'Managing and Reducing Cardiovascular Risk in Type 2 Diabetes Mellitus Essay\r'

'Diabetes mellitus is a metabolic disorder in which the form’s capacity to make social occasion of glucose, fat and protein is disturbed due to insulin deficiency or insulin resistance. It is a hormone secreted from pancreas that friends glucose from nutriment to enter the be’s cells where it is transformed into energy required by muscles and tissues to function. Diabetes is fixd either because the pancreas does not secrete adequate insulin, or because cells do not react to the insulin that is produced.\r\nDue to this antecedent, an several(prenominal) with diabetes does not take up glucose take into accountly and glucose continues move in the line of work (hyperglycemia) harming tissues over time. This damage leads to crafty health complications. The classic symptoms of diabetes mellitus atomic design 18, Polyuria ,Polydipsia ,Polyphagia ,lethargy and weighting spillage. There ar legion(predicate) causes for mellow crinkle glucose levels in the body and so a outcome of fibers of diabetes exist. Diabetes mellitus occur end-to-end the world. Based on the use up conducted by IDF, the number of diabetics on earth stands at 365 million some 8. 5% of the global commonwealth.\r\nIt is more widespread in the more developed countries. The greatest raise in incidence is, however, expected to happen in Africa and Asia, where mass of the diabetes patients entrust most resemblingly be lay down by 2030. Diabetes mellitus is categorised into four broad groups: sign 1, Type 2, Gestational diabetes & adenylic acid; â€Å" early(a) item display cases”. Scientists in US take hold found a Type 3 diabetes, it is still continuing upgrade study. Type 1 diabetes is absolute insulin deficiency principlely affects children and young adults. Type 2 Diabetes is an insidious modern complaint that is often diagnosed late when complication ar present.\r\nDunning (2004) described it as a long condition complication with neuropathy , cardiovascular infirmity and retinopathy. It is a universal proposition metabolic disorder affecting more than 2 million flock in the United landed estate and up to 750,000 more ar expected to engender it without knowing they do. Studies conducted show that 80% of population change by diabetes live in developing and underdeveloped countries and the absolute majority of flock with diabetes is between 40 to 59 years of age. It is also estimated that 183 million people (50%) with diabetes atomic number 18 undiagnosed. It is noticed that Diabetes ca employ 4. million deaths in 2011 and caused sharp make up in medical expenditure.\r\nI am a staff nurse working in the cardiac ward and we often receive patients with cardiac chores as a long call complication of casing 2 diabetes. Cardiovascular affection is a major cause of hospital admission and mortality in people with diabetes. Most of them atomic number 18 not diagnosed until they are admitted. During the course of this study the medical history and interest and interposition provided to a patient named Mr M Davies who was admitted in my ward is chosen to learn or so managing and reduction cardiovascular disease among patients with type 2 diabetes.\r\nIn 1998 UKPDS pointed out the richness of reducing lipids origination obligate and profligate Glucose to boil down the peril of cardiovascular disease. gritty railway line cart leads to thicker, less elastic billet vessel walls and summation the strain on the boob. Studies indicated that there is a additive correlation between the diastolic blood wedge and the eventual outcome of type 2 diabetes. Standl & Schnell (2000) pointed out that as a result of ischemia-induced remodelling tough changes occur in the heart and the make of hyperglycaemia on the endothelium of stupendous blood vessels that causes heart to failure.\r\nMr M Davies (Mr. MD) is a 61-year-old pensioner with a 4 years history of type 2 diabetes. He was diagnosed in 2008 and he had symptoms of hyperglycaemia for 2 years in advance diagnosis. His fasting blood glucose records indicated values of 6â€7 mmol/L, which were explained to him as symptomatic of â€Å"borderline diabetes. ” During the preliminary diagnosis, he was informed to slim weight (â€Å"at least(prenominal) 10 lb. ”), but no further pull through was taken. Other medical problems include obesity and hypertension. He was admitted in the ward with recurrent chest pain. (Appendix 1) This appellative is about managing and reducing cardiovascular jeopardy in type 2 diabetes mellitus.