Diabetes Battle Continues, More Self-Care Needed
San Francisco—As the lyrics to Bob Dylan’s “The Times They Are a-Changin” played, Marjorie Cypress, PhD, C-ANP, CDE, American Diabetes Association President, Heath Care & Education, took the stage to deliver her keynote address. She urged more activism by healthcare professionals in the fight against diabetes.
“The fight to stop diabetes continues, and we are losing that war,” said Dr. Cypress, adult nurse practitioner, Albuquerque Health Partners. A study by Selvin et al published in Annals of Internal Medicine in 2014 reported fewer people with undiagnosed diabetes. However, the study showed that rates of obesity and diabetes continue to rise. “It is estimated that one-fifth to one-third of all Americans will have diabetes in 2050 if current trends continue,” she said.
Issues Contributing to Disease Prevalence
Many issues contribute to this increased prevalence, and Dr. Cypress touched upon 4 specifically: (1) stigma; (2) costs; (3) healthcare delivery; and (4) health literacy and numeracy. “While we all know that individual lifestyle behavior contributes to increased risk, we also know it is not the whole story,” she said. “Why are we so afraid to recognize our own behavior? We in the medical community may be making this stigma worse by telling people they need to lose 50 or 100 pounds. We all know that starting to lose weight makes a big difference in blood glucose control. So, do we discount the 5 or 10 pounds that patients lose?”
Another part of stigma is the belief that people should take personal responsibility for their health. While that is not wrong, Dr. Cypress said clinicians need to go beyond looking individually at patients and their families and instead focus on public health. “The work that enables real change must be done on a grander and higher level,” she added. “We will only see real change when policy drives and promotes health.”
The economic burden of diabetes is staggering. “Financially, diabetes is destroying us,” said Dr. Cypress. She referenced a 2013 ADA report published in Diabetes Care that estimated the total economic cost of treating diabetes in 2012 at $245 billion, a 41% increase from a previous estimate of $174 billion in 2007. More than 1 in 5 healthcare dollars in the United States goes to treating diabetes. She asked, “Where are our legislators? Why are they not appalled by this? Why do we have to fight so hard for baby steps?”
Delivery of care is also an important issue. “We know there is a shortage of primary care doctors and endocrinologists,” acknowledged Dr. Cypress. “In order to increase productivity, we need to expand the scope of practice of other healthcare professionals, like certified diabetes educators, nurse practitioners, physician assistants, pharmacists, and behaviorists. Others can monitor patients, adjust medications, and educate and counsel patients. We can deliver more services even with fewer physicians.”
Health literacy and numeracy issues among individuals is another factor in the rise of diabetes. Dr. Cypress highlighted findings from a 2013 Institute of Medicine report, which found that 91% of previously uninsured adults cannot understand glucose meter readings, interpret sliding scale insulin regimens, titrate oral medications or insulin, or adjust insulin for carbohydrate content. “If we do not address this, we will fail in our efforts to help people with diabetes,” she said.
The ADA’s Role
The ADA continues to work on initiatives to help address the rising rates of diabetes and obesity in the United States. The Safe at School Campaign is 1 initiative Dr. Cypress discussed. At the time of publication, 25 states and the District of Columbia had passed Safe at School legislation. “The Safe at School program advocates to keep children with diabetes medically safe at school so more teachers, nurses, and other personnel will know what they need to do to keep kids with diabetes safe,” she explained. She cautioned that more work is needed and the ADA cannot do it alone. “We need you,” Dr. Cypress told attendees. “I urge you to get involved. Donate your time. Become a professional member and add your voice.”
Diabetes Self-Care
Following Dr. Cypress’ address, this year’s Outstanding Educator in Diabetes Award Lecture was given by Katie Weinger, EdD, RN, FAADE, who focused on the importance of understanding and meeting the challenges of self-care for successful diabetes management. She stressed that it is not enough for clinicians and educators to teach individuals with diabetes how to manage their disease—they also need to understand how it feels to live with diabetes.
“We not only ask people with diabetes to believe impossible things about themselves and their disease, we ask them to do impossible things,” said Dr. Weinger, investigator, clinical, behavioral, and outcomes research, Joslin Diabetes Center, assistant professor of psychiatry, Harvard Medical School.
During her lecture, she explained that diabetes education is the process of helping individuals with diabetes and their families find and learn to use information and skills to understand their treatment and integrate diabetes self-care into their lives. Studies have found education that includes a behavioral component is most effective at improving the management of diabetes.
Phases of Diabetes
Individuals with diabetes typically experience 4 distinct phases. “Each phase can influence the type of emotional support and the diabetes education needed at that point in their lives,” she explained.
The initial phase—disease onset—is different for type 1 and type 2 diabetes. With type 1 diabetes, the onset is usually acute; often a crisis forces an individual to develop a new set of survival skills. Type 2 diabetes has a slower, more insidious onset that can be mistaken for so-called normal aging, particularly if other family members have diabetes.
Once patients get used to living with diabetes, they enter the health maintenance and prevention phase. This is the phase where individuals should spend most of their lives. “Our goal is to keep them there for as long as possible until someone finds a cure,” she said. During this phase, Dr. Weinger pointed out that some individuals put diabetes on the “back burner,” as other competing demands and priorities takeover, thus diminishing self-care.
When diabetes self-care becomes a lower priority, it leads into the next phase, early complications. For some patients, the recognition of complications can serve as a wake-up call, changing their attitudes and behaviors. For others, however, complications can reinforce persistent negative attitudes. She said that these individuals could become fatalistic and unable to cope with strategies necessary to delay disease progression. “Each person may need a different type of support and education to help cope with the disease and to maximize health and quality of life,” Dr. Weinger said.
The final phase—complications dominate—is the stage where the entire focus of healthcare can shift from diabetes to managing serious complications, such as cardiovascular disease and progressive kidney disease.
Diabetes requires a collaborative approach with patients, family members, and providers all working as a team and agreeing on treatments. However, this assumes “they are all on the same page,” she noted. For successful diabetes care, all 3 players must agree on treatment strategies and approaches.
It is also important to recognize that diabetes care is built on reaching 2 distinct types of goals. Providers tend to focus on medical goals, which are often laboratory based. Patients and families tend to focus on self-care goals, including food choices, portion control, and glucose monitoring. Meeting these self-care goals is a key element in meeting medical goals that are used to manage and assess diabetes control, she said.
In closing, Dr. Weinger stressed the importance of providers understanding how it feels to live with diabetes and the factors that influence self-care for each person. Diabetes care requires an individualized, educational approach tailored to fit each patient’s strengths and needs.—Eileen Koutnik-Fotopoulos
