Nursing Research and Diabetes
What is Diabetes
According to the Diabetes Research Working Group's recent report Conquering Diabetes: A Strategic Plan for the 21st Century, diabetes is the 6th leading cause of death in the US, primarily resulting from cardiovascular disease.
Diabetes is a disease that affects people of all ages and from every racial background. African, Hispanic, Native, and Asian Americans, the fastest growing segments of the US population, are particularly vulnerable to diabetes and its most severe complications (National Institute of Diabetes and Digestive and Kidney Diseases, 2003).
For examples, heart disease, stroke, kidney disease, blindness, and death due to diabetes are more common in African-American versus Caucasian adults.
Diabetes And Its Diagnosis
The simplified criteria for diagnosis of diabetes using fasting plasma glucose ≥ 126 mg/dl or casual plasma glucose > 200 mg/dl with classic symptoms confirmed on a subsequent day may be impacting the numbers of persons identified as having diabetes (American Diabetes Association, 2003 ).
The total prevalence of diabetes in the United States is estimated to be 18.2 million: 13 million diagnosed and 5.2 million undiagnosed (Centers for Disease Control, 2003). Along with the tendency for obesity, inactivity, and an ever aging population, the incidence of diabetes is expected to grow.
In pediatric
populations, an emerging epidemic of type 2 diabetes is occurring due to higher
rates of overweight and sedentary behavior in youth as young as 10 years of
age, seen predominantly in ethnic minorities (Fagot-Campagna, 2000).
Diabetes As A Health Challenge
Given these sobering statistics, there is strong evidence that the United States will face ongoing public health challenges to address the potential burgeoning onslaught of individuals who face declining health status, quality of life (QoL), and lost productivity related to an earlier onset of diabetes.
Tighter glycemic control is shown to decrease the progression of diabetes complications in persons with type 1 and type 2 diabetes (Diabetes Control and Complications Trial Research [DCCT], 1993; United Kingdom Prospective Diabetes Group Study [UKPDS], 1998).
The conundrum facing nurse researchers is how best to develop
interventions that promote effective, individualized self-management in persons
diagnosed with diabetes and to implement screening procedures for early
detection and prevention in those most at risk for developing diabetes.
Nursing Research And Diabetes
The majority of nursing studies focus on adults with diabetes, particularly in African-American women and Mexican and Native Americans with type 2 diabetes.
The nurse researchers investigating symptom management, self-management or self care, and community based interventions using culturally sensitive approaches include Sharon Brown at the University of Texas at Austin; Felicia Hodge at the University of California, San Francisco; Gail Melkus at Yale University; and Anne Skelly at the University of North Carolina, Chapel Hill.
Although each of the principal investigators has developed specific aims for their individual programs of research using quasi-experimental designs, there are some common areas of study.
Examples of the diabetes-related outcomes that these investigations are addressing are diabetes knowledge, health beliefs and behaviors, metabolic control of glucose, body mass index, lipid levels, blood pressure, self-efficacy, and QoL.
Focus groups with diverse populations are commonly used to gain a more comprehensive understanding of the sociocultural concerns of the study participants regarding diabetes management, to assist with tailoring culturally sensitive and feasible interventions, and to allow for detecting differences in more successful versus less successful results.
Most of the studies included longitudinal evaluations of the interventions, which address diabetes education in nutrition, exercise, home glucose monitoring, and coping skills training.
Type 2 Diabetes And Research
Limited research with adults who have type 2 diabetes was available on the physiological benefits of interventions.
Laurie Quinn at the University of Illinois at Chicago has collaborated with James Rimmer, an exercise physiologist, to identify the feasibility of a health promotion intervention with predominantly low income, low-education, American women with multiple chronic conditions (eg, obesity , hypertension, joint pain, and depression) in addition to diabetes.
The 12-week intervention consisted of health behavior training with peer support, nutrition education, and prescribed exercise based upon personal aerobic capacity (peak V0). Using a 3 day per week format with transportation provided, subjects had significant improvements in total and LDL cholesterol, cardiovascular fitness, muscular strength, and nutrition knowledge.
Thus, there is a compelling need to devise interventions that target. approaches for individuals with complex sociocultural, economic, and educational backgrounds (Rimmer, Silverman, Braunschweig, Quinn, & Liu, 2002). Studies of youths with diabetes are ad-dressing the needs of adolescents and their families.
The nurse researchers examining issues in this population are Margaret Gray at Yale University, Carol Dashiff at the University of Alabama at Birmingham, and Melissa Faulkner at the University of Illinois at Chicago.
Family and developmental perspectives are incorporated into the designs of studies of youths. Key variables are self-care or self-management, self-efficacy, QoL, coping, family adaptation, and autonomy as related to improvement in metabolic control.
Gray is conducting a longitudinal study using QoL and metabolic control to evaluate the effects of coping skills training (CST) in youths receiving intensive diabetes management. This investigation is the longest ongoing clinical trial specifically testing the efficacy of an intervention with youths who have type 1 diabetes.
Adolescents who received CST and intensive diabetes management had significantly better metabolic control and less impact of diabetes on their QoL. than youths receiving intensive diabetes management alone after 1 year. Such evidence lends support for devising interventions to optimize both glycemic control and perceptions of QoL in youths with diabetes.
Dashiff is developing a model of influences on the development of adolescent autonomy and family processes for self-care and diabetes control in early and middle adolescence.
Her data will reflect the
evolutionary development of the parent adolescent subsystem prospectively over
a 2-year period with the goal of identifying factors that improve diabetes
control when providing family based interventions.
Diabetes And Long Term Complications
Consistent with the overall aim of preventing long-term diabetes-related complications as teens make the transition to adulthood, Faulkner is investigating cardiovascular risks in adolescents with type 1 and type 2 diabetes.
The intent is to describe potential sociodemographic, behavioral, or physiological factors that predispose youths with either type of diabetes to subsequent heart disease.
This research is partly based upon earlier work that found decreased
heart rate variability, a marker for early cardiovascular autonomic disease,
associated with having type 1 diabetes and poorer metabolic control (Faulkner,
Hathaway, Milstead, & Burghen , 2001).
Improvement In Glucose Level Control
Improvements in glycemic control through individualized interventions developed and tested through scientific inquiry will increase the odds for minimizing complications of diabetes, which affect personal QoL and productivity and contribute to the economic burden associated with diabetes care.
Future research must embrace not only better outcomes, including decreasing health disparities in minorities, but also the enormous need for prevention in those predisposed to the disease.
Newer technologies for insulin delivery, continuous glucose sensing, and genetic engineering for individual therapies are on the horizon. Through their leadership in interdisciplinary science, nurse researchers will remain integral to the advancement of evidence-based diabetes care.
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