August 27, 2014

New Approach for Diabetes Patients

William H. Polonsky, PhD, CDE, has it correct when it comes to dealing with diabetes patients. Dr. Polonsky is a clinical psychologist and co-founder of the Behavioral Diabetes Institute in San Diego, CA. He said, “We've got the right medications, we have so much knowledge, and we have great tools to help people manage their diabetes effectively. Unfortunately, none of those things will work if we can't convince our patients to make use of them, and that is why we all know it comes down to behavior.”

I will be using his article in Medscape to write about this. He wrote this column based on the talk he gave when accepting the Richard R. Rubin Award at the 2014 annual meeting of the American Diabetes Association.

Dr. Polonsky says all he has done for the past 25-30 years is focus on the behavioral aspects of diabetes, both as a clinician and as a researcher. I may not be quoting him correctly, but he has said, “Diabetes causes nothing, it is the lack of diabetes management that causes complications.” I firmly believe he is correct, yet there are some that have been very vocal in their desire to have him be more politically correct and stop using this statement. Shame on them.

In some cases, Dr. Polonsky says, “The way that we use behavior-change interventions with our patients may work very, very well. But sometimes, these seemingly simple and brilliant behavior-change interventions -- such as collaborative goal setting and action planning -- just don't work at all.”

I think the reason we have so many frustrations with trying to encourage and promote behavior change with our patients is because we make 3 fundamental mistakes. I often make them myself.”

I feel that Dr. Polonsky is writing as a clinical psychologist, but I see this also in CDE's. The three mistakes he outlines are:

#1. Probably the most important mistake is that we push a little too hard. “Most of us are so concerned about our patients -- we so much want to help and we are so overtrained as problem-solvers -- that we essentially demand behavior change before our patients are ready for it. They may not be convinced that what we are encouraging them to do is really worthwhile, even if they seem to be cooperating with us. They may harbor suspicions about medications, or question whether they can really make dietary changes, or whether those changes will even make any difference.”

He says that learning to take your time and setting the right mood is important for patients.

#2. The second mistake involves what he calls the principle of the mundane. “We often "overfocus" on the obstacles that our patients face. We view these barriers to behavior change as big, dramatic complications, and that is probably the fault of researchers like me. I have made a big deal out of these things over the years: depression, eating disorders, fear of hypoglycemia.”

The one Dr. Polonsky focuses on is what he calls "meh," or apathy or indifference. Many of the patients do not view diabetes as a priority in their lives, and that may be totally justified because the patients are much like us. Life gets in the way.

So, we need to appreciate that the biggest barriers to behavior change may not be big stuff but little stuff. People may simply be overwhelmed by diabetes, just stressed and confused, and not dealing with the disease at the best problem-solving level.”

#3. The third principle is what he calls ATMs (actions that matter). “Many of my colleagues who are somewhat skilled in behavior change have fallen into this trap of diabetes empowerment: When they talk to their patients and ask where they might want to make some lifestyle changes, they imply that the particular answer doesn't matter. "Mrs. Smith, what do you want to do?" "Well, I guess I should drink more water every day. I can do that. Or maybe I should have fewer tortillas at every meal, or maybe..."

Certainly, the patient should be the decision-maker in this, but I think we must remember to get the most "bang for the buck." Instead of giving the impression that any change is admirable and will lead to even more positive behavior, we should be willing to collaborate and inform our patients about the facts. "Look, you have diabetes and there are probably 100 different things that you could do to improve your health, but they are not all equally important. We can put them in order of priority: knowing your glucose numbers is critical; smoking is a bad thing; being on the right medication and then taking it may be the most important thing. That is where you can get the biggest bang for your buck."

I quoted much of his article because it is important. There is much we as patients can learn from this. I will also be using this in my role as a peer mentor and as a peer-to-peer worker. Too often I find myself pushing and expecting because I have experiences to relay that the others should be more willing to accept my words. I have found out this does not always work and that those I am working with do not want to make changes and are looking for something easier that they can do.

One person that Allen and I had been working with kept insisting that there had to be something that he could take and reverse his diabetes. Nothing we were saying was accepted and we could tell he was not even following us. After several meetings, we had to tell him that after he wasted his money, he would be back, probably having complications, and then we would be able to help him. We did not have that chance as he passed the following week. We have learned that his blood glucose became so high that he went into a coma and died the following day.

His daughter did tell us this and asked for information on several bottles she had found on his table. We were able to find information on them and as you might have guessed, they were either for supposed cures or reversing diabetes and none were of any value. We suggested that she have a talk with his doctor and have him consider showing them to other patients and explain that they do not help. His doctor agreed and has been successful with this approach.

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