Looking back at 19 yrs of Diabetes Advancements – PART TWO (by Jackie Jung, RN, CDE)
Jackie Jung, RN, CDE
We’ve Come a Long Way…. Part Two
Part one of this great editorial is available at www.OntarioNewsNorth.com/?p45980
2013 is my 35th year Anniversary of becoming a Registered Nurse and 19 years of that working in the field of Diabetes. I thought it might be enlightening to see how far we have come and how empowered the person with diabetes can be.
In Banting and Best days it was all about Type 1 diabetes and saving lives with the discovery of insulin. Today Type 2 Diabetes is our epidemic with over 90% (my practice is probably 98% Type 2) having this type of diabetes. There are many questions as to why this is a world-wide concern. Most can be contributed to our changing world, our lifestyle choices, and our ever growing waistlines.
Never mind BMI’s, as in the old days, our waist circumference is our key to reducing one of the risk factors for Pre-Diabetes and Diabetes. It is all about our shape – apple or pear and where we store fat. People who are apple shape tend to store fat in their abdomen (stomach) areas are more at risk to develop insulin resistance and along with that risks for diabetes and cardiovascular disease (heart and stroke). Women’s risks go up with a waist measurement of over 35” and a man’s increases with a waist of greater than 40”. To note for men, this is not their pant size! We have many a man that is screened for diabetes with a pant size of 38” but in actuality their waist is 42”. It seems that men are quite comfortable with their bellies overhanging their belt line! There is a great Heart and Stroke resource kit with information and a measuring tape we have in the office that we can give out.
Other risk factors are:
- Genetic factors. Insulin resistance is known to run in families.
- Obesity. Being overweight keeps the muscles from using insulin properly, as it decreases the number of insulin receptors on cell surfaces. Obesity is a risk factor for the development of type 2 diabetes, high blood pressure, and coronary artery disease.
- Low level of physical activity. Because muscle tissue takes up 95 percent of the glucose (sugar) that
insulin helps the body use. Inactivity further reduces the ability of muscles to use insulin effectively.
- Aging. The aging process affects the efficiency of glucose use.
Type 2 remains our biggest challenge because Insulin Resistance is more complicated to treat. Someone with Type 2 Diabetes still produces insulin, but the body just doesn’t respond to insulin normally and glucose is less able to enter the cells. People with insulin resistance may or may not go on to develop Type 2 Diabetes. The person’s pancreas isn’t able to make enough extra insulin to overcome this insulin resistance.
To complicate this epidemic we have Pre-Diabetes. Millions are thought to have pre-diabetes, which is a condition marked by elevated levels of blood glucose after fasting or a meal. A majority of pre-diabetes people will develop type 2 diabetes within 10 years unless they lose between 5 and 7 percent of their body weight. Insulin resistance has been linked to a group of risk factors for heart disease and stroke. An elevated waist circumference; blood triglycerides; blood pressure; fasting blood sugar level and a low level HDL cholesterol (the so-called “good” cholesterol) puts people at risk for Pre-Diabetes and Diabetes. http://medical-dictionary.thefreedictionary.com/insulin+resistance
Many advances in medications have helped with Type 2 Diabetes, but it often requires numerous types of pills to get blood sugars down. The other challenge to get people on the right medication is cost. A number of the new, more improved medications are not covered under Government plans and only under some Insurance plans and they are more costly. This limits what can be used as people just can’t afford these medications. Diabetes is an expensive disease when people don’t have coverage, the cost of strips, lancets, insulin, pen needles and medications can be overwhelming.
Eventually, because it is a deteriorating disease, people will need insulin. When the pancreas can no long produce enough or enough working insulin to squirt out to cover a meal or keep blood sugars down throughout the day and night then we start insulin. There is no oral insulin, although there is continuing research to overcome the stomach juices that break down an insulin pill. Type 2’s often require large doses of insulin compared to Type 1 people because of this insulin resistance. Their own insulin is resistant at the cellular level and so is the insulin they inject, requiring more insulin.
We also have newer drugs that are injectable, but aren’t insulin. They work differently than previous medications and one of the side effects is a feeling of fullness and thus there is weight loss. This is a great side effect for Type 2 where being overweight is the norm. Sometimes people are more likely to take these injectable medications over insulin. A lot of people are very scared of insulin as they know someone from the past who had a bad experience. Insulin has come a long way and is just a tool we use like any other medication. The injections are far less painful than the finger pokes because the needle is now so fine and the length is so short.
In the past people with diabetes were managed by only their Doctor and seen only a few times a year. Now we have specialized teams of Nurses and Dietitians and other team partners who work in Diabetes Education Centres. They follow people with diabetes, educate them on how to self-manage their disease and provide support and expertise in care. Doctors, Family Health Teams, Social Workers, and Pharmacists are all part of the team that centres on the person with diabetes. There is a shift in how we educate and teach with the emphasis on the educated patient learning to manage their disease and make decisions vs. the Health Professions dictating how things will be done. Years ago, people who were put on insulin were put on a set dose and they were not to change this amount. Only their Doctor could do this. So the patient could not intervene and react and adjust their insulin when blood sugars were high or low. Now patients are given guidelines and taught how to safely adjust their insulin based on their blood sugars, activity, illness or stress etc. This leads to better blood sugar control and improved A1c tests and usually a risk reduction in complications. Major studies, the DCCT and UKDPS, proved this and did away with views that better blood sugar control did little to prevent complications. We know this is not the case.
When I first started in diabetes, we did not worry about people with high cholesterol levels, it was all about the blood sugars. Now research has proven that these levels are just as much of a concern as blood sugar levels. We know that one of the biggest risks for people with diabetes is heart and stroke. Now our focus is just as much on cholesterol levels, blood pressures and decreasing people’s risk factors – smoking, sedentary lifestyles, lower fat meals etc. as it is on blood sugar levels.
We have new and improved treatments for diabetes complications and they are diagnosed much earlier due to screening. People are aware they need a dilated eye exam every year – if there are any small bleeds in the retina (back of the eye) they can be treated early with laser. Without this dilated eye exam to diagnose, these people would not know there was trouble brewing, because these bleeds do not affect their vision until it is too late. Vision may be permanently lost or decreased, greatly affecting a person’s quality of life. Kidney checks are simple with a sample of urine and there is a type of blood pressure pill that can actually reverse some damage if caught early enough. High blood pressure can be treated with medications (often requiring a number of different types) and lifestyle changes can be made for things that are in a person’s control – inactivity, high salt intake, weight, stress etc. Loss of limbs is a frightening thought for people with diabetes and people with diabetes all seem to have known of someone that has lost a leg. Improved access to foot care, education on self-care of feet and what to watch for, earlier and improved treatments for ulcers have reduced this complication, but we still have a lot of work to do in this area.
So although we hope and pray that a cure will be found, we can be thankful for the improvements that have been made and recognize we have come a long way! Wonder what the next 35 years will bring?
Jackie Jung, RN, CDE
Manitouwadge Diabetes Health & Wellness Program
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