Diabetes Talkback: Vol 4 No 3

The person with diabetes
Approximately 18 months ago, after a routine urine test and a follow-up blood test, Louise (58) was diagnosed as being a ‘non-insulin-dependent, diet-controlled diabetic’. Her GP advised her to cut out sugar and lose weight, both of which she managed to do. After 4 months, Louise’s GP also prescribed exercise at the local gym. One year later, during her usual annual blood test, the GP also checked her HbA_1c level. Upon phoning for her results, Louise was told that they were ‘normal’. Louise thinks that she should have been given more information about diabetes, or at least told where to look for more information. Should she have harassed an already overworked GP or should she have been given more advice to start with? Without the help of two friends who work with diabetes healthcare professionals, Louise feels as though she would have no information on her recently diagnosed condition, and not know what to expect.

AGP’s view
Dr Paul Sheldon, GP and Director of the DTC Primary Care Training Centre, writes:
I agree 100% with Louise’s thoughts. Is she registered with the right practice? She has been given the impression that she has ‘mild’ diabetes when, just by being diagnosed as having type 2 diabetes, she automatically has at least a 20% risk of having a heart attack within 10 years, even if she is a non-smoker with normal blood pressure and serum cholesterol. This risk can be reduced to single figures.

Incidentally, it sounds as if the GP is very out of date. When was the term ‘non-insulin-dependent diabetes’ abolished? Louise might well have had raised levels of blood glucose for many years without realising it. In addition, she is overweight, and so already has two of the criteria for insulin resistance syndrome.

If her surgery has a diabetes mini-clinic, which might well be run by a diploma- or certificate-trained practice nurse, she should attend it. If her surgery does not have such a clinic, Louise should ask herself the question posed at the start even more forcefully.

At a mini-clinic, Louise should be given more realistic advice, not only about lifestyle but also about footcare and all the other aspects of aggressive management of type 2 diabetes. The clinic will have all sorts of educational tools to help Louise appreciate the gravity of her situation. This is very important as the concept of risk and risk management is difficult for patients to grasp.

To sum up, Louise should receive the ‘Full Monty’ of aggressive coronary heart disease risk management – blood glucose control, cholesterol control (she should almost certainly be on a statin), blood pressure control (she should almost certainly be on an ACE inhibitor) and antithrombotic control (she should almost certainly be on low-dose aspirin). It seems drastic, but if Louise is to have a realistic chance of enjoying old age then her diabetes nettle has to be grasped. If this is done by both healthcare professionals and patient, both the quantity and the quality of Louise’s remaining life should be restored to normal.

Louise’s response
I have to say that I found some of the GP’s remarks quite frightening. They made me question whether I would get better service in another practice. The GP talks about insulin resistance syndrome; what is this? Something else for me to worry about? Again, I have received no information on this. Should I take statins despite having normal cholesterol? It’s in my nature not to take any medication without proof of need! To sum up, I think that giving too much (speculative?) information might frighten patients with diabetes. Surely, a happy medium can be found where the healthcare professionals give newly diagnosed patients the immediate information they need to take control of the disease, without terrifying them with possible future scenarios?

A Diabetes Specialist Nurse’s view
Jennefer Richmond, Senior Diabetes Specialist Nurse in Stockport, writes:
I understand Louise’s concerns regarding information about diabetes when initially diagnosed. People with diabetes need knowledge and advice about the disease early on, so that they can develop the necessary skills to enable them to care for themselves properly. Education is a vital part of the total diabetes care package and is essential for management of the disease. However, this said, some patients are unreceptive to education programmes at diagnosis. Nevertheless, patients should have access to a structured education programme, which should ideally take place as soon after diagnosis as possible. Unfortunately, patient education has been found to be inadequate in many hospitals and general practices (Audit Commission, 2000; Husband and Chegwidden, 2002). People with diabetes need to make informed choices regarding their management and they can only do this by accessing the necessary information.

Ideally, every newly diagnosed person with diabetes should be seen by a dietitian and have a full dietary assessment. Unfortunately, because of a national shortage of dietitians, this does not always take place. All aspects of diabetes care should be discussed as part of a comprehensive care package. In addition, I always think that it is helpful to tell patients what their targets are and why they should be trying to achieve them – this creates a greater understanding of diabetes and people are more likely to accept what is being asked of them.

The difficulty for healthcare professionals is the increasing numbers of people being diagnosed with diabetes; this naturally restricts the time they are able to spend with each patient. The sensible way forward to ensure that people are being educated is, therefore, to offer education in group sessions, which some areas do. In addition, all people with diabetes, whether newly diagnosed or not, should be pointed in the direction of Diabetes UK, who have leaflets on every aspect of the disease and can put people in touch with their local diabetes support group.

Louise does not say whether her GP is a single-handed practice or whether she has access to a practice nurse. Often, it is the practice nurses who deal with diabetes and have been trained in diabetes care. Those who have the required training are an invaluable source of advice and information. Louise could have approached the practice nurse if she felt unable to contact her GP again. If this was not an option, the local hospital could have put Louise in contact with the district’s diabetes specialist nurses.

Unfortunately, there are still some people with diabetes who are not getting the information and advice they would like. These people need to ask their healthcare professionals for the information they require or ask to be put in touch with someone who can give them the answers they need. 

Louise’s response
The nurse’s reply was very true; she appreciates the difficultly I had in getting information. My main concern was that, upon my diagnosis, I was not pointed in any direction for information and so I presumed, perhaps incorrectly, that I had a very minor complaint. Although, as the nurse says, some patients are unreceptive to diabetes education, I think it should at least be offered. For example, I would have liked help in understanding the targets associated with the control of diabetes. As for going to a diabetes clinic, I was not give this option. I appreciate that diabetes might be a commonplace illness to doctors and nurses, but I urge them to remember that such a diagnosis comes as a shock to many patients.