Diabetes affects over 3 million adults in Australia alone-of which 90% is type 2 (Baricevic, 2007) non-insulin dependent diabetes mellitus (NIDDM-for the sake of this essay diabetes is referring to type 2 NIDDM). There are numerous biological and socioeconomic determinants of the disease which has developed into Australia’s fastest growing chronic disease. Whilst it is “often considered a lifestyle disease (Scobie & Samaras, 2009)” this is a common misunderstanding with many other contributing factors such as genetics, the environment and economic circumstances. Whilst much research has gone into the management/treatment of diabetes, work on addressing the ‘upstream’ determinants has begun. Physiotherapists play a vital role in the prevention and treatment of the condition with them often prescribing exercise programs for diabetic patients.
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Diabetes results from a total or partial insulin deficiency, resulting in hypoglycaemia. This deficiency prevents glucose movement between the blood and cells, creating a build-up of glucose in the bloodstream. As a result of the hypoglycaemia, several key symptoms are present including blurred vision; increased healing times; unexplained weight gain; increased passing of urine; thirstiness; tiredness and dizziness. In 2010 diabetes accounted for 6.6% of Australia’s total burdens of disease and has been identified as one of the eight national health priorities (AIHW, 2010).
Section 1
Hamdy, Goodyear, & Horton (2004) contend that there are three key contributing factors to the onset of diabetes. These include genetic predisposition, decreased insulin action and a defect in the pancreatic β cell.
However the most well-known biological and behavioural determinants of the condition relate to obesity with the relative risk being 1.8 for an overweight person and a staggering 3.2 for obese people (Marks, Coyne, & Pang, 2001). Weight related determinants include obesity (morbid and moderate), sedentary lifestyle, poor diet and low levels of physical activity (Ramlo-Halsted & Edelman, 1999). Hamdy, Goodyear & Horton (2004) suggest the primary reason for such societal changes leading to the dramatic rises in the rates of both obesity and more so diabetes is urbanisation. They suggest that the recent world-wide urbanisation and increase in technology has created a society where traditional incidental forms of exercise have been alleviated in favour of technology and the advances that it has facilitated. Ethnic groups have particularly been affected by these changes with their traditional forms of life transformed as they too are impacted by globalisation.
An example of such a group in Australia is the Indigenous Australians. As with nearly all areas of health, they are severely over represented in the percent suffering from diabetes. __________
Other factors contributing to the onset of the disease include older age,
Section 2
Despite these factors being well documented as some of the primary causes of diabetes, Scobie & Samaras (2009) argue that these factors accelerate the onset rather than being the primary cause.
-biological/behavioural determinants of health
Age
Genetic background-parental history
-groups at particular risk:
Elderly
People with a family history
Certain ethnic groups (eg Aboriginal Australians)
Low SES
Section 2 (link back in with individual determinants)
-“Factors such as poverty, poor education, social exclusion, unemployment and lack of or poor quality housing all contribute to health inequalities.”
-socioeconomic determinants of health
Policyƒ PA levels in schools, NPAG, education
Communityƒ access to parks/paths
Environmentalƒ safety, access to fresh food
Societalƒ urbanisation and increase in technology = down incidental exercise
Economicƒ employment/occupation, income, wealth
Section 3
Traditionally treatment of diabetes has focused on the ‘downstream’ factors, with the focus being at an individual level. Exercise and weight loss are key aspects of the treatment, given that ________. Exercise alone leads to a significant improvement in insulin sensitivity (Misra, et al., 2008). In line with the National Physical Activity Guidelines (Department of Health and Ageing, 2010), it is recommended that individuals participate in at least 30 min of walking 5 days per week. The guidelines highlight four key points for all adults regarding physical activity, with these being particularly important for people with diabetes. They are:
Think of movement as an opportunity, not an inconvenience
Be active every day in as many ways as you can
Put together at least 30 minutes of moderate-intensity physical activity on most, preferably all, days
If you can, also enjoy some regular, vigorous activity for extra health and fitness (Department of Health and Ageing, 2010)
In conjunction with exercise, a healthy diet is essential for the effective treatment of diabetes (DA Victoria, 2002). This has been proven to have the single greatest natural impact on blood glucose levels; as well as aiding weight loss and decreasing insulin resistance. Foods should not be limited to low GI, with a diet focussed on high protein (such as fish and low fat dairy); high carbohydrates (such as pasta, bread and fruit) and low saturated fat/sugar (Baricevic, 2007).
