The general population needs to know if they are at risk of diabetes, what they can do about their risk and the symptoms of undiagnosed diabetes. There are about five million people in England1 at high risk of diabetes or 12.3 million UK2 residents at increased risk of diabetes. Several online tools can assess the risk of diabetes, such as those on the Diabetes UK website.3
The NHS Diabetes Prevention Programme1 is a nine-month educational resource to help people to reduce their risk of type 2 diabetes, and is the first national diabetes prevention programme in the world. Initial data shows that over the nine months, overweight people lost an average of 3.7 kg,4 which should translate into less risk of developing diabetes, although this is not known for certain yet.
Advertising campaigns for the symptoms of diabetes do significantly increase public awareness afterwards,5 although much undiagnosed type 2 diabetes is asymptomatic.6
The close families of diabetic people also need to know an accurate drug list in case of emergency, and a working idea of a diabetic diet (which is actually a “Healthy Diet” that would benefit most of us). In cases of hospitalisation, one still sees family bringing in inappropriate food and drink such as Lucozade (although Lucozade is a valuable treatment for hypoglycaemia); I would highly commend the diet sheet from The Nutrition Advisory Group for Elderly People (NAGE), a subgroup of The British Dietetic Association, which is straightforward, sensible and not too strict.7
Depending on the patient’s ability to self manage diabetes problems, families might also need to watch at-risk feet, be able to deal with possible hypoglycaemia, monitor glucose levels, and give injections. Often the onus is on the family to become more involved, rather than being approached by the healthcare professional in a semi-routine fashion. This does presume that the family is willing and able to help, and the spouses of elderly people may be poorly able themselves.
Diabetic people need information to manage their diabetes and its complications.
There are now structured education programmes (Level 3) such as DAFNE and BERTIE for type 1 diabetes, DESMOND, and X-PERT Diabetes courses for type 2 diabetes and various locally organised courses.8 These courses concentrate on glucose management, but also include more general diabetes information. There is evidence that these courses improve outcomes.
A systematic review of education in type 2 diabetes, mean age of subjects 60 years, showed that structured education improved fasting blood glucose levels, HbA1c, self-management skills, diabetes knowledge, self-efficacy/empowerment, patient satisfaction and body weight at 12 months.9 However, in the DESMOND programme, initial improvements in weight loss, depression and quality of life were not maintained at three years, although a better understanding of diabetes was maintained.10,11 Perhaps, the education programmes need to be ongoing to reinforce and consolidate the initial gains.
In type 1 diabetes, the Dose Adjustment For Normal Eating (DAFNE) programme had initial improvements in glycaemic control, dietary freedom, quality of life, general wellbeing and treatment satisfaction12 and at seven years, there was still an improvement in HbA1c.13 Unfortunately, there was not a reduction in severe hypoglycaemia.
Another problem is that only 1–12% of diabetic people attend these courses.14 There is also evidence that less formal approaches (level 2) such as face-to-face group-based education, peer-based approaches, and technology and internet-based approaches are useful to some people,15 and many diabetic people and their families find help at diabetes.co.uk, a peer based diabetes forum. Diabetes UK also produces many valuable information sheets (level 1 learning). Although the elderly person may have difficulty using some of these resources, their families could make good use of them.
People with diabetes are best served by having a choice of different education options (in addition to support from healthcare professionals); hence, individuals can identify what best suits their needs, lifestyle and learning style, and therefore engage with the education process. However, it is also important to recognise that some people are less interested in their health and may not engage, no matter what one offers.15
Diabetes education programmes can have long-term benefits on knowledge, psychosocial functioning, glycaemic control, foot care and eye care for diabetic patients. Indeed, analysis of a trial of an educational programme for all ages showed that both young and old improved glycaemic control, but older adults showed the greatest glycaemic improvement.16 However, continual reinforcement may be necessary for maximum benefit in some areas.
Having decided the topics for teaching, requirements for teaching elderly diabetic people would include:17
- Small bites of information
- Large print handout
- Carer involvement
- Demonstrating pens and devices
- Appropriate, quiet environment.
Putting aside one’s feelings about politicians, one cannot but agree with “education, education, education”. The educational resources exist, (particularly with the extra money promised to the NHS by Boris and the Brexiteers); we should support them, develop them and make full use of them. But there are many barriers to overcome.
