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Review of Artcile 6 - The impact of Diabetes Mellitus and other chronic medical conditions on health-related quality of life: is the whole greater that the sum of its parts

Around the world, more individuals are residing in large towns and cities with a very occupied and hasty kind of life. With these circumstances, people neglect the importance of eating a healthy and well balanced meal, the substance brought by exercise and the significance of regular checkups with health care providers. The devastating consequences of these actions result to a greater number of people suffering from Diabetes Mellitus.

Diabetes Mellitus is a serious condition for the individual, family and society. Its prompt escalation in the global prevalence is a significant cause for concern. According to the Who Health Organization (WHO), as of the year 2009, Diabetes affects more than 250 million people worldwide. The largest number coming from India with over 31.7 million people currently with Diabetes Mellitus in the adult population. Followed by the United States of America with over 17.7 million people affected by this condition. In the Philippines an alarming 2.7 million people are affected by this world wide alarming concern. By the year 2030 the forecast of the WHO is that over 366 million people would suffer from Diabetes Mellitus.

Some facts and figures presented by the International Diabetes Federation during the World Diabetes Congress are as follows:
> Each year 7 million people develop Diabetes Mellitus.
> Each year 3.8 million deaths are attributable to diabetes. An even greater number die from cardiovascular disease made worse by diabetes-related lipid disorders and hypertension.
> Every 10 seconds a person dies from diabetes-related causes.
> Every 10 seconds two people develop Diabetes Mellitus.
> Diabetes is the fourth leading cause of global death by disease.
> Type 2 diabetes constitutes about 85% to 95% of all diabetes cases in developed countries and accounts for an even higher percentage in developing countries
> By 2025, the largest increases in diabetes prevalence will occur in developing countries.

Based on the facts presented above, it thoroughly depicts a disturbing increase in the number of people around the world acquiring this condition however the public awareness remains low. Increased urbanization, westernization and economic development in developing countries have already contributed to a considerable increase of this situation. All over the world, conventional lifestyles and dietary patterns that sustained people over generations are vanishing. The socio-economic reality is that families are often forced to move from rural areas into urban areas to seek for better employment. Diabetes Mellitus is largely condensed in urban areas and this characteristic is meant to further increase in the future as a result of rapid industrialization in many countries.

Brief background on Diabetes Mellitus

Diabetes Mellitus refers to a group of metabolic diseases characterized by an elevation of blood glucose levels or a condition known as hyperglycemia (Bullock & Henze 2000). This condition results from defects in insulin secretion or action. Diabetes Mellitus is a silent killer, since many people are not aware that they have this condition until they develop one of the life-threatening complications. The prevalence of this disease increases with age. Other risk factors may include familial history or genetic factors, overweight, lack of exercise, hypertension, HDL cholesterol level <35 mg/dl, trigylceride level >250 mg/dl and members of high-risk ethnic group: African American, Hispanic, American Indian.

This phenomenon is further classified as Type 1 or Type 2. Type 1 Diabetes Mellitus refers to hyperglycemia as the result of autoimmune destruction of the pancreatic B cells. On the other hand, the hyperglycemia due to a range of insulin alterations, such as insulin deficiency and insulin resistance characterizes Type 2. Gestational Diabetes as a result of pregnancy is classified as Type IV.

Diabetes Mellitus causes a variety of complications, which are responsible for the morbidity and mortality associated with the disease. In terms of acute or chronic complications, the acute complications can be life threatening and require immediate treatment. In contrast, the chronic complications appear to be due to prolonged hyperglycemia. The acute complications associated with DM primarily revolve around the state of hyperglycemia which can lead to Diabetic Ketoacidosis (DKA) or Hyperglycemic Hyperosmolar Non-ketosis (HHNK) if left untreated. The chronic complications include (1) microvascular diseases, (2) macrovascular diseases and (3) neuropathy.

Research / Journal Review

The research entitled “The impact of Diabetes Mellitus and other chronic medical conditions on health-related quality of life: is the whole greater that the sum of its parts?” dealt mainly with the evaluation and significant effects of Diabetes Mellitus to other co-existing chronic medical conditions on health-related quality of life (HRQol) which could be additive, synergistic or subtractive in nature. As taken from the background analysis of this study the researchers defined the following terms. “Additive relationship is the combined effect of two or more chronic medical conditions on the HRQol approximates the sum of the independent effect of each of the conditions while in a synergistic relationship, the combined effect is greater than the sum of the independent effect of each of those conditions and in a subtractive relationship the combined effect is smaller than the sum of the independent effect of each of these conditions.”

