Lifestyle Changes For Diabetes Health And Social Care Essay

Diabetes mellitus is a heterogeneous group of disorders, all characterized by increased plasma glucose. In the majority of patients with diabetes, the etiology of the disease is not understood. Expert panels have recommended one set of criteria for diagnosis and another set for classification . The criteria serve two purposes. One is to secure optimal treatment of the patient. The other is to support research aimed at understanding the aetiology and pathogenesis of diabetes syndromes Diabetes mellitus type 2 or type 2 diabetes (formerly called non-insulin-dependent diabetes mellitus (NIDDM), or adult-onset diabetes) is a disorder characterized by high blood glucose in the context of insulin resistance and relative insulin deficiency.(Robbins et al ,2004)

More than 220 million people worldwide have diabetes. In 2005, an estimated 1.1 million people died from diabetes.Almost 80% of diabetes deaths occur in low- and middle-income countries. Almost half of diabetes deaths occur in people under the age of 70 years; 55% of diabetes deaths are in women. WHO projects that diabetes death will double between 2005 and 2030.Healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use can prevent or delay the onset of diabetes.(WHO,2009)

Many types of diabetes are recognized (Tierney.L.M et al,2002) the principal three are:

Type 1: Failure to produce insulin by body mechanism resulting in diabetes. It is estimated that 5-10% of Americans who are diagnosed with diabetes have type 1 diabetes. Currently patients with type 1 diabetes take insulin injections.

Type 2: Results from insulin resistance, a condition in which cells fail to use insulin properly, may be combined with absolute insulin deficiency. Majority of patients world over who are diagnosed with diabetes have type 2 diabetes.

Gestational diabetes: Pregnant women who previously never had diabetes before but who have sudden increase in blood sugar (glucose) levels during pregnancy mainly due to change in their diet are said to have gestational diabetes. Gestational diabetes affects about 4% of all pregnant women. It may precede development of type 2 (or rarely type 1) Diabetes mellitus .

Type 1 Diabetes

Diabetes is a long-term (chronic) condition caused by the increase in level of glucose (sugar) in the blood. It is also known as diabetes mellitus.

In the UK, diabetes is seen in around 2.3 million people, and it’s estimated that there are more than half a million more people who have the condition but are not aware of it.

Normally a hormone called insulin regulates the blood sugar level, which is produced by the pancreas (a gland behind the stomach). When food is digested and enters the bloodstream, insulin moves any glucose out of the blood and into cells, where it is broken down to produce energy.

However, in those with diabetes, the body has higher level of glucose as it is stored and is unable to break down glucose into energy because there is either not enough insulin to breakdown glucose and store it as energy or because the insulin produced is not enough or does not work as required.

Gestational diabetes is caused by excess weight, obesity and Insulin Resistance are a condition that develops in the third trimester of pregnancy and affects 4-5 % of all pregnant women in the U.S. That is around 135,000 cases each year. With Gestational Diabetes, the insulin production by pancreas is normal but it doesn’t lower the mother’s blood sugar levels. The symptoms are only detectable by laboratory testing. Pregnant women can test their blood glucose level by urine dip stick test with each pre-natal visit. This test may show glucose in the urine, which is sign and will require health care provider to carry out further examinations for the presence of Gestational Diabetes, also known as Gestational Diabetes Mellitus http://weight.insulitelabs.com/Gestational-Diabetes.php

There are two types of diabetes – type 1 and type 2.

Type 1 diabetes occurs when the body produces no insulin. It is often referred to as insulin-dependent diabetes. It is also sometimes known as juvenile diabetes, or early-onset diabetes, because it usually develops before the age of 40, often in the teenage years.

Type 1 diabetes is far less common than type 2 diabetes, which occurs when there is too little insulin produced by the body to work, or when the cells in the body do not react properly to insulin. People with type 1 diabetes make up only 5-15% of all people with diabetes.

type 1 diabetes, will need insulin injections for life as well as blood glucose levels stay balanced by eating a healthy diet and carrying out regular blood tests http://www.nhs.uk/conditions/diabetes/Pages/Introduction.aspx

The main symptoms of diabetes are:

feeling very thirsty(polyphagia)

producing excessive amounts of urine(polyurea)

tiredness and lethargy

weight loss

muscle wasting (loss of muscle bulk).

Symptoms of type 1 diabetes can develop quickly, over weeks or even days. Other symptoms are: 

itchiness around the vagina or penis or getting thrush regularly,

blurred vision (caused by the lens of your eye becoming very dry), 

muscle cramps,

constipation

skin infections.