\r\nHeart disease is sanitary acknowledged as a chronic problem of diabetes, and is the major reason of morbidity and mortality in patients from middle-age onwards. Type 2 diabetes is associated at the onset with risk actors for heart disease such as hypertension and obesity, raising the question of whether diabetes is the autarkic risk factor for heart disease. In 2 001 Morrish et al pointed out that the majority of cardiovascular deaths are specifically due to heart disease and this is supported by Fisher, Miles, (2008) commenting that heart disease is the major cause of morbidity and mortality at young as well as senior(a) ages.\r\nButler (1997) verbalise that enlarged life forecast has led to an increase in the number of people over 65 years of in twain the developed and developing worlds. Marso (2003) pointed out that due to the make believe association between age and the development diabetes, this increase in the number of older individuals in the population will inevitably contribute to the change magnitude prevalence of diabetes. Watkins (2008) mentioned that Type 2 diabetes is a disease of recounting prosperity, prosperity leads to overweight and physical indolence.\r\nInsulin resistance, increasing with obesity, associated with industrial failure of insulin secretion in relation to aging underlies the development of diabete s. It is anticipated that by 2025 the number of people with type 2 diabetes will be or so 380 million and people with damage glucose tolerance will be around 418 million. Diabetes is the foremost global cause of premature mortality that is broadly underestimated, because only a few among the diabetic patients die from reasons uniquely link up to the condition.\r\nNearly one half of type 2 diabetes patients die prematurely of a cardiovascular reason and approximately 10% die of renal failure. Diabetes is a condition that required to be managed every twenty-four hour period. The counsel of Diabetes merchantman refer to dealing with short bourne measures like high and low blood lolly to regulating it over the long term for sheath by attaining to grips with knowing the condition. All patients with Type 2 diabetes require active nourishmentetic steering throughout their disease. Watkins (2008) pointed out that weight loss in the fat is extremely valuable but is separate from foodary manipulations to control blood glucose.\r\nTreatment typically includes diet control, exercise, monitoring blood lollipop at home, and in some cases, oral medication and/or pickings insulin. Based on the type diabetes medicines are sort into different groups and each category of diabetes pills functions differently. Commonly used medicines to control diabetes are Sulfonylureas, Thiazolidinediones, Biguanides, Alpha-glucosidase inhibitors, Meglitinides and, Dipeptidyl peptidase IV. Sulfonylureas reduce blood net by affect the pancreas to produce more insulin. Sulfonylureas medicines like Glimeperide, Gliclazide,.\r\nBiguanides improve insulin’s capacity to deepen sugar into cells bumpicularly into the muscle cells. They also pessary the liver from releasing stored sugar. Biguanides are not certified to be used in people who have heart failure or kidney damage. Biguanides medicines such as metformin. Thiazolidinediones like Pioglitazone and Rosiglitazone enhan ces effectiveness of insulin in muscle and in fat tissue. Alpha-glucosidase inhibitors, such as Precose (acarbose) and Glyset (miglitol) prevent enzymes that help digest starches, reducing the rise in blood sugar.\r\nThese medicines may cause diarrhea or gas. They send away decrease hemoglobin A1c by 0. 5%-1%. Meglitinides, like Prandin (repaglinide) and Starlix (nateglinide) reduces blood sugar level by stimulating the pancreas to secreate more insulin. Dipeptidyl peptidase IV (DPP-IV) inhibitors, such as Januvia (sitagliptin), Onglyza (saxagliptin), and Tradjenta (linagliptin) lowers blood sugar level in patients with type 2 diabetes by accelerating insulin secretion from the pancreas and lowering sugar production. The case history of Mr.\r\nMD indicated that he was rede to manage blood sugar level by diet control and mending exercise. It was also well-advised to take metformin degree Celsius0mg twice a day when diet and exercise are not tolerable to manage blood sugar level . The history showed that Mr. MD was non-compliance with any of these. On admission his random blood sugar was 20 mmol/L. As he was ineffectual to tolerate oral intake due to unwellness and chest pain, GKI was commenced for a day to control his blood sugar. On second day his blood sugar level was controlled and he started eating and drinking normally.