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Journal of Endocrinology, Metabolism and Diabetes of SouthAfricaPublication details, including instructions for authors and subscription information:http://www.tandfonline.com/loi/oemd20
Holistic diabetes careempowering patients andpractitionersFraser Pirieaa Department of Diabetes and Endocrinology Nelson R Mandela School of Medicine University ofKwaZulu-Natal DurbanPublished online: 12 Aug 2014.
To cite this article: Fraser Pirie (2005) Holistic diabetes careempowering patients and practitioners, Journal of Endocrinology,Metabolism and Diabetes of South Africa, 10:3, 76-76, DOI: 10.1080/22201009.2005.10872123
To link to this article: http://dx.doi.org/10.1080/22201009.2005.10872123
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o. 3 A number of landmark studies have made it abundantly
clear that the goals of diabetes care involve striving foroptimal metabolic and blood pressure control. Themessage is now loud and clear: lower HbA1C, lower low-density lipoprotein cholesterol, and lower blood pressure.Failure to achieve these targets makes the person withdiabetes susceptible to macrovascular and microvasculardisease, with the attendant consequences. In the clinicalsituations faced by many practitioners in South Africa,however, attainment of these goals is an unrealisticexpectation. Although this should not detract from effortsto maximise metabolic control, the difficulties in achie-ving treatment targets are an inevitable consequence ofthe numerous impediments hindering the efforts of eventhe most dedicated practitioners and patients.
The current issue of JEMDSA describes the barriers thatobstruct initiation of insulin therapy in patients with type2 diabetes in the public health system in Cape Town (p. 94). The description will be familiar to many who workin similar circumstances, and Haque and colleagues areto be congratulated on eloquently highlighting a realproblem in diabetes health care delivery. Insulinresistance in both patient and practitioner, as well as theproblems in the health care system that detract fromprovision of appropriate therapy as stipulated by theguidelines, is not unique to the Western Cape, and frompersonal experience is just as much of a problem inKwaZulu-Natal. No doubt many other parts of the countryare similarly affected.
What can be done to improve the situation? It is clearfrom the findings of the Cape Town study that educationof health care professionals as well as people withdiabetes is a key factor. One of the fears voiced by themedical practitioners in the study was that of hypogly-caemia a concern echoed by many others and expres-sed by Cryer1 as follows: were it not for the devastatingeffects of hypoglycaemia, diabetes would be rathersimple to treat. Yet sulphonylurea-induced hypoglycae-mia, particularly with glibenclamide and other long-acting agents with active metabolites, is perhaps more ofa problem than insulin in causing severe hypoglycaemia.
Providing practitioners with the tools to make informedmanagement decisions is another issue that requiresattention. Deciding to advise a person with diabetes totake insulin on the basis of a random capillary glucoselevel is not optimal. This point was highlighted in therecently published International Diabetes FederationGlobal Guidelines (accessible at http://www.idf.org),which state that site-of-care capillary plasma glucose
monitoring at random times of day is not generallyrecommended. As a minimum, fasting capillary plasmaglucose should be used to assess control and provide thebasis for clinical decisions. In the average primary healthcare clinic, however, waiting times are long and askingpatients to fast for many hours is not a practical solution.Assessment of overall glycaemic control with HbA1C,complemented by self-monitoring of blood glucose(SMBG), is clearly the ideal means of arriving at thedecision to initiate insulin (or other therapy adjustments).Measurement of HbA1C should not be seen as a facilityavailable only to secondary and tertiary hospitals; itneeds to be made available to primary care clinics on alarge scale, and health care officials need to be convincedof the clinical usefulness and cost effectiveness ofproviding such support services. Furthermore, there are anumber of finger-prick HbA1C machines available andthese provide a practical, point-of-care solution thatwould significantly aid in diabetes management at theprimary care level.
Once the decision to implement insulin therapy has beenmade and accepted, it is equally important to give theperson using insulin the tools to monitor therapy by homeglucose readings. This requires regular issue of glucosemonitoring strips, and clinics in many parts of thecountry do not provide people with diabetes with theseessential items. Again, the IDF guidelines recommendthat persons using insulin should be provided withglucose monitoring strips, although the statement in theminimal care section is rather vague: SMBG usingmeters with strips, or visually read blood glucose strips,should be considered for those on insulin therapy.
With the support of scientific studies and of internationaland national guidelines, the barriers not only to insulintherapy but to contemporary holistic diabetesmanagement need to be breached for the benefit of theincreasing numbers of people with diabetes. This calls forincreased advocacy on the part of the organisations thathave been established for this purpose and widespreaddissemination of knowledge both to the health careprofessions and people with diabetes. Empoweringpeople in self help and practitioners in competence hasbecome essential.
Department of Diabetes and EndocrinologyNelson R Mandela School of MedicineUniversity of KwaZulu-NatalDurban
1. Cryer PE. Hypoglycemia is the limiting factor in the management ofdiabetes. Diabetes Metab Res Rev 1999; 15(1): 42-46.
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