This thesis explores the possibility of using the Collective System Design Methodology to design systems that will improve the health of people. The focus of the thesis is on the reversal of type-2 diabetes.

Diabetes has gained growing attendance as one of the key non communicable diseases (NCD) with the World Health Organization identifying it as the focus of the World Health Day 2016. It is reported that more than 420 million people suffer from diabetes, a number predicted to rise in the coming years. This report forms part of a broader, long term focus project that aims to establish a systems approach to type 2 diabetes (T2D), the variant that accounts for more than 90% of reported diabetes cases. The broader project objectives are to identify possible biomarkers for the onset and the progression of T2D as a precursor to enable potential future approaches to delay onset, or even reverse disease states, via active bio-compounds and/or establishment of beneficial nutritional patterns. The 6-month master’s work reported here is sub-project that focused specifically on cell level vesicle trafficking processes. These processes are believed to be crucial in understanding the formation amyloid plaques, which compromise or kill the insulin secreting beta cells. Up until now, there has been a lack of appropriate experimental techniques to directly observe this process in live cells.  Hence we have developed 2 new techniques: (i)               a method of imaging the actin and tubulin network reorganization during exocytosis of the insulin containing granules while exploring novel ways of characterizing the network. (ii)             a method of imaging the granules themselves and using particle tracking microrheology to analyze their movement patterns during stimulation with glucose. These new techniques open the door to follow up experiments which would allow development of a cell scale mathematical model or simulation correlating short term glucose dynamics to risk of amyloid plaque formation and T2D.

ABSTRACT Background: T2DM is a growing public health problem worldwide. One of the cornerstones of treating diabetes is self-care. Motivation for self-care is overshadowed in several cases by the burden of having diabetes, as well as the fact that the social situation can affect the person's sense of self-control. The literature describes that there is a lack of tools and time to address the issue of motivation for lifestyle changes, which is considered a threat to the quality of care. Purpose: To describe people's experiences of living with T2DM with a focus on motivation from a self-care perspective. Method: A meta-synthesis based on 18 articles with qualitative design. Main result: Central to the results is a reflection on different approaches regarding motivation for self-care. From the included articles, four themes emerge: Reflection within social groups / contexts, knowledge / insight through reflection, reflection on different methods / tools and self-care / lack of self-care without active reflection right now when the person has landed / stoppover in an approach for various reasons. Conclusion: Motivation for self-care at T2DM seems to be influenced by reflection within the groups / contexts the person is in to. Reflection takes place about knowledge / insight as well as about the methods / tools that are applied in self-care. The motivation can be of a different nature and is a dynamic process that sometimes stops. The person may have already incorporated lifestyle changes as part of life. Events in life can make self-care away from prioritizing or it can be a matter of unwillingness to make lifestyle changes take over and put self-care on the waiting list. Keywords: Type 2 diabetes, self-care, motivation, Self-Determination theory / SAMMANFATTNING Bakgrund: T2DM är globalt sett ett ökande folkhälsoproblem. En av hörnstenarna vid behandling av diabetes är egenvård. Motivation till egenvård skuggas i flera fall av bördan av att ha diabetes, liksom att den sociala situationen kan inverka på personens känsla av egenkontroll. Litteraturen beskriver att det saknas verktyg och tid för att angripa frågan om motivation till livsstilsförändringar, vilket anses vara ett hot mot kvaliteten på vården. Syfte: Att beskriva personers upplevelser av att leva med T2DM med fokus på motivation ur ett egenvårdsperspektiv. Metod: En metasyntes baserad på 18 artiklar med kvalitativ design. Huvudresultat: Centralt ur resultatet återkommer reflektion kring olika förhållningssätt gällande motivation till egenvård. Ur de inkluderade artiklarna framgår fyra teman. Reflektion inom sociala grupper/sammanhang, kunskap/insikt via reflektion, reflektion runt olika metoder/redskap samt egenvård/brist på egenvård utan aktiv reflektion just nu då personen landat/mellanlandat i ett förhållningssätt av olika skäl. Slutsats: Motivation till egenvård vid T2DM tycks påverkas av reflektion inom de grupper/sammanhang personen befinner sig. Reflektion sker kring kunskap/insikt liksom kring de redskap/verktyg som tillämpas vid egenvård. Motivationen kan vara av olika karaktär och är en dynamisk process som ibland stannar av. Personen kan redan ha införlivat livsstilsförändringar som en del av livet. Händelser i livet kan göra att egenvård prioriteras bort eller också kan det handla om att olust till livsstilsförändringar tar över och sätter egenvård på väntelista.  Nyckelord: Type 2 diabetes, egenvård, motivation, Self-Determenation theory

