Barriers to Self-Management of Type-2 Diabetes in Older Adults

Chapter one Introduction

1.1 Study Purpose

Diabetes is a chronic health condition in which the blood glucose level is increased due to insulin resistance in the body or a lowered production of insulin in the body (Saeedi et al., 2019). Type-2 diabetes is the commonest type of diabetes, and its management is required through effective self-care and medication support (Rubie et al., 2014). However, older adults show hindered ability in self-management of type-2 diabetes which causes a worsening of their health (Powers et al., 2021). Thus, the review is developed to identify the barriers which lead to hindered self-management of type-2 diabetes in older adults and to suggest strategies to overcome them. For adults who are struggling with self-management of type-2 diabetes, associating with healthcare dissertation help to get valuable guidance toward better health management practices.

1.2 Rationale

1.2 The National Institute of Health and Care Excellence (NICE, 2020) and Diabetes UK (2019) state that type-2 diabetes is the commonest kind of diabetes, and it is present in nearly 90% of the diabetic population which is 4.9 million people in the UK in 2021. In 2014, it was predicted that by 2025 more than 5 million people would be diagnosed with type-2 diabetes in the UK (NICE, 2020; Diabetes UK, 2019). However, this figure has already been reached in 2021, which indicates that the prevalence of type-2 diabetes patients is occurring beyond the expected rate as the prediction made in 2014 for 2025 is already fulfilled. 13.6 million people in the UK are at risk of developing diabetes and many have a family history of diabetes (Diabetes UK, 2021). This makes type-2 diabetes a key issue in the UK as there is a high probability of an increased number of people becoming affected by the disease. Type 2 diabetes mainly occurs due to lack of effective care or self-care management (diabetes.org.uk, 2021). This results in negative health consequences and is a financial burden on the NHS (Diabetes UK, 2014). Thus, identifying barriers regarding self-care management for diabetes is one of the key issues to be focussed on to develop action in controlling the increased prevalence of the disease in the UK (Diabetes UK, 2014).

The discussion regarding self-care management of type-2 diabetes is required as according to a report by Diabetes UK (2014), nearly 24,000 people in the UK who are suffering from diabetes die each year, with 700 people with diabetes dying prematurely each week (Diabetes UK, 2014). Moreover, diabetes is one of the prominent causes of blindness in people of working age who are suffering from the illness (Guo et al., 2020). Furthermore, nearly 185 leg amputations are carried out each week globally on patients suffering from diabetes which equates to 9600 leg amputations a year (Winell et al.,2013). The lack of effective control of blood sugar in type-2 diabetes patients makes them at risk of nerve damage that leads to blindness along with amputation due to hindered wound healing ability (Guo et al., 2020). Thus, the discussion regarding barriers of self-care in type-2 diabetes is essential as it would help to understand the problems which are responsible in worsening the disease in the UK. It is stated by Diabetes UK that nearly a quarter of hospital beds are used by people with diabetes and many of them are hospitalised due to lack of effective self-care management regarding the disease (Diabetes UK, 2014). Thus, it indicates that discussion regarding the barriers for self-care in managing diabetes for older adults would help nurses to identify the way care is to be modified. this approach should result in fewer type two diabetes patient being hospitalized, overcoming the barriers so that fewer diabetes patients are hospitalised.in turn, greater opportunities for patients with complicated health issues would be provided with easier assess to get hospitalisation.

The National Health Service (NHS) states that nearly £10 billion are spent every year in controlling diabetes, and that is nearly 10% of the entire budget for the NHS. Nearly 90% of the money is used for treatment of the complications of uncontrolled type-2 diabetes (diabetes.org.uk, 2021). This indicates that a huge amount of money is required in the management of diabetes in the UK. Effective identification of barriers to management are, therefore, important to understand for lowering expenditure. This is because it would provide insight into possible strategies to be adopted and the hindrances to be managed in overcoming the barriers for smooth care delivery to patients.

According to the Nursing and Midwifery Council (NMC) Code of Conduct (2018), nurses are responsible in caring for patients in their best interest, to ensure well-being and good health. They are responsible for detecting the risk present in care and barriers in care delivery which must be resolved to ensure quality care (NMC, 2018). Thus, the current review is important as it would help me as a nurse to abide by these specified duties. With equally, the identification of the barriers regarding self-care for type-2 diabetes in older adults would help me to determine the care strategies to be implemented aimed at overcoming the barriers. The key personal reason for conducting this review is that, as a nurse in different placements at various health departments, it is seen that many of the patients have queries regarding the way they are to manage their diabetes medication and care. In some cases, diabetic patients avoided compliance in care with the health professionals in managing their health. Thus, the review is developed to identify the reason behind the behaviour of the patients regarding hindered self-care and compliance with care from health professionals.

1.3 Aim

1.3 The aim of the study is to identify the barriers faced by older adults with type-2 diabetes regarding their self-care in order to promote their well-being.

1.4 Objectives

To identify the barriers to self-care among older adults with type-2 diabetes

To assess the factors preventing older adults with type 2 diabetes from complying with care provided by healthcare professionals

To develop recommendations to overcome challenges and barriers to self-care in older adult patients with type-2 diabetes

1.5-Background

Type-2 diabetes is a long-term condition affecting many people globally. According to The World Health Organisation (WHO) (2020), type-2 diabetes is a chronic metabolic disease which causes elevated levels of blood sugar in the body and over time damages the blood vessels, nerves, heart, eyes, kidneys and other parts of the body leading to hinder their effective functioning. It is stated that globally 422 million people are living with diabetes, and it is considered that diabetes, along with other major chronic diseases such as cancer and heart attack, is one of the leading causes of mortality (Chatterjee et al., 2017).

Diabetes is mainly of two types which are type-1 and type-2, of which the latter is the most commonly occurring type of diabetes (Kurkela et al.,2021). The development of type-1 diabetes is mainly related to a genetic condition which leads the pancreas to produce little to no insulin (Azam et al.,2021). However, type-2 diabetes is common and occurs due to various factors such as a congenital and lifestyle choices: and it leads to either resistance to the use of insulin or hindered production of insulin leading the body to have elevated levels of glucose in the blood (Barron et al., 2020). The symptoms of type-2 diabetes include increased thirst, urination, increased hunger, blurred vision, fatigue, frequent infections and unintended weight loss (Roden and Shulman, 2019). Type-2 diabetes has increased occurrence in adults above the age of 45 years (Piko et al., 2021). This fact is because with age, adults are seen to engage in less physical activity or exercise, show lower muscle mass and become overweight which leads the body to develop hindered ability in using insulin produced to convert glucose in the body to energy to be used (Zheng et al., 2018). This is evident as the presence of increased body weight in older adults influences the muscles to become resistant and unable to use insulin produced in the body which creates insulin resistance, in turn, resulting in type-2 diabetes (Roden and Shulman, 2019).

