E-tailoring Online: Customer Views and Impacts on Services

E- lavoring Online Customer Views and Impacts on ServicesAbstractAn increasing material body of clients ar turning to the network to make their purchases, as a vast part of goods and run atomic number 18 now lone(prenominal) a mo spend click away. E-tailing clothes is heretofore more than than challenging, with new e-tailers hoping to deplumate and retain satisfied online customers, atomic number 18 constantly creating new opportunities for them, and in order to do that they need to know what evaluative criteria customers use when selecting an e-tailer as well as what they pass on purchase online. ultimo seek has provided almost insight into what characteristics customers appreciate whilst devising this choice. This report has not been without its limitations. Consequently, the present study utilizes a literature review, qualitative and quantitative research to bring out the core customer behavior towards this pathway, In accompaniment, results of the analysis s how that the type of crop on chap and the web attributes (determinants) ar predictors of customers bearing toward online obtain for garment and their perception hence, providing an understanding of how they be responding to the new online bargaining opportunities.1. IntroductionThis research report is divided into 5 Chapters. Chapter 1 is meant to introduce the coveringground of the research subject ara field with aims and objectives and focus of the study providing guidelines into subsequent chapters. This hence will be followed with Chapter 2 having literature review of the matter liberal an insight of the research area that will be referred, equationd with the data accumulation and analysis will be made in Chapter 4. However, Chapter 3 will be discussed introductory to the actual data collection as it is necessary to identify Research Methodology to be used for the research. Finally, Chapter 5 will bind conclusions and recommendations with any limitations faced and with the mention of area for foster research if any.The expansion in electronic commerce (E-commerce) has been phenomenal, with most of todays business transactions world contained through the Internet. The emergence of this electronic retail (E-tail) market vest has been extraordinary. E-tailing is as well a gaining popularity and changing the retail landscape, it is pervasive in what we thought of it six months ago is probably opposite to what we depend of it today and in addition what we will think of it in six months time.Customers decision making process has also altered outstandingly with the introduction of this medium and more so as an alternative channel for shopping. Online shopping concept has already caused a stir in the retail industry in the UK, as more mint are opting to buy online collectible to various reasons, a vast array of goods and dos are increasingly being made available now through a click of the mouse, creating a new experience and cultur e. Many retailers are already de coloureding broad(prenominal) value, personalised products and services at a fraction of the cost thereby making it more low cost and also appealing to the consumers (Birch et al, 2000). The number of consumers shopping online has increased markedly, accord to Jardine (1999) muckle charter increasingly become harm sensitive and lots compare termss of goods both online and offline before making the final purchase, in turn increasing competition amongst the retailers. This is the general overview of the e-tailing concept, as understood by most of us.However, the mean of this study is to concent range on the online clothing market in the UK specifically London, in order to determine predictors of customers purchase intentions for clothing products via this channel. E-tailing of clothing items online has always been debatable, peculiarly since clothing are feel-and-touch products, and foundationnot be bought without engaging this sensory aspect , un alike former(a) cognitive products like books, computer software, dvds and music which do not really deal this. Nevertheless, customers ladder to buy more clothing products when they perceive the features of the online store, such(prenominal) as a convenience and secure system of ordering and payment, returns policy, the focus on product display, and the offering of products that consecrate a range of acceptable fits as opposed to a precise fit and most of all choice this are just about of the most general attributes a customer considers whilst shopping online for clothes.The attributes that enhance the online experience bathroom be particularly influential for products such as clothing, which generally take somatogenic interaction and evaluation prior to purchase. Web experience attributes can affect primeval decision making stages (search and pre-purchase evaluation) and influence purchase intent of the customer. With the flow fragmented nature of the subject area an d to hold on up with the rapidly developing technology as well the customer attitudes, the author aims to fabricate on the current body of knowledge, investigating and drawing to reduceher the hear aspects which influence online shopping for clothes, so as to understand how the customers are responding to the new acquire opportunities presented to them by the e-tailers in UK then concentrating on London where the survey was conducted by collecting data from a sample of participants, which aided in exploring the capabilities and come along to determine consumer conduct and customer relationship management patterns in relation to E-tailing, thus the research objectives being set as1. To explore the impact of e-tailing in London.2. To determine customers attitude towards shopping online.3. To investigate customers perception of shopping online for clothing in London.In order to deliver the goods the results of the set objectives, the author has explored the determinants the cust omers consider most important when making a purchase online and to what extent they create an impact on their perceptions. The first hand elements collated from the survey has helped to gain rich insights into customers behaviour and attitudes towards this channel. The petty(a) data which is coating in the second chapter under the literature review the author here has studied and explained the general E-tailing concept and picked relevant data to help understand the subject matter and provide a better insight into the field of e-commerce, covering a wider area (UK), then narrowing it down to specific location (London) which in turn has helped to achieve the set objectives and later also support the resultant decisions in terms of the primary data collected via the survey by the author.2. literature ReviewXing (2001) stresses that The emergence and explosive growth of e-commerce through online work have ushered in a new era of retail business.2.1 The Commercialisation of the Inte rnetThe Internet, once a tax-sustained and a government-regulated endeavour, is no longer restricted to non-commercial traffic. The early commercialisation of the Internet, in the mid 1990s gave originate to the e-commerce phenomenon. The Internet population