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Introduction
Today, diabetes is a serious public health concern that bothers millions of people around the whole world. In the United States, approximately 30.3 million people have diabetes as their primary diagnosis, with only 23.1 million people who are diagnosed and 7.2 million people who are not diagnosed because of their unawareness or poor awareness of this diseases peculiarities (Centers for Disease Control and Prevention, 2017). There is also one interesting fact that the same number of people, 23.1 million, includes the adults who are aged 65 years or older and have prediabetes. Diabetes mellitus type 2 accounts for 95% of all cases of this disease. By 2035, the population with type II DM is expected to rise to 592 million (Pradeep & Haranath, 2014). Type I diabetes is not as frequent as type II, and it is usually observed among children and adolescents who are younger than 20 years. In this paper, diabetes mellitus (DM type 2) will be reviewed through a synthesis of relevant information about its pathophysiology, genomic issues, diagnosis, and treatment to develop an effective care plan with appropriate follow-ups and referrals for diabetes patients.
Pathophysiology
Diabetes mellitus is a metabolic disease that is characterized by a high blood sugar level that tends to increase due to insulin resistance or an insufficient insulin secretory response (Pradeep & Haranath, 2014). Type II DM is a major type of diabetes, and 8.3% of adult patients have it. The review of its pathophysiology is one of the first steps to be taken to comprehend its urgency and identify as many effective treatment approaches as possible. Insulin secretion and resistance are two important processes in pancreatic beta cells. Obesity or overweight is defined as one of the possible causes of type 2 diabetes because this condition leads to an increased level of free fatty acids and amino acids in plasma (Kahn, Cooper, & Del Prato, 2014). As a result, glucose can neither be produced to its full extent nor be transported to muscle cells, causing insulin resistance in a short period.
The production of fat cells also leads to lipid breakdown and an increased level of glucagon in the blood (Pradeep & Haranath, 2014). The release of glucagon promotes the development of hyperglycemia and unpredictable and uncontrollable changes in ±-cells and ²-cells. The work of the central nervous systems, as a key regulator of a metabolic process, undergoes certain changes as well. One of the nervous systems functions is to control the level of glucose in the blood through neuronal input. The vagus is the nerve that is responsible for insulin secretion, and its destruction influences hepatic glucose production and promotes lipid accumulation.
In general, the pathophysiology of glucose metabolism in DM type 2 may be developed in four different ways: an increased production of glucose in the liver, increased carbohydrate intake, a decreased peripheral glucose intake, and decreased insulin secretion. Regarding the age continuum for the chosen disease, these problems may be developed in different ways. It is suggested to separate early-onset DM type 2 into two types of patients: pediatric (younger than 19 years) and adult (older than 19 years) (Wilmot & Idris, 2014). For example, type II DM diagnosis may be associated with a myocardial infarct in patients younger than 45 years. Frailty progression is usually observed in the elderly until the end of life.
Genomic Issues
Despite numerous approaches to understanding the pathophysiology of type II DM, this disease is still poorly investigated from a genomic point of view. The results of various genome-wide association studies, it is possible to investigate the genetic basis of type II DM and the reasons for patients vulnerability to this disease (Mahajan et al., 2014). Many researchers tie the prevalence of this disease to the raised rates of obesity among the population, high energy intake, a lack of physical activities, and such crucial risk factors as ethnicity or family history (Wilmot & Idris, 2014). Genetic predisposition to diabetes is a crucial aspect, especially when it interplays with certain environmental factors.
There are several ways of how it is possible to discover causal genes for type II DM, and one of them is a family-based linkage analysis in terms of which the relation between genotype and phenotype has to be identified (Billings & Florez, 2010). With the help of such a genetic method, it turns out to be possible to clarify if there are DNA segments of an ancestor that contain phenotypic information about diabetes. Mutations in genes may influence glucose levels and increase the risk of having type II DM. The attention should be paid to the following genes: ABCC8 (regulation of insulin), GLUT2 (glucose movement through pancreas), TCF7L2 (insulin secretion), and GCGR (glucagon hormone) (Billings & Florez, 2010).
