SAN FRANCISCO – Getting patients to abandon unhealthful behaviors to better control diabetes can be hard, and sometimes the physician is the problem, according to behavioral psychologist William H. Polonsky, Ph.D.
"I think we’re a little too in love with the idea of behavior change," Dr. Polonsky said in the Richard R. Rubin Award lecture at the annual scientific sessions of the American Diabetes Association. "The major thing I’ve learned from my patients is we need to look in the mirror" to figure out why efforts at behavior change aren’t working.
Dr. William H. Polonsky
Certainly, healthy behaviors are incredibly helpful. Patients who reported a high level of disease self-management were nearly 40% less likely to die over a 12-year period in a study of 340 patients with type 2 diabetes (Diabetes Care 2014; 37:1604-12). But when behavior change isn’t happening, think about three common mistakes that clinicians make in the process, said Dr. Polonsky, president of the nonprofit Behavioral Diabetes Institute, San Diego:
1. Not taking enough time. Don’t rush patients to change their unhealthful behavior too soon, Dr. Polonsky advised. Make certain your patient believes that the selected behavior change is worthwhile.
"I push my patients way too hard, and I push them when I shouldn’t be pushing them," he said. "It’s this urge we have because we care and probably because we’re overtrained as problem-solvers."
Many clinicians now employ motivational interviewing, for example, which is supposed to end with formulation of concrete, realistic goals for change. However, in reviewing four fairly large randomized, controlled trials published in 2010-2013 that compared motivational interviewing techniques to usual care in managing patients with diabetes, Dr. Polonsky found that the change in hemoglobin A1c (HbA1c) levels differed between groups by an average of only 0.1%. Two other studies found that using motivational interviewing was significantly less effective than diabetes education in changing HbA1c levels.
Perhaps, the emphasis on formulating a concrete goal does not allow enough time to convince a patient that a specific behavior change would be worthwhile, he said.
2. Not focusing on the mundane. Clinicians in recent decades have tended to focus on dramatic factors that may influence behavior in people with diabetes, such as depression, eating disorders, or fear of hypoglycemia. Certainly these conditions should be treated when clinically significant, but these may not be as common as clinicians believe, he said.
Old data suggested that 23%-45% of people with diabetes have depressive symptoms, but newer data suggest that only 5% of people with type 1 diabetes and 4% of those with type 2 diabetes meet the criteria for major depressive disorder, comparable to percentages in the general population, Dr. Polonsky said. Other data suggest that eating disorders may affect 10% of middle-aged adults with type 2 diabetes and 10% of young women with type 1 diabetes. "My hunch is that it’s not as big an issue as we think it is," he said. As many as 26% of people with type 2 diabetes and an unknown proportion of people with type 1 diabetes may fear hypoglycemia, "but I’m not sure we’re talking about big, dramatic fears," he said.
A bigger obstacle may be what Dr. Polonsky called "diabetes meh" – indifference or apathy, when patients just don’t’ really care. This can manifest in statements like, "I have more important things to worry about than diabetes," or "This disease will eventually get me no matter what I do," or "Changing how I eat is too much of a bother."
A related concept is "diabetes distress" – patients’ feelings that diabetes takes up too much mental and physical energy, that the disease controls their lives, and that they often fail with their diabetes regimen. "Should we rename this ‘diabetes fatigue’?" he asked. As many as 39% of patients with type 1 diabetes and 35% of patients with type 2 diabetes may suffer from diabetes distress and its sense of powerlessness, based on research reports.
Try focusing on conveying the "worthwhileness" of interventions, Dr. Polonsky suggested. One way to do that is by "making the invisible visible" by asking patients to check their blood glucose levels right before and right after taking a 45-minute walk each day for just 1 week. The results may surprise them in a motivating way.
3. Not helping patients choose actions that matter. Help patients understand which actions and strategies are more valuable than others. Think of it as looking for "the biggest bang for your buck," he said.
For most patients, that would be knowing their numbers (for glucose and HbA1c), and taking the right medications. Those are more important than, for example, a deprivation strategy like choosing to eat two fewer tortillas per day, he said. Collaborate with patients to select actions that can make a real difference.