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OVERVIEW :

• Patient-centred priority setting and supported self-management form

the modern approach to diabetes care

• Control targets should be tailored to the individual

• Patients are more likely to adhere to treatment plans that they have

formulated themselves

• Self-efficacy and ‘ownership’ of the condition should be nurtured

through structured education

Introduction

Living with diabetes is a long personal journey. Throughout the journey

patients require information, education, support and self-management

skills. They also require prescribed medication, monitoring, surveillance

and regular review. This journey is a joint venture between the individual,

their carers and a multidisciplinary team of health professionals (Box 3.1).

Box 3.1 Aims of treatment of

diabetes :

• Absence of symptoms

• Avoidance of severe

hypoglycaemia

• Control of blood glucose to

patient-centred targets

• Control of other

cardiovascular risk factors

• Prevention, early detection and effective treatment of

complications

• Lifestyle sufficiently flexible to suit the person’s needs

• Normal life expectancy

Patient-centred priority setting

In the past, patients were expected to passively follow the doctor’s

instructions. Those who failed to reach targets were simply not complying.

This approach was never very effective in diabetes, but it is increasingly

insufficient in the modern world of patient autonomy, access to

information, and personal responsibility for health. We now know that

individuals are much more likely to adhere to decisions they have

formulated themselves. The emphasis of diabetes care should be self-

management, supported by a team of health professionals (Figure 3.1).

Shared decision making

The Autonomous Patient: Ending paternalism in medical care by Angela

Coulter (2002) suggests three models of clinical decision making

(Table 3.1).

The shared decision making model is increasingly used in primary care,

where patients are usually not acutely ill. The clinician must provide and

share information, whilst the patient must be prepared to discuss

personal values and preferences.

Both accept shared responsibility for the treatment decisions. A successful

clinician-patient relationship built on mutual trust allows the model to be

adapted flexibly to the situation.

Development of a serious acute illness might shift the emphasis towards

Professional choice, whilst the need to choose a hospital for non-urgent

cataract surgery might be purely a Consumer choice.

Targets :

Treatment targets are often recommended for the entire population with

diabetes, but in fact should be tailored to different patient types

depending on co-morbidity, life expectancy, patient preferences and

other factors. Discussing personalised goals with the patient and sharing

responsibility for keeping within targets is an important step in successful

control of risk factors. Generally: aim for HbA1c ≤7.0% (53 mmol/mol) in

all patients and ≤6.5% (48 mmol/mol) in the majority; keep blood

pressure ≤140/80 for everyone and ≤130/80 if possible; control total

serum cholesterol to ≤4.0 mmol/l and LDL cholesterol to ≤2.0 mmol/l.

This is particularly important

in type 2 patients with established cardiovascular disease or risk factors

for it. In practice, this includes the majority with type 2 diabetes (see

Chapter 5).

Realistic weight reduction

targets should be set. Gradual,

sustainable weight loss is far

more beneficial than sudden

loss, which is initially

encouraging but then

demoralising when the weight

returns. The same applies to physical activity, which should be gradually

increased to a moderate level over a period of time.

Some targets are easier to achieve than others (Table 3.2). Controlling

blood pressure and lipids is usually possible provided the individual

concords with prescribed drug therapy. The more difficult areas are those

requiring self-management skills and lifestyle change. Glycaemic targets

may need adjusting based on risk of hypoglycaemia, and hypoglycaemia

awareness. A frail, elderly patient may have different needs and priorities

to a younger, more active

individual (Box 3.2).

Main issues to cover in the first

Consultation

• The biochemical basis for diabetes in lay terms (raised blood sugar,

insufficient insulin, body not responding to insulin properly)

• Diabetes can cause problems with a number of organs and body systems,

which can be prevented

through a joint effort between

the patient and the practice

team

• Controlling blood glucose levels reduces the chances of complications of

diabetes, but controlling blood pressure and cholesterol are equally

important

• The importance of lifestyle: weight control and exercise not only reduce

blood glucose, blood pressure, and cholesterol, but also make the body’s

own insulin work more effectively

• Realistically, over time there is a tendency for the glucose levels to rise

further, so that medication usually needs to be ‘stepped up’ as time goes

by, even in the patient who ‘does everything right’.

It is important that patients don’t feel demoralised by such an escalation

(Box 3.3)

• Mention in outline the range of treatments – lifestyle change, tablets,

insulin. Discuss insulin in a positive way (even though not needed now)

and not as a ‘last desperate resort’. This will help in future if the time

comes when it is needed

• Refer to ‘lifestyle’ or ‘dietary’ changes rather than to ‘dieting’ to avoid

the patient believing that their treatment will involve a strict ‘crash’ diet

that they are unlikely to sustain

Keeping on the same side

Newly diagnosed patients

sometimes feel overwhelmed at

the prospect of self-managing a

complex and potentially serious medical condition. Such individuals need

structured education, support and confidence building, provided by a

consistent and integrated team of health professionals. Developing our

patients’ knowledge and skills towards a state of self-efficacy (Box 3.4) is

one of the most valuable things we can offer them in the early stages of

diabetes.

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