essay on diabetes type 2

Type 2 Diabetes Essay

Introduction.

Diabetes is a health condition that is developed when sugar level in the blood increases above normal levels. The two major types of diabetes are type 1 diabetes and type 2 diabetes. Type 2 diabetes is more prevalent than type 1 diabetes. This essay discusses some of the most frequently asked questions about type 2 diabetes through a sample dialogue between a patient and a doctor.

Patient: What is type 2 Diabetes and how is it developed?

Doctor: Type 2 diabetes can be described as a complication in the metabolic processes characterized by a relative shortage of insulin and high levels of glucose in the blood (Barnett, 2011). It differs from type 1 diabetes where there is a complete deficiency of insulin caused by destruction of pancreatic islet cells.

In addition, type 2 diabetes is more common in adults unlike type 1 diabetes which is prevalent amongst young people. The typical symptoms of type 2 diabetes include: recurrent urination, excessive thirst, and persistent hunger (Wilson &Mehra, 1997).

Type 2 diabetes is caused by a mixture of lifestyle and hereditary factors. Even though some factors, like nutrition and obesity, are under individual control, others like femininity, old age, and genetics are not. Sedentary lifestyle, poor nutrition and stress are the major causes of Type 2 diabetes.

Particularly, excessive consumption of sugar and fats increases the risk of infection. Genetic factors have been linked to this condition. For instance, research indicates that if one identical twin is infected, there is a 90% probability of the other twin getting infected. Nutritional condition of a mother for the period of fetal growth can as well lead to this condition. Inadequate sleep is associated with Type 2 diabetes since it affects the process of metabolism (Hawley & Zierath, 2008).

Patient: How is type 2 Diabetes transmitted?

Doctor: Type 2 diabetes cannot be transmitted from one individual to another, since it is not caused by micro-organisms that can be spread. Instead, it is a health condition where the body is unable to create sufficient insulin to maintain the blood sugar level.

Nevertheless, a child from diabetic parents is likely to develop the complication due to genetic inheritance. According to Hanas & Fox (2007), there are some genes that may result in diabetes. As in 2011, research showed that there are more than thirty-six genes that increase the risk of type 2 diabetes infection.

These genes represent 10 per cent of the entire hereditary component of the complication. For instance, a gene referred to as TCF7L2 allele, increases the probability of diabetes occurrence by 1.5 times. It is the greatest threat amongst the genetic invariants. Children from diabetic parents are, therefore, likely to get infected since genes are transferrable from parents to the offspring.

Patient: How is type 2 Diabetes treated?

Doctor: The first step in the treatment of type 2 diabetes is consumption of healthy diet. This involves avoiding excessive consumption of foods that contain sugar and fats as they are likely to increase the levels of sugar in the blood. In addition, getting involved in physical activity and losing excessive weight are also important.

These management practices are recommended because they lower insulin resistance and improve the body cells’ response to insulin. Eating healthy food and physical activity also lower the level of sugar in the blood. There are also pills and other medications that can be injected when these lifestyle changes do not regulate the blood sugar (Roper, 2006).

Type2 diabetes pills function in different ways. Some pills work by lowering insulin resistance while some raise the level of insulin in the blood or decrease the rate of food digestion. Even though the non-insulin injected medicines for this condition work in complex ways, essentially, they lower the levels of blood glucose after injection.

Insulin injection treatment basically raises the insulin level in the blood. Another treatment for type 2 diabetes is weight loss surgery that is recommended for obese people. This treatment has been proved effective since most of the patients can maintain regular levels of sugar in their blood after surgery (Codario, 2011).

Multiple prescriptions can be applied in controlling the levels of blood sugar. Actually, combination treatment is a popular remedy for Type 2 diabetes. If a single therapy is not sufficient, a health care provider may prescribe two or more different kinds of pills.

For instance, individuals with type 2 diabetes have high fat levels in the blood and high blood pressure. Therefore, doctors can prescribe medicines for treatment of these conditions at the same time. The kind of medication prescribed depends on the health condition of the patient (Ganz, 2005).

Patient: What are the chances of survival?

Doctor: Diabetes is one of the major causes of deaths in the United States each year. Statistics indicates that it contributes to approximately 100,000 deaths every year. In the United States, there are over 20 million reported cases of diabetes, the majority being Type 2 diabetes. Proper remedy including change of lifestyle and medications is known to improve the health condition of a patient. If properly used together, lifestyle changes and medication can increase the chances of survival of a patient by up to 85 per cent (Rosenthal, 2009).

Barnett, H. (2011). Type 2 diabetes. Oxford: Oxford University Press.

Codario, A. (2011). Type 2 diabetes, pre-diabetes, and the metabolic syndrome. Totowa, N.J: Humana Press.

Ganz, M. (2005). Prevention of Type 2 Diabetes . Chichester: John Wiley & Sons.

Hanas, R., & Fox, C. (2007). Type 2 diabetes in adults of all ages. London: Class Health.

Hawley, A., & Zierath, R. (2008). Physical activity and type 2 diabetes: Therapeutic effects and mechanisms of action. Champaign, IL: Human Kinetics.

Roper, R. (2006). Type 2 diabetes: The adrenal gland disease : the cause of type 2 diabetes and a nutrition program that takes control! . Bloomington, IN: AuthorHouse.

Rosenthal, S. (2009). The Canadian type 2 diabetes sourcebook. Mississauga, Ont: J. Wiley & Sons Canada.

Wilson, L., & Mehra, V. (1997). Managing the patient with type II diabetes . Gaithersburg, Md: Aspen Publishers.

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Hypothesis and theory article, type 2 diabetes mellitus: a pathophysiologic perspective.

• Department of Medicine, Duke University, Durham, NC, United States

Type 2 Diabetes Mellitus (T2DM) is characterized by chronically elevated blood glucose (hyperglycemia) and elevated blood insulin (hyperinsulinemia). When the blood glucose concentration is 100 milligrams/deciliter the bloodstream of an average adult contains about 5–10 grams of glucose. Carbohydrate-restricted diets have been used effectively to treat obesity and T2DM for over 100 years, and their effectiveness may simply be due to lowering the dietary contribution to glucose and insulin levels, which then leads to improvements in hyperglycemia and hyperinsulinemia. Treatments for T2DM that lead to improvements in glycemic control and reductions in blood insulin levels are sensible based on this pathophysiologic perspective. In this article, a pathophysiological argument for using carbohydrate restriction to treat T2DM will be made.

Introduction

Type 2 Diabetes Mellitus (T2DM) is characterized by a persistently elevated blood glucose, or an elevation of blood glucose after a meal containing carbohydrate ( 1 ) ( Table 1 ). Unlike Type 1 Diabetes which is characterized by a deficiency of insulin, most individuals affected by T2DM have elevated insulin levels (fasting and/or post glucose ingestion), unless there has been beta cell failure ( 2 , 3 ). The term “insulin resistance” (IR) has been used to explain why the glucose levels remain elevated even though there is no deficiency of insulin ( 3 , 4 ). Attempts to determine the etiology of IR have involved detailed examinations of molecular and intracellular pathways, with attribution of cause to fatty acid flux, but the root cause has been elusive to experts ( 5 – 7 ).

Table 1 . Definition of type 2 diabetes mellitus.

How Much Glucose Is in the Blood?

Keeping in mind that T2DM involves an elevation of blood glucose, it is important to understand how much glucose is in the blood stream to begin with, and then the factors that influence the blood glucose—both exogenous and endogenous factors. The amount of glucose in the bloodstream is carefully controlled—approximately 5–10 grams in the bloodstream at any given moment, depending upon the size of the person. To calculate this, multiply 100 milligrams/deciliter × 1 gram/1,000 milligrams × 10 deciliters/1 liter × 5 liters of blood. The “zeros cancel” and you are left with 5 grams of glucose if the individual has 5 liters of blood. Since red blood cells represent about 40% of the blood volume, and the glucose is in equilibrium, there may be an extra 40% glucose because of the red blood cell reserve ( 8 ). Adding the glucose from the serum and red blood cells totals about 5–10 grams of glucose in the entire bloodstream.

Major Exogenous Factors That Raise the Blood Glucose

Dietary carbohydrate is the major exogenous factor that raises the blood glucose. When one considers that it is common for an American in 2021 to consume 200–300 grams of carbohydrate daily, and most of this carbohydrate is digested and absorbed as glucose, the body absorbs and delivers this glucose via the bloodstream to the cells while attempting to maintain a normal blood glucose level. Thinking of it in this way, if 200–300 grams of carbohydrates is consumed in a day, the bloodstream that holds 5–10 grams of glucose and has a concentration of 100 milligrams/deciliter, is the conduit through which 200,000–300,000 milligrams (200 grams = 200,000 milligrams) passes over the course of a day.

Major Endogenous Factors That Raise the Blood Glucose

There are many endogenous contributors that raise the blood glucose. There are at least 3 different hormones that increase glucose levels: glucagon, epinephrine, and cortisol. These hormones increase glucose levels by increasing glycogenolysis and gluconeogenesis ( 9 ). Without any dietary carbohydrate, the normal human body can generate sufficient glucose though the mechanism of glucagon secretion, gluconeogenesis, glycogen storage and glycogenolysis ( 10 ).

Major Exogenous Factors That Lower the Blood Glucose

A reduction in dietary carbohydrate intake can lower the blood glucose. An increase in activity or exercise usually lowers the blood glucose ( 11 ). There are many different medications, employing many mechanisms to lower the blood glucose. Medications can delay sucrose and starch absorption (alpha-glucosidase inhibitors), slow gastric emptying (GLP-1 agonists, DPP-4 inhibitors) enhance insulin secretion (sulfonylureas, meglitinides, GLP-1 agonists, DPP-4 inhibitors), reduce gluconeogenesis (biguanides), reduce insulin resistance (biguanides, thiazolidinediones), and increase urinary glucose excretion (SGLT-2 inhibitors). The use of medications will also have possible side effects.

Major Endogenous Factors That Lower the Blood Glucose

The major endogenous mechanism to lower the blood glucose is to deliver glucose into the cells (all cells can use glucose). If the blood glucose exceeds about 180 milligrams/deciliter, then loss of glucose into the urine can occur. The blood glucose is reduced by cellular uptake using glut transporters ( 12 ). Some cells have transporters that are responsive to the presence of insulin to activate (glut4), others have transporters that do not require insulin for activation. Insulin-responsive glucose transporters in muscle cells and adipose cells lead to a reduction in glucose levels—especially after carbohydrate-containing meals ( 13 ). Exercise can increase the glucose utilization in muscle, which then increases glucose cellular uptake and reduce the blood glucose levels. During exercise, when the metabolic demands of skeletal muscle can increase more than 100-fold, and during the absorptive period (after a meal), the insulin-responsive glut4 transporters facilitate the rapid entry of glucose into muscle and adipose tissue, thereby preventing large fluctuations in blood glucose levels ( 13 ).

Which Cells Use Glucose?

Glucose can used by all cells. A limited number of cells can only use glucose, and are “glucose-dependent.” It is generally accepted that the glucose-dependent cells include red blood cells, white blood cells, and cells of the renal papilla. Red blood cells have no mitochondria for beta-oxidation, so they are dependent upon glucose and glycolysis. White blood cells require glucose for the respiratory burst when fighting infections. The cells of the inner renal medulla (papilla) are under very low oxygen tension, so therefore must predominantly use glucose and glycolysis. The low oxygen tension is a result of the countercurrent mechanism of urinary concentration ( 14 ). These glucose-dependent cells have glut transporters that do not require insulin for activation—i.e., they do not need insulin to get glucose into the cells. Some cells can use glucose and ketones, but not fatty acids. The central nervous system is believed to be able to use glucose and ketones for fuel ( 15 ). Other cells can use glucose, ketones, and fatty acids for fuel. Muscle, even cardiac muscle, functions well on fatty acids and ketones ( 16 ). Muscle cells have both non-insulin-responsive and insulin-responsive (glut4) transporters ( 12 ).

