SERMINAR: DIABETIC COMPLICATIONS .

WHAT MEASURES SHOULD PATIENTS

TAKE
ABSTRACT

Diabetes mellitus is among the top four leading non communicable diseases after cardiovascular
diseases, cancer and respiratory diseases; and has been increasing worldwide with its prevalence
increasing in Kenya as well. Diabetes mellitus has been described by WHO (2014) as a chronic
disease which occurs when the pancreas does not produce enough insulin or when the body
cannot effectively use insulin it produces leading to increased glucose in the blood. Poorly
managed diabetes mellitus leads to complications such as kidney failure, blindness and limb
amputations due to poor blood circulation to the heart and limbs. Diabetes mellitus is one of the
common public health issues facing the world with its management and premature mortality
affecting the total health care expenditure in several countries, especially in less developed and
poor ones.

even though several million people all over the world are effected with diabetes, not all
are well informed about the nature of the disease. in diabetes, there is excessive glucose in blood
and urine due to inadequate production of insulin or insulin resistance. diabetics can lead a
normal life, provided they take prescribed durgs and make certain changes in their lifestyle,
particularly in their diet and physical activity. uncontrolled diabetes leads to some of the
complication so some of the home remedies also play a major role to prevent the diabetes.

Keywords: Types, Symptoms, Complications, Diet, Exercise, Home remedies.

ABBREVIATIONS AND ACRONYMS

T2DM -Type two diabetes Mellitus

NCDs - Non-communicable diseases

CVD -Cardio vascular diseases

KNH -Kenyatta National Hospital

WHO -World Health Organizations

FBO -Faith Based Organizations

NGOs -Non Governmental Organizations

LMICs -low- and middle-income countries

IDF -International Diabetes Federation

DMI - Diabetes Management and Information Centre

DSMS -Diabetes self monitoring system

DSME -Diabetes Self management Education

WDF - World Diabetes Federation

CDC -Center for Disease Control and Prevention

ADA -American Diabetes Association

CDA -Canadian Diabetes Association

SSA -Sub Saharan Africa

MENA -Middle East and North Africa

SEA -South East Asia

AFR -African Regions

SPSS -Statistical Package for Service Solution

AMPATH -Academic Model Providing Access to Healthcare

INTRODUCTION

Diabetes is a serious, chronic disease that occurs either when the pancreas does not produce
enough insulin (a hormone that regulates blood glucose), or when the body cannot effectively
use the insulin it produces (1). Raised blood glucose, a common effect of uncontrolled diabetes,
may, over time, lead to serious damage to the heart, blood vessels, eyes, kidneys and nerves. The
number of people with diabetes is increasing due to population growth, aging, urbanization, and
increasing prevalence of obesity and physical inactivity.

Diabetes mellitus is a growing public health affecting people worldwide both in

developing and developed countries, and poses a major socio-economic challenge [2], [3]. A
chronic metabolic disorder of multiple aetiologies is assuming epidemic proportions worldwide
[4]. It is also a complex disorder with profound consequences both acute and chronic. Genetic
and environmental factors play a role in the development of the disease [5]. The cells of the body
cannot metabolise sugar properly due to a total or relative lack of insulin. The body then breaks
down its own fat, protein, and glycogen to produce sugar resulting in high sugar levels in the
blood with excess by products called ketones being produced by the liver [6]. Diabetes causes
disease in many organ systems, the severity of which may be related to how long the disease has
been present and how well it has been controlled. The term diabetes mellitus describes a
metabolic disorder of multiple aetiology characterised by chronic hyperglycaemia with
disturbances of carbohydrate, fat, and protein metabolism resulting from defects in insulin
secretion, insulin action or both [7],[8],[9],[10]. Diabetes mellitus may present with characteristic
symptoms such as thirst, polyuria, blurring of vision and weight loss [6]. The abnormalities of
carbohydrate, fat, and protein metabolism are due to deficient action of insulin on target tissues
resulting from insensitivity or lack of insulin [7].

The effects of diabetes mellitus include long-term damage, dysfunction, and failure of various
organs [7]. Type 1 diabetes mellitus encompasses the majority of diabetes, which are primarily
due to pancreatic islet beta cell destruction and are prone to ketoacidosis [10]. If diabetes is not
taken care of, complications such as heart, kidney, and eye diseases, incurable wounds leading to
amputations of the extremities and mental disorders follow. Besides this, diabetes related
complications inevitably cause high cost of treatment and opportunities for the concerned people
and their families especially for poor families the disease and its complications cause severe
economical burden.

In developing countries, non- communicable diseases are evolving rapidly [9]. Diabetes mellitus
places serious constraint on patients’ activities [11]. Despite the high prevalence, serious long-
term complications, and established evidence based guidelines for management of diabetes
mellitus, the quality of care is still deficient in developing countries [12]. Diabetes mellitus is
emerging as an epidemic all over the world, represents an important public health problem, and
is of clinical concern [13], [14], [14]. Type 1 diabetes has been estimated to affect approximately
19,000 people in the worlds poorest countries but there is lack of good data on the disease
prevalence in developing countries and in particular in sub-Saharan Africa[16].

Non-communicable disease such as diabetes mellitus, cardiovascular disease (especially

ischaemic heart diseases and hypertension), stroke, cancer and chronic kidney and respiratory
diseases have become the leading causes of mortality both in developed and developing nations
of the world. The rising prevalence of these diseases is thought to be due to adoption of western
lifestyles and urbanization [17]. With the current trend of transition from communicable to non-
communicable diseases, it is projected that the later will equal or even exceed the former in
developing nations thus culminating in double burden [17]. There is need for health care
providers to intensify efforts in educating people living with type 2 diabetes about good personal
and environmental hygiene. Emphasis is on early diagnosis of diabetes, good glycaemic and
blood control and proper education, programmes for health workers caring for diabetic patients
as well as public awareness talks [18]. The prevalence of diabetes mellitus varies between
different countries. Diabetes mellitus is defined as a chronic disorder, which is characterised by
an elevated level of glucose in the blood due primarily in inadequate secretion or utilization of
insulin [19].

Gestational diabetes mellitus is pregnancy induced diagnosed typically in the second half of
pregnancy. It occurs when beta cells reserve is unable to counter balance the insulin resistance
caused by placental hormone. Systemic hypertension and diabetes mellitus are common chronic
conditions that frequently coexist and can significantly affect the health care needs and clinical
outcome of affected individuals [20].
The excess global mortality attributable to diabetes in the year 2000 was estimated to be 2.9
million deaths, equivalent to 5.2% of all deaths. Excess mortality attributable to diabetes
accounted for 2-3 % of deaths in poorest countries [21]. Diabetes is a serious illness with
multiple complications and premature mortality accounting for at least 10 % of total health care
expenditure in many countries. Diabetes is often perceived as a disease of affluent countries. A
serious chronic disease leads to a substantial reduction in life expectancy, decreased quality of
life and increased costs of care [22].

Management of diabetes mellitus is multidisciplinary and this is not readily available in low
resource settings. Dietary management is essential in the treatment and it alone may be adequate
to achieve and maintain the therapeutic goals to normoglycaemia and normolipidaemia [23]. The
care for diabetic patients includes a change in their life style, where the diet plan represents an
important pillar of care so they can meet their goals. The management of people with diabetes
mellitus is complex and good control significantly reduces the risk of complications yet studies
from around the world concisely demonstrate inappropriate variations in care [24]. The main aim
of this seminar is to expose what diabetes complications and what measures could be taken to
solve the already deteriorating problem. This will go a long way to sensitize the general public
and diabetic patients on the risk of diabeties, risk factors, prevention and the management
options. It is thus the objective of this study;

 To outline the variouse preventive measures against diabetes mellitus

 To explose the various management strategies of diabetes mellitus
 To explore the various challenges in the effective management of diabetes mellitus

For ease of understanding, this work will be divided into 3 part.

 PART ONE

1.1 THE VARIOUSE PREVENTIVE MEASURES AGAINST DIABETES MELLITUS

Diabetes mellitus is defined as a chronic disorder, which is characterised by an elevated level of

glucose in the blood due primarily in inadequate secretion or utilization of insulin [19].

