Helping those who are overweight and poorly controlled

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Helping those who are overweight and poorly
controlled

• Chas Skinner

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Self-Management Behaviour

• Self-Report
• Follow exercise recommendations 34
• Follow foot care recommendations 47
• Follow dietary recommendations 59
• Follow monitoring recommendations 69
• Follow medication recommendations 95
• (Toobert et al 2001)

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Adherence ( days drug taken) to oral
antidiabetic treatment
40
34
35
31
30
Per cent adequateadherence (gt90)
25
20
13
15
10
5
0
SU (n1,329)
Met (n531)
SU Met (n1,060)
SUsulphonylurea Metmetformin
Adapted from Morris AD et al. Diabetes 200049.
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Patients Obtaining Less than 20 of Prescribed
Medication
Benner et a. Long-term persistence in use of
statin therapy in elderly patients. JAMA Jul
24/Jul 31, 2002 288, 4 pg. 455
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• 25 oral contraceptive not presented to
  pharmacist (Beardon, 1993)
• 18 renal transplant not taking medication as
  prescribed (Rovelli, 1989)

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Systematic Reviews of Interventions

• Current efforts to improve or to facilitate
  adherence of people with type 2 diabetes to
  treatment recommendations do not show significant
  effects nor harms. The question whether any
  intervention enhances adherence to treatment
  recommendations in type 2 diabetes effectively,
  thus still remains unanswered
• E Vermeire, J Wens, P Van Royen, Y Biot,
  H Hearnshaw, A Lindenmeyer. Cochrane Database of
  Systematic Reviews 2006 Issue

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Systematic Reviews of Interventions

• 26 of 58 interventions reported in 49 RCTs were
  associated with improvements in adherence
• Current methods of improving adherence for
  chronic health problems are mostly complex and
  not very effective, so that the full benefits of
  treatment cannot be realized. High priority
  should be given to fundamental and applied
  research concerning innovations to assist
  patients to follow medication prescriptions for
  long-term medical disorders RB Haynes, X Yao,
  A Degani, S Kripalani, A Garg, HP McDonald
  Cochrane Database of Systematic Reviews 2006
  Issue 4

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Why so little success ?

• Pub Med
• compliance 72784
• reviews 9524
• meta-analyses 240
• adherence 41115
• reviews 4348
• Meta-analyses 119

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Adherence/ Compliance

• the extent to which a persons behaviour
  taking medication, following a diet, and/or
  executing lifestyle changes, corresponds with
  agreed recommendations from a health care
  provider.
• (WHO 2005 http//www.who.int/chronic_conditions/a
  dherencereport/en/

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Assumptions

• There is a clear instructions to comply with
• That health care professionals agree on what
  should be done
• There is agreement about what decisions have been
  made
• That health care professionals accurately recall
  what they tell people with diabetes
• That behaviour is one-dimensional

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• An elderly patient who was taking several
  medications complained to her pharmacist that she
  was having trouble taking her potassium. The
  pharmacist asked, What seems to be the problem?
  Are you taking it as instructed?
• The patient replied, Yes, thats no problem. I
  take it just like it says on the label Take one
  tablet each morning in water. But I prefer to
  take my bath at night, not in the morning.
• A nine month-old baby had to be admitted to the
  hospital with a sever infection because his
  mother misunderstood the labelled instructions
  for an antibiotic Take one-half teaspoonful
  three time a day for infection until all gone.
  The mother continued the drug for about three
  days, until the baby appeared to be getting
  better. The mother then stopped giving the
  antibiotic a super-infection developed and the
  baby was hospitalised
• A patient returned to the pharmacy complaining of
  side effects apparently caused by his medication.
  The patients records indicated he had been
  dispensed 30 nitroglycerin patches. Both the
  pharmacist and physician told him to apply one
  daily. The patient opened hi shirt to reveal 27
  nitro patched.