Hypoglycaemia (low blood glucose)

If a patient has diabetes, their blood glucose levels can become very low. This is known as hypoglycaemia (or a ‘hypo’), and happens because insulin produced by the body is more and has reduced the level of in the bloodstream.

In most cases, hypoglycaemia occurs if there is overdose of insulin, although it can also happen if you skip a meal, exercise very vigorously or drink alcohol on an empty stomach.

Symptoms of a ‘hypo’ include:

feeling shaky and irritable,

sweating

tingling lips

feeling weak

hunger

nausea

A hypoglycaemia can be brought under control simply by eating or drinking something with sugar in it . If a hypoglycaemia is not brought under control it can lead to confusion, slurred speech and unconsciousness. If this occurs there will be a need to have an emergency injection of a hormone called glucagon. This hormone will raise the level of glucose in your blood as it suppress the effect of insulin.

Hyperglycaemia (high blood glucose)

As diabetes occurs as a result of your body being unable to produce any, or enough, insulin to regulate your blood glucose level, your blood glucose levels may become very high. This happens because there is no insulin to breakdown glucose from the bloodstream and into the cells to produce energy.

Blood glucose levels become too high, it lead to  hyperglycaemia. The symptoms are similar to the main symptoms of diabetes, but they may come on suddenly and severely. They include:

extreme thirst

a dry mouth

blurred vision

drowsiness

a frequent need to pass urine.

If left untreated, hyperglycaemia can lead to complications such as diabetic ketoacidosis, which can eventually cause unconsciousness and even death. Diabetic ketoacidosis occurs when your body begins to break down fats for energy instead of glucose, leading to a build-up of acids in your blood urgent medical attention if diabetes develop in the body and this are the general signs and symptoms seen in case of diabetes

a loss of appetite,

nausea or vomiting (feeling or being sick),

a high temperature,

stomach pain or severe abdominal pain

a fruity smell on your breath, which may smell like pear drops or nail varnish.

http://www.nhs.uk/Conditions/Diabetes/Pages/Symptoms.aspx

The “McKeown thesis” and its Impact:

The McKeown thesis attempted to reason the phenomenal growth in population of the from late 18th century to the present day .McKeown’s thesis can be summarized as a steep growth in population was primarily due to decline in mortality form infectious diseases and the change in economic conditions due to industrial revolution ,which lead to improvement in rising of living standards and brought a gradual change in nutritional status that improved the human body’s resistance towards various diseases. The development in medical fields achieved by modern science did not make a significant contribution towards the population growth and was largely due to economic forces and changes in living and social conditions. This lead to McKeown reclassifying various fatal diseases recorded by General record office (GRO).McKeown classification was generally of three types

(1)Infectious diseases spread through air -Respiratory tuberculosis, Pneumonia, Bronchitis

(2) Infectious diseases spread through water or food – Cholera, Diarrhoea, Typhoid

(3) All other diseases contagious and degenerative

When a population develops it is important that the individuals are in a position to fight diseases and problems that can arise from them, this depends on the resources that they have. These resources could be knowledge, social setup, power, money. Those people who have access to resources have advantage and can gain health benefits from the public health system from those who are not in position to direct access to public health system. Resources are important in two different ways first , they can develop the individual’s behaviour towards health by helping them access and make choices and whether they could afford them all helping towards health enhancing behaviours and Second, resources are shaped across a broad range of contexts such as communities, neighbourhoods, social network , occupation and the risk as well as protecting factors .Housing for poor people would always be associated with pollution, noise, indifferent social conditions . Access to broad range of problems lie with socio economic condition of the individual like knowledge of best doctors and ideal treatment of medical problems and the freedom in making choices .The reason for social condition always being important is resources shape the access to health relevant circumstances . The social condition has been responsible for determining the quality of life and plays an important role as health determinant. (Link.B.G and Phelan.J.C 2003)

Mckeown was the former chairman of World health organization’s advisory group on health research strategy concludes that the average life expectancy had improved by 23 years in first half of century and medical therapy was responsible for only for few years of it. Meckeown believed that most this decrease was due to identification of bacilli which causes respiratory tuberculosis was not done till year 1882 and effective pharmacotherapy was not available till year 1947.

Between 1700 and 1915, the mortality rate in England declined from 27.9 deaths per thousand living to 14.4 and average life expectancy at birth Increased from 37.1 (in 1701) to 53.5 (in 1910-12). These figures reflect a major Improvement in the life-chances of the British population over the course of the Period, and therefore it is hardly surprising that the ‘McKeown thesis’, which attempts to account for the decline of mortality and the ‘modern rise of population’, has played a big role in economic, social and medical history as well as history of epidemiology and population studies In the years following the publication of McKeown thesis it is argued that it’s unlikely the dietary standards would have improved during the second half of 18th century as the value of wages was falling as there were apparent contradictions between real wages and mortality. (Wrigley and Schofield, 1981). McKeown argued that there was no means to fight air borne diseases in 18th century and the reduction in deaths was more likely due to improved human body resistance towards these diseases.

