NURS6018 Assessment 1A – Chronic Condition Report & Field Note

Introduction

The primary aim of this report is to discuss how people manage chronic conditions within the

context of their whole life. Discussion will revolve around a patient, [Alejandro] (name changed to

maintain privacy), who is a 60 year old asian male living in Sydney, Australia. Alejandro has type 2

diabetes mellitus (T2DM), hypertension (HTN), and hypercholesterolaemia. Of these chronic

conditions (Gorina, Limonero, & Alvarez, 2018), T2DM will be the focus in this report. All

information provided by Alejandro was obtained with his written consent, on the 4th, 5th and 6th of

May 2019, via a total twenty hours of observation and conversation.

The report will begin with a description of the pathophysiology of T2DM and risk factors relevant

to Alejandro (both modifiable and non-modifiable). Following this, there will be a discussion with

reference to literature regarding how T2DM affects Alejandro’s life and what strategies he employs

to self-manage the condition. Relevant social determinants of health that affect his ability to self-

manage will also be addressed. Finally, recommendations that aim to maximise Alejandro’s ability

to self-care will be provided. These recommendations will be guided by literature and professional

guidelines.

Overview

T2DM is a complex metabolic disorder characterised by hyperglycaemia, which occurs mainly as a

result of increased insulin resistance; impaired insulin secretion by pancreatic β-cells; and impaired

secretion and activity of incretins, such as glucagon-like peptide-1 (GLP-1) and gastric inhibitory

peptide (GIP) (Brunton, 2016; Zaccardi, Webb, Yates, & Davies, 2016). In terms of insulin

resistance, the predominant contributor is the accumulation of fat in hepatic and muscle cells

(DeFronzo, 2004). Accumulated fat disrupts intracellular insulin signalling, which impairs insulin-

mediated glucose uptake, resulting in hyperglycaemia (DeFronzo, 2004). Regarding β-cell

dysfunction, many factors have been implicated, including the ‘exhaustion’ of β-cells as they

become unable to produce enough insulin to compensate for increasing insulin resistance (Halban et

al., 2014; Zaccardi et al., 2016). In terms of incretins, GLP-1 and GIP increase insulin secretion,

while GLP-1 also reduces glucagon secretion (Drucker, 2006). Both are normally secreted from the

intestine after ingestion of food (Drucker, 2006), however GLP-1 secretion has been found to be

significantly reduced in those with T2DM (Holst, Knop, Vilsboll, Krarup, & Madsbad, 2011). This

results in a reduced postprandial level of GLP-1, leading to decreased insulin secretion, increased

glucagon secretion, and thus hyperglycaemia (Zaccardi et al., 2016).

Persistent hyperglycaemia is concerning because it leads to increased formation of advanced

glycation end products (AGEs) (Janda et al., 2015). Over time, AGEs accumulate in various areas

of the body, including the heart, leading to cardiac dysfunction; and blood vessels, where they

contribute to accelerated plaque formation (Janda et al., 2015). Thus, poorly managed T2DM leads

to microvascular complications, including nephropathy, retinopathy, neuropathy, and sexual

dysfunction (Faselis et al., 2019); as well as macrovascular complications, including coronary artery

disease, cardiomyopathy, arrhythmias, peripheral artery disease, and cerebrovascular disease

(Viigimaa et al., 2019).

There are a myriad of risk factors that increase a person’s likelihood of developing T2DM

(McCulloch & Robertson, 2018). Two non-modifiable risk factors that apply to Alejandro include

his Asian ethnicity (Rosella et al., 2012; Shai et al., 2006) and a family history of T2DM in first-

degree relatives (Meigs, Cupples, & Wilson, 2000) (Alejandro has two brothers with T2DM). His

modifiable risk factors include an increased body mass index (BMI) (Menke, Rust, Fradkin, Cheng,

& Cowie, 2014) and poor dietary habits (Pan et al., 2013; van Dam, Rimm, Willett, Stampfer, &

Hu, 2002). Moreover, increased BMI and poor diet are also risk factors associated with worse

T2DM outcomes (Huang et al., 2016; Ryan & Yockey, 2017).

