Dr Syamala Reddy College of Nursing, Marathahalli, Bangalore

RAJIVGANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

6. BRIEF RESUME OF INTENTED WORK:

INTRODUCTION:-

“This is the day when people reciprocally offer, and receive, the kindest and the warmest wishes, though, in general, without meaning them on one side, or believing them on the other. They are formed by the head, in compliance with custom, though disavowed by the heart, in consequence of nature”

- Philip Dormer Stanhope

“He in a few minutes ravished this fair creature, or at least would have ravished her, if she had not, by a timely compliance, prevented him”

- Hendry Fielding

The pancreas is a long, slender gland lying behind the stomach and in front of the first and second lumbar vertebrae. The pancreas has both exocrine and endocrine functions. The exocrine function of the pancreas contributes to the process of digestion. Endocrine function occurs in the islets of langerhans, whose beta cells secrete insulin, alpha cells secrete glucagon; delta cells secrete somstostatin; and F cells secrete pancreatic polypeptide1.

Insulin is the principal regulator of the metabolism and storage of ingested carbohydrates, fats and proteins. Insulin facilitates glucose transport across cell membranes in most tissues. When the blood glucose rises, insulin is released from the pancreas to normalize the glucose level1.

Diabetes is an iceberg disease. It is a complex condition with global health consequences. The term “diabetes mellitus” is derived from the Greek word, “diabetes” means “to go through” or a siphon and the word “mellitus” is derived from the Latin word “mel” meaning honey describing the sweet odour of urine2.

Diabetes Mellitus is a chronic multisystem disease related to abnormal insulin production, impaired insulin utilization, or both. Diabetes Mellitus is a serious health problem throughout the world and its prevalence is increasing rapidly1.

According to WHO (1994) diabetes mellitus is characterized by hyperglycemia and disturbance of the carbohydrate, fat and protein metabolism that is associated with the absolute or relative deficiencies of insulin action or secretion3.

The American Diabetes Association uses the acronyms “DIABETES” and “CAUTION” help to identify the warning signs of diabetes.

Drowsiness, Itching, A family history of diabetes, Blurred vision, Excessive Weight, Tingling numbness or pain in extremities, Easy fatigue, Skin infection, slow healing of cuts and scratches especially on the feet.

Other signs are, Constant urination, Abnormal thirst, Unusual hunger, The rapid loss of weight, Irritability, Obvious weakness and fatigue, Nausea and vomiting4.

India has now been declared by WHO as the diabetes capital of the world. The choice of treatment and compliance is important for the metabolic control to be achieved by the patients. While diet, exercise and oral drugs are useful in controlling diabetes in many patients, it is now recognized that a large number of Type 2 diabetic patients require insulin therapy5

India has the world’s largest population of people with diabetes- 50.8 million as per latest statistics of International Diabetes federation. Diabetes is the leading cause of adult blindness, end-stage renal disease and non traumatic lower limb amputations. It is also a major contributing factor for heart disease and stroke. Adults with diabetes have heart disease death rates two to four times higher than adults without diabetes. The risk for stroke is also two to four times higher among people with diabetes. In addition, about 73% of adults with diabetes have hypertension6

A study was conducted for one and half years by the Manipal Hospital Bangalore with diabetes and Hypertension patients and it revealed that almost 40% to 60% of patients had both the conditions. And 50% had at least two risk factors like high cholesterol or overweight. About 20% to 30% were smokers. Compliance became a major issue. Explaining the lack of compliance and integrated diabetes support- Earlier patients used to come with a predisposed idea that if they are asked to take insulin, they would refuse and try to avoid it for at least a year. Hypertension did not receive as much attention as diabetes mainly because “diabetes is a silent killer and the onset is very early” 6.

The latest Compliance is on drug how well a patient follows the instructions for taking his/her medication. Poor compliance is a leading cause of failed medical treatment and drug-resistant conditions. Diabetes is the fourth leading cause of death in developed world; it affects the blood vessels, nerves, heart, kidneys and eyes7.