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / In this article, we propose a technological architecture that supports the remote medical care service for elderly people suffering from Type 2 Diabetes Mellitus in Peru. The problem is based on the limitations that elderly people have with compliance with medical controls, which leads to increased complications of the disease and the patient's quality of life. The design of the technological architecture is based on 6 layers: 1) devices, 2) software, 3) channels, 4) data storage, 5) data processing and 6) information visualization. Through the solution, patients are able to autonomously manage their disease through periodic glucose control and the execution of an updated treatment in real time. In the same way, the specialist doctor periodically analyzes the glucose level and it is notified in real time about the out-of-range indicators, which allows him to make treatment decisions as the anomaly occurs. The focus of the solution is to reduce the complications generated by the disease through efficient glucose control and periodic medical advice. The solution was validated in a nursing home with adults over 60 and an endocrinologist from a medical office in Lima, Peru. For the study, we measured the constancy of the glucose record, the average response time of the doctor in case of emergencies or indicators out of range, the percentage of reduction of complications and the level of satisfaction of the Telehomecare solution in older adults. The results show that patients interact more frequently as they adapt the solution as part of their daily routine. On the other hand, the response time was approximately 4.13 minutes from the anomaly record. The percentage of complication reduction was 14% and the level of satisfaction of the solution was reflected in the dimensions of the response time and understanding of the user's need. / Revisión por pares

Objective: To assess whether the prevalence of low physical activity levels and time spent watching TV differ depending on glycemia status. Methods: A secondary analysis using data from a population-based study was conducted. Two were the outcomes: physical activity levels, derived from the International Physical Activity Questionnaire, and sitting time watching TV. The exposure was glycemia status, defined based on results of the oral glucose tolerance tests (OGTT): euglycemia, dysglycemia, and T2DM. The T2DM group was further split into: aware and unaware of T2DM diagnosis. Prevalence ratios (PR) and 95% CI were reported using Poisson regression models. Results: Data of 1607 individuals, mean age 48.2 (SD: 10.6) years, 809 (50.3%) females, were analyzed. Dysglycemia and T2DM was present in 16.9% (95% CI: 15.1%–18.8%) and 11.0% (95% CI: 9.5%–12.6%) of participants, respectively. A total of 605 (37.6%; 95% CI: 35.2%–39.9%) participants had low levels of physical activity and 1019 (63.3%; 95% CI: 60.9%–65.7%) subjects spent ≥2 h per day sitting watching TV. In multivariable model, there was no significant association between glycemia status and physical activity levels (PR = 1.14; 95% CI: 0.95–1.36). Similar result was found between glycemia status and sitting time watching TV. However, those aware of T2DM diagnosis were more likely to have low levels of physical activity (PR = 1.31; 95% CI: 1.06–1.61) compared to the euglycemia group. Conclusions: We found a no relationship between glycemia status and physical activity level or sitting time watching TV, pointing out similar levels of physical (in)activity among those with euglycemia, dysglycemia and T2DM. Individuals aware of having T2DM were 30% more likely to have low physical activity levels compared to the euglycemic group. There is a need to increase physical activity levels among T2DM individuals. / Revisión por pares

