Diabetic education                                                           Content        Next
	The need for a comprehensive plan for diabetic education has been long felt. Its relevance cannot be neglected when one recalls that diabetes is a disease for which no cure has so far been found out. A person, once diagnosed as a diabetic has to live his whole life with the disease. All the more, this disease affects several aspects of the victim's life like his diet, his life style, physical well-being, mental state, economic conditions, sexual and marital life etc. So in any discussion regarding diabetes, not only the patient, but his family also should actively take part. Once a diabetic is started on treatment and in between something goes wrong, naturally his relatives will be worried and question how it happened and why? Here arises the need for a Diabetic Education Programme.     As the National Conference on Preventive Medicine2 in USA puts, like any health education programme, diabetic education also should be 'one which informs, motivates and helps diabetics to adopt and maintain healthy practices and life styles, advocates environmental changes as needed to facilitate this goal and should conduct professional training and research to the same end. The Plan     The Ideal Educator to a diabetic would be the treating physician or diabetologist, because he is the one who has the dominant role while he is treating an ill diabetic. The education planl should go through 3 phases in parallel with the course of the disease.   They are : The Primary or Initial Education The Secondary or In-depth Education The Tertiary or continuing Education.     The first phase of diabetic education starts when a person is detected as a diabetic, for the first time. As with any other disease, disclosing to one that he is a diabetic imparts some degree of psychological trauma to the patient and his family, more so in insulin dependent diabetes (IDDM). The Educator should explain to the patient and his family what diabetes is, how to live with it, what are the possible complications if the required life-style and medications are not adhered to. It is always imperative to explain the disease in simple terms. Educator should build up in patient's mind a concept that more than considering it as a disease, DM should be considered as an altered metabolic state that is some what different from other people. Diabetes can be explained as a state where there is deficiency of insulin or defective action of insulin. In IDDM, there is an absolute insulin deficiency while in NIDDM there is some residual insulin in the pancreatic gland. Insulin is a major hormone required for the efficient utilisation of glucose, protein and fat. This hormone transports glucose from blood into the cells where glucose is metabolised to generate energy. It also transports glucose to liver and stores it there as glycogen. The production of fat from carbohydrate and its storage is also effected by insulin. Protein build-up is also a function of insulin. So, in the absence of insulin, there will be accumulation of glucose in blood i.e, hyperglycemia, liberation of fat from stores for the purpose of energy production and protein breakdown. These changes lead to the metabolic complications of diabetes. It is also adviceable to start teaching the patient the technique of insulin injection if it is required. Also, he should be taught to monitor urine and blood glucose periodically. Sick day rules denotes the modifications in insulin dosages to be done in case the diabetic is sick. The Secondary Education     Once the diabetic becomes adapted to the disease and accepts it, this phase can be started. This can be carried out in the consulting office or in fields. This includes lectures on foot care, diabetic diet and the self adjustment in insulin dosages. Tertiary Education     This extends to the whole life span of the patient. Each clinic visit is used as an occasion for education. This should particularly stress on the adequacy of follow ups, adequacy of blood sugar control and diet. This can include advise regarding travel (especially air travel if needed) pregnancy etc. The basic contents for the above phases of education should preferably include the following points; and should be done in the same vernacular of patient.    1) An idea about the basic nature and pathophysiology of the disease, both IDDM and        NIDDM.    2) The genetic factors in diabetes.    3) Diagnosis of diabetes.                                   Table 1. The essentials to be dealt in diabetic education     Primary Secondary Tertiary 1. Overview l.Self insulin ajdustment by supplements a) Care of DM during travel 2. Meal Plan 2. Foot care b) DM with pregnancy 3. Technic of insulin injections 3. Meal exchange c) Chronic complications. 