Illich was not content in criticizing modern medicines for to improve life expectancy , he proposed that medical interventions were in fact responsible for increasing the mortality rate by using ineffective and hazardous medical therapies which at times not tested or researched properly .Illich stated that chronic usages of drugs lead to numerous side-effects , infections acquired from hospitals , poorly performed surgeries as well as false positives and false negative tests from medical tests.

McKeown was aware that higher rate in fertility was responsible for increase in population rather than reduced mortality rate but dismissed it on grounds that higher birth rate means higher infant mortality as well due to the high risk parity of mothers so would not account for such a high rate of population growth. McKeown pointed out that mortality rates for most of the infectious diseases reduced considerably before any effective medical measure was in place. McKeown concluded that public health measure such as sewage disposal system, public waste disposal, and supply of clean and potable water and pasteurization of milk was important only from year1870, so the reason behind the decline mortality rate before this was according to McKeown due to improvement in living standards .Improvement in nutrition due to increase in agriculture productivity was also responsible for the increase in resistance to airborne infectious diseases such as Tuberculosis.(Grundy,2005). Preston’s article concluded that the increase in life expectancy all over the world between 1930s and 160s could not be totally attributed to increase in living standards and suggested that advances in medical care and public health did make significant contribution towards decline in mortality. Preston’s did make an effort to prove McKeown thesis wrong but had little influence on conventional belief and the theory of improved standard of living became conventional wisdom for that present time. (Mackenbach J P,2006)

It has recently been shown that McKeowns interpretations of his very own epidemiological data is flawed in many respects, firstly smallpox and diphtheria are two diseases that have been eradicated totally all over the world by vaccinations which is a preventive health measure .Positively the only three diseases to be eradicated before great world war was- cholera , typhoid and smallpox all these are attributed to public health measures and not nutrition .When all this data is analysed it goes to show that public health measures taken played the most decisive role in reduction of mortality . Furthermore since McKeowns work was published two significant forms of new evidence has appeared which slams the nutrition/living standard theory by McKeown. The first half of the century, the period which is under review suggests that as when the wages across sectors started improving, the reduction in mortality rate showed a slight decline from previous years and if wage increase meant better nutrition these was not seen in children .The growing cities and towns where the wage improvement were seen showed a trend of areas which had highest mortality rate and children were poorly developed (R.Woods and J.Woodward.1984).Although the points raised here are relevant they skew the main issue here which is that growth in income is not necessarily same all over the world and can vary considerably from developed countries to developing and underdeveloped countries .There are no patterns in cross-sectional associations between the income of a nation and progress in developing health standards as well as life expectancy of their population. Preston’s analysis underestimated the effects of economic development and its relation with reduction in mortality rate, that the relationship between the economic development and the developments in medical field are crude conceptualization between the two.

McKeown’s study can be explained by relevance of the question that underlines them. This concerns the importance of medical interventions, social, economic, political measures which affects the health status and health inequalities. Study suggest that measures need to be taken to improve health inequality and medical interventions and social changes has to be taken as complimenting rather than opposing each other .

Interventions

Type 1 diabetes is approached by primary, secondary, and tertiary intervention Primary intervention includes treatment of all individuals with diabetes. The possibility of using autoantigens new medium to combat diabetes as a vaccination is currently being explored not only in animal experiments but also in human tests. The selection of children on the basis of HLA type is being used to treat newborns with either oral or nasal insulin. Animal experiments have shown that treatment of spontaneously diabetic nonobese diabetic mice with GAD as a peptide, protein, or expressed in potatoes reduced diabetes. Vaccinations studies done both children and adults remain a future possibility to test determine whether type 1 diabetes can be prevented. (Lernmark.A.1999)

Secondary intervention involves screening for genetic, autoantibody, and other possible markers at birth, in school children, or in adults . Individuals classified with type 2 diabetes but positive for islet autoantibodies (representing slow-onset type 1 diabetes, latent autoimmune diabetes in the adult, or type 1.5 diabetes) are also being tested to determine whether they are suitable for immune intervention to preserve their ß-cell function. Recent studies in Japan suggested that early insulin treatment preserves ß-cell function. Several intervention trials are pending, including the use of subcutaneous or oral insulin in the Diabetes Prevention Trial for Type 1 Diabetes, milk formula or nasal insulin in Finland, aerosol insulin in Melbourne, or nicotinamide in the European Nicotinamide Diabetes Intervention Trial. In the next few years studies would find out the extent of such intervention trials preserve ß-cell function in subjects at risk for type 1 diabetes.(Lernmark.A.1999)

