So c ia l Sa b o ta g e o f the Pe rso n with Dia b e te s A T - - PowerPoint PPT Presentation

So c ia l Sa b o ta g e o f the Pe rso n with Dia b e te s

A T ria l Cha lle ng ing Our Appro a c h to Ca re

Me g a n Muño z, MSN, CMSRN, CDCE S

Ba c he lo r’ s a nd Ma ste r’ s o f Nursing Ce rtific a tio ns in Me dic a l Surg ic a l Nursing & Dia b e te s Ca re & E duc a tio n UnityPo int I npa tie nt Glyc e mic Ma na g e me nt & Outpa tie nt E duc a to r Ho st o f T ype 2a ndYo u with Me g Disc lo sure s: Se lf-Ma na g e d Sto c k in T a nde m a nd De xc o m

Ob je c tive s

 I

de ntify c urre nt pe rso na l, so c ia l, a nd he a lthc a re b ia se s tha t e xist a g a inst the pe rso n with dia b e te s (PWD)

 I

de ntify a t le a st two wa ys the se b ia se s impa c t the PWD’ s he a lth a nd a b ility to re c e ive time ly, a ppro pria te he a lthc a re

 E

xa mine e vide nc e tha t c ha lle ng e s the se b ia se s a g a inst the PWD

 De sc rib e te c hniq ue s fo r re duc ing stig ma s a nd

fo ste ring the he a lth a nd we llb e ing o f the PWD

Pe o ple ’ s L ive s De pe nd o n Yo ur De c isio n T

• da y…

 Yo u Be the Judg e …

Pro se c utio n: “dia b e tic s” in o ur so c ie ty…

Co mmo n Me ssa g ing : Are T he re T ruths in T he se Me ssa g e s?

“Sho uld Pa ula De e n lo se a

lo t o f we ig ht a nd influe nc e

• the rs to do so , a nd sho uld

she sho w tho se who wa tc h he r sho w ho w to do it, she c o uld b e c o me a g o dde ss.“

• Ca rla Wo lpe r in 2012 ABC Ne ws

Re po rt title d: “Pa ula De e n T e a ms Up with Dia b e te s Drug ma ke r No vo No rdisk”

“T his me a ns we c a n no w se e type 2 dia b e te s a s a simple c o nditio n whe re the individua l ha s a c c umula te d mo re fa t tha n the y c a n c o pe with…….thro ug h die t a nd pe rsiste nc e , pa tie nts a re a b le to lo se the fa t a nd po te ntia lly re ve rse the ir dia b e te s.”

• Pro f. Ro y T

a ylo r (c o -le a d o f DI RE CT study) in 2020 Me dic a lNe wsT

• da y a rtic le title d: “S

tudy re ve als what c ause s type 2 diabe te s and ho w to re ve rse it.”

T he Pro se c utio n’ s Clo sing Arg ume nts

 T

2D is a life style dise a se

 T

2D c a n b e re ve rse d o r pre ve nte d in mo st c a se s

 We ig ht is a mo difia b le risk fa c to r fo r T

2D a nd its c o urse

 Using me dic a tio n, inc luding insulin, is no t c o mmo n

a nd is a n indic a to r o f po o r se lf-c a re …T 2D de ve lo pme nt a nd its c o urse is he a vily de pe nde nt o n the de dic a tio n o f the individua l to c a re fo r the mse lve s….

AND NOW… T HE DE F E NSE

Wha t if this me ssa g ing is no t

• nly ina c c ura te b ut ha rmful?

E xhib it A: “L ife style Dise a se ” tha t c a n b e pre ve nte d AK A “I t’ s Yo ur F a ult…”

E xhib it A1: T 2D Risk F a c to rs

1.

Ove rwe ig ht o r ”o b e se ”

2.

Ove r a g e 45

3.

F a mily histo ry o f dia b e te s

4.

Afric a n Ame ric a n, Ala ska Na tive , Ame ric a n I ndia n, Asia n Ame ric a n, Hispa nic / L a tino , Na tive Ha wa iia n, o r Pa c ific I sla nde r

5.