Possible Dual Role of an Insulin-Dependent Glucose-Transporter (glut4)

A common metaphor is to think of the insulin/glut transporter system as a key/lock mechanism. Common wisdom states that the purpose of insulin-responsive glut4 transporters is to facilitate glucose uptake when blood insulin levels are elevated. But, a lock serves two purposes: to let someone in and/or to keep someone out . So, one of the consequences of the insulin-responsive glut4 transporter is to keep glucose out of the muscle and adipose cells, too, when insulin levels are low. The cells that require glucose (“glucose-dependent”) do not need insulin to facilitate glucose entry into the cell (non-insulin-responsive transporters). In a teleological way, it would “make no sense” for cells that require glucose to have insulin-responsive glut4 transporters. Cells that require glucose have glut1, glut2, glut3, glut5 transporters—none of which are insulin-responsive (Back to the key/lock metaphor, it makes no sense to have a lock on a door that you want people to go through). At basal (low insulin) conditions, most glucose is used by the brain and transported by non-insulin-responsive glut1 and glut3. So, perhaps one of the functions of the insulin-responsive glucose uptake in muscle and adipose to keep glucose OUT of the these cells at basal (low insulin) conditions, so that the glucose supply can be reserved for the tissue that is glucose-dependent (blood cells, renal medulla).

What Causes IR and T2DM?

The current commonly espoused view is that “Type 2 diabetes develops when beta-cells fail to secrete sufficient insulin to keep up with demand, usually in the context of increased insulin resistance.” ( 17 ). Somehow, the beta cells have failed in the face of insulin resistance. But what causes insulin resistance? When including the possibility that the environment may be part of the problem, is it possible that IR is an adaptive (protective) response to excess glucose availability? From the perspective that carbohydrate is not an essential nutrient and the change in foods in recent years has increased the consumption of refined sugar and flour, maybe hyperinsulinemia is the cause of IR and T2DM, as cells protect themselves from excessive glucose and insulin levels.

Insulin Is Already Elevated in IR and T2DM

Clinical experience of most physicians using insulin to treat T2DM over time informs us that an escalation of insulin dose is commonly needed to achieve glycemic control (when carbohydrate is consumed). When more insulin is given to someone with IR, the IR seems to get worse and higher levels of insulin are needed. I have the clinical experience of treating many individuals affected by T2DM and de-prescribing insulin as it is no longer needed after consuming a diet without carbohydrate ( 18 ).

Diets Without Carbohydrate Reverse IR and T2DM

When dietary manipulation was the only therapy for T2DM, before medications were available, a carbohydrate-restricted diet was used to treat T2DM ( 19 – 21 ). Clinical experience of obesity medicine physicians and a growing number of recent studies have demonstrated that carbohydrate-restricted diets reverse IR and T2DM ( 18 , 22 , 23 ). Other methods to achieve caloric restriction also have these effects, like calorie-restricted diets and bariatric surgery ( 24 , 25 ). There may be many mechanisms by which these approaches may work: a reduction in glucose, a reduction in insulin, nutritional ketosis, a reduction in metabolic syndrome, or a reduction in inflammation ( 26 ). Though there may be many possible mechanisms, let's focus on an obvious one: a reduction in blood glucose. Let's assume for a moment that the excessive glucose and insulin leads to hyperinsulinemia and this is the cause of IR. On a carbohydrate-restricted diet, the reduction in blood glucose leads to a reduction in insulin. The reduction in insulin leads to a reduction in insulin resistance. The reduction in insulin leads to lipolysis. The resulting lowering of blood glucose, insulin and body weight reverses IR, T2DM, AND obesity. These clinical observations strongly suggest that hyperinsulinemia is a cause of IR and T2DM—not the other way around.

What Causes Atherosclerosis?

For many years, the metabolic syndrome has been described as a possible cause of atherosclerosis, but there are no RCTs directly targeting metabolic syndrome, and the current drug treatment focuses on LDL reduction, so its importance remains controversial. A recent paper compared the relative importance of many risk factors in the prediction of the first cardiac event in women, and the most powerful predictors were diabetes, metabolic syndrome, smoking, hypertension and BMI ( 27 ). The connection between dietary carbohydrate and fatty liver is well-described ( 28 ). The connection between fatty liver and atherosclerosis is well-described ( 29 ). It is very possible that the transport of excess glucose to the adipose tissue via lipoproteins creates the particles that cause the atherosclerotic damage (small LDL) ( Figure 1 ) ( 30 – 32 ). This entire process of dietary carbohydrate leading to fatty liver, leading to small LDL, is reversed by a diet without carbohydrate ( 26 , 33 , 34 ).

Figure 1 . Key aspects of the interconnection between glucose and lipoprotein metabolism.

Reducing dietary carbohydrate in the context of a low carbohydrate, ketogenic diet reduces hyperglycemia and hyperinsulinemia, IR and T2DM. In the evaluation of an individual for a glucose abnormality, measure the blood glucose and insulin levels. If the insulin level (fasting or after a glucose-containing meal) is high, do not give MORE insulin—instead, use an intervention to lower the insulin levels. Effective ways to reduce insulin resistance include lifestyle, medication, and surgical therapies ( 23 , 35 ).

The search for a single cause of a complex problem is fraught with difficulty and controversy. I am not hypothesizing that excessive dietary carbohydrate is the only cause of IR and T2DM, but that it is a cause, and quite possibly the major cause. How did such a simple explanation get overlooked? I believe it is very possible that the reductionistic search for intracellular molecular mechanisms of IR and T2DM, the emphasis on finding pharmaceutical (rather than lifestyle) treatments, the emphasis on the treatment of high total and LDL cholesterol, and the fear of eating saturated fat may have misguided a generation of researchers and clinicians from the simple answer that dietary carbohydrate, when consumed chronically in amounts that exceeds an individual's ability to metabolize them, is the most common cause of IR, T2DM and perhaps even atherosclerosis.

While there has historically been a concern about the role of saturated fat in the diet as a cause of heart disease, most nutritional experts now cite the lack of evidence implicating dietary saturated fat as the reason for lack of concern of it in the diet ( 36 ).

The concept of comparing medications that treat IR by insulin-sensitizers or by providing insulin itself was tested in the Bari-2D study ( 37 ). Presumably in the context of consuming a standard American diet, this study found no significant difference in death rates or major cardiovascular events between strategies of insulin sensitization or insulin provision.

While lifestyle modification may be ideal to prevent or cure IR and T2DM, for many people these changes are difficult to learn and/or maintain. Future research should be directed toward improving adherence to all effective lifestyle or medication treatments. Future research is also needed to assess the effect of carbohydrate restriction on primary or secondary prevention of outcomes of cardiovascular disease.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author Contributions

The author confirms being the sole contributor of this work and has approved it for publication.

Conflict of Interest

EW receives royalties from popular diet books and is founder of a company based on low-carbohydrate diet principles (Adapt Your Life, Inc.).

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: type 2 diabetes, insulin resistance, pre-diabetes, carbohydrate-restricted diets, hyperinsulinemia, hyperglycemia

Citation: Westman EC (2021) Type 2 Diabetes Mellitus: A Pathophysiologic Perspective. Front. Nutr. 8:707371. doi: 10.3389/fnut.2021.707371

Received: 09 May 2021; Accepted: 20 July 2021; Published: 10 August 2021.

Reviewed by:

Copyright © 2021 Westman. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Eric C. Westman, ewestman@duke.edu

This article is part of the Research Topic

Carbohydrate-restricted Nutrition and Diabetes Mellitus

• Patient Care & Health Information
• Diseases & Conditions
• Type 2 diabetes

Type 2 diabetes is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel. That sugar also is called glucose. This long-term condition results in too much sugar circulating in the blood. Eventually, high blood sugar levels can lead to disorders of the circulatory, nervous and immune systems.

In type 2 diabetes, there are primarily two problems. The pancreas does not produce enough insulin — a hormone that regulates the movement of sugar into the cells. And cells respond poorly to insulin and take in less sugar.

Type 2 diabetes used to be known as adult-onset diabetes, but both type 1 and type 2 diabetes can begin during childhood and adulthood. Type 2 is more common in older adults. But the increase in the number of children with obesity has led to more cases of type 2 diabetes in younger people.

There's no cure for type 2 diabetes. Losing weight, eating well and exercising can help manage the disease. If diet and exercise aren't enough to control blood sugar, diabetes medications or insulin therapy may be recommended.

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Symptoms of type 2 diabetes often develop slowly. In fact, you can be living with type 2 diabetes for years and not know it. When symptoms are present, they may include:

• Increased thirst.
• Frequent urination.
• Increased hunger.
• Unintended weight loss.
• Blurred vision.
• Slow-healing sores.
• Frequent infections.
• Numbness or tingling in the hands or feet.
• Areas of darkened skin, usually in the armpits and neck.

When to see a doctor

See your health care provider if you notice any symptoms of type 2 diabetes.

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Type 2 diabetes is mainly the result of two problems:

• Cells in muscle, fat and the liver become resistant to insulin As a result, the cells don't take in enough sugar.
• The pancreas can't make enough insulin to keep blood sugar levels within a healthy range.

Exactly why this happens is not known. Being overweight and inactive are key contributing factors.

How insulin works

Insulin is a hormone that comes from the pancreas — a gland located behind and below the stomach. Insulin controls how the body uses sugar in the following ways:

• Sugar in the bloodstream triggers the pancreas to release insulin.
• Insulin circulates in the bloodstream, enabling sugar to enter the cells.
• The amount of sugar in the bloodstream drops.
• In response to this drop, the pancreas releases less insulin.

The role of glucose

Glucose — a sugar — is a main source of energy for the cells that make up muscles and other tissues. The use and regulation of glucose includes the following:

• Glucose comes from two major sources: food and the liver.
• Glucose is absorbed into the bloodstream, where it enters cells with the help of insulin.
• The liver stores and makes glucose.
• When glucose levels are low, the liver breaks down stored glycogen into glucose to keep the body's glucose level within a healthy range.

In type 2 diabetes, this process doesn't work well. Instead of moving into the cells, sugar builds up in the blood. As blood sugar levels rise, the pancreas releases more insulin. Eventually the cells in the pancreas that make insulin become damaged and can't make enough insulin to meet the body's needs.

Risk factors

Factors that may increase the risk of type 2 diabetes include:

• Weight. Being overweight or obese is a main risk.
• Fat distribution. Storing fat mainly in the abdomen — rather than the hips and thighs — indicates a greater risk. The risk of type 2 diabetes is higher in men with a waist circumference above 40 inches (101.6 centimeters) and in women with a waist measurement above 35 inches (88.9 centimeters).
• Inactivity. The less active a person is, the greater the risk. Physical activity helps control weight, uses up glucose as energy and makes cells more sensitive to insulin.
• Family history. An individual's risk of type 2 diabetes increases if a parent or sibling has type 2 diabetes.
• Race and ethnicity. Although it's unclear why, people of certain races and ethnicities — including Black, Hispanic, Native American and Asian people, and Pacific Islanders — are more likely to develop type 2 diabetes than white people are.
• Blood lipid levels. An increased risk is associated with low levels of high-density lipoprotein (HDL) cholesterol — the "good" cholesterol — and high levels of triglycerides.
• Age. The risk of type 2 diabetes increases with age, especially after age 35.
• Prediabetes. Prediabetes is a condition in which the blood sugar level is higher than normal, but not high enough to be classified as diabetes. Left untreated, prediabetes often progresses to type 2 diabetes.
• Pregnancy-related risks. The risk of developing type 2 diabetes is higher in people who had gestational diabetes when they were pregnant and in those who gave birth to a baby weighing more than 9 pounds (4 kilograms).
• Polycystic ovary syndrome. Having polycystic ovary syndrome — a condition characterized by irregular menstrual periods, excess hair growth and obesity — increases the risk of diabetes.

