Pathophysiology of T2DM and its Links to Melanie’s Case
1. Diabetes is defined as a group of metabolic disorder which is characterised by severe hyperglycaemic conditions resulting from lack of proper functioning of insulin hormone. Type 2 diabetes mellitus (T2DM) results from the combination of genetic factors associated with impaired secretion of insulin hormone from the beta cells of pancreas and environmental factors like obesity, lack of proper physical exercise, over-eating, increased level of stress and aging (Kahn, Cooper & Del Prato, 2014). In the case study, both the genetic and the environmental factors found significance behind the diabetes development. As per the case study, both the mother and older sister of the patient were diagnosed with T2DM during their early 50s. This presence of genetic history of T2DM makes patient genetically pre-disposed to T2DM. Case study further highlighted that patient is over-weight (105 kilogram, normal weight for 167 cm woman is 70 kilogram maximum) (Hall, 2015). She also has no significant physical activity due to pain in the joint area arising out of Baker’s cyst and is lately passing through over-eating due to over-consumption of ice-creams in order to manage stress. Thus it can be said that the environmental factors are also pronounced in the patient, which lead to the development of T2DM. The main pathophysiology underlying the development of T2DM is development of insulin resistance and impaired insulin secretion.
Figure: The factors leading to T2DM development
(Source: Kahn, Cooper & Del Prato, 2014)
Genetic factors make glucose unresponsive to the beta adrenergic receptors, making glucose molecule in the blood insulin resistant. Increase in the glucose concentration in blood, cause hyperglycemia leading to the development of T2DM. Moreover, prolong increase in the glucose level in the blood hampers the equilibrium of the insulin secretion from the pancreas. Thus in the absence of the proper insulin secretion and insulin resistance of the glucose molecule, severity of the T2D increases along with increase in hyperglycemia (Murea, Ma & Freedman, 2012).
Figure: Pathophysiology and progression of T2DM
(Source: Kahn, Cooper & Del Prato, 2014)
Apart from hyperglycemia, the possible complications arising out of T2DM include diabetic retinopathy which results loss of vision, foot complications known as diabetic foot disease, difficulty in wound healing, increase in blood pressure level, increased tendency of developing cardiovascular disease (Ozougwu et al., 2013). Patient has high level of blood glucose which is evident from her 22.9 mmol/L of BGL and HbA1c: 11%. The increase threats of cardiovascular disease is evident from high blood pressure (140/80 mmHg) and moderately high respiratory rate (22 breaths/minute) (Hall, 2015).
The main treatment options for the management of T2DM include effective lifestyle modifications along with effective use of pharmacological interventions and non-pharmacological interventions (Kahn, Cooper & Del Prato, 2014).
Figure: The interventions for the management of T2DM
(Source: Kahn, Cooper & Del Prato, 2014)
In the case study, the main interventions which can be used for the effective management of T2DM is proper regulation of diet. She was lately consuming ice-creams and is facing difficulty in managing her diet. However, upon reviewing her blood glucose level and weight, she had stopped eating for the last two week. According to Ozougwu et al. (2013), consumption of ice-creams which is high on sugar and calorific content is detrimental for T2DM progression. Ozougwu et al. (2013) further stated that starvation further hampers the disease progression. Regular and timely intake of food which is rich is fruits and green vegetables and low in carbohydrate and sugar content is instrumental in managing T2DM, however, the diet plan must be designed under the controlled supervision of a professional dietician. Chen, Magliano and Zimmet (2012) are of the opinion that external administration of insulin through sub-cuteneous injection is effective in patients with T2DM suffering from high blood glucose level as in the case study. Non-pharmacological interventions for the patient will be management of stress under controlled supervision of mental health nurse. Ozougwu et al. (2013) stated that effective management of stress and anxiety helps to control elevating blood glucose level.
Differences between T2DM and T1DM
2. Disease development for Type 1 Diabetes (T1DM) includes development of auto-immunity where body’s immune system attacks and destroys the pancreatic cells producing insulin. In T2DM, development of insulin resistance by the glucose causes disease development. Onset of T1DM is early onset during young adult and childhood stage and T2DM is late onset during the older adults’ stage. The causative agent o T1DM is genetic mutations leading to development of auto-immunity and T2DM is genetic predisposition and lifestyle factors. Treatment option for T1DM is external injection of insulin. In T2DM, lifestyle modifications and external insulin uptake are regarded as main source of treatment. In T1DM, pancreas is damaged due to the attack of the auto-antibodies. I T2DM, no damage of the pancreas occurs as pancreatic beta cells is not attacked by the auto-antibodies. Major threats of T1DM is diabetic retinopathy and T2DM is cardiovascular diseases (Ozougwu et al., 2013).
