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2. METHODS

Chapter 11

Type 2 Diabetes Mellitus

Anne Merete Boas Soja & Malene Ejlertsen

11.1 Introduction

In the first part of the project period, we found that patients with type 2 diabetes mellitus were being inadequately treated in relation to the existing recommendations (1–4). In addition, we suspected that several of the patients had type 2 diabetes without having been diagnosed. To improve the diagnosis of type 2 diabetes and to improve the results of the treatment of patients with heart disease and diabetes,we developed a special diabetes module to supplement the comprehensive cardiac rehabilitation.

Type 2 diabetes mellitus – supplementary module

Illustration af Dibetes Mellitus type 2 – supplerende modul

This chapter describes the diabetes module, which includes screening for type 2 diabetes, individual counselling on diabetes, group education, individual education and a meeting on impaired glucose tolerance (pre-diabetes). Chapter 7 describes the individual counselling with a dietitian on diet and type 2 diabetes.


10.2 Evidence On Type 2 Diabetes And Ischaemic Heart Disease

The prevalence of type 2 diabetes in Denmark has increased sharply in recent years. An estimated 200,000 people in Denmark have type 2 diabetes (2;5). The prevalence of cardiovascular disease is 2–6 times as high among people with type 2 diabetes as among people without type 2 diabetes; cardiovascular disease accounts for 70–80% of the total mortality of people with type 2 diabetes (5). Systematic management of risk factors can prevent the development of late microvascular complications, such as retinopathy and nephropathy, and macrovascular diseases, such as stroke and cardiovascular diseases (6–15).

Type 2 diabetes seems to develop as a continuous process of disturbed glucose metabolism over many years, shifting from impaired glucose tolerance to manifest type 2 diabetes. The risk of cardiovascular disease among people with impaired glucose tolerance is 1.5–2 times higher than among people with normal glucose tolerance; strong evidence shows that intensive lifestyle intervention can prevent type 2 diabetes, and apparently with more success than with pharmaceutical treatment alone (16–18).

Type 2 diabetes is a hidden disease among the general population and among patients with heart disease (2;19;20). Type 2 diabetes has been carefully investigated among patients with ischaemic heart disease. Studies (19;20) indicate that 20% have previously diagnosed type 2 diabetes and 16–25% newly diagnosed type 2 diabetes. Cardiologists have tended to accept relatively high blood glucose concentrations in the acute phase among patients with heart disease as a natural response to a severe disease. Neither acute nor outpatient cardiology has traditionally managed the clinical assessment of type 2 diabetes status,much less delegated this task to general practitioners or type 2 diabetes clinics. The importance of diagnosing type 2 diabetes among patients with heart disease is emphasized by the fact that, among patients with heart disease, intensively rehabilitating those with type 2 diabetes provides greater absolute benefits than rehabilitating those without type 2 diabetes. Mortality after myocardial infarction is twice as high among people with type 2 diabetes as among those without type 2 diabetes (21;22). Strictly controlling blood glucose has been shown to influence the rates of complications and survival (23). Few studies have focused on the effects of intensive rehabilitation of patients with heart disease and type 2 diabetes, but the standardized cardiac rehabilitation programmes do not seem to be adequate (24).

According to recommendations in Denmark (2) and elsewhere (1;25), systematic management of risk factors through lifestyle intervention and pharmaceutical treatment including strict control of blood glucose are important aspects of treating patients with type 2 diabetes. The recommendations on cardiac rehabilitation (25–27) similarly emphasize the importance of systematically managing risk factors among patients with heart disease and type 2 diabetes.


11.3 Purpose

The purposes of the supplementary type 2 diabetes module of the comprehensive cardiac rehabilitation programme are 1) to screen patients for unrecognized type 2 diabetes and pre-diabetes and 2) to integrate systematic risk factor management of late macrovascular and microvascular complications in the overall rehabilitation of patients with both heart disease and type 2 diabetes through lifestyle intervention and pharmaceutical treatment with the aim of early detection of any vascular damage. Another purpose has been to integrate the rehabilitation of type 2 diabetes and heart disease physically and draw on the expertise of a core team in cardiac care and diabetes care.


11.4 Methods

11.4.1 Screening for type 2 diabetes and pre-diabetes

Patients without known type 2 diabetes are screened for diabetes with an oral glucose tolerance test (the procedure is available in Danish at www.cardiacrehabilitation.dk) about 3 months after the comprehensive cardiac rehabilitation programme starts and immediately before the 3-month consultation with the physician, regardless of the previous concentration of glycosylated haemoglobin A (Hb A1c).This test can determine whether the patient has undiagnosed type 2 diabetes, impaired glucose tolerance or impaired fasting glycaemia or none of these.