has since big tremendously, as a result of its opening to the commercial traffic in 1991. Its utilisation has since become remarkably more wide and varied in businesses the maintain of internet has self-aggrandizing rapidly over the last several years, due to its contribution of the ever evolving new reading technology and its positive gains to the business organisations. Its use apart from being internal its also employed externally and its used more commonly referred to as E-business (electronic business) derived from such terms as e-mail and e-commerce, which is the conduct of business on the Internet, not only buying and selling but also servicing customers and collaborating with business partners.IBM was 1 of the f irst organisations to use the term E-business (electronic business) when, in October 1997, it launched a thematic campaign built around the term. Today, major corporations have reconsidered their businesses in terms of the Internet and its new culture and capabilities. Companies are utilising the Web to buy parts and supplies from another(prenominal) companies, to collaborate on sales advances, and to do joint research, exploiting the convenience, availability, and world-wide reach of the Internet, using it successfully.2.2 The E-tailing ConceptThe emergence and explosive growth of e-commerce through online trading have ushered in a new era of retail business says Xing (2001). It was seen as a new channel for sale of products and services along with the traditionalistic channel as well as a market penetration strategy for others. E-tail or E-retail the term, came into discussions or rather its origins as early as 1995, its an addition in the computing subject such as, e-mail, e- business and e-commerce. The business of e-retail has been defined as the sale of goods and services via internet or other electronic channels, for personal or household use by consumers (Harris and Dennis, 2002).Its more efficiently used as a marketing tool, which is integrated into traditional business strategies, and also being viewed as a new marketplace by existing businesses as well as new business ventures as the market place becomes more private-enterp swot(a) and unpredictable, due to this, the growth of the electronic retail market has been rapid, evidentially expanding reach in terms of people, location and range being variety of instruction, the World huge Web has created benefits for both the marketers as well the consumers. For consumers, the Web can provide access to a wide range of products and services with low cost (Bakos, 1997), coarse and tailored information, at home convenience for product comparisons, enhanced interactivity (Cross and Smith, 1995), hence facilitating the formation of virtual communities for users with common interests.E-tailing and E-trading operates in all four of the major market segments business to business, business to consumer, consumer to consumer and consumer to business. Initially, much direct selling (or e-tailing) was taking place on the internet of computer- reachd equipment and software, one of the first to report successful sales in the millions of dollars directly from the Web was Dell Computer, there subsequently other businesses started employing the concept in various fields from Travel bookings, Holidays, Books, Clothing and other accessories, this has particularly grown in the Business to Consumer market segment directly or indirectly as a result of the wide usage of the internet. The Internets greatest commercial benefit is said to be the reduction in transaction cost that directly lowers the prices for consumer (Pavitt, 1997), and therefore E-tailing is said to be a low-cost, efficient way to display merchandise, quarter customers, and handle purchase orders (bellman, 2001).2.3 Online shopping in the UKHome shopping in various forms has been available to the consumer market for more than 100 years in the UK, base catalogue being the first and the oldest form illustrated with Victorian ladies and do-it-yourself house kits a lot has changed since, in terms of improvements and choice, then came the emergence of home shopping television, however none has had the influence or the expected impact of shopping, as much as the World Wide Web. E-commerce has grown steadily in the UK since the early 1990s. According to Exley (2006, cited in Haymarket, 2006) consumers have become comfortable shopping on the internet and e-tailing is clearly a part of retails future. He adds that e-tail does not have to interchange traditional bricks and mortar stores, all retailers need to do is to provide a good in-store experience (Exley, 2006, cited in Haymarket, 2006).Since 2000, Internet sh opping has soared by over 5,000% with UK consumers spend an astounding 200 billion during this period. Internet shopping is clearly the bright spot in the UK retail sector, but this industry is placid young and has capableness for further growth. (Tina Spooner, director of information, Interactive Media in sell Group (IMRG), cited in press release, May 2009). No doubt, online shopping is rising steadily in the UK (from a consumers perspective) as internet access has become cheaper, gritty bridle-path cyber cafs are increasing and Internet service providers (ISPs) have already eliminated subscription fees (Daniel, 2000). Furthermore as technology is set to get even more advanced, hand-held devices have become internet-enabled and nowadays most mobile phones connect to the web (Daniel, 2000). With all the preceding(prenominal) possible ways of shopping more customers are getting accustomed to the online shopping experience and utilising the new channel. This exceptional growth of Internet shopping is also driven by greater emphasis on customers efficient use of time, as well as the ever increasing number of computer learn customers, hence giving it a positive outlook and a further opportunity for growth to the existing and perspective e-tailers.A wide range of products and services are available for the customers in the UK to buy online from a variety of retailers, which also piddles them a better choice, so why would they go buy anywhere else? Although one reason whitethorn be convenience, sadly another is fraud fraud poses the biggest threat to online shopping (Economist, 2004) but concord to Pavitt (1997) consumers fear of shopping online is already obstinate by the use of encryption technology.Moreover, the security systems are rapidly improving by the day, further dispelling the notion which is perceived by a majority of people worldwide that online shopping is a risky business. For eccentric, secure digital systems such as encryption tools, di gital signatures and the guarantee about security or privateness concern provided by the e-tailers have reduced security inhibitors and thus have increased consumers willingness to visit or purchase from sites (Ah-Wong et al., 2001 Han and Maclaurin, 2002).UK is the second largest e-taling market in atomic number 63 like Germany, it combines a large consumer market with internet penetration above the European average (Datamonitor, 2002). in that location are six track downing online shopping companies that look out over the UK