Basic HTML Version
SA JOURNAL OF DIABETES & VASCULAR DISEASE
DRUG TRENDS
VOLUME 9 NUMBER 2 • JUNE 2012
99
other treatments can be problematic. ‘In an
ideal world, I’d love to be able use it earlier
in the disease process, before patients
become insulin dependent’, she observes.
‘Its beta-cell-protective qualities would
make it especially valuable in these patients,
helping to prevent the development of
downstream complications. If it were more
affordable, I would introduce it second only
to metformin.’
Psychological processes in diabetes
and its interventions
A diagnosis of type 2 diabetes requires a
complete lifestyle overhaul that can leave
a patient feeling overwhelmed. ‘Diabetes
is a balancing act’, says Liane Lurie, clinical
psychologist, Norwood, Johannesburg.
‘It’s natural for patients to feel confused
and angry at the time of diagnosis, the
impact of which can be devastating and
exhausting. Doctors often intimate that had
a patient taken more of a central role in their
own care, this could have been prevented.
We need to preserve the health of the body
without destroying the mind.’
When faced with such life-changing
news, patients typically go through the
process described by psychiatrist Elisabeth
Kubler-Ross as the five stages of grief:
denial
•
anger
•
bargaining and guilt
•
depression
•
acceptance.
•
With enough information and support,
the patient will reach stage five and realise
that ‘it’s going to be OK. While the situation
can’t be changed, it can be managed.’
Lurie underscores that the role of the
physician/therapist/educator is critical to
the acceptance process and should never
be underrated. ‘Patients fight a diabetes
diagnosis on many psychological levels,
resisting the dietary and lifestyle changes
that are the cornerstone of treatment. They
are distressed by the weight gain that comes
with many pharmacological treatments and
resent being perceived by others as a “sick
person”. Should they require insulin, there is
often fear associated with the need to inject
oneself, and the possibility of hypoglycaemic
episodes.’
Whileonemight expect patients to take an
active and central interest in their healthcare
for its own sake, in reality this is often
not the case, according to Lurie. ‘Patients
usually need instrumental motivation that
allows them to see how the health benefits
can enhance other aspects of their lives.
Many factors come into play here, including
social support, stress, genetic loading and
patient willingness and readiness to make
the required changes. Each patient must
therefore be treated as an individual, not as
a number and not simply with a prescription
pad.’
Even if the healthcare professional avoids
lecturing and provides a therapeutic regimen
that produces tangible results, change may
remain elusive. ‘We can provide all the
necessary information, but insight does not
always lead to change.’
Psychological barriers
Lurie elaborates on these barriers as follows.
‘Some patients may not acknowledge the
need to change, while others see the required
changes as insurmountable. Still others buy
into the myth of invincibility. Diabetes does
not fade; it requires constant attention to diet
and exercise, compliance with medication,
and self-monitoring, a process that can take
months or years to perfect.’
Patients need to embrace three key
beliefs if they’re to accomplish this process:
Susceptibility: they need to accept that
•
they are not invulnerable.
Severity: they need to understand that
•
they will pay a high price if they fail to
take control of their diabetes.
Benefits: they will reap the rewards, and
•
psychological enhancers can help them
achieve these.
Psychological enhancers
The presence of support: social isola-
•
tion is a risk for morbidity and mortal-
ity. A support network can provide care
and motivation, while acting as a buffer
against feelings of hopelessness.
Seeing the need for and value of
•
change: once a patient is ready, he/she
feels motivated to set realistic, feasible
goals as he/she realises that the benefits
of change far outweigh the current situ-
ation, with increased well-being affect-
ing other areas of his/her life.
Instant gratification: healthcare profes-
•
sionals need to highlight the immediate,
concrete rewards of adherence to treat-
ment.
The ultimate goal of all medical inter-
ventions should be to restore physical and
psychological balance. ‘We are holistic beings
and treatment needs to address us on a bio-
psycho-social level. This is essential to ensure
better outcomes. Diabetes treatments must
improve patients’ quality of life as well as
their disease, so they experience the tangible
benefits of improved glucose control in the
form of reduced complications and feeling
better,’ concludes Lurie. ‘Counselling is vital
to helping patients cope with the identity
shift that goes with the change from being
healthy to having a chronic illness, and
support needs to be ongoing if compliance
with treatment regimens is to be achieved.’
Julia Aalbers
Marre M, Shaw J, Brandle M, Bebakar WM,
1.
et al
.
Liraglutide, a once-daily human GLP-1 analogue,
added to a sulphonylurea over 26 weeks produces
greater improvements in glycaemic in weight control
compared with adding rosiglitazone or placebo in
subjects with type 2 diabetes (LEAD-1 SU).
Diabetes
Med
2009;
26
(3): 268–278.
NauckM, FridA, Hermansen K, ShahNS,
2.
et al
. Efficacy
and safety comparison of liraglutide, glimepiride, and
placebo, all in combination with metformin, in type
2 diabetes: The LEAD-2 study.
Diabetes Care
2009;
32
(1): 84–90. Epub 2008 Oct 17.
Garber A, Henry R, Ratner R,
3.
et al
. Liraglutide
versus glimepiride monotherapy for type 2 diabetes
(LEAD-3 Mono): a randomized, 52-week, phase III,
double-blind, parallel-treatment trial.
Lancet
20097;
373
(9662): 473–481. Epub 2008 Sep 24.
Russel-Jones D, Vaag A, Schmitz O, Sethi BK, Lalic
4.
N, Antic S,
et al
. Liraglutide vs insulin glargine
and placebo in combination with metformin and
sulfonylurea therapy in type 2 diabetes mellitus
(LEAD-5 met+SU): a randomized controlled trial.
Diabetologia
2009;
52
(10): 2046–2055. Epub 2009
Aug 14.
Zinman B, Gerich J, Buse JB, Lewin A,
5.
et al
. Efficacy
and safety of the human glucagon-like peptide-1
analog liraglutide in combination with metformin
and thiazolidinedione in patients with type 2
diabetes (LEAD-4 Met+TZD).
Diabetes Care
2009;
32
(7): 1224–1230. Epub 2009 Mar 16.
Farilla L,
6.
et al.
Glucagon-like peptide 1 inhibits cell
apoptosis and improves glucose responsiveness of
freshly isolated human islets.
Endocrinology
2003;
144
: 5149–5158.
Maedler K, Carr RD, Zuelig RA,
7.
et al.
Sulfonylurea
induced beta-cell apoptosis in cultural human islets.
J Clin Endocrinol Metab
2005;
90
(1):502-6. Epub
2004 Oct 13.
Courie CC, Rust KF, Ford ES,
8.
et al.
Full accounting
of diabetes and pre-diabetes in the US population
in 1988-1994 and 2005-2006.
Diabetes Care
2009;
32
(2): 287–294.
Zoungas S, Woodward M. Diabetes: Insights from
9.
the extended follow-up of the ACCORD trial.
Nat
Rev Cardiol
2011;
8
(6): 308–310.
Meier J. Abstract presented at EASD Congress
10.
2011.