Abuse is a complex psychosocial problem that affects large numbers of adults as well as children throughout the world.

It is listed in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR) must be prepared to discuss personal values and preferences. Both accept shared responsibility for the treatment decisions. A successful clinician-patient relationship built on mutual trust allows the model to be adapted flexibly to the situation. Development of a serious acute illness might shift the emphasis towards Professional choice, whilst the need to choose a hospital for non-urgent cataract surgery might be purely a Consumer choice. Targets Treatment targets are often recommended for the entire population with diabetes, but in fact should be tailored to different patient types depending on co-morbidity, life expectancy, patient preferences and other factors. Discussing personalised goals with the patient and sharing responsibility for keeping within targets is an important step in successful control of risk factors. Generally: aim for HbA1c =7.0% (53 mmol/mol) in all patients and =6.5% (48 mmol/mol) in the majority; keep blood pressure =140/80 for everyone and =130/80 if possible; control total serum cholesterol to =4.0 mmol/l and LDL cholesterol to =2.0 mmol/l. This is particularly important in type 2 patients with established cardiovascular disease or risk factors for it. In practice, this includes the majority with type 2 diabetes (see Chapter 5). Realistic weight reduction targets should be set. Gradual, sustainable weight loss is far more beneficial than sudden loss, which is initially encouraging but then demoralising when the weight returns. The same applies to physical activity, which should be gradually increased to a moderate level over a period of time. Some targets are easier to achieve than others (Table 3.2). Controlling blood pressure and lipids is usually possible provided the individual concords with prescribed drug therapy. The more difficult areas are those requiring self-management skills and lifestyle change. Glycaemic targets may need adjusting based on risk of hypoglycaemia, and hypoglycaemia awareness. A frail, elderly patient may have different needs and priorities to a younger, more active individual (Box 3.2). Table 3.2 Type 2 diabetes meeting the needs. Readily achieved Difficult to achieve Blood pressure control Durable control of glycaemia Lipid management Post-prandial glucose levels Screening for complications Abdominal obesity Glycaemic control in early stages of disease Smoking cessation Physical inactivity Box 3.2 Key attributes to nurture in our patients Knowledge about the condition, and how it may affect them now and in the future Ownership of their diabetes Shared responsibility for decision making The confidence to plan changes and take control Trust in us to act for their benefit Main issues to cover in the firstStructured education As well as regular input from the practice team, patients may benefit from entering a structured education programme. This is particularly valuable following diagnosis but can be offered at any time. In the UK, available programmes include DESMOND and The Diabetes Manual (for type 2 patients) and DAFNE for type 1

patients. DESMOND (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed) is an educational package to help people with type 2 diabetes, particularly those who are newly diagnosed. It has been shown to have benefits on weight loss and smoking cessation and positive improvements in beliefs about illness. All aspects of self-management are covered, in a group setting. The Diabetes Manual is also designed for type 2 patients but involves one to one education and is therefore suitable for those who prefer to avoid group education settings. In addition to a comprehensive manual, audiotapes are provided, and practice nurses are trained to deliver the educational material. DAFNE (Dose Adjustment For Normal Eating) is a 5-day training programme for people with type 1 diabetes. It involves learning accurate carbohydrate counting and adjustment of insulin doses according to need. It is suitable for well-motivated patients whose diabetes is less than adequately controlled, who have been diagnosed for at least 6 months, and who are prepared to monitor four to six times a day and inject frequently using a basal bolus regimen. It is based on the idea that tailoring insulin doses to the person s usual diet (which is in principle unrestricted) is the best way of achieving glycaemic control without increased hypoglycaemia. It has been consultation The biochemical basis for diabetes in lay terms (raised blood sugar, insufficient insulin, body not responding to insulin properly) Diabetes can cause problems with a number of organs and body systems, which can be prevented through a joint effort between the patient and the practice team Controlling blood glucose levels reduces the chances of complications of diabetes, but controlling blood pressure and cholesterol are equally important The importance of lifestyle: weight control and exercise not only reduce blood glucose, blood pressure, and cholesterol, but also make the body s own insulin work more effectively Realistically, over time there is a tendency for the glucose levels to rise further, so that medication usually needs to be stepped up as time goes by, even in the patient who does everything right . It is important that patients don t feel demoralised by such an escalation (Box 3.3) Mention in outline the range of treatments lifestyle change, tablets, insulin. Discuss insulin in a positive way (even though not needed now) and not as a last desperate resort . This will help in future if the time comes when it is needed Refer to lifestyle or dietary changes rather than to dieting to avoid the patient believing that their treatment will involve a strict crash diet that they are unlikely to sustain Box 3.3 Lifestyle changes and drug therapy Lifestyle change is important for the majority of patients, but some may feel disinclined to change their behaviour if they are immediately prescribed drug therapy. A period of behavioural adaptation following diagnosis before drugs are commenced may be beneficial unless the indication is strong. Three months is the traditional interval Interactions Patients should always tell their doctor and dentist when they are taking barbiturates. Barbiturates should generally not be taken with other drugs used to treat mental disorders. There are a number of drugs that barbiturates should