e-tailing market. These are pathsonline.co.uk, Jungle.com, Amazon.com, Lastminute.com, Thomascook.com and Egg.com, all these providing a variety of products and services. What is the future of elevated street stores when most analysts agree that in five years time, online shopping could be cost 200billion? This does represent few form of concern to high street stores in the UK as a percentage or it could be of the sales they lose. Nevertheless according to Brewer (2006) cited in Haymarket (2007) the future is brightest for those high street stores that could adopt a multi-channel strategy. However, Murphy (2006) cited in Haymarket (2007) says that we have the most vibrant, competitive high street in the world and high street shopping is one of our biggest leisure pursuits. Can high street shopping be our biggest leisure pursuits since they boast to sell a variety of diverse products in-store? It is therefore inconceivable that the future of retail would be solely online, although the number of customers making purchases online is also on the rise in the UK as mentioned earlier in this report.2.4 The extent to which e-tailing builds relationshipsThe impact of e-tailing will be felt differently and at different times by various retailers. In the context of use of buyer behaviour preferences (Daniel, 2000) says that e-tail is a transactional-sales medium rather than a relationship- expression medium which means that e-tail cannot su bstitute personal contact such as customer service advisors, that makes it the most critical differentiation aspect to high street stores today.This emphasises the need further research on the customers perception of e-tail, i.e. to what extent does e-tailing build relationships? If empirical research suggests that e-tailing is a transactional sales medium then ultimately there whitethorn be an opportunity for e-tail to focus building relationships with customers that will create the need for further research on how e-tail may be able to become a relationship-building medium. Personal contact with highly trained and motivated salespeople, the service factor is still the critical differentiator for such businesses, and on-line experiences have yet to match that or offer a suitable counter value (Quelch, 1999 cited in Maruca, 1999).As Pavitt (1997) states that the impact of e-tail on high street stores may result in changes on three key fronts change in the nature of product offerin gs, customer buying patterns and its place in the value chain. The changes in product offering may alter as a result of advances in digital technology. For example media products delivered via the internet or newspapers being published electronically, that would be a direct impact on high street stores (Pavitt, 1997). There is privation of empirical evidence to show what customers perceive of digital medium against physical goods, as an simple example, would customers prefer buying a DVD from a high street store, so as to get a feel of the physical aspect of this product as well as more information from the back cover of the DVD case, or from the Internet where information on the product is limited in two dimensional form.There will be a great deal of change in the value chain as well due to shrinkage in distribution channels, (Bellman, 2001). E-tailing eliminates traditional chain of wholesalers, agents, and other intermediaries thus creating a new distribution model focusing on m anufacturer to consumer direct that implies a great potential for savings (Bellman, 2001). Today, majority of the manufacturers do not want to take the responsibility of dealing with wholeness customer queries, which is one reason why they sell their products through intermediaries even on the Internet. With lack of evidence it still remains to be investigated as to what extent is the internet an intermediary?Another common question which arises in this case is do e-businesses have any storage for products they advertise or do they order them directly from the manufactures or other traders as postulate? However, this can also be different in the case of businesses which use internet as a secondary channel for sell or distribution of their products, which they also sell in their physical store. Another issue that arises is to investigate potential shoppers perception in relation to price. Smith et als (1999) cited in cardinal and Lee (2005) indicated that online shoppers believe t hat online stores enjoy a cost advantage over traditional channels in terms of administrative cost, overheads and transaction cost. These features of the online retail channel add to the perception of online shoppers that prices generally tend to be much lower online than that of the high street stores. Considering this then, do customers shop online because they perceive it to be cheaper? If so then how and in what ways is online shopping cheaper compared to the high street stores where lots of products are reduced at competitive prices even at times with offers such as buy one get on free or a second product at half price, are always there. Is price an issue of concern or is it about building relationships? Would customers be willing to pay that extra price in exchange for good service, remains to be investigated? Good service may be classed by online shoppers such as providing a tracking system for their ordered goods, free return policy and delivery of the goods or a full money back guarantee on items that customers return which is in place with most e-businesses today.With regards to customers online shopping behaviour, Brown (2000) states that a survey by BT found out that consumers choose long-familiar brands when shopping online and those consumers want to be served immediately, be remembered and treated as individuals. Therefore, in what ways can e-businesses build relationships? According to Kalyanarm and Winer, (1995) Chandrashekaran, (2001) cited in Lii and Lee (2005) prior studies have revealed that in the off line retail channels, customers may use the advertised original price as a frame for reference to assess the accompanying sale price. The resulting price comparison between the original price and the sale price makes the price promotion more appealing (Biswas and Blair, 1991 Grewal et al, 1996 cited in Lii and Lee, 2005). On the other hand on line retailing enables potential customers to have quick and easy access to price and other product attributes and information necessary for price evaluations. An example is amazon.co.uk website. The Internet has empowered on line shoppers to better detect price discrepancies and bargains (Balasubramanian, 1997 Bakos, 1997 Hoffman and Novak, 1997 cited in Lii and Lee, 2005).Today Majority of e-tailers attract customers through promotion codes normally available through advertisement and marketing media from which customers, can usually claim some money off or some percentage of discount on their online shopping. What remains to be assessed is whether the promotional codes attract new customers and also retain existing customers to shop online? If e-tailers start providing regular promotion codes to new customers as well as regular customers with this, then will it add up to