All patients without previously diagnosed type 2 diabetes are screened using the oral glucose tolerance test as part of a scientific project. This is an extended indication for performing an oral glucose tolerance test (1;5).


11.4.2 Initial type 2 diabetes consultation

The same physician and nurse manage the supplementary type 2 diabetes module to ensure continuity in treatment.

Initial type 2 diabetes consultation with a physician
The consultation with a physician for patients with both heart disease and type 2 diabetes is conducted based on the principles for the initial consultation in the comprehensive cardiac rehabilitation programme (Chapter 4). The physician attempts to get a through overview of the overall course of illness for both type 2 diabetes and cardiovascular disease.The physician gathers substantial supplementary information on type 2 diabetes that is systematically registered in the joint patient records (the type 2 diabetes interview guide is available in Danish at www.CardiacRehabilitation.dk).

History: The physician asks patients about familial disposition for type 2 diabetes, any previous type 2 diabetes during pregnancy, the duration of type 2 diabetes, previous dietary guidance, follow-up and treatment regimens and any participation in type 2 diabetes education. The physician assesses the degree to which patients understand the disease and exercise self-care, focusing on checking one’s own blood sugar and/or urine, symptoms of hyperglycaemia and hypoglycaemia and examining one’s feet. The physician asks the patient about symptoms of peripheral or autonomic neuropathy and arteriosclerotic manifestations from other vascular regions. The physician emphasizes detecting existing late diabetic complications such as retinopathy, nephropathy, neuropathy, previous foot ulcers and/or amputation. Records of followup within other specialties such as ophthalmology and orthopaedics are requested if needed.

Review of pharmaceutical treatment: The physician ensures that patients are receiving optimum prophylactic pharmaceutical treatment and that any plans for changing medicine or increasing the dosage of medicine are registered in the joint patient records. Based on the recently tested value of Hb A1c, the physician often assesses whether antidiabetic pharmaceutical treatment is necessary, but unless patients have very high values the physician usually waits to receive the 24-hour blood sugar profile.

Clinical examination: In addition to the objective cardiological examination, the physician always examines patients’ feet thoroughly: peripheral pulse, capillary response, examination for any gangrene or foot ulceration (arterial and neuropathic), and checks scars to see whether they are infected.

Paraclinical examination and tests: To supplement the objective cardiological examination, the physician often performs several simple tests to characterize the extent of arteriosclerosis and autonomic neuropathy (the paraclinical examination and tests are described in Danish at www.CardiacRehabilitation.dk). Blood pressure is measured for 24 hours if the physician suspects arterial hypertension. The physician uses several biochemical parameters to assess blood sugar control (fasting plasma glucose, blood sugar and Hb A1c) and to diagnose microalbuminuria (ratio of albumin to creatinine in morning spot urine). If microalbuminuria or macroalbuminuria is suspected, urine is always collected for 24 hours. Patients are referred to the Department of Nephrology for macroalbuminuria and elevated renal parameters: elevated serum creatinine and serum urea that cannot immediately be explained in other ways.

Treatment plan: The physician and the patient jointly determine realistic treatment goals that are recorded in the joint patient records and in the patient’s treatment plan. The treatment goals are set based on the standard goals of the comprehensive cardiac rehabilitation programme for patients with type 2 diabetes (Chapter 4). The physician assesses the need for further individual follow-up of type 2 diabetes with the physician and/or nurse. The physician emphasizes the importance of regular eye examinations and check-ups with a chiropodist/podiatrist.

Initial type 2 diabetes consultation with a nurse
The initial type 2 diabetes consultation with a nurse often takes place a few days before the initial type 2 diabetes consultation with a physician or the same day after the physician consultation.The nurse ensures that patients measure their blood sugar correctly and understand what to do about both hyperglycaemia and hypoglycaemia. The forms required to apply for public subsidies for expenses associated with type 2 diabetes are completed, and the nurse gives referral papers for the chiropodist and any written material on type 2 diabetes considered appropriate.

The nurse assesses the patient’s degree of self-care. This concept has especially been used in diabetes care and refers to several elements and methods that enable people with type 2 diabetes to master their illness. Diabetes care has many years of experience with self-care that can be transferred to and developed within cardiac care (28;29).The integrated cardiac and diabetes rehabilitation in the comprehensive cardiac rehabilitation programme attempts to expand and unify the self-care concept from each specialty.

