The aim of this essay is to delve into the importance and

The aim of this essay is to delve into the importance and key details of promoting healthy living and optimising self-care of patients by using a carefully designed personalised healthcare framework which takes into consideration the family needs and requirements of the individual. In order to achieve the primary goal of this essay, the first step is the creation of a health promotion leaflet which will provide crucial information regarding pharmacotherapy and specific lifestyle changes pertaining to the individual’s health needs. For the purpose of this essay, the case study is a 45 year old woman named Martha whose mother had recently died from diabetes mellitus and the health promotion leaflet will be referred to as “prediabetes leaflet”. This essay will provide detailed insight into the health promotional strategy adopted to treat and manage Martha’s prediabetes and also the theories and/or concepts which support the strategy. It will also provide a rationale for the design and presentation of the leaflet while also providing evidence that justifies the information contained in the health promotion leaflet. Government guidelines and policies regarding personalised healthcare and prediabetes will also be discussed with illustrations of successfully implemented government programmes.Clinical history taking for the purpose of healthcare needs assessment is a procedure that allows patients to present their account of the problem and provides essential information for the health practitioner (Lloyd and Craig, 2007). Crumbie (2006) emphasised that it is arguably the most important aspect of patient assessment. Initial history and physical examination often result in the identification of life-threatening conditions that can be promptly stabilised (Toney-Butler and Unison-Pace, 2019). The need and importance of this procedure influenced the history taking of 42 year old female, Martha, when she scheduled an appointment to check her blood sugar after the death of her mother.Since haemoglobin A1c testing avoids the problem of day-to-day variability of glucose values as it indicates the average plasma glucose (PG) over the previous 2 to 3 months as opposed to oral glucose tolerance test (OGTT) and gives a better overview of blood sugar patterns, Martha was made to undergo a haemoglobin A1c (HbA1c) test and the score was 6.0% (American Diabetes Association, 2012). When compared to normal plasma glucose levels of 4.0% – 5.6%, Martha’s test results indicated that she had borderline diabetes or prediabetes (American Diabetes Association, 2014). According to López-Jaramillo et al., (2017), development of prediabetes is characterised by an insulin-resistance stage followed by an increase in blood glucose levels and it occurs prior to the onset of type 2 diabetes mellitus. Tabák et al. (2012) suggested that there is a 5-10% risk of people with prediabetes progressing to type 2 diabetes mellitus every year. However, studies have shown that there are various ways to control prediabetes and prevent or delay the onset of type 2 diabetes mellitus and other cardiovascular diseases associated with type 2 diabetes: these methods include lifestyle changes (in terms of diet plan and physical activities) and pharmacotherapy (Kanat et al., 2015; Hays et al., 2016).The patient’s clinical history showed a family history of type 2 diabetes mellitus which according to CDC (2018) is one of the risk factors associated with prediabetes. Other risk factors associated with prediabetes include obesity, lack of exercise or reduced physical activities, high blood pressure and high cholesterol (Kanat et al., 2015; CDC, 2018; Mohamed et al., 2018). Many of the risk factors are modifiable and part of a person’s lifestyle which is the aggregate of daily behaviours such as physical, activities, nutrition, psychological factors that influence the individual’s physiology and health (Rippe, 2013; aus Berlin, 2017). Due to the nature of Martha’s ailment and health requirements, it was determined that a personalised healthcare plan would be the best method of ensuring optimal management of her condition. The healthcare plan would require a diabetes specialist nurse to provide health education and strategies to help Martha manage and adjust her behaviours relating to diet, exercise, medications and lifestyle changes (Lau-Walker, 2014). One of the facets of these lifestyle changes is to tackle the issue of obesity by specific dietary restrictions and regular exercising. Earlier research has shown that dietary restrictions and regular exercising that results in weight loss (5%–7% of total body weight) reduce the risk of prediabetes progressing to diabetes by 58% (Knowler et al., 2002). This was further validated by Hansen et al. (2010), who illustrated that dietary restrictions reduce the progression risk to type 2 diabetes mellitus by 