Welcome Understanding Behavioral Change to Help Improve Diabetes Outcomes.

WelcomeUnderstanding

Behavioral Change to Help Improve

Diabetes Outcomes

Understanding Behavioral Change

to Help Improve Diabetes Outcomes

Jocelyne DuerksenRN, BSN, CDE

Endocrinology and Metabolism Program

Diabetes, Hypertension and Cholesterol Centre

Educator

Roche Diagnostics Canada

Promoting Behavior Change in Diabetes: Secrets of

the Seven Tipping Points

Authors: William H. Polonsky, PhD, CDEPresident and Founder

Behavioral Diabetes Institute

Associate Clinical Professor, PsychiatryUniversity of California

San Diego, California

Ralph’s Story

• Age 54; type 2 diabetes for 8 years; has never paid much attention to it

• Knows he’s overweight (BMI 32); suspects his diabetes is not in the best control

• Knows at next medical visit he’ll be told to exercise and stop smoking (has been told this often); doesn’t feel there is anything he can/wants to do about this

• Has been labeled “in denial”

Ralph’s Story

• Loves eating; not really concerned about his weight

• Knows diabetes can harm him; has other things to worry about that seem more pressing

• Never checks BGs; sees no point to it (“it is always high”)

• Has many family members with diabetes; some doing well; some doing poorly

• Feels luck plays a big role in what happens with diabetes

Motivation in Diabetes

Polonsky WH, Boswell SL, Edelman SV. Diabetes. 1996;45(Supp 2):14a Abstract 41.

“Strong” endorsements by physicians

Poor self-discipline 53.2%

Poor willpower 50.0%

Not scared enough 36.9%

Not intelligent enough 16.3%

True Nature of Motivation in Diabetes

• Almost no one is unmotivated to live a long and healthy life

• Problem:– Rewards for good diabetes care may seem not

so rewarding– Obstacles to self-care often outweigh possible

benefits, tipping patients into poor self-care– There are many potential tipping points

Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American Diabetes Association; 1999.

Seven Tipping Points1. Depression

Polonsky WH. Unpublished data.

Depression Rates in Diabetes• Rates 1.5–2.0x higher

– Review of controlled studies (n=20): 20.5% patients with diabetes were depressed vs. 11.4% controls1

– Recent Kaiser study compared 16,000 type 2 patients to 16,000 matched controls: 17.9% patients with diabetes were depressed vs. 11.2% controls2

1. Anderson RJ, et al. Diabetes Care. 2001;24:1069-1078.

2. Nichols GA, Brown JB. Diabetes Care. 2003;26:744-749.

How Depression Influences Diabetes• Depression makes it harder to initiate and

maintain healthy behavior changes– Poor self-management1

– Poor BG control2

– Strongest predictor of increased hospitalization3

– 3x higher incidence of CAD and retinopathy4,5

– 2x higher risk of mortality6

1. Polonsky WH, Parkin CG. Practical Diabetology. 2001;Dec:20-29. 2. Lustman PJ, et al. Diabetes Care. 2000;23:934-942. 3. Rosenthal MJ, et al. Diabetes Care. 1998;21:231-235. 4.de Groot M, et al. Psychosom Med 2001;63:619-630. 5. Kovacs M, et al. Diabetes Care. 1995;18:1592-1999. 6. Katon WJ, et al. Diabetes Care. 2005;28:2668-2672.


2. “No big deal”• “I feel fine, so why worry?”



2. “No big deal”

3. Inevitability• “Diabetes is a death sentence, so why

bother trying?”




3. Inevitability

4. Treatment skepticism• “No matter what I do, these numbers are

always high!”




3. Inevitability

4. Treatment skepticism

5. Unrealistic plans for action• “I know, I know. I need to eat perfectly and

never cheat.”




3. Inevitability


5. Unrealistic plans for action

6. Poor social support




3. Inevitability




7. Environmental pressures


Courtesy of WH Polonsky.



3. Inevitability








3. Inevitability





And there are many more!Polonsky WH. Unpublished data.

Tipping Points Are Additive1

• Diabetes is perceived as more difficult/ pointless as these issues accumulate

• Patients come to believe that diabetes cannot be managed, or it is not important enough to manage2

• Slowly but surely, patients become apathetic or drop out of treatment

1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American Diabetes Association; 1999. 2. Polonsky WH. Current Diabetes Reports. 2002;2:153-159. 3. Peyrot M et al. Diabetes Care. 2006;29(6):1256-1262.