The nurse is responsible for asking patients about symptoms of type 2 diabetes and late complications and informing patients about preventing foot ulceration and on social support schemes, the Danish Diabetes Association and local associations. The nurse also maintains contact with the home nurse and sometimes the general practitioner. In addition, the nurse is responsible for teaching patients how to correctly measure blood sugar; mastering angina pectoris by using a diary and nitroglycerin; tackling the initial signs of poor regulation, such as weight gain, through self-administered diuretics and nitroglycerin; and mastering crisis, anxiety and depression.

The physician largely focuses on managing risk factors and early treatment of late complications, whereas the nurse’s efforts in integrating cardiac and diabetes rehabilitation creates a good basis for patients to change lifestyle and to manage to master with greater flexibility the challenges that arise if more complications emerge.


11.4.3 Follow-up type 2 diabetes consultations

The individual clinical assessment and follow-up of type 2 diabetes among patients with heart disease depend on the degree of dysregulation, but the staff attempt to perform as much of this as possible during the planned follow-up consultations when rehabilitation starts and at the follow-up consultations after 3, 6 and 12 months. Among patients with heart disease, those with type 2 diabetes often have more severe heart disease and more difficult-to-treat risk factors than those without type 2 diabetes. This therefore requires more individual follow-up consultations with both the physician and the nurse, and starting insulin treatment always requires intensive follow-up and assessment by the physician and nurse and often renewed dietary guidance to avoid weight gain.

Physician
At the follow-up consultation, the physician determines whether patients have achieved the treatment goals set, and if these have not been achieved, revises the previous treatment plan for the rest of the rehabilitation programme in cooperation with patients. The physician determines individually how often patients have to monitor blood sugar for 24 hours at a time. When patients are increasing the dose of antidiabetic agents, more follow-up and 24-hour profiles by the physician may be necessary. The physician discusses the examination results from various specialist health professionals (ophthalmologists, chiropodists, orthopaedic surgeons and dermatologists) with patients.Any patients who have not achieved the treatment goals at the 3-month follow-up consultation (Hb A1c < 6.5%, fasting blood sugar <6.0 mmol/l and blood sugar after eating a meal <8.0 mmol/l) despite optimum change in lifestyle and maximum antidiabetic pharmaceutical treatment are prepared for starting insulin treatment. The physician follows Denmark’s current guidelines for dosage at the start and enters the plan for increasing dosage in the patient records. The physician from the Cardiac Rehabilitation Unit is present for the first few times when insulin treatment is started, and the nurse follows up thereafter (the instructions for starting insulin treatment are available in Danish at www.CardiacRehabilitation.dk).

Nurse
At follow-up consultations, the nurse ensures that patients optimally master self-care for both type 2 diabetes and cardiovascular disease. The nurse and patient discuss the patient’s outstanding questions about measuring blood sugar and the concentrations obtained as well as sex and marital relations. The nurse assesses whether patients need to update their knowledge or action related to changing lifestyle. The nurse asks the patient about any variation in blood sugar, focusing on hypoglycaemia with or without manifest symptoms.The nurse examines the patient’s feet for new ulceration and examines the needle marks of patients receiving insulin. The nurse measures the patient’s blood pressure if necessary and follows up on any plans to increase the dose of medicine.


11.4.4 Group type 2 diabetes education

The type 2 diabetes education in the comprehensive cardiac rehabilitation programme is mainly group education.The groups comprise patients who have had type 2 diabetes for many years and ones who have been diagnosed recently, and the education is adapted to this.The ideal interval between each meeting is 14 days, and they are planned for the same time and day of the week. The meetings are conducted in connection with the heart-health meetings in the intensive part of the comprehensive cardiac rehabilitation programme, and 6–8 patients with type 2 diabetes are recruited from two or more of the ongoing heart-health groups. The physician and nurse conduct three type 2 diabetes meetings of 2.5 hours each. They introduce each meeting by briefly describing the purpose and duration.A special educational programme has been developed for each meeting (available in Danish at www.CardiacRehabilitation.dk), and patients get copies of the educational material to place in their heart-health orientation binder.

All three meetings focus on giving patients insight into the necessity of intensive multifactorial rehabilitation with changing lifestyle as a key component to prevent late complications and reduce their progression. The patients are encouraged to take responsibility for ensuring that this process succeeds. The meetings are structured around the following themes and slides for each that are viewed at each meeting:

Type 2 diabetes meetings
Meeting Topic
1 Type 2 diabetes – a cardiovascular disease
2 The significance of lifestyle – risk factors and late complications
3 Living and coping with type 2 diabetes as a patient with cardiovascular disease


Type 2 diabetes meeting 1
Type 2 diabetes – a cardiovascular disease

Purpose
The purposes of the meeting are to educate patients and family members on the causes and symptoms of type 2 diabetes and late arteriosclerotic complications and to teach patients how to measure their blood sugar concentration.