Complications

Type 2 diabetes affects many major organs, including the heart, blood vessels, nerves, eyes and kidneys. Also, factors that increase the risk of diabetes are risk factors for other serious diseases. Managing diabetes and controlling blood sugar can lower the risk for these complications and other medical conditions, including:

• Heart and blood vessel disease. Diabetes is associated with an increased risk of heart disease, stroke, high blood pressure and narrowing of blood vessels, a condition called atherosclerosis.
• Nerve damage in limbs. This condition is called neuropathy. High blood sugar over time can damage or destroy nerves. That may result in tingling, numbness, burning, pain or eventual loss of feeling that usually begins at the tips of the toes or fingers and gradually spreads upward.
• Other nerve damage. Damage to nerves of the heart can contribute to irregular heart rhythms. Nerve damage in the digestive system can cause problems with nausea, vomiting, diarrhea or constipation. Nerve damage also may cause erectile dysfunction.
• Kidney disease. Diabetes may lead to chronic kidney disease or end-stage kidney disease that can't be reversed. That may require dialysis or a kidney transplant.
• Eye damage. Diabetes increases the risk of serious eye diseases, such as cataracts and glaucoma, and may damage the blood vessels of the retina, potentially leading to blindness.
• Skin conditions. Diabetes may raise the risk of some skin problems, including bacterial and fungal infections.
• Slow healing. Left untreated, cuts and blisters can become serious infections, which may heal poorly. Severe damage might require toe, foot or leg amputation.
• Hearing impairment. Hearing problems are more common in people with diabetes.
• Sleep apnea. Obstructive sleep apnea is common in people living with type 2 diabetes. Obesity may be the main contributing factor to both conditions.
• Dementia. Type 2 diabetes seems to increase the risk of Alzheimer's disease and other disorders that cause dementia. Poor control of blood sugar is linked to a more rapid decline in memory and other thinking skills.

Healthy lifestyle choices can help prevent type 2 diabetes. If you've received a diagnosis of prediabetes, lifestyle changes may slow or stop the progression to diabetes.

A healthy lifestyle includes:

• Eating healthy foods. Choose foods lower in fat and calories and higher in fiber. Focus on fruits, vegetables and whole grains.
• Getting active. Aim for 150 or more minutes a week of moderate to vigorous aerobic activity, such as a brisk walk, bicycling, running or swimming.
• Losing weight. If you are overweight, losing a modest amount of weight and keeping it off may delay the progression from prediabetes to type 2 diabetes. If you have prediabetes, losing 7% to 10% of your body weight may reduce the risk of diabetes.
• Avoiding long stretches of inactivity. Sitting still for long periods of time can increase the risk of type 2 diabetes. Try to get up every 30 minutes and move around for at least a few minutes.

For people with prediabetes, metformin (Fortamet, Glumetza, others), a diabetes medication, may be prescribed to reduce the risk of type 2 diabetes. This is usually prescribed for older adults who are obese and unable to lower blood sugar levels with lifestyle changes.

More Information

• Diabetes prevention: 5 tips for taking control
• Professional Practice Committee: Standards of Medical Care in Diabetes — 2020. Diabetes Care. 2020; doi:10.2337/dc20-Sppc.
• Diabetes mellitus. Merck Manual Professional Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/diabetes-mellitus-dm. Accessed Dec. 7, 2020.
• Melmed S, et al. Williams Textbook of Endocrinology. 14th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Dec. 3, 2020.
• Diabetes overview. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/all-content. Accessed Dec. 4, 2020.
• AskMayoExpert. Type 2 diabetes. Mayo Clinic; 2018.
• Feldman M, et al., eds. Surgical and endoscopic treatment of obesity. In: Sleisenger and Fordtran's Gastrointestinal and Liver Disease: Pathophysiology, Diagnosis, Management. 11th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed Oct. 20, 2020.
• Hypersmolar hyperglycemic state (HHS). Merck Manual Professional Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/hyperosmolar-hyperglycemic-state-hhs. Accessed Dec. 11, 2020.
• Diabetic ketoacidosis (DKA). Merck Manual Professional Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/diabetic-ketoacidosis-dka. Accessed Dec. 11, 2020.
• Hypoglycemia. Merck Manual Professional Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/hypoglycemia. Accessed Dec. 11, 2020.
• 6 things to know about diabetes and dietary supplements. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/tips/things-to-know-about-type-diabetes-and-dietary-supplements. Accessed Dec. 11, 2020.
• Type 2 diabetes and dietary supplements: What the science says. National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/providers/digest/type-2-diabetes-and-dietary-supplements-science. Accessed Dec. 11, 2020.
• Preventing diabetes problems. National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/all-content. Accessed Dec. 3, 2020.
• Schillie S, et al. Prevention of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recommendations and Reports. 2018; doi:10.15585/mmwr.rr6701a1.
• Caffeine: Does it affect blood sugar?
• GLP-1 agonists: Diabetes drugs and weight loss
• Hyperinsulinemia: Is it diabetes?
• Medications for type 2 diabetes

Associated Procedures

• Bariatric surgery
• Endoscopic sleeve gastroplasty
• Gastric bypass (Roux-en-Y)
• Glucose tolerance test

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Essay on Diabetes for Students and Children

500+ words essay on diabetes.

Diabetes is a very common disease in the world. But people may never realize, how did they get diabetes and what will happen to them and what will they go through. It may not be your problem but you have to show respect and care for the one who has diabetes. It can help them and also benefited you to know more about it and have a better understanding of it. Diabetes is a metabolic disorder which is identified by the high blood sugar level. Increased blood glucose level damages the vital organs as well as other organs of the human’s body causing other potential health ailments.

Types of Diabetes

Diabetes  Mellitus can be described in two types:

Description of two types of Diabetes Mellitus are as follows

1) Type 1 Diabetes Mellitus is classified by a deficiency of insulin in the blood. The deficiency is caused by the loss of insulin-producing beta cells in the pancreas. This type of diabetes is found more commonly in children. An abnormally high or low blood sugar level is a characteristic of this type of Diabetes.

Most patients of type 1 diabetes require regular administration of insulin. Type 1 diabetes is also hereditary from your parents. You are most likely to have type 1 diabetes if any of your parents had it. Frequent urination, thirst, weight loss, and constant hunger are common symptoms of this.

2) Type 2 Diabetes Mellitus is characterized by the inefficiency of body tissues to effectively respond to insulin because of this it may be combined by insulin deficiency. Type 2 diabetes mellitus is the most common type of diabetes in people.

People with type 2 diabetes mellitus take medicines to improve the body’s responsiveness to insulin or to reduce the glucose produced by the liver. This type of diabetes mellitus is generally attributed to lifestyle factors like – obesity, low physical activity, irregular and unhealthy diet, excess consumption of sugar in the form of sweets, drinks, etc.

Get the huge list of more than 500 Essay Topics and Ideas

Causes of Diabetes

By the process of digestion, food that we eat is broken down into useful compounds. One of these compounds is glucose, usually referred to as blood sugar. The blood performs the job of carrying glucose to the cells of the body. But mere carrying the glucose to the cells by blood isn’t enough for the cells to absorb glucose.

This is the job of the Insulin hormone. Pancreas supply insulin in the human body. Insulin acts as a bridge for glucose to transit from blood to the body cells. The problem arises when the pancreas fails to produce enough insulin or the body cells for some reason do not receive the glucose. Both the cases result in the excess of glucose in the blood, which is referred to as Diabetes or Diabetes Mellitus.

Symptoms of Diabetes

Most common symptoms of diabetes are fatigue, irritation, stress, tiredness, frequent urination and headache including loss of strength and stamina, weight loss, increase in appetite, etc.

Levels of Diabetes

There are two types of blood sugar levels – fasting blood sugar level and postprandial blood sugar level. The fasting sugar level is the sugar level that we measure after fasting for at least eight hours generally after an overnight fast. Blood sugar level below 100 mg/dL before eating food is considered normal. Postprandial glucose level or PP level is the sugar level which we measure after two hours of eating.

The PP blood sugar level should be below 140 mg/dL, two hours after the meals. Though the maximum limit in both the cases is defined, the permissible levels may vary among individuals. The range of the sugar level varies with people. Different people have different sugar level such as some people may have normal fasting sugar level of 60 mg/dL while some may have a normal value of 90 mg/dL.

Effects of Diabetes

Diabetes causes severe health consequences and it also affects vital body organs. Excessive glucose in blood damages kidneys, blood vessels, skin resulting in various cardiovascular and skin diseases and other ailments. Diabetes damages the kidneys, resulting in the accumulation of impurities in the body.

It also damages the heart’s blood vessels increasing the possibility of a heart attack. Apart from damaging vital organs, diabetes may also cause various skin infections and the infection in other parts of the body. The prime cause of all type of infections is the decreased immunity of body cells due to their inability to absorb glucose.

Diabetes is a serious life-threatening disease and must be constantly monitored and effectively subdued with proper medication and by adapting to a healthy lifestyle. By following a healthy lifestyle, regular checkups, and proper medication we can observe a healthy and long life.

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Acknowledgments

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In a special series of the ADA Journals' podcast Diabetes Core Update , host Dr. Neil Skolnik interviews special guests and authors of this clinical compendium issue. Listen now at Special Podcast Series: Focus on Diabetes or view the interviews on YouTube at A Practice Guide to Diabetes-Related Eye Care .

Summary and Conclusion

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Thomas W. Gardner; Summary and Conclusion. ADA Clinical Compendia 1 July 2022; 2022 (3): 20. https://doi.org/10.2337/db20223-20

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Diabetes is a multifactorial disease process, and its long-term management requires the active involvement of people with diabetes and their families, as well as a large multidisciplinary care team to ensure optimal health, quality of life, and productivity. Keeping up with new medications, emerging technology, and evolving treatment recommendations can be challenging, and the language and care processes commonly used by practitioners in one discipline may be less familiar to other diabetes care professionals.

In the realm of diabetes-related eye care, our ability to prevent the progression of diabetes-related retinal disease and thereby preserve vision has never been greater. However, far too many people with diabetes still are not receiving appropriate screening to identify eye disease early and ensure its timely treatment.

It is our hope that this compendium has provided information and guidance to improve communication and encourage collaboration between eye care professionals and other diabetes health care professionals and allow them to more effectively cooperate to reduce barriers to care and improve both the ocular and systemic health of their shared patients.

Editorial and project management services were provided by Debbie Kendall of Kendall Editorial in Richmond, VA.

Dualities of Interest

B.A.C. is a consultant for Genentech and Regeneron. S.A.R. is a speaker for Allergan, Inc., and VSP Vision Care. No other potential conflicts of interest relevant to this compendium were reported.

Author Contributions

All authors researched and wrote their respective sections. Lead author T.W.G. reviewed all content and is the guarantor of this work.

The opinions expressed are those of the authors and do not necessarily reflect those of VSP Vision Care, Regeneron, or the American Diabetes Association. The content was developed by the authors and does not represent the policy or position of the American Diabetes Association, any of its boards or committees, or any of its journals or their editors or editorial boards.

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Type 2 Diabetes - Free Essay Examples And Topic Ideas

Type 2 Diabetes is a chronic condition that affects the way the body processes blood sugar (glucose). Essays could explore the risk factors, prevention strategies, and management of Type 2 Diabetes. Discussions on its socioeconomic impact and the challenges in managing this condition in various healthcare settings could also be enlightening. We have collected a large number of free essay examples about Type 2 Diabetes you can find at PapersOwl Website. You can use our samples for inspiration to write your own essay, research paper, or just to explore a new topic for yourself.

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Diabetes is a type of illness which is metabolic in nature leading to deficiencies in insulin. There are 2 types of diabetes (Type 1 and Type 2). Type 1 Diabetes (5-10% with diabetes), is known to be dependent in insulin, and would usually occur during childhood. This type of diabetes is a result of an autoimmune obliteration of Pancreatic ??-cell function. Another is Type 2 or the non-insulin dependent, correlates for 90-95% of those people with the diabetes. The onset […]

Diabetes Type 2: a Chronic Disease

Diabetes type 2 is a chronic disease which is widespread around the world. According to Mayo Clinic, type 2 diabetes is the most common type of diabetes that occurs due to high blood sugar and the lack of ability of the body to use insulin properly or make enough of it. Diabetes type 2 does not have a cure. However, it can be prevented or delayed. The most common causes of diabetes relate to people's lifestyle and their genetics. Physical […]

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Type 2 diabetes

Affiliations.