The AIHW (2010) suggests that the most appropriate method of treatment is initially through diet and exercise, progressing only later to medication. Diabetes medication primarily acts to help regulate the blood glucose levels. Given that with this condition insulin is unable to effectively function, it becomes important to have a way to regulate blood sugar. The normal range is 3.5-6 mmol/L prior to meals and 3.5-8mmol/L directly afterwards (DA Victoria, 2002). Glucose management is very important to keep the risk of cardiovascular disease down, and without regulation the person may suffer from hypo/hyperglycemia. That said, Ramlo-Halsted & Edelman (1999) point out that the “optimal regimen particularly for medication will change for each individual as the condition progresses.” There are two different options for medication-tablets or insulin injections. The tablets are taken orally and decrease the release of stored glucose in the liver, keeping blood sugar levels down. In contrast, insulin injections come in the form of a needle (syringe) or a pen and are used when the pancreas is unable to produce the required amounts of insulin (Baricevic, 2007).
Diabetes, as with many health conditions, requires a multi-disciplinary team for successful treatment and management. Diabetes Management in General Practise (2009) describes the roles of at least eight different team members in the treatment of diabetes. These include:
General practitioner
Exercise specialist (commonly a physiotherapist)
Podiatrist
Optometrist
Oral health professional
Diabetes educator (nurses etc)
Dietician
Endocrinologist/diabetologist
Whilst not all of these health professionals will necessarily be involved in every individual’s treatment, the team’s cooperation is vital for long-term treatment.
To help with individual treatment of diabetes, the Australian Government has established the National Diabetes Services Scheme (NDSS). The program has in excess of 900 000 registered people with diabetes and is continuing to grow. There are several key elements of the scheme with subsidised products and information as well as education. Through this program, there are 2200 outlets which supply discounted products for treatment to the registrants.
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Whilst treatment is very common, alongside it is an extensive management plan. DA Victoria (2002) describes several aspects to proper management. Aside from being physically active and eating well as previously mentioned, it is preferable for a diabetic to link up with a local support team for help, support and to maintain a positive attitude. Additionally testing blood glucose regularly and medicating appropriately as prescribed is also important. Diabetes Management in General Practise (2009) also emphasises the need to quit smoking (if applicable), have less than two standard drinks per day and ensure BMI (body mass index) in less than 25 to achieve general wellbeing.
Hawley & Zierath (2008) also outline the importance of minimising the risks and effects of complications. They state that this can be achieved through controlling glycaemia, blood pressure and lipid levels; in conjunction with regular health checks (focussing on eye, kidney and foot problems).
Section 4
Prevention of diabetes is an absolute priority especially when over 60% of type 2 cases are preventable. With diabetes being the 7th leading cause of death in Australia (AIHW, 2010), there is no question why the Australian Government has made the condition a national health priority. According to Weeson (2000), “upstream” treatment by primary health professionals should be the focus of all approaches. These upstream factors include______________.
Simple steps can easily help prevent or delay the onset of diabetes (Type 2 Diabetes, 2011) through implementing a healthy lifestyle. Diabetes Australia encourages individuals to maintain a healthy weight, participate in regular physical activity, eat healthy food, manage blood pressure/cholesterol and not smoke, to decrease the onset of the condition (Type 2 Diabetes, 2011). There is a very strong link between physical activity and diabetes as previously mentioned, however it should benoted that participation in a moderate or preferably brisk walking regimen can decrease the incidence of diabetes by 30% (Jeon, Lokken, & van Dam, 2007). Furthermore Jeon, Lokken & van Dam (2007) describe this strong relationship saying that there is also a link between the amount of physical activity and the reduction of risk-an amazing 58% decrease in the incidence of prediabetes can be achieved through exercise previously stated.
