L12-CHP-Diabetes mellitus

Important endocrine organs

Pineal gland, hypothalamus, pituitary gland, thyroid gland, thymus, adrenal glands, pancreas, ovary and testis.

Insulin and glucose balance

Insulin enters the bloodstream via de pancreas and glucose enters via the digestive system and liver. Insulin leaves the body and binds to the cell. The cell then responds by taking up more glucose to use as fuel.

Insulin

Hormone produced by the pancreas and a key regulator of the metabolism. High glucose levels in the bloodstream due to insulin insufficiences. Insulin triggers the body (liver, muscle, and fat) to store glucose as glycogen. Insulin enhances learning and memory, especially verbal.

Type I diabetes prevalence

onset in people under 30, but can occur at any age. Prevalence of 1 in 10 people who have diabetes have type I. In dutch population, 10% have type I of the 1.2 million that have diabetes. Estimated 1 in 3 are undiagnosed with diabetes.

Type II diabetes prevalence

Onset: most often in older people, but can occur at any age. 9 in 10 are type II of all diabetes patients have type II. 90% of 1.2 million diabetes patients have type II in the dutch population. The prevalence of diabetes was 9.7%, accounting for 92.4 million adults with diabetes in China.

Type I diabetes

Also known as insulin dependent diabetes (IDDM). The body completely ceases to produce insulin. Blood sugar levels are abnormally high. Autoimmune disease where the body destroys cells that produces insulin. Symptoms include unsual thirst, frequent urination, weight loss, extreme fatigue, hunger and irritability, and a blurred vision. Risk factors inlcude family history, genetics, and geography but also possibly viral exposure, low vitamin D, dietary factors and young mothers.

Certain consequences of Type I diabetes

• Retinopathy; 50% of adults experience this after 7 years, 90% after 20 years. Treatment is difficult thus prevention is important

• Nephropathy (kidney problems); starts 5 years after diagnosis type I, severe after 20y among 35% of patients.

• Neuropathy; nerve damage

Type II diabetes

Also known as non insulin dependent diabetes (NIDDM). Body produces too little insulin and/or body is insulin resistance. Again, high bloodsugar levels. Has a slow onset. Symptoms; similar to type I, cuts and bruises that heal slowly, tingling or numbness in the hands or feet, recurring skin, gum or bladder infections. Often have no symptoms. Similar consequences to type I, but also cardiovascular disease,

Treatment diabetes

Aim is to balance blood sugar levels. Healthy diet, exercise, limited alcohol use and no smoking. Type I needs daily injections or insulin pump, type II needs weight reduction oral medication or blood pressure medication.

Hyperglycemia

High glucose levels above 10mmol, linked to blood vessel disease, neuropathy, renal dysfunction, visual impairment, and hypertension. Injection of insulin needed.

Hypoglycemia

Low blood sugar levels, below 4mmol. Can cause irritability, anxiety episodes, disorientation, and even coma. Hypo unawareness can be dangerous. eat food high on carbs/injection glucagon.

Diabetes self-management education DSME

Important component of disease management, consists of healthy eating, physical activity, self-monitoring glucos, taking prescribed meds, problem solving, healthy coping and reducing risks. Intended to influence short and long term improvement.

Behavioral interventions for diabetes

Lifestyle modification for diabetes prevention, cognitive behavioral therapy, problem-solving therapy (also in children), motivational interviewing, treatment for depression, behavioral Family Systems Therapy (mainly in children), coping skills training (mainly children).

Reasons for psychological referral for diabetes

Adjustment to illness, poor diabetes control (poor adherence), psychosocial problems (eating disorders, depression, anxiety), stress (which influences symptoms), and cognitive problems

Problems with adjustment to diabetes

Most people adjust well, however, diabetes demands a constant awareness and is therefore one of the psychologically most burdensome chronic diseases.

Adherence to control diabetes

Treatment is lifelong, burdensome, complex, no immediate reward. From onset already 10% show non-adherence. 13-64% for oral treatment and 19-46% for injections. Nonadherence to diet and exercise are unknown (assume little adherence). Consequences are complications, hospitalizations and increased health care costs. Poor adherence may be referred to psychologist.

Non-adherence associated problems in diabetes

anxiety, depression, personality may influence adherence, coping skills, illness attributions, perceived ability to self-manage, environmental barriers, costs vs. benefits, lack of social support.

Psychological aid in non adherence

Ask patients (in interview) about medication use, blood glucose testing, eating behavior and physical exercise. Not all patient receive clear diet and exercise instructions. Relies on self-report which can be unreliable, interview direct family or friends. Explain why adherence is important and find out why a person may not adhere to treatment.

