Diabetes care and education

Awareness and improved diabetes education is needed to prevent disease-related complications

Diabetes care and education


iabetes is a non-communicable disease (NCD). NCDs are not caused by infections, nor are they contagious. They are often brought on by unhealthy lifestyles/ behaviours. Altering an individual’s lifestyle can be challenging. This requires counselling, education and developing an understanding of the disease and how it can be controlled. A systematic review and meta-analysis of diabetes in Pakistan published in 2019 revealed that approximately 15 percent of the population have diabetes and a significant number remain undiagnosed (PJMS 2019). This means that there are millions in the country with undiagnosed diabetes who need access to healthcare, including appropriate education about the condition.

We find it relatively easy to adhere to pharmacological regimens as compared to healthy lifestyle choices. Therefore, education about a healthy lifestyle is pivotal. A healthier lifestyle includes regular exercise and intake of low-calorie foods. Appropriate quality and quantity of meals at regular times are important. Jaggery, refined sugar, refined flour and juices should be avoided by diabetics or those at risk of developing it. Whole wheat or barley bread and raw fruits and vegetable intake are recommended. Protein and fats should be taken in an equal ratio. Brisk walking at least 150 minutes per week is recommended, especially after a Type 2 diabetes diagnosis; a seven percent reduction in weight results in a fifty-eight percent reduction in pre-diabetes and diabetes risk. Fast foods and increasing sedentary habits are becoming prevalent in society, especially among children and adolescents. Healthy lifestyle choices of parents can act as a guiding principle for children. Preventing diabetes acquisition and its complications is important for a healthy family. If parents regularly exercise and acquire healthy dietary patterns, children will follow them.

Awareness among the general public about screening and diagnostic investigations used in various forms of diabetes is vital. Screening tests are important because blood sugars have to be very high for symptoms to become apparent. Large clinical trials have revealed that people can go on 10-12 years with diabetes before being diagnosed. In the South Asian region, where the prevalence of diabetes is already high, waiting for symptoms to appear may be irresponsible. Therefore, the identification of high-risk populations like all adults under the age of 45 years who have a strong family history of diabetes and additionally have a sedentary lifestyle or females who have been diagnosed with diabetes during pregnancy should get annual check-ups done.

In order to prevent complications, it is crucial to control diabetes as soon as it is identified. Screening tests for diabetes are available nationally at discounted rates. Moreover, basic health units and dispensaries have glucometers and finger-prick tests available, which can check random capillary blood glucose levels. It is, however, preferred to use this method in those who have established a diagnosis of diabetes. The non-diabetic person has a fasting blood sugar of <100mg/dl. For diagnosis of Type 2 diabetes, overnight fasting glucose readings of 126mg/dl and above are sufficient.

Out of every 500 people, one child under 20 will have Type 1, which is insufficient production of insulin in the body. The other more prevalent type of diabetes is non-insulin-dependent diabetes. Not every diabetes medication is suitable for a person. Selecting the proper medication requires careful discussion between the primary physician and the patient. A newly diagnosed Type-1 diabetic or those with T2DM requiring insulin need to be counselled regarding its use. Considering the huge burden of disease, capacity building of primary care physicians and advanced nurse practitioners is needed.

Awareness among the general public about screening and diagnostic investigations done in various forms of diabetes is vital. Screening tests are important because blood sugars have to be very high for symptoms to become apparent. Large clinical trials have revealed that people can go on 10-12 years with diabetes before being diagnosed.

“Gestational diabetes” (or commonly “baby sugar in pregnancy”) develops during the pregnancy. These are women (especially >35 years of age; BMI >30; previous large babies) who did not have diabetes before the pregnancy, and diabetes only developed once pregnancy was established because of inadequate insulin production during pregnancy. Hence, the developing baby in the womb is exposed to the same amount of sugar as in the mother’s blood through the placenta. Timely screening can protect both mother and baby from complications. The latest guidelines emphasise checking blood sugar levels at least two times during nine months in high-risk groups: once at booking and another between 24-28 weeks of pregnancy, when hormonal levels are high. Educating new mothers about uncontrolled diabetes is essential. Usually, in tertiary care centres, both gynaecologists and physicians, in collaboration with dietitians, guide and educate women about diabetes management during and after pregnancy. Following are the points which can be discussed:

Frequent/ daily glucometer charting of blood sugars to adjust appropriate medications and lifestyle advice. Mothers must be aware of the target glucose levels.

Baby having increased weight and/ or increased water content in the water bag surrounding the baby.

The percentage of cardiac anomalies are high in babies; therefore, regular ultrasounds are necessary.

Mothers with gestational diabetes who control the condition through diet can carry their babies to full term.

Low-dose aspirin is used in Type 1 diabetes to prevent hypertension and its complications during pregnancy.

Premature delivery of the baby and resulting respiratory distress.

Baby may have a rapid drop in blood sugar immediately after delivery.

The newborn might also acquire jaundice which requires phototherapy.

Gestational diabetes mostly resolves after delivery; however, an oral glucose tolerance test is necessary at six weeks postpartum, which can diagnose full-blown Type 2 diabetes. Moreover, the risk of acquiring Type 2 diabetes does not end here, as women are still vulnerable to developing diabetes within five years of having gestational diabetes. Therefore, such patients should be educated that they must check their blood sugars on every birthday of the newborn for proper screening. A study published in PJMS 2018, found that guidance to women regarding blood glucose checks is often neglected by doctors working in the peripheral areas of the country resulting in increased maternal morbidity and mortality.

Reducing the risk of complications is another aspect of diabetes education. Diabetes can affect the eyes, feet and kidneys, as well as heart and brain circulation. Eye changes must also be monitored by an ophthalmologist annually. Management of complications is a huge burden on a country’s economy. In a developed country like the UK, 10 percent of the NHS budget is taken up for diabetes care. Out of this, 70 percent is utilised for treating the complications of diabetes. After the diagnosis of diabetes (especially Type 2 or non-insulin dependent diabetes), the patient should be educated about the protection of their feet. This is important because neither the patient nor the doctor knows exactly when the newly diagnosed individual actually developed diabetes in their body. It is imperative that general physicians, the frontline healthcare givers, teach the patient proper inspection of web spaces of the feet for corns and ulcers. Moreover, emphasising wearing slippers in the house, proper daily washing of the feet with soap and water and drying them completely with the straight cutting of toenails are also essential.

In Pakistan, the number one cause of kidney failure is uncontrolled diabetes; this is expected to rise exponentially in the next two decades. Diabetes causes a slow deterioration of kidney function because it causes damage to the filtering apparatus of the kidney. The kidney initially adapts but ultimately, the filter breaks down. This can manifest as recurrent urinary tract infections and genital thrush. Pedal oedema is also an alarming sign that kidneys are getting badly affected. Monitoring through annual kidney function tests can prevent dialysis and renal transplant.

In short, there are various aspects of diabetes education, and there is a great deal of disparity regarding motivation for education. Because this disease is so prevalent medical professionals have an obligation to learn more about how it affects patients. Family support and education play a positive role in this regard, as there is a lot of frustration seen among diabetics regarding the disease.

The writer is a  family physician

Diabetes care and education