Diabetes in the UK: Prevalence and Costs

Introduction

The World Health Organisation (WHO) (2019) states that, diabetes is one of the leading causes of death worldwide; where 422 million of people are affected. WHO (2019) further states that, there are two main types of diabetes Mellitus: type 1 (T1DM) is a lack of insulin and type 2 (T2DM) is due an incapacity of the pancreas to produce sufficient insulin, which then results in hyperglycaemia (high blood glucose level). In addition, T2DM, is considered to be a long term condition (LTC), is not curable, but it can be managed by using medication and therapies to control the disease process (Department of Health (DOH), 2012). As a result LTCs makes up to 66% of emergency admission and approximately 80% of the NHS budget (White paper; Health and social (WPHS), 2016). With a growing population, it is estimated by 2035, 4.9 million of the UK population will have diabetes (PHE, 2016). In England, diabetes is more prevalent in men than women, 9.6% of men compared to 7.8% of women and T2DM accounts for 90% of all cases and T1DM make up the other (Public Health England (PHE), 2016). Furthermore, T2DM is the main cause of premature deaths and also estimates that around 22,000 people die from T2DM in England each year. However, this might not necessarily mean that, T2DM is the sole cause, but rather with the condition related complications such as cardiovascular disease. According to diabetes UK (2015) England have the highest prevalence of diabetes cases in the UK, as it accounts for 2,913,538; whilst Scotland has 271,312; then Wales 183,348 and finally Northern Ireland 84,836. For those pursuing in-depth studies, seeking healthcare dissertation help can provide valuable insights into these pressing issues.

This case study will discuss a patient with type 2 diabetes and the care he received in the hospital for a diabetic foot ulcer. The study will also discuss the path physiology, physical, Medical/ Nursing intervention then psychosocial and socioeconomic impact of the condition, integrated care and health promotion.

Case study

Sun is a pseudonym given to the patient in order to comply with the Nursing and Midwifery Council (NMC) code of professional conduct, confidentiality statement as a duty to protect patients’ information (NMC, 2018 section 5.2). Sun is 57 years, salesman who lives with his wife (Hairdresser) and two young daughters. He was diagnosed with T2DM 6 years ago and has a family history of the condition which was a contributing factor of his chances to develop T2DM. Prior to his diagnosis, Sun had hypertension (HTN) as pre-existing condition which is a disease that results in constant high blood pressure (Tortora and Derrickson, 2015). Moreover, T2DM is mainly associated with (HTN), less physical activity, and obesity is known to greatly increase the chances of developing cardiovascular diseases (NICE, 2019). In order to reduce Sun’s chances of developing cardiovascular complications, he is on Ramipril for his HTN; a drug is used to control blood pressure by making it easy for the heart to pump blood through the body (NHS, 2019). Nonetheless, Sun has Diabetic Neuropathy (DN) as a result of diabetes long-term complications, which led to his current foot ulcer due to reduced sensation. He reported having cut his foot on the beach in November 2018 but had no medical input until 3/3/1019 when he was in severe pain. Sun could not feel any pain until after the wound was seriously infected. Dunning (2014) stated that, T2DM could eventually lead to serious complications such as cardiovascular complications, neuropathy, nephropathy and retinopathy. Holt and Kumar (2015) described DN as a reduced sensation of the foot, which leads to unnoticed injury making it more susceptible to significant trauma. As a result, Sun was admitted due to an onset of diabetic foot ulcer in the ward, where I met him. During Sun’s hospital admission, it was discovered that, sun had Osteomyelitis after an X-ray. Holt and Kumar (2015) believed that, it is important to perform a clinical examination and an x-ray to confirm any presence of Osteomyelitis after a serious foot ulcer. Loss of sensations to extremities (feet) might lead to an infection this would then spread to the bone because of DN (NHS, 2017). Sun is on Metformin and Gliclazide each once a day (OD) to manage his diabetes. Metformin is an oral anti-hyperglycaemic medication, used to balance glycaemia level into the blood stream (BS) by acting on the liver to inhibit hepatic glucose release. (Ashelford et al, 2019). Then Gliclazide is also a glycaemic control drug, which acts on the pancreas to stimulate the beta cells to increase insulin production which will reduce the blood glucose level (NHS, 2019). Sun’s treatment involves pharmacology and on dual treatment to control his glucose level, because the first medication could not control his diabetes. Nice (2016) recommended that, if the first medication was ineffective or the symptoms gets worse overtime, then the Patient should be offered a combination of medicines on top of the existing drug. Additionally If there is persistent hyperglycaemia after the first initiation of treatment, then it is important to consider increasing the drug treatment (NICE, 2016).