In black and Hispanic ethnic individuals, it is seen that they show an increased risk of developing type-2 diabetes. This problem is because of the influence of the genetic constructs in the ethnic individual which are responsible for increasing chances of type-2 diabetes (Miguel-Escalada et al., 2019). However, Ingelsson and McCarthy (2018), state that another causal factor is a certain mutation in genes which is responsible for causing increased the risk of type-2 diabetes in adults. The genes include KCNQ1, TCF7L2 and KCNJ11 as key replicated genetic constructs which prevent the body from making enhanced amounts of insulin or using insulin in managing normal blood glucose levels, in turn, resulting in the development of type-2 diabetes (Miguel-Escalada et al., 2019). A family history of type-2 diabetes also increases risk in adults to suffer from this health issue (Bellary et al.,2021). This is because the hindered genetic information which causes type-2 diabetes is passed on from the parents to the offspring from the family line. Lifestyle factors, including an increased intake of alcohol and fast food are also responsible for causing type-2 diabetes (Popa et al., 2021). Such a lifestyle leads to a lower level of high-density cholesterol or good cholesterol in the body, and it increases the level of tri-glyceraldehyde which causes insulin resistance in the body, leading to the development of type-2 diabetes (Hackett and Jacques, 2009).

The presence of type-2 diabetes is diagnosed in patients through the testing of glucose content in the blood and is done by measuring the fasting plasma glucose level (Wasana at el.,2021). The normal fasting plasma glucose level is 7mmol/L and values above that are considered as high insulin level seen in type-2 diabetes patients (De Sanctis et al.,2021). The test is performed by taking blood in the morning after a period of fasting to determine the efficiency of the body to have used the glucose produced after the last diet (Sattar et al., 2019). The plasma glucose level after two hours is next measured of which more than 11.1 mmol/L value indicates glucose resistance of the body and indicates the individual is suffering from type-2 diabetes (Hassanein et al.,2020). The Glycated haemoglobin (HbA1C) ≥ 48 mmol/mol is required to be confirmed through repeated experiment on different days to diagnose type-2 diabetes (Nanayakkara et al., 2018). According to World Health Organasation, (WHO) the fasting glucose level between 5.6 to 7 mmol/L is considered as impaired fasting glucose level and individuals above or at the 7.8 mmol/L but not more than 11.1 mmol/L are considered as having impaired glucose tolerance (Hulman et al., 2017).

Regarding an analysis of type-2 diabetes in the United Kingdom, (UK) it is seen that nearly half of the total population who are suffering from the disease have not been diagnosed (Carlton et al., 2017). Thus, late or no diagnosis of type-2 diabetes in the UK population limits the establishment of holistic care to ensure lower prevalence in the country (Fiabetes.org.uk, 2020). The situation regarding type-2 diabetes in adults may be far worse compared to current reports which have not been revealed due to the undiagnosed number of people present in the UK. According to gender, nearly 56% of men in the UK are at risk of suffering diabetes whereas in women it is 44% (Diabetes UK, 2020). This informs that more men compared to women are at increased risk of facing worsen condition related to diabetes if appropriate care is not provided to them (Fang et al.,2020). The Health Survey of England reports that 2.3 times more suffering from diabetes is to be expected in people living in the lowest quartile compared to the highest quartile in the UK (Diabetes.org.uk, 2020). This indicates that people with less privilege in the UK are showing increased risk of suffering from diabetes compared to rich individuals.

In the UK, the demographic pattern for the incidence of diabetes indicates that 10.67% of 40-49 years of age are at risk of developing the diseases whereas in ages 60-69 years, 70-79 years and above 80 years the risk of presence of diabetes is 26.2%, 23.9% and 13.3% (Diabetes, 2020). This indicates that older adults in the UK are at increased risk of suffering from diabetes compared to the younger population.

There are a range of preventive measures for diabetes, among which lifestyle management is one key measure (Godman et al., 2020). This is because effective lifestyle management that includes healthy eating and physical exercise is effective in managing the risk of type-2 diabetes such as increased weight gain and high cholesterol (Cha et al., 2017). This is evident as Martín-Pelaez et al., (2020) advises that the Mediterranean diet that includes low carbohydrate intake is effective in controlling type-2 diabetes. This is because the intake of complex or low carbohydrates leads the body to take time and have less opportunity to develop increased glucose that may lead the individual with hindered glucose management to develop uncontrolled type-2 diabetes. However, many of the individuals in the UK are seen to lack knowledge regarding the aspect and are found to be suffering from uncontrolled type-2 diabetes (NICE, 2017).

One of the key measures in diabetes management is everyday monitoring of blood glucose levels in patients to keep track on the glycaemic control and impact of treatment provided to them on controlling the illness (National Institute for Health and Care Excellence, NICE, 2017). However, many patients lack the understanding of the way to use glucose meters in tracking their blood sugar level (Ikpasaja at el., 2021). This results in them being unaware of the position of their health regarding type-2 diabetes and facing hindered health management regarding the disease (Longo et al., 2021). NHS England has developed NHS Diabetes Prevention Program (NHS DPP) with the key aim to inform individuals of all ages regarding the causes and risk factors of diabetes and ways to maintain a healthy diet along with behaviour patterns effective in controlling normal blood glucose levels to avoid diabetes (NHS, 2016). The other program developed by Diabetes UK is “Know Your Risk” in which people are supported to know the level of risk they have in developing diabetes (diabetes.org.uk, 2019).

