Info

Clinician decides,

Information shared,

Clinician informs, patient

patient consents

both decide together

makes decision

Reproduced with permission from Coulter A, The Autonomous Patient, 2002.

Reproduced with permission from Coulter A, The Autonomous Patient, 2002.

must be prepared to discuss personal values and preferences. Both accept shared responsibility for the treatment decisions. A successful clinician-patient relationship built on mutual trust allows the model to be adapted flexibly to the situation. Development of a serious acute illness might shift the emphasis towards Professional choice, whilst the need to choose a hospital for non-urgent cataract surgery might be purely a Consumer choice.

Targets

Treatment targets are often recommended for the entire population with diabetes, but in fact should be tailored to different patient types depending on co-morbidity, life expectancy, patient preferences and other factors. Discussing personalised goals with the patient and sharing responsibility for keeping within targets is an important step in successful control of risk factors. Generally: aim for HbA1c <7.0% (53 mmol/mol) in all patients and <6.5% (48 mmol/mol) in the majority; keep blood pressure <140/80 for everyone and <130/80 if possible; control total serum cholesterol to <4.0 mmol/l and LDL cholesterol to <2.0 mmol/l. This is particularly important in type 2 patients with established cardiovascular disease or risk factors for it. In practice, this includes the majority with type 2 diabetes (see Chapter 5).

Realistic weight reduction targets should be set. Gradual, sustainable weight loss is far more beneficial than sudden loss, which is initially encouraging but then demoralising when the weight returns. The same applies to physical activity, which should be gradually increased to a moderate level over a period of time.

Some targets are easier to achieve than others (Table 3.2). Controlling blood pressure and lipids is usually possible provided the individual concords with prescribed drug therapy. The more difficult areas are those requiring self-management skills and lifestyle change. Glycaemic targets may need adjusting based on risk ofhypo-glycaemia, and hypoglycaemia awareness. A frail, elderly patient may have different needs and priorities to a younger, more active individual (Box 3.2).

Main issues to cover in the first consultation

• The biochemical basis for diabetes in lay terms (raised blood sugar, insufficient insulin, body not responding to insulin properly)

• Diabetes can cause problems with a number of organs and body systems, which can be prevented through a joint effort between the patient and the practice team

• Controlling blood glucose levels reduces the chances ofcomplica-tions of diabetes, but controlling blood pressure and cholesterol are equally important

• The importance of lifestyle: weight control and exercise not only reduce blood glucose, blood pressure, and cholesterol, but also make the body's own insulin work more effectively

• Realistically, over time there is a tendency for the glucose levels to rise further, so that medication usually needs to be 'stepped up' as time goes by, even in the patient who 'does everything right'. It is important that patients don't feel demoralised by such an escalation (Box 3.3)

• Mention in outline the range of treatments - lifestyle change, tablets, insulin. Discuss insulin in a positive way (even though not needed now) and not as a 'last desperate resort'. This will help in future if the time comes when it is needed

• Refer to 'lifestyle' or 'dietary' changes rather than to 'dieting' to avoid the patient believing that their treatment will involve a strict 'crash' diet that they are unlikely to sustain

Box 3.3 Lifestyle changes and drug therapy

Lifestyle change is important for the majority of patients, but some may feel disinclined to change their behaviour if they are immediately prescribed drug therapy. A period of behavioural adaptation following diagnosis before drugs are commenced may be beneficial unless the indication is strong. Three months is the traditional interval

Table 3.2 Type 2 diabetes - meeting the needs.

Readily achieved Difficult to achieve

Blood pressure control Durable control of glycaemia

Lipid management Post-prandial glucose levels

Screening for complications Abdominal obesity

Glycaemic control in early stages of disease Smoking cessation

Physical inactivity

Keeping on the same side

Newly diagnosed patients sometimes feel overwhelmed at the prospect of self-managing a complex and potentially serious medical condition. Such individuals need structured education, support and confidence building, provided by a consistent and integrated team of health professionals. Developing our patients' knowledge and skills towards a state of self-efficacy (Box 3.4) is one of the most valuable things we can offer them in the early stages of diabetes.

Box 3 .2 Key attributes to nurture in our patients

Knowledge about the condition, and how it may affect them now and in the future

'Ownership' of their diabetes

Shared responsibility for decision making

The confidence to plan changes and take control

Trust in us to act for their benefit

Box 3.4 Self-efficacy

'Self-efficacy' is a key element to the success of behavioural change in diabetes. The term refers to the individual's personal ability to take action and make changes. Self-efficacy is the basis for a number of diabetes management interventions, including DAFNE, DESMOND and the Diabetes Manual

Figure 3.2 Armande Voizin, played by Judi Dench. From the film Chocolat. Photo credit: David Appleby/Courtesy of Miramax Film Corp.