Hig h b lo o d pre ssure

6.

L

• w le ve l o f HDL(“g o o d”) c ho le ste ro l, o r a hig h le ve l o f trig lyc e ride s

7.

Hx o f g e sta tio na l dia b e te s o r g a ve b irth to a b a b y we ig hing 9 po unds

• r mo re

8.

No t physic a lly a c tive

9.

Hx o f he a rt dise a se o r stro ke

10.

De pre ssio n

11.

Po lyc ystic o va ry syndro me (PCOS)

12.

Ac a ntho sis nig ric a ns—da rk, thic k, a nd ve lve ty skin a ro und yo ur ne c k

• r a rmpits

13.

Adve rse Childho o d E ve nts (ACE S): in priso ne d pa re nt, drug / a lc o ho l a b use , physic a l, e mo tio na l, o r se xua l a b use , ne g le c t, pa re nt se pa ra tio n

14.

Chro nic stre ss: inc luding ra c ism, we ig ht stig ma

15.

Affo rda b le / e a sy a c c e ss to he a lthc a re

16.

E xpo sure to c he mic a ls (a g e nt o ra ng e )

17.

T hyro id c o nditio ns

18.

Bing e e a ting diso rde r

19.

E duc a tio n lo we r tha n a hig h sc ho o l diplo ma

20.

L

• we r inc o me

21.

Ro ta ting shifts/ po o r sle e p ro utine s

22.

F e w so c ia l c o nne c tio ns o r suppo rts

Braveman & Gottlieb, 2014; U.S. Dia b e te s Surve illa nc e

Syste m. Gis.c dc .g o v. (2020

E xhib it A1: T 2D Risk F a c to rs

2 4 6 8 10 12 Ra c e / E thnic ity 8 11 12

CDC’ s Ra te o f Dia b e te s Ba se d o n Ra c e / E thnic ity White AA Hispanic

Afric a n Ame ric a n, Ala ska Na tive , Ame ric a n I ndia n, Asia n Ame ric a n, Hispa nic / L a tino , Na tive Ha wa iia n, o r Pa c ific I sla nde r

Braveman & Gottlieb, 2014; U.S. Dia b e te s Surve illa nc e

Syste m. Gis.c dc .g o v. (2020

Adve rse Childho o d E ve nts (ACE s) Chro nic Stre ss L

• we r E

duc a tio n Disa dva nta g e d Ne ig hb o rho o ds Hig he r Ra te s o f T

• b a c c o / Alc o ho l Use

L e ss Ac c e ss to He a lthy F

• o ds, Re c re a tio na l Ac tivitie s

L e ss Ac c e ss to He a lthc a re

Syste mic Ra c ism

25- 30%

De te rmina nts o f Po pula tio n He a lth

So c ia l/ E nviro nme nta l He a lthc a re He a lth Ha b its Ge ne s/ Bio lo g y

E xhib it A1: He a lth I nflue nc e rs

 Me tfo rmin: 34% fe we r pe o ple

de ve lo pe d T 2D*

 “L

ife style :” 56% fe we r pe o ple de ve lo pe d T 2D* *At 3 ye a rs c o mpa re d to no inte rve ntio n

E xhib it A2: Wha t We K no w Ab o ut Pre ve nting T 2D

 De la ye d a T

2D dia g no sis b y 2-4 ye a rs

E xhib it A2- Dia b e te s Pre ve ntio n Pro g ra m a nd Outc o me s Study

L ife style a t 15 ye a rs - 55%

De ve lo pe d Dia b e te s No Dia b e te s

Me tformin a t 15 Ye a rs - 56%

Dia b e te s De ve lo pe d No Dia b e te s

Pla c e bo a t 15 ye a rs

• 62%

Dia b e te s De ve lo pe d No Dia b e te s

E xhib it A2- Dia b e te s Pre ve ntio n Pro g ra m a nd Outc o me s Study

“Pre -dia b e te s re pre se nts a hig h-risk sta te fo r dia b e te s… de spite I L S (inte nsive life style ).”