Apart from his past medical history (PMH), Sun’s Body Mass Index (BMI) is 39 and not considered be within the normal range of being healthy. A BMI is the method (tool) used to classify a person’s health in relation to their height and weight, a BMI of 23 or more is at increased risk and 27.5 or above is at a very high risk of developing obesity related problems (NHS, 2018). Therefore, an additional waist circumference is used to classify a person health in relation to their weight; if 80cm or more for women and 94 or above for men then they are more likely to suffer from obesity related conditions (NHS, 2018). Some obesity related conditions are: T2DM, stroke, cardiovascular disease and some types of cancers (PHE, 2019). The risks factors of developing T2DM are age, family history, ethnicity, body mass index (BMI), waist circumference, life style choices and environment (Diabetes UK, 2019). Sun’s HTN, obesity, age and family history of T2DM are largely contributing factors of his condition. Diabetes UK (2019) states that, an individual is more likely to develop T2DM, if he or she is white and over 40, have ever had HTN, obese or big around the middle and has family history of T2DM, this makes their chances 2 to 6 times higher to develop the condition.

Pathophysiology of T2DM

The human body requires insulin in order to function. Insulin does a vital job for the human body as it acts like a swipe card, to enable glucosein the (BS) to access the cells, which then produces energy for muscle movement. This happens, when the carbohydrates consumed from food and drinks are broken down into glucose for energy. Then ATP (Adenosine Triphosphate) is produced. (C6 H12 O6) a chemical process formulae of when glucose combined with oxygen to produce energy during cellular respiration (Diabetes UK, 2019). The normal glycaemia level of a non-diabetic individual is between 3.5 and 6.5mmol/L. This is kept in equilibrium by a hormone called insulin and glucagon. Glycaemia is kept to an optimum level by a process called homeostasis via negative feedback (Ashelford, et al, 2019). Every time there is rush of glucose into the BS, the pancreas releases insulin. The pancreas is both an endocrine and exocrine organs because it contains clusters of endocrine cells known as islets of Langerhans (ILs). The ILs is from both alpha and beta cells. Alpha cells synthesise and releases glucose. Ashelford, et al (2019) added that; Insulin is unique because it converts excess glucose into glycogen then stores it in the liver. The pancreas beta cells are triggered to release insulin. Then insulin binds with its receptors to unlock the glucose channels so that high glucose in the BS can access the cells, which reduces glucose concentration into the BS for equilibrium. In case the cells want glucose, they will send a message to the liver request more glucose for energy. Then stored glycogen will be converted into glucose by glucagon of the alpha cells of the ILs and pushed to the BS to increase the blood glucose level. This process goes on as a normal regulation blood sugar level (homeostasis) (Ashelford, et al, 2019). However, if for any factor insulin loses its ability to perform adequate function then this results to hyperglycaemia because there would be glucose accumulation in the BS (Ashelford, et al., 2019). Considering Sun’s case his obesity might be the main cause of his hyperglycaemia as the cells would starve of glucose because the inability of insulin to effectively bind with its receptors due to fat deposits that might have altered the insulin receptors’ shape. Ashelford, et al (2019) added that, the cells would keep requesting for more glucose in dire need of glucose for energy production. The body will then try to restore the equilibrium by converting stored glycogen into glucose and sends it into the bloodstream, which results into severe glucose accumulation, as there is already a high quantity of glucose into the BS and then leads to hyperglycaemia.