\r\nMr MD was referred to diabetic specialist nurse and dietician . diabetic specialist nurse advised to stop GKI and advised to start OHA. Mr. MD commenced on metformin one hundred0mg tercet times a day (Learning outcome 1). Metformin has long been accepted as a appropriate first-line choice of oral medicine for Type 2 diabetes as it is the only oral hypoglycaemic element related with no weight gain or even weight reduction. They decrease hepatic gluconeogenesis, hike peripheral glucose uptake and also lower the acculturation of carbohydrate from the gut lumen.\r\nBecause metformin functions on insulin esthesia and with only endo genous glucose stimulated insulin secretion, it virtually neer causes hypoglycaemia on its own and patients using it with diet and exercise do not need routinely to self-monitor blood glucose. The UK Prospective Diabetes Study (UKPDS, 2002) demo a significant survival advantage for Type 2 patients started on metformin as first-line therapy, with less cardiovascular mortality, although it should be noted that they only used the medicate in obese patients. Obesity is a world(a) problem.\r\nBarnett (2009) pointed out that obesity and overweight are independent risk factors for cardiovascular morbidity and mortality. Various studies produce that obesity is a major cardiovascular disease risk factor across world’s populations. Risk of morbidity and mortality begins to increase at body mass index (BMI) >25 kg/m 2 and the risk raises sharply at BMI >30 kg/m 2. Each kg of weight put on from the age of 18 years was linked with 3. 1% higher risk of cardiovascular disease. I n 1998 Gunnell observed that over weight in adolescence is a forecaster of these dangers in matureness .\r\nThese finding were supported by Must in 1992,who explained that this increased risk extends to overweight children and adolescents, who may be at risk of premature cardiovascular morbidity and death. The mechanism by which obesity causes increased cardiovascular morbidity and mortality is attributed to associated co-morbidities and risk factors such as hypertension, dyslipidaemia, type 2 diabetes and insulin resistance. The co-occurrence of some or all of these risk factors along with obesity is termed the cardiometabolic syndrome.\r\nOn examination it was noticed that Mr. MD has a high BMI (30. 9). West (2007). Suggested that addressing obesity is an essential aspect of managing diabetes, because type2 diabetes and many other health problems coexist. However it is fundamental to escort the individual’s specific nutritional necessitate rather than just providing them with a ‘weight loss designing,’ ‘diabetic diet,’ a ‘standard meal plan or information about healthy eating. ’ Mr. MD was referred to the dietician. Dietician gave dietetic advice and educated about importance of weight management by diet and regular exercise.\r\nHe was advised to avoid take-away foods, reduce alcohol consumption and taking balanced food to prevent hypo and hyper glycaemia (Learning outcome 1).. Hypertension-Prevention & direction is very important in the management of metabolic diseases. In 1985 Modan et al pointed out that there is a strong relationship between high blood pressure and insulin resistance. This findings is supported by Reaven, (1999) . He verbalize that the prevalence of insulin resistance in hypertension has been estimated at 50%. Scheen, (2004) proposed several possible mechanisms for this.\r\nCoutinho et al. (1999) said that impaired fasting blood glucose is related with high cardiovascular risk part icularly if accompanied by hypertension. henry et al. , (2002) said that in people with diabetes, cardiovascular disease risk is increased two to fourfold compared with those with normal glucose tolerance. This was supported by the study conducted by Heffner et al. , (1998) who said that diabetic people without past history of myocardial infarction may have as high a risk of myocardial infarction as non-diabetic patients with a history of previous myocardial infarction.\r\nNon-pharmacological interventions are cheap than pharmacological interventions and have no cognise dangerous effects. A range of life-style changes reduce blood pressure and the occurrence of hypertension. Non-pharmacological interventions such as weight loss in the overweight, exercise programmes, constrictive alcohol intake and a diet with increased fruit and vegetables and limited saturated fat content, minimising dietary sodium consumption and increased dietary grand intake.