“L ife style Dise a se ”= ST I GMA

HE AL T HCARE

GE NE T I CS

SOCI AL E NVI RONME NT AL

GE NE T I CS

HE AL T HCARE

E NVIRONME NT AL / SOCIAL



T he MI L E S-2 study sho we d a sso c ia tio ns b e twe e n stig ma s & de pre ssio n/ a nxie ty & dia b e te s distre ss



Dia b e te s distre ss is linke d to po o re r g lyc e mic

• utc o me s & lo we r e ng a g e me nt in se lf-c a re



L e ss tha n 7% o f pe o ple with T 2D a re re fe rre d to DSMT a t dia g no sis



1 in 3 pe o ple re po rt no t a tte nding DSMT se rvic e s due to fe a r o f stig ma tiza tio n

 He a lth c a mpa ig ns e mpha sizing a pe rso n’ s ro le

in c hro nic dise a se de ve lo pme nt inc re a se s “b la me -induc e d stig ma s”

Holmes-Truscott, et al. (2020); Fiishe r, He ssle r, Po lo nsky &

Mulla n, (2012); Po we rs, e t a l. (2015); Winkle y, e t a l. (2015); Sc ha b e rt, Bro wne , Mo se ly, & Spe ig ht. (2013).

A Windo w into the I mpa c t

• f Stig ma ….

E xhib it B: Dia b e te s Ca n Be Re ve rse d/ L iving with Dia b e te s is a Cho ic e Me dic a tio n is a Sig n Of Po o r Se lf- Ca re

E xhib it B1: T 1D

 Be fo re the disc o ve ry o f insulin in 1921, life spa n o f

so me o ne with T 1D a fte r dia g no sis typic a lly le ss tha n 1 ye a r

 Auto immune

E xhib it B1: T 2D “Re ve rsa l”

“Pa rtia l Re missio n”

• Off me ds
• A1c < 6.5%

fo r a t le a st

• ne ye a r

“Co mple te Re missio n”

• Off me ds
• A1c < 5.7%

fo r a t le a st

• ne ye a r

“Pro lo ng e d Re missio n”

• Off me ds
• A1c < 5.7%

fo r a t le a st five ye a rs

https:/ / do i.o rg / 10.2337/ dc 09-9036

2009 ADA E xpe rt Co nse nsus

E xhib it B1: T 2D “Re ve rsa l” Study F la ws

DI RE CT & L

• o k AHE

AD study

1

• Hig he r pa nc re a s func tio n

2

• Se ve re c a lo rie re stric tio ns

3

• I

nte nsive suppo rt tha t is diffic ult to tra nsla te into the “re a l” wo rld

4

• De fine re ve rsa l , o r “c ure ” a s le ss tha n 6.5% x1 ye a r a nd
• ff me ds

5

• T

he numb e r in re missio n de c line d e a c h ye a r o f the study

E xhib it B1: T 2D “Re ve rsa l” Study F la ws-Ga stric Bypa ss

1

• T

e nd to b e sma lle r studie s

2

• BMI

in studie s we re o fte n sma lle r tha n “re a l wo rld” c rite ria

3

• Ana to mic a lly diffe re nt a fte r a po rtio n o f sto ma c h a nd

inte stine is a mputa te d

4

• Re c o mme nde d lo ng -te rm da ily c a lo ric inta ke 900 to 1,000

c a lo rie s o fte n with lo ng -te rm vita min/ supple me nts1

5

• Re missio n de fine d a s A1c le ss tha n 6.5% a nd o ff me ds

(va rie d time line s)

6

• Suic ide a nd me nta l illne ss strug g le s a re sig nific a ntly hig he r

tha n g e ne ra l po pula tio n

K a ise r He a lth Syste m Study…

 Ge ne ra l po pula tio n re missio n ra te (in a study o f

• ve r 122,000 pe o ple ) =

https:/ / do i.o rg / 10.2337/ dc 14-0874

Dura tio n o f dia b e te s a nd insulin use a t time o f surg e ry = lo we r c ha nc e

• f re missio n

E xhib it B2: T 2D is Pro g re ssive ….

