Pathophysiological Analysis

Diabetes Self-Management must first begin with understanding Diabetes Mellitus. Microaneurysm formation presents as the earliest expression of diabetic retinopathy. Chances for microaneurysms to form are due to the release of vasoproliferative influences, weakness within the capillary wall, or amplified intra-luminal pressures. Vascular permeability typically results from Microaneurysms. Vascular permeability can also lead to macular edema. “Vascular permeability in the macula can lead to macular edema and can threaten central vision. Obliteration of retinal capillaries can lead to intraretinal microvascular abnormalities (IRMAs). As capillary closure becomes extensive, intraretinal hemorrhages develop” (Zimmerman, 2013, p. 1).

Proliferative retinopathy progresses due to ischemia as well as release of vasoactive substances. This can be VEGF or vascular endothelial growth factor, which fuels new blood vessel creation as a development of non-proliferative retinopathy. Such vessels blow up through the exterior of the retina and develop on the posterior surface of the named vitreous humor. These kinds of vessels are very friable. Meaning, it can lead to vitrified hemorrhages. The vitrified humor may contract leading to retinal detachment.

Moving into neuropathy, the pathophysiology of neuropathy remains complex to examine. Diabetes is connected to dyslipidemia, low insulin, and hyperglycemia, as well as growth factor abnormalities. Such abnormalities are linked with glycation of nerves and blood vessels. Furthermore, autoimmunity can affect nerve structure. Nerve entrapment and trauma can lead to physical nerve damage plus axonal atrophy and loss, segmental demyelination, and progressive demyelination. The culmination of effects cause neuropathy. “Several agents including laminin B2, immunoglobulin FI (IGFI) and II, nerve growth factor (NGF), insulin, and neurotrophin-3 (NT3) are potential growth factors that may restore nerve function” (Zimmerman, 2013, p. 1).

Increased glomerular capillary flow often causes diabetic nephropathy that in turn promotes an amplified extracellular matrix production as well as endothelial damage, leading to augmented glomerular perviousness to macromolecules. Interstitial sclerosis and mesangial expansion follows leading to progression of disease and glomerular sclerosis. The macrovascular problems of diabetes come from hyperglycemia, insulin resistance, and excess free fatty acid. These cause amplified oxidative stress, protein kinase initiation and triggering of RAGE or the receptor for advanced glycation end products. These elements act on the endothelium. It does this by first decreasing nitric oxide, increasing endothelin, and increasing angiotensin II, which causes vasoconstriction that generates hypertension as well as cell growth of vascular smooth muscle.

Second, is a decrease in nitric oxide, activation of nuclear factor-KB or NFKB, and an increase in angiotensin II. Furthermore, there is activation of triggered protein-1 that causes increased inflammation, resulting in the release of cytokines, chemokines, and expression of “cellular adhesion molecules.” Last, are decreased levels of nitric oxide, increased levels of tissue factor, increased plasminogen activator inhibitor-1, as well as decreased prostacyclin; resulting in thrombosis, platelet activation, hyper-coagulation, and decreased fibrinolysis. Each pathway can ultimately lead to atherosclerosis. Atherosclerosis is the main cause of the macrovascular problems found in diabetes patients.

Current Research

Current research offers some practical approaches to diabetes self-management. Internet-based programs may provide positive potential for inexpensive, practical, continuing disease self-management programs. Glasgow et al., reported 12-month results derived from an online-based diabetes self-management program, optional additional support, paralleled to improved typical care within a 3-arm applied randomized trial. 463 patients were randomized and only 77.3% accomplished 12-month follow-up. Main outcomes were vicissitudes in the health behaviors of physical activity, healthy eating, and medication taking. Ancillary results were hemoglobin A1C, lipids, body mass index, psychosocial factors, and blood pressure. The results were positive. “Internet conditions improved health behaviors significantly vs. usual care over the 12-month period (d for effect size = .09 — .16). All conditions improved moderately on biological and psychosocial outcomes. Latinos, lower literacy, and higher cardiovascular disease risk patients improved as much as other participants” (Glasgow et al., 2012, p. 81).

