San Francisco—Diabetes care requires a truly collaborative approach where patients and clinicians relate as equals, according to David G. Marrero, PhD, JO Ritchey Society, professor of medicine, Indiana University School of Medicine. Dr. Marrero was among a group of experts at the ADA meeting who discussed the importance of behavioral change in the management of diabetes.
Social Ecological Model
Referencing a paper he and colleagues published in Diabetes Care in 2013, Dr. Marrero discussed how a social ecological model might be used to better understand and integrate diabetes care. The model outlines influences on behavior that operate within the individual, the family, and other groups at a community level, including cultural, governmental, and policy influences.
Individual perspective—both psychological and biological aspects—is the centrality of behavior affecting outcomes and the first component of the model. The behaviors of the individual have a direct influence on the fundamental disease process of energy metabolism. “I can make my glucose go up and down by simple behavioral changes,” said Dr. Marrero, who has had type 1 diabetes for 38 years. This mindset is reflected in the development of self-management education. “We know diabetes education is essential and can work if done appropriately,” he added.
Negative emotions are also a contributor to poor diabetes management. Many individuals with diabetes experience a variety of psychological problems or distress that can interfere with diabetes management. Although healthcare providers recognize that psychological problems adversely affect adherence, many do not feel confident in their ability to identify psychological problems in their patients or to intervene effectively, he explained.
Family, friends, and small groups are also an integral component of the model. He said the effects of diabetes education alone generally wane after 6 months so the individual needs self-management support. Government, policies, and large healthcare systems are the final part of the model. “Ongoing follow-up and support for self-management are not recognized as an important service at the policy level,” according to Dr. Marrero, noting that in the United States, many insurance payers regulate or deny use of glucose strips for type 2 diabetes patients and continuous glucose monitoring systems are not easily obtainable through insurance.
“Although truly comprehensive care in many cases will need a redesigned care system, there are elements that can be meaningfully implemented in almost any existing system of care. These start with how we approach establishing therapeutic goals with our patients,” noted Dr. Marrero (Table).
Heather L. Stuckey, DEd, department of medicine, Pennsylvania State University College of Medicine, highlighted the US results from the DAWN2 [Diabetes Attitudes, Wishes, and Needs] study. DAWN2 built on a new, wider model of the needs of people with diabetes, particularly with the addition of family members. DAWN2 included 15,438 respondents from 17 countries. Of the respondents, 8596 were people with diabetes, 2057 were family members, and 4785 were healthcare providers.
Dr. Stuckey, who was part of the DAWN2 study group, highlighted some of its findings. DAWN2 demonstrated a need for improved self-management behaviors among people with diabetes in the United States. Self-management behaviors differ by ethnicity, as the results found Chinese Americans tested their blood sugar as recommended by their doctor less often than non-Hispanic whites and blacks.
“Diabetes is more than a burden on self-management behaviors, it also impacts psychosocial outcomes,” according to Dr. Stuckey, who reported that 20% of people with diabetes still experience high diabetes distress. Social support is also crucial in individuals managing their disease. The findings also showed that psychological outcomes were worse for family members if diabetes was perceived as severe or diabetes treatment involved insulin. However, psychological outcomes were better for family members who had more support from their social networks and had participated in diabetes education, reported Dr. Stuckey. “We must involve people with diabetes and family members as equal partners when developing new care solutions,” she said.
Effective Coping—The Educator’s Role
For many patients with diabetes, self-care requires behavioral change. Carolyn T. Thorpe, PhD, MPh, assistant professor, University of Pittsburgh School of Pharmacy, continued by discussing how healthy coping can be integrated into diabetes self-care and the role of the diabetes educator. The American Association of Diabetes Educators (AADE) developed the AADE7™ Self-Care Behaviors® framework to measure behavior change. Healthy coping is 1 of the 7 self-care behaviors. She said healthy coping is more than the absence of depression and psychological distress. It is the acceptance of diabetes and integration of its reality into one’s life. Individuals with healthy coping can handle stressors and negative emotions and do not let them overwhelm or impede diabetes management. Healthy copers have positive attitudes about diabetes, positive relationships with others, and have a high quality of life.
The diabetes educator is a key point person for helping to identify when problems with coping exist and for assessing different aspects of healthy coping so they can be addressed in diabetes self-management education (DSME), she said.
The first step in DSME is patient screening via a brief evaluation to determine the likelihood that the patient has a specific condition or characteristic (eg, clinical depression, anxiety, diabetes-related distress). If the patient screens positive, the educator should follow-up with a comprehensive assessment to confirm the diagnosis, determine the severity, and identify contributing circumstances.
Along with identifying coping issues, the educator can do many things in the delivery of DSME to support healthy coping in patients who have existing problems. For example, she said problem-solving is 1 of the key problem-focused strategies. “This is integral to delivery of DSME because the evidence for problem-solving approaches and problem-solving as a type of therapy is strong,” she explained, noting that it is included in AADE7™ Self-Care Behaviors® and is now part of most DSME.
While problem-solving can easily be applied to diabetes management, Dr. Thorpe said it can also be applied to any emotional relationship or psychosocial issue that may interfere with self-management and healthy coping.
Because many approaches can be incorporated into DSME, Dr. Thorpe said the challenge is how to choose among them. She said comparative effectiveness data on one approach versus another are lacking. Furthermore, what works best for 1 patient may not work for another.
She concluded by offering suggestions that diabetes educators may want to consider when implementing DSME, including analyze the current program and services, determine what are the greatest unmet needs of the population, pilot test new interventions on a small scale, and continually reassess.For more information, visit the Diabetes Initiative Web site at www.diabetesinitiative.org.—Eileen Koutnik-Fotopoulos