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Information Not Comprehensible

• Reviewing data on diabetes web information pages
• The reading levels of the tested materials ranged
  from 11 to 15, which showed that these materials
  would not be understood by at least 80 of the
  adult population. Kusec et al 2002
• Readability of dental patient information
  leaflets
• meaning that 70-80 of the UK population would be
  able to understand them J Orthod. 2004
  Sep31(3)210-9
• Quality of hayfever information leaflets
• All the leaflets had readability scores requiring
  at least secondary education (SMOG score equal or
  greater than 9). At least one factual inaccuracy
  was identified in four-fifths of leaflets

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• Being physically active, exercising regularly?
• Not Smoking?
• Testing your blood sugars glucose regularly?
• Recording your blood glucose results?
• Eating five portions of fruit and vegetables a
  day?
• Eating a low fat diet
• Not eating many sweet things?
• Taking your medication / insulin as prescribed?
• Adjusting your insulin / medication dose or time
• Eating a diet low in salt
• Limiting how much alcohol you drink?
• Making sure you get regular medical tests for
  diabetes-related problems (e.g. eye exams)?

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Advice on the Internet

• Consider therapeutic trials of TENS
  (http//www.patient.co.uk/showdoc/40000922/
• A variety of techniques utilise physical
  stimulation to counteract painful sensations. A
  TENS (Transcutaneous Electrical Nerve
  Stimulation) machine is a small batterypowered
  device that delivers an electrical current to a
  pair of pad electrodes. The machine can deliver
  either low (Lo TENS) or high (Hi TENS) frequency
  background stimulation to the affected areas.
  Bursts of intense stimulation can also be applied
  during periods of severe pain. (http//www.neuroce
  ntre.com/mainpages/education/dn/page13.htm)
• TENS seems to aggravate rather than help.
  (http//www.coventrypainclinic.org.uk/nervepain-pe
  ripheralneuropathy.htm)

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What do you consider as ideal target of HbA1c ?
All health professionals in participating centres
Hvidoere Childhood Diabetes Study Group
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Agreement on Decisions

• GPs Patient Concordance on Goals
• Chose 3 given from list of 13
• No overlap 19
• 1 overlap 40
• 2 overlaps 36
• All 3 same 5
• Heisler et al 2003)

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Agreement on Decisions

• Decisions Made
• Complete Disagreement 21
• Pat Decreasing and increasing insulin
• Prof Less blood tests, to see at follow-up in 2
  months
• Pat To use oil instead of fats, also change from
  full creamed milk to semi- skimmed
• Prof Ensure does blood testing throughout day,
  not just before breakfast
• Some Agreement 32
• Prof to increase insulin to get BG lt10 premeal
• Pat to adjust my insulin get blood sugars above
  10 before meals
• Complete Agreement 47

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Agreement on Decisions

• Patient holding copy of GP letter
• Agreement on Decisions
• 7 Complete Disagreement
• 53 Some Agreement
• 40 Complete Agreement

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Patient Recall Inaccurate ?

• Type 1 diabetes patients were interviewed
  immediately after a follow-up visit to an
  outpatient clinic to determine which of the
  recorded instructions delivered by professionals
  were recalled by patients.
• The health care team reported giving an average
  of seven recommendations per patient, or a total
  of 168 items listed by team members as important.
  
• Patients recalled an average of two
  recommendations, or a total of 50 items
• 40 of which had not been recorded by team
  members.
• Page et al, 1981, Diabetes Care, Vol 4, Issue 1
  96-98,

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• For a decision to be recorded, two criteria had
  to be met
• i) the health professional, or patient, had to
  make a clear statement, questions such as what
  do you think about increasing your insulin? were
  not considered as a recommendation, or a
  treatment decision
• ii) the statement needed to include an action
  that either the patient or professional was to
  undertake.

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Recall of Decisions

• Patients recalled a mean of 2.5(SD 1.4) decisions
  per consultation
• Professionals a mean of 3.2(SD 1.6) decisions per
  consultation,
• Patients and professionals agreeing on a mean of
  1.0 (SD 1.2) decision per
• A mean of 2.2 (SD 1.1 range 4) decisions per
  consultation were identified on the audiotapes.

