Clinical Care

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Lifestyle and nutritional management

It is often stated that dietary management is a cornerstone of diabetes care. More recently, physical activity has also been recognized as a useful fundamental intervention. When it is realized that both of these can affect a variety of the problems that bedevil people with diabetes – including excess body weight, high blood glucose levels, high blood fat levels, and high blood pressure – it is not difficult to see why these issues might be regarded as fundamental.

Patient education and psychological care

People with diabetes deliver most of their own care. This reflects the observation that diabetes and its associated features touch on most aspects of daily living, and aspects as fundamental as eating and physical activity. To deliver such care requires knowledge, but even with knowledge it may not be easy to adjust to optimal self-care. This makes patient education a complex therapeutic issue.

Outpatient and inpatient diabetes care delivery

Diabetes care is inherently complex – hence the need for 19 chapters of evidence review and recommendations in the Global Guideline. Pulling all the recommendations together to ensure the implementation of effective delivery of care therefore needs some organization of its own, as is discussed in this article. A special situation is that of people with diabetes in hospital, who are often subject to disruption of lifestyle due to illness, procedures, or surgery, with knock-on effects on their diabetes management.

High costs, low awareness and a lack of care - the diabetic foot in Nigeria

Nigeria, with a population of about 128 million people, is Africa’s most populous country. Life expectancy at birth is 47 years; about 60% of the population live below the poverty line. While healthcare structures and institutions are inadequate, and there is a chronic lack of skilled healthcare personnel, diabetes is on the increase. Uncontrolled urbanization is the driving force behind rising obesity levels and a subsequent boom in levels of type 2 diabetes.

Children

The relatively recent emergence in children of type 2 diabetes, a condition once considered ‘late-onset’, has been viewed with consternation around the world. Guidelines directed at healthcare professionals dealing with children have generally focused on type 1 diabetes; it is only now becoming apparent that type 2 diabetes in children is a serious condition and that it is at least as demanding to manage. The chapter on children in the Global Guideline seeks to raise awareness of these problems, which are faced by increasing numbers of families.

Pregnancy

Diabetes increases the risks in pregnancy for both the mother and her infant. However, pre-pregnancy advice where possible, detection of undiagnosed or new (gestational) diabetes in pregnancy, and careful management of diabetes throughout pregnancy, with close liaison between healthcare professionals involved in diabetes, obstetric and neonatal care, can all help to achieve the desired outcome of a healthy mother and baby. The Global Guideline only addresses areas of pregnancy care that are commonly affected by the

Protecting eyesight, feet, and the nervous system

Classically, diabetes complications are thought of as damaging the heart and blood vessels, eyes, kidneys and nervous system. Blood vessel damage, together with nerve damage, leads to foot problems. Protection of the heart, blood vessels and kidneys is dealt with in an earlier article, as is protection of all of these by control of blood glucose levels. Here we describe how disabling problems which are developing in the eyes, feet, and nervous system despite those measures can be managed optimally.

Cardiovascular risk, blood pressure, and kidney damage

People with type 2 diabetes suffer badly from heart disease, strokes, and damage to the blood supply to their feet. Indeed, these cardiovascular conditions are the major causes of ill-health and death in people with the condition. A significant proportion of that ill-health is preventable, including by attention to the levels of fats and sugar in the blood, the clotting tendency of the blood, and blood pressure. Raised blood pressure is also responsible for worsening of eye damage and kidney damage in people with type 2 diabetes, and is therefore particularly well worth treating.

Use of oral glucose-lowering drugs and insulin

It is important not to think of diabetes as being ‘treated’. And it is important not to think of diabetes management as being about lowering blood glucose levels alone. Other aspects of management are important enough to require separate chapters, both in the Global Guideline and in this Supplement. Nevertheless, the control of blood glucose is central to the management of type 2 diabetes, and nearly all people with the condition will need oral glucose-lowering drugs or insulin to help optimize this important cardiovascular risk factor.

Glucose control: measures, levels and monitoring

Blood glucose control is central to the very nature of diabetes, and the late complications which can develop. Unfortunately, it cannot be sensed by the person with diabetes unless levels are very high or very low. Accordingly, blood glucose control has to be measured reliably, and this needs to be done in the clinic and in normal life. Evidently, the results have then to be related to the risks of developing complications – hence targets and intervention levels.

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