Diabetes education in the USSR: how to begin?

[History of patient education for chronic diseases (with diabetes mellitus as an example): from an idea to the branch of modern medicine]

The article describes the history of the formation of therapeutic education as one of the most essential components of the treatment of chronic diseases, in particular diabetes. The varieties and methods of programs for patients existing in the Russian Federation are considered in detail.

Effectiveness and cost-benefit analysis of intensive treatment and teaching programmes for type 1 (insulin-dependent) diabetes mellitus in Moscow--blood glucose versus urine glucose self-monitoring

In a prospective controlled trial the effects of a 5-day in-patient treatment and teaching programme for Type 1 (insulin-dependent) diabetes mellitus on metabolic control and health care costs were studied in Moscow. Two different intervention programmes were compared, one based upon urine glucose self-monitoring (UGSM, n = 61) and one using blood glucose self-monitoring (BGSM, n = 60). Follow-up was 2 years. A control group (n = 60) continued the standard treatment of the Moscow diabetes centre and was followed-up for 1 year. Costs and benefits with respect to hospitalizations and lost productivity (according to average wage) were measured in November 1992 rubles (Rb.), with respect to imported drugs and test strips in 1992 German marks (DM). In the intervention groups there were significant decreases of HbA1 values [UGSM: 12.5% before, 9.4% after 1 year, 9.2% after 2 years (p < 0.0001); BGSM: 12.6% before, 9.3% after 1 year, 9.2% after 2 years (p < 0.0001) compared to no change in the control group (12.2% before, 12.3% after 1 year)], and of the frequency of ketoacidosis. The frequency of severe hypoglycaemia was comparable between the UGSM (10 cases during 2 years), BGSM (10 cases during 2 years), and the control group (8 cases during 1 year).(ABSTRACT TRUNCATED AT 250 WORDS)

Association of blindness to intensification of glycemic control in insulin-dependent diabetes mellitus

Intensive glycemic control (IGC) in previously hyperglycemic insulin-dependent diabetes mellitus (IDDM) patients is associated with a decreased long-term risk of progression of diabetic retinopathy (DR); up to 12 months after institution of IGC, however, the risk of progression of DR transiently increases. In an observational study, a cohort of 122 patients with IDDM was followed prospectively for changes in glycosylated hemoglobin (HbA1, normal < 8%) and in DR 0-12 months after institution of IGC. In six of these patients (women, mean age 24 years, duration of diabetes 14.3 years, with incipient nephropathy and retinopathy) a total of seven eyes went blind after 6-12 months of IGC, despite laser coagulation treatment. From the whole sample, a control groups of eight patients (six women) was set up, matched for age, duration of IDDM, degree of retinopathy, visual acuity, blood pressure, and microalbuminuria, with preserved vision after 12 months of IGC. In the case patients, the mean (95% confidence interval) initial HbA1 was 14.9% (13.8%-16.1%), versus 13.4% (12.4%-14.4%) in the control patients (p < 0.05). The mean HbA1 decrements after 4 months of IGC, were 3.0% (1.9%-4.1%) in the cases, and 2.1% (1.2%-3.0%) in the controls (NS); and after 12 months, the respective decrements were 4.9% (2.4%-7.4%) in the cases versus 2.0% (0.5%-3.5%) in the controls (p = 0.04). In conclusion, IGC with a decrement of > 2% per year is associated with a high risk of progression of antecedent diabetic retinopathy to blindness in IDDM patients with an extremely high initial HbA1.(ABSTRACT TRUNCATED AT 250 WORDS)

Diabetes education and insulin therapy: when will they ever learn?

The Diabetes Education Study Group of the European Diabetes Association was founded in 1979 with its major goal to make effective patient training an integral part of any diabetes therapy. However, even today, in many places diabetes education is not an obligatory part of treatment, but is regarded as an optional service to the patient which is frequently fragmentary and haphazard. On the other hand, many physicians still subject their patients to rigid dietary instructions and obedience training, an approach which is mistaken for diabetes education. Several misconceptions about diabetes education keep counteracting the spread and hence the availability of effective treatment and teaching programmes for all Type 1 diabetic patients. One such misconception is that diabetes education could compensate for deficiencies of inappropriate insulin treatment regimens. Studies failing to demonstrate the impact of diabetes education on metabolic control, typically used an insulin treatment regimen with only one or two insulin injections per day, the predominant use of intermediate acting insulin preparations, and without (day-to-day) adjustment of insulin dosages by the patients themselves. A further reason for a lack of success of diabetes education is an unstructured approach which is frequently mistaken for individualized care. The deleterious effects of putting patients on intensified insulin therapy without offering them sufficient and systematic training have manifested themselves at various places by an excessive increase in the risk of severe hypoglycaemia, and of ketoacidosis during therapy with continuous subcutaneous insulin infusion. The effective and safe performance of insulin therapy requires both a rational system of insulin substitution and intensive training of the patients to carry it out. The injection of regular insulin before main meals and the use of intermediate or long-acting insulin preparations for the substitution of basal insulin requirements combined with daily metabolic self-monitoring and (day-to-day) adaptation of insulin dosages by the patients themselves allow a substantial improvement of glycaemic control without an increase in the risk of severe hypoglycaemia and the adoption of a more flexible life style largely freed from forcing and directive dietary and other impositions. Each diabetes centre should continuously evaluate the quality of care offered to their patients as a basis for a specific and systematic improvement of its treatment and education programmes. Such quality control measures must include a recording of the patients' degree of metabolic control and the frequencies of severe hypoglycaemia and ketoacidosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Diabetes education: whose priorities are met?

Two hundred Type 2 diabetic patients newly referred to the diabetes centre at a large university teaching hospital were studied over an 8-month period. Patients completed a diabetes knowledge questionnaire, and specified their educational priorities by selecting six diabetes-related topics from a list of 14. After giving 1 h of individual education and using the same list, the educators selected six topics which they considered to be most important for that particular patient to know. Choice of educational priorities differed between the patients and the corresponding educator (p less than 0.001). In only 38% of cases did the educators' first three priorities coincide with those of the patients. The major discrepancies were in the selection of 'sick day management' and 'complications', especially favoured by patients, as against 'oral hypoglycaemic agents' and other therapy-related topics, especially favoured by educators. Diabetes knowledge was a determinant of educational priority for patients (p less than 0.001) but not educators. In contrast, only the educators' overall choices were affected by duration of diabetes (p less than 0.001). Diabetes treatment type influenced both patients' and educators' selection of priorities (p less than 0.001). We conclude that an educational strategy which relies on health professionals' perceptions to determine what diabetic patients need to know may be inadequate.