Sample Research Proposal on Managing Type 2 Diabetes

Introduction: Diabetes mellitus is a common disease affecting approximately 5 % of the population (WHO, 1995).  Diabetes is a chronic life – long condition impacts upon almost every aspect of life. The two major forms of diabetes are type 1 (previously called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes) and type 2 (previously called noninsulin-dependent diabetes mellitus (NIDDM) or maturity-onset diabetes) occurs after age 40, often between the ages of 50 to 60, and the disease develops gradually. Type 2 diabetes mellitus is caused by decreased sensitivity of target tissues to the metabolic effect of insulin. This reduced sensitivity is often referred to as insulin resistance. Type 2 diabetes usually need to change their lifestyle, but this can be difficult to do if the individual does not feel ill or the impact of not doing so does not have immediate repercussions. This syndrome like type 1 diabetes is associated with multiple metabolic abnormalities, although high levels of keto acids are usually not present in type 2 (Guyton & Hall, 2000). The frequency of diabetes in England is higher in men than in women. However, women with diabetes are at relatively greater risk of dying then men. This may be because of gender compounds other aspects of inequality. The key interventions underpinning the standards in this NSF are based on research evidence. The views and the experiences of people with diabetes, the work of the Audit Commission and the report of the Health Services Ombudsman have informed the development of this NSF. The typology below has been developed to distinguish between the different levels of supporting evidence. Levels of Evidence: Level 1: Meta – analyses, systematic reviews of randomized controlled trials, or randomized controlled trials Level 2: systematic reviews of case – control or cohort studies, or case – control or cohort studies Level 3: non – analytical studies, e.g. case reports, case series Level 4: expert opinion (in the absence of any above) Figure 1: Levels of Evidence Source: Department of Health: Modern standards and services The Diagram below summarizes the prevention and the management of diabetes.      Diagram 1: summary of the prevention and the management of diabetes Source: Department of Health: Modern standards and services Empowering people with diabetes: Standard 3 Aim: to promote self-reliance in attaining the best quality of life in managing diabetes type 2 Key interventions: Structured education can improve knowledge, blood glucose control, weight and dietary management, physical activity and psychological well – being, particularly when it is tailored to the needs of the individual and includes skills – based approached to education (level 1). Personal care plans can help empower people with diabetes (level 4) Patient held/accessed records can facilitate self – care (level 4) Telephone or postal reminders (Griffin, 1998) prompting people with diabetes to attend clinics or appointments are an effective method in improving attendance (level 4) Implications for service planning:             According to Kimmonth, A; level one evidence, patient's satisfaction and knowledge improve when lifestyle interventions are delivered by primary care staff who have been trained to take a patient – centered approach (1998). The health care professional's task is to develop a working alliance with the person with diabetes to enhance and support their capacity to self- care. The components of self- care include: adopting and maintaining a healthy lifestyle; self- monitoring; and concordance with medication (See Box 1). Box 1: components of diabetes Self - Care Lifestyle: Eating a balanced diet and other changes in eating habits, such as the timing of meals Regular physical activity Maintaining a healthy weight Smoking cessation Self – monitoring Blood glucose self – monitoring and / or monitoring urine for glucose Monitoring for symptoms of hypoglycemia and hyperglycemia Monitoring for signs of long – term complications e.g. undertaking regular foot checks Concordance with medication Oral hypoglycemic agents Other medications, such as antihypertensive drugs and lipid lowering drugs   Box 1: Components of Diabetes Self – Care Source: Department of Health: national service framework for diabetes Diabetes Education should: equip people with the confidence and competence to manage their day to day diabetes care provide people with diabetes with the necessary knowledge and skills to enable them to improve their blood glucose control and make the lifestyle changes necessary to reduce their likelihood of developing the complications of diabetes be tailored to the beliefs, attitudes and social environment of the individual, their capacity to learn, and their changing life circumstances, knowledge and treatment goals  allow and enable people with diabetes to practice the skills required for effective self- care. See Box 2 for topics to be covered in education programmes for people with diabetes. Box 2: Topics to be covered in education programmes for people with diabetes Nature of diabetes Significance and implications of a diagnosis of diabetes; the impact of diabetes Aims and different types of treatment Relationship between blood glucose levels, dietary intake and physical activity Short and long- term consequences of poorly controlled diabetes Nature and prevention of long – term complications Importance of annual surveillance for complications Day – to – day management of diabetes ·        Importance of healthy lifestyle, especially physical activity, a balanced diet and smoking cessation ·        Importance of self – management ·        Self – monitoring – glucose monitoring or urine testing ·        Interpreting the results of self- monitoring and tests  of long – term blood glucose control ·        Importance of regular foot care, choice of footwear, foot hygiene, the role or podiatry ·        Importance of oral hygiene and regular dental check – ups Specific Issues: Other illness and diabetes – 'sick day' rules must be given to al people with diabetes; immunizations. Living with diabetes Importance of carrying personal identification, such as Medic – Alert, and a warning card including the name, contact address and telephone number of a person who can help them Driving: notification of the DVLA and insurance company and the importance of avoiding hypoglycemia while driving Holidays Implications of diabetes for employment, life insurance and travel insurance Making best use of health care services: what care to expect; when to contact local services for what; how to get more information (NB people with diabetes are entitles to receive an annual free eye examination by an optometrist/ophthalmic medical practitioner; those receiving treatment with either tablets or insulin are exempt from paying prescription charges) Contacting other people with diabetes Information about Diabetes UK and other local support groups   Box 2: Topics to be covered in education programmes for people with diabetes Source: Department of Health: national service framework for diabetes Care of people with foot ulcers: 1. For a new foot ulcer, urgent (within 24 hours) assessment by an appropriately trained health professional should be arranged (level 4) 2. ongoing care of an individual with an ulcerated foot should be undertaken without delay by a multidisciplinary foot care team (level4). 