Despite the efforts to control the growing number of diabetes patients, yet, the number of adults
with diabetes worldwide is predicted to almost double over the next 25 years, from
approximately 171 million in 2000 to 366 million by 2030 (25). Diabetes mellitus is now getting
close to what could be reffered to as epidemic proportions. In the United States, diabetes
prevalence and incidence is on the increase in the past 2 decades. According to data from the
NHIS for the period from 1980 to 2005, the age-adjusted prevalence of diabetes that were
diagnosed was little bit stable at about 3.0% from 1980 to 1990, it started to rise. In 1990, the
age-adjusted prevalence rate was 2.9%." It moved up to 4.5% in 2000 and to 5.3% in 2005.
Therefore, the overall prevalence of diagnosed diabetes rises with age and the rate of increase
over the period has been noted to be the largest among the people over 65 years of age(26). It is
observed that human and economic costs of diabetes and its complications are abnormally high.
In every 10 seconds, diabetes causes one death and one amputation every 30 seconds. It is also
associated with adult-onset blindness as the major cause, as well as cardiovascular disease
(CVD), and renal failure. Nonetheless, diabetes can be kept under control through small
investments, and can be wholy prevented through interventions that are simple and cost-
effective. Current International Diabetes Federation data suggest that by 2025, 380 million
people are expected to have diabetes, while most of them will experience lifestyle-related type 2
disease(27). Another concern is the increase in prevalence of obesity among children and
adolescents. For example, collected data for the National Health and Nutritional Examination
Survey shows that 17% of children and adolescents aged 2–19 years in the USA were
overweight in 2003–2004, and that the prevalence of obesity had increased since 1999–2000
from 13.8 to 16.0% in girls and from 14.0 to 18.2% in boys (28). Diabetes mellitus is a
metabolic disease which, when not properly treated or untreated is characterized by chronic
hyperglycaemia and disordered carbohydrate, lipid and protein metabolism and is associated
with the development of specific microvascular complications and of non-specific macrovascular
disease (29). From the insulin angle of reasoning, diabetes mellitus is described as a group of
chronic metabolic conditions, all of which are characterized by elevated blood glucose levels
which is resulted from the inability of the body to produce insulin or resistance to insulin action,
or both (30). It has been described as a killer disease in so many situations. Diabetes is now
ranked among one of the most common non-communicable diseases in the world. It falls within
4th–5th leading cause of death in most developed countries and there are facts and figures that it
is epiidemic in many developing and newly industrialized countries. Diabetes is a progressive
condition initially characterized by insulin resistance, where muscle and adipose tissue become
relatively insensitive to the effects of insulin. As the condition progresses, declining beta cell
activity results in relative insulin deficiency and blood glucose levels rise above normal levels.
(31.) Meanwhile, the global burden of diabetes was 110 million in mid 90’s and it is projected to
increase to 221 million by the year 2010 (32).
1.2 TYPES OF DIABETES

Type 1 diabetes occur as a results of auto-immune beta-cell destruction in the pancreas,

characterized by a total absence of insulin production. Type 1 diabetes is reesponsible for 5% to
10% of all cases of diabetes. Associated risk factors include autoimmune, genetic, and
environmental factors. Untill the present time, known solutions to prevent diabetes have not been
discovered (33). In type 1 diabetes, also referred to as insulin-dependent diabetes mellitus
(IDDM) or as juvenile onset is relatively early in life, in childhood or adolescence and usually
before the age of thirty. This type of diabetes is a relatively homogeneous disease in which the
insulin secretion of beta cells in the pancreas declines and eventually ceases totally(29). Type 2
diabetes can be linked to be accounting for around 90 per cent of all cases, it is a chronic
metabolic disorder, in which the body is unable utilize glucose from food because of the inability
of the pancreas to produce insulin or produces insufficient insulin, or the insulin itself is inactive
(34). Type 2 develops when there is an unexpected increased resistance against the action of
insulin and the body cannot produce proportionate insulin to counter the resistance. The
incidence of Type 2 diabetes in children and adolescents is noted to be on a dramatic increase. It
accounts for 90% to 95% of all diagnosed cases of diabetes (30) Many societies in this present
society view overweight individuals from an an unfavourable angle. This could be linked to the
belief that obese individuals cannot impact self-control on themselves and have lower
intelligence (35).

The global epidemic of type 2 diabetes mellitus grossly affects indigenous and developing
populations. Although genotypic variants related to energy balance may be responsible for the
epidemic (36). Type 2 diabetes (T2D) is a metabolic disorder that affect organs in multiples, and
its incidence is on the increase at the world level. Presently, over 170 million people and 37
million people in China that are affectec by T2D is accounting for 90% of total patients with
diabetes. Estimation shows that in 2010, the total number of patients with diabetes will be up by
nearly 50%, most especially in the developing countries of Africa, Asia, and South America.
Although the pathogenesis of T2D is still obscure but the available medical treatments, together
with controlled diet and exercise, have proven to be effective in controlling hyperglycemia and
prolong patients’ lifespan. (37.)
Gestational diabetes, could be described as a form of glucose intolerance that affects some
women during pregnancy. This kind of diabetes is triggered during pregnancy. Most GDM is
resolved naturally after delivery, but 5-10 percent of women affected during pregnancy are later
found to have diabetes, especially Type 2, after pregnancy. Furthermore, women who have had
history of gestational diabetes have a 40-60 percent chance of developing diabetes in the
following 10 years. Therefore, changes in lifestyle implemented to normalise blood glucose
during pregnancy become essential preventive measures against development of Type 2 diabetes.
Pre-diabetes affect 54 million adults and this places them at risk of developing diabetes later in
the nearest future(38). There are other groups of types of diabetes caused by specific genetic
defects of beta-cell function or insulin secretion, diseases of the pancreas drugs or chemicals
(30). Apart from the above-mentioned types of diabetes, there is what is called pre- diabetes. Pre-
diabetes is described as a precursor condition to diabetes in which a person is experiencing
elevated blood glucose levels but not yet up to diagnostic criteria for diabetes. People with pre-
diabetes normally suffer from impaired fasting glucose or impaired glucose tolerance, or both.
From 1988 to 1994, approximately 25% of cross-sectional sample of US adults 40 to 74 years of
age were classified as having pre-diabetes. For the year 2000, this would mean that 12 million
people in the United States had pre-diabetes (30)

STRATEGIES FOR PREVENTION OF DIABETES

Two major strategies have been evaluated for reducing the incidence of diabetes, i.e.
lifestyle interventions and drugs (pharmacotherapy). These are aimed at changing the risk factor
profile of diabetes mellitus. Diabetes risk factors can be classified into modifiable risk factors
and non-modifiable risk factors (Table 1). The modifiable risk factors are the subject matter of
intervention. The present epidemic of diabetes is very significantly fuelled because of growing
problem of overweight and morbid obesity, which also is a major global health problem.
Excessive truncal adiposity is very well corelated with the risk for diabetes, hypertension and
cardiovascular disease. The other important reason in the changing lifestyle is the lack of
physical activity. This is associated with stress at work. To sum it up there is a marked increase
in the intake of energy dense food with very little or no physical activity. Therefore, the question
arises whether we can prevent type 2 diabetes by lifestyle interventions?
 *Intrauterine environment and Polycystic ovarian disease can be possibly kept as modifiable
risk factors, since dietary factors and medications can help reduce the risk of diabetes.

NUTRITION

In the prospective Nurses’ Health Study conducted in 84941 female nurses followed for 16
years, a series of risk factors related to dietary behaviour, physical activity, weight and cigarette
smoking were identified and targeted, and this was associated with a remarkable 91% reduction
in the risk of developing diabetes. Even with a family history of diabetes the risk reduction was
88%. In theory, therefore, diabetes can be prevented, largely by lifestyle changes irrespective of
genetic background. Some pioneering studies showed that this is feasible. In case of over-weight
individuals reduction of weight by restricting calories and increasing exercise is of vital
importance. However it has been observed that it is not necessary to reduce the weight to the
level of ideal body weight; but a reduction of about 5-10% in the body weight gives substantially
good results.

Physical Activity

Physical activity is important both in the prevention as well as the management of diabetes in all
its stages. It is recommended that around 30-40 minutes of aerobic activity like brisk walking
should be encouraged for at least 5 days a week and preferably for all 7 days (equivalent to 150
minutes/week). The beneficial effects of physical activity are manifold viz. improved insulin
sensitivity, reduction in overall adiposity and central obesity, improved glucose tolerance, and
increased vitality. It is universally accepted that sticking to an exercise schedule over the years is
difficult. However, a combination of dietary modification and physical activity is considered the
best bet for prevention of diabetes and for health promotion.