It is a known fact that Diabetes Mellitus is a chronic illness which can lead to debilitating effects if not detected and treated at an early stage. However, if diagnosed and treated early, control and delay of its complications can be observed. In this study, it was not mentioned whether the status of the diabetic subjects are at early, controlled stage or in the late complicated stage since this will have a greater weight in the outcome on their health related quality of life. Some of the chronic medical conditions are also considered complications of Diabetes Mellitus itself, and their occurrence in one patient cannot be predicted, hence, it can occur either as one or two or more disease entity at the same time.

One thing proven in this study is that the effect of diabetes and a second chronic medical condition which is identified as hypertension (HTN), heart disease (HD) and musculoskeletal (MS) on HRQoL was in general additive than synergistic in nature. The researchers utilize the instruments SF-36 which is the short form 36 health survey and SF-6D. Using these tools they prove that in this multiethnic and population-based study, the subjects with diabetes experienced lowering of HRQol as compared to subject without diabetes. The presence of other chronic medical conditions in subjects with diabetes led to further lowering of HRQol and that the effect is generally additive. As described above the additive relationship is the combined effect of two or more chronic medical conditions on the HRQol approximates the sum of the independent effect of each of the conditions. This finding is of great value to the medical field as this would emphasize the importance of early detection, diagnosis and treatment, thereby preventing complications to occur and hinder a faster progression of the disease which may lead to the mortality or morbidity of the patient. Furthermore, the researchers prove that the impact of these co-existing chronic medical conditions in diabetes is not only in increasing healthcare costs and mortality but also in increasing the physical and psychological burden of diabetic patients.

References

A. Published Materials
Bullock B. & Henze R. (2000). Focus on Pathophysiology 5th Edition. United States, Philadelphia: Lippincott Williams & Wilkins.
Burnard, P.R., & Chapman, C.M. (2004). Professional and Clinical Issues in Nursing 3rd Edition. Philadelphia: Elsevier Lmtd.
Perry, A.G., & Potter, P.A. (2005). Fundamentals of Nursing 6th Edition. Philadelphia: Mosby Inc.

B. On-line Resources
World Health Organization. Diabetes Programme. http://www.who.int/diabetes/en/
International Diabetes Federation. http://www.idf.org/

Guide Questions

1. Do you believe that Diabetes Mellitus and its co-existing chronic medical conditions affect the health related quality of life having this condition? how?
2. As a health care provider, how can you make a difference in the alarming situation on Diabetes and its acute and chronic complications world wide?
3. Do you think the Philippine Government specifically the Health Care Department is prepared for the out growing number of Diabetes in the country? Why or why not?

Diabetes mellitus and all its co-existing conditions have an immense impact upon the life of the afflicted. As stated in the study conducted Graham et al (2007) on Mexican Americans with diabetes, participants had lower Physical Composite Scale scores (composed of Physical Functioning Scale, Role Limitation due to Physical Function Scale, Bodily Pain Scale, and General Health Scale) than those without diabetes. [1] This is primarily due to the limitations imposed to prevent the existence of diabetes’ leading comorbidities (primarily, increase in BMI, stroke, heart attack, hypertension, and visual impairment). More restrictions to physical activities, primarily decrease their scores in the said scales. The same results were also drawn on a similar study conducted by Bennett et al (2008) on clients with diabetes subjected to physical activity. The participants with diabetes had lower Health Related Quality Of Life (HRQOL) physical component scores, role-physical scores, vitality scores, and general heaslth scores than those without diabetes. [2]
The difference then is in the prevention of early onset of diabetes. As we know, the current trend of lifestyle diseases is leaning toward the younger population because of unfit lifestyles the younger generation live out. Health teaching therefore, should be one of the paramount strategies which a health care provider must improve upon. However, health teaching is not readily acceptable among people who have grown close living out unhealthy lifestyles. A study by Gordon and Iribarren (2008) proposes that we as health care providers ought to consider several factors in improving health teaching, among them educational background, income, health status, health behaviours, IT access, and individual health education modality preferences. [3]
In the Philippines, the local Health Department has a prepared plan to combat the onslaught of diabetes [4], and in my opinion, is very ready legislatively to say the least. I have heard of some local hospitals setting up diabetic clinics under their Out Patient Departments, and other public hospitals are quickly following suit.

