Guide Difficult Diabetes (Challenges In)

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For people with diabetes who are planning travel, consideration needs to be given to every stage of a journey, starting with deciding when to travel, what to pack, and purchasing travel insurance, and then to passing through airport security and anticipating consequences of late or delayed flights, through assessing the impact of crossing multiple times zones and jet lag.

More than half of travelers with diabetes report difficulties in managing their blood sugar levels during their journey or in the first 24 hours after arriving at their destination. A simple trip to and from an airport carries risk for people with diabetes. Being late arriving at an airport or at the destination hotel dramatically increases the risk for hypoglycemia, putting adults and children at risk for serious complications, including loss of consciousness, collapse, seizure, coma, and rarely death, as well as missing their journey altogether. David C. These people face many difficulties including, in many cases, navigating through airport security with paraphernalia that can require special scrutiny, losing supplies that cannot easily be replaced, lacking access to healthy food choices, needing a place to exercise in an unfamiliar location, and experiencing stresses that can greatly affect glucose levels.

Endocrinology Advisor: What are the implications for clinicians; for example, how might they help address some of these issues with individual patients? Dr Kerr: Clinicians need access to better tools to personalize the advice they give to people with diabetes. A journey begins and ends at home, but the clinician needs to consider all aspects including the impact of time zones on the timing and dose of insulin and other medications.

Dr Klonoff: Clinicians need more sources of information to convey to their traveling patients with diabetes. Electrolyte imbalances are also common and are always dangerous. As with DKA, urgent medical treatment is necessary, commonly beginning with fluid volume replacement. Hypoglycemia , or abnormally low blood glucose, is an acute complication of several diabetes treatments.

It is rare otherwise, either in diabetic or non-diabetic patients. The patient may become agitated, sweaty, weak, and have many symptoms of sympathetic activation of the autonomic nervous system resulting in feelings akin to dread and immobilized panic. Consciousness can be altered or even lost in extreme cases, leading to coma, seizures , or even brain damage and death.

In patients with diabetes, this may be caused by several factors, such as too much or incorrectly timed insulin, too much or incorrectly timed exercise exercise decreases insulin requirements or not enough food specifically glucose containing carbohydrates. The variety of interactions makes cause identification difficult in many instances. Decrements in insulin, increments in glucagon, and, absent the latter, increments in epinephrine are the primary glucose counterregulatory factors that normally prevent or more or less rapidly correct hypoglycemia.

In insulin-deficient diabetes exogenous insulin levels do not decrease as glucose levels fall, and the combination of deficient glucagon and epinephrine responses causes defective glucose counterregulation. Furthermore, reduced sympathoadrenal responses can cause hypoglycemia unawareness. The concept of hypoglycemia-associated autonomic failure HAAF in diabetes posits that recent incidents of hypoglycemia causes both defective glucose counterregulation and hypoglycemia unawareness. By shifting glycemic thresholds for the sympathoadrenal including epinephrine and the resulting neurogenic responses to lower plasma glucose concentrations, antecedent hypoglycemia leads to a vicious cycle of recurrent hypoglycemia and further impairment of glucose counterregulation.

In many cases but not all , short-term avoidance of hypoglycemia reverses hypoglycemia unawareness in affected patients, although this is easier in theory than in clinical experience. In most cases, hypoglycemia is treated with sugary drinks or food. In severe cases, an injection of glucagon a hormone with effects largely opposite to those of insulin or an intravenous infusion of dextrose is used for treatment, but usually only if the person is unconscious.

In any given incident, glucagon will only work once as it uses stored liver glycogen as a glucose source; in the absence of such stores, glucagon is largely ineffective. In hospitals, intravenous dextrose is often used. Diabetic coma is a medical emergency [7] in which a person with diabetes mellitus is comatose unconscious because of one of the acute complications of diabetes:.

The damage to small blood vessels leads to a microangiopathy , which can cause one or more of the following:. Macrovascular disease leads to cardiovascular disease, to which accelerated atherosclerosis is a contributor:. The immune response is impaired in individuals with diabetes mellitus. Cellular studies have shown that hyperglycemia both reduces the function of immune cells and increases inflammation. Type 2 diabetes in youth brings a much higher prevalence of complications like diabetic kidney disease, retinopathy and peripheral neuropathy than type 1 diabetes, though no significant difference in the odds of arterial stiffness and hypertension.