Lifestyle Interventions

Lifestyle measures which include medical nutrition therapy and physical activity aim to address
the issue of overweight and obesity, improve insulin sensitivity, prevent progression of impaired
glucose tolerance (IGT) and impaired fasting glucose (IFG) to overt diabetes and control
inflammation. The Swedish Malmo study was one of the earliest lifestyle intervention studies for
the prevention of type 2 diabetes and was conducted in male subjects aged 47-49 years. Men
who participated in the lifestyle intervention had a lower incidence of type 2 diabetes and a
greater reversal of glucose intolerance compared to those men who received usual care. At the
end of 12 years, the IGT men who underwent lifestyle intervention had similar mortality as
compared to normal glucose tolerance men, but had less than half the mortality rate when
compared to IGT men who received usual care. The Chinese Da Qing study showed that diet
intervention alone was associated with a 31% reduction, while the exercise alone showed a 46%
reduction in the risk of developing type 2 diabetes. However, the combined diet and exercise
group had a similar 42% reduction in the risk of developing type 2 diabetes during a 6-year
follow-up period. In the Finnish Diabetes Prevention Study (DPS), weight loss in overweight
subjects with impaired glucose tolerance, averaging just 3-4 kg over 4 years, led to improvement
in measures of lipemia and glycemia, and reduced diabetes risk. At 2-year follow-up, incidence
of type 2 diabetes in the intervention group was less than half that observed in the control group.
It was also reported that the impact of lifestyle changes in reducing incidence of diabetes was
maintained for at least 4 years after the intensive intervention finished. A similar result was
achieved in the Diabetes Prevention Program (DPP) in the United States, in which lifestyle
intervention involving exercise and dietary change over a 3-year period in subjects with impaired
glucose tolerance reduced incident diabetes by 58%. Although the results of these lifestyle
intervention programmes look impressive, but in routine day-to-day practice, lifestyle
management is not easy to execute, as these interventions are labour intensive, and moreover, the
results may not be as replicable as to a research setting, even in well-funded healthcare systems.

Pharmacotherapy for Prevention

Considerable interest has been focused on the prevention of diabetes with the use of drugs which
are used for the treatment of diabetes as well. Table 2 gives the important drug trials in
prevention of type 2 diabetes. For instance, the Diabetes Prevention Programme Research Group
study found a 31% reduction in the incidence of diabetes with metformin (at 2.8 years).
Previously troglitazone was shown to be effective in controlling blood sugar levels but had to be
withdrawn because of serious liver toxicity during the TRIPOD (TRoglitazone In Prevention Of
Diabetes) study. In people with obesity, orlistat (pancreatic lipase inhibitor) has been shown to
reduce the risk of diabetes by 37% when compared with placebo.

Table 2: Review of Pharmacological Interventions for Prevention of Diabetes

STUDY DRUG Relative risk Duration of study

reduction (%) (years)
DPP Metformin 31 3
India DPP Metformin 26 3
DPP Troglitazone 75 1
STOP- NIDDM Acarbose 25 3
Xendos Orlistat 37 4
DREAM Rosiglitazone 60 3

Signs and symptoms

•Polydipsia

•Polyuria

•Nocturia

•Visual disturbance

•Fatigue

•Weight loss

•Infections

Diagnosis of Diabetes

•Symptoms + gluc>11.0 mmol/l

•2X FG > 6.9 mmol/l

•2X 2hr GTT > 11.0 mmol/l

SUMMARY OF PREVENTIVE MEASURES AGAINST VARIOUS TYPES OF

DIABETES
Prevention of type 1 diabetes

Insulin

•Diabetes Prevention Trial

•Diabetes Prediction and Prevention Project

Preventionoftype2 diabetes

Lifestyle modification

•Da Qing Study

•Finnish Diabetes Prevention Study

Lifestyle vs medication

•Diabetes Prevention Program

•STOP-NIDDM

Type 2 diabetes

•Often characterized by insulin insensitivity and relative rather than absolute insulin deficiency
•A progressive condition

•Mostpeoplewithtype2 diabetes willneedinsulinwithin5 to10 years of diagnosis

2.3 CAUSES AND RISK FACTORS

The reduction in the prevalence of complications over the past 40 years is undoubtedly due to
greater appreciation of risk factors for those complications and consequent improvements in
patient management (28). The sudden development of short-term complications, such as
ketoacidosis and severe hypoglycaemia that can lead to coma and, if untreated, death, are a daily
threat to the many people worldwide with diabetes who have major difficulty in accessing
essential treatment supplies (including insulin) (27)
There are numerous situations that could cause diabetes or serve as risk factors. The risk of
cardiovascular disease (CVD) is increased in patients with type 2 diabetes. These patients are
two to three times more likely to develop coronary heart disease (CHD) and at least twice as
likely to die as a result of CHD as individuals with normal glucose tolerance (39). Its increased
prevalence is associated with patterns of development, changes in employment, residence, use of
time, diet and nutrition, and increased sedentary lifestyle (40). Prominent risk factors are obesity,
family history of diabetes, previous GDM, and race/ethnicity. In the next 50 years, diagnosed
diabetes is predicted to increase by 165% in the United States, with the largest relative increases
seen among African Americans, American Indians, Alaska Natives, Asian and Pacific Islanders,
and Hispanic/Latino persons(41) .

International management guidelines for the prevention of CVD now recognize type 2 diabetes
as an important independent risk factor, defining it as a ‘coronary equivalent’ (40).
Carbohydrates are recognized to cause a postprandial rise in blood glucose, many factors
contribute to the extent of the rise. These factors include the amount of carbohydrate consumed,
the composition of this carbohydrate (constituent proportions of glucose, fructose, lactose,
amylase, amylopectin, or starch), the effects of cooking or processing on food structure, and
other components of the meal (such as fats that may slow digestion). Hyperlipidemia is one of
the risk factors for the development of cardiovascular diseases(37). More so, worldwide, loss of
traditional lifestyles—i.e, low-energy diets high in vegetables and pulses and low in animal fats,
added sugar, and salt, together with the need for regular physical activity for parts of daily life
such as work, transportation, and feeding is weaving a web of risk factors into the lives of
already vulnerable people. Left unchecked, the burgeoning epidemic of diabetes in developing
countries will exact a terrible toll from people and economies(27). The increased incidence of
CVD in type 2 diabetes is attributed to a cluster of metabolic disturbances that are largely a result
of insulin resistance and are compounded by hyperglycemia and hypertension. Evidence suggests
that dyslipidemia is a major modifiable CVD risk factor in patients with type 2 diabetes that
should be a target of primary risk reduction(39).In the study of an audit of diabetes control,
dietary management and quality of life in adults with type 1 diabetes mellitus, and a comparison
with non-diabetic subjects. Only a few know they have complications of diabetes. Most find
compliance with a dietary programme based on monitoring carbohydrate intake reasonably
straightforward. Their total fat intake is not much different from non- diabetic peers(42). For
physical activity, behavioral and control beliefs distinguished high- from low-activity
participants whereas behavioral and normative beliefs differentiated those engaging in greater
rather than less low-fat food consumption (43).

PREVENTION OF DIABETES MELLITUS COMPLICATIONS

For people who have not experienced complications, the possibility of developing them is a
relevant point of discussion in counseling. Clients should be educated about potential
complications and helped to develop realistic ways of coping with this possibility. Many people
mistakenly fear that complications are inevitable; therefore, counselors should emphasize that
while glucose control is fundamental, prevention does not require blood sugars to be "perfect." It
should also be noted that some people appear to be genetically protected from complications
regardless of their success in controlling their diabetes(38). For instance, only 40% of people
with diabetes are prone to nephropathy, and diabetic complications affect individuals of different
ethnic and racial groups unequally. There is currently no way to predict who is prone to
complications, but if people do not have a complication after 15 to 20 years of having diabetes
they are unlikely to develop it (38). Ways of preventing complications are low protein intake and
carbohydrate intake European guidelines advise protein intake at the low end of the range (about
0.8 g/kg body weight) for diabetic patients with evidence of nephropathy, with a minimum daily
intake of 0.6 g/kg body weight because of risk for malnutrition at lower levels (44).

