Download Philippine Practice Guidelines on the Diagnosis and Management of Diabetes Mellitus (DRAFT) (PDF)

2011 DIABETES PHILIPPINES SCHEDULED ACVITIES

42nd Diabetes Workshop Iloilo Business Hotel, Iloilo City July 15, 2011 (Friday)
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7th Diabetes Forum Iloilo Business Hotel, Iloilo City July 16, 2011 (Saturday)
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43rd Diabetes Workshop AsiaBlooms Hotel, Resort and Restaurant National Highway, Brgy. Patimbao, Sta. Cruz, Laguna October 7, 2011 (Friday)

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8th Diabetes Forum AsiaBlooms Hotel, Resort and Restaurant National Highway, Brgy. Patimbao, Sta. Cruz, Laguna October 8, 2011 (Saturday)
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28th Annual Convention of Diabetes Philippines 7th Course on Diabetes and Vascular Disease Century Park Hotel November 9 11, 2011 (Wednesday-Friday)

Download Preliminary Programme (PDF) Download Registration Form (PDF)

Gimik Diabetes Year 5 World Diabetes Day Celebration/Lay Annual Convention November 12, 2011 (Saturday) FOR INQUIRIES PLEASE CALL: Diabetes Philippine Secretariat Telefax: (632) 531-1278 Tel.: (632) 534-9559 Email: diabetesphilippines@pldtdsl.net Website: www.diabetesphil.org

. This page features the full text of Republic Act No. 8191
National Diabetes Act of 1996 AN ACT PRESCRIBING MEASURES FOR THE PREVENTION AND CONTROL OF DIABETES MELLITUS IN THE PHILIPPINES, PROVIDING FOR THE CREATION OF A NATIONAL COMMISSION ON DIABETES, APPROPRIATING FUNDS THEREFOR AND FOR OTHER PURPOSES.

Section 1. Short Title. This Act the "National Diabetes Act of 1996."

shall

be

known

as

Sec. 2. Declaration of Policy. The State shall protect and promote the right to health of the people and instill health consciousness among them. There shall be priority for the needs of the underprivileged sick, elderly, disabled, women and children. Sec. 3. The National Commission on Diabetes. There is hereby created a National Commission on Diabetes, hereinafter referred to as the "Commission," which shall be composed of nine (9) members, as follows: one (1) shall be a practising clinical diabetologist, one (1) shall be a licensed

physician involved in research and education on diabetes, one (1) shall be an epidemiologist, one (1) shall be a nutritionist with experience in the control of diabetes, one (1) shall be a social scientist, one (1) shall come from a non-government organization engaged in the prevention and treatment of diabetes, one (1) shall come from the academe and one (1) shall be a diabetic with a record of public service in reducing the impact of the disease on affected individuals and their families. The Undersecretary for Public Health Services shall serve as the ex officio Chairperson of the Commission. The members of the Commission shall be appointed by the President within thirty (30) days from the promulgation of the rules and regulations as specified in Section 14 of this Act, upon the recommendation of the Secretary of Health. Each member shall be entitled to a monthly honorarium to be determined by the Secretary of Health subject to the pertinent budgetary laws, rules and regulations on compensation, honoraria and allowances. The Commission shall be attached to the Department of Health (DOH) for administrative, technical and budgetary purposes. Sec. 4. Duties and Functions. The Commission shall: (a) assess the social and economic impact of diabetes mellitus on individuals, families, households, communities and the nation; (b) evaluate the adequacy of national resources devoted to the prevention, diagnosis, and treatment of diabetes mellitus; and (c) formulate, in accordance with Section 7 of this Act, the National Diabetes Prevention and Control Plan. Sec. 5. Meetings. The Commission shall meet not later than thirty (30) days after it has been fully constituted and not less frequently than every month thereafter of the call of the Chairperson
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of

the

Commission.

Sec. 6. Secretariat and Technical Staff . The Commission shall have a secretariat and technical staff to provide administrative support and technical assistance to the Commission to effectively carry out its functions.

