Far from the “mild” disease it has traditionally been thought, diabetes is a chronic, progressive disease process with potentially life threatening complications (NSF, 2001). There are currently more than a million people in the UK diagnosed with diabetes, and the number is steadily rising (NSF, 2001). In fact, it is estimated that there may be as many as 50% of people with type 2 diabetes who are undiagnosed, perhaps suffering only mild symptoms that they live with as “normal” for them (Krentz, 2000). In nursing practice it is vital to understand the condition and to be aware of the health implications for all affected patients. It is a condition that affects all ages and races, and both sexes.
The aim of this essay is to examine the disease process, to discuss the impact of diagnosis on the physical, mental, social and emotional health of a patient, and to evaluate the care of one patient, especially during his changing therapy requirements. Research has shown that good glycaemic control throughout the whole life of a person with type 1 or type 2 diabetes will prevent or delay the onset of complications (DCCT, 1993 & UKPDSG 1998a), but in practice this is recognized as being very hard to achieve. The focus of diabetes care in the UK has changed from being treatment based to aiming at empowering the patient through education, support and regular screening for complications (Jerreat, 1999).
The writer at present works as part of the multi-disciplinary team in an adult diabetes centre within a large, busy general hospital. The team consists of consultant diabetologists, registrars, specialist clinical assistants and senior house officers, diabetes specialist nurses, a nurse trained in screening for complications, clinic nurses, dietitians, podiatrists and retinal screeners and technicians. There are also close links with consultant ophthalmologists, nephrologists and other related specialists as necessary.
When a patient is diagnosed with diabetes they are referred to one of the consultants for ongoing care, and in most cases will have a consultation with one of the diabetes specialist nurses (DSN) first. This is an opportunity to begin to assess the level of knowledge the patient may already possess, so that misconceptions can be corrected at an early stage. The DSN will hopefully begin to build up a rapport with the patient so that if he or she has worries or queries about their health, they will feel able to communicate with the nurse. As this is a condition that will affect the rest of a person’s life, a good start to building a working relationship with the diabetes care team is an important step towards empowering the patient to be in control, rather than be controlled by the diabetes (Jerreat, 1999).
The patient chosen for the care study portion of this essay is a man with type 2 diabetes, and is quite representative of a large proportion of the diabetic population seen at the clinic. All names and identities of people and places have been changed to protect the privacy of patients and staff in accordance with UKCC guidelines (UKCC, 1998).
Diabetes Mellitus has been recognized for over 100 years but until the discovery of insulin in 1922, accredited to Frederick Banting and Charles Best, most people were treated with a diet close to starvation levels, and certainly children with type 1 did not usually survive past their second birthday (Scobie, 2002). The reason for the onset of diabetes is still not fully understood in all cases (Scobie, 2002). From all over the developed world there is an immense amount of ongoing research into treatment for people with diabetes, especially in the areas of patient education and empowerment, and health outcomes are improving greatly (Jerreat, 1999). However, there is still some way to go to reduce the incidence of complications to meet even the targets set by the St. Vincent’s Declaration in 1989 (Jerreat, 1999).
Diabetes Mellitus is now known as Type 1 or Type 2 (WHO, 1985). (It is not within the scope of this essay to discuss the other types of diabetes). In a healthy body the level of glucose in the blood (and therefore available to the tissues for energy) is largely governed by the production of the hormone insulin. The beta cells in the islets of Langerhans in the pancreas produce the insulin in response to a rise in blood glucose levels. This allows glucose not needed immediately for energy to be stored in the liver and muscle tissues as glycogen. When the body has need of energy, and blood glucose levels are insufficient, the lowered insulin levels stimulate the conversion of the stored glycogen back to glucose (ref).
Type 1 diabetes is an autoimmune condition in which destruction of the beta cells leads to a total lack of insulin produced in the pancreas, and the resulting rise in blood glucose levels cause more urine to be produced by the kidneys in an attempt to rid the body of the excess glucose. It seems likely that an environmental factor such as a virus may be the trigger mechanism for the autoimmune response in a person with a genetic predisposition (Scobie, 2000). A person whose pancreas fails in this way will have severe symptoms, and be extremely unwell. Insulin replacement therapy is absolutely essential for this condition (Scobie, 2002). If undiagnosed or inadequately treated, the rapid onset can lead to ketoacidosis, fitting, coma and even death (Williams & Pickup, 2000). Approximately 15% of people with DM in England have type 1, and the onset is usually in childhood or early adulthood (NSF, 2001).
