Latent Autoimmune Diabetes in Adults Patient Case Study

Case Study

The purpose of this case study is to critically explore the issues related to the assessment, intervention and management of a patient with complex diabetes that has been recently managed by members of the multi-disciplinary team. This paper will consider the case of Amy, a 49-year-old lady with complex health needs following a diagnosis of type 1 diabetes. Her name has been changed to protect her identity and promote confidentiality in accordance with the Nursing and Midwifery Code of Conduct (NMC, 2017). The Oxford Dictionary (2017) defines the term complex as ‘consisting of many different and connected parts.’ This term can therefore be applied to the multifaceted approach to managing this diabetic case between members of the multidisciplinary team, centring on the patient.

This case study will explore the anatomy, physiology and pathophysiology of various types of diabetes. However, it will focus predominantly on Latent Autoimmune Diabetes of Adulthood (LADA). As there is no standardised definition of LADA, it is important to highlight that is currently treated and managed in accordance with the National Institute for health and Care Excellence (NICE) type 1 diabetes guidelines. This guidance will be referred to in this study (NICE, 2015). This paper, will review and critically evaluate the interventions of the inter-professional teams involved in her care. The cultural, physiological and psychological impact on Amy, in living with type 1 diabetes will be explored. Finally, three government strategies implemented in England will be scrutinised and their application to general practice will be evaluated. Fundamentally, this paper will help illustrate how complex a successful, holistic approach to managing diabetes can be.

The following summary of events will serve as a basis for discussion of the previous issues. Amy is married with two teenage children, and works part time in marketing. She has no diagnosed chronic conditions and no familial history of diabetes. She presented to the general practitioner 4 years previously with symptoms of lethargy, polyuria, polydipsia and unintentional weight loss of 15kg in 9 months, all typical symptoms of diabetes (WHO, 2015). Her body mass index on examination was 17.1kg/m². A diagnosis of diabetes was assumed, and she was referred to hospital. A set of diagnostic blood tests showed an HbA1C of 155mmol/mol and a fasting blood glucose of 16mmol/L. She also presented with hypertension (156/94mmHg) and hyperlipidaemia (6.92 mmol/L); both common co-morbidities (Dunning, 2014). In hospital she was diagnosed with Diabetic Ketoacidosis (DKA) (Chaudhry et al. 2017). Once treated, she was diagnosed with type 2 diabetes and treated with a biguanide, metformin accordingly (Unger, 2013b). This proved ineffective at managing her blood glucose levels and nine months later, she was initiated on insulin therapy by the secondary care team. 2 years after diagnosis that she was diagnosed with Latent Autoimmune Diabetes of Adulthood (LADA). This was following positive serum results to glutamic acid decarboxylase (GAD) autoantibodies, islet cell autoantibodies (ICA) and falling C-peptide serum levels. Her hypertension was treated with 10mg of amlodipine daily. Her management moved to primary care after a series of missed hospital appointments. Amy had opted out of some screening services, specifically the digital retinopathy screening, cervical screening and breast screening services. “She did not want to be a lab rat.” Her latest HbA1C was 77mmol/mol and her hypertension continues to be poorly controlled. In addition, she refuses to use a statin to aid the management of her hypercholesterolaemia.

The pathophysiology of diabetes mellitus is complex. For cells to function, they require glucose. Dunning (2014) recognises that diabetes mellitus (DM) is a condition where the body is unable to utilise glucose in the absence of insulin: instead, the body depends on proteins and fats for energy. The beta cells in the pancreas, are in the islets of Langerhans and produce the insulin. They are surrounded by the alpha cells which secrete glucagon (Nepton, 2013). When blood glucose levels are low, glucagon stimulates the liver cells to release glucose from the stored chains in the form of glycogen. This in turn promotes gluconeogenesis (the break-down of fatty acids from amino acids). Conversely, glucagon levels drop when carbohydrates are ingested to prevent hyperglycaemia. In the absence of diabetes, the normal glucose range is 4-8mmol/L. This is the ideal target range in most cases of diabetes management (Diabetes UK, 2017). This may vary depending on the person’s age and comorbidities (NICE, 2015). DKA occurs when ketones, a by-product of fat metabolism, are produced and circulate within the blood. Chaudhry et al. (2017) in their study of DKA found that without treatment, this produces a metabolic or lactate acidosis which can lead to acute kidney injury, cardiac arrhythmias and ultimately, death.