Bakgrund Diabetes typ 2 är en folksjukdom som ökar globalt. Hanteringen av diabetes typ 2 innebär ett stort ansvar för individen för att inte utveckla allvarliga komplikationer. Sjuksköterskan har ett ansvar att utbilda och motivera individer med diabetes typ 2 för att förenkla utförandet av olika livsstilsförändringar. Syfte Syftet var att belysa erfarenheter av motivation till genomförandet av livsstilsförändringar hos vuxna individer med diabetes typ 2. Metod Studien utfördes utifrån en icke-systematisk design och för att kunna besvara syftet sammanställdes 15 vetenskapliga artiklar. Artiklarna inhämtades från databaserna PubMed och CINAHL med hjälp av relevanta sökord. Artiklarna kvalitetsgranskades sedan utifrån Sophiahemmet Högskolas bedömningsunderlag, vidare utfördes en integrerad dataanalys för att identifiera olika kategorier. Resultatartiklarna indelades i två huvudkategorier med tillhörande underkategorier. Resultat De två huvudkategorierna som identifierades var inre motivation och yttre motivation. Sammanfattningsvis avhandlar den inre motivationen bland annat om hur känslor kring att leva med diabetes typ 2 och hur rädslan för komplikationer bidrog till att individer gjorde livsstilsförändringar. Den yttre motivationen handlar om stödet omgivningen bidrog med samt hur den kulturella och socioekonomiska faktorn hade en betydande roll för hur individer kunde hantera diabetes typ 2. Individerna ansåg att kost och fysisk aktivitet utgjorde hinder för att genomföra livsstilsförändringar, till exempel att kroppsliga besvär var ett hinder till att utöva fysisk aktivitet. Slutsats De motiverande faktorerna skilde sig åt mellan individerna. Av sjuksköterskan krävs ett personcentrerat förhållningssätt som utgår från patientens nuvarande livssituation för att på bästa sätt ge anpassad information och råd som betraktas vara rimliga i förhållande till individens förutsättningar. / Background Diabetes mellitus type 2 is a public health disease that is increasing globally. The management of diabetes mellitus type 2 requires a great responsibility for the individual, in order to not develop serious complications. The nurse has a responsibility to educate and motivate individuals with diabetes mellitus type 2 to simplify the implementation of different lifestyle changes. Aim The study aimed to explore experiences of motivation for the implementation of lifestyle changes in adults with diabetes mellitus type 2. Method The design of the study was a non-systematic review where 15 scientific articles were used to answer the aim. The articles were gathered using relevant keywords in the databases PubMed and CINAHL. The articles were quality reviewed by using Sophiahemmet University´s assessment form. An integrated analysis was used to identify categories. The result articles were divided into two main categories with associated subcategories. Results Two main categories were identified in the result, those were internal motivation and external motivation. In summary, the internal motivation refers to the feelings of living with diabetes mellitus type 2. Further, it includes how the fear of complications contributed to making certain lifestyle changes to avoid complications. Support from the surroundings is important to manage diabetes mellitus type 2, which can be referred to external motivation. Cultural and socioeconomic factors were also important in how individuals manage their diabetes mellitus type 2. Individuals considered that diet and physical activity were barriers and therefore had difficulties implementing changes. For example, that physical problems were a barrier to practice physical activity. Conclusions There were differences in which factors that were considered motivating for the individuals. The nurse requires to have a person-centered approach based on the patient´s current life situation, to provide adjusted information and advice that is considered reasonable in relation to the individual’s capability.

