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The purpose of this educational portfolio is to enable you to identify and achieve the prescribed learning outcomes within the overall context of Management of Chronic Disease (Singapore)

Introduction

Briefly introduce your allocated condition in your introduction. This should include a definition of what a long-term condition is and an explanation of your allocated condition along with a brief overview of its epidemiology and aetiology. The introduction must also outline how you searched for academic evidence to support this portfolio to answer the learning outcomes for this assessment

A search strategy outlining the relevant search terms you used, the research databases you searched and the number and type of results you obtained should be provided. This can be given in a table format to ensure you stay within the word count for this section.

Portfolio Entry 1

Describe the pathophysiology of the allocated condition, supported by relevant academic literature.

You must demonstrate your ability to understand the anatomical and physiological changes that occur for your allocated condition. This should include describing normal physiology and the changes that occur at the cellular, tissue/organ or bodily system level in relation to your allocated condition. This must be evidence based using appropriate academic sources.

Portfolio Entry 2

Select one symptom and

  1. Explore how this could affect your patient
  2. Evaluate 1 assessment tool (consider advantages/ disadvantages)
  3. Based on best evidence discuss the nursing management required to enable the patient to maximise their health and well-being and self-manage their condition.

This must demonstrate a holistic approach (physical, emotional, social and spiritual).  You should include reference to the support of family/carers and the role of other members of the multidisciplinary team and the voluntary sector where relevant.

Portfolio Entry 3

In this final section, summarise the key aspects discussed in the portfolio and make recommendations on how learning may influence your future practice

Conclusion

Key aspects discussed in the portfolio.

Portfolio Entry 1

Chronic illness or a long term illness can be defined as a characteristic health condition which is persistent in its impact and affects an individual over an extended course of time. A disease condition is termed ‘chronic’ if the disease condition lasts within an individual for a period of three months and more. Arthritis, asthma, chronic obstructive pulmonary disease (COPD), Diabetes and viral disorders such as Hepatitis C form some examples of the chronic disorders that impact individuals. These disorders are often referred to as long term disorders and require appropriate symptom management for the recovery over the course of the years.

The allotted case scenario, deals with the case study of Madam Kwok, who is 60 years old and has been living with her husband in Singapore. The client has two children who live nearby and is going to attend the scheduled appointment as a part of the national screening program of Singapore. The patient mentions that recently she has been passing frequent urine overnight and has been feeling extremely lethargic. In addition to this, it is worth noting that the patient history reveals that she has been suffering from hypertension and angina. Also, for her angina it has been reported that the client has been taking the GTN spray and in order to manage her high blood pressure she has been taking Ramipril. It is also essential to note in this context that lately, the client has reported to experience pain in her right foot which has resulted in her impaired mobility. The client leads an unhealthy lifestyle with poor nutritional intake which is rich in carbohydrate and fatty substance content and minimal physical exercise activity. It is reported that the client does not smoke or consume alcohol and also does not take pain killers to manage the persisting pain in her right foot. During the previous clinical visit, the vital signs that were reported for the patient comprised of the following:

Blood pressure: 180/70mmhg

Temperature: 36.0

Blood Glucose: 15.2mmol/l

In addition to the same, the client was alert and oriented during the previous clinical visit.

On analysing the vital signs and the existing symptoms of the patient, it can be stated that the client is suffering from the chronic illness condition of Diabetes. As per American Diabetes Association (2018), the normal blood glucose level should be in between 3.9 to 7.1mmol/L or in between 70 to 130 mg/dl. However, the reported vital sign assessment suggests that the blood glucose level of the patient is equivalent to 15.2mmol which is significantly higher than the optimal or the normal blood glucose range.

Portfolio Entry 2

As per P Phan et al. (2014), it has been mentioned that the existing population within Singapore is rapidly ageing and on account of an unhealthy and inactive lifestyle, in the recent years the incidence rate of Type II Diabetes has considerably increased. Research studies mention that the prevalence of obesity would multiply four time and increase from 4.3% as reported in the year 1990 to 15.9% by the year 2050. Also, it has been predicted that the prevalence of Type II Diabetes would increase from 7.3% as reported in the year 1990 to 15% by the end of the year 2050. The aetiology of diabetes has been studied to be genetic predisposition along with comorbid factors such as physical inactivity, obesity, being overweight and the phenomenon of insulin resistance. In this case, it can be said that the reported BMI of the client is 33.3 which reveals that she falls under the obese category. Also, on account of her poor nutritional intake and reduced physical activity along with medical history of hypertension and advancing age, it can be said that the client has developed Diabetes and for fostering recovery, appropriate symptom management is required.