Sec. 7. The National Diabetes Prevention and Control Plan. The long range national plan for the prevention and control of diabetes mellitus shall provide for: (a) the development of strategies and programs, including awareness campaigns and the continuing education of health personnel and concerned individuals, to prevent diabetes mellitus and its complications;
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(b) the adoption of cost-effective and appropriate screening methods for the detection of diabetes mellitus in its early or pre-symptomatic stages; (c) the investigations into the epidemiology, etiology, diagnosis, treatment, prevention and control of diabetes mellitus; (d) the evaluation of measures employed, including drug and diet therapies, in the control of diabetes mellitus; (e) the establishment of mechanisms to reduce the socioeconomic impact of diabetes mellitus on affected individuals and families; (f) the granting of incentives and support for organizations of affected individuals and families; (g) the establishment of coordinated health systems, which shall involve clinicians, researches, allied health professionals, community based health workers and lay volunteers, for dealing with diabetes mellitus and its complications; (h) the participation of local government units, alongside with concerned government agencies and non-government organizations, in the implementation of programs on diabetes prevention and control; (i) the periodic review of research needs and potential in the control of diabetes mellitus; (j) the systematic utilization of public and private resources to achieve the objectives enumerated above; and (k) the recommendations of the Commission for legislation.

Sec. 8. Implementation of the Plan. The DOH, through its Office of Public Health Services shall implement the National Diabetes Prevention and Control Plan.
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Sec. 9. Comprehensive Report. The Commission shall submit to both Houses of Congress and the Secretary of Health, within one (1) year of its initial meeting, the National Diabetes Prevention and Control Plan, specified in Section 7 hereof. A report which describes the activities and expenditures of the Commission shall likewise be submitted. Sec. 10. The Oversight Committee for the Prevention and Control of Diabetes. Upon submission of the report, the National Commission on Diabetes created by virtue of this Act shall cease to exist and be reconstituted as the Oversight Committee for the Prevention and Control of Diabetes, hereinafter to as the "Committee." The Committee shall continuously be attached to the DOH. Sec. 11. Function of the Committee. The Committee shall review and evaluate the implementation of the National Diabetes Prevention and Control Plan and make recommendations to the Secretary of Health for the attainment of the objectives set forth in such plan. Sec. 12. Sunset Provision. The Oversight Committee for the Prevention and Control of Diabetes provided in Section 10 hereof shall cease to exist five (5) years after its organization. Its functions, duties and responsibilities together with all of its records, assets and obligations shall devolve to the DOH. Sec. 13. Appropriations. The amount necessary to carry out the provisions of this Act shall be included in the General Appropriations Act of the year following its enactment into law and thereafter. Sec. 14. Rules and Regulations. The Secretary of Health shall within ninety (90) days from the approval of this Act, promulgate the rules and regulations necessary for the effective implementation of this Act. Sec. 15. Separability Clause. If any provision of this Act is declared invalid, the remainder of this Act or any provision not affected thereby, shall remain in form and in effect.chan robles
virtual law library

Sec. 16. Repealing Clause. All laws, presidential decrees, executive orders, administrative orders and their implementing rules inconsistent with the provisions of this Act are hereby repealed, amended or modified accordingly.chan
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Sec. 17. Effectivity. This Act shall take effect fifteen (15) days following its publication in the Official Gazette or in at least two (2) newspapers of general circulation.chan robles virtual
law library