4. Monitoring of urine and blood sugar     5. Hypoglycemia     6. Sick day rules                                      Table 2. Suggested Methodology for teaching   1. Verbal - Didactic - Discussion - Seminars - Demonstrations 2. Printed material magazines, cartoons 3. Audio visual -films, video exhibition, flip chart, slides, radio etc. 4. Other methods - Games - Play drama - Computer programmes 5. Conducting camps, exhibitions, diabetic clubs etc.      4) Therapeutic measures    5) Complications of diabetes       a) Acute complications Hypoglycemia Ketoacidosis Hyperosmolar coma       b) Chronic complications           Growth impairment in IDDM Renal complications Cardiac complications Nervous           system complications Eye problems Intestinal problems Food and skin problems    6) Prevention of complications    7) Blood sugar, Urine sugar/Ketone monitoring    Pregnancy in diabetes    9) Technical problems and doubts regarding usage of insulin and oral hypoglycemic        agents. An idea about the illness and its nature should be provided initially as discussed        before. While discussing the importance of genetic factors in diabetes most people are        worried about disease transmission to the succeeding generation. Hence many ask        whether marriage with a diabetic or one from a family of diabetics is advisable or not. It        is wise to advise such people that NIDDM has more chance of being transmitted to        children than IDDM. Still, the percentage of possibility is difficult to predict because of         the variable mechanisms of genetic transfer in DM.       The diagnosisS of DM is made by blood sugar estimation. If the fasting value is 120 mg% and the 2hr post prandial value islSO mg% it is diagnostic of DM (WHO). Urine sugar is a less sensitive indicator in that it does not detect latent DM. Only after the blood sugar rises to a particular level (180 mg%- normal renal threshold) glucose will appear in urine. In day to day control in elderly diabetics, urine sugar estimation may be fallacious due to higher renal threshold; hence the importance of getting bloodsugar to be emphasised.     About therapeutic measures, there is a confusion in patients whether insulin is absolutely needed or can the disease be checked by drugs only including some indigenous preparations. They should be informed that IDDM needs insulin replacement whereas NIDDM can be controlled by diet, exercise and oral drugs to some extent, because of the difference in their pathogenesis. The indigenous drugs are less effective than OHA, and their use should not be prompted lacking sound scientific basis regarding their mechanism of action, side effect etc. OHA has to be taken as per physician's advice. All diabetics should be taught how to identify the acute complications of diabetes and to guard against the long term complications. The most common acute complication is hypoglycemia.6 This is especially common in patients who are on insulin and in elderly as well as those who have anorexia. If they take the normal dosage of insulin severe hypoglycemia can occur. Long acting oral drugs like chlorpropamide in elderly patients with poor oral intake can lead to prolonged hypoglycemia. So all diabetics should be advised to reduce the dosage of insulin or OHA if their food intake is poor due to some reason.     Symptoms to be watched for hypoglycemia: Severe sweating, palpitations, light headedness, headache, nightmares, hunger,- nausea, vomiting. These can lead to stupor and coma.     This should be detected by the patient himself in the early stage and self treated either by fruit juice or oral glucose.      Ketoacidosis is another dangerous complication in diabetics(DKA), more so in patients with IDDM - can also occur in NIDDM when they are subjected in stressful conditions like heart attack, surgery and infections etc. This arises due to an absolute lack of insulin. Identifying DKA by patient needs giving attention to the following symptoms.      Increased thirst, polyuria, nausea, vomiting, abdominal pain, muscle cramps, dyspnoea. If such symptoms occur in a known diabetic, it should be immediately brought to physician's notice and treated.     About the chronic complications diabetics should be well informed. They should be taught that by keeping blood sugar at optimum level most of these complications can be delayed. Diabetic should get his eye checkup done at least once in every year to detect evidence for retinal damage. Similarly regular follow-up in diabetic clinic is advised to get the BP check up done, to identify any cardiovascular, renal complications etc. Urine examination for albumin or micro- albuminuria must be done at least once in a year in long standing diabetes.       