Individualised Care; what does that really mean? When we have someone sitting in our consulting room who has been newly diagnosed, how do we approach their diabetes in a way that will help and motivate them?
I was both surprised, and at the same time encouraged, to read an article in the current Diabetes in Primary Care journal that focuses on this very issue and in particular that of dietary advice at this stage of someone’s diabetes journey.
I have been intrigued with Professor Roy Taylor’s research and the books written by Michael Mosley, which explain the science behind the way so-called ‘blood sugar’ diets take effect.
A few of my colleagues have expressed concern or, at best, reservations about the potential these diets presents to our numerous weight-challenged patients. They seemed surprised that Diabetes UK were supporting such a move.
Just under a year ago, I wrote about this possible dietary change and, at the time, had a few patients who had embarked on the ‘8-week blood sugar diet’, as Michael Mosley has called it.
I have one patient who has come off all his diabetes medication and reduced his Hba1c down to 37mmol/mol by undertaking this diet and increasing his physical activity. I have another patient who was really struggling to control his diabetes with maximum oral medications and who was very reluctant to have to take insulin.
The last time I saw him, his Hba1c was much improved; his blood sugars had dropped significantly day to day and he had lost weight, as well. He has not been able to come off medication, but this may well be related to other factors, such as the length of time since diagnosis.
When I discussed this diet with our team’s supervising consultant, he was of the view that if individuals were keen to try it, we could support them but we could not suggest this as a way forward.
When it comes to helping people to address the issue of increasing their physical activity, are we able to ‘think outside of the box’? I have learnt over my years involved in diabetes care that what I enjoy as physical activity, may be totally beyond the grasp of many. Teaching DESMOND education has helped with this, and so if someone has a Wii Fit and this encourages greater activity, then I believe that I must support them with this.
NICE Guidance for Type 2 Diabetes management also emphasises the need for individualised care, in our choice of medications? How easy is this to do really? We find ourselves having to defend our positions to medicines management teams from our CCGs who tell us all the time how we need to save money? If we are trying to personalise care, we may recommend certain medications for one person at second or third line, where with someone else we might not even consider it. One example is the use of Gliclazide and other sulphonylureas, which are great if we are trying to reduce Hba1c and blood sugars quickly, but long term may promote weight gain and lead to hypoglycaemic episodes, and interfere with peoples’ ability to drive safely.
Recently, I was presented with a man in his forties, for whom Metformin seemed to benefit very little. As someone who has not been keen to use gliclazide routinely, I had to think this through carefully. We added in gliclazide, and at even a low dose of 40mg once daily, it was bringing sugars that had been top teens and 20s down to 4s and 5s. This man is a keen sportsperson and keeps himself very active. Now on just 30mg Gliclazide (slow release) per day, his issues with weight gain are minimal and he is not getting hypos.
All the time we need to address individual issues and be prepared to work outside what may be our comfort zones.