Diabetic camp - Mauritius - nongovernment organization - self-care - therapeutic education - Type 1 diabetes - Type 1 diabetes mellitus support
The Importance of a Camp in Mauritius
The aim is to allow the patients to enjoy as well as to improve their knowledge and competence on the management of their medical condition in a nontraditional environment. It is an opportunity for them to be “separated” from their parents and to nurture an improved sense of community and friendship with people of the same age group and medical condition. It is also an occasion to perform clinical research[2] that will enable T1Diams to promote the impact of diabetic camp internationally. The patients learn to live a normal lifestyle with their diabetic condition among other children with Type 1 diabetes. Furthermore, T1Diams' diabetic camp is a real world diabetic experience for nondiabetic volunteers to step in the shoes of patients with Type 1 diabetes. Finally, this diabetic camp is a unique opportunity to reinforce the experience of staff working in the association and to help the patients to have the best possible glycemic control.[2]
Duration and funding
T1Diams is the only expert nongovernmental organization with know-how in setting up diabetic camps in Mauritius. The diabetes management protocol is not significantly different from that used by the American Diabetes Association,[6] Canada and the French Aide aux Jeunes Diabetiques (AJD).[7] The specificity of these camps is that they are organized in winter with an average temperature of 14°C–16°C. Winter season lasts from May to September. The T1 members are on school holidays for about 2 weeks, and the camp lasts for one whole week. About forty patients with Type 1 diabetes attend this camp annually. The camp's budget is funded by donations from the corporate sector; no funding from the government is available. In France, the association AJD organizes camps ranging from 1 to 3 weeks, and these are sponsored by the government and private donors.[7]
Diabetes management
According to the Diabetes Control and Complications Trial Research Group, the goal for glycemic control during diabetic camps is to prevent hypoglycemia as in these camps the stay is short and associated with increased energy expenditure through more frequent physical activities.[8] T1Diams also follows the same principle. Two months before the camp, a camp questionnaire is sent to the members where they fill in their name, address, weight, height, past medical history, any allergy, particular food regimen, immunization record, ongoing illness, history of severe hypoglycemia, diabetes regimen (types of insulin, dose and time of injection, and latest glycated hemoglobin [HbA1c]), and any psychosocial issues. These data are compiled and analyzed by a committee (consisting of diabetic educators, doctor, psychologist, and camp director) 1 week before the camp. On the camp, each member has a personal file where these data are available. They are advised to bring their glycemia logbook where any particular adjustment to the dose of insulin can be done when the latter returns home.
On this camp, every member has her/his own glucometer and does a test before each meal, at bedtime and in case of hypoglycemia or hyperglycemia. The values are recorded in the logbook and also on a large white board. The activities and meals are also recorded. According to one of the protocols used, hyperglycemia is corrected with a bolus of long-acting insulin, and 2 h after the injection, the glucose levels are checked. This is applied over a 24 h period. Any member attending the camp for the first time is encouraged to always check her/his blood glucose levels to check for hypo/hyperglycemia. These children benefit from the support of the elder patients with Type 1 diabetes.
For the reference blood glucose values, the recommendations from IDF/ISPAD guideline[9] are used, i.e., 4.4–6.6 mmol/L fasting blood glucose, before lunch and before dinner. At bedtime, up to 10 mmol/L is considered acceptable.
Age group and diabetic education
The age range of members with Type 1 diabetes in T1Diams varies from 12 months to 18 years with an average of 14 years. The camp duration is 7 days. The age group is divided into two: 0–11 years (children and parents) and 12 years and over (adolescents only). For the past several years, the first 4 days of the camp are devoted for adolescents only, whereas the remaining days are for the children and parents group. The objectives for the two groups are different. T1Diams follows the same recommendation as AJD,[7] France, where they have different targets to achieve for different age groups.
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0–11 years: These parents and children are new to Type 1 diabetes. It is an opportunity for them to learn the basics of Type 1 diabetes outside a hospital setting. They learn how to do a blood glucose test, know their equipment (glucometer, glucose strips, insulins, glucagon, and needles), learn how to plan a healthy diet, recognize the symptoms of hypoglycemia, and learn what Type 1 diabetes is. The parents are empowered on how to treat hypoglycemia and how to set up a hypokit for their children at school. Furthermore, it is an occasion where the children learn to perform a blood glucose test alone so that they are empowered to do it on their own at school. These children are educated through games and the numbers showing hypo-hyperglycemia
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Age 12 and above: The aim is to consolidate their skills on Type 1 diabetes management. On the camp, they will apply all the therapeutic education carried out during the year. For example, they learn how to adapt their doses of insulin or where to inject insulin in case of physical activities.
Diabetes therapeutic education
The diabetic camp is built on five pillars, namely:
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Diabetic education
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Technical plateau
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Sports
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Nutrition
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Peer group experience.
Diabetic education is done every day, on an individual basis or in groups. Games and educational tools are used to achieve the objectives.
The technical plateau includes strengthening the capacity of the children to perform a blood glucose test, carry out insulin injection, fill in the diabetic logbook, and learn how to recognize hypo-hyperglycemia and the respective treatment.