Self-management

Alejandro was diagnosed with T2DM back in 2009. He has not developed any T2DM-related

complications and expressed that it [T2DM] “doesn’t have a big effect on my life”. Day-to-day, the

main things he does to actively manage his T2DM are take medications and ‘watch’ his diet.

Moreover, he has regular blood tests and sees various doctors for management, including his

general practitioner (GP), endocrinologist, and ophthalmologist.

In terms of medication, Alejandro takes Janumet 50/850 (50mg sitagliptin/850mg metformin)

(Sitagliptin, 2019), 1 tablet twice a day, with breakfast and dinner. He organises his medications in a

7-day pill box and revealed that he will occasionally miss doses due to “forgetting or being busy”.

Further discussion revealed that missed doses usually occurred in the context of a missed breakfast

or dinner at home, or because he was busy gardening outside. He explained how his pillbox is

placed on the meals table and acts as a prompt during breakfast and dinner. Alejandro’s reasons for

missed doses are reflected in research by Vietri, Wlodarczyk, Lorenzo, & Rajpathak (2016) which

involved 2031 adults in the US with T2DM. The study reviewed the prevalence and self-reported

reasons for missed dosages of oral antihyperglycaemics (Vietri et al., 2016). Of those that

accidentally missed one or more doses in the last 4 weeks (n=503), nominated reasons included

‘just forgot to take it’ (35.8%), ‘away from home unexpectedly’ (10.3%), ‘did not eat at my regular

time, so missed taking medication as well’ (8.3%), ‘change in routine/schedule’ (7.4%), and

‘focussed on work/other activities’ (7.4%) (Vietri et al., 2016). Potential strategies to remedy missed

doses will be discussed in the recommendations section.

Regarding lifestyle management, Alejandro has a BMI of 24 (60kg, 158cm). As per the World

Health Organisation (WHO Expert Consultation, 2004) this is considered overweight for an asian

male. He notes that he has lost 12kg since being diagnosed with T2DM and that his endocrinologist

only recommends losing another 1-2kg. Alejandro explained that his weight loss mainly occurred as

a result of dietary modification as opposed to changing his level of physical activity. He is

conscious about what and how much he eats and does not avoid eating things he enjoys, rather, he

just eats less of it. This method of caloric restriction is a proven strategy for weight loss (Varady,

2011). In terms of things he feels he could improve, he admits that his diet contains minimal

vegetables and that he eats white rice almost every day. He also reports getting intermittent cravings

for unhealthy baked goods, such as doughnuts and scones. Similar experiences are described in

literature; for example, participants in a study by Laranjo et al. (2015) described ‘cravings for

sweets’ as barriers to their T2DM self-management. Recommendations for improving Alejandro’s

dietary management will be addressed below. Regarding physical activity, Alejandro does not

engage in purposeful exercise, however he remains physically active through his volunteering with

the Salvation Army (16hrs/week) and gardening activities (20+hrs/week). Based off this

information, it is likely that Alejandro is achieving the recommended (Briffa et al., 2006) 30

minutes of moderate physical activity on most, if not all days of the week.

Alejandro understands the importance (RACGP, 2016) of following up with his GP,

endocrinologist, and ophthalmologist to make sure he is ‘on track’ and to monitor for diabetic

complications. He explained that his GP organises and reviews his blood tests, provides medication

scripts, and writes specialist referrals; his endocrinologist reviews his glycaemic control,

medications, and checks his feet; and his ophthalmologist checks for retinal damage. Currently, he

sees his endocrinologist and ophthalmologist yearly, and GP roughly every 3 months; this is

consistent with guideline recommendations (RACGP, 2016).

Alejandro is also cognisant of the need to regularly check his “sugar control” [HbA1c –

glycosylated haemoglobin] (Healy & Dungan, 2015). He tests roughly every 3 months which is

adherent with RACGP (2016) guidelines. Moreover, his past 4 results have ranged between 6.4-

7.0% which is in line with his recommended targets (RACGP, 2016).

In terms of finances, Alejandro and his wife receive Newstart payments and a stipend from his

wife’s superannuation. Overall, it is a small amount of money, therefore the low cost of Alejandro’s

medication (Janumet) is a facilitating factor for his medication adherence. His Australian

Government Health Care Card (HCC), allows him to receive medications at $5.50 per script. Over a

year, Janumet treatment would cost him $699 at the regular price versus $72 at the subsidised price.

