E ngaging the Disengaged: Stra te g ie s fo r Pro mo ting Be ha - - PDF document

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E ngaging the Disengaged: Stra te g ie s fo r Pro mo ting Be ha vio r Cha ng e in Dia b e te s Willia m H. Po lo nsky, PhD, CDE whp@ b e ha vio ra ldia b e te s.o rg Disc lo sure s Co nsulta nt fo r L ivo ng o , Sa no fi, Se rvie r, I

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SLIDE 1

E ngaging the Disengaged:

Stra te g ie s fo r Pro mo ting Be ha vio r Cha ng e in Dia b e te s

Willia m H. Po lo nsky, PhD, CDE whp@ b e ha vio ra ldia b e te s.o rg

Disc lo sure s

Co nsulta nt fo r L ivo ng o , Sa no fi, Se rvie r, I nsule t, L ife sc a n, Ab b o tt, L illy, Ro c he , Xe ris, No vo No rdisk, Ma nnkind, a nd Asc e nsia .

Pe rc e nta g e o f Pa tie nts Ac hie ving ADA T re a tme nt T a rg e ts

% reaching ADA target Kazemian et al, 2019 25%

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SLIDE 2

Why Suc h Po o r Ca rdio me ta b o lic Outc o me s?

  • Ma c ro e c o no mic fa c to rs (e .g ., po ve rty)
  • L

imita tio ns o f c urre ntly a va ila b le to o ls

  • HCP b e ha vio r (e .g ., c linic a l ine rtia )
  • Pa tie nt b e ha vio r (e .g ., se lf-ma na g e me nt)

An I llustra tio n

3295 insulin-na ïve T 2Ds we re ide ntifie d who ha d b e e n re c o mme nde d insulin:

  • 984 (29.9%) de c line d
  • Of the 984 who de c line d, 374 (38%) e ve ntua lly

sta rte d insulin

  • Of the 374 who fina lly initia te d, me a n time to

insulin initia tio n wa s 790 da ys.

Hosomura et al, 2017

HCP Attrib utio ns Re g a rding Po o r Adhe re nc e in Dia b e te s

HCP to p 5 c o mpla ints:

  • 1. Pa tie nts sa y the y wa nt to c ha ng e , b ut a re no t willing

to ma ke the ne c e ssa ry c ha ng e s

  • 2. No t ho ne st/ Only te lls me wha t the y think I wa nt to he a r
  • 3. Do n’t liste n to my a dvic e
  • 4. Dia b e te s no t a prio rity/ Uninte re ste d in the ir c o nditio n/

”In de nia l”/ Do n’t c a re / Unmo tiva te d

  • 5. T

he y do no t ta ke re spo nsib ility fo r se lf-ma na g e me nt

Edelman et al, 2012

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SLIDE 3

Re a l L ife with Dia b e te s

  • 1. L

iving with dia b e te s c a n b e to ug h

  • It is a time -c o nsuming jo b
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SLIDE 4

Re a l L ife with Dia b e te s

  • 1. L

iving with dia b e te s c a n b e to ug h

  • It is a time -c o nsuming jo b
  • It is a b a la nc ing a c t tha t re q uire s

vig ila nc e a nd a n a b ility to de a l with frustra tio n

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SLIDE 5

Mo tiva tio n in Dia b e te s

  • No o ne is unmo tiva te d to live a lo ng a nd

he a lthy life

  • T

he re a l pro b le m: Ob sta c le s to se lf-c a re

  • utwe ig h po ssib le b e ne fits
  • And the re a re a T

ON o f o b sta c le s!

  • T

he unde rlying the me to mo st o b sta c le s is a la c k

  • f “wo rthwhile ne ss”

L a c k o f Wo rthwhile ne ss

  • An invisib le a nd no n-urg e nt dise a se

“Look, I’ll start worrying about my diabetes as soon as something something falls off.”

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SLIDE 6

L a c k o f Wo rthwhile ne ss

  • An invisib le a nd no n-urg e nt dise a se
  • Ho pe le ssne ss

“What’s the difference? This disease is going to get me no matter what I do.

L a c k o f Wo rthwhile ne ss

  • An invisib le a nd no n-urg e nt dise a se
  • Ho pe le ssne ss
  • Disc o ura g e me nt

“I did everything I was supposed to, and now you’re telling me I have to take even more medications?!”

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SLIDE 7
  • T

he fe lt b urde n o f living with a to ug h, de ma nding dise a se

  • De spa ir: “I

will e nd up with se rio us lo ng -te rm c o mplic a tio ns, no ma tte r wha t I do ”

  • Disc o ura g e d: “I

a m o fte n fa iling with my dia b e te s”

  • Ove rwhe lme d: “T

his is ta king up to o muc h o f my me nta l a nd physic a l e ne rg y e ve ry da y”

Wha t I s Dia b e te s Distre ss?

Polonsky et al, 1995; Polonsky et al, 2005

  • Dia b e te s distre ss
  • T

ype 1 dia b e te s (n = 224): 42%

  • T

ype 2 dia b e te s (n = 36,998): 36%

  • L

inke d to se lf-c a re a nd g lyc e mic c o ntro l

  • Dia b e te s distre ss is o fte n c hro nic
  • Of tho se with e le va te d distre ss a t b a se line : 74%

re ma in e le va te d le ve ls a t 9 mo nths.