Type 2 diabetes has two main causes. Either one, or more commonly both, may be present for diabetes to occur. The beta cells in type 2 may gradually become less effective at insulin production, or there may be a degree of resistance to insulin in the tissues. Insulin resistance is more common in those who are overweight, and as the average weight of the UK population is increasing (ref) this is thought to be leading to the increase in development of diabetes.
Type 2 diabetes is more commonly diagnosed in adults over 40, but is becoming more common in a younger age group also (NSF, 2001). This condition is more complex, being of slower onset, with less severe symptoms, and may be undiagnosed for some years before being recognized. There must be a genetic predisposition for the condition to develop, and usually a patient will present following a “trigger”, e.g., an illness or trauma, which they may perceive to have “started” the diabetes. However a person receiving a diagnosis of diabetes may be quite devastated if they realize that the condition can have far reaching implications for their future life and expectation of health (Jerreat, 1999).
The definition of Diabetes Mellitus has recently been reviewed and updated to consider the aetiology of the condition, and place less emphasis on the mode of treatment (WHO 1985). Previously, diabetes was defined by the method of treatment the patient was using to control blood sugar levels. Thus it was known as insulin dependent or non-insulin dependent diabetes mellitus (IDDM or NIDDM). In some cases, patients who have had diabetes for some time, at first treated by oral hypoglycaemic agents (OHAs), may need additional insulin therapy to try to improve their increasingly poor control. In the previous definition of diabetes their type of diabetes seems to change, when in reality they are still producing a little insulin from the pancreas, but it is either insufficient for the needs of the body, or the resistance in the peripheral tissues is such so as to render it partially or almost completely ineffective. This can be the case in severely obese people (Williams & Pickup, 2000). The first diagnosis would therefore still be accurate, but it would be noted that they have type 2, insulin treated, diabetes. IT is however possible for the condition to change, especially if there is other aetiology occurring in the body (Scobie, 2000), and the medical team must always be aware of this possibility.
Diabetes is a condition that requires the use of huge resources and places a very large financial demand on the National Health Service. Current estimates are that around ten percent of the NHS budget is spent on the on going treatment of people with diabetes. The government has been reviewing the standard of care given over the last few years, and produced a National Service Framework to provide an equal level of care across the whole country, and to all individuals (NSF, 2001). The goal of improving the long-term health of people with diabetes has been at the forefront of much research and development for many years, but was highlighted at the World Health Organisation Regional Committee for Europe in 1991. Known worldwide as the St. Vincent Declaration, recommendations were put forward to reduce the impact of diabetes. There have been considerable developments in some areas, and especially in research since then, but the UK is still lagging behind some other developed countries in the areas of blood glucose and blood pressure control (NSF, 2001).
Local district diabetes registers have been set up following the recommendations of the St. Vincent Declaration, and these have made possible the assessment of need and delivery of care in communities (McCarlie et el, 2002). The NSF (2001) aims to join these into a national register, which will allow statistical analysis of care across the UK. Since diabetes is also more common in some ethnic groups (NSF, 2001), the burden of care falls disproportionately on some communities than others. The NSF (2001) aims to provide the evidence needed by such districts to allow appropriate funding to be allocated. It is recognized that poorer areas have less uptake of screening facilities, and subsequently a higher level of complications in the diabetic population (NSF, 2001). Winocour (2001) states that without the necessary funding being made available to set up an integrated and flexible database, the care will continue to be uneven across the UK.
The difficulty with the aims of such initiatives, however, is that improvements in figures on paper do not always reflect the true picture from the patient’s perspective. The following case study illustrates that for the patient, diabetes can be a life-sentence of denying himself the food he would like to eat, and feeling guilty when he doesn’t do what he knows he should.
Tom Stevens, a forty seven year old man has had type 2 diabetes for eight years. He was aware of the condition, as his mother has had diabetes for all Tom’s adult life. Aged thirty-nine he started to develop typical symptoms of polyuria, nocturia and excessive thirst, and being aware of the familial tendency of diabetes (Jerreat, 2000), he recognized the probable cause and went to his GP immediately.
A firm diagnosis was given to Tom by his GP, following an oral glucose tolerance test (OGGT). This is an internationally recognized means of determining the diagnosis, and is positive if the fasting blood-glucose level is above 6.9 mmols/litre of venous blood. If below this, the person is given 75 mg glucose in solution to drink, and repeat blood and urine tests taken at one and two hours following (WHO, 1985). A blood-glucose level of 11.1 mmols/l at two hours is also a positive result, although this may indicate impaired glucose tolerance, rather than clearly indicate diabetes, if the fasting blood glucose level was satisfactory (Scobie, 2002). The person interpreting the results must have an idea of the patient’s medical history for maximum accuracy. Results are repeated at least once more to ensure the result is accurate, and not affected by another health issue, such as illness or infection.