not be combined with because the barbiturates may increase the metabolism of these drugs and thus, reduce the amount of these drugs available to be of benefit. These drugs include oral corticosteroids such as predisolone, methylprednisolone, prednisone, or dexamethasone, estrogen and oral contraceptives, blood-thinning medications such as warfarin (Coumadin), the antibiotic doxycycline (Vibramycin), and anticonvulsants such as phenytoin (Dilantin). Barbiturates should not be combined with alcohol because the combination produces additive depressant effects in the central nervous system. Barbiturates may lower the amount of absorption of the vitamins D and K. Resources BOOKS Consumer Reports Staff. Consumer Reports Complete Drug Reference. 2002 ed. Denver: Micromedex Thomson Healthcare, 2001. Ellsworth, Allan J., and others. Mosby s Medical DrugAbuse is a complex psychosoci al problem that affects large numbers of adults as well as children throughout the world. It is listed in the Diagnostic and Statistic Manual of Mental Disorders (DSM-IV-TR) under the heading of Other Conditions That May Be a Focus of Clinical Attention. Although abuse was first defined with regard to children when it first received sustained attention in the 1950s, clinicians and researchers now recognize that adults can suffer abuse in a number of different circumstances. Abuse refers to harmful or injurious tlude not only the direct costs of immediate medical and psychiatric treatment of abused people but also the indirect costs of learning difficulties, interrupted education, workplace absenteeism, and long-term health problems of abuse survivors.Autoantibodies in type 1 diabetes Islet cell autoantibodies are present at diagnosis but will gradually decline and disappear in ensuing years. This means that if there is diagnostic uncertainty, islet cell antibodies can be checked early during presentation. Specific tests have been devised recently including anti-GAD (glutamate decarboxylase) antibodies and also anti-IAP (inhibitor of apoptosis protein) antibodies. The presence of both together is associated with a significantly higher risk of developing type 1 diabetes. The use of these tests in clinical practice is restricted to situations where there is doubt about the diagnosis of the type of diabetes and to distinguish from type 2 diabetes. Clinically, the implication is that if the tests are negative the patient might then not require insulin. Attempts to prevent type 1 diabetes in these susceptible individuals has thus far not proved successful. Type 2 diabetes Type 2 diabetes is a complex heterogeneous condition and recent genetic studies have revealed numerous sub-types. Children presenting with mild hyperglycaemia present diagnostic problems as they may have latent slowly progressing type 1 diabetes. These children may then progress to requiring insulin. On the other hand, with increasing prevalence of obesity more children are now presenting with type 2 diabetes, particularly from ethnic minorities. In the USA, in some areas, up to 50% of children with diabetes are now presenting with the type 2 form.

Latent autoimmune diabetes in adults (LADA) is thought to comprise about 5% of all patients with type 2 diabetes. These people have autoantibodies usually seen in type 1 diabetes, but their clinical presentation is like someone with type 2 diabetes. This is a group that may present an excellent opportunity for subsequent prevention of diabetes if an effective intervention can be developed to prevent further beta cell destruction. Monogenic diabetes (previously referred to as maturity onset diabetes in the young, MODY) Monogenic diabetes is the term used for a collection of conditions that cause diabetes now shown to result from single gene defects. One feature of these conditions is that they show autosomal dominant inheritance patterns where the disease appears to be vertically transmitted (e.g. through several generations). It is also diagnosed before the age of 25 years, but, unlike type 1 diabetes patients, monogenic diabetes patients do not often require insulin for at least 5 years after diagnosis. Genetic testing in these cases can confirm the particular sub-type of diabetes. This can have significant clinical implications. Patients with HNF1a (hepatocyte nuclear factor 1a) mutations, for example, exhibit exquisite sensitivity to sulphonylureas and can be successfully treated with tablets. Knowledge of the mutation, therefore, can help in the management of this disorder, even in children who would otherwise have been put onto insulin. This is also one form of type 2 diabetes where we would use a sulphonylurea in preference to metformin when initiating therapy. Patients with HNF1 have renal cysts. Patients with glucokinase mutations are less common but the diagnosis is significant for the individual and their families. Such patients are much less likely to develop complications of diabetes because they mainly have mild fasting hyperglycaemia without significant post meal hyperglycaemia. Maternally inherited diabetes with deafness (MIDD) This is a form of diabetes due to mutations in mitochondria, most commonly related to 3243A > G mitochondrial DNA mutation. Mitochondria in an individual are inherited from the mother rather than from the father, therefore one clue would be evidence of strong maternal transmission of diabetes, particularly when this is associated with a sensorineural deafness. Some patients may also have peripheral vision problems, particularly night blindness. These patients often require insulin.