Evidence-Based Practice Diabetes
Diabetes is a disease which stays with the patient life-long except in some cases where the diabetes is gestational which occurs during pregnancy and often goes back to normal after the delivery. Typically there are two types of diabetes which are type 1 and type 2 diabetes but less common are gestational diabetes and other types which contain features of both type 1 and type 2 diabetes (Cowle et al., 2006). The management of diabetes mostly depends on the patient himself/herself because in diabetes it is all about self-care. But of course the guidance comes from the nurses and doctors and they need to educate the patients in order to control their condition. In order to prevent (in cases where there are chances of diabetes occurrence) or control (in cases where the person already has diabetes) diabetes it is very essential to take care of patient’s weight, blood pressure, blood sugar and blood lipids (National Diabetes Fact Sheet, 2007).
Morbidity and Mortality
Diabetes is one of the top five causes of death around the world. Approximately 247 million people all over the world have been diagnosed with diabetes. Whereas, 8% of Americans are affected by diabetes but at the same time one third of these people do not even know that they have diabetes (ADA, 2010). However, the mortality of diabetes is not evenly distributed among people; instead it has been found that women, ethnic minorities, older people and people in low-middle class are affected by it more than others (Brown et al. 2004).
There is an increased risk for people with an increase in central obesity for heart diseases and diabetes. Increased caution is required for lean people with type 2 diabetes at every age, as type 1 diabetes can occur in older people and with a slower onset than is normally seen in the young (Davis et al., 2007).
Types of Diabetes
Diabetes may be type 1, type 2 and gestational diabetes (American Diabetes Association, 2010).
In type 1 diabetes the insulin produced by the pancreas is either very less or nil due to which sugar is not absorbed in the cells and thus the sugar remains in the blood stream. Type 1 diabetes is also known as insulin-dependent diabetes. Type 1 diabetes is an autoimmune disease which means that the immune system of the body is sometimes the cause of the disease. This type of diabetes is often left undetected (Roglic & Unwin, 2010).
Type 2 diabetes is far more common than type 1 diabetes. It is also referred to noninsulin-dependent diabetes. As the name suggests, in this type of diabetes the patient does not necessarily need insulin shots. This type is usually developed in adults rather than juveniles.
Another type of diabetes is Gestational diabetes which develops in the course of pregnancy, mostly in the last trimester. This normally happens because of the hormonal changes taking place during pregnancy. This type of diabetes is normally temporary. 2% to 5% of the pregnant women experience this type of diabetes (National Diabetes Fact Sheet, 2007). Once a woman develops gestational diabetes during pregnancy, it normally goes back to normal after delivery of the baby. However, woman having gestational diabetes are more likely to develop it again, especially type 2 diabetes later on. Majority of the pregnant women are screened for gestational pregnancy.
It is not fully understood why different types of diabetes develop in people, however, only certain factors based on evidence have proved to be causes of diabetes (Shaw et al., 2010).
Both types of diabetes, 1 & 2 can be transferred genetically. If someone in the immediate family has diabetes, there are greater chances that person is prone to have diabetes (Aekplakorn et al., 2007).
Obesity is one of the major causes of diabetes. The fatty tissues especially around the abdomen cause the muscles and tissue cell to be resistant to the insulin produced by the pancreas. Inactivity People who are less physically active are prone to developing diabetes because excessive sugar in their blood is not utilized. Secondly, the fats in the body are not burnt. Physical activity helps in controlling weight (Aekplakorn et al., 2007).
Age is one of the causes of diabetes. The reason is that with age, the person becomes less active. Less blood sugar and fats are utilized resulting in more sugar in the blood stream (Concannon, Rich, Nepom, 2009).
Race or ethnicity is one of the factors of developing diabetes. Although it is not known why this is so. But researches have shown that some races have a greater tendency of diabetes than other like, Hispanics, blacks American Indians are known to have greater expectancy of diabetes (Aekplakorn et al., 2007).
There are a number of diagnostic tests for detecting diabetes, which are:
Finger-Prick Blood Sugar Screening
Screening tests are simple, economical and sometimes even free by the health care providers. This test takes only a few minutes. A dingle drop of blood is pricked from the tip of the finger and is placed on a strip. This strip is injected into a small device which finds out the level of blood sugar in the sample provided and displays the value on its screen. If the value exceeds 126 mg/dL, then fasting blood sugar test is required to be done (AACE, 2007).
