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Managing Clinical Problems in Diabetes, Case Study #6: Mrs. KB

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath

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Mrs. KB was referred to an endocrinologist by her GP:

Thank you for advising about this 59-year-old woman with type 2 diabetes. She has all the risk factors for cardiovascular disease, has early retinopathy and has been admitted several times to stabilize her diabetes. She is on very large doses of insulin; current dose 120 units/day overall. Her HbA1c at the moment is 16%; BMI 35 kg/m2. She has seen both the dietitian and diabetes educator but does not listen to a thing they say. What to do?

 

Psychologist 

This brief letter gives little to go on, but the last statement is a common complaint of many health care professionals and warrants consideration. The assertion is that Mrs. KB “does not listen to a thing they say”. The question I would ask is: How do the diabetes educator and dietitian know she does not listen? It is worth noting that both patient and professional recall of consultations is more inaccurate than accurate, with many professionals recalling making recommendations in consultations that were never actually made (Skinner et al. 2007). What these health professionals probably mean is that they do not see any evidence that Mrs. KB changes her behavior, because her HbA1c is still high and her BMI does not reduce. So health professionals feel they are not being listened to. 

Assuming the diabetes educator gives very clear information and has checked that Mrs. KB understands the information, the factors that prevent Mrs. KB from following the advice given need to be identified. In reality, she probably has more reasons for not following the advice than reasons to follow it. One issue to consider is how the messages Mrs. KB receives from a range of health professionals could differ and influence her self-management behaviors. It is common for health professionals to point out to people with type 2 diabetes: how serious the complications of diabetes are; to reiterate that they will undoubtedly get complications if they do not control their diabetes; and encourage them to adopt a range of behavior changes in order to control their diabetes. The health professionals’ behaviors are largely based on the premise that the more serious and at-risk an individual perceives him- or herself to be, the more likely he/she is to take action, and that most people underestimate their risk.

Research suggests that people with type 2 diabetes tend to substantially overestimate their risk of heart disease and strokes in the next 10 years by about 20% (Frijling et al. 2004; Asimokopoulou et al. 2006). These findings differ from the widely held belief that people exhibit ‘optimistic bias’ and underestimate their risk. However, research, predominantly with student samples but also in the patient and genetic counseling literature, consistently shows that people overestimate risk (Butow et al. 2003). Such pessimistic bias would not necessarily be a problem if the individual were able to take the necessary actions to reduce the risk.

Unfortunately, in combination with low self-efficacy beliefs, high perceptions of risk are unlikely to motivate behavior change. People with diabetes often learn through the media, multiple conversations with multiple health care professionals, and from family and friends, a long list of things they need to do to reduce their risk of getting complications. These messages include reduce the amount you eat, increase your fruit and vegetable consumption, reduce the amount of fat you eat, reduce the amount of saturated fat you eat, eat more fiber, reduce your salt intake, increase your levels of physical activity, stop smoking, reduce the amount of sugar in your diet, reduce the glycemic index of the food you eat, eat more oily fish, take your medication, monitor your blood glucose levels. Long lists of ‘do and do not’ can be so overwhelming that people feel unable to do all of these things and rationalize that ‘if I can’t do all of that, what’s the point,’ and do not do anything.

So how could we help Mrs. KB? First, we need to help her understand her personal risks: that is personalize the risk information for her. There are plenty of risk engines available free to all health care professionals to facilitate this. These risk engines can also be used to help Mrs. KB understand the impact of each different risk factor (BMI, HbA1c, lipids, hypertension) on her overall risks. The information can be used to negotiate with Mrs. KB to focus on one risk factor and help her identify the strategies she can use to reduce that risk factor.

Focusing on one thing at a time and having the patient select the risk factor they want to focus on and the ways to address it is more likely to be successful. She can be involved in developing an initial plan, focusing on one or two behaviors initially and have a clear strategy for deciding whether the changes she makes help her to reduce the risk factor. There is an old, very relevant Chinese proverb that suits Mrs. KB’s situation, “A thousand mile journey begins with a single step.”

 
Diabetes Educator

I agree with the strategy outlined by the psychologist. Mrs. KB clearly has insulin resistance, which needs to be investigated. Insulin resistance is a feature of type 2 diabetes and is multifactorial in nature. Genetic makeup and lifestyle factors such as inappropriate diet and lack of exercise play a role.

However, it is important to determine whether Mrs. KB’s weight gain is due to lifestyle or whether she has an underlying endocrine disorder or is taking any medicines that compound the lifestyle risk factors. Her cardiovascular risk is a concern and needs to be investigated. Her lipid levels are not provided but they are probably high given her blood glucose level. Infection needs to be ruled out. 

A list of medicines was not provided. It is important to review the medicines she is taking, some of which could be contributing to her weight. It would be worth checking her insulin administration technique to ensure she is actually taking the prescribed doses, and checking her injection sites. 

A possible strategy is to admit Mrs. KB and give her an insulin infusion to reduce the blood glucose and correct her lipids and then commence insulin again. If she is not on insulin analogues, they could be commenced. Bariatric surgery might be considered. I would refer her to an endocrinologist to ensure she does not have an underlying endocrine disorder.

 
Endocrinologist 

As well as the considerations outlined by the psychologist, medical causes of Mrs. KB’s insulin resistance need to be excluded, which would include: 

  • microurine culture and chest X-ray to exclude occult sepsis;
  • insulin-like growth factor 1 (IGF-1) to exclude acromegaly;
  • 24-hour urinary free cortisol to exclude Cushing’s syndrome; and
  • thyroid function tests to exclude hyper- or hypothyroidism.

With more severe insulin resistance, insulin receptor antibodies could be measured.

 

 

Podiatrist 

This woman’s macro and microvascular risk profile and non-compliance put her at risk of foot ulcers. She needs a thorough foot assessment and most probably foot self-care education.

 

The aims of the book are to: (1) address commonly encountered diabetes management problems; (2) develop comprehensive responses from a range of relevant health professionals who suggest management approaches relevant to their area of practice. The specific health professionals who provide comments about each case depend on the specific clinical issue; and (3) stimulate thought and discussion. 

The target readership is health professionals from a range of professional backgrounds and general as well as specialist professionals such as general practitioners, nurses, dietitians, and podiatrists. The book will be particularly useful for beginner practitioners specializing in diabetes. In addition, it will provide suggestions or food for thought for more experienced practitioners. The cases will be excerpts from the book are all real and are presented exactly as the information was received from the person making the referral. General practitioners, diabetes educators and people with diabetes referred most of the cases; some were self-referrals by people with diabetes. They represent referrals to various diabetic health professionals and concern commonly encountered clinical issues.

Next Week: Another Case Discussion

For more information on the book, just follow this link to Amazon.com, Managing Clinical Problems in Diabetesalt

Copyright © 2008 by Blackwell Publishing Ltd, UK

Edited by Trisha Dunning AM, RN, MEd, PhD, CDE, FRCNA and Glenn Ward MBBS, BSc, DPhil (Oxon), FRACP, FRCPath