In order to develop a clear understanding about the chronic illness disorder of Diabetes, the associated aetiology and the epidemiology, a rigorous search was conducted across the electronic databases of Google Scholar and PubMed. Specific exclusion and inclusion criteria were used while conducting the research. The inclusion criteria that were included comprised of factors such as inclusion of research journals published from 2013 to 2018, journals published in English and journals that could be accessed for complete text. On the other hand, the exclusion criteria comprised of research papers that were published in foreign languages, published before 2013 and were not accessible for complete text. The following key words were used to conduct the search:

Diabetes, prevalence, aetiology, epidemiology, risk factors, Singapore, old age, symptoms, vitals, hypertension, obesity, normal blood glucose level and patient outcome
The listed search terms were used in combination with Boolean operators such as OR/AND so as to obtain research journals that were aligned to the learning outcome of the provided case study. The case study was thoroughly analysed in relation to relevant research journals and accordingly the findings were established.

The level of insulin in the body and the capability of the body to uptake and utilise the insulin for carrying out physiological conditions determines the pathophysiology of Diabetes. In this context, it should be noted that a stark reduction of insulin within the body gives rise to Type I Diabetes (American Diabetes Association, 2018). Whereas, Type II Diabetes occurs when the impact of the insulin is obstructed by the peripheral tissues within the body. The Beta cells present within the Islets of Langerhans within the pancreas are responsible for secreting the insulin hormone within the body (American Diabetes Association, 2018). The synthesis of insulin is triggered when the glucose concentration within the body arises. For the maintenance of the normal functioning of the brain, glucose is required. The condition of lack of glucose or hypoglycaemia is characterised due to the use of pharmaceutical drugs that are known as anti hyperglycemics and are used for management of Diabetes. The plasma concentration of glucose directs the pathophysiology of Diabetes and it is triggered by the concentration of glucose and the signalling of the central nervous system to make use of the energy reserves (Guideline Development Group, 2008). Factors such as cerebral blood flow, tissue integrity and arterial plasma glucose level, the level at which the blood glucose concentration rise and fall and the ability of the body to make use of the metabolic fuel collectively determine the pathophysiology of Diabetes (Rayman & Kilvert, 2012). It is worth noting in this context that reduced level of glucose within the blood plasma, leads to an acute rise within the autonomic activity within the body. Reduced plasma glucose level qualifies as the diagnosis for hypoglycaemia (Grundy et al., 2004). The immediate intervention for the treatment of hypoglycaemia requires the identification of reduced insulin secretion and enhanced secretion of glucose and epinephrine that are identified as the counter-regulatory hormone and elicit an amplified sympathoadrenal response that give rise to symptoms such as coma, seizures and cognitive dysfunction (Ramachandran, Snehalatha, Shetty & Nanditha, 2012). Patients with impaired glucose tolerance might also develop poor glucose tolerance which can eventually give rise to initial Type I or Type II Diabetes. Research studies further suggests that Diabetic patients often develop hypoglycaemia after the consumption of a diet rich in the proportion of carbohydrate. It is interesting to note in this context that the pathophysiology of the disorder involves the complex interaction of a number of hormones which include the growth hormone, insulin and glucagons. Irrespective of the type of Diabetes, the condition results in poor uptake and utilization of the insulin hormone (Chen, Ovbiagele & Feng, 2016). The phenomenon of insulin resistance has been studied to be strongly associated with the development of Diabetes Type II. In this regard, risk factors such as obesity and hypertension have been studied to be strongly related with the manifestation of the disorder. The phenomenon of insulin resistance is regulated by genetic factors and abdominal obesity. Research studies have revealed a strong relationship between the development of Type II obesity and obesity. As per Zaccardi et al. (2016), it has been observed that approximately 80% of the patients suffering from Type II Diabetes are obese. Majorly the body fat are restricted within the regions of the upper body. Excessive accumulation of fat within the body cells act as a stressor and as a result the endoplasmic reticulum within the cells contain more nutrients to process that it can normally process. As a response, the endoplasmic reticulum down regulates the expression of the insulin receptors on the cell surface (Scheen, 2015). This consequently results in higher blood glucose concentration and this leads to the development of the phenomenon known as insulin resistance (Scheen, 2015). Also, the condition of Diabetes results in the damaging of the arteries and causes the condition of atherosclerosis. This elevates the blood pressure and can lead to fatal conditions such as renal failure, heart attack or blood vessel damage (Scheen, 2015).