Random Blood Sugar Test
This test is normally carried out during a routine physical exam. The blood sample is taken from a vein of a person and is sent to the laboratory for a number of laboratory tests. Even if one has just consumed and his/her blood sugar is at its highest, the blood sugar should not be exceed 200 mg/dL. But of the result exceeds this limit then the physician asks the patient to go for fasting blood sugar test (Troisi et al., 2000).
Fasting Blood Sugar Test
The level of blood sugar is normally maximum after eating a meal and lowermost after an overnight fast. But normally it is preferred by the doctors to go for overnight fasting which is normally about 8 hours. Blood sample is taken and is evaluated. Normal fasting blood sugar is between 70 mg/Dl to 110mg/Dl. If the level of blood sugar exceeds 126mg/Dl, then the person is diagnosed with diabetes. However, if the results are normal then it is advisable to get the test done after every 3 years. In case a person has marginal diabetes, that is, the blood sugar level is between — 111 to 125 mg/dL — he/she then it is recommended that the individual must get a fasting blood sugar test done every year (Troisi et al., 2000). Most doctors do not screen for diabetes during routine visits, though they generally request a fasting or random blood sugar test as part of a more comprehensive examination.
Glucose Tolerance Test
This test is not very common because it is comparatively more expensive than other methods. This test is done after overnight fasting. 75g of sugar is taken by the patient in a liquid form. The blood sugar is checked before taking the liquid and after taking it. If a person is diabetic, his/her level of blood sugar increases more than estimated. If the blood sugar at the 2-hour blood test is 200 mg/dL or above, the person has diabetes (Saiidek et al., 2008). In order to get accurate results it is very important that the person getting the test done is physically active, not taking any kind of medication, takes healthy diet and has no medical condition or problem. This test is usually carried out to test for gestational diabetes in pregnant women.
Glycated Hemoglobin Test
The World Health Organization (WHO) diagnostic criteria 6 were ratified in 2000 and are still in use today; although it is likely that glycosylated hemoglobin (HbA1c) will be adopted in future. In the absence of symptoms, the test should be repeated to confirm the condition.
However, there are some groups in whom HbA1c will not be a reliable diagnostic tool and it is likely that the WHO method will be retained for them. They include: pregnant women; people with renal failure, haemoglobinopathy and anemia; and, possibly, frail elderly patients (American Diabetes Association, 2010).
HbA1c targets figure highly in the Quality and Outcomes Framework (QOF) of the General Medical Services contract, gaining the maximum number of points awarded. The QOF is not about performance management, but incentivizing and rewarding good practice. The rewards to the practice are highest by achieving goals in HbA1c, blood pressure and cholesterol, but holistic care is paramount (Molinaro, 2007). Agreeing plans with patients to achieve goals can also significantly improve their future quality of life. Diabetes itself accounts for the highest number of points awarded for any condition; if we add heart disease, renal disease and depression, among others, all of which are more common in diabetes, its seriousness becomes evident (Kahn et al., 2006).
Evidence-Based Practice Used In Treatment, Prevention and Management of Diabetes
The focus on evidence-based medicine (EBM) over the past two decades has generated significant activity across disciplines involved in diabetes management, as health professionals are encouraged to adopt this approach to patient care. At the same time, EBM has garnered critiques, particularly from social scientists, who question its underlying assumptions, impact on professional practice, and broad reinforcement of medical authority. Little empirical work has been done, however, to explore these concerns (Gabbay, 1999).
The term “evidence-based medicine” was formalized at McMaster University in the 1980s as part of a new approach to problem-based learning in medical education (Gabbay, 1999). Its philosophical roots, however, can be traced to the mid-nineteenth century when medicine began aggressively to position itself as a science. The concept has spread widely beyond medicine and is often referred to as evidence-based practice to encourage its adoption by diverse health disciplines such as nursing, midwifery, physiotherapy, psychology, and dietetics (Bogdan-Lovis and Sousa, 2006).
The founders of EBM define it as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients,” and suggest it as a means of “integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Fain, 2001).
Medical practice based on the best available evidence is meant to supplant that based on physician authority, intuition and ritual, or experience.
The Diabetes Prevention Program
The Diabetes Prevention Program or DPP is a program which was developed to study the lifestyle changes to prevent diabetes. This program provided a means to develop evidence-based practice whose guidelines are followed in treating patients with diabetes. The main focus of this program and thus evidence-based practice is the change in lifestyle and proper medication of the patient in order to prevent, manage and treat diabetes (McGuire, 2005).
