Treating Type 1 Diabetes

People with Type 1 diabetes administer themselves with insulin and monitor their own blood sugar levels.

Following the initial diagnosis, people with Type 1 diabetes will be referred to the diabetes care team who will draw up a care plan to cover the first few months.

The care team will also carry out the following checks to find out more about the individual's condition and needs:

• to make sure the symptoms are not being caused by another condition;
• to see if the patient has any other medical conditions or is taking any other medicines that might affect treatment or the results of any tests;
• any other things that might make the patient at risk of having problems with blood vessels (such as smoking);
• on the health of the eyes, heart, feet and kidneys that could be affected by diabetes later.

Patients will also be asked about:

• their home and work life and leisure time activities;
• their food preferences and daily diet;
• the kind of exercise (if any) that they take;
• their feelings about diabetes and their role in managing it;
• any other things that may affect the way that their diabetes is managed.

The care plan should be put together on the basis of the above and should incorporate the patient's views and preferences. The plan should contain the following:

• details of the sessions where the patient can learn more about diabetes;
• details of how the diabetes is to be managed and how the patient is going to check his or her own blood glucose levels;
• details of how members of the diabetes care team may be contacted and how often the patient should see someone;
• arrangements for managing the risk of any clinical complications that may arise.

Patients should be encouraged to give feedback about their care plan and to put forward any amendments that they may wish to make.

Insulin

People with type 1 diabetes have to inject themselves with insulin every day in order to control their glucose levels. Different people have different needs and preferences which is why the care team should spend time devising an individualised insulin regime and agreeing this with the patient.

There are five main types of insulin:

• rapid acting insulin analogues which aim to work like the insulin normally produced to cope with a meal- their effect falls away quickly;
• short-acting insulins which work more slowly, their effects last for up to 8 hours;
• intermediate-acting insulins which have an effect that lasts longer and can last through the night;
• long-acting insulins which have an effect that can last for a longer period eg a whole day;
• biphasic insulin is a mixture of rapid or short acting and intermediate acting insulins:

Diet and nutrition

A person's diet has an effect on blood glucose levels. For this reason, patients should be given dietary advice according to their lifestyle and personal food preferences. This advice should be given at the time of diagnosis and updated regularly.

In addition, programmes should be made available to enable patients to make choices about the variety of foods that they wish to consume and insulin dose changes needed to reduce raised glucose levels when taking different quantities of those foods.

Information should be given to patients on-

• effects of different alcohol-containg drinks on blood glucose and calorie intake;
• use of high calorie and high sugar treats;
• use of foods of high glycaemic index (those foods that are known to raise blood glucose levels).

Nutritional advice should be modified if any of the following are present:

• excess weight and obesity;
• underweight;
• eating disorders;
• raised blood pressure;
• renal failure.

Patient Education

Patient education is viewed as a cornerstone of diabetes care because people administer their own insulin and monitor their blood sugar levels. Self-management requires both skills and knowledge and efforts are made to ensure that patients' knowledge are regularly updated.

The NICE guidance recommends that "a programme of structured education covering all major aspects of diabetes self-care and the reasons for it should be made available to adults with Type 1 diabetes in the months after diagnosis and periodically thereafter". The US standards for diabetes self- management education indicated the follwing content areas for an education programme:

• describing the diabetes disease process and treatment options;
• incorporating appropriate nutritional management;
• incorporating physical activity into lifestyle;
• utilising medications (if applicable) for therapeutic effectiveness;
• monitoring blood glucose and urine ketones (where appropriate) and using results to improve control;
• preventing, detecting and treating acute complications;
• preventing (through risk reduction behaviour), detecting and treating chronic complications;
• goal-setting to promote health, and problem-solving for daily living;
• integrating psychosocial adjustment to daily life.
• promoting preconception care, management during pregnancy and gestational diabetes management.

The NICE guidance lists the following as appropriate components of an education programme for people with Type 1 diabetes.

Around the time of diagnosis:

• the aims of management and outcome of good self-management;
• self-injection and self-monitoring skills;
• nutritional information for people on insulin injection therapy;
• detection and management of hypoglycaemia;
• establishing healthy lifestyle.

In the period following diagnosis:

• reinforcement of above;
• use of professional advisors and the healthcare system;
• integration of flexible eating and insulin dosing;
• goals of self-management;
• long-term risks and their amelioration (including arterial risk);
• management of intercurrent illness and developing complications;
• role of preventative therapeutic interventions, side effects and importance;
• lifestyle issues including employment, travel (including across time zones), driving;
• contraception, pregnancy and children.

In the longer term:

• self-care of late complications including foot care;
• reinforcement based on annual review of need;

The guidance goes on to recommend that education programmes should be flexible so that they can be adapted to "specific educational, social and cultural needs". They should include modules designed to empower adults to participate in their own healthcare through:

• enabling them to make judgements and choices about how they effect that care;
• obtaining appropriate input from the professionals able to advise them.

It is recommended that professionals involved in the delivery of diabetes care should consider incorporating "educational interchange" at all instances of contact with a person with Type 1 diabetes.

Self-monitoring of blood glucose levels.

Shortly after diagnosis people with Type 1 diabetes will be given instruction as to how to monitor their own blood glucose levels, they will be told about the different options and encouraged to choose the one that suits them best.

Blood is taken from the fingertips - it is not yet known whether other sites on the body will give reliable results.

The patient's doctor will agree a target blood glucose level which will be normally within the range of 4.0-7.0 mmol/litre before food and under 9.0 mmol/litre after food.

Patients will need to be aware that major life events can have an effect on their blood glucose levels.

At the patient's annual review the self-monitoring equipment will be checked and the patient's experience of self-monitoring will be reviewed.

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