Regarding other expenses, Alejandro receives bulk-billed GP and blood test services; and for his

specialist appointments, pays an $85 and $72 gap with his endocrinologist and ophthalmologist

respectively. Alejandro explained that he has previously delayed seeing his endocrinologist and

ophthalmologist by a few months in order to save money. Despite this, Alejandro feels that the

subsides provided by the government are very helpful in making management of his T2DM

affordable. Comparing with Alejandro’s experience, Henderson, Wilson, Roberts, Munt, & Crotty

(2014) explore the financial implications of T2DM self-management within the Australian setting.

Despite provision of various subsidies, participants noted that there are other prohibitive costs that

can impede the optimal management of their T2DM; for example, the cost of gap payments,

‘healthy’ food, and podiatrist-prescribed footwear (Henderson et al., 2014). Notably, a lack of

financial capital has been linked with reduced access to healthcare and poorer health outcomes in

those with T2DM; thus, it is important to address this social determinant whenever necessary

(Glazier, Bajcar, Kennie, & Willson, 2006).

In addition to the management aspects outlined above, Alejandro is aware of the various

complications of T2DM (Faselis et al., 2019; Viigimaa et al., 2019), listing that T2DM can cause

‘poor [wound] healing, blindness, feet numbness, as well as heart and kidney damage’. His insight

regarding the disease process and management principles of T2DM reflect a relatively high degree

of health literacy (Marciano, Camerini, & Schulz, 2019). This high level of health literacy is a likely

contributor to his good glycaemic control (Marciano et al., 2019) and self-management efficacy

(van der Heide et al., 2014).

Recommendations

In T2DM, adherence to medications (Curtis, Boye, Lage, & Garcia-Perez, 2017) and an appropriate

dietary regime (Huang et al., 2016) are significantly linked to improved T2DM-related outcomes.

One strategy that Alejandro could employ to improve his medication adherence would be to set

himself regular medication reminders using his mobile phone. A study by Vervloet et al.

(2012) found that participants who received SMS reminders to take their medication had a

significantly higher medication adherence. Despite these SMS reminders being linked to a real-time

electronic detecting and dispenser system (Vervloet et al., 2012), it is reasonable to assume that

regular mobile reminders would have a similar effect. Another recommendation is to seek further

education regarding diabetes management, as this has been found to significantly increase

medication adherence (Collins-McNeil et al., 2012; Ramanath, Balaji, Nagakishore, Kumar, &

Bhanuprakash, 2012) .

In regards to diet, a systematic review and meta-analysis by Ajala, English, & Pinkney (2013) found

that low-carbohydrate, low-glycaemic index, Mediterranean, and high-protein diets all led to a

significant reduction in HbA1c, with the Mediterranean diet having the largest reduction. The

Mediterranean and low-carbohydrate diet also led to significant weight reduction (Ajala et al.,

2013). Based on this information, it is recommended for Alejandro to reduce the percentage of

carbohydrates in his diet by reducing his intake of bread, pasta, and especially rice; as well as

introduce more foods from the Mediterranean diet such as fruit, vegetables, legumes, unrefined

cereals, and olive oil (Ajala et al., 2013). In order to promote long-term adherence, it is important

that dietary transition is incremental and tailored to Alejandro’s preferences and motivation

(Koenigsberg & Corliss, 2017).

Conclusion

Poorly managed T2DM can result in a range of microvascular and macrovascular complications. In

terms of self-management, Alejandro actively engages in taking medication, dietary control,

monitoring his HbA1c, and following up with medical professionals. Of these, he requires strategies

to improve his medication adherence and dietary habits. Recommendations to improve his

medication adherence include regular reminders and further education regarding T2DM. Regarding

his dietary habits, it is recommended that he adopt a Mediterranean and/or a low-carbohydrate diet.

Adopting these recommendations is likely to lead to improved T2DM-related outcomes. In terms of

affordability, the various subsidies provided by the Australian government facilitate Alejandro’s

ability to self-manage his T2DM. Moreover, his high level of health literacy is a likely contributor

to his relatively good glycaemic control and self-management efficacy.