Ada pte d fro m AACE Clinic a l Pre se nta tio n o f type 2 dia b e te s me llitus. https:/ / www.a a c e .c o m/ dise a se -sta te - re so urc e s/ dia b e te s/ de pth-info rma tio n/ c linic a l-pre se nta tio n-type -2-dia b e te s-me llitus. Ac c e sse d Ma rc h 1, 2020.

Ac c o rding to the CDC, 3 o ut o f 4 pe o ple with dia b e te s use me dic a tio n

E xhib it B2: T he E g re g io us 11

A Windo w into the I mpa c t

• f Stig ma ….

 Clinic a l ine rtia is pe rva sive in o ur me dic a l

c o mmunitie s

 Re sista nc e to use o f dia b e te s me dic a tio ns is

c o mmo n

 Re po rte d 59% (like ly g re a te r) o f tho se with

dia b e te s use supple me nts—DE SPI T E we a k o r no n- e xiste nt e vide nc e

 F

DA Cra c k Do wn

 Stro ke s & Othe r Co mplic a tio ns

Ame ric a n Dia b e te s Asso c ia tio n (2019). Ove rc o ming T he ra pe utic I ne rtia : Summa ry o f Pro c e e ding s. E de lma n & Po lo nsky, 2017’ L i, Ga thirua -Mwa ng i, & So ng (2018)

E xhib it C: We ig ht lo ss is a tta ina b le & ma inta ina b le fo r e ve ryo ne ” We ig ht lo ss is the o nly wa y to suc c e ssfully ma na g e dia b e te s AK A “T hinne ss=He a lth”

Ge ne tic s Po o r Sle e p Pa tte rns Stre ss Ho w Our F

• o d I

s Ma de E ndo c rine / Ho rmo ne Me dic a tio ns I nte rg e ne ra tio na l e ffe c ts

E xhib it C1: We ig ht Shifts

We ig ht L e ptin (Hig h Hung e r) Me ta b o lism Musc le ma ss Gluc o se le ve ls 700-800 c a lo rie s pe r/ da y le ss tha n b e fo re to minimize we ig ht re g a in

E xhib it C1: We ig ht Shifts

F

• the rg ill e t a l. (2016)

E xhib it C1: We ig ht Shifts

 Mo st c o mpre he nsive re vie w o f we ig ht-lo ss

re se a rc h (31 studie s) in 2007

Up to 2/ 3s o f die te rs re g a ine d mo re we ig ht Ma ny study fla ws Mo st die te rs re g a in we ig ht within 5 ye a rs We ig ht c yc ling ma y c a rry risks

Die ting is o ne o f the to p pre dic to rs

• f we ig ht g a in

“Yo -Yo ” die ting ha s b e e n linke d to inc re a se d risk

• f CV e ve nts,

inc luding de a th.

Hig he r We ig ht Va ria tio n Risks in Pa tie nts with CAD

(Co mpa re d to L

• we st We ig ht Va ria tio ns):
• Co ro na ry o r CV e ve nt 64%-85%

hig he r

• De a th 124% hig he r
• Myo c a rdia l infa rc tio n 117% hig he r
• Stro ke 136% hig he r

Ho w We ll Do “L ife style ” Cha ng e s Wo rk in Ma inta ining We ig ht L

• ss?
• Ma ximum we ig ht lo ss is typic a lly 6-12

mo nths

• We ig ht re g a in 2-5 ye a rs a fte r we ig ht

lo ss

A B C D E F

E xhib it C1: We ig ht Re a litie s

E xhib it C1: We ig ht Re a litie s

Ac id/ Ba se

Oxyg e n/ Ca rb o n Dio xide Ba la nc e

Ho rmo ne s T e mpe ra ture

I ntra c ra nia l pre ssure

E le c tro lyte s He a rt ra te F luid Vo lume Blo o d pre ssure Blo o d sug a r

Re spira to ry Ra te

T hin = He a lth = ?