Dia b e te s Distre ss

Fisher et al, 2016; Perrin et al, 2017

So Wha t T

  • Do ?
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SLIDE 8

Pa tie nt-HCP Co mmunic a tio n

A vide o e xa mple ………

  • T

he info rma l a ppro a c h:

  • “Wha t’ s o ne thing a b o ut dia b e te s tha t’ s driving

yo u c ra zy? ”

  • T

he fo rma l a ppro a c h:

  • Use se lf-re po rt instrume nts

Ste p 1. Asse ss

Dia b e te sdistre ss.o rg

  • T

1-DDS & DDS in E ng lish & Spa nish

  • Auto ma tic a lly

sc o re d, with printa b le re po rts

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SLIDE 9

Dia b e te sdistre ss.o rg A T 1-RE DE E M Pa rtic ipa nt

“ I t wa s to ta lly une xpe c te d a nd surprising . I ha ve ha d dia b e te s fo r 35 ye a rs. I n a ll tha t time no o ne ha s e ve r a ske d me wha t it wa s like fo r me to ha ve dia b e te s a nd wha t it wa s a b o ut dia b e te s tha t I fo und mo st distre ssing . And e ve n if the y did a sk, I do ub t tha t the y wo uld ha ve ta ke n the time o r ha d the inte re st to liste n c a re fully to my a nswe r.”

  • Do n’ t try to fix yo ur pa tie nt’ s fe e ling s
  • I

nste a d, liste n, a c kno wle dg e a nd no rma lize

  • “Give n the na ture o f dia b e te s, fe e ling this wa y is

pe rfe c tly re a so na b le a nd ma ny o the r pe o ple fe e l the sa me .”

Ste p 2. Re spo nd with E mpa thy

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SLIDE 10

HCP E mpa thy a nd He a lth Outc o me s

A re la tive ly re c e nt lite ra ture re vie w inc lude d 7 studie s (UK , US, a nd the Ne the rla nds):

  • “T

he re is a g o o d c o rre la tio n b e twe e n HCP e mpa thy a nd pa tie nt sa tisfa c tio n a nd a po sitive re la tio nship with stre ng the ning pa tie nt e na b le me nt. E mpa thy lo we rs pa tie nts' a nxie ty a nd distre ss a nd de live rs sig nific a ntly b e tte r c linic a l o utc o me s”

Derksen et al, 2013

Co nsulta tio n a nd Re la tio na l E mpa thy

Ho w g o o d wa s yo ur HCP a t:

  • 1. ma king yo u fe e l a t e a se
  • 2. le tting yo u te ll yo ur sto ry
  • 3. re a lly liste ning
  • 4. b e ing inte re ste d in yo u a s a who le pe rso n
  • 5. fully unde rsta nding yo ur c o nc e rns
  • 6. sho wing c a re a nd c o mpa ssio n
  • 7. b e ing po sitive
  • 8. e xpla ining thing s c le a rly
  • 9. he lping yo u to ta ke c o ntro l

10.ma king a pla n o f a c tio n with yo u

Dambha‐Miller et al, 2019 Dambha‐Miller et al, 2019

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SLIDE 11

HCP E mpa thy a nd Mo rta lity Outc o me s

“I n this 10-ye a r fo llo w up o f pa tie nts with ne wly dia g no se d type 2 dia b e te s, tho se re po rting b e tte r e xpe rie nc e s o f e mpa thy in the first 12 mo nths a fte r dia g no sis ha d a sig nific a ntly lo we r risk (40% to 50%) o f a ll- c a use mo rta lity o ve r the sub se q ue nt 10 ye a rs c o mpa re d with tho se who e xpe rie nc e d lo w pra c titio ne r e mpa thy.”

Dambha‐Miller et al, 2019

Ste p 3. Ma ke the I nvisib le Visib le

Back on Track Feedback

Name: Molly B. Tests Your Targets Last Results FID #: Your score should be

SAFE: At

  • r better

than goal NOT SAFE: Not yet at goal

A1C 7.0% or less 8.7% x Blood Pressure 130/80 125/75 x LDL 100 or less 116 x

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SLIDE 12

Ste p 3. Ma ke the I nvisib le Visib le

  • Be no n-judg me nta l.
  • F

e a r ta c tic s ma y b e c o unte rpro duc tive :

  • “Do yo u wa nt to g o b lind, do yo u? ”
  • “I

f yo u do n’ t do b e tte r, yo u’ ll e nd up o n insulin. I s tha t wha t yo u wa nt, is it? !”

  • Ra the r tha n de sc rib ing numb e rs a s “g o o d/ b a d”
  • r “hig h/ lo w”, use “sa fe / unsa fe ”.

Ste p 3. Ma ke the I nvisib le Visib le

  • Be no n-judg me nta l.
  • Offe r c o ng ra tula tio ns whe n po ssib le .