Bakgrund Diabetes är en sjukdom som drabbar människor över hela världen. Sjukdomen medför många komplikationer om inte patienten får rätt behandling. En enkel åtgärd som kan fördröja eller förhindra förekomsten av komplikationer är egenvård och den utgör en stor del i behandlingen av diabetes typ 2. Det är viktigt att undersöka patienternas erfarenheter av egenvård för att sjuksköterskan ska få mer kunskap om behandling för att kunna planera omvårdnaden bättre. Syfte Syftet med denna litteraturstudie är att beskriva egenvårdserfarenheter hos patienter med diabetes typ 2. Metod En deskriptiv litteraturstudie som inkluderade 14 vetenskapliga artiklar som svarade på litteraturstudiens syfte. Dessa artiklar söktes fram genom Medline via Pubmed. Dessa artiklar har analyserats av författarna och resultatet har kategoriserats i teman. Resultat Huvudteman som framkommit i resultatet är: Erfarenheter om hinder för egenvård, erfarenheter av motiv för egenvård och erfarenheter av stödet från sjukvården. Patienterna upplevde att det fanns flera hinder som påverkade egenvården negativt bland annat bristande sjukdomsinsikt, ekonomiska hinder och rädslor för sprutor. Det sociala livet upplevdes av flera patienter som stressande då patienterna inte kan motstå att äta av maten som serverades. Oro för komplikationer och acceptans upplevdes vara motiverande för egenvård. Utbildning från sjukvården och stöd från familj och vänner visade sig också vara viktiga faktorer som underlättade vissa patienters egenvård. Slutsats Föreliggande litteraturstudie visade att patienterna upplevde olika hinder i egenvården, men utbildning, anpassad information samt stöd från familjen och från sjukvården har visat sig vara viktiga faktorer för att patienterna skulle känna motivation för egenvård och för att känna kontroll över sjukdomen. Patienterna upplevde att utbildningen inte är tillräckligt anpassad till deras behov och ville ha individanpassad information från sjukvården. / Background Diabetes is a disease that affects people all over the world. The disease causes many complications if the patient does not receive the right treatment. A simple measure to delay or prevent the frequency of complications is self-care which is a large part in the treatment of type 2 diabetes. It is important to examine patients' experiences of self-care so that the nurse can gain more knowledge about the treatment in order to plan the care. Aim The aim of this literature study is to describe self-care experiences in patients with diabetes mellitus type 2. Method A descriptive literature study that included 14 scientific articles which answered the aim of the study. The articles were searched through Medline via Pubmed. These articles have been analyzed by the authors and the results have been categorized into themes. Results The main themes that emerged in the results are Experiences about barriers to self-care, experiences of motives for self-care and experiences of support from healthcare. The patients experienced that there were several barriers that negatively affected self-care, including lack of understanding of the disease, financial barriers and fear of injections. The social life was perceived by several patients as stressful as the patients could not resist eating the food that was served. Concerns about complications and acceptance were perceived as motivating for self-care. Education from health care and support from family and friends proved to be important factors that facilitated some patients' self-care. Conclusion This literature study shows that patients experienced various barriers in self-care, but education, tailored information and support from the family and from health care have proven to be important factors for patients to feel motivated for self-care and to feel control over the disease. The patients felt that the education was not sufficiently adapted to their needs, and they wanted individualized information from the healthcare system.

Objectives To evaluate the effectiveness of pharmacist-physician collaboration in the treatment of type 2 diabetes mellitus (DM) with severe insulin resistance, using 500 U/mL concentrated regular insulin (U-500) in a primary care clinic that is not staffed by an endocrinologist. Methods A retrospective chart review was conducted searching for patients who were prescribed U-500 insulin from January 1, 2008 through December 31, 2014. Subjects were included in the analysis if the pharmacist initiated U-500 insulin therapy, received treatment for at least 6 months, and who attended at least one follow-up visit with the pharmacist. Anyone who received U-500 insulin before the initial pharmacist consultation, managed by an endocrinologist, or who was missing follow-up hemoglobin A1c (HbA1c) laboratory values during the follow-up period was excluded. The primary endpoint was the change in HbA1c from U-500 initiation to 6 months later. Secondary endpoints included changes in weight, confirmed hypoglycemia events, changes in other anti-DM medications and the number of pharmacist and primary care physician visits during the follow-up period. Results Eighty-one patients were identified and screened, and 44 patients were included in the analysis. Baseline HbA1c (mean ± standard deviation) was 9.7% ± 1.6% and decreased to 8.6% ± 1.6% after 6 months of follow-up, representing a reduction of 1.1% (95% confidence interval -1.6 to -0.6, P < 0.001). Body weight increased (mean ± standard deviation) by 6.7 ± 15.1 lb from baseline (P = 0.005). The frequency of confirmed hypoglycemia events was low (0.8 events per patient). Treatment with metformin was preserved, whereas most other DM medications were discontinued. A similar number of pharmacist and physician follow-up visits were completed by the end of the study period (2.0 and 2.7 visits, respectively; P = 0.805). Conclusions Initiation of U-500 insulin by clinical pharmacists collaborating with primary care physicians results in improved DM control in patients with severe insulin resistance. Our findings suggest this interprofessional partnership provides an alternative referral approach for primary care physicians when endocrinology services are absent or limited.

