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Case Study Presentation
- 1. Hey Sugar, Diabetes Got You Down? Kelly Knopf Dietetic Intern
- 6. Overview DKA Diarrhea Possible depression ETOH abuse Neuropathy ↓ Urine output Kidney stones Nausea and vomiting Abdominal pain Polydipsia Weight loss Type 1 Diabetes Mellitus
- 7. Overview DKA Diarrhea Possible depression ETOH abuse Neuropathy ↓ Urine output Kidney stones Nausea and vomiting Abdominal pain Polydipsia Weight loss Type 1 Diabetes Mellitus Non-compliance
- 16. Thank you for your time and attention!
Editor's Notes
- May 20, 2011
- May 20, 2011
- May 20, 2011
- May 20, 2011
- May 20, 2011
- May 20, 2011
- Motivation - I assessed the patient’s level of motivation through interview. He often referred to his financial barriers and lifestyle difficulties (being 40 yo, unemployed, living w/parents). All of these suggest a level of depression which directly affects motivation. That, in combination with his frequent change in discussion topic) led me to believe that he was not very motivated. He had many personal rationalizations of why he ate the way he did. Goals - Although his ability to access food and medication would likely be his most important goal, the more immediate goal would be to follow a consistent carbohydrate ADA diet because this is something he can start doing immediately within his parent’s home. Through discussion with the patient, his parents seem quite supportive. Compliance - Although the patient says that he is motivated to make the changes, he would often send the conversation on a tangent and would make excuses for why he doesn’t follow his diet. I do not feel that his motivation is at a good level nor do I feel that his compliance will improve after discharge. Barriers - The patient is unemployed so financial issues are certainly of concern, both in paying for medications and purchasing food. However, he does live with his parents and often eats at least one meal per day with them. I am not aware of whether he gets unemployment or of his insurance situation, but the social workers would be able to help him sort out ways to get medications and help him get SNAP or food bank assistance. His educational level seems sufficient to understand the material, however he seems to suffer from depression which is a strong motivational barrier. May 20, 2011
- As health care providers we ask DM patients to undertake quite a bit – dietary changes, exercise, self monitoring, self medicating, self injecting, and frequent visits to clinic. We educate, educate, and educate again…..yet we get such low compliance. Education is not enough, so much of self-care is influenced by cognitive function, including depression May 20, 2011
- 14.8 million– that’s how many people are affected by depression each year 23.5 million – that’s how many people are affected by diabetes each year 20-25% - the % of those with diabetes that experience depression 1.6-2.0 – the relative risk for experience depression in the diabetic population compared to general population Even at subclinical levels, having depression along with diabetes is associated with worse DM control and increased risk of complications. Ultimately these complications can lead to an increased risk of mortality 1.76 – relative risk of mortality in women with depression 1.71 – relative risk of mortality in women with diabetes 3.11 – relative risk of mortality in women with both depression and diabetes Clearly suffering from a combination of these conditions increases risk of mortality to a startling degree May 20, 2011
- Much emphasis is placed on clinical management of diabetes, but even when patients have received repeated education, patients are often non-compliant. There must me more at work. How patients feel about their condition plays a major role. Patients with diabetes may show earlier cognitive decline or even depression; a compounding factor that occurs more frequently in diabetics than the general population. Early health behavior related studies investigated things like demographics and social characteristics and their effect on behavior, but most of these were not found to be good indicators of behavior, largely because most of them are difficult if at all possible to change. Therefore the findings of these studies were not especially helpful in designing interventions. Psychological aspects were better predictors so new theories were developed. Use of the Health Belief Model can help us understand the factors at play. If a patient is falling short in one or more of the 5 aspects of the HBM, this could lead to symptoms of depression and poor self-care. The 5 dimensions of the HBM include: perceived severity of the condition perceived susceptibility of vulnerability to the disease process perceived benefits costs/barriers cues to action (internal-symptoms or external-education). Perceived severity was found to have the biggest impact on long term regimen adherence. Perceived susceptibility was found to have the greatest impact on preventative self-care behavior Perceived benefits was found to have the greatest impact on sick-role behavior, in other words, behavior just after diagnosis Costs/Barriers was found to have the greatest impact on self-care behavior in young people, especially those transitioning from pediatric to