WASHINGTON — Although there are gaps in the literature about the psychosocial aspects of diabetes management, evidence-based strategies do tend to work for many patients, Leonard Jack Jr., Ph.D., said at the annual meeting of the American Association of Diabetes Educators.
A major review of 84 published articles pertaining to diabetes self-management training found that, overall, evidence supports the efficacy of such training for patients with type 2 diabetes, particularly in the short term.
The authors concluded that further research is needed to assess the effects of self-management interventions on sustained glycemic control; cardiovascular disease risk factors; and, ultimately, microvascular disease and quality of life (Diabetes Care 2001;24:561–87).
The literature is inadequate in many areas, including details about the interventions, assessment of patient satisfaction, the influence of family on patient outcomes, and the particular impact of diabetes self-management interventions on men.
Nearly all the published studies are comprised mostly of female patients, noted Dr. Jack, team leader of Applied Behavioral Research, Epidemiology, Surveillance, and Evaluation at the Centers for Disease Control and Prevention's division of diabetes translation, Atlanta.
Despite the gaps, the literature does support the following counseling strategies for all patients with diabetes:
▸ Frame the teaching to match the patient's perceptions. Simply by asking the question “When you think of diabetes, what do you think of?” can elicit the information needed to focus the teaching based on the patient's perceptions or misperceptions, he said.
▸ Fully inform patients of the purpose and expected effects of interventions—and when to expect these effects. This helps avoid discouragement when results are not immediate. If potential setbacks are likely, warn the patient of this and offer suggestions on what to do.
▸ Suggest small lifestyle changes rather than large ones. Patients can be asked to do just slightly more than they're doing now, such as adding 5 more minutes of walking if they're already doing 10. Many studies on self-efficacy suggest that enhancing a patient's faith in his or her capabilities improves the chances of success.
▸ Be specific. Tell the patient exactly how much to exercise, how often to eat, how intensely to work out, and explain the rationale for the recommendation. Demonstrate your instructions if possible, and write them down on a prescription sheet.
▸ Remember that it's easier to add new behaviors than to eliminate old ones. If weight loss is a goal, it may be more effective to suggest that they begin taking short walks or other light physical activity than to change their current eating patterns. In all studies, dietary habits are harder to change than anything else, Dr. Jack noted.
▸ Link new behaviors to old ones. Suggest that a patient exercise before eating lunch, or use an exercise bike while watching the evening news, or take his or her medication when brushing teeth. Family routine is important too—make sure that what you're telling the patient doesn't interfere with established family activities.
▸ Use the power of the profession. Don't be afraid to tell a patient outright to stop smoking, cut the fat out of the diet, get out of the house more often, or seek additional help.
▸ Get explicit commitments from patients. Ask patients to describe how they plan to follow the intended regimen. Ask them, “What specifically do you plan to do this upcoming week?” If the patient expresses uncertainty, try to brainstorm with him or her about the scenario and alternatives, Dr. Jack said.
▸ Use a combination of strategies. Individual counseling, group psychoeducation, written materials, and community resources will each work for some patients some of the time. Combining them improves the chances for success, he said.
▸ Involve your office staff. A multifaceted team approach, including a nurse, certified diabetes educator, dietitian/nutritionist, and others, is optimal for managing patients with diabetes.
▸ Refer patients with complex problems. Those with severe depression, psychosis, or suicidal ideation need expert help, as do those with less severe but still complicated problems such as difficulty with interpersonal relationships.