Tertiary intervention involves the treatment of patients diagnosed with type 1 diabetes very recently. Previous studies have demonstrated that treatment plans with satisfactory results are not present such as immunosuppression with cyclosporin and other agents has not been able to stop the pathogenetic process in new-onset patients. A future innovative treatment is planned so that it represents an antigen-specific immune intervention. Animal experiments have demonstrated that in case of early diagnosis or in patients with early onset the timely administration of antigen or insulin, at the time of clinical onset may slow the disease process.(Lernmark.A.1999)

Being active is referred to as physical activity (exercise) and is defined as the act of expending energy. It is generally categorized into two different types aerobic (requiring oxygen to maintain muscular effort) or anaerobic (not requiring oxygen to maintain muscular effort). The term exercise is used as a general label for being active and physical activity as well as exercise. Major challenges to decision making about exercise include how to develop and implement an efficient and effective exercise regimen, how to modify it to an individual patient’s motivation level knowing his mindset and barriers so that exercise will be initiated and maintained, and how to select, measure, and achieve specific, desired outcomes. Given these decision-making challenges Exercise interventions aimed at achieving these outcomes usually vary by type, intensity, duration and frequency. As with any type of self-care behaviors, barriers to exercise vary and are individual to particular patients depending on their health status as well as mindset. Among potential considerations for barriers has to be devised for individual patients type of exercise and duration, intensity, and frequency may need to be tailored to severity of progression of diabetes since complications such as neuropathy and retinopathy may affect the exercise capabilities of a diabetes patient. In addition, patients may consider availability of time, among many other factors such as age, job profile, social status and other medical complications, as posing a substantial barrier to integrating regular exercise or physical activity into normal daily lifestyle. Each of these poses challenges to the initiation and maintenance which is the more difficult part of exercise for patients and therefore to the measurement, monitoring, and management of exercise intervention outcomes for providers. Exercise is one of the most important features to both type 1 and type 2 diabetes patients. For type 2 diabetes patients, engaging in regular exercise may improve glycemic control and reduce the risk of vascular complications, increase insulin sensitivity, reduce stress and stave off depression and contribute to control of lipids and blood pressure, thereby reducing the risk of cardiovascular disease, the leading cause of death in diabetes patients.

Type 2 diabetes is determined primarily by lifestyle related factors and hereditary factors.

Lifestyle

A number of lifestyle factors are known to be important to the development of type 2 diabtetes. In one study, those who had high levels of physical activity, a healthy diet, did not smoke, and consumed alcohol in moderation had an 82% lower rate of diabetes. When a normal weight was included the rate was 89% lower. In this study a healthy diet was defined as one high in fiber, with a high polyunsaturated to saturated fat ratio, and a lower mean glycemic index. (Mozaffarian.D.et al 2009) Obesity has been found to contribute to approximately 55% type 2 diabetes, and decreasing consumption of saturated fats and trans fatty acids while replacing them with unsaturated fats may decrease the risk.(Saad.F.2009) increased rate of childhood obesity in between the 1960s and 2000s is beleived to have lead to the increase in type 2 diabetes in children and adolescents. (Rosenbloom.A. et al.2003)

Environmental toxins may contribute to recent increases in the rate of type 2 diabetes. A positive correlation has been found between the concentration in the urine of bisphenol A, a constituent of some plastics, and the incidence of type 2 diabetes. (Lang.A.2008)

Medical conditions

Subclinical Cushing’s syndrome (cortisol excess) may be associated with DM type 28The percentage of subclinical Cushing’s syndrome in the diabetic population is about 9%.Diabetic patients with a pituitary microadenoma can improve insulin sensitivity by removal of these microadenomas. (Taniguchi T.2008)

Hypogonadism is often associated with cortisol excess, and testosterone deficiency is also associated with diabetes mellitus type 2, even if the exact mechanism by which testosterone improve insulin resistance is still not known. (Farrell JB,2008)

Genetics

Both type 1 and type 2 diabetes are partly inherited. Type 1 diabetes may be triggered by certain infections, with some evidence pointing at Coxsackie B4 virus. There is a genetic element in individual susceptibility to some of these triggers which has been traced to particular HLA genotypes (i.e., the genetic “self” identifiers relied upon by the immune system). However, even in those who have inherited the susceptibility, type 1 diabetes mellitus seems to require an environmental trigger.