adult care. As dietitians, we can use this information to curtail our message depending on where in the spectrum the patient falls; putting emphasis on the appropriate aspect of the HBM. The Theory of Planned Behavior is another tool that can be used to evaluate barriers to self-care. While historically used to evaluate one-time behavior decisions, Shankar et al used the TPB to predict repeated self-care in diabetes patients. The main focus of TPB is intention, how hard someone is willing to work for an end. Or more specifically, intention refers to an individual’s attitude about a behavior and their expectations of an outcome. It also refers to the individual’s perception of social pressure to perform the action whether or not they are motivated to comply with the pressure. For example, a diabetic man’s motivation to comply with pressure he receives from his wife and family to adhere to his self-care regimen. Researchers found that the saying, “past behavior is a good predictor of future behavior”, holds true. That being said, they also found that people’s intention to self-monitor was high and that most of their participants checked their blood sugar at least twice daily. In addition the researchers found that the stronger barrier to adherence was not intention or control, but perceived difficulty. In other words, they found it difficult to check their blood sugars at work or in social settings. Again, as dietitians, we need to be sensitive to the needs of each patient. Rather than more clinical education on blood sugar monitoring, programs that increase patient’s self-efficacy (overcoming perceived difficulties) would be more beneficial in the long run. When preventable diseases are diagnosed, how does blame and anger affect management? A research study by DePalma et al published in the American Journal of Health Behavior, investigated how blame and anger affect diabetes management. Their results were mixed, depending on the level of blame experienced by the subjects. Those subjects with especially high levels of anger and blame regarding their disease were less likely to maintain good glycemic control. On the other hand, they found that those individuals with low levels of blame and anger translated these emotions into responsibility for their medical maintenance and had improved glycemic control. This begged the question, should we change how our patients think about their disease? Researchers vehemently discouraged this thought process. Ultimately, researchers concluded that self-blame and anger regarding disease interfered with effective glycemic control. The researchers suggested that while much emphasis is placed on clinical control (ie education) of diabetes, not enough is done to contend with the psychological/social aspects of diabetes management. May 20, 2011
- The American Association of Diabetes Educators (AADE) has found that people with diabetes have improved management when they are able to deal with psychosocial issues in their lives. In fact, they feel it is so important that it has now been included in their revised AADE-7 Self-Care Behaviors guidelines. These guidelines are: healthy eating being active monitoring taking medication problem solving reducing risk healthy coping. I am going to focus on the last of these 7 guidelines – healthy coping. Good coping behaviors include: fulfilling health care obligations expressing emotions seeking help demonstrating basic problem-solving skills physical activity being proactive demonstrating self-efficacy overcoming barriers being motivated and optimistic. There is a plethora of barriers to good coping: low social support financial stress or constraint external locus of control low problem-solving ability stressful life events low educational level low health literacy external focus poor prioritization skills lack of access to providers and diabetes educators compounding health problems perceived stigma attached to admitting an inability to cope And the DAWN study (Diabetes Attitudes, Wishes, and Needs) revealed that greater than 40% of the respondents reported low psychosocial well being. Clearly psychosocial health and coping are major concerns for those with diabetes. Currently, most assessment tools identify unhealthy coping strategies, but few target healthy coping strategies so the AADE is working on development of a tool that will focus on positive coping strategies related to the AADE7 and provide a composite score that can be shared with the patient. Any health provider from nurses, physicians, mental health professionals, dietitians, and pharmacists, can utilize this tool and others already in existence to screen for depression in their patients with diabetes. Study published just this year looked at the associations of depression with glycemic control and compliance to self-care activities in adult patients with T2DM. Specific self-care activities included taking dose on time taking dose as advised dietary restriction exercise foot care. They found a significant relationship between depression and female gender which supports the earlier statistic of increased depression and mortality in women. They also found that women were less likely to follow recommendations of exercise and more likely to have higher BMIs. Special consideration in screening and intervention should be taken with this population. The researchers found that depressed diabetic patients were less likely to adhere to all self-care factors than their non-depressed counterparts. A possible explanation offered by the researchers puts depression and poor glycemic control into a cyclic relationship. Depression and psychological stress increase sympathetic nervous system activity, inflammation, platelet aggregation, and decreased insulin sensitivity which leads to poor glycemic control, which increases the risk of complications, which increased depression. The key is to break the cycle, but how? May 20, 2011