3. The three underlying reason for which patient’s BGL is high at the time of hospital admission include
- Development of Type 2 Diabetes: According to Kahn, Cooper and Del Prato (2014) T2DM is associated with the increase in the blood glucose level in the body because of the development of insulin resistance. Under insulin resistance, the glucose molecule present in the blood fail to respond to the insulin hormone due to inability to bind with the insulin receptors (adnergic receptors) leading to high blood glucose level (BGL). Kahn, Cooper and Del Prato (2014) stated that unmanaged T2DM like lack of proper medication further increase BGL. The patient takes no specific medications for T2DM management and this further heightened the BGL.
- Poor lifestyle habits: Murea, Ma and Freedman (2012) are of the opinion that one of the sole parameters for the management of BGL in case of T2DM is effective management of the lifestyles. Under lifestyle management, the first preference is given to diet plan. Patient’s physicians also advised her to “watch” what she eats. However, due to her mood fluctuations she use to consume ice-creams which might have increased her BGL. Murea, Ma and Freedman (2012) stated that ice-creams are high calorie food which scores high on calorific value of glucose content. Due to the development of Baker’s Cyst, the patient in the case study was unable to perform regular exercise, the sedentary lifestyle promoted a rise in BGL.
- High level of stress: Asmat, Abad and Ismail (2016) stated that the majority of the depressed patients are sickened from diabetes-specific emotional stress. The consequences of stress hamper the endocrine system bringing change in the glucose metabolism process and insulin resistance and thereby causing hyperglycemia. Stress increases the secretion of dopamine catecholamine neurotransmitter and its sustained stimulation leads to hyperglycemia. In the case study, the patient was suffering from anxiety and stress due to her impending surgery for Baker’s cyst and weight gain. The stress and anxiety factor lead to high BGL.
According to Frush and Noyes (2015), injection of corticosteroid (cortisone) directly into the joint or the soft tissue liming next to the painful joint which is also known as bursa helps in the reduction of inflammation and to provide pain relief. The reduction in the pain relief helps in the effective implementation of the successful physical therapy. Frush and Noyes (2015) are of the opinion that cyst aspiration done with corticosteroid injection helps to get effective pain relief and reduction in the cyst volume of patients suffering from Baker’s cyst and concomitant knee osteoarthritis. However, the use of corticosteroid is associated with numerous complications. Frush and Noyes (2015) stated that prolong injection with corticosteroid like cortisone leads to crystallization of the cortisone inside the body. The crystalline cortisone gets deposited in the joints thus negatively acting on knee pain. It also caused elevation in the blood glucose level. Increase in the BGL is detrimental for her as she is suffering from T2DM and has high blood pressure.
According to Huang, Castelino and Peterson (2014), metformin is an extended release table that is used as an oral antihyperglycemic drug for the management of T2DM. Metformin improve the glucose tolerance of patient’s with T2DM by lowering both the postprandial plasma glucose concentration and basal glucose concentration. Metformin mainly decreases the production of glucose from the hepatic cells along with decrease in the intestinal absorption of glucose. This activity helps in the improvement of insulin sensitivity through increase in the peripheral glucose uptake and utilization and thereby helping to reduce BGL. Under metformin medication, the insulin secretion remains unchanged but the fasting insulin conditions and the day-long plasma insulin response might decrease gradually. However, Huang, Castelino and Peterson (2014) highlighted that prolong use of metformin for a considerable period of time leads to the generation of physical weakness and muscle pain. The weakness and pain might be debilitating for the patient as it might hamper her healthy living and quality of life making per unable to perform mild to moderate physical activity. Other side-effects of metformin include sudden lowering of the blood glucose level and thus glucose level must be monitored and the adjustment of the dosage must be done accordingly. Metformin also includes constipation, bloating and abdominal distention. Ng et al. (2014) are of the opinion that long-term use of metformin cause cognitive decline among the older adults.
Glipizide is used along with regular physical activity and proper diet plan in order to control the high blood sugar level of people who are suffering from type 2 diabetes mellitus. The side-effects of Glupizide includes nausea, loss of appetite, vomiting, diarrhea, stomach upset, constipation, instant gain in weight and headache. Gain in weight can generate serious health issues, as she is already obese. Thus in order to get quality results from Glipizide use, effective management of the diet plan and physical activity is important (Hong et al., 2013).
HbA1c is used to test the presence of glycated haemoglobin and thereby helping to an overview of the level of glucose molecule in the blood that is present in a bounded form with the red blood cells. HbA1c test is mainly helpful in getting a brief overview of the level of blood sugar for the last 2 to 3 months as the average life expectancy of RBC is 3 months. High blood glucose level indicates high HbA1c test results. The normal range of HbA1c test is between 4% to 5.6%. HbA1c level within 5.7% and 6.4 % indicates higher chances of developing diabetes and levels higher than 6.5% indicates diabetes (Gailliot & Baumeister, 2018).
