REVIEW OF RELATED LITERATURE AND STUDIES
This chapter presents related literature and studies relevant to the study on the predictors of health outcomes among patients with Type II Diabetes Mellitus. Related literatures are provided information taken from the reliable resources such as journals, books, and government and non-government organizations website. Related studies are the previous studies conducted by the several researchers to explore and examine the variables being studied. Some of the variables used in the previous studies are the same variables being used in this present study. However, this present study will further examine the predictors of health outcomes among diabetic patients. Hence, this will help the present study to determine of what is not yet known and unknown.
Though diabetes mellitus cannot be cured, this chronic disease usually requires a combination of therapies including adherence to health-promoting behaviors such as prescribed maintenance blood glucose-regulating drugs, prescribed diet, regular exercise and regular blood glucose self-monitoring in order to prevent the progression of diabetes-related complications. Therefore, health care providers need effective ways to develop, implement and support health promotions among diabetic individuals.
However, the most important thing than the medical management prescribed by the health care providers is the patientsâ key role in the self-care management. On a daily basis, patients have to take responsibility for a large number of behavioral choices and activities to manage their condition, predominantly outside the healthcare setting (Jarvis et al., 2009). The choices that patients make during daily life have a greater impact on health outcomes than those made by the health care providers. Once patients are outside the healthcare setting, they themselves are in control. They decide whether or not to implement recommendations in their daily life (Funnell et al., 2004).
According to Nola Penderâs Health Promotion Model, personal factors are defined as those distinguishing characteristics, which might affect behavior. It categorized as biological, psychological, or socio-cultural factors (Tomey & Alligood, 2002). The following personal factors used in this study were age, sex, education, civil status, occupation, financial status, length of disease diagnosis, perceived health status and body measurements.
Age. Age can affect the diabetes treatment care regimen, especially in older individuals. Older diabetic individuals are often have poor financial status, experience higher frequency of social isolation and depression, and are often more susceptible to hypoglycemic episodes (Sinclair, 2006). Age is also associated with worsening of diabetic-related complications such as diabetic retinopathy, nephropathy and neuropathy. This can cause to be more challenging for the older diabetic individuals on their self-management.
Recent epidemiological studies have shown a clear relationship between age and prevalence of Type II Diabetes Mellitus in the United States. Approximately 11% of individuals aged 65 years and older and 6% of those aged 45 to 64 years have Diabetes Mellitus, while only 1.5% among those aged 18 to 44 years is affected by this chronic disease. At the same time, younger age groups are being diagnosed with Type II Diabetes Mellitus (Harris, 1998).
Sex. Health behaviors are dynamically different between men and women. While most studies have found that men are more physically active than women. Womenâ exercise patterns are more health-promoting and sustainable relative to those of men (Dean, 1989). Women and men also differ in health care utilization, with men generally utilizing fewer health services (Courtenay, 2000). Although women are more likely to seek preventive care, extensive research has documented sex disparities in the care that men and women receive (Bird et al., 2007).
Educational Attainment. The associations between educational attainment and health behaviors are particularly important in diabetes mellitus, given the critical role of health behaviors, including diabetes self-care management and health-related lifestyle (Mirowsky, 1998).
According to American Medical Association (1999), functional health literacy is the ability to read and understand the prescription bottles, appointment slips, and other health-related materials of which will be required to successfully function as a person. Functional health literacy may mediate the relationship between low financial and health status (American Medical Association, 1999). Lower educational attainment is strongly associated with worse health literacy (Baker et al., 1998) and inadequate health literacy has been linked to poorer health status (Street et al., 1993). Diabetic individuals who have inadequate or marginal literacy are less likely to know the hypoglycemic symptoms (Williams, 1998) and they have higher results of glycosylated hemoglobin A1c (Schillinger, 2002).
Financial Status. In 2012, nearly 1.5 million deaths were directly caused by Diabetes Mellitus and over 80% of Diabetes Mellitus deaths were come from in low- and middle-income countries (World Health Organization, 2012). The influence of wealth on healthcare access and utilization of healthcare services affects the individualâs adherence to health promoting behaviors. Even within publicly and universally accessible systems, there is evidence that individuals from lower financial groups have impaired access to care reflected in longer wait times and fewer referrals to specialist care (Dunlop et al.; 2002). This might contribute to the observation of worse health outcomes, such as the increased rate of diabetic-related complications (Booth et al., 2003).