Medication to Prevent Diabetes
The Diabetes Prevention Program study tested not only the impact of lifestyle. It also tested the value of a medicine, metformin, in preventing diabetes. Metformin is a medicine that is commonly used to treat diabetes. It works primarily by decreasing the amount of sugar made by the liver and by reducing insulin resistance (Corrie & Callanan, 2001).
Because slowly developing insulin resistance underlies type 2 diabetes, it made sense that using a medication that reduces insulin resistance might prevent diabetes. It was found that metformin worked. It decreased the possibility of developing diabetes by 31%, a significant decrease. However, it did not work as well as lifestyle modification, which decreased the possibility of diabetes by 58%. And, as with any medication, metformin carries some risk of side effects. Lifestyle modification, in contrast, has few side effects (Toman et al., 2001). The combination of lifestyle modification and metformin was not tested to see if it might have reduced the risk of diabetes even more than 58%.
Future studies may show that a combination of medication and lifestyle modification is the most potent way to prevent diabetes. Indeed, for the treatment (as contrasted to the prevention) of several major chronic diseases, the combination of lifestyle change and medications is often advised. And, sometimes, the lifestyle intervention can eliminate, or at least reduce, the need for medications (Webb, 2001).
Lifestyle interventions should not be viewed as a substitute for medications. Many controlled clinical trials have established the powerful effects of cholesterol- and blood pressure — lowering drugs to decrease the development, or recurrence, of heart disease. In some people, both lifestyle changes and medications will be needed (Sackett et al., 2006). The tricks to successfully managing type 1 diabetes and maintaining the near-normal blood-glucose levels necessary to stay healthy are paying attention to daily schedule, understanding the effects of lifestyle on blood sugars, and adjusting insulin to maintain blood-sugar levels in the range the patient and the doctor health-care team agree is right.
Maintaining some consistency in mealtimes and meal sizes will help during the early stages of adjustment; however, as time goes on the patient will learn how to adjust even if he has inconsistencies. For example, if a person has planned to eat a large Sunday breakfast of cereal, eggs, toast, and orange juice, he would check his blood sugar before starting to eat. If he found that his blood-sugar level was on the high side — let’s say 150 mg/dL — he would consider giving ten units of rapid-acting insulin, approximately four units more than the usual dose, because of his relatively high blood-sugar level and the greater carbohydrate content of the meal he is about to have (Franz et al., 2003).
As another example, if a person has planned to play tennis at 10:00 A.M., knowing that exercise lowers blood sugar, he would decrease the usual dose by several units. This kind of attention to lifestyle takes place day in and day out. Before twenty years ago, diabetes took command of lifestyle. Now, millions of people with type 1 diabetes have been able to master the lifestyle requirements and command their diabetes.
Lifestyle Changes to Treat Type 1, 2 Diabetes and Associated Diseases
If someone has type 1 diabetes, his/her lifestyle is key to achieving stable blood-sugar levels as close to normal as possible without episodes of severe hypoglycemia. Few with type 1 diabetes need to accept a life with [brittle diabetes,] with roller-coaster high and low blood sugars (Tuomilehto, 2001). If the patient works toward consistency in lifestyle (consistency with insulin injections by time of day, consistency in carbohydrate intake at meals and snacks from day-to-day, and consistency in his/her exercise routines), patient’s blood sugars will be consistent and more stable, too. It is important that the patient finds a health-care team that specializes in diabetes so that he/she can benefit from their years of experience in working through all the factors that contribute to erratic blood-sugar patterns and episodes of severe hypoglycemia.
Whether a person has type 1 or type 2 diabetes or pre-diabetes, he/she can always use his/her lifestyle to manage the ABCs of diabetes — A1c (hemoglobin A1c), blood pressure, and cholesterol profile — to minimize the risk of diabetes-related complications, heart disease, and stroke — and maximize the quality of life. If one has type 2 diabetes, lifestyle has a major impact on his/her diabetes — especially blood-sugar control — and that lifestyle changes can have a beneficial effect (McGuire, 2005).
Type 2 diabetes represents the end of a long and somewhat complicated road on which insulin resistance, or decreased insulin sensitivity, and the inability to make enough insulin contribute to rising blood sugars. At first, blood sugar levels begin to rise slightly after meals because, in the setting of insulin resistance, the breakdown products of the meal are not normally stored in the muscle and liver. During this pre-diabetic phase, there are no symptoms and fasting blood-sugar levels remain in the near-normal range (AACE, 2007). Pre-diabetes can sometimes be detected with a fasting blood-sugar test, but more often a stress test called a glucose-tolerance test is required. In most persons who are destined to develop diabetes, the next five to ten years are characterized by increasing insulin resistance and decreasing insulin secretion.