Armande, the character played by Judi Dench in the 2000 film Chocolat, conceals her insulin-dependent diabetes at the local chocolaterie. Defying pressure from her daughter to enter institutional care, she follows the village's general slide into temptation, and dies through overindulgence in chocolate. Set in rural France in 1959, the story reflects the shifting social trend towards freedom of choice, and her death is portrayed as a victory for personal autonomy. But the basis for her defiance is a lack of self-efficacy, and the absence of a non-judgemental clinician she can trust. Adult patients rarely opt for the rebellion route if given sufficient support and a feeling of ownership of their condition.

How can we help patients change their lifestyles?

• Engage with the patient from the time of diagnosis

• Reinforce positive moves to change and praise achievements, even small ones

• Give consistent, supportive messages from all members of the team, using written material

• Encourage the patient to access educational resources themselves, including reliable websites that support the same messages as the health team

• Take it a little at a time and set realistic short-term goals

• Emphasise the need to maintain change, which is more difficult than achieving it in the first place

• Provide the actual figures: most patients can easily understand the basic indices and targets and by feeling a sense of 'ownership' of the data will accept responsibility for them (Box 3.5)

Box 3.5 Tools for use in a consultation

Use open questions Listen to answers Acknowledge beliefs and feelings Be non-judgemental Reflect and paraphrase

Help the patient define an action plan, and set timescales

Structured education

As well as regular input from the practice team, patients may benefit from entering a structured education programme. This is particularly valuable following diagnosis but can be offered at any time. In the UK, available programmes include DESMOND and The Diabetes Manual (for type 2 patients) and DAFNE for type 1 patients.

DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) is an educational package to help people with type 2 diabetes, particularly those who are newly diagnosed. It has been shown to have benefits on weight loss and smoking cessation and positive improvements in beliefs about illness. All aspects of self-management are covered, in a group setting.

The Diabetes Manual is also designed for type 2 patients but involves one to one education and is therefore suitable for those who prefer to avoid group education settings. In addition to a comprehensive manual, audiotapes are provided, and practice nurses are trained to deliver the educational material.

DAFNE (Dose Adjustment For Normal Eating) is a 5-day training programme for people with type 1 diabetes. It involves learning accurate carbohydrate counting and adjustment of insulin doses according to need. It is suitable for well-motivated patients whose diabetes is less than adequately controlled, who have been diagnosed for at least 6 months, and who are prepared to monitor four to six times a day and inject frequently using a basal bolus regimen. 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 HbA1c levels (as well as quality of life scores) without increasing the frequency of severe hypoglycaemia.

'Yo-yoing'

There is a thriving market for faddish diets and alternative dietary advice, which should be resisted. Patients are understandably attracted to media publicity or anecdotal accounts of rapid weight loss, but such approaches are rarely sustainable, and 'yo-yoing' (fluctuating weight with no overall trend towards reduction) has been shown to be actively harmful. Yo-yoing is less likely if newly diagnosed patients are presented with a positive image of healthy food rather than a simple list of prohibited items. Many type 2 patients have developed diabetes at least partly because they adore food. To disregard this long-established devotion is simply futile.

Their interest in food needs to be redirected rather than extinguished. Offering a wide range of healthy options in a positive way will avoid the impression of a gastronomic prison sentence. See Chapter 10 for dietary advice for diabetes.

Semantics

Whilst many do not object to the term 'diabetic', a proportion finds it stigmatising. The term, when referring to an individual, has been 'banned' from many of the major publications including the British Medical Journal. Its use as an adjective (e.g. 'the diabetic foot') is generally considered acceptable, but it should no longer be used as a noun. The same has occurred for people with epilepsy. The term 'patient' is appropriate in context, but we should not forget that for most of the time people with diabetes are not ill.

Summary

Modern diabetes care needs to be patient-centred, recognising that people are on the whole more likely to succeed in achieving targets if they themselves have formulated, or helped formulate, the management plan. Care should also be individually tailored, whilst maintaining standards that are common to all patients. Confidence building to promote self-efficacy, and keeping on the same side, are important and deserve the necessary time commitment particularly in the early stages after the diagnosis.

Further reading

Coulter A. The Autonomous Patient: Ending paternalism in medical care. The

Nuffield Trust. The Stationary Office, London, 2002. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. BMJ 2002; 325:746

Davies MJ, Heller S, Skinner TC, et al. Diabetes Education and Self Management for Ongoing and Newly Diagnosed Collaborative. Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ 2008;336(7642):491-5. Sturt J, Taylor H, Docherty A, et al. A psychological approach to providing self-management education for people with type 2 diabetes: the Diabetes Manual. BMC Fam Pract 2006;7:70. 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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