Optimal Diabetes Management: What's Stopping Your Patients?
Patients with diabetes experience many barriers to achieving optimal glycemic control.
During the holidays, I like to pause and reflect on the year and what's gone well, and what can be improved. In that spirit, let's explore some of the most challenging, most common obstacles to living well with diabetes. I'm hoping that someday we'll have a cure, and this topic will be of historical interest only. Until then, however, excluding the well-known challenges related to time and money, here are a few barriers.
Fear of change
Three months ago, I saw a patient who was new to me, and steadfastly declined adding another medication to his regimen, which consisted of metformin, glipizide, and sitagliptin (Januvia®, Merck). His HbA1c was 8.9%. After an extensive discussion about the potential increased risks of complications due to continued suboptimal control, he very politely replied, “Doc, I'm already on a lot of meds, and I'm very sensitive when I add on a new one. I want to just keep things the way they are.” Fast forward 3 months later, his HbA1c was again 8.9%. Despite no change at all, his response was the same. He seemed to adhere to the saying, “Better the devil you know than the one you don't.”
Some patients are afraid of change, even if change holds promise for avoiding something negative, such as potentially devastating complications of diabetes, like myocardial infarction or toe amputations, or offering a brighter future that includes a greater sense of pride from successful self-management of diabetes. This puzzled and worried me. Here was a patient who had clear evidence that his glycemic control had not improved one iota, and yet he still felt it would be more painful to do something—anything—different. Why?
To many individuals, these are but mere abstractions. The potential benefits I listed can seem unimportant, easily being lost in the sea of pressing day-to-day demands—work, children, bills, and 101 things that are not related to diabetes.
Lack of data and/or knowledge
How do you know where you're going if you don't know your SMBGs? I'll offer patients an analogy with trying to drive without having a speedometer or an odometer. Often, when I gently inquire about why a patient isn't testing, they respond, “They're always high, so what difference does testing make if they're going to be the same?”
Aversion to injections
This one can affect both the willingness to test but also may influence the willingness to accept another medication that can enhance control, whether it's insulin or a GLP-1 receptor agonist. The fact that these agents involve injections is another disincentive. I find it fascinating that needles can be at once the key to living with diabetes and one of the largest obstacles to doing so. A phobia or an aversion to needles can hamper a patient.
So, where do I start?
If patients have consistently had glucose levels of 200 mg/dL or greater, and it seems like no matter what he or she tries, there's not any noticeable improvement, it's easy to get caught in a vicious cycle. “Why even bother trying?” the patient may ask. Any one of us can put things off by deceiving ourselves, waiting for the “perfect time” to take back control—to test regularly, stop smoking, and lose weight. But there will always be distractions and urgent things that pop up that threaten to knock us off course. I advise patients to start now, and you can always fine-tune and adjust. Putting things off and hoping for an ideal time, however, is an invitation to continue stagnating or, worse, backsliding.
What can patients do, and how can we help?
1. Get motivated.
We all know that it starts with the patient, not their partner or spouse, and not their physician. If a patient is ready to change and has enough compelling reasons to take new actions that can feel awkward, scary, and totally out of their comfort zone, the patient will more likely succeed than someone who doesn't. We have to help by asking patients to identify these reasons for change. I'll always remember a patient who said he'd hit upon a strong enough reason that worked best for him: “I want to be around to dance at my youngest daughter's wedding.” Dr Steve Edelman asks his patients, “What bothers you about your diabetes?” This is one way physicians can start a conversation with their patients.
2. Break it down.
Motivational interviewing counsels inviting the patient to select 1 item—a single thing— to change. Otherwise, the individual can easily become overwhelmed. We must be mindful of this when we formulate a plan of action. In our eagerness to help and be comprehensive, we want to advise diet changes, exercising 150 minutes a week, checking your feet, and oh, don't forget that medication titration or addition!
3. This is an ongoing process, and it takes a team.
Our system of 20- or 30-minute appointments is not conducive to optimal diabetes care. Primary care providers and endocrinologists, among others, are trying to squeeze in all of these elements into short time slots. Myriad solutions, such as involving others, including dietitians, nurses, and pharmacists, can help. We also must remind patients that this is a marathon and not a sprint. They may be running, but it's never alone; they're accompanied by a team of professionals as well as their families.
I'm certainly not suggesting these are the only challenges or that the potential solutions are all here or that any of this is easy. But let's start and continue a dialogue—one that respects the patient and works within any number of constraints that real life can impose—to help facilitate a better quality of life.
Edward C. Chao, DO, practices at the VA San Diego Healthcare System and is associate clinical professor of medicine at the University of California, San Diego.