Linkage analysis is used when it is necessary to detect rare genetic loci and get a patient prepared for any possible complications. Considerable progress in genetic knowledge cannot be neglected. BMI values were used to identify the connection between the risk of diabetes and the risk of obesity. The effects of visceral fat accumulation were discovered. New metabolic factors were introduced to explain the connection between ²-cells and insulin-sensitive tissues (Kahn et al., 2014). However, many fields remain to be unknown and unexplained. It is necessary to investigate such concepts as an allelic spectrum, pleiotropy, and appropriate loci of genes in regards to their biological relevance and insight.
Literature Review: Data Collection
One of the most important aspects of current research is to collect the needed information properly. All facts and findings have to be credible and up-to-date. In this case, web-based data was collected to develop a systematic literature review. Such databases as Medscape, PubMed, and PsycINFO were utilized to gather the required number of scholarly articles from different academic journals. GoogleSholar was chosen as the main search engine in this project. To save time and find the necessary material, several excluding details were added. First, the period of publication was established: the last seven years (from 2010 to 2017). Second, the location was specified (the US sources). Finally, several keywords, including type 2 diabetes , diabetes mellitus , US population , diagnosis , treatment , and patient care were used. They were combined in different ways to find articles that can be used to cover different points of the current paper.
To introduce the latest electronic clinical tools and guidelines, it was decided to address the International Diabetes Federation (2017) and their recent clinical practice recommendations that could be used for managing type 2 diabetes. The choice of such a source is explained by the necessity to investigate various approaches to diabetes treatment and utilize recent information about diabetes, its prevalence, and care plans.
Disease Basics and Treatment: Literature Review
Type II DM is a chronic disease that has to be properly diagnosed and treated under long-term expert attention. Many complications and threats to life can be observed in diabetes patients. During the last several years, diabetes took the seventh position on the list of the diseases that might lead to death among the American population (Tucker, 2017). There is also a condition that is called prediabetes when the level of blood sugar is higher than normal, but not high enough to be a sign of type 2 DM. Prediabetes may be treated with the help of lifestyle changes so that no serious pharmacological interruptions are necessary. In the United States, the total estimated cost of diabetes and prediabetes was $245 billion ($176 billion on direct medical expenses and $69 billion on reduced productivity) in 2012 (Slabaugh, Curtis, Clore, Fu, & Schuster, 2015). Still, many people are unaware if they might have diabetes, who do not know about its main symptoms, and who cannot understand when it is time to address a doctor and be checked for this disease.
Among the most frequent symptoms of type 2 DM, there are frequent urination, excess thirst, constant hunger, unexplainable weight loss, blurred vision, fatigue, and the changes of skin color (Pradeep & Haranath, 2014). Sometimes, people are confused by such signs and believe that they suffer from depression or some kind of insignificant infection. However, it is necessary to remember that diabetes is dangerous due to the possibility of the immune system to destroy cells which are responsible for the production of insulin. The body becomes unable to protect itself, and a healing process slows down promoting the development of new infections (Pradeep & Haranath, 2014). Insulin resistance makes it impossible to move glucose through cells. Glucose is the source of energy, and instead of sharing this energy with other blood cells, it promotes the creation of new bloodstreams with a high blood sugar level. Such dysfunctions may occur because of the presence of at least one risk factor and lead to serious complications.
Potential complications type II DM patients may suffer from include kidney and liver problems, cardiovascular diseases, nerve damage, problems with eyes or hearing, and a poor skin condition (Billings & Florez, 2010; Slabaugh et al., 2015; Wilmot & Idris, 2014). Intensive therapy and the presence of pharmacological and non-pharmacological treatment are important inpatient care. However, before, a patient should be tested to make sure that diabetes type 2 is a correct diagnosis. As a rule, such tests are offered: Random/fasting plasma glucose tests to measure the level of blood glucose, glycated hemoglobin test to identify the level of glucose during the last three months, and oral glucose tolerance test to check the level of sugar in the blood (Pradeep & Haranath, 2014). Treatment is based on the use of such medications as insulin, sulfonylurea, metformin, or different inhibitors to reduce the level of blood sugar.