Zimmet (2000) emphasises that diabetes cannot be stooped by traditional medical approaches. Given the scale and enormity of the issue, he contends that drastic socioeconomic and cultural status changes are required to make progress. Zimmet (2000) says that international diabetes and public health organisation need to lobby and mobilise politicians and non-government agencies. Through this, the issues causing the pandemic (socioeconomic, behavioural, nutritional and public health) can be addressed. A multi-disciplinary task force is suggested to aid in the reversal of the socioeconomic issues, as Zimmet feels that individuals alone acting to change will not make a big enough difference (Zimmet, 2000).
The National Evidence Based Guidelines for the Primary Prevention of Type 2 Diabetes (Colagiuri, Girgis, Gomez, Walker, Colagiuri, & O’Dea, 2009) describe four key areas to creating effective preventative action for diabetes. These include:
“Having a strong theoretic base for the program”
“Designing the program with clear messages, incorporating a multifaceted approach to deliver these messages”
“Encouraging family involvement”
“Intensive and sustained campaign over a long duration”
The guidelines also discuss the facets within the broader community that should be targeted for prevention of the condition. One of the central elements to effectively targeting the population is education (Colagiuri, Girgis, Gomez, Walker, Colagiuri, & O’Dea, 2009). Through media, the guidelines propose that the education can change attitudes as well as levels of knowledge. This can have a particularly profound impact on the short term increase in physical activity. This was seen in the ‘Life be in it’___________
In terms of prevention for individuals, the guidelines also provided several points specifically targeting those in the risk groups. The guidelines (Colagiuri, Girgis, Gomez, Walker, Colagiuri, & O’Dea, 2009) specify individuals at particular risk as having a score greater than or equal to 15 on the AUSDRISK risk assessment tool. There are three levels of action to prevent the onset of diabetes. Initially lifestyle modifications such as weight management, progressing to pharmacological interventions where necessary and in cases with severe risk bariatric surgery may be considered. Furthering the treatment dietary considerations previously mentioned, in order to prevent diabetes sugar-sweetened drinks have been identified with fast food as items that pose the largest threat of inducing diabetes (Hu, van Dam, & Liu , 2001). Fish oil and polyunsaturated fats have also been proven to help with the prevention of the condition.
Other
-conversion from high risk to low risk lifestyle = moderate style
Physiotherapists play a large role particularly in the treatment, but also the prevention of diabetes. Ozdirenc, Kocak & Gutekin (2004) highlighted the importance of physiotherapy in the accurate prescription of exercise. They suggested that any exercise prescribed in the interest of decreasing complication with diabetes or preventing it should be undertaken at 65-75% of a person’s VOâ‚‚ max and emphasised the necessity of a professional in such prescription. According to their study, physical exercise can lead to a significant decrease in physical impairment and provide improvements to functional limitations that the person had suffered. In contrast, they determined that low levels of activity caused a decreased cardio respiratory capacity and hence lessened ability to walk longer distances. These effects of inactivity too have the potential to be improved through the implementation of a physical activity regime (Ozdirenc, Kocak, & Gutekin, 2004). Physiotherapists also play an important role in the prevention of diabetes through education and public health promotion. At an individual level such professionals can help their clients who are identified as being at risk (of diabetes) to make behavioural modifications to lessen their personal risks. In addition to this, physiotherapists can help their patients with diabetes develop an exercise program to aid in weight loss and improving their future prognosis.
At a broader level physiotherapists can be involved in policy development and other awareness campaigns. For example the National Physical Activity Guidelines require experts and other professional’s inputs to develop programs with the key elements previously mentioned such as strong theoretical bases.
Conclusion
-prevention must be a key focus given that -“a condition that is highly amenable to primary intervention”
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