Volume 12 Number 4, 1999, Page 195
Dreams for the New Millennium
Trisha Dunning, RN, MEd, FRCNA
"It is more important to know what sort of person has a disease than to know what sort of disease has a person."Hippocrates 450-360 B.C.
At the dawning of the Age of Aquarius, it is timely to reflect on where we have come from in order to plan where we are going. The past 100 years have seen great strides in understanding fuel homeostasis and the pathophysiology of diabetes. Insulin has ensured survival for people with type 1 diabetes. Oral hypoglycemic agents have given us the potential to control type 2 diabetes. With increased survival rates and the consequent longer duration of diabetes have come long-term complications and the personal and economic burdens they represent.
Three major, diabetes-specific events in the past 50 years drive current management. First, research demonstrated the importance of normoglycemia and blood pressure control in preventing long-term complications1,2 and gave us accurate methods of monitoring blood glucose control. Second, technological advances led to improved management, education, and communication strategies. Third, economic rationalism emerged as a world priority. Although all three events have many positive features, they place huge burdens on people with diabetes and represent increased accountability for health professionals to aim for the best diabetes management possible. In addition, the community is better informed about their health care options and expect more of health services.
Despite the research and better treatment methods and education, morbidity and mortality associated with diabetes has not significantly decreased. We face 2000 knowing:
These factors imply that management strategies to identify and apply practices that promote healthnot just treat diseaseare needed to improve outcomes.
Clinical experience tells us that we do not achieve good control in a great many cases, that diet plus exercise plus medication does not equal good control. Although many of the barriers to good control have been identified, the resources to overcome them are often lacking. In fact, cost cutting and budget restraints may contribute to the overall cost of diabetes.3 The question is, can we afford the cost of good control? We must also consider its corollary, can we afford the cost of inadequate control?
Diabetes cannot be understood only as applied biochemistry. The effects of social and psychological factors on individual health behaviors and the effects of diabetes on quality of life must be addressed if we are to make a real difference to diabetes outcomes in the next millennium.
Psychological and social research findings should be promoted and incorporated into practice with the same vigor with which we adopt the results of metabolic research.
Inadequate control is associated with depression. Some degree of depression is common in people with diabetes. It often goes unrecognized and is inadequately treated. Depres-sion contributes to inadequate blood glucose control. Improved control reflects improved mental outlook and quality of life.4 Perhaps depression should be included on the list of diabetes complications, and mental status should be monitored as part of the complications screening process.
Psychological research, especially in the last decade, has emphasized the importance of personal empowerment in achieving good control. Empowerment is a complex issue. Even when individual goals and priorities are considered, the resources may not be available to support empowerment-based management strategies. Where resources and support are scarce, health professionals are also disempowered. The challenge for health professionals is to deliver individual, holistic care in the face of cost containment and in situations in which basic treatment requirements, such as insulin, are not available.
The pattern of modern life involves competition and power relationships. The future requires an environment of cooperation and collaboration, in which available resources are equitably shared and duplication is avoided. Global trade and competition agreements and the amalgamation of pharmaceutical companies will affect future health policies, service delivery, and costs. Partnerships already established between industry and diabetes organizations will be an important aspect of service delivery and education.
The need to address community health issues is embodied in much of the world's public policies. The question is, can we link population needs with individual priorities in health promotion and prevention strategies? Is it time to look outside the world of diabetes for some of the answers? What can advertising and marketing skills contribute? Should business and marketing skills be included in health professional training programs? After all, informing a person about diabetes is essentially selling an unattractive product to a reluctant buyer.
The essential unit of diabetes care is an effective, trusting relationship between health professionals and people with diabetes. Better outcomes are reported where care relationships exist.5 Such relationships involve learning from, as well as about, people with diabetes and from each other as well as from experts.
Complementary philosophies have a great deal to teach us about therapeutic relationships and the factors that contribute to health and well-being. The increasing public interest in and utilization of complementary therapies, especially by those with chronic diseases, means that we must at least ask about their use and keep an open mind in order to give appropriate advice.
Many types of treatment exist within the complementary health care field. Some, such as massage, contribute to improved metabolic control by decreasing stress and improving well-being. In many parts of the world, these treatments are only "complementary" where "orthodox" medicine is the dominant system. Hiding behind the catch cry "complementary therapies are not scientifically proven" is no longer appropriate. This head-in-the-sand approach will not encourage people to disclose the use of complementary therapies to their orthodox care providers and can result in adverse drug interactions, trauma, and delayed treatment for illnesses and complications. The climate is right to explore the integration of both systems to develop truly holistic models of care.
The new millennium is a perfect time for reflection. Maybe we need to change the emphasis from "cure" to "care," to use "holistic management" rather than "blood glucose control," and to focus on the benefits of control, rather than on treatment and control itself. Helping health professionals and people with diabetes find ways to cope may be as important as striving for optimal control.
Research, both qualitative and quantitative, offers exciting possibilities for the future. At present, the diligent application of what we know is vital. Not all care will be successful, nor will it always occur in ideal situations. The challenge is to do the best we can with what we have and to work together to continually improve what we have. Good care begins when a person is ready to accept it. The challenge for health professionals is to prepare for that time and then to seize the day.
1The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications of insulin-dependent diabetes. N Engl J Med 329:977-86, 1993.
2UK Prospective Diabetes Study Group: Cost-effectiveness analysis of improved blood pressure control in hypertensive patients with type 2 diabetes: UKPDS 40. Br Med J 317:720-26, 1998.
3Assal J, Albeanu A, Peter-Reisch B, Vaucher J: The cost of training a diabetes mellitus patient: effects on the prevention of amputation. Diabetes Metab 19(Suppl 5):491-95, 1993.
4Mazze R, Lucido D, Shamoon H: Psychological and social correlates of glycemic control. Diabetes Care 7:360-66, 1994.
5Heymann J: Building partnerships with patients. Ann Allergy Asthma Immunol 78:1-4, 1997.
Trisha Dunning, RN, MEd, FRCNA, is a clinical nurse consultant in diabetes education in the Department of Diabetes and Endocrinology at St. Vincent's Hospital in Victoria, Australia.
Copyright © 1999 American Diabetes Association
Last updated: 12/99