Clinical Guideline for Diabetes
Nowadays, it is possible to find several clinical guidelines that can be appropriate for treating diabetes online. In this paper, the guidelines of the International Diabetes Federation (2017) will be utilized. The IDF working group admits that it is possible to prevent type 2 diabetes in case a healthy lifestyle is adopted in time. Many steps can be taken to reduce the mortality level in people who have to live with diabetes. In addition to the necessity to take insulin or other medication that can control the level of sugar in the blood, cooperation with doctors and nurses is highly appreciated.
Up to 50% of people who have diabetes are still undiagnosed (International Diabetes Federation, 2017). Such negligence leads to the development of new diseases and diabetes complications. Therefore, screening for type 2 DM is the priority in treatment. People who are obese or have diabetes family history have to be screened regularly. Prevention of diabetes includes the necessity of lifestyle modifications, weight reduction up to 7%, and increased physical activities. Tests and glucose control and monitoring are usually required in special populations. Patients have to be educated about the importance of physical activities regarding their age and diets. People with diabetes should also avoid such habits as smoking and excess alcohol intake (International Diabetes Federation, 2017). Obesity is the condition that has to be properly treated by diabetes patients because the presence of free fat cells is one of the reasons for insulin resistance. Therefore, even if obese patients take insulin, it cannot be as helpful as possible because of the development of new risk factors.
Diabetes Treatment
In many clinical guidelines, it is recommended to combine pharmacological and non-pharmacological approaches to the treatment of type II diabetes. Sometimes, patients choose one way of treatment only and deprive themselves of an opportunity to increase their chances and live with diabetes longer.
Pharmacological Approach
Pharmacological treatment usually includes the use of certain medications that have to be prescribed by a doctor after a thorough examination of a patient. One of the most famous medications for diabetes patients is insulin. However, this kind of injection maybe not enough. Therefore, alternative options are developed, including metformin that improves glucose tolerance and decreases the level of sugar in the blood, alpha-glycosidase inhibitors that support blood-glucose concentration, and sulfonylurea that helps to control blood sugar level and promotes insulin production in the pancreas (Pradeep & Haranath, 2014). To take these medications properly, it is recommended not to overdose and controlling glucose levels with specially developed medical devices.
Non-Pharmacological Approach
Patient education is one of the approaches to treat diabetes. Patients have to learn what may promote diabetes complications. Nurses should explain to patients what attitudes and beliefs are important for diabetes treatment. Also, it is possible to change a lifestyle when patients discover new interests, replace poor habits with healthy ideas, and follow all medical prescriptions and referrals (International Diabetes Federation, 2017). Diet is another non-pharmacological approach that can be offered to patients (Billings & Florez, 2010). No sugar, no salt, a limited number of snacks, and caloric food are the restrictions to be followed. Finally, physical activities and no harmful habits are appreciated. Long walks (if age allows), fresh air, and exercises may help patients with diabetes to avoid serious health complications.
Final Treatment Approach
The goal of care that is offered to patients with type 2 diabetes is to detect all symptoms and eliminate them not at the expense of other body functions. Treatment should also aim at preventing complications and risks connected with blood pressure. In addition to such recommendations as smoking cessation and a decreased use of alcohol, a patient has to follow a certain diet and take physical exercises regularly (International Diabetes Federation, 2017). The role of glycemic treatment is also important. Hyperglycemic drugs are appropriate for different stages of diabetes. In the sulfonylurea category of drugs, Glucotrol 5 mg before breakfast can be chosen. It helps to increase the production of insulin in the pancreas and promote its distribution through the blood. Sulfonylurea is the type of drug that does not increase macrovascular risks. However, this drug may cause some allergic reactions and liver or kidney problems. Blood and urine tests should be taken every week, and the level of glucose should be checked regularly. Therefore, every change in the body has to be reported to the physician. If there is no necessity, other drugs should be avoided at the initial stage of this treatment. As a rule, this medication cannot be bought without a refill. Patients have to cooperate with their doctors to achieve positive results in treatment.
