Dr. P. Ushabala is with the Diabetes Education and Treatment Centre, Hyderabad

Epidemic of Diabetes?
Diabetes is an alarming and rapidly emerging health problem in our country, and awareness of diabetes has also more than ever increased. Most of us encounter more and more people with diabetes in our clinics, as well us outside the clinics. Diabetes is as debilitating as any other infectious disease. Indians seem to be more prone to diabetes than others, and further, Indians tend to develop diabetes at a relatively young age of 45 years which is about 10 years earlier than Westerners. As diabetes is a non-communicable disease, it does not warrant serious preventive measures. However, if proper care is not taken, diabetes can be as harmful as any other infectious disease as it does not spare any organ in the body.

Largely Undiagnosed
In our country, more than 15 million people have diabetes making it the 5th largest killer disease. But the irony is that half of those with diabetes do not know that they have diabetes and hence no treatment till the last stages. Diabetes invariably leads to organ damage. Diabetes is a functional disorder or metabolism and it continues to be so for many years before it causes permanent damage to the blood vessels or nerves. Thus it is not a disease initially, and it is unique in a way that a person with diabetes may not even be aware of it for many years. Diabetes is a life long companion. So it should ideally be managed with the long-term objective of attaining freedom from all complications for which education is the most important tool. In addition to the two common types of diabetes (Type 1 & 2), there are others like maturity onset diabetes in young, diabetes in pregnancy, impaired glucose tolerance, malnutrition-related diabetes etc. Thus, as against earlier beliefs, it not only is a problem of the affluent societies, but also of the less privileged populations.

Predictable and Preventable?
Though diabetes is not a problem of a single origin, as there are many types of it arising due to many different reasons, it is possible to make a reasonable ‘guess’ about who will develop diabetes. If one is over 45 years, obese, and has diabetes within the family, it is almost certain that he or she is going to have diabetes soon. At this stage we can postpone the onset of the disease by taking certain precautions - by maintaining ideal body weight, leading an active life, following regular exercise and maintaining normal blood glucose levels.
Often, a person with diabetes is described as a ‘diabetic’ or ‘patient’. ‘Patient’ derives from the Latin for sufferer, and we need to remember that diabetics do not see themselves in relation to the health services we provide them; they see themselves as individuals who happen to have chronic disease, and do not necessarily want to be defined by their disease. International Diabetes Federation, therefore, encourages the use of ‘people with diabetes’, rather and ‘patient’ or ‘diabetic’.

Diabetes Education

Societal solution
Diabetes is one of the few ailments in which the total involvement of the people with diabetes and the society’s support are required. Not only people with diabetes but also those close to them should remain at the centre of all activities while planning quality care at the primary health care level. As, most importantly, identifying the problem at an early date is the essential component of the diabetes management programme, voluntary organisations should come forward to provide regular diabetes detection services. Apart from providing screening services diabetes awareness and education programmes should also be conducted by non-governmental service organisations to help the society combat the problem of diabetes.

Living with diabetes
Education in diabetes is compared to a table top, while diet, exercise, monitoring and medication are its four legs. This emphasizes how important is the education in the management of diabetes, as the four legs of the table do not serve any purpose without the top. And, in no other ailment education plays such a major role. Education of people prepares them to live with diabetes by improving their understanding of the disease.

Group discussion
Individual education certainly helps the person with diabetes to some extend, but group education does help to a greater extent. The person with recently detected diabetes develops self-confidence by seeing many people affected for longer periods with the same ailment and leading a normal and productive life. Secondly, in group discussions many doubts may be cleared which would otherwise linger forever.

The right technique
Education methods usually differ from person to person as they depend on age, socio-economic status, intellectual level, type of diabetes, (whether drugs or insulin is required) and many other such factors. An education technique that works with one need not necessarily work with another. So many different teaching methods are needed to be employed. A method is right as long as it is effective from the benefactor’s point of view. However, we should constantly review the methods we employ in diabetes education, and strive to continually improve our communication skills.

Who should be educated?
People with diabetes among family members are more prone to get diabetes than others, as the chances of getting diabetes in them are as high as 70%. So such persons should be made to be a cautious and to monitor their blood glucose after 30 years of age at least once in a year. There is evidence that people with sedentary occupations are more at risk to get diabetes than active persons. Psycho-social stress may precipitate diabetes in those with or without family history or other risk factors. Education on life style modulations so as to cope up with stress as well as to manage stress by yoga and medication are also beneficial.

The public awareness
Many with type 2 diabetes are without symptoms and are diagnosed during routine investigations, before surgery or during an innocuous eye, tooth or skin check up. So, it is important to educate the general population about the symptoms of diabetes. Among those who are past 40 years age and just overweight - some do not know about their disease as they are asymptomatic or may have symptoms but they do not know that it is because of diabetes; some doubt about their diabetes but do not get it confirmed and some even after knowing that they have diabetes ignore or keep it as a secret to avoid dietary discipline and treatment. Not only the people with diabetes, or those at risk of developing diabetes, but also parents, siblings, relatives, friends, class mates, teachers in school and colleagues at work should be informed of hypoglycemic symptoms and the ways to deal with it. This is very important so that they can also help save a life in time.

When to start education?
Education should be started by the family physician who has diagnosed diabetes for the first time. It is not justifiable to just prescribe a drug and to send away a person with diabetes. The primary care clinician has to explain everything from the pathogenesis to the target organ damage, while encouraging the person to develop self-confidence at it may sometimes be shocking to hear about diabetes for the first time. A physician may be too busy in his clinic to explain all this, so the paramedical staff like nurse, dietitian, special diabetic educator in a bigger set up should take the responsibility of educating the person with everything about diabetes. It is not possible to do all this in a single sitting or during the first visit itself. A person with diabetes may also be scared or confused to hear too much. So, diabetes education should be a continuous process, relevant to the situation and step by step.

Self-care
It is the team work of the doctor, nurse educator or social worker and the person with diabetes which makes it possible for him to have a normal, healthy and active life. According to Dr . R.D. Lawrence, the pioneer in diabetology, "every diabetic should be his own dietitian, nurse and doctor". As alarmingly more and more Indians are getting affected by diabetes, there is an urgent need for a concerted effort from all corners to help people with diabetes to know about the disease and to adopt self-care. Imparting correct informations on the disease, its prevention and complications to the persons with diabetes is the major objectives of the health educator or advocates of self-care.

The guidelines for self-care:

• examine feet on a regular basis.
• follow good life style practices. These include choosing the right food, maintaining a healthy weight, getting regular exercise and avoiding smoking.
• know when to contact health care team.
• keep in regular contact with health care team about any questions or concerns one may have.
• speak to health care team, others with diabetes, and to local or national diabetes associations.
• read pamphlets and books about diabetes provided by health care team or diabetes associations.
• make sure that the diabetic’s family and friends know about their needs.

Who should organise education programmes?
Under the guidance of treating physicians or diabetologists, people with diabetes can form small groups and arrange meetings once in a fortnight or a month. Meetings can also be arranged by voluntary organisations like Lions Clubs, Rotary Clubs or Ladies Clubs. While people with diabetes wait in the clinics, education programmes can be shown on video or dietitians can conduct small classes to upgrade the knowledge of the participants.
We, as doctors may be teachers, but we should also be learners.

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