Copilot A

Figure 10.5 The 'CoPilot' programme for assisting in management of diabetes. Reproduced with kind permission from Abbott Laboratories Limited.

Some of the problems with prospective responses to blood glucose results include:

• 'Chasing the tail': Displacement of the glucose level is detected, but the response is to over-correct, resulting in displacement in the opposite direction. This may again lead to over-correction, repeating the cycle, and so on

• Overlap of insulin doses: Self-monitoring may occur before the most recent insulin dose has taken full effect, so that a high blood glucose level is treated with an unnecessary corrective dose, when restoration of a normal level would have occurred without any interference

• Inappropriate adjustment of long-acting insulin: In another common scenario, the patient detects a raised measurement prior to the daily long-acting insulin dose, and increases the long-acting dose accordingly. This action is delayed, and then overlaps with other insulin doses hours later or the following day

• Inappropriate response to a non-significant fluctuation in the glucose level: As Figure 10.3 demonstrates, glucose levels may fluctuate quite widely over a period of an hour or two, and some of this fluctuation represents dynamical 'noise' that should be ignored rather than used as a basis for prospective action. Impulsive responses to such noise will worsen control

These problems are typical of the 'tampering' phenomenon, in which self-monitoring results in deterioration rather than improvement in control, justifying past caution over this prospective

Figure 10.6 The retrospective and prospective approaches should ideally complement each other. After all, no good driver attempts to control the vehicle without using both the windscreen and the rear mirrors.

approach. But the modern patient is likely to want to develop prospective control skills to provide flexibility (Figure 10.6). The DAFNE approach (Box 10.4) involves an individually tailored algorithm for dose adjustment, combined with accurate carbohydrate counting. There is no dietary restriction, and insulin doses are adapted to carbohydrate intake choices. It is the only evidenced-based programme currently on offer for type 1 patients wishing to adjust doses flexibly. An adapted programme for the 11-16 year age group is under development.

Box 10.4 DAFNE

DAFNE ('Dose Adjustment For Normal Eating') is a 5-day training programme for adults with type 1 diabetes. It involves accurate carbohydrate counting and adjustment of insulin doses according to need. It is suitable for well-motivated patients who have been diagnosed for at least 6 months, and who are prepared to monitor four to six times a day and inject insulin frequently. It is based on the idea that tailoring insulin doses to the person's usual diet (which is in principle unrestricted) is the best way of achieving glycaemic control without increased hypoglycaemia. It has been shown in a randomised controlled trial to improve HbAlc levels (as well as quality of life scores) without increasing the frequency of severe hypoglycaemia. It is not known whether in the long term metabolic outcomes are affected by the dietary freedom, but short-term cardiovascular risk factors were unaffected. The details of the DAFNE approach are not widely available as it is important that patients using this technique are properly trained by attending the 5-day course. For the reference to the DAFNE trial report, see Chapter 3. For details on how to apply or refer, see: www.dafne.uk.com

Self-monitoring techniques

There is now a wide variety of self-monitoring systems available. It is preferable for the whole health care team to be familiar with the same device or a small number of alternatives.

Whilst the devices are not themselves prescribable in the UK, manufacturers will usually supply them free of charge to diabetes teams (e.g. general practices or hospital diabetes centres) to distribute to patients. The testing strips can then be prescribed. The monitors must be user-friendly in a range of environments and the best options will provide the following features:

• Small, compact, and easily carried in clothing or a handbag

• Only require a small amount of blood for a measurement

• Beep to confirm that sufficient blood has been applied, but not so loudly that monitoring cannot be done discreetly

• Give an accurate reading in a short time frame e.g. 12 seconds

• Do not require blood to be 'wiped off the end of the strip

• Have a luminescent screen and so usable in the dark

• Use testing strips that can be disposed of by flushing away

• Preferably include the option of testing for blood ketones

• Have a memory for recall of past results

• Increasingly, patients will want to upload results to a personal computer for retrospective analysis, a feature available with some but not all devices

Blood maybe taken from the distal edges of the fingers (the central pulp of the fingers should be avoided to preserve nerve ending function in the long run), from the forearms (less pain sensitive) from the thenar or hypothenar eminences (see Figure 10.7), or from the ear lobes (which are usually very vascular and bleed easily even when other sites do not).

Ideal frequency of self-monitoring

The expected benefits and frequency of self-monitoring should be agreed between patient and clinician before starting. Patients on insulin whose diabetes is intensively (and 'prospectively') managed will need to monitor four to six times per day to gain maximum benefit, particularly when flexibility is required. Other patients, including those with type 2 diabetes whose carbohydrate intake is relatively constant in quantity and timing will require readings less often, provided hypoglycaemia awareness is intact. For patients who are not taking insulin but in whom it has been decided that monitoring is beneficial, a measurement taken twice a week may be appropriate, increased during illness. Those taking oral medication (and certainly those taking insulin) may benefit from monitoring before driving - a policy recommended by the Driving and Vehicle

Figure 10.7 Sites on the hand suitable for blood sampling.