1 - James E Graham, Diane G Stoebner-May, Glenn V Ostir, Soham Al Snih, M Kristen Peek, Kyriakos Markides, and Kenneth J Ottenbacher (2007), Health related quality of life in older Mexican Americans with diabetes: A cross-sectional study, lifted from the Bio Med Central Health and Quality of Life Outcomes, accessed June 22, 2009 retrieved from www.pubmedcentral.nih.gov
2 - Wendy L Bennett, Pamela Ouyang, Albert W Wu, Bethany B Barone, and Kerry J Stewart (2008), Fatness and fitness: how do they influence health-related quality of life in type 2 diabetes mellitus?, lifted from the Bio Med Central Health and Quality of Life Outcomes, accessed June 22, 2009 retrieved from www.pubmedcentral.nih.gov
3 - Nancy P Gordon and Carlos Iribarren (2008), Health-related characteristics and preferred methods of receiving health education according to dominant language among Latinos Aged 25 to 64 in a large Northern California health plan, lifted from the Bio Med Central Public Health, accessed June 22, 2009 retrieved from www.pubmedcentral.nih.gov
4 – Diabetes – Department of Health, Philippines, http://www.doh.gov.ph/programs/diabetes

Since diabetes mellitus is a chronic metabolic disease, it affects all other areas of the body. In this case the life of an individual suffering from the disease can be affected in many ways because of its complication. Diet, exercise and medications should be maintained according to the individual’s needs. A neglect with only one of the three could aggravate the suffering of the individual. In order to control the widespread of diabetes mellitus, Health care providers should make a thorough health teaching and distribution of information. The media is a great channel to this intervention.
Given that DM, specially Type II is experienced by 90 – 95 %, successful outcome of the treatment of the disease not only entails the contribution of the government but also the absolute participation of the client.


Reference:


Frances Precilla L. Cuevas et. Al, Public Health Nursing in the Philippines, (10th ed.), p 195

Clients with Diabetes Mellitus have increased risks for developing chronic complications that causes morbidity and mortality cases. These complications could be devastating to clients and their families as it affects the body systems of the patient. These complications are classified into three types: Macrovascular, Microvascular, and Neuropathic Complications.

Macrovascular complication includes Coronary Artery Disease, Cerebrovascular Disease, Hypertension, Peripheral Vascular Disease, and Infection. While Microvascular complications have Retinopathy and Nephropathy. The third type has Sensorimotor Neuropathy and Autonomic Neuropathy. Prevention of these all-too-common complications should be implemented to avoid major complications that could endanger the health and life of the clients and their families.



REFERENCE: Black, J., Hawks, J. (2005). Medical – Surgical Nursing: Clinical Management for Positive Outcomes. 7th Edition. Volume 1. Philadelphia, W.B. Saunders, Elsevier PTE LTD.

Quote:

2. As a health care provider, how can you make a difference in the alarming situation on Diabetes and its acute and chronic complications world wide?

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Diabetes Mellitus is a serious condition for the individual, family and society. Its prompt escalation in the global prevalence is a significant cause for concern. According to the Who Health Organization (WHO), as of the year 2009, Diabetes affects more than 250 million people worldwide. In the Philippines an alarming 2.7 million people are affected by this world wide alarming concern. By the year 2030 the forecast of the WHO is that over 366 million people would suffer from Diabetes Mellitus.

The daunting empirical data on the prevalence of DM presented on the previous paragraph definitely indicate a global concern not only among the community but amongst health care providers as well. The role of the Physician and Nurse in Primary Health Care Prevention is an integral part in reducing the incidence of this debilitating disease. Therefore, appropriate measures should be implemented to safeguard the well-being of the society in combatting this serious health condition.


