Yet another DSN who isn't a lot of use

[Patch]

My oh my !!!someone post a simple thing regarding what happened when seeing her d/n and whooooo!!! everyone seems to look for a fight at the end of the day no-one and I mean NO_ONE can tell any of us what to eat , we all choose to eat what we want, and as I have said before, it seems the norm is carb for us, and honestly how many of us take the advice from these D/N's??? ......... hope everyone has a nice day

Check you're BG, mate - sounds like you might need a "carby snack" to bring it up a little.

[Note: I am not a medical proffessional, and nothing I say should be construed as advice. Everything I say should be taken with a pinch of salt - again, not medicial advise.]

Peace, Love and Nutitionally Balanced Shakes.

 

[Sid Bonkers]

now what the discussion should really be about is if the NICE guild-lines constitute best advice...

If you are referring to their advice on bg levels then I think they are at a realistic level, lets not forget that 70% of diabetics fail to get under them and they are stated as being 'no higher than' levels. I think it would be pointless to set them any lower, you would just see more people fail and that would be even worse, don't you think?

 

[jopar]

I'm not protecting HCP's the HCP isn't hear to be able to redress what's being said..

I give some examples..

My opinion of my surgery DSN is that of a friends who's husband is under the same DSN, I know what my friend says is untrue her husband plight has nothing to do with my DSN at all, the problem lays at their doorstep... I know that on many occasions my DSN has advised them to reduce his carb intake, but they refuse to budge even the dietiean has failed boy was they miffed when her advise was that he needed to reduce his carb intake by at least an half :shock:

I have even myself tried to help them understand the importance of carbs, even explained to my friend how she could make changes to things like plate size, portioning of foods to give the perception that he's has the same size meal.. But it actually cuts back on the Carb side of it, to no avail..

So why should a DSN who does her best to advise them get slagged off because they don't listen to what being said... Reality is more diabetics suffer due to thier own hands, as they choose to ignore anything their care team say.. But then have the gore to lay the blame at the door step of the health care professional..

 

[Grazer]

You miss the point that sometimes we DO listen to what they say, and sometimes what they say is wrong. NOTE, I didn't say ALWAYS, but sometimes, and you need to consider that when you reply to people's posts. Or maybe you're right, and it's all our fault.
Malc

 

[Patch]

now what the discussion should really be about is if the NICE guild-lines constitute best advice...

If you are referring to their advice on bg levels then I think they are at a realistic level, lets not forget that 70% of diabetics fail to get under them and they are stated as being 'no higher than' levels. I think it would be pointless to set them any lower, you would just see more people fail and that would be even worse, don't you think?

Targets aren't there to be MET. They're there to be AIMED FOR! I wish I could change my targets at work th eway GP's do! :lol: (try getting that past the boss!)

If less people were passing driving tests, would they make the tests easier? NO. People would have to work harder to pass!

There's a reason for that - we don't want **** drivers on the road. Same as we don't want uncontrolled diabetics taking up hospital beds in years to come because they maintained a level of control that was "achievable" and not "optimal". I don't want to be given a target that is set due it being achievable. I want a target that is set because reaching it will keep me in good health.

It's all ticks in boxes. I don't care if my GP can tick the box that says "70% of my diabetics meet the (achievable) criteria". I care if I get problems with my feet or eyes or heart in the future because I didn't keep my BG low enough.

They're giving us targets that are not in line with achieving the end result. The end result is GOOD HEATH.

 

[Snodger]

ooh I really want to get into a big rant about HbA1c targets, setting people up to fail, what counts as 'poor health' and why severe hypos never seem to get included in discussions of what is good HbA1c, dodgy evidence bases for trying to get people to normoglycaemia....


...but it's too hot and you'll all jump down my throat and tear me to pieces, and anyway that would be hijacking the thread, so have a nice picture of a lovely owl.

 

[Patch]

That IS a lovely owl... I feel placated already...

Zzzzzzzz...

[P.S - I'm with you on the "setting people up to fail" thing.]

 

[Pneu]

I have just deleted my long rant reference HbA1c targets!

