VOLUME 9 NUMBER 4 • NOVEMBER 2012
149
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Another study reported inadequate control of hypertension,
major neglect of lipid profiles and defeatism towards life-
style modification and behavioural changes. A multifactorial
intervention and use of shared care or a team approach is often
lacking.
9
Although diabetes is a progressive disease, often the treatments
are not re-assessed or changed to achieve the desired targets.
10
Patients who need tighter control are commonly seen only every
six months instead of three monthly or more often if necessary.
Hence many patients are not treated to target, as required.
The use of check lists for initial assessment and follow-up visits
or the use of a diabetes diary, health card or ‘health passport’,
or an analysis or profile of patients’ readings are sadly lacking in
many cases. Missed opportunities with regard to assessment of
patients with obesity and with the metabolic syndrome, especially
with regard to screening and regular follow up and risk-factor
assessments are a serious problem.
11-13
The frequent use of alternate or traditional medicines or over-
the-counter preparations are common and need special attention,
as many are not proven to be of benefit but are widely advertised
to the public. This could cause patients to not use effective
prescribed medications. There appears to be a reluctance to
use some of the newer forms of preparations available, which
are effective and have fewer side effects, such as metformin XR,
diamicron MR and the DPP4 inhibitors or incretins.
14
The incretins
are effective but unfortunately expensive.
There is often poor follow up, management and appropriate
referral of diabetic foot problems.
15-17
Erectile dysfunction in
the male is often a missed opportunity for the investigation of
widespread vascular disease involving target organs.
Failure to respond to oral hypoglycaemic agents is often
discovered late or is delayed, hence the late commencement of
insulin. Both patient and doctor/nurse inertia are often to blame
for this. It has been observed that high-risk patients are not
screened early enough.
Psychological stress and emotional, social and environmental
factors play a major role in achieving good glycaemic control. It is
not uncommon to find that beta-blockers, thiazides, steroids and
other medications are the reason for not achieving better control
in diabetic patients.
Many patients on insulin do not have glucometers to monitor
their glucose levels at home. This is currently the situation at
Edendale and Greys hospitals. They are then advised on using the
colour coding on the container of the Accu-Check strips, which
is supplied. The current policy on receiving donations of these
machines to the province needs to be reviewed for better patient
care.
Challenges for the family physician
Family physicians have an important role in addressing some of
the above problems to improve the quality of diabetes care and
obtain better patient outcomes. An important priority for family
physicians is to become actively involved in the screening of high-
risk individuals and to shift attention to prevention or delaying
the onset of diabetes, and the prevention or early detection of
complications involving target organs.
The many challenges that confront family physicians in treating
the patient with diabetes require the development of a number of
action plans to be implemented to address these problems. The
current 2012 Society for Endocrinology, Metabolism and Diabetes
of South Africa (SEMDSA) guidelines are meant to form the basis
for achieving optimal care in South Africa.
18
The health professional
must ensure that there is sufficient education for nurses and doctors
dealing with patients with diabetes.
The family physician should ensure improved record keeping for
all patients with diabetes and other associated chronic diseases.
This should include diabetes diaries, health cards, electronic
records, diabetes check lists, follow-up records, and recall and
referral systems. The profiling of all results is a useful tool as a guide
towards reaching targets.
Multi-factorial interventions, which address all risk factors should
be the standard of care. For example, the ABC(DE)SS approach
for diabetes management: HbA
1
c
Albuminuria, Blood pressure,
Cholesterol, Dietary guide (the Zimbabwean hand jive), Exercise,
Smoking cessation and Salicylates.
19
A good doctor–patient relationship should be the hallmark of
diabetes care and should be patient-centred, holistic, integrative,
comprehensive, and provide continuity of care. Family physicians
should encourage their patients to belong to a chronic diabetes
management programme, such as the Centre for Diabetes and
Endocrinology (CDE).
Good communication skills in the physician will enhance
adherence to therapy and therefore good outcomes. It is important
to address the patient’s fears, ideas, thoughts, feelings and various
facts and myths about diabetes and provide the patient with the
facts in a way he/she will understand. Brief motivational interviewing
techniques by family physicians have been shown to be effective in
changing behaviour, for example smoking cessation and lifestyle
modification.
20,21
Family physicians should make available a list of all the local
diabetes community resources. All uncontrolled high-risk patients
should be referred to doctors with a special interest in diabetes or
to specialist physicians, endocrinologists or diabetologists.
Family physicians should be educated in diabetic foot care and
institute a foot-care programme for all patients under their care,
for example the ABCS approach to foot care and management:
Anaesthesia (peripheral neuropathy), Blood supply (peripheral
vascular disease), Care (routine preventive foot care), Structure
(
abnormal foot structure).
Apply the 5As when dealing with a diabetic patient: Ask about
symptoms, Assess signs, Advise on foot care, Assist by involving
other carers, and Arrange regular reviews and specialist referrals,
and if indicated, provide a practical framework for foot care.
17
Some action plans for managing diabetes in family
medicine
Cardiovascular risk assessment and management
It is important to appreciate that type 2 diabetes is in fact a
vasculopathic disorder that affects both micro- and macrovascular
vessels.
22
Both hypertension and dyslipidaemia contribute to
atherosclerosis, which accounts for the high mortality rate. It is now
accepted that diabetes is a coronary artery disease risk equivalent
and should be managed as if the patient has had an infarct. The
individual patient’s future risk of developing coronary artery disease
should be estimated.
Patients with the metabolic syndrome should be screened for
diabetes and cardiovascular disease. All diabetics should be treated
with a statin because of the coronary artery disease equivalent.
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