The National Institute for Health and Care Excellence (NICE) working in the UK have developed various guidance to be followed by healthcare professionals in supporting enhanced management of type-2 diabetes in patients (NICE, 2019). However, irrespective of the presence of guidance, the healthcare professionals are reporting lack of patient knowledge regarding barriers which is leading to lower levels of self-management of diabetes. There are various other programs to raise awareness regarding the management of diabetes in older as well as the younger population (Umaefulam et al.,2020). However, no effective programs have been found that promote detailed self-management information regarding type-2 diabetes management for older adults (Liang et al.,2020). Moreover, in many cases, older adults are reported to face hindrance in self-management of their care but the exact barriers leading to the problem remain unidentified (Haye et al.,2020). Thus, the current study is developed to determine the key barriers leading older adults with type-2 diabetes to face hindrance in self-management for the disease which would ensure their enhanced health outcome and well-being. It is also important as older adults are the most at-risk group in the UK as well as globally, due to which they are required to be the key focussed population in the study.

1.6-Methodology

The methodology of this paper is literature review, which involves a process in evidence of a clearly formulated question is used for explicit identification, selection and critical appraisal of relevant primary evidence and research (Munn et al., 2018). This is to extract valuable evidence to analyse the data to be included in the review for resolving the raised question (Pollock et al., 2021). Moreover, a literature review helps in providing foundation knowledge regarding any topic due to which it helps clarified description of the root causes and management of the raised problem (Vatamanescu et al. 2019).

An electronic search process was used in formulating the study. This is because electronic searching limits the physical barriers faced in gathering evidence for type 2 diabetes (Kurniawati et al.,2020). Moreover, it uses less time in identifying information due to which wider data is gathered in the minimum amount of time (Ruiz-Roso et al.,2021). It is also cost-effective as most of the articles are free to access through different academic websites and a few of them are charged with a nominal fee (Dornan et al., 2019). The electronic search also helps in gathering worldwide data without any barriers helps enriched information to be gathered for the study (Dornan et al., 2019). The electronic databases used in executing the searches were CINHL, Medline and Pubmed. This is because each of the platforms includes valued and well-represented journals that contain information which are proved with scientific experimentation. Moreover, the articles present in the sites are logically informed and contain a variety of information regarding various medical topics (Somal and Foley, 2021). The keywords used were barriers, obstacles, challenges, difficulties, diabetes, type-2 diabetes, self-care management and self-motivation.

The inclusion and exclusion criteria are used for selection of articles to be included in study. This is because exclusion and inclusion criteria help to determine the characteristics which are important for the study to frame it in an enhanced way (Kruse et al., 2017). The exclusion criteria used were articles on type-1 diabetes, partially accessible articles, published before 2010, non-academic papers, containing populations who are above 64 and below 45 years of age, written in languages other than English and not executed in Ireland or the UK. The inclusion criteria for articles were type-2 diabetes, full-text, published on and after 2010, academic journals, written in English, contain population who are within 45-64 years of age and studies executed in the UK and Ireland.

Articles written in English were included and others excluded because the researcher only has knowledge of English. The use of articles written in other languages could not be meaningfully interpreted by the researcher to draw valuable evidence needed for framing the study and therefore, it is included as exclusion criteria. The articles related to type-2 diabetes and elderly population above 65 years of age were excluded as they do not meet the population specified for the study and the type 2 diabetes was explored to understand the barriers in the specific care. Articles published on and after 2010 were included as they contain the most recent information and scientific data regarding the topic to be explored. Articles before 2010 are considered to have outdated information which may be currently useless through the advanced research published in recent articles. Therefore, to avoid errors, the most recent articles within 10 years were chosen and included in the study.

The current study is set in the UK and therefore, the articles relevant to the area were included in the study and others excluded. The articles which are fully accessible were included in the study because they would allow the research to gather detailed data to be used in the findings to present the study in a critical and meaningful way. Articles which are non-academic in nature were excluded as they do not contain logically explained data with scientifically proven experimentation to ensure the information is authentic. Primary articles are included in the study because they contain direct information from the participants which are not manipulated by the beliefs of intervention of the researchers.

In the study, 10,881 articles were identified among which initially158 primary articles were chosen. It was further narrowed down to 99 articles from which based on the limitation, 10 primary articles are chosen to frame the study.

Chapter 2: Results and Discussion

Ten (10) primary research articles were selected for this review. The thematic analysis process was used for data analysis of the information gathered in the study. This is because it is the easiest data analysis process for which no advanced training or support is required by the researchers. Moreover, it provides flexibility to the researchers in gathering information and presenting them in systematic way to avoid duplication of information (Marshal et al., 2017). A total of 3 themes were developed for analysis. Out of the three identified themes, the first theme lack of effective knowledge and education regarding type-2 diabetes is to be mainly explored. For this purpose, seven articles were found which contained the theme and among them six are quantitative and one is qualitative in nature. According to Leppala et al., (2020), qualitative research includes gathering of non-numerical data and informs about the attitude and perspectives of people regarding the problem. It provides greater insight to the researchers regarding the way quantitative information is developed. In contrast, quantitative research helps in establishing generalised information regarding a topic (Karakaya-Ozyer and Yildiz, 2021).

2.1-Analysis and appraisal of lack of education and knowledge regarding selfcare of T2D-

T2D, which is a complicated illness, requires adequate self-care and monitoring, but barriers are faced in achieving self-care which hinders the well-being of patients suffering from the illness. Therefore, it is essential to know and understand the barriers for diabetes care so that they can be resolved to improve health outcomes for patients (Nam et al., 2011; Shi et al., 2020; Ahola and Groop, 2012). The study by Shi et al., (2020) says that it is essential to educate individuals living with diabetes regarding the extent of their deteriorated health condition and impact along with the importance of self-care. This is because it would make them understand that administering anti-diabetic medication is not enough and they need additional care from themselves to control their blood sugar. Similarly, the study by Tidy et al., (2016) informs that educating individuals regarding diabetes is essential because enhanced skills and knowledge of the patients in taking control of their health condition can help them lower their blood sugar level.

In the study by Gardsten et al., (2018), the aim is to identify challenges regarding self-management of diabetes among recently diagnosed adults with the disease and patients who are experiencing T2D long-term. The study used a qualitative descriptive design with multiple focus group interviews for gathering data from two groups of people with T2D. One of these groups consisted of patients with T2D diagnosed for less than 3 years and the second group consisted of patients with T2D diagnosed for more than 5 years. The interview was executed in a primary care. As asserted by Moule and Goodman (2014), interviews are implemented by researchers for addressing questions which are related to explore the personal experience and opinion of the participants. Thus, the study by Gardsten et al., (2018) has used the right method in executing the study.