Central to preventing these complications is not only good glucose control, which depends on
day-to-day and even hour-to-hour self-care, but also behaviors such as frequent glucose self-
monitoring, regular exercise, and eating healthfully. This self-care regimen does not come easily
to most people (38.)

Family-based behavioural procedures such as goal-setting, self-monitoring, positive

reinforcement, behavioural contracts, supportive parental communications, and appropriately
shared responsibility for diabetes management have improved regimen adherence and glycaemic
control (35). In addition to self-monitoring, average blood glucose level is monitored by the
health care team with a glycosylated hemoglobin test (HbAlc; reported as a percentage), which
indicates the average glucose level over the previous three months (38)
 PART TWO

THE VARIOUS MANAGEMENT STRATEGIES OF DIABETES MELLITUS

GLYCEMIC CONTROL

1. HbA1c should be measured in patients with diabetes at least annually, and more
frequently (up to 4 times per year) if clinically indicated, to assess glycemic control over
time.
2. Self Monitoring of Blood Glucose (SMBG) may be used to monitor glycemic control and
adjust treatment in the following conditions:
3. Patients, for whom SMBG is appropriate, should receive instruction on the proper
procedure, the importance of documenting results, and basic interpretation and
application of results to maximize glycemic control.
4. SMBG results should be discussed with the patient to promote understanding, adjust
treatment regimens, and facilitate treatment adherence. [B]
5. Remote electronic transmission of SMBG data should be considered as a tool to assess
glycemic patterns.
6. The frequency of SMBG in patients using insulin should be individualized based on the
frequency of insulin injections, hypoglycemic reactions, level of glycemic control, and
patient/provider use of the data to adjust therapy.
7. A combination of pre-and postprandial tests may be performed, up to 4 times per day.
8. The schedule of SMBG in patients on oral agents (not taking insulin) should be
individualized, and continuation justified based upon individual clinical outcomes.
Consider more frequent SMBG for the following indications:
 Initiation of therapy and/or active adjustment of oral agents
 Acute or ongoing illness
 Detection and prevention of hypoglycemia when symptoms are suggestive of
such, or if there is documented hypoglycemia unawareness
 Detection of hyperglycemia when fasting and/or post-prandial blood glucose
(PPG) levels are not consistent with HbA1c.

GLYCEMIC TARGET RANGE

 1. Treat diabetes more aggressively early in its course.
2. The target range for glycemic control should be individualized, based on the provider’s
appraisal of the risk-benefit ratio and discussion of the target with the individual patient.
3. Providers should recognize the limitations of the HbA1c measurement methodology
reconciling the differences between HbA1c readings and self-monitoring results on a
case-by-case basis.
4. Setting the initial target range should consider the following:
a. The patient with either none or very mild microvascular complications of
diabetes, who is free of major concurrent illnesses, and who has a life
expectancy of at least 10-15 years, should have an HbA1c target of <7
percent, if it can be achieved without risk.
b. Any patient with diabetes should have a HbA1c target of <9 percent to
reduce symptoms of hyperglycemia.
c. The patient with longer duration diabetes (more than10 years) or with
comorbid conditions, and who require combination medication regimen
including insulin, should have an HbA1c target of < 8 percent.
d. The patient with advanced microvascular complications and/or major comorbid
illness, and or a life expectancy of less than 5 years is unlikely to benefit from
aggressive glucose lowering management and should have a HbA1c target of 8-9
percent.
e. Risk of hypoglycemia should be considered in recommending a target goal.
5. Risks of a proposed therapy should be balanced against the potential benefits, based upon the
patient’s medical, social, and psychological status.
6. The patient and provider should agree on a specific target range of glycemic control after
discussing the risks and benefits of therapy.
7. The patient should be assessed for knowledge, performance skills, and barriers (e.g.,
psychosocial, personal, or financial), and if necessary referred to a primary care case manager or
endocrine/diabetes clinic to address barriers for achieving treatment goals.

CONSULTATION/ REFERRAL

The indications to consider a consultation or referral to specialty include patients who:

 • Have type 1 DM; especially patients with history of hospitalizations for metabolic
complications and/or patients who are receiving intensive insulin therapy)
• Have new-onset insulin-requiring DM
• Have marked insulin resistance
• Have contraindications or intolerances to medications typically used in managing
diabetes
• Have recurrent episodes of incapacitating hypo- and/or hyperglycemia
• Have poor recognition of hypoglycemia and who have a history of severe hypoglycemic
reactions (including coma, seizures, or frequent need for emergency resuscitation)
• Have visual and/or renal impairment
• Have psychosocial problems (including alcohol or substance abuse) that complicate
management
• Have HbA1c > 9.0 percent and are considered for aggressive management on an
expedited basis.
• Are not achieving glycemic control despite comprehensive treatment with complex
regimen of combination pharmacotherapy including insulin
• Require evaluation or management beyond the level of expertise and resource level of
the primary team.

TREATMENT OPTIONS

1. Patients with type 1 diabetes mellitus (DM) must receive insulin replacement therapy.
2. Patients with type 2 diabetes, or diabetes of undetermined cause who exhibit significant
or rapid weight loss and/or persistent non-fasting ketonuria, have at least severe relative
insulin deficiency and will require insulin therapy on an indefinite basis.
3. All patients with type 1 DM should be managed by a provider experienced in managing
type 1 DM in a multidisciplinary approach or by a diabetic clinic team with
multidisciplinary resources (e.g., diabetologist, diabetes nurse, educator/manager, and
registered dietitian) for institution and adjustment of insulin therapy.
4. When expeditious referral is not possible, the primary care provider should institute
“survival” insulin therapy comprised of total daily insulin (TDI) 0.5 units/kg/day; half as
basal insulin and half as meal time insulin.
 5. Patients with diabetes should be regularly assessed for knowledge, performance skills,
and barriers to self-management.
6. Patients with recurrent or severe hypoglycemia should be evaluated for precipitating
factors that may be easily corrected (e.g., missed meals, incorrect administration of
insulin [dosage or timing], and exercise).
7. If psychosocial, personal, or financial barriers are identified, additional resources should
be consulted, as applicable (e.g., mental health, medical social work, or financial
counselors).
8. Individual treatment goals must be established with the patient based on the extent of the
disease, comorbid conditions, and patient preferences.

Non-pharmacological Therapy

1. Institution of dietary modification and exercise alone is usually the appropriate initial
management in patients with new onset type 2 diabetes, depending upon severity of
symptoms, psychosocial evaluation, patient motivation, and overall health status.
Encourage diet and exercise and lifestyle modifications.
2. Use various approaches (e.g., individual or group, counseling, coaching, motivational
interviewing) to promote healthful behaviors, such as healthful diet, adequate physical
activity, and smoking cessation.
3. If treatment goals are not achieved with diet and exercise alone, drug therapy should be
initiated while encouraging lifestyle modifications.

Pharmacotherapy

1. When selecting an agent, consideration must be given to efficacy, contraindications, drug

interactions, and side effects. Educate patient about treatment options and arrive at a
shared treatment plan with consideration for patient preferences.
2. Insulin should be considered in any patient with extreme hyperglycemia or significant
symptoms; even if transition to therapy with oral agents is intended as hyperglycemia
improves. (See Section on insulin for further details.)
3. Metformin (preferred) or sulfonylureas (SU) should be given as first line agents unless
there are contraindications.
 4. Alternative monotherapy agents such as thiazolidinediones (TZDs), alpha-glucosidase
inhibitors (AGIs), meglitinides, dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagon-
like peptide-1(GLP-1) agonists should be reserved for patients who have
contraindications to or are unable to tolerate metformin or SU.
5. Patients and their families should be instructed to recognize signs and symptoms of
hypoglycemia and its management. [I

Combination Therapy

6. Metformin + sulfonylurea is the preferred oral combination for patients who no longer
have adequate glycemic control on monotherapy with either drug.
7. Other combinations (TZDs, AGIs, meglitinides, DPP-4 inhibitors, and GLP-1 agonists)
can be considered for patients unable to use metformin or a sulfonylurea due to
contraindications, adverse events, or risk for adverse events (
8. Addition of bedtime NPH or daily long-acting insulin analog to metformin or
sulfonylurea should be considered, particularly if the desired decrease in HbA1c is not
likely to be achieved by use of combination oral therapy.
9. Patients and their families should be instructed to recognize signs and symptoms of
hypoglycemia and its management. [I]

Insulin Therapy

10. Use of insulin therapy should be individualized, and managed by a healthcare team
experienced in managing complex insulin therapy for patients with type 1 DM.
11. Use intermediate- or long-acting insulin to provide basal insulin coverage.
12. Insulin glargine or detemir may be considered in the NPH insulin-treated patient with
frequent or severe nocturnal hypoglycemia.
13. Use regular insulin or short-acting insulin analogues for patients who require mealtime
coverage.
14. Alternatives to regular insulin (aspart, lispro, or glulisine) should be considered in the
following settings:
• Demonstrated requirement for pre-meal insulin coverage due to postprandial
hyperglycemia AND concurrent frequent hypoglycemia
 • Patients using insulin pump.