Approved: June 11, 1996

Statistics on Diabetes Mellitus, obesity and hypertension are startling. In the United States, a report says that 2 out of 3 (66.6%) adult Americans, and 15% of the children, are overweight. In the United States alone, there are about 17 million diabetics. Five to 10% have Type I (juvenile), and the rest, Type II (adult onset) diabetes. Before insulin was discovered in the early 1920s, type 1 diabetes had 100% mortality. In the past 10 years, there has been a 33% increased in the number of diabetic patients. It is indeed scary. In another report by the Medical Observer, Diabetes is not only a disease of the middle age. More and more, high school and elementary students [are being affected]. At age 22, bulag na e hindi pa kumikita (blind already while not yet earning money). At age 20 plus, nagdadialysis na, possibly stroke and heart attack, says Dr. Tommy Ty Willing, president of the Philippine Diabetes Association (PDA), during the recent observance of World Diabetes Day in November. Pediatric endocrinologist Sioksoan Chan-Cua said that patients as young as five years old are coming to her clinic with type 2 diabetes, a disease usually associated with people 40 years old and above. Im getting patients with blood sugar of more than 1,000. They come in with diabetic ketoacidosis, a breakdown of fat tissues when the body cannot utilize the glucose very well anymore, she said. While there are no clear data yet among the young on the running incidence of type 2 diabetes, related statistics add up to a grim scenario. Type 1 diabetes is rising by three percent worldwide, with 17 percent of children 14 and below developing the disease each year. Chan-Cua said the Philippines is still low on this score compared with other countries, but we are also seeing an increase every year. My perception on this is simple Filipinos love sweets and fatty foods. Also, our staple food is rice, which is a starchy food item. This makes diet as the primary risk factor to diabetes in the Philippines in my view. Moreover, mathematical modelling on projection yields that 380 million people are expected to develop diabetes by 2025 based on International Diabetes Federation/World Health Organization data, a good percentage will be coming from Southeast Asian countries, including the Philippines. This finding is no longer astonishing considering the latest statistics on Pinoys afflicted with diabetes and hypertension which continues to increase on the scale of medical records. This goes to show that statistics on Diabetes Mellitus in the Philippines continues to be unfavorable to the general population because of the continuous rise in the number of Filipinos developing diabetes every year which adds to the number of people who cannot enjoy life and are becoming less productive due to this disease.

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http://www.jpsimbulan.com/2008/07/26/incidence-of-type-1-and-type-2-diabetes-in-thephilippines-and-worldwide/ The epidemiology of diabetes mellitus in the AsiaPacific region CS Cockram The Asia-Pacific region is at the forefront of the current epidemic of diabetes. There are currently more than 30 million people with diabetes in the Western Pacific region alone. The World Health Organization predicts that this number will rise dramatically by the year 2025, by which time India and China may each face the problem of dealing with 50 million affected individuals. The problem in the region results from a combination of large population size with rapidly rising prevalence rates, particularly of type 2 diabetes mellitus. Although much heterogeneity exists, rising prevalence rates are being seen throughout the region and appear to be closely associated with westernisation, urbanisation, and mechanisation. The risk for diabetes appears to result from a combination of genetic predisposition and lifestyle change. The most important lifestyle changes relate to changes in dietary habits and physical activity and diabetes risk, particularly in younger individuals, is associated with the development of obesity and particularly central obesity. In some populations, for example Chinese, the relationship between diabetes and weight gain begins to appear at levels of body weight that would not be conventionally regarded as representing obesity. The increasing trend for type 2 diabetes to develop in young people is of particular concern. In children and adolescents in some parts of the region, type 2 diabetes now outnumbers type 1 diabetes by a ratio of 4:1. In view of the severity of the long-term complications of diabetes, the health consequences of this epidemic will become increasingly devastating and threaten to overwhelm the health care systems in the most vulnerable countries. There is an urgent need for prioritisation of diabetes as a key issue by governments throughout the region. Diabetes prevention programmes can be justified on economic, as

well as humanitarian grounds. At the level of primary prevention, such programmes can be linked to other non-communicable disease prevention programmes which also target lifestylerelated issues. HKMJ 2000;6:43-52 Key words: Diabetes mellitus/epidemiology; Forecasting; Incidence; Prevalence; World health Western Pacific region, along with the Indian subcontinent, is at the forefront of the current epidemic of type 2 diabetes mellitus. In 1998 it was estimated that, globally, there were already 140 million people with diabetes. Predictions compiled by Dr Hilary King of the World Health Organization (WHO) indicate that this figure will rise to 300 million by the year 2025. Of these, more than 150 million will be in Asia. The figures for India are predicted to rise from an estimated 15 million in 1995 to 57 million in 2025. For China, current estimates are 15 to 20 million, with a predicted rise to 50 million by 2025. Thus, more than 30% of the global number of people with diabetes in 2025 will be in these two countries alone. 1 In some countries, much epidemiological information is available, while in others, data are scarce or44 HKMJ Vol 6 No 1 March 2000 Cockram non-existent. Prevalence rates of diabetes vary greatly, and generally parallel the level of affluence and degree of industrialisation of individual countries. Geographically, Australia and New Zealand belong to the Asia-Pacific region. With their predominantly Caucasian populations, patterns of diabetes in Australia and New Zealand generally resemble those of Caucasian populations in Europe and North America. However, even these countries demonstrate diversity as a result of the presence of the Aboriginal population in Australia, and the Maori and Pacific Island populations in New Zealand. Both countries also have significant immigrant populations from other parts of Asia, living mainly in urban areas. Comparison and interpretation of prevalence studies are also sometimes rendered difficult by differences in methodology, diagnostic criteria, or age of subjects studied. This is particularly true of older studies. Prevalence figures for diabetes require age standardization to allow meaningful comparisons to be made. Where possible age-standardised data will be given, unless otherwise stated.