References

Ajala, O., English, P., & Pinkney, J. (2013). Systematic review and meta-analysis of different

dietary approaches to the management of type 2 diabetes. The American Journal of Clinical

Nutrition, 97(3), 505–516. https://doi.org/10.3945/ajcn.112.042457

Appropriate body-mass index for Asian populations and its implications for policy and intervention

strategies. (2004). Lancet (London, England), 363(9403), 157–163.

https://doi.org/10.1016/S0140-6736(03)15268-3

Briffa, T. G., Maiorana, A., Sheerin, N. J., Stubbs, A. G., Oldenburg, B. F., Sammel, N. L., & Allan,

R. M. (2006). Physical activity for people with cardiovascular disease: recommendations of the

National Heart Foundation of Australia. The Medical Journal of Australia, 184(2), 71–75.

Brunton, S. (2016). Pathophysiology of Type 2 Diabetes: The Evolution of Our Understanding. The

Journal of Family Practice, 65(4 Suppl).

Collins-McNeil, J., Edwards, C. L., Batch, B. C., Benbow, D., McDougald, C. S., & Sharpe, D.

(2012). A culturally targeted self-management program for African Americans with type 2

diabetes mellitus. The Canadian Journal of Nursing Research = Revue Canadienne de

Recherche En Sciences Infirmieres, 44(4), 126–141.

Curtis, S. E., Boye, K. S., Lage, M. J., & Garcia-Perez, L.-E. (2017). Medication adherence and

improved outcomes among patients with type 2 diabetes. The American Journal of Managed

Care, 23(7), e208–e214.

DeFronzo, R. A. (2004). Pathogenesis of type 2 diabetes mellitus. The Medical Clinics of North

America, 88(4), 787–835, ix. https://doi.org/10.1016/j.mcna.2004.04.013

Drucker, D. J. (2006). The biology of incretin hormones. Cell Metabolism, 3(3), 153–165.

https://doi.org/10.1016/j.cmet.2006.01.004
Faselis, C., Katsimardou, A., Imprialos, K., Deligkaris, P., Kallistratos, M., & Dimitriadis, K.

(2019). Microvascular complications of type 2 diabetes mellitus. Current Vascular

Pharmacology. https://doi.org/10.2174/1570161117666190502103733

Glazier, R. H., Bajcar, J., Kennie, N. R., & Willson, K. (2006). A systematic review of interventions

to improve diabetes care in socially disadvantaged populations. Diabetes Care, 29(7), 1675–

1688. https://doi.org/10.2337/dc05-1942

Gorina, M., Limonero, J. T., & Alvarez, M. (2018). Effectiveness of primary healthcare educational

interventions undertaken by nurses to improve chronic disease management in patients with

diabetes mellitus, hypertension and hypercholesterolemia: A systematic review. International

Journal of Nursing Studies, 86, 139–150. https://doi.org/10.1016/j.ijnurstu.2018.06.016

Halban, P. A., Polonsky, K. S., Bowden, D. W., Hawkins, M. A., Ling, C., Mather, K. J., … Weir, G.

C. (2014). beta-cell failure in type 2 diabetes: postulated mechanisms and prospects for

prevention and treatment. Diabetes Care, 37(6), 1751–1758. https://doi.org/10.2337/dc14-0396

Healy, S. J., & Dungan, K. M. (2015). Monitoring glycemia in diabetes. The Medical Clinics of

North America, 99(1), 35–45. https://doi.org/10.1016/j.mcna.2014.08.017

Henderson, J., Wilson, C., Roberts, L., Munt, R., & Crotty, M. (2014). Social barriers to Type 2

diabetes self-management: the role of capital. Nursing Inquiry, 21(4), 336–345. https://doi.org/

10.1111/nin.12073

Holst, J. J., Knop, F. K., Vilsboll, T., Krarup, T., & Madsbad, S. (2011). Loss of incretin effect is a

specific, important, and early characteristic of type 2 diabetes. Diabetes Care, 34 Suppl 2,

S251-7. https://doi.org/10.2337/dc11-s227

Huang, X.-L., Pan, J.-H., Chen, D., Chen, J., Chen, F., & Hu, T.-T. (2016). Efficacy of lifestyle

interventions in patients with type 2 diabetes: A systematic review and meta-analysis.