A study over 41 months found that improved glucose control led to initial worsening of complications but was not followed by the expected improvement in complications. Research from suggested that in type 1 diabetics, the continuing autoimmune disease which initially destroyed the beta cells of the pancreas may also cause neuropathy, [28] and nephropathy.

Challenges in Diabetes Management: Glycemic Control, Medication Adherence, and Healthcare Costs

The known familial clustering of the type and degree of diabetic complications indicates, that genetics play a role in causing complications:. Chronic elevation of blood glucose level leads to damage of blood vessels called angiopathy. The endothelial cells lining the blood vessels take in more glucose than normal, since they do not depend on insulin.

They then form more surface glycoproteins than normal, and cause the basement membrane to grow thicker and weaker. The resulting problems are grouped under " microvascular disease " due to damage to small blood vessels and " macrovascular disease " due to damage to the arteries. Studies show that DM1 and DM2 cause a change in balancing of metabolites such as carbohydrates, blood coagulation factors, [36] and lipids.

The role of metalloproteases and inhibitors in diabetic renal disease is unclear. Numerous researches have found inconsistent results about the role of vitamins in diabetic risk and complications. Thiamine acts as an essential cofactor in glucose metabolism, [40] therefore, it may modulate diabetic complications by controlling glycemic status in diabetic patients. Low serum B12 level is a common finding in diabetics especially those taking Metformin or in advanced age.

Low plasma concentrations of folic acid were found to be associated with high plasma homocysteine concentrations. Free radical-scavenging ability of antioxidants may reduce the oxidative stress and thus may protect against oxidative damage. Modulating and ameliorating diabetic complications may improve the overall quality of life for diabetic patients.

Many observational and clinical studies have been conducted to investigate the role of vitamins on diabetic complications, [45].

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Vitamin D insufficiency is common in diabetics. Vitamin C has been proposed to induce beneficial effects by two other mechanisms. It may replace glucose in many chemical reactions due to its similarity in structure, may prevent the non-enzymatic glycosylation of proteins, [59] and might reduce glycated hemoglobin HbA1c levels.

From Wikipedia, the free encyclopedia. The lead section of this article may need to be rewritten. Please discuss this issue on the article's talk page. Use the lead layout guide to ensure the section follows Wikipedia's norms and to be inclusive of all essential details. The quantitative phase of the study involved a cross sectional survey and data analysis. This was followed by qualitative telephone interviews of a subsample of the participants in order to provide a more complete and comprehensive understanding of the results which were integrated into the data interpretative phase [ 44 ].

Qualitative data were collected through individual telephone interviews which further explored additional factors that serve as enablers and barriers to diabetes self-management. The survey questions were divided into two parts. First, the following health characteristics which were likely to influence skills and self-efficacy for diabetes management were assessed: type of diabetes, duration of diagnosis and whether participants had recently received within the previous 12 months diabetes self-management education DSME from a member of their health care team.

Second, novel LMC Skills, Confidence and Preparedness Index SCPI tool was used to assess skills and self-efficacy in core behaviours central to diabetes self-management such as healthy eating, blood glucose monitoring, being active, healthy coping, medication adherence, problem solving and reducing risk [ 11 , 45 ]. The SCPI tool had been previously validated, where its construct validity for different ages, ethnicity, gender and level of education was established [ 32 ]. Additionally, the validity of the tool for use in different settings is established by the fact that, as a new tool, the questions reflect the current recommended self-management regimen for diabetes patients, and this has not been fully explored by previous tools [ 45 ].

It has excellent readability and reliability. Permission was obtained to use the tool. The SCPI tool consists of three subscales: skills, confidence and preparedness. The skills subscale was used to assess perceived ability to perform the self-management activities mentioned above. The confidence subscale was used to assess self-efficacy in being able to perform the skills.

The preparedness scale was not used in this study because this subscale assesses the readiness of patients to implement behavioural changes following an educational session; which was not applicable in the present study. The skills and confidence domains consist of nine 9 and eight 8 items respectively. Two of these items focus on skills and confidence to use insulin. All items were rated using a visual analogue scale, with scores between 1 and Each of the items in the domains produced its own score out of The total score was the mean score in each of the subscales, where higher scores denoted better skills and confidence.

