Education is undoubtedly essential to achieve the high standards of self-management on which good diabetic control depends. Diabetes is a prevalent disorder and needs the involvement of the whole community for successful control measures. The community needs to be made aware of the existing problems and be sensitised to ensure participation, support and resource availability. Like other chronic diseases, diabetes is an expensive disease in terms of loss of income from abstinence and sickness, cost of transportation and medications; and to the community from the increasing burden of health care and rehabilitative facilities.
Health education is the most important, effective and the least costly way of fighting all chronic diseases including diabetes. The educational strategies need to be directed to preventive aspects of the disease at all levels of the health care delivery. Adequate level of knowledge and its periodic updating for the primary ‘health worker’ is of major importance towards the success of preventive health measures. Evaluation is an effective part of all intervention programmes so as to assess effectiveness and to make appropriate changes, when necessary.
Patient and Community Education
Diabetes is a serious chronic disease, that cannot be easily conquered. Its treatment is complex, demanding and lifelong. The progressive nature of the disease associated with its chronic complications, adherence to diet, regular medication, monitoring control and psychological and economic stresses adds to the difficulties. The major part of the treatment, thus, has to be provided at home by the patients themselves and their families. Hence, the families of the patient become active members of the health care team. Probably there is no other disease in which so much is expected of the patient and his families.
At an individual level, diabetes education is an essential aspect of the treatment. The aim of education is to motivate and educate the diabetic and his family, so that they acquire adequate knowledge and necessary skills, gain confidence in the management of his condition and become responsible for his health. Self-care is essential for survival of the diabetic. The educational process is not easy. It is gradual, time consuming and requires considerable patience. Education needs to be individualised and adapted to meet the diabetic’s requirement.
The availability of educational materials in the form of posters, pamphlets, booklets, newsletters, tapes, slides and other audiovisual aids is essential. The initial information needs to be simple and concise for the immediate management of the condition. Ideally though, all diabetics should have a well planned indepth education on all aspects of diabetes.
The major topics that should be covered, during this education programme, are:
a) What diabetes is; its signs and symptoms; and its management.
b) Diet and food exchange system.
c) Advise on:
• Diabetes tablets
• Sterilisation and care of needles and syringes
d) Monitoring control
e) Blood testing
f) General health care and social aspects
To get the message across to the diabetics and their relatives in particular and the community on the whole, an extensive use of mass media would undoubtedly be of great value. No diabetic care programme will be successful without considerable time, energy and skill being devoted to developing and providing education. Like diabetes, its educational programmes too are a lifelong commitment.
Counselling may be defined as a process through which one person helps another by purposeful conversation in an understanding atmosphere.
In counselling, the emphasis should be on how the person feels about his own problems. The emotional adaptation to the problem following the diagnosis of diabetes, is mainly from the feeling for the loss of health and a change in lifestyle. This is often mixed up with depression and anxiety regarding the disease, its treatment, its long-term complications and the final outcome. Most patients pass through this phase successfully however some are unable to compromise. This may lead to moderate or severe depression.
Features of Moderate and Severe Depression
• Sleep disturbance, fatigue, loss of energy
• Loss of appetite, loss of weight
• Loss of interest, inactivity
• Inability to concentrate
• Marked anxiety
• Suicidal thoughts
Maladaptation may result in anger or fear, preventing the patient from taking on personal responsibility for managing his own diabetes. Sometimes this results in denial, which may be seen as an attempt to protect himself from the burden of the disorder. These emotional retarders make it difficult for the patient to recognise and learn what is relevant to his own management. Careful counselling may be needed before he is able to come to terms with the problem and accept advice.
Diabetics, who are otherwise physically fit and not suffering from blackouts, are normally allowed to hold ordinary driving licences. The law demands that all new diabetics, whether on treatment by only diet restrictions, or even with tablet or insulin, must declare it on the application form (transport authorities) at the time of filling.
Healthy diabetics, treated with diet or tablet, are normally allowed to hold both heavy goods vehicle and public service vehicle’s licences. Diabetics on insulin treatment may not be allowed to hold license because of the serious potential consequences of hypoglycemia.
All insulin-treated diabetics, who drive, should always keep a supply of sugar in their cars. They should try not to drive if they experience warning symptoms of hypoglycemia, eg., when a person begins to see double, i.e. to see two cars or two roads.