• 1 Diabetes Research Centre, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Leicester, UK.
• 2 Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, South Korea.
• 3 Family Medicine Department, Korle Bu Teaching Hospital, Accra Ghana and Community Health Department, University of Ghana Medical School, Accra, Ghana.
• 4 Diabetes Research Centre, University of Leicester and the Leicester NIHR Biomedical Research Centre, Leicester General Hospital, Leicester, UK. Electronic address: [email protected].
• PMID: 36332637
• DOI: 10.1016/S0140-6736(22)01655-5

Type 2 diabetes accounts for nearly 90% of the approximately 537 million cases of diabetes worldwide. The number affected is increasing rapidly with alarming trends in children and young adults (up to age 40 years). Early detection and proactive management are crucial for prevention and mitigation of microvascular and macrovascular complications and mortality burden. Access to novel therapies improves person-centred outcomes beyond glycaemic control. Precision medicine, including multiomics and pharmacogenomics, hold promise to enhance understanding of disease heterogeneity, leading to targeted therapies. Technology might improve outcomes, but its potential is yet to be realised. Despite advances, substantial barriers to changing the course of the epidemic remain. This Seminar offers a clinically focused review of the recent developments in type 2 diabetes care including controversies and future directions.

Copyright © 2022 Elsevier Ltd. All rights reserved.

Publication types

• Diabetes Mellitus, Type 2* / drug therapy
• Diabetes Mellitus, Type 2* / epidemiology
• Pharmacogenetics
• Precision Medicine
• Young Adult

A .gov website belongs to an official government organization in the United States.

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• Risk Factors
• Providing Care
• Living with Diabetes
• Clinical Guidance
• DSMES for Health Care Providers
• Prevent Type 2 Diabetes: Talking to Your Patients About Lifestyle Change
• Employers and Insurers
• Community-based Organizations (CBOs)
• Toolkits for Diabetes Educators and Community Health Workers
• National Diabetes Statistics Report
• Reports and Publications
• Data and Statistics
• Current Research Projects
• National Diabetes Prevention Program
• State, Local, and National Partner Diabetes Programs for Public Health
• Diabetes Self-Management Education and Support (DSMES) Toolkit

About Type 2 Diabetes

• About 1 in 10 Americans has diabetes; most have type 2.
• More children, teens, and young adults are developing type 2 diabetes than in the past.
• Type 2 diabetes can be prevented or delayed with lifestyle changes.

More than 38 million Americans have diabetes (about 1 in 10), and about 90% to 95% of them have type 2 diabetes. Type 2 diabetes most often develops in people 45 or older, but more and more children, teens , and young adults are also developing it.

Type 2 diabetes symptoms often develop over several years and can go on for a long time without being noticed. Sometimes there aren't any noticeable symptoms at all.

Risk factors

You're at risk for type 2 diabetes if you:

• Have prediabetes.
• Have overweight.
• Are 45 or older.
• Have a parent, brother, or sister with type 2 diabetes.
• Are physically active less than 3 times a week.
• Have ever had gestational diabetes (diabetes during pregnancy) or given birth to a baby who weighed 9 pounds or more.
• Are an African American, Hispanic or Latino, American Indian, or Alaska Native person. Some Pacific Islander people and Asian American people are also at higher risk.

If you have non-alcoholic fatty liver disease you may also be at risk for type 2 diabetes.

You can prevent or delay type 2 diabetes with proven lifestyle changes. These include losing weight if you have overweight, eating a healthy diet , and getting regular physical activity .

Insulin is a hormone made by your pancreas. It acts like a key to let blood sugar into cells in your body for use as energy. If you have type 2 diabetes, cells don't respond normally to insulin. This is called insulin resistance .

Your pancreas makes more insulin to try to get cells to respond. Over time your pancreas can't keep up, and your blood sugar rises, setting the stage for prediabetes and type 2 diabetes.

High blood sugar is damaging to the body. It can cause other serious health problems, such as heart disease , vision loss , and kidney disease .

A simple blood test will let you know if you have diabetes. If you've gotten your blood sugar tested at a health fair or pharmacy, follow up at a clinic or doctor's office to make sure the results are accurate.

Managing diabetes

Diabetes is managed mostly by you, with support from your health care team, family, and other important people in your life. Managing diabetes can be challenging, but everything you do to improve your health is worth it!

You may be able to manage your diabetes with healthy eating and being active. Or your doctor may prescribe insulin or other diabetes medicines to help manage your blood sugar and avoid complications . You'll still need to eat healthy and be active if you take insulin or other medicines.

Ask your doctor how often to check your blood sugar and what your target blood sugar levels should be. Keeping your blood sugar levels close to target will help you prevent or delay diabetes complications.

Stress is a part of life, but it can make managing diabetes harder. Regular physical activity, getting enough sleep, and relaxation exercises can help. Talk to your doctor and diabetes educator about these and other ways you can manage stress.

Make regular appointments with your health care team to be sure you're on track with your treatment plan. You can also find out about new ideas and strategies if needed.

Whether you were just diagnosed or have had diabetes for some time, meeting with a diabetes educator for support and guidance is a great idea.

Diabetes is a chronic disease that affects how your body turns food into energy. About 1 in 10 Americans has diabetes.

For Everyone

Health care providers, public health.

Home — Essay Samples — Nursing & Health — Diabetes — The Type 1 and Type 2 Diabetes

The Type 1 and Type 2 Diabetes

• Categories: Diabetes

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Published: Jan 29, 2019

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• Published: 14 May 2024

Association of type 2 diabetes with family history of diabetes, diabetes biomarkers, mental and physical disorders in a Kenyan setting

• David M. Ndetei 1 , 2 , 3 ,
• Victoria Mutiso 2 , 3 ,
• Christine Musyimi 2 , 3 ,
• Pascalyne Nyamai 2 , 3 ,
• Cathy Lloyd 4 &
• Norman Sartorius 5  

Scientific Reports volume  14 , Article number:  11037 ( 2024 ) Cite this article

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• Endocrinology
• Risk factors

This study aimed to determine the degree of family relations and associated socio-demographics characteristics, clinical/physical and mental disorders in type 2 diabetes mellitus in a Kenyan diabetes clinic. This study was part of a large multicentre study whose protocol and results had been published. It took place at the outpatient diabetes clinic at a County Teaching and Referral Hospital in South East Kenya involving 182 participants. We used a socio-demographic questionnaire, the Hamilton Depression (HAM-D) and PHQ-9 rating scales for depression, the MINI International Neuropsychiatric Interview (MINI; V5 or V6) for DSM-5 diagnoses, the WHO-5 Well-being scale and Problem Areas in Diabetes Scale (PAID). We extracted from the notes all physical conditions. We enquired about similar conditions in 1st and 2nd degree relatives. Descriptive, Chi-square test, Fisher’s exact test, one way ANOVA, and Multinomial logistic regression analysis were conducted to test achievements of our specific aims. Of the 182 patients who participated in the study, 45.1% (82/182) reported a family history of diabetes. Conditions significantly ( p  < 0.05) associated with a degree of family history of diabetes were retinopathy, duration of diabetes (years), hypertension, and depressive disorder. On average 11.5% (21/182) scored severe depression (≥ 10) on PHQ-9 and 85.2% (115/182) scored good well-being (≥ 13 points). All DSM-5 psychiatric conditions were found in the 182 patients in varying prevalence regardless of relations. In addition, amongst the 182 patients, the highest prevalence was poor well-being on the WHO quality of life tool. This was followed by post-traumatic disorders (current), suicidality, and psychotic lifetime on DSM-5. The least prevalent on DSM-5 was eating disorders. Some type 2 diabetes mellitus physical disorders and depression have increased incidence in closely related patients. Overall, for all the patients, the prevalence of all DSM-5 diagnoses varied from 0.5 to 9.9%.

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Introduction.

Family history is a non-modifiable risk factor for diabetes 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 . The risk of developing type 2 diabetes mellitus (T2DM) increases approximately two to four times when either or both parents have T2DM 5 . Between 60 and 68.8% of diabetes patients have at least one family member with a history of diabetes 2 , 6 . Paternal history is significantly associated with higher chances of having T2DM 1 . An early age onset of T2DM is more likely if a family member had also an early onset of diabetes 2 , 8 , 9 , 10 .

A positive family history of diabetes is associated with increased levels of obesity, impaired glucose tolerance, fasting triglycerides, hemoglobin AIc (HbA1c), insulin dose per kilogram, lower levels of high-density lipoprotein cholesterol 3 , 8 , 11 , 12 , a greater waist to hip ratio as well as greater body mass index (BMI) 13 and a high prevalence of diabetes complications, particularly retinopathy and dyslipidemia compared to those without a relative with diabetes 9 . More specifically and in addition, there is an impact on leptin, (a hormone that regulates fat storage in the body) 14 , a high prevalence of hypertension, and lower low-density lipoprotein (LDL) cholesterol levels in those with fathers with T2DM as opposed to those with mothers with diabetes 15 . Various physical conditions are associated with diabetes. These include cardiovascular diseases 16 , 17 , hypertension 18 , thyroid abnormality, and diabetes complications such as retinopathy, neuropathy, and stroke 17 , 19 , 20 as well as high levels of biomarkers such as hemoglobin AIc (HbAIc) and cholesterol 21 .

Mental disorders such as schizophrenia, major depressive disorder, and bipolar disorder are associated with a family history of diabetes 22 , 23 , 24 . The risk of developing diabetes is three times higher in individuals with schizophrenia than in the normal population 23 . Siblings of schizophrenic parents are more likely to develop T2DM than those whose parents do not have schizophrenia 25 .

T2DM is also associated with anxiety, Post Traumatic Stress Disorder (PTSD), depression 26 , 27 , 28 , and eating disorders 29 , 30 , 31 . Research in this area is lacking in a Kenyan setting and is urgently required in order to inform clinical practice and potential community-based interventions.

Studies in African countries on the association between diabetes and family history have largely confirmed the global trends, showing an increased frequency of T2DM in persons with a family history of diabetes and an early onset of diabetes between 18 and 30 years 32 , 33 , 34 , 35 . Significantly higher blood glucose levels have been reported in those with a maternal family history of diabetes than in those without such a history 36 . Kenyan studies have found that people with T2DM are likely to have a positive family history specifically a first-degree relative and are also likely to develop diabetes early in life 37 , 38 . First-degree relations include an individual's biological parents, siblings, and children. Second-degree relatives include an individual's grandparents, grandchildren, uncles, aunts, nephews, nieces, and half-siblings. No study in Kenya has examined how physical conditions and mental disorders are comorbid in patients with T2DM or has examined the degree of family relations and how these vary with socio-demographics, measures of well-being, stress levels related to diabetes, and the prevalence of DSM-5 diagnoses in the Type 2 Diabetes. This information would inform an integrated approach to management. This study sought to fill these gaps.

The primary objective of this study was to determine the degree of family relations and associated socio-demographic characteristics, physical and mental disorders in people with T2DM. The secondary objective was to determine the overall prevalences of physical disorders and mental disorders in T2DM regardless of family relations.

The primary specific aims were:

To determine the relationships between social demographics in T2DM in different degrees of family relations

To determine the patterns of physical disorders and physical characteristics of T2DM in different degrees of family relations

To determine the mental health and disorders associated with T2DM in different degrees of family relations

To determine the independent predictors of T2DM in different degrees of family relations

The secondary specific aims were:

To determine the overall prevalence of physical disorders in T2DM

To determine the overall prevalence of mental disorders (stress, wellbeing, and psychiatric disorders) in T2DM

To determine the independent predictors of depression in T2DM

Study design and setting

This study was part of a larger multicentre study whose protocol has been published previously 39 . It took place between September 2013 and May 2015 at an outpatient diabetes clinic in one of the County Teaching and Referral Hospital in South East Kenya approximately 60 Kilometres from Nairobi. The clinic is run by a diabetologist and a team trained in diabetes management, offering psychoeducation, and counselling.

