diabetes essay uk

Diabetes in the UK: 2019

Affiliations.

• 1 Southern Health NHS Foundation Trust, Research & Development Department, Moorgreen Hospital, University of Southampton, Southampton, UK.
• 2 Diabetes UK, London, UK.
• 3 Human Development and Health, University of Southampton, Southampton, UK.
• PMID: 31901175
• DOI: 10.1111/dme.14225

Aim: Diabetes impairs the quality of life of people living with the condition and is a major public health concern. The aim of this paper is to create a state of the nation report of diabetes in the UK.

Methods: Diabetes UK collates information about diabetes from diverse sources. This paper synthesizes these data to create a national report.

Results: Some 7% of the UK population are now living with diabetes; approximately one million people have undiagnosed type 2 diabetes, 40 000 children have diabetes and more than 3000 children are diagnosed every year. Forty-nine per cent of people with type 1 diabetes were offered structured education, but only 7.6% attended; the corresponding figures for type 2 diabetes were 90% and 10.4%, respectively. Among people with diabetes, 28% reported having issues obtaining medication or equipment for self-management. Fifty-seven per cent of people with type 1 diabetes and 42% with type 2 diabetes do not receive all eight annual health checks. Around 40% of people with diabetes have diminished psychological well-being. One-third of people have a microvascular complication at the time of diagnosis of type 2 diabetes. Diabetes is responsible for 530 myocardial infarctions and 175 amputations every week. The National Health Service spends at least £10 billion a year on diabetes, equivalent to 10% of its budget; 80% is spent treating complications. One in six hospital inpatients has diabetes.

Conclusion: Diabetes continues to place a significant burden on the individual with diabetes and wider UK society. This report will be updated annually to understand how diabetes is changing across the UK.

© 2020 Diabetes UK.

Publication types

• Research Support, Non-U.S. Gov't
• Diabetes Complications / economics
• Diabetes Complications / epidemiology*
• Diabetes Complications / therapy
• Diabetes Mellitus / economics
• Diabetes Mellitus / epidemiology*
• Diabetes Mellitus / therapy
• Disease Management
• England / epidemiology
• Guideline Adherence
• Health Expenditures / statistics & numerical data*
• Mental Health
• Northern Ireland / epidemiology
• Patient Education as Topic
• Scotland / epidemiology
• State Medicine
• Undiagnosed Diseases / epidemiology
• United Kingdom / epidemiology
• Wales / epidemiology

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Type 2 diabetes: an update for community nurses

Linda Nazarko

Nurse Consultant Physical Health, West London NHS Trust

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There are now over four million people living with diabetes in the UK, the majority having type 2 diabetes. The prevalence of type 2 diabetes is rising in line with growing obesity levels. This article will explore prevalence of type 2 diabetes, its prevention and treatment. It also provides guidance on how nurses can work with people at risk of diabetes, to prevent it, induce remission and create awareness of medications used to treat it.

Type 2 diabetes a growing problem

Diabetes is a chronic, metabolic disease characterised by elevated levels of blood glucose (or blood sugar), which over time, can lead to serious damage to the heart, blood vessels, eyes, kidneys and nerves. Type 1 diabetes, once known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little to no insulin by itself. However, the most common type is type 2 diabetes, usually seen in adults, which occurs when the body becomes resistant to insulin or doesn't produce enough of it. In the past 3 decades, the prevalence of type 2 diabetes has risen dramatically in countries of all income levels ( WHO, 2021a ).

In the UK, and globally, the prevalence of type 2 diabetes has risen in line with growing obesity levels ( WHO, 2021a : WHO, 2021b ). In the UK, diabetes mellitus (DM) affects 7.4% of the population but 15% of those with severe mental illness ( Diabetes UK, 2021 ; Public Health England, 2018 ). Figure 1 illustrates the increasing numbers of people in the UK with diabetes ( Diabetes UK, 2021 ).

Health consequences of diabetes

Diabetes can have a major effect on a person's life, their family, the health service and society as a whole. Undiagnosed or poorly managed diabetes leads to premature death ( Harding et al, 2016 ). People who develop type 2 diabetes under the age of 40 are more likely to experience rapid deterioration in pancreatic function and have a greater incidence of adverse outcomes ( Magliano et al, 2020 ). High blood glucose levels cause lack of energy, lack of reserves and increased risk of tissue damage. Diabetes leads to problems with vision, circulation, increases the risk of heart disease, stroke, dementia, nerve damage and sexual difficulties ( National Institute of Health and Care Excellence (NICE), 2022a ).

The main complications of diabetes are microvascular-such as diseases affecting the eyes, nerves and kidneys, and macrovascular, such as diseases leading to cardiovascular disease (CVD), cerebrovascular disease and lower extremity arterial disease ( Vithain and Hurel, 2010 ).

Each week, diabetes leads to 2,000 cases of heart failure, 680 strokes, 530 myocardial infarctions and 169 amputations ( Diabetes UK, 2019 ). This is illustrated in Figure 2 .

Some individuals with diabetes can develop various eye problems-cumulatively known as diabetic eye disease. These conditions include diabetic retinopathy, diabetic macular oedema, cataracts and glaucoma (Pearce et al, 2018). Microvascular damage can also increase the risk of stroke, impaired cognition and depression ( van Sloten et al, 2020 ). People who are overweight and have diabetes are at increased risk of severe and progressive changes in their brain structure and of dementia ( Sujung Yoon et al, 2017 ).

Diabetes affects the heart and blood vessels and increases the adverse effects of hypertension. These changes increase the risk of cardiovascular disease and this is the leading cause of death in people with diabetes ( Strain and Paldánius, 2018 )

Type 2 diabetes can lead to ill health, diminished quality of life and premature death. In order to help people improve their health and well-being, the nurse needs to adopt a three-pronged strategy, to prevent the disease, induce remission, and treat it. Figure 3 illustrates this.

Detection of those at risk and prevention

Diabetes risk factors can be divided into two categories: modifiable-those we can change, and non-modifiable, those we cannot change, Figure 4 illustrates modifiable and non-modifiable risk factors.

The risk of diabetes increases with age, due to individual factors and age–related changes. Individuals can gain weight as they age and ageing is associated with a decrease in muscle mass and an increase in fat. Insulin is produced in the Islets of Langhern's and there is a decrease in functional cells as people age. This means that older people produce less insulin and they also become less sensitive to insulin ( Meneilly and Elliot, 1999 ; Ingelfinger and Jarcho, 2017 : Hermann et al, 2021 ).

Men are at greater risk of developing type 2 diabetes than middle aged women with higher body mass indexes (BMIs). This is thought to be because men and women carry fat in different ways. Men tend to have central obesity and higher levels of fat around the abdominal organs, that is, visceral fat. Women tend to deposit more fat around the hips and have lower levels of visceral fat ( Karastergiou et. al, 2012 : Kautzky-Willer et. al, 2016 ).

In people of South Asian, Chinese, and African-Caribbean family origin, the risk of type 2 diabetes increases at an earlier age and at a lower BMI level ( NICE, 2018 ).

People of South Asian and Chinese origin have a lower muscle mass than Caucasian populations and are at greater risk of developing diabetes than the white European population ( Jenum et al, 2019 ).

An estimated 13.6 million people in the UK are at an increased risk of diabetes ( Diabetes UK, 2020 ).

In England, the NHS has set up diabetes prevention programmes. These offer intensive behavioural intervention and set goals for weight loss, diet and physical activity. The programmes aim to enable people to make simple changes to reduce the risk of developing diabetes. The programme is open to people who are not pregnant, are aged 18-79, do not currently have diabetes and have received a score of 16 or over when using the ‘know your risk tool’. Links to the assessment tool and the programme is in the resources section.

Box 1.Finnish Diabetes Risk Score (FINDRISC) NOTE: Total risk score: <7 = low risk; 7–11 = slightly elevated risk; 12–14 =moderate risk; 15-20 = high risk; >20 = very high risk

NOTE: Total risk score: <7 = low risk; 7–11 = slightly elevated risk; 12–14 =moderate risk; 15-20 = high risk; >20 = very high risk

Source: Lindström and Tuomilehto (2003)

Although an individual's ethnicity can increase diabetes risk, biology is not destiny and the person at greater risk can take steps to reduce that risk.

Calculating diabetes risk

Risk assessment scores aim to identify people who have certain risk factors and to measure the level of risk an individual has of developing a certain disease or problem. The risk of developing diabetes varies according to ethnic group, weight and genetic factors. The NHS England website has an online calculator that asks seven questions to calculate diabetes risk, see resources for details. The Finnish Diabetes Risk Score (FINDRISC) was developed in Finland and works out a person's risk of developing type 2 diabetes; it is slightly more comprehensive as it checks diet and exercise ( Lindström and Tuomilehto 2003 ). Table 1 shows the FINDRISC.

Diagnosing diabetes

NICE (2022a) guidance recommends testing for diabetes if a person shows some of its clinical features.

A HbA1c blood test is commonly used to diagnose or monitor diabetes. It measures the amount of glucose attached to the haemoglobin over a 2 to 3 month period, as this is how long the blood cells typically last for in the body ( Medline plus, 2021 ). Fasting blood glucose (FBG) levels can be checked using capillary or venous blood.

The WHO states that diabetes is defined as HbA1c greater than 48mmol/mol or a FBG greater than 7mmol. However, these tests should be repeated to confirm the diagnosis (WHO, 2011). In 2011, the WHO stated that HbA1c can be used to diagnose type 2 diabetes due to increased convenience for the patient, reduced need for fasting, and reduced dietary preparation ( NHS London, 2018 ).

Inducing remission

In the past, people with type 2 diabetes were encouraged to lose weight and to increase activity levels. Most people were prescribed medication. We now know that dietary interventions that lead to weight loss can enable many people with type 2 diabetes to go into remission. The Diabetes Remission Clinical Trial (DiRECT) showed that 86% of people with type 2 diabetes who had been diagnosed in the previous 6 years could achieve remission if they lost weight rapidly. A weight loss of 15kg led to 86% remission and a weight loss of 10kg led to a 46% remission (Lean et al, 2017). This ground-breaking study has led to NHS England introducing a new programme to enable the remission of type 2 diabetes. The programme will initially provide 5,000 people in 10 areas with access to a meal replacement programme “soups and shakes” for 3 months. These provide around 900 calories daily. The programme will provide ongoing support from clinicians and coaches to enable people to maintain healthy lifestyles. ( NHS England, 2020 : NHS England, 2021 ).

A number of different classes of medication can be used to treat type 2 diabetes these are, biguanides, SGLT2 inhibitor, DPP-4 inhibitors, glitazones and sulphonylureas. Figure 5 illustrates treatment pathways.

Metformin, a biguanide class drug, was developed from lilacs and was used in herbal medicines for centuries ( Skugor, 2018 ). It is normally used as a first line of treatment in type 2 diabetes. It reduces the amount of glucose released by the liver and enables cells to take in insulin by reducing insulin resistance. It also helps to reduce the risk of heart disease.

Metformin does not cause hypoglycaemia when used as a monotherapy. It can lead to weight loss (3–5% of body weight), and it has been shown to decrease plasma triglycerides concentration (10–20%).

The most common side-effects of metformin are diarrhoea, nausea, abdominal discomfort and a metallic taste in the mouth. These side effects often resolve with continued use.

It is normally given twice daily or once daily (modified release). The normal starting dose is 500 mg daily. It is gradually titrated to reduce the risk of gastro-intestinal side effects, starting at 500 mg with breakfast and increasing by 500 mg in weekly intervals, until a dose of 1000 mg with breakfast and dinner or two grams MR once daily with breakfast is ingested. The maximum dose is 2550 mg per day but most practitioners use up to 2000 mg per day ( Skugor, 2018 ).

Metformin can cause very rare, but life-threatening lactic acidosis (<1 in 100 000). It should be used with caution in people with renal failure. The dose should be reviewed when estimated glomerular filtration rate (eGFR) falls below 45ml/min and should not be used when eGFR is 30ml/min or below ( NICE, 2022a ).

Sodium glucose cotransporter 2 inhibitors

There are four Sodium glucose cotransporter-2 inhibitors (SGLT2) available: dapagliflozin, canagliflozin, empagliflozin, ertugliflozin ( NICE, 2022a ). SGLT-2 enables the proximal renal tubules in the kidneys to reabsorb around 90% of glucose from tubular fluid. SGLT2 inhibitors block the reabsorption of glucose by the kidney, and increase the amount of urine excreted by the kidney. This reduces blood glucose levels in people with diabetes who have elevated blood glucose levels. SGLT2 inhibitors work independently of insulin and can be used in combination with insulin. They reduce major adverse cardiovascular and cerebrovascular events, such as stroke, myocardial infarction and cardiovascular death, as well as the number of hospital admissions for heart failure ( Vallon, 2015 : Zelniker et al, 2019 )

Common side effects include candida infections, back pain, increased amount of urine passed, dizziness and a mild skin rash. Serious, life-threatening, and fatal cases of diabetic ketoacidosis (DKA) are rare in people with type 2 diabetes. Gangrene (necrotising fasciitis of the genitalia or perineum) is a rare but serious and potentially life-threatening infection, has been associated with the use of sodium-glucose co-transporter 2 (SGLT2) inhibitors. They should not be prescribed if estimated glomerular filtration rate (a measure of renal function) is less than 60 mL/minute, as they are dependent on good renal function to act ( British National Formulary (BNF), 2022 ).

NICE (2022a) guidelines recommend that if the person with diabetes who has been prescribed metformin has heart failure, cardiovascular disease or risks of either, an SGLT2 should be prescribed in addition to metformin. Metformin should be initiated first and the SGLT2 added when the person is stabilised on metformin.

SGLT2 inhibitors can be combined with insulin in people with type 2 diabetes. They improve HbA1c, reduce body weight and decrease the required dose of insulin without increasing the risk of hypoglycaemia ( Yang et al, 2017 ).

DDP-4 inhibitors

DPP-4 inhibitors, known as gliptins, work by blocking the action of DPP-4, an enzyme which destroys the hormone incretin. Incretins help the body produce more insulin only when it is needed and reduce the amount of glucose being produced by the liver when it is not needed ( NICE, 2022a ).

The DPP-4 inhibitors (alogliptin, linagliptin, saxagliptin, sitagliptin, vildagliptin) are usually well-tolerated but hepatic, renal and cardiac function should be checked prior to prescribing. Linagliptin can be used safely in renal failure at a normal dose but dose should be reduced in the other gliptins ( NICE 2022b ).

They should be avoided in people with a past history of pancreatitis as they are associated with acute pancreatitis. Patients should be advised to report severe upper abdominal pain and medication should be stopped if this occurs ( BNF, 2022 ). There is an increased risk of heart failure in all gliptins other than linagliptin ( Li et al, 2016 ; McGuire et al, 2019 ; NICE, 2022b ).

The only glitazone licensed for use in the UK is pioglitazone. It works by treating insulin resistance ( Singh et al, 2022 ). It is contraindicated in heart failure, can cause fluid retention, increase fracture risk in post-menopausal women and increases the risk of bladder cancer ( NICE, 2022d ). NICE (2022a) recommend pioglitazone as a second line medication. A careful assessment of the risks and benefits of this medication should be undertaken before use.

Sulfonylureas

There are five sulfonylureas-glibenclamide, gliclazide glimepiride, glipizide and tolbutamide ( NICE, 2022c ). Sulfonylureas stimulates the beta-cells in the pancreas to produce more insulin and decrease clearance of insulin by the liver. They are only effective if there are functioning pancreatic beta-cells ( Sola et al, 2015 ). Sulfonylureas can cause hypoglycaemia and should be used with caution in older people, as hypoglycaemia is damaging to the ageing brain and can contribute to ill-health and cognitive decline ( Mathur et al, 2015 ; Thorpe et al, 2015 ). Sulfonylureas lead to weight gain, so long-term use is best avoided in people who are obese.

Glucagon-like Peptide 1 receptor agonists (GLP-1)

There are five GLP-1 agonists-exenatide, liraglutide, lixisenatide, dulaglutdie, semaglutide ( Nice, 2022d ). GLP-1 agonists work by activating GLP-1 receptors in the pancreas, which leads to an increase in insulin release, reduces glucagon release and slows gastric emptying, aid in the reduction of blood glucose and body weight ( Shaefer et al, 2015 ). GLP-1 agonists generally do not cause hypoglycaemia alone; however, they can contribute to hypoglycaemia if used in combination with Sulfonylureas and insulin ( Filippatos et al, 2014 ).

Diabetes-a global and national emergency

In the 20th century, there were fears that a rising global population would lead to famine. In the 21st century diabetes is affecting 537 million people. In 2021, 6.7 million people died of diabetes – that accounts for one person every 5 seconds. It is one of the top causes of premature death ( International Diabetes Federation, 2021 ).