The findings from Gardsten et al., (2018) inform that both groups lacked certainty regarding blood glucose levels and the way it is affected by their eating habits and medication intake. Gardsten et al., (2018) stated that both the groups differ in regard to challenges faced by them. One group lacked knowledge regarding the body and its reaction for managing low blood sugar levels, while the other group lacked information regarding the way they are to accept the illness and cope with the difficulties related to suffering from T2D. The limitation of the study is use of focus group as the data collection method. The impact of the weakness was that it may have led to create biased results in the study and the information shared may not be true representation of the target group as many are not able to freely share their opinion (Gardsten et al., (2018). However, the strength of the study is that it explains the clinical implications of the results. Thus, the impact of the strength is that the study states effective ways in which the information gathered can be used in clinical field to improve T2D care (Gardsten et al., (2018).

The study by Gien et al., (2017) used a qualitative study design to explore the challenges faced by rural residents with T2D. The study included two focus groups one of which included 7 participants suffering from T2D sharing knowledge and experience regarding living with the illness, and another group included 5 healthcare professionals who discussed their experience regarding caring and working with patients with T2D. The study informs that patients were confused regarding the desired level of blood sugar they needed to achieve and maintain which also acted as barrier towards self-management of their illness. The participants stated that they were frustrated with identifying reliable information regarding T2D and had difficulty accessing healthcare professionals who can effectively clarify the way they are executing self-care. The study also stated that many participants were stressed that they are receiving inadequate or no meaningful information regarding self-care for T2D. However, no participants tried to overcome the problem by attending the diabetes education centre available in their locality. Nevertheless, the researchers stated that the participants may not be aware of the presence of the centres.

The study by Gien et al., (2017) stated that one of the healthcare professionals disclosed it is the duty of doctors to refer patients with T2D to educational centres. This is because if they do not get referred, the patients remain uneducated regarding how to care for T2D. It is also claimed that even though patients with T2D are referred to the education centres, in many cases they do not attend the centres and the reason remains unexplained and unknown by the health professionals. The sample in the study was chosen solely by a single researcher without consultation with others that may have led to self-selection bias (Moule and Goodman, 2014). It creates a barrier towards true sample selection in the study ((Moule and Goodman, 2014). The researchers stated that during the entire study, reliability and validity along with trustworthiness criteria in the study was effectively observed. The trustworthiness in the study was maintained by collecting the information in a precise, and consistent manner. This is important as reliability and validity assurance in the study ensures avoiding biases in the study for data collection (Moule and Goodman, 2014).

Similarly, Khairnar et al., (2019) aimed to determine the barriers and facilitators for self-care regarding diabetes to assist in improving health outcomes for patients. In the study, 2100 survey participants were included, and 210 responses were received (10% response). According to Polit et al., (2001), low response rate indicates bias in the study. Thus, it can be determined that the study has the presence of bias. Khairnar et al., (2019), used a cross-sectional study design, and survey data of the patients was used. The study highlighted that the developed survey was effective in gathering enhanced demographics, attitude, knowledge, level of self-management and readiness regarding health behaviour among the participants. Moule and Goodman (2014) state that surveys are effective in statistically measuring the level of attitude and behaviour of people regarding any particular study topic. Thus, it indicates that the use of a survey was a strategic and effective research design in the study by Khairnar et al., (2019).

The study findings stated that enhanced knowledge regarding diabetes in patients can improve their self-care of diabetes (Khairnar et al., 2019). Therefore, the researchers advised that increased interventions, like in-clinic diabetes education programmes should be promoted to explore different aspects of patient’s knowledge regarding the disease. This will enable an evaluation of the level of understanding they have regarding the illness and the level of support required to ensure better clinical outcomes. The findings also stated that patients can make behaviour and lifestyle changes on their own which are effective to improve their health outcomes. However, it is still stated by Khairnar et al., (2019) that despite high levels of patient readiness regarding lifestyle change acceptance, nearly 75.5% of them did not perceive that lack of knowledge regarding lifestyle change in diabetes management was a barrier towards their care. However, it is a potential barrier as without effective knowledge of the way to make lifestyle change in the diabetic management the individuals would be unable to strategically follow the care and perform enhanced self-support required to control T2D.

The study of Khairnar et al (2019) include limitation regarding the response rate from the sample participants which is only 10% in the study. The high rate of non-responsiveness from the participants create bias in the study because it leads to loss of valuable data. Another limitation present in the study is social desirability bias of information which is tendency in participants to avoid reporting socially unreported attitudes and feelings. This leads to develop answers in the study which are preferred commonly in the society rather than the own selected opinion of the participants at times. It may have impact to create biased results in the study (Khairnar et al., 2019).

The study by Khan et al., (2011) aimed to identify prevalence as well as reasons for poor control of glycaemic condition in patients with T2D. The study was conducted as a part of routine review of patients with T2D in three different healthcare centres. The databases of the healthcare centres were searched for the patients with T2D for more than one year. Nearly 28,677 people were found among which 1261 patients were contacted and their illness of T2D was reviewed over 1 year. Khan et al., (2011) stated that finally they were able to form two-way communication with 143 patients who were invited to attend a control review regarding their glycaemic level. However, the study stated that finally 128 patients connected and provided their perspectives regarding the review. The review was carried out through interviews where the initial phase included discussion regarding glycaemic management and understanding patients’ knowledge of diabetes management by use of a brief diabetes knowledge questionnaire.

The study by Khan et al., (2011) highlighted that 8 out of the 10 diabetes-related quiz is not properly answered by most of the participants indicating many of them lack effective knolwdege of diabetes. Moreover, 73 individuals (56%) reported that they lack enhanced engagement opportunity in diabetes management which has led to create barriers for them in achieving enhanced self-care and glycaemic control. Khan et al. (2011) also reported that after identifying the barriers a care plan was developed by the nurses in supporting the patients. The six-month follow-up review of the plan showed that 75.8% of the patients expressed improvement regarding controlling their blood sugar. The inclusion of patients in the study by searching through different databases of primary healthcare centres could have resulted in concerns about confidentiality of the patients and raise issues around informed consent. As stated by Moule and Hek (2011), individuals who participate in studies must provide written consent regarding their awareness about the study and the way their responses are to be used. This is to allow them to understand if they wish to participate in the study or withdraw from it. In the study by Khan et al., (2011), informed consent was not taken, indicating it violated the right of the participants and ethical consideration in the study was not effectively followed.