Tipping Points Are Additive1

• Diabetes is perceived as more difficult/ pointless as these issues accumulate

• Patients come to believe that diabetes cannot be managed, or it is not important enough to manage2

• Slowly but surely, patients become apathetic or drop out of treatment

And providers may feel this way, too!2,3

1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American Diabetes Association; 1999. 2. Polonsky WH. Current Diabetes Reports. 2002;2:153-159. 3. Peyrot M et al. Diabetes Care. 2006;29(6):1256-1262.

Tipping Points Overlap• Tipping points influence each other1,2

• This is problematic, but also presents opportunities

• For example:– Unrealistic action plans may lead to treatment

skepticism– Treatment skepticism may lead to inevitability

1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia: American Diabetes Association; 1999. 2. Polonsky WH. Current Diabetes Reports. 2002;2:153-159.

Addressing the DiabetesTipping Points Is an ART!



AAssess



AAssess

RReview (discuss & prioritize)



TTreat

AAssess



The Assessment StepTP1: Depression

ASSESS• “During the past month,

have you often: a. been bothered by

feeling down, depressed, hopeless?

b. had little interest/ pleasure in doing things?”

• See PHQ-91

CORE FEATURE• Symptoms of depression

(i.e., low mood, sleep problems, fatigue, and anhedonia) are interfering with patient’s ability to function well in his life2

1. Kroenke K et al. J. Gen Intern Med. 2001;16:606-613. 2. DSM-IV-TR 2000. Available at: http://online.statref.com/document.aspk?fxid=37&docid=192. Accessed March 16, 2007.

The Assessment Step

ASSESS• “What worries you about

having diabetes?”• “Do you ever think that

you might develop complications?”

• “Your last A1C was 9.2%, what does that mean to you?”

CORE FEATURE• Patient indicates no need

to worry about diabetes because he “feels fine” and/or doesn’t expect diabetes to harm him1,2

TP2: “No Big Deal”1

1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American Diabetes Association; 1999. 2. Skinner TC. European J Endocrinol. 2004;151:T13-17.

The Assessment Step

ASSESS• “What worries you about

having diabetes?”• “Do you ever think that

you might develop complications?”

• “Your last A1C was 9.2%, what does that mean to you?”

CORE FEATURE• Patient indicates that

complications, or worsening complications, are inevitable

• “This disease is going to get me and there is nothing I can do about it.”

TP3: Inevitability


The Assessment Step

ASSESS• “How well are your

prescribed treatments helping you to control your diabetes and improve your health?”

CORE FEATURE• Patient indicates little faith

in at least one recommended self-care behavior1

• “No matter what I do, these numbers are still too high!”

• “I’ve done everything, but I don’t feel any different.”

TP4: Treatment Skepticism

1. Skinner TC. European J Endocrinol. 2004;151:T13-17.

The Assessment Step

ASSESS• “What does taking good

care of your diabetes mean to you?”

• “What exactly should you be doing?”

CORE FEATURE• Patient describes plan for

self-care that is unachievable

• May be due to – vagueness (“I should lose

weight.”) – extreme demands (“I must eat

perfectly.”) – pointlessness (“I’m not sure

why I’m supposed to do this.”)

TP5: Unrealistic Plans of Action


Hagar © King Features Syndicate. April 6, 1999.

The Assessment Step

ASSESS• “Ever feel that:

a. family/friends don’t support your self-care

efforts?”b. family/friends don't appreciate the difficulty of living with diabetes?”c. you’re all alone with diabetes?”

CORE FEATURE• Patient feels isolated and

unsupported regarding his diabetes care

TP6: Poor Social Support


The Assessment Step

ASSESS• “What is it about your daily

life that makes diabetes self-care difficult?”a. Financial pressures?b. Competing demands?c. Life stresses?d. Hard-to-change habits?

CORE FEATURE• When it comes to

successful diabetes self-care over time, patient feels that life is getting in the way

TP7: Environmental Pressures


The Review Step• Tackle one tipping point at a time

– Even a single tipping point removed may be enough to tip the mindset, producing huge change

• All tipping points are not created equal; Start at the top of the tipping points list and work down

• Earlier tipping points are not more important than later tipping points, but later tipping points may not be resolvable until earlier tipping points are addressed

• Discuss and review with patient


The Review Step

TIPPING POINTLEVEL OF CONCERN

? Low Medium High

1. Depression


3. Inevitability






Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care professional’s diagnosis.

Ralph’s Assessment Review


? Low Medium High

1. Depression X

2. “No big deal” X

3. Inevitability X

4. Treatment skepticism X

5. Unrealistic plans for action X

6. Poor social support X

7. Environmental pressures X

Polonsky WH. Unpublished case study.