From a personal point of view, I find it difficult to tell patients the negative picture of increased risk of vascular disease and many other diseases including dementia and malignancy; however, I need to put this in the perspective of the benefits of attaining atherothrombotic goals.18,19
And one still has the problem that people, diabetic and non-diabetic (or not known to be diabetic) may not be interested in engaging with the educational process. How many educators does it take to change a light bulb? One, but the light bulb has got to want to change.20
Dr Simon Croxson is a Consutant Physician specialising in diabetes in older patients.
A longer read called Diabetes Knowledge: could do better, try harder is available.
1. NHS England. NHS Diabetes Prevention Programmehttps://www.england.nhs.uk/diabetes/diabetes-prevention/
2. Diabetes UK. Facts and Figures. https://www.diabetes.org.uk/professionals/position-statements-reports/statistics
3. Diabetes UK. https://www.diabetes.org.uk/professionals/diabetes-risk-score-assessment-too
4. Wise J. NHS diabetes prevention programme helps weight loss, analysis shows. BMJ 2018; 360 :k1196
5 Singh B M, Prescott J J W, Guy R, W, et al. Effect of advertising on awareness of symptoms of diabetes among the general public: the British Diabetic Association Study. BMJ 1994; 308: 632
6. Croxson SCM, Burden AC. Polyuria & polydipsia in an elderly population: its relationship to previously undiagnosed diabetes. Practical Diabetes International 1998; 15(6): 170–72
7. Diabetes UK. Diabetes self-management education. https://www.diabetes.org.uk/professionals/resources/resources-to-improve-your-clinical-practice/diabetes-self-management-education
8. BERTIE. Welcome to the BERTIE Type 1 Diabetes Education Programme. https://www.bertieonline.org.uk
9. Steinsbekk A, Rygg LO, Lisulo M, et al. Group based diabetes self-management education compared to routine treatment for people with Type 2 diabetes mellitus. A systematic review with meta-analysis. BMC Health Services Research 2012; 12; 2131
10. Davies MJ, Heller S, Skinner TC, et al. Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed Type 2 diabetes: cluster randomised controlled trial. British Medical Journal 2008; 336; 491–9
11. Khunti K, Gray LJ, Skinner TC, et al. Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed Type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. British Medical Journal 2012; 344: e2333
12. DAFNE Study Group. Training in flexible, intensive insulin management to enable dietary freedom in people with Type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial. British Medical Journal 2002; 325; 746
13. Gunn D, Mansell P. Glycaemic control and weight 7 years after Dose Adjustment For Normal Eating (DAFNE) structured education in Type 1 diabetes. Diabetes Medicine 2012; 29(6); 807–12
14. Diabetes UK. Diabetes education: the big missed opportunity in diabetes care. https://diabetes-resources-production.s3-eu-west-1.amazonaws.com/diabetes-storage/migration/pdf/Diabetes%2520UK_Diabetes%2520education%2520-%2520the%2520big%2520missed%2520opportunity_updated%2520June%25202016.pdf
15. Wenzel L. Informal and flexible approaches to self- management education for people with diabetes Kings Fund Report commissioned by Diabetes UK, 2016.https://diabetes-resources-production.s3-eu-west-1.amazonaws.com/diabetes-storage/migration/pdf/
16. Beverly EA, Fitzgerald S, Sitnikov L, et al. Do Older Adults Aged 60–75 Years Benefit From Diabetes Behavioral Interventions? Diabetes Care 2013; 36(6): 1501–506
17. Croxson SCM, Johns H, Jones E. Education of the older person with diabetes. International Diabetes Federation Bulletin 1997; 42(2): 24–26
18. Shi, Qian, et al. Long-term outcomes associated with triple-goal achievement in patients with type 2 diabetes mellitus (T2DM) Diabetes Research and Clinical Practice; 140: 45–54
19. Croxson SCM. Hypoglycaemia, and the older person. Hawthorn G (Ed). In: Diabetes Care for Older patient; A practical handbook London; Springer-Verlag; 2012, pp 55–74
20. Blair, Tony. Full text of Tony Blair’s speech on education. Guardian 23/05/2001 https://www.theguardian.com/politics/2001/may/23/labour.tonyblair