General epidemiological points Despite the diversity within the region, a number of common themes can be found with regard to patterns of diabetes and prevalence rates. 2 With the exception of Australia and New Zealand, type 1 diabetes is relatively less common throughout the region than in European populations, with some of the lowest incidence rates in the world (1-2 per 100 000 personyears). As a result, type 1 diabetes accounts for less than 3% of the total burden imposed by diabetes. Type 2 diabetes prevalence rates show marked differences throughout the region, according to lifestyle, affluence, mechanisation, and urbanisation. They remain low in traditional societies but are rising rapidly in association with urbanisation and modernisation, to rates which are among the highest reported anywhere (in excess of 30% of the adult population). Type 2 diabetes is also becoming increasingly common in younger people and (except in Australia and New Zealand) outnumbers type 1 diabetes, even in the very young. Teenagers and children with type 2 diabetes are emerging with increasing frequency. In those developed countries with predominantly Caucasian populations, most people with diabetes are older than 65 years. In developing countries, however, the majority are aged between 45 and 64 years. Epidemiological studies consistently demonstrate that more than 50% (up to 85%) of identified cases had not been previously diagnosed and are therefore not receiving treatment. Commonality of environmental risk factors is also invariably observed: notably changing nutrition, obesity and central obesity, decreasing physical activity levels, and urbanisation. However, as discussed later, the quantitative details may vary between different populations and ethnic groupsfor example, quantitative definitions of obesity risk among Chinese and Pacific Island populations. Prevalence rates of impaired glucose tolerance (IGT), with few exceptions, generally mirror those of diabetes, and in many countries the IGT prevalence rates are higher than those of diabetes. High rates of IGT can be taken to indicate that a future rise in diabetes prevalence is likely. Changing lifestyles, human history, and diabetes prevalence

Homo sapiens, and his probable direct ancestors within the genus Homo, have a lengthy history dating back at least 2 million years. For the vast majority of this time, a hunter-gatherer lifestyle was pursued. In some parts of the region, this either continues or has continued until within the last few generationsfor example, in Papua New Guinea and Australia. Palaeoanthropological evidence indicates that this lifestyle has involved a mixed carnivorous-herbivorous diet. Regional dietary variations would have existed according to habitat, but overall fat intakes consistently below 25% of total energy intake seem probable. The hunter-gatherer lifestyle is characterised also by very high levels of physical activity and by periodic shortages of food. The development of agriculture in certain parts of the Asia-Pacific region may date back 10 000 years, but is still very recent in terms of evolutionary time. Agriculture probably had little or no impact on the risk of metabolic disorders such as obesity and diabetes. Physical activity levels remained high and dietary patterns shifted towards a greater herbivorous food intake and an even lower fat intake. There would also have been an increased risk of famine as a result of crop failure and dependence upon relatively few crops. The main change which agriculture allowed was an increase in population density. Thus, there is strong and lengthy evolutionary pressure for adaptation to a hunter-gatherer lifestyle. More recent selective evolutionary pressures may have operated in a specific manner in response to adaptation to different environments and habitats, and such pressures may explain, for example, the different bodyHKMJ Vol 6 No 1 March 2000 45 Epidemiology of diabetes mellitus builds of the slender Chinese and Japanese compared to the heavily built Polynesians. The stocky build of the Polynesians, with high muscle and fat mass, may be a specific adaptation to a harsh oceanic environment, combined with geographical isolation, cultural acceptance of relative obesity, and an abundant supply of high-quality food staples and seafood. This baseline physique of Polynesians has been described as healthy obesity. In general terms, metabolic adaptations during human evolution have developed in response to the principal environmental stressor: food shortage and weight loss. This is in keeping with the thrifty gene