Continuous Subcutaneous Insulin Infusion (CSII)

1. CSII therapy should only be initiated and managed by an endocrinologist/diabetes team

with expertise in insulin pump therapy.
2. CSII therapy should only be considered in patients who have either documented type 1
diabetes [history of DKA, low c-peptide or evidence of pancreatic autoimmunity] or be
insulin deficient with a need for intensive insulin therapy to maintain glycemic control
and are not able to maintain it using multiple daily injections (MDI) therapy. This may
include patients with:
a) Poor glycemic control (including wide glucose excursions with hyperglycemia
and serious hypoglycemia and those not meeting HbA1c goal) despite an
optimized regimen using MDI in conjunction with lifestyle modification.
b) Marked dawn phenomenon (fasting AM hyperglycemia) not controlled using
NPH at bedtime, glargine or detemir.
c) Recurrent nocturnal hypoglycemia despite optimized regimen using glargine or
detemir.
d) Circumstances of employment or physical activity, for example shift work, in
which MDI regimens have been unable to maintain glycemic control.
3. Patients using CSII should have:
a) Demonstrated willingness and ability to play an active role in diabetes self-
management to include frequent self-monitoring of blood glucose (SMBG), and
to have frequent contact with their healthcare team.
b) Completed a comprehensive diabetes education program.
4. The use of CSII over MDI regimens is not recommended in most patients with type 2
diabetes.

Hospitalized Patients

• In patients with known DM, it is reasonable to document the DM diagnosis in the

medical record. Because of the potential harm from omission of insulin in patients with
type 1 DM, it is suggested that the type of DM also be documented.
• In order to identify potentially harmful hyperglycemia and hypoglycemia, blood glucose
monitoring may be ordered in hospitalized patients with diagnosed DM and/or
hyperglycemia (BG > 180 mg/dl) on admission. There is no evidence to support a given
frequency of monitoring. Therefore, the frequency of monitoring should be based upon
clinical judgment taking into account the management of diabetes, the reason for
admission, and the stability of the patient.
• Due to safety concerns related to potential adverse events with oral anti-hyperglycemic
medications, it is prudent to thoughtfully review these agents in the majority of
hospitalized patients. It may be reasonable to continue oral agents in patients who are
medically stable and have good glycemic control on oral agents at home.
• For patients with DM and/or hyperglycemia who are not medically stable or who are
poorly controlled with oral anti-hyperglycemic medications at home, initiating insulin
therapy should be considered. It is appropriate to continue pre-hospitalization insulin
regimens, but reasonable to reduce the dose in order to minimize the risk of
hypoglycemia. In the ICU, continuous intravenous insulin infusion is recommended.
Scheduled subcutaneous insulin is appropriate in the non-ICU setting and may include a
long-acting basal insulin as well as nutritional insulin for those eating discrete meals or
receiving enteral nutrition. A supplementary correction (sliding) scale is also
recommended but correction scale insulin regimens as sole therapy are discouraged
• Insulin should be adjusted to maintain a BG < 180 mg/dl with the goal of achieving a
mean glucose around 140 mg/dl. Evidence is lacking to support a lower limit of target
blood glucose but based on a recent trial suggesting that blood glucose < 110 mg/dl may
be harmful, we do not recommend blood glucose levels < 110 mg/dl.
• Insulin therapy should be guided by local protocols and preferably “dynamic” protocols that
account for varied and changing insulin requirements. A nurse-driven protocol for the treatment
of hypoglycemia is highly recommended to ensure prompt and effective correction of
hypoglycemia.
• To minimize the risk of hypoglycemia and severe hyperglycemia after discharge it is reasonable
to provide hospitalized patients who have DM and knowledge deficits, or patients with newly
discovered hyperglycemia, basic education in “survival skills”.
• Patients who experienced hyperglycemia during hospitalization but who are not known to have
DM should be re-evaluated for DM after recovery and discharge. [B]
RESPONSE TO THERAPY

1. The patient with recurrent or severe hypoglycemia should be evaluated for precipitating factors
that may be easily correctable (e.g., missed meals, exercise, incorrect administration of insulin
dosage or timing).
2. If the patient does not achieve his/her target range, the provider should identify barriers to patient
adherence to the treatment regimen (e.g., miscommunication, lack of education or understanding,
financial/social/psychological barriers, and cultural beliefs).
3. If barriers are identified referral to a case manager or behavioral/financial counselor should be
considered as appropriate.
4. Treatment goals should be periodically reassessed based upon patient specific factors, including
changes in the patient’s health status, adverse drug reactions, adherence to therapy, and
preferences.

FOLLOW-UP

5. Patients should be scheduled for appropriate follow-up to evaluate response, tolerability to

therapy, goal re-assessment, and management of acute and chronic problems:
 The frequency of follow-up visits for patients with diabetes who are meeting treatment
goals and who have no unstable chronic complications should be individualized
 When there is a sudden change in health status or when changes are made to the
treatment regimen, follow-up within one month or sooner may be appropriate
6. Treatment goals should be periodically reassessed based upon patient-specific factors, including
changes in the patient’s health status, adverse drug reactions, adherence to therapy, and
preference

SELF-MANAGEMENT AND EDUCATION

Diabetes self-management education (DSME) is considered necessary by most healthcare organizations

to assist persons with diabetes in their day-to-day self-management and with making informed self-care
choices. DSME includes providing the patient with behavioral strategies to help him/her establish and
maintain a healthy lifestyle. Comprehensive education programs should address the patient’s fluctuating
diabetes clinical state over a lifetime and provide clinically relevant knowledge and skills to facilitate
implementation of ever-changing treatment plans.
1. Education in core competencies, also known as “survival skills,” should be provided to all
patients newly diagnosed with diabetes. Core competency education includes: response to acute
complications (hyperglycemia and hypoglycemia); how and when to take medication(s);
selfmonitoring of blood glucose, basic diet guidelines; sick day management; and guidance on
when and how to seek further treatment or medical advice.
2. Comprehensive education on self-management and diet should be provided to all patients newly
diagnosed with diabetes. Education should be individualized and tailored to the patient’s needs.
Education can be provided through an in-house comprehensive diet consultation for Medical
Nutrition Therapy (MNT), or a comprehensive DSME program recognized by the American
Diabetes Association (ADA). If neither of these options is available, comprehensive DSME
should be provided at the provider’s facility.
3. Upon completion of the initial DSME/MNT education, behavioral goals should be set and a
follow-up visit schedule determined by the healthcare team and patient.
4. Information sources (e.g., books, pamphlets and web sites) and points of contact for organizations
and other relevant resources should be provided to all patients.
5. Assessment of the following factors should be completed to determine the extent of the patient’s
educational and skills deficit and his/her ability for self-management: knowledge of the diabetes
disease process, treatment goals, management skills, cultural influences, health beliefs/behavior,
attitudes, and socioeconomic factors and barriers.
6. At follow-up, the patient’s understanding of, and knowledge about, DM should be reviewed. The
healthcare team should consider referring the patient to case management or other specialized
care, if the patient exhibits poor glycemic control, has high-risk factors, or fails to demonstrate
good knowledge of self-care. The healthcare team should coordinate the patient’s care with
caregivers to whom the patient has been referred and obtain updates on the patient’s condition
and needs.
7. The healthcare team should always be ready to respond to the patient’s ad hoc inquiries about
new treatments, problems, or concerns.
8. As the patient’s DM control and status improves or declines, the healthcare team should readjust
the follow-up schedule for less- or more-frequent visits. Continuing education may be necessary,
based on the patient’s needs.
9. There is a wide variety of means to provide self-management education and to promote
selfmanagement behaviors. The use of approaches such as group visits and telehealth should be
considered in providing education. Chose the method most consistent with the patient, clinical,
and organizational contexts.
SELF MANAGEMENT AND EDUCATION DIAGRAM
 PART THREE

CHALLENGES IN THE EFFECTIVE MANAGEMENT OF DIABETES MELLITUS

3.1 Barriers Faced by Healthcare Providers

Even with the genetic component of the disease, diabetes can often be prevented through
lifestyle modification (45). Knowledge of the factors that contribute to the disease will aid in
motivating the patient to adhere to treatment plans (46). However, in some places there seem to
be extra challenges that prevent healthcare providers from reaching the population to educate
them regarding their risk factors. With proper knowledge, individuals can prevent or delay the
progression of diabetes with preventative care. This prevention could reduce the morbidity and
mortality of this disease (47). Barriers to care that will be discussed include lack of healthcare
providers, inadequate health literacy, poverty and economic status, and cultural characteristics of
residents of some areas e.g Appalachian.