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Recall of Decisions

• Patients correctly recalled a mean of 0.6 (SD
  0.8, range 3) decisions/consultation,
• Patients recall mean 1.7 decisions/consultation
  we cant find on tape
• Professional correctly recalled identified
  decisions a mean of 0.8 (SD 0.9 range 3)
  decisions/consultation
• Professional recall 2.3 decisions/consultation we
  cant find on tape
• Skinner et al In Press

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Where do the errors come from

• Ask patients questions, that are then recorded as
  a decision or recommendation
• Have thought that an action should be taken, but
  never actually say it in the consultation

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• N gt 2700, type 1 type 2 diabetes
• Correlations among the SDSCA scales measuring
  different regimen behaviors in each study were
  generally low and consistent with previous
  research (mean r 0.23).
• Toobert et al 2000

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358 12-30 year olds Type 1 Diabetes
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2600 11-18 year olds type 1 diabetes
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Assumptions

• There is a clear instructions to comply with
• That health care professionals agree on what
  should be done
• There is agreement about what decisions have been
  made
• That health care professionals accurately recall
  what they tell health care professionals to do
• That behaviour is one-dimensional

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What can I do

• USE OPEN QUESTIONS TO
• Find out what people think they should be doing ?
• Check what they have taken from the consultation
  ?
• Find out what stops them doing what they think
  they should ?

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Depressed adults have a 37 increased risk of
developing type 2 diabetes mellitus.
Knol et al, Diabetologia Volume 49, Number 5 837
- 845 .
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Depression

• Strong consistent evidence that depression is a
  risk factor for clinical CHD.
• Association exists for men women, across
  countries and age groups
• Risk is directly related to severity of
  depression
• 1-2 fold minor depression
• 3-5 fold major depression
• Bunker et al Med J Aust. 2003 Mar 17178(6)272-6

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Depression in Diabetes

• People with type 2 diabetes have a 1.77 increase
  in rates of depression (Alli et al 2006),
• but this maybe a function of co-morbidity/complica
  tions (Pouwer et al 2004)
• Clinical depression in people with diabetes is
  associated with worse biomedical outcomes,
  quality of life and health care costs (De Groot
  et al., 2001)
• Following a heart attack, individuals who
  experience clinical depression have a 4-5 fold
  increase in mortality (Barefoot et al. 1996 ).

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Depression Treatment Improves Control ?
Lustman et al 2000
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Mechanism ?

• Physiological
• HPA Axis Dysregulation
• Heightened sympathetic activity
• Decreased sympathetic activity
• Vagal nerve tone
• Parasympathetic responsively
• Stimulation of inflammatory response
• Health Behaviour
• Increase energy intake
• Decreased physical social activity
• Increased drug intake (nicotine alcohol)

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NICE Guideline Depression
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What can I do ?

• Look out for depression
• Normalise Explain
• Use resources
• Beating the blues
• Mind over mood
• Give choice of medication
• Refer when appropriate

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(a) permanent recording of the performance, (b)
presence of an evaluative audience during the
task (c) presence of a negative social
comparison (the real or potential
out-performance by a confederate or other
participant).
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Weight Loss

• 36 studies met the inclusion criteria
• Overall, 3495 participants were evaluated.
• Behaviour therapy was found to result in
  significantly greater weight reductions than
  placebo when assessed as a stand-alone weight
  loss strategy (WMD -2.5 kg 95 CI -1.7 to -3.3).
  
• When behaviour therapy was combined with a diet /
  exercise approach and compared with diet /
  exercise alone, the combined intervention
  resulted in a greater weight reduction.
• Increasing the intensity of the behavioural
  intervention significantly increased the weight
  reduction (WMD -2.3 kg 95 CI -1.4 to - 3.3).
• Cognitive-behaviour therapy, when combined with a
  diet / exercise intervention, was found to
  increase weight loss compared with diet /
  exercise alone (WMD -4.9 kg 95 CI -7.3 to -
  2.4).