Portfolio Entry 3

Therefore, it can be stated that pathophysiological alteration is synonymous to functional defect and occurs when there is an impaired equilibrium between the production and demand for the insulin hormone. Type I diabetes occurs when the beta cells within the pancreas responsible for the synthesis of insulin are damaged (Baynes, 2015). This leads to a stark deficiency of the beta cells which ultimately causes a deficiency of insulin within the blood. On the other hand, in case of Type II Diabetes, the body is not able to produce sufficient insulin required to metabolise and maintain the regulation of glucose (Baynes, 2015). Another diabetes type known as the gestational diabetes occurs during the phase of pregnancy where the body has increased amount of counter insulin hormones. The condition can also be categorized on account of inactivation of the insulin receptors (Steven et al., 2016).

Therefore on the basis of the understanding about the different kinds of Diabetes and their pathophysiology, it can be mentioned that the client has been suffering from Diabetes Type II which is characterised by the inability of the body to sufficiently uptake glucose and utilise it for the metabolism of glucose within the body.

On the basis of the information supplied by the case scenario, it can be said that the patient reports a total of three symptoms which include, feeling lethargic and thirsty, passing frequent urine at night and experiencing pain within the right foot which is restricting her ability to mobilise conveniently. In this context it is worth noting that the diabetic foot pain experienced by the patient is one of the most common symptoms of Type II Diabetes and is referred to as Peripheral Neuropathy. The symptom is an expression of the fact that the damage caused to the nerves during the progression of the disease (Cornell, 2015). Research studies further mention that a total of three kinds of neuropathy exists which include the sensory neuropathy, the autonomic neuropathy and the motor neuropathy (American Diabetes Association, 2018). The most pronounced neuropathy in diabetic patients is known as the sensory neuropathy which is also known as the sensitive pain and the amount of the pain is not equivalent to the intensity of the impulse (Steven et al., 2016; Cornell, 2015; Brunton, 2015). For instance, simple activities such as pulling a sheet over the feet could cause numbness and pain within the feet. Associated symptoms of sensory neuropathy can lead to symptoms such as the essence of a stabbing pain, tingling or a burning sensation. Research studies suggest that peripheral neuropathy increases the risk of experiencing vulnerable infections or injuries. Also, in serious conditions, the wound healing and recovery from infections might be significantly delayed which might require amputation for facilitating recovery. It is essential to note in this regard that neuropathy can impact different regions within the body which might cause a diverse range of symptoms. The symptoms of the condition tend to appear slowly and patients confirm to experience feelings such as pain and a stinging sensation within the feet. Research studies mention that the condition of diabetic neuropathy occurs when there is a poor equilibrium between the repair and the damage of the nerve fibre (Cryer, 2016; Cornell, 2015). On account of the nerve damage the autonomic and the distal sensory nerve fibres are affected which results in loss of sensation. Apart from the mentioned metabolic factors, inflammation as well as ischemic factors also lead to the development of diabetic neuropathies. Research studies mention that metabolic factors dictate the condition of length dependent polyneuropathy however, in cases of focal neuropathies, the inflammation is imposed on the nerve lesions that are ischemic in origin (Asmat, Abad & Ismail, 2016; Gallagher & Suckling, 2016). It should further be noted that hyalinization as well as thickening of the minor blood vessel walls result in recurrent duplication of the basal lamina layer that surrounds the endothelial cells and this explains the mechanism of neural ischemia that revolves around the phenomenon of diabetic neuropathy (Pop-Busui et al., 2017). It should further be noted that the condition of polyneuropathy includes the reduction of the endoneurial oxygen tension within the sural nerves in the Diabetic patients (Pop-Busui et al., 2017).