Study participants

Between September 2013 and May 2015, a sample of consecutive outpatient clinic attendees with T2DM were invited to participate in the study. Inclusion criteria were adults aged 18–65 with T2DM diagnosed at least 12 months earlier and able to give informed consent. Exclusion criteria included: communication and cognitive difficulties; life threatening or serious conditions in the previous 6 months and being an inpatient (as this may have indicated a serious condition); pregnant women or in the first 6 months post-partum clinic; substance use dependency or a current schizophrenic illness. All patients who met the inclusion criteria and did not have any exclusion criteria consented to the study and were included.

The trained research assistant completed a form that contained information from the medical records such as age, duration of diabetes, and presence/history of diabetes complications i.e. cardiovascular disease, retinopathy, peripheral neuropathy, peripheral vascular disease, and renal disease and associated disorders as well as the most recent measurement of blood pressure, HbA1c, height and weight.

For this study, we recorded the family history of T2DM in the following:

History of diabetes in 1st degree relatives (parent or sibling)

History of diabetes in 2nd degree relatives (grandparents, aunt, uncle, and cousin)

History of diabetes in both 1st and 2nd degree relatives

Study instruments

A standardised template for extracting information from the medical records on socio-demographic data and various medical complications known to be associated with T2DM, and laboratory indicators of T2DM was utilised. We also enquired about the history of smoking.

The following psychometric instruments were administered by a trained research assistant: (i) the Patient Health Questionnaire (PHQ-9), (ii) the Hamilton Depression (HAM-D) rating scale, (iii) the WHO-5 wellbeing scale, (iv) the Problem Areas in Diabetes Scale (PAID) and (v) the MINI International Neuropsychiatric Interview (MINI; V5 or V6). The psychometric properties of these instruments have been described in the protocol for this study 39 but also summarized here for quick reference. The PHQ-9 consists of 9 items on a 4-point Likert-type scale (0 = not at all; 1 = several days; 2 = more than half the days; 3 = nearly every day) with a total score ranging from 0–27. It has good psychometric properties and has been used extensively in many culturally diverse countries 40 . PHQ-9 scores with cut-off points of 1, 5, 10, 15, and 20 represent minimal, mild, moderate, moderately severe, and severe depression, respectively. Moderate to severe depressive symptomatology was defined as PHQ-9 scores >  10 , as this was a research study rather than clinical practice where a significant level of symptoms would usually be considered as PHQ-9 scores above 15 41 . The Hamilton Depression (HAM-D) Rating Scale has been considered a gold standard in depression studies and a preferred scale in the evaluation of depression treatment 42 .

It is the most widely employed depression scale on a global scale 43 and has been administered to various patient populations ranging from psychiatric, medical, and other research settings 44 . The HAM-D Rating Scale is a 17-item tool that takes 20–30 min to administer and scored between 0 and 4 points. Scores of 0–7 indicate normal, 8–16 indicate mild depression, 17–23 moderate depression, and counts over 24 are indicative of severe depression 42 . It has good psychometric properties with sufficient reliability (internal, inter-rater, and retest safety) and efficacy (convergent, discriminant, and predictive validity) 44 . The WHO-5 wellbeing scale is a 5-item questionnaire that measures a person’s overall psychological wellbeing 45 . The items are ‘I have felt cheerful and in good spirits’, ‘I have felt calm and relaxed’, ‘I have felt active and vigorous’, ‘I woke up feeling fresh and rested’, and ‘My daily life has been filled with things that interest me’. Poor wellbeing was defined as WHO-5 scores <  13 . The PAID is a 20-item questionnaire which measures the extent of diabetes-related emotional distress 46 . Items include ‘feeling overwhelmed with your diabetes’ and ‘feelings of guilt or anxiety when you get off track with your diabetes management’. Moderate-severe levels of diabetes-related distress are defined as scores (standardized to 100) >  40 46 . The MINI has been widely used in a range of different populations—including those with serious illnesses and in community surveys and is a reliable diagnostic tool according to DSM-V criteria 47 . It can be administrated by trained non-mental health specialists. Individuals diagnosed with depression (or other psychiatric disorders such as anxiety disorders) were advised to consult their physician for further assessment and treatment with a view to referral to the hospital psychiatric services. If any individual indicated suicidality (question 9 on the PHQ-9) immediate referral was made to the psychiatric service at the hospital.

Ethical consideration

Ethical approval was granted by the Kenyatta National Hospital—University of Nairobi (KNH-UoN) Ethics and Research Committee (ERC) (#P470/09/2013). All methods were performed in accordance with relevant guidelines and regulations as per the World Medical Association Declaration of Helsinki—ethical principles for medical research involving human subjects. Informed written consent was obtained from participants. For illiterate participants, informed written consent was obtained from their guardian/legally authorised representative.

Data analysis

This was performed using SPSS version 21 (IBM, Chicago, IL). All continuous variables were tested for normality using the Shapiro–Wilk test. Basic descriptive statistics in the form of frequency, percentage, mean, and standard deviation were carried out. The chi-square test or Fisher's exact test were used where appropriate to analyze the difference in the prevalence between family history of diabetes across different categories of socio-demographics, physical and mental disorder variables. Differences in levels of continuous variables were examined using the one way ANOVA for parametric data. Multinomial logistic regression was employed to identify the impact of a family history of diabetes on the risk factors of diabetes in the participants. Statistical significance was considered at p value < 0.05.

Socio-demographic characteristics

Table 1 summarizes the socio-demographic characteristics (frequencies and percentages) of the participants and the association between the degree of family history of diabetes and socio-demographic characteristics.

The mean age was 50.1 (± 11.1) years. The majority of respondents were female (74.2%), married/co-habiting (78.6%), had a regular income household (66.3%), were daily/weekly exercisers (74.6%) and non-smokers (90.7%), with the smallest proportion living in an urban area (18.1%) and the biggest proportion having access to health services (90.1%).

Of the 182 study participants, 45.1% (82/182) reported a family history of diabetes. The prevalence of diabetes in 1st degree relatives (parent, sibling) and 2nd degree relatives (grandparent, aunt, uncle, cousin) was 24.2% (44/182) and 12.1% (22/182) respectively; 8.8% (16/182) reported a family history of diabetes in both 1st degree and 2nd degree relatives.

The degree of family history of diabetes was not significantly ( p  > 0.05) associated with any socio-demographic variable.

Physical conditions and clinical characteristics in family relations

Table 2 summarizes the associations between the degree of family history of diabetes and physical conditions/clinical characteristics while Fig.  1 summarizes various physical conditions in descending prevalence.

Prevalence of the various physical conditions in descending order (N = 182).

The physical conditions significantly ( p  < 0.05) associated with the degree of family history of diabetes were retinopathy, duration of diabetes (years), and history of hypertension. The clinical characteristics significantly ( p  < 0.05) associated with the degree of family history of diabetes were HbA1C (%) and hypertension.

Mental disorders

Table 3 summarizes the association between the degree of family history of diabetes and mental disorders, mean scores of HAM-D, WHO-5 Well-being, PAID, and PHQ-9. It also summarizes the various DSM-5 diagnoses.

Only depressive symptoms (as measured by the HAM-D) were significantly ( p  = 0.030) associated with the degree of family history of diabetes. PHQ-9 unlike HAM-D did not reveal any significant trends ( p  > 0.05). All other measures were not significantly associated with a family history of diabetes ( p  > 0.05).

Independent predictors of T2DM in family relations

Table 4 summarizes the predictors of T2DM in different degrees of family relations.

Participants who had diabetes in both 1st and 2nd degree relatives had 6.28 increased odds of having retinopathy compared with participants who did not have a family history of diabetes. Diabetes in both 1st and 2nd degree relatives was associated with a higher duration of diabetes (years) and higher HbA1C (%).

Diabetes in 1st degree relatives was associated with higher HAM-D total scores.

PHQ-9 depression symptoms prevalence.

Figure  2 depicts the prevalence of various depression symptoms measured by PHQ-9.

Prevalence of PHQ-9 aspects in descending order (N = 182).

Most respondents had experienced profound fatigue or low energy levels, with over half indicating trouble with sleep patterns. Notably, a significant portion, comprising 15.40% of respondents, reported thoughts of being better off dead or of hurting themselves in some way.

Diabetes type 2 regardless of family relation

Table 5 summarizes the prevalence of the various aspects of mental health disorders as measured by the various instruments used in all the 182 patients attending the clinic, regardless of family relations. The prevalence of these various conditions is summarized in Fig.  3 in descending order. HAM-D was by far the most common mental health disorder while eating disorders (bulimia and anorexia) were the least with suicidality occupying the third position in the descending order, while elevated PAID was among the least.

Prevalence of HAM-D, poor WHO wellbeing, PHQ-9, PAID and DSM-5 mental disorders in descending order (N = 182).

Table 6 summarizes the independent predictors of depression in Diabetes. These predictors are diabetic foot problems, poor WHO-5 Wellbeing, and suicidality.

This report serves two main purposes: to provide context-appropriate evidence for Kenya to support the holistic and liaison approach to the management of T2DM and secondly to contribute to the global data pool by offering recommendations that can be replicated in similar contexts.

To our knowledge, this is the first Kenyan cohort study that reports different genetic loading (family history in different degrees of relations) and the significant independent predictors of T2DM and the associations between T2DM and socio-demographic characteristics, physical conditions, and mental disorders. As far as we were able to establish, this is not just a first for Kenya but also in Africa.

Family history

The finding of 45.1% of family history is lower than the reported 60–68.9% in the literature. This discrepancy could be attributed to the selection of the research participants in various studies. Ours was an outpatient clinic that excluded those admitted and presumably with severe forms of T2DM and possibly higher genetic loading. However, the finding of 45% is still significant for the Kenyan context, given that it is a non-modifiable contributor, hence the need for concerted efforts to focus on modifiable factors that are feasible in the Kenyan situation with limited resources, besides genetic counseling.

Social-demographics

There were no significant differences between a family history of diabetes and all the socio-demographic variables studied, nor was any socio-demographic variable a predictor of T2DM. It is noteworthy that smoking status was not associated with any type of T2DM family history. This could be a reflection of no history of smoking in the cohort studied, a practice that should be encouraged and no doubt the policy in Kenya to put social pressure against smoking and also counseling at the clinic. Another unexpected finding though not reaching a significant level was that of only 25% males of the total clinic patients. This could be explained as a gender preference to attend this public facility or a reflection of the differential gender prevalence of diabetes in the communities served by this public facility. A further possible explanation is a trend though not significant that the overwhelming majority (84–87%) of females, as opposed to 12.5% -22.7% of males, had a family history of T2DM. Mixed methods studies are required to explain these findings.

Physical conditions and biomarkers

Our study has shown that the higher the genetic loading the higher the association of retinopathy with T2DM in 1st and 2nd degree relatives compared with other levels of family history. Additionally, the highest association with diabetes in both 1st and 2nd degree relatives was found for the duration of diabetes in years, hypertension, and two specific biomarkers—HbAIC (%) and blood pressure (BP). BP and by extension hypertension can be easily monitored in the community, with the support of a relative, using easily available and affordable but reliable and valid BP monitors at home or the nearest health facility. This is an efficient way of monitoring and preventing T2DM, especially in those with a high genetic loading of diabetes. There is a new policy for every Kenyan family and all the individuals in that family to be reached at their homes on a regular basis by the newly created cadre of Primary Health promoters. They will not only attend to health promotion through awareness and attend to minor ailments but also take blood pressure. This community approach to monitoring blood pressure if successful is likely to have a critical impact on diabetes. Routine screening for blood pressure achieves extra significance given that 16.5% of our study patients were aged 60 + on age group. It is at this age group where various dementing conditions increase and hypertension is a risk factor for dementia 48 , 49 . The same principle applies to a routine determination of HbAIC (%) in those with the highest family loading of genetic risk for diabetes. In the Kenyan situation, blood samples for these can be taken at the nearest facility, and analysis carried out in that or the nearest available facility. Routine liaison consultation with the easily available ophthalmic clinical officers, (with the option to refer) for ophthalmoscopy is required for all patients with T2DM and more mandatory for patients with the highest genetic family history of T2DM in all diabetes clinics everywhere. Good history taking on the duration of diabetes is a routine practice that is reemphasized.

