diabetes education and care: helping students adhere to diet and medication regimens robin martinez,...

Diabetes Education and Care: Helping

Students Adhere to Diet and Medication

Regimens

Robin Martinez, RN, BSNCertified Diabetes Educator

Certified Integrated Chronic Care Specialist Trainer

Objectives

• Identify current goals for treatment• Identify barriers to adherence to a

diabetes management plan• Identify methods to promote self

empowerment• Identify methods to promote problem

solving and coping skills

©RMartinez RN,BSN,CDE

Darnell

• 19 years old• Type 2 diabetes for two years (he thinks)• His mother has Type 2 diabetes and goes to dialysis 3 times a week• His grandmother has diabetes and had toes, foot, then leg

amputated below the knee; since the age of 14, he has been responsible for administering her insulin

• He smokes several cigarettes per day• He eats whatever he wants• He does not exercise but walks a lot because he doesn’t have a car• He does not have a glucose meter• Has been prescribed medication but can’t remember what it was or

what it was for

What are the next steps for Darnell? How can he manage his diabetes?

What will you do for him?

Disease Process

Type 1• Beta cell destruction that

causes insulin deficiency• Genetic predisposition• Environmental exposure• Most often occurs before

30 years old• Sudden onset• Ketosis

Type 2• Insulin secretory deficiency• Insulin resistance• Increased production of

glucose from the liver• Most often occurs after age

30• Genetic predisposition• Obese• Ketoacidosis is rare until

late in disease progression or with severe hyperglycemia


Goals for Treatment

• A1C below 7%• BG 70-130 before meals• BG Below 180 1-2 hours after meals• Blood Pressure below 130/80• LDL below 100• Smoking cessation• Annual dilated eye exam


AADE7™ Self Care Behaviors

“Measurable behavior change is the desired outcome of diabetes education.”•Healthy eating•Being active•Taking medication•Monitoring•Problem solving•Reducing risks•Healthy coping


Healthy Eating


• Small, frequent meals• Fiber: 21-25 g/day for women, 30-38 g/day for men• Protein: 10 to 20% of daily calories• Carbohydrates: 130 g/day; 50-60% of daily calories• Saturated fat: less than 7% of total calories• Limit trans fat• Cholesterol: less than 200 mg/day • Sodium: 2300 mg/day or less• Approximately 2000 calories/day depending upon

goal for weight

Plate Method


Being Active• 150 minutes per week of exercise for fitness• 1 hour for weight loss• Pre-exercise examination• 150 minutes of aerobic activity at moderately intense levels

each week• Resistance training three times per week• Documented evidence of improved blood glucose control• Decreases cardiovascular risk factors• Weight loss• Increases being well


Medications

Insulin• Rapid acting• Intermediate• Long Acting• Mixtures

Oral Medications• Sulfonylureas• Meglitinides• DPP 4 inhibitors• Biguanides• Thiazolidinediones• Glucosidase inhibitors


Taking Medication


• Medication reconciliation• Medication adherence

Monitoring• Annual exam with optometrist or ophthalmologist• A1C every three months• Annual blood and urine tests to measure kidney

function• Measure fasting lipids annually• Monitor BP each office visit• Check BG• Check weight• Dental care• Foot care


Barriers


Problem Solving

• Cultural issues• Financial issues• Family issues• Lack of skill re. problem solving• Developmental issues• Knowledge deficit re. disease process

and disease management


Underserved Population/Healthcare Providers

Underserved Communities• Distrustful• Poor health literacy• Inadequate access to

resources• Knowledge deficits

Healthcare Providers• Frustrated and

discouraged by what appears to be “noncompliance”

• Inadequate resources• Unaware of cultural

issues that may lead to nonadherence to treatment plan


Latino Americans• A1C results among Latino Americans reveals that in

comparison to other ethnic groups, Latino Americans have increased numbers of complications, greater rates of mortality, and higher rates of inadequate disease management

• Type 2 diabetes is affecting the Latino community at exorbitant rates and the number of Latino Americans with diabetes is expected to swell over 100% by 2020

• Today’s Latino American children have a 50/50 chance of being diagnosed with Type 2 diabetes over the course of their lives

• Culturally diverse group• Extent of assimilation determines impact of culture


Asian Americans• May not initiate questions• Less likely to verbalize dissent with health care provider• 1st generation have greater incidence of Type 2 diabetes

than general population despite lower weights that would not usually indicate risk

• Subsequent generations are heavier and are at risk for developing Type 2 diabetes at an earlier age

• Lower levels of physical activity• Believe foods, disease processes, and treatments are hot or cold• Achieving balance is crucial• Once balance is achieved, may believe interventions are no

longer necessary• Food for the family is more important than individual health

needs


African Americans• Delay seeking assistance• More likely to use informal sources of assistance• Experience poor access to resources regardless of

socioeconomic levels• Higher risk for depression and other mental

disorders but fewer than half receive clinical treatment. Those who do tend to terminate treatment early

• Higher rates of morbidity, mortality, and severity of disease


Age 16 to 24: What were you like?

• Full of questions?• Knew all the answers?• Introspective?• Angry?• Happy go lucky?• Full of angst?• Full of romance?