But I will say this... HCP's are going to give guidance based on guidelines.. many of us would agree those guidelines are incorrect. But its a pointless exercise to shoot the messenger!

In my opinion the NHS needs to be far more open about the truth of diabetes... there is no point beating around the bush! diabetes kills, it does horrid things to your body and to top it all off... you can go for many years without seeing any of this damage..

How many people come to this site for advise and guidance post complications? surely its better to arm people with the information to make an informed decision before the damage is done?

 

[borofergie]

But I will say this... HCP's are going to give guidance based on guidelines.. many of us would agree those guidelines are incorrect. But its a pointless exercise to shoot the messenger!

I agree that we shouldn't shoot the messenger. I guess that they have to "tow the company line", even if that company line is wrong. However, I get the distinct impression that some of them don't realise that there are "alternative" approaches to diabetes management, and will simply resort to reading from the (badly photocopied) script.

Maybe I expect too much, but as an informed and intelligent patient, I'd like to be able to discuss all of the treatment options with my HCP. In medecine, as in life, there is rarely a single answer to any problem, and if there was, it wouldn't look anything like the standard dietry guidelines that they force onto less informed diabetics. They are supposed to be Health Care PROFESSIONALs after all.

 

[catherinecherub]

Most Nurses in surgeries are just that, General trained Nurses and they do not have a speciality.

Test it out by asking at reception if you can see the DSN. If the receptionist doesn't know what you mean they my bet is that they haven't got one. Even easier, ask the Nurse that you see if you can see her Certificates for her Diabetes Courses.. A professional would be quite happy to oblige.

I think it is a bit much to expect them to specialise in a subject that they have no training in. They have a role in the surgery for any and everything that is thrown at them. It costs more to hire a Specialist Nurse and so these Nurses cannot be expected to keep updated with all things diabetes .
They are usually coached with a few NHS pamphlets and told to ask the Dr. if there is anything that they do not understand.

It is another cost cutting exercise. There are not enough DSN's to go around.

 

[Sid Bonkers]

Oh OK I'm wrong Duh!!!


Lets get the targets set for HbA1c's under 6% then, suits me just fine Of course it wont make a bit of difference to the 70% of diabetics who dont currently get within the current guidelines, they will just be joined by another 20%. That makes so much sense :roll:

Patch, targets aren't meant to be met? In that case they may as well be scrapped then :lol:

 

[Patch]

Scrapping them wouldn't make much difference. People withg poor control would still have poor control, and people with great control would still have great control.

 

[Sid Bonkers]

Scrapping them wouldn't make much difference. People withg poor control would still have poor control, and people with great control would still have great control.

So why are you arguing for them being too high

 

[Patch]

I'm not arguing.

I don't rely on being told what to aim for. I'm not a sheep. I couldn't care less what the guidlines/targets are.

'Cos the guidelines are for the Dr's to achieve (a tick in the box), and NOT for ensuring WE are kept as healthy as possible for as long as possible.

Which is what they SHOULD be for.

 

[Grazer]

This is why targets should be personalised for individuals. If they are too hard for some people at, say, 6.5% then those people probably won't bother. They'll just get disheartened which in itself isn't good for control. For others, 6.5% won't be stretching enough and they could just get complacent. What we need is people that really understand diabetes, who can set stretching but achievable targets for individuals. Hopefully, after a while, those people (probably like a lot of us), can then set their own targets.
Malc

 

[catherinecherub]

I thought agreeing targets was something that NICE recommended?

 

[Grazer]

Yes, but in general terms that is for people struggling to achieve 7%. They still have a catch-all that below 7% is O.K. That, of course, is nice and safe for them, as regards people on meds not getting Hypos. If they set lower "guidelines", there would be more dangers of hypos.
In contrast, Canada sets below 6.5% as a guideline. The US association of Endocrinologists use 6.5%. The American diabetes organisation say "Below 6% if safe"
Dr Christiansson, at the Copenhagen? (I think) summit argued that as 5.5% poses an extra risk for non-diabetics compared to a non-diabetic on 4.6%, then levels even lower should be achieved.
Because of risk, targets should vary according to meds and other criteria.
Who's got it right?