Travel and Diabetes Mellitus
Diabetes does not prevent travel even over long distances but careful planning, adequate supplies of medication and sensible self-monitoring is essential. Diabetic patients should always carry dextrose tablets or other rapidly absorbed carbohydrate. Whether on holiday or not, carrying additional carbohydrates, such as a packet of biscuits, is also advisable. Intake of low calorie drink must be encouraged. Patients must be fully instructed regarding what to do during diarrhoea, vomiting or other intercurrent illness.
Many diabetic patients, on holiday, wish to have a holiday from blood and urine test. However, even though holiday activity and lifestyle may be very different from usual activity, monitoring is particularly important. Some people take more exercise on holiday and may try new sporting activities while others may do less than usual. It is, therefore, important to understand the effect of activity on blood sugar.
The airline should be informed that a client is a diabetic at the time of booking.
Time changes, on long distance air travel, will inevitably make diabetes control difficult for a few days. It is best to change the time of injection by two to three hours; there should be no difficulty in adjusting to a six-hour change of clocktime with in 24 hours.
Diabetics may use the same anti-seasickness tablets as for non-diabetics; these drugs do not change diabetic control.
Breakage or Loss of Equipment
Diabetics must carry ample supplies of syringes, insulin, needles and testing equipment.
Storage of Insulin
In a temperate climate, for some months insulin can be kept at room temperature. Refrigeration would be advisable for prolonged stay in tropical climates. Insulin should never be deep frozen or left in the luggage hold of the aircraft where it may freeze. Vaccination and Inoculation
These are quite suitable for diabetics and should be given for the same indication as for non-diabetics.
Holiday and travel are opportunities for the unexpected to happen and it may be impossible to anticipate every problem that the patient may encounter. It is, therefore, essential that every diabetic patient is educated in the basic principles of his own management, to enable him to react sensibly to any eventuality.
Heredity plays an important role in conferring susceptibility to the disease. A family tendency to the disease has been commonly found but the mode of inheritance has not yet been fully understood. Physicians can tell the diabetic of the risks involved during pregnancy and chances of the offspring being a diabetic too. Many diabetics have healthy children in spite of all the possible inherited risks.
Genetic counselling regarding diabetes has two aspects; firstly, the risk of a given individual developing the disorder, and secondly, in areas like morbidity, mortality and the quality of life. The aim of genetic counselling is to estimate the disease risk as accurately as possible.
Going in for an Early Family
A couple having a family history of diabetes on either or both sides, are advised to go in for an early family. The risk of diabetes for both husband and wife, at any time, is present. Such a risk increases for women with advancing age. Information and counselling, to have a family early, may solve the problem to quite an extent.
Most diabetic women can safely have children but pregnancy is contra-indicated by advanced nephropathy, ischaemic heart disease, severe neuropathy and untreated retinopathy. It may be necessary to advise sterilisation in a patient with serious diabetic complications. Contraceptive advice must be tailored carefully to the couple.
Associated problems of diabetes may affect sexuality, specially in diabetic men. At times, diabetic men complain of decreased virility, problem in the erection of the penis during the sexual intercourse, though the sex drive remains intact. Repeated failures lead to frustration for either or both the partners. Gradually self-gratification may also be hampered. Psychological blocks of such kind may prove hazardous for normal family life. The spouse of the diabetic should be forthright regarding the problem, with the physician. Timely sexual counselling by the attending doctor may prove beneficial.
Employment and Hobbies
Insulin-treated diabetic patients are barred only from a few occupations where hypoglycemia poses particular hazards to themselves or others, eg., public transport, armed forces, the police, the merchant navy and the fire brigade. Shift work, especially night shifts, should be avoided, if possible, by those using insulin. Non-insulin-treated patients should enjoy the same job prospects as non-diabetic people. Their risk of hypoglycemia is negligible. Special life insurance policies are available for diabetic people. The risks of developing coronary heart and macrovascular diseases are markedly increased by diabetes. Diabetic patients must be strongly discouraged from smoking and alcohol.
Medical and Dietary Counselling
Physicians and dietitians play a vital role in educating and counselling the patient and society as a whole. They advise in detail about the disease, the do’s and don’ts to be followed regarding the drugs, insulin, diet and exercise. They educate the patients and train them in self-estimation of urine and blood tests. Doctors encourage them to maintain a record of these tests and at times distribute diaries to record systematically the level of blood sugar during the day, dosage of drugs, insulin intake and diet.
Maintaining a diabetic diary helps the doctor to evaluate a patient’s condition at a glance and gives an idea whether the patient is on correct dose or else any modification is required. This helps in preventing long-term complications arising due to inappropriate balance between dietary intake, insulin or drug therapy.