November 2010 Issue

Winning Ways in Diabetes Management — Experts Share Best Strategies for Counseling Newly Diagnosed Patients
By Juliann Schaeffer
Today’s Dietitian
Vol. 12 No. 11 P. 36

To help clients gain control of their disease and achieve meaningful change, educators must identify which teaching techniques work—addressing patients’ fears and meeting them where they are, for starters—and which don’t.

Data from the 2007 National Diabetes Fact Sheet (the most recent year for which data are available) put the total number of U.S. children and adults with diabetes at 23.6 million, which translates to almost 8% of the population. And each year, another 1.6 million adults receive the diagnosis from their physician.

Especially for adults with type 2 diabetes, which is strongly associated with unhealthful lifestyle behaviors, this diagnosis sometimes comes with guilt and often stirs up fears and concerns. Either with regrets about past lifestyle behaviors or traumatic memories of a family member’s diabetic complications, newly diagnosed type 2 diabetes patients always come with baggage—but it’s the baggage of their life. While each patient brings unique character traits and life circumstances to the counseling table, there are several strategies that experts believe work best for certified diabetes educators (CDEs) and dietitians who treat patients newly introduced to the world of type 2 diabetes.

A Different Role in Diabetes Care
When a patient presents with an acute illness or condition, healthcare professionals are adept at observing symptoms, diagnosing issues, and prescribing treatments to cure such health concerns. But type 2 diabetes calls for a different paradigm, and it requires both the patient and the healthcare professional to take on partner roles in long-term disease management.

Rule No. 1, according to Martha M. Funnell, MS, RN, CDE, research investigator in the department of medical education and the Michigan Diabetes Research and Training Center at the University of Michigan: Both healthcare professionals and patients need to understand and accept their respective place in the diabetes care equation.

“It’s important to realize that it doesn’t matter where you are in terms of your diagnosis. The reality is that most of the day-to-day management of diabetes is done by the patient. So one of the key things from the very beginning to help people to understand is what their role is,” explains Funnell. “While we want to get into the nitty-gritty and tell people how their pancreas works and what they need to eat, the more important things to start with are really helping patients get some understanding of what this is all going to mean for their lives.”

Funnell explains to patients that “what happens as you live with diabetes is going to be largely in your hands. … I’m going to be there to help you, but at the end of the day, your life is going to be different. There are decisions that you’re going to have to make that you didn’t have to make before.”

She says CDEs should help patients understand the significance of their role in their diabetes management while also recognizing their own role (which is not to get people to change) so that both can work in tandem to effect the best change possible for each individual patient.

Empower Patients in Partnership
The philosophy of patient empowerment, which involves engaging and involving patients in their diabetes care vs. giving them purely factual information about their disease in a strict, regimented lecture format, has received much attention recently and has proven successful in diabetes management.

This doesn’t surprise Funnell, who says patient empowerment is inherent in diabetes care: “Patient empowerment just is. It’s not something we give to patients. The reality of diabetes is they’re taking care of it 99.9% of the time, so they are in power at the end of the day. They go home and decide [whether] to take this pill, work on weight loss, exercise, etc … all of those decisions are out of our hands. [Patient empowerment] is inherent in a self-managed illness.”

Funnell explains it to patients in this way: “I know a whole lot about diabetes, but I don’t know you. You are the world’s foremost expert on yourself, and you know what’s going to work for you. So let’s put those two things together. We’re going to keep trying different things, and if they don’t work, it doesn’t mean you’re resistant to change; it doesn’t mean you’re noncompliant or a bad patient. It just means that we need to try something else, and there’s a whole lot of things we can try.”

She says a solid partnership can serve as a great foundation for positive behavior change and overall better diabetes management.

The benefits of patient empowerment can be seen particularly in the education process. The empowerment model leaves behind the lecture format of diabetes education and instead leans on patients themselves: their experiences, questions, and solutions.

“All the numbers and facts that go along with lectures, there’s no humanization to it,” says Robin Nwankwo, MPH, RD, CDE, of the Michigan Diabetes Research and Training Center. “The empowerment process recognizes the expertise of the patient and then builds from that so that patients don’t feel that they are a subject or a student sitting in a classroom. Their life is brought into focus, and we talk about how to integrate diabetes management strategies into their life.”