Dunning (2014) characterises type 1 diabetes by a complete lack of insulin production that can affect children and adults of any age. It is thought to be autoimmune in origin with genetic and environmental factors triggering its onset (Kawasaki, 2014, Simmons and Michels, 2015). Although other theories have been proposed, evidence for them is sparse and conflicted. Its incidence has been linked to viral infections and an increased insulin demand (Diabetes.org.uk, 2017). Vitamin D deficiency has also been the focus of the research.  Dong et al (2013) showed a positive correlation between vitamin D deficiency and type 1 diabetes in children in their meta-analysis of the literature. Conversely, George et al, (2012) concluded that vitamin D supplementation shows little benefit in improving glycaemia or insulin resistance in patients with diabetes, normal fasting glucose or impaired glucose tolerance. As some of this research only applies to children, the health professional needs to ensure that the research guiding their practice is sound and applicable to their population.

Unger (2013b) describes type 2 diabetes as a progressive disease, with a genetic link, that can occur over several years. It is characterised by hyperglycaemia that occurs as the result of the development of reduced insulin secretion from the beta cells and increased insulin resistance at cellular level (Dunning, 2014). It is a condition influenced by lifestyle choice as it’s likelihood increases with obesity, inactivity, high fat and high sugar diet as well-being. Appel and Jones (2012) state that approximately 10% of people who are initially diagnosed as type 2 diabetics are later diagnosed with Latent Autoimmune Diabetes of Adulthood (LADA). LADA patients, such as Amy, tend to be younger than type 2 diabetics at diagnosis, their body mass index is usually lower, and they tend to need insulin treatment much sooner. As the diabetes progresses and medications prove ineffective in managing the blood glucose, the body undergoes a period of poor glycaemic control which can precipitate the associated vascular complications. O’Neal et al (2016) argue that a lack of awareness of LADA amongst clinicians and a lack of standardised diagnostic could be contributing factors to misdiagnosis. Despite NICE (2015) advocating the use of early intensification of treatment, Reach et al. (2017) found clinical inertia, a reluctance to intensify treatment, is a common factor amongst clinicians and is directly related to poorer outcomes, as is demonstrated in this case.

Landmark studies such as the DIAMOND project (WHO, 1990) and EURODIAB (2000) provide epidemiological data for type 1 diabetes. Although breakthrough at the time, the incidence of type 1 diabetes has increased dramatically globally and may not accurately reflect the current climate. It estimated that of the 2.1million people diagnosed with diabetes every year in the UK, approximately 10% of those are diagnosed with type 1 diabetes (Diabetes UK, 2017). The need for adequate glycaemic control for Amy was emphasised, for the data shows that women have substantively poorer outcomes. Pociot and Lernmark, (2016) found that women with type 1 diabetes are 40% more likely to suffer death from all causes than men. Those with type 2 diabetes have a 37% increased chance of stroke compared to men and are 44% more like to die from renal failure than men (Diabetes.org.UK, 2017). It is speculated that the hormonal changes women go through at the time of puberty create difficulties in obtaining good glycaemic control. However, there seems to be very little statistically significant published literature that focuses on the influence of the menopause on glycaemic control in LADA, likely due to misdiagnosis or the impact of the menopause in causing LADA. This lack of research is apparent in all types of diabetes. It is therefore suggested that new research is undertaken in order to analyse this possible correlation further in a possible bid to improve outcomes for women such as Amy.

In 2015, NICE published guidelines for managing Type 1 Diabetes in Adults but does not offer a standardised definition of LADA. It recommends that diagnosis is made on clinical features and not with autoantibody tests alone. The evidence for using diagnostic tests is limited by low quality research. However, their own review of the literature, found that GAD antibodies were present in 77.2% of adults with LADA compared with 10.8% in type 2 and 54.8% of type 1 diabetics. Anti-islet cell antibodies were also detected in 47.8% of newly diagnosed LADA patients compared with 9.1% of type 2 diabetics and 52.5% of type 1 diabetics. In addition, O’Neal et al (2016) argue that C-Peptide testing has a higher predictive value with increasing time from presentation which, makes it a useful tool in differentiating it from type 1 or type 2 diabetes. This suggests that although are practical barriers to testing for specific autoantibodies, such as the high cost of testing, and challenges in interpreting the results, they may play a very important role in offering a prompt diagnosis and should not be withheld on financial grounds. It is proposed that the delay in the diagnosis of LADA should therefore, provide an incentive to educate healthcare professionals on its presentation, its method of diagnosis and its subsequent management to prevent the complications of hyperglycaemia.