building a relationship?2.5 Customers general online shopping preferences in the UKOn the basis of the objectives of this research, its crucial to investigate customers e-tail shopping preferences in the UK in general first, since ultimately perception leads to action. When consumers are confronted by new forms of retail channels such as on line shopping, they may decide whether the difference between the on line shopping and off line shopping is significant to them. If the difference is perceived to be insignificant, customers may classify the two retail channels as the same. On the other hand, if the differences are perceived as significant, customers may classify the two shopping channels as different and make their purchase decision differently (Lii and Lee, 2005).Perception involves the process of categorization, and people tend to place new experiences into existing classifications of familiar experiences (Monroe, 1990 cited in Lii and Lee, 2005).Late darkness shopping in the UK is fast becoming a way of life and a new culture, since for many people 24-hour high street shopping is invaluable as it allows them to fit it around their lifestyles, this is very common in the larger citi es like London where this sort of service fits in well with the metropolitan lifestyle whereby time is crucial, however having said that, its also being almost equally favoured by people living in smaller towns or suburbs. The changes occurring in buyer behaviour patterns are alarming to high street retail stores as more and more people are beginning to work partly or wholly from home and they may prefer their goods bought online to be delivered at home, this is also rapidly picking up for supermarkets where the consumers prefer their grocery as well as other items shopped on line to be delivered at their doorstep (Haymarket, 2006).Whatever may be the case, Cottam (2006, cited in Haymarket, 2006) says that high street retailing is facing stiff competition with on line anytime culture, meaning that customers are shopping 24/7 and therefore even high streets supermarkets such as Asda and Tesco have also launched 24-hour stores. Customers perceptions about 24/7 shopping remain to be in vestigated, since some high street supermarkets that tend to provide 24/7 services are closed on Sunday afternoons due to Sunday trading laws, but this has also changed in recent years. Once more it raises the question, what are customers perception of 24/7 culture in relation to the internet and high street stores, a white example to portray, the 24/7 concept proved to be costly, in comparison to profitability against cost, for a superstore like Sainsburys as Sainsbury failed in its attempt, even though it believed it had the winning formula (Haymarket, 2006). The reason behind the failure was that Sainsburys could not attract enough customers as there is no guarantee that a fair percentage of existing or new customers will change their habits to take advantage of 24-hour shopping (Haymarket, 2006). Indeed this is a lesson for others (organisational learning) and thus most retailers are being cautious in their approach to 24/7 services. Bearing this in mind customers are constantl y taking advantage of such facility and are trying or even getting used to shopping around the clock says Gladding (2006, cited in Haymarket, 2006). Analysts argue that 24-hour retailing is less in all likelihood to grow beyond its current levels as retailers have raised little awareness of the fact, hence stores such as Asda and IKEA are being cautious about this approach by advertising their long opening hours in the form of outside signage and flyers (Haymarket, 2006). The key question that arises from this scenario is the customers perception of the availability of 24/7 online shopping versus the high street 24/7 timings. Do customers really want go to shopping at high street stores and supermarkets at night (freely) compared to doing online shopping at night? Security is another issue that could be a vital sign of failure for high street stores or supermarkets to remain open 24/7 and be able to achieve their budget.Depending on the type of product, Andrew and Currim,(2004) hav e highlighted some key characteristics of customers shopping on line, despite the additional aspects. They say that consumers shopping online for products such as groceries differ from those who shop in high street stores claiming that on line grocery shoppers tend to be more frequent, heavy shoppers, less price sensitive, prefer larger sizes and do more screening on the basis of brand genss. Alternatively, Morganosky and Cude ,(2000) suggest that convenience is the main motivation for on line shoppers, and according to Keh and Shieh,(2001) on line shopping is ideal for time-starved customers such as couples with two careers, children, and above-average income who want to spend time with their families instead. These suggestions are valid and can be use to the reasons for consumers behaviour towards shopping online, however it also differs to the type of market and the products on offer. Hence, for those people, convenience is more of a priority than price stresses, Keh and Shieh, ( 2001). Also Professionals, running(a) women and single independent hard working individuals are just some of the people who do not have time on their hands and their perceptions of online shopping oddly for items such as grocery remains to be determined. Keh Shieh, (2001) simply claim, with being deficient in practical evidence, that such customers dislike grocery shopping and only those with busy schedules will consider on line purchasing as a viable option. Online shopping may save time and money as the frustration of dealing with children at a store or supermarket that involves pushing carts up and down the aisles, waiting in long lines at guaranteeout counters, and finding parking spaces, could be eliminated, Keh Shieh,(2001).Whilst on the other hand, as more people today having the opportunity to surf from their occasions, they are more likely to shop during office hours and thus may prefer to collect their online shopping at convenient stores on their way back home (Pavi tt, 1997). Vaughan (1999) cited in Jardine (1999) head of consulting at Retail Intelligence says that consumers might do their main shopping on the internet once a week but will still need to line of reasoning up on fresh foods locally and this is the alternative method that supermarkets have taken by opening convenience stores such as Tesco Express, Sainsburys Local, and MS scarce Food, (Jardine, 1999).According to Lii and Lee (2005), their study on examining customers perception of shopping on line suggests competitive pricing being the main reason. It allows them to compare prices of products more quickly and easily than when shopping in stores. (Korgaonkar and Wolin, 1999 Ernst Young, 2001 cited in Lii and Lee, 2005). According to the author, Mysupermarket.co.uk is a classic example The website allows registered shoppers to compare their online shopping from high street supermarkets in the UK which are Tesco, Asda, Sainsbury and Ocado which is fully online based. Furthermore it allows users to switch at a click if