 

[Patch]

ME!

I'm always right. Ask anyone.

8)

 

[Zoroaster]

I considered posting this in another thread, but didn't want to go off topic - it looked so exciting... talking about diet again...So, here goes:

Recommendation 16 in NICE Guidelines CG66 (published in 2008) says

R16 When setting a target glycated haemoglobin HbA1c:

•  involve the person in decisions about their individual HbA1c target level, which may be above that of 6.5 % set for people with Type 2 diabetes in general
•  encourage the person to maintain their individual target unless the resulting side effects (including hypoglycaemia) or their efforts to achieve this impair their quality of life
•  offer therapy (lifestyle and medication) to help achieve and maintain the HbA1c target level
  
• inform a person with a higher HbA1c that any reduction in HbA1c towards the agreed target is advantageous to future health
•  avoid pursuing highly intensive management to levels of less than 6.5 %.

My reading is that the target should be personalised and that it will be the exception rather than the norm to set it above 6.5%. However, intensive management (whatever that is) should not be pursued to maintain an HbA1c below 6.5%.

NICE guidelines CG87 (published in 2009) discuss at which point specific medications should be prescribed and use the 6.5% and 7.5% boundaries as points at which to use those medications should be prescribed and therefore shouldn't be used to indicate what targets should be.

DUK suggest a target HbA1c for children of 8.5%, but it's down to the paediatric care team to set targets. NICE Guidelines CG15 (published in 2004 and revised in 2009 and 2010), however, suggest a target of less than 7.5%.

For adults with type 1 NICE Guidelines CG15 say:

Blood glucose control should be optimised towards attaining DCCT-harmonised HbA1c targets for prevention of microvascular disease (less than 7.5%) and, in those at increased risk, arterial
disease (less than or equal to 6.5%) as appropriate, while taking into account:

• the experiences and preferences of the insulin user, in order to avoid hypoglycaemia
• the necessity to seek advice from professionals knowledgeable about the range of available meal-time and basal insulins and about optimal combinations thereof, and their optimal use

DUK's recommendations for adults with diabetes are in line with those from NICE:

For most people with diabetes, the HbA1c target is below 6.5 per cent, since evidence shows that this can reduce the risk of developing diabetic complications, such as nerve damage, eye disease, kidney disease and heart disease.

In 2009 the Quality Outcomes Framework (the means by which GPs are measured and rewarded) required practioners to

...lower blood glucose levels in half of their patients with type 2 diabetes to below 7%

As for pre and post prandial blood glucose targets, DUK say

There are many different opinions about the ideal range to aim for. As this is so individual to each person, the target levels must be agreed between the person and their diabetes team.

I'm not sure where our HCPs dream up their targets, it sure isn't from NICE, nor from DUK, and not from QOF. I must be relatively lucky then, my GP is happy for me to be in the 5% club.

Sources:
NICE Guidelines CG15 - http://www.nice.org.uk/nicemedia/live/10944/29390/29390.pdf
NICE Guidelines CG66 - http://www.nice.org.uk/nicemedia/live/11983/40803/40803.pdf
NICE Guidelines CG87 - http://www.nice.org.uk/nicemedia/live/12165/44318/44318.pdf
DUK - Information for parents - http://diabetes.org.uk/Information-for-parents/Diabetes-care/HbA1c/
DUK - HbA1c - http://www.diabetes.org.uk/Guide-to.../Glycated_haemoglobin_HbA1c_and_fructosamine/
DUK - Blood Glucose Targets - http://www.diabetes.org.uk/Guide-to-diabetes/Monitoring/Blood_glucose/Blood_glucose_targets/
Medical News Today - New Diabetes Target Will Waste Resources And May Be Harmful http://www.medicalnewstoday.com/releases/141526.php

 

[catherinecherub]

The UKPDS Study advises, Individual targets need to be assessed in relation to age, general health and other risk factors. There hasn't been another study of this size that I am aware of and NICE do quote this study on occasions.

http://medweb.bham.ac.uk/easdec/prevent ... 0study.htm