Unlike to T1DM, T2DM could remain undiagnosed for years because the symptoms are not usually visible until an acute phase. Therefore, HbA1c is used to measure the amount of haemoglobin, which has glucose attached to it (glycosylated). This test enables clinician to have an idea of the severity of the sugar levels in the BS over a period of time and plan for a suitable treatment (Ashelford, et al, 2019). Those tests are laboratory and are conducted as followed: fasting blood glucose (FBG) if higher than 7.8 mmol/L then there is hyperglycaemia, (OGTT) oral glucose tolerance between or (RBG) random blood glucose for both (OGTT) and (RBG) if higher than 11.1 mmol/L then there is diabetes (Ashelford, et al, 2019).

Physical Impact of T2DM

Hyperglycaemiacan cause lethargy, blurred vision, polydipsia (increased thirst), polyuria (frequenturination), pruritus vulvae (an itching of the genital surrounding)and slow wound healing as more bacteria will bleed through the fresh wound which hinders wound healing (Diabetes UK, 2019). Therefore it is evident that, Sun’s wound was affected by his constant hyperglycaemia. Sun’s recurrent illness is hindering his ability to perform day to day activities and socialise as before because he tends to be lethargic and in severe pain (Neuropathy). Sun’s constant hyperglycaemia have led to adverse physical complications and eventually impacted his mobility due to the foot ulcer. Apart from continuous lethargy, Sun is experiencing an immense pain because of the wound infection and this has reduced his quality of life. Dunning (2014) highlighted that, T2DM could have a great impact on the individual’s quality of life due to its long term complications such as neuropathy.

Medical and Nursing intervention

Earlier on in the community Sun was prescribed 2 courses of oral antibiotics previously, which had no effect as the wound was swollen, red, oozing with a very offensive smell. Investigations found that he had pyrexia: temperature 38.2, tachycardia: heart rate 127 also was in agonising pain. After initial diagnosis from GP sun was referred straight to the hospital querying sepsis because of his high temperature and heart rate. If a patient is experiencing a very high temperature and they have painful, swollen, red wounds, then they are more likely to suffer from septicaemia (sepsis) (NHS, 2019). After Sun’s admission, National Early Warning score used detect early signs of deterioration (NEWS 2) was used to his blood pressure, heart rate, oxygen saturation and temperature. The NICE guidelines 2019, recommends, health providers to use NEWS 2, while assessing the patients with suspected infection or sepsis in acute hospitals. Sun scored very high and this was a concerning situation according to the tool used. However, this tool might not work for everyone, because it is meant for deteriorating patient and these patients are more likely to have a low blood pressure. But, it could also be argued that, the patients with a systolic of 180 will not be picked up as they would still scores 0 and this could be fatal for heart failure (HF) patient, because HF is associated with HTN. Sun was put intravenous antibiotics (ABT) and on sliding scale to maximise immunity and promote (ABT) response. Dunning, (2014) stated that, those with constant hyperglycaemia may have a reduced immunity, this results in slower wound healing and this put them at high risk of infection such as sepsis and have poor response to antibiotics (Dunning, 2014). PMH changed to insulin on sliding scale due to his body need, as he is having persistent hyperglycaemia and less compliant with his sugar level. Furthermore NICE (2015) recommends: if a patient’s routine is restricted or modified due recurrent poor blood glucose level, then you should consider using insulin. Then the doctor referred Sun to the diabetes foot team, Podiatric team and Tissue viability nurse (TVN) (to manage the leg ulcer), dieticians (to encourage healthy eating), and infection control team (for his infection and barrier nursing) and arranged for an MDT discussion regarding his foot ulcer. In addition, the Nice (2016) recommended that, if a patient has a limb threatening diabetic foot problem, they should be immediately referred to specialist team, which will then assess and put a tailored plan to improve the patient’s health. Abbey pain scale was used to assess Sun’s pain, then strong analgesia prescribed for pain control as sun complained of pain and this was very effective. The wound was investigated, measured (10mm depth) and swabbed. In accordance to NICE guidelines recommendations on diabetic foot ulcer: A diabetic foot ulcer should be assessed and documented by measuring the wound (position and depth) (NICE, 2016). Surgical debridement done by TVN, removing the necrotic tissue and washed with saline water before applying UrgoStart contact dressing, then secured with secure k-Soft and lite bandage. NICE guidelines (2019) recommends that, use of UrgoStart dressing and states that, there is evidence supporting that this dressing increases wound healing process in diabetic foot ulcers and also proven to be cost effective and estimates that the NHS could save up to 5.4 million per year.