they decide to change their preference to the cheapest supermarket. The problem associated with this is that it may be time eat going through the tedious process of comparison because consumers may dislike switching from their preferred supermarket. In the authors view high street supermarkets also offer this service. A good example is that of Sainsburys supermarket where there is often a price comparison sheet placed next to their own shelf edge price tags showing their prices as compared to Tesco and Asda. If not then Sainsburys have opened small kiosks often located towards end of an isle where the customer advisor can compare their prices for customers with other competing supermarkets and if their prices are high then they do price match or sell the item even cheaper. This shows that the high street physical stores are also doing their best to match the benefits of on line shopping.Another factor that may drive away consumers from shopp ing on line is transportation cost. Bellman (2001), says that growing numbers of e-tailers are eliminating these costs as they find that customers often cancel orders after going through the entire ordering process and then considering the transportation cost being high, and this may be the key factor that drives potential customers away.The other fear of shopping online is privacy. Most web users refrain giving out their details, especially data in the form of credit card details as they fear exploitation of their privacy (Bellman, 2001). Insufficient product information on screen also contributes to decline of purchase. Apart from this, all secured websites do have a time-out function where user sessions are based on time limits. If time-out occurs, customers risk losing their entire shopping basket, which is quite frustrating from a customers point of view. These are some of the most common factors which may keep away customers from shopping online and reason their preference to shop in high street stores simply because they are well aware of the location, store layout, product plectron and return policies as well as the stores reputation (Greenbury, 1999 cites in Maruca, 1999).Online e-tailing has a great and growing future, but the high street is still an important name and address for customers. The limiting factor of e-businesses could be, a simple example, such as one cannot buy a piece of fruit via shopping online but can do so from a store. Furthermore, there is no empirical evidence to justify what drives customers to shop on line instead of high street stores, ultimately unbelieving what customers online shopping preferences are?2.6 The E-tail clothing sector in UKFashion is a sensitive and rapidly moving market which is growing at a speedy pace in the UK, in comparison to its other European counter parts. Shopping on line for clothing products is also fast gaining popularity in the UK. Although buying over the Internet remains small in compari son with buying through the traditional channels, such as the brick-and-mortar physical stores, it is growing and clothing is a substantial portion of the e-tail sector in the UK.The online clothing sector caters for almost all segments of the UK market starting from the low cost value clothing to high end designer clothing including bespoke tailoring to couture clothing, the choice is unlimited and the options ever increasing. One can buy a single handkerchief to a full suit online, even clothing and accessories for all age ranges are available, whereby the customer can buy clothes for new born babies to clothes for older citizens, therefore making this shoppingDiabetes Questions and AnswersDiabetes Questions and AnswersDIABETESDiabetes MellitusThe medical name for diabetes mellitus comes from the Greek word that means to siphon and the Latin word that means sweet like honey.Diabetes mellitus is the name given to a group of conditions where there is too much glucose in the prodig al. It affects approximately 3% of the population. There are currently 1.4 million people with diabetes mellitus in the UK and it is expected that by 2010 that there will be a further 1 million. It costs the NHS 4.9 billion a year and affects a million people without them even knowing that they have it. (Devendra et al 2004)RELATED BIOLOGYWhich organ is involved in the regulation of Blood Glucose Levels?The pancreas.Where is it located?Retroperitoneally, within the curve of the duodenum and with the tail extending to the posterior surface of the spleen.What type of tissue is it made up of?Primarily glandular tissue that has both endocrine (Insulin) and exocrine (Pancreatic digestive enzymes) functions.Which area of this organ is responsible for producing the hormones involved in the regulation of blood plunder levels?The Islets of LangerhansWhat are the main functions of insulin?To reduce the levels of blood sugar by facilitating the uptake of glucose from the bloodstream into the cells.It increases the rate of glycogen synthesis in the liverIt promotes the synthesis of fatty acids in the liverIt inhibits the breakdown of fatty acids in adipose tissueIt stimulates the uptake of amino group acidsIt increases cell permeability to potassium(after Wills C et al 2003),What type of substance is insulin made of? Circle the correct answer.Carbohydrate Protein FatsName the calls that produce the hormone glucagon. of import cellsWhat are the main functions of glucagon?An insulin antagonist, it raises blood glucose levels by increasing hepatic glycogen breakdown.It activates hepatic glyconeogenesisIt enhances lipolysis of triglyceridesOne of these hormones has a Catabolic action and the other an Anabolic action. invoke what these terms mean and identify which hormone falls into which category.CATABOLICCatabolism is the breakdown of complex biological molecules into smaller component onesGlucagonANABOLICAnabolism is the synthesis of complex biological molecules from sim pler components.InsulinWhat are considered normal limits of blood sugar readings?Fasting blood sugar 3.0 to 6.1 mmol/l (Client note this is variable I have quoted WHO figures check what your tutor recommends and add it here)Those with levels of 6.1 to 7.0 mmom/l are said to have impaired glucose tolerance(WHO 1985)CLASSIFICATION OF DIABETES MELLITUSState the 4 main categories.To the client this is a loaded question. There are many different classification schemes. I quote the categories as defined in RECD 1997Type 1 diabetes mellitusType 2 diabetes mellitusGestational diabetes mellitusSecondary diabetes mellitus intromitsGenetic defects of beta-cell functionGenetic defects in insulin actionDiseases of the exocrine pancreasPancreatitis detriment/pancreatectomyNeoplasiaCystic fibrosisHemochromatosisEndocrinopathiesAcromegalyCushings syndromeGlucagonomaPheochromocytomaHyperthyroidismSomatostatinomaAldosteronomaDrug- or chemical-inducedVacorPentamidineNicotinic acidGlucocorticoidsTh yroid hormoneDiazoxideBeta-adrenergic agonistsThiazidesPhenytoinAlfa-interferonInfectionsCongenital rubellaCytomegalovirusUncommon forms of immune- mediated diabetesOther genetic syndromes sometimes associated with diabetesDown syndromeKlinefelters syndromeTurners syndromewest syndromeFriedreichs