In the UK, 13.6 million people are at increased risk of type 2 diabetes and the number of people with a diabetes diagnosis is expected to rise to 5.5 million by 2030 ( Diabetes UK, 2021 ).

Primary care will provide most of the treatment and care for people with type 2 diabetes.

Currently one in 16 adults has diabetes and it is estimated that by 2030 this number will increase to one in 10. The most important risk factor is obesity. Community nurses can help stem the tide of diabetes on a personal and a professional level.

On a personal level, staff working in healthcare do not always manage to maintain a healthy body weight. Department of Health (DOH) research indicates that 21% of the healthcare workforce, an estimated 300,000 staff were obese ( DOH, 2009 ).

A study of English healthcare workers found that two groups of healthcare workers, nurses and unregistered healthcare workers were most likely to be obese. The study found that 25.1% of registered nurses and 31.9% of unregistered healthcare workers were obese ( Kyle et al, 2017 ). Community nurses need to look after themselves as well as their patients.

On a professional level, nurses can screen people for diabetes risk, discuss this with the individual at risk and advise self-referral or refer the person to a diabetes prevention programme. People who have been diagnosed with diabetes can be referred to for the ‘soups and shakes programme’ in an effort to induce remission. People who require medication can be supported to manage diabetes.

Community nurses can make a real difference to the health and well-being of people who are at risk of or who have diabetes.

• The incidence of diabetes has reached epidemic proportions, globally and nationally
• There will be 5.5 million people with diabetes by 2030 if no action is taken
• The prevention and treatment of diabetes is to change radically with prevention programmes and the Soups and Shakes diets which will help induce remission
• Type 2 diabetes shortens lives and impairs health but it is preventable
• At an individual level, we can improve health and well-being.

CPD reflective questions

• Do you know your diabetes risk? If not, have it checked. If its abnormal what changes would you make to reduce your risk of developing diabetes?
• What factors have led to the increase of diabetes over the last 30 years?
• If you were in charge of the Department of Health and Social Care, what changes would you make to reduce the number of people developing diabetes?

Home Essay Examples Health Diabetes

The Issue Of Diabetes In The

• Category Health
• Subcategory Disease
• Topic Diabetes

Diabetes is a condition affecting 3.9 million people in the UK with 90% of these cases being type 2 diabetes. This is including the many people who are living with the condition but are currently undiagnosed. Type 2 diabetes is caused by problems with the hormone insulin, the body may resist the effects of insulin or the pancreas may not produce enough insulin to control blood glucose levels. The number of people being diagnosed with diabetes each year is rapidly increasing in the UK with an increase of more than 100,000 from 2018 to 2019. At this rate, the number of people with diabetes, including the undiagnosed population, is expected to rise to 5.3 million by 2025. (Diabetes UK, 2020)

A variety of modifiable lifestyle factors increase the chance of developing type 2 diabetes such as a sedentary lifestyle, lack of physical activity, smoking and alcohol consumption. (Wu, Ding, Tanaka and Zhang, 2014) Type 2 diabetes can be caused by having a family history of type 2 diabetes, especially when it is diagnosed at a younger age. (NHS, 2020)

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However, the main factor is obesity, it is responsible for 80 to 85% of the cases of type 2 diabetes and three in five cases could be prevented by individuals living a healthier and more active lifestyle. (Diabetes UK, 2020) The increase in the incidence of the condition is being fuelled by the rapidly increasing obesity rates in the United Kingdom. Abdominal fat in particular is known to increase the risks of type 2 diabetes, this is due to the visceral fat-releasing pro-inflammatory chemicals which disrupt the function of insulin causing insulin resistance which is the cause of type 2 diabetes. Reducing body weight can improve the body’s insulin sensitivity and therefore greatly reduce the risk of diabetes. (Diabetes and Obesity, 2020) A diet high in saturated fat and low in fibre has been shown to increase diabetes risk as opposed to a diet high in sugar. (BNF, 2020) In addition to this, people in lower socio-economic groups have an increased risk of type 2 diabetes as deprivation is strongly associated with higher levels of obesity, physical inactivity, smoking and an increased energy intake. ( Nutrition Foundation, 2019) There is also a link between increasing age and higher diabetes prevalence, 9.0% of people aged 45 to 54 are estimated to have diabetes and 23.8% aged 75 years and over. (Public Health England, 2020) However, the number of younger people being diagnosed with the condition is also increasing.

As the number of people with diabetes is increasing, there are many more social and financial consequences developing. Type 2 diabetes is one of the biggest causes of premature illness and death, this is mostly due to the increased risk of cardiovascular disease in people with diabetes. Diabetes, when not managed sufficiently through diet, exercise and medication can cause serious problems such as loss of sight, heart failure, stroke, nerve damage which can lead to amputation and kidney failure. ( Nutrition Foundation, 2019) At the time of diagnosis, half of the people with type 2 diabetes already show early signs of these health conditions and within 20 years of being diagnosed, 60% of people have some degree of retinopathy. (Diabetes Complications, 2020) This highlights the importance of preventative measures in order to tackle the condition.

In addition to these complications, type 2 diabetes can cause mental health problems such as depression and anxiety. Being diagnosed with a long-term condition such as this can be challenging to come to terms with. In addition to this, the development of complications, dealing with new medication and the stress of managing their diabetes daily can impact the emotional wellbeing of individuals. Around 40% of people with diabetes, type 1 and 2, struggle with their mental health, often because of the demands diabetes has on their life. (Peyrot et al., 2005) Also, as the condition is more prevalent in older people, they are more likely to struggle to make changes to their lifestyle and diet as their lifelong habits may be hard to break. Anxiety can be caused by the diagnosis as the greater chance of health problems may affect their ability to work and would cause them to worry about income for themselves and their family.

The large number of people living with this condition is putting an unsustainable strain on the NHS. Prescriptions for both types of diabetes cost NHS England alone more than £1 billion a year. However, it is estimated that the total cost of diabetes to the NHS may be over £10 billion a year when diabetes complications and diagnostic and monitoring devices are considered. (BBC News, 2020)

However, although the diagnosis of type 2 diabetes may be hard to come to terms with and daunting for the individual, it can be managed through diet and medication. In addition, with support, the potential complications of type 2 diabetes can be minimised. It is also possible for some people to put their type 2 diabetes into remission through losing weight with a healthy balanced diet and exercise. The diagnosis may also help people take control of their health and are an opportunity for them to be educated on how to eat a balanced diet and exercise regularly in order to live a healthy life.

Due to the fact that three out of five cases of type 2 diabetes can be prevented, the PHA has developed the Diabetes Prevention Programme which is currently running in Northern Ireland and in other parts of the United Kingdom. It is aimed at people with pre-diabetes, this is when the blood glucose levels are slightly out of the normal range but not in the diabetic range. It is a free nine-month long programme delivered by health coaches. They offer help and assistance to participants for them to change their lifestyle, diet and physical activity with the aim of delaying the onset and reducing the likelihood of complications of type 2 diabetes. (HSC Public Health Agency, 2020) However, this requires people to be proactive about their health and to find out if they are at risk as they must be referred to the programme by a nurse, doctor or pharmacist.

Diabetes UK is working to raise awareness of the condition, they have a free ‘Know Your Risk’ online tool for people to assess their risk of developing type 2 diabetes with information such as ethnicity, BMI and age being collected to inform people of their risk. The charity is also encouraging people living in England aged 40 or over to get a free NHS health check which is available to them every five years. (Diabetes UK, 2020)

Chris Askew, the Chief Executive at Diabetes UK, has also highlighted the importance of actions by the government being ‘supported by industry’ in order for real change to be made. (Diabetes UK, 2020) There has been an example of this recently when the government imposed a sugar tax that caused companies to reformulate their products in order to avoid the excess costs on their products.

In conclusion, the threat to the health of the UK population and the financial burden of the rapidly increasing number of diabetic patients is soon going to be unsustainable for the NHS. In many cases, type 2 diabetes is a preventable condition, in order to tackle this there is a need for widespread age and culturally appropriate educational literature that informs the population of the importance of a healthy active lifestyle. (Diabetes UK, 2019) There has been industry intervention with reducing sugar, salt and fats in foods in many cases. However, people are largely responsible for their own diet and lifestyle, for behavioural change individuals need to be proactive in working to improve this. 

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• Health and social care
• Public health
• Health conditions
• Health matters: preventing Type 2 diabetes
• Public Health England

Health matters: preventing Type 2 Diabetes

Published 24 May 2018

© Crown copyright 2018

This publication is licensed under the terms of the Open Government Licence v3.0 except where otherwise stated. To view this licence, visit nationalarchives.gov.uk/doc/open-government-licence/version/3 or write to the Information Policy Team, The National Archives, Kew, London TW9 4DU, or email: [email protected] .

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This publication is available at https://www.gov.uk/government/publications/health-matters-preventing-type-2-diabetes/health-matters-preventing-type-2-diabetes

This professional resource outlines how to optimise the NHS Diabetes Prevention Programme ( NHS DPP ) in order to identify those already found to be at risk of developing Type 2 diabetes and offer support that will help them reduce their risk of developing the disease.

Scale of the problem

Diabetes is a non-communicable disease ( NCD ) where the amount of glucose in the blood is too high. Type 1 diabetes is an autoimmune disease whereby the body is unable to produce any insulin, and Type 2 diabetes develops when the body stops producing enough insulin or the body’s cells stop reacting to insulin produced.

Type 2 diabetes is associated with lifestyle factors – being overweight or obese is the major modifiable risk factor for Type 2 diabetes. The onset of Type 2 diabetes can be delayed or prevented through support to change behaviour around lifestyle choices. Type 1 diabetes is not related to lifestyle issues, and at this point cannot be prevented.

The global burden of diabetes

Globally, an estimated 108 million adults were living with diabetes in 1980, and by 2014 this figure had almost quadrupled to 422 million adults; an increase in global prevalence from 4.7% in 1980, to 8.5% in 2014. This is largely due to the rise in Type 2 diabetes, which is estimated to account for 90% of all diabetes cases in the UK. The growing overweight and obesity epidemic is a major driver behind this rise in Type 2 diabetes.

According to the World Health Organisation (WHO), diabetes was the sixth highest cause of global death in 2015. There were an estimated 1.6 million deaths from diabetes in 2015, which included deaths from complications and other diseases that arose from high blood sugar.

The national burden of Type 2 diabetes

Type 2 diabetes is a major cause of premature mortality, with around 22,000 people with diabetes dying early each year in England. It is often not Type 2 diabetes itself that causes death, but complications of the disease, including cardiovascular disease ( CVD ).

The condition is progressive, requiring action at the population and individual level to support changes in lifestyle, particularly diet and physical activity. It also requires oral drugs and insulin for most people over time.

Risk factors for Type 2 diabetes

The obesogenic environment and associated lifestyle risk factors.

The increasingly obesogenic environment we live in makes it harder for individuals to avoid unhealthy lifestyle choices. The obesogenic environment can be considered to be at the root of the prevention challenge in Type 2 diabetes.

From childhood, people are exposed to ultra-processed, energy-dense, nutrient-poor foods, which are cheap and readily available. Opportunities for physical activity, both in and out of school and the workplace, have been reduced and more time is spent on screen-based and sedentary leisure activities. As a result, high proportions of children and adults have increasingly been defaulting to unhealthy lifestyle choices including unhealthy diets, low levels of physical activity, and sedentary behaviour. These all give rise to higher risk of Type 2 diabetes:

• overweight or obesity with a body mass index ( BMI ) of 25 or more
• a large waist circumference – more than 80cm or 31.5 inches in women and 94cm or 37 inches in men

Therefore, being overweight or obese is the main modifiable risk factor for Type 2 diabetes, with the likelihood of developing the disease and the risk of complications being closely linked to BMI . There is a 7 times greater risk of diabetes in obese people compared to those of a healthy weight, and a threefold increase in risk for overweight people. Severely obese people, with a BMI of 40 or over, are at an even greater risk than obese people with a lower BMI ranging from 30 to 39.9.

Whilst it is known that body fat distribution is an important determinant of increased diabetes risk, the precise mechanism of the association between obesity and Type 2 diabetes remains unclear. It is also uncertain why not all people who are obese develop Type 2 diabetes, and why not all people with Type 2 diabetes are obese.

A large waist circumference is also a preventable risk factor, which often coincides with obesity. Men with an increased waist circumference are 5 times more likely and women are over 3 times more likely to have diagnosed Type 2 diabetes than those without a raised waist circumference.

Deprivation

Individuals from more deprived backgrounds face greater challenges in making healthier lifestyle choices.

Deprivation and low socioeconomic status are closely associated to heightened risk of obesity. Data from the Health and Safety Executive shows that in 2014 in the most deprived quintile compared to the least, obesity was 13% and 50% higher for men and women, respectively.

Prevalence of Type 2 diabetes is 60% more common among individuals in the most deprived quintile compared with those in the least deprived quintile in England.

Demographic and medical history risk factors

In addition to modifiable risk factors associated with the obesogenic environment and associated lifestyles, there are risk factors related to ethnicity and medical history, which cannot be controlled or prevented, including:

• a family history of Type 2 diabetes
• age – being older than 40 or older than 25 for some black and minority ethnic ( BME ) groups
• certain ethnicities

Health impact of Type 2 diabetes

Those who develop Type 2 diabetes are subsequently at greater risk of developing complications from the disease:

Macrovascular complications

• CVD including heart attack and stroke – Type 2 diabetes leads to a 2 fold excess risk of CVD

Microvascular complications

• blindness – diabetic retinopathy is the leading cause of preventable sight loss among people of working age in England and Wales
• nerve damage
• kidney disease and failure
• peripheral neuropathy
• diabetic foot disease

Mental health and social consequences

A Type 2 diabetes diagnosis can also negatively impact quality of life and social contact, which can have an adverse effect on mental health. Depression is more prevalent among people living with Type 2 diabetes, compared with those who are not. This, as well as many other complications of Type 2 diabetes, increases their risk of premature death.

A survey conducted by Diabetes UK also found that:

• 3 in 5 people (64%) living with diabetes experience emotional or mental health problems as a result of their condition
• just 3 in 10 people living with diabetes said they definitely felt in control of their condition
• nearly a third of people living with diabetes had at some point relied on self-help materials
• one in 5 people living with diabetes had used support or counselling from a trained professional to help them manage their diabetes

There is also evidence that minor psychological morbidities lower adherence to Type 2 diabetes treatment, which can have knock-on effects on patients’ health.

In addition to mental health and quality of life, the important social consequences of Type 2 diabetes include impacts on individuals’ family life, education and employment. Whilst these factors are typically under-recognised in health research, from a public health perspective they are wider consequences that are just as important as health outcomes. They also tend to be highlighted as important by people living with Type 2 diabetes, as they have far-reaching impacts.

Diabetic foot disease

Diabetic foot disease is a potential consequence of the microvascular complication of peripheral neuropathy and the macrovascular complication of peripheral vascular disease.

Latest figures show that between 2014/2015 and 2016/2017, there were 132,114 hospital spells for diabetic foot disease. The median length of stay in hospital was 8 days and the total number of days spent in hospital for diabetic foot disease was 1,730,072.

There were 7,305 major amputation procedures performed, giving a directly age and ethnicity standardised rate of 8.2 major amputations per 10,000 population-year. This is one of the lowest amputation rates worldwide.

Costs to the NHS and wider economy

80% of the direct costs are related to the complications of Type 2 diabetes. There are also major indirect costs, such as loss of productivity due to increased death and illness and the need for informal care. It is estimated that in 2010 to 2011, indirect costs in the UK were approximately £13 billion.

The national response to diabetes prevention

The national response to diabetes prevention includes multiple different behavioural interventions that address lifestyle choices that lead to individuals being at high risk of developing Type 2 diabetes. This edition of Health matters will focus specifically on the Healthier You: NHS Diabetes Prevention Programme ( NHS DPP ).

Healthier You: NHS Diabetes Prevention Programme

The NHS DPP is a joint commitment from PHE , NHS England and Diabetes UK. The Programme, launched in 2015, delivers evidence based behavioural interventions at scale for individuals identified as being at high risk of developing Type 2 diabetes.

The NHS DPP is underpinned by a strong evidence base. PHE has published a systematic review and meta-analysis examining the effectiveness of diabetes prevention programmes.

The goals of the NHS DPP are to:

• reduce the incidence of Type 2 diabetes
• reduce the incidence of complications associated with Type 2 diabetes – heart, stroke, kidney, eye and foot problems related to diabetes
• reduce health inequalities associated with incidence of Type 2 diabetes, over the longer term

In the short-term, the Programme recognises that a stronger focus on identifying people who are at risk of diabetes is likely to increase recorded incidence of diabetes as more undiagnosed cases are uncovered. This is important to recognise as it is possible to live for some time with undiagnosed Type 2 diabetes; in 2015, an estimated 900,000 people had Type 2 diabetes but were undiagnosed.

