Guest Post by David Mapletoft, Diabetes Educator
In my experience working in a large Sydney teaching hospital as a diabetes educator most people I met as an inpatient (in hospital for any reason and having at some time in the past diagnosed with diabetes) had limited or no self management education about diabetes.
Visits with our health care professionals (especially after only recently being diagnosed with diabetes) often focus on a limited range of things: diet, exercise, medication, hypoglycaemia, blood glucose levels.
This may lead to some of the ‘smaller’ issues being forgotten, neglected.
Nobody knows everything.
Every month there is roughly 40 articles published in scientific journals relating to diabetes.
So, let’s take a look at some of the ‘little things’ that are of significance in the diabetes self care planning and may not have been discussed by your team, even after several years of being diagnosed with diabetes.
Appropriate Needle Length and Injection Technique
One of those small details, an easy thing to miss when there is so many other ‘important’ issues to work on.
In the past there has been no good research about needle length. Now we have some good evidence to show that the length is only required to get the insulin into a layer of fat in the body.
12.5mm and 8mm needles are no longer required by any people living with diabetes, not even the obese.
Evidence: “A 5-mm needle is similar to an 8-mm needle in obese patients with diabetes with respect to metabolic control, injection-related complaints, or patient preference and can be used safely.”
Evidence: “Proper injection technique is vital to avoiding intramuscular injections, ensuring appropriate delivery to the subcutaneous tissues and avoiding common complications such as lipohypertrophy.”
Evidence: “Studies have shown that not all patients receive education about injections and for those who do, not all essential topics are covered.
Essential topics include:
– the injecting regimen
– the choice and management of the devices used
– the choice, care and self-examination of injection sites
– proper injection techniques (including site rotation, injection angle and possible use of skin folds)
– injection complications and how to avoid them
– optimal needle lengths
– safe disposal of used sharps .
Decisions regarding these injection parameters should be made in a discussion context where the patient is a partner and the HCP offers experience and advice. When educating in a group setting, there is evidence that better compliance and lower subsequent HbA1c values are achieved if the HCP has formal training as an educator.”
If you are using insulin and have not discussed these issues with your diabetes educator, consider this as an integral part of your next visit.
Sick Day Planning
In my experience as a diabetes educator most people living with type 2 diabetes want to know 3 things: what to eat; how much exercise they need to do; and if they can avoid medications. Often once these questions are answered the person living with type 2 diabetes feels as though they have enough knowledge about managing their diabetes.
The diabetes educator is unlikely to have discussed sick day planing in the first 3 months after diagnosis. Often sick day planning is not discussed with clients as they don’t complete the diabetes self care education program.
We all get sick occasionally, especially during winter with things like the common cold.
Being pro-active – prepared for the unexpected – a comprehensive sick day plan may not only keep you out of hospital, but may save your life.
Insulin for People Living with Type 2 Diabetes
So many times I hear people living with type 2 diabetes disillusioned and sometimes depressed that they feel they have ‘failed’ themselves in their diabetes self care plan.
This is often because they have not been advised that at some time in the future they may need inulin as a part of their treatment.
Type 2 diabetes is progressive. The pancreas over time will make less insulin, no matter how good your self care is.
• The HCP should prepare all newly-diagnosed patients with type 2 diabetes for likely future insulin therapy by explaining the natural, progressive nature of the disease, stating that it includes insulin therapy and making clear that insulin treatment is not a sign of patient failure.
• Both the short- and long-term advantages of good glucose management should be emphasized. Finding the right combination of therapies leading to good glucose management should be the goal, rather than minimizing the number of agents used.
• Through culturally appropriate metaphors, pictures and stories, HCPs should show how insulin injections enhance both the duration and quality of life.” from ‘New Injection Recommendations for patients with diabetes’
“Negative attitudes to insulin therapy are common. Results from the Diabetes Attitudes, Wishes and Needs (DAWN) study show that barriers to achieving adequate glycemic control include misconceptions and concerns of patients and providers regarding the use of insulin. Data from DAWN highlight the importance of addressing psychosocial factors as an integral component of care for patients with diabetes. Strategies to deal with the initiation of insulin therapy can provide ways to overcome barriers to effective therapy and bridge the gap between diabetes targets and clinical practice. By identifying and addressing patient and provider concerns regarding initiation of insulin therapy, providers can facilitate effective self-management of diabetes and help patients achieve current targets for glycemic control.” More here
Insulin Dose Adjustment
For people living with type 1 diabetes the problem is often that they have not been taught how to safely and effectively self adjust their doses of insulin.
For people living with type 2 diabetes the problem is often a type of insulin prescribed does not fit with their lifestyle e.g. shift work; irregular daytime activities.
“In a real-world study, patients using a dose self-adjustment algorithm had significantly greater fasting plasma glucose reductions (P<0.0001) than those randomized to standard physician-driven adjustments.
Patient-driven dose adjustment led to slightly but significantly more non-major hypoglycemic events than physician adjustment (P<0.0001), but rates were still substantially lower than at baseline for both, they reported at the American Diabetes Association meeting. ….. patient-driven dose adjustments “appear to be a safe and effective alternative to physician-directed dose adjustment in the primary care setting.”” More here.
“The use of an information management system, coupled with an easily understood training manual, enables patients to improve glycemic control by performing accurate and timely self-adjustments to their insulin regimens. The results of this study show that use of an information management system by patients with T1DM is associated with improved glycemic control and reduced incidence of hypoglycemia compared with the use of logbooks.” More here
If you feel that you need to become more self reliant in adjusting your doses of insulin to suit your day to day lifestyle (which is often different each day) talk with your doctor, diabetes educator, & dietitian – they may have different goals to yours.
Please comment below about any matters raised here, or ask any questions relating to any aspects of your diabetes self care plan.
David, Diabetes Educator