Diabetes … now what?

Picture this: a customer walks into your pharmacy with a puzzled expression. You ask how you can help. The customer says they’ve just been diagnosed with type 2 diabetes and they’re confused and anxious about what they’re supposed to do next. “Diabetes … now what?” they ponder.

Community pharmacists have an opportunity to make a significant difference in the lives of diabetic customers. Whether it’s dealing with those who are newly diagnosed, those who’ve had the condition for years, or those in between, through various pharmacy services, scientifically backed advice, or regular check-ins, pharmacists can play an important role within the diabetes management team.

Type 2 diabetes: a refresher 

Diabetes Australia (DA) defines type 2 diabetes mellitus (T2DM) as a condition where the body becomes resistant to the actions of insulin, a hormone in the body that’s produced by the pancreas and responsible for regulating blood glucose levels. Insulin resistance results in elevated blood glucose levels.

“Over time, the pancreas gradually loses the capacity to produce enough insulin,” a spokesperson said. This leads to T2DM.

Community pharmacist and master herbalist Gerald Quigley says T2DM occurs when “blood glucose gets out of control” because of the body’s inability to react to insulin – or insulin resistance, which is typically caused by “poor pancreatic function”.

Addressing T2DM causes, DA cites a “combination of genes and lifestyle factors”.

“The risk factors for T2DM can be divided into non-modifiable and modifiable,” the spokesperson said.

These non-modifiable risk factors include:

  • Family history of diabetes.
  • Age – being over 55, with the risk increasing with further age.
  • Age and background – over 35 years and from an Aboriginal/Torres Strait Islander background, or Pacific Island, Indian subcontinent, or Chinese cultural background.
  • Being a woman who has given birth to a child weighing more than 4.5kg, or who had gestational diabetes when pregnant, or who has polycystic ovarian syndrome.
  • Being someone with a mother who had gestational diabetes when they were in utero.

Modifiable risk factors, according to DA, include:

  • Being overweight.
  • Storing excess weight around the waistline – being apple-shaped.
  • Smoking.
  • Being physically inactive.
  • Having a poor diet, especially one high in saturated fat.
  • Having high cholesterol or high blood pressure.

Management 

DA says that while T2DM is a condition that can’t be cured, it can be managed through lifestyle changes, and in some cases, medication.

“Effectively managing diabetes is the best way to prevent diabetes-related complications,” the spokesperson said.

Lifestyle modification required to manage T2DM includes changing dietary habits, being physically active every day and managing stress.

Mr Quigley says lifestyle changes can be simple measures, an example being a switch to a largely Mediterranean style of eating – “eating sensibly and moving away from processed food”. He adds that “comfortable exercise” is also important, advocating for such activity “every day in some way, shape or form”.

DA, elaborating on lifestyle modification, says healthy eating is an important part of managing T2DM.

“Eating a healthy diet helps to keep blood glucose levels within the target range, which reduces the risk of developing diabetes-related complications,” the spokesperson said. “Healthy eating can also help reduce high cholesterol and reduce blood pressure.

“There’s no such thing as a diabetic diet. People living with diabetes can enjoy the same foods as everybody else. As a starting point, it’s recommended people follow the Australian Dietary Guidelines. Seeing a dietitian is helpful for individualised dietary advice, particularly for those with high cholesterol, hypertension, or who are overweight.

“Daily exercise of at least 30 minutes of moderate-intensity activity is recommended for all Australians and helps people living with T2DM to manage blood glucose levels and other risks. Exercise can be split into shorter bouts of 10-15 minutes two to three times a day. Moderate-intensity physical activity is being active enough that your heart is beating a little bit faster, and you’re ‘lightly puffing’ but can still hold a conversation. If you can sing or whistle a tune [during exercise], you need to work a little bit harder.

“Keep in mind that the above recommendations are for general health. If your goal is to lose weight, you may need to do more than 30 minutes [a day]. Two sessions of resistance activity each week are recommended as well. People living with T2DM should see their GP for exercise clearance first. They should also consider seeking advice from an exercise physiologist for an exercise program tailored to their individual needs.