? Low Medium High

1. Depression X


3. Inevitability X









? Low Medium High

1. Depression X


3. Inevitability X





I feel OK, so I figure–no problem!





? Low Medium High

1. Depression X


3. Inevitability X





I understand that diabetes will get me in the long run.





? Low Medium High

1. Depression X


3. Inevitability X





Never checks BGs; sees no point to it.





? Low Medium High

1. Depression X


3. Inevitability X





Good diabetes care means eating birdseed.





? Low Medium High

1. Depression X


3. Inevitability X





Has other things to worry about that seem more pressing.





? Low Medium High

1. Depression X


3. Inevitability X







Helping Patients Succeed with Diabetes Is an ART!

TTreat

AAssess

RReview/prioritize treatment targets


Helping Patients Succeed with Diabetes Is an ART!

TTreat

AAssess

RReview/prioritize treatment targets


The Treatment Step: What Doesn’t Work

• Urging more willpower – “If you would just try harder”

• Threatening bad outcomes– “You’ll go blind if you don’t do what I tell you

to do…”

• The gift of advice– “Maybe if you joined a nice fitness center…”


Cullum, L. The New Yorker. May 9, 2005.

The Treatment Step

TREAT• Refer for formal evaluation

and treatment– Antidepressant medications1 – Cognitive behavioral

therapy1 – Regular exercise1 – See http://impact-uw.org– Promote sense of self-

efficacy in diabetes care2

REMEMBER• Diabetes patients may

benefit less from current treatments than other patients2

• Chronic hyperglycemia, complications, and diabetes-related distress may be linked to poorer outcomes1,2

TP1: Depression

Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American Diabetes Association; 1999. 2. Polonsky WH, Parkin CG. Practical Diabetology. 2001;Dec:20-29.

The Treatment Step

TREAT• Use A1C results and other

metabolic feedback to make diabetes more real, not just frightening1

– Lead with your leverage (“I know you’re interested in living a long, healthy life…”)

– Must be a discussion, not a lecture1

REMEMBER• “I already told him it was

too high” is not a sufficient intervention1,2

TP2: “No Big Deal”

1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American Diabetes Association; 1999. 2. Hoover JW. Diabetes Educ. 1983;9:41-43.

Overcoming “No Big Deal”HCP: What worries you about diabetes?

R: Not much. I feel OK, so I figure—no problem! I understand that diabetes will get me in the long run, but that’s the way life goes.

HCP: You’ve taken the time to be here, so I know you are interested in living a long, healthy life. At the same time, you’re not sure that putting more effort into diabetes care will be worth the effort. True?

R: Well, yeah.


HCP: May I share some info with you?

R: Sure.

HCP: First, the bad news. You may not be doing as well as you think you are, even if you feel OK. This could mean bad things for your health—and soon. Second, the good news. With some effort, odds are pretty good you could live a long, healthy life with diabetes. What do you think of that?

Overcoming “No Big Deal”


R: Yeah, but how do I do that? I don’t want to eat just birdseed.

HCP: The first step is to find out about the A1C test—that 3-month average blood sugar test. Does that sound familiar?

R: I think my doc told me that my A1C was 8.8%—whatever that means.

HCP: The A1C test is a useful tool for us. And it is one good way to know how well you are managing your diabetes.

Overcoming “No Big Deal”


HCP: Even if you feel OK, if your A1C is high, then bad things could be happening. But if you get your A1C into a safe range— typically that means <7.0%2,3, you make it more likely that you can live a long, healthy life. Your last number, 8.8%, tells us you are right to worry.

R: OK, I see what you mean, but what can I do?

Overcoming “No Big Deal”1

1. Polonsky WH. Unpublished case study. 2.American Diabetes Association. Checking your blood glucose. Available at: http://www.diabetes.org/type-1-diabetes/blood-glucose-checks.jsp. Accessed: March 19, 2007. 3. Canadian Diabetes Association. About diabetes. Available at: http://www.diabetes.ca/section_about/index.asp. Accessed: March 27, 2007.

The Treatment Step

TREAT• Challenge inaccurate

beliefs – Ask patients to estimate

their risk of complications– Share the good news

REMEMBER• Patients need a sense of

hope that complications and an early death are not inevitable

TP3: Inevitability


FACTS AND FICTIONSQ. Diabetes is the leading cause of adult blindness,

amputation, and kidney failure. True or false?

American Diabetes Association, Complications of Diabetes in the United States. Available at: http://www.diabetes.org/diabetes-statistics/complications.jsp. Accessed March 21, 2007.