\r\nFrom the medical history of Mr MD it is noticed that he was taking Ramipril 5 mg/day and bisoprolol2. mg/daily. It is established that where non-pharmacological interventions are not enough to come through the objectives then Pharmacological interventions are required. Several drug interventions are of proven value in minimising cardiovascular risk in people with diabetes and hypertension. Low-dose aspirin is suggested in diabetes whether or not there is evidence of large vessel disease. Williams et al. , (2004) noticed that the British Hypertension caller recommends 75 mg of aspirin for all with hypertension and diabetes, unless contraindicated.\r\nAntihypertensive therapy diminishes the risk of macrovascular complications by around 20%. Reducing blood pressure reduces progression of retinopathy, albuminuria and progression to nephropathy. Staessen et al. , (1997) observed that clinical trials with ACE inhibitors, beta-blockers, diuretics, angiotonin receptor blockers and calcium channel blockers have d emonstrated benefit of treatment of hypertension in type 2 diabetes (Learning outcome 1).. On admission blood pressure level of Mr MD was very high. He was recommended treatment with antihypertensive drugs.\r\nConsultant prescribed Losartan 100 mg/day and increased ACE inhibitor (ramipril 10 mg/day) and beta-blocker (bisoprolol 5 mg/dayl). Studies show that treatment with ramipril in addition to standard therapy minimised combined myocardial infarction, stroke and cardiovascular death by about 25% and stroke by 33% compared with placebo confident(p) conventional methods. This was supported by Sowers and Haffner, (2002) saying that near all patients with hypertension and diabetes require combinations of blood pressure reducing drugs to attain the recommended blood pressure targets.\r\nDuring the treatment Mr. MD was advised non-pharmacological methods of blood pressure management and importance of diet control and referred to cardiac rehabilitation for regular exercise. Management of high cholesterin plays an important role in the management of diabetes. Lipid abnormalities are common in type 2 diabetes and can be broadly categorized into two groups: those that are common to the general population, for example marvelous congeries and LDL cholesterol; and additional diabetes-related abnormalities, for example elevated triglycerides and reduced HDL cholesterol.\r\nCurrent US and European guidelines emphasize reducing LDL-C level to less than 100 mg/dL (2. 59 mmol/L). To reduce the cholesterol Mr. MD was undergone intensive lipid-lowering treatment with atorvastatin 80 mg/day. Dietary therapy was also a part of the treatment which was found effective to lower Lipids. Interventions to stabilize lipids in order to decrease the risk of CVD are warranted in people with type 2 diabetes. both Fibrates and Statins improve lipid profiles in people with diabetes. many an(prenominal) studies have established the safety and effectiveness of the fibrates (gemfibrozil, bezofibrate, fenofibrate) in diabetes.\r\nFibrates stimulate the peroxisome proliferator-activated receptor-a, changing the expression of a number of enzymes that regulate lipid metabolism, including lipoprotein lipase. Statins inhibit hepatic 3-hydroxy-3-methylglutaryl coenzyme A reductase, which is rate restrictive in cholesterol production. another(prenominal) major strategy in the management diabetes is lifestyle interventions. Lifestyle interventions can progress lipid levels. Studies conducted on weight loss and lipids in type 2 diabetes have varied greatly as to the study diet, design and duration.\r\nA Meta-analysis of 89 studies and 1800 subjects with type 2 diabetes reported that a weight loss of 5% or greater reduced triglyceride levels by 10±40% and total cholesterol by 5±15%. These effects were greatest with very low-calorie diets, and the effects were seen in studies up to 6 months. A shape of diets can alter the lipid profile in people with type 2 diabetes. The placement of diabetes assistance is very important in the long term management of diabetes care. Diabetes is the significant disease confronting the United farming’s (UK) health care system.\r\nAs a result, understanding how best to manage diabetes facilities is an important vault of heaven if the health system is going to deal with the offshoot in both the demand for and cost of diabetes treatment. armorial bearing should be planed at reducing symptoms and minimizing the danger of long-run problems. It is pointed out that a proper balance of glucose and other cardiovascular risk factors such as smoking, hypertension, motionless lifestyle, dyslipidaemia and obesity is very crucial (UKPDS, 2002) in the organisation care of diabetes.\r\n'