The instrument was administered in English Language. Through online survey, all participants were invited to an individual telephone interview session. They were requested to indicate interest by providing their best contact number and availability. A single independent resource person male who is an experienced researcher in qualitative studies conducted all interviews. The interviewer was trained on the aims of the study and the interview guide by the first author of this study MDA. The guide was then pilot tested between the interviewer and MDA before actual use.

Additionally, MDA was present in the first three interviews to ensure appropriateness of data collection. While the interviews were used to reflect on the interview guide, no changes were made to the guide afterwards. There was no interaction or previous relationship between MDA and the participants. Prior to the commencement of the interview, each respondent was asked if they were located in a comfortable place for an interview, and were briefly presented with the general idea of the study and key diabetes self-management activities.

The interviewer did not have prior relationship with the participants. Each Interview was audio recorded and lasted between 7 and 20 minutes in duration. Data saturation was achieved through recurring explicit ideas [ 46 ] after completing the 14 th interview. However, the interview was conducted for the remaining two participants who had indicated interest in order to ensure that no main idea was unintentionally discarded. Repeat interviews were not required and due to the remoteness of the study participants, there was no post interview debriefing.

The semi-structured interview guide was developed by the research team. Topics covered in the interview included open ended questions and probes to facilitate discussion See S1 Appendix for details of the interview questions. The protocol contained detailed information on the ethical obligations of researchers toward participants engaging in online research activities.

Essentially, these obligations included confidentiality, anonymity, scientific value, maximising benefits, minimizing harms, and informed consent [ 47 ]. All these obligations were strictly adhered to during the research process. Furthermore, as part of the application process for advertisement of the study on the website of health organisations, the ethics approval document was made available to the appropriate and designated officials of these organisations. All prospective study participants were provided with the study information along with the privacy policy prior to the survey.

Therefore, participants were informed about the use of their answers for analysis under anonymity. Informed consent was implied by submission of the online survey, while all telephone interviewees provided verbal consent. SPSS Version 23 was used for quantitative data analysis. Items in the skills and self-efficacy domains were reported as means and standard deviations SD. Mean scores were calculated for demographic and health variable subgroups. Specifically, t-test was used for variables with two categories i.

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Effect sizes were calculated using Eta squared values to show the magnitude of difference in mean scores between categories within each variable. Pearson correlation coefficients were used to estimate the strength of association between skills and self-efficacy scores. Significant variables in the bivariate analysis were included in the regression. For qualitative data analysis, audio recordings were transcribed verbatim by an independent professional transcriber and reviewed by the first author MDA for accuracy.

Type 2 Diabetes - Nucleus Health

Emerging themes were identified using in-depth inductive thematic analysis [ 48 ] undertaken in six steps: i re-reading of data line by line to ensure familiarization ii identification of patterns within data and organization into codes iii grouping of initial codes through constant comparison to identify emerging themes iv grouping and review of identified themes into general themes v refining themes and vi selection of representative quotes to support themes [ 48 ].

The first coding and generation of themes was done by MDA. In order to enhance result credibility and validity, raw data transcripts, coded data and themes were independently reviewed by the last-named author BMA. Discrepancies were resolved through discussion and mutual agreement. Key themes were reported along with relevant quotes affixed with an assigned number code and the type of diabetes the respondent has for instance P3, T2D.

A total of complete responses to the online survey was received. The mean age of respondents was More than half of the respondents had type 2 diabetes About half of them were diagnosed in the last 5 years Over half of the respondents A total of 31 respondents However, about half of them declined at time of interview or never responded to phone calls, leaving a final respondent number of 16 individuals who were interviewed.

The participants were mostly males; Table 1 shows the mean scores for each of the items across the skills and self-efficacy domains. Participants scored lowest in their confidence for healthy coping with stress 6. Table 2 shows the relationship between demographic and health characteristics and the levels of skills and self-efficacy for diabetes management in participants.

All demographic characteristics except geographic location, gender and age, were significantly associated with perceived skills and self-efficacy. Two major themes were identified as factors which could facilitate diabetes self-management. Participants ensured that they engaged in the necessary lifestyle behavioural activities due to their determination to maintain better quality of life and thereby avoid what was observed in their peers who had already developed some form of diabetes complications:.