E xhib it C2: I sn’ t “Ob e sity” K illing Us?

L ife e xpe c ta nc y tre nds in the USA ha ve ra ng e d fro m 78.4-78.9 ye a rs, with a DE CL I NE in the pa st 3 ye a rs…

CDC Na tio na l Ce nte r fo r He a lth Sta tistic s F ig ure 001(2018). https:/ / www.c dc .g o v/ nc hs/ hus/ c o nte nts2018.htm? se a rc h=L ife _e xpe c ta nc y, https:/ / www.c dc .g o v/ me dia / re le a se s/ 2018/ s1129-US-life - e xpe c ta nc y.html

Drug Ove rdo se Ra te s Suic ide Ra te s

Pe o ple in “o ve rwe ig ht” c a te g o ry live d lo ng e r tha n tho se in “no rma l” we ig ht

JAMA.

E xhib it C2: I sn’ t “Ob e sity” K illing Us?

T ho se mildly

• r

mo de ra te ly “o b e se ” live d a s lo ng a s “no rma l” we ig ht a dults

E xhib it C2: I sn’ t “Ob e sity” K illing Us?

F itne ss (o ve r BMI

• r b o dy size ) is a b e tte r pre dic to r o f

de a th o r c hro nic illne ss

Unfit thin me n a nd wo me n we re 2x mo re like ly to die tha n tho se who we re fit a nd “o b e se ”

10 20 30 40 50 60 70 80 90 100 "No rma l" BMI 18.5- 24.9 "Ove rwe ig ht" BMI 25- 29.9 "Ob e se " BMI 30 o r hig he r

He a lth Sta tus “Healthy” “Unhealthy” “Unhealthy”

E xhib it C3: Bo dy Size & He a lth

20 40 60 80 100 120 "No rma l" BMI 18.5- 24.9 "Ove rwe ig ht" BMI 25- 29.9 "Ob e se " BMI 30 o r hig he r

He a lth Sta tus “Unhealthy” “Healthy” “Unhealthy” “Unhealthy” “Healthy” “Healthy”

Unfit thin me n a nd wo me n we re 2x mo re like ly to die tha n tho se who we re fit a nd “o b e se ” AK A: F itne ss o ve r BMI is a b e tte r pre dic to r

• f he a lth

E xhib it C3: Bo dy Size & He a lth

1.

E a ting 5 o r mo re fruits a nd ve g e ta b le s da ily

2.

E xe rc ising re g ula rly (a ro und 3 time s a we e k)

3.

Co nsuming a lc o ho l in mo de ra tio n

4.

No t smo king

E xhib it C3: Ca rdio me ta b o lic He a lth-- A Be tte r I ndic a to r o f He a lth tha n BMI

We ig ht L

• ss is

Ne e de d to I mpro ve Dia b e te s He a lth

I nsulin Re sista nc e

E xhib it C4: Re duc ing I nsulin Re sista nc e / I mpro ving Gluc o se

E xhib it C4: Re duc ing I nsulin Re sista nc e / I mpro ving Gluc o se

A1c Blo o d Pre ssure Cho le ste ro l Me dic a tio n Adhe re nc e Utiliza tio n o f He a lthc a re Dia b e te s Distre ss E

stima te d Co mplic a tio n Risk

DSMT ST UDI E S CONS I S T E NT L Y SHOW I MPROVE ME NT S I N:

Brunisho lz,, K D e t a l 2014; L ui, L e e & Bra te a nu, 2014

E xhib it C5: Se lf-Ca re Ac tio ns

A Windo w into the I mpa c t

• f Stig ma ….