- Clearly, improved counseling for patients with diabetes is needed. Diabetes educators should be trained to assess psychosocial well-being in their patients and refer them to specialists as needed. One possible approach involves Cognitive Behavioral Therapy as part of a team approach. A 2010 case series study investigated the effect of CBT on adherence and depression (CBT-AD) in T2DM. Intervention consisted of 1 visit with a nurse diabetes educator, 2 visits with a dietitian, and 10-12 sessions of CBT-AD with a psychologist. Participants met with the nurse diabetes educator at baseline to set goals for treatment regimen: medication, self-monitoring of blood glucose, and foot care. At baseline, the dietitian performed a comprehensive assessment of self-management behavior in terms of weight loss, physical activity, blood glucose monitoring. Then the dietitian helped each participant set 2 nutrition goals and 1 physical activity goal. The second dietitian visit occurred at 6-8 weeks into the program. At this visit the dietitian and the participant evaluated the progress of the goals and collaborated on revision if necessary. The 10-12 visits with the psychologist consisted of an initial orientation visit followed by 9-11 visits called “Life Steps”. The Life Steps program worked the participants on changing their cognitions, or thoughts about their conditions. A variety of tools were used to measure adherence and depression at both baseline and conclusion of the intervention. Adherence was also monitored by use of electronic pill caps and glucometer log. HgbA1c was evaluated at both baseline and conclusion of the program. While the study had only 5 participants, all adults with suboptimally controlled T2DM despite use of oral hypoglycemics, and with depression, the results were promising. All 5 participants had an improvement in depressive symptoms. 4 of the 5 had improvements in both depressive symptoms and glycemic control. 4 of the 5 had an increase in medication adherence post intervention when compared to baseline. At baseline all participants reported difficulty with diet and at the conclusion of the study all participants reported improvement in diet and related activities. The researchers felt that the diet intervention in conjunction with the CBT was implemental in both improved depression and improved glycemic control. Researchers found that a team approach to diabetes control is the best way to improve depression and adherence in diabetic patients. We saw with the Theory of Planned Behavior that intention was less of a barrier to good self-care then perceived difficulty. It is important to make good self-care accessible to patients with diabetes, this includes in the workplace. Diabetes is considered a disability under federal employment regulations, but this does not guarantee that every person with diabetes will be protected by the Americans with Disabilities Act (ADA). Protection is determined on a case by case basis based on whether or not the individual’s condition impairs one or more major life activities. Diabetes, like other disabilities, can have an impact on an individual’s ability to perform certain jobs and a 2001 study revealed that people with diabetes earned only 72% of what non-diabetics earned and were two times as likely to be unemployed as a result of complications. Challenges in the workplace include difficulty working rotating shifts jobs requiring a significant amount of physical activity or standing for long periods of time limited time and location to self-monitor and self-medicate access to medication storage. When patients are confronted with these challenges, it can undermine their motivation, intention, and adherence to self-care regimen. Addressing these challenges with specific accommodations such as frequent breaks and rest areas, padded carpeting, flexibility to sit or stand during shift, shorter work days with extended work week, and job sharing can enhance compliance and reduce depressive symptoms. Diabetic patients who are also experiencing depression may need additional accommodations of stress reduction, stress management, or time off to attend counseling. Something important to consider, however is the disclosure of diabetes status. Counselors on the multidisciplinary team should help patients determine when it is appropriate to reveal their diabetes status. In some instances, as when the disability is visible or help from others may be required, as in unstable glycemic control, it is both necessary and beneficial to reveal status. In some instances it is not necessary and may, in fact, be harmful to disclose diabetes status, for example, during the hiring process. May 20, 2011
