The role of the doctors and their team will be to teach people with diabetes, design therapeutic options for the individual diabetic person, and arrange regular checkups (Table 1.17). Their role is also to encourage and support the patients, give ongoing advice, and help in acute and chronic problems. However, the doctors cannot take responsibility for the correctness of daily management and for therapeutic failures due to noncompliance on the part of the patients.
Teaching should enable the diabetic subjects (and if possible people in their social environment) to understand the disease and its treatment and to detect and manage complications early on (Table 1.18). Transferring knowledge and abilities is important. More important, however, is empowerment. The diabetic persons should not simply take on the doctors recommendations, but should develop their own health beliefs. Instead of obeying prescriptions, they should want to attain good control and wish to practice self-monitoring, treatment adaptation, and a healthy life style. In other words, they should be able to develop appropriate self-care behavior.
Table 1.17 Nonpharmacological management of diabetes mellitus
| A. The role of the patients: Learn about diabetes Develop health consciousness and self-management behavior Set goals for your therapy Express and discuss your wishes and expectations with your health care team Control and correct yourself regularly Adopt a healthy life style Profit from the expertise of your health care team Don't “suffer” from your diabetes Decide to want what you have realized as being good for you |
| B. The role of the doctor and the diabetes team: Teaching and training, ongoing advice, back-up. empowerment, and motivation of the persons with diabetes Discussion and consensus on goals of individual therapy Design of individual therapy Nutrition counseling and self-management plan |
Table 1.18 Topics for teaching and training of people with diabetes
| What does diabetes mellitus mean? (causes, symptoms, natural course, prevention, rights and roles) |
| Sensible eating (what to eat, nutrients and energy content, metabolic effect, shopping, cooking) |
| Physical activity (pros and cons of different activities, metabolic and cardiovascular effects, joint loading, monitoring) |
| Self-monitoring (blood glucose, body weight, skin, blood pressure, how and when to do, how to document) |
| Hypoglycemia (causes, symptoms, prevention, treatment) |
| a Oral antidiabetic drugs (action, when to take, side effects) |
| a Isulin (action, how to inject, pens and other devices, schedule, dosage) |
| Care of skin and feet (how to examine, instruments for care) |
| a Not smoking (importance, how to give up smoking) |
| Blood pressure (importance, measurement, how, when, actions at high blood pressure) |
| Chronic complications (symptoms, regular check-ups, risk, prevention, treatment) |
| When to contact the doctor or diabetes care team |
| Special situations (traveling, being ill) |
| Social problems (driver's license, insurance, diabetes risk of descendants) |
a If reasonable
An important aim of patient teaching and training is regular self-monitoring of blood glucose, body weight, skin, particularly of the feet, and blood pressure (Table 1.19). Urinary glucose determination is inadequate as the only method. Aglucosuria does not constitute proof of good metabolic control, because the renal threshold for glucose may be far above the treatment goal. Furthermore, only blood glucose self-monitoring can show the risk of hypoglycemia, which is the greatest obstacle to strict metabolic control.
Nutrition of diabetic people should contain no more than 30% of energy as fat and only 10% as saturated fatty acids. This is much less than is usually consumed in Western diets. Protein intake should not exceed 20% of energy. The majority of energy intake should be in the form of carbohydrates, preferentially complex carbohydrates. However, trained people with good metabolic control may also take some sugar (about 50 g per day) in several portions combined with food rich in fibers. Alcohol should be limited to 15 g per day for women and 30 g per day for men. Salt should be used in moderation [203,349]. About 80% of diabetic people are obese. For these people, restriction of energy intake combined with physical activity is essential in order to achieve slow but continuous weight loss. Nutritional advice must aim to keep eating enjoyable and to help diabetic subjects to satisfy their nutritional preferences within the limits of sensible eating.
Nonpharmacological treatment is the basis for management of all types of diabetes mellitus. Whether it will be successful depends not only on the commitment of the doctor and his team, but also on the cultural background and the all-round educational level of the diabetic person. Only educated, well-trained, independent-minded patients will claim their right to choose among different therapeutic options, will know what kind of service they are entitled to demand from the health care system, and will realize what they themselves have to contribute to the management of their diabetes. Only these patients will have a realistic chance of effective diabetes management and a good long-term prognosis.
Table 1.19 Rules for self-monitoring of metabolic parameters
| • Blood glucose testing is preferable for metabolic control. It is mandatory for patients on insulin or oral antidiabetic drugs that stimulate insulin secretion. It is a vital safeguard against hypoglycemia. Perform urine ketone tests during illness or when blood glucose increases above 20 mmol/l. Document all results. |
| • In well-controlled, stable patients: Fasting, before main meals, at bedtime. 1-2 times per week. |
| • In poorly controlled, unstable patients or during illness: Fasting, postprandially. before meals, at bedtime, daily until stabilized. |
| • During intensified insulin treatment: Before each insulin dose, if necessary postprandially. |
| • If hypoglycemia is suspected. |
| Other self-monitoring: |
| • Check body weight, inspect feet at least weekly. |
| • Check blood pressure, if normal monthly, if elevated more often, possibly several times per day until targets of control are achieved. |
| • Record special events. |
The benefit of nonpharmacological treatment has been shown. Weight reduction reduces mortality considerably [63]. Teaching improves metabolic control and may reduce the need for pharmacotherapy [347,350]. Well-established tools of pharmacological treatment of diabetes cannot be used without teaching, training, and empowerment of the patient.
Pharmacological Treatment of Type 1 Diabetes
General Aspects
The