VOLUME 10 NUMBER 4 • NOVEMBER 2013
135
SA JOURNAL OF DIABETES & VASCULAR DISEASE
EDUCATOR’S FOCUS
The gold standard of diabetes care currently in South Africa is outlined
in the 2012 SEMDSA guidelines.
6
To achieve excellence in diabetes care,
these guidelines should be implemented by all healthcare profession-
als, especially family physicians who are community based. However, the
road to excellence in diabetes care is littered with a number of obstacles
or barriers that have to be overcome and addressed effectively. These
include various cultural, economic, social, environmental, political, edu-
cational and health-management issues.
7
This article highlights some of the obstacles or barriers encountered
in everyday practice that impact on achieving excellence in diabetes
care. These include, among others, the management of pre-diabetes,
implementing behavioural change, risk-factor assessment, prevention
and early detection of complications, patient and health professional
education, managing patients to achieve targets, patient-centred care,
and comprehensive, integrative approaches to care, smoking cessation,
medical nutritional therapy, organisation of chronic care, achieving opti-
mal glycaemic control, screening of high-risk individuals and keeping of
diabetes records that easily profile progress and detect trends or abnor-
malities that require action or referral.
PRE-DIABETES
This is a term used to describe the state of impaired fasting glucose
(6.1–6.9 mmol/l) or impaired glucose tolerance (fasting < 7 mmol/l and
two-hour 7.8–11 mmol/l). Pre-diabetes has a high risk of progression to
develop diabetes mellitus (25–50% lifetime risk). Its importance lies in the
fact that pre-diabetes increases the risk of cardiovascular complications
by 1.5-fold, and diabetes increases the risk by two- to four-fold, making
the importance of prevention through lifestyle changes imperative.
8
Research studies have highlighted the value of lifestyle changes in the
prevention of type 2 diabetes. There are several national and interna-
tional studies and initiatives that have addressed preventive measures
successfully. This fact emphasises the need for education and lifestyle
modifications, and in some cases, the addition of medication for the pre-
vention of diabetes. This role is best filled by a diabetes educator who
will teach the skills needed to live a healthy life. These skills will enable
patients to change their health through responsible self-care, knowledge
and diabetes skills training. Changes in attitude, motivation, adherence
and strict care with regard to diet and exercise are more effective in
delaying diabetes onset than medication.
High-risk individuals should be screened for diabetes. This includes in-
dividuals with a family history of type 2 diabetes, hypertension, hyperlipi-
daemia, high-risk ethnic groups, the obese (body mass index > 35 kg/m
2
),
increased waist circumference (> 94 cm in men and > 80 cm in women),
a history of gestational diabetes, patients with the metabolic syndrome,
underlying cardiovascular disease, the presence of polycystic ovarian
syndrome, those with impaired glucose tolerance and impaired fasting
glucose levels, sedentary lifestyle, alcohol abuse and those on certain
medications such as long-term steroids, beta-blockers, thiazide diuretics,
etc. People who are not controlled with lifestyle modifications and who
are at high risk would benefit from the addition of metformin.
9
ASSISTING PATIENTS WITH DIABETES TO MAKE CHANGES
People with diabetes need knowledge, skills and motivation to assess
their risks in order to understand how they will benefit from changing
behaviours or lifestyle, and to act on that understanding by engaging in
appropriate behaviour. Diabetes is a self-managed condition. It requires
those with it not only to understand the nature of their condition and its
consequences, but also to take practical action in a number of ways on
a daily basis in order to prevent diabetes from impacting negatively on
their lives.
These actions include monitoring blood glucose levels and blood pres-
sure, and recording these in a diabetes diary, injecting insulin correctly,
taking tablets regularly, detecting and dealing with hypoglycaemia, and
paying attention to the amount, type, content and timing of food and drink
intake, as well as physical activity. Thinking and planning ahead is essen-
tial to prevent problems with various activities such as driving, employ-
ment or working in risky environments and engaging in social activities.
Living successfully with diabetes is more about taking knowledgeable
decisions or actions than simply having knowledge. It is a behavioural
condition. Knowledge alone will not change behaviour.
Collaborative self-management interventions where people responded
to clinical information and goal setting were more effective in improv-
ing clinical outcomes. Promoting self-management and a partnership in
decision making is the key skill of a health professional such as a family
physician. There are a number of models that inform how to do this.
These include chronic disease self-management, therapeutic patient
education, a heart manual, and patient empowerment.
As health professionals and especially as family physicians, our role is
about promoting active and successful decision making by addressing
the patient’s thoughts, ideas, feelings, fears, beliefs, myths, as well as
their knowledge. Patients are more likely to adhere to decisions they have
made themselves and to goals they have set themselves, i.e. to promote
self-efficacy or confidence in their ability to take action for their own
benefit. This will promote behavioural change.
10
Brief motivational interviewing (BMI) is an approach to motivating be-
havioural change and has great potential if used in general healthcare
settings, especially in managing chronic conditions such as diabetes.
11
Our role as healthcare practitioners is to enquire whether the patient
is ready to change, does he/she understand the need for change, have
appropriate treatment targets been set, are monitoring programmes in
place, and is referral necessary, e.g. dietician, exercise physiologist, clini-
cal psychologist.