European Journal of Internal Medicine, 27, 37–47. https://doi.org/10.1016/j.ejim.2015.11.016

Janda, K., Krzanowski, M., Gajda, M., Dumnicka, P., Jasek, E., Fedak, D., … Sulowicz, W. (2015).

Vascular effects of advanced glycation end-products: content of immunohistochemically

detected AGEs in radial artery samples as a predictor for arterial calcification and

cardiovascular risk in asymptomatic patients with chronic kidney disease. Disease Markers,

2015, 153978. https://doi.org/10.1155/2015/153978

Koenigsberg, M. R., & Corliss, J. (2017). Diabetes Self-Management: Facilitating Lifestyle

Change. American Family Physician, 96(6), 362–370.

Laranjo, L., Neves, A. L., Costa, A., Ribeiro, R. T., Couto, L., & Sa, A. B. (2015). Facilitators,

barriers and expectations in the self-management of type 2 diabetes--a qualitative study from

Portugal. The European Journal of General Practice, 21(2), 103–110.

https://doi.org/10.3109/13814788.2014.1000855

Marciano, L., Camerini, A.-L., & Schulz, P. J. (2019). The Role of Health Literacy in Diabetes

Knowledge, Self-Care, and Glycemic Control: a Meta-analysis. Journal of General Internal

Medicine. https://doi.org/10.1007/s11606-019-04832-y

Meigs, J. B., Cupples, L. A., & Wilson, P. W. (2000). Parental transmission of type 2 diabetes: the

Framingham Offspring Study. Diabetes, 49(12), 2201–2207.

Menke, A., Rust, K. F., Fradkin, J., Cheng, Y. J., & Cowie, C. C. (2014). Associations between

trends in race/ethnicity, aging, and body mass index with diabetes prevalence in the United

States: a series of cross-sectional studies. Annals of Internal Medicine, 161(5), 328–335.

https://doi.org/10.7326/M14-0286

Pan, A., Sun, Q., Bernstein, A. M., Manson, J. E., Willett, W. C., & Hu, F. B. (2013). Changes in red

meat consumption and subsequent risk of type 2 diabetes mellitus: three cohorts of US men

and women. JAMA Internal Medicine, 173(14), 1328–1335.

https://doi.org/10.1001/jamainternmed.2013.6633
Ramanath, K., Balaji, D., Nagakishore, C., Kumar, S. M., & Bhanuprakash, M. (2012). A study on

impact of clinical pharmacist interventions on medication adherence and quality of life in rural

hypertensive patients. Journal of Young Pharmacists : JYP, 4(2), 95–100.

https://doi.org/10.4103/0975-1483.96623

Rosella, L. C., Mustard, C. A., Stukel, T. A., Corey, P., Hux, J., Roos, L., & Manuel, D. G. (2012).

The role of ethnicity in predicting diabetes risk at the population level. Ethnicity & Health,

17(4), 419–437. https://doi.org/10.1080/13557858.2012.654765

Ryan, D. H., & Yockey, S. R. (2017). Weight Loss and Improvement in Comorbidity: Differences at

5%, 10%, 15%, and Over. Current Obesity Reports, 6(2), 187–194.

https://doi.org/10.1007/s13679-017-0262-y

Shai, I., Jiang, R., Manson, J. E., Stampfer, M. J., Willett, W. C., Colditz, G. A., & Hu, F. B. (2006).

Ethnicity, obesity, and risk of type 2 diabetes in women: a 20-year follow-up study. Diabetes

Care, 29(7), 1585–1590. https://doi.org/10.2337/dc06-0057

van Dam, R. M., Rimm, E. B., Willett, W. C., Stampfer, M. J., & Hu, F. B. (2002). Dietary patterns

and risk for type 2 diabetes mellitus in U.S. men. Annals of Internal Medicine, 136(3), 201–

209.

van der Heide, I., Uiters, E., Rademakers, J., Struijs, J. N., Schuit, A. J., & Baan, C. A. (2014).