- As we have seen, there is limited research on diabetes and depression. Cognitive Behavioral therapy has proven to be a possible treatment option, but researchers have come up with a randomized controlled trial study design focused on mindfulness. Mindfulness is defined as self-regulation of one’s attention focusing on direct experience, while adopting a curious, open, and accepting attitude towards these experiences, especially one’s psychological processes, such as thoughts and feelings. Similar “mindfulness” studies showed positive effects on patients with chronic pain and those with cancer. It has also show positive effects on patients with non-diabetes related depression and anxiety. Since diabetes patients have a unique set of circumstances to deal with; diet, physical activity, self-monitoring, and self-medicating, the researchers want to see if a mindfulness intervention will produce positive results for this population as well. The theory is that mindfulness interventions will enhance emotional well-being. Better mood – better self-care behaviors. In addition, mindfulness interventions put a considerable focus on bodily sensations. Those who become more mindful will be in better tune with their bodies signals leading to improved self-care. Dependent variables: emotional distress (depression, anxiety), quality of life, mindfulness, self-esteem, improved self management, improved glycemic control, and controlled blood pressure. Independent variable: intervention (Mindfulness-Based Stress Reduction and Mindfulness-Based Cognitive Therapy programs. 8 weekly, 2 hour sessions. Each session has a different theme, but follows the same format: exercise, discussion of exercise, discussion of previous week’s homework, discussion of week’s theme, more exercises, homework assigned, and concluding with a short meditation, poem, or relevant story. Subjects: adult men and women with either T1 or T2 DM with a score of <13 on the WHO-5 well being index. Assessment: Baseline HgbA1c and blood pressure readings are taken on initial interview. HgbA1c, and blood pressure will be assessed again at completion of intervention. HgbA1c will be reassessed at intervals following intervention until 6mos post intervention in the experimental group at which time the waitlist, control group will begin receiving intervention. Various tools will be used to measure things like stress, anxiety and depressive symptoms, mood, quality of life, self-care behavior, mindfulness, and self-esteem. These assessments will also take place periodically up to 6 mos post intervention. Challenges: Recruiting sufficient number of subjects who are willing to commit to the 8 weeks of 2hr interventions and homework 5 days per week. Researchers hope to have preliminary results available early next year. Review of interventions targeting diabetes self-management reveals that effectiveness of intervention is significantly related to duration of intervention. Many interventions would not be practical in the long term. Clearly there is a need for cost-effective on-going intervention. Proposed randomized control trial that would use automated, interactive telephone interventions to help improve self-care in diabetes patients. Subjects: 340 adults with T2DM in either experimental or control group. Dependent variable: HgbA1c, quality of life, self-efficacy, anxiety and depression, diet, physical activity, and BMI to name a few. Independent variable: automated telephone intervention. Variables would be measured at baseline and again at conclusion of intervention (24 weeks) and yet again at 12 mos post intervention. Methods: Control group is asked to continue their present management. In the intervention group, patients would phone in on a weekly basis to share their adherence to regimen and receive an education on one of 3 topics depending on the week and their circumstance. These education sessions would focus on medication, physical activity, and healthy eating. For individuals who do not have medical clearance for physical activity, their PA messages would be replaced with messages on the other topics. Likewise for those individuals who do not use medication. In addition, all participants (both experimental and control) will receive a quarterly newsletter to help maintain participation. The TLC Coordinator will call participants after their first two calls and then at weeks 6, 12, and 20 in order to resolve any issues (technical or otherwise) that the participants have experienced. TLC Coordinator will also be available to resolve issues on an as needed basis. Measurement: HgbA1c, other chemistries, height, weight, and various tools to measure self-care, anxiety, depression, etc. Information will also be collected on program costs and related to cost-effectiveness compared to other intervention strategies. Automated TLC systems have been effective in adherence to other chronic disease states, but has never been used for diabetes self-care adherence. Role of Dietitians: Be vigilant in assessing patients. Learn to recognize signs and symptoms of diabetes-related anxiety and depression. Try to determine why patients are non-compliant as opposed to re-educating, re-educating, re-educating. Know when to refer patients out to mental health specialists and therapists. May 20, 2011
- May 20, 2011
- May 20, 2011