In a study conducted in 2007 on the "Patient-provider interaction from the perspectives of type 2 diabetes patients in Muscat, Oman: a qualitative study" by authors Abdulhadi, et al., the following information were recommended to further develop the Nurse's and Physician's role in DM Care:





Therefore, two of the major roles that health care providers should learn to develop in this medical crisis is the focus on Patient-Centered Approach and Teamwork. These two concepts, although very simple, could create a big difference regarding the patient's outlook on his condition thus encouraging him more to balance his lifestyle practices and at the same time adhere to the medications advised to him by the nurse.




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REFERENCES:


1. Abdulhadi, N.; Al Shafaee, M.; Freudenthal, S.; Östenson, C. & Wahlström, R. 2007. Patient-provider interaction from the perspectives of type 2 diabetes patients in Muscat, Oman: a qualitative study. BMC Health Services Research. Retrieved on June 23, 2009 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2174468&tool=pmcentrez

2. Peek, M.; Cargill, A. & Huang, E.S. 2008. Diabetes Health Disparities
A Systematic Review of Health Care Interventions. Pub Med Central. Retrieved on June 23, 2009 from http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2367214&tool=pmcentrez

“2. As a health care provider, how can you make a difference in the alarming situation on Diabetes and its acute and chronic complications world wide?”

Decades ago, cases of diabetes are low. But as mentioned earlier,

“Its prompt escalation in the global prevalence is a significant cause for concern. According to the Who Health Organization (WHO), as of the year 2009, Diabetes affects more than 250 million people worldwide”


Therefore, health teaching has a vital role. In comparison before and nowadays, the health beliefs and attitudes of the people has already evolved. It will be observed that there are more fried/process foods and fast food establishments than having a traditional food or meal. Also, having a sedentary lifestyle and increasing number of obese people is a big factor to consider. So, dissemination of knowledge would be the best tool in prevention and management of diabetes mellitus. Further, the public should be motivated to have a healthy and active lifestyle, have a proper diet, reduce and maintain ideal body weight.



Reference:
Ho, L.S., Gittelson, J., Harris, S.B., & Ford, E. (2006). Development on integrated diabetes prevention program with first nation in Canada. Health Promotion International, 21(2): 88-97. Retrieved June 18, 2009, from Oxford Journals database.

Parry O., Peel, E., Douglas M., & Lawton, J.(2005). Issues of cause and control in patient accounts of type 2 diabetes. Health Education Research, 21(1): 97-107. Retrieved June 18, 2009, from Oxford Journals database.

Media and the internet have contributed in informing the public. The Department of Health has its own website with information regarding different conditions. There are also a number of segments in shows and infomercials about Diabetes and other medical conditions.

However modern lifestyle can be a hindrance in maintaining a quality of life for patients. Starting form unhealthy foods down to inactive lifestyle, these factors keep sneaking up on patients lives.

As a health provider the best I could do is to educate clients to the best of my ability. But at times it might be an overwhelming task because of the number of DM patients, alone, is significantly high. Add that to patients with other chronic medical conditions, effective health education to every single one of them is probably next to impossibility.


Department of Health. Diabetes. Retrieved June 23, 2009 from http://www.doh.gov.ph/programs/diabetes

Diabetes is a disease in which your blood glucose, or sugar, levels are too high. Glucose comes from the foods you eat. Insulin is a hormone that helps the glucose get into your cells to give them energy. With Type 1 diabetes, your body does not make insulin. With Type 2 diabetes, the more common type, your body does not make or use insulin well. Without enough insulin, the glucose stays in your blood.

Over time, having too much glucose in your blood can cause serious problems. It can damage your eyes, kidneys, and nerves. Diabetes can also cause heart disease, stroke and even the need to remove a limb. Pregnant women can also get diabetes, called gestational diabetes.

Symptoms of Type 2 diabetes may include fatigue, thirst, weight loss, blurred vision and frequent urination. Some people have no symptoms. A blood test can show if you have diabetes. Exercise, weight control and sticking to your meal plan can help control your diabetes. You should also monitor your glucose level and take medicine if prescribed.

As a health care provider, we should take a first step with diabetes and give enough informations and instructions to prevent DM and its complications.

REFERENCE
National Institute of Diabetes and Digestive and Kidney Diseases