Insulin replacement regimens include the use of basal-bolus preparations. Lantus once daily in the morning and a short acting Novorapid prior to meals, both administered subcutaneously. Due to the prolonged basal action of Lantus, which is an insulin glargine, the risk of early morning hypoglycaemia is increased over nocturnal hypoglycaemia. This was likely a possible factor contributing to Amy’s fear of hypoglycaemia. The multiple blood capillary glucose measurements taken throughout the day reassured her it was safe to administer the insulin, a typical self managing behaviour seen in diabetics on insulin (Nishio and Chujo, 2017). Dosing of insulin was influenced and complicated further if she exercised. An alternative solution, a continuous subcutaneous insulin infusion via a pump, was suggested as they have demonstrated better targeted glycaemic control and a reduced incidence of hypoglycaemia (Uduku and Oliver, 2017). Such pumps have proven hugely successful in improving quality of life and outcomes for the majority of type 1 diabetics who use them. However, the stigma of a subcutaneous pump attached to the patient can be a barrier. According to NICE guidelines (2008) Amy met the criteria for initiation, frequent hypoglycaemia and poor glycaemic control, but she refused. She displayed clinical inertia, not the practitioner. The lack of specialist diabetic education may have contributed to her reluctance to trial the new medical management technique and this will be discussed further in the paper.

The time of diagnosis tends to be an extremely turbulent time for many diabetics and in 2014, Belton et al, argued that the conversation held at diagnosis between doctor and patient influenced the clinical outcome. Shaban (2017) dictated that patients preferred a clear diagnosis, delivered with empathy. They adhered more to treatment if they were told their diabetes could be successfully managed and were given a clear plan of action. In addition, the change in Amy’s diagnosis from type 2 to type 1 diabetes could be a contributing factor to her perception of her diabetes and her apparent diabetes distress.

The latest NICE guidelines on diabetes (2015) recommend that the medical management of type 1 diabetes involves testing of Hba1C every three to six months at a minimum. The target HbA1C of 48mmol/L and below, serves to minimize the risk of complications which may develop such as; peripheral arterial disease, retinopathy, neuropathy and nephropathy. Amy’s latest HbA1C demonstrated worsening control at 77mmol/ mol from 72 mmol/mol six months earlier. It was recognised that Amy did not regard her medical visits as an opportunity to discuss her own thoughts, beliefs and ideas about her condition which NICE (2012) consider to be a vital part of any patients experience in healthcare. Healthcare professionals are being urged to offer individualised, person centred care, and move away from the traditional disease cantered care which manages the condition rather than the whole person. However, due to the ever-increasing constraints on the National Health Service, the practitioners may find it difficult to incorporate time into the review to expand on areas which are important to the patient, in this case, the reasons for the poor glycaemic control. It seems probable that this could adversely impact on the professional and therapeutic relationship between the patient and doctor for this may be interpreted as a lack of empathy by the patient. The display of empathy from the health professional is critical in providing psychological support to the diabetic patient (Ulbricht, 2012).

The nursing management of type 1 diabetes involves an annual face to face review. This offers an opportunity to assess the patients understanding and control of diabetes. In 2017, NICE recognised that despite the publication of strategies commissioning specialist services there was great variation regionally in outcomes. This could be explained by the fact that until recently, nurses were providing this service to patients without having participated in formal, postgraduate training. The nurse can be regarded as the coordinator, discussing every aspect of the patient’s health with regards to diabetes and referring to members of the multi-disciplinary team as necessary. It allows an opportunity for the patient to discuss how they are feeling at that moment in time, in their own words. A holistic care plan is devised with them. This enables them to state their own goals and priorities and encourages them to work with the nurse, to formulate ways they can achieve them. The nurse also has the role in the gathering of vital statistics, such as body mass index, blood pressure as well as the gathering of blood specimens which have already been discussed. There are challenges to performing these tasks within a restricted time frame.