Theme 2: Analysis and appraisal of lack of family support regarding self-management of type-2 diabetes among elderly

Self-management is challenging for the diabetic elderly due to their deteriorated health condition and often require family support in managing the condition which does not receive in the home. It is evident from the study by Ravi et al. (2018) aimed to identify if supportive family behaviours promote self-management of diabetes in the elderly population. For, this purpose a cross-sectional study design was used and a survey of 200 consecutive patients from a diabetes outpatient department was done. The use of cross-sectional study design is appropriate for the research because it helps in gathering potential information in time-effective and cost-effective way (Blatch-Jones et al., 2018). However, the limitation faced with its use is that cause and effect relationship between the independent and dependent variables in the study could not be established (Wang and Cheng, 2020). The results gathered in the study revealed that many of the patients failed to receive effective family support for the self-management of their diabetic condition. However, the small number of diabetic individuals who were able to receive family support expressed greater efficiency in diabetes self-management (β = 0.527; p = 0.015). The strength of the study is that it explored the way family dynamics impact diabetes self-management in the elderly. However, the limitation of the study is that it failed to determine the extent of change could occur in glycosylated haemoglobin in the diabetes elderly with the support of family members due to resource constraints.

The study by Mayberry et al. (2019) aimed to assess the helpful and harmful family and friend involvement in T2D self-management among adults. The study used the mixed-research method in gathering information indicating it implemented survey as well as cognitive interviews in gathering information. The mixed-method is appropriate for the study because it helped in gathering statistical data and data describing the reason for the statistical information being gathered regarding the impact of family and friends involved in T2D self-management (Greenhalgh et al., 2018). The results reveal that harmful involvement of family and friends in diabetes self-management lead to worsened HbA1c results (β=0.08, p=.03) which worsened more in the next three months (β=0.12, p=.04). The family support or involvement in self-management of diabetes by the patients were related to blood glucose management, medication adherence and diet control in the patients. The limitation in the study is selection bias used for examining the reliability of family involvement at three months of diabetes self-management.

In similar, the study by Whittmore et al. (2019) aimed to identify the challenges faced in diabetes self-management by the elderly under lower resource settings. The study used qualitative descriptive design to gather information from selected sample participants. The use of the design is appropriate because it allows to present comprehensive and detailed information which explains the reason for the raised problem in the study and the factors contributing to the problem (Hawkins, 2018). In this study, the use of the qualitative descriptive design allowed detailed presentation of the challenges of self-management faced by diabetic elderly and way it is creating obstacles for them to achieve enhanced well-being. The study used convenience sampling and semi-structured interview in gathering participants and collecting information from them in resolving the raised question in the study. The use of convenience sampling is beneficial for the study because it helps in presenting data from the perspective of the participants regarding the identified problem in the study (Bhardwaj, 2019). Thus, its use helped in gathering personal perspective of the elderly with diabetes regarding the challenges they faced with self-management which is creating issues for their health control regarding diabetes. However, the problem with using convenience sampling is that the results cannot be generalised and may led to create biased results due to lack of reason regarding few people in the sample being involved in the study (Hu and Qin, 2018).

The study is carried out in three primary care facilities and the results reveal that lack of family support in completing the demands of the elderly made them face hindrance with self-management of diabetes care. The other challenges faced which created difficulty for the elderly in self-management of diabetes condition are lack of resources, mental health issues and cultural beliefs. The lack of family support led the elderly with T2D to face hindrance with eating that contributed to lower nutrition in diabetes patients, Moreover, the lack of family support led the elderly feel lack of motivation in taking own care and take proper medications leading them to show improper self-management of diabetes condition. The limitation of the study is that the data is gathered from participations from a single geographic location due to which it cannot be generalised to be used in countries where similar social situation like the area in which the study is performed are not prevalent.

Chapter 3:

Conclusion

The current review was conducted because in the UK, the number of patients with type 2 diabetes (T2D ) was found to be rising at an exponential rate. However, many of the patients with T2D were found to be suffering from the condition irrespective of the presence of enhanced healthcare and support for controlling the disease. Thus, the review was carried out to determine the barriers which are hindering the self-care of adults with T2D irrespective of having adequate support in self-controlling the disease. Regarding the review, ten articles were included in order to address the research question. The common information found in most of the articles was regarding lack of education and knowledge of self-management in patients with T2D which created barriers towards self-care among older adults. Therefore, the theme of analysing lack of education and knowledge impact in caring for T2D was developed.

The analysis and appraisal of articles regarding lack of T2D education and knowledge concluded that participants in most of the studies are facing similar problem and barriers. The barriers are indicated as the reason which is leading diabetic individuals unable to execute effective self-care required for them to effectively manage T2D. From the analysed studies, the frequent barriers reported include lack of knowledge of desirable blood glucose levels, hindered understanding of the cause of diabetes and way T2D development affects the body. For instance, the participants in the Gardsten et al., (2018) mentioned barriers faced regarding self-care of T2D condition is lack of proper knowledge of the level of blood glucose to be reached to remain healthy. The facts are similarly presented in the study by Khairnar et al., (2019). The overall unawareness of the desirable blood glucose level and hindered understanding regarding diabetes along with its concept is the most reported barrier by the patients in the evaluated studies. Thus, it can be argued that barriers occurred in patients for self-care management of diabetes care due to their lack of knowledge and understanding of the health condition.

The systematic review has explored that apart from lack of knowledge and education, the lack of family involvement in self-management of diabetes among the elderly act as a barrier for them to attain effective care and management for reaching well-being and good health. It is evident from the studies by Ravi et al. (20198), Mayberry et al. (2019) and Whittemore et al. (2019) who informed lack of family support led to poor control of blood glucose level as measured from HbA1c test in elderly who were involved in self-management of diabetes. This is because without family support, the diabetic elderly lack enhanced assistance in cooking meals as per the diet chart provided to them which led to their poor nutrition management causing them to face poor diabetes control (Kristianingrum et al., 2018). In diabetic self-management, the Mayberry et al. (2019) mentioned lack of family support created low motivation among diabetic elderly in controlling their health which led to poor self-management of the disease. This is evident as lack of motivation among the diabetic elderly in managing their health makes them avoid adherence to effective meal plans and medication suggested for glycaemic controlling which make them develop uncontrolled diabetes with poor self-management (Werfalli et al., 2020). The suggestion of the studies that lack of family support does create barriers in self-management of diabetes among the elderly is evident as it leads the elderly to avoid adhering to key diabetes management areas such as glucose testing, taking insulin injection, avoiding foods with simple carbohydrates and others (De Man et al., 2019).