Conclusion

Research studies further suggest that the most obvious mechanisms of neuropathy comprise of phenomenon such as oxidative stress, the pylol pathway, nonenzymatic glycosylation, the protein kinase C pathway, the poly (ADP-ribose) polymerase pathway and the reduction of the neurotrophic factors which might synergistically act and cause Diabetic Neuropathy (Gallagher & Suckling 2016; Feldman et al., 2017).

The diagnosis of Diabetic Neuropathy can be confirmed with the help of a physical assessment exam and accordingly the medical history and symptom of the patient must be reviewed for the confirmation of the diagnosis of Diabetic Neuropathy. The primary considerations while performing the assessment would comprise of checking tendon reflexes, assessing sensitivity to touch and vibration and assessing the overall muscle strength and tone of the patient. In addition to the same, the feet of the patient would be checked for the presence of any potential sores, cracked skin, bone or joint problems and presence of blisters (Volmer-Thole & Lobamann, 2016). It is recommended by the American Diabetes Association (2018) that patients suffering from Diabetes must undergo a comprehensive and elaborate foot exam once every year. In addition to this, the client would also be referred to a number of diagnostic tests that would help to evaluate the intensity of the condition. These tests would comprise of conducting a filament test. The test primarily involves the brushing of a nylon fibre against the areas of the skin that are sensitive to touch. In addition to this, the patient would also be referred to a quantitative sensory testing and the test would help to assess the manner in which the nerves of the patient respond to changes within the temperature and the manner in which the patient responds to vibrations (Juster-Switlyk & Smith, 2016). In addition to this, the patient would also be referred to nerve conduction studies. The rationale for the referral to this test can be explained as its feasibility to assess and measure the manner in which the nerves can transmit signals quickly. The method is widely recommended to diagnose the carpal tunnel syndrome (Bhupathiraju & Hu, 2016). Further, the process of electromyography would also be recommended to the patient. The rationale for the same can be explained as the feasibility of the test to appropriately estimate the electrical discharges that are produced and accumulated within the muscles (Bhupathiraju & Hu, 2016). Also, the autonomic test would be recommended on account of the fact that the test helps to estimate the change in the level of blood pressure on the basis of the different positions maintained such that maintenance of the postures allow normal sweating (Feldman, Nave, Jensen & Bennett, 2017). In addition to this, in order to obtain a clear overview about the quality of pain, a pain assessment of the patient would also be conducted. The rationale for the same can be explained as development of a clear idea about the quality of the pain such that appropriate interventions can be applied so as to facilitate accelerated recovery (Volmer-Thole & Lobmann, 2016). In this case, the assessment tool that would be used for assessing the symptom of the patient would comprise of referring the patient for an autonomic testing (Pop-Busui et al., 2017). The supporting rationale for the same can be explained as the effectiveness of the test to determine the change in the quality of pain in relation to the change in blood pressure at different postures of positions (Juster-Switlyk & Smith, 2016). The advantages associated with the chemical investigation can be explained as the increased efficiency to assess the severity and the distribution of the autonomic failure as well as the increased sensitivity of the test to accurately detect subclinical dysautonomia (Gallagher & Sucking, 2016). Disadvantages associated with the recommended assessment is limited to factors such as time and technology intensive in nature, pre-requisite of patient preparation and increased cost (Feldman, Nave, Jensen & Bennett, 2017).

Epidemiology and Aetiology of Diabetes

It is worth noting in this context that apart from the mentioned assessment, the pain assessment would also be carried out. The supporting rationale for the same can be explained as the development of clear overview about the nature of the pain. The pain of the patient would be monitored and the patient would be asked to rate the pain score such that a detailed explanation can be formulated about the nature, intensity and progression of the pain throughout the day (Asmat, Abad & Ismail, 2016).