Lack of Healthcare Providers

Residents of some areas often have limited access to healthcare. Rural areas in general tend to
have fewer accessible physicians than urban areas (48). As a result, as discussed earlier, residents
often must travel long distances to reach a health provider (49). This limited access to healthcare
that these populations face can have an effect on mortality and morbidity rates (50).Inadequate
number of healthcare professionals . In many areas of rural America, such as Appalachia, the
ratio of healthcare providers to the population is significantly lower than the ratio found in urban
areas. Typically, urban areas have one primary care physician for every 600 people, while rural
areas have one for every 2,000 people. The U.S. government categorizes areas with a low
physician:patient ratio (one primary care physician for every 3,500 or more people) as a Health
Professional Shortage Area, or HPSA (48). High numbers of HPSA’s exist throughout
Appalachia. The U.S. Department of Health and Human Services currently records 113 HPSA’s
in West Virginia, 185 in Kentucky, and 69 in Appalachian counties of Tennessee (Health
Resources and Services Administration, 2013). Because of the sparse population of some areas,
the distance between the patients and the available healthcare provider may be great (51). One
reason for the shortage of healthcare providers is that many new graduates simply do not desire
to work in rural locations. Healthcare Financial Management conducted a study of three hundred
medical residents, all of whom stated that they did not wish to work in an area with a population
of fewer than ten thousand people. These medical residents cited reasons for choosing more
urban areas that included “family issues, spouse’s careers, schools, shopping, entertainment, and
social life” (48). If these reasons do indeed impact their plans, then much of Appalachia is
composed of areas that would not attract new physicians. Throughout Appalachia, some
counties have a lower population density than the rest of the country. If physicians are not drawn
to these counties, then the populations within could perhaps be at risk for inadequate healthcare.
Because there are few rural health professionals, a lack of initial physician interaction exists,
decreasing the amount of preventative education that can occur (Della, 2011). The U.S.
Department of Health and Human Services estimates that over eighty percent of diabetes care is
provided by primary care physicians (52). Because diabetes is often closely related to lifestyle,
education regarding risk factors and lifestyle modification can sometimes help prevent a person
from developing the disease (47). Specifically, research has indicated that modifications to diet
and exercise can indeed prevent or delay the onset of type two diabetes (53). Because of the
shortage of physicians, and particularly specialists, in Appalachia limits the availability of this
education (47). Even when physicians are available, one study indicated that populations in rural
locations, and particularly the elderly residing in these areas, are less likely to receive screening
tests than patients in urban areas (51). Because of such disparities, receiving adequate
management for chronic diseases, such as diabetes, can pose a challenge for residents of
Appalachia (48). Not only are primary care physicians in short supply, but, following this trend,
specialists also are often not available in Appalachian communities. One study performed in
2009 surveyed health providers throughout Appalachia regarding diabetes care, and the results
indicated that most healthcare facilities did not employ specialists such as endocrinologists (42).
Slightly more than one third of the facilities that responded to the survey in this study indicated
that they employ a certified diabetes educator, less than one third indicated that they have non-
certified diabetes educators, and over 85% did not have an endocrinologist (48). Compared to
non-distressed counties in the area, the facilities in distressed or at-risk counties were less likely
to hire specialists in diabetes care or education (48). The Appalachian Regional Commission
labels counties in Appalachia as distressed, at-risk, or non-distressed based on three criteria
(Appalachian Regional Commission [ARC], 2012a). The following criteria designate a county
as distressed: three-year average unemployment rate of one hundred fifty percent of more of U.S.
average, per capita market income of sixty seven percent or less of U.S. average, and poverty
rate of one hundred fifty or more of U.S. average (54). At-risk counties have unemployment and
poverty rates of one hundred twenty five percent or more of the U.S. average and per capita
market income of sixty seven percent or less of U.S. average (55). This shortage of specialists is
somewhat expected, considering the more scarce patient population in Appalachian areas (56).
In the survey of medical residents that was conducted by Healthcare Financial Management,
referenced earlier in this paper, some residents say that they would not consider practicing in a
rural area because their specialty could not be supported in an area with such a small population
(48). As a result, residents of some Appalachian areas must travel to more urban areas to receive
specialized treatment (57). Hospital closings . Not only are there limited numbers of healthcare
providers for the population, but the situation is also continuing to worsen because of hospital
closings. In the 1980s and 1990s, a high rate of hospital closures (up to 10%) was recorded, due
to a multitude of reasons, including Medicare reimbursement levels, a changing economy, and
shortages of healthcare providers (58). Over the last decades, as the U.S. national economy has
weakened, many citizens, and particularly residents of rural locations, have lost jobs and are
therefore unable to afford healthcare (American Hospital Association, 2011). In addition, a
shortage of healthcare providers already exists, and many researchers project that this shortage
will only continue to increase as much of America’s “baby boomer” population ages and requires
more care (53). Finally, limited Medicare reimbursement places a financial burden on hospitals
across the nation (58). Local reasons for hospital closures include rural poverty, widespread
unemployment, a lack of health insurance, and an aging population. As the population ages and
unemployment rates continue to rise, the disparity between increasing needs and available
healthcare continues to widen (58). As mentioned earlier, the elderly make up a significant
portion of the population of Appalachia. Poverty rates, unemployment, and a lack of health
insurance are all socioeconomic characteristics of Appalachia that will be described later in more
depth. Because of these characteristics, though, patients may not be able to afford healthcare,
which can lead to an inability of the hospitals to afford provision of healthcare. Limited income
also is related to a decreased tax base (which then affects hospital funding) and a lack of
donations to hospitals for patient care (58). In addition, because community hospitals are often
smaller and therefore provide less specialized care, those who can afford care often bypass these
hospitals for those in neighboring urban areas, contributing to closures (58). When a rural
hospital closes, the community’s healthcare and economy are affected. While the loss of the
hospital obviously leads to a deficit of acute care, it also impacts community-based services, for
such services and hospitals are often mutually dependent on each other financially (58).
Hospitals are major employers for healthcare providers, and when this system is altered,
healthcare professionals often leave the area for other career opportunities (59). Because of the
loss of healthcare and support jobs, the economy of the community often suffers, potentially
discouraging new physicians from settling in the area for the reasons listed above. In the 1990s,
while many of the hospital closures were occurring, a case study was performed that examined
the perspectives of healthcare providers of various healthcare providers practicing in the areas
where closures had occurred. These health care providers provided a variety of responses, and
this study explained some of the effects that they cited, including a decrease in access to
healthcare, a need to learn to adapt to a greater travel distance to reach hospitals, and, in some
communities, a slower rate of growth of per-capita Medicare expenditures (60). Concerns
expressed by many of the participants included access to care for vulnerable populations, such as
the elderly, those with a low socio-economic status, and those with disabilities. In addition, they
were concerned about recruiting physicians to the area, as well as about the lack of local
emergency care (60). In 1997, the Balanced Budget Act enacted legislation that allowed for the
classification of some rural hospitals as Critical Access Hospitals (CAH), allowing them to
receive cost-based Medicare reimbursement to help with the cost of providing care (50). Across
the nation, 40% of rural hospitals are CAH status (60), and many hospitals throughout
Appalachia are a part of this program. In West Virginia, 18 rural hospitals are CAH status
(WVOCHS, 2005). Because these hospitals receive cost-based reimbursement, the services that
they provide to Medicare beneficiaries are repaid at a rate of 101%. This is in contrast to the
Prospective PaymentSystem that is used in non-CAH hospitals (Holmes et al., 2006). In typical
hospitals, the facility receives reimbursement for the type of service provided and the number of
patients served, not for the actual cost of these services (60). On average, Medicare pays 98
cents per dollar for the care of Medicare patients, and Medicaid pays 96 cents per dollar
(American Hospital Association, n.d.). When a patient does not have health insurance, the
hospital is obligated to provide basic treatment according to the Emergency Medical Treatment
and Labor Act, but the hospital usually absorbs the cost of caring for this patient (American
Hospital Association, n.d.). Tax subsidies sometimes help public hospitals with a portion of the
bill for these patients (usually 12 cents per dollar) (American Hospital Association, n.d.).
However, in Appalachia, tax revenue is low because of unemployment and a damaged economy
(61). The CAH rogram helps rural hospitals attempt to avoid the debt that occurs from treating
Medicare patients, but it does not cover all of the costs associated with healthcare, nor does it
assist with those who are uninsured (62). In addition, new healthcare legislation in the form of
the Patient Protection and Affordable Care Act will begin to impact many areas of healthcare in
the next few years, leading to uncertainty regarding the future status of small rural hospitals (62).