ataxiaHuntingtons choreaLawrence-Moon Beidel syndromeMyotonic dystrophyPorphyriaPrader-Willi syndrome (RECD 1997)Diabetes mellitus can be due to a deficiency in insulin synthesis, secretion and also in some cases resistance. It is also thought that some diabetics may have a combination of both.State 5 causes of Primary Diabetes Mellitus aetiology.Primary Diabetes Mellitus is subdivided into Type 1 and Type 2 varietiesetiology of Type 1 is multifactorial. It is auto immune and trigger factors can be genetic or environmentalEnvironmental causes include exposure to Coxsackie B virus, epidemic roseola virus and Cytomegalovirus and exposure to cows milk.Aetiology of Type 2 is also multifactoria l. It includes genetic factors and environmental factors including western diet, lack of exercise, obesity and hypertension (Todd W et al 2000)NB Causes are still unknown, the above are thought to be trigger factors.State 4 causes of Secondary Diabetes Mellitus.Causes of secondary Diabetes Mellitus. There are several types of secondary Diabetes Mellitus includinggestational diabetesmalnutrition-related diabetespancreatic diseases causing diabetesendocrine diseases causing diabetesdrugs and chemicals causing diabetesgenetic conditions causing diabetesCauses depend on the variety but include pregnancy, pancreatitis and various drugs includingsteroidsthiazide diureticsphenytoindiazoxidestreptozotocinPancreatic diseases can cause Diabetes Mellitus includingacute and chronic pancreatitispancreatic carcinomacystic fibrosishaemochromatosisDisease processes can also cause secondary Diabetes Mellitus includingacromegalyCushings syndromeglucagonomaphaeochromocytomaComplete the chase chart by using the recommended textbooks to compare the two main types of Diabetes.TYPE 1 TYPE 2 sequence at onset juvenile (% of all cases about 10% about 90%Acute/insidious acute insidiousBody build sparse obeseGenetic link high lowProne to ketoacidosis yes noAutoimmune Disease yes noTreatment insulin diet, oral hypogs(Harris M 1995).What age group in the general population has the highest incidence of Type 2?Typically the 55-75 age range (Harris M 1995).Certain groups in the general population have an increased risk of developing Type 2 and currently Diabetes UK is promoting a campaign to identify those most at risk earlier, so that they do not develop the major complications associated with this chronic disease. This is called the Missing Million Campaign.Names these At Risk Groups1. History of Heart Disease2. History of bezzant3. Obese (BMI30)4. Over 50s5. Over 40s if from African Caribbean or Asian backgroundsPATHOPHYSIOLOGY / CLINICAL FEATURESDEFINITIONSDefine the termsGluconeogens isBiosynthesis of glucose from sources other than glycogenGlycogenolysisOxidisation of hepatic glycogen into glucoseBriefly describe how insulin deficiency / absence can cause the above processes to occur.Insulin deficiency and/or low glucose levels promote the secretion of glycogenGlucagon promotes the activation of the enzyme adenylate cyclase in the liver which triggers glycogenolysis. This is exactly the opposite process to gluconeogenesis and is mediated by a number of enzymes, the most significant being pyruvate kineaseClinical Presentation Complete the followingWhen blood glucose levels arise above a certain amount the nephritic threshold in the kidneys is exceeded and glucose spills over in to the urine. This is called glycosuria. This excess glucose sucks up the water so that it can flow from the body this is called. Large amounts of urine are excreted. This is called polyuria. superabundanceive thirst is called polydipsia.Excessive urination can result in lowered blood pressure and shock. Blurred vision can be caused by fluctuations in the amount floaters and water in the lens of the eyes during periods of dehydration. This is called osmotic myopia of the lens. Cells are not able to access glucose so they do not receive any fuel and as a consequence cannot produce energy. This triggers the brain to entrust a message of hunger. This excessive hunger is called polyphagia. Lack of energy makes the individual feel tired and weak. Other sources of energy are sought. Fat stores are upset down to provide energy. This may result in ketosis. Breakdown of fats results in the production of ketone bodies which are excreted in the urine. These are acidic and alter the blood PH.There is a sweet smell of ketones on the breath. This is called ketotic respirations. Weight loss also results. Breakdown of protein stores results in muscle wastage. Skin infections are common e.g. Staph boils, erysipelas . Excess glucose suppresses the natural defence mechanisms and the action of the lymphocyte* cells. Electrolyte imbalances occur. The electrolyte potassium affects cardiac muscle causing arrythmias if deficient. Urea and electrolyte imbalances also result in the following symptoms 1. Dry gumshield 2. Thirst 3. Muscle weakness 4. Lethargy 5. Cardiac arrythmias.Numbness and tingling in the feet and cramps may result from peripheral neuropathy.Client Note (*) this is debatable your tutor may have a specific answer in mid for this oneThe recommendations of the W.H.O Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications were formally adopted in the UK on the 1st June 2000. The key recommendation, with regard to diagnosis is that fasting plasma glucose should be lowered from 7.8mmol/L to 7mmol/L.What is an OGTT?The Oral Glucose Tolerance TestIn the oral glucose tolerance test the affected role, after fasting for 15 hours, drinks 75 g of glucose in 300 ml of water, over 5 minutes. Blood glucose is measured before the d rink and after 30, 60, 90 and 120 minutes. Urine is collected before the drink, and after 60 and 120 minutes. Before the test, for a period of 6 hours, the patient should avoid smoking and drinking coffee.There is a normal glucose tolerance if the venous plasma value is less than 7 mmol/l after the 2 hour period,If after 2 hours after the glucose load the value is between 7 and 11 mmol/l, then there is impaired glucose tolerance.If glucose is greater than or equal to 11.1 mmol/l this is diagnostic of Diabetes Mellitus other(a) TESTS / SCREENING PROCEDURESWhat is an HbA1c Test and why is it carried out?This is a measure of glycosylated haemoglobin in the blood. It is a longer term measure of the degree of blood glucose control. (DCCRG 1993) tenuous target is 6.5 7.5 HbA1cWhen would Urea and Electrolyte levels and Blood Gases be tested?Normally only if metabolic imbalance is suspected, dehydration, renal involvement or occasionally as a screen for end-organ pathology (kidneys). Us + Es may be requested as part of a supervise procedure. Blood gases may be useful if severe ketoacidosis is present.When would a Full blood count, specimen check and chest X-rays be carried out?This is more likely to be make as a screening or monitoring procedure (FBC or Urinalysis) unless there was an obvious clinical reason for doing them such as suspected anemia etc. A CXR would be less likely to be carried out unless pulmonary or cardiac pathology was suspected (Client this is contentious as different clinicians have different rationales for these investigations.)When