According to the study of Rabi and colleagues (2006), they explored the association between financial status with prevalence and utilization of diabetes acre services. Their findings showed that low income earners have higher prevalence of Diabetes Mellitus than those high income earners. In another study conductes, only 30% were treatment regimens compliant and the non-compliant were greater among groups belonging to the lower socio-economic status (Shrivastava et al., 2013).
Length of Disease Diagnosis. According to the study conducted by Rhee and colleagues (2005) and Lee and colleagues (2009), they explored the relationship between personal factors and glycemic control, which was defined as glycosylated hemoglobin A1c levels. Rhee and colleagues explored the relationship between age, length of diabetes diagnosis, and glycosylated hemoglobin A1c levels and the study obtained significant results.
The length of diabetes diagnosis was found to be positively related to glycosylated hemoglobin A1c level. The longer the diagnosis the higher the glycosylated hemoglobin A1c level. Age was negatively related to glycosylated hemoglobin A1c level, indicating that the older the individual the lower the glycosylated hemoglobin A1c level. Conversely, Lee and colleagues explored the relationship between the same variables (age, length of diabetes diagnosis, and glycosylated hemoglobin A1c levels) but no significant relationship was found. The Rhee and colleagues study had a sample size of 1,560 whereas the Lee and colleagues study only had a sample size of 55.
Perceived Health Status. Perceived health is a subjective assessment that people make about their own health state and it is an indicator of over-all health status (European Community Health Indicators and Monitoring, 2010). It is included as one of the World Health Organization (WHO) health targets. Perceived health status is not a substitute for more objective health outcomes but rather complements them (The European Commission, 2011). Perceived health status accords well with objective health status (Unden et al., 2001).
According to Mitchell and colleagues (2004) study, they explored the relationship between perceived health status, blood glucose self-monitor, and glycosylated hemoglobin A1c levels but no significant relationship was found between these variables. Another study conducted by Vincze and colleagues (2004), they explored the relationship between personal factors and adherence to blood glucose self-monitor. The personal factors of age, length of diabetes diagnosis, and perceived health status were included. No significant relationship was found between these personal factors and adherence to blood glucose self-monitor.
Perceived Barriers to Action
According to Nola Penderâs Health Promotion Model, perceived barriers to action are defined as anticipated, imagined, or real blocks and personal costs of undertaking a given behavior (Tomey & Alligood, 2002). The perceived barriers to action used in this study were too many treatments to manage.
There are a number of potential barriers to self-management. People may not be able to access the information, resources or services that will enable them to develop their self-management skills, or the actual services and information may not be available. Physical barriers include the nature of their condition or conditions where people have different needs. Financial or logistical barriers include physical limitations of access to services, time and locations, financial cost, local availability of services and ongoing support once people have had self-management training or guidance. System barriers include conflicting advice or a lack of collaborative working between healthcare social care professionals in providing joined-up information, services and ongoing support for self-management (Diabetes UK, 2009).
Perceived barriers to action have an important role in the self-care process among diabetic individuals. Important barriers are non-awareness of health nutritional program, lack of social support and self-care management perception (Nagelkerk et al., 2006). According to Rothman and colleagues (2008) study, they showed inappropriate diet and sport habit among diabetic patients were related with perceived barriers. In the study of Glasgow and colleagues (2001), there is a significant but reverse relationship between perceived barriers to action and self-care behaviors.
Perceived barriers to action have been associated with lower rates of adherence to a variety of self-care regimens including diet, exercise, blood glucose self-monitor, and medication adherence behaviors (Aljasem et al., 2001). The increased impact of these barriers, in turn, may have longer reaching implications, including influencing metabolic control and overall functioning. In one study, greater reported frequency of barriers to general diabetes self-care among Type I and II diabetic patients was associated with higher glycosylated hemoglobin A1c levels, demonstrating poorer metabolic control and increased likelihood complications (Mollem et al., 1996).
