Editor’s viewpoint: A severe case of doing well

Modern care of people with type 1 diabetes is a complicated business. An enormous amount of time, effort and resources is spent educating and empowering individuals so that they can self-manage their diabetes and achieve a satisfactory level of blood glucose control without suffering unduly from hypoglycaemia. Practically, this involves multiple visits to diabetes centres, individual and group meetings with specialist nurses, dietitians, physicians, occasionally psychologists and increasingly with other patients some of whom are experts in the diabetes condition. This is modern intensive diabetes therapy. To not have participated in a recognised and structured intensive education programme is considered passé in diabetes circles.

A 29-year-old part-time postman was admitted to hospital with uncontrolled new onset diabetes in March 2003. At presentation, he was acidotic (pH was 7.1), ketonuric and hyperglycaemic (blood glucose 35mmol/l). He also had a concurrent pneumonia. Prior to admission he had a short history of polyuria, polydipsia and weight loss of 3 stone. His HbA_1c at presentation was 18%.

Five days after admission he considered himself to be well enough to go home. On the ward he had been taught by the diabetes specialist nurse the nuances of coping with four injections of insulin and blood glucose monitoring. Two weeks later he had one-to-one input from a dietitian. The patient did not take up the offer of enrolment in a recognised intensive education programme. Three months after diagnosis his HbA_1c was 6.6% and he had experienced no episodes of hypoglycaemia.

His next encounter with a healthcare professional (apart from picking up prescriptions) was in February 2004. At this time he described himself as ‘feeling fantastic, coping very well and enjoying family life’. He was playing first team rugby and training hard at kick-boxing. The patient brought his glucose log along which showed that he tested four times every day. There were no reported episodes of hypoglycaemia, his HbA_1c was 7% on 0.8 units of insulin/kg bodyweight and his family agreed that there were no problems.

The medical literature abounds with case reports of rare conditions or unusual presentations of common conditions. Reports of unusual health are unusual (Asher, 1987). Here, a patient with new onset type 1 diabetes appears to be doing well without having had the benefits of formal intensive education. Cynics may argue that he must be suffering from hypoglycaemia and that everything will unravel in the not-too-distant future. My view is that he is well and any intervention at this stage is meddlesome. Diabetes remains a fantastically interesting, mysterious but completely individualistic condition.