hypothesis proposed by Neel in 1962 which basically states that individuals with a genotype which is favourable in terms of metabolic economy in times of famine, may be most at risk when exposed to overnutrition and physical inactivity. 3 It is also in keeping with recent suggestions that infants with low birthweight (reflecting intrauterine poor nutrition) may also be more prone to obesity, diabetes, and hypertension in adult life. 4 The advent of industrialisation, modernisation, and urbanisation is associated throughout the region with rapidly rising prevalence rates of both diabetes and obesity. It is significant that particularly high diabetes prevalence rates are being seen in Papua New Guinea and in Australian Aborigines who have moved directly from a hunter-gatherer lifestyle to an urbanised setting within only one to two generations. The difference in baseline body buildsfor example, between Chinese and Pacific Island populations makes correlation between diabetes and obesity difficult to quantify. However, within all populations studied, diabetes prevalence rates rise rapidly with increasing obesity, particularly central obesity. In the slender Chinese and Japanese, the presence of such obesity may only be recognised by careful examination and conventional criteria cannot be applied. By contrast, in Nauru, massive obesity is associated with a diabetes prevalence exceeding 40% of the population. 5 At present, the extreme circumstances of Nauru, Papua New Guinea, and Australian Aboriginals are associated with extremes in diabetes prevalence (35%-40%). 5 It remains to be seen whether other populations in the region carry the same potential degree of risk or whether diabetes prevalence rates will stabilise at lower levels. Since prevalence rates of type 2 diabetes are generally lower in Caucasian populations, it has been suggested that, in Caucasians, the risk may have become attenuated by a more lengthy exposure to the lifestyle changes of the modern era. The epidemiological transition

The rising prevalence of diabetes in the region reflects overall changes in disease patterns. Improvements in nutrition, hygiene, and control of infectious diseases have led to increases in life expectancy and to the emergence of non-communicable diseases as the foremost health problems. This shift in disease patterns has been termed the epidemiological transition, and is seen in its completed form in developed countries. Many newly industrialised nations in Asia have undergone, or are undergoing, this transition at a very rapid rate and may be caught by a double burden from both ends of the spectrum if development is patchy, heterogeneous or very rapid. China is a good example of this. The WHO estimates that in China, 15% of the population remains traditional, the emphasis remaining on infectious disease while 25% have already undergone transition, the emphasis being non-communicable diseases. The remaining 60% are in the transition phase and are threatened by a double burden. The concept of epidemiological transition can also be applied within diabetes. In those countries which have not yet undergone epidemiological transition (eg Cambodia) diabetes prevalence rates remain low, but the problems are still considerable. Such countries experience particular problems with infectious complications of diabetes, notably severe foot sepsis, pneumonia, and tuberculosis. Diabetic ketoacidosis also poses problems, due to combinations of chronically poor glycaemic control, superimposed infections, and lack of adequate treatment facilities. Medical care and availability of supplies may also be patchy and erratic, and drugs and insulin may not always be available. As epidemiological transition occurs, prevalence rates of diabetes rise and the familiar pattern of chronic diabetic complications becomes increasingly apparent. However, at the same time, improved delivery of health care helps to reduce the burden imposed by infections and their associated problems. Countries undergoing rapid transition may again show a double burden, reflecting the legacy of the immediate past together with the consequences of rapid change. All three situations may coexist within one country (eg Indonesia and the Philippines), particularly where there is marked maldistribution of wealth and resources. South East Asian Peninsula and ASEAN The countries forming the Association of SouthEast Asian Nations (ASEAN) are Thailand, Malaysia,

Indonesia, Singapore, the Philippines, Myanmar, and Vietnam. Cambodia and Laos also fall naturally into46 HKMJ Vol 6 No 1 March 2000 Cockram this region. Economic diversity is considerable as reflected, for example, by the affluence of Singapore compared with Cambodia. No reliable epidemiological data are available from Cambodia, Laos, or Myanmar and the magnitude of the problem of diabetes is unknown. Since these countries are, at best, in the early stages of epidemiological transition, it seems probable that diabetes prevalence rates remain relatively low. In Cambodia, there are no trained diabetologists, 50% of people with diabetes use traditional remedies, and the main problems encountered are tuberculosis, other infections and lack of supplies. One vial of U40 insulin (40 U/mL) costs US$7 compared with an average monthly income of less than US$10 (S Hel, written communication, 1999). Recent prevalence rates reported from this part of the region are summarised in Table 1. Literature Review on the Best Methods for helping DM Patients to Maintain Optimal Blood Sugar Level