For a person starting on insulin, a purely lecture-based education session could explain the basics of how to clean the skin, pinch up the skin, etc. But for patients who’ve likely learned this from an office visit or an earlier session, “they need to talk about why sometimes it hurts or the times when they wondered if they took enough insulin,” says Nwankwo of what someone would gain from a more patient-centered educational session. “They have specific questions that don’t get covered in a generalized education program designed on what people feel people with diabetes need to know.

“With the patient empowerment model, there’s also the understanding that education is ongoing and lifelong. It does acknowledge and appreciate that diabetes changes and learning needs change and that people form a team that will hopefully be a lifelong experience,” she adds.

Address Concerns
Newly diagnosed patients often exhibit feelings of guilt for “causing” a disease that can be delayed or prevented in some cases or fear from memories of loved ones who faced diabetic complications. Nwankwo sees this as one of the main challenges in counseling newly diagnosed patients. “Patients frequently say that it’s their fault they got diabetes. [They feel] they didn’t exercise enough, [didn’t] listen to their doctors, ate the wrong foods, etc. They see themselves as the source of the problem and they don’t know how to get out of it,” she says.

These feelings and concerns are also known as diabetes-related distress, which a majority of newly diagnosed diabetes patients experience and which can be detrimental if not addressed. “We know from [a previous] study that about 85% of patients experience severe distress at the time of diagnosis and that 15 years later, about 43% of patients are still experiencing [many] of those same feelings. Those feelings are the primary determinant of [patients’] self-management behavior,” explains Funnell.

She says educators should acknowledge these feelings from the very beginning of a patient’s journey with the disease and help patients understand that they’re not alone. “Reassure patients that these feelings are common, that you’re there to work with them, and try to help them identify some sources of support as they go through their life with diabetes because it’s going to make a difference in their long-term outcomes.”

In addressing such emotional concerns, Funnell says it helps to know who you’re trying to reach. In adults, type 2 diabetes accounts for the vast majority (90% to 95%) of all diagnosed cases, according to the National Institutes of Health. Because of this, Funnell advises taking note of how adults learn.

“Adults want to know what they want to know when they want to know it and when they’re going to use it,” she explains. In speaking to patients’ concerns and questions, she uses the following analogy: “When I first got a computer on my desk, I didn’t need to know how it worked. I wanted to know how to turn it on, how to get to my e-mail, how to get to the Internet, and how to type something and print it out. And our patients are the same way. [Patients] don’t need to know about their beta cells at first. They have some concerns, some fears, and worries, and we need to teach to those as opposed to a curriculum.”

And while this can be done individually or in a group environment, she says the first questions she asks of a newly diagnosed person are “What’s your biggest concern about this diagnosis?” and “What’s the hardest thing for you right now with your diabetes?”

Nwankwo adds the following to her list of questions for the newly diagnosed:

• How did you feel when you were diagnosed?

• What experiences have you had with diabetes before your own diagnosis?

• What information do you want to know?

After gathering those answers, she feels she then has “a framework of life to work with so that I can make some suggestions.”

Start Where the Patient Is
Because each patient is at a different place in his or her life at the time of diagnosis, there is no one road on which to start patients when they first come to see an educator. But CDEs say listening skills can be key to helping each individual find a path for successful diabetes management. To best help those newly diagnosed, you must start wherever they say they are, not where a curriculum sheet designates.

Nwankwo explains: “A lot of times with wound healing, the wounds are left open with just packing so they can heal from the inside out. It’s the same process for education for diabetes. You have to start where the patient is sitting or thinking at that point and then build out.”

To illustrate this principle, Nwankwo does a 24-hour food recall with patients to form a basis for their typical food choices, their routines, the frequency of their meals, etc. She then discusses with patients different improvements they might make to better manage their diabetes. “Give them several options and then they can choose one thing that they can do to make a difference (regarding their food, timing of their medicine, or building in exercise). But it’s still just starting where the patient is and being specific to their life,” she says.

In the process, she also uses food models, which she finds help patients better visualize the concept of portions. “If you can take exactly what they’re eating at that moment and build from there, it helps them assimilate it much quicker, and they’re often making much better choices with their food the next time you see them,” she says.

Marlisa Brown, MS, RD, CDE, CDN, a certified diabetes educator and chef, stresses that each individual requires a plan to meet his or her unique needs and life circumstances. “Even if I have an idea of what should be done, take into consideration what the patient can do. Make concessions to meet the reality of the situation,” she says.

