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Meeting the national service framework standards for diabetes

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Linda Nazarko, MSc, BSc (Hons), PGDip, RN, FRCN, Consultant Nurse - Older People.

Richmond and Twickenham Primary Care Trust, and Visiting Senior Lecturer, South Bank University, London

Diabetes is the fourth leading cause of death in the UK (Alberti, 1997). Its incidence rises with age (Meneilly and Tessier, 1995), but older people with diabetes have fewer symptoms of diabetes than younger people (Sinclair, 1994). Half of all older people with diabetes remain undiagnosed. Those who are diagnosed have often had diabetes for many years before diagnosis (Harris et al, 1992).

Diabetes is the fourth leading cause of death in the UK (Alberti, 1997). Its incidence rises with age (Meneilly and Tessier, 1995), but older people with diabetes have fewer symptoms of diabetes than younger people (Sinclair, 1994). Half of all older people with diabetes remain undiagnosed. Those who are diagnosed have often had diabetes for many years before diagnosis (Harris et al, 1992).

Around 5% of people with diabetes will require social services intervention. The average annual cost of providing social services to a person with diabetes was £2450 in 1999 (DoH, 2002). Most - around 75% - of those costs are associated with purchasing nursing and residential care, and 20% are associated with providing home care.

Prevention, early detection and good management of diabetes are some of the top health priorities in the UK. Government policy on diabetes is outlined in the National Service Framework for Diabetes standards (Department of Health, 2002). The recently published National Service Framework Delivery Strategy outlines what steps must be taken to prevent, detect and manage diabetes well (DoH, 2003).

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. The World Health Organization classification of diabetes is shown in Box 1 (WHO, 1999).

Type 1 diabetes
Less than 20% of people with diabetes have Type 1 diabetes. There are between 138 000 and 345 000 people with Type 1 diabetes in the UK (DoH, 2002). Type 1 diabetes, insulin-dependent diabetes mellitus, is a condition that leads to the destruction of the beta cells of the pancreas. In Type 1 diabetes no insulin is produced by the beta cells of the pancreas (Vadheim and Rotter, 1992). This type may be rapidly or slowly progressive (Zimmet et al, 1994). In rapidly progressive Type 1 diabetes the rate of beta cell destruction is rapid. This form is common in children but can also occur in adults (Humphrey et al, 1998). The slowly progressive form of diabetes is rare, usually occurs in adults and is sometimes referred to as latent auto-immune diabetes adult (LADA). People with slowly progressive Type 1 diabetes may have sufficient beta cells to prevent ketoacidosis for many years (Willis et al, 1996). However, their diabetic control can rapidly deteriorate when the body is stressed by infection, trauma or surgery (Zimmet, 1995). People with slowly progressive Type 1 diabetes will eventually become insulin-dependent. Type 1 diabetes can occur in all age groups (Molbak et al, 1994).

The causes of Type 1 diabetes are not yet fully understood. There appear to be several factors. Type 1 diabetes is primarily an auto-immune disease (Verge et al, 1996). People with auto-immune diseases such as Graves' disease, Hashimoto's thyroiditis and Addison's disease have an increased risk of developing diabetes. Some people are more genetically susceptible to developing antibodies that lead to the destruction of the beta cells than others. Viral infections such as congenital rubella, mumps and Coxsackie's virus B3 or B4 can trigger diabetes in people who are genetically susceptible (Gorsuch et al, 1982).

Environmental factors are also thought to play a part in the development of Type 1 diabetes, but their relationship to the development of diabetes is not yet fully understood.

Some people have idiopathic diabetes, where there is no evidence of auto-immune disease.

Type 2 diabetes
Over 80% of people with diabetes have Type 2 diabetes (Marks, 1996). There are 1.4 million adults in the UK who have been diagnosed with Type 2 diabetes, and an estimated further one million adults who remain undiagnosed (Diabetes UK, 2001). Different races have different incidences of diabetes. In the adult population 4% of white Caucasians, 20% of black African/Caribbeans, 25% of Asians and 5% of Chinese have diabetes (British Diabetic Association, 1996). The incidence of diabetes increases with age, and 20% of elderly Caucasians are diabetic (Meneilly and Tessier, 1995). Type 2 diabetes is more common in overweight people (Group and Tuomi, 1997).

In Type 2 diabetes the beta cells of the pancreas produce insulin normally when the condition begins. This insulin is released into the bloodstream but the body is unable to use the insulin effectively.