Diabetes mellitus is a syndrome resulting from a variable interaction of hereditary and environmental factors, and characterized by abnormal insulin secretion and a variety of metabolic and vascular manifestations reflected in a tendency toward inappropriately elevated blood glucose levels, thickened capillary basal lamina, accelerated nonspecific atherosclerosis, and neuropathy (Robbins, 1998). The syndrome has no distinct etiology, pathogenesis, invariable set of clinical findings, specific laboratory tests, or definitive and curative therapy, although it is nearly always associated with fasting hyperglycemia and decreased glucose tolerance. A relative or absolute lack of insulin secretion associated with an excess of circulating stress hormones (including glucagon, catecholamines, and cortisol) is responsible for inappropriate elevation of blood glucose and associated

alterations in lipid metabolism characterizing the metabolic syndrome (Guyton & Hall, 2000). Diabetes mellitus increases the risk of coronary heart disease, myocardial infarction and peripheral vascular disease as well. High blood sugars are linked with accelerated development of atherosclerosis as well as high levels of serum lipids and triglycerides. Closely monitoring blood sugar levels in diabetics and checking blood sugar levels in all patients for the development of increased levels is an important nursing function. Control of blood sugar levels can greatly reduce risk and slow development of atherosclerosis (Kozier & Erb, 2004). The primary objective in the treatment of diabetes mellitus is to achieve the patients optimal health and nutrition. Whether treatment of asymptomatic hyperglycemia decreases morbidity and mortality is unknown, and there is significant risk of hypoglycemia in elderly patients given oral hypoglycemic agents or insulin therapy. Therefore, it appears best not to use drug treatment for glucose intolerance in elderly patients with normal fasting plasma glucose levels or asymptomatic fasting hyperglycemia. Some diabetes rapidly progress with a course complicated by episodes of ketoacidosis and vascular manifestations, while others go through life with mild nonprogressing glucose intolerance and few other manifestations of the syndrome. The earliest symptom of elevated blood glucose is polyuria from the osmotic diuretic effect of glucose. Continued hyperglycemia and glucosuria may lead to thirst, hunger and weight loss. This paper will attempt to discuss and critique five research-based journal articles that relate specifically to the chosen specific nursing topic which is about the best methods for helping diabetes mellitus (DM) patients to maintain optimal blood sugar level. A review or an analysis will be written regarding the chosen articles and a conclusion shall be formulated about the topic based on the articles reviewed.

Journal Article 1: A Controlled Trial of Population Management: Diabetes Mellitus: Putting Evidence into Practice. There are already many studies about nutrition principles and recommendations for diabetes and related complications. Long ago, this has

been based on scientific evidence and diabetes knowledge when available and, when evidence was not available, on clinical experience and expert consensus. The particular study is about population level strategies to organize and deliver care that may improve diabetes management. The research design employed in the study is both a combination of the qualitative and quantitative approach. Measurement of cholesterol levels and blood pressure could be considered as quantitative approaches in collecting data while the use of administrative records and billing claims can fall under the qualitative approach. This is appropriate for the kind of data that is needed in the study. Evidence-based nutrition recommendations attempt to translate research data and clinically applicable evidence into nutrition care. However, the best available evidence must still be moderated by individual circumstances and preferences. The goal of evidence-based recommendations is to improve the quality of clinical judgments and facilitate cost-effective care by increasing the awareness of clinicians and patients with diabetes of the evidence supporting nutrition services and the strength of that evidence, both in quality and quantity (Wheeler, 2002). The current nutrition principles and recommendations for diabetes focus on lifestyle goals and strategies for the treatment of diabetes. Whether for management or prevention of diabetes and its complications, basic to the nutrition recommendations is the underlying concern for optimal nutrition through healthy food choices and an active lifestyle. Population-level clinical registries combined with summarized recommendations had a modest effect on management. The intervention was limited by good overall quality of care at baseline and temporal improvements in all control clinics, it is unknown whether this intervention would have had greater impact in clinical settings with lower overall quality. Overall, the study can be used to further educate health care practitioners in helping DM patients. Further research into more effective methods of translating population registry information into action is still required though.