According to Wen and colleagues (2004) study, they showed as perceived barriers to action among their research groups increase, prescribed physical activity and following nutritional diet increase. Koch (2002) study indicated a negative significant relationship between perceived barriers to action and self-care behaviors. Corina (2004) study showed as perceived barriers to action increase, a significant decrease happens in diabetic self-acre action. These were the same results seen in both Karter and colleagues (2000) and Adams and colleagues (2003) studies.
According to the study of Nagelkerk and colleagues (2006), they provided examples of common barriers to diabetes self-care management. Frequently reported barriers were time constraints, limited social support, limited coping skills, lack of knowledge related to diet management, helplessness and frustration from lack of glycemic control, and continued disease progression despite of treatment adherence. Although some of these barriers may appear static and not likely to change and many of these perceived barriers to action can vary in intensity from day to day.
In spite of different studies, which demonstrated reverse and significant relationship between self-care behaviors and perceived barriers to action, one study did not receive this negative correlation (Gillibrnad et al., 2006). In fact, according to Janz & Becker (1984) study, in a review of the general medical literature, concluded that the increased presence of perceived barriers to treatment was consistently reported as the strongest predictor of health action.
According to Nola Penderâs Health Promotion Model, situational influences are defined as those personal perceptions and cognitions of any given or context that can facilitate or impede behavior. It includes perceptions of options available, demand characteristics, and aesthetics features of the environment in which a given health-promoting behavior is proposed to take place. It may have direct or indirect inlfuences on health behavior (Tomey & Alligood, 2002). Situational influences used in this study were the diabetes-related emotional distress.
Diabetes-related emotional distress can be defined as a range of emotional responses and reactions to life with diabetes, especially those related to the treatment regimen and self-care demands. It is part of a personâs experience of managing diabetes and its treatment in the social context of family and health-care personnel (Fisher et al., 2012; and Polonsky et al., 2005). The under recognition of emotional problems, such as depression, anxiety, and diabetes-specific emotional distress, has been reported (Pouwer et al., 2006), and when such concerns are recognized, problems might be identified as depression, even in patients whose problems are directly related to diabetes and its treatment related to diabetes and its treatment (Gonzales et al., 2011).
The ability to self-manage also includes how people are supported by peers, family and care givers. The provision of emotional and psychological support should be an integral part of a diabetes service. Emotional and psychological needs of a person with diabetes have to be properly assessed in partnership with the person as part of the care planning process. It is important that people are made aware of the support available, so that they are able to choose if and when they need to access it (Diabetes UK, 2009).
Family relationships play a significant role in diabetes care management. Studies have demonstrated that low levels of conflict, high levels of cohesion and organization, and good communication patterns are linked with better treatment adherence (Delameter et al., 2001). Higher levels of social support, specifically the diabetes-related support from partners and their significant others are linked with better treatment adherence (Glasgow et al., 1998). Social support serves as to buffer the adverse reactions of stress on diabetes care management (Griffith et al., 1990).
Poor stress management and coping mechanism have been linked with more adherence problems (Peyrot et al., 1999). Diabetes-related emotional distress such as anxiety, depression, and eating disorders has also been associated with worse diabetes care management in both young and adult diabetic population groups (Delametrer et al., 2001). According to the recent Diabetes Attitudes, Wishes and Needs Study (2001) initiated by Novo Nordisk, the study showed that a significant number of diabetic patients have poor psychological well-being and those health care providers handling them reported that there psychological problems adversely affected the treatment adherence (Peyrot et al., 2005).
Depression may exert its effect through poor self-care behaviors such as over-eating, not exercising, or failing to keep medical appointments (Trief, 2007). The over-all depression rate in people with chronic illnesses is 20% to 70% paralleled to the estimated 5% seen in the general population group. The incidence of depression in diabetic individuals has been approximately estimated to 25% (Madden, 2010). Identifying and treating depression in Diabetes Mellitus is strongly recommended (Trief, 2007). One of the issues linked with Diabetes Mellitus is that many individuals are not clinically depressed but still experience feelings that are associated to depression in the course of living with their chronic disease. This state is sometimes referred to as diabetes-related emotional distress, and is associated to depression but not suffice to qualify a diagnosis of depression (Solowiejczyk, 2010).