“Yo ur A1C is still to o hig h. Do n’ t yo u unde rsta nd the c o nse q ue nc e s? Why a re n’ t yo u wo rking ha rde r o n this? ” “Its g re a t tha t yo u to o k the time to g e t yo ur A1C do ne to da y. T he numb e rs ha ve n’ t mo ve d muc h, whic h te lls us tha t so me thing diffe re nt is ne e de d.” VS.

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SLIDE 13

Ste p 4. Sha re the Go o d Ne ws

  • Q. Dia b e te s is the le a ding c a use o f a dult

b lindne ss, a mputa tio n, a nd kidne y fa ilure . T rue o r fa lse ?

  • A. F

a lse . T

  • a la rg e e xte nt, it is po o rly c o ntro lle d

dia b e te s tha t is the le a ding c a use o f a dult b lindne ss, a mputa tio n a nd kidne y fa ilure .

We ll-c o ntro lle d dia b e te s is the le a ding c a use o f… NOT HI NG!

F a c t Che c k

T his do e sn’ t me a n: g o o d c a re will guar

antee

tha t yo u will no t de ve lo p c o mplic a tio ns T his do e s me a n: with g o o d c a re ,

  • dds ar

e good

yo u c a n live a lo ng , he a lthy life with dia b e te s

T 1D Co mplic a tio ns Afte r 30+ Ye a rs

% of patients with this complication

Deckert et al, 1978

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SLIDE 14

T 1D Co mplic a tio ns Afte r 30+ Ye a rs

% of patients with this complication

DCCT/EDIC Research Group, 2009

What About T ype 2 Diabetes? Hear t Attac ks in T ype 2 Diabetes

Rate per 10,000-person years

Rawshani et al, 2018

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SLIDE 15

Hear t Attac ks in T ype 2 Diabetes

Rate per 10,000-person years

Rawshani et al, 2018

Hear t Attac ks in T ype 2 Diabetes

Rate per 10,000-person years

Rawshani et al, 2018

Hear t Attac ks in T ype 2 Diabetes

Rate per 10,000-person years

Rawshani et al, 2018

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SLIDE 16

Move to Sweden!

“To live a long and healthy life, develop a chronic disease and take care of it.”

‐ Sir William Osler

Diabetes and Your Health

We E ve n Put it o n Mug s!

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SLIDE 17

Ste p 5. Addre ss Disc o ura g e me nt

  • Ma ke b e ha vio ra l suc c e ss e a sie r
  • Pla n fo r a c tio ns must b e do a b le
  • F
  • c us o n the b e ha vio r, no t the o utc o me
  • Co lla b o ra tive a g re e me nt a nd c o mmitme nt

“S

  • just to make sure we ’re o n the same page ,

what’s o ne diabe te s-re late d ac tio n yo u’re aiming to do o ve r the ne xt fe w mo nths?”

One Ste p a t a T ime Ste p 5. Addre ss Disc o ura g e me nt

  • Ma ke b e ha vio ra l suc c e ss e a sie r
  • Re -fra me the me dic a tio n c o nve rsa tio n
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SLIDE 18

Ste p 5. Addre ss Disc o ura g e me nt

  • Ma ke b e ha vio ra l suc c e ss e a sie r
  • Re -fra me the me dic a tio n c o nve rsa tio n
  • T

a king yo ur me ds is o ne o f the mo st po we rful thing s yo u c a n do to impro ve yo ur he a lth.

  • T

he re a re a lwa ys pro ’ s a nd c o n’ s; the c o n’ s a re pro b a b ly no t a s b ig a s yo u think.

  • Mo re me ds do e sn’ t me a n yo u’ re sic ke r, fe we r

me ds do e sn’ t me a n yo u’ re he a lthie r.

Ste p 5. Addre ss Disc o ura g e me nt

  • Ma ke b e ha vio ra l suc c e ss e a sie r
  • Re -fra me the me dic a tio n c o nve rsa tio n
  • Pro vide the 3 to o ls ne e de d fo r suc c e ss
  • Ong o ing suppo rt

Ste p 5. Addre ss Disc o ura g e me nt

  • Ma ke b e ha vio ra l suc c e ss e a sie r
  • Re -fra me the me dic a tio n c o nve rsa tio n
  • Pro vide the 3 to o ls ne e de d fo r suc c e ss
  • Ong o ing suppo rt
  • Me dic a tio ns
  • De vic e s
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SLIDE 19

QOL a nd CGM

Polonsky et al, 2017

Ste p 5. Addre ss Disc o ura g e me nt

  • Ma ke b e ha vio ra l suc c e ss e a sie r
  • Re -fra me the me dic a tio n c o nve rsa tio n
  • Pro vide the 3 to o ls ne e de d fo r suc c e ss
  • Offe r c o ng ra tula tio ns whe ne ve r po ssib le

I n Summa ry

  • Asse ss
  • Re spo nd with e mpa thy
  • Ma ke the invisib le visib le
  • Sha re the g o o d ne ws
  • Addre ss disc o ura g e me nt
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SLIDE 20

T ha nks fo r L iste ning !

www.behavioraldiabetes.org