The human forkhead box O1A (FOXO1A) gene on chromosome 13q14.1 is a key transcription factor in insulin signaling in liver and adipose tissue and plays a central role in the regulation of key pancreatic β-cell genes including IPF1. We hypothesized that sequence variants of FOXO1A contribute to the observed defects in hepatic and peripheral insulin action and altered β-cell compensation that characterize type 2 diabetes (T2DM). To test this hypothesis, we screened the three exons, 3′ untranslated region, and 5′ flanking region for sequence variants in Caucasian and African-American individuals with early onset (<45 years) T2DM. We identified only six variants; none altered the coding sequence, and except for one variant in the 3′ untranslated region, they were rare or absent in Caucasians. To increase coverage of the gene, we selected seven additional variants in the large first intron and 5′ flanking region, thus providing 13 variants that spanned 116.4 kb. Based on frequency and linkage disequilibrium patterns in a subset of individuals, we selected eight SNPs to type in a Caucasian population comprising 192 unrelated nondiabetic control individuals and 192 individuals with T2DM, and 10 SNPs to type in 182 controls and 352 diabetic individuals of African-American ancestry. No variant was associated with T2DM (African-Americans, p > 0.08; Caucasians, p > 0.09). Of the 8 Caucasian SNPs, six comprised a single haplotype block spanning over 100 kb and including most of the large first intron. In contrast, no block was observed among SNPs typed in African-Americans. No haplotype was associated with T2DM. FOXO1A variation is rare and is unlikely to contribute to T2DM in either Caucasian or African-American populations.

Bakgrund: Typ 2-Diabetes är en av världens vanligaste folksjukdomar. Varje år dör fyra miljoner människor av diabetes och dess komplikationer. Det har ökat genom åren och det är 8,5 procent av världsbefolkningen över 18 år som drabbas av typ 2-diabetes. Typ 2-Diabetes ses inte längre som en sjukdom för äldre utan drabbar även yngre personer. Denna sjukdom är ärftlig och kan drabba patienter som är överviktiga. Egenvård har en stor del i att hur diabetes ska behandlas. Syfte: Att beskriva patienters upplevelse av egenvård vid typ 2-diabetes. Metod: En litteraturstudie med beskrivande design. Databassökning gjordes i PubMed och Cinahl. Studiens resultat grundar sig i elva artiklar. Tio kvalitativa artiklar och en mixad design. Resultat: I studiens resultat framkom två huvudteman livstilförändring samt stöd och information. Fem underrubriker framkom, frustration över vardagen, upplevelse av kost, rollen av fysisk aktivitet, vikten av rätt stöd, samt patienters upplevelse av teknikens hjälp. Slutsats: Denna studie visade på hur patienter upplevde egenvård vid typ 2-diabetes. Patienter upplevde frustration över att behöva ändra sin vardag samt att patienter kände att dem inte blev hjälpt av sjukvården försen det uppkommit komplikationer även att de bara fick hjälp med den medicinska delen. Patienter vill att anhöriga ska vara mer involverad i deras egenvård för att få bättre stöd.