Diabetes is a chronic complex condition that potentially can affect all systems of the body. Diabetes management incorporates several elements such as administering of oral medications and/or injections, participation with home blood glucose monitoring in addition to adhering to diet and exercise recommendations.  Consequently, the person living with diabetes should be central to the management of their condition. This involvement requires that the person be given appropriate information, in a manner that best suits their individual needs. 

Strategies to delay or prevent the complications from diabetes are reliant on diabetes patient education. Therefore, an understanding  of how people learn and modify their behaviour is essential.

Diabetes management

When considering diabetes management there is a general tendency to focus on medication management to achieve optimal glycaemic control to prevent the acute and chronic complications of the condition. Frequently, complex treatment regimes are used to achieve this goal. Patients are generally provided with information on these treatments in relation to administration and the potential side-effects. 

In reality, diabetes management is not just this one-dimensional platform but rather a complex process which incorporates several elements. Underpinning any treatment regime for diabetes management is diet and exercise adherence. For the majority of people this will require some degree of lifestyle change and behaviour modification which will need to be maintained in the long-term, however in reality these aspects of care – while their importance is acknowledged – are often given little more than lip service.  

There is no magic treatment for this and it requires a strength of will on the part of the person living with diabetes to adhere to the recommendations continuously.  Yet psychological support for adults with diabetes is practically non-existent in this country. In its absence other strategies have been employed to help people learn to live with diabetes, particularly through patient education programmes.  

Patient education

The aim of diabetes education is to assist people living with this condition and their families to understand the disease and its treatment, to co-operate with healthcare providers, to live healthily and to maintain or improve their quality of life.¹

To facilitate this, the healthcare providers must take into account how the person will adapt to their condition and what their beliefs are about diabetes and its effect on them. Health education involves more than just providing information.¹

The goal of diabetes education is to help those with diabetes to live well. This can ultimately be achieved by assisting those with the condition to integrate their diabetes care into their lifestyles and, if necessary, to adapt their lifestyle to incorporate healthy living and adherence to treatment recommendations.¹

Knowledge is central to any decision-making process, therefore patient education is imperative if people with diabetes are to become active participants in the management of their diabetes.²

In relation to diabetes care people are not only required to understand their condition, how it affects them and how treatment modalities work, but they are also required to participate in that care.  

There is often an additional difficulty faced by people living with a chronic illness in accepting the responsibility for their own treatment and thereby taking on a new role. For people living with diabetes they become not just treatment receivers but also the subjects of their own treatment.

Some would argue that this is rarely made clear to people and highlights the need for training programmes not only for the people living with diabetes but also for the healthcare providers so that each can perform their role. 

People living with diabetes cope differently with their diagnosis. There are many factors that will have an impact on how an individual will manage their condition.  Locus of control has been described as one such influence. 

Those with an internal locus of control believe they are responsible for their health whereas people with an external locus believe they are at the mercy of fate.³ It is necessary therefore that those involved with patient education have an understanding of this concept as ultimately the aim is to empower these individuals to make informed decisions about their diabetes management. 

It has been suggested that healthcare professionals tend to “take credit for our patients’ successes and blame them for our failures”.⁴ The reality is that while the responsibility is shared, the person living with diabetes has the ultimate control of the outcome.⁵

Structured patient education programmes

Structured patient education has been defined by the HSE as a planned and graded process that facilitates the knowledge, skills and ability for diabetes self-management and empowers individuals to live healthily, to maintain and improve their quality of life and assume an active role in their diabetes care team.⁶

Ideally, all people with diabetes should be able to avail of a structured education programme. While this aspiration has not yet been realised in Ireland, there has been an increased availability of these programmes for people with both type 1 and type 2 diabetes nationally. 

These programmes are delivered in groups by healthcare professionals, predominantly diabetes nurses and dietitians, and the benefits shown include an increased application by the person living with diabetes of their knowledge of the condition and their participation in their own care.  This has been associated with an improvement in the person’s understanding of diabetes self-management and ultimately improved clinical outcomes.  

There are currently two courses available to adults with type 1 diabetes in Ireland: Dose Adjustment For Normal Eating (DAFNE); and the Berger programme. While there are differences between the courses, both focus on insulin adjustment for the carbohydrate content of food consumed.  For adults with type 2 diabetes there are currently three options, Community Orientated Diabetes Education (CODE), Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) and the X-pert (Patient Education versus Routine Treatment). 

Again, there are differences between these courses, but all aim to equip people with type 2 diabetes to actively engage with their self-care in an informed manner.  Many of the courses facilitate a family member to attend also to support the person with diabetes to engage with self-care.

While participation with these programmes has been shown to be advantageous, one should be cognisant that not all people are suited to learning in a group situation. Appropriate patient selection for referral to one of these courses is imperative if people living with diabetes are to benefit from attendance. In these circumstances individual education sessions are provided.

Conclusion

Diabetes care involves an unremitting management plan that requires daily adherence to diet and exercise plans, home blood glucose monitoring and adherence with therapeutic modalities.  While healthcare professionals are comfortable and familiar with the therapeutic modalities and competently impart this information, there is much less support for the other aspects of care which can have a significant impact on diabetes control, namely lifestyle and behaviour modification. 

Healthcare professionals need to work in partnership with the people living with diabetes and try to incorporate their personal goals into the treatment plan to achieve the best possible outcome. One solution has been the increase in the availability of specifically developed structured education programmes for people with diabetes although there is limited availability as yet in Ireland. Diabetes management continues to remain a challenge for all.  

Rita Forde is an advanced nurse practitioner at the Diabetes Centre in the Mater Hospital, Dublin

References

1. The American Diabetes Association. The Complete Nurses Guide to Diabetes Care 2005. American Diabetes Association
2. International Diabetes Federation.  Guidelines for Diabetes Care, A desktop Guide to Type 1 Diabetes Mellitus (1998). International Diabetes Federation, Belgium
3. Lo R.  Correlates of expected success at adherence to health regimen of people with IDDM. J Adv Nurs 1999; 30(2): 418-424
4. Funnell M. Helping Patients Take Charge of Their Chronic Illnesses. Fam Pract Manag 2000; 7(3): 47-51
5. Wolpert H, Anderson B. Management of diabetes: are doctors framing benefits from the wrong perspective? BMJ 2001; 323: 994-996
6. Health Service Executive  (2009). Review of Diabetes Structured Education Health Service Executive