Aims, education and lifestyle

Almost all those with newly diagnosed type 1 diabetes and some with type 2 present with symptoms of uncontrolled diabetes, and initial management is to reverse these symptoms and prevent metabolic decompensation. Prolonged hyperglycaemia damages both small blood vessels (microvascular complications) and arteries (macrovascular complications), and the goal here is to keep the long-term blood glucose as normal as feasible. The first steps towards this are patient education, increased physical activity, diet and weight control. These measures are typically supplemented by oral or injectable therapies to control glucose levels. These therapies require careful monitoring in order to maximise benefit and reduce unwanted consequences of treatment such as hypoglycaemia. Other measures such as control of blood pressure or lipids and smoking cessation may also be needed to prevent cardiovascular disease, the major cause of excess mortality in diabetes. Preventive measures such as these are supplemented by regular screening for complications and early referral to specialist services (ophthalmology, nephrology etc). Management plans should be discussed with and endorsed by the person concerned, supplemented by the social, emotional and (sometimes) psychological support needed by those who carry the burden of chronic illness.

Introduction

WHO defines health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. This definition might be considered aspirational rather than realistic: very few of us would qualify according to these criteria! Maslow's hierarchy of needs
Maslow's hierarchy of needs

A more realistic approach makes use of Maslow's hierarchy of needs, which progresses from physiological needs to safety and security, from there to love and belonging to esteem (social acceptance) and finally to self-actualization. This hierarchy is also somewhat aspirational in that Maslow believed that only 2% of the population (himself included) could achieve self-actualization. The rest of us may fail to reach the top of the pyramid, but should at least be enabled to engage in the personal pursuit of happiness without unnecessary hindrance from medical conditions such as diabetes.

Within this context, diabetes management sets out to ensure that the physiological requirements of someone with diabetes are provided, to assure their future safety from possible adverse consequences of diabetes or associated conditions, and to ensure, so far as possible, that the physiological, psychological, social and pathological consequences of diabetes do not affect an individual's quest for self-fulfilment.

Diabetes-specific health needs

Diabetes care, like all health care, is the art of the possible. The aims are to restore and maintain near-normal metabolic regulation, to screen for and (to the extent possible) prevent potential adverse consequences of hyperglycaemia; to identify and manage associated risks such as overweight and hypertension; and to provide education, support and encouragement - with additional psychological input when needed. Last but not least, time, emotional support and palliative measures are needed for those who have experienced disabling complications.

The management of diabetes is best achieved by teamwork involving people with a range of specialist skills, and works best when (a) there is a clear structure and (b) patients are empowered to direct the course of their own treatment.

At diagnosis, the immediate priority is to reverse the pathophysiological disturbance in order to relieve symptoms of uncontrolled diabetes and to assure short term safety and well-being.

Treatment may be needed for associated conditions associated with previously undiagnosed diabetes - e.g. infections (sometimes atypical), vascular problems such as coronary heart disease or peripheral vascular disease, or metabolic complications such as cataracts and neuropathy.

Following diagnosis the immediate medical concern is to ensure long-term safety from metabolic decompensation and late complications. Metabolic regulation is achieved by education and ready access to medical care and advice. Prevention of diabetes-associated complications is achieved by seeking the best achievable level of glucose control, a target which may need to be adjusted to individual risk, capacity, motivation and choice.

Improving prognosis. Many unwelcome developments threaten the future of the person with diabetes, and most of these are preventable. Glucose-associated risk, especially small vessel complications such as retinopathy and nephropathy, predominates in young people with diabetes. Older people also risk microvascular complications, but are more likely to die or become disabled as a result of large vessel disease. Cardiovascular risk reduction by smoking cessation and treatment of blood pressure and lipids thus becomes a leading priority. Over and above this, many people with diabetes will benefit from adoption of healthier habits such as increased exercise and improved diet, and these should be presented as the basis upon which other therapies will rest.

Monitoring progress. Regular review is an essential part of the management of diabetes. This permits preset goals to be measured (weight, glucose control etc),facilitates ongoing education and support, and allows risk status (blood pressure, glucose, lipids) to be assessed. It is linked to monitoring for early complications:

Screening for early abnormalities. Microvascular complications can be detected and treated more effectively in their early stages. Thus, nephropathy may be predicted by testing for microalbuminuria and partially prevented by treating blood pressure; retinopathy can be detected by retinal photography or ophthalmoscopy, and partially prevented by control of blood glucose and blood pressure.

Minimising the unwanted effects of treatment. Diabetes is a condition that imposes a heavy burden upon the patient, and successful management will not be achieved unless this burden is understood and willingly accepted by the person who has to bear it. This burden includes denial of simple pleasures, side effects of oral medication (often underestimated by carers), injections and finger-prick blood tests, and ranges upwards to much-feared complication such as hypoglycaemia. These concerns are much more immediately present to the patient than the intangible benefits of future risk reduction, and corresponding attention to these concerns is required from their carers.