 Up to 40% o f PWD a re e stima te d to ha ve a n

e a ting diso rde r

 HCPs re po rte d spe nding up to 28% le ss time with

“o b e se ” pa tie nts & c o mmo nly vie we d the m a s “la zy, undisc ipline d a nd we a k-wille d”

 We ig ht stig ma is no w e stima te d to b e g re a te r

tha n ra c ia l stig ma a nd c o ntrib ute s to :



Chro nic so c ia l stre ss



I nc re a se s mo rta lity



I nc re a se s e a ting pa tte rns, de c re a se s a c tivity pa tte rns, & inc re a se s c o rtiso l



Pre dic ts we ig ht g a in

T he De fe nse ’ s Clo sing Arg ume nts

Simplistic , ide a l vie w

• f dia b e te s c a use s

a nd ma na g e me nt We ig ht-c e ntric vie w a nd tre a tme nt

• f dia b e te s

Cre a tio n o f We ig ht & Dise a se Stig ma

“In health facilities, the

manifestations of stigma are widely

documented …… as a result,

stigma is a barrier to care

for people seeking services for

• 1. disease prevention
• 2. treatment of acute or chronic

conditions

• 3. support to maintain a healthy quality of

life”

Nyblade et al 2019

L e ss like ly to a c c e ss

he a lthc a re syste m AND

mo re like ly to re c e ive

ina ppro pria te c a re

We ig ht L

• ss a s a n I

de a l Dia b e te s Ma na g e me nt Pla n: We ’ re Se lling a L e mo n!

We ig ht lo ss is no t a lo ng -te rm, a c hie va b le pla n fo r mo st Se nse o f ho pe le ssne ss o r fa ilure a t no t a c hie ving o r ma inta ining we ig ht lo ss A se nse o f c a ring po o rly fo r dia b e te s witho ut we ig ht lo ss L e ss e ng a g e d in he a lthc a re a nd se lfc a re Hig he r risk fo r po o r he a lth o utc o me s

Decreased access and utilization of services

Clinical inertia & reduced medication adherence

Weight and disease stigma

Emphasizes lifestyle and de‐emphasizes

environment, genetics, social and

healthcare influencers

Increased risk for eating disorders and disordered eating Diabetes distress

De trime nta l I mpa c t o f E mpha sizing “L ife style ” & “We ig ht-Ce ntric ” I de a ls Dia b e te s

Patient labeling ‐ “non‐compliant”

Disregards progressive nature of T2D

T ho se w/ T 1D L ive unde r T 2D Misc o nc e ptio n Sha do ws & Ha ve Mo re Visib le Se lf-Ca re

Wha t’ s the Ve rdic t?

Guilty o r no t-Guilty?

 T

2D is a life style dise a se

 T

2D c a n b e re ve rse d o r pre ve nte d in mo st c a se s

 We ig ht is a mo difia b le risk fa c to r fo r T

2D a nd its c o urse

 Using me dic a tio n, inc luding insulin, is no t c o mmo n

a nd is a n indic a to r o f po o r se lf-c a re …T ha t T 2D de ve lo pme nt a nd its c o urse is he a vily de pe nde nt o n the de dic a tio n o f the individua l to c a re fo r the mse lve s….

Not- Guilty!

T he Ro a d We Ne e d to T a ke —T he 4 Cs

Cha lle ng e Own Bia se s; Ado pt

Re spe c t

 L

a ng ua g e tha t is e mpa the tic , no n- stig ma tizing

 Mo tiva tio n inte rvie wing  Ask pe rmissio n

 PWD sig nific a ntly o ve re stima te the ir risk fo r

c o mplic a tio ns

 F

e a r ta c tic s a re NOT e ffe c tive

Ca ll Out Stig ma tizing Me ssa g ing

He lp pub lic & PWD unde rsta nd the

RE S E ARCH b e hind

• de ve lo pme nt o f

dia b e te s

• pro g re ssio n o f

dia b e te s

• we ig ht-lo ss

re a litie s

Co nne c t PWD to Re so urc e s

Whic h Re duc e Stig ma s a nd/ o r T he ir I mpa c t

We ig ht-ne utra l he a lthc a re

pro fe ssio na ls

Pe e r Suppo rt Se lf-E

ffic a c y/ Co ping Skill T ra ining

Holmes-Truscott, et al. (2020)

Ce nte r T

ra ining o n Ac tio ns & F unc tio ning We ll

T HE DE F E NSE T ha nks YOU fo r Yo ur T ime !