Normally circulating insulin is taken up by glucose receptors in muscle, fat and the liver. The body's reduced ability to use insulin effectively is known as insulin resistance. Insulin resistance leads to high blood glucose levels. The beta cells respond to high blood glucose levels by producing more insulin in an effort to reduce blood glucose levels. This excessive glucose production fails to maintain normal blood glucose levels and the pancreas works harder and harder. Eventually the beta cells are exhausted by the over-production of insulin and begin to fail, and diabetes develops.

Insulin-resistance syndrome
Insulin resistance is associated with being overweight. It is linked to a number of other abnormalities. These include hyperinsulaemia, central obesity, defective lipid metabolism and blood coagulation and disturbances in blood pressure homeostasis (Donnelly and Garber, 1999). These abnormalities are known as insulin-resistance syndrome (IRS) (Took, 1999). IRS increases the risk of macrovascular damage and arterial disease.

Consequences of diabetes
Diabetes leads to elevated blood glucose levels (hyperglycaemia). Hyperglycaemia leads to:

- Lack of energy. This is because glycolysis, the process that enables sugar to be broken down into adenosine triphosphate (ATP), is affected. ATP enables cells and tissues to obtain energy

- Lack of reserves. This is because glycogen normally stored in the liver is broken down. High blood glucose prevents the body drawing on emergency reserves of glycogen

- Increased risk of tissue damage. This is because hypoglycaemia leads to high levels of circulating amino acids and urea.

- Undiagnosed or poorly treated diabetes leads to premature death. At least 20 000 people in the UK die prematurely each year because of diabetes (Diabetes UK, 2001). Undiagnosed or poorly controlled diabetes has the following effects:

- It increases the risk of cerebrovascular disease and stroke 12-fold

- It increases the risk of coronary heart disease 12-fold

- It increases the risk of peripheral neuropathy 16-fold (Currie et al, 1996)

- A quarter of all people with Type 2 diabetes suffer nephropathy, although they usually die of cardiac problems before they reach end-stage renal failure (Marks, 1996)

- It increases the risk of blindness - almost everyone who has had diabetes for 20 years has retinopathy.

Disease progression - Type 2 diabetes is often thought of as mild, but it is not. Many people with Type 2 diabetes progress to insulin therapy. The rate at which diabetes deteriorates is related to ethnicity. Twenty years after diagnosis of Type 2 diabetes most Caucasians require insulin therapy. The disease progresses more rapidly in other ethnic groups - most Asians require insulin therapy after 10 years (Burden, 1996).

National Service Framework standards
There are 12 standards in the NSF for Diabetes. They aim to prevent diabetes, to identify and empower people with diabetes and to ensure that people with diabetes receive high-quality, evidence-based care.

Standard 1. Prevention of Type 2 diabetes - The UK, in common with other advanced industrial societies, is experiencing a rise in obesity. Fifty years ago obesity was rare. The average female dress size was size 12, it is now size 16. The average male had a 30 inch waist - it is now 34 inches (Donnellan, 2003). Now 60% of adults have a body mass index of 25 or over and are overweight or obese (National Audit Office, 2001). In around 85% of cases of Type 2 diabetes, the onset of diabetes could have been avoided or significantly delayed if the person maintained normal weight and exercised. Standard 1 aims to promote a balanced diet and exercise, help people lose weight and maintain weight loss.

Standard 2. Identification of people with diabetes - Many people with Type 2 diabetes remain undiagnosed for years. In those years complications of untreated diabetes often develop. Standard 2 aims to identify people with diabetes early. The UK National Screening Committee is currently carrying out research on the best ways to screen both high- and low-risk groups and will report to the DoH in 2005. In the meantime the key interventions are:

- Increased awareness of the clinical features of diabetes among both health professionals and the general public

- Follow up and regular testing of individuals at increased risk of developing diabetes

- Case finding of people with multiple risk factors for diabetes.

Standard 3. Empowering people with diabetes - This standard signals a real change from the old order when professionals were considered to know best and people with diabetes who openly managed their disease were considered deviant. Diabetes is a chronic disease and people with chronic diseases can easily become disempowered by professionals who have a greater knowledge base and may consider that they know best. This standard aims to enable people with diabetes to exercise personal control over the day-to-day management of their condition and to experience the best possible quality of life. It moves the professional's role from one of disease management to that of an enabler. The key interventions to enable this are:

- Structured patient education to improve knowledge, blood glucose control, weight, diet, activity and well-being

- Personal care plans

- Patient-held records to facilitate self-care.

Standard 4. Clinical care of adults with diabetes - This standard aims to ensure that people with diabetes receive high-quality evidence-based clinical care that reduces the potential impact of diabetes. Most people with Type 2 diabetes are overweight, 70% are hypertensive and more than 70% have raised cholesterol levels. Overweight, hypertension and raised cholesterol increase the risks of cardiovascular and microvascular disease. This standard aims to enable professionals to work with people who have diabetes to ensure that weight is controlled, activity levels are increased and blood glucose and cholesterol is tightly controlled and hypertension treated. The key interventions are:

- Improving blood glucose control

- Controlling hypertension

- Smoking cessation

- Regular recall and review.