Journal Article 2: A Revitalized Battle Against Diabetes Mellitus for the New Millennium.

Diabetes mellitus, one of the worlds most serious health problems and most prevalent diseases, has been a major cause of morbidity worldwide. Nurses are continuously employing new research findings and aggressive strategies to help overcome the disease. A significant population has one or more risk factors for developing diabetes. This particular study aims to inform and educate health care professionals, most especially the nurses in the control and treatment of DM. Managing diabetes successfully is a lifelong commitment, which emphasizes continual education and management adjustments as health status and conditions change. Components of the diabetes management plan include: medical nutrition therapy, physical activity, blood glucose monitoring, diabetes medications (if needed), behavioral strategies to promote lifestyle changes, and education regarding how to integrate the above components and related healthy habits. This particular study is basically an evidence and research based paper which discusses the various control and treatment strategies for DM patients. Nursing care strategies are being discussed more specifically. Aside from that, the role of the DM patient in learning about how to overcome the disease is also emphasized. This particular paper could help health care professionals and DM patients alike in being more aware of the proper control and treatment measures for the disease. This could be a good source of education for both the health care professionals and the DM patients alike. The study concluded that more aggressive approaches to diagnose and treat diabetes are now a critical goal for health care providers. The number of treatment modalities for diabetes is increasing as researchers develop more new oral anti-diabetic agents. Nursing care needs to be "in sync" with this new proactive stance against diabetes. Nurses in acute care will be using new drug combinations to treat patients with diabetes. Nurses in all settings must understand the significance of glycemic control. The health care system is declaring war on diabetes, one of the oldest diseases known to man. Nurses are on the front line armed with new strategies for the new millennium.

Journal Article 3: Relationship of Depression Medication Adherence, and Preventive Care.

and Diabetes Self-Care,

This particular study assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness. One study has concluded that that the initial occurrence of clinically significant depression, major depressive disorder (MDD), results from either biochemical changes directly due to type 2 diabetes or its treatment or from the psychosocial demands imposed by the illness or its treatment do not seem to be supported. MDD in diabetic individuals represents a multi-determined phenomenon resulting from interactions between biologic and psychosocial factors. This interaction may increase the probability of developing type II diabetes in otherwise healthy individuals (Nouwen, 2000). Empirical studies strongly suggest that depression is more prevalent among adults with diabetes than among the general population. To date, the reasons for the higher prevalence rates of depression in diabetic patients are not yet fully understood. The two dominant hypotheses concerning the initial occurrence or recurrence of clinically significant depression in individuals with diabetes are as follows: 1) it results from biochemical changes directly due to the illness or its treatment and 2) it results from the psychosocial demands or psychological factors related to the illness or its treatment (Nouwen, 2000). In this study, the research design and methods used are of the qualitative approach. In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services. This is suitable for the kind of data that the research needs. The results of the study showed that in a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes.

In particular, diabetic patients with depression need support for selfmanagement activities such as lifestyle modifications and medication adherence, this study can somehow help health care practitioners in how to provide appropriate services that can help DM patients. Further research is needed to evaluate whether integrating depression screening and treatment into comprehensive care of diabetes could enhance self-management, adherence, and patient outcomes.

Journal Article 4: Increasing Incidence of Diabetes After Gestational Diabetes: A Long Term Follow-Up in a Danish Population. The objective of this research was to study the incidence of diabetes among women with previous diet-treated gestational diabetes mellitus (GDM) in the light of the general increasing incidence of overweight and diabetes and to identify risk factors for the development of diabetes. Gestational diabetes mellitus (GDM) is defined as any degree of glucose intolerance with onset or first recognition during pregnancy. The definition applies regardless of whether treatment includes diet modification alone or in combination with insulin. It does not exclude the possibility that unrecognized glucose intolerance may have antedated or begun concomitantly with the pregnancy (Gabbe, 1998). Maternal morbidity due to GDM may be immediate or long-term. Many studies have documented an increase in preeclampsia, polyhydramnios, and operative delivery in pregnancies complicated by GDM. Infants of mothers with GDM (IGDM) are not at increased risk for congenital anomalies unless these women have preexisting diabetes mellitus. However, IGDM do have an increased risk of perinatal mortality and morbidity, including hyperbilirubinemia, macrosomia and birth trauma, and hypoglycernia (Gabbe, 1998). In the research design and method, women with diet-treated GDM during 1978-1985 (old cohort, n = 241, also followed up around 1990) or 1087-1996 (new cohort, n = 512) were examined in 2000-2002. Women were classified by a 2-h, 75-g oral glucose tolerance test according to the World Health Organization criteria or an intravenous glucagon test supplemented by measurement of GAD