3. The multidisciplinary foot care team should compromise highly trained specialist podiatrists and orthotists, nurses with training in dressing of diabetic foot wounds and diabetologist with expertise in lower limb complications. They should have unhindered access to suites for managing major wounds, urgent inpatient facilities, antibiotic administration, community nursing, microbiology diagnostic and advisory services, orthopedic / podiatic surgery, vascular surgery, radiology and orthotics (level D). 4. Patients who may benefit from revascularization should be referred promptly. 5. Patients with non-healing or progressive ulcers with clinical signs of active infection (redness, pain, swelling or discharge) should receive intensive, systemic antibiotic therapy (level 3). 6. In the absence of strong evidence of clinical or cost – effectiveness, healthcare professionals should use wound dressings that best match clinical experience, patient preference, and the site of the wound, an consider the cost of the dressing (level 4). 7. Wound should be closely monitored and dressings change regularly (level 4). 8. Dead tissues should be carefully removed from foot ulcers to facilitate healing, unless revascularization is required (level 2). 9. Total contact casting may be considered for people with foot ulcers unless there is ischemia (level 2). 10. For patients with foot ulcers or prevention amputation, healthcare professionals could consider offering graphic visualizations of the sequelae of disease, and providing clear, repeated reminders about foot care (level 2).     Dietary management: There is no one diet prescription for people with diabetes. Four possible alternative methods for planning diets use: 1) the Plate Model, 2) the Diabetic Exchange Lists, 3) Carbohydrate Counting, and 4) the Food Guide Pyramid. The Plate Method is a simple method for teaching meal planning. A 9-inch dinner plate serves as a pie chart to show proportions of the plate that should be covered by various food groups. This meal planning approach is simple and versatile. Vegetables should cover 50 percent of the plate for lunch and dinner. The remainder of the plate should be divided between starchy foods, such as bread, grains, or potatoes, and a choice from the meat group. A serving of fruit and milk are represented outside the plate.                 Figure 2: the plate method Source: Diet and Diabetes   The Diabetic Exchange Diets, in this food system the food is separated into six categories based on macro nutrient content (i.e., starch [cereals, grains, pasta, bread, beans, and starchy vegetables], meat and meat-substitutes, non-starchy vegetables, fruits, milk and fats). Individuals, with the help of a physician or dietitian, design a daily meal plan based on a set amount of servings from each category. The Food Exchange method allows a person to measure rather than weigh food. This saves time and encourages compliance. Any food may be substituted for another within the same food exchange list. As with other methods, all meals and snacks should be eaten at about the same time each day and be consistent in the amount of food consumed. The Carbohydrate Counting; some people choose to count the grams of carbohydrate in various foods, and adjust the amount of carbohydrate consumed during the day as a reflection of blood glucose levels. One choice from the starch, fruits, milk, or sweets and dessert list supplies about 15 grams of carbohydrate. Each selection is considered one carbohydrate choice. A meal plan outlines the number of carbohydrate choices a person may select for meals and snacks. This method requires great diligence with diet and blood glucose monitoring. The Dietary Guidelines/Food Guide Pyramid this provides a conceptual framework for selecting the kinds and amounts of various foods, which together provide a nutritious diet. The Pyramid focuses on variety and on reducing the amount of added fat and sugar in the diet. The bread/cereal, vegetable and fruit groups make up the base of the diet.                   Figure 3: The Food Pyramid Source: A guide for daily food choices   Psychological Interventions:             Depression is more common on people with diabetes than in the general population. The presences of microvascular and macrovascular complications are associated with a higher prevalence of depression and lower quality of life (Lustman et al. 1998). Remission of depression is often associated with an improvement glycaemic control (Talbot & Nouwen, 2000).             Antidepressant therapy with a selective serotonin reuptake inhibitor (SSRI) is a useful treatment in depressed patients with diabetes and may improve glycaemic control (Lustman et al. 2000); however tricyclic antidepressant may adversely affect metabolic control (Lustman et al. 1997).             Cognitive behavioural therapy (CBT) is a psychological treatment which attempts to find links between the person's feelings and the patterns of thinking which underpins their distress. CBT, psychotherapy programmes and coping skills training are useful in treating depression in patients with diabetes (Spiess et al, 1995). However, CBT is less effective in patients with complications (Lustman et al. 1998).   Pharmacologic Management: New oral medications make these targets easier to achieve, especially in patients with recently diagnosed diabetes. Acarbose, metformin, miglitol, pioglitazone, rosiglitazone and troglitazone help the patient's own insulin control glucose levels and allow early treatment with little risk of hypoglycemia. Two new long- acting sulfonylureas (glimepiride and extended-release glipizide) and a short-acting sulfonylurea-like agent (repaglinide) simply and reliably augment the patient's insulin supply. Combinations of agents have additive therapeutic effects and can restore glucose control when a single agent is no longer successful. Oral therapy for early type 2 diabetes can be relatively inexpensive, and evidence of its cost- effectiveness is accumulating. (Am Fam Physician 1999;60:2613-20.)             In particular, we may conclude that Diabetes per se is of need of long term rehabilitation since its incurable and has to be managed day to day through out the patient's life in order to prevent further complications. Different strategies must be implemented with the use of multidisciplinary health care teams in order to manage it effectively since, there is proper referrals for a specific type of management.