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Diabetes Talkback: Vol 3 No 1

Poor glucose control increases the risk of complications. There is incontrovertible evidence supporting this. Healthcare professionals working in diabetes know this, and patients should also know this.Pam, who features in the current Diabetes Talkback, is the type of patient that can represent a dilemma for healthcare professionals. She has less than optimal control, and realises this. For her, this is an acceptable compromise for leading an active and dynamic lifestyle and maintaining quality of life. What is the role of the healthcare professional in this situation? Is it to accept the patient’s actions while not condoning them? In the wider context, how much and what type of education should be provided to people with diabetes? A GP and a health visitor provide comment on Pam’s case. Pam finally gives her response to the healthcare professionals.

The person with diabetes
Pam is 40 years old and was diagnosed with type 1 diabetes at the age of 18 months. She chooses to receive her care from her GP rather than the local hospital, and has a regular check-up every six months. She knows that it is important to maintain good diabetic control, but feels that she is a law unto herself in this respect. Her blood sugar levels average between nine and eleven. She says that some people, like her, ‘just run high’. She understands that this can result in complications in later life, but says that most of these conditions ‘come with old age to everyone – even non-diabetics.’

She feels that to hold down a job, run a household with a partner who works shifts, and still get the most out of life while remaining fit, that she needs to sacrifice low blood sugar levels. At her latest visit to the GP, she was told that her levels were too high, again, at nine to eleven – they have been at this level  constantly for the past two years. Sitting back in his chair, throwing his pencil on the table before him and laughing, the GP said, ‘Pam, you indulge in alcohol on occasion, you smoke, you do everything you are not supposed to do, but you are the fittest diabetic I have on my books – you make me sick! I will see you again in six months.’

Pam says that she knows herself well enough, and doesn’t feel that she needs to ask for help in controlling her diabetes. She does not like to make a fuss and feels that it is her problem to cope with in her way…but sometimes she wonders if she should accept the advice that is offered to her and stop being so independent and arrogant in thinking that she can manage alone.

A GP’s view
Huw Evans, GP, Isle of Wight, writes:

Before trying to deal with this situation, I am assuming that during the year Pam has:

  • Had an assessment of her fundi (with dilated pupils).
  • Had her cholesterol checked. 
  • Her blood pressure under control.

There is no doubt that type 1 diabetes imposes restrictions on one’s lifestyle. However, there is also a mass of data showing that the tighter the control of risk factors in diabetes, the lower the incidence of complications. 

I have sympathy for Pam’s attitude but I would also try to explain to her the reasons why it is desirable to keep the blood glucose, cholesterol and blood pressure as close to normal as possible. Complications may arise later in her life but it would be better for her to have a life worth living with as little disability as possible by getting things under control now.

If Pam is on twice daily insulin, a change to four injections per day may allow her greater ability to achieve a more flexible lifestyle, balanced with the need for twice as many injections.

Pam’s response:
I thank Dr Evans for his comments. My intuition leads me to believe that Dr Evans, in common with most GPs, ‘goes by the book’, neither ‘having’ or ‘giving’ sufficient time for each individual.

In the last two months, I have been allocated to a new four times a day insulin very unsuccessfully. My blood glucose test results have become erratic and difficult to stabilise. 

I am also menopausal – just another problem to contend with.

Occasionally, I will – unwillingly – break routine, only to find the ball back in my court. I am then left to re-establish what is right for me. I shall be requesting a return to my old insulin.

Healthwise, I have no complications. My eyesight is normal for my age group. Cholesterol levels are well ‘below’ normal; my blood pressure only rises above normal when I lose my temper!

I do not wish to frighten or influence people newly diagnosed with diabetes into thinking that they can do as they like. It does not work that way at all. You have to be realistic and sensible. Sometimes, doctors do not get it right and you have to have confidence in yourself and know your own limitations, and not be afraid to say so. Even I get it wrong sometimes. There are no hard and fast rules that apply to all people. 

A health visitor’sview
Eileen Emptage, Health Visitor (Diabetes) and Vice-Chair (Primary Care Diabetes UK), Melksham, Wiltshire, writes:

I feel that Pam should be congratulated on her management, having had diabetes for nearly 40 years with no obvious signs of complications.

Pam has managed to cope with all the problems of childhood, adolescence and life in general and still manage her diabetes in a positive way.

Over the years she has had to make decisions about lifestyle, such as smoking, alcohol and exercise, the same as any other person and with the knowledge that some of these can affect her diabetes control and health. The important factor here is that these are Pam’s decisions made with the appropriate understanding of the risks associated.

Although her blood glucose levels, at 9 to 11, are on the high side, the fact that these have been constant for the past two years, is most probably better than having excessive periods of very high and very low readings. This stability can be attributed to a satisfactory balance between diet, exercise and insulin requirements.

Another important factor appears to be that she has managed to achieve this and get the most out of life at the same time, not allowing her diabetes to rule her life. As Pam states, she knows herself well enough and manages her diabetes in her own way and this should not be seen as being arrogant . However, as I am sure Pam is aware, there are times when it helps to discuss issues with other people. If she feels that the time is right to be making changes in her life to prevent possible complications then talking to the practice nurse could be beneficial. 

I feel it would be helpful for Pam to identify any areas she felt changes could occur, e.g. smoking – the occasional alcoholic drink is not detrimental to her general health. I would also recommend that discussions about health and lifestyle should not be centred around her diabetes; these are the same issues that affect all people and should be addressed to prevent complications in later life. Pam has enough knowledge and skills to change her diabetes management to accommodate any changes she may have decided to make, and consequently will most probably find that her blood sugar levels will fall as a result.

Pam’s response:
Many thanks to Eileen for her answers. With all due respect to Dr Evans, I feel that I would be able to communicate better with Eileen because of the empathy shown. Her response displays patience and understanding for both the person with diabetes and the condition. This is a commendable and rare talent, which allows her to understand why it is important to achieve a balance.

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