Associations among health literacy, diabetes knowledge, and self-management behavior in

adults with diabetes: results of a dutch cross-sectional study. Journal of Health

Communication, 19 Suppl 2, 115–131. https://doi.org/10.1080/10810730.2014.936989

Varady, K. A. (2011). Intermittent versus daily calorie restriction: which diet regimen is more

effective for weight loss? Obesity Reviews : An Official Journal of the International

Association for the Study of Obesity, 12(7), e593-601. https://doi.org/10.1111/j.1467-

789X.2011.00873.x
Vervloet, M., van Dijk, L., Santen-Reestman, J., van Vlijmen, B., van Wingerden, P., Bouvy, M. L.,

& de Bakker, D. H. (2012). SMS reminders improve adherence to oral medication in type 2

diabetes patients who are real time electronically monitored. International Journal of Medical

Informatics, 81(9), 594–604. https://doi.org/10.1016/j.ijmedinf.2012.05.005

Vietri, J. T., Wlodarczyk, C. S., Lorenzo, R., & Rajpathak, S. (2016). Missed doses of oral

antihyperglycemic medications in US adults with type 2 diabetes mellitus: prevalence and self-

reported reasons. Current Medical Research and Opinion, 32(9), 1519–1527.

https://doi.org/10.1080/03007995.2016.1186614

Viigimaa, M., Sachinidis, A., Toumpourleka, M., Koutsampasopoulos, K., Alliksoo, S., & Titma, T.

(2019). Macrovascular complications of type 2 diabetes mellitus. Current Vascular

Pharmacology. https://doi.org/10.2174/1570161117666190405165151

Zaccardi, F., Webb, D. R., Yates, T., & Davies, M. J. (2016). Pathophysiology of type 1 and type 2

diabetes mellitus: a 90-year perspective. Postgraduate Medical Journal, 92(1084), 63–69.

https://doi.org/10.1136/postgradmedj-2015-133281
Appendix

Description

I spent a Saturday (May 4, 2019) with Alejandro at his home where I observed his self-management

in regards to taking his medications. I observed him taking his T2DM medication (Janumet) in the

morning along with his breakfast and in the evening after dinner. In addition to the Janumet he also

took perindopril in the morning for his hypertension and atorvastatin in the evening for his

hypercholesterolaemia. All his medications were in a pillbox with 14 compartments; AM and PM

for 7 days, with the week starting on Sunday. He explained that he prepares it himself each Saturday

night, refilling it after taking the last Saturday PM dose. I noticed that there were 2 compartments

(Wednesday AM and Thursday PM) with the medication still inside. He lamented that he forgot to

take those doses and said that he occasionally forgets to take his medication. He explained that

because his pillbox lives on the meals table, he sometimes forgets a dose if he does not have

breakfast or dinner at home, or if he is busy outside gardening. This corroborated with the 2 missed

doses; on the Wednesday he had breakfast at the Salvation Army where he volunteers, and on the

Thursday he went out to dinner for a family friend’s birthday. He said that he understood the

importance of medications in managing his T2DM but also stated that “I don’t think it matters too

much if I miss a dose here or there”.

Evaluation

After observing Alejandro, I learned about the potential impact of seemingly minor events on

medication adherence. Despite having taken medication for his T2DM for around 10 years,

Alejandro still occasionally forgets to take doses due to a change in meal routine or being ‘busy’

outside gardening. I also learned that having a relaxed attitude towards medication adherence can be

a potential barrier for optimal management of T2DM.

Analysis

It appears that the cause of missed doses for Alejandro is multifactorial. Firstly, it is clear that work,

social events, and hobbies lead to a change in his meal routine and this removes a crucial prompt

(proximity of the pillbox at the meals table) for taking his medication. Secondly, despite having a

theoretical understanding about the importance of medication adherence it is clear that he also has a

relaxed attitude towards medication adherence (‘okay to miss a couple of doses’). This disparity

between theory and practice demonstrates that adequate knowledge does not always translate to

optimal attitudes and behaviours.

Conclusion

Alejandro’s sound knowledge regarding the importance of medication adherence does not translate

into attitudes and behaviours required for optimal medication adherence. This disparity reflects the

difficulty of translating theory to practice.