There is strong international evidence that demonstrates how behavioural interventions, with a focus on supporting people to maintain a healthy weight and be more active, can significantly reduce the risk of developing Type 2 diabetes. The NHS DPP behavioural intervention reflects this evidence, as it is underpinned by 3 core goals:

• achieving a healthy weight
• achievement of dietary recommendations
• achievement of the Chief Medical Officers’ ( CMO ) physical activity recommendations

Dr Jonathan Valabhji outlines the aims of NHS Diabetes Prevention Programme

Who is eligible?

The NHS DPP provides a behavioural intervention for individuals aged 18 years or over with nondiabetic hyperglycaemia ( NDH ), which is defined as having an HbA1c of 42 to 47 mmol/l or 6.0 to 6.4% or fasting plasma glucose ( FPG ) of 5.5 to 6.9 mmol/l. These individuals are at high risk for progression to Type 2 diabetes. The blood result indicating NDH must be within the last 12 months to be eligible for referral.

Individuals with blood glucose levels in the normal range (HbA1c less than 42 mmol or less than 6.0%) and those with a diagnosis of Type 2 diabetes are not eligible for the NHS DPP intervention. A diagnosis requires 2 separate blood tests within the diabetic range (HbA1c greater than or equal to 48 mmol or FPG greater than or equal to 7 mmol/l).

Dr Jonathan Valabhji describes how the NHS Diabetes Prevention Programme is reaching those most at risk

What is involved?

The intervention consists of a series of predominantly group-based sessions delivered in person across a period of at least 9 months. There are at least 13 sessions, lasting between 1 and 2 hours, and at least 16 hours of contact time.

Each session covers topics geared towards the Programme’s main goals of weight reduction and improved glycaemic control through dietary improvements, and increased physical activity and reduction in sedentary behaviour. They are underpinned by behavioural theory and involve the use of behavioural techniques.

NHS DPP coverage in England

In June 2016, the process for roll out of the NHS DPP began with a first wave of 27 areas covering 26 million people, half of the population in England, and making up to 20,000 places available. In April 2017, the Programme mobilised across a further 13 sustainability and transformation partnerships ( STPs ), achieving 75% population coverage in England.

The programme rolled out to all remaining clinical commissioning groups ( CCGs ) and local authorities ( LAs ) in England that were not previously included in the Programme, achieving full coverage from April 2018, with referrals due to start in July 2018. There have been over 185,000 referrals and over 78,000 taking up the programme to date.

Dr Jonathan Valabhji describes the roll out of the NHS Diabetes Prevention Programme

Early outcome data and provisional analyses suggest that over 50% of the individuals that started the intervention completed it. Completion is defined as attendance to 62% or more of the Programme sessions, which is 8 out of 13 sessions in the curricula of most providers, aligning to the financial incentives for providers to retain participants on the programme.

Digital approach

A digital pilot of the NHS DPP was launched in November 2017 and referrals to digital services commenced in December 2017.

The digital stream offers an alternative service to face-to-face programmes, with the potential to widen access to diabetes prevention. It offers similar support, assistance and guidance using technologies, including wearables and apps. An estimated 5,000 people are expected to gain access to these digital interventions over the 18 to 24 month duration of the pilot.

The 8 digital pilot sites implementing digital services are:

• Buckinghamshire, Oxfordshire and Berkshire
• Bristol, North Somerset and South Gloucestershire
• Central and West London, Hammersmith and Fulham, Hounslow and Ealing
• North East London
• Humber Coast and Vale

Dr Jonathan Valabhji describes the digital stream of the NHS Diabetes Prevention Programme

The referral routes: identifying those who can benefit from the NHS DPP

Referral routes into the Programme vary according to local case finding pathways. Three primary mechanisms for referral are:

• the NHS Health Check Programme, which should be made available to 15.5 million eligible adults aged 40-74 years of age every 5 years. These checks should include a diabetes risk assessment or filter, which should lead onto blood testing for those identified at risk. Those people identified as having NDH should be offered a referral to the NHS DPP in accordance with the local protocol.

Find out more about the NHS Health Check Programme in this previous edition of Health Matters.

• those who have already been identified as having an appropriately elevated risk level (HbA1c or FPG ) in the past and who have been included on a register of patients with high HbA1c or FPG
• those who are identified with NDH through opportunistic assessment as part of routine clinical care

Lifestyle interventions and national policies

National policies to tackle obesity and prevent type 2 diabetes.

The association between overweight and obesity and risk of developing Type 2 diabetes is well established. Therefore, it is crucial to tackle obesity as a means of preventing future cases of Type 2 diabetes.

The following national policies are predicated on acting on the obesogenic environment:

Calorie reduction programme

The calorie reduction programme challenges the food industry to achieve a 20% reduction in calories by 2024 in product categories that contribute significantly to children’s calorie intakes (up to the age of 18 years) and where there is scope for substantial reformulation and/or portion size reduction.

Although the programme focuses on foods consumed by children up to the age of 18 years, the programme is supporting all family members in reducing their calorie consumption, particularly with continued support through PHE ’s OneYou and Change4Life campaigns. The OneYou campaign encourages adults to follow a simple rule of thumb: 400-600-600 – the number of calories to aim for at breakfast, lunch and dinner, with healthy snacks in between.

Sugar reduction programme

A broad, structured sugar reduction programme is being led by PHE to remove sugar from the products children eat most. All sectors of the food and drinks industry will be challenged to reduce overall sugar, across a range of products that contribute to children’s sugar intakes, by at least 20% by 2020, including a 5% reduction in year 1.

A soft drinks industry levy

The government’s childhood obesity plan outlined plans for a soft drinks industry levy across the UK, which was brought into law in April 2018. Sugary soft drinks provide 26% of the total sugar intakes for 11 to 18 years olds in England, according to the National Diet and Nutrition Survey . The Scientific Advisory Committee on Nutrition ( SACN ) recently concluded that sugar consumption increases the risk of consuming too many calories. In England, the revenue from the levy will be invested in programmes to reduce obesity and encourage physical activity and balanced diets for school age children.

PHE ’s marketing campaigns

PHE has a number of national marketing campaigns that can be used at a local level to encourage people to improve their lifestyle behaviours. Downloadable content is available from the PHE Campaign Resource Centre .

Diabetes Prevention Week

NHS England, PHE and Diabetes UK launched the first Diabetes Prevention Week in April 2018. The week-long campaign raised awareness of Type 2 diabetes, the complications associated with it, high-risk groups, and how to prevent it.

A Diabetes Prevention Week toolkit was made available for GP practices and other local organisations to order for free from the PHE Campaign Resource Centre . This includes everything needed to host your own local diabetes prevention events and advertise your local NHS DPP service, from posters and leaflets, to briefing documents, videos and social media plans.

The week was a success, with nearly 5,000 toolkits ordered from practices across the country. We plan to make the week an annual event with the next Diabetes Prevention Week taking place in April 2019.

Call to action

It is important to have a smooth referral pathway that works hand in hand with the NHS DPP providers. To achieve this, the number of GP referrals must be realistic so that demand matches the providers’ supply capacity. This, in turn, can minimise waiting times and therefore minimise drop-off from the programmes.

This section outlines the specific actions that primary care professionals and local authorities can take to enable a successful referral process, and maximise the number of individuals identified as being at risk of Type 2 diabetes taking up and completing the NHS DPP .

Primary care providers

Primary care engagement is crucial for the effective implementation of the NHS DPP , as primary care professionals are required to identify individuals at high risk of developing Type 2 diabetes and refer them into the Programme. As such, their support to individuals is important to encourage take up and completion of the 9-month Programme.

There are a few simple steps primary care providers can take to ensure the Programme is successful, including:

• working closely with the diabetes clinical network and intervention providers
• making connections with NHS DPP providers to identify and promote wider community assets that can support people to achieve their goals
• considering the quality of referrals and whether individuals are sufficiently motivated to attend the Programme
• maintaining an up-to-date register of people with NDH
• conducting annual follow-ups and recording results, as per NICE guidelines, for all individuals in NDH category
• ensuring inclusion of a diabetes risk assessment in the NHS Health Check and providing follow-up blood tests for those identified as being at high risk

Case study: Driving clinical engagement in diabetes prevention

Case study: Practice based nurse case finding approach

Application of behavioural insights

There are 3 key aspects of the NHS DPP that would benefit from the application of behavioural insights:

• uptake of diabetes prevention programmes
• retention to diabetes prevention programmes
• lifestyle change

The EAST framework, developed by PHE ’s Behavioural Insights Team, is a simple framework for thinking about behaviour change that can be applied to the 3 key aspects of the NHS DPP listed above. The premise of the framework is to make the process ‘ EAST ’, which stands for Easy, Attractive, Social and Timely. PHE has published further advice on this.

Local authorities and Clinical Commissioning Groups ( CCGs )

Identify and increase uptake to the programme.

CCGs and local authority ( LA ) commissioners should work with their local voluntary sector to raise awareness and commission tailored lifestyle interventions to high risk BME communities.

NHS commissioners should work alongside LAs to increase uptake and identify those who could benefit from a NHS Health Check, as it includes a diabetes filter that pinpoints those at high risk of developing the condition.

CCGs and LAs will need to integrate the NHS DPP into the local care pathway, and work with providers to manage this process of referrals, including appropriate data processing and data sharing agreements where required.

NHS commissioners can use the NHS RightCare Diabetes Pathway which shows the core components of an optimal diabetes service, including risk detection using the NHS DPP .

Case study: Marketing approaches to promote engagement

Case study: Targeted case finding approaches

Provide and deliver lifestyle interventions

Commissioners have a key role to play in ensuring that patients identified through the programme are offered lifestyle advice to achieve:

• a healthy weight
• dietary recommendations
• CMO physical activity recommendations

It is anticipated that the NHS DPP will encourage the uptake of other resources which should be made available in the local community such as:

• exercise classes
• walking groups
• swimming offers
• weight management programmes

Population-level interventions to prevent diabetes

In the long term, it remains the case that to address obesity and therefore reduce the risk of Type 2 diabetes, local health economies ( STPs , and community, voluntary and private sectors) must work together in implementing population-level approaches.

Specific guidance from NICE on approaches to working strategically on diabetes prevention at the population level is available ( NICE guidelines PH35 ). This guidance covers specific steps to integrate local and national action, promote food and physical activity at the population level, and to target groups who9 are particularly at risk of developing diabetes.

You can also find out more about population-level interventions for obesity in the previous edition of Health matters.

Download references .

Download the Health matters infographics .

Read the Health matters blog .

Watch Health matters videos .

Download case study: Driving clinical engagement in diabetes prevention .

Download case study: Practice based nurse case finding approach .

Download case study: Marketing approaches to promote engagement .

Download case study: Targeted case finding approaches .

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• World J Diabetes
• v.6(6); 2015 Jun 25

Diabetes mellitus: The epidemic of the century

Correspondence to: Akram T Kharroubi, PhD, Associate Professor of Biochemistry and Endocrinology, Dean of Faculty of Health Professions, Department of Medical Laboratory Sciences, Faculty of Health Professions, Al-Quds University, P.O. Box 51000, Abed Elhamaid Shoman Street, Beit Hanina-Jerusalem, Jerusalem 91000, Palestine. [email protected]

Telephone: +972-2-2791243 Fax: +972-2-2791243

The epidemic nature of diabetes mellitus in different regions is reviewed. The Middle East and North Africa region has the highest prevalence of diabetes in adults (10.9%) whereas, the Western Pacific region has the highest number of adults diagnosed with diabetes and has countries with the highest prevalence of diabetes (37.5%). Different classes of diabetes mellitus, type 1, type 2, gestational diabetes and other types of diabetes mellitus are compared in terms of diagnostic criteria, etiology and genetics. The molecular genetics of diabetes received extensive attention in recent years by many prominent investigators and research groups in the biomedical field. A large array of mutations and single nucleotide polymorphisms in genes that play a role in the various steps and pathways involved in glucose metabolism and the development, control and function of pancreatic cells at various levels are reviewed. The major advances in the molecular understanding of diabetes in relation to the different types of diabetes in comparison to the previous understanding in this field are briefly reviewed here. Despite the accumulation of extensive data at the molecular and cellular levels, the mechanism of diabetes development and complications are still not fully understood. Definitely, more extensive research is needed in this field that will eventually reflect on the ultimate objective to improve diagnoses, therapy and minimize the chance of chronic complications development.

Core tip: Diabetes mellitus is rising to an alarming epidemic level. Early diagnosis of diabetes and prediabetes is essential using recommended hemoglobin A1c criteria for different types except for gestational diabetes. Screening for diabetes especially in underdeveloped countries is essential to reduce late diagnosis. Diabetes development involves the interaction between genetic and non-genetic factors. Biomedical research continues to provide new insights in our understanding of the mechanism of diabetes development that is reviewed here. Recent studies may provide tools for the use of several genes as targets for risk assessment, therapeutic strategies and prediction of complications.

DEFINITION OF DIABETES MELLITUS

Diabetes mellitus is a group of metabolic diseases characterized by chronic hyperglycemia resulting from defects in insulin secretion, insulin action, or both. Metabolic abnormalities in carbohydrates, lipids, and proteins result from the importance of insulin as an anabolic hormone. Low levels of insulin to achieve adequate response and/or insulin resistance of target tissues, mainly skeletal muscles, adipose tissue, and to a lesser extent, liver, at the level of insulin receptors, signal transduction system, and/or effector enzymes or genes are responsible for these metabolic abnormalities. The severity of symptoms is due to the type and duration of diabetes. Some of the diabetes patients are asymptomatic especially those with type 2 diabetes during the early years of the disease, others with marked hyperglycemia and especially in children with absolute insulin deficiency may suffer from polyuria, polydipsia, polyphagia, weight loss, and blurred vision. Uncontrolled diabetes may lead to stupor, coma and if not treated death, due to ketoacidosis or rare from nonketotic hyperosmolar syndrome[ 1 - 3 ].

CLASSIFICATION OF DIABETES MELLITUS

Although classification of diabetes is important and has implications for the treatment strategies, this is not an easy task and many patients do not easily fit into a single class especially younger adults[ 1 , 4 - 6 ] and 10% of those initially classified may require revision[ 7 ]. The classical classification of diabetes as proposed by the American Diabetes Association (ADA) in 1997 as type 1, type 2, other types, and gestational diabetes mellitus (GDM) is still the most accepted classification and adopted by ADA[ 1 ]. Wilkin[ 8 ] proposed the accelerator hypothesis that argues “type 1 and type 2 diabetes are the same disorder of insulin resistance set against different genetic backgrounds”[ 9 ]. The difference between the two types relies on the tempo, the faster tempo reflecting the more susceptible genotype and earlier presentation in which obesity, and therefore, insulin resistance, is the center of the hypothesis. Other predictors of type 1 diabetes include increased height growth velocity[ 10 , 11 ] and impaired glucose sensitivity of β cells[ 12 ]. The implications of increased free radicals, oxidative stress, and many metabolic stressors in the development, pathogenesis and complications of diabetes mellitus[ 13 - 18 ] are very strong and well documented despite the inconsistency of the clinical trials using antioxidants in the treatment regimens of diabetes[ 19 - 21 ]. The female hormone 17-β estradiol acting through the estrogen receptor-α (ER-α) is essential for the development and preservation of pancreatic β cell function since it was clearly demonstrated that induced oxidative stress leads to β-cell destruction in ER-α knockout mouse. The ER-α receptor activity protects pancreatic islets against glucolipotoxicity and therefore prevents β-cell dysfunction[ 22 ].

TYPE 1 DIABETES MELLITUS

Autoimmune type 1 diabetes.

This type of diabetes constitutes 5%-10% of subjects diagnosed with diabetes[ 23 ] and is due to destruction of β cells of the pancreas[ 24 , 25 ]. Type 1 diabetes accounts for 80%-90% of diabetes in children and adolescents[ 2 , 26 ]. According to International Diabetes Federation (IDF), the number of youth (0-14 years) diagnosed with type 1 diabetes worldwide in 2013 was 497100 (Table ​ (Table1) 1 ) and the number of newly diagnosed cases per year was 78900[ 27 ]. These figures do not represent the total number of type 1 diabetes patients because of the high prevalence of type 1 diabetes in adolescence and adults above 14 years of age. One reported estimate of type 1 diabetes in the United States in 2010 was 3 million[ 28 , 29 ]. The number of youth in the United States younger than 20 years with type 1 diabetes was estimated to be 166984 in the year 2009[ 30 ]. The prevalence of type 1 diabetes in the world is not known but in the United States in youth younger than 20 years was 1.93 per 1000 in 2009 (0.35-2.55 in different ethnic groups) with 2.6%-2.7% relative annual increase[ 26 , 31 ]. Type 1 diabetes is mainly due to an autoimmune destruction of the pancreatic β cells through T-cell mediated inflammatory response (insulitis) as well as a humoral (B cell) response[ 25 ]. The presence of autoantibodies against the pancreatic islet cells is the hallmark of type 1 diabetes, even though the role of these antibodies in the pathogenesis of the disease is not clear. These autoantibodies include islet cell autoantibodies, and autoantibodies to insulin (IAA), glutamic acid decarboxylase (GAD, GAD65), protein tyrosine phosphatase (IA2 and IA2β) and zinc transporter protein (ZnT8A)[ 32 ]. These pancreatic autoantibodies are characteristics of type 1 diabetes and could be detected in the serum of these patients months or years before the onset of the disease[ 33 ]. Autoimmune type 1 diabetes has strong HLA associations, with linkage to DR and DQ genes. HLA-DR/DQ alleles can be either predisposing or protective[ 1 ]. This autoimmune type 1 diabetes is characterized by the absence of insulin secretion and is more dominant in children and adolescents.

