Managing diabetes is not all about expensive medication

After 2 1/2 years, Dr Justin Coleman finishes as Editor of the Diabetes Management Journal. He will continue to remain involved with the DMJ, as a member of its Editorial Advisory Board. This is his final editorial.

Around 100 articles have hit this editor’s desk over the past 2½ years, journeying us through a hundred different aspects of managing diabetes.

The desk itself has gone on a journey too, when last year I transported it from Brisbane in the southern half of Australia (yes, check the map) to almost as far north as you can go. The Tiwi Islands just cling on to the nation, counterbalancing Australia’s only larger island—Tasmania—on the opposite edge.

In terms of diabetes issues, the people walking into my general practice have considerably more in common with East Timor to the north than with most Australians to the south. Here, type 2 diabetes (T2D) is so common that it is a general expectation.

My small community of 1600 includes 22 people on haemodialysis, with almost as many again waiting in the big city to ‘return to Island’ when a haemodialysis bed becomes free. Where I live, ‘new bed available’ has become a sad euphemism to mark the ultimate end-point of our diabetes and renal management.

So when an article lands on my desk discussing cutting-edge technology around the artificial pancreas, or a drug research breakthrough, I have to remind myself that most Australians live in surroundings where these advances will improve lives. This progress heralds an exciting future for those who are already effectively accessing what we have now, and many readers of the DMJ will soon be delivering it. Exciting stuff!

Yet in my time at the helm, I have also made sure to commission plenty of articles that go back to the basics, to ensure we do them well. After all, it is at the ‘blunt edge’ of medicine—far from the news headlines—that most health gains are made.

Primary health care, rather than the specialist diabetes clinic, is the health home of most Australians who have T2D. A few dip in and out of tertiary clinics and private hospitals offering advanced complex care, but it is the daily work of general practitioners, diabetes educators, dietitians and exercise physiologists—often generously supported by endocrinologists—that meets the bulk of the care needs for Australians with diabetes.

If asked to list the things that really matter, I’d note that diet, physical activity, weight loss and simple, cheap pharmaceuticals (hypoglycaemics and cardiovascular preventatives) carry the load. Management of these basic factors does not require much advanced technical knowledge, but absolutely requires skills around ‘what is likely to work’ for the individual with diabetes sitting in front of us.

Take something as simple, cheap and basic as physical activity. By any measure we know it is beneficial for people with diabetes; let’s not limit the claim—it is beneficial for life as a human!

For a sedentary person, the end-goal of ‘more activity’ is backed by more research than a health professional could possibly need, and has greater health benefit than any front-page medical advance this century.

Yes, the goal is obvious, but not so the solution.

After all, that same goal would equally apply to a Brisbane business executive attending a corporate health check and to a Tiwi man I opportunistically pluck from my waiting room. The real skill—the subtle art—is in finding the ‘solution’: an approach to management tailored to that individual.

The  exec may benefit from their GP having read DMJ articles about High Intensity Interval Training, tai chi (see p23) and barriers to exercise, while my clinic staff might take more note of DMJ features on poverty and diabetes, free community exercise programs and exercise with diabetes complications.

A sedentary lifestyle, a poor diet, and an obesity issue are all wicked problems that demand that the health professional has access to a kit full of evidence-based, low-tech tools. Selecting the right tool requires communication, trust and an ongoing relationship nurtured over time.

Sometimes the intervention will involve something new, exciting and shiny—wearable technology or a novel drug class—but don’t confuse the ‘thing’ with the ‘process’.

Diabetes management is no sprint race.

The Feb 2020 edition of the DMJ is available here.

About Dr Justin Coleman

Justin is a GP on the remote Tiwi Islands at the top of Australia. He edits a medical journal and two medical textbooks, and is a medical writer and educator. Further details at https://drjustincoleman.com/
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2 Responses to Managing diabetes is not all about expensive medication

  1. Thank you for sharing such a wonderfully written article Dr Coleman. Thank you for your many valuable DMJ articles. They have benefited me and my patients immensely.

  2. Q says:

    Thanks Justin, I’ve often thought about this point too being in the research/academia space in one job, and the GP/AMS setting in another.

    Often a technical advance in management does not translate readily to the clinical setting, where the challenge is implementing what we already know (eg. lifestyle modification, eg. facilitating patients to take first line medications such as metformin).

    Winnie

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