In relation to the available evidence based studies, it can be mentioned that there is no established cure for the condition of Diabetes neuropathy. However, the treatment goals would focus on reliving pain, preventing the progression of the disorder and managing the symptom complication to restore physiological function. In order to achieve the articulated goals it is essential to manage the symptoms of Diabetes. The first intervention that would be devised would comprise of managing the blood glucose level of the patient. For the same, the patient would be referred to a nutritionist and a physical exercise trainer. Research studies mention that uncontrolled diet forms one of the primary reasons that interfere with the maintenance of normal blood glucose level within affected patients. In addition to this, a number of research studies have established the relationship between obesity, accumulation of body weight and the phenomenon of insulin resistance which interferes with the normal metabolism of glucose (Bhupathiraju & Hu, 2016; Verma & Husaain, 2017). For the maintenance of an optimal blood glucose level and optimise the symptoms of Diabetes, the patient would be referred to a physical trainer and a nutritionist. The nutritionist would chalk out a diabetic tolerant diet plan for the patient and the physical trainer would make use of rigorous physical training to assist the patient with positive weight loss (Komaroff, 2017). It is expected that the combination of a nutritious diet and physical exercise training would help the patient lose weight which would subsequently help to control the blood glucose level of the patient.

The intervention that would be undertaken for fostering recovery from the diabetic related nerve pain would comprise of administering prescription pain relief medications. Further, as recommended by the American Diabetes Association, the patient can also be administered anti-seizure medications such as pregabalin or gabapentin that are widely used for the treatment of neuropathy (American Diabetes Association, 2018). However, in case the medications are administered, additional interventions would be undertaken to ensure that the patient is relived from the side effects of dizziness, inflammation or drowsiness. Administration of the drug in consultation with the physician would help to treat the symptom of pain and numbness within the feet (American Diabetes Association, 2018). In addition to this, the patient can also be administered serotonin or norepinephrine which constitute the type of antidepressants that are responsible for the reuptake of the inhibitors such as SNRIs and help to alleviate the symptoms of pain. The evidence base in this regard mentions that a combination of the antidepressant and the anti-seizure drug might help to relieve the symptoms of pain within the feet (Yamazaki, Hitomi & Nishiyama, 2018).

Pathophysiology of Diabetes

Further in order to treat the symptoms of urinary tract issues, the patient would be encouraged to urinate every hour to inculcate the habit of timed urination. The patient would be encouraged to apply mild pressure within the bladder area and urinate. Depending upon the condition of the patient, the patient might be referred to the process of self-catherization such that urine is removed completely from the damaged bladder (Yamazaki, Hitomi & Nishiyama, 2018).

In addition to the mentioned interventions, the patient would be imparted health literacy about Diabetes and would be made aware about the risk factors that interfere with the normal maintenance of the blood glucose level. The patient would be trained with self-management techniques such as medication management, self-glucose monitoring with glucometer strips and a chart about the normal blood glucose level would be provided to the patient such that the patient is able to monitor the blood glucose level conveniently (Alloubani, Saleh & Abdelhafiz, 2018).

Further as mentioned within the case scenario, the social interaction level of the patient has diminished considerably. For improving social interaction, the patient would be referred to veteran social groups that pursue interest of the client such as cooking. This would improve the level of social interaction of the client. In addition to this, the patient would also be referred to attend spiritual motivation talk sessions which would improve the spiritual and emotional health of the patient and foster positive recovery (Atallah, Cote & Bekarian, 2019).

For the purpose of emotional wellness, the patient would be referred to a psychological counsellor. The case scenario suggests that the patient experiences fatigue and lack of energy and at the same time the patient is not motivated to adhere to the prescribed treatment regimen and for the same reason the patient arranging a consultation with the psychological counsellor would help to improve the symptoms of emotional and psychological wellbeing (Phan et al., 2014).

Therefore on the basis of the analysis of the case scenario a total of five recovery goals can be articulated which would include optimal blood glucose management, pain management, psychological wellness and appropriate self-management of the Diabetes symptoms. With the use of the above intervention strategies, recovery would be reinforced.

Therefore in conclusion, it can be mentioned that the provided case scenario deals with the chronic illness condition of Type II Diabetes which affects the 60 year old patient, Madam Kwok. The patient confirms to experience symptoms that include frequent urination over the night, pain within the right leg, increased thirst and increased fatigue. In addition to this, it is worth noting that the patient has a medical history of hypertension, angina and is obese. The Type II Diabetes disease condition is triggered with the insufficient synthesis and uptake of insulin within the body to metabolise glucose. Research studies have also suggested that a strong relationship exists between obesity, hypertension and elevated blood glucose level. For the assessment of the symptom of diabetic neuropathy, a physical assessment would be conducted followed by referral to a number of chemical investigations. Further, the recovery intervention would comprise of recommendation and administration of pharmaceutical medications in combination with blood glucose monitoring, organizing referral to a nutritionist and a physical activity expert for the purpose of weight management. Apart from the same, the patient would also be referred to a psychological counsellor and a spiritual leader as well as a social group for improving social interaction and reinforcing positive recovery.