Even where there is no significant association with a family history of T2DM, our findings suggest there is a need for liaison practice, especially with renal and cardiology expertise. This expertise is usually but not always, available at all the 47 County Referral and Teaching hospitals in Kenya including the hospital where this study took place. While all physical conditions associated with T2DM were found in this cohort, only diabetic foot problems predicted depression. The holistic approach in that clinic could have mitigated other physical conditions as predictors of depression.

Although there was co-morbidity of diabetes with various mental disorders including alcohol abuse and dependence, WHO-5 wellbeing and diabetic stress, only depression, as determined by HAM-D was significant but less common in those with the highest level of genetic loading i.e., in both 1st and 2nd degree relatives.

Unlike HAM-D, PHQ-9 did not show any significant trends, suggesting the HAM_D scale is probably more sensitive and also the possibility that it is more valid than PHQ-9 in the type of patients we studied. While we do not have a conclusive explanation for this finding, we note that our sample size was small so no strong inferences could be made. Nevertheless, we venture a plausible explanation.

Firstly, if there are other family members with diabetes you are less likely to be depressed or anxious because there is support around you to help with your diabetes, therefore, less diabetes distress and more knowledge and understanding of diabetes.

However, we do not know whether individuals were living alone, an unlikely possibility in the Kenyan social-cultural context, if not they could still have family contacts through the still operational extended family and family social support systems in Kenya, though, this is diminishing towards nuclear centered families. It is also possible—that if there was a more laissez-faire attitude towards diabetes in relatives, then that might also lead to lower levels of anxiety and stress. On the other side, this attitude could at the same time lead to poorer glycemic control and so increased risk for microvascular disease. Either way, there are important implications for practice—screening for diabetes as well as depression, and improved knowledge of the risks of diabetes. The depression could be secondary to the onset of T2DM and most likely related to the burden of care in patients with T2DM.

The prevalence of various mental disorders found in this study was less than has been reported previously in the wider non-diabetic general clinical population in Kenya during a past study 50 .

Although there were no significant associations of all other types of mental disorders with a family history of T2DM, the high co-morbidity, ranging up to 13.6% and with a particular note of suicidality, calls for liaison with mental health experts in the management of T2DM. Apart from the findings on family relations, there are other incidental but clinically important findings. Of note is that although the association with psychotic conditions did not achieve significance, these psychotic conditions could negatively affect the overall management of T2DM. It is likely that the patients with these symptoms were treatment naive or not yet diagnosed and had therefore not received appropriate treatment for their psychosis. We therefore recommend routine screening for mental disorders using easily self-administered tests for all patients attending diabetes clinics. This self-screen is recommended because diabetologists are not necessarily experts in mental health and may not have the time to take a full history or make a diagnosis using a clinician-administered tool. Secondly, more importantly, the patients themselves may not be aware of, or may not feel able to report their mental health problems. Thirdly, joint management of diabetes and any mental disorder may have a better outcome for both conditions. This is feasible at local health center facilities, which are widely accessible at the community level, using stepwise upward referrals to the higher levels where there is the necessary expertise. Recommendations for treatment can then be provided using a stepwise downward referral process so that the patients can be managed in their communities. This will enhance the availability and accessibility of services and benefit capacity building in skills at the grassroots level.

The low-level prevalence of emotional stress (2.7%) does not allow us to test significant associations. While being diagnosed with diabetes can cause anxiety and depression and lead to emotional distress, the cause-effect could also be bi-directional—i.e. diagnosis leading to emotional distress or conversely emotional distress from other unidentified factors such as physical conditions leading to anxiety and distress. This calls for a qualitative approach that explores at a clinical level any directional relationship in a particular patient.

This finding of 2.7% prevalence of diabetes-related emotional distress is one of the lowest as compared to 12.8–46% reported in the literature 51 , 52 , 53 . We speculate that this is a reflection of the type of engagement of the patients that goes beyond the prescription of drugs in that particular clinic. It is the integrated management of diabetes that we speculate reduces emotional distress within a setting where the patients are fully educated on their conditions and management. It is likely that the levels of emotional distress would be similar to those reported in the literature for other situations and clinics that do not incorporate such holistic practices. If indeed that is the case, then it is a reflection of good practice in that specific clinic which could be replicated elsewhere.

Only combined methods—quantitative and qualitative have the potential to delineate these associations. Overall, our findings suggest the need for screening for depression, WHO-5 wellbeing, and suicidality in routine clinical management of T2DM at least in all patients with T2DM. Any positive screening findings should be integrated into the management of the patient.

Conclusions

Family relationships are important in both physical disorders and depression, suggesting shared genetic predisposition, and/or modulation by shared environmental factors. Depression emerges as the common mental disorder in individuals with Type 2 Diabetes, irrespective of relational factors. Additionally, all examined patients exhibited various mental health concerns and DSM-5 disorders. This Kenyan study contributes to the global database on the topic of Types of diabetes and family relations and associated mental and physical conditions. We have achieved all our aims for this study.

Based on all the achieved general and specific aims, we have suggested some clinical and community health practices and policies.

Limitations and recommendations to overcome the limitation

This study was carried out in a cohort of patients attending a diabetes clinic and therefore does not reflect the wider population of people with T2DM. This study excluded those untreated patients in the community or where clinics do not provide psychoeducation as in this clinic. Conversely, this holistic approach could be replicated in other clinics and contexts.

Secondly, we could not establish any directional relationships using the quantitative methods, given that our data is cross-sectional. Only mixed qualitative and quantitative methods could address this.

Although we achieved our aims, we recommend more studies at the community level to include those who may have T2DM and go for other services or are not treated by a specialist. Such a study though necessary for better understanding would be expensive and would require more complicated logistics.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

All the study participants and the staff of Machakos County Referral and Teaching Hospital Diabetes Clinic, the Association for the Improvement of Mental Health Programs, Switzerland, and the Africa Mental Health Research and Training Foundation.

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Ndetei, D.M., Mutiso, V., Musyimi, C. et al. Association of type 2 diabetes with family history of diabetes, diabetes biomarkers, mental and physical disorders in a Kenyan setting. Sci Rep 14 , 11037 (2024). https://doi.org/10.1038/s41598-024-61984-6

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Development of a hypoglycaemia risk score to identify high-risk individuals with advanced type 2 diabetes in DEVOTE

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• Other Affiliation: Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
• Other Affiliation: Department of Internal Medicine and Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX, United States
• Other Affiliation: HCA Midwest Health Heart and Vascular Institute, Overland Park, KS, United States
• Other Affiliation: Scripps Whittier Diabetes Institute, San Diego, CA, United States
• Other Affiliation: Department of Internal Medicine, Medical University of Graz, Graz, Austria
• Other Affiliation: Imperial Clinical Trials Unit, Imperial College London, London, United Kingdom
• Other Affiliation: AdventHealth Translational Research Institute, Orlando, FL, United States
• Other Affiliation: Novo Nordisk A/S, Søborg, Denmark
• Affiliation: School of Medicine
• Aims: The ability to differentiate patient populations with type 2 diabetes at high risk of severe hypoglycaemia could impact clinical decision making. The aim of this study was to develop a risk score, using patient characteristics, that could differentiate between populations with higher and lower 2-year risk of severe hypoglycaemia among individuals at increased risk of cardiovascular disease. Materials and methods: Two models were developed for the risk score based on data from the DEVOTE cardiovascular outcomes trials. The first, a data-driven machine-learning model, used stepwise regression with bidirectional elimination to identify risk factors for severe hypoglycaemia. The second, a risk score based on known clinical risk factors accessible in clinical practice identified from the data-driven model, included: insulin treatment regimen; diabetes duration; sex; age; and glycated haemoglobin, all at baseline. Both the data-driven model and simple risk score were evaluated for discrimination, calibration and generalizability using data from DEVOTE, and were validated against the external LEADER cardiovascular outcomes trial dataset. Results: Both the data-driven model and the simple risk score discriminated between patients at higher and lower hypoglycaemia risk, and performed similarly well based on the time-dependent area under the curve index (0.63 and 0.66, respectively) over a 2-year time horizon. Conclusions: Both the data-driven model and the simple hypoglycaemia risk score were able to discriminate between patients at higher and lower risk of severe hypoglycaemia, the latter doing so using easily accessible clinical data. The implementation of such a tool ( http://www.hyporiskscore.com/ ) may facilitate improved recognition of, and education about, severe hypoglycaemia risk, potentially improving patient care.
• type 2 diabetes
• severe hypoglycaemia
• https://doi.org/10.17615/jcwn-3528
• https://doi.org/10.1111/dom.14208
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• Diabetes, Obesity and Metabolism
• National Institutes of Health, NIH
• National Center for Advancing Translational Sciences, NCATS, (UL1TR002489)
• Novo Nordisk
• National Institute of Diabetes and Digestive and Kidney Diseases, NIDDK, (P30DK124723)
• Blackwell Publishing Ltd

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Written reflection in an eHealth intervention for adults with type 2 diabetes mellitus: a qualitative study

Silje s lie.

1 Department of Public Health, Faculty of Health Sciences, University of Stavanger, Stavanger, Norway

Bjørg Karlsen

Christopher p niemiec.

2 Department of Clinical and Social Sciences in Psychology, University of Rochester, Rochester, NY, USA

Marit Graue

3 Center for Evidence-Based Practice, Western Norway University of Applied Sciences, Bergen, Norway

Bjørg Oftedal

Individuals with type 2 diabetes mellitus (T2DM) are responsible for the daily decisions and actions necessary to manage their disease, which makes self-management the cornerstone of diabetes care. Many patients do not reach recommended treatment goals, and thus it is important to develop and evaluate innovative interventions that facilitate optimal motivation for adequate self-management of T2DM.

The aim of the current study was to explore how adults with T2DM experience using reflection sheets to stimulate written reflection in the context of the Guided Self-Determination (GSD) eHealth intervention and how written reflection might affect their motivation for self-management of T2DM.

We used a qualitative design in which data were collected through individual interviews. The sample consisted of 10 patients who completed the GSD eHealth intervention, and data were analyzed using qualitative content analysis.

The qualitative content analysis yielded 2 main themes. We labeled the first theme as “Written reflection affects awareness and commitment in diabetes self-management”, which reflects 2 subthemes, namely, “Writing creates space and time for autonomous reflection” and “Writing influences individuals’ focus in diabetes self-management”. We labeled the second theme as “Written reflection is perceived as inapplicable in diabetes self-management”, which reflects 2 subthemes, namely, “Responding in writing is difficult” and “The timing of the writing is inappropriate”.

Our findings indicate that written reflection in the context of the GSD eHealth intervention may be conducive to motivation for diabetes self-management for some patients. However, it seems that in-person consultation with the diabetes nurse may be necessary to achieve the full potential benefit of the GSD as an eHealth intervention. We advocate further development and examination of the GSD as a “blended” approach, especially for those who consider written reflection to be difficult or unfamiliar.

