Dunning, 2003).

Coronary heart disease, a macrovascular complication of diabetes, is the greatest cause of death in persons with type 2 diabetes in Caucasian and industrialised countries. The estimated mortality rates of coronary heart disease range between 50% and 60% (Panzram, 1987), conferring a 2 to 4 fold increase in mortality risk compared with the non-diabetic population (Jarret, 1984). Small-vessel disease or

microangiopathy involves the small blood vessels all over the body; its clinical manifestations occur in only two organs, the kidney and the eye. According to the American Diabetes Association, diabetic retinopathy is the most frequent cause of new blindness among adults aged 20 to 74; after 20 years with type 2 diabetes, nearly 60% of patients have some degree of retinopathy (ADA, 1998b).

The relationships between factors and the development of diabetes complications must be clarified. A number of factors might play a role in the development of diabetic complications. Studies have showed that the most important factors for macrovascular complications were the duration of diabetes, age, hypertension, hyperglycaemia and smoking (Morrish et al, 1991; Wandell, 1998). A study has also showed that, for microvascular complications, the most important factors were the duration of diabetes and age (Wandell, 1998). For microvascular complications the 51

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risk factors include high blood pressure, high serum total and LDL cholesterol, low serum HDL cholesterol and raised serum triglycerides, poor glucose control and smoking. In 1998, the United Kingdom Prospective Diabetes Study demonstrated the importance of controlling blood pressure to reduce the risk of cardiovascular disease and of lowering blood glucose to reduce the incidence of microvascular complications (UKPDS, 1998).

In Taiwan, the high complication rate of diabetes places a heavy financial burden on the government. Recent complication rates for diabetes include: retinopathy (31.8%); peripheral vascular disease (26.6%); neuropathy (21.2%); and chronic renal failure (0.8%) (Lin et al., 2001). The prevalence of large vessel disease (LVD) in diabetic and non-diabetic subjects has been found to be 20.0% and 12.9%, respectively. Among diabetics, 15.8% have ischemic heart disease (IHD), 1.7% leg vessel disease, and 2.5% stroke. Diabetics have a significantly higher prevalence of macrovascular disease than non-diabetic subjects (Chang et al., 2000). Moreover, diabetes mellitus is one of the chronic diseases facing Taiwanese people today; it is the fourth leading causes of death in Taiwan, while the cerebrovascular diseases and heart diseases, the second, and third leading causes of death in Taiwan respectively, are also the complications of diabetes (see Chapter 2). Its complications can cause severe problems for affected individuals and their families and are known to impose a heavy burden on health services. The treatment of diabetes-related complications is a heavy financial burden and needs to be considered seriously.

Interestingly, reducing the risk of developing most complications is preventable through appropriate blood glucose control or by lowering factors that cause the disease to progress. For example, the relationship between microvascular 52

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complications and the level of metabolic control measured as HbA1 C is firmly established (Dahl-Jorgensen, Brinchmann-Hansen, Bangstad & Hanssen, 1994). Moreover, the UKPDS has provided strong support for the American Diabetes Associations position that vigorous treatment of diabetes can decrease the morbidity and mortality of the disease by reducing its chronic complications (American Diabetes Association, 2002a). The chronic complications of diabetes can be avoided by striving to achieve normal levels of serum glucose, blood pressure and lipids. They can be effectively treated if they are detected early. Although aggressive therapy can prevent or improve the progression of diabetic complications and should be started at the time of diagnosis (Bell & Ala, 2002), establishing self-care responsibilities for people with diabetes is a base solution for effective management of diabetes. According to Anderson (1985), people with diabetes indicate that they consider the daily regimen of self-care activities more difficult than the diagnosis of diabetes itself. The topic of self-care of diabetes becomes an important role of effective management of diabetes and will be described in the next section.

3.3 Self-care of diabetes

There is an increasing trend to have patients take an active role in regulating their treatment and self-care (Downer, 2001). Effective management of diabetes requires a team care approach that may include the following members: diabetologist; diabetes nurse specialist or educator; dietician; podiatrist; social worker; psychologist; general practitioner and the patient (Dunning, 2003); however, the person with diabetes is the most crucial player in the team. In fact, diabetes is a self-managed disease; over 95% of diabetes management is done by patients themselves. For diabetes care to succeed,

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