Education is key to control

Rory Hafford examines how doctors should be responsible for ensuring their diabetic patients are educated to the limit of their ability

The aims of treating patients with diabetes is to abolish the symptoms; to correct hyperglycaemia; and to achieve and maintain an appropriate body weight.
According to diabetic specialist Dr Joyce Baird, patients should realise as soon as possible that it is upon themselves that success or failure will depend. “The doctor can only advise,” said Dr Baird. “As adherence to a diabetic regime demands from the patient self-discipline and a sense of purpose, every effort should be made to ensure that the object of each aspect of management is understood. Accordingly, time must be spent on the education of the patient and the doctor must be responsible for ensuring that all diabetic patients are educated to the limit of their abilities and that, as far as possible, they have adjusted adequately to their condition and have sufficient knowledge to undertake the day-to-day management of their diabetes competently.”
l Structured patient education should be made available initially and as part of an on-going process. One of the main reasons why a diabetes treatment regime fails is non-compliance. Consequently, information and advice on things like diet, physical exercise and smoking cessation should be a mainstay of any long-term treatment approach.
l Check height and weight and calculate BMI; also, measure waist circumference. Waist circumference is significantly associated with the risk of cardiovascular disease. Indeed, atherosclerosis occurs commonly and extensively in diabetes. The pathological changes in diabetics are not specific in a qualitative sense, but they occur earlier and are more widespread than in non-diabetics. Thus, diabetics are more prone at an earlier age than other people to myocardial infarction and hypertension.
l Check smoking status and offer appropriate cessation advice.
l Glucose control: offer self-monitoring of plasma glucose to newly diagnosed patient with type II diabetes. Discuss its purpose and agree how it should be interpreted and, crucially, acted upon. Urine glucose monitoring should be offered if blood glucose testing is unacceptable.
l Neuropathic pain: ask about neuropathic symptoms at diagnosis and at every review. If required, offer a tricyclic drug, starting at low doses and titrate as tolerated.
l Diet: dietary advice should be personalised and take on board the individual’s needs, cultural influences and willingness to make changes. Ideally, a health professional who has expertise in nutrition should be used for this. Diet should ideally include high-fibre, low-glycaemic sources of carbohydrate, such as fruit, vegetables, whole grain and pulses; low-fat dairy products and oily fish; and limited intake of saturated and trans fatty acid-containing foods. For people who are overweight, the target should be an initial body weight loss of 5-10 per cent. The National Institute for Clinical Excellence recommends that the nutritional advice given to insulin-dependent patients may need to be modified to take into account those who are underweight, have eating disorders, hypertension or have renal failure.
l Exercise: NICE also gives advice concerning the role of physical exercise in type II diabetes. Formalise exercise on a regular basis, i.e. brisk walking for 30 minutes a day or active swimming for one hour three times a week. Also, warn that alcohol may exacerbate the risk of hypoglycaemia after exercise; the risk of foot damage from exercise; and the need to consider ischaemic heart disease in those beginning new exercise programmes.
Sources:
Dr Hayley Willacy, Patient UK. Davidson’s Principles & Practice of Medicine.