There is a stronger inheritance pattern for type 2 diabetes. Those with first-degree relatives with type 2 have a much higher risk of developing type 2, increasing with the number of those relatives. Gene expression promoted by a diet of fat and glucose as well as high levels of inflammation related cytokines found in the obese results in cells that “produce fewer and smaller mitochondria than is normal,” and are thus prone to insulin resistance.

COMPLICATIONS of Diabetes

Early complications-

Diabetic ketoacidosis is a medical emergency, because it can cause coma and death. Hospitalization, usually in an intensive care unit, is necessary. Large amounts of fluids are given intravenously along with electrolytes, such as sodium, potassium, chloride, and phosphate, to replace those fluids and electrolytes lost through excessive urination. Insulin is generally given intravenously so that it works quickly and the dose can be adjusted frequently. Blood levels of sugar, ketones, and electrolytes are measured every few hours. Doctors also measure the blood’s acid level. Sometimes, additional treatments are needed to correct a high acid level. However, controlling the levels of sugar in the blood and replacing electrolytes usually allow the body to restore the normal acid-base balance.( Robbins and Cotran,2007)

Late Complication of Diabetes Mellitus:

Macro-vascular complications as: Atherosclerosis with MI, CVA, peripheral vascular disease

Micro-vascular complications as: Diabetic Retinopathy Diabetic retinopathy refers to progressive pathologic alterations in the retinal microvasculature. In type 2 diabetes, though the incidence of blindness is lower, higher disease prevalence results in an even larger number of patients affected with severe visual loss.

Diabetic Neuropathy Diabetic neuropathy (DN) is a common and troublesome complication of diabetes mellitus, leading to great morbidity and mortality and resulting in a huge economic burden for care of the patient with diabetes mellitus. It is the most common form of neuropathy in the developed countries of the world, accounts for more hospitalizations than all the other diabetic complications combined, and is responsible for 50% to 75% of nontraumatic amputations and patients have serious co-morbid conditions, especially heart, eye, and peripheral vascular diseases.

Diabetic neuropathy is a heterogeneous disorder that encompasses a wide range of abnormalities affecting proximal and distal peripheral sensory and motor nerves as well as the autonomic nervous system. The major morbidity associated with somatic neuropathy is foot ulceration, the precursor of gangrene and limb loss. (Robbins and Cotran,2007)

Research on diabetes

The features of Type 1 diabetes in humans as well as mice in labororatory environment is significantly dependent on an relation between the environmental factors and genetic feature of humans as well as the study animal. Studies by Giulietti.A.et al(2004) al point towards vitamin D as being one of the environmental factors that can modulate the incidence of diabetes. This study further shows that in mice that developing Type 1 diabetes are generally at higher risk due to its genetics as well as vitamin D deficiency which leads to features seen in early part of life leading to a more aggressive form of the disease causing earlier onset, and a higher final incidence of the disease. This model of subtle vitamin D deficiency in early life, with only a marginal vitamin D deficiency in blood, but no effect on calcium concentration in serum or bone calcium content.

This is most probably the reflection of the vitamin D status in many infants and small children as this model has temporary and limited vitamin D deficiency, even in areas with high exposure to sunlight, since infants always are shielded from UV B exposure or direct exposure of sunlight. The application of vitamin D supplement is advised in many countries it is far from strictly controlled and many times, these supplements are omitted or administered irregularly or not paid enough importance to keep tab on their supply and demand. The higher incidence of Type 1 diabetes in the past two decades may be seen due the nutritional rickets which has never been completely eradicated in many countries and may be reappearing in may industrialize countries (Giulietti.A.et al, 2004).

It was found that the risks for diabetes in African-Americans, Hispanics, and Native Americans are approximately 2, 2.5, and 5 times greater, respectively, than in Caucasians being the least. Various national and ethnic populations within the U.S. to the total U.S. population were analyzed to find possible risk factors for the development of type 2 diabetes this was done by number of cross-sectional studies and prospective studies . Studies of the prevalence of type 2 diabetes in Mexican Americans and non-Hispanic whites in San Antonio showed that there is an inverse relationship between prevalence of diabetes generally and their current socioeconomic status. The cultural effects lead to an increased incidence of obesity in these populations which may also be related to their diet and physical activities, which may lead to insulin resistance. Genetic factors may also be a contributing factor. (Haffener.S.M 1998)

There are no high quality data on the research about the long lasting effectiveness of the dietary treatment of type 2 diabetes, however the data available indicate that the adoption of exercise which is a change in lifestyle appears to improve glycated haemoglobin at six and twelve months in people with type 2 diabetes. There is an urgent need for more well-designed studies which will analyse the wide range of interventions, at various points during follow-up (Moore.H. et al 2004)