Setting priorities. Although heath care provider and patient share the same goals, they may approach this from quite different points of view. The provider will typically be driven by guidelines directed towards a series of measurable outcomes: HbA1c, weight, blood pressure and so forth. Computers are however lacking in empathy, and the patient may reasonably have more immediate practical concerns, such as the demands of the treatment regimen. At worst, real communication between the two may be lost, with the result that the patient pays lip service to formal advice but behaves quite differently. Patient-centred care should ideally avoid this outcome, and is best achieved by providing reliable information in a form accessible to the person concerned, and then working together to achieve their personal objectives.

Diabetes specialists should be particularly aware of the risk of "glucocentricity", i.e. placing a higher premium upon optimal glucose control than on the global health status and well-being of the person who has the diabetes.

PATIENT INFORMATION AND EDUCATION

Good diabetes management requires an integrated effort of both patient and care-giver to handle the disease in such a way that the impact of the disease on patient's well-being is minimised. Given the important role of the patient in his/her own treatment, it is imperative that the patient is well informed and educated about the disease. The patient should be well aware of the various factors contributing to the disease and the possible complications that may result, and should be helped in making informed choices about treatment modalities, some of which may sometimes affect his daily life more than the disease itself.

When someone is newly diagnosed with diabetes they need to be given information about the condition in a form that they can understand and use. This may be given orally, through written materials or through web based packages. Guidelines in the UK [1]and several other countries recommend that people newly diagnosed with diabetes should be referred to a group education programme (E.g. DAFNE (for type 1 diabetes)[2] or for type 2 diabetes DESMOND[3] or X-Pert[4]) On these courses people are given the opportunity to understand how they can put the information they have received into practice so that appropriate changes in lifestyle including weight reduction and increased activity may be achieved.

LIFESTYLE CHANGE

Lifestyle change is advocated as the cornerstone of the management of type 2 diabetes. Most people newly diagnosed with type 2 diabetes are overweight and do not engage in regular physical activity, so weight reduction through eating less and increased physical activity is a vital part of management.

Exercise

The precise definitions of physical activity and exercise vary but many articles and papers define physical activity as regular movement such as walking and define exercise as structured activities such as jogging or cycling.[5] In people living with type 2 diabetes there is good evidence that increased physical activity and exercise can reduce risk factors such as hyperglycaemia (as measured by HBA1), and raised blood pressure.[6]

Those living with type 1 diabetes should be encouraged to increase physical activity and Exercise as this improves insulin sensitivity. Living with diabetes does not mean that you cannot take part in extreme sports nor does it mean that you cannot be a world class sportsperson. There are specific websites that provide sources of information and advice about how people living with type 1 diabetes can achieve their maximum performance in sport. [7]

Weight Control

There is good evidence that weight loss in the overweight with type 2 diabetes will help to reduce hyperglycaemia and raised blood pressure. Weight reductions of 5% of body weight are clinically useful and many people can be encouraged to have a goal of loosing 1lb (450 gm) in weight per week and continuing this over a number of weeks.[8]

There is little evidence that specific “diets” are beneficial in the long term as substantial weight loss on a restrictive diet is often accompanied by weight gain to pre diet levels when the diet is stopped.[9]

It is better to adopt a regular more healthy eating pattern with increases in fruit and vegetables, stopping adding sugar, and reducing fat, whilst adopting smaller portion sizes overall. Such changes in eating patterns are easier to implement when all of the family are involved and agree to such healthy lifestyle change. Healthy foods may be perceived as being more expensive than more energy dense “junk” food and socio-economic considerations may need to be taken into account when these aspects of weight loss are discussed.

Peer support helps individuals loose weight and commercial weight reduction programmes are often recommended as being helpful to those trying to loose weight.

Recent evidence suggests that weight loss of over 25% of body weight in the overweight or obese person with type 2 diabetes can result in the remission of type 2 diabetes.[10]Such degrees of weight loss are demanding to achieve and may need to be agreed with and supervised by an appropriate healthcare professional.

If someone with type 1 diabetes becomes overweight or obese, weight control will be beneficial, although maintenance of healthy weight is a more typical goal.

References

  1. ^ NICE Clinical Guideline CG87 2009 Type 2 Diabetes NICE London 2009 www.nice.org.uk

  2. ^ www.dafne.uk.com (last accessed 11 June 2014)

  3. ^ www.desmond-project.org.uk (last accessed 11 June 2014)

  4. ^ www.xperthealth.org.uk (last accessed 11 June 2014)

  5. ^ Avery L, Flynn D, Wersh AV Changing Physical Activity Behaviour in Type 2 Diabetes Diabetes Care 2012 35: 2681-2689

  6. ^ Hu F Diet and exercise for type 2 diabetes Lancet 2011 378: 101-102

  7. ^ www.runsweet.com/DiabetesAndSport.html (last accessed on 17 June 2014)

  8. ^ Gerstein HC Do lifestyle changes reduce serious outcomes in Diabetes N Eng J Med 2013

  9. ^ Obesity – the prevention, identification, assessment and treatment of overweight and obesity in adults and children. Clinical guidelines CG43. NICE London 2004

  10. ^ Lim EL et al Reversal of type 2 diabetes Diabetologia 2011 54: 2506-2514

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