31%. In order to properly educate Martha on the benefits of these diet interventions, a specialist dietician was invited to provide more information on the dangers of high cholesterol food and high salt intake. The dietician also educated Martha on the kind of foods to focus on and assisted her in developing a healthy eating plan which included increased dietary fibre and reduced intake of total and saturated fat (Lindstrom et al., 2003). In the course of the teaching sessions, Martha seemed to be considerably knowledgeable about her condition and showed keen interest and attention to the teaching sessions. This display of fervent interest in the subject matter could be attributed to the fact that her mother had recently passed away due to diabetes mellitus as well as the strategy employed by the dietician during the teaching sessions. The strategy adopted by the dietician revolved around methods – which have been approved by various literature – such as acknowledging the patient’s prior knowledge and developing a personal connection which would help ease any anxiety (Cooke, 2010; Day et al., 2011; Hays, 2014).In a bid to supplement the information provided during the teaching sessions, a prediabetes leaflet was designed for Martha’s personal use. This leaflet contains adequate information regarding her condition, the risk factors associated with it and the lifestyle interventions she would need to adopt in order to properly manage her condition and forestall the progression to type 2 diabetes mellitus. The resolution to adopt the use of the prediabetes leaflet stems from the knowledge that patients tend to remember little of the information discussed with them by their physician, specialist nurse, dietician or pharmacist and immediately forget as much as 40% – 80% of the verbal information provided during their medical encounter (Kessles, 2003; Sherlock and Brown, 2014). Having understood the aforementioned, the use of a health promotion leaflet enables the patients to have a more self-directed approach towards the learning process as they will be allowed to participate fully in evaluating their learning needs and implement the information or knowledge they have acquired (Kapur, 2015). The design of the leaflet used both illustrations and text which facilitate learning by providing clarifying examples, extra-lingual information, contexts for interpretation, and redundancy which aids recall (Dewan, 2015). As pointed out by Reed (2010), cognitive abilities to comprehend, remember, reason, solve problems, and make decisions are dependent on a rich combination of words and images; this statement further validates the rationale behind the design and presentation of the leaflet.The information provided in the leaflet can be justified by various literature. Genetic predisposition contributes to type 2 diabetes mellitus risk, but the disease development is also strongly associated with excess body weight and lifestyle factors (CDC, 2014). Early research in 2002 by the Diabetes Prevention Program which involved over 3000 people diagnosed with prediabetes showed that a carefully designed intensive lifestyle intervention which involves changes in diet and moderate physical activities reduced the progression risk of prediabetes to the type 2 diabetes mellitus by 58% in individuals with prediabetes who lost just 5% of their total body weight and participated in 150 minutes of physical activity per week (Knowler et al., 2002). Aerobic exercise, resistance training, and the combination of both have proven to be effective in reducing glycated haemoglobin (HbA1c) by about 0.6% (Yang et al., 2014). Reducing the amount of calories consumed is highly important for those at high risk for developing type 2 diabetes mellitus, however, recent evidence suggests that the quality of fats consumed in the diet is more important than the total quantity of dietary fat (Chiuve et al., 2012; Ley et al., 2014; Jacobs et al., 2015).Although overall healthy low-calorie consumption plans ought to be encouraged, there is also some evidence that particular dietary components which have a noticeable effect on diabetes risk such as higher intakes of nuts, berries, yoghurt, coffee, and tea are associated with reduced diabetes risk (Afshin et al., 2014, Chen et al., 2014; Mursu et al., 2014; Mozaffarian, 2016; ADA, 2018). On the other hand, red meats and sugar-sweetened beverages are associated with an increased risk of type 2 diabetes mellitus (Ley et al., 2014). A consensus of the American Diabetes Association and the European Association for the Study of Diabetes recommended that overweight and obese patients should be informed of the health benefits of weight loss and be urged to take part in a programme of intensive lifestyle management, which may include food substitution and also of the benefits of increasing physical activity in improving glycaemic control (Davies et al., 2018).The use