Patient education as the basis for diabetes care in clinical practice and research

Abstract

Despite the obvious improvements made in the field of diabetes therapy during this century [1] the quality of diabetes care has, in general, remained poor. The widespread failure to acknowledge the impact of patient education appears to evolve as the primary reason for this unsatisfactory situation. Despite the firm and well founded recommendations put forward by some of the pioneers of modem diabetology, e.g. Drs. E.P.Joslin and R.D. Lawrence in the 1920s, it has taken almost 50 years for the beneficial effects of patient education to have finally and unequivocally been proven. The recently developed strategies for a global approach to diabetes therapy which combines biomedical, psychosocial and educational elements represents an exemplary therapeutic model for the care of many chronic diseases. The complexities of diabetes and of diabetes careThe metabolic manifestations of diabetes mellitus oscillate from hypoglycaemia to hyperosmolar or ketoacidotic decompensation and coma. The long-term complications of the disease may involve almost all organs with disabling consequences from benign dysaesthesia of the legs to the total loss of pain sensation with the severe risk of foot lesions; from background diabetic retinopathy without any impairment of visual function to proliferative diabetic eye disease leading to blindness; from potentially reversible microproteinuria to endstage kidney failure; and from minor arterial insufficiency of the lower limbs to gangrene and amputations. The threat of acute and long-term complications as well as the need for daily monitoring (blood or urine glucose levels, foot care, blood pressure, etc.) represent a considerable psychological stress to diabetic patients and their families.Treatment of metabolic disturbances and care of diabetic patients are not simple. There are numerous factors involved in the control of blood glucose levels. Although the underlying cause of the disease is an endocrine disorder (i. e. the absolute or relative lack of insulin secretion and/or the insensitivity to insulin at the level of the liver and some peripheral tissues), many additional factors play important roles in regulating the level of glycaemia in diabetic patients. These include the nutritional status of the patients, their dietary habits, their emotional constitution and way of coping with the disease, their familial, professional and social environment and many others. There is a constant interaction between these factors, most of which keep fluctuating extensively even within the same day. Thus, physicians and patients often find it difficult to identify the factor(s) which might have been responsible for a deterioration of metabolic control. Because the majority of these factors are closely related to the patients' behaviour, it appears evident that the achievement of longterm metabolic control is the consequence of a complex process simultaneously involving psychosocial, endocrine, and pharmacological factors. Obtaining (near)normalization of glycaemia may require the patient to perform ...

Sustained good glycaemic control in NIDDM patients by implementation of structured care in general practice: 2-year follow-up study

“…However, doctor-related, as for example attitude and knowledge, and organisational factors may be even more important barriers [12][13][14]. The availability of a diabetic patient register and recall system, education facilities, professional support from a network of medical and non-medical professionals and systematic quality assessment are organisational factors which influence diabetes care [15]. The guidelines for the treatment of NIDDM have stimulated physicians to improve the quality of management.…”

“…GPs reported increased enthusiasm after 2 years of participation, probably reflecting a positive attitude towards diabetes care. Secondly, individual diabetes education (e. g. by diabetes nurse and dietitian) may have enhanced self-care and patient compliance [15]. Patient motivation is also reflected by the fact that, by using blood glucose selfmonitoring, they were easily motivated to start insulin therapy.…”

Improving management of type 1 diabetes in the UK: the Dose Adjustment For Normal Eating (DAFNE) programme as a research test-bed. A mixed-method analysis of the barriers to and facilitators of successful diabetes self-management, a health economic analysis, a cluster randomised controlled trial of different models of delivery of an educational intervention and the potential of insulin pumps and additional educator input to improve outcomes

“…The age of participants varies between 18 and 80 years and the duration of diabetes of those participating can range from newly diagnosed to > 50 years. The curriculum has been built on adult education principles, emerging from the concept of therapeutic education (a principle advanced by Assal et al 8 in the early 1980s), and adheres to the precept of social learning theory. 9 It encourages inclusivity and participation and involvement by all.…”

Development and Implementation of Advanced Training Course for Diabetes Educators in Argentina

“…However, this type of program should start with the doctors." 32 Education is now widely accepted as an integral part of diabetes therapy, 33 but its implementation is not the norm among people with diabetes.…”