antibodies. Historical data from index-pregnancy and anthropometrical measurements were collected. This is a qualitative form of research and is suitable for this type of data. The results of the study showed that the incidence of diabetes among Danish women with previous diet-treated GDM was very high and had more than doubled over a 10-year period. This seems to be due to a substantial increase in body mass index (BMI) in women with GDM. The study supports previous findings that women with GDM are at high risk for subsequent diabetes. The risk is further increased if obesity is present before pregnancy. The importance of this study is that this could provide further information for health care professionals in helping women with GDM.

Journal Article 5: How Well Do Patients Assessments of Their Diabetes SelfManagement Correlate with Actual Glycemic Control and Receipt of Recommended Diabetes Services? Although patient diabetes self-management is a key determinant of health outcomes, there is little evidence on whether patients' own assessments of their self-management correlates with glycemic control and key aspects of highquality diabetes care. Because of this, there is a need for further research on this area, and that is why this study was conducted. For this study, the researchers abstracted information on achieved level of glycemic control and diabetes processes of care from medical records of 1,032 diabetic patients who received care from 21 VA facilities and had answered the Diabetes Quality Improvement Program survey in 2000. The survey included sociodemographic measures and a five-item scale assessing the patients' diabetes self-management (medication use, blood glucose monitoring, diet, exercise, and foot care). Using multivariable regression, the researchers examined the associations of patients' reported self-management with glycosylated hemoglobin [HbA1c] level and receipt of each diabetes process of care. The researchers then adjusted for diabetes severity and comorbidities, insulin use, age, ethnicity, income, education, use of VA services, and clustering at the facility level.

The study used the qualitative method of research and employed statistical computations to come up with the needed data. There was further explanation in the paper on the overall strategy of how the researchers came up with the data. The results showed that higher patient evaluations of their diabetes selfmanagement were significantly associated with lower HbA1c levels and receipt of diabetes services. Those in the 95th percentile for self-management had a mean HbA1c level of 7.3, whereas those in the 5th percentile had mean levels of 8.3. For every 10-point increase in patients' ratings of their diabetes selfmanagement, even after adjusting for number of outpatient visits, the odds of receiving an HbA1c test in the past year increased by 15%, of receiving an eye examination increased by 16% (7-27%), and of receiving a nephropathy screen increased by 13%. Measurement of HbA1c thus provides information useful for the management of DM. Since the mean half life of an erythrocyte is 60 days, the HbA1c level reflects the average blood glucose concentration over the preceding 6-8 weeks. And elevated HbA1c, which indicates poor control of blood glucose level, can guide health care professionals in the selection of appropriate treatment more rigorous control of diet or increased insulin dosage (Murray, et al, 2000). The findings of this study were useful in reinforcing the usefulness of patient evaluations of their own self-management for understanding and improving glycemic control. The mechanisms by which those patients who are more actively engaged in their diabetes self-care are also more likely to receive necessary services warrant further study.

Conclusion Diabetes mellitus is a syndrome of impaired carbohydrate, fat and protein metabolism caused by either lack of insulin secretion or decreased sensitivity of the tissues to insulin. The basic effect of this lack in insulin is the increase in blood glucose concentration. In the journals discussed, there are several methods for helping DM patients maintain optimal blood sugar levels. This includes administering enough

insulin so that the patient will have metabolism that is as normal as possible. Dieting and exercise are also recommended in an attempt to induce weight loss and to reverse insulin resistance. If these methods fail, drugs may be administered to increase insulin sensitivity or to stimulate increased insulin production.

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