Although Tom and his family were not surprised at the result, (a fasting blood-glucose of 10.4 mmols/l), there was still a feeling of shock and he and his wife became very apprehensive about his future health. His knowledge of the possible health outcomes suddenly applied to him, and was not just facts on paper. It is vital to be accurate about diagnosing diabetes because there are many long-term implications in the area of employment, insurance, driving, etc., quite apart from the health risks.
The GP referred Tom to the local diabetes care team and he met a diabetes specialist nurse (DSN). At first there was little progress made towards a good working relationship. Tom was reluctant to accept the doctor and nurse’s suggestions of ways to change his lifestyle. He felt that his own knowledge was disregarded and that the nurse and his own GP were too eager to start oral medication or insulin therapy, as his initial blood glucose readings were so high.
Because of his family history Tom knew of the possible difficulties that would bring, especially in the area of driving, and that he would be likely to put on more weight (Krentz, 2000). The author can only surmise that perhaps insulin was mentioned at this point as a possibility later on, if diet, exercise and oral medication did not reduce the blood glucose levels within a reasonable time frame. It is the aim of the whole diabetes care team to be honest with the patients, and involve them in each change in treatment by education and support, as opposed to imposing a regime without ensuring full understanding.
There has been a huge increase in access to medical knowledge by patients with the rise in use of the Internet, and it is necessary to recognize this when commencing a new consultation. The patient may have extensive knowledge of the subject, however, not all information gained in this way is accurate, and the practitioner needs to diplomatically assess the level of understanding before trying to educate a newly diagnosed patient (DoH, 2001b). Research recently on diabetic websites has shown that whilst sites of professional diabetic organizations, such as Diabetes UK, have reliable information, they do not provide patients with a “question and answer” type service, and those that do so are not all accurate (Kelly, et. al. 2002). It seems that many people do have questions they want to ask, but the answers do not always come from those qualified in the area of diabetes. Of course, if it is made clear that what is being stated is a personal experience, it may have credibility, but can be of an alarmist nature, and raise unnecessary fears in a new patient.
Tom’s job at that time involved a lot of walking around sites, and he was quite fit as he swam fairly regularly and played sports and games with his son. However, he is not a tall man, and his weight had been steadily increasing over the past 10 years, so that his body mass index (BMI) was 35 upon diagnosis. Research shows that a BMI of less than 30, and preferably between 20 and 25 is of benefit to a person with diabetes (Jerreat, 2000). He had spent some time between diagnosis and the DSN consultation looking at diabetes care on the Internet, and was aware that more exercise and losing weight would help to bring down his blood-glucose level (NICE, 2002a).
Tom and the DSN set certain goals together, and both agreed to give this program of diet control and exercise a trial for a few months. Tom commenced a regular program of swimming before work, and brisk walks in the evenings, as well as weekly sessions at a gym. He was taught to use a blood glucose meter and advised when to test. He adapted to this very well at first, and reported an increase in fitness and a reduction in weight. His blood glucose records showed pre-meal readings gradually reduced to about 6-7 mmols/l. This continued for two years and the annual complications checks for retinopathy, nephropathy and neuropathy showed no changes from Tom’s initial screening.
However, after this period Tom changed his job and was unable to keep up the increased level of activity, and although his weight had initially reduced, he began to increase in weight and regained his pre-diagnosis weight. This reached a plateau, and remained constant for a further year, but then his glucose levels gradually began to rise. At first he did nothing about this, as his weight began to reduce a little, which he was pleased about, as it had been of concern to him. However, when his daily blood tests were averaging 10-11 mmols/l he contacted the DSN for advice.
The DSN suggested that Tom try OHAs to reduce his glucose levels, and contacted the GP to prescribe metformin tablets. These have the added advantage of reducing insulin resistance in the tissues, and can help to reduce weight (Jerreat, 1999). However, they can have moderate to severe gastro-intestinal side effects, and unfortunately Tom did suffer from abdominal discomfort and diarrohea at first. As metformin is the most suitable for overweight patients, he was persuaded to try a little longer before abandoning its use entirely. Fortunately the side effect symptoms did recede enough for him to remain on metformin.