would and ECG and Lipid levels be checked?ECGs are likely to be checked on diagnosis, as a monitoring procedure or if arrythmias have been detected. They may also be done as a baseline investigation, with hypertension or if cardiac involvement is suspected.Lipids are very likely to be abnormal in Diabetes Mellitus. They would be checked as a monitoring investigation at most visits. (DCCRG 1993)When would a neurol ogical assessment and follow-up of the lower limbs be carried out?Peripheral neuropathy and vascular impairment are common sequelae to Diabetes Mellitus and this would be actively considered and evaluated at each monitoring visit. Probably at least twice a year or more frequently if indicated. (DCCRG 1993)why are protein levels checked?Proteinuria is a good indicator of diabetic nephropathy. Urine protein should be checked at every monitoring appointment. Serum proteins are less sensitive but if renal pathology is established then it may be a useful investigation. (DCCRG 1993)When is urine checked for ketones?In the movement of dehydration, clinical suspicion of ketonuria, pregnancy and as a monitoring procedure. (DCCRG 1993)When would an eye reappraisal / photography be carried out and why is this done?Retinopathy is a potent cause of visual impairment and commonly found in the diabetic state. It is commoner with poorly controlled Diabetes Mellitus and Type I diabetes mellitus. It is one of a number of ophthalmic complications seen with diabetes and should be actively screened for at every routine visit. (DCCRG 1993)Why would a diabetic require having their blood pressure regularly recorded and what value is recommended?Hypertension is a common cardiovascular complication of Diabetes Mellitus and is an independent risk factor in Type II diabetes mellitus. The presence of hypertension and Diabetes Mellitus coexisting in the same patient will increase the overall morbidity risk of both cardiovascular disease and cerebro-vascular accident.A blood pressure reading below 130/85 mmHg is an ideal goal for most people with diabetes who dont have kidney complications, but some authorities may recommend an even lower blood pressure goal (below 120/75 mmHg) for people with diabetes who have kidney complications. (DCCRG 1995)State the main complications get around-termHypoglycaemia, dizziness, lethargy, impaired conscious level drowsiness.Hyperglycaemia, nausea, head ache, malaise, ketosis.Coronary heart disease,Cardiovascular disease (macro- microvascular disease)Retinopathy which can lead to blindnessNephropathy, which can lead to kidney failure and the need for dialysisNeuropathy which can lead to, among other things, ulceration of the foot requiring amputationMicrovascularRetinopathy,NephropathyNeuropathyThese are generally related to HbA1c levels with the highest incidence of complication occurring when HbA1c levels are above 12%Atherosclerosis induration of the arteriesBoth processes can lead to heart diseasestrokeperipheral vascular disease(Stratton I et al 2000)What are the SIGN Guidelines and name those that relate to Diabetes.A set of guidelines originally drawn up by Scottish Intercollegiate Guidelines Network. They includevisual impairment (SIGN 4)pregnancy (SIGN 9)children and young people (SIGN 10)renal disease (SIGN 11)foot disease (SIGN 12)cardiovascular disease (SIGN 19).Treatment- Give PrinciplesType 1Always insulin dependent. Active treatment involves titrating insulin dose against glucose levels and then maintaining levels by use of the insulin regimeConstant monitoring by either patient or physicianConstant vigilance for complicationsType 2Depends on cause, but in most cases treatment involves lifestyle modification, weight loss, dietary carbohydrate restriction.If not successful then progression to oral hypoglycaemics and occasionally to insulin.Constant monitoring for the presence of complicationsReduction of secondary causes of complication i.e. cessation of smoking.INSULINInsulin was identified as a substance that prevented diabetes in the early 1890s. Banting and Best extracted insulin from the pancreas of a dog in 1921 and the first human received a crude extract of insulin from the pancreatic glands of cattle in 1922. Over the years there have been many advances in the synthesis of insulin. Insulin is a protein. Insulin injections are vital for people with Type 1 diabetes as they are unable to produce insulin them selves and also for many with Type 2 diabetes whose condition has progressed to a point where tablets and diet cannot control it adequately. The aim of this treatment is to ensure that blood glucose levels are maintained at less that 6.5 mmol/l. (Client see forward comments)Name 4 factors which influence control1. Weight2. Severity of disease process3. Diet4. Level of exercise(Wing RR, et al 2001)There are a variety of insulins available on the market.The two main sources are animal and human.How is human insulin produced?By recombinant DNA technology inserting human genes into bacteria such as E.coli which then produces insulin in commercial quantities.The majority of diabetics are now on Human insulin but unfortunately some people are still required to take animal insulin. Many drug companies are wishing to phase out animal insulin and at present Diabetes UK is campaigning to maintain these.Why does insulin have to be given by injection?Being a protein it can not be given by mouth as it would be denatured in the gastro-intestinal tract.What other route is being researched as an alternative?A great deal of research has been lavished on alternative modes of drug delivery.Transdermal routes do not give reproducible and consistent blood levels.Oral insulin has not been a possibility in the absence of a specific peptide carrier system that would work in the gut.Nasal administration has been tried, but there was low bioavailability and absorption enhancers were needed, in addition the clinical effect was only over a very short period.Pulmonary routes appear to be promising but we already know that the pulmonary route is comparatively inefficient and requires ten times the amount of insulin to achieve the same clinical effect.Initial clinical trials show no side effects and research is currently continuing. (Heinemann L 2001)SIDE EFFECTSInitially on the commencement of insulin people may experience sensitivity around the injection site.How woul d you recognise this?This is a form of allergy.It can be local, in which case the local skin becomes red and itchy at the injection site.It may (rarely) be systemic giving rise to a uticarial reaction, tachycardia and tachypnoea. Very rarely a patient may experience anaphylaxis.Symptoms of hypoglycaemia may occur if too much insulin is injected or if not enough carbohydrate is consumed or if there is increased exercise without taking extra food.Hard lumps under the skin may occur at injection sites if they are not rotated.What is the correct medical term for these?LipodystrophyThe number of units prescribed is calculated depending on time of day, age, weight and lifestyle.Typical dose is 0.7-1.0 units per Kg of body weight.WARNINGSInsulin should never be administered in cases of HYPO.The body may get used