Depression may affect the communication with healthcare providers, self-care management behaviors, utilization of healthcare services, and metabolic control. In a study conducted by Ciechanowski and colleagues (2000), among diabetic individuals with more depressive symptoms were found to have higher rates of non-adherence to oral anti-diabetes medications than those with fewest symptoms, with the results of 15% and 7% respectively. A meta-analysis study revealed a positive correlation between depression and glycosylated hemoglobin A1c levels (Lustman et al., 2000). Though, it is not known whether the treatment of depression is linked with better Diabetes Mellitus management.
According to the study of Fisher and colleagues (2012), they found non-linear relationships of diabetes-specific emotional distress with glycosylated hemoglobin A1c, diet, self-efficacy, and physical activity in two samples of persons with Type II Diabetes Mellitus, with stronger relationships for lower levels of diabetes-specific emotional distress.
According to Nola Penderâs Health Promotion Model, health-promoting behavior is defined as endpoint or action outcome directed toward attaining positive health outcome directed toward attaining positive health outcomes such as optimal well-being, personal fulfillment, and productive living (Tomey & Alligood, 2002). The following health-promoting behaviors used in this study were health responsibility, medication adherence, dietary and exercise behaviors.
In spite of the remarkable success in improving the lives of those living with diabetes mellitus with technological innovation in biomedical sciences, the management of Type II Diabetes Mellitus lies largely with those with diabetic individuals. It includes the practices that must be carried out by the patients themselves. Such practices include eating a healthy diet, performing physical activity, taking prescribed medications, self-monitoring of blood glucose level, regular clinic appointments, and stress management, among other practices (American Diabetes Association, 2002).
There are seven essential self-care behaviors in diabetic individuals which predict the good health outcomes. These are healthy eating, being physically active, self-monitoring of blood glucose level, compliant with prescribed medications, good problem-solving skills, healthy coping skills, and risk reduction behaviors. All these seven behaviors have been demonstrated to be positively associated with good glycemic control, reduction of diabetic-related complications, and quality of life improvement (Shrivastava et al., 2013).
Adherence to the prescribed maintenance blood glucose-regulating drugs, blood glucose self-monitoring, prescribed diet, and regular exercise are often identified as health-promoting behaviors. Diabetic individuals are expected to follow a multifaceted set of behaviors to manage their chronic disease on a daily basis. These actions include positive lifestyle behaviors engagement such as following a meal plan, do an appropriate physical activity, taking prescribed medications, self-monitoring blood glucose levels, responding to and self-treating diabetes-related symptoms, following foot-care guidelines, and seeking individually appropriate medical care for Diabetes Mellitus or other health-related problems (Shrivastava et al., 2013).
Health-responsibility behaviors. Successful self-care management requires knowledge about the condition, how it needs to be treated and what needs to be done. The key of self-care management activities specific to diabetes care and living with Diabetes Mellitus are: (1) managing the relationships between food, activity and medications; (2) self-monitoring of blood glucose, blood pressure and having retinal screening carried out; (3) targeting goals tailored to individual need, for example around foot care, weight loss, injection technique and self-monitoring activities; (4) applying sick day rules when ill, or what to do if going into hospital; (5) understanding diabetes, what care to expect and how to access services; (6) managing acute complications such as hypoglycemia and hyperglycemia; and (7) understanding legislative issues such as those related to employment and driving (Diabetes UK, 2009).
Successful control of diabetes mellitus requires lifelong adherence to multiple self-management activities in close collaboration with the health care professionals. Lack of adherence to such activities has been revealed to be linked with negative health outcomes. For instance, prescription refill adherence to Diabetes Mellitus medications correlates with improved glycosylated hemoglobin A1c results (Schectman et al., 2002).