Weight loss improves glycemic control with magnitude of improvement related to both magnitude of weight and characteristics of patient , the amount of weight loss required to reduce blood glucose is large, even modest weight loss produces glycemic control .The most important issue is how to improve weight loss especially long term weight loss, in type 2 diabetic patient .Dietary modification is most important direction in weight loss program (Hertzel.C.et al)

Implications for developing world

Type I diabetes is the only major organ-specific autoimmune disorder not to show a strong female bias. The overall sex ratio is roughly equal in children diagnosed under the age of 15 but while populations with the highest incidence all show male excess, the lowest risk populations studied, mostly of non-European origin, characteristically show a female bias. In contrast, male excess is a consistent finding in populations of European origin aged 15-40 years, with an approximate 3:2 male:female ratio. This ratio has remained constant in young adults over two or three generations in some populations. Further, fathers with Type I diabetes are more likely than affected mothers to transmit the condition to their offspring. Women of childbearing age are therefore less likely to develop Type I diabetes, and – should this occur – are less likely to transmit it to their offspring. Type II diabetes showed a pronounced female excess in the first half of the last century but is now equally prevalent among men and women in most populations, with some evidence of male preponderance in early middle age. Men seem more susceptible than women to the consequences of indolence and obesity, possibly due to differences in insulin sensitivity and regional fat deposition. Women are, however, more likely to transmit Type II diabetes to their offspring. Understanding these experiments of nature might suggest ways of influencing the early course of both forms of the disease.(Gale.E.A.M. et al 2001)

It is recognized that there will be substantially increased costs of widely applying the recommendations of study in the U.S on the Diabetes control and complications trial (DCCT). There will also need to be additional efforts to ensure professional education, so that health practitioners are implement this recommendations through the trial are able to effectively and safely implement the therapy employed in the DCCT. It is hoped that the benefits of trial are long term healthier; more productive lives with fewer complications will offset the costs of tight control. The cost-benefit ratio for intensive therapy in diabetes in this trial is in a range similar to other accepted treatments in the U.S that are of high priority.(American Diabetic Association, 2003)

Spin off in interventions of diabetes (American diabetic association)

The Diabetes Prevention Program (DPP) was a major multicenter clinical research study to find out whether any modest weight loss through dietary changes and increased physical activity or treatment with the oral diabetes drug metformin (Glucophage) could prevent or delay the onset of type 2 diabetes in study participants who currently where not diabetic but had all the requirements for a diabetic patient. At the beginning of the DPP, participants were all overweight and had blood glucose, also called blood sugar, levels were on the higher side than normal but not high enough to be classified as diabetic -a condition called pre-diabetes. The DPP found that participants who underwent lifestyle changes and lost a modest amount of weight through dietary changes and increased physical activity and did not get back to their old dietary habits sharply reduced their chances of developing diabetes. Taking metformin also reduced risk, although was less dramatic.

The American Diabetes Association recommends that testing to detect pre-diabetes and type 2 diabetes be given more importance and should be made mandatory in adults without symptoms but who are overweight or obese and have one or more additional risk factors for diabetes. In those without these risk factors, testing should begin at age 45.

Risk factors for pre-diabetes and diabetes-in addition to being overweight or obese or being age 45 or older-include the following:

being physically inactive

having a parent, brother, or sister with diabetes

having a family background that is African American, Alaska Native, American Indian, Asian American, Hispanic/Latino, or Pacific Islander

giving birth to a baby weighing more than 9 pounds or being diagnosed with gestational diabetes-diabetes first found during pregnancy

having high blood pressure-140/90 mmHg or above-or being treated for high blood pressure

having HDL, or “good,” cholesterol below 35 mg/dL, or a triglyceride level above 250 mg/dL

having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT) on previous testing

having other conditions associated with insulin resistance, such as severe obesity or a condition called acanthosis nigricans, characterized by a dark, velvety rash around the neck or armpits

having a history of cardiovascular disease and hypertension

If results of testing are normal, testing should be repeated at least every 3 years. Doctors may recommend more frequent testing depending on initial results and risk status.

Healthy life-style

Healthy lifestyle which follows nutrition recommendations for the general public are also good enough for individuals with type 2 diabetes since many patients with type 2 diabetes are overweight most often and insulin resistant. There should be emphasizing on lifestyle changes that result in reduced energy intake and increase of energy expenditure through various physical activity. As many individuals also have hypertension modifying their diet by reducing saturated and trans fatty acids, cholesterol, and sodium is often desirable. Therefore, the first nutrition priority is to encourage individuals with type 2 diabetes to implement lifestyle changes that will improve glycemia and blood pressure and control their body weight.