Number of subjects with type 1 diabetes in children (0-14 years), with diabetes in adults (20-79 years) and with hyperglycemia (type 2 or gestational diabetes) in pregnancy (20-49 years)

Data extracted from International Diabetes Federation Diabetes Atlas, 6th ed, 2013.

In addition to the importance of genetic predisposition in type 1 diabetes, several environmental factors have been implicated in the etiology of the disease[ 9 , 33 ]. Viral factors include congenital rubella[ 34 , 35 ], viral infection with enterovirus, rotavirus, herpes virus, cytomegalovirus, endogenous retrovirus[ 36 , 37 ] and Ljungan virus. Other factors include low vitamin D levels[ 38 ], prenatal exposure to pollutants, improved hygiene and living conditions decreased childhood infections in countries with high socioeconomic status leading to increased autoimmune diseases (hygiene hypothesis), early infant nutrition such as using cow’s milk formula instead of breast feeding[ 39 ] in addition to insulin resistance in early childhood due to obesity or increased height growth velocity. The role of environmental factors remains controversial[ 40 ]. Recent evidence supported the causative effect of viral infections in diabetes[ 41 - 43 ].

Type 1 diabetes often develops suddenly and can produce symptoms such as polydipsia, polyuria, enuresis, lack of energy, extreme tiredness, polyphagia, sudden weight loss, slow-healing wounds, recurrent infections and blurred vision[ 27 ] with severe dehydration and diabetic ketoacidosis in children and adolescents. The symptoms are more severe in children compared to adults. These autoimmune type 1 diabetes patients are also prone to other autoimmune disorders such as Graves’ disease, Hashimoto’s thyroiditis, Addison’s disease, vitiligo, celiac sprue, autoimmune hepatitis, myasthenia gravis, and pernicious anemia[ 1 ]. The complete dependence on insulin of type 1 diabetes patients may be interrupted by a honeymoon phase which lasts weeks to months or in some cases 2-3 years. In some children, the requirement for insulin therapy may drop to a point where insulin therapy could be withdrawn temporarily without detectable hyperglycemia[ 44 ].

Idiopathic type 1 diabetes

A rare form of type 1 diabetes of unknown origin (idiopathic), less severe than autoimmune type 1 diabetes and is not due to autoimmunity has been reported. Most patients with this type are of African or Asian descent and suffer from varying degrees of insulin deficiency and episodic ketoacidosis[ 45 ].

Fulminant type 1 diabetes

This is a distinct form of type 1 diabetes, first described in the year 2000, and has some common features with idiopathic type 1 diabetes being non-immune mediated[ 46 , 47 ]. It is characterized by ketoacidosis soon after the onset of hyperglycemia, high glucose levels (≥ 288 mg/dL) with undetectable levels of serum C-peptide, an indicator of endogenous insulin secretion[ 48 ]. It has been described mainly in East Asian countries and accounted for approximately 20% of acute-onset type 1 diabetes patients in Japan (5000-7000 cases) with an extremely rapid and almost complete beta-cell destruction resulting in nearly no residual insulin secretion[ 48 , 49 ]. Both genetic and environmental factors, especially viral infection, have been implicated in the disease. Anti-viral immune response may trigger the destruction of pancreatic beta cells through the accelerated immune reaction with no detectable autoantibodies against pancreatic beta cells[ 48 , 50 ]. Association of fulminant type 1 diabetes with pregnancy has also been reported[ 51 ].

TYPE 2 DIABETES MELLITUS

The global prevalence of diabetes in adults (20-79 years old) according to a report published in 2013 by the IDF was 8.3% (382 million people), with 14 million more men than women (198 million men vs 184 million women), the majority between the ages 40 and 59 years and the number is expected to rise beyond 592 million by 2035 with a 10.1% global prevalence. With 175 million cases still undiagnosed, the number of people currently suffering from diabetes exceeds half a billion. An additional 21 million women are diagnosed with hyperglycemia during pregnancy. The Middle East and North Africa region has the highest prevalence of diabetes (10.9%), however, Western Pacific region has the highest number of adults diagnosed with diabetes (138.2 millions) and has also countries with the highest prevalence (Figure ​ (Figure1 1 )[ 27 ]. Low- and middle-income countries encompass 80% of the cases, “where the epidemic is gathering pace at alarming rates”[ 27 ]. Despite the fact that adult diabetes patients are mainly type 2 patients, it is not clear whether the reported 382 million adults diagnosed with diabetes also include type 1 diabetes patients.

Comparative prevalence of diabetes in adults (20-79 years) in countries with high prevalence (≥ 10%). Data extracted from International Diabetes Federation Diabetes Atlas, 6th ed, 2013.

More than 90%-95% of diabetes patients belong to this type and most of these patients are adults. The number of youth (less than 20 years) with type 2 diabetes in the United States in the year 2009 was 0.46 in 1000 and accounted for approximately 20% of type 2 diabetes in youth[ 26 ]. The increased incidence of type 2 diabetes in youth is mainly due to the change in the lifestyle of the children in terms of more sedentary life and less healthy food. Obesity is the major reason behind insulin resistance which is mainly responsible for type 2 diabetes[ 52 - 54 ]. The ADA recommends screening of overweight children and adolescence to detect type 2 diabetes[ 55 , 56 ]. The prevalence of obesity in children in on the rise[ 6 ] which is probably the main reason for the increased incidence of type 2 diabetes in the young (30.3% overall increase in type 2 diabetes in children and adolescence between 2001 and 2009)[ 26 ].

Insulin resistance in type 2 diabetes patients increases the demand for insulin in insulin-target tissues. In addition to insulin resistance, the increased demand for insulin could not be met by the pancreatic β cells due to defects in the function of these cells[ 18 ]. On the contrary, insulin secretion decreases with the increased demand for insulin by time due to the gradual destruction of β cells[ 57 ] that could transform some of type 2 diabetes patients from being independent to become dependent on insulin. Most type 2 diabetes patients are not dependent on insulin where insulin secretion continues and insulin depletion rarely occurs. Dependence on insulin is one of the major differences from type 1 diabetes. Other differences include the absence of ketoacidosis in most patients of type 2 diabetes and autoimmune destruction of β cells does not occur. Both type 1 and type 2 diabetes have genetic predisposition, however, it is stronger in type 2 but the genes are more characterized in type 1 (the TCF7L2 gene is strongly associated with type 2 diabetes)[ 58 ]. Due to the mild symptoms of type 2 diabetes in the beginning, its diagnosis is usually delayed for years especially in countries where regular checkup without symptoms is not part of the culture. This delay in diagnosis could increase the incidence of long-term complications in type 2 diabetes patients since hyperglycemia is not treated during this undiagnosed period.

In addition to diabetes, insulin resistance has many manifestations that include obesity, nephropathy, essential hypertension, dyslipidemia (hypertriglyceridemia, low HDL, decreased LDL particle diameter, enhanced postprandial lipemia and remnant lipoprotein accumulation), ovarian hyperandrogenism and premature adrenarche, non-alcoholic fatty liver disease and systemic inflammation[ 6 , 54 ]. The presence of type 2 diabetes in children and adolescence who are not obese[ 59 - 61 ], the occasional severe dehydration and the presence of ketoacidosis in some pediatric patients with type 2 diabetes[ 55 ] had led to the misclassification of type 2 to type 1 diabetes.

Some patients with many features of type 2 diabetes have some type 1 characteristics including the presence of islet cell autoantibodies or autoantibodies to GAD65 are classified as a distinct type of diabetes called latent autoimmune diabetes in adults (LADA)[ 62 ]. People diagnosed with LADA do not require insulin treatment. In a recent study, Hawa et al[ 63 ] reported 7.1% of European patients with type 2 diabetes with a mean age of 62 years, tested positive for GAD autoantibodies and the prevalence of LADA was higher in patients diagnosed with diabetes at a younger age. This classification of LADA as a distinct type of diabetes is still controversial[ 6 , 64 - 66 ].

Insulin resistance and signaling

Defects in the insulin-dependent substrate proteins IRS-1 and IRS-2 mediated signaling pathway are implicated in the development of metabolic disorders, mainly diabetes. This pathway mediates the cellular response to insulin and involves a large array of insulin-stimulated protein kinases including the serine/threonine kinase AKT and protein kinase C (PKC) that phosphorylate a large number of Ser/Thr residues in the insulin receptor substrate (IRS) proteins involved in the metabolic response to insulin[ 67 ]. In addition, other non-insulin dependent kinases including the AMP-activated protein kinase, c-Jun N-terminal protein kinase and G protein-coupled receptor kinase 2 that are activated under various conditions can phosphorylate the two insulin responsive substrates[ 67 - 71 ]. Disruption in the AKT and PKC kinases is central to the development of diabetes[ 72 ] and is associated with all major features of the disease including hyperinsulinemia, dyslipidemia and insulin resistance[ 73 ]. Replacing the wild type IRS-1 with a mutant version of the protein having alanine instead of tyrosine in three locations using genetic knock-in approach provided evidence to the central role of IRS-1 phosphorylation in the development of insulin resistance[ 74 ]. Using a similar approach to generate IRS-1 mutant with a single mutation involving a specific tyrosine residue, confirmed the role of IRS-1 phosphorylation in the development of insulin resistance pathogenesis[ 75 ]. The large cumulative evidence indicates a complex array of factors including environmental factors[ 76 ] and a wide range of cellular disturbances in glucose and lipid metabolism in various tissues[ 77 ] contribute to the development of insulin resistance. This condition generates complex cellular metabolic changes in a variety of tissues, mainly liver and muscles, that include the inability of the liver to transport and dispose glucose, control glucose production via gluconeogenesis, impaired storage of glucose as glycogen, de novo lipogenesis and hypertriglyceridemia[ 77 ]. Among the factors implicated in the development of insulin resistance, obesity is the most predominant risk factor leading to insulin insensitivity and diabetes which involves several mechanisms that participate in the pathogenesis of the disease[ 78 ]. Obesity-induced insulin resistance is directly linked to increased nutrient flux and energy accumulation in tissues that directly affect cell responsiveness to insulin[ 77 ]. However, it seems that other insulin-independent mechanisms are involved in the overall metabolic disturbances of glucose homeostasis and diabetes including activities in extra-hepatic tissues in addition to the central role of liver.

OTHER TYPES OF DIABETES MELLITUS

Monogenic diabetes.

Characterization of the genetic etiology of diabetes enables more appropriate treatment, better prognosis, and counseling[ 79 ]. Monogenic diabetes is due to a genetic defect in single genes in pancreatic β cells which results in disruption of β cell function or a reduction in the number of β cells. Conventionally, monogenic diabetes is classified according to the age of onset as neonatal diabetes before the age of six months or Maturity Onset Diabetes of the Young (MODY) before the age of 25 years. However, certain familial defects are manifested in neonatal diabetes, MODY or adult onset diabetes[ 2 , 9 , 80 ]. Others believe that classification of diabetes as MODY and neonatal diabetes is obsolete and monogenic diabetes is currently used relating specific genetic etiologies with their specific treatment implications[ 79 ]. Beta cell differentiation depends on the expression of the homeodomain transcription factor PDX1 where mutation in the gene results in early onset diabetes (MODY) and its expression decreases before the onset of diabetes[ 81 ]. The angiopoietin-like protein 8 (ANGPTL8) may represent a potential “betatrophin” that acts to promote the proliferation of beta cells, however, studies using mice lacking the ANGPTL8 active gene or overexpressed protein indicated that it did not seem to play a role in beta cells proliferation[ 82 ].

Mitochondrial diabetes is due to a point mutation in the mitochondrial DNA associated with deafness and maternal transmission of the mutant DNA can result in maternally-inherited diabetes[ 1 , 83 ].

Mutations that result in mutant insulin or the inability to convert proinsulin to insulin result in glucose intolerance in some of these cases. Genetic defects in the insulin receptor or in the signal transduction pathway of insulin have been demonstrated to result in hyperinsulinemia and modest hyperglycemia to severe diabetes[ 1 ].

Disease of the exocrine pancreas

Damage of the β cells of the pancreas due to diffused injury of the pancreas can cause diabetes. This damage could be due to pancreatic carcinoma, pancreatitis, infection, pancreatectomy, and trauma[ 1 ]. Atrophy of the exocrine pancreas leads to progressive loss of the β cells[ 84 ]. Accumulation of fat in the pancreas or pancreatic steatosis could lead to diabetes due to decreased insulin secretion but may require a long time before the damage to β cells occurs[ 85 ]. In most cases, extensive damage of the pancreas is required before diabetes occurs and the exocrine function of the pancreas is decreased in these patients[ 86 ]. Cirrhosis in cystic fibrosis may contribute to insulin resistance and diabetes[ 2 ].

Hormones and drugs

Diabetes has been found in patients with endocrine diseases that secrete excess hormones like growth hormone, glucocorticoids, glucagon and epinephrine in certain endocrinopathies like acromegaly, Cushing’s syndrome, glucagonoma, and pheochromocytoma, respectively[ 1 ]. Some of these hormones are used as drugs such as glucocorticoids to suppress the immune system and in chemotherapy and growth hormone to treat children with stunted growth.

Genetic syndromes

Diabetes has been detected in patients with various genetic syndromes such as Down syndrome, Klinefelter syndrome, Turner syndrome and Wolfram syndrome[ 1 ].

PREDIABETES

Individuals with prediabetes do not meet the criteria of having diabetes but are at high risk to develop type 2 diabetes in the future. According to the ADA Expert Committee, individuals are defined to have prediabetes if they have either impaired fasting plasma glucose (IFG) levels between 100-125 mg/dL (5.6-6.9 mmol/L) or impaired glucose tolerance test (IGT) with 2-h plasma glucose levels in the oral glucose tolerance test (OGTT) of 140-199 mg/dL (7.8-11.0 mmol/L). The World Health Organization (WHO) still adopts the range for IFG from 110-125 mg/dL (6.1-6.9 mmol/L). Prediabetes has been shown to correlate with increased cardiovascular mortality[ 87 , 88 ] and cancer[ 89 ]. The definition of prediabetes with the indicated cut off values is misleading since lower levels of glucose in the normal range are still correlated with cardiovascular disease in a continuous glycemic risk perspective[ 90 ]. In accordance with the recommendation of the ADA in 2009 to use hemoglobin A1c (HbA1c) to diagnose diabetes, ADA also recommended the use of an HbA1c (5.7%-6.4%) to diagnose prediabetes[ 91 ]. The number of people with IGT according to IDF was 316 million in 2013 (global prevalence 6.9% in adults) and is expected to rise to 471 million in 2030[ 27 ]. According to a report in 2014 by the Center for Disease Control and Prevention, 86 million Americans (1 out of 3) have prediabetes[ 92 ]. Four of the top ten countries with the highest prevalence of prediabetes are in the Middle East Arab States of the Gulf (Kuwait, Qatar, UAE and Bahrin with prevalence of 17.9%, 17.1%, 16.6% and 16.3%, respectively)[ 27 ]. The number of people diagnosed with prediabetes is different according to the method and criteria used to diagnose prediabetes. The number of people with prediabetes defined by IFG 100-125 mg/dL is 4-5 folds higher than those diagnosed using the WHO criteria of 110-125 mg/dL[ 93 ]. Diabetes and prediabetes diagnosed using an HbA1c criteria give different estimates compared to methods using FPG or OGTT. Higher percentages of prediabetes were diagnosed using HbA1c compared to FPG[ 94 - 96 ]. Prediabetes is associated with metabolic syndrome and obesity (especially abdominal or visceral obesity), dyslipidemia with high triglycerides and/or low HDL cholesterol, and hypertension[ 97 ]. Not all individuals with prediabetes develop diabetes in the future, exercise with a reduction of weight 5%-10% reduces the risk of developing diabetes considerably (40%-70%)[ 98 ]. Individuals with an HbA1c of 6.0%-6.5% have twice the risk of developing diabetes (25%-50%) in five years compared to those with an HbA1c of 5.5%-6.0%[ 99 ].

