About Diabetes
Core Concepts in Diabetes Mellitus
Michael A.J. Brown – Accredited Diabetes Educator
Centre for Diabetes and Endocrinology, Houghton
You may know that Diabetes Mellitus is a disorder of carbohydrate, fat and protein metabolism that results in high blood glucose, other metabolic disturbances and if uncontrolled, long-term mainly vascular damage and dysfunction. However, to gain insight into the holistic management of diabetes it is essential to have a good understanding of the Core Concepts involved.
Diabetes is a Common, Costly and Challenging Chronic Condition with no satisfactory Cure at present. Most cases of diabetes are Classified into two major types. Although people who develop diabetes may Complain of Classic symptoms most do not - they do not know they have it and continue to feel relatively well despite an underlying cardiovascular risk. Uncontrolled diabetes can result in Complications, but the good news is that diabetes is Controllable. Control can and should be achieved and maintained in the Community, using 3 Cornerstones of treatment together with regular Checking of outcomes. But that is not all - Choice Care should be a “Team” facilitated process that has Continuity, is Congruent and which strives for Concordance between the Team and the person with diabetes. Good Communication is vital and will give that person the best chance of achieving Confidant Self-Care. However, many strange and mythical Conceptions are associated with the condition. Before successful diabetes management can be achieved, Change in our and our patient’s ways of thinking is required, through a Continuous process of, Conscious, and Contemplative self-review.
Let us have a look at these 25 Core Concepts:
Diabetes is Common: Diabetes affects an estimated 8-10 % of the South African population. Worldwide, the number of people affected by it is increasing dramatically.
Diabetes is Costly: Figures for the costs of diabetes management in South Africa are unknown, but 2007 US statistics showed that average medical expenses among people with diagnosed diabetes were 2.3 times higher than they would be in the absence of diabetes. The same study showed a prevalence of diabetes of 7.8% and that approximately 1 in 10 health care dollars is attributed to diabetes. This however does not take into account costs of illnesses that are often not attributed to diabetes as well as indirect costs such as absenteeism, reduced productivity, and lost productive TotalSeats due to complications and early mortality. Much of the excess cost in diabetes is preventable as it relates to over-servicing, unnecessary hospitalisation, and the burden of the complications of poorly controlled diabetes.
Diabetes is Challenging: In the Diabetes Attitudes, Wishes and Needs (DAWN) Study, only about 10 % of the respondents described their “well being” as “good”. One third described their “well being” as “poor” and about 56% as “Moderate”. Conclusions from this large psychosocial study were that:
Living with diabetes is “demanding” and can be “stressful”. About 50% of patient experienced severe anxiety about their weight, the future and hypoglycaemia This psychosocial stress has serious consequences. People who have diabetes experience higher rates of depression (10-30%) and eating disorders (5-10%) than the general population Stigma and lack of awareness make living with diabetes more difficult Social support and emotional wellbeing are pivotal to achieve effective self-management (at least as important as medication)
No Cure: At this time there is no satisfactory and cost-effective cure for diabetes. Present Islet cell and organ transplant technologies, whilst providing hope along the road to a complete cure for Type 1 diabetes, presently just swap a hormone deficiency (Type 1 diabetes) for a non-viral acquired immune deficiency (secondary to the necessary immunosuppressive therapy). Transplants are therefore only suitable for those people who have severe complications of uncontrolled diabetes (e.g. renal failure). In this scenario, the potential negative side effects of a multi-organ transplant and follow-up therapy are a lesser threat compared with their present poor quality of life and tendency to increased morbidity and mortality. Other promising technologies are on the horizon but for now, diabetes remains a chronic condition.
Chronic means lifelong. A lifetime of “control” of lifestyle, blood glucose, blood pressure, and serum cholesterol and body weight is needed. This can be a large spiritual, psychosocial and financial burden to bear.
Diabetes is a “Condition”. Diabetes is not a disease – uncontrolled diabetes is. Well-controlled diabetes is a condition that is a risk factor for disease. A person who has diabetes should be regarded as “well”, and not unnecessarily put into a hospital. If a person with diabetes is treated as “well” rather than “sick”, they are more likely to continue functioning as an active and useful member of their family and community.