The first nutrition priority for individuals requiring insulin therapy is to work out an insulin regimen with their general practioners into their lifestyle. With the many insulin options now available, the most suitable insulin regimen can usually be developed to conform to an individual’s lifestyle such as meal routine, food choices, and physical activity pattern. Insulin-to-carbohydrate ratios can be used to vary mealtime insulin doses. Estimation of the nutrient content of meals, including carbohydrate counting, the exchange system, and experience-based estimation the several methods used . Improvement in A1C without a significant increase in severe hypoglycemia was demonstrated, as were positive effects on quality of life, satisfaction with treatment, and psychological well-being, even though increases in the number of insulin injections and blood glucose tests are necessary. Regular physical activity can help lower fasting and postprandial plasma glucose concentrations and may be used as an adjunct to improve maternal glycemia. If insulin therapy is added to Medical Nutritional Therapy, maintaining carbohydrate consistency at meals and snacks becomes a primary goal.( Bantle.J.P.et al American Diabetic association,2006)

A study done on the effects of aerobic training program by addition of resistance training and its effects on insulin sensitivity as well as changes in skeletal muscle character and abdominal obesity in postmenopausal women with type 2 diabetes. The findings of the study were significant that combination of aerobic plus resistance program produced improvement in insulin sensitivity in comparison to the control group. The training regimes produced a high degree of reduction in body weight as well as abdominal obesity specifically subcutaneous abdominal fat cells. Training had a significant effect as reduction of low-density component of thigh muscle along with simultaneous increase in the normal-density component, with an gradual increase in effect seen with aerobic plus resistance training. The change in insulin resistance was related to changes in abdominal subcutaneous and muscle cross-sectional area and density and visceral adipose tissue.(Cuff.J.D. et al American diabetic association,2003)

Hard to reach groups and inequality

Global economic policies concerning agriculture, trade, investment and marketing affect what the world eats. They are therefore also global food and health policies. Health policy makers should pay greater attention to these policies in order to address some of the structural causes of obesity and diet-related chronic diseases worldwide, especially among the groups of low socioeconomic status.(Hawkes.C.2006)

Creating and promoting a better understanding between those who provide and manage health services and end users who seek these require these services will create better understanding of tailoring the services to demands. As the user awareness increases it will increase the health concerns and is likely to be key part of the process of moving to “fully engaged” scenario. Involvement of different ideas over voluntary organizations who are themselves commissioned by public sector under taking to take responsibility and this leads to them disengaging from the process of causing further rise in health inequality. User involvement is more meaning full only when it not a one off intervention or a discreet program of work , but a much more broader and engaging way of work that effects every aspect of delivering health care and reducing inequalities (Elizabeth Dowler,2007)

A persons educational level does not appear to define health problems to their GP but health inequalities were shown to be substantial in 2001 and persistent over time. Socio-economic differences were shown to be similar using self-assessed health data and GP data. educational attainment did not appear to play a part in presenting health problems to the GP. (Westert .G.P. 2005)

Study by Chang.H.k et al (2008) found that people in the traditional and marginalized modes have higher rate of acculturative stress (e.g., depression and greater perceived discrimination) than those people in the more integrated and have a cultured and systematic life modes. Studies also show that people with depression, a common response to environmental stress, have a 37% increased risk of type 2 diabetes. One finding that need more analysis and investigation is that Native Hawaiians in the traditional way of lifestyle experience more psychosocial or environmental stress than Native Hawaiians in the other modes of life , thus increasing their risk for type 2 diabetes. (Chang K.H et al 2008)

There are an estimated 370 million indigenous peoples living in more than 70 countries worldwide. They represent a rich diversity of cultures, religions, traditions, languages and histories; yet continue to be among the world’s most marginalized population groups. The health status of indigenous peoples varies significantly from that of non-indigenous population groups in countries all over the world from one country to another. In all regions of the world, traditional healing systems and Western biomedical care co-exist. However, for indigenous peoples, the traditional systems play a more important role in their healing strategies more so because of their age beliefs and lack of access to conventaional health care due either cost factor or location of these facilities. (WHO 2007)

A study done on the general population in Trinadad has evaluated the relationship between diabetes, health status, household income and expenditure on health care . Diabetes is associated with worse health status and more frequent expenditure on medical services but greater financial barriers to access in terms of low income and lack of health insurance. Policies for diabetes should specifically address the problem of income-related variations in risk of diabetes as the poor and needy would not be able to afford treatment of diabetes which need a very long term treatment plan , health care needs and barriers to uptake of preventive and treatment services need changes such that even poor people has access to it otherwise inequalities in health from this condition may increase. (Gulliford.M.C , Mahabir.D et al)