Professionals will require ongoing education to ensure that they have the skills to facilitate this.

Standards 5 and 6. Clinical care of children and young people with diabetes - The number of young people with diabetes is rising - this may be because people with Type 1 diabetes, once a death sentence, are now living to a greater age. Most young people have Type 1 diabetes but there are growing numbers of children and young people who have developed Type 2 diabetes. Obese young people of African/Caribbean and Asian decent are at particular risk. A diagnosis of diabetes in childhood can be associated with a decrease in lifespan of 20 years, and many young diabetics develop long-term complications before they reach middle age. Standards 5 and 6 recognise the special needs of children and young people with diabetes and aim to work with them and their families to ensure the provision of high-quality care and a smooth transition from paediatric to adult services when appropriate. The key interventions are set out in Box 2.

Standard 7. Management of diabetic emergencies - People with diabetes may be at risk of falling into a hyperglycaemic coma, of which there are two types: diabetic ketoacidotic coma (DKA) can occur in Type 1 diabetes and hyperosmolar non-ketotic coma (HONK), which can occur, but is rare, in Type 2 diabetes.

Illness can upset diabetic control and cause blood glucose levels to rise. However, because the person feels unwell and does not want to eat, insulin or tablets are omitted. Blood glucose levels rise and coma may follow.

- DKA is much more common in people with Type 1 diabetes. It is rare in people with Type 2. In DKA urine testing shows that the person is ketotic. If the person is dehydrated, vomiting for more than four hours and unable to take oral fluids, hospital admission may be required. Box 3 outlines the clinical features of DKA

- HONK (Box 4) usually affects older people; around 60% of people who develop HONK have undiagnosed diabetes (MacIsaac et al, 2002). Over 40% of older people who develop HONK will not survive. Thiazide diuretics, infection and glucose drinks can lead to HONK developing. People with HONK develop it slowly over a period of weeks. The person is often severely dehydrated, uraemic and drowsy. Diagnosis is straightforward: check blood glucose levels.

HONK is treated with fluid replacement. Half-strength normal saline is used due to high sodium levels. Insulin is used to reduce blood glucose. Standard 7 aims to enable people with diabetes to avoid coma and hypoglycaemic episodes by improved blood glucose management.

Standard 8. Care of people with diabetes in hospital - People with diabetes are admitted to hospital twice as often, stay twice as long as those without diabetes and occupy one in 10 acute beds, but they frequently experience poor-quality care. They find that hospital staff lack knowledge in diabetes care, meal times are inflexible and food is inappropriate. Timing of medication, poor communication and discharge delays are also problems. Standard 8 recommends that a diabetes specialist nurse oversee their care and improved communication between hospital staff and the diabetes specialist team.

Standard 9. Diabetes and pregnancy - Around 16% of pregnant women have diabetes or develop impaired glucose tolerance in pregnancy. Tight control of blood glucose reduces the risks of perinatal mortality and congenital malformation. Women who develop gestational diabetes are at increased risk of developing Type 2 diabetes later in life. Standard 9 aims to ensure tight blood glucose control before and during pregnancy to reduce risks to mother and baby.

Standards 10, 11, 12. Detection and management of long-term complications - Standard 10 aims to ensure that young people and adults with diabetes are checked regularly to detect complications. Standard 11 aims to ensure that the NHS develops, implements and monitors agreed protocols and systems of care to ensure that people who develop long-term complications receive prompt investigation and treatment to reduce risk of disability and premature death. Standard 12 aims to ensure that people who require support because they have developed complications receive integrated health and social care.

Conclusion: the challenge
Those of us who care for older people today care for people who have lost vision and sensation and developed complications because of their diabetes. The NSF for Diabetes may make these complications a rarity for the next generation. The NSF for Diabetes gives integrated evidence-based standards that aim to provide coherent care for people with diabetes throughout their lives. It aims to reduce complications and promote well-being. It will take decades for some of the results of this strategy to become evident - in 20 years' time we may see a reduction in cardiovascular and microvascular disease because of strategies implemented now. The introduction of the NSFs means we have a health service that concentrates not only on treating illness but also working in partnership with people who live with chronic diseases to promote well-being.

Our challenge as professionals is to make diabetes a priority and agree local targets to implement the diabetes NSF. We must also work with people with diabetes to avoid the complications that mar quality of life.

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