6.1 NEED FOR STUDY:-

One of the challenges faced by the modern world is diabetes mellitus. Diabetes mellitus has been recognized as a chronic condition that challenges every aspect of personal, emotional, social, physical, psychological and spiritual life of an individual. It is the leading cause of non traumatic amputations and blindness8.

Diabetes is a chronic disease that occurs when the pancreas doesn’t produce enough insulin or alternatively. Diabetes is currently considered an epidemic disease that is largely preventable and treatable through diet, exercise and life style changes. Diabetes is among the leading causes of kidney failure and 10-20% of people with diabetes die of kidney failure. Diabetes increases the risk of heart diseases and stroke; 50% of people with diabetes die of cardio vascular diseases9.

According to the American Diabetes association, the prevalence of Diabetes mellitus has increased dramatically during the past few decades, and it is expected to increase even more in the future. In the United States an estimated 20.8 million people, or 7% of the population have diabetes mellitus and more than 2 million Canadians have diabetes. Over 6 million people with diabetes mellitus are not diagnosed, and these individuals are unaware that they have the diabetes. Diabetes mellitus is the fifth leading cause of the death in the United States, but it is under reported10.

India’s diabetic population is around 51 million now and is expected to touch 87 million by 2030. Every minute, six people die due to diabetes and its complications. Despite an adult prevalence rate of 6.2%, only 6-7 million people are treated. The increasing incidence of multi-organ complications arising from diabetes has become a major cause for concern. Complications include cardiovascular diseases, diabetic neuropathy, diabetic nephropathy, stroke, blindness and limb amputation6.

While incidence if Type1 diabetes is increasing, Type 2 is also being found in younger age groups. The problems are lifestyle- related. Infact, nutrition and proper diet should start at the fetal stage, because most development happens then6. In regard with diabetes control, an observational study to collect information on prevalence of diagnosed and undiagnosed diabetes and hypertension cases in outpatient clinics in major Indian cities and to understand the extent of risk factors among these patients. Also now mass screening program for diabetes and hypertension has been initiated by TamilNadu Government11.

According to WHO, in India 31 million people are affected by diabetes which is highest in the world (2002) and 5% of Bangaloreans have diabetes and about 30,000 of these develop foot problem annually12. According to the new Indian press (2004) Hyderabad and Chennai is the diabetes capital of India. Hyderabad tops the metropolitan cities in the prevalence of diabetes (16.6%) followed by Chennai (23.5%), Bangalore (12.4%) Kolkata (11.6%) and Mumbai (9.3%). The most important aspect of diabetes in occurrence of complications that increases the cost of management13.

There are approximately 3.5 crore diabetic clients in India, and this figure is expected to increase up to 5.2 crore by 2025. Every fifth client visiting a consulting physician is a diabetic and every seventh client visiting a family physician is a diabetic14.

In 2005, an estimated 1.1 million people died from diabetes. Almost 80% of the deaths occur in low and middle income countries with half of the deaths occurring in people under the age of 70 years. WHO projects that deaths due to diabetes will be more than 50% in the next ten years without appropriate measures. Deaths due to diabetes are projected to increase by over 80% in upper middle income countries between 2006-2015. In another estimate by International Diabetes Federation (IDF) 200 million people around world have diabetes by 2025 and it is expected to increase to 333 million15.

Self care is the practice of activities that individuals initiate and perform on their own behalf in maintaining life, health and well being. Self care in diabetes is crucial. It has been claimed that as much as 98% of diabetes care is self care. Self-care in diabetes falls mostly on the patients and their families. It is essential that individuals with diabetes adhere to self care and to prevent the complications associated with diabetes16.

Diabetes self management education is the process of teaching individuals to manage their diabetes and has been considered an important part of the clinical management of individuals. The goals of the self management education are to optimize metabolic control, prevent acute and chronic complications and optimize quality of life, while keeping costs acceptable17.

A cross sectional survey was conducted in a resettlement colony of Chandigarh about knowledge and practices regarding diet, hygiene, care of foot, wound, complication of diabetes and medication. This study has concluded that there is a need to reorient and motivate health personnel in educating diabetics about self- care18.