The meeting
The nurse and physician inform patients about the causes of type 2 diabetes and the close relationship between type 2 diabetes and subsequent arteriosclerosis diseases, especially cardiovascular diseases. They explain the significance of genetics, gender, tobacco use, overweight and physical inactivity and the importance of multifactorial intervention. The nurse manages the practical exercises in measuring blood sugar. The patients measure their blood sugar at least twice under supervision and discuss the values obtained. All patients borrow a measuring device until they achieve the desired level of skill and have obtained their own machine. The patients receive a preprinted form with precise instructions for the desired times for measuring blood sugar and are encouraged to complete this for the second meeting.


Type 2 diabetes meeting 2
The significance of lifestyle – risk factors and late complications

Purpose
One purpose is to get patients to understand the relationship between the accumulation of risk factors and the development of type 2 diabetes and that type 2 diabetes can contribute to late complications if it is not well regulated. Another purpose is for patients to learn and act upon variation in blood sugar concentration. The message communicated is that the progression of type 2 diabetes can optimally be prevented by changing lifestyle and by strictly controlling blood sugar, blood pressure, serum cholesterol and other parameters.

The meeting
The nurse explains how to measure blood sugar and describes the symptoms and treatment of hyperglycaemia and hypoglycaemia. The physician informs patients about action to reduce risk factors and type 2 diabetes, focusing on the significance of various risk factors for type 2 diabetes and preventing or promoting late macrovascular and microvascular complications. Pharmaceutical treatment is reviewed, often referring to the products used by the attending patients. This includes information on antidiabetic agents (including insulin) and medicine for treating cardiovascular disease. The goal is that patients understand that treatment with several types of medicine is necessary to prevent or reduce late complications. The patients have the opportunity to reflect about the often drastic changes in lifestyle they are implementing, and each patient has an opportunity to evaluate his or her own course of illness, both type 2 diabetes and cardiovascular disease. The relationships between these two types of disease are explained, and patients can ask questions about symptoms and other illness-related events. The nurse ensures that patients have learned to measure their blood sugar correctly. The group discusses any problems in measuring blood sugar at home, and patients who need help in measuring blood sugar are supervised.


Type 2 diabetes meeting 3
Living and coping with type 2 diabetes as a patient with cardiovascular disease

Purpose
The purposes are to communicate the necessity of a high level of self-care for both type 2 diabetes and heart disease and to inform patients about the need for close clinical assessment and follow-up by general practitioners, ophthalmologists and chiropodists. Patients should learn about social support schemes and local activities related to type 2 diabetes.

The meeting
The nurse and the patients discuss the measured blood sugar concentrations. The physician reviews the late complications of type 2 diabetes and explains the background for establishing treatment goals, future blood tests and follow-up by ophthalmologists and chiropodists, including social support schemes. The group discusses sex and marital relations.The nurse informs about future control, including which tests are performed, how and how often, buying home medical supplies and buying ideal shoes. The nurse informs about the Danish Diabetes Association and the activities of local associations and how they can support individuals in the future. Finally, all patients get individual appointments with the nurse and physician for clinical assessment and follow-up consultations.

Individual type 2 diabetes education
A few severely dysregulated patients or patients with special needs may require individual follow-up between group type 2 diabetes meetings. The comprehensive cardiac rehabilitation programme offers individual type 2 diabetes education for patients in crisis, patients with an especially complicated course of illness and patients who want an individual programme. This education is organized to review as many of the topics from the group education as possible.


11.4.5 Meeting on impaired glucose tolerance

All patients in the comprehensive cardiac rehabilitation programme who are determined to have impaired glucose tolerance are invited to a 2.5-hour meeting. The physician and nurse conduct the meeting jointly. They inform patients that impaired glucose tolerance is not a disease but a condition that can be normalized or develop into type 2 diabetes and that 3–5% of the people with impaired glucose tolerance develop type 2 diabetes each year.

Many patients will experience this meeting as a summation of the knowledge they have received on changing lifestyle from the heart-health meetings.The main message communicated by the meeting is that the optimum treatment of impaired glucose tolerance is losing weight and keeping it off, exercising at least 30 minutes daily and quitting smoking.


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