to low levels of blood glucose and therefore the warning signs for HYPOs are reduced. Individuals who have lost these may be advised to raise their blood glucose levels slightly fo r up to 3 months to resensitise themselves to symptoms. Some people have also found that they have lost some or all of their symptoms of HYPO when transferring from animal to human insulin.Insulin dosages may have to change if there is disease of the adrenal pituitary and thyroid glands and also in the presence of liver and kidney disease. Taking of steroids will increase the insulin requirement.During illness, puberty or emotional trauma glucose levels can become elevated and therefore insulin doses require to be adjusted and more regular blood sugar monitoring is essential.During pregnancy insulin requirements may decrease in the first trimester and increase in the second and third trimester.The following drugs may increase blood glucose levels and therefore lead to a need for more insulin SteroidsContraceptivesAsthma InhalersSome drugs lower blood glucose levels and therefore result in a reduction in insulin. These are-aspirinBeta blockersMono-amine oxidase inhibitors.There are f our categories of insulin. Give an example of each.Very short playing ANALOGUE e.g. Humalog.Short acting SOLUBLE, NEUTRAL e.g. Actrapid, Human Velosulin.Medium and long acting ISOHANE, PROTAMINE ZINC e.g. Human Insulotard.Combination of short and medium acting MIXED, BIPHASIC e.g. Human Mixtard.Who would most likely be prescribed very short acting insulins?The very touch-and-go or out of control diabetic. Children more likely than adults.How long before a meal does short acting insulin require to be injected?Depends on type. Sol. Insulin starts working within 30-60 mins and lasts about 6-8 hrs. Other types such as Insulin aspart and insulin lispro both start working within 15 minutes and last for up to five hours.The glucose rise after a meal typically begins within about 15 mins so the insulin should ideally be in the system to counteract it.How often workaday would you require to take the following insulins-Short acting about 2-4 times a day( when stable)Medium acting about twice a day big acting Once (or perhaps twice) a dayThese answers depend on the age and size of the patient, as well as the severity of the disease process.Why is short acting insulin sometimes given with medium acting insulin?To give a smoother blood glucose profile and also to fill in the sally before the medium acting insulin becomes biologically active.Where should insulin be stored?In the fridge, but not frozen.Briefly discuss the types of equipment that are used to administer insulin?Commonest is still the usable insulin syringe. Syringe should always be calibrated to match the insulin type. Most are U-100 now.Other options include the pen devices (expensive but convenient and largely fool demonstration).Jet injectors are occasionally seen, but not very common.In hospital surroundings insulin pumps (drivers or infusers) can be used.Ambulatory subcutaneous pumps are increasingly used to deliver continuous infusion. Very expensive but arguably capable of producing the best control.(HSG 1997)What advice would you give to a diabetic who is planning to go abroad on holiday with regard to their insulin?Take plenty with you as your brand may not be available abroad.Make sure you can keep it refrigerated.Run your blood glucose levels slightly higher than you are used to a) because of probable increased exercise and b) to reduce the risk of Hypo whilst away from home.Be extra vigilant with the blood sugar monitoring. Strange diet may have unexpected consequences.ORAL HYPOGYCAEMICSBelow are the main categories of drugs. Give an example of each, including periodical dosage and side effects?SulphonylureasChlorpropamide250 mg (100 mg in the elderly)This is a very long acting drug, usually taken once daily with breakfast. inebriant may cause flushing to the face.BiguanidesMetforminStart at 500 mg twice a day or 850 mg once daily. The uttermost daily dose is 2550 mg given in three divided dosesGastrointestinal side effects are a common occurrence in people taki ng metformin. Problems often include bloating, flatulence, nausea, stomach cramps and diarrhoeaOccasionally a metallic taste in the mouth. Rare complication lactic acidosis(Knowler WC et al 2002)Prandial glucose regulatorRepaglinide0.5 to 4 mg with each mealOccasional gastro intestinal side effects(Bokvist K et al 1999)Alpha glucosidase inhibitorAcarbose50 mg then titrated against clinical effect.Flatulence soft stools or diarrhoea.Glitazones new drugRosiglitazone4mg as starting dose increasing to 8mg if requiredPossible toxic effects on the liver (theoretical rather than practical)(Park JY et al 2004)ACUTE COMPLICATIONSThe most common is Hypoglycaemia. It results from an imbalance between glucose intake, endogenous glucose and glucose utilisation.A decrease in the blood glucose level normally leads to stimulus of catecholamine secretion. Identify 5 causes.Insufficient carbohydrate intakeExcessive carbohydrate utilisation (exercise)Intercurrent acute illnessOverdose of insulinOther illnesses (viz glycogen storage diseases)AlcoholName 8 clinical features that the patient experiences.PallorShakingPerspirationFatigueA feeling of weaknessRapid heartbeat (Tachycardia)Hunger upthrustDifficulty concentratingIrritabilityBlurred visionTemporary loss of consciousnessConfusionConvulsionsComa.What would be given in order to treat it?Depending on severity. If minor, warm up sweet (glucose containing) drinksIf major, IM Glucagon. Monitoring essential until fully recovered.What is ketoacidosis?A clinical condition almost invariably associated with low insulin levels. As a result, the blood glucose levels rise and the intracellular glucose levels fall. This requires the metabolism at a cellular level to be fuelled with fat derivatives rather than carbohydrates and this produces acidic ketones. These ketones normally require the presence of insulin for their catabolism. In its absence, they build up causing a metabolic acidosis and spill over into the urine when the concentr ation is high enough.Identify 5 causesFluctuations in insulin regimeIntercurrent illnessTraumaReduction in carbohydrate intakeDehydration +- severe exerciseState 10 clinical features of this clinical stateHigh blood sugar levelsFrequent urination (polyuria) and thirstFatigue and lethargyDry skinFacial flushingNauseaVomitingAbdominal painFruity odour to breathRapid, intricate breathing (Air hunger)Muscle stiffness or achingComaThe principals of management are-Prompt administration of insulin (usually on a sliding scale) to reduce the hyperglycemia and ketonaemiaReplacing fluid loss (from polyuria and vomiting) usually by intravenous fluidsRestabilising electrolyte imbalances secondary to dehydration, metabolic acidosis and hypokalaemia.Treatment for any underlying cause such as infection. farsighted TERM COMPLICATIONSThere are 10 steps that the diabetic patient can take to reduce his chances of developing complications.Regular screening of BP and maintain at 140/80 or lower.Regular HbA1c testing.Maintain blood glucose levels between 4-7mmols/L before meals.A