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中文Diabetes is one of the most frequently occurring chronic diseases in the world affecting nearly 2-4% of the population. (WHO, 1998 p88). Research has shown that lifestyle factors such as diet, physical activity smoking and levels of stress have a direct as well as confounding impact on the glucose metabolism and insulin sensitivity which in turn influences the disease. (DeSouza 2004) Health promoting behaviors consist of positive actions, taken by the individual to promote health, such as healthy nutrition, balanced diet, regular exercise, keeping fit, rest and sleep, and the avoidance of negative or risk behaviors, such as alcohol, drug, or tobacco use. (Pender1990) Several factors may influence these behaviours and the effect of these on the health behaviour of a patient with type-2 diabetes will be discussed.
Mental
Health The incidence of depressive illness is high amongst patients with chronic illnesses such as diabetes. Depression has a major impact on the development of self-management practices and the development of positive health behaviours. Diabetic patients with lower levels of depressive symptoms are more likely to follow diet and exercise programs to improve their diabetic control. (Baer 2006)
The patient was an obese 60-year-old gentleman who had had type-2 diabetes for 12 years. The diagnosis of diabetes was a great shock to him and had a significant impact on his life in terms of having to alter his diet, being asked to lose weight, having to check glucose levels regularly as well as attend clinic appointments regularly. The realisation that he would also need to be on diabetic medication after diet alone had failed to control his glucose levels also affected him negatively. The changes in lifestyle that having a chronic disease and enforced on him as well as the regular surveillance of his health contributed to this patient showing signs of low mood, apathy towards his diabetes and some mild depressive symptoms. Failure of diet to control his glucose levels and development of diabetic foot disease in the form of foot ulcers caused him to feel that his efforts towards trying to change things were in vain. As a result, his motivation towards lifestyle changes such as weight loss was reduced and was not always compliant with medication.
The decline in this patient’s mental health caused by the pressure of having a chronic illness thus resulted in negative health behaviour.
Habit
Habit has a significant role to play with regards to the ability of individuals to change health behaviours that may adversely affect their disease. (Reach 2005) With regards to diabetes, habit has implications for diet modification, physical activity as well as smoking cessation. These are all factors that directly influence diabetic control.
Long-term habits also made it more difficult for this patient to make some of the lifestyle changes that were required for diabetic control. Dietary changes proved to be a particular problem as he and his family regularly had takeaways and purchased large quantities of refined calorific foods from the supermarket. Although he tried hard to eat healthily following his diagnosis of diabetes it was a losing battle as there was always access to sugary foods in the house. Following stern warning from physicians about the importance of diabetic control the whole family attempted to change their eating and shopping habits and this had positive effects on his glucose control. He also regularly visited the pub with friends after work. Alcohol was therefore part of his normal routine and he felt that his overall quality of life would be severely affected if he omitted this from his routine and was very unwilling to do so.
Addiction
he prevalence of smoking amongst diabetic patients is high. (Jung 2006)
This patient has smoked since the age of 15. Over the years he had made 5 serious attempts at smoking cessation but had failed. Soon after his diagnosis of diabetes he attempted to give up smoking but failed yet again. His nicotine addiction was thus a great impediment in terms of his health behaviour. He still continues to smoke albeit at a much reduced level.
Knowledge and Education
The amount and quality of education given to patients with diabetes influences what health choices they make and the effort put into trying to develop positive health behaviours. The patient knew that his diet affected his blood glucose levels but was not aware that increasing his physical activity and losing weight could also significantly affect his diabetes control. Neither was the patient aware that being overweight increased his chances of getting diabetic complications. His knowledge about diabetic complications and the aetiology of these and thus his motivation to make lifestyle changes such as increased exercise and weight loss was perhaps not as high as it might have been.