Blood glucose self-monitoring is a cornerstone of Diabetes Mellitus management that can warrant patient participation in specific glycemic controls achievement and maintenance. It has been utilized for over 25 years with current technological innovations making the procedure very easy to practice. Research has exhibited that higher blood glucose self-monitoring practice is linked with glycemic control improvement. In spite of the technology advancement, however, patients often do not adhere well to this diabetes care regimen (Delamater, 2008).
Daily blood glucose self-monitoring is believed to be essential for the diabetic patients under treatment to detect asymptomatic hypoglycemia and to guide the patients and healthcare providersâ behaviors toward reaching the adequate blood glucose control (Harris, 2001). Blood glucose self-monitoring provides detail about current glycemic status and assessment of current therapy including modifications in medication, diet, and exercise in order to attain the optimal glycemic control (Shrivastava et al., 2013)
Among diabetic patients treated with insulin and either oral medications or diet and exercise, only 39% and 5% respectively were adhered to daily blood glucose self-monitoring of at least one blood glucose check per day (Harris et al., 2001). According to Delamater (2008) study, blood glucose self-monitoring adherence between diabetic patients treated with insulin and either oral medications or diet and exercise was 70% and 64% respectively and appointment keeping adherence was 71% and 72% respectively.
Medication adherence behaviors. The goal of the medical treatment is primarily to save life and alleviate symptoms. Secondary goals are to prevent long term diabetic-related complications and, by eliminating various risk factors, to increase longevity. Insulin replacement therapy is considered to be one of the cornerstones for the patients with Type I Diabetes Mellitus while diet and lifestyle modifications are for the treatment and management of Type II Diabetes Mellitus patients. Oral hypoglycemic agents are also useful in the treatment of Type II Diabetes Mellitus (Bastaki, 2005).
Diabetes progression can be prevented by adequate glycemic control (Funnell, 2000). However, unfortunately, diabetic individuals often do not follow their prescribed glucose-regulating regimen. Considering that 95% of Diabetes Mellitus treatment is by self-care management (Funnell, 2004), non-adherence to treatment results in significant increase of the diabetes progression, higher costs to the healthcare system, and frustration in both patients and healthcare providers.
The results from the study of Diabetes Attitudes, Wishes, and Needs (DAWN) conducted by Novo Nordisk, the study showed patient-reported medication adherence rates between Type I and Type II Diabetes Mellitus were 83% and 78% respectively (Delamater, 2008). Another study using a large national sample of patients with Type II Diabetes Mellitus showed that only 24% of insulin-treated patients, 65% of oral medications-treated patients, and 80% of those treated by both diet and exercise alone either never practiced blood glucose self-monitoring or did so less than once a month (Harris et al., 2001). Two studies showed that adherence to oral medications in patients with Type II Diabetes Mellitus were 53% and 67% respectively when measured by electronic monitoring (Delamater, 2008).
Dietary behaviors. Dietary management is considered to be one of the cornerstones in treatment of Diabetes Mellitus. It is based on the adherence of healthy diet behaviors in the context of social, cultural, and psychological influences on food choices (Ekore et al., 2008). Dietary practice refers to patientsâ food intake selections based on the diabetes nutrition education that provides importance on low fat and sodium intake, and high fiber intake (Shamsi et al., 2013). Several studies have shown that healthy diet behaviors could lead to significantly lower glycosylated hemoglobin A1c levels among diabetic patients (American Diabetes Association, 2008).
Patients newly diagnosed with Type II Diabetes Mellitus have similar diet behaviors compare to general population groups. Both external and emotional diet behaviors are linked with high-energy intake and controlled diet behavior with low-energy intake upon diagnosis. Women with high scores for emotional diet behavior were seemed to be less able to make initial dietary changes after being diagnosed with Diabetes Mellitus and having received dietary advice by healthcare providers (Laar et al., 2006).
Moreover, both external and emotional diet behaviors were linked with increased energy and fat intake. On the other hand, controlled diet behavior displayed an inverse relationship between energy and fat intake. External diet behavior, but not emotional diet behavior, revealed a significantly relationship with a decrease in energy intake in women and found no statistically significant relationships between diet behavior which was measured upon diagnosis and changes in energy and fat intake between diagnosis and four years (Laar et al., 2006). Diet behaviors adherence rates between Type I and Type II diabetic patients were 39% and 37% respectively (Delamater, 2008).
