Evidenced Based Paper – Diabetes Mellitus


In its initial state, diabetes was discovered at around 1500 B.C.E. Its first discovery was done by Europeans although they viewed it as a condition that was completely rare since a person lost a lot of weight and excessively urinated. An experiment done by Matthew Dobson in 1776 proved that glucose concentration in the urine had increased in a great percentage. (Polonsky, 2012).

In our days, there is an increase in the number of those people who have diabetes worldwide, ranging from 170 million that was discovered in 2000 to around 366 million which is described in the vision 2030 (Laffel, Svoren, & Wolfsdorf, 2014). Diabetes will soon contribute to a major health burden, particularly in the industrial countries where morbidity and mortality from communicable diseases are declining. The medical expenditures of those people with diabetes are more due to chronic complications compared to those of people without diabetes. Diabetes mellitus that is considered to be of type 2 diabetes is generally characterized by different characteristics which may include resistance of insulin, hyperglycemia as well as impairment of the secretion of insulin.

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The prevalence of diabetes mellitus type 2 increases depending on the level of obesity and the sedentary lifestyle (Laffel, Svoren, & Wolfsdorf, 2014). T2DM and comorbidities are risk factors for vascular diseases later in life. As a result, it is crucial for health care providers to recognize and treat children and adolescents with this disorder. Studies have shown how diabetes is connected to conditions that tend to be nonvascular like the association with different types of cancers. On the other hand, statements made by the association of diabetes in America and the cancer society in America as well proved that there are no clear arguments to support the idea that the associations are said to be direct or even indirect or as a result of shared risk factors as obesity or combination of this (McCulloch & Robertson, 2014).

The evidence based paper will concentrate on the pathophysiology of diabetes type II, diagnostic criteria, management, clinical preventative service and treatment plan based on the evidence of practice. The topics include priorities in translating clinical trial results into primary and secondary prevention, diagnostic criteria improvement and monitoring methods, assessment and management of comorbidity with infectious diseases, surveillance and economic evaluation of interventions.

Pathophysiology of Diabetes Type II

Many different factors make the understanding of type 2 diabetes’ pathogenesis much more difficult than expected. Patients who tend to have different unstable levels of the resistance of insulin and any deficiency that is related to insulin and there is a large percentage that the two have a contribution to causing type 2 diabetes. Environmental and generic influences contribute to different clinical features thus causing difficulties in establishing the correct source and especially in the case involving an individual patient. (McCulloch ; Robertson, 2014).

Hypertension as well as high serum and low-density – lipoprotein cholesterol concentration are factors that accompany diabetes type two, and an increases cardiovascular risk which is caused by low-serum as well as high-density lipoprotein cholesterol (McCulloch ; Robertson, 2014). Hyperinsulinemia happening in reaction to the resistance of insulin contribute to the geneses that are associated with the abnormalities. Metabolic syndromes as well as diabetes type 2 are influenced by factors like an increase in the levels of fatty acid in one’s body, oxidative factors and inflammatory cytokines from fat.

There exist different multifaceted relations between many environmental factors and genes and they are mostly represented by diabetes type 2. Risk factors that are polygenic result to a generic risk for diabetes type 2. Diabetes type 2 is more prevalent in Americans who are just Native, African American, Americans who are Hispanic and Indians who are Pimas. Surveys conducted conclude that, for every thirty-nine percent of diabetes type 2 patients there exist one parent who has the disease.

The role of obesity, diet, and inflammation play the major role in the frequency of the tolerance of impaired glucose and diabetes type 2 in the United States. Among the patients who have type 2 diabetes, different features arise like physical activities which mostly increase the risk of suffering from diabetes. For instance, a condition like obesity is known for causing resistance to the entire glucose uptake that are insulin-mediated and decrease beta-cells sensitivity to glucose. Inflammation links obesity to atherosclerosis as well as to diabetes pathogenesis and it is generally associated to the rising levels of inflammation makers such as the C-creative protein.

Prenatal exposure as low/high birth weight may also be linked with greater than normal risk of diabetes. Many different drugs have the ability to weaken the intolerance of glucose which is mainly through a reduction on the secretion of insulin, an increase on the levels of production of hepatic glucose or even causing the action of insulin to resist. These drugs may include drugs like oral contraceptives, antihypertensive drugs which may include thiazide diuretics, beta blockers, statins, acids containing nicotine and inhibitors that are purposely used for the treatment of the infection of HIV, and glucocorticoids among other drugs.