DIAGNOSTIC CRITERIA FOR DIABETES MELLITUS

Diabetes mellitus is diagnosed using either the estimation of plasma glucose (FPG or OGTT) or HbA1c. Estimation of the cut off values for glucose and HbA1c is based on the association of FPG or HbA1c with retinopathy. Fasting plasma glucose of ≥ 126 mg/dL (7.0 mmol/L), plasma glucose after 2-h OGTT ≥ 200 mg/dL (11.1 mmol/L), HbA1c ≥ 6.5% (48 mmol/mol) or a random plasma glucose ≥ 200 mg/dL (11.1 mmol/L) along with symptoms of hyperglycemia is diagnostic of diabetes mellitus. In addition to monitor the treatment of diabetes, HbA1c has been recommended to diagnose diabetes by the International Expert Committee in 2009[ 100 ] and endorsed by ADA[ 101 ], the Endocrine Society, the WHO[ 102 ] and many scientists and related organizations all over the world. The advantages and disadvantages of the different tests used to diagnose diabetes have been reviewed by Sacks et al[ 103 ]. The advantages of using HbA1c over FPG to diagnose diabetes include greater convenience and preanalytical stability, lower CV (3.6%) compared to FPG (5.7%) and 2h OGTT (16.6%), stronger correlation with microvascular complications especially retinopathy, and a marker for glycemic control and glycation of proteins which is the direct link between diagnosis of diabetes and its complications[ 104 - 109 ]. It is recommended to repeat the HbA1c test in asymptomatic patients within two weeks to reaffirm a single apparently diagnostic result[ 110 ].

A cut off value for HbA1c of ≥ 6.5% (48 mmol/mol) has been endorsed by many countries and different ethnic groups, yet ethnicity seems to affect the cut off values to diagnose diabetes[ 111 , 112 ]. Cut-off values of 5.5% (37 mmol/mol)[ 113 ] and 6.5% (48 mmol/mol)[ 114 ] have been reported in a Japanese study, 6.0% (42 mmol/mol) in the National Health and Nutrition Examination Survey (NHANES III), 6.2% (44 mmol/mol) in a Pima Indian study, 6.3% (45 mmol/mol) in an Egyptian study as reported by Davidson[ 105 ]; and three cut-off values for Chinese[ 112 ]. The Australians recommended the use of two cut-off values: ≤ 5.5% to “rule-out” and ≥ 7.0% to “rule-in” diabetes[ 115 ]. Variations in the prevalence of diabetes[ 94 , 116 - 119 ] and prediabetes[ 120 ] due to ethnicity have been documented. Most studies diagnosed less subjects with diabetes using HbA1c compared to FPG or OGTT[ 121 - 123 ]. Yet, other studies reported more subjects diagnosed with diabetes using HbA1c[ 96 , 124 - 126 ].

GESTATIONAL DIABETES

Hyperglycemia in pregnancy whether in the form of type 2 diabetes diagnosed before or during pregnancy or in the form gestational diabetes has an increased risk of adverse maternal, fetal and neonatal outcome. Mothers with gestational diabetes and babies born to such mothers have increased risk of developing diabetes later in life. Hyperglycemia in pregnancy is responsible for the increased risk for macrosomia (birth weight ≥ 4.5 kg), large for gestational age births, preeclampsia, preterm birth and cesarean delivery due to large babies[ 127 ]. Risk factors for gestational diabetes include obesity, personal history of gestational diabetes, family history of diabetes, maternal age, polycystic ovary syndrome, sedentary life, and exposure to toxic factors[ 3 ].

Diagnosis of type 2 diabetes before or during pregnancy is based on criteria mentioned before. Fasting plasma glucose ≥ 126 mg/dL (7.0 mmol/L) or 2-h plasma glucose ≥ 200 mg/dL (11.1 mmol/L) after a 75 g oral glucose load. However, gestational diabetes has been diagnosed at 24-28 wk of gestation in women not previously diagnosed with diabetes using two approaches: the first approach is based on the “one-step” International Association of the Diabetes and Pregnancy Study Groups (IADPSG) consensus[ 128 ] and recently adopted by WHO[ 129 ]. Gestational diabetes is diagnosed using this method by FPG ≥ 92 mg/dL (5.1 mmol/L), 1-h plasma glucose after a 75 g glucose load ≥ 180 mg/dL (10.0 mmol/L) or 2-h plasma glucose after a 75 g glucose load ≥ 153 mg/dL (8.5 mmol/L). This criteria is derived from the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study[ 127 ] even though the HAPO study showed a continuous relationship between hyperglycemia and adverse short-term pregnancy outcome with no threshold reported[ 130 ]. The second approach is used in the United States and is based on the “two-step” NIH consensus[ 131 ]. In the first step 1-h plasma glucose after a 50 g glucose load under nonfasting state ≥ 140 mg/dL (7.8 mmol/L) is followed by a second step under fasting conditions after a 100 g glucose load for those who screened abnormal in the first step. The diagnosis of gestational diabetes is made when at least two of the four plasma glucose levels are met. The four plasma glucose levels according to Carpenter/Coustan criteria are: FPG ≥ 95 mg/dL (5.3 mmol/L); 1-h ≥ 180 mg/dL (10.0 mmol/L); 2-h ≥ 155 mg/dL (8.6 mmol/L); and 3-h ≥ 140 mg/dL (7.8 mmol/L)[ 1 ].

The use IADPSC criteria in comparison with the Carpenter/Coustan criteria was associated with a 3.5-fold increase in GDM prevalence as well as significant improvements in pregnancy outcomes, and was cost-effective[ 132 ]. In another retrospective cohort study of women diagnosed with gestational diabetes, Ethridge et al[ 133 ] have shown that newborns of women diagnosed with gestational diabetes by IADPSG approach have greater measures of fetal overgrowth compared with Carpenter-Coustan “two-step” approach neonates. A strategy of using fasting plasma glucose as a screening test and to determine the need for OGTT is valid[ 134 , 135 ]. According to Sacks[ 136 ], correlation of glucose concentrations and the risk of subsequent complications will eventually lead to universal guidelines.

The use of ADA/WHO cut off value of HbA1c ≥ 6.5% (48 mmol/mol) to diagnose gestational diabetes is not recommended by the “one step” IADPSC criteria or the “two-step” NIH criteria. Further investigation is required in light of recent reports on HbA1c in combination with OGTT and its usefulness to predict adverse effect of gestational diabetes or obviate the use OGTT in all women with gestational diabetes[ 137 - 141 ].

DIABETES AND GENETICS

Diabetes is a complex disease that involves a wide range of genetic and environmental factors. Over the past several years, many studies have focused on the elucidation of the wide spectrum of genes that played a role in the molecular mechanism of diabetes development[ 142 - 144 ]. However, despite the vast flow of genetic information including the identification of many gene mutations and a large array of single nucleotide polymorphisms (SNPs) in many genes involved in the metabolic pathways that affect blood glucose levels, the exact genetic mechanism of diabetes remains elusive[ 145 , 146 ]. Evidently, a major complication is the fact that a single gene mutation or polymorphism will not impose the same effect among different individuals within a population or different populations. This variation is directly or indirectly affected by the overall genetic background at the individual, family or population levels that are potentially further complicated by interaction with highly variable environmental modifier factors[ 147 , 148 ].

Molecular genetics and type 2 diabetes

One of the major focuses of biomedical research is to delineate the collective and broad genetic variants in the human genome that are involved in the development of diabetes. This major effort will potentially provide the necessary information to understand the molecular genetics of the different forms of diabetes including type 1, type 2 and monogenic neonatal diabetes among individuals of all populations and ethnic groups. Despite the fact that linkage and association studies allowed the identification and characterization of many candidate genes that are associated with type 2 diabetes[ 144 , 149 , 150 ], however, not all of these genes showed consistent and reproducible association with the disease[ 151 ]. Genome wide association studies (GWAS) in various populations identified 70 loci associated with type 2 diabetes and revealed positive linkage of many mutations and SNPs that influence the expression and physiological impact of the related proteins and risk to develop type 2 diabetes. One study involved several thousand type 2 diabetes patients and control subjects from the United Kingdom allowed the identification of several diabetes putative loci positioned in and around the CDKAL1 , CDKN2A/B , HHEX/IDE and SLC30A8 genes in addition to the contribution of a large number of other genetic variants that are involved in the development of the disease[ 152 ]. Two similar studies from the Finns and Swedish populations and the United States resulted in the identification of similar single nucleotide variants[ 153 ] that are linked to the risk of acquiring type 2 diabetes[ 154 , 155 ]. The study in the United States population included in addition to type 2 diabetes, the association of the identified SNPs with the level of triglycerides in the tested subjects[ 155 ]. These SNPs are located near several candidate genes including IGFBP2 and CDKAL1 and other genes in addition to several other variants that are located near or in genes firmly associated with the risk of acquiring type 2 diabetes. Other GWAS analysis studies were performed in the Chinese, Malays, and Asian-Indian populations which are distinct from the European and United States populations in addition to meta-analysis of data from other populations in the region revealed relevant findings among patients with European ancestry[ 156 ]. The results of the combined analysis showed significant association of SNPs in the CDKAL1 , CDKN2A/B , HHEX , KCNQ1 and SLC30A8 genes after adjustment with gender and body mass index. More recently, meta-analysis of GWAS data involving African American type 2 diabetes patients identified similar loci to the previous studies with the addition of two novel loci, HLA-B and INS-IGF[ 157 ]. These results provide strong evidence of common genetic determinants including common specific genes that are linked to diabetes. A small list of specific genetic markers seem strongly associated with the risk of developing type 2 diabetes including the TCF7L2 [ 158 ] and CAPN10 [ 159 , 160 ] genes which also play a significant role in the risk and pathogenesis of the disease[ 158 , 159 ]. The association of TCF7L2 gene variants with type 2 diabetes and its mechanism of action received special attention by several investigators[ 161 , 162 ]. Over expression of the protein was shown to decrease the sensitivity of beta islet cells to secrete insulin[ 163 , 164 ] and was more precisely involved in the regulation of secretary granule fusion that constitute a late event in insulin secretion pathway[ 165 ]. The role of TCF7L2 in insulin secretion was partially clarified[ 166 ] that involves modifying the effect of incretins on insulin secretion by lowering the sensitivity of beta cells to incretins. Several other genes have been found to be significantly associated with the risk of developing type 2 diabetes including a specific SNP in a hematopoietically-expressed homeobox ( HHEX ) gene[ 167 ]. The islet zinc transporter protein (SLC30A8)[ 168 ] showed positive correlation with the risk of developing type 2 diabetes where variant mutations in this gene seem protective against the disease which provides a potential tool for therapy[ 169 ]. More recently, a low frequency variant of the HNF1A identified by whole exome sequencing was associated with the risk of developing type 2 diabetes among the Latino population and potentially may serve as a screening tool[ 170 ]. Genetic variants and specific combined polymorphisms in the interleukin and related genes including interlukin-6 ( IL-6 ), tumor necrosis factor-α and IL-10 genes were found to be associated with greater risk of developing type 2 diabetes[ 171 ], in addition to genetic variants in the genes for IL12B , IL23R and IL23A genes[ 172 ]. In a study involving the hormone sensitive lipase responsible for lipolysis in adipose tissues, a deletion null mutation, which resulted in the absence of the protein from adipocytes, was reported to be associated with diabetes[ 173 ]. Nine specific rare variants in the peroxisome proliferator-activated receptor gamma ( PPARG ) gene that resulted in loss of the function of the protein in adipocytes differentiation, were significantly associated with the risk of developing type 2 diabetes[ 174 ]. In addition, certain SNPs in the alpha 2A adrenergic receptor ( ADRA2A ) gene, involved in the sympathetic nervous system control of insulin secretion and lipolysis, were found to be associated with obesity and type 2 diabetes[ 175 ]. Link analysis between the melatonin MT2 receptor ( MTNR1B ) gene, a G-protein coupled receptor, identified 14 mutant variants from 40 known variants revealed by exome sequencing, to be positively linked with type 2 diabetes[ 176 ]. The authors suggested that mutations in the MT2 gene could provide a tool with other related genes in modifying therapy for type 2 diabetes patients based on their specific genetic background to formulate personalized therapies which potentially may ensures the optimum response. Interestingly, mutations in the clock[ 177 , 178 ] and Bmal1 [ 179 ] transcription factor genes which are involved in beta cells biological clock affecting growth, survival and synaptic vesicle assembly in these cells, resulted in reduced insulin secretion and diabetes. Evidently, prominent metabolic functions involve the production of specific reactive metabolites, leading to oxidative stress, which affect lipids, proteins and other biological compounds leading to serious damage in various tissues and organs. Mutations and SNPs in the antioxidant genes, including superoxide dismutase, catalase and glutathione peroxidase, that decrease their activity are implicated in the risk and pathogenesis of type 2 diabetes[ 180 ]. The metabolic syndrome was shown to be associated with the development of type 2 diabetes in a population that is described as highly endogenous especially in individuals over 45 years of age[ 181 ]. Since consanguinity marriages is high in this population, screening for this syndrome among families could provide an informative marker on the risk of developing type 2 diabetes[ 181 ].

Molecular genetics of type 1 diabetes

Even though type 1 diabetes is basically described as an autoimmune disease that results in the destruction of pancreatic beta cells, however, single gene mutations and SNPs have been found to be associated with the susceptibility to this type of diabetes. Initially, two gene mutations were linked to the development of type 1 diabetes including the autoimmune regulator ( AIRE ) gene which affect the immune tolerance to self antigens leading to autoimmunity[ 182 ] and the FOXP3 gene which results in defective regulatory T cells[ 183 ]. In addition, a mutation in the histone deacetylase SIRTI gene predominantly expressed in beta cells involved in the regulation of insulin secretion[ 184 ] and played a role in modulating the sensitivity of peripheral tissues to insulin[ 185 ] was detected in type 1 diabetes patients[ 186 ]. Recently, additional mutations and SNPs in the CTLA-4 +49A/G and HLA-DQB1 and INS gene VNTR alleles were found to be associated with type 1 diabetes, which have the advantage of differentiating between Latent autoimmune type 1 diabetes and type 2 diabetes[ 187 ]. The HLA-DQB1, in combination with HLA-DR alleles and a polymorphism in PTPN22 gene seem to be associated with the age onset of late type 1 diabetes[ 188 , 189 ]. Two specific polymorphisms in the promoter region of a transmembrane protein (DC-SIGN) gene expressed in macrophages and played an important role of T- cell activation and inflammation were found to be protective against type 1 diabetes[ 190 ]. An innovative non-parametric SNP enrichment tool using summary GWAS DATA allowed the identification of association between several transcription factors and type 1 diabetes and are located in a type 1 diabetes susceptibility region[ 191 ]. Nine SNP variants in several genes associated with type 1 diabetes, not including the major histocompatibility gene region, were identified using extensive GWAS analysis[ 192 ]. Furthermore, several novel SNPs in a region in chromosome 16 located in the CLEC16A gene were shown to be associated with type 1 diabetes and seem to function through the reduced expression of DEX1 in B lymphoblastoid cells[ 193 ]. Since more than 40 regions in the human genome were identified to be associated with the susceptibility to type 1 diabetes[ 194 - 196 ], a weighted risk model was developed utilizing selected genes SNPs could be used for testing infants for these genetic markers that could provide insights in the susceptibility to type 1 diabetes development or safe prevention of the disease among young children[ 197 ].

Molecular genetics of monogenic diabetes

A large array of genes were identified to be involved in the development of monogenic diabetes[ 80 ] which represent about 2%-5% of diabetes patients. Monogenic diabetes results primarily from gene defects that lead to a decrease in beta cell number or function. Monogenic diabetes genes were identified using linkage studies or code for proteins that directly affected glucose homeostasis. The majority of genes responsible for monogenetic diabetes code for either transcription factors that participate in the control of nuclear gene expression or proteins that are located on the cell membrane, cytoplasm and endoplasmic reticulum, proteins involved in insulin synthesis and secretion, exocrine pancreatic proteins and autoimmune diabetes proteins[ 80 ]. The collective function of these proteins is their participation in glucose metabolism at different levels. Evidently, the hierarchy of a specific gene in the overall glucose metabolism pathway determines the onset of diabetes in the patient and whether it is neonataly expressed or have late onset expression (adulthood). Consequently, molecular defects in the structure and function of these genes lead to the disturbance of plasma glucose level, the primary pathological sign of diabetes. The molecular mechanism of permanent neonatal diabetes mellitus (PNDP) in addition to MODY explains the observed phenotype of monogenetic diabetes that involves loss of function of the expressed mutant protein. The first gene implicated in monogenic diabetes was the glucokinase ( GCK ) gene[ 198 ] which functions as a pancreatic sensor for blood glucose where more than 70 mutations in the gene were identified that affected its activity[ 199 ]. A recent study on GCK gene mutations causing neonatal and childhood diabetes showed that the majority of mutations resulted in the loss of the enzyme function primarily due to protein instability[ 148 , 150 ]. Two hepatocytes nuclear factor genes that code for the HNF4A and HNF1A transcription factors were closely associated with MODY1 and MODY2[ 148 , 149 ]. Definitely, a whole list of other genes involved in monogenic diabetes are either overlooked or included in the genetic determinants of type 1 and type 2 diabetes which will be identified and clarified through more careful future studies.