Diabetes is Classified into 2 major types:
- Type 1 (previously known as Insulin Dependent Diabetes Mellitus) consisting of 5-10% of the population who have diabetes. This is an autoimmune condition in which the body turns on itself and destroys the beta-cells of the endocrine pancreas that produce the blood glucose lowering hormone (chemical messenger) insulin. It is generally found in younger people and children and should be easily diagnosed with the onset of severe “Classic” symptoms. Treatment requires Hormone Replacement Therapy of two to four insulin injections daily for life. The person is otherwise healthy if well controlled.
- Type 2 (previously known as Non-Insulin Dependent Diabetes Mellitus) consisting of 90-95% of the population who have diabetes. This is a complex, serious and progressive disorder where a relative lack of insulin occurs together with resistance to its action. Type 2 diabetes has a strong association with the Western lifestyle of “gluttony and sloth”. Lack of exercise, poor eating habits and weight gain result in insulin resistance and eventual diabetes. Half of the people who have Type 2 diabetes in South Africa are unaware of it, although they are at risk of developing heart and blood vessel complications. A good indicator of risk is a “beer gut” or fat tummy. Previously Type 2 diabetes was a problem of older people, but tragically, more young people including children are being diagnosed. Treatment always begins with lifestyle change (exercise, healthy eating and weight loss) to which tablets will also be added as well as insulin injections over the next few years as beta-cell failure progresses.
People with undiagnosed diabetes or whose diabetes is uncontrolled may Complain of Classic symptoms: These may include the passing of excessive amounts of urine (polyuria), extreme thirst (polydipsia), frequent night time urination (nocturia which may present as bed-wetting in children) and weight loss. Symptoms are most often associated with Type 1 diabetes. In Type 2 diabetes, these symptoms may present but often only many years after developing this initially silent condition. As a result, there may be up to a 10-year delay in diagnosis after onset – by this time 30% of patients already have a chronic complication of diabetes. Thus an important “take-home message” in type 2 diabetes (and many other chronic diseases such as hypertension, dyslipidaemia, HIV / AIDS etc) is that symptoms are not a reliable indicator for the presence or absence of these conditions. More often, serious negative outcomes are the first sign of their presence.
Uncontrolled diabetes may result in Complications: These can be:
- “Acute” (metabolic) complications which are caused by diabetes treatment or lack of it:
- Hypoglycaemia [low blood glucose – give sugar]
- Hyperglycaemia [high blood glucose] or ketoacidosis [a serious illness due to lack of insulin]. Acute complications are easily treated if caught in time. Even better is prevention! This is the function of the Diabetes Team working together with the patient and their family.
- “Chronic” (mainly cardiovascular) complications which may be
- Macro-vascular:
- heart attack (myocardial infarction)
- stroke (cerebrovascular accident) and
- amputation (peripheral vascular disease) or
- Micro-vascular: disease of the small blood vessels in the
- eyes (retinopathy)
- heart (cardiomyopathy)
- kidneys (nephropathy)
- nerves (neuropathy)
- skin (dermopathy) and
- sexual organs (erectile dysfunction).
- Macro-vascular:
These are preventable! How? Read the next line….
Diabetes is Controllable: Daily glycaemic control is now attainable in the well educated patient who can self monitor their blood glucose responses to life and who has access to the oral agents, insulins and regimens that are now available. The Diabetes Control and Complications Trial (DCCT) and the United Kingdom Prospective Diabetes Study (UKPDS), have shown that with intensive treatment and tight glycaemic control, chronic micro-vascular complications can be delayed or even prevented in type 1 and type 2 diabetes respectively.