Psychological and Socioeconomic impact of T2DM

Carrier (2016) highlighted that, T2DM being an LTC may have a wider effect on the individual’s life: physically, psychologically and socioeconomically. This includes everyday socialisation, employment, financial and also hinders good family relationships and results into adverse psychological impact to the individual. Hilson, (2008) believes that if a patient has constant hyperglycaemia, then they are more likely to suffer from early long-term complications, such as neuropathy which might result into limb amputation and this could limit the individual sense of life enjoyment, eventually leads to depression and continuous anxiety. However, the fear of likelihood to lose a limb, restriction from socialising, the effect on family life and employment might be overwhelming and depressing for Sun. Levy (2011) further argued that, T2DM do not seem to have adverse psychological impact other than a temporary anxiety. Hilson, (2008) debated that; high blood glucose level may affect the brain function. A study of T2DM showed patients with 16.5mols vs. 4.5 had impaired information processing, mood swings, increased sadness and anxiety. However the statements above are controversial. This leads to different opinions, an individual with T2DM psychological health might be influenced by his environment, life style, severity of his condition and socioeconomic status. The NMC, (2018) states that, Nurses should be able to understand when a person using their service is distressed or anxious and also respond to it with respect and compassion. After assessing Sun’s needs the nurse referred him diabetes specialist nurse and dieticians. A psychological intervention (Cognitive behavioural therapy) was added to support Sun deal with his anxiety and empower him. Nice (2009) recommended to all the healthcare professionals to be vigilant on signs of depression on patients with LTCs and physical impairment. This might improve patient quality life and self-care. Depression is common in LTCs and has some vibrant signs in diabetes (Holt and Kumar, 2015) Sheehan and Ulchaker, (2012) identified depressions in T2DM as an association of different psychosocial problems and could hinder family dynamics. Although Sun’s daughters are not directly involved in his care, however they are still affected by his condition as they had to stay for days without him. Sun’s condition also has a profound impact on his wife, because they are both stressed about living costs due to her inability to work as she takes care of him and this make him non-compliant to his glucose level his wife reported. Hillson (2008) added that, 42 studies review found that patient with diabetes are more likely to suffer from mood swings than the general population. Depressed individuals are not keen to follow their diet and treatment than those who are not (Hillson, 2008).

According to the DH (2012) LTCs account for 70% of the money spend in health and social care because there are more than 15 million individuals living with LTCs that are using the health services (DH, 2012). This condition is estimated to use up to 5% of the UK’s healthcare money and 10% of the NHS (NICE, 2019). Although the NHS is funded by taxpayers is free at point of use, when we need it, we pay towards it indirectly, every month, through National Insurance payments. Antimicrobial dressings and advanced dressings therapies cost the NHS more than £110 million.

Integrated care and health promotion

People with LTCs require both social and health needs at some stage. In the process they may encounter a wide variety of health care professionals known as multidisciplinary team (MDT), working hand in hand in a very coordinated way using different skills, shared data to deliver holistic, person cantered and compassionate care(Carrier, 2016). The MDT worked together to support Sun in each step, striving to make him better and help him be in control of his condition by making every contact count (MECC). MECC inspires individuals to opt for healthier choices that improve their health (NHS England, 2016). As a result after a long discussion with Sun and his wife about foot ulcer, the doctor informed them that Sun could lose his limb, and then advised on the association with foot ulcer and amputation. The doctor’s advice had a positive impact on Sun. Now, that sun is aware of the implications of poor blood glucose control and the severity of his condition. He took a decision based on reality not on fantasy, which is to strictly follow health advice from healthcare professionals. It could be concluded that, Sun is on (Trans-Theoretical) model of behaviour change (contemplation) as he displayed a willingness to improve his health. Reickman, et al. (2011) state that, taking a step towards behaviour change in relation to health education might empower patients to achieves positive outcomes. Those steps are classified into 5 stages: Pre-contemplation (awareness of the problem but do want to engage), Contemplation (showing willingness to engage into healthy behaviours), Preparation (starting gradually the change by setting up small goals), action (when the goals are put into action) and maintenance (enhance action by avoiding any negative impact that might promote relapse). Healthcare professionals play a significant role into achieving a positive behavioural change from patients. They use good communication integrated into the 6C’s, known as a fundamental principal aligned with effective delivery of care; combined with compassion, commitment, competence, courage and care (cummings and Bennett, 2012). Health promotion is all about providing strategies and information to patients, which enables them to manage elements of their LTC (Royal College of Nursing, 2017). This would reduce complications and Hospital admissions. (House of Commons Health Committee, 2014) state that, approaches to improve health and reduce incidences of acute admission would enhance both mental and physical co-morbidities and enables the staff to meet patients’ holistic need.