According to Plotnikoff and colleagues (2009) study, they explored the relationship between dietary behaviors, body mass index, and exercise. A significantly relationship was found for both body mass index and exercise for patients who reported more fruit and vegetable intake. Dietary behavior practice was associated with lower body mass index and an increase in frequency of physical activity. This study showed that adherence to dietary behaviors can be related with another health-promoting behaviors and health outcomes. Study demonstrated that the three types of diet behaviors distribution including energy fat intake at diagnosis, changes in energy and fat intake between diagnosis, and both eight weeks and four years were similar in patients with Type II Diabetes Mellitus and the general population groups.
Exercise behaviors. Exercise has long been considered as essential component of diabetes care management. Diabetes Mellitus Specialists have established exercise as one of the four cornerstones of health-promoting behaviors, along with medication, diet and blood glucose self-monitor. Exercise appears to support in the visceral fat loss. More recent study suggested that exercise may exert favorable effects on emerging vascular disease risk factors. Exercise may also play a protective role by increasing patient resilience to the emotional stress and depression often experienced with Diabetes Mellitus care management (Zecker, 2004). Irrespective of weight loss, regular physical activity engagement has beed exhibited to be related with health outcomes improvement among diabetic individuals. The National Institutes of Health and the American College of Sports Medicine (NIHACSM) recommend that all adults including those with Diabetes Mellitus should engage in regular physical activity (Shrivastava et al., 2013).
A weekly 150-minute moderate-intensity exercise can improve glycemic control. These exercises include cardiopulmonary function-improving activities such as brisk walking, biking, badminton, tai-chi, and aerobics mediated by repeated exercise involving large muscle groups (Haskell et al., 2007).
Another study by Diedrich and colleagues (2010), they explored the exercise program outcomes on weight, body fat, glycosylated hemoglobin A1c levels, and blood pressure. The participants who completed the program showed a significantly decrease in weight, body fat, glycosylated hemoglobin A1c levels, and in their diastolic blood pressure. The participants also showed an increase in their daily steps as indicated by a pedometer. This study showed that the exercise behaviors can be related with the health outcomes including glycosylated hemoglobin A1c levels, and the loss of weight and body fat could be interpreted as an improvement in the health outcome of body mass index. The exercise behaviors adherence rates between Type I and Type II diabetic patients were 37% and 35% respectively (Delamater, 2008).
Moreover, in a study conducted by Castillo and colleagues (2010), they explored the effect of a diabetes empowerment education program on diet, exercise, blood glucose self-monitoring, depression, and glycosylated hemoglobin A1c levels. A significant effect was seen on all the variables from the diabetes empowerment program. A significantly increased in dietary, exercise, and blood glucose self-monitor behaviors were noted while a significantly decreased in reported depression and glycosylated hemoglobin A1c levels were seen.
According to Vallis and colleagues (2005) study, they explored the effect of the diabetes management education program on blood glucose self-monitor, diet, exercise, and glycosylated hemoglobin A1c levels. A significant effect was seen on all the variables from the diabetes management education program. A significantly increased in blood glucose self-monitoring, dietary, and exercise behaviors were noted while significant decreases in glycosylated hemoglobin A1c levels were seen.
Treatment for Diabetes Mellitus involves restoring blood glucose to or near normal levels in all patients. The American Diabetes Association (ADA) recommends a treatment target for diabetes that includes a glycosylated hemoglobin A1c (HbA1c) level less than 7% and a fasting blood sugar (FBS) of less than 120 mg/dl (American Diabetes Association, 2000). Treatment for Type II Diabetes Mellitus is designed to maximize the effect of endogenous insulin by decreasing insulin resistance (American Diabetes Association, 2000). However, significant patientâs key role in self-management is necessary to achieve the positive overall health outcomes. The following health outcomes used in this study were body mass index (BMI), lipid profile, fasting blood sugar (FBS) and glycosylated hemoglobin A1c (HbA1c).