A study conducted on 45 practices in Liverpool and shows that many general practices are now organized to provide systematic diabetes care. Payment for chronic disease management as well as the large number of new cases that are seen in modern lifestyle and dietary habits may have influenced the increase in numbers of practices providing a diabetes mini-clinic and recall system. Lack of organization is the biggest obstacle in provision of systematic care for diabetes and its related complications in general practice. Larger practices and practices with GPs or nurses with an interest in diabetes are more likely to have organized routine recall and to operate diabetes mini-clinics. However, deprivation is not a barrier to providing structured diabetes care. The study explained only a small part of the variation in practices possessing a recall system or a diabetes mini-clinic. Variations are therefore likely to be due to other unmeasured factors. Diabetes is associated with worse health status and continuous or more frequent expenditure on medical services for years together but greater financial barriers to access in terms of low income and lack of health insurance. Policies for have to include needs assessment poor and marginalized communities in diabetes and should specifically address the problem of income-related variations in risk of diabetes, health care needs and barriers to uptake of preventive and treatment services, otherwise inequalities in health from this condition may increase and widen the already existing gap between the rich and poor . http://www3.interscience.wiley.com/journal/118782218/abstract)

In present day Europe the issue of public health is high on the policy agenda and health care is one of most important issues in current political scenario with new policies being proposed to reduce inequality. This is important because the health gap between groups with different socio-economic status is present in most Western European countries. Studies show that inequalities in health remained the same over time and there is ever increasing gap and evidence to prove it. In six conditions inequalities were shown to be stable over time, but in two cases inequality increased. Diabetes doubled in prevalence between the two surveys indicating that it needs more analysis on policies front to reduce inequalities. Health inequalities for diabetes and rheumatoid arthritis were not apparent in 1987, but the lower educated had statistically significant higher chances of having diabetes or rheumatoid arthritis in 2001(Westert .G.P. 2005)

Conclusion

Diabetes is a life threatening condition. Recent WHO calculations indicate that worldwide almost 3 million deaths per year are attributable to diabetes. It is predicted that 200 million individuals worldwide will have diabetes by 2010 and 300 million by 2025. However, there is compelling evidence from many studies that for subjects with impaired fasting glucose or impaired glucose tolerance the presentation of type 2 diabetes can be delayed by lifestyle modification. There are positive healths benefits of lifestyle modification in the prevention of type 2 diabetes and type 1 diabetes cannot be prevented by just lifestyle and nutritional recommendations. Increasing physical activity and altering the diet reduced the progression of Type 2 diabetes. The natural history for people at high risk of developing type 2 diabetes is weight gain and deterioration in glucose tolerance. All individuals, especially family members of persons with type 2 diabetes, should be encouraged to engage in regular physical activity to decrease the risk of developing type 2 diabetes.

Recommendations (American diabetic association)

Preventing diabetes (primary prevention)

Structured programs for individuals with high risk of developing diabetes that emphasis on making lifestyle changes which include dietary changes, physical activity, moderate weight loss

Individuals with high risk of type 2 diabetes should need to modify their diet to include food containing whole rains and dietary fibres

Even though there is no evidence to suggest that low glycemic load reduces the risk of diabetes food with high fibre and low glycemic load have to be promoted

Alcohol consumption has to controlled for individuals with risk of diabetes although reports of moderate alcohol consumption saying it is good for diabetic patients

Type 1 diabetes cannot be prevented by nutritional recommendations

It is reasonable to apply approaches demonstrated to be effective in adults, as long as nutritional needs for normal growth and development are maintained in case of youth.

Controlling diabetes (secondary prevention)

Carbohydrate in diabetes management

Include foods from vegetables, fruits, whole grains, in the dietary pattern and promote drinking of low fat milk

Restriction of diet to low carbohydrate diet of below 130 gs per day is not recommended

Glycemic control can be achieved by monitoring the carbohydrate intake estimation of dietary intake remains a key strategy to control diabetes

The use of glycemic index and load may provide a modest additional benefit over that observed when total carbohydrate is considered alone

Sucrose-containing foods can be substituted for other carbohydrates in the meal plan or, if added to the meal plan, covered with insulin or other glucose-lowering medications. Care should be taken to avoid excess energy intake of this food substances

Sugar alcohols and non-nutritive sweeteners are safe when consumed within the daily intake levels and not over the limit established by the FDA.

As for the general population, people with diabetes are encouraged to consume a variety of fiber-containing foods. However, evidence is lacking to recommend a higher fiber intake for people with diabetes than for the population as a whole.

Appendix

Source WHO 2009