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Managing type 2 diabetes: a dynamic approach

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VOL: 97, ISSUE: 07, PAGE NO: 42

Sue Cradock, MSc, RGN, DipN, is clinical nurse specialist, Portsmouth Diabetes Centre, Queen Alexandra Hospital, Portsmouth

Chas Skinner, PhD, is a lecturer in Psychology, University of Bath

Type 2 diabetes is a serious health problem in the UK. This was highlighted by Diabetes in the UK: The Missing Million (Diabetes UK, 2000). This report states that 41% of NHS money for type 2 diabetes is spent on inpatient care, that is treating complications that, in many cases, are preventable.

Type 2 diabetes is a serious health problem in the UK. This was highlighted by Diabetes in the UK: The Missing Million (Diabetes UK, 2000). This report states that 41% of NHS money for type 2 diabetes is spent on inpatient care, that is treating complications that, in many cases, are preventable.

The report by Diabetes UK, formerly the British Diabetic Association, stresses the role of self-management by people with type 2 diabetes and recommends tight control of the condition by:

- Losing weight;

- Eating a low-fat, high-fibre diet;

- Stopping smoking;

- Exercising.

Recent studies have highlighted a lack of effective self-care in a significant number of patients. Education is important and nurses play a vital role in coaching people with diabetes in effective self-care. Specialist diabetes nurses in primary and secondary care already provide patient education programmes, but increasing evidence suggests that the effectiveness of traditional education methods is limited (Evans et al, 1999; Toobert et al, 2000).

Challenges to effective self-care
There have been rapid developments in our understanding of the pathophysiology of diabetes, but health care professionals still face a number of non-medical challenges (see box).

Medication

Once prescribed, medication will be effective only if it is taken appropriately and in sufficient quantities. Unfortunately, we know this does not happen in most cases of diabetes.

The DARTS/MEMO electronic database in Dundee, Scotland, collates data from all medical-related databases across the Tayside region - hospitals, pharmacies, general practices and optometrists. Comparing prescriptions with the amounts of medication obtained from pharmacies, it showed that only about one in three patients on monotherapy get enough medication to fill their prescription. Furthermore, about 20% of patients did not get any blood-glucose testing strips during the three-year study period (Evans et al, 1999).

Lifestyle

The self-management of diabetes requires individuals to manage their diets and levels of physical activity, but there is no objective data on UK patients' lifestyle behaviours.

However, data from several large-scale studies in the USA indicates that lifestyle management is the most difficult area of diabetes management. People with the condition reported following their dietary recommendations on average 50% of the time, their recommendations for physical activity 35% of the time and foot care advice 47% of the time. The available data also suggests that the prevalence of smoking among people with diabetes is no different from that in the general population, which is about 32% of men and 27% of women (Toobert et al, 2000).

Depression

In addition to the medical and lifestyle management of diabetes, patients also have to manage their emotions. Many people who have recently been diagnosed with diabetes do not necessarily accept that they actually have the condition. The slow, insidious onset of diabetes leads many to think they are asymptomatic or to misattribute their symptoms to old age, stress or other comorbid conditions.

Once diagnosis has been accepted patients can experience a plethora of emotions, including guilt, anger and grief. However, depression is the most important issue. Studies consistently show that people with diabetes are two or three times more likely to have depression than those in the general population, that is 20-30% of people with diabetes are clinically depressed at any one time (Peyrot and Rubin, 1997; Lustman et al, 2000).

Depression is associated with poor self-care, poor metabolic control, the early onset of complications and their rapid progression. Furthermore, it is often not diagnosed or treated. Helping patients with type 2 diabetes to care for themselves effectively therefore requires the nurse to recognise the need for an integrated, coordinated approach.

Effective self-management
After a review of the available evidence, the Centre for Advancement of Health (2000) made the following recommendations for effective self-management interventions:

A population-based approach

A diabetes registry that is regularly updated and provides feedback on managing patients will enable health care providers to identify areas of need in their patient group and monitor the success of interventions.

Planned and proactive visits

Effective self-care and behavioural change require ongoing support. Those patients who work the hardest to improve their self-care are often considered to be doing well (which they are) and therefore not in need of support (which is not so).

Collaborative goal-setting

Patients are usually trying to achieve goals that are set by health care professionals. For any goal to be achievable it must be fixed in a collaborative setting between patients and providers.

Identification of barriers and support

For goals to be achieved, any potential barriers in patients' day-to-day social environments need to be explored. Nurses can help patients to do this by getting them to 'play act' the necessary changes in their lives before leaving the consultation, identifying possible barriers to the implementation of changes. These can then be discussed and alternative measures considered. This ensures a greater chance of success.

Patient-centred education

During the consultation, the focus should be on:

- Identifying the patient's current frustrations with diabetes self-care;

- Exploring the problems, specifically the emotional expression of these problem;

- Considering the potential options for change. This may include providing the patient with information to aid decision-making;

- Committing to action. Once the patient has worked through the range of potential options for change and chosen one, focus specifically on the additional resources (knowledge, equipment, support) required and how the patient will know the goal has been achieved (Anderson et al, 1999).

Systematic follow-up

Behavioural change, learning new skills and practising self-management techniques require active follow-up by those delivering health care. Effective communication between health care professionals regarding the behavioural goals being worked on by the patient is also necessary.

Integration with other resources

A variety of different health care professionals can be involved in providing care to people with diabetes. Their work should be coordinated towards agreed pathways of care. Although it may be difficult to ensure that 'everyone is saying the same thing', the more local health care providers meet and discuss diabetes care issues the lower is the risk of giving conflicting messages to patients.

Conclusion
The patient-centred approaches mentioned have been found to provide superior results in both traditional care and more knowledge-based diabetes education sessions. The role of group-based interventions has also been shown to be more effective in relation to outcomes and costs (Griffin et al, 1998; Centre for Advancement of Health, 2000; Vrijhoef et al, 2000).

There is compelling evidence that health care providers must see these interventions as a priority in achieving effective self-management.

Although there is a lack of evidence on the roles of different health care professionals in providing quality care to people with chronic diseases such as diabetes, the emerging evidence points to the central role that specialist nurses can play.

- Next week: monitoring blood glucose.

The first two articles in this series appeared in Nursing Times on February 1 and 8.

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