The foot assessment is an integral nursing intervention and serves to identify risk factors for injury early, in order to prevent the development of complications. Peripheral neuropathy is prevalent in over 20% of type 1 diabetics after 20 years. It occurs in both the sensory and the motor nerves and is characterised by reduced sensation and unpalpable pulses. Diabetic foot ulcers precede more than 80% of amputations in people with diabetes. NICE (2017) suggested that up to 85% of all amputations can be prevented with appropriate care and education. In 2012, NHS Diabetes estimated that around £650 million a year is spent on managing foot ulcers and amputations. An explanation for such variation may be explained in the level of training undertaken at a local level, mostly dictated by podiatrists.

A landmark study undertaken in 1997, the Diabetes Control and Complications Trial (DCCT) demonstrated that good glycaemic control reduced the likelihood of diabetic complications such as peripheral arterial disease, retinopathy, neuropathy and nephropathy developing. However, in order to achieve adequate glycaemic control in type 1 diabetes, a source of exogenous insulin is always required (Bell et al., 2014). As a result, hypoglycaemia is a common barrier to successful diabetes treatment (Dunning, 2014). NHS Choices (2017) defines hypoglycaemia as a blood glucose of less than 4mmol/L and impacts tremendously on the physical health of a diabetic. Symptoms include palpitations, sweating, blurred vision, disorientation and drowsiness. These symptoms induced a fear of hypoglycaemia in Amy. Fear of hypoglycaemia is recognised in the literature as a major barrier to achieving optimum glycaemic control (Unger, 2013a, and Ahola et al, 2016). This fear, resulted in the adoption of harmful self-management techniques such as a reduction in insulin dosing and the consumption of excess calories in order to induce a hyperglycaemic state. The resulting consequential hyperglycaemia that ensued was, for Amy, more acceptable than the risk of a potentially life threatening, hypoglycaemic episode.

During the diabetic review with the nurse, there is an opportunity to discuss hypoglycaemia in detail. The nurse has the responsibility of ensuring the patient knows how to recognise and manage the signs and symptoms of hypoglycaemia and offering techniques and education on how to deal with them (NICE, 2015). NICE (2015) also suggests that a Blood Glucose Awareness Training programme could have been recommended to Amy to assist her in self-managing her hypoglycaemia in a less harmful way (Cox, 2006). By empowering and educating her in balancing her requirements, it proposes to avoid extremes in glucose levels. This education programme demonstrates prevention of hypoglycaemia and improves patient outcomes, in America and the Netherlands. However, this programme is not a UK based programme and there does not seem to be a UK equivalent. This highlights a fundamental shortfall in the provision of relevant education in the UK. In response to this demand, Kings College London (2017) have proposed the Hypoglycaemia Awareness Restoration Programme for people with type 1 diabetes despite otherwise optimised self-care (HARPdoc). It is due for completion in 2020 and aims to compare a new structured education programme to the established BGAT programme. It is therefore imperative that the nurse undertaking the annual review ensures they are able to comprehensively discuss hypoglycaemia awareness and offer management strategies to each patient with diabetes to prevent episodes of hypoglycaemia.

Psychologically, Amy was experiencing many emotions. These included anger grief, depression, frustration, denial and fear. The diagnosis appeared to have a profound psychological effect on Amy. She felt traumatised by it and vocalised her thoughts when attending her annual diabetic review with the practice nurse, as recommended by national guidelines (Diabetes UK, 2017, NICE, 2015).  In 1997, a landmark paper by Kübler-Ross identified these emotions as part of the grieving process following the death of a significant other. Many authors and agencies, including Diabetes UK (2017) tend to agree that being diagnosed with diabetes provokes a grief response similar to that described by Kübler-Ross. However, Nash (2014) claims that there is dynamic movement between these emotions in all directions. This can lead to challenges in supporting the diabetic individual from a psychological perspective as it may lead to undesirable behaviours. Chew et al., (2014) argue that for treatment to succeed and importantly, for the patient’s quality of life to be optimised, the practitioner must be able to identify barriers to treatment, whatever their nature. Some of these psychological barriers to treatment could be discussed during the regular reviews. Practical obstacles such as difficulties with blood glucose monitoring and injection technique should also be discussed.

Psychologists can provide invaluable support to a harmonious transition into the diagnosis of diabetes (Shaban, 2013). Kreider (2017) argues that the presence of major depressive disorder (MDD) may be up to three times more common in diabetics than the general population and multiple authors has been documented that up to 20% of type 1 diabetics may have clinical depression. Although Amy had no clinical diagnosis of depression, there did appear to be signs of ‘diabetes distress,’ a term used that identifies significant psychological distress but does not meet the characteristics of depression (Fisher et al., 2014).