Diabetes is also connected to the development of such conditions as depression, anxiety, and fatigue, which may affect treatment adherence and worsen the outcomes (International Diabetes Federation, 2017). Screening for depression is highly recommended for diabetes patients once per month. If there are no evident complications, it is suggested to continue treatment at home and follow all prescriptions given. Hospitalization is not a requirement for diabetic patients if no life threats are observed.
Follow-up and Referral
Follow-up and referrals are two integral parts of a care plan for patients with diabetes. If there are no surgical interventions in treatment, follow-ups do not include too many tasks to be followed. Still, each requirement helps to prevent the development of disease complications. As a rule, patients with diabetes have to get ready to develop long-term relationships with their doctors. First, diabetes assessments are required every three months. If new symptoms or complications occur, the frequency of visits may be changed. Regular monitoring and control are obligatory. There are specific random plasma glucose tests (RPG) which may be taken anytime without fasting (as usually required for other tests). This test measures the level of glucose in the blood. If the test shows 200 mg/dL or more, diabetes is present and continues developing. The task is not to reach serious rates, which may threaten a patient.
Several specific recommendations for the referral may be given. First, it is possible to address an endocrinologist or diabetologist to improve poor metabolic control (International Diabetes Federation, 2017). Nutritionists can help to choose an appropriate diet and keep to it regularly. A clinical exercise physiologist is another doctor for diabetes patients to cooperate with. This expert aims at developing special programs during which patients improve their lifestyles, get used to living with diabetes, and think about appropriate attitudes and beliefs about their future. Finally, several visits to a psychologist may be offered to make sure that no mental or emotional disorders challenge patients.
In general, patients with type 2 diabetes have several options for diagnosis, treatment, and follow-up. Modern health care and training programs help to choose an appropriate medication and a good care plan to meet the demands of a patient, eliminate diseases symptoms, and prevent the development of complications that may influence the work of the body.
References
Billings, L. K., & Florez, J. C. (2010). The genetics of type 2 diabetes: What have we learned from GWAS? Annals of the New York Academy of Sciences, 1212(1), 59-77.
Centers for Disease Control and Prevention. (2017). National diabetes statistics report. Web.
International Diabetes Federation. (2017). IDF clinical practice recommendations for managing type 2 diabetes in primary care. Web.
Kahn, S. E., Cooper, M. E., & Del Prato, S. (2014). Pathophysiology and treatment of type 2 diabetes: Perspectives on the past, present, and future. The Lancet, 383(9922), 1068-1083.
Mahajan, A., Go, M. J., Zhang, W., Below, J. E., Gaulton, K. J., Ferreira, T.,& Saleheen, D. (2014). Genome-wide trans-ancestry meta-analysis provides insight into the genetic architecture of type 2 diabetes susceptibility. Nature Genetics, 46(3), 234-244.
Pradeep, T., & Haranath, C. (2014). A review on diabetes mellitus type II. International Journal of Pharma Research & Review, 3(9), 23-29.
Slabaugh, S. L., Curtis, B. H., Clore, G., Fu, H., & Schuster, D. P. (2015). Factors associated with increased healthcare costs in Medicare Advantage patients with type 2 diabetes enrolled in a large representative health insurance plan in the US. Journal of Medical Economics, 18(2), 106-112.
Tucker, F. M. (2017). Americas diabetes crisis: There is no reason! Exigence, 1(1). Web.
Wilmot, E., & Idris, I. (2014). Early onset type 2 diabetes: Risk factors, clinical impact and management. Therapeutic Advances in Chronic Disease, 5(6), 234-244.
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