A. False. To a large extent, it is poorly controlled diabetes that is the leading cause of adult blindness, amputation and kidney failure.




A. False. To a large extent, it is poorly controlled diabetes that is the leading cause of adult blindness, amputation and kidney failure.

Well-controlled diabetes is the leading cause of… nothing.


Joslin 50-Year Medalists

Courtesy of Joslin Diabetes Center.

Joslin 50-Year Medalists1984–2005

0

20

40

60

80

100

120

140

160

180

Number ofMedal Winners

Data on file. Joslin Diabetes Center.

The Treatment Step

TREAT• Select appropriate goals,

de-select inappropriate ones • Set-up home experiments;

Show patients their actions make a difference– Exercise affects BGs– Insulin affects fatigue– Overall efforts affect A1C

REMEMBER• It is exhilarating to actually

see that your actions can positively influence your health

• Experiments should be suggested with some caution. Take a holistic approach.

TP4: Treatment Skepticism


Example: Sam’s Exercise Experiment

For 1 week, measure BG right before and after

my walk

Daily walk (30 minutes)

Day Pre-ExercisePost-

ExerciseBG Change

1 7.8 mmol/L 6.2 mmol/L -1.6 mmol/L





6 11.4 mmol/L 7.4 mmol/L -4 mmol/L


Average BG change: -2.2 mmol/LPolonsky WH. Unpublished case study.

0

1

2

3

4

5

6

7

8

9

3 Mos Priorto Insulin

BeginInsulin 3 Mos 6 Mos 9 Mos 12 Mos

Example: How Insulin Affects Feelings of Fatigue for Maddy

F

atig

ue

Lev

el

None

Extreme

With Insulin Treatment


6

7

8

9

Baseline 3 Months 6 Months 9 Months 12 months

Hem

og

lob

in A

1C L

evel

(%

)Example:

Mary’s Diabetes Management Over 1 Year

With Diabetes Management


The Treatment Step

TREAT• Emphasize that patients don’t

have to do “everything”1

• Start with 1-2 actions only – Not attitudes, numbers, or

actions to stop2

– Concrete, achievable, and personally meaningful1

• Set implementation steps – “What exactly will you do

tomorrow morning?”1

REMEMBER• Patients may feel

overwhelmed by the needed self-care tasks1

• Therefore, make use of the “bang for your buck” concept1

TP5: Unrealistic Plans for Action

1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American Diabetes Association; 1999. 2. Rollnick s et al. BMJ. 2005;331:961-963.

Ralph: Action PlanningHCP: To reach our goal for your A1C

number, we can start anywhere you want—small changes to how you eat, new medications, exercise, or perhaps something else. What do you think?

R: Walking doesn’t seem that tough. I guess I could give it a try.

HCP: How do you think it might help you?

R: I know it can give me more energy, but if it can also really help me to live a longer, healthy life and keep diabetes from getting me, that sounds pretty good.


HCP: If you’re ready to get started, what is your first step?

Ralph: Action Planning

R: I think I’ll ask my wife if she’d like to walk to the coffee shop with me tomorrow morning. It’s about ½ mile each way.

HCP: Sounds good. How often do you want to do that this week?

R: Well, if we don’t make coffee, we’ll have to start going every day. That shouldn’t be so tough…


The Treatment Step

TREAT• Clarify the support needed,

urge patients to ask for it• Suggest inviting family

members to attend/ participate at visits and determine who is responsible for tasks

• Encourage support group attendance

REMEMBER• Diabetes self-care becomes

much easier when the burden can be shared with others

TP6: Poor Social Support


The Treatment Step

TREAT• Acknowledge what cannot

be addressed1

• Encourage environmental changes to support self-care efforts– www.foodpsychology.org– Encourage patient’s own

problem solving2

– Do not debate time issues

REMEMBER• Make good use of patient’s

expertise regarding their own lives and ability to problem solve1

• “Given the situation, what might you do?”

TP7: Environmental Pressures

1. Polonsky WH. Unpublished data. 2. Skinner TC. European J Endocrinol. 2004;151:T13-17.



3. Inevitability






Tipping Points Profile Form


? Low Medium High

1. Depression


3. Inevitability








TTreat

AAssess




TTreat

AAssess


GOAL: Promote a new mind-set, by tipping those tipping points in a positive direction


Addressing the Diabetes Tipping Points1

• Take hope!• As patients become

more successful, providers report greater job satisfaction2

• Overcoming patient burnout can lead to overcoming provider burnout as well

1. Polonsky WH. Unpublished data. 2. Clark CM, et al. Diabetes Care. 2001;24:1079-1086.

Time for Practice

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