Inadequate Health Literacy

A national issue that is also present and very prevalent in Appalachia is a lack of health literacy.
Health literacy involves how well a person can read and understand health information, such as
medication bottles, patient brochures, or informed consent forms (48). According the American
Medical Society, health literacy is defined as “the degree to which individuals have the capacity
to obtain, process, and understand basic health information and services need to make
appropriate health decisions” (52). In 1992, the National Adult Literacy Survey was performed,
surveying Americans and rating their literacy level on a scale from one to five, with one
representing the poorest reading capability (difficulty with printed materials), three representing
the minimum reading capacity that will allow for success in culture, and five representing
reading well (47). This study found that the average American reads at the level of an eighth or
ninth grader, and that one in five Americans reads below the level of a fifth grader (48).
Throughout Appalachia, educational attainments are often lower than other areas of the nation; in
many counties in 2000, only 49.2 to 68.7% had completed high school, and only 4.9 to 11.5%
had completed college (60). Although educational attainment does not always indicate
functional literacy, those who are illiterate are more likely to have had fewer years of education
than those who are literate (63). Because of that fact, much of Appalachia is likely to have a
comparatively low level of literacy. The literacy survey was performed in Ohio, and, in three of
the four Appalachian counties that were included in the study, more than 50% of participants had
a literacy level of one or two, indicating that their literacy level was below the minimal capacity
that allows for success in today’s culture (Denham & Rathbun, 2005). In a qualitative study in
which researchers interviewed focus groups from southwestern West Virginia, participants said
that they believed that people living in their region have low levels of medical knowledge (57).
Three of the most common causes of illiteracy are socioeconomic status, poverty, and low
parental educational attainment (61), all of which are factors in many Appalachian communities.
Compared to the rest of the population, elderly and minorities are more likely to have impaired
literacy (63). As the primary users of Medicare and Medicaid (Foulk et al., 2001), this
population does have healthcare available, but their literacy level may prevent them from
actually being able to understand much of the material that is provided to them. As a result,
individuals with low literacy are less likely to seek health care, but have an increased risk for
acute illness and hospital stays (47). Although the average American reads at an eighth or ninth
grade level, and many at a much lower level, most healthcare materials are written above the
tenth grade level (48). This disparity prevents those with a lower literacy from truly
understanding the risk factors, process, and treatments for a disease. Foulk, Carroll and Wood
emphasize that this presents a problem specifically to those with chronic diseases, such as
diabetes. People with diabetes or other chronic diseases particularly need to understand health
behaviors and lifestyle modification, but illiteracy prevents education (63). A study of
healthcare in Appalachia cites educational deficit as being associated with a lack of participation
in activities that promote health (49). In addition, those who are illiterate are less likely to seek
help in disease or use screening tests (63). Low health literacy has been associated with poor
glycemic control, a low likelihood of achieving glycemic control, and higher prevalence of
retinopathy and diabetes complications .Those with lower health literacy are also more likely to
be admitted to a hospital

Poverty and Economic Status

In many areas, poverty is a prevalent aspect of Appalachian culture (65). In the 1960’s,
President Lyndon Johnson declared a “war on poverty” after visiting Appalachia and seeing the
conditions in which people were living in this region (66). At that time, the income of residents
of Appalachian Kentucky was only 40% of the national average, only 32% percent of adults had
graduated from high school, and 12% of people had not complete school through the fifth grade
(66). Since that time, conditions have improved dramatically throughout most of Appalachia;
the income of residents of Appalachian Kentucky is now 20% below the national average, and,
throughout all of the region, 82.3% of adults have obtained a high school diploma (63).
However, regions still exist where educational attainments are lower (as discussed earlier) and
where the economic situation is less promising. Out of the 410 counties in Appalachia (67), 98
counties are currently classified as “distressed” by the Appalachian Regional Commission based
on three criteria discussed earlier (54). In addition to the counties that are distressed, more
counties are labeled as “at-risk” (ARC, 2012a). Compared to the 223 counties that were
distressed in 1960, drastic improvements have indeed occurred. However, since 21.7% of
Appalachian counties are still distressed, economic issues remain (67). Reasons for the
depressed economy of distressed counties are varied depending on the location and
characteristics of the county, but there are a few overarching contributors to the issue. First,
throughout the United States, depressed counties are usually not proximate to urban areas
(Wood, 2005). This trend continues in Appalachia, particularly Central Appalachia, and this
region in fact has the lowest levels of urbanization in the nation (67). This isolation not only
decreases access to healthcare, as described earlier, but also increases the distance that residents
must travel in order to reach their occupations. For some, the distance may be too great for a
commute to be feasible (Wood, 2005). In addition, many of the distressed counties were
formerly dependent on professions related to natural resources, such as forestry, agriculture, and
coal mining (67). As these professions have employer fewer and fewer people, the areas have
become more depressed. Many of these counties were distressed in the 1960s as well, because
counties associated with coal mining have historically been associated with higher poverty and
unemployment rates and lower income and education rates (67). Wood points out the following
observations regarding employment and economic changes in Central Appalachia: As
employment in Central Appalachia’s mining sector has declined over time, with levels of
employment in the mining industry being 10 percent in 1960 and declining to only 2 percent in
2000, many counties that were already typically experiencing poor and tenuous economic
circumstances in the past have been unable to successfully adapt to changing economic
conditions. Furthermore…Central Appalachian counties that have remained distressed over time
have tended to have low levels of employment in key industries, such as in manufacturing and
professional services, Manufacturing industries have provided jobs that have helped bring
manycounties in Southern Appalachia out of distress (Wood, 2005), but these industries have not
taken root in Central Appalachia, as they tend to be successful only in the “most productive,
capital-intensive sectors” (67). Even when manufacturing jobs are available, an economy that is
not diversified with a mix of professions can be easily depressed by changes in the major source
of employment (for example, the closing of a factory) (66). Because of the economics of the
region, low income and unemployment are common. Compared to the 2009 United States
average income of $39,635, the Appalachian average income was $32,426. However, in at-risk
counties, the average was between $25,546 and $29,476, and in distressed counties, the average
was $15,506 to $25,545 (ARC, 2012b). The overall Appalachian average of rates of
unemployment of 9.7% is only slightly higher than the national rate of 9.6%, but, again, certain
distressed counties are in worse condition, with rates as high as 19.7% (ARC, 2012c). As
described by Foulk, Carroll & Wood, populations with a higher socioeconomic status are more
likely to live with a healthier lifestyle than those who are poorer or less educated (2001). These
economic challenges affect healthcare because certain risk factors for diabetes, including obesity,
physical inactivity, smoking, and low birth weight, are all associated with low socioeconomic
status (65). One study found that diabetes itself is strongly associated with populations with low
socioeconomic status (Connolly et al., 2000). In general, patients in rural areas with a lower
socioeconomic status and education level are less likely to participate in positive behavior
change than those with a higher socioeconomic status and more education (68). In addition,
populations with a low socio-economic status are more likely to engage in less physical activity
and to smoke, increasing their risk for diabetes (Connolly et al., 2000). This association with
risk behaviorsand the decreased likelihood of positive behavior change (68), along with the
inability to actually afford self-management (65), can be a barrier for health care for Appalachian
populations. Lack of insurance. Because of uncertain employment and low wages, many
residents of Appalachia are focused on meeting their basic needs, not on healthcare or changing
lifestyles in a healthy way (65). Affording healthcare is one of the barriers to diabetes care, but
another challenge involves affording the lifestyle changes necessary to managing the
diseaseeffectively. Even if a person does have access to care because of insurance, they could
potentially still believe that they do not have adequate income for nutritious food choices or
other prevention strategies. In a qualitative study of residents of West Virginia, researchers found
that economic hardship did change the way that the patients managed their disease, with many
ignoring medical care because of financial reasons (65). Diabetes medications place a financial
burden on individuals with the disease, especially those who are uninsured. A recent study
conducted over two and a half years found that, during the time of the study, the average patient
with diabetes spent $772 on prescription testing strips and supplies and $2,078 on insulin
prescriptions and supplies (Yeaw, Lee, Aagren & Christensen, 2012). In addition, oral diabetes
medications can range in cost from $4 to $26 per month for metformin, to $135 to $285 per
month for thiazolidinediones (Consumer Reports, 2011). Food insecurity. Obesity is one of the
major risk factors for diabetes, as well as other chronic diseases such as cardiovascular disease
and cancer (Amarasinghe et al., 2009). Studies indicate that, compared to the general
population, the obesity rate is higher among racial minorities or among those with lower income
and the least amount of education (Amarasinghe et al., 2009). Appalachian areas have the
highest obesity rates in the nation; for example, West Virginia has the third highest obesity rate
in the nation, following Mississippi and Alabama (Amarasinghe et al., 2009). This is probably
related to the fact that people with a low income who are living in a rich society often cannot
afford high quality diets, resulting in a lack of nutritious foods such as fresh fruits and
vegetables, lean meats, and fish (Amarasinghe et al., 2009). According to Amarasinghe et al.,
the economy impacts the food choices made by those in poverty, linking these choices with
obesity (2009). In general, fatty and sweet foods are less costly than foods that are rich in
nutrients (Drewnowski, 2009). Diabetes risk has been correlated with intake of dietary fat,
regardless of caloric intake (Franz et al., 2002), putting those with a diet high in fat at risk for
developing the disease. Food-insecure participants in one study self-reported higher rates of
diabetes than those who were food-secure (Holben & Pheley, 2006). As defined by the study
performed by Holben and Pheley, food security means “having access, at all times, to enough
food for an active, healthy life without resorting to using emergency food supplies, begging,
stealing, or scavenging for food” (2006, p. 1). When that particular study was performed, the
sample of participants from Appalachian Ohio was found to have an incidence of food insecurity
that was two and a half times the 1999 national average rate of 10.1% (Holben & Pheley, 2006).

