Diabetes management: more than drugs

Traditionally, the management of diabetes has centred around pharmacological intervention to treat hyperglycaemia and cardiovascular risk factors, often with minimum input from a health care professional. However, from a patient perspective, daily living consists of multiple choices such as appropriate dietary intake, physical activity as well as drug compliance. Over recent years, the importance of patient education has developed as a means to acquire the skills necessary for active responsibility in the day to day self management of their condition. Indeed, this is recognised in the 2008 NICE guidelines for diabetes as well as the 2011 NICE quality standards.

There are a variety of programmes for both Type 1 and 2 diabetes. For Type 2, DESMOND (The Diabetes Education and Self Management for ONgoing and Newly Diagnosed) was one of the first to meet these criteria. This intervention is delivered by health care professionals (educators) as a group education programme following a curriculum, delivered in a community setting and integrated into routine care. The programme is 6 hours long, delivered in one full or 2 half days. Whilst after 1 year, evidence suggests that patients with newly diagnosed T2DM improve smoking cessation, weight loss and positive improvements in beliefs about illness. After 3 years, only the impact on illness belief is maintained. The authors of this research (who are also the developers of DESMOND) suggest that this supports the model of an ongoing education programme, incorporated into new modules (DESMOND foundation developed for patients with existing diabetes as well as DESMOND BME for ethnic minorities). Interestingly, there is little evidence supporting improvement in HbA1c although this usually occurs soon after diagnosis which may mask the impact of the structured education.

For Type 1 Diabetes, the pre-eminent education program is DAFNE (Dosage Adjustment For Normal Eating). DAFNE is a structured education programme in intensive insulin therapy and self management where people with T1DM are taught detailed carbohydrate counting allowing them to match their insulin to their chosen food. It takes place over 5 consecutive days (38hours) and is therefore mainly suited for highly motivated patients used to a basal bolus insulin regimen. Evidence has shown that participants in DAFNE have significantly improved HbA1c (with no change in hypoglycaemia frequency), improved dietary freedom and quality of life.

With structured education increasingly part of national guidance, healthcare professionals need to appreciate its effectiveness and that it represents one element of a patient centred approach to diabetes care and not just another box to tick at the time of annual review.

Dr Mark Freeman