Make Goals Measurable
When making goals with patients, Funnell says one of the first steps should be to identify what’s important for them and their motivating factors. “What is it you’re struggling with?” she asks them. “Part of helping people understand what they’re struggling with is where the motivation to change comes from.”

Once patients verbalize their struggles, educators can start recommending that they experiment with solutions and formulate goals. Goals for diabetes patients are paramount to success, but note that not all goals are equally beneficial.

Funnell explains: “For example, if a patient is interested in losing weight, to set a goal of losing weight is not very helpful. [I tell patients to] pick one or two things that [they’re] going to do in the next four or five days and start there,” which allows patients to gain some self-efficacy and sense of accomplishment.

She also encourages educators and patients to think of this solution-finding as experiments. “A reason to think of it as an experiment is because you often learn as much from what doesn’t work as from what does work,” she says. Try different things and see what works. When one possible idea or goal doesn’t work, suggest patients try something else vs. thinking of themselves as a failure. “It’s a constant process of trying new things and seeing what works,” says Funnell.

For patients who enter a session feeling defeated and downtrodden for failing to reach a goal, making note of at least one thing they’re doing right can also be helpful. Any positive reinforcement can help build confidence and a feeling of accomplishment, which can lead to more accomplishments and a better-managed disease.

Nwankwo advises making sure clients’ goals are of an iSMART nature: inspiring, specific, measurable, achievable, relevant, and time specific. “It’s something that’s finite enough for them to accomplish within a day or two, and they can continue [with the goal] until the next time I see them,” she says.

Instead of the vague “I want to lose weight” goal, an example of a more specific short-term iSmart goal would be increasing vegetable intake by eating broccoli on Thursday, carrots on Wednesday, and cabbage on Monday (all details that would be decided upon by each patient).

“And that’s going to help them increase their vegetable intake, which will facilitate less dependency on carbs and therefore achieve the weight loss they’re hoping to get,” says Nwankwo. “So they’ll see the connection as they drill down to a goal that’s going to be more tangible—because losing weight is something that you can’t measure in the next day, but getting in cabbage on Monday is measurable.”

In addition, Brown finds that having a hard copy of goal specifics can aid in patients’ efforts at behavior change. “I put the goals that we come up with on a goal sheet with them when they’re [at my office] and I print it for them,” she says.

Get Past Patients’ Resistance to Change
Many healthcare providers who deal with patients with type 2 diabetes, a disease in which lifestyle behavior is a big determinant of disease course, note patient resistance to change as a big obstacle. However, Funnell advises educators to see through patients’ eyes to another perspective to better help them succeed.

“The whole concept of resistance to making change is clearly a challenge that healthcare providers identify,” notes Funnell. “Yet if you ask a group of patients [whether they believe they’re resistant to change], they would give you a very different answer. They would probably identify struggling with making changes but not that they’re resistant—just that it’s darn hard [to make changes]. If it wasn’t, we wouldn’t live in a country where obesity is a major public health burden.

“I think education and helping people learn how to make changes in behavior go hand in hand. You just don’t change everything all at once,” she adds.

A number of studies on the topic have shown that the previous standard of teaching patients clinical information in a general lecture format does not help them change their behavior. “We’ve evolved [in how we educate these patients]. We used to focus on giving people a lecture on content; then we learned that we needed to teach them some behavioral strategies. These aren’t things we apply to them; these are things we teach them so they can use them in their own lives,” Funnell says.

Funnell asks educators and other providers to not hold this fallacy of “resistance” against patients, as all patients with diabetes want to live a happy and healthy life, no matter what choices they’ve made by the end of each day.

Funnell encourages educators to keep in mind a truth that colleague Robert Anderson, EdD, has conveyed to her: “People aren’t resistant to change; people are resistant to other people trying to change them. And we have for too long in healthcare viewed our job as trying to change people as opposed to helping them figure out what it is that they’re interested in changing and then helping them figure out some ways to do that.”

Speak With Patients, Not to Them
When counseling patients newly diagnosed with diabetes, the way in which educators speak to a patient can make for an open ear or a brick wall. “If you just tell patients what to do, you’re going to get a wall,” says Brown.