Introduction

Type 2 diabetes mellitus (T2DM) is a chronic health condition whose worldwide prevalence has increased rapidly in recent decades. 1 Individuals with T2DM are responsible for the daily decisions and actions necessary to manage their disease, which makes self-management the cornerstone of diabetes care. 2 Self-management can be defined as an “individual’s ability to manage the symptoms, treatment, physical and psychosocial consequences and life style changes inherent in living with a chronic condition”. 3 Adequate self-management of T2DM is therefore a complex process that requires motivation for managing medication as well as lifestyle changes in diet and physical activity to reach treatment goals for glycosylated hemoglobin (HbA 1c ), cholesterol, and blood pressure in order to prevent serious long-term complications. 4 , 5 Indeed, long-term complications associated with T2DM include cardiovascular disease, neuropathy, nephropathy, and periodontal disease, among others. 1 , 5 Patients have described adequate self-management of T2DM as difficult to attain because of the following reasons: cumbersomeness of lifestyle changes in diet and physical activity, and the long-term complications of T2DM and other chronic conditions. 6 Moreover, the values that people hold can conflict with the recommended behaviors for adequate self-management of T2DM, which can undermine the motivation for lifestyle changes. 7 Hence, it is important to develop and evaluate innovative interventions that facilitate optimal motivation for adequate self-management of T2DM.

Indeed, eHealth interventions have been shown to have potential to support adequate self-management of T2DM, and recommendations suggest that eHealth interventions be theory-based and include “soft-touch” strategies such as personal feedback to enhance efficiency and engagement. 8 – 11 Such features enable asynchronous and flexible follow-up for each patient, which can bridge the gap between diabetes care and adequate self-management. Based on these recommendations, in the development phase of our project, we adapted the Guided Self-Determination (GSD) self-management support program to be an eHealth intervention for adults with T2DM. 12 Originally, the GSD program was developed for type 1 diabetes, and research indicates that the program is effective in facilitating the development of life skills and lowering psychosocial distress. 13 – 20

Based on self-determination theory (SDT), the GSD program is intended to enhance autonomous problem solving, goal setting, and action planning among individuals with diabetes. 21 SDT is an organismic approach to human motivation, which has been applied to health care and health behavior change, including management of T2DM. Central to SDT is the specification of 3 basic psychological needs, namely, autonomy (an experience of volition and choicefulness), competence (an experience of capability and mastery), and relatedness (an experience of support from and connection with important others); the satisfaction of these needs is necessary for optimal motivation, physical health, social integration, and psychological wellness. 22 – 24 Indeed, past research has shown that support for the basic psychological needs is associated with higher levels of autonomous motivation for diabetes self-management, medication adherence, quality of life, dietary self-care, and glucose control. 4 , 22 , 25 – 28

An important feature of the GSD program is the use of semistructured reflection sheets, which are designed to afford patients an opportunity to express their experiences and personal difficulties with diabetes, as well as to enable them to participate actively in their care process. 13 Such expression and active participation can empower patients to become self-determined and develop the skills necessary for adequate self-management of diabetes. 12 Written reflection requires the translation of emotions and experiences into words, and this cognitive process can benefit individuals in a variety of situations. 29 The use of writing as a therapeutic approach has been examined in a variety of populations, including college students who are vulnerable to depression, cancer survivors, and individuals with chronic pain and various physical diseases, and findings indicate that this approach can improve treatment outcomes and quality of life. 30 – 33 In addition, a systematic review of interventions for women with breast cancer found that expressive writing can improve their physical health. 34 To our knowledge, written reflection has not been examined in the context of eHealth interventions, and the current study was designed to fill this gap in the literature.

The aim of the current study was to explore how adults with T2DM experience using reflection sheets to stimulate written reflection in the context of the GSD eHealth intervention, and how written reflection might affect their motivation for self-management of T2DM.

The current study, which was conducted as a pilot study, is part of a larger project that developed a complex eHealth intervention for adults with T2DM who are treated in general practices in Norway. 12 We used a qualitative design in which data were collected through individual interviews that were conducted between December 2015 and December 2016. Interviews provide valuable information on patients’ experiences and opinions, which is important when piloting clinical interventions in real-life contexts. 35

Description of the GSD eHealth intervention

Nurses who were trained in the GSD method and had experience with diabetes care delivered the GSD eHealth intervention to patients in general practices. The GSD eHealth intervention was delivered along with regular care, which for individuals with T2DM in Norway consists of structured annual consultations at general practices, regular measurement of HbA 1c , and additional consultations as per individual needs. 5 Initially, nurses and participants met face-to-face in order to establish a relationship, during which the nurse explained the aim of the GSD program, how to log on to the Web portal ( www.MinJournal.no ) and use the secure messaging system, and how to complete the reflection sheets. The Web portal requires electronic identification via BankID, which is aligned with the level of security necessary to allow for transfer of sensitive information in Norway. All participants received a comprehensive manual that described how to use the Web portal. After the initial meeting, participants received the reflection sheets in PDF format via 4 eHealth consultations. They were asked to reflect on and write about their thoughts, feelings, experiences, and difficulties related to the self-management of T2DM, as well as to formulate goals and action plans for adequate self-management of T2DM, and return the completed reflection sheets to the diabetes nurse via secure messages.

The GSD eHealth intervention was initially conducted as a “pure” eHealth intervention by recording responses to the reflection sheets in writing and communicating via secure messages. Due to a long duration (up to 35 weeks) and a large dropout rate, the approach was modified to a “blended” intervention, including 1 in-person consultation with the nurse following the third eHealth consultation. 36 The participants who were offered an additional in-person meeting completed the intervention in about 12 weeks. Figure 1 presents an overview of the GSD eHealth intervention for T2DM, along with the topics of the 13 reflection sheets and a description of the 1 additional in-person meeting.

Overview of the GSD eHealth program for adults with T2DM.

Abbreviations: GP, general practitioner; GSD, Guided Self-Determination; HbA 1c , glycosylated hemoglobin; T2DM, type 2 diabetes mellitus.

Patients and methods

Participants and procedure.

At 8 general practices in Norway, participants were recruited by their nurse or general practitioner to participate in the GSD eHealth intervention. Patients were eligible if they had been diagnosed with T2DM for >3 months, were at least 18 years of age, could read and communicate in Norwegian, had regular access to the Internet and a computer, and had a registered BankID (a secure personal electronic identification that was necessary to access the Web portal). Patients were excluded if they had severe physical or mental illness that would limit their ability to participate in the study.

A total of 25 patients (18 in the “pure” eHealth intervention, and 7 in the “blended” intervention) from southwestern Norway were invited to participate in the study. Five of the 18 patients in the “pure” eHealth intervention completed the study, and the large proportion of dropouts in this group has been described elsewhere. 36 Five of the 7 patients in the “blended” intervention completed the study. Hence, the current study included 10 participants (6 female, 4 male). After completing the intervention, participants were asked by their nurses to take part in an individual interview with an investigator at a time and place of their choosing. All 10 participants agreed to this request. Table 1 presents the characteristics of the study participants.

Characteristics of the study participants

Abbreviations: BMI, body mass index; HbA 1c , glycosylated hemoglobin.

Data collection

A semistructured interview guide was used to organize the interviews. Participants were invited to speak freely about the theme addressed in the main question, namely, “What was your overall experience with the GSD eHealth counseling program?” During the conversation, the interviewer asked supplementary questions to clarify and elaborate on participants’ responses, including “How did you experience writing your reflections on the digital reflection sheets?” and “How did writing reflections influence your motivation for diabetes self-management?” At the end of each interview, participants were asked to supplement their responses with other experiences related to the GSD eHealth intervention in order to ensure adequate representation of their perspective in the data. On average, interviews took 70 minutes to complete, and all interviews were audiotaped and transcribed verbatim. The interviews were conducted in Norwegian. Relevant meaning units were translated into English during the analysis process, and the translation has been text edited. Demographic and clinical data were collected via a questionnaire at baseline.

Ethical considerations

The Norwegian Regional Committee for Medical and Health Research Ethics (REK West, number 2015/60) approved the study protocol. Prior to the beginning of the study, participants signed a written consent form and were guaranteed anonymity and the right to withdraw from the study at any time. Anonymity was ensured by severing the link between participant names and the ID numbers and transcripts of the interviews.

Data analysis

We performed a qualitative content analysis, as described by Graneheim and Lundman, 37 which involved reading in full the unit of analysis (namely, all 10 transcribed interviews). Data from both groups of participants were analyzed together, as the theme focused on experiences with the reflection sheets and writing reflections in the context of the GSD eHealth intervention and how doing so might affect motivation for self-management of T2DM. Meaning units that corresponded to the aim of the study (namely, experiences with using reflection sheets to stimulate written reflection, and how written reflection might affect motivation for self-management of T2DM) were identified and shortened while retaining the main experience, and then labeled with codes. Codes were systematically organized according to their similarities and differences and placed in categories, which describe “what” participants talked about and represent the manifest content of the text. Revision of the codes and the names of categories occurred several times during the process of analysis. Finally, the latent content, or underlying meaning, was interpreted and represented in the subthemes and main themes, which characterize the “‘meaningful essence’ that runs through the data”. 38 Table 2 presents the themes and subthemes derived from the qualitative content analysis. Abstraction was done in collaboration with coauthors to ensure credibility and to enhance the likelihood that a probable interpretation of the text was obtained.

Themes and subthemes derived from the qualitative content analysis

The qualitative content analysis yielded 2 main themes ( Table 2 ) that describe how adults with T2DM experience using reflection sheets to stimulate written reflection in the context of the GSD eHealth intervention and how written reflection might affect their motivation for self-management of T2DM. We labeled the first theme as “Written reflection affects awareness and commitment in diabetes self-management”, which reflects 2 subthemes, namely, “Writing creates space and time for autonomous reflection” and “Writing influences individuals’ focus in diabetes self-management”. We labeled the second theme as “Written reflection is perceived as inapplicable in diabetes self-management”, which reflects 2 subthemes, namely, “Responding in writing is difficult” and “The timing of the writing is inappropriate”. In the following sections, we describe in detail the content of these themes and subthemes using direct quotations from participants.

Written reflection affects awareness and commitment in diabetes self-management

Participants suggested that by creating space and time to express thoughts and feelings, writing affords an opportunity for reflection on what is important for them in diabetes self-management. In addition, writing creates transparency and concretizes ideas, which influences focus in diabetes self-management. Hence, written reflection affects awareness and commitment in diabetes self-management.

Writing creates space and time for autonomous reflection

Participants appreciated the opportunity for reflection in the peace and quiet of their homes, as well as the ability for written reflection without interruption. Participants also valued the opportunity to decide on the timing of their written reflection amid their busy lives, as well as the opportunity to let thoughts “simmer” for a while, which was conducive to mature and thoughtful responses.

I appreciated having the opportunity to sit and relax and fill out [the reflection sheets] in peace and quiet, and to do it when it suited me. That I had time to sit down and prioritize doing it. To sit down and be able to use the time I needed to think through my answers […]. [Participant 10]

With reflection, participants came to discover aspects of themselves and their reactions to situations of which they had not been aware previously. Participants also appreciated the intellectual stimulation represented by written reflection, through which they could focus on concrete issues and express mature thoughts.

Writing challenges you much more intellectually. That is why writing is very useful. If you just sit and talk, you may put much more emotions into things. When you sit down and write, you dispose some of the emotional, the sentimental, part. You write down your thoughts, cognitive, how you experience the situation. That is why I like to be challenged on that. [Participant 1]

Participants valued the personal nature of written reflection, which afforded an opportunity to think through their responses thoroughly rather than be interrupted with clarifying questions, as typically happens in conversations. Participants considered written reflection to be a useful clinical tool (in addition to traditional health care) because the reflection sheets focused on the psychosocial aspects of having and managing diabetes, and such experiences are important to share with the diabetes nurse.

Earlier follow-up has just been blood samples and other tests, and then finished and “good bye”. I have not had time to express thoughts and emotions, and […] That was what I appreciated, that I could finally communicate with someone about it. How I experience all of it. [Participant 2]

For some participants, written reflection sparked an interest in discussing matters related to self-management of T2DM with their family, which afforded an opportunity for enhanced openness and understanding with important others.

Writing influences individuals’ focus in diabetes self-management

Participants used reflection sheets to create focus in diabetes self-management, as their responses were “in writing”. With the opportunity for written reflection, participants created a positive commitment to their goals and action plans, which became specific, concrete, transparent, and manageable and, moreover, could be reviewed after the conclusion of the eHealth consultations.