Ethnicity
This gentleman was of Indian origin. His ethnicity had two major effects on his health behaviour with regards to diabetes. Firstly he found it difficult to follow advice from dietary leaflets that were given to him at clinic. This was because the foods that he regularly ate were not featured in these leaflets and thus continued to consume high amounts of fat and sugar in his diet. Following discussion with his doctor, he was referred to a dietician who was knowledgeable about Indian cuisine and was thus able to give him and his wife dietary advice that was more relevant to him.
Secondly, as part of his cultural health beliefs, he did not normally seek medical help unless he felt quite unwell. This gentleman therefore found it difficult to adjust to making regular visits to the doctor and taking medication despite not feeling unwell. This led to him missing appointments and not taking medication, as he did not feel it was necessary. His culture and ethnicity therefore had a significant influence on his health behaviour.
PART 2: The strategies and skills needed to achieve maximum health benefits for a type 2 diabetic patient who smokes.
Diabetes is multi-factorial chronic disorder that can have an immense impact on the lives of patients. The management of this disorder is thus challenging and health professionals will require several skills and strategies to help patients to achieve maximum health benefits.
Education of care providers
Micro-vascular and macro-vascular complications of diabetes such as diabetic retinopathy and stroke are responsible for major morbidity and mortality. Prevention of these complications should therefore be one of the major aims in the management of diabetes. Glycaemic control, vigorous control of blood pressure, increased physical activity and smoking cessation have all been shown to reduce the incidence of complications. Healthcare workers must therefore be knowledgeable about the disease and risk factors for complications in order to be able to guide patients towards identifying health behaviours that need to be altered. Similarly, one must also be knowledgeable about therapeutic strategies such as anti-platelet and cholesterol reducing therapy that will additionally improve outcome for patients, thus enabling them to achieve maximum health benefits.
Patients with chronic diseases are at a greater risk of mental disorders. It is important therefore that people caring for patients with diabetes are educated about this increased risk and trained to recognise mental illness particularly depression in diabetic patients as this has a great impact on the patient’s motivation and likelihood to adhere to treatment or develop positive health behaviours to improve their illness.
Education of health care providers is thus an important strategy in the management of diabetes.
Individualised guidance
With regards to helping a diabetic patient to achieve maximum health benefits, it is essential that lifestyle advice given to patients be tailored to make it relevant. This is likely to improve adherence to treatment and advice. One important aspect of this is to ensure that advice is culturally and ethnically relevant. In certain situations, the religious practices of patients may also need to be taken into account. Individualised intervention of this kind is often necessary as commonly used educational and advice models may not always be applicable to patients of different ethnic backgrounds.
When giving dietary advice to patients from particular ethnic groups for instance, it is useful if the healthcare worker has an understanding of the kinds of foods that are regularly consumed by that ethnic group so that advice can be adapted. This will make it easier for patients to transfer information gained into real lifestyle changes. Understanding the relevant health behaviours of patients also allows appropriate health strategies to be designed for patients. Specific advice for instance may be necessary for diabetic Muslims who wish to fast during Ramadan and health care workers dealing with these patients will need to be knowledgeable about these practices in order to be able to guide patients appropriately.
It is thus essential that healthcare workers are familiar with the ethnic groups in the areas they serve and are knowledgeable about the relevant health behaviours and dietary practices to be able to help patients achieve maximum health benefits.
Communication skills
In order to effectively communicate with diabetic patients to alter health behavior with a view to achieving health benefits, health care workers must possess good communication skills to be able to negotiate with patients. This process consists of recognizing the problems in the patient’s health behavior, offering proposals as solutions to the problem and reaching an agreement with the patients on improving health behavior. Involving patients in this manner is a patient centered approach to disease management and this helps to empower patients in regards to control of their illness.