MOLECULAR GENETICS OF DIABETES COMPLICATIONS

In addition to the genetic determinants of diabetes, several gene mutations and polymorphisms have been associated with the clinical complications of diabetes. The cumulative data on diabetes patients with a variety of micro- and macrovascular complications support the presence of strong genetic factors involved in the development of various complications[ 200 ]. A list of genes have been reported that are associated with diabetes complications including ACE and AKR1B1 in nephropathy, VEGF and AKRB1 in retinopathy and ADIPOQ and GLUL in cardiovascular diseases[ 200 ]. A study on Chinese patients revealed a single SNP in the promoter region of the smooth muscle actin ( ACTA2 ) gene correlates with the degree of coronary artery stenosis in type 2 diabetes patients[ 201 ]. Furthermore, the alpha kinase 1 gene ( ALPK1 ) identified as a susceptibility gene for chronic kidney disease by GWAS[ 202 ], was demonstrated in type 2 diabetes patients[ 203 ]. Three additional genes have been strongly correlated with this risk of diabetic retinopathy (DR) including the vascular endothelial growth receptor, aldose reductase and the receptor for advanced glycation products genes[ 204 ] where specific polymorphisms in these genes seem to increase the risk of DR development in diabetes patients[ 204 ]. A significant differential proteome (involving 56 out of 252 proteins) is evident that characterizes vitreous samples obtained from diabetes patients with the complication in comparison to diabetes patients without the complication and control individuals[ 205 ]. Interestingly, a large portion of these proteins (30 proteins) belong to the kallikrein-kinin, coagulation and complement systems including complement C3, complement factor 1, prothrombin, alpha-1-antitrypsin and antithrombin III that are elevated in diabetic patients with retinopathy[ 205 ]. In addition, 2 single nucleotides polymorphisms in the human related B7-I gene seem to mediate podocyte injury in diabetic nephropathy[ 206 ]. Furthermore, increased concentration of the ligand of B7-1 correlates with the progression of end-stage renal disease (ESRD) in diabetes patients[ 206 ]. These results indicate that B7-I inhibition may serve as a potential target for diabetes nephropathy prevention and/or treatment. Recently, it was shown that direct correlation is evident between circulating levels of tumor necrosis factors 1 and 2 and increased risk of ESRD in American Indian patients[ 207 ]. The link between diabetes and proper bone development and health is evident. Studies using animal models with major significant reduction in insulin receptor (IR) in osteoprogenitor cells resulted in thin and rod-like weak bones with high risk of fractures[ 208 ]. Similar findings were observed in animal models with bone-specific IR knockdown animals which points to the central role of IR in the proper development of bones[ 208 ]. Type 2 diabetes is also associated with mitochondrial dysfunction in adipose tissues. Using knockout animal models of specific mitochondrial genes led to significant reduction in key electron transport complexes expression and eventually adipocytes death[ 209 ]. These animals exhibited Insulin resistance in addition to other complications that can potentially lead to cardiovascular disease[ 209 ].

Diabetes mellitus is the epidemic of the century and without effective diagnostic methods at an early stage, diabetes will continue to rise. This review focuses on the types of diabetes and the effective diagnostic methods and criteria to be used for diagnosis of diabetes and prediabetes. Evidently, diabetes is a complex disease with a large pool of genes that are involved in its development. The precise identification of the genetic bases of diabetes potentially provides an essential tool to improve diagnoses, therapy (more towards individualized patient targeted therapy) and better effective genetic counseling. Furthermore, our advanced knowledge of the association between medical genetics and the chronic complications of diabetes, will provide an additional advantage to delay or eradicate these complications that impose an immense pressure on patient’s quality of life and the significantly rising cost of health-care services.

Conflict-of-interest: The authors declare that there is no conflict of interest associated with this manuscript.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Peer-review started: November 23, 2014

First decision: February 7, 2015

Article in press: April 14, 2015

P- Reviewer: Hegardt FG, Surani S, Traub M S- Editor: Gong XM L- Editor: A E- Editor: Wang CH

Essay on Diabetes

Introduction

Diabetes is a healthcare condition that has continued to affect so many people, both young and old. Understanding more about Diabetes will help people live a healthy lifestyle by avoiding all the possible things that might cause it. In this assignment, I will assess why Diabetes is a significant health issue to individuals and the world. I will discuss the background of Diabetes, its definitions, and the types of Diabetes. Besides, I will discuss what is needed to promote individual and group health for people who have Diabetes. By the end of the assignment, one will have better knowledge about Diabetes since I will also discuss the causes and preventive measures that can be undertaken to prevent the disease. Towards the end of the assignment, I will describe three achievable health promotion goals, hence helping fight against Diabetes. I will also describe some of the interventions and roles that different people, groups, and organizations play to reduce the high cases of Diabetes in the world.

During the medieval ages, being diagnosed with Diabetes was like a death sentence. The pioneers of diabetes treatment were Thomas Willis, Sushruta, and Arataeus (Mandal, 2021). The three were Greek physicians who encouraged people to exercise on horsebacks to prevent excess urination. They also described other therapies like overfeeding and taking wine to reduce starvation and excessive loss of fluids (Mandal, 2021). On the other hand, the ancient Indians would test for Diabetes by taking ants near a person’s urine. If the human urine attracted the ants, then the person would be diagnosed with urine (Mandal, 2021). Diabetes is a disease that is the leading cause of high blood sugar levels. People who have Diabetes have bodies that cannot make enough insulin, or their bodies cannot use the insulin they have effectively (Healthline, 2021). Insulin is the hormone that moves sugars from the blood to the body cells. There are several types of Diabetes, including type 1 diabetes, type 2 diabetes, gestational diabetes, prediabetes, and Diabetes insipidus (Healthine, 2021). All these types affect our bodies differently, and they all have different effects, hence different coping strategies.

The rationale for Choosing Diabetes

Diabetes is among the most severe health issues in the world. This is the reason why I chose to discuss it to create awareness about it. The bad thing with Diabetes is that one can get it and not know that they have it. By the time they realize that they have Diabetes, the condition is worse, and the person is highly affected. According to Genesis Medical Associates (2015), one out of three adults have higher blood sugar levels; a condition referred to as prediabetes. If the persons do not change their lifestyles, the sugar levels increase, leading to other types of Diabetes (Genesis Medical Associates, 2015). Learning about Diabetes will allow people to support each other in the fight against Diabetes. This includes eating healthy meals and maintaining a healthy lifestyle through exercising (Dowshen, 2021). Another reason why I chose to discuss Diabetes is to learn more about the causes and how to manage the disease. Since most people do not know about the condition, it is crucial to educate them so that in case they feel any symptoms, and they can get the treatment as early as possible (Dowshen, 2021). It is easy to deal with Diabetes as long as the signs are detected early enough and the patient follows the given guidelines on healthy living.

Epidemiology

Diabetes is a significant health concern since it affects so many people in the world. Diabetes can affect any person. However, some ethnic groups are affected more than others. The Alaska Natives and the American Indians are more affected by Diabetes as compared to all other ethnic groups. In terms of age, more than sixty-five years are more prone to getting diabetes than young people. According to Shaikh (2021), % of the people who are more than 65 years have diabetes. However, the young people are also affected but at a meager percentage compared to the older people.

The risk factors for Type 1 diabetes are hereditary, hence easily transferred from parents to children. Type 1 diabetes primarily affects young children and teenagers. Also, white Americans are at a higher risk of getting the disease than African Americans and Latino Americans (Shaikh, 2021). Type 2 diabetes affects middle and old age persons. Also, other risk factors for type 2 diabetes include genes, being overweight, a history of gestational pregnancy, and giving birth to a baby that is more than 9lbs (Shaikh, 2021).

It is important to note that diabetes is more prone in rural areas where people do not have access to health services and education. In the United Kingdom, 28% of the people with diabetes have issues obtaining medication due to a lack of health services and knowledge on how to go about diabetes treatment (Whicher et al., 2019 p.243). Besides, most of the people who are in the rural do not go for annual health checkups; hence their conditions get worse daily.

Assessment and assessment tools for Diabetes

Different tools are used during the assessment of diabetes. Assessing diabetes is very important as it helps differentiate between different types of diabetes and the extent of the condition. The Diabetes Prevention Screening Tool helps identify the persons at risk of getting diabetes (Diabetes Education Services, 2021). Such people are encouraged to join the CDC prevention program. There is also the Risk Test for Pre Diabetes patients to understand the risks they face as pre-diabetics (Diabetes Education Services, 2021).

The Diabetes Risk calculator is a tool that is used to detect undiagnosed diabetes and prediabetes. The social Support Assessment Tool helps diabetic patients to have a support system (Diabetes Initiative, 2020). Patients who have Diabetes need a lot of support from family and friends. The support shown will help them adhere to the doctor’s instructions, hence improving the chances of being better. Another assessment is the Mental Health Progress Report. The report is filled up during the patient’s follow-up visits. The assessment involves questions determining if the patient is affected by the condition mentally (Diabetes Initiative, 2020). It helps the doctors to guide the patient on how they can cope mentally with Diabetes.

Health Promotion Goals that you will like to Achieve

One of the goals that I would like to achieve is to reduce the high number of people diagnosed with Diabetes. I will encourage people to ensure they exercise at least thirty minutes a day to become physically fit. To make this goal achievable, I will create small groups that will act as support systems. This will help push people towards healthy living, preventing them from being diagnosed with the condition (Cecelia Health, 2021). My goal is realistic since it is easy to adopt a good eating habit and exercise at least thirty minutes daily. Still, it becomes easier when these activities are done in groups so that members feel motivated. To ensure that the goal is achieved, I will set a time frame of three months. Each member must have dropped at least 10 pounds within three months and managed to exercise at least 30 minutes daily, consistently.

The second goal is to enhance a better diabetes management program. Most people who have diabetes do not know what they should avoid, while others ignore the advice given to them by the doctors. In this case, I will form a group of people of different ages who are diabetic. The group formed will be a support system that will help each other cope with Diabetes. I will encourage the group members to remain healthy by eating the right food and exercising daily (McDermott, 2020). For those that are older, they can do simple exercises like jogging and walking a few kilometers daily. After five months, I will assess each patient’s changes in sugar levels and the general healthcare status (McDermott, 2020). I expect the sugar levels to be expected or close to normal for most patients within this period. Besides, the patients will have adapted to the new lifestyle since they got used to it.

Interventions for your health promotion goals

As indicated above, the first goal is to reduce the high numbers of people diagnosed with diabetes. The first health intervention is by ensuring that people are engaging in vigorous activities and exercises. Before one retires to bed, they must ensure that they have done a bit of practice to increase the metabolic activities of their bodies (Harvard T.H CHAN, 2021). Exercising helps maintain a moderate weight; hence, the high obesity and overweight people will reduce significantly. Besides, exercise helps increase insulin sensitivity in the body. As a result, the body cells can consume the sugars that are in the bloodstream.

For this intervention to work, both individuals and groups work together. A person must know that they have a personal responsibility to ensure that they maintain healthy body weight. Besides, organizations can play a significant role by ensuring that they create team-building activities (Harvard T.H CHAN, 2021). Organizations can set a day or two per month whereby all the employees and employers are involved in various team-building activities. This will help to ensure that at least all members keep fit, even if some of the members might not be keeping fit at a personal level. Since young people are also at a very high risk of getting diabetes, schools should develop a schedule to see all the students engage in exercise activities (John Muir Health, 2021). For example, the school can decide to have a physical exercise lesson after every two days.

Another intervention that will see few people being diagnosed with diabetes is maintaining a healthy eating lifestyle. Most people, especially teenagers, eat food that is full of calories. First, one should ensure they increase the fiber intake (Science Daily, 2018). Fiber is essential as it helps to slow down the digestion of carbs and sugars. Foods that contain more fibers include legumes, vegetables, and whole grains. Too many carbs place a person at a very high risk of getting diabetes. Another healthy eating habit is taking plenty of water to stay hydrated at all times (John Muir Health, 2021). When one takes a lot of water, it also helps the kidney eliminate excess sugars through the urine (Science Daily, 2018). A well-hydrated person is at a lower risk of getting diabetes. However, one should avoid sugar-sweetened drinks as they raise the level of glucose in the blood.

Both individuals and organizations have a role to play when it comes to maintaining a healthy eating lifestyle. Families should ensure that they prepare meals that are balanced diet. As an individual, one has a choice to eat whatever they want. Following this, one should avoid taking foods with high carb content instead of increasing the intake of high fiber meals. Organizations should also participate in this intervention by preparing healthy meals for their employees (Science Daily, 2018). Communities should be encouraged to grow more fibers and take the origin foods rather than rely on ready-made foods with high calories. Also, schools can be involved by ensuring that they have a reasonable timetable for all the meals, and the fiber intake for each student should be higher than the carb intake.

The second goal is enhancing better management for people who are living with diabetes. Individuals have a tremendous responsibility to ensure that they follow the given guidelines to stabilize sugar levels efficiently. As a diabetic patient, one should know the type of diabetes they are suffering from and the measures they are supposed to take to become better (NIH, 2021). The first step that a diabetic person should take is to ensure that they are not stressed. Stress triggers sugar levels, hence raising them. To reduce stress triggers, one can listen to their favorite music, take a walk, breathing in and out, or doing their favorite activities (Diabetes UK, 2021). Also, a person needs to have a support system to reach out in case they feel stressed.

The second step that one can take to deal with diabetes is ensuring that they eat well. After being assessed by the doctor, a health care team should help the sick person come up with a meal plan (Diabetes UK, 2021). The meal plan should contain fewer calories, fewer sugars and salt, and high saturated fats. Also, a diabetic person should eat foods that have high fiber, like rice and bread. Instead of drinking sweetened juices, a diabetic person should ensure that they take plenty of clean drinking water. This helps to keep the body hydrated at all times.

Both individuals and groups have a significant role in ensuring that diabetic persons are taken care of. They have the necessary things needed for them to reduce sugar levels. Health facilities should make sure that they do follow-ups so that if a patient has forgotten to go for checkups, they can go upon being reminded. Besides, other organizations like NGOs should develop fiber for needy people who might not afford such things.

Evaluation of your Health Promotion Care

Maintaining a healthy lifestyle through exercise is not hard to achieve as long as the people involved know the benefits of exercising. Exercising is an effective strategy that will help prevent diabetes and prevent other diseases like heart attack and stroke (Diabetes UK, 2021). However, people should be allowed to choose the kind of exercise that they want to do. Instead of going for a run, one can engage in other activities like playing football, netball, or swimming (Harvard T.H CHAN, 2021). Since people are not the same, one should not be forced to go for a morning jog, yet they like swimming. If this is done, the exercises will be more effective since people will be doing them willingly. I would recommend that the government makes it paramount for organizations to have different days from engaging in other activities like swimming, running, jogging, etc. Also, schools should ensure that there are various exercises for all the students to have one or two activities that they can engage in easily.

The second promotion of care was encouraging people to eat healthy meals. From the above discussion, it is evident that people need to engage in healthy lifestyles. Whether a person has diabetes or not, engaging in a healthy lifestyle is very important (Science Daily, 2018. Following this, one should ensure that they avoid high calories and have high fibers. This healthcare plan can be effective only if the government and other non-governmental organizations are willing to provide the proper meals for the people in need. Some diabetic people do not have access to medical care; hence they cannot do follow-ups about their conditions. As a result, the health care plan will become hard to achieve if the doctors and health care workers do not follow up on their patients to ensure they have taken the right medicines and that the sugar levels are not increasing (John Muir Health, 2021. For this, I would recommend that treatment of diabetes becomes free of charge in all public healthcare institutions. This will make it easy for the poor diabetic people to go for checkups since they know they will not be asked for any money to get the services they need. During the Diabetes Awareness week in the country, the government led by the health care sector should ensure that people are educated about diabetes. This will help people learn more about it and engage in activities that will help reduce diseases.

Tannahill Health Promotion Model

The Tannahill Health Promotion Model helps in the prevention of diabetes and protection of people who have diabetes. As discussed above, diabetes can be prevented through eating the right foods and ensuring that one is physically fit. The Tannahill Health promotion strategy also suggests a good communication flow between the patient and the health care providers (Queens University Belfast, 2021). In this case, the healthcare providers should do the follow up’s for their patients. The third aspect of the Tannahill Health promotion program is that the citizens should be given health protection through the legislature, social measures, and financial measures (Queens University Belfast, 2021). This includes helping needy people eat healthy meals and ensuring that organizations and companies give their employees the proper meals. Besides, Companies, organizations, and schools should set aside specific days where each person is engaged in other activities like swimming, ring, and playing their favorite games.

