Thursday, 23 September 2010

Type 2 diabetes

Sausages cooking on a grill
The days are whizzing by, and I'm starting to feel threatened by the looming start of term, and the need to buckle down for another semester of university life.

Each year has been marked by a significant increase in the difficulty and intensity of the work, and a raising of the expected standard. I've been told that this year should be easier than last year, although I'm not sure why that should be true, other than half of this semester will be taken up by my 'research'. I suppose that should be less stressful than lectures and exams because I will be in control of progress, and also because I already have an interest in the research task and its outcomes.

In my last remaining days of freedom I have been engaged in a university-related task. One of my lecturers is doing a PhD about the value of communications skills in the dietetic consultation. As part of this work she is video recording qualified dietitians carrying out a consultation with a simulated patient before and after they go on a communications skills training course. The different styles of communication that I found within the group of dietitians I was shadowing over the summer was one of the most interesting parts of the placement for me, so when she asked me to act as one of the simulated patients, I was very happy to agree.

There were two qualified dietitians to video, and this was the session before their course. I was pretending to be a patient newly diagnosed with type 2 diabetes, and I was given a scenario containing all the details of my history and condition that I needed for consistency.

Both of the consultations were all right, I suppose. The assessment was not about the accuracy of the information or advice given, but about the manner in which the meeting was conducted, and the effectiveness of the communication. Which was a good thing, because unqualified though I am, I'm sure that both of them actually gave me incorrect information about healthy eating for type 2 diabetes. To be fair, one was a paediatric dietitian and the other a renal dietitian, so they don't routinely give advice specifically about type 2 diabetes.

It was very illuminating to be on the receiving end of a consultation, rather than observing or leading. I learned a few powerful lessons from this experience that I hope to implement in my future dietetic practice.

The first is to concentrate on the key messages, and try not to introduce extraneous material. Treatment of diabetes is about helping the body deal with the blood sugar that comes from sugary food and starchy carbohydrate. The main methods are by drug treatment, by diet and by exercise. Stick to these, and explain them well, and that's enough.

The second, and more important message, is to talk about what is now happening rather than what might be. The drug prescribed for type 2 diabetes in my scenario helps the endogenous insulin remove glucose from the blood rather than stimulating pancreatic insulin production, and so cannot cause hypoglycaemia. So don't mention hypoglycaemia, it's not relevant, and will just introduce another bit of information and potential concern for the already overloaded patient.

That last phrase is also the key to an effective consultation from my vantage point as the patient. There's a lot of information and advice that can be given in a consultation, but any more than three things is too many. In both the consultations, I felt the dietitian did more talking than listening. It would have been much more useful to have a clearer description of just a few things than the large amount of confusing stuff that I was given.

So the things I think might feature in a consultation with a type 2 diabetes patient might be:
  1. A very simple and basic description of the condition:
    Some of the food we eat is turned into sugar, transported around the body in the blood and used for energy when required. Insulin is the substance that enables sugar to be taken from the blood and used for energy. A diagnosis of type 2 diabetes means that there is too much sugar in the blood, either because there is not enough insulin being produced, or because our insulin is not acting as well as it should.

  2. How any prescribed medication works:
    Either it helps the body to produce more insulin, or makes the insulin there is work better.

  3. Why it is helpful to work towards a healthy weight (if the patient is overweight):
    If blood sugar is to be used effectively for energy, it must get out of the blood through a 'door' into cells. Insulin is the key, but the body provides the lock. Excessive weight can distort the shape of the lock, so that the insulin key doesn't work as well as it could. Losing weight removes some of the distortion, so insulin works better. Losing weight may allow medication to be reduced.

  4. The role of physical activity and diet in weight management and control of blood sugar:
    Physical activity also removes some of the distortion in the 'lock' so that blood sugar can get out of the blood and produce energy. It also helps with weight loss. A healthy diet can also help you lose weight, and the types of foods eaten will affect the control of blood sugar as well.

  5. Specific aspects of diet, tailored to the individual patient:
    This is where a diet history is useful, to see what the patient's normal diet looks like so that appropriate suggestions can be made. Examples would be:
    - avoid sugary food and drinks, or replace them with sugar-free alternatives if possible
    - eat plenty of salad and vegetables, and some fruit
    - eat starchy carbohydrate foods in moderation, but include some in every meal.
    There should be no more than three specific recommendations for action as a result of the consultation. It is best if they are proposed by the patient, rather than by the dietitian.
On my last placement I had no opportunities at all to observe dietitians or work with patients with type 2 diabetes. The nearest thing was my session on gestational diabetes. I am hoping to be able to get this experience on my final placement, when I shall look back at this list to see how right or wrong I was.

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