During the clinical experience the investigator has noticed that majority of patients with diabetes mellitus do not take prescribed treatment, neglecting the do’s and don’ts of diet and do not know the importance of exercise and foot care which leads to complications. The investigator has observed that a number of diabetic patients are hospitalized because of uncontrolled hyperglycemia, ulcers on foot, diabetic nephropathy, neuropathy, hypertension and artherosclerosis19.

Patient noncompliance is a major medical problem in America. Consequently, numerous studies and reports have been performed to articulate the meaning of the problem and to suggest improvements. The literature however, in its effort to explore all facets of the current compliance situation, has produced a complex construct, making it exceedingly difficult for clinicians and researchers to understand the problem. This report was undertaken to unify the current spectrum of compliance literature, to make sense of the adherence situation. A variety or research methods was used, including MEDLINE and PubMed searches, university medical library searches, general Internet searches, and clinical text reviews. The result was a categorization of the literature into six segments, including articles identifying adherence as a problem, identifying the causes of noncompliance and exploring possible solutions, analyzing adherence with respect to specific ailments, and exploring the patient's role, the pharmacist's role, and the physician's role with respect to compliance. After the exploration and synthesis of the current literature, we suggest that future research concentrate on the practitioner for a better understanding of the compliance situation and the creation of a universal method of ensuring compliance39.

Diabetes imposes life long demands on client’s families. They have to make a multitude of decisions related to managing diabetes and compliance, as diabetes affects all age group worldwide. People with diabetes need to monitor their blood glucose, take medication, exercise regularly and modify life styles. As outcomes are largely based on the decision they take, it is of paramount importance that people with diabetes receive ongoing, high-quality diabetes education that is tailored to their need and delivered by skilled health care providers. During the clinical experience the investigator has noticed that majority of patients with diabetes mellitus do not take prescribed treatment, neglecting the do’s and don’ts of diet and do not know the importance of exercise and foot care, etc which leads to complications. The investigator felt the need to assess the level of compliance among patients. Which would help community health nurses to plan implement culturally focused teaching program.

6.2. REVIEW OF LITERATURE:

“Man can learn nothing except by going from the known to unknown”

- Claude Bernard

Diabetes mellitus is silent disease and recognized as one of the fastest growing threats to public health in almost all countries of the world. It is also called the “Disease of prosperity”. It’s a chronic disorder with elevated blood sugar level and it requires careful monitoring and control.

THE LITERATURE REVIEW HAS BEEN ARRANGED AND PRESENTED IN THE FOLLOWING HEADING:

1. Studies related to Incidence and Prevalence of the Diabetes mellitus.
2. Studies related to self management and education.
3. Studies related to compliance of Diabetic Clients.

1. INCIDENCE AND PREVALENCE OF DIABETES MELLITUS:

World Health Organization (WHO) in 2007 reported that worldwide there are 246 million diabetic clients. 17.7 million in united states (US), 20.8 million in china, and 6.8 million in Japan. In the United Kingdom the prevalence of known diabetes is about 2% and the age standardized prevalence of undiagnosed diabetes is 2% among the over frontier and 31.7 million cases in India. In the year 2008, India was estimated to have 40.2 million diabetes. WHO forecasts that the number will rise to 14.5 million by the year 2025 21. But by the year 2030, the estimated prevalence of diabetes mellitus was 30.3 million in US, 42.3 million in China, 13.9 million in Japan and 79.4 million in India. Diabetes Mellitus is the fourth leading cause of death22. Arab Diabetes Survey 2006 reported that 10% of the population was affected by diabetes mellitus. Out of which, 5.7% exists in urban areas, 4.1% in rural areas and 1.5% among desert communities. Serious complications may affect a considerable proportion of the population if the disease is not properly managed23.