Diabetes is indeed one of the most severe diseases in the world. Diabetes affects both the young and the old and people of all ages. Although people at the age of 65 and older are more prone to being diagnosed with diabetes, other factors also determine if a person is prone to getting diabetes (Healthline, 2021). For example, a child can get diabetes from their parents; hence they get hereditary diabetes. Women who have experienced gestational diabetes are also at a very high risk of contracting the disease again (Shaikh, 2021). People who are not physically fit are also prone to getting diabetes. Following this, it is evident that although some people are more prone to getting diabetes, several other factors play a significant role.

Although diabetes is a severe condition worldwide, it can be controlled and the high rates reduced. This can be achieved through two maintaining it; exercising and eating suitable meals. Since some people cannot afford the healthy diet recommended for diabetic people, the government and other non-governmental organizations can provide such meals to the people (Whicher et al., 2019 p.243. Also, ensuring that the medication services are accessible at the public hospitals will encourage most people to go for follow-ups. Exercising is easy since there are so many activities that help burn calories (Shaikh, 2021). That is why it is essential to let the person choose activities they are good at and concentrate on them. Generally, although diabetes is a serious condition, it is easy to prevent and manage it if all resources are available.

Cecelia Health, 2021.  How to Set and Achieve SMART Goals — in Life and Diabetes – Cecelia Health . [online] Cecelia Health. Available at: <https://www.ceceliahealth.com/how-to-set-and-achieve-smart-goals-in-life-and-diabetes/> [Accessed 1 June 2021].

Diabetes Education Services, 2021.  Screening Tools for Diabetes – Diabetes Education Services . [online] Diabetes Education Services. Available at: <https://diabetesed.net/screening-tools-for-diabetes/> [Accessed 1 June 2021].

Diabetes Initiative, 2020.  Tools: Assessment Instruments . [online] Diabetesinitiative.org. Available at: <http://www.diabetesinitiative.org/resources/type/assessmentInstruments.html> [Accessed 1 June 2021].

Diabetes UK, 2021.  10 Tips for Healthy Eating with Diabetes . [online] Diabetes UK. Available at: <https://www.diabetes.org.uk/guide-to-diabetes/enjoy-food/eating-with-diabetes/10-ways-to-eat-well-with-diabetes> [Accessed 1 June 2021].

Dowshen, S., 2021.  Diabetes Control: Why It’s Important (for Teens) – Nemours KidsHealth . [online] Kidshealth.org. Available at: <https://kidshealth.org/en/teens/diabetes-control.html> [Accessed 1 June 2021].

Genesis Medical Associates, 2015.  The Importance Of Understanding And Preventing Diabetes – Genesis Medical Associates, Inc . [online] Genesismedical.org. Available at: <https://www.genesismedical.org/blog/the-importance-of-understanding-and-preventing-diabetes> [Accessed 1 June 2021].

Harvard T.H CHAN, 2021.  Simple Steps to Preventing Diabetes . [online] The Nutrition Source. Available at: <https://www.hsph.harvard.edu/nutritionsource/disease-prevention/diabetes-prevention/preventing-diabetes-full-story/> [Accessed 1 June 2021].

Healthline, 2021.  Everything You Need to Know About Diabetes . [online] Healthline. Available at: <https://www.healthline.com/health/diabetes#:~:text=Diabetes%20mellitus%2C%20commonly%                                                                                 20known%20as,the%20insulin%20it%20does%20make.> [Accessed 1 June 2021].

John Muir Health, 2021.  Preventing Diabetes . [online] Johnmuirhealth.com. Available at: <https://www.johnmuirhealth.com/health-education/conditions-treatments/diabetes-articles/preventing-diabetes.html> [Accessed 1 June 2021].

Mandal, A., 2021.  History of Diabetes . [online] News Medical. Available at: <https://www.news-medical.net/health/History-of-Diabetes.aspx#:~:text=The%20term%20diabetes%20was%20probably,sweet%20taste%20of%20the%20urine.> [Accessed 1 June 2021].

McDermott, A., 2020.  7 Long-Term Goals for Better Diabetes Management . [online] Healthline. Available at: <https://www.healthline.com/health/type-2-diabetes/living-better-with-type-2-diabetes/long-term-goals-everyone-with-type-2-diabetes-should-make> [Accessed 1 June 2021].

NIH, 2021.  4 Steps to Manage Your Diabetes for Life | NIDDK . [online] National Institute of Diabetes and Digestive and Kidney Diseases. Available at: <https://www.niddk.nih.gov/health-information/diabetes/overview/managing-diabetes/4-steps> [Accessed 1 June 2021].

Queens University Belfast, 2021.  Health Promotion.  [online] Queens University Belfast. Available at  https://www.qub.ac.uk/elearning/public/HealthyEating/HealthPromotion/  [Accessed 1 June 2021]

Science Daily, 2018.  Physical exercise reduces the risk of developing diabetes, study shows . [online] ScienceDaily. Available at: <https://www.sciencedaily.com/releases/2018/02/180220102420.htm> [Accessed 1 June 2021].

Shaikh, J., 2021.  What Population Is Most Affected by Diabetes? . [online] MedicineNet. Available at: <https://www.medicinenet.com/what_population_is_most_affected_by_diabetes/article.htm> [Accessed 1 June 2021].

Whicher, C., O’Neill, S., and Holt, R., 2019. Diabetes in the UK: 2019.  Diabetic Medicine , [online] 37(2), pp.242-247. Available at: <https://onlinelibrary.wiley.com/doi/epdf/10.1111/dme.14225> [Accessed 1 June 2021].

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Essay on Diabetes for Students and Children

500+ words essay on diabetes.

Diabetes is a very common disease in the world. But people may never realize, how did they get diabetes and what will happen to them and what will they go through. It may not be your problem but you have to show respect and care for the one who has diabetes. It can help them and also benefited you to know more about it and have a better understanding of it. Diabetes is a metabolic disorder which is identified by the high blood sugar level. Increased blood glucose level damages the vital organs as well as other organs of the human’s body causing other potential health ailments.

Types of Diabetes

Diabetes  Mellitus can be described in two types:

Description of two types of Diabetes Mellitus are as follows

1) Type 1 Diabetes Mellitus is classified by a deficiency of insulin in the blood. The deficiency is caused by the loss of insulin-producing beta cells in the pancreas. This type of diabetes is found more commonly in children. An abnormally high or low blood sugar level is a characteristic of this type of Diabetes.

Most patients of type 1 diabetes require regular administration of insulin. Type 1 diabetes is also hereditary from your parents. You are most likely to have type 1 diabetes if any of your parents had it. Frequent urination, thirst, weight loss, and constant hunger are common symptoms of this.

2) Type 2 Diabetes Mellitus is characterized by the inefficiency of body tissues to effectively respond to insulin because of this it may be combined by insulin deficiency. Type 2 diabetes mellitus is the most common type of diabetes in people.

People with type 2 diabetes mellitus take medicines to improve the body’s responsiveness to insulin or to reduce the glucose produced by the liver. This type of diabetes mellitus is generally attributed to lifestyle factors like – obesity, low physical activity, irregular and unhealthy diet, excess consumption of sugar in the form of sweets, drinks, etc.

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Causes of Diabetes

By the process of digestion, food that we eat is broken down into useful compounds. One of these compounds is glucose, usually referred to as blood sugar. The blood performs the job of carrying glucose to the cells of the body. But mere carrying the glucose to the cells by blood isn’t enough for the cells to absorb glucose.

This is the job of the Insulin hormone. Pancreas supply insulin in the human body. Insulin acts as a bridge for glucose to transit from blood to the body cells. The problem arises when the pancreas fails to produce enough insulin or the body cells for some reason do not receive the glucose. Both the cases result in the excess of glucose in the blood, which is referred to as Diabetes or Diabetes Mellitus.

Symptoms of Diabetes

Most common symptoms of diabetes are fatigue, irritation, stress, tiredness, frequent urination and headache including loss of strength and stamina, weight loss, increase in appetite, etc.

Levels of Diabetes

There are two types of blood sugar levels – fasting blood sugar level and postprandial blood sugar level. The fasting sugar level is the sugar level that we measure after fasting for at least eight hours generally after an overnight fast. Blood sugar level below 100 mg/dL before eating food is considered normal. Postprandial glucose level or PP level is the sugar level which we measure after two hours of eating.

The PP blood sugar level should be below 140 mg/dL, two hours after the meals. Though the maximum limit in both the cases is defined, the permissible levels may vary among individuals. The range of the sugar level varies with people. Different people have different sugar level such as some people may have normal fasting sugar level of 60 mg/dL while some may have a normal value of 90 mg/dL.

Effects of Diabetes

Diabetes causes severe health consequences and it also affects vital body organs. Excessive glucose in blood damages kidneys, blood vessels, skin resulting in various cardiovascular and skin diseases and other ailments. Diabetes damages the kidneys, resulting in the accumulation of impurities in the body.

It also damages the heart’s blood vessels increasing the possibility of a heart attack. Apart from damaging vital organs, diabetes may also cause various skin infections and the infection in other parts of the body. The prime cause of all type of infections is the decreased immunity of body cells due to their inability to absorb glucose.

Diabetes is a serious life-threatening disease and must be constantly monitored and effectively subdued with proper medication and by adapting to a healthy lifestyle. By following a healthy lifestyle, regular checkups, and proper medication we can observe a healthy and long life.

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Community Diabetes Specialist Nurse drafts essay on frailty diabetes care in Wales

Is current guidance relevant, or even detrimental in the management of the Frail/Elderly person with diabetes in a care home setting in Wales

  Introduction

The International Diabetes Federation (IDF) (1), currently estimates that there are 463 million people living in the world with diabetes, these figures, however, do not include people over the age of 80 years. In the UK, of the 4.9 million people registered with diabetes, approximately 13% are over the age of 80, which equates to one in five people over the age of 80 have type 2 diabetes (2).

With increasing ageing of the population, the epidemiology of diabetes is shifting towards old age especially among individuals between the ages of 60 and 79 years (3). The high prevalence of type 2 diabetes among the elderly has also been confirmed in a prospective population-based study in The Netherlands, showing that the elderly aged 70 years and over, account for 50% of the population who have type 2 diabetes (4).

Effectiveness and quality of care

Guidelines have been developed to cover a range of aspects in diabetes care from inpatients to medications managed in the UK and elsewhere. It has been stated that guidelines have a range of purposes, to improve effectiveness and quality of care, to decrease variations in clinical practice and to decrease costly and preventable mistakes and adverse events.

Extensive research has been undertaken over the last thirty years on the methods underpinning clinical practice guidelines (CPG’s), including their development, updating, reporting, tailoring for specific purposes, implementation and evaluation. However, it also needs to be taken into account that the most important limitation of guidelines, is that the recommendations may be wrong (or at least wrong for individual patients), and that scientific evidence about what is recommended is often lacking, misleading or misinterpreted (5).

Although people with diabetes are widely represented in clinical practice, focus on diabetes care in this age group is still relatively scarce, a recent analysis showed that only 0.6% of interventional trials in diabetes specifically targeted elderly people, 30.8% excluded people older than 65 years and the majority excluded those aged over 75 years altogether (6).

The IDF supports this, stating that it accepts that an important limiting factor for producing specific evidence-based clinical guidelines for older people with diabetes is the need to extrapolate evidence from clinical studies in younger adults and that the lack of well-designed studies on cost effective diabetes care for older people prevents specific recommendations in this aspect of service development (7).

The working group of The National Institute of Health and Care (NICE), in a more recent report, has also recognised that a number of clinical areas in diabetes receive little or no attention in many published clinical guidelines. They also found that there is a lack of data from published studies where individuals included were over 70 years of age, where the risk of complex comorbidity, frailty and dependency is so often seen (8).

It is suggested that effective management of diabetes in older adults requires the appreciation by both clinicians and policy makers that care has to take into account the increasing complexity of the illness, that such care may need to operate over four decades (60-90 years and older) and respond to the changing circumstances of an individuals health status. The same piece of work found that these individuals are, however, routinely excluded from clinical trials, with only 1.4% of clinical trials explicitly recruiting older adults and a smaller percentage still, specifically recruiting frail older adults.

Frailty and sarcopenia (age-related muscle loss associated with reduced power) are emerging as newly recognised complications of diabetes in older people. Frailty has been described as an adverse health state represented by an increased vulnerability to physical or psychological stressors as a result of decreased physiological reserve, affecting multiple organ systems that create a limited capacity to maintain homeostasis (9). It has been acknowledged that frailty is a common finding and may be present in 32-48% of adults aged 65 years and over with diabetes, and is associated with adverse outcomes and reduced survival (6).

Long-life expectancy

Diabetes management strategies for high functioning older people with an anticipated long-life expectancy are similar to those for younger people. Such strategies applied to functionally impaired or frail individuals, however, maybe inappropriate and potentially unsafe if interventions with more immediate adverse effects are used. Furthermore, generic metabolic targets, whether they be glycaemic, lipid or even blood pressure, ignore the importance of holistic personalised care in the presence of multi-morbidity or moderate to severe frailty (10).

Hypoglycaemia is a physical stressor that frail adults may have difficulty responding to, and it has been discussed in the literature that elderly and frail individuals with diabetes are at marked increase in risk of adverse effects of treatment for diabetes including hypoglycaemia. Hypoglycaemia in the elderly is associated with serious morbidity, including cardiovascular events, stroke, arrythmias, falls, and frequently resulting fractures (6).  The Accord study in 2008, showed that intensive blood glucose control had no significant effect on macrovascular events, however, more patients undergoing intensive control were hospitalised due to severe hypoglycaemia. Other trials people have shown that there is a strong association between severe hypoglycaemia and cardiovascular mortality, especially in the elderly population (11).

The physiological differences of frail/elderly are substantial, due to their failing renal function, hepatic function, autonomic nervous system, incretin system which includes both production and sensitivity to the incretin hormones, and cognitive decline. Older people and those with dementia, are also at an increased risk of hypoglycaemia because appetites are often poorer, resulting in weight loss (12). Although hypoglycaemia in older people (greater than 75 years) with diabetes is common, its recognition can sometimes be difficult, making a diagnosis uncertain in this age group.

It has been explained that due to the predominance of neurological rather than autonomic symptoms, hypoglycaemia may present with symptoms such as dizziness or visual disturbance resulting in another diagnosis. Another diagnostic challenge, is the similarities in the clinical presentation of hypoglycaemia with that of dementia, where individuals present with agitation, increased confusion or behavioural changes (13).

Frailty has a significant impact in terms of increased adverse outcomes and reduced survival

There is also evidence that HbA1c may be artificially higher in older adults owing to red cell fragility, as a result, this client group, if treated to a specific target HbA1c, will be at further risk of hypoglycaemia. Drivers of over treatment of the elderly was due in part to the introduction of the General Medical Services (GMS) contract in 2004 for GPs in the UK incentivised glycaemic monitoring as part of the quality outcome framework. It has been explained that this “payment by results” approach, led to an overall improvement in the blood pressure and glycaemic and lipid management in people with diabetes in the UK. However, the contract did not differentiate based on age, limited life expectancy or frailty. As a result, a significant proportion of older adults were commenced on agents that could cause hypoglycaemia years ago to improve glycaemic control, but despite significant changes in the client’s overall wellbeing and physical status, these medicines have not been reviewed (14).

Since the IDF produced their guidelines in 2013 (15), there has been increasing evidence that, older age and frailty has a significant impact in terms of increased adverse outcomes and reduced survival, and that frailty is now emerging as a recognised and diagnosable condition (16).

The objective of this essay is to review the clinical guidance currently used in practice, and to discuss how the more recent guidelines (17,9), may influence the management of the frail/older person with diabetes.

The National Institute of Health and Care (NICE), describes itself as a public body that provides national guidance and advice to improve health and social care in England and wales. They use information from scientific research, testimonials from practitioners and from people using these services on which to base their recommendations. To date, NICE have produced over 340 guidelines, two specific guidelines in regard to adult diabetes care which are applicable to the older person with diabetes are the diagnosis and management of Type 1 diabetes (18), and the management of type 2 diabetes in adults (19).

In 2015, NICE updated both of these guidelines, suggesting considering relaxing target HbA1c for people who were older or frail, however, no specific targets were recommended. Both of these guidelines were updated again in 2019, reasons given for this update was that there was availability of new evidence and several key developments which had prompted an update, specifically in relation to managing blood glucose levels, anti-platelet therapy and erectile dysfunction.  However, again no mention was made of recommendations specifically in regards to the frail elderly.

The NICE Guidelines on Cardiovascular risk (20), and Hypertension (21), (both updated in 2020) do suggest that clinical judgement is needed for people with frailty, multimorbidity and polypharmacy. These guidelines also agreed with current thoughts, discussing the lack of evidence for targets in people over 80 years, and suggested that further research in this area would be helpful, explaining that current healthcare professionals should refer to NICE guidelines on multimorbidity for further advice.