of medication has also been recommended for the treatment of diabetes. The benefits and efficacy of pharmacotherapy have been evaluated across various literature. The first line treatment of prediabetes, in terms of pharmacotherapy, is usually metformin which is a biguanide that reduces the production of glucose by the liver and causes moderate weight loss in overweight and obese patients (Rydén et al., 2013). Metformin is available as an immediate release formulation that is typically administered twice a day and as extended-release formulations for once-daily or twice daily administration with both formulations being equally effective with no consistent differences in side effect profile (ADA, 2018; Aggarwal et al., 2018). Metformin at lower doses of 250 mg has been shown to effectively reduce the progression rate to type 2 diabetes mellitus 14.5% while an 850 mg dose twice daily reduces the progression risk of prediabetes to type 2 diabetes mellitus by 31% (Ryden et al., 2013; López-Jaramillo, 2017). Nathan et al. (2015) argued that the use of metformin as a means to treat prediabetes has an overall lesser effect than lifestyle modifications. The American Diabetes Association recommends that “metformin therapy for prevention of type 2 diabetes mellitus should be considered in those with prediabetes, particularly for those with BMI greater than or equal to 35 kg/m2 and those less than 60 years of age” (ADA, 2018 p. S53). Metformin doses of 500 – 1700 mg daily should be prescribed to individuals with abdominal obesity and prediabetes if blood glucose levels remain the same after the implementation of lifestyle changes (López-Jaramillo, 2017). There are other drugs with can be used to manage prediabetes such as sulfonylureas, thiazolidinediones and DPP-4 inhibitors but their use has been discouraged because of their side effects which include but are not limited to hepatotoxicity, increased incident of congestive heart failure, fluid retention and musculoskeletal side effects (ADA, 2014; Lewis et al., 2015; Kernan et al., 2016; Mascolo et al., 2016; Tkáč and Raz, 2017; Viscoli, et al., 2017),The government has policies set in place which significantly influence how an individual accesses public and/or private healthcare facilities. It also set guideline that provides structured care for the treatment of diabetes and prediabetes. The NHS guidelines for treatment of prediabetes and diabetes recommend that a healthcare team be assigned to an individual and the team should include a diabetes specialist nurse who will play an important role in helping and supporting people like Martha in managing their condition and a pharmacist with special training in a wide range of medical conditions, medications and treatment and will be able to answer questions about medications, like side effects (NHS, 2019). There are support systems and programmes that have been put in place by the government that aim to assist prediabetes patients in their recovering process while also supplying them with the information they need to know about maintaining healthier lifestyles. An example of such policy is the NHS Diabetes Prevention Programme which provides tailored, personalised help to reduce the risk of diabetes by identifying those at risk and referring them to a behaviour change programme (NHS England, n.d). Other governments in various countries have also implemented diabetes prevention programmes that utilise intensive lifestyle modifications and have shown to yield favourable results. One of the earliest of such programmes is the Da Qing Study in China which showed a 43% reduction in the progression of prediabetes to type 2 diabetes mellitus over after 20 years (Li et al., 2002). The Finnish Diabetes Programme is another one of such programmes and over reduction rates of 43% and 38% were recorded after a period of 7 and 13 years respectively (Knowler et al., 2009; Lindstrom et al., 2013). And most recently, the U.S. Diabetes Prevention Program Outcomes Study recorded 7% reduction at 15 years (Nathan et al., 2015). Nurses have an important role to play in health promotion and education. The focus of health promotion by nurses as traditionally been on disease prevention and modifying the behaviour of an individual with regards to their health (Kemppainen et al., 2013). The role of nurses as health promoters is however more complex because they possess multi-disciplinary comprehension and experience of promoting health in their nursing practice (Kemppainen et al., 2013). A patient’s view regarding the role of nurses in health promotion has to do with changing the individual’s health behaviour rather than influencing the environment, social conditions, policy or any other thing beyond the individual (Hamdan and Kawafhah, 2015). According to Papathanasiou et al., (2014), the critical thinking skills applied during the nursing process helps to provide a decision-making