Reasons for Melanie’s High BGL on Admission
It is used to get an instant overview of the blood sugar level and thus also known as random blood glucose test. It can be done through the use of glucometer. The normal blood glucose level range, during fasting condition was in between 4.0 to 5.4 mmol/L (72 to 99 mg/dL. When BGL is done after meal, the normal range is up to 7.8 mmol/L (140 mg/dL) (Gailliot & Baumeister, 2018).
The blood test report after the administration of Metformin and Glipizide is BGL 8.8/L; HbA1c:8%. This indicates the blood glucose level though under the diabetic band in comparison to the normal units, the blood glucose level has decreased significantly from the previous instances (blood glucose level (BGL) was 22.9 mmol/L; HbA1c: 11%) during the fasting condition. the main reason behind the decrease in the BGL is administration of anti-hyperglycemic medications.
3. Generally T2DM is referred as insulin independent diabetes mellitus and T1DM is regarded as insulin independent. However, at present such classifications do not hold prominent patho-physiological significance as T2DM are at times insulin dependent. Moreover, the concept of early and late onset in diabetes mellitus is also extinct. Previously T2DM is classified as mature onset and T1DM is classified as early onset. However, the survey conducted by Dabelea et al. (2014) highlighted that unhealthy lifestyle among the young adults and the children have increased the tendency of developing T2DM. The unhealthy lifestyles that have prompted the development of T2DM among the children and the young adults include higher consumption of junk food, early onset of smoking, drinking, and sedentary lifestyle.4. Teach-back method is a way to confirm the level of understanding of the service users in their own words. This method generates an opportunity for effective communication with the healthcare professionals (Tamura-Lis, 2013). Tamura-Lis (2013) are of the opinion that it is helpful to use written/visual material to reinforce the teaching points in order to improve the service users level of satisfaction and understanding.
Under teach back method, I will introduce working principle of BGL machine and will demonstrate a live manual regarding how to use the machine. After demonstrating the entire action, I will ask the patient to give her overview regarding why she things the use of BGL machine is important for her T2DM management. Then I will ask her to provide a demonstration of the machine usage. If I find that she is unable to use the machine, I will again help her with the process of usage. If the patient is scared of the pain about the sudden pricking of the thumb then I will help her to overcome this phobia. Repeating the information will help to close the gap in understanding. I will again ask her to repeat the process and will indulge in effective patient-centred communication to iron out any additional confusion or query regarding the machine usage.
References
Asmat, U., Abad, K., & Ismail, K. (2016). Diabetes mellitus and oxidative stress—a concise review. Saudi Pharmaceutical Journal, 24(5), 547-553..
Chen, L., Magliano, D. J., & Zimmet, P. Z. (2012). The worldwide epidemiology of type 2 diabetes mellitus—present and future perspectives. Nature reviews endocrinology, 8(4), 228.
Dabelea, D., Mayer-Davis, E. J., Saydah, S., Imperatore, G., Linder, B., Divers, J., … & Liese, A. D. (2014). Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. Jama, 311(17), 1778-1786.
Frush, T. J., & Noyes, F. R. (2015). Baker’s cyst: diagnostic and surgical considerations. Sports health, 7(4), 359-365.
Gailliot, M. T., & Baumeister, R. F. (2018). The physiology of willpower: Linking blood glucose to self-control. In Self-Regulation and Self-Control (pp. 137-180). Routledge
Hall, J. E. (2015). Guyton and Hall textbook of medical physiology e-Book. Elsevier Health Sciences.
Hong, J., Zhang, Y., Lai, S., Lv, A., Su, Q., Dong, Y., … & Zou, D. (2013). Effects of metformin versus glipizide on cardiovascular outcomes in patients with type 2 diabetes and coronary artery disease. Diabetes care, 36(5), 1304-1311.
Huang, W., Castelino, R. L., & Peterson, G. M. (2014). Metformin usage in type 2 diabetes mellitus: are safety guidelines adhered to?. Internal medicine journal, 44(3), 266-272.
Kahn, S. E., Cooper, M. E., & Del Prato, S. (2014). Pathophysiology and treatment of type 2 diabetes: perspectives on the past, present, and future. The Lancet, 383(9922), 1068-1083.
Murea, M., Ma, L., & Freedman, B. I. (2012). Genetic and environmental factors associated with type 2 diabetes and diabetic vascular complications. The review of diabetic studies: RDS, 9(1), 6.
Ng, T. P., Feng, L., Yap, K. B., Lee, T. S., Tan, C. H., & Winblad, B. (2014). Long-term metformin usage and cognitive function among older adults with diabetes. Journal of Alzheimer’s Disease, 41(1), 61-68.
Ozougwu, J. C., Obimba, K. C., Belonwu, C. D., & Unakalamba, C. B. (2013). The pathogenesis and pathophysiology of type 1 and type 2 diabetes mellitus. Journal of Physiology and Pathophysiology, 4(4), 46-57.
Tamura-Lis, W. (2013). Teach-back for quality education and patient safety. Urologic Nursing, 33(6), 267.
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