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So what can I do ?
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• Depressed, Stressed or Burnt Out

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Emotional Distress in Diabetes
indicating some level of distress
This study shows how worrying about developing
complications and feeling hopeless about diabetes
are very common concerns. At least 50 of people
with both type 1 and 2 diabetes in these studies,
felt to some degree that diabetes controlled
their lives.
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Emotional Distress in Diabetes
indicating some level of distress
In the same study, a sense of feeling like a
failure was reported in 50-75 of study
participants. Feeling angry, depressed, and
overwhelmed with the tasks of diabetes were also
commonly reported.
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Patients Tend to Overestimate Risk

• Differences between perceived and actual 10-year
  risk were
• 22.9 (95 CI 21.824.0) for MI
• 24.6 (23.425.8) for stroke.
• 50 of overestimated risk by more 20.
• Freijling et al 2004

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What is your risk for . ?
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Unable to Act

• Aware of all treatment recommendations
• Feel unable to do all of them
• So do none of them
• Unaware changes accumulate
• Change one risk factor makes a difference
• Which changes make difference

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Burnout

• Unable to act
• Feel that nothing they can do will make a
  difference
• Feeling helpless
• Nothing anyone else can do to help them
• Irritability
• Constant frustration of little or no benefit
  gained from self-care efforts
• Feeling overwhelmed
• Diabetes is controlling them
• Feeling alone with diabetes
• There is little support or understanding from
  those around them

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Address the Burnout

• Illicit concerns
• Provide specific individualised risk information
• Illicit risk factor to address
• Provide specific information on reducing risk
  factor
• Negotiate a Specific, Monitorable, Action,
  Realistic Time-limited

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Individualised vs Generic Risk Information
Edwards, Unigwe, Elwyn Hood 2003. BMJ
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UKPDS risk calculator
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SMART Goal Setting

• S so you want to exercise more, but how much
  more?
• M do you think you could keep track of how
  often you do that, it will help us know how
  successful it has been?
• A so you want to get your blood pressure down
  to 150, but what are you going to do to achieve
  this?
• R do you think you will be able to cook
  separate meals for you both every day?
• T so when do you want to come back to see how
  successful it has been ?

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Living with diabetes is hard. It's easy to get
discouraged, frustrated, and burned out. Here's
an author that understands the emotional
rollercoaster and gives you the tools you need to
keep from being overwhelmed, addressing such
issues as dealing with friends and family, and
how you can better handle the stress for better
health. Written with compassion and a sprinkle of
humor.
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SynopsisImprove the outcomes of your diabetes
treatment with the resource that covers
hard-to-find topics such as empowerment, female
eating disorders, and minority patients. Leading
behavioral scientists have taken their findings
on the latest behavioral information for diabetes
management and translated them into practical
guidelines. Six years worth of information packed
into one book that covers Understanding and
Treating Professional Burnout Eating and
Diabetes A Patient-Centered Approach Smoking
Cessation in Diabetes Working with Children Who
Have Type 1 Diabetes Involving Family Members in
Diabetes Treatment Recognizing and Managing
Depression in Patients with Diabetes
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Self-Management Model with 5 As (Glasgow, et al,
2002 Whitlock, et al, 2002)
Assess Beliefs, Behaviour, Knowledge
Advise Provide specific information about health
risks and benefits of change
Arrange Specify plan for Follow-up (e.g.,
Visits, Phone calls, Mailed Reminders)
Personal Action Plan 1. List specific goals in
behavioural terms 2. List barriers and strategies
to address barriers. 3. Specify Follow-up Plan 4.
Share plan with practice team and patients
social support
Agree Collaboratively set goals based on
patients interest and confidence in their
ability to change the behaviour.
Assist Identify personal Barriers, Strategies,
Problem-solving techniques and Social/
Environmental Support
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