“Managing stress and mental well-being is also important for people living with diabetes. Stress increases blood glucose levels and can affect motivation to make and maintain changes, so asking for a referral from a general practitioner to a psychologist might be appropriate for stress management strategies.

“Quitting smoking is recommended for all Australians, but particularly for people living with diabetes, as smoking greatly increases the risk of longer-term complications.”

Additionally, those with T2DM need to self-manage their overall health, DA says.

“This includes taking medication as prescribed, following an annual cycle of care to help prevent or enable early identification and treatment of possible long-term complications, and having a supportive healthcare team consisting of [a patient’s] local doctor, dietitian, diabetes educator, exercise physiologist, optometrist, podiatrist, pharmacist or specialist doctor as required,” the spokesperson said.

“Self-monitoring of blood glucose levels is recommended for people on insulin and sulfonylureas, those who are having problems achieving ideal glycaemic control, or for those whose glycosylated haemoglobin measurements are considered unreliable. A diabetes educator can teach people living with T2DM how to monitor blood glucose levels.

“Research shows that it’s possible for some people with T2DM to achieve T2DM remission. We define this as an HbA1c of under 6.5 per cent (48mmol/mol) for at least three months without the need for glucose-lowering medications. The most common ways people have achieved remission is by substantial weight loss following very intensive dietary changes or through bariatric surgery.”

Medical management 

According to DA, the medical management of T2DM requires person-centred care from a multi-disciplinary team for self-management education and assessment.

“The GP is the hub who refers their patients to allied health professionals, often under a care plan, and prompts the patient to have an annual cycle of care,” the spokesperson said.

“Patients are registered with the National Diabetes Services Scheme [NDSS], so they’re eligible for subsidised products and free face-to-face or online education programs.

“Management is monitored via pathology, including glycosylated haemoglobin, blood fats, kidney function and blood pressure.

“If management is adequate, then diet and exercise are all that’s required. However, T2DM is a progressive condition and often high blood fats, hypertension, and central fat storage, often called metabolic syndrome, go hand in hand and require medication management.” 

Role of pharmacy 

Pharmacists need to understand the causes, signs and symptoms, and management options to help and support those with T2DM, according to a pharmacist from the Pharmacy Guild. They should also be across other diabetes-related health services where customers can be referred, including diabetes educators, dietitians, exercise physiologists and specialists.

“Pharmacists can support patients with diabetes in many ways, including, but not limited to, timely access to medicines, the provision of expert medicines advice and education, medical device demonstration and familiarisation, professional service provision such as diabetes MedsChecks and point of care testing, supply of monitoring devices and testing strips, supply of products for treatment of hypoglycaemia, and education on possible complications of diabetes and the need for regular eye and foot checks,” the Guild pharmacist said.

“The pharmacist is an integral part of a patient’s diabetes management team for medicines supply, advice and education, medicine compliance monitoring, and supply of NDSS consumables and monitoring devices. Collaboration between all members of the diabetes management team helps achieve the best health outcomes for the patient and ensures that the information the patient receives is consistent across all members of the team.”

The Guild pharmacist continued: “Pharmacists can play an important role in diabetes screening and management through the provision of blood glucose and HbA1C monitoring services. Blood glucose monitoring may be used to identify high or low blood glucose levels at a specific point in time, whereas HbA1C shows blood glucose control over months.”

Other services that pharmacists can offer to patients with diabetes, according to the Guild pharmacist, include the NDSS for test strips and needles, diabetes management education (including medicines, medical device and lifestyle modification information), home medicines reviews and dose administration aid services to help with medicines management.

Mr Quigley says that if pharmacists want to make a real difference, they must put themselves “in the shoes of the person with diabetes”. This way, he says, pharmacists can get to know their customers – “what they think and how they think, and what they perceive as the challenges to their quality of life”. This enables them to offer other services, “outside of [simply] dispensing”, he adds.

This feature was originally published in the July issue of Retail Pharmacy magazine. 

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