For a further two years Tom remained stable and showed no signs of diabetic complications at routine annual screening. He then began to have a problem with his knee and required an arthroscopy to investigate the problem. During the wait for the operation, he was unable to walk far, and although he swam from time to time, he was not able to maintain his exercise routine. His home blood glucose monitoring (HBGM) showed average readings of around 10 mmols/l before meals, and there was regular glycosuria.
Although the occasional high reading will have little impact, it is recognized that if not treated, persistently high blood glucose levels will cause damage to bodily tissues at a micro-vascular level (Pickup & Williams, 1998). If raised glucose levels are maintained for even a relatively short period of time, this tissue damage may be irreversible (Riddle, 2001). The particular areas that are likely to become affected are the kidneys (nephropathy), the retina (retinopathy) and the nervous system, especially that which serves the extremities, (neuropathy) as each are served by extremely small blood vessels (Jerreat 1999).
Tom became aware that his vision was not as clear, and went to his optician, who prescribed glasses and suggested he try to bring forward his retinal screening appointment. The subsequent retinal photograph showed small changes to the vessels of the retina, requiring assessment by an ophthalmic consultant. He diagnosed mild background diabetic retinopathy, and although no treatment was required at that stage, Tom was booked for six monthly retinal photographs, instead of the usual year.
With his health seeming to become much worse in a relatively short time frame, Tom was very understandably becoming quite despondent at this point. He was fortunate in that his employer was quite understanding, and allowed time off for appointments, but he didn’t enjoy asking, and did miss appointments with the DSN. It is generally thought that many patients see an appointment with a doctor, or at which something is “done” to them or for them (such as a retinal photograph) as of more value than talking with a nurse. However, the meetings with the specialist nurse can be of immense value in that they look at the whole area of lifestyle, and cover diet, exercise, medication as well as symptoms and recordable information (such as blood tests). It is noted that coming to terms with diabetes can be likened to a grieving process (Coles, 1996, cited in Jerreat 1999). In some patients the initial feeling of being in control changes to one of hopelessness, as in Tom’s case. An empathetic and honest approach by the DSN can help the patient to feel that the deterioration is not their fault, and help to re-motivate their actions (Jerreat, 1999 & Clark, 2002).
When contact was again restored with the nurse, Tom was found to have been “comfort eating” as he felt that whatever he did would make no difference – “things would get worse, no matter what”. Coupled with the lack of exercise, this had caused an increase in glucose levels. As well as gaining weight, his daily pre-meal readings had again risen to an average of 10-12 mmols/l. He was also feeling “down”. Depression is more common in people with diabetes than in the non-diabetic population (Krentz, 2000), understandably so when the future health implications are considered, but it is often not acknowledged or treated adequately. With the NSF (2001) emphasis on empowering the patient, the patient’s emotional state will need to be understood in order for the patient to be able to set realistic goals.
Tom’s diet, exercise and medication were reconsidered, and his tablets were increased, with the addition of a sulphonylurea, and the addition of insulin was discussed for some time in the future if reasonable control could not be gained. He agreed to try to increase his amount of exercise, as it had been very helpful previously in maintaining a satisfactory HbA1c, but was aware that his job took up most of each day, and both he and the DSN were less hopeful that it would be enough to reduce and maintain his blood glucose levels. Another feature of this development in his medication therapy is that sulphonylureas can induce hypoglycaemia, whilst taking metformin this was not a risk as it does not lower blood glucose levels in the same way (Jerreat, 1999). This was discussed with Tom, and he was advised to maintain a regular eating pattern, and take the tablets half an hour before breakfast and his evening meal. He continued to have regular meetings with his DSN.
Tom was given a date for his arthroscopy only a few weeks after he commenced the new medication, and went in for pre-assessment. His glucose levels were still persistently high, and due to this it was decided to delay the surgery, which Tom was understandably very unhappy about. He had a consultation with the DSN and agreed to try insulin therapy in addition to his OHA. Because he had had time to think about it, and the implications with regard to driving and his ongoing health, he had made the decision himself at this time, and did not feel pushed into it by the medical team.
He was given an insulin delivery “pen” and taught to use it, and as he had been quite comfortable with the fingertip blood testing, found it easier than he thought it would be. Patients are often pleasantly surprised that the insulin injection feels relatively painless. This is because the needle is considerably narrower than the lancet used to obtain a drop of capillary blood for testing, and also that it is given into a much less sensitive area. The fingertip is very well supplied with nerve endings for normal touch sensation, and the arm, thigh or abdomen where insulin is injected is less sensitive. He was advised where to inject, and to rotate the sites for maximum absorption of the insulin (Krentz, 2000).