In line with reducing incidents and admissions the (NHS England, 2014) set out guidelines, the ‘five year forward view’ a document for change rather than only adaptation to the changes in innovation of advancing science. It also focuses to create more engaging relationship with patients and cares to promote health and prevent illness. Diabetes UK (2019) intensifies that insulin deficiency might be due to genetic factors, environmental, obesity, unhealthy life style and a lack of exercise. Therefore promoting a healthy life style is vital in hyperglycaemia. Nurses focussed to support Sun and aimed to improve his health by increasing the coordination in the quality of care that the Sun was receiving. Nicol (2015) stated that, aiming to provide coordinated care allows the professionals to deliver the right care to the right patient in the right place and at the right time. The nurse played a good role in health promotion, by maximising communication. Sun was seen by dieticians who emphasised the important of low carbohydrates diet. Glycaemic index (GI) diet increases the rise of blood glucose carbohydrates rich food: starch and sugars. GI is a tool used to rank foods that can cause a rapid rise in blood sugar level when consumed (Randall and Ford, 2011).The nurse advised both Sun and his wife on the implications of foot problems, given clear explanation on his condition, shown some pictures on stages of foot ulcers before and after amputation, how to care for his foot after discharge, who to contact in emergency, effective wound care and emphasised on the importance of glycaemia control and HTN. The nice guideline supported the NHS England ‘five year forward plan’ by stating that, management should mainly focuses on educating patients and their carers on how to manage cardiovascular risk, monitoring blood glucose levels, identifying and managing long term complications and advice on healthy eating. (NICE, 2019).

Nurses played a vital role into improving Sun’s health by promoting quick healing process. They ensured that Sun’s health needs were responded adequately with compassion by preventing ill health and promoting wellbeing, this can happen when the patient's interest are put first, making their care and safety your priority and treat them with respect (NMC, 2018). The care provided should always reflect the way you would like to be treated if you were in the patients' position.

Conclusion

In order to summarise it all Sun’s condition was improving well. This is due the support of the well dedicated healthcare team involved in his care. The most fascinating thing of his journey was, that they were able to salvage his leg, because the conservative management of the team worked and that was a big relief for him and that increasingly gave him the willingness to be in control of his blood sugar levels. Sun’s wife and daughters were happy on the discharge day as they thank team for making him better. They got a thank you card a box of chocolate to the staff. He was very happy and healing well when discharged with a plan to be followed in the community along the right contact for support. I could not follow up his care in the community. However, the care plan was tailored to help and support him in each step of his journey until he fully recovered by empowering him. Although T2DM is a very common disease but can also be prevented by always keeping a healthy weight, exercising, following a well-balanced diet NICE, (2019) stated that, if an individual is diagnosed with T2DM, then they should take the following measures to delay or prevent diabetes related complications whether acute or chronic and helps the patient to be on top of their health by following a healthy well-balanced diet, exercising, keeping a close eye on their sugar level and having a good understanding on their numbers. Seeking support when required, getting their eyes, kidney function and feet checked yearly ensure that, their blood pressure is within a normal parameter, which reduces the risk of heart condition and it might lead to neuropathy and foot problems (NICE, 2019).