Implications

The implication of the review is that it could be used by the nurses to determine the factors acting against self-care in patients with type 2 diabetes. Moreover, the review would inform the nurses regarding the actions to be taken and in the different aspects of self-care among adults suffering from T2D so that the strategies required to promote better diabetic control can be developed. The other implication of the study is that it can be used as evidence to inform the family members of the elderly diabetic patients regarding the importance of their need to support in self-management of diabetes by the elderly. The report could also be implemented in practice to make the nurses understand the important of them to promote family involvement in supporting successful self-management of diabetes among the elderly. It can also be used to instruct the family members trying to involve in supporting diabetes self-management of the elderly regarding the aspects such as diet, emotional health, glucose monitoring and others they are to get involved in supporting successful health management of the diabetic elderly.

Recommendations

The following recommendations are developed from the results gathered in the review:

Educate T2D patients regarding diabetes management:

The T2D patients who are diagnosed with the condition or at risk are to be recommended to attend Diabetes Education and Self-Management for Ongoing and Newly Diagnosed (DESMOND) program. DESMOND is one of the structured education programs in the NHS UK which aims to increase the knowledge of diabetes and its cause among the affected patients. It also aims to encourage the individual affected by the disease to develop skills in self-managing their condition so that they avoid being a burden of care on others (NHS, 2020). Thus, inclusion of diabetic patients in the program would help them gradually develop positive behaviour and attitude in overcoming diabetes and maintaining stable health conditions without creating any adversities for them out of uncontrolled T2D management.

Train T2D patients regarding way to use glucose meter: The T2D patients are to be trained regarding the way they are to personally use glucose meter in measuring the glucose level in the blood. During the training, it is recommended that the patients are mentioned the number of times they are to measure their blood sugar each day and way to remain alert through glucose measurement to avoid exacerbation of the disease.

Limitation of the Study

The limitation of the review is that due to shortage of time and money, adequate exploration of wider data for enriched execution of the review could not be achieved. The lack of adequate time also led to collection of the selected studies in rapid manner which created hindrance in effective analysis of various facts in them for better presentation of information in the study. Moreover, the presence of only one researcher in analysing the results from existing studies and presentation without the information being cross-checked for its authenticity by other researcher led to limit the presentation of data in reliable manner. This is because the condition could not assure whether the presentation of information has been influenced by the personal belief of the researcher.

References

Adu, M.D; Malabu, U.H; Malau-Aduli, A.E.O and Malau-Adli, B.S. (2019), ‘Enablers and barriers to effective diabetes self-management: A multi-national investigation’. PloS one 14(6) PP.1-22

Ahola, A.J and Groop, P.H. (2012), ‘Barriers to self-management of diabetes. Diabetic Medicine, 30(2013) pp.413-420

Barron, E., Bakhai, C., Kar, P., Weaver, A., Bradley, D., Ismail, H., Knighton, P., Holman, N., Khunti, K., Sattar, N. and Wareham, N.J., 2020. Associations of type 1 and type 2 diabetes with COVID-19-related mortality in England: a whole-population study. The lancet Diabetes & endocrinology, 8(10), pp.813-822.

Bhandari, P (2020), ‘An introduction to qualitative research. Available at https://www.scrbbr.com/methodolgy/qualitative-research. [Accessed: 26/5/2021]

Bhardwaj, P., 2019. Types of sampling in research. Journal of the Practice of Cardiovascular Sciences, 5(3), p.157.

Blatch-Jones, A.J., Pek, W., Kirkpatrick, E. and Ashton-Key, M., 2018. Role of feasibility and pilot studies in randomised controlled trials: a cross-sectional study. BMJ open, 8(9), p.e022233.

Cha, S.A., Lim, S.Y., Kim, K.R., Lee, E.Y., Kang, B., Choi, Y.H., Yoon, K.H., Ahn, Y.B., Lee, J.H. and Ko, S.H., 2017. Community-based randomized controlled trial of diabetes prevention study for high-risk individuals of type 2 diabetes: lifestyle intervention using web-based system. BMC Public Health, 17(1), pp.1-9.

Chatterjee, S., Khunti, K. and Davies, M.J., 2017. Type 2 diabetes. The lancet, 389(10085), pp.2239-2251.

De Man, J., Aweko, J., Daivadanam, M., Alvesson, H.M., Delobelle, P., Mayega, R.W., Östenson, C.G., Kirunda, B., Kasujja, F.X., Guwattude, D. and Puoane, T., 2019. Diabetes self-management in three different income settings: cross-learning of barriers and opportunities. Plos one, 14(3), p.e0213530.

Denny, E and Weckesser. (2018), ‘Qualitative research: what it is and what is not’, International journal of obstetrics and Gynaecology, 126(3) pp.369

Diabetes UK (2014), ‘The cost of diabetes report’. Available at www.diabetes.org.uk [Accessed: 31/12/2020]

Diabetes UK (2019), ‘Diabetes Prevalence’. Available at https://www.diabetes.org.uk/professionals/position-statements-report/statistics/diabetes-prevalenec. [Accessed: 30/12/20]

Diabetes UK (2019), ‘Treatment for type 2 diabetes. Available at Treatment for Type 2 Diabetes [Accessed: 5/5/2021]

diabetes.org.uk 2019, Diabetes Prevalence 2019, Available at: https://www.diabetes.org.uk/professionals/position-statements-reports/statistics/diabetes-prevalence-2019 [Accessed on: 19 May 2021]

diabetes.org.uk 2020, Diabetes Statistics, Available at: https://www.diabetes.org.uk/professionals/position-statements-reports/statistics [Accessed on: 19 May 2021]

DiabetiesUK 2021, Diabetes Statistics, Available at: https://www.diabetes.org.uk/professionals/position-statements-reports/statistics [Accessed on3 September 2021]

Dornan, L., Pinyopornpanish, K., Jiraporncharoen, W., Hashmi, A., Dejkriengkraikul, N. and Angkurawaranon, C., 2019. Utilisation of electronic health records for public health in Asia: a review of success factors and potential challenges. BioMed research international, 2019.

