June 2015, Volume 65, Issue 6

Primary Care Diabetology

Self-management of diabetes in primary care

Sanjay Kalra  ( Department of Endocrinology, Bharti Hospital & BRIDE, Karnal, India. )
Yashdeep Gupta  ( Department of Medicine, Government Medical College, Chandigarh, India. )


This article defines and discusses diabetes self-management education and diabetes self-management support in the context of primary care. It offers practical advice to help primary care physicians begin and enhance the quality of self-management education and support services in their practice.
Keywords: Diabetes self-management education, Diabetes self-management support, Diabetes counseling.


Primary care is a challenging task, where physicians are expected to manage a wide spectrum of medical and surgical conditions, with limited resources. This situation becomes more challenging when the burden of managing chronic disease, including diabetes, is added to the multiple responsibilities a primary care physician has to fulfill.
Simple strategies to meet this challenge include sharing responsibility for diabetes care with people with diabetes. Effective education, counseling and support of people with diabetes will help improve the quality of self-care and self-management that people with diabetes can provide themselves. Therefore, diabetes self-management education (DSME), which is a critical element of diabetes care, becomes even more important in primary care settings.


DSME is defined as "the ongoing process of facilitating the knowledge, skill, and ability necessary for prediabetes and diabetes self-care."1 This is similar to, but different from, diabetes self- management support (DSMS), which indicates "activities that assist the person with prediabetes or diabetes in implementing and manage his or her condition on an ongoing basis, beyond or outside of formal self-management."1

Scope in Primary Care

Primary care physicians should integrate DSME and DSMS in their day-to-day clinical practice. The South Asian socio cultural ethos, and the community-based character of primary care services, makes it easier to involve family and community members in the care of people with diabetes.
A pragmatic primary health care provider understands the limitations of his or her environment. At the same time, he or she tries to improvise and innovate in order to overcome these limitations. The United States National Standards state that providers of DSME will determine who to serve, how best to deliver diabetes education to that population, and what resources can provide ongoing support for that population.1 The primary care physician, by virtue of his or her close contact with the community is the appropriate person to do so.
Various organizations, including the Baqai Institute of Diabetes and Endocrinology, and the Diabetic Association of Pakistan, offer support to primary care physicians in Pakistan. The Journal of Pakistan Medical Association has also started a regular column on diabetes care, targeting the needs of primary care physicians.

Pragmatic Guidance

We propose pragmatic guidance for primary health care providers to provide best possible DSME and DSMS to people with diabetes in their care. We hope this will motivate DSME and DSMS provision across the region.

Curriculum Content

*Focus upon the seven healthy self-care behaviours: healthy eating, being active, taking medications, monitoring, problem solving, healthy coping and reducing risks2
*Use accepted curricula as guides, while modifying the contents to suit local needs2,3
*Focus upon primary needs [e.g., diet, insulin technique] before discussing complex situations [e.g., management of sexual dysfunction].

Self Improvement

u Continually update oneself with regards to current trends in diabetes management.
u Explore novel ways of continuing medical education, including web-based, print-based and face-to-face channels.

Team Improvement

*Utilize paramedical personal to provide DSME and DSMS,4,5 monitoring and supervising their activities.
*Provide them on-the-job training, coupled with formal education if possible.
*Ensure regular staff meetings to discuss problems and find solutions to them.

Patient Involvement

*Address the "felt" needs of the person with diabetes. Understand that these are dynamic, and change with time.
*Help the person realize his "actual" needs, with relation to diabetes care and address those as well.
*Encourage the person to write down queries while presenting for a consultation.
*Explain the concept of shared decision making and patient empowerment.
*Encourage the person with diabetes to articulate his or her wishes, values and preferences, in the spirit of person-centred care.

Family and Community Involvement

*Encourage family members to attend clinic consultations and education sessions
*Ensure that family members are trained in primary self-care activities such as hypoglycaemia management, dietary modification and insulin technique
*Involve the community, friends and colleagues in diabetes care activities.

Utilization of Resources

*Search for easily understandable patient education material, in local languages.
*Use other people with diabetes as peer support.
*Request capable people with diabetes to volunteer as diabetes educators in- clinic or in- site (in the community).
*Consider taking the help of cross-specialty colleagues.


Make a beginning in providing DSME/DSMS, and in creating a team to manage diabetes. It is not mandatory that all education/support be provided in a single session, under one roof. Education and support are continuous, and dynamic, processes, not one-off, static exercises. It is essential, however, to make a conscious effort to begin, and enhance, DSME activities in primary care.


1.Haas L, Maryniuk M, Beck J, Cox CE, Duker P, Edwards L, et al. National standards for diabetes self-management education and support. Diabetes Care 2013; 36 (Supplement 1), S100-S108.
2. AADE7 Self-care behaviors. (Online) (Cited 2014 October 12). Available from URL: http://www.diabeteseducator.org/ ProfessionalResources/AADE7.
3. International Curriculum for Diabetes Health Professional Education. (Online) (Cited 2014 October 12). Available from URL: http://www.idf.org/webdata/docs/ Curriculum_Final%20041108_EN.pdf.
4. Kalra S, Kumar B, Kumar N. Prevention and management of diabetes: The role of the physiotherapist. Diabetes Voice 2007; 52: 12-5.
5. Kalra S, Kalra B. Answering the urgent need for diabetes care professionals in Northern India. Diabetes Voice 2006; 51: 11-3.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: