Type 1 diabetes education and care: time for a rethink?

Over the last century, the focus of healthcare professionals managing Type 1 diabetes has evolved, from improving shortterm survival to improving long-term survival to reducing complications risk (both macroand microvascular) to improving quality of life whilst achieving all of the above. The tools that assist in these goals are insulin, blood glucose monitoring, medications for vascular risk reduction, professional and patient education and psychological support. Thesetoolshavecomplementaryrolesinachievingthetherapeutic goals, although at given times in our history, ‘fashion’ in healthcare delivery has tended to favour some over others. For example, following the publication of the Diabetes Control and Complications Trial, we concentrated on insulin and insulin regimens, often forgetting the intensive processes that were required to support people. Many programmes have been designed to reduce the anxiety and depression associated with living with Type 1 diabetes [1]. Due-Christensen and colleagues [2], in this edition of Diabetic Medicine, continue the academic search for the programme that will help the struggles that many still face with Type 1 diabetes despite ‘good control’. Their study searches for the elements that we could add to our current care delivery system to reduce the burden of living with Type 1 diabetes. Following diagnosis, many receive ‘intensive’ 1:1 care that helps them develop the skills to administer insulin and monitor blood glucose; this is then followed with ‘regular’ reviews of complication status. Healthcare professionals who have worked with people with Type 1 diabetes know that insulin action is often far from predictable and does not respond exactly as expected, and many of our patients blame themselves for being unable to ‘control’ their blood glucose. We need to use all available advances together if weare to improve theoutcomes for all (rather than some) of our patients, recognizing that, for each individual, one or more of the developments in diabetes care may take priority. Since the initial discovery of insulin, endocrinology-based physicians treating diabetes and pharmacological scientists have tried to produce the ‘best’ insulin possible. Whilst the formulation purity and pharmacological properties of synthetic insulin and insulin analogues, and the means by which these are delivered, have made progressive step changes, it remains true for the majority of patients with Type 1 diabetes that the insulin should be matched to the desired goal. The early attempts to understand insulin action by the use of ‘periodic’ (‘three times a day’; ‘test occasionally before and after meals’) blood glucose monitoring have been recognized as unplanned and unfocused. There is now a more focused strategic approach to self testing. People with Type 1 diabetes are nowexpected to be supported to master the use of self-testing ‘tools’ (meters and strips ⁄ continuous glucose monitoring system) to adjust their insulin in a more informed way. Following the recognition of the challenges of using insulin day to day, clinicians and researchers set out to seek new ways to help people use their insulin more effectively [3–5] and some sought to help people focus on positive emotional responses [6], but, over the last four decades, apart from in a few specialist centres, the way care is delivered to many with Type 1 diabetes has not significantly changed, despite the ever-increasing expectation of improved outcomes. In recognition of Einstein’s defined definition of insanity as ‘doing the same thing over and over again and expecting different results’, it may be time to reflect on how and with which care processes we may offer greater help in reducing the risk of complications, at the same time as reducing the emotional burden. Indeed, it seems that reduction of the emotional burden of diabetes, through programmes such as the one by Due-Christensen and colleagues, may materially assist in the reduction of HbA1c without specific focus on insulin. Helping people gain mastery over their insulin is important, but gaining mastery over emotions and subsequent behaviours is now clearly seen as a means of improving overall health in those with long-term conditions. Given the uncertainties of its action, administering insulin and monitoring its effects on blood glucose are, not surprisingly, linked with anxiety and stress; the physiological responses to stress can lead to fluctuations in blood glucose and the behavioural effects of stress and stressavoidance strategies will also lead to erratic blood glucose. It is not surprising then that researchers have sought to test the effect of programmes to reduce diabetes-related stress [7]. A recent study published in this journal suggests that diabetesrelated distress is the mediating factor between depression and poor glycaemic control [8]. In their study, Van Bastellar et al. also noted that the areas of diabetes-related distress that were most frequently endorsed by the participants were: concerns regarding complications, feelings of guilt about diabetes self care and feeling overwhelmed by their diabetes. Could the way that care is delivered (infrequent 1:1 discussions about ‘improving’ HbA1c) and the ‘routine’ advice we give (your HbA1c is out of target, increase your insulin by 2 units) be responsible for some of the distress in our patients? May we somehow set expectations high and then not provide support, honesty or DIABETICMedicine