Another doubt raised often is about the prognosis of diabetes with pregnancy. Once the blood sugar is well controlled, there is no additional risk to the baby compared to a non diabetic. Diabetes mellitus if not diagnosed previously should be suspected in a pregnant lady with the following back ground.     Family H/o DM H/O giving birth to child of 4.0 kg birth wt. H/O habitual stillbirths H/O polyhydramnios in pregnancy Undue weight gain in pregnancy.     Diagnosis is confirmed by blood sugar estimation. If FBS is 110mg% and 2hr PPBS 140mg% it is diagnostic of DM. Values in between the above needs screening for impaired glucose tolerance. This is done by giving oral glucose 75g and measuring the rise in blood sugar level at 1/2 hrly intervals till 2.5hrs. Table 3. Highlights on a few mistakes often committed by diabetics    1. Omiting or insulin during illness. This is disastrous and causes D.K.A.    2. Going to test blood sugar after stopping OHA or insulin. This is wrong because most of         the OHA or insulin have a duration of action of less than 24hr. Hence the blood sugar         result will be high.    3. Getting FBS done after cup of tea or breakfast. The resultant value will become random        blood sugar.    4. Treating urine only and being happy that it is negative for sugar. This is falacious        because in higher renal threshold group urine sugar will not appear before a        substantially high blood sugar is reached.    5. 'Feast and fast' both should be avoided. Practice of taking more food with more insulin        or OHA should be discouraged as it leads to obesity.    6. 'Rice to avoid' statement to diabetics is wrong. Rice eaters can take measured        quantities of rice -3/4 cup of cooked rice = 1 average size chappati (30grm of Atta)    7. Avoid fruit juices and ask to take whole fruits like small apple or 250gms of papita.       Whole fruit has fibre and is good for DM.    8. Sprouted grains are advisable as they contain antioxidant vit E and fibres.    9. With good control of DM minor refractive changes can occur. So a diabetic should go for        refraction studies and for glasses only when the glycemic state is stable.   10. Adjustments of insulin during air travel has to be taught to some diabetics who has to        travel abroad. Best is to switch to regular insulin and take frequent injections before        meals. A Few Practical Problems    1. Blood sugar estimation : Diabetic should be taught the technique for blood sugar        estimation. This saves his time and money and avoids the long wait in the laboratory.        Nowadays, the freely available glucometers can give a visual reading of blood sugar        with a single drop of blood.    2. Urine sugar estimation: Done with the help of a urine Glucostix. If not available, should        be done with Benedicts's reagent. Adding O.Scc of urine to 5cc of reagent (8 drops),        heating to boil and to look for colour change. Blue Normal (No sugar), Green - 0.5%,        orange - 0.5-1%, yellow - 1- 2%, Red- 2%.     3. Urine ketone estimation: Done with urine Ketodiastix, if not available, can be done with        Gerhardt's reagent.    4. Injecting insulin by patient: It is better to teach either the patient or one of his        responsible family members, the technique of subcutaneous injection. They should be        made aware that by giving frequent injections at the same site, one can lead to fat        atrophy or fat hypertrophy at the site of injection. So the site of injection is periodically         changed from thigh to shoulders and so on.    5. Superior Quality Insulin: Purified porcine and human insulin are among them. They        prevent lipodystrophy, insulin allergy as well as insulin resistance. During intermittent        Insulin therapy in NIDDM they are preferred. In DM with pregnancy these are the       choice.    6. Storage of insulin: Insulin should be kept in refrigerator and should not be used if the        general appearance shows cloudiness,    7. Identity cards: Diabetics should be provided with 'I'm a diabetic' type of card duly        certified by the medical authority. This should include the type of medication being        taken, the complications one is suffering from etc. It should have the full address of the        patient and telephone number.   REFERENCES         1. P. Shah, S. Setia, R. Vijay, U. Dhiman, NOVO NORDISK Diabetes mellitus update             149, 1994.         2. Somers, Anne R. Preventive medicine 406, 1977.         3. WHO technical report series 727, 1985         4. KGMM Alberti, Diabetic Emergencies In British medical Bulletin 251, 19S9.         5. Podolsky - Diabetes mellitus 1988.         6. Walter A. Hultner: Hypoglycemia - In problem oriented medical diagnosis 345-349, 1996.