Patient education and self-management strategies
Chronic illness permeates many aspects of a patent’s life and often results in significant lifestyle alterations. There is good evidence that chronic disease self-management programs enhance health behaviour and this is thus an important strategy in helping patients to achieve maximum health benefits. Educating patients about diabetes, and arming them with skills to manage the condition, helps to motivate patients by giving them control over the disease. It improves health behaviour, self-efficacy and overall outcome. Such education must emphasise the important roles of reduced dietary fat and increased physical activity in the aetiology of the disease as well as practical skills such as foot care.
Diabetic patients may benefit from group based educational programmes. In these programmes, information about the disease and practical self-management skills such as self blood glucose monitoring and diabetic foot care, as well as diet and lifestyle advice is provided to patients in small groups. The advantage of this is that it allows patients to apprecuiate that they are not alone in their endeavour and also allows them learn from each other and share experiences. Group based educational programmes are thus effective strategies that may be used to help patients to achieve maximum health benefits.
Smoking cessation strategies
Helping patients, particularly diabetic patients to give up smoking is a very worthwhile, though difficult health intervention. Diabetic patients are already at an increased risk of macro and micro-vascular complications, as well as thrombo-embolism. Smoking significantly increases this risk. Smoking thus represents a greater risk to diabetic patients than non-diabetic patients. Several factors including habit, behavioural and chemical addiction, interact to make smoking cessation very challenging. In order to help patients to achieve maximum health benefits, healthcare workers must be educated about the risks of smoking and ways in which they can help patients to give up smoking. A very important aspect of this is that they must possess good communication skills in order to be able to present information to patients in an empathetic manner, and in a way that patients can understand.
Smoking cessation adjuncts such as nicotine patches are effective ways of helping patients to give up smoking. Health care workers must therefore be knowledgeable about these and pharmacological therapies that have been shown to be effective.
Motivational interviewing is also a strategy that may be used to help patients with diabetes to stop smoking. This involved face to face motivational interviewing and telephone counselling as part of a self-management training programme. Such high intensity counselling programmes may provide patients with more in-depth information and support. They are however more costly and time intensive and may thus not be very cost effective when compared to usual care. Strategies aimed at helping diabetic patients to give up smoking should therefore not focus on high intensity counselling services but should rather focus on encouraging more health care workers to offer simple, straightforward smoking cessation advice and support to patients.
Increased access to health professionals
Diabetes patients, whether primarily managed by their general practitioner or hospital consultants often require input from other health professionals such as diabetic nurse specialists and dieticians. Diabetic nurse specialists are very skilled at counselling and educating patients with diabetes. They have more time available to spend with patients and are invaluable especially when a patient is newly diagnosed. The problem however is that patients may sometimes have to wait for long periods of time to see nurse specialists due to availability problems.
Similarly, dieticians are very important assets in the management of diabetes. They spend time with patients, educating them about ways in which their diets can be altered to improve their blood glucose control. Dieticians are especially useful in the case of patients from ethnic minorities who may not find standard dietary advice leaflets very as it may not be applicable to their particular diets. As with diabetes specialist nurses, patients may sometimes have to wait long periods for appointment with dieticians during which time disease control may have suffered. An important strategy therefore in helping diabetic patients to achieve maximum health benefits lies in increasing the availability of such health professionals to ensure that patients receive timely guidance.
Exercise Referral Schemes
Increased physical activity and weight reduction are well recognised ways of reducing the risk of complications and improving disease outcome in patients with diabetes. For the obese patient or patients not accustomed to physical exercise, the prospect of trying to lose weight through physical exercise can be very daunting and this is an important reason why patients are unsuccessful in this endeavour. Exercise referral programmes are government schemes whereby General Practitioners and other health professionals may refer patients whose medical conditions will benefit from exercise to participating gyms. Here patients are educated about the benefits of exercise. Exercise programmes are then specifically designed to meet the needs of individual patients. This may include gym-based exercises, walking, swimming, exercise classes and other activities. These programmes provide help and support to patients to encourage them to increase their physical activity and lose weight. Exercise referral programmes are thus an important strategy that may be used to help patients with diabetes to achieve maximum health benefits.
