The thought of illness itself causes a state of confusion and fear in the mind of the patient. When an otherwise healthy man suddenly comes to know from the clinical tests that he is diabetic, he gets a tremendous shock. At first he refuses to believe, it, for he experiences neither pain nor any physical abnormalities, and thereafter refuses to accept the disease. Considering himself a diabetic, he feels that his good days of life have come to an end and he has to be always at the mercy of the doctors and dietitians. He considers himself helpless, unproductive and a useless member of the society. Unrealistic and inapproprite feelings work on his mind and he approaches the doctor with innumerable questions.
The patient needs guidance, supervision and expert advice for treatment and follow-up. All this could only be achieved by ‘team approach’.
The patient is the most important and active member of the team. The success of treatment is substantially dependent upon his cooperation. A more informed and knowledgeable patient cooperates better in the long run.
Role of the Doctor as a Team Member
Diabetic care, in general practice, must aim to maintain the patient in as nearly a normal glycemic state as possible, in the hope of minimising the risk of long-term complications.
The physician shoulders great responsibility in formulating a positive approach towards the problem. He has to convince the patient that a diabetic today leads a normal life with timely treatment, together with adequate diet, exercise and the patient’s cooperation. The life expectancy of these, in majority of the cases, is almost equal to a normal person.
With the advancement of medical science, various devices and procedures have come into existence which help in the early detection and timely treatment of diabetes. Early detection of the problem is of utmost importance in preventing development of long-term complications.
A diabetic patient needs to know:
a) The nature of his diabetes and the recommended measures.
b) Details of the dietary regimen.
c) Importance of weight control.
d) The dose, time interval, site and method of administration of insulin and / or hypoglycemic drugs, if required.
e) Importance of skin and foot care.
f) Maintenance of personal hygiene.
g) Symptoms of hypoglycemia and immediate measures to be taken.
h) Importance of regular periodic visits to the doctor and review of treatment and its progress.
No two diabetics present similar symptoms. The goal, to be achieved in the management of diabetes, should be related to each individual. A treatment for insulin-dependent diabetic would not be quite the same as for a non-insulin dependent diabetic. Likewise, the treatment for a young juvenile diabetic would be totally different from a middle-aged diabetic. No two diabetics are comparable regarding treatment, diet regulation and exercise.
Role of a Dietitian
Despite insulin and oral hypoglycemic drugs, diet forms the cornerstone of the treatment of diabetes. In planning the diet, the patient’s individual needs and desires must be respected. A dietitian should give the list of foods to be taken liberally, in moderation or to be totally restricted depending upon the severity of the disease. This helps in providing variety in the patient’s diet. Many patients are of the view that if they stop eating sugar or any starchy food, their blood sugar must come to normal. It should be made clear to them that the basic defect in diabetes is either deficiency of insulin or its ineffectiveness. Hence, curtailing certain foods is not the proper treatment. Weight reduction and calorie restriction is required for an overweight diabetic by maintaining a well balanced proportion of carbohydrate, protein, fat, vitamins, minerals and fibre.
A rigid diet plan is not favoured as it restricts the patient’s dietary intake to an extent that he feels that he is on a starvation diet. The dietitian, when advising about the diet, must take care to give positive advice stressing on foods that are to be taken rather than laying emphasis on the limitations. This helps to build up interest to continue dietary regulations. A dietitian must initiate a practical approach for selecting a proper diet, keeping the patient’s requirement in view without sacrificing the taste and pleasure of eating.
Role of Family Members
As diet plays a vital role in the management of diabetes, the family members need to be educated on the dietary regulations and restrictions. Each member of the family, especially the houswife, should understand that the diet for a diabetic patient is a normal diet, which requires just certain modifications depending on the severity of the problem, treatment and body weight.
Too many restrictions on food intake tend to frustrate a patient to an extent that he deliberately eats the restricted foods. For instance, seeing preparations like sweets, puddings and potatoes too often on the table tend to tempt one and weaken his control. It is advisable not to cook such things too often at home. At times, due to too many restrictions and regulations, the patient tends to get influenced by quacks claiming hundred per cent cure of diabetes. He follows them blindly, totally ignoring the regular medicines. These false hopes eventually confront him with the dreaded condition of severe complications which, at times, are fatal. The spouse of the patient shoulders great responsibility to make him feel comfortable and at ease. He should provide adequate support and willingness in coping with the problem. He needs to understand the changes in behaviour and interest during the course of the problem and should assist in maintaining a peaceful and happy family life.
Members of the family also need to be aware of the complications that could arise and should know the emergency measures required to be initiated. For instance, if the breath of a diabetic smells of acetone or akin to a nail-polish remover, he needs to be immediately hospitalised as it is an indication of increased acetone in blood. Prompt measures are required to control the problems which prevent severe complications.
Role of Diabetic Specialist Nurse
It is now generally accepted that the diabetic must understand his diabetes and how to manage it, in order to achieve sufficiently good control and to avoid the acute metabolic problems of the disease. The primary objective of the diabetes specialist nurse is to educate people about diabetes so that they can regain as much independence as possible and to live life fully within the constraints of their disease. This task often requires patience, tact, tenacity, as well as sound theoretical and practical knowledge of diabetes. In addition to being an educator, the nurse will have to develop skills as a general coordinator of the diabetic management team and as an advisor in emergencies.
It is best to bring diabetics together into properly organised clinics so that they can benefit from the wide range of available special services needed for their proper care. These clinics should include foot service too, besides diabetic service for those with diabetic nephropathy. Foot service should include a chiropodist, an orthopaedic surgeon and a shoe fitter. The eye service should provide facilities in the clinic for testing visual acuity and an ophthalmologist should be available on call. Arrangements for those with nephropathy and renal impairment to be seen by a renal physician should exist.
Antenatal clinics for pregnant diabetics are ideally conducted by the diabetic physician and an obstetrician.
Care of Children and Adolescents
This is ideally undertaken in clinics separate from the routine adult clinics where there is close liaison with the paediatricians. Care in specialist clinics rather than routine outpatient clinics is just as important for children as for adults.
The diabetic clinic provides both treatment and education for diabetics. Education is undertaken at the medical consultation between the patient and the physician with essential help from the health visitor and nurses. Other form of education, i.e., classes, seminars, audiovisuals aids are also useful and will obviously vary according to the needs and interests.