The NICE guideline on multimorbidity (22), last published in 2016 and updated in 2020, explains that the Health Care Professional (HCP) needs to be aware that the evidence for recommendations in NICE guidance on single health conditions, is regularly drawn from people without multimorbidity and taking fewer prescribed regular medicine. The guideline also states that an approach to care that takes account of multimorbidity if the person has frailty or falls should be considered. However, as per previous NICE guidelines, there are no recommended targets for HbA1c, lipids or blood pressure for the frail/elderly with diabetes. This concern was also identified in another review which found that there are no clinical guidelines that gave clear advise as to when to deintensify hypoglycaemic medications if appropriate (23).

Frailty, as well as emerging as a recognisable and diagnosable condition, has also been described as a third category of complications in addition to those of the traditional micro and macrovascular disease processes (24). A report into the rates of complications and mortality in older people with diabetes actually found that the 4-year incidence of cardiovascular complications and hypoglycaemia traded positions, among most frequent non-fatal complications of diabetes, while microvascular complications and acute hyperglycaemic events occurred at much lower rates (25).

It has been identified that frail elderly people are more prone to develop complications from hypoglycaemia such as confusion and dementia (26). In one large observational cohort study of 16,667 older adults with diabetes, a single hypoglycaemic episode was associated with a 26% increased risk of cognitive impairment, and an individual experiencing three or more hypos had almost twice the risk of future dementia (27). Hypos have also been found to be associated with a 45-70% increased risk of fall-related fracture in people over 65 years, as well as with an increased risk of cardiovascular events and cardiovascular mortality (14).

Current guidelines in many instances, fail to take account important elements of care, specific to the frail/elderly which are complex illness management, necessitating an individual approach to care, and appreciation of age-related physiology and pharmacology which increases the risk of iatrogenic adverse drug reactions. Key features of a modern diabetes service sensitive to the specific needs of older people have been identified as needing an active de-prescribing policy, and a review of diabetes and frailty status (9).

Frailty has a significant impact in terms of increased adverse outcomes and reduced survival. Recent publications of international clinical guidelines have provided a modern but still general, overview of management approach for older people with diabetes (17). The IDF Global guidance (7), was one such document which did for the first time, give recommendations for those with dependency including frailty. However, the Association of British Clinical Diabetologists (ABCD) felt that there were many areas where specific advice was still needed within local NHS settings which would help the clinician in decision making (17).

This was further supported in a research paper written in 2017, which stated that there were no clinical guidelines that clearly advised when to deintensify hypoglycaemic medications or de-scribe. The paper suggested that clinical practice should view prescribing and deprescribing, as two sides of the same coin and that care for older people with diabetes should weigh up the risks and benefits of treatment, that is dynamic, and shifts with deteriorating function including weight loss and frailty.

Severe vascular disease

The following year, a further review was published which had two main objectives, the first objective was to look at how the care home population was characterised, what interventions had been undertaken to improve care, and what guidelines were available to enhance quality indicators. The second objective was to define what was needed to be done urgently to address the needs of this vulnerable sector of the population with diabetes, and how the information gathered could provide a new framework for implementing diabetes care within care homes.

The study found, that as previously reported, individuals in care homes were likely to have severe vascular disease, to be physically and cognitively impaired and have high levels of dependency. There were also other factors identified such as physiological dysregulation and disturbed homeostasis which would result in frailty and disability. It was suggested that these various factors caused the individual with diabetes to enter into a downward decline eventually resulting in sarcopenia and frailty.

The report suggested eleven priority areas that needed to be addressed, these were the need for screening of diabetes at admission, lack of assessment and monitoring, lack of specialist input, poor communication channels between primary and secondary care professionals, patchy staff education and training and a call for tighter regulation to improve care (28). The call for tighter regulation has been partially met by a relatively recent Care Quality Guidance (CQC) issued to inspectors of Care Homes in England that highlight important features that a care home should have in place (29). In its introduction the guidance explains that diabetes is the most common metabolic problem in our ageing society, affecting up to one in four residents of care homes who are often frail, and have high rates of admission to hospital when their health deteriorates, however, in Wales there does not appear to be any evidence of this happening.

Even though it is recognised that the incidence of those individuals in care homes who have diabetes is high, research has shown that diabetes is often still poorly understood and managed in care homes. Key findings of an audit carried out England wide in 2013/14, showed that two thirds of care homes have no policy on screening for diabetes, nearly two thirds of homes did not have a designated member of staff  with responsibility for diabetes management, more than one in three did not have a written policy for managing hypoglycaemia and one third admitted that they do not have access to local diabetes educational and training courses (30).An admission avoidance and diabetes guidance for clinical commissioning groups and clinical teams (31), in 2013 recommended that a diabetes service should support diabetes education, footcare and management in residential and nursing homes, with recurrent staff training in identifying highest risk residents which may reduce admissions by more than 50% in this population.

If a person with diabetes is admitted to hospital, then this should be seen as an opportunity to revisit previous targets and to individualise goals appropriate to the persons degree of frailty. However, any changes made in the treatment regimens and goals need to be communicated clearly to the nursing home staff, with the rationale for changes explained clearly (16). To achieve this, it has been concluded that clinicians will need to adopt a new set of outcome measures in the management of frailty and diabetes both in hospital settings and in community and primary care. This process will also require a culture change by the diabetes healthcare team and a phase of upskilling in assessment procedures.

The document further explains that it is common for people with severe acute hypoglycaemia to be seen by ambulance crews after an emergency call, most patients are treated at home, but many are taken to the emergency department some of these individuals are then admitted. Available data at that time, suggested 70-100,000 emergency calls outs per year in the UK at significant cost to the NHS, as well as the resulting anxiety and distress to those needing treatment. It has been estimated that the cost of one hypoglycaemic episode needing admission could be as much as £2152 (2015). The use of a Local Impact Hypoglycaemia Tool could be used to estimate the cost of hypoglycaemia for the frail/elderly person with diabetes, this would provide the opportunity to explore how reducing hypoglycaemia rates could result is substantial savings to the NHS (32).

Conclusion/Recommendations

Clinical guidelines can help patients by influencing public policy. They call attention to under recognised health problems, clinical services, preventative interventions and to neglected patient populations and high-risk groups. They offer explicit recommendations for clinicians who are uncertain about how to proceed, overturn the beliefs of doctors accustomed to outdated practices, improve the consistency of care, and provide authoritative recommendations that reassure practitioners about the appropriateness of their treatment policies (5).

The most recent guideline published by the Association of British Clinical Diabetologist ABCD (17), represents a timely initiative to address the important issues of frailty and its association with diabetes. The new Guidance has been structured into three main section headings, which deal with definition of, and the clinical importance of frailty, a summary of areas of management including glucose regulation, role of exercise interventions and hypoglycaemia. Unlike previous guidelines, the recommendations provide specific advice to aid clinicians when making therapeutic decisions for the older person. Not only that, but stress that clinicians should also be made aware of the need for a reverse algorithm to de-intensify complex insulin regimes in frail older adults. The guideline also recommends that HCP caring for older people with diabetes should evaluate their risk of hypoglycaemia and develop individualised HbA1c and blood glucose goals to reduce the risk of hypoglycaemia.

Specific advice

It is clear that up to date clinical guidelines provide specific advice to aid clinicians in making safer therapeutic decisions for older frail people with diabetes. However, guidance alone does not appear to solve the problems of sub-optimal care which has been identified in the literature. For example, the IDP-ABCD audit (31), found that one in three care homes admitted they do not have a written policy for managing hypoglycaemia even though there are numerous clinical guidelines available. The consequences of hypoglycaemia as already discussed can be serious, with physical injury including fractures, head injury, cardiovascular events, psychological harm affecting quality of life (32) and in some cases death.

This essay recommends that a whole system approach is also needed to introduce the new guidance specific to the needs of those frail/elderly with diabetes in a care home setting. This approach should include primary and secondary care, ambulance, trusts, local clinical networks or clusters and specialist HCP’s who are based or work mainly in the community such as Community Diabetes Specialist Nurses, Podiatrist, Dieticians, Dementia Intervention Teams all needing to be familiar with the recent recommendations. Highlighted areas include introduction of an assessment tool for frailty on admission to the home, and re-assessment as indicated, the need for regular audit of diabetes care against established standards should be prioritised.

At the same time the review on “Failing to meet the needs of generations of care home residents with diabetes: a call for action” (28), has concluded that sustainable effective diabetes care within care homes requires additional resources, including trained staff, equipment, modification of facilities to allow for implementing new audit programmes. A call of action is proposed to address these requirements which include a greater prominence to be given by health professionals to older people with diabetes living in a care home environment, all residents with diabetes should be named on a local diabetes register to increase their opportunity to be involved in clinical audits. Health professionals, researchers and research funding bodies should do more to overcome the barriers to effective diabetes audit and research in care homes. As the article states, such a call to action can only succeed if new initiatives are disseminated to influence policy, clinical behaviour and the wellbeing of this neglected population with diabetes.

While researching for this piece of work it became apparent that there is a distinct lack of information in regards to all aspects of care being delivered not only to those frail/elderly individuals but also in regard to any person who has type 1 or type 2 diabetes needing nursing care in Wales.

The ongoing Covid-19 pandemic, has however, raised awareness of the vulnerability of the frail/elderly with diabetes and the need to maintain safety and quality of life to those living in care homes. Guidance was issued to care homes in a response to Covid-19 (33), following on from this, it was identified that such homes often have an ill prepared care workforce to manage acutely ill residents with diabetes, that there is a lack of joined up thinking and collaboration between care homes and local health and social services, and that there is an absence of tried and tested communication channels.

In Wales, a government initiative was implemented during this pandemic to offer health care services in a safe and secure way to see individuals via a video link. It also allowed relatives to be able to communicate with their families, technology in the form of i-pads, was provided to each nursing home along with IT support and education. Looking forward, this initiative could be the first of many, to develop virtual aids for communication with residents, but also, as a means of providing education to care home staff, and for consultations from other HCP’s involved in the persons diabetes care. However, a robust auditing strategy will need to be implemented at the same time, to ensure the momentum for change, which Covid-19 has provided, continues.

A National Advisory Panel is soon to be set up to focus on diabetes in care homes, led by Professor Alan Sinclair. The aim of the advisory panel will be to produce a Strategic Document of Diabetes Care which will help ensure that the highest standard of care possible will be delivered.

This essay concludes then, that guidelines currently in use could potentially cause harm, for example, by setting HbA1c targets too low, which could result in hypoglycaemia, when caring for those frail/elderly individuals with diabetes. However, the implementation of new guidelines will provide specific advice to aid clinicians in making safer therapeutic decisions for older frail people with diabetes. New initiatives how-ever, will need to be disseminated if they are to influence policy, clinical behaviour, and the well-being of this neglected population with diabetes.

This highlights the essential role of the Community Diabetes Specialist Nursing Team, in providing education, advice and support, to both the residents and staff of care homes across Wales.

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Type 1 diabetes

If you have type 1 diabetes, your blood sugar is too high because your body can’t make a hormone called insulin.   

Fewer than one in 10 people in the UK who have diabetes have type 1 diabetes. There is nothing you can do to prevent yourself or others developing type 1 diabetes. The exact causes are not known.

Although it’s often diagnosed in childhood, people can develop type 1 diabetes at any age. You are at a slightly higher risk of type 1 diabetes if your mother, father, brother or sister has it.  

Insulin is the main treatment for type 1 diabetes. You can’t live without insulin injections or using an insulin pump. Checking and managing your blood sugar levels is important to help you reduce your risk of serious short or long-term health problems. These are called diabetes complications. 

There is currently no cure for type 1 diabetes, but we’re funding lots of research to help find new treatments and a cure.  

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Diabetes essay sample

People refer to diabetes as a lifestyle disease. They do this because people who have diabetes have to live with it for the duration of their entire life. In most cases, we know people who have at least one other person suffering from it in their family. There are also the exceptions – people who don’t have this disease in the family, but still develop it and have to live with it. In the United States alone, approximately 30.3 million people are affected by this disease. This equals 9.4% of the entire population, which is higher than the number for most diseases people suffer from. It also means that about one person in four people have diabetes, but don’t know about it. There are many people who suffer from it but haven’t received a diagnosis or any kind of medical attention just yet.

But what is diabetes, really? This disease affects the metabolic functions of the human body i.e. the way our bodies utilize digestion to grow and source energy. The food we consume daily gets broken into glucose which forms sugar in our blood. It’s what fuels the body and provides it with much-needed energy. When the blood sugar or glucose becomes higher than normal, many problems arise. This happens in people who suffer from diabetes. The natural, undisturbed body process allows for the cells and tissues of the body to use up the glucose to source energy, help the body grow and repair itself. In order for the sugar to get inside the cells i.e. their membranes, insulin must be available. This hormone is produced by the pancreas, a large gland located behind the human’s stomach.

Whenever we consume food, our pancreas gets a signal from the brain to produce insulin. This is what happens in the body of a healthy person. But, if a person suffers from diabetes, it means that their pancreas does not produce enough insulin for the body to use up the glucose. In most cases, it stops doing this altogether. It’s what medicine calls insulin resistance. When it happens, the insulin which allows glucose to enter the body cells is not there at all. The result is a build-up of glucose in the person’s bloodstream, the sugar that cannot be converted to fuel the cells with energy.

What happens next is that the excessive sugar in the bloodstream builds up in the tissues that surround the heart, kidneys, nerve endings, and even the eyes. This is where complications arise – both short-term and long-term.

How do you know that you have diabetes, you might wonder? If a person is in the early stages of this lifelong disease, some minor symptoms will appear. They will vary and can easily be misread, making people think that they are simply dehydrated, have weak blood, or allergies when their skin itches and becomes dry. According to Mayfield, some of the symptoms include frequent urination, sores, extreme hunger, extreme thirst, wounds that heal up slowly, bruises that last a long time, unapparent weight loss, itchy and dry skin, blurry vision, lack of sensation in the feet and hands, tingling in the feet and hands, gum, bladder, or skin infections, abnormal drowsiness, etc. All of these things can indicate different things, problems, and conditions, but they may also indicate that you have or are at the brink of having diabetes.

Diabetes can be classified in two types: Diabetes 1 and Diabetes 2. Type one Diabetes means that the person has a deficiency of insulin in his blood caused by the loss of beta cells that produce insulin in the pancreas. This is a frequently found diabetes type in children, but it is not uncommon for adults to have it, too. Most people who suffer from type 1 diabetes get it from their parents and require regular insulin administration. You are far more likely to have this type of diabetes if one of your parents has it. Type 2 diabetes, on the other hand, means that your body tissues cannot respond effectively to insulin because of insulin deficiency. This is the most common diabetes type found today. Thankfully, this type of disease can be improved or even eliminated. People who suffer from it take medications to improve their body’s response to insulin.

The reason why type 2 diabetes is more common than type 1 is that it is not hereditary. It’s attributed to lifestyle and lifestyle decisions. People who are more likely to develop this disease have low physical activity, are obese, consume an unhealthy and/or irregular diet, consume excessive amounts of sweets and sugar beverages, etc.

There is no rule as to who can have diabetes. This disease affects people of all races and ages. However, research has distinguished several groups who are at greater risks of having diabetes based on age, gender, and ethnicity. This disease is more prevalent among females. Females who have it have a poorer quality of life and lower survival rates than males who have the same disease. They also suffer from more complications such as blindness and can acquire this disease while they are pregnant (this is called gestational diabetes).

In terms of race, African Americans, American Indians, Mexicans, and Asians are at a higher risk for diabetes, especially type 2. Meanwhile, people who live unhealthy lifestyles are at a much higher risk of this disease. Those who consume high cholesterol and are focused on eating meals low in fiber, are overweight, or lead a sedentary life, are much more likely to get type 2 diabetes.

Lastly, diabetes is hereditary. If you have a family history of diabetes, the odds of getting it too because of genes are much higher. This doesn’t mean that you’ll definitely have it if your parent does, but the odds are higher than for people who don’t have it in their family. Diabetes is a very serious, life-threatening disease. There is no reason to think that you cannot live a long life without it. But, to do so, you need to constantly monitor it and take proper medication, as well as live a healthy lifestyle. People who suffer from it can have a long, healthy life if they take good care of themselves.

Works cited: National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes#:~:text=An%20estimated%2030.3%20million%20people,can%20be%20affected%20by%20diabetes. Mayfield, Jennifer. (1998). How do I know if I have Diabetes. https://familydoctor.org/condition/diabetes/ https://www.endocrineweb.com/conditions/type-2-diabetes/type-2-diabetes-causes#:~:text=Insulin%20resistance%20is%20the%20most%20common%20cause%20of%20type%202%20diabetes.&text=Type%202%20diabetes%20can%20be,chance%20of%20developing%20type%202.