Eddy, A. (2016), ‘Understanding Quantitative research Methodogy result-what do the numbers mean. Austalia and New Zeeland Nursing. 83(2) pp.7-8

Elliott, J.H., Synnot, A., Turner, T., Simmonds, M., Akl, E.A., McDonald, S., Salanti, G., Meerpohl, J., MacLehose, H., Hilton, J. and Tovey, D., 2017. Living systematic review: 1. Introduction—the why, what, when, and how. Journal of clinical epidemiology, 91, pp.23-30.

Gardsten, C; Blomqvist, K; Rask, Mikael; Larsson, A; Lindberg, A and Olsson, G. (2018), ‘Challenges in everyday life among recently diagnosed and more experienced adults with type 2 diabetes: A multistage focus group study. Journal of clinical nursing. Available at https://doi.org/10.1111/jocn.14330

Gien, L; Porr, C; Parson, K; Allison, J and Donovan, C. (2017), ‘Challenges in self-management of type 2 diabetes mellitus (T2DM) in a rural community of eastern Canada's, 39(3) pp.6-15

Gildea, C.M; Lantaff, W.M and Olenik, N.l. (2017),’ Identifying barriers to glycemic control in patients with type 2 diabetes after completion of an accredited education program, Journal of the American Pharmacists Association. 57(2011) pp.211-216

Greenhalgh, T., Shaw, S., Wherton, J., Vijayaraghavan, S., Morris, J., Bhattacharya, S., Hanson, P., Campbell-Richards, D., Ramoutar, S., Collard, A. and Hodkinson, I., 2018. Real-world implementation of video outpatient consultations at macro, meso, and micro levels: mixed-method study. Journal of medical Internet research, 20(4), p.e9897.

Guo, W., Li, M., Dong, Y., Zhou, H., Zhang, Z., Tian, C., Qin, R., Wang, H., Shen, Y., Du, K. and Zhao, L., 2020. Diabetes is a risk factor for the progression and prognosis of COVID‐19. Diabetes/metabolism research and reviews, 36(7), p.e3319.

Hackett, E and Jacques, N. (2009), ‘Type 2 diabetes pathophysiology and clinical features, clinical pharmacist, 1(2009) pp.475-478

Hawkins, J.E., 2018. The practical utility and suitability of email interviews in qualitative research. The Qualitative Report, 23(2).pp.45-90.

Hu, Z. and Qin, J., 2018. Generalizability of causal inference in observational studies under retrospective convenience sampling. Statistics in medicine, 37(19), pp.2874-2883.

Hu, J; Amirehsani, K; Wallace, D.C and Letvak, S. (2013), ‘Perceptions of barriers in manage diabetes: Perspectives of Hispanic Immigrant Patients and Family Member’. The diabetes educator, 39(4) pp.494-503

Hulman, A., Simmons, R.K., Brunner, E.J., Witte, D.R., Færch, K., Vistisen, D., Ikehara, S., Kivimaki, M. and Tabák, A.G., 2017. Trajectories of glycaemia, insulin sensitivity and insulin secretion in South Asian and white individuals before diagnosis of type 2 diabetes: a longitudinal analysis from the Whitehall II cohort study. Diabetologia, 60(7), pp.1252-1260.

Ingelsson, E. and McCarthy, M.I., 2018. Human genetics of obesity and type 2 diabetes mellitus: past, present, and future. Circulation: Genomic and Precision Medicine, 11(6), p.e002090.

Jolley, J. (2013), ‘Introducing research and evidence-based practice in nursing and healthcare professionals. 2nd ED, London: Pearson education limited.

Karakaya-Ozyer, K. and Yildiz, Z., 2021. Design and evaluation of an electronic performance support system for quantitative data analysis. Education and Information Technologies, pp.1-28.

Kaya, Y (2013), ‘Comparision of Quantitative and Qualitative Research Traditions: Epistemoloigacl, Theoretical and Methodological difference’. European journal education, 48(2) pp.311-325

Khairnar, R; kamal, K.M; Giannetti, V; Dwibedi, N and McConaha, J. (2019), ‘Barriers and facilitators to diabetes self-management in a primary care setting-patient perspective’. Research in social and administrative pharmacy. 15(2019) pp.279-286

Khan, H; Lasker, S.S and Chowdhury, T.A. (2011),’ Exploring reason for very poor glycaemic control in patients with type 2 diabetes. Primary care diabetes 5(2011) pp251-255

Kristianingrum, N.D., Wiarsih, W. and Nursasi, A.Y., 2018. Perceived family support among older persons in diabetes mellitus self-management. BMC geriatrics, 18(1), pp.1-5.

Kruse, C.S., Smith, B., Vanderlinden, H. and Nealand, A., 2017. Security techniques for the electronic health records. Journal of medical systems, 41(8), pp.1-9.

Leppälä, S., Lamminpää, R., Gissler, M. and Vehviläinen-Julkunen, K., 2020. Humanitarian migrant women's experiences of maternity care in Nordic countries: A systematic integrative review of qualitative research. Midwifery, 80, p.102572.

Longo, M., Scappaticcio, L., Caputo, M., Maiorino, M.I. and Esposito, K., 2021. Mediterranean diet in type 2 diabetes: An updated overview of pharmacological activities of cardiometabolic and reproductive outcomes. Current Opinion in Pharmacology, 60, pp.27-33.

Marshall, Z., Welch, V., Thomas, J., Brunger, F., Swab, M., Shemilt, I. and Kaposy, C., 2017. Documenting research with transgender and gender diverse people: protocol for an evidence map and thematic analysis. Systematic reviews, 6(1), pp.1-6.

Martín-Peláez, S., Fito, M. and Castaner, O., 2020. Mediterranean diet effects on type 2 diabetes prevention, disease progression, and related mechanisms. A review. Nutrients, 12(8), p.2236.

Mayberry, L.S., Berg, C.A., Greevy Jr, R.A. and Wallston, K.A., 2019. Assessing helpful and harmful family and friend involvement in adults’ type 2 diabetes self-management. Patient education and counseling, 102(7), pp.1380-1388.

Miguel-Escalada, I., Bonàs-Guarch, S., Cebola, I., Ponsa-Cobas, J., Mendieta-Esteban, J., Atla, G., Javierre, B.M., Rolando, D.M., Farabella, I., Morgan, C.C. and García-Hurtado, J., 2019. Human pancreatic islet three-dimensional chromatin architecture provides insights into the genetics of type 2 diabetes. Nature genetics, 51(7), pp.1137-1148.