To avoid this situation, Funnell instead discusses possible options for treating diabetes. “I always start by asking patients what they want to do and what they believe will work for them. I also talk to patients about what we know (not what you should do). If patients are having a hard time finding a solution, I’ll say, ‘Here are some things we’ve learned about what helps people lose weight. Let me tell you what some of those are, and tell me what you think of them and if you think any of those would work for you.

“For example, we know that people who eat breakfast tend to be thinner and tend to be able to maintain weight loss. A multitude of studies have shown that,” she adds. “But I [convey this information to patients] not in a ‘you should do it this way’ but from an information perspective so people can consider it when they are developing behavioral strategies or solving problems they encounter.”

Problem solving with patients is another way for educators to distinguish themselves from the scolding teacher type, says Brown, who seeks to be seen as more of a partner to whom patients are more willing to listen. “Come up with problem-solving strategies to make it possible for them to make small changes without completely interfering with their lifestyle,” she says, noting that she’s found success with this approach.

Prescribe Ongoing Education
While there’s no magic number for how many hours of education individuals with diabetes will need to best manage the disease, experts say patients should be advised at diagnosis on the long-term nature of diabetes, noting that ongoing education should be stressed to best manage a disease that can change over time.

“One thing we’ve learned very clearly is that a one-time education program is not adequate and that people need ongoing help, particularly in making and sustaining literally a hundred behaviors a day that they need to maintain for a lifetime,” says Funnell. So to think that a patient could see a dietitian or an educator a few times and be sufficiently prepared for the twists and turns of this disease is shortsighted.

In terms of overall diabetes management, the data show that group education is just as effective as individual education, but Funnell says one exception could be meal planning with an RD. “I think there’s a real benefit to doing that on a one-to-one basis as opposed to talking about what I like to eat in front of 20 people,” she says.

However, the group dynamic of patients with diabetes can be enormously beneficial in myriad ways, and the difference is in how effectively an educator uses the group. “If the only difference is that I use a PowerPoint instead of a conversation, neither one is very effective,” Funnell explains. However, “if instead of being an educator I can be a facilitator of the group, then I can involve the group in problem solving and ideas can come out of the group that way. It’s always much more meaningful when those things come from people who are there and living it than from an educator.”

Know What Doesn’t Work
Sometimes knowing what doesn’t work can be as helpful—if not more so—than knowing what does. And when it comes to managing type 2 diabetes, Funnell knows two things that haven’t worked in the past.

“I think we can say … that telling people they should lose weight and exercise doesn’t work. We’ve tried that for many, many years, and that’s why we believe patients are resistant to change,” she says.

She also notes that giving people lots of “shoulds” and new ways to do things instead of helping people think through how they can fit a change into their life also isn’t helpful in the long run. “We’ve learned that giving people a lecture on content doesn’t accomplish much and that just focusing on behavior change doesn’t accomplish much. You really have to focus on the knowledge piece, the behavior piece, and the emotional side of it all as one thing because that’s how patients think about it,” she says.

“We need to involve and engage groups of patients in the educational process,” Funnell continues. “I think more and more educators are recognizing what their job is, which is not to teach patients but to collaborate with them and be a partner with them, which is what true patient-centered care is all about.”

Be Open to Change—and Make a Difference
No matter the barriers to such a patient-centered way of treating patients with type 2 diabetes (though Funnell doesn’t see any), she believes it’s the best way forward—if healthcare professionals can put in the effort alongside patients.

“What it does take [for this patient-centered approach to work] is healthcare professionals to make changes in how they do things. And health professionals are no less resistant to being changed than our patients are resistant,” she notes. “It’s much more comfortable to give a lecture as an educator; it’s much harder to engage a group of patients. It’s much harder to let go of the control and ask patients how they handle things.”

Yet Brown says it’s crucial for healthcare professionals to stay in the fight to help patients best manage their disease because of what’s at stake: “As a dietitian and a diabetes educator, you have a significant chance to make a major impact on patients’ lives and on their health—in this particular situation especially. People who have type 2 diabetes when they’re first diagnosed can get themselves into normal blood sugar and reduce the chances of almost all complications significantly. And if you can get their brain to merge with your brain so that they hear you and you give them information they can use, you can dramatically change the course of their life.”

— Juliann Schaeffer is an editorial assistant at Today’s Dietitian.