Furthermore, the determination to prevent diabetes complication was expressed by refusal to purchase certain foods which participants believed could increase the risk of progressing type 2 diabetes management into requiring the use of insulin injection:. I have to remind myself of that always. Respondents acknowledged that having good knowledge and problem solving skills in diabetes has proven useful to aid their self-management.

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Awareness of how foods impact their health was reported as highly essential:. Also , I found understanding what hypo or hyper , and understanding how my body reacts and how I can resolve that has been very useful in managing my diabetes. Participants mentioned the use of mobile technological devices specifically, smart phone application apps , insulin pump and continuous glucose monitors CGM as supporting tools which have enhanced their self-management.

They noted that having access to such previously stored data on their phones gave them insight into the best self-management strategy which had assisted in adequate glycemic control:. But in these days , I record it using a smart phone app , which allows me to search. So it allows me to access the data quickly and make a sort of best guess for now based on what happened in the past.

Reminder feature in apps were found useful to give alert for recurring tasks such as taking medications thereby improving medication taking behaviour especially during busy schedules:. Also, motivations and encouragements were received through the use of app especially in the event of unstable blood glucose control. Participants stated that whenever their blood glucose level fluctuated and differed from the prescribed limits despite all efforts to stabilize it, looking at good data previously stored in apps provided an assurance that their blood glucose levels will not always be unstable:.

Being able to flip back on my smart phone. In this regard, one participant stated that:. Participants also indicated that use of insulin pump provided additional support and relief from pains experienced while using needles:. My insulin pump definitely helps. In spite of the factors that foster effective self-management of diabetes, the key themes that emerged from the interview indicated that people with diabetes encountered diverse challenges in performing their self-management due to the: i dynamic and chronic nature of diabetes; ii financial constraints iii work and environment related factors; and iv unrealistic expectations.

The most common complaint reported by participants was the dynamic and chronic nature of diabetes and how these attributes make diabetes self-management require multiple needs. Participants felt there were many reasons including environmental conditions, which may demand an adjustment in their self-management even within short time periods. They believed the constant requirement to modify needs of the condition denoted certain things they were not doing right in their self-management and they always had to put in great effort to meet up with their health requirements:.

It could be so much easier if you could just work out what your insulin to carb sensitivity portion is , work out how to behave around exercise , work out correction factors and that would be all. Then the weather get warmer , you may need to re-evaluate your insulin sensitivity and carb ratio. Likewise, the effects of self-management on diabetes outcome was referred to as a system which could not be automatically controlled.

Participants described how similar behavioral activity such as eating the same diet over time could impact their health differently. You can eat something today and you can be okay , eat something tomorrow and it can be completely different. The weariness about the never-ending need for self-management because diabetes is a lifetime disease was expressed:. Participants were sometimes unwilling to undertake their self-management because they felt it is not a permanent cure for the disease, diabetes is chronic, so what is the point?

The presence of other diabetes related complications or health problems such as neuropathy and depression in some participants limited their ability to actively engage in behavioral activities especially physical exercise or healthy eating:. The difficulty in meeting the financial cost for some diabetes medical tests and other treatment requirements was also identified as a barrier.

Participants voiced out the financial burden they experienced by citing the need to pay for some clinical tests and diabetes supplies which are not covered by their health insurance such as the glycosylated hemoglobin HbA1c test and continuous glucose monitor. They expressed the desire to receive more support from the government:. Participants stated that the inability to get healthy choices of foods in most restaurants or public places when unavoidably required to eat out due to travelling long distances to fulfill their job requirements:.

Like during the summer , the heat hits me big time. Unrealistic expectations and advice about self-management from family or friends especially those not diagnosed with diabetes could be a hindrance to effective care.

Because I need to eat this. Participants felt that some recommendations from HPs were contrary to their opinions on what their diabetes self-management should entail:. To the best of our knowledge, this is the first mixed methods study that has investigated enablers and barriers to general self-management among a multinational audience of people who have type 1 or type 2 diabetes. Most importantly, our findings emphasise the consequential impact of currency of exposure to DSME within the previous 12 months , duration of diagnosis, level of educational qualification and use of technological devices on self-management skills and self-efficacy, regardless of geographical location or ethnicity.

