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Controlling Diabetes
By Phil Eager
Who hasn't ever fallen into this common trap? When it comes to home blood sugar monitoring the patient who just fails to test his or her blood sugar as recommended is labeled "non-compliant". What interventions or steps the doctor or diabetes educator can take to help motivate this sort of patient to check their blood sugar with more regularity is an important part of assisting patients to get the benefits of tighter blood sugar control.
Not Everyone Is a Candidate for Tighter Control
Before embarking on promoting tighter control and a routine of 3 or more a day blood glucose monitoring it is important to decide if this is really in the best interest of the patient who is hearing your recommendation. Is the patient really motivated to follow this tight intensive management? Do they understand the benefits and risks? You might survey their knowledge.
Have you taken the time to educate the patient about the Diabetes Control and Complications Trial (DCCT)? Make sure they understand it.
I recommend both talking to them and testing them to make sure they understand the importance of good blood sugar control and their role in it.
It is important to ask the patient in both written and verbal form if they agree with this and also to get their signature on a "letter of agreement"
that spells out the need to monitor blood sugars at least 3-4 times a day and when to check their blood sugars, including testing at 3AM at least twice a month, if necessary. This will weed out people who clearly are not ready to embark on the path to tighter control.
Persons who have a history of severe hypoglycemia or no sensation of hypoglycemia may not be candidates for intensive blood glucose management. Children under 13 and senior citizens also need to be closely evaluated before being put on an intensive program.
Determining if someone is a candidate for regular blood sugar monitoring
To help you determine who is a reliable candidate for home blood glucose monitoring it is helpful to assess the patients level of motivation by having them rate themselves on the following type questions:
On a scale of 1 being least interested to 5 most interested rate yourself on the following items:
1. How interested are you in attaining a near normal HbA1c (6.0 - 7.0)?___.
2. How interested are you in checking your sugar 4x or more a day?___.
3. How interested are you in maintaining records of your blood sugar?___.
4. How interested are you in communicating with the diabetes care team
regarding your blood sugar results? ___.
5. How interested are you in checking your sugars when you just don't feel
feel right? ___.
6. How interested are you in feeling "good"? ___.
7. How interested are you in avoiding diabetic complications? ___.
8. How interested are you in gaining and maintaining good control
of your blood sugar?___.
9. How interested are you in being in control of your diabetes?___.
10. How interested are you in following your doctor's advice?___.
Scoring
A. 0 -10 = Very low motivation to complete blood glucose monitoring.
B. 11- 20 = Low motivation to complete blood glucose monitoring.
C. 21 - 30 = Medium motivation to complete blood glucose monitoring.
D. 31 - 40 = High motivation to complete blood glucose monitoring.
E. 41- 50 = Very high motivation to complete glucose monitoring.
By assessing which category A - E that the patient is in we get a better understanding of the level of care necessary to help the patient become motivated to perform the regular blood glucose monitoring that is the cornerstone of a good diabetes management plan.
Plan of Action
Before beginning to address the needs of a patient to become "motivated" it is important to determine if they are even close to being motivated. For Persons in category A, it is important to have a frank talk about the DCCT and how the patient feels about their future? If they are very fatalistic I would strongly suggest they seek a professional consult with a psychiatrist, licensed psychologist, certified counselor or diabetes educator. If they "just don't get it", it would be important to have them read and see videos of people who are in good control as a demonstration of the fact that it can be achieved. I would also suggest a membership in a diabetes support group that allows them the opportunity to meet with people who have gone from "poor control" to "in control", much like AA affords alcoholics the chance to learn and gain meaningful support from others who are going from "out of control" to "in control".
Persons who are in categories B, C, or D are the primary targets of your interventions. These represent the majority of patients who can benefit
from your interventions and from each others insights into glucose testing.
Those who are in category A probably need counseling or psychological intervention by a specialist to help them along. Those in category E probably are doing fine already and just need some minor suggestions (these are the sort of patients that know themselves very well and that you can often learn a lot from).
Working with those who have low, medium, and high motivation will help them learn from each other. How to set this up is to schedule a regular once a month meeting, where they can all attend - say on a Saturday. At this meeting you will review in an open and supportive environment a discussion on what challenges people face when it comes to blood sugar testing. On a wall paper page write them all down and then get some themes like - "It is a real inconvenience", "I don't like other's seeing me test in public", "I don't have the place or time". Then ask others to share what strategies they have used to overcome these obstacles. The goal is get them to learn from each other and to allow you to slip in the secrets your expertise in a manner that says "how about this" rather than "do it this way - I am the expert after all".
In this class which should be no shorter than an hour and no longer than two hours. You can go over the benefits of good control the negative impact of poor control and ways people feel when the have to deal with various facets of diabetes. An educational blood sugar testing event is to have a representative from one of the monitor companies visit to demonstrate and calibrate meters. Or use your own calibrated meters for this exercise. Ask all persons to guess where their blood sugar is and to write it on a piece of paper with their name on it. Let them know the person with the nearest guess will win a prize (perhaps a meal donated by a kind hearted merchant). This demonstrates how far off people can guess. In the case of a tie ask trivia questions about diabetes until someone misses.
Conclusion
The significance of frequent blood glucose monitoring in achieving blood glucose control is indisputable. It is important to determine if someone is a candidate for frequent monitoring and tight control. By giving the patient a survey to assess their level of motivation to test their blood you can rule out those that either are too unmotivated or motivated to the degree that they may not profit from your intervention(s). Once you've identified common barriers it is helpful to get group input and to offer your insights. By having a fun blood glucose experiment that tests peoples accuracy in guessing their blood sugar you can prove that testing is needed to make sure your clients know where they are. Giving much positive feedback to the patients for their efforts is important. Letting them know they are capable of gaining and maintaining control through consistent testing is something that must be striven for even if it is not totally achieved.
