VOLUME 7 NUMBER 3 • SEPTEMBER 2010
115
SA JOURNAL OF DIABETES & VASCULAR DISEASE
education in hospital on the use of a glucometer and self injecting, but few
receive any follow up or ongoing life skills training in diabetes manage-
ment. In general, medical aids will only cover the costs of one annual visit
to a dietician and there is no specific allocation for diabetes education.
Certain medical aids are affiliated to the Centre for Diabetes and Endo-
crinology (CDE), which is the only doctor-based managed healthcare pro-
gramme in South Africa. It is considered the premier diabetes programme
in the country, giving comprehensive diabetes treatment and manage-
ment programmes and providing one-on-one and group education.
9
Alternative approaches to intensive insulin therapy
in type 1 diabetes
The DCCT/EDIC
10
showed that the intensive insulin therapy approach, us-
ing either multiple daily injections or insulin pump therapy, is the best
treatment for individuals with type 1 diabetes regardless of age.
11
It pro-
vides greater glycaemic control and reduces the risk of complications.
The Global Partnership for Effective Diabetes Management recommends:
‘It is important that patients adjust their insulin doses appropriately in
response to factors such as carbohydrate intake, lifestyle, exercise and
inter-current illness to minimise the risk of hypo- or hyperglycaemia. As
described above, insulin pumps may allow greater flexibility of dosing, but
as all patients will not have access to pump therapy, alternative strategies
are needed and education is required for all patients. Modification of in-
sulin dosages based on diet and exercise can be challenging for patients
and should be considered an essential part of patient education.’
11
Despite randomised trials
12
showing insulin pump therapy (CSII) pro-
vides some advantages over multiple daily injections in type 1 diabetes for
both children and adults, multiple daily injections are the most commonly
prescribed insulin regimen for type 1 diabetics in South Africa. Although
insulin pump therapy is becoming more common, it remains expensive
and costs are only covered by a few medical aids.
A new equation has been derived at the North-West University, Pretoria
to estimate bolus insulin need,
12
and should be able to estimate insulin
dosage requirements for bolus insulin in a patient with type 1 diabetes
more accurately than with carbohydrate counting. Further investigations
are continuing. This would be an asset for both multiple daily injections
and pump therapy.
Effectiveness of structured training in intensive
insulin therapy in type 1 diabetes
There is much evidence to show the effectiveness of structured edu-
cation. In a Portuguese review of 40 articles published between 2000
and 2007,
10
focusing on diabetes educational programmes designed for
children, young adults and their families and regular pump users, they
assessed recommendations and standards of intervention, and methods
of education in self-management. They found that education in self-man-
agement improved glycaemic control whether given on an individual or
group basis, and the longer the education the more effective it was.
According to The Global Partnership for Effective Diabetes Manage-
ment, structured educational programmes have been demonstrated to
have substantial benefits in terms of outcomes. These programmes dem-
onstrate that appropriate education can improve glycaemic control while
giving the individual more flexibility in terms of diet, rather than having to
adhere to rigid calorie control and fixed insulin doses.
Other important considerations include the use of carbohydrate count-
ing, a common meal-planning method used by patients, which must of
course be adapted to local diet and lifestyle. Appropriate adjustment of
insulin doses surrounding exercise is also important. In addition, many
patients may not know the effect of factors such as exercise or alcohol on
glucose levels and the need for appropriate adjustment of insulin therapy,
highlighting the importance of education on this subject.
11
For example, the Dose Adjustment For Normal Eating (DAFNE) pro-
gramme
14
has been shown to improve glycaemic control, with a reduction
in severe hypoglycaemic episodes and an improved quality of life. This
UK-based
14,15
programme has shown similar results in Australia.
14
In the
Dusseldorf Diabetes Treatment and Teaching programme (DTTP), which
involves a five-day in-patient course for individuals with type 1 diabetes,
HbA
1c
levels fell significantly from 8.1 to 7.3% over the subsequent year,
as did the number of severe hypoglycaemic episodes.
The CASCADE trial
16
is currently assessing long-term effectiveness of
structured, intensive education programmes for self-management of dia-
betes and their cost effectiveness. The XPERT programme
17
is a six-week
structured patient education programme that has also shown improved
diabetes control and more confidence in the self-management of dia-
betes. An American trial
18
also showed that structured diabetes educa-
tion was more effective in improving metabolic control in type 1 diabetic
adolescents.
Current status of structured training programmes
for type 1 diabetes in South Africa
South Africa has no structured education programme for either public or
private healthcare settings. One of the problems in South African is that
many people live in rural areas so any health education system for people
with diabetes needs to be effective in the primary-care clinics, where re-
sources are poor. Even those attending a tertiary-care hospital have prob-
lems with poverty, transport and distances to be travelled. A monthly endo-
crinology clinic visit can mean a round trip of six hours or more in transit.
Most education if any, at primary-clinic level is done by nurses who
have had no specialised education in diabetes, and is very generalised
and outdated – certainly not suitable for type 1 diabetics. At specialised
units in tertiary hospitals, type 1 diabetics are more likely to receive some
one-on-one or group education, but the effectiveness is varied.
Most structured training programmes are three to five days in duration.