Classical finger-prick areas. The tips and pulp of the fingers should be avoided to preserve sensitivity. Choice of site should be rotated.

Alternative areas for blood sampling. These areas are less painful and may improve acceptability particularly in children, but the blood glucose mesasurements respond more slowly following carbohydrate ingestion, particularly at the forearm.

Licensing Authority. Insulin users should monitor before setting off and every 90 minutes during the journey. Ramadan is a situation when individuals who do not usually monitor may benefit from doing so. Frequency of self-monitoring should be increased at times of sickness, particularly for type 1 patients (Box 10.5).

Box 10.5 Sick day rules

Glycaemic control may become very difficult during intercurrent illness, particularly when vomiting occurs. The basic principles are to monitor frequently (every 2-4 hours), not to stop insulin (as more than the usual dose is typically needed), to titrate insulin doses to blood glucose results, and to maintain a regular intake of easily digested simple carbohydrate. If this is not possible, admission to hospital is needed. Regular testing of the urine or blood for ketones during the illness is useful to detect the onset of ketoacidosis, which requires prompt treatment with intravenous fluids and insulin.

New technologies

The past 15 years have seen a rapid development of technologies to assist patients in self-management. These include computer assisted self-management programmes and flow sheets, telemedicine options, Internet-based educational software, and automated telephone products. In a systematic review in 2006 Jackson and colleagues found that as well as improvements in HbA1c reported in most studies, IT-based interventions improved health care utilisation, behaviours, attitudes, knowledge and skills. However, ethnic minorities are not well represented in the research literature, and unless the problem of access is addressed the development of such technologies is likely to widen rather than reduce health inequalities.

Maintaining an active life-style Physical activity and diabetes

Regular moderate aerobic physical activity for at least 30 minutes on 5 days of the week, recommended for the whole population, is particularly valuable in those with diabetes. Generally speaking, the activity should be sufficient to make the person breathless and raise the heart rate. This activity should:

• increase the chances of sustained weight loss

• improve the lipid profile

reduce blood pressure

It also increases insulin sensitivity and can improve glycaemic control, provided appropriate account is taken for the exercise in adjusting insulin doses and carbohydrate intake. Increasing the exercise beyond a moderate level is likely to result in little further benefit and may be risky. The risks are not only those of hypoglycaemia (particularly in insulin-treated patients) but also of actual physical injury. A sprained ankle is easily gained and may preclude exercise for several weeks. Cardiovascular benefits are not sustained for long after an exercise programme ceases, and regular moderate activity is far more beneficial than unprepared excessive exertion. Like crash dieting, such behaviour is counter-productive and should be discouraged.

For some patients, obesity and associated arthritis or other physical problems may make exercise difficult or impossible. Advice and guidance is now widely available through personal trainers, but such people must be adequately trained themselves. Swimming is a usually safe and effective form of exercise, as is brisk walking. For those who cannot manage this, any amount of physical activity, however small, is better than nothing and some people may be able to increase their activity significantly simply by rearranging their work environment. Using a toilet on a different floor, avoiding using the lift, walking to visit others in different office rooms rather than telephoning, and other simple changes to everyday habits may be very beneficial.

Summary

The emphasis of diabetes care is on self-management, but the availability of medical expertise is as important as ever. Patients need to be taught a range of skills in order to take control and 'ownership' of their condition. These include advice on nutritional management and exercise to achieve sustained weight loss and improved cardiovascular risk, and training in managing blood glucose levels through self-monitoring where appropriate. Through these measures the patient can work together with the health care team to develop the confidence and self-efficacy to overcome the day to day challenges of diabetes.

Further reading

Farmer A, Wade A, Goyder E, et al. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial. BMJ 2007;335:132 (21 July), doi:10.1136/bmj.39247.447431.BE Jackson CL, Bolen S, Brancati FL, et al. A Systematic Review of Interactive Computer-assisted Technology in Diabetes Care. J Gen Int Med 2006;21:105-10.

Connor H, et al. Nutritional Subcommittee of the Diabetes Care Advisory

Committee of Diabetes UK. Diabetic Medicine 2003;20:786-807. Department of Health. The expert patient: a new approach to chronic disease management for the twenty-first century. London: Department of Health, 2001; www.ohn.gov.uk/ohn/people/expert. Tattersall R. The expert patient: A new approach to chronic disease management for the twenty-first century. Clin Med JRCPL 2002;2:227-9.

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