Mogre, V; Johnson, N.A; Tzelepis, F and Paul, C. (2019). ‘Barriers to diabetes self-care: A qualitative study of patients and healthcare providers’ perspectives. Pp-2296-3008. Available at DOI:10.1111/JOCN.14835

Moule, P and Goodman, M. (2014), ‘Nursing research: An introduction. 2nd Ed London. SAGE.

Moule, P and Hek, G. (2011), ‘Making sense of research: An introduction for Health and Social Care Practitioners. 2nd Ed. London. SAGE.

Munn, Z., Peters, M.D., Stern, C., Tufanaru, C., McArthur, A. and Aromataris, E., 2018. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC medical research methodology, 18(1), pp.1-7.

Nam, S; Chesla, C; Stotts, N.A; Kroom, L and Janson, S.L.(2011), ‘Barriers to diabetes management: patient and provider factors. International diabetes federation, 93(2011) pp.1-9

Nanayakkara, N., Ranasinha, S., Gadowski, A., Heritier, S., Flack, J.R., Wischer, N., Wong, J. and Zoungas, S., 2018. Age, age at diagnosis and diabetes duration are all associated with vascular complications in type 2 diabetes. Journal of Diabetes and its Complications, 32(3), pp.279-290.

National Institute for Health and Care Excellence [NICE] (2020), ‘Diabetes type 2: How common is it. Available at https://cks.nice.org.uk/topic/diabetes-type-2/backgorund-information/incidence-prevalence. [Accessed: 30/12/20]

NHS 2016, NHS Diabetes Prevention Program, Available at: https://www.england.nhs.uk/wp-content/uploads/2016/08/dpp-faq.pdf [Accessed on: 19 May 2021]

NHS 2020, DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) programme, Available at: https://www.nottinghamshirehealthcare.nhs.uk/desmond-programme-for-type-2-diabetes [Accessed on: 22 February 2022]

NICE 2017, NICE type 2 diabetes prevention guideline, Available at: https://www.guidelines.co.uk/diabetes/nice-type-2-diabetes-prevention-guideline/455203.article [Accessed on: 19 May 2021]

Nursing and Midwifery Council (NMC) (2018), ‘The Code: professional Standard of practice and behaviour for nurses, midwifery and nursing associate. Available at www.nmc.org.uk [Accessed: 31/12/2020]

Polit, D.F; Beck, C.T and Hungler, B.P. (2001), ‘ Essentials of Nursing Research: Method, Appraisal and Utilization. 5th Ed. USA.

Ravi, S., Kumar, S. and Gopichandran, V., 2018. Do supportive family behaviors promote diabetes self-management in resource limited urban settings? A cross sectional study. BMC public health, 18(1), pp.1-9.

Saeedi, P., Petersohn, I., Salpea, P., Malanda, B., Karuranga, S., Unwin, N., Colagiuri, S., Guariguata, L., Motala, A.A., Ogurtsova, K. and Shaw, J.E., 2019. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas. Diabetes research and clinical practice, 157, p.107843.

Sattar, N., Rawshani, A., Franzén, S., Rawshani, A., Svensson, A.M., Rosengren, A., McGuire, D.K., Eliasson, B. and Gudbjörnsdottir, S., 2019. Age at diagnosis of type 2 diabetes mellitus and associations with cardiovascular and mortality risks: findings from the Swedish National Diabetes Registry. Circulation, 139(19), pp.2228-2237.

Shi, CH; Zhu, H; Liu, J; Zhou, J and Tang, W (2020), ‘Barriers to self-management of type 2 diabetes during Covid-19 medical isolation: A qualitative study. Diabetes, metabolic syndrome, and obesity: Targets and Therapy 2020(13) pp. 3713-3724

Sina, M; Graffy, J and Simmons, D. (2017), ‘Associations between barriers to self-care and diabetes complications among patients with type diabetes’. Diabetes research and clinical practice, 141(2018) pp.126-131

Siopis, G; Colagiuri, S and Farinelli, M.A. (2020), ‘People with type 2 diabetes report dietitians, social support and health literacy facilitate their dietary change’. Journal of nutrition education and behaviour, 000(000) pp.1-11

Smith, J and Noble, H. (2016), ‘Reviewing the Literature’, BMJ, 19(1) PP.2-3

Somal, K. and Foley, T., 2021. A Literature Review of Possible Barriers and Knowledge Gaps of General Practitioners in Implementing Advance Care Planning in Ireland: Experience from Other Countries. International Journal of Medical Students, 9(2), pp.145-156.

Stewart, D; Shamdasani, P and Rook, D. (2017), ‘Focus group: Theory and practice. 2nd ED. London. Sage.

Streefkerk, R (2021), ‘Qualitative and Qualitative research’. Available at https://scribbr.com/methododgy/qulatitavie-quanititative-research. [Accessed: 27/5/2021]

Tidy, C. (2016), ‘ Diabetes Education and self-management programmes. Available at Diabetes Education and Self-management Programmes. Patient | Patient [Accessed: 26/5/2021]

Vătămănescu, E.M., Gorgos, E.A., Ghigiu, A.M. and Pătruț, M., 2019. Bridging intellectual capital and SMEs internationalization through the lens of sustainable competitive advantage: a systematic literature review. Sustainability, 11(9), p.2510.

Wang, X. and Cheng, Z., 2020. Cross-sectional studies: strengths, weaknesses, and recommendations. Chest, 158(1), pp.S65-S71.

Werfalli, M.M., Kalula, S.Z., Manning, K. and Levitt, N.S., 2020. Does social support effect knowledge and diabetes self-management practices in older persons with Type 2 diabetes attending primary care clinics in Cape Town, South Africa?. PloS one, 15(3), p.e0230173.

Whittemore, R., Vilar-Compte, M., De La Cerda, S., Marron, D., Conover, R., Delvy, R., Lozano-Marrufo, A. and Pérez-Escamilla, R., 2019. Challenges to diabetes self-management for adults with type 2 diabetes in low-resource settings in Mexico City: a qualitative descriptive study. International journal for equity in health, 18(1), pp.1-10.

World Health Organisation [WHO] (2020), ‘Diabetes’. Available at Diabetes (who.int) [Accessed: 31/12/20201]

Zheng, Y., Ley, S.H. and Hu, F.B., 2018. Global aetiology and epidemiology of type 2 diabetes mellitus and its complications. Nature Reviews Endocrinology, 14(2), pp.88-98.

Appendix