The family meal, or commensality, is an important cultural commitment and something Amy enjoyed and appreciated very much prior to her diagnosis. It could be considered a ritual of family life for some, bringing family members together and contributing to their physical, mental and social well-being (Brannen et al. 2013). When discussing family meals, she became distressed and almost mourned her previous experiences commensality. Despite there being evidence that most family members want to be involved in the management of diabetes, Amy wanted to shield her glucose testing and insulin administration from her family for fear of stigma (Nishio and Chujo, 2017). Her hatred of insulin and insecurity over her body made her resentful towards her diabetes and she exhibited signs of self-stigmatisation. Recent research studying the association of family meal frequency and attitudes to family meals in type 1 diabetics is sparse. However, Rintala et al. (2013) studied these associations and found that these feeling are not uncommon. Psychological counselling is an important intervention here to promote a positive body image and to reinforce mealtimes as an opportunity to provide opportunities for exposing the family to a variety of healthy food choices that may not have been considered before.

The government recognises the enormous burden of managing diabetes at an individual, a local and at a national level (NICE, 2015). It is estimate that £14 billion is spent every year in treating and managing diabetic complications (Diabetes UK, 2017). Subsequently, many government strategies have evolved with the intention of improving diabetes outcomes. One such strategy involves the provision of a structured dietary education program to all diabetics relevant to their type of diabetes (NICE, 2015). Examples of such courses include DAFNE (dose adjustment for normal eating) for type 1 diabetics, DESMOND (Diabetes education and self-management for ongoing and newly diagnosed) for type 2 diabetics and carbohydrate counting courses. Amy attended a carbohydrate counting course at diagnosis, in line with recommendations that all diabetics should attend one in the first year following diagnosis (NICE, 2015). These courses remain accessible to all diabetics, or those at high risk of diabetes, regardless of how long they have been diagnosed and should be routinely offered to each patient at every nurse and doctor review to promote safe and effective self-management of their cholesterol, weight and dietary intake (NICE, 2015).

In a meta-analysis of the literature, Fu et al., (2016) found that individuals who count their carbohydrate intake and dose their insulin accordingly, improve their HbA1C and quality of life quite significantly. As well as showing efficacy in preventing hyperglycaemia, they have another beneficial effect in that they reduce the likelihood of hypoglycaemic episodes. However, there are many barriers to their uptake, include the location, time of day the class is held and the duration of the course. As there is no provision in the United Kingdom for time off work for example, for patients to attend these classes, a six to nine-month DAFNE course may not be suitable for working individuals such as Amy. Grant et al. (2013) acknowledged that some patients may prefer group sessions where they can rely on others for support whilst other may prefer to manage independently support for fear of stigma or embarrassment of their condition. It is therefore paramount that the referring practitioner discusses the type of courses available with the patient to ensure the maximum benefit is gained from attendance. With this in mind, local provisions may extend to utilising the skills of dietitians to provided one-on-one education in accordance with national guidance (NICE, 2015). It is suggested that Amy may have benefitted from a private session with the dietician.

A second government initiative in England, entitles all diabetics to free prescriptions on the National Health Service, if they are managed with medication or insulin (Diabetes UK, 2017). This initiative encourages patients to take medication as prescribed to improve glycaemic control and subsequently reduce the likelihood of complications. It eases their financial burden and ensures that treatment is accessible to all. However, in 2016, NHS Digital published that the NHS in England now spends £956.7 million a year on drugs to treat all types of diabetes. In 2015-16, prescriptions for diabetes accounted for over 10% of the cost of primary care prescriptions. They suggest this huge increase in expenditure is directly related to the increase in number of people diagnosed with type 2 diabetes. Hex et al. (2012) estimated that type 2 diabetes costs the society considerably more than type 1 diabetes. They estimate that in 2035, the cost of prescriptions for managing type 1 diabetes will be £310 million per year compared to £1.1billion for type 2 diabetes. This raises the question whether the NHS can support the continuing demand for free prescriptions as the number of diabetics living in England continues to rise to epidemic proportions.