Empowerment

• Disease management• Culturally competent

providers• Motivation• Promoting behavior

change


Reducing Risks• Smoking cessation• Weight loss• Medication adherence• Dietary adherence• Active• Stress reduction• Following the plan of treatment


Healthy Coping• Stress management• Seeking alternatives to negative behaviors• Developing an action plan• Following the treatment plan• Reevaluating and modifying the treatment

plan when necessary


Cultural Competency• Blend of action,

beliefs, perspective, and performance guidelines that promote the ability to work effectively in a culturally diverse setting


Impact of Cultural Competency

• Improves outcomes• Increases health

literacy• Promotes empathy

and mutual understanding

• Narrows gap created by disparities in healthcare


Closing the Gap• Interaction with healthcare

providers is more reserved but a friendly, personal relationship is expected

• Nonverbal cues are used to indicate respect

• Alternative treatments are important

• May believe that emotions cause illness: susto, espana, nervios

• Fatalistic and focused upon present moment

• Family plays important role


Narrowing the Gap• Close-ended questions

and simple language will assist with negotiating language barriers

• Encourage questions repeatedly to decrease fear of being disrespectful

• Trained interpreters vs. family members

• Involve family©RMartinez RN,BSN,CDE

Closing the Gap• Eye contact at the

individual’s level• Establish trust• “Speaking”• Skin color• Judicious use of

physical contact– HAIR****


Motivation: What Triggers Engagement?

• Intriguing and significant

• Requires attention and skill but not too difficult

• Individual meaning• Ability• Connection between

the activity and future plans


Stages of Change• Not even thinking

about it• Thinking about it• Getting ready for

change• Making the change• Sustaining the

changes over time


Meeting People Where They Are

• Reason for change• Perception of ability to change• Readiness for change


Facilitating Behavior Change• Active Listening• Open questions• Mutual understanding

– Do you understand what the patient is saying?

– Does the patient understand the information provided?

• Support, respect and collaboration


The Action Plan: Keeping it Real

• Wave the magic wand!!!

• Must be relevant• Must originate with the

client not the provider• Provider plays a supportive

role• Achievable goal• Time frame• Reasonable interventions• Adaptable• Reevaluate• Change when necessary


Janie D.

• 19 years old• Gestational diabetes• Scared• Blood sugar ranges

150 fasting 250 random

• Not eating because it will make her sugar go up


Is Janie ok? What will you tell her?

What’s her treatment plan?

Darnell is Back…Any New Ideas?

• 19 years old• Type 2 diabetes for two years (he thinks)• His mother has Type 2 diabetes and goes to dialysis 3 times a week• His grandmother has diabetes and had toes, foot, then leg

amputated below the knee; since the age of 14, he has been responsible for administering her insulin

• He smokes several cigarettes per day• He eats whatever he wants• He does not exercise but walks a lot because he doesn’t have a car• Does not have a glucose meter• Has been prescribed medication but can’t remember what it was or

what it was for

What are the next steps for Darnell? How can he manage his diabetes?

What will you do for him?

References AADE7 Self-Care Behaviors. Available at:

https://www.diabeteseducator.org/ProfessionalResources/AADE7/ Accessed May 1, 2011 AADE, & Pharma. (2009). Pitfalls & Opportunities in Diabetes Prevention and Care

[Brochure]. Chicago: Author. African American Profile. (2009). Retrieved December 3, 2009,from Minority Health Web

site: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=51:AfricanAmericanProfile

Asp, A. (2005). Diabetes Mellitis. In E. Copstead & J. Banasik (Eds.), Pathophysiology (3rd ed., pp. 1000-1005). St. Louis, MO: Elsevier Saunders.

A Provider’s Handbook on Culturally Competent Care African American Population (2nd ed.). (2003). Oakland, CA: Kaiser Permanente

A Provider’s Handbook on Culturally Competent Care Asian and Pacific Islander Population (2nd ed.). (2003). Oakland, CA: Kaiser Permanente

A Provider’s Handbook on Culturally Competent Care Latino Population (2nd ed.). (2003). Oakland, CA: Kaiser Permanente

References• Caballero, A. E. MD., & Tenzer, P. MD. (2007). Building Cultural Competency for Improved Diabetes Care:

Latino Americans and Diabetes. The Journal of Family Practice, 56(9),

• Centers for Disease Control and Prevention: National Diabetes Surveillance System. Available online at: http://apps.nccd.cdc.gov/DDTSTRS/default.aspx. Retrieved 5/7/2011.

• Dawes, N., & Reed, L. (2010, November). How youth get engaged: Grounded-theory research on motivational development in organized youth programs. Developmental Psychology, 47(1), 259-269.

• Gavin, J., III, Wright EE, Jr.(2007) Building cultural competency for improved diabetes care: African Americans and diabetes. The Journal of Family Practice. ; 56(9 ),S22-28.

• Gavin, J.,III. (2007). African Americans and Diabetes. The Journal of Family Practice, 56 (9), 22-28

• Hsu, W. MD., & Yoon, H. MD. (2007). Building Cultural Competency for Improved Diabetes Care: Asian Americans and Diabetes. The Journal of Family Practice, 56(9), S15-S21.

• Mead H, Cartwright-Smith L, Jones K, Ramos C, Woods K, Siegel B. Racial and Ethnic Disparities in U.S. Health Care: A Chart book. The Commonwealth Fund. 2008.

• Shafer, S. (2001). Diabetes 2 Complete Food Management Program. New York: Prima Publishing.

• Rollnick, S., Mason, P., & Butler, C. (2005). Health Behavior Change A Guide for Practitioners. Philadelphia: Churchill Livingstone. (Original work published 1999)

• Steinberg, L. (April 2011). Demystifying the adolescent brain. Educational Leadership, 68(7), 41-46.

• What Is Cultural Competency? Available at: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=11. Accessed December 3, 2009.

diabetes education and care: helping students adhere to diet and medication regimens robin martinez,...

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