framework to develop and guide a healthcare plan for the patient and incorporate evidence-based practice concepts. The educational model of Martha’s health promotion process was based on the theory of andragogy which is a science of adult education that focuses on the learning process and the learner’s internalised needs (McCall et al., 2018). The key to andragogy is self-directed learning which, in the broadest sense, means that the learner takes initiative, with or without the help of others, diagnoses the learning needs, formulates learning goals, identifies both human and non-human resources, chooses and implements appropriate learning strategies and then evaluates the learning outcomes (Kapur, 2015). The self-directed learning approach further validates the decision to provide Martha with the prediabetes leaflet as she will be able to participate fully in evaluating her learning requirements and also plan and implement whatever learning activity or method she would be most comfortable with while using the prediabetes leaflet as a guide. Therefore, she will be able to assess relevant information pertaining to her health at her own convenience and under flexible, informal conditions. The Health Belief Model is a behavioural concept that focuses on an individual’s health-related behaviour for predicting future preventive health actions (Yakourt, 2016). This theoretical framework is based on the motivation of an individual to take action and can provide an organised assessment data about a patient’s abilities and motivation to make needed changes concerning their health status (Tarkang and Zotor, 2015). Physicians try to improve adherence of patients to treatments through health promotion tools like the prediabetes leaflet, however, patients do not necessarily follow the given recommendations even though they want to be informed (Zapata et al., 2013). Many people will not engage in health-protective behaviours without initially understanding that they are at risk for an adverse outcome and asides initial behaviour change, the most pertinent problem in changing health behaviour is in long term adherence (aus Berlin, 2017; Guidry et al., 2019). Generally, health promotion leaflets do not guarantee that required behavioural changes will be made and some authors are of the opinion that improving or modifying the behaviour of the patient is not the role of health promotion leaflets and that the patient’s choice must be respected (Fox, 2006; Zapata et al., 2013). However, health promotion leaflets can help a patient in making informed choices concerning lifestyle changes and medication. It is for this reason that the decision to provide Martha with the prediabetes leaflet is logical; it will enable her to make educated decisions regarding what method or approach she chooses to adopt to assist in her journey to live a healthier life. When health promotion tools such as the prediabetes leaflet are written properly and used at the appropriate time, it can improve the knowledge of a patient, their satisfaction and also encourage better adherence to treatment, diet and to lifestyle advice, especially in the short term (Sustersic et al., 2016). It should be noted that the theories and strategies applied in a patient’s personalised healthcare is tailored to specifically address the health needs and requirements of that individual rather than a particular group of people, therefore, in order to ensure that the targeted behavioural changes are made in an individual, the ideal approach would be to develop an integration of strategies and theories that best suit the needs of the patient rather than a one-size-fits-all approach.ConclusionThe entirety of this essay has carefully examined the importance of designing a personalised healthcare plan for 45 year old Martha which would allow her to comprehend the significance of lifestyle modifications pertaining to her diet and physical activities. These were validated by NHS and ADA guidelines and recommendations. The personalised plan considered her age, learning needs and access to information before adopting andragogical and health belief theories to support the approaches and strategies that would best suit the needs of the patient. During the course of developing this personalised healthcare plan, it was discovered that implementing the appropriately designed plan would reduce Martha’s risk of developing type 2 diabetes mellitus significantly and effectively manage her condition through intensive lifestyle interventions and pharmacotherapy. Subsequently, a prediabetes leaflet was designed for Martha’s personal use. The leaflet contained information of import regarding foods to focus on, medications to use and other vital information that would help her make the necessary lifestyle modifications for preventing or delaying the incipience of type 2 diabetes mellitus.

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