Diagnostic Criteria

The changes in diagnostic criteria over the past years make it hard to estimate time trends in the global burden of pre-diabetes. In 2011, the Center for Disease Control estimated that 79 million Americans – 35% of people over the age 20 – had pre-diabetes. A significant proportion of people with diabetes and pre-diabetes remain undiagnosed. According to American Diabetes Association (ADA), adults above 45 years without additional risk factors or even adults who are below the age of 45 but have excess weights still bear other additional risk factor and should receive a screening test for diabetes or pre-diabetes (ADA, 2015).

The screening test supposed to be HbA1c, fasting glucose or 2 hr glucose, and repeated at least at 3-year interval; once yearly in those diagnosed with pre-diabetes. The U.S task force that is concerned with offering preventive services does not at all recommend routine screening since mostly there is inadequate data that would give clear outcomes after the screening. It only recommends screening if it is involving an asymptomatic adult who has a blood pressure that is sustainable because for targeting on lower blood pressure when there is an establishment on the diagnosis of diabetes.

The Expert Committee that deals with classifying diabetes mellitus and diagnosing it in conjunction with Who and ADA suggested, in 1997, that there should be minimization on the levels of plasma and lowering of the diagnostic threshold as well. The levels should be lowered to 126 mg in a single deciliter, that is, the level at which any unique microvascular is able to complicate diabetes, retinopathy and be able to be noticed (Inzucchi, 2012).

According to the conclusions of OGTT, many patients who undergo the fasting test of plasma glucose have diabetes. The test has several limitations which may include larger cost, reduced reproductivity and complication. The United States thus prefers the test of fasting plasma glucose and it is conducted on different dates for accurate results and confirmation. If the plasma glucose levels are diagnosed randomly and the results show that the levels in symptomatic patients are either 200mg per deciliter or even more, then the results do not require any confirmation process for clarity (Perrealt ; Faerch, 2014).

Hemoglobin that is glycated has been used for a long period to control or manage established diabetes to become a biomarker that is able to control long-term glycemic. The levels obtained after the control process match to a great percentage with the blood glucose average levels during the period of the previous 2 or 3 months. The test of the glycated hemoglobin has been standardized globally and thus the results obtained from a clinical laboratory are able to be compared with the ones reported from diabetes test aimed at controlling the process (Inzucchi, 2012). In 2009, the International Expert Committee (IEC), responded by recommending diagnosis of diabetes tests having a threshold of 6.5%.

Initial management of blood glucose in adults with Type II diabetes

Initial treatment of patients suffering from diabetes type 2 is individualized based on patient’s age, gender, life expectation but always includes education, evaluation for any complications, attempts to achieve a reduction of cardiovascular issues, normal glycemic levels as well as other factors that tend to be long-term. There should also be complete avoidance of those drugs that have the ability to aggravate abnormalities related to insulin or even rapid metabolism.

Resistance of insulin and the secretion of insulin are affected by hyperglycemia both adversely and reversibly. To improve glycemia control, practices like balanced diet, reduction of weight and a lot of exercise are used. The patients with diabetes type 2 should take medication.

Diabetes type 2 can be greatly improved by a modification of one’s diet in different aspects like hypertension, obesity, release of insulin and responsiveness. Any improvements on the glycemia control are influenced by the level of caloric restriction as well as a reduction on weight which enhances liver function. Patients who are not given high levels of calories, high fat, carbohydrate diet that is of high complex tend to have a long-term efficacy of their diagnosed diabetes type 2. The patients who are treated with diet are able to achieve and maintain concentration of blood glucose that was desired and being below 108 mg/dl.

Patients of diabetes type 2 benefit from exercises in the sense that they lose weight thus improving the control of glycemic condition since there is an increase in the responsiveness of insulin. The tolerance of impaired glucose can also be delayed for the purpose of averting diabetes. These changes are mostly due to the reduction of weight which is through exercises. Regular exercise regime can only be maintained by a diabetes type 2 patient.

Patients suffering from diabetes type 2 and having psychological interventions may at times experience stress that is related to different responsibilities of self-care thus optimizing glycemic control. Self-care can also be interfered with through a long-period depression. On the other hand, psychological distress is reduced by psychotherapy thus leading to an improvement of the glycemic control though not in all studies.

Clinical Prevention Services

Evidence-based care allows health care providers to recognize people at a high risk of prediabetes or diabetes and take early intervention to prevent the development of type II diabetes, and thus significantly decrease the chance of developing diabetic complications and reduce the large cost associated with spending on diabetes and its complications, and can therefore improve the treatment outcome. The estimated number of adults with diabetes mellitus in the United States is 1.8 million.