The article concluded with stating online interference meets the feasibility and reach criteria for a hypothetically comprehensive public health impact. Nevertheless, 12-month scale of effects was small, signifying that dissimilar or more concentrated approaches are essential to support long-term results. Research is needed to comprehend the connections between maintenance and intervention processes as well as downstream outcomes.

In a second article from 2012, researchers discuss automatic self-management interventions and how they should be integrated and tailored into primary care. The article also mentions how links to community resources may enhance patient self-management or DSME, diabetes self-management education. DSME is a crucial aspect of care for all persons with diabetes including those in danger for developing the illness. It is essential in order to avert or postpone the complications of diabetes. DSME has elements associated with lifestyle changes that remain essential for persons with prediabetes to prevent it.

The National Criteria for DSME are intended to define excellence in DSME and support as well as to help diabetes educators in offering evidence-based education, instruction, and self-management support. These Standards are pertinent to educators within solo practice and those in big multicenter programs — along with everyone in between. Numerous good models exist for the delivery of support and diabetes education. The Standards do not sanction any one method, but rather pursue to define the commonalities amid effective and outstanding self-management education approaches. These are the principles used within the field for acknowledgement and accreditation. Furthermore, they serve as a guide for nonrecognized programs and providers.

Due to the lively nature of diabetes-related and health care research, the Standards are revised and reviewed roughly every 5 years. Fall 2011 as described by the Haas et al., article brought together a Task Force that was mutually convened AADE or the American Association of Diabetes Educators and AdA, the American Diabetes Association. Participants of the Task Force comprised of specialists from the fields of public health, underserved populaces including country primary care as well as other rural well-being services, individual practices, and great urban specialty practices. They also brought in persons with diabetes, registered nurses, diabetes researchers, registered dietitians, certified diabetes educators, physicians, and a psychologist. “The Task Force was charged with reviewing the current National Standards for Diabetes Self-Management Education for their appropriateness, relevance, and scientific basis and updating them based on the available evidence and expert consensus” (Haas et al., 2012, p. S100). The Standards and Task Force are meant to help DSME expand into a more applicable aspect of patient care for those with diabetes.

Public Health Application

In an article about MATCH or The Mexican-American Trial of Community Health workers, results demonstrated The MATCH cohort exhibited lower rates of medication adherence. They also had lower numbers in relation to glucose monitoring. Seventy percent had insufficient glycemic control with high A1C levels (over 7.0), and over half had high blood pressure. Through community intervention, MATCH conserved community sensitivity and demonstrated the need for public health application in relation to DSME. (Rothschild et al., 2012, p. 369).

There is a need for patient education and groups at high risk for diabetes complications development require additional instruction and participation from the community of healthcare workers around them. This could perhaps prove to be useful in increasing positive patient behavior in relation to diabetes self-management. Culturally, local healthcare workers offer the greatest impact in at risk populations. If DSME became standard practice in all hospitals and clinics, perhaps the statistics displayed in the MATCH article will decrease.

References

Glasgow, R., Kurz, D., King, D., Dickman, J., Faber, A., & Halterman, E. et al. (2012). Twelve-month outcomes of an Internet-based diabetes self-management support program. Patient Education And Counseling, 87(1), 81-92. http://dx.doi.org/10.1016/j.pec.2011.07.024

Haas, L., Maryniuk, M., Beck, J., Cox, C., Duker, P., & Edwards, L. et al. (2012). National Standards for Diabetes Self-Management Education and Support.Diabetes Care, 36(Supplement_1), S100-S108. http://dx.doi.org/10.2337/dc13-s100

Rothschild, S., Martin, M., Swider, S., Lynas, C., Avery, E., Janssen, I., & Powell, L. (2012). The Mexican-American Trial of Community Health workers (MATCH): Design and baseline characteristics of a randomized controlled trial testing a culturally tailored community diabetes self-management intervention.Contemporary Clinical Trials, 33(2), 369-377. http://dx.doi.org/10.1016/j.cct.2011.10.013

Zimmerman, R. (2013). Diabetes Mellitus: Disease Management.Clevelandclinicmeded.com. Retrieved 17 October 2015, from http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/endocrinology/diabetes-mellitus/