Search Strategies

Recommendations for future nursing practice would comprise of fostering health literacy to the immediate family members of the patient. The rationale for the same can be explained as fostering the sense of responsibility among the family members to assist the patient with the procedure of recovery and symptom management (American Diabetes Association, 2018). In addition to this, I would also make sure that the patient attends follow up sessions regularly in accordance to the schedule such that the patient can lead a healthy lifestyle (Scheen, 2015; Zaccardi et al., 2016).

References

Alloubani, A., Saleh, A., & Abdelhafiz, I. (2018). Hypertension and diabetes mellitus as a predictive risk factors for stroke. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 12(4), 577-584. Doi: https://doi.org/10.1016/j.dsx.2018.03.009

American Diabetes Association. (2017). 8. Pharmacologic approaches to glycemic treatment. Diabetes Care, 40(Supplement 1), S64-S74. Doi: ttps://doi.org/10.2337/dc18-S008

American Diabetes Association. (2018). 1. Improving Care and Promoting Health in Populations: Standards of Medical Care in Diabetes-2018. Diabetes Care, 41(Suppl 1), S7. Doi: https://doi.org/10.2337/dc18-S001

American Diabetes Association. (2018). 10. Microvascular complications and foot care: standards of medical care in diabetes—2018. Diabetes Care, 41(Supplement 1), S105-S118. Doi: https://doi.org/10.2337/dc18-S010

American Diabetes Association. (2018). 3. Comprehensive Medical Evaluation and Assessment of Comorbidities: Standards of Medical Care in Diabetes-2018. Diabetes Care, 41(Suppl 1), S28. Doi: https://doi.org/10.2337/dc18-S003

American Diabetes Association. (2018). 4. Lifestyle management: standards of medical care in diabetes—2018. Diabetes Care, 41(Supplement 1), S38-S50. Doi: https://doi.org/10.2337/dc18-S004

Asmat, U., Abad, K., & Ismail, K. (2016). Diabetes mellitus and oxidative stress—A concise review. Saudi Pharmaceutical Journal, 24(5), 547-553. Doi: https://doi.org/10.1016/j.jsps.2015.03.013

Atallah, R., Côté, J., & Bekarian, G. (2019). Evaluation of the effects of a nursing intervention on the therapeutic adherence of people with type 2 diabetes. Recherche en soins infirmiers, (1), 28-42. Doi: 10.3917/rsi.136.0028

Baynes, H. W. (2015). Classification, pathophysiology, diagnosis and management of diabetes mellitus. J diabetes metab, 6(5), 1-9. Doi:10.4172/2155-6156.1000541

Bhupathiraju, S. N., & Hu, F. B. (2016). Epidemiology of obesity and diabetes and their cardiovascular complications. Circulation research, 118(11), 1723-1735.Doi: https://doi.org/10.1161/CIRCRESAHA.115.306825

Brunton, S. (2016). Pathophysiology of type 2 diabetes: the evolution of our understanding. J Fam Pract, 65(4 Suppl). Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/27262256

Chen, R., Ovbiagele, B., & Feng, W. (2016). Diabetes and stroke: epidemiology, pathophysiology, pharmaceuticals and outcomes. The American journal of the medical sciences, 351(4), 380-386. Doi: https://doi.org/10.1016/j.amjms.2016.01.011

Cornell, S. (2015). Continual evolution of type 2 diabetes: an update on pathophysiology and emerging treatment options. Therapeutics and clinical risk management, 11, 621. Doi: 10.2147/TCRM.S67387

Cryer, P. (2016). Hypoglycemia in diabetes: pathophysiology, prevalence, and prevention. American Diabetes Association. Doi: 10.1016/j.ecl.2010.05.003

Feldman, E. L., Nave, K. A., Jensen, T. S., & Bennett, D. L. (2017). New horizons in diabetic neuropathy: mechanisms, bioenergetics, and pain. Neuron, 93(6), 1296-1313. Doi: 10.1016/j.neuron.2017.02.005