Sports include low intensity to vigorous physical activities. The aim is to create awareness on the importance of physical activities and to empower them to link Type 1 diabetes with sports and to remove the taboo that they cannot perform physical activities just because they are patients with Type 1 diabetes.
Nutrition plays a very important role on the camp. The meal plan is designed by a dietician to meet the energy and carbohydrate needs of patients with Type 1 diabetes s. The meals are also served as a teaching tool to better understand the concept of carbohydrate counting.
Further, the peer group experience enables the children of the same group age to meet and share their experience with each another on the management of their condition.
Diabetic education
On the camp, several educational topics on Type 1 diabetes are covered in view of empowering the members to manage their diabetes efficiently. The topics include:
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Human body function
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What is Type 1 diabetes
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Hypoglycemia
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Hyperglycemia
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Types of insulin
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Adaptation of insulin doses
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Nutrition
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Psychosocial issues
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Diabetes and pregnancy
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Diabetes complications
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Sports
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Insulin injection techniques
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Blood glucose monitoring
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Importance of HbA1c and microalbumin tests.
Medical team and staff training
The diabetic camp is a medical recreation camp comprising a doctor, a nurse, medical students, and a diabetes educator. A doctor experienced in the management of Type 1 diabetes is present. He instructs the nurses when there are medical emergencies and provides guidance and his expertise on any particular medical issue arising. He also makes the lists of drugs that are necessary on the camps for conditions such as anaphylactic shock, asthma, nonhypoglycemic fits, pain, fever, abdominal pain, vomiting, sore throats, and allergies. We also have a first aid kit for minor injuries. With the assistance of the administrative staff, they make provision for glucose strips, glucometers, insulin, and needles.
The nursing staff consists of one nurse and one diabetes educator who are assisted by medical students. Whenever there is an incident of severe hypoglycemia, the nurses are trained to put an intravenous line with glucose 30% or glucagon injection. The Ministry of Health of Mauritius regularly sends one or two diabetes nurses to attend and gain experience. The medical students are recruited from the University of Mauritius on as volunteers. One month before the camp, they are trained during a 2-day session on the management of Type 1 diabetes. Then, on the camp, they will do appropriate adjustment to insulin doses with respect to physical activities and food intake. All the time they will be under the supervision of the camp doctor. Furthermore, the nursing staff gets a crash course on Type 1 diabetes. During the training of the medical staff, each medical staff member is allocated her specific job description.[10]
Every day, the dietician is present on the camp. She plans the menu according to activities so that members do not fall in hypoglycemia during activities and could follow the same example at home or during outing. She designs menus that are acceptable to all cultural groups.
During the camp, there are also interventions from professionals (nutritionist, psychologist, social worker, endocrinologist, ophthalmologist, podiatrist, and dentist) so that residents get a complete medico-social follow-up.
Administration
The camp is managed by an administrative staff. It consists of a manager, an administrative coordinator, and a field worker. The manager has the responsibility to ensure the overall smooth running of the camp. Meetings are scheduled on a daily basis to ensure that all activities and meals are properly planned for the following day. The smooth running of the daily camp routine creates the proper environment for members onsite to learn more about their diabetic condition that will help them when they return back home.
Diabetes-related emergencies
The medical staff is trained by a medical doctor on how to recognize and manage hypo/hyperglycemia.
Hypoglycemia
A protocol for hypoglycemia treatment is available in the medical room. Hypoglycemia is defined as a blood glucose level ≤3.3 mmol/L (0.6 g/L). Five grams of oral glucose per 20 kg of body weight is given, and we wait for 10 min for symptoms to subside. In case, there is persistence of hypoglycemia, we repeat the oral glucose dose. In case of severe hypoglycemia, the medical staff is trained on the administration of 30% glucose intravenous solution or intramuscular injection of glucagon. At 22.00 h, a blood glucose value of 8–10 mmol/L is considered acceptable.
Before physical activity, the dose of insulin is decreased, and a 10 g glucose equivalent snack is given.
Hyperglycemia
In case of blood glucose readings ≥14 mmol/L, the child is requested to do a urine ketone level test. There is a set protocol for the management of hyperglycemia with or without ketosis. For hyperglycemia without ketosis, the amount of insulin needed is calculated to correct the elevated blood glucose reading (1 unit of rapid-acting insulin = 99/[total dose of insulin over 24 h]). In the presence of ketosis, the child is given water to prevent dehydration, and a calculated amount of insulin is given to reverse ketosis. No physical activity is allowed during that period. The child's condition is followed up using a flow sheet. If the symptoms persist, the child is referred to the nearby regional hospital.
Glycated hemoglobin and microalbuminuria
T1Diams is the only nongovernmental organization on the Island to have an HbA1c and microalbuminuria apparatus validated by the Government Central Laboratory of Mauritius. This point of care is of extreme importance for our members on the camp. The HbA1c test is done on all patients on the camp, and it serves as a reference because many patients do not even know their last values.
Since the patients report that they never did a urine test for microalbumin at the hospital, the test is done on the camp. The screening for microalbumin in urine is done for those living with more than 10 years of diabetes and who never had a microalbumin test done at the hospital. The test is done to detect diabetes-related kidney complications. If a child shows a positive test, a medical report will be provided to the treating doctor of the patient for prompt action.