Type 2 diabetes is eventually an about of supply and demand. The body requires and thus demands more insulin which the pancreas is not able to produce.When diabetes finally develops, it is usually the result of too little insulin being secreted to do the job (AACE, 2007). Blood-sugar levels rise more dramatically, including the fasting blood-sugar level, and the complications associated with hyperglycemia begin to develop over time.
The most common cause of increasing insulin resistance is being overweight and having decreased physical activity levels. Changing the lifestyle factors that lead to overweight and obesity can reverse, to a great extent, their damaging effects. The same benefits can be seen even after diabetes has developed. Therefore, changes in lifestyle that lead to increased activity levels and decreased weight can improve type 2 diabetes even after it is entrenched (Toman et al., 2001).
It is possible to turn back type 2 diabetes after it has started because the insulin resistance that has contributed to causing type 2 diabetes can be reversed by lifestyle changes. It is also possible because the exhausted pancreas — which gives out after many years of making large amounts of insulin to compensate for the effects of insulin resistance — can recover if it gets a breather. The insulin-secreting beta cells are fatigued, but they aren’t dead, especially early in the course of type 2 diabetes. There are some diseases that are irreversible once they occur. When someone has a heart attack, for example, the affected part of the heart muscle remains dead ever after. With type 2 diabetes, however, there is a window of time when the disease can be reversed with lifestyle changes (Sackett, 2006). The earlier those changes are implemented, the more likely that improvement will occur.
The first treatment strategy that is almost always applied in the 90% of people with type 2 diabetes who are overweight or obese is to implement a weight loss program characterized by both changes in diet and increased exercise or activity. These lifestyle changes can have near miraculous results with regard to blood-sugar levels — even before much weight is lost. The need medication is reduced to zero only if less calories are taken which decreases the blood sugar
(Sackett, 2006). This has been demonstrated in numerous studies. Why a decrease in calories, even before weight loss occurs, improves blood-sugar levels so dramatically is not entirely clear, but the most likely explanation is that there is an improvement in insulin secretion that occurs rather quickly with levels of insulin resistance falling more slowly (Franz et al., 2003).
Increased physical activity also can lower blood-sugar levels even before one has had substantial weight loss, because it makes the muscles more sensitive to insulin, which drives sugar from the blood into the muscles. Over time, increased physical activity will contribute to achieving and maintaining weight loss. The more prolonged changes in lifestyle that result in weight loss will also have the effect of decreasing insulin resistance with a further recovery of insulin secretion.
Many health-care practitioners and people with diabetes are skeptical about the value of diet changes in treating type 2 diabetes. That’s because they know how hard it can be for people to continue their diets over the long-term. However, the diet and exercise programs used in the Diabetes Prevention Program could be maintained by most of the participants over several years.
Studies in recent years have clearly shown that weight loss — achieved in a number of different ways — can make type 2 diabetes much less severe and can even make it disappear. A dramatic example is what happens in enormously obese people — who are usually at least 100 pounds overweight — who undergo so-called bariatric or weight loss surgery (Franz et al., 2003).In these individuals, weight loss of 80 to 120 pounds often occurs in the first year after surgery, and almost 90% have reversal of their diabetes. At a minimum, such persons can stop most of their medications, and many of them are able to stop all diabetes medications and maintain normal blood sugars (Franz et al., 2003).
The Diabetes Prevention Program has proved that losing 7% of body weight and increasing physical activity level by 150 minutes in a week will lessen the threat of having diabetes by 58% — a more powerful effect than using any medicine. If there is a risk for type 2 diabetes (if a person is overweight, and has a sedentary lifestyle, and has close relatives with diabetes), then the lifestyle changes can help: it can not only prevent diabetes from developing but reverse blood sugars that are in the pre-diabetes range back to normal levels. It takes effort, but there is proof that it can be done.
Diabetes is caused due to a number of factors and the main factors are environment and genetics. To treat, prevent and manage diabetes medication along with change in lifestyle is required. For example, If a person already has type 2 diabetes, making similar lifestyle changes will minimize the amount of medication that he/she need to keep his/her blood-sugar levels as close to normal as possible. In fact, some people with type 2 diabetes have been able to manage their blood-sugar levels without medication, and others have been able to avoid insulin and control their diabetes with just lifestyle changes and pills.
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