It becomes more concrete than when it is just in your head. Maybe for some people when they have written it down, I will not say that it becomes a contract, but yet more concrete than when it is just feelings and thoughts. [Participant 4]

Yet interestingly, some participants expressed the opposite sentiment, such that written reflection can be embellished and/or forgotten after the responses are sent to the diabetes nurse. In response to the Interviewer’s question, “Would you go back and check on your goal setting?” 1 participant said, “No, there is no imminent danger of that ever occurring.”

Written reflection is perceived as inapplicable in diabetes self-management

Some participants found it difficult to understand the reflection sheets and respond in writing. Other participants perceived the questions to be repetitive or unnecessary for them. Finally, some participants thought that the timing of the writing was inappropriate, for various reasons. Hence, written reflection is perceived as inapplicable in diabetes self-management.

Responding in writing is difficult

Some participants mentioned that they struggled with writing in general, whereas others suggested that the writing would have been easier if the reflection sheets were on paper rather than digital. One participant found it difficult to comprehend the questions and, therefore, enlisted family members to help make sense of the reflection sheets. For some of the participants who were offered an in-person meeting following the third eHealth consultation, it was important to discuss the reflection sheets with the diabetes nurse.

I had some problems understanding some of the questions on the reflection sheets. So when I came to see the nurse, I had to say “I don’t know what this means”, and then she had to explain what it meant. [Participant 7]

Some participants noted the importance of further instruction on how to complete the reflection sheets. Additionally, some participants found the language of the reflection sheets to be “too academic”. Other participants found some of the reflection sheets (especially on “Work with changes” [ Figure 1 ]) to be repetitive and difficult to understand/respond to in writing.

But then there were these reflection sheets where I felt like […] first you were supposed to write about your observations, your thoughts, and feelings. I found those a little hard to separate really. Your observations […]. What do they mean with that? And then your thoughts and feelings. And then the observations. There you were supposed to write a little without thoughts and feelings? I found this difficult […]. [Participant 5]

Finally, due to the “locked-to-form” nature of the reflection sheets, some participants perceived less opportunity for elaboration of responses based on individual needs and preferences.

The timing of the writing is inappropriate

Some participants suggested that the GSD program was introduced either too early or too late in their disease trajectory for them to receive a benefit from written reflection. For some participants, written reflection conflicted with their expectations for a self-management support program. In particular, these participants viewed working with the reflection sheets as too time consuming, likely to create unnecessary problems and concerns, and inapplicable to their current life experience. Other participants focused on personal matters, such as family, relationships, and multimorbidity that undermined their perceived benefit from and opinion of written reflection. They assumed that they were supposed to deal only with specific diabetes self-management behaviors, such as diet and exercise in their written reflections and goal setting. Taken together, the timing of the writing was inappropriate for some participants.

Because you also have other things to deal with. You cannot just put all that aside and simply focus on [diabetes self-management behaviors], right. The other things are there all the time, in the back of my head. [Participant 6]

The aim of the current study was to explore how adults with T2DM experience using reflection sheets to stimulate written reflection in the context of the GSD eHealth intervention and how written reflection might affect their motivation for self-management of T2DM. The findings indicate that participants had diverse experiences with the digital reflection sheets and written reflection more broadly. Some participants experienced written reflection as positively affecting their awareness and commitment in diabetes self-management. On the other hand, some participants experienced difficulties in writing their reflections and perceived this as inapplicable in diabetes self-management. In the following sections, we discuss our findings in the context of previous research and SDT.

One important finding in the current study is that the writing initiated by the digital reflection sheets creates space and time for autonomous reflection, which was experienced as more positive than ordinary follow-up at the general practice. With written reflection, participants were able to identify and put into words their personal experiences and difficulties with self-management of T2DM. As the necessary behaviors for self-management of T2DM are demanding and may not have inherent interest for the individual, it is important to support autonomy in health care in order to facilitate optimal, autonomous motivation for diabetes self-management. 22 , 27 Individuals experience a sense of autonomy when their behavior is congruent with deeply held values, beliefs, and interests. 24 Written reflection in the context of the GSD eHealth intervention may be perceived as autonomy supportive, such that it engenders an experience of self-governance and volition in patients. These findings build on previous research in which adults with type 1 diabetes perceived their health care climate as more autonomy supportive after participating in the GSD intervention. 13

Another important finding is that writing influences individuals’ focus in diabetes self-management. For some participants, responding to the reflection sheets and then sending these to the diabetes nurse assist in helping to create specific goals and clear action plans, in addition to concretizing what is necessary to attain their goals. The autonomous reflection and the focus created by the writing may have facilitated healthy, autonomous goal setting in the self-management of T2DM. This is important because specific goals are much more effective than general goals for developing effective self-management behaviors. 7 , 39 Previous research has shown that active involvement in goal setting is conducive to patients’ regulating their self-management behaviors and attaining positive treatment outcomes. 23 Moreover, competence is supported when individuals pursue goals that they have an opportunity to attain, thereby experiencing a sense of achievement in reaching their goals. 24 , 27

Our findings indicate that the GSD eHealth intervention may provide support for patients’ competence – as well as autonomy. Indeed, support for competence has been associated with treatment adherence, quality of life, and glycemic control in patients with T2DM. 4 , 26 With these findings in mind, we suggest that written reflection in the context of the GSD eHealth intervention may be conducive to positive treatment outcomes because of its potential to support autonomy and competence around self-management of T2DM.

Our findings also indicate that the GSD eHealth intervention may be described as a “double-edged sword”. For some participants, written reflection may affect their awareness and commitment in diabetes self-management in a positive way, whereas for other participants, written reflection was perceived as inapplicable in diabetes self-management. Our findings suggest that responding in writing is difficult and that the timing of the writing is inappropriate for some patients, and thus participants may not value and/or benefit from written reflection in a uniform way. These findings suggest that the reflection sheets might require further adaption for adults with T2DM in an eHealth intervention.

In the current study, the reflection sheets were completed electronically, which contrasts with previous research on the GSD intervention. 13 , 14 , 18 Research on therapeutic writing has shown that the effectiveness of writing as a therapeutic tool depends on support and assistance during the writing process. 31 Moreover, in previous research showing that the GSD intervention can develop life skills and reduce psychosocial distress in individuals with type 1 diabetes, participants completed the reflection sheets on paper at home as preparation for an in-person consultation with health care personnel, which may facilitate dialogue around assistance with, explanation for, and tailoring of the intervention. 13 – 19 The fact that the written reflection and communication with health care personnel occurred primarily electronically may have undermined perceptions of support for some participants.

It is interesting to note that some participants who were offered an in-person meeting following the third eHealth consultation mentioned that their meeting with the diabetes nurse was crucial for understanding the reflection sheets. This finding underscores the importance of in-person consultation that offers assistance to participants around the GSD eHealth intervention and builds on our previous research that revealed participants’ missing of in-person consultations with the diabetes nurse as an important contributor to dropping out from the study. 36 In-person consultation with health care personnel allows for advice based on user reactions to be communicated in real time, which can facilitate engagement in eHealth interventions. Of course, additional in-person consultation can increase the cost and time required for completion of eHealth interventions, in addition to reducing reach into the population. 40 Nonetheless, we anticipate that the benefits associated with in-person consultation are likely to outweigh the costs.

Some participants considered the timing of the writing to be inappropriate, and thus this aspect of the intervention did not suit them for various reasons. Whereas some participants had a different focus and/or additional challenges in life, others were able to manage their diabetes well without much to consider in written reflection. Hence, it is important to consider the timing of eHealth interventions with regard to disease trajectory, personal needs, and anticipated strains in life. 41 Furthermore, although – ideally – the reflection sheets can be used to consider a broad range of topics in life, participants tend to focus on specific diabetes self-management activities in their goal setting, such as diet and exercise. Future research on written reflection might attempt to strike more of a balance between focusing participants on broad life issues versus specific issues relevant to diabetes self-management.

It is also interesting to consider how the concept of causality orientations within SDT 42 might affect perceptions of the timing of the writing as inappropriate. The concept of a causality orientation describes differences in how individuals initiate and regulate their behaviors over extended periods of time, and this concept has received considerable empirical attention. 24 , 43 With an autonomy orientation, individuals initiate and regulate their behavior based on personal interest, value, and choice. In contrast, with a controlled orientation, individuals initiate and regulate their behavior based on self- and/or other-imposed perceptions of pressure, coercion, and control. 42 Certainly, differences in causality orientation might affect the focus of written reflection, the self-management goals that are adopted, and the perception of the GSD eHealth intervention as appropriately timed and beneficial. It is reasonable to speculate that those participants who asserted that written reflection affects awareness and commitment in diabetes self-management (Theme 1) are more likely to have an autonomy causality orientation than those who asserted that written reflection is inapplicable in diabetes self-management (Theme 2). Indeed, individuals who score higher on the controlled causality orientation tend to benefit less from health initiatives such as the GSD program. 42 Future research on written reflection might examine whether and how the causality orientations affect the amount of benefit that participants derive from the GSD eHealth intervention.

Strengths and limitations

Several strengths and limitations deserve mention. One strength of the current study was its qualitative design with semi-structured interviews during which participants could give voice to their experience with the GSD eHealth intervention. One limitation was the small number of informants (n=10); yet it is important to note that the sample consisted of all participants who completed the GSD eHealth intervention, which precluded the possibility of further recruitment. Indeed, the fact that all participants who completed the intervention agreed to take part in our interviews is a notable strength of the current study. A second strength was that 1 investigator conducted all of the interviews in order to ensure the credibility of the data collection. Undeniably, our findings and interpretations were discussed by all coauthors during analysis and manuscript drafting, which may enhance the trustworthiness of our conclusions. That being said, because a text can have >1 meaning and interpretations are subjective, we cannot dismiss the possibility that others would have interpreted our findings in a different way. 37 , 38 A second limitation was the heterogeneity in educational status of the study participants, which might have affected how participants responded to the reflection sheets. Half of the participants in the current study had primary or secondary education as their highest level of education. That being said, we found no indication that participants with less education experienced writing as more difficult than those with more education, which may be due to the limits of our small sample size. Thus, it is important for future research with a larger sample size to examine how educational status affects responses to and benefits from written reflection, given the cognitive demands of this component of the eHealth intervention.

Written reflection stimulated by digital reflection sheets may affect awareness and commitment in diabetes self-management in a positive way by creating space and time for autonomous reflection and influencing individuals’ focus in diabetes self-management. Interpreted through the lens of SDT, it is possible that written reflection in the context of the GSD eHealth intervention can support patients’ autonomy and competence, which are conducive to autonomous (ie, optimal) motivation for diabetes self-management and positive treatment outcomes. That being said, the structured nature of written reflection in the context of the GSD eHealth intervention may be inapplicable for some participants, as responding in writing can be difficult and the timing of the writing can be inappropriate. Therefore, it seems that in-person consultation with the diabetes nurse may be necessary to achieve the full potential benefit of the GSD as an eHealth intervention. Hence, we advocate for further development and examination of the GSD as a “blended” approach, especially for those who consider written reflection to be difficult or unfamiliar.

Acknowledgments

The authors express special thanks to the participants involved in the current study. In addition, we express our gratitude to the 8 study nurses and the involved general practices for recruiting the patients and conducting the intervention.

The current study, which was conducted in collaboration between Western Norway University of Applied Sciences and the University of Stavanger, was funded by a grant from the Norwegian Research Council (project number 221065), and funds from the University of Stavanger and Western Norway University of Applied Sciences, Norway.

Author contributions

SSL, BK, MG, and BO developed the study design. The interviews, transcriptions, tentative analysis, and first draft of the article were performed by SSL. BK, CPN, MG, and BO were involved in analysis of the data, writing the manuscript, and revising the manuscript for intellectual content. All authors gave final approval of the version to be published and agree to be accountable for all aspects of the work.

The authors report no conflicts of interest in this work.