Diabetes is a threat of disabling as well as complications that may be life-threatening like kidney failure, retinopathy, and lower-extremity amputation and microvascular diseases as myocardial infarction, stroke, or hyperglycemic crisis. There also exist many other complications, among them a reduction to the resistance to infections like pneumonia, diseases that are dental based, and many other different complications that may occur during birth among pregnant women suffering from diabetes (Gregg, Li, & Wang, 2014).

Other than nephropathy diabetes development, other factors also exist contributing to diabetes hypertension and these include hyperinsulinemia, expansion of the volumes of extracellular fluid and an increase on the arterial stiffness. Patients suffering from diabetes should seek for early treatment to prevent cardiovascular disease and to minimize diabetes retinopathy and renal disease progression. The Association American Diabetes 2015 follow-up argues that among the many patients who have systole blood pressure ranging between 120 and 139 mmHg or even a diastolic pressure that ranges from 80 to 89, nonpharmacologic methods are supposed to be used to reduce blood pressure. Patients suffering from type 2 diabetes combined with either cardiovascular disease or any other risk factors that are related to cardiovascular disease have a suggested goal for systolic blood pressure that is less than 120 mmHg. (ADA, 2015).

Many people with diabetes are at the higher PAD risk due to certain factors like increase in age, if the diabetes takes a long duration on any neuropathy present. A primary health care provider needs to obtain a full family history on patient intake and physical exam on the initial visit. History should include pain assessment or discomfort that may be experienced when doing exercises or even taking a walk but all that is resolved though taking rest. The pain is caused by inadequacy of blood flow to the part of the body affected.

The physical exam should include head to toe assessment, vital signs, height and weight, and lab work results, such as complete blood count, comprehensive metabolic panel, hemoglobin A1c, fasting lipid panel, microalbuminuria, and baseline electrocardiogram. Diabetic foot ulcers are common but controlled through regular foot inspection, caring of the foot, and having sufficient footwear. The patients should examine their ability to reach or even see one’s feet and be able to do a routine inspection of the feet. Peripheral artery diseases examination should also be done even if it is yearly (Deshpande, Harris-Hayes, ; Schootman, 2008).

Among the people suffering from diabetes, retinopathy is the popularly known complication of microvascular issues and it is associated with prolonged hyperglycemia and it can even develop even at a period of 7 years before the clinical diagnosis is conducted. The possible blindness can be prevented if treated at an early stage. Therefore all the patients suffering from diabetes should undergo an annual eye examination which is supposed to be performed by an ophthalmologist who is well qualified and then later screened for retinopathy, glaucoma and cataracts (Deshpande, Harris-Hayes, ; Schootman, 2008).

Diabetic nephropathy is generally a proteinuria that is completely persistent in the patients who do not have an infection on urinary tract or other different diseases which may cause proteinuria and can be present at diagnosis. Among the risk factors of modification is a metabolic regulation that is very strict as well as using proteinuria progression. All the patients have to undergo a screening session due to the increases of excretion of urinary albumin annually (Deshpande, Harris-Hayes, ; Schootman, 2008).

The trial of controlling diabetes and any complications and prospective study of the United States concluded that control of improved glycemic is related to the reduction of complications caused by microvascular and the reduction of the microvascular disease in a long-term period. A decrease of the vascular diseases and any mortality associated with it can be enhanced through reducing the levels of cholesterol, ensuring low blood pressure and avoiding the usage of tobacco. Patients should undergo a regular screening of any complications that may occur in order for them to be treated of any presence of diabetes at the early phase.

Depending on the disease control as well as prevention, diabetic patients must also be careful with regards to the flu. Diabetes increases the effort it takes to fight flu viruses. In addition, the flu, along with any other viral infections, can cause added stress on the body, and can have an adverse effect on the body’s blood sugar levels, and can increase the chances of diabetic complications (CDC, 2015). The CDC also states that the flu vaccine is important for people 65 or older and with certain chronic diseases, young children, and people with a weakened immune system, because the flu can make them much sicker than healthy people.

A flu vaccination can help and protect them and reduce the risk of getting the flu throughout the flu season from October to March. In addition, the flu vaccine also helps to prevent the spread of the flu from person to person (CDC, 2015). The CDC recommends people get the flu vaccine every year. Furthermore, the CDC also recommends that people who are 65 or older or people with some health conditions, and weakened immune system receive the pneumococcal vaccine (CDC, 2015). The recommendation for pneumococcal vaccine is people who get their first dose before 65 will need to have the repeated second dose after five years. However, people who get the pneumococcal after 65 do not need an extra dose for the rest of their lives (CDC, 2015).

Additionally, the best and most effective way to prevent diabetes complications is to have a healthier lifestyle, and to educate people about the disease process. Proper education about the disease process given to patients will reduce the threat of complications of the disease, the need for emergency room visits, and hospitalization.

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