Holistic Approach

Gallagher, H., & Suckling, R. J. (2016). Diabetic nephropathy: where are we on the journey from pathophysiology to treatment?. Diabetes, Obesity and Metabolism, 18(7), 641-647. Doi: https://doi.org/10.1111/dom.12630

Grundy, S. M., Hansen, B., Smith Jr, S. C., Cleeman, J. I., Kahn, R. A., & Conference Participants. (2004). Clinical management of metabolic syndrome: report of the American Heart Association/National Heart, Lung, and Blood Institute/American Diabetes Association conference on scientific issues related to management. Circulation, 109(4), 551-556. Doi: https://doi.org/10.1161/01.CIR.0000112379.88385.67

Guideline Development Group. (2008). Guidelines: management of diabetes from preconception to the postnatal period: summary of NICE guidance. BMJ: British Medical Journal, 336(7646), 714. Doi: 10.1136/bmj.39505.641273.AD

Horr, S., & Nissen, S. (2016). Managing hypertension in type 2 diabetes mellitus. Best practice & research Clinical endocrinology & metabolism, 30(3), 445-454. Doi: https://doi.org/10.1016/j.beem.2016.06.001

Juster-Switlyk, K., & Smith, A. G. (2016). Updates in diabetic peripheral neuropathy. F1000Research, 5. Doi: 10.12688/f1000research.7898.1

Komaroff, A. L. (2017). The microbiome and risk for obesity and diabetes. Jama, 317(4), 355-356. Doi: 10.1001/jama.2016.20099

Phan, T. P., Alkema, L., Tai, E. S., Tan, K. H., Yang, Q., Lim, W. Y., ... & Chia, K. S. (2014). Forecasting the burden of type 2 diabetes in Singapore using a demographic epidemiological model of Singapore. BMJ Open Diabetes Research and Care, 2(1), e000012. Doi: https://dx.doi.org/10.1136/bmjdrc-2013-000012

Pop-Busui, R., Boulton, A. J., Feldman, E. L., Bril, V., Freeman, R., Malik, R. A., ... & Ziegler, D. (2017). Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes care, 40(1), 136-154. Doi: https://doi.org/10.2337/dc16-2042

Ramachandran, A., Snehalatha, C., Shetty, A. S., & Nanditha, A. (2012). Trends in prevalence of diabetes in Asian countries. World journal of diabetes, 3(6), 110. Doi: 10.4239/wjd.v3.i6.110

Rayman, G., & Kilvert, A. (2012). The crisis in diabetes care in England. Doi: https://doi.org/10.1136/bmj.e5446

Scheen, A. J. (2015). Aggressive weight reduction treatment in the management of type 2 diabetes. Diabetes, 110897. Retrieved from: https://www.em-consulte.com/en/module/displayarticle/article/79692/impression/vue4

Steven, S., Hollingsworth, K. G., Al-Mrabeh, A., Avery, L., Aribisala, B., Caslake, M., & Taylor, R. (2016). Very low-calorie diet and 6 months of weight stability in type 2 diabetes: pathophysiological changes in responders and nonresponders. Diabetes care, 39(5), 808-815. Retrieved from: https://www.mdedge.com/content/pathophysiology-type-2-diabetes-evolution-our-understanding-0

Verma, S., & Hussain, M. E. (2017). Obesity and diabetes: an update. Diabetes & Metabolic Syndrome: Clinical Research & Reviews, 11(1), 73-79. Doi: https://doi.org/10.1016/j.dsx.2016.06.017

Volmer-Thole, M., & Lobmann, R. (2016). Neuropathy and diabetic foot syndrome. International journal of molecular sciences, 17(6), 917. Doi: 10.3390/ijms17060917

Yamazaki, D., Hitomi, H., & Nishiyama, A. (2018). Hypertension with diabetes mellitus complications. Hypertension Research, 41(3), 147-156. Retrieved from: https://www.nature.com/articles/s41440-017-0008-y

Zaccardi, F., Webb, D. R., Yates, T., & Davies, M. J. (2016). Pathophysiology of type 1 and type 2 diabetes mellitus: a 90-year perspective. Postgraduate medical journal, 92(1084), 63-69. Doi: https://dx.doi.org/10.1136/postgradmedj-2015-133281

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