Culture and Attitudes of Residents of Appalachia

Within the Appalachian region, distinct characteristics and attitudes form a unique culture. In a
qualitative study of residents of Southern West Virginia, participants characterized Appalachian
residents as “kind,” “outgoing,” “open-hearted,” and “helpful” (Coyne et al., 2006, p. 2). These
participants also identified the following strengths in their population: “spiritual beliefs or faith
in God,” “family values,” “good moral values,” “sense of community,” “commitment and
dedication to work,” “mutual respect,” “hospitality,” and “pride” (Coyne et al., 2006, p. 3).
Perceptions of diabetes held by Appalachian residents are often negative and judgmental. Many
believe that the disease is a new development in Appalachia, as jobs requiring physical labor,
such as farming and coal mining, have decreased (Della, 2011). In addition, researchers found
that participants stigmatized diabetics as “lazy, irresponsible, and overindulgent” (Della, 2011, p.
5). Another study found that participants believed that diabetes is self-induced, resulting from
sugar over-consumption and lack of physical activity. The participants blamed diabetics as being
morally weak or lacking self-control, often leading patients with diabetes to feel guilty about
their disease (Smith & Tessaro, 2005). BARRIERS TO DIABETES CARE IN APPALACHIA
22 Perceptions of healthcare are often negative, and many Appalachian residents viewhealthcare
as a last resort, rather than an ongoing part of life (Coyne et al., 2006). Participants of the
qualitative study indicated that they are uncomfortable with the lack of American-born
physicians and with the turnover rate in their area, saying that these factors prevent them from
building trust with their healthcare providers (Coyne et al., 2006). Although they did
acknowledge that specialized care is sometimes necessary, some participants revealed that they
did not trust specialists and that they were fearful of addiction to prescription medication (Coyne
et al., 2006). Finally, many residents of Appalachia are self-reliant, preferring to manage
diabetes and other health-related issues on their own instead of seeking medical attention Della,
2011). Instead of using prescriptions, they often prefer herbs or over-the-counter medications
(Smith & Tessaro, 2005). In addition, they believe that each individual is responsible for his or
her own disease management, often disapproving of governmental assistance (Smith & Tessaro,
2005). As Della (2011) observes, “unlike substance abuse or cancer, which were viewed as an
unanticipated and frightening scourge, heart disease and diabetes were discussed as an
unfortunate result of changing community circumstances, occurring from the inside” (p. 8).
Because they do not see the disease as an important issue, they may not take the prevention
measures that are available to slow development of the disease (Della, 2011).
Conclusion

The evidence base for prevention of diabetes mellitus is quite robust with risk factor
based identification of individuals followed by confirmation of their prediabetes stage (IFG or
IGT or both, or HbA1c between 6-6.5%). Lifestyle interventions- diet and activity, although
difficult to adhere to in the long run, are better than use of pharmacological agents. Among the
pharmacological agents, metformin is the most studied and robust,

although acarbose and orlistat also have evidence in their favour. Newer agents viz. the DPP-4
inhibitors may be suitable candidates, alone or as an adjunct, but results from newer trials only
can provide the evidence in their favour. Exercise and Nutrition counselling in office visits, at
society level, at the level of school children and college students will go a long way in promoting
healthy lifestyle and preventing diabetes mellitus. Providing healthy food alternatives,
encouraging and rewarding physical activity in formative years are measures which need to be
adopted to prevent diabetes in the community setting.

Oral hypoglycemic agents and insulin therapy have remarkable significance in

management of diabetes mellitus. Sadly, it is document in literature that all these agents are
bedeviled by adverse effects arising from their usage. This should invoke the interest of scientists
particularly in diabetology and pharmacology to engage in efforts aimed at developing safer but
equally effects agents. Biotechnology and genetic engineering can also aid in these efforts.
Literature is also rich with information that some medicinal plants have been found to be
hypoglycemic. Indeed, as seen in this review, some of the conventionally used antidiabetic
agents are plant-derived. Perhaps, pharmacognosy may also be of help in this regard.

These barriers include remote locations, a lack of healthcare providers and hospitals,
health illiteracy, poverty and a distressed economy, and cultural attitudes regarding diabetes.
These barriers present a challenge that must be addressed in communities on multiple levels for
behavior change to occur. Clear education regarding affordable, culturally-sensitive behavior
change in individuals, families, and communities could potentially lead to positive lifestyle
modifications. Members of churches who are healthcare personnel could volunteer to lead
educational programs at their church, or at other churches in the area, allowing a wide variety of
ages and a large number of people to be reached with information that is presented by someone
from their own community. In addition, according to the distinct needs of each community,
coalitions could plan interventions and seek to improve characteristics of their communities

Recommendation

It is recommended that with the limited resources available for managing diabetes in the health
facilities there is the need:

 To provide free oral medications and insulin drugs for diabetes patients as the case of
HIV and AIDS and Ttuberculosis to prevent complications related to diabetes mellitus.
 The government of each country through the Ministry of health should provide adequate
screening and diagnostic equipment at subsidized screening charges levied to enhance
early detection of diabetes mellitus to the general public.
 The government of countries through Ministry of Health should ensure adequate capacity
building and training of diabetes specialists. This will help curtail the continuous increase
in the incidence of diabetes in the country and the management of the complications
associated with diabetes mellitus in people who live with diabetes.
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