Diabetes and many of its complications can and should be controlled in the Community wherever possible. With the right counselling and education process, people with diabetes are quite capable of managing their condition at home, work or school. Not only is this financially more cost-effective, but it is also more appropriate in terms of the level of care often needed. A person who is managed in the community (e.g. for hyperglycaemia and ketonuria / hypoglycaemic coma) is kept in a “wellness” role which bodes better for their future psychosocial wellbeing. It is obvious that this scenario requires good diabetes team services, a well-educated patient and family and good access to communication with and care from the diabetes Team. Groups such as Diabetes Associations are vital to provide support where most of diabetes care occurs – in the community. Encourage your patients to join Diabetes South Africa. It is not a bad idea for you to join as well!
3 Cornerstones of treatment of diabetes are exercise, healthy eating and the right medication at the right dose and at the right time for the appropriate pathophysiology.
Checking or regular monitoring of outcomes is essential to ensure that diabetes is “Treated to Target”. This involves frequent self blood glucose checks by the patient. In addition, patients need to ensure that they get their A1C* checked 2-4 times yearly. Never neglect to also check blood pressure, serum cholesterol, microalbuminuria, body weight (growth in kids), eyes (annual Ophthalmologist examination) and feet (daily self and annual Podiatrist check) as well! *The A1C is a simple and “gold standard” laboratory test of good diabetes control. An A1C goal of < 7% for non-pregnant adults in general is recommended for the prevention of microvascular disease prevention. It must however be emphasized in the light of recent data, that ideal and safe control for each person must be individualised with his or her Diabetes Team, particularly if they have severe cardiovascular disease.
Choice diabetes Care is a lifelong process. For care to be successful there must be:
- Continuity: Care is organised around a person who has a life full of events both good and bad. The aim is to build up a coherent picture of their needs and their health status over time. Ideally the same caregivers should facilitate this care at each visit to engender trust and to improve the continuity of thought, process and action.
- Congruence in care: everyone in the Health Team should not only be giving the same information, but should also have the same insightful approach (based on a set of commonly shared and communicated values attitudes and beliefs) towards diabetes management. The person with diabetes will be reassured by the agreement and harmony they see and be more Confident (a feeling of “self-efficacy”) to practice what they have been taught.
- Concordance or agreement within the Team (including the patient): A person with diabetes has to balance the demands of life, diabetes and diabetes management with the resources (emotional, spiritual, structural, financial, family, friends, etc.) available to them. All must understand and accept the degree of tension that is being experienced and of the ability of the person with diabetes to cope with it. This will go a long way to ensuring an open, trusting care process and achieving maximum adherence to therapy. Of course, agreement is not possible without good Communication – patient and diabetes team must be open and truthful at all times and most importantly must LISTEN to each other.
Care should be managed:
- Self-Care and management is vital and requires patients to do more for themselves and to assume more responsibility (people are not inherently comfortable with this role). The focus is on the prevention of ill health and not its treatment.
- Facilitation of self-care by a Management Team of health care professionals with specialised training and knowledge has been shown to be essential in the control of diabetes. They provide diagnosis, counselling, education, treatment and lifestyle options, support and motivation. This reduces sickness, death, costs and hospitalisation due to diabetes. In addition to the Doctor, input from a Diabetes Educator, Dietician, Podiatrist, Ophthalmologist, Pharmacist, Biokineticist and Psychologist (amongst others), is necessary at different times to maximise care and quality of life. The doctor is not the head of this team – it is the person with diabetes and their family. Again, Diabetes Associations are a vital part of the team to provide support where most of diabetes care occurs – in the community.
Conceptions of diabetes are often coloured by experiences of diabetes treatment and failures. A set of values, attitudes and beliefs develop which guide future feelings and behaviours towards diabetes. These must be assessed and factored into any treatment plan.
A Change in your way of thinking is needed to help others change also and adjust to a condition that must be mainly self-managed and that requires life-long care and control. Change however, is not an on-off switch but often a long and stop-start-relapse process. It requires a Continuous bringing to Consciousness (self-awareness), Contemplation (self-reflection) and testing of the validity of our own attitudes, values and beliefs about something (in this case diabetes); for it is these “internal” drives that determine our eventual behaviour and what our patients / clients experience as a result.
If you are willing and able to change, you can help to Change Diabetes Care
