Living with diabetes: a team approach
Helen Signy relates one patient’s experience of life with type 2 diabetes and speaks to the army of experts involved in his care.
Ian Grant, a 40-year-old customer advisory worker from Melbourne, was sitting in his office gazing out of the window when he realised he couldn’t clearly read the number plates of the cars parked outside. Nor could he make out the time on a nearby clock. A visit to his GP shortly afterwards revealed the cause of his visual disturbance: he had type 2 diabetes.
That was in 1986. Since then, Ian’s life has changed dramatically, and his story serves as a stark reminder of the multitude of complications that may result from uncontrolled diabetes.
Ian has been insulin dependent for the past 15 years, he lost part of his right leg in 2007 – numbness in his toes led to a blister that became infected, requiring a below-knee amputation. He has also had a toe on his left foot amputated due to worsening peripheral vascular disease.
He needs frequent laser treatment to control his retinopathy but has already lost 40% of his vision, which means he is unable to work and survives on a disability pension. He also has severe and chronic kidney disease and is waiting for a renal transplant.
The familial links which are so frequently seen in cases like Ian’s have become apparent, too, with both his parents and both brothers also diagnosed with diabetes in recent years. When Ian was diagnosed in the 1980s, he was unaware what the future would hold if his diabetes was not well controlled.
With help from his current GP, he has mastered the monitoring of his blood sugar levels and adjusts his insulin accordingly. He has also focused more on diet and lifestyle changes.
Despite advances in specialist diabetes knowledge over the last 25 years, Ian still feels that more support from GPs is vital in helping patients control their condition.
"I wish doctors would have more contact with people with diabetes and not just wait for people to visit them. Patients are really managing this disease on their own. I have got control of it now – but it’s also very, very easy to lose that control," he says.
THE DIABETES EDUCATOR
Diabetes Nurse Educator Team Leader, Diabetes Australia – Vic
Familiar with many cases like Ian’s, Catherine Prochilo, a diabetes educator for the past eight years, says diabetes education is all very well, but health professionals need to understand the disease from the patient’s perspective.
Public health messages concerning obesity and exercise are largely ignored and there is a general lack of awareness of the psychological issues that may have led to the lifestyle that caused diabetes in the first place.
For example, almost everyone who goes on a diet eventually regains the weight unless these issues are addressed. For people with diabetes, particularly, losing weight may be a near-impossible task.
"It’s not just about education – that’s limited if people are suffering from depression or they have other concerns and diabetes isn’t their primary focus. I think there are a lot of other things that need to be implemented," she says.
The day-to-day management of diabetes can also be exhausting for patients, Ms Prochilo says. "It impacts on every part of their lives. It’s about limiting their food intake, increasing exercise, monitoring their blood sugar, checking their feet and eyes – there are so many aspects to it."
It’s vital that, in a multidisciplinary approach to a patient’s management, every health professional involved understands what the patient’s goals are, she says.
"The GP’s goal may be to improve sugar levels, but the patient’s might be to be able to play with their grandchildren."
The best way to achieve that, in her experience, is to offer practical solutions rather than information overload.
Dr Murray Gerstman MBBS, FRACP
Maroondah Hospital, Melbourne
"I would say Ian is one of the most severe patients I see."
In the years since Dr Murray Gerstman started treating diabetes, two things have changed. First, he’s now seeing people diagnosed with the disease at increasingly younger ages. While type 2 diabetes in children was virtually unheard of 20 years ago, he’s now regularly seeing young people with the disease.
"There have been a number I have seen who have come back at the age of 25-27, with a guide dog because they are blind, or they are waiting for a renal transplant," he says.
But secondly, the good news is that more aggressive cholesterol and blood pressure control in people with diabetes means they are developing fewer complications and achieving better management of their condition, he says.
An ongoing problem is a lack of co-ordination among the specialists who manage people with diabetes.
For instance, specialists might treat a patient’s vascular disease but they don’t worry about getting blood pressure under control.
"I still see people who are told 'it's just mild diabetes' – but they are slowly developing peripheral neuropathy.
"This disease can still cause very serious damage over time," he says.
New treatments, particularly in the area of weight control, are starting to offer hope. But even so, Dr Gerstman says, most therapies wear out; the patient eventually goes onto insulin and loses control.
"We still haven’t got to the basis of the underlying cause."
Dr Mark Daniel MBBS, FRANZCO, FRACS
Director of Ophthalmology, Royal Melbourne Hospital
As director of ophthalmology at the Royal Melbourne Hospital, most of the patients Dr Mark Daniel sees have had their vision compromised by poor glycaemic control or hypertension.
While Ian’s case is one of the most severe Dr Daniel has treated, he is by no means alone.
"I’m seeing a lot of end-stage diabetics with multiple problems. In general, if they are picked up early, before they have lost vision, it’s much easier to keep it with early laser intervention," he says. Given the inability of many patients to control their blood sugars, he believes it’s up to GPs to screen patients for vision problems.
"Anyone with retinopathy should be referred, and all patients with diabetes should be screened every two years."
While the majority of Dr Daniel’s patients are successfully treated so they can lead normal lives with normal vision, he is particularly saddened by the serious cases he sees, especially among pregnant women.
"In the worse cases with poorly controlled diabetes in pregnancy, despite everything we do, they lose their eyesight," he says.
And even with a range of new treatments on the horizon that are offering hope for macular oedema and retinal detachment, diabetic complications of the eye remain a major public health issue.
"Diabetes is the commonest cause of blindness in the adult population," he says.
Dr Philip Wood MBBS
Dr Wood credits taking an active role in the practical management of patients with diabetes with helping people like Ian Grant take control of their condition.
However, like many GPs, at times he feels "absolutely overwhelmed" by the magnitude of diabetes as a problem in our community and the pressures it places on GPs.
"Our diabetes load is getting bigger every day. I’ve diagnosed three more people this week – I had one today whose sugars were 32. We are not referralists – we try to manage all our patients with diabetes, including the insulin-dependent ones, in-house."
Dr Wood’s surgery prides itself on a high standard of care and tries to be supportive of all its patients with chronic diseases.
"Ian would probably call me a mate – we are very active in his care."
Professor Paul Zimmet MBBS, MD, PhD, FRACP, FRCP (UK), FACE, FACN, FAFPHM
Director emeritus of the Baker IDI Heart and Diabetes Institute.
As one of the authors of the AusDiab study, and a diabetes researcher for more than 40 years, Professor Paul Zimmet has devoted his professional life to highlighting the magnitude of the diabetes epidemic in Australia.
It was an under-recognised area of medicine when he entered the field in 1967, but diabetes is now acknowledged as one of the most serious public-health problems Australia has ever faced. During his career, Professor Zimmet has seen the controversy wax and wane over the role of metabolic control in reducing the complications of diabetes – but he believes that better management over the last 20 years is reducing the rate of kidney failure and retinopathy and this will contribute to cases like Ian’s becoming less common. And he applauds the Government’s introduction of more funding for GPs to manage diabetes.
"They might not have worked out how they’re going to work it, but the concept is there," he says.
As well as lobbying for more Government intervention in diabetes, Professor Zimmet is looking at the role of epigenetics in diabetes. He’d also like to see a genetic test that could pinpoint people susceptible to diabetes, and better classification of the genetic causes of the disease in patients so therapies can be targeted more accurately.
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