Data published by NHS Digital in November of 2017 clearly demonstrates an improvement in the percentage of people achieving their treatment targets. Type 1 diabetics increased from 16.1% in 2012-13 to 18.9% in 2016-17, with at total increase of 2.8%. A similar increase is seen in the type 2 diabetic group. In 2012-13 37.3% achieved their treatment targets compared to 40.8% in 2016-17, with a total increase of 3.5%. This does not provide enough reassurance that the cost of prescriptions to the NHS is efficacious. There is much debate amongst authors over the correct way of managing prescription costs. In 2015, the British Medical Journal publishing group declared the current system is outdated, unfair and illogical as free prescriptions benefit only come long term conditions and not all. Jenkins (2013) goes as far to suggest that charges become voluntary. Appleby (2014) studied the effect of the abolishment of prescription charges in Wales and concluded that there was no difference to the uptake of treatments compared to paid for prescriptions. Amy could face spiralling costs if prescriptions incurred a charge. However, In England, this is not being considered. Instead, practitioners are advising all patients to consider buying some prescription medications over the counter to increase revenue for the NHS. This is likely to be met with resistance and hostility and it is suggested that this must be done with caution to prevent a public outcry. Fundamentally, although the trend is improving with regards to management of diabetes, the incidence and prevalence rates of type 2 diabetes must show some considerable signs of reversing or at least slowing down or the free prescriptions and accessible treatments for patients like Amy will no doubt come under threat.

The third government initiative to be discussed is the introduction of an NHS diabetic eye screening programme in 2004, incorporating the role of the ophthalmologist (Department of Health, 2003). Loss of vision is a feared complication for many patients with diabetes. In addition to treating retinopathy, ophthalmologists can play an important role in educating and motivating patients to achieve better metabolic control. Screening is therefore a fundamentally important part of diabetes management which involves a collaborative approach amongst health professionals (Royal College of Ophthalmologists, 2012). This initiative has enabled changes to the retina to be identified early which reduces the likelihood of progression to a retinopathy. Diabetic retinopathy is a microvascular complication of diabetes and approximately 1200 people are diagnosed each year (Dunning, 2014). Public Health England (2014) declare it is one of the most common causes of sight loss in people of working age and Mathur et al. (2017) argues that most type 1 diabetics will go on to develop some degree of retinopathy within 20 years of diagnosis.

The screening pathway came under scrutiny in 2014 when patients were missed out of the screening program due to a coding irregularity on the primary care computerised systems (Hammond, 2016). This classification of ‘diabetes resolved’ has since been renamed ‘Diabetes in remission’ and the programme is fully functional with a streamlined care pathway published in 2017 (Public Health England, 2017). Despite this setback, diabetic eye screening is a popular free service which all diabetics are entitled to annually. In 2016 it achieved an uptake of 82.5% nationally, with 2,012,885 diabetic attendees (Public Health England, 2016). Of these attendees, 1 in 41 diabetics were referred with pre-proliferative retinopathy. Nevertheless, on analysis, the data suggests that approximately 10,500 of eligible diabetics who do not attend screening may have undiagnosed retinopathy. Strutton et al (2016) studied reasons for non-attendance and found an array of explanations which may explain Amy’s withdrawal from screening. It was evident that Amy was quite disengaged with her diabetes care in general and she did exhibit signs of anxiety of denial during her nurse appointment. The implications of this were the withdrawal from the screening service and high risk of retinopathy in subsequent years due to her poor glycaemic control, hypertension and hyperlipidaemia (Dunning, 2014). Despite, local level initiatives to improves uptake, such as invitations by text message and letters, Moreton et al (2017)found that there is little commonality in the patterns of uptake across practices. This suggests that some other practice specific factors are involved in uptake. It is therefore imperative that an empirical, reactive approach is taken to managing this. It is thereby proposed that each practice should perform their own audits to target the non-respondent groups in an appropriate manner.

In conclusion, the complex nature of diabetes requires a multi-faceted approach to diagnosis and management. It is imperative that the prompt recognition of LADA could prevent the unnecessary complications associated with poor glycaemic control which results from misdiagnosis. The diagnosis conversation should display empathy and understanding to motivate and instil confidence in the person with diabetes. The use of the multi-disciplinary team must be co-ordinated in order to provide the patient with continuous support in self-managing their diabetes. The role of the psychologist is under-valued. It is imperative that they are utilised more frequently to assist in managing the fear and anxieties surrounding treatments. Ultimately, despite local, national and worldwide initiatives, the incidence of diabetes continues to increase to epidemic proportions. Although collaborative approach amongst health professionals in educating the public is required to slow this epidemic down, it is also recognised that there must be an individual desire to improve one’s health in this sedentary era of convenience.

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