Reasons for non-adherence and solutions

• If medication adherence is the problem; web based solutions, tune up clinic (pharmacists creates individualized plan for their metabolic goals) or LATE intervention (nurse calls when a prescription has not been picked up)

• If diet or exercise is the problem; many options but must aim at improving healthy diet and more exercise.

Depression problems for diabetes

Prevalence of 28% of diabetes patients. Associated with poorer quality of life, increases in hyperglycemia, health care utilization, risk of complications, functional impairment, and risk of mortality. Depression is a consequence of diabetes, but depression may also be a risk factor for diabetes onset (41% increased risk type I, 32% type II). Possibly bidirectional.

Anxiety problems for diabetes

Prevalence if 18%, 31% amoung youth with type I. High prevalence cuase by endocrine abnormalities, complex self-management, hypoglycaemia fear.

Assessment of mood problems

Rule out other diseases; If an underlying disease is present, consult the physician about the possibility that depression/anxiety is a symptom of these diseases. When assessing depression/anxiety in diabetics, watch out for symptom overlap.

Depression treatment for diabetes

Pharmacological and psychological interventions decrease depression. CBT improved depression and glycemic values. Collaborative care and health education improved depression and glycemic values. Pharmacological treatment improved depression only. Treatments for depression among diabetics can include: antidepressants, psychotherapy, or combination therapies with medication and psychotherapy.

Anxiety treatment for diabetes

Specific interventions to treat anxiety in diabetics are rare. Lack of research in this area! Provide information to patient on relationship between anxiety symptoms and symptoms of low blood glucose levels. Beta-blockers can reduce physiologically caused anxiety symptoms but can mask hypoglycemia symptoms.

Diabulimia

Diabetics with an eating disorder: Prevalence can be up to 60%. Around 11–15% of type I patients report intentionally omitting insulin to control weight.

Eating disorders for those with diabetes

Rates lower, similar to, and higher than healthy same aged peers have been found. Prevalence in females with type 1 diabetes range from 4–28% for patients classified as bulimic or having binge eating disorder, and 38–40% when insulin omission is considered purging.

Risk factors for developing eating disorder for diabetes

Age, female gender, greater body weight, body image dissatisfaction, history of dieting and history of depression. Consequences include poor glycemic control and hence higher possibility of complications such as nephropathy, retinopathy and premature death

How to assess eating disorder for diabetes

Can be difficult due to type of diet that increases focus on food proportions, most scales dont take insulin omission into consideration, standard eating disorder criteria may be too conservative. Diabetes Eating Problem Survey is a brief screening tool that can be used

Interventions for eating disorders in diabetes

Treatment is usually best delivered through the efforts coordinated of the diabetes care provider and a mental health professional. Education is a frequent focus in treating an eating disorder in a diabetic patient. The risks of diabetic complications and the importance of dietary management are repeatedly stressed. Hoever, many patients ar every well informed of the risks, thus education may not be beneficial

Treatment bulimic diabetes patient

Structured psychotherapies such as cognitive-behavioral therapy or interpersonal therapy, as well as the use of antidepressants.

Treatment anorexia nervosa for diabetes

Nutritional rehabilitation, weight restoration, and adequate diabetes control. Psychotherapy for the patient and family (but not when the patient is in a starvation mode).

Physiological effect of stress on diabetes

The prevalence of serious psychological distress among United States adults with diabetes is 7.6%. Stress can affect blood glucose levels. Daily stress related to work and the perceived risk of stress influencing one's physical health may influence outcomes for adults with diabetes.

Stress assessment for diabetes

Interview patient on disease, symptoms, complications, hospitalizations, treatment, self-management of disease, blood glucose control, and other diseases. Let patient fill out stress questionnaire and take notes of blood glucose levels every day.

Stress interventions for diabetes

Psychotherapeutic group settings and stress management interventions are beneficial in reducing psychological distress among patients with diabetes and in improving metabolic control. Mindfulness-based interventions appear to have benefits on HbA1c, depression, stress and diabetes related distress in people with diabetes.

Cognitive impairment related to diabetes

Acute hypoglycaemia: visual problems, diminished concentration and planning ability.

Type 1 diabetes: Deficits in attention and psychomotor efficiency. Especially if diabetes was diagnosed before the age of 5.

Type 2 diabetes: Learning and memory impairments, and psychomotor slowing.

Assessment of cognitive impairment in diabetes

Cognitive problems should be assessed by a neuropsychologist. Be careful when interpreting results, always keep diabetes or other endocrine complications in mind. During prolonged cognitive testing, patients should be given the opportunity to eat, to test blood glucose levels, and use medication regularly.

Interventions for cognitive functioning in diabetes

Discuss implications of impairment on relationships, work, daily responsibilities, self-care (including disease care), and general well-being with patient and significant others. Teach patient compensatory techniques and acceptance of their disabilities.