Furthermore, this study presents an in-depth understanding of the experiences of diabetic patients and provides useful insights to health professionals and researchers on how to improve the frequency and quality of self-management support provided to diabetic patients to achieve better health outcomes. The overall skills score was found to be high and many participants reported good level of ability for self-management.

This is specifically in the area of accurate monitoring to assess the impact of diet, medication or physical activities on blood glucose levels. Similar findings were observed in a previous study [ 25 ].

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Accurate monitoring of blood glucose in relation to foods consumed and physical activities are important because they predict good outcomes in diabetes management [ 50 ]. Although the participants in this study scored high in their ability to monitor blood glucose, their capacity to interpret their blood glucose patterns over time was only moderate. Self-monitoring of blood glucose is important to assess glycemic pattern, hence accurate interpretation of these patterns is highly important to ensure effective management of glycaemia related problems encountered in diabetes management [ 51 ].

Participants in this study possessed lower skills related to planning for physical exercise in order to avoid hypoglycemia and adjusting medication to reach targeted blood glucose levels. This result corroborates previous findings [ 52 ]. The ability to manage and make appropriate adjustment to multiple regimens often determines success with other core areas of diabetes self-management and glycemic control [ 51 ].

Diabetic patients have an increased risk of developing hypoglycemia particularly when treated with insulin or insulin secretagogues [ 53 ]. Hence, they should be provided with regular refresher courses and continuous training on blood glucose levels awareness and strategies to balance exercise which could promote glycemic control and adherence to self-management.

Healthy coping strategies to identify and manage the impact of stress on diabetes management may be a difficult aspect of diabetes care because the participants in this study scored lowest in this area for both the skills and self-efficacy domains. All forms of stress either physical or mental, negatively impact blood glucose levels in those with diabetes [ 54 ] and it is a potential obstacle to attaining effective self-management and optimal health outcomes [ 55 ]. This can include regular educational information on the impact of stress on health of diabetes patients and suggestions to reduce it.

Contrary to the findings of a previous study [ 56 ] that reported people with type 1 diabetes as having poorer self-management; our study participants who had type 1 diabetes scored higher than those with type 2 diabetes in skills and self-efficacy to care for their diabetes. Additionally, there was a significant positive relationship between the duration of diabetes and both skills and confidence for self-management.

Patients with type 1 diabetes are typically diagnosed at an early age that may correspond to longer duration of diabetes. This pattern might have afforded them prolonged and regular exposure to health education, which is a significant predictor of successful diabetes self-management [ 20 ]. Overall, the strong correlation between the level of skills and self-efficacy found in this study strengthens the body of evidence supporting this link [ 32 ]. This pattern may be related to high level of education among most of the study respondents as also observed in a previous study [ 57 ].

Patients who possess higher skills usually have higher perceived level of efficacy and are most likely to actually engage in their self-management [ 25 , 32 ]. Regular encouragement which could either be provided verbally or through other means of contact e. While for those with limited educational backgrounds, the use of clear and simple communication styles when providing diabetes education to them will be essential to foster their skills and confidence [ 57 ].

Based on the results of the interviews, the most commonly perceived factor that fostered regular self-management was the will to prevent the development of diabetes complications.

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This result corroborates previous findings [ 12 , 59 ] and indicates that the participants in this study took responsibility for their choices and respective consequences. Discipline and proactive approaches to self-management are essential to reducing or preventing the development of diabetes complications.

Furthermore, our study findings confirm those of other studies that the use of mobile technologies such as smartphone applications [ 19 ], insulin pump [ 60 ] and continuous glucose monitor [ 61 ] could enhance diabetes self-management in patients. Technology interventions have positive impact on diabetes outcomes such as adherence to self-management activities, glycosylated hemoglobin and diabetes self-efficacy [ 19 ].

Therefore, health professionals could recommend the use of mobile health technologies to patients who are capable of using them as they benefit from them. The lack of enthusiasm towards regular self-management due to the chronic and dynamic nature of diabetes was not entirely unexpected. High diabetes distress results in sub-optimal diabetes management and compromised quality of life [ 3 , 63 ].

Diabetes distress is common among patients and impacts on their self-management and health outcomes.