According to the new data released by the International Diabetes Federation (IDF) November 2009, 285 million people worldwide have diabetes which affects 7% of the world’s adult population, 50.8 million of diabetes in India, 43.2 million in China, 26.8 million in US, 9.6 million in Brazil, 7.5 million in Germany, 7.1 million in Pakistan, 7.1 million in Japan, 7 million in Indonesia and 6.8 million in Mexico. It indicates that people in low and middle income countries are bearing the brunt or burden of the epidemic, and that the disease is affecting far more people of working age than previously believed24.

Diabetes is now emerging as one of the main threats to human health in the 21st century. The past two decades have seen an explosive increase in the number of people diagnosed world-wide. In recent years, India has witnessed a rapidly exploding epidemic of diabetes. Indeed India today leads the world with its largest number of diabetics in any given country. It has been estimated that in 1995, 19.4 million individuals were affected by diabetes in India and these numbers are expected to increase to 57.2 million by the year 2025 (one sixth of the world total) 25.

In the recent National Urban Diabetes Survey (NUDS) the prevalence of diabetes was found to be 13.5% among Chennai residents, in Bangalore-12.4%, Hyderabad-16.6%, Kolkata-11.7%, New Delhi-11.6% and Mumbai-9.3%. The survey also concluded that there is a large pool of individuals with impaired glucose tolerance (IGT) at risk of conversion to diabetes especially among the younger age group below 40 years25.

In the 14 year study conducted in 8793 hospitalised diabetics in Mumbai, 81.8% developed complications. Hypertension was observed in 42.2%, ischemic heart diseases in 27.2%, cerebrovascular complications in 9.2% and peripheral vascular disease in 4.2%25.

A study conducted to estimate the prevalence of diabetes and the number of people with diabetes who are less than 20 years of age in all countries of the world for three points of time in 1995, 2000, and 2025. The data obtained by WHO was collected from 75 communities in 32 countries, was analysed for developing and developed countries separately. Prevalence of diabetes in adults worldwide is estimated to be 4.0% (135 million) in 1995 and is expected to rise to 5.4% (300 million) in 2025. Thus by the year 2025, more than 75% of people with diabetes will reside in developing countries as compared to 62% in 1995. In developing countries the majority of people with diabetes are in the age group of 45-64 years and in the developed countries more than 64 years. Thus the study has concluded that diabetes is a global burden26.

2. STUDIES RELATED TO SELF MANAGEMENT AND EDUCATION

Management of clients with diabetes includes restoring and maintaining blood glucose levels to near normal as possible by balancing the diet, exercise, and the use of oral hypoglycemic agents or insulin. The treatment of diabetes is highly individualized, and it depends on type of diabetes, complications, and presence of other active medical problems, age and general health at the time of diagnosis. Diabetes can be managed with proper care, clear understanding of the problem, proper treatment and regular follow up27.

The effects of a culturally competent diabetes self management education was studied among Mexican Americans with Type 2 diabetes at Texas Mexican border. A total of 256 patients between 35 to 70 years of age with Type 2 diabetes were randomly assigned to experimental and control group. The intervention involved 3 months of weekly instructional sessions on nutrition, self – care topics, exercise and self-monitoring of blood glucose. Data was analyzed by descriptive statistics. Experimental group showed significantly lower levels of HbA1c and fasting blood glucose at 6 and 12 months and higher diabetes knowledge score (r=0.88, p< 0.01) than the control group. This study confirms the effectiveness of culturally competent diabetes self-management education on improving health outcomes particularly for those individuals with HbA1c levels >10%28.

An evaluative study was conducted in Hawaii to assess the effectiveness of Diabetes Out patient Intensive Treatment Program (DOIT) over educational mailing (Edupost). Diabetic patients (Type 1 and 2) with poor glycemic control were randomly assigned to DOIT and educational mailing .Group education and skills training experience combined with daily medical management was carried out over a period of 6 months. The result showed a significant drop in HbA1c values in both treatment groups and greater glycemic control was evidenced in DOIT group. DOIT group also repo rted significant improvement in self-care (blood glucose monitoring, exercise and diet) whereas Edupost patients showed no improvement. For DOIT patients glycemic improvement was significantly associated with self-reported change in diet (r=0.41, p<0.02) 29.