Body Mass Index. Body Mass Index (BMI) is an accurate indicator of fat in adults. The most commonly used BMI is Queteletâs Index, which is obtained by dividing weight in kilograms by height in meters squared (Dillon, 2007). According to the National Institutes of Health (NIH) interpret BMI values for adults with one fixed number, regardless of age or sex, using the following guidelines: (1) underweight: below 18.5; (2) normal weight: 18.5 to 24.9; (3) overweight: 25.0 to 29.9; and (4) obese: more than 30 (Dillon, 2007).
Nearly 90% of individuals with Type II Diabetes Mellitus are overweight or obese. Both body mass index (BMI) and body fat distribution are considered as strong predictors of obesity-related health risks, especially the Type II Diabetes Mellitus. The American Diabetes Association has stated that modest weight loss and reduced energy intake will help the insulin-resistant individuals to improve their glycemic control (Boucher et al., 2007).
Achievement of the ideal body mass index has been recommended among diabetic individuals. Adherence to both diet and exercise behaviors have been considered to contribute weight loss, which reduces the body mass index (Franz, 2007). Even though the patient is still considered as overweight, as little as 5% to 10% of weight loss from the initial weight can help to prevent the weight-related complications such as hypertension, dyslipidemia, and Type II Diabetes Mellitus. However, weightwatchers may not be satisfied with such modest goals and sometimes conclude that a desirable weight loss is unachievable (Kazaks & Stern, 2003). According to Franz (2007) study, he stated that although a reduction of body mass index has been linked with an improvement in Diabetes Mellitus is still unclear if the weight loss itself is linked with reduction in glycosylated hemoglobin A1c levels or if it is from the dietary changes of a decrease in total energy intake.
Weight loss of more than 3% from the initial weight was linked with glycemic control improvement in patients who are newly treated for Type II Diabetes Mellitus. Anti-diabetics medicines associated with weight loss or neutrality were associated with greater weight loss and glycosylated hemoglobin A1c goal attainment and may facilitate efforts to co-manage weight and blood sugar in the ambulatory-care setting (McAdam et al., 2014).
Diabetic control measures. The ideal of diabetic control was mainly assessed by measuring fasting blood sugar (FBS), glycosylated hemoglobin A1c (HbA1c), blood pressure and low density lipoprotein-cholesterol (LDL-C) (American Diabetes Association, 2008). Reduced incidences of diabetes-related complications have been reported when blood glucose, blood pressure and blood lipid are well controlled (American Association of Diabetes Educators, 2008).
Lipid abnormalities are common in people with Type II Diabetes Mellitus. Insulin resistance and central obesity are two closely linked factors that are important in determining the additional lipid abnormalities found in Type II Diabetes Mellitus (Brunzell & Hokanson, 1999). The role of insulin resistance in the pathogenesis of Type II Diabetes Mellitus was recognized by Himsworth (1936) over 60 years ago. According to Vague (1956) study, central obesity was recognized as a risk factor for the development of Type II Diabetes Mellitus over 40 years ago and many succeeding studies have confirmed this relationship.
The measurement of the glycosylated hemoglobin A1c (HbA1c) is a target indicator suggested by the American Diabetes Association which provides a stable and longer term measurement of glycemic control status. A glycosylated hemoglobin A1c can provide a reliable blood sugar history of the previous 120 days, and most accurately reflects the previous two to three months of glycemic control status. The American Diabetes Association recommends routine glycosylated hemoglobin A1c testing, two times per year in diabetic patients maintaining adequate glycemic control, and more frequently among diabetic patients who have not maintained glycemic control or who have changed their therapeutic regimen. The American Diabetes Association recommends the goal of therapy as a glycosylated hemoglobin A1c of less than 7%, and recommends that treatment be re-evaluated when glycosylated hemoglobin A1c exceeds 8% (American Diabetes Association, 2008).
Overall Summary of the Review
The literature and studies mentioned above provide information on the determinants of the two variables of this study. The reviews will help bridge the known from the unknown and as well as give mutual benefits between the patients involved and the healthcare providers of explaining the possible results of this study.
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