186
VOLUME 9 NUMBER 4 • NOVEMBER 2012
REPORT
SA JOURNAL OF DIABETES & VASCULAR DISEASE
a person, a human being who happens to
have diabetes, as opposed to a diabetic
who happens to be human. Don’t just talk
to them, ask whether they’ve understood.
Often we talk so quickly, we don’t realise
we’ve lost them at the start. Diabetes is
a constant battle for most patients. As a
multidisciplinary healthcare team, it’s up to
us to give them the tools and the strength
to cope.’
Improving adherence (self-manage-
ment) in type 2 diabetes
Mr Michael Brown, Centre for Diabetes
and Endocrinology, Houghton,
Johannesburg
‘
Worldwide, current diabetes manage-
ment often fails to reach target.’ So began
Michael Brown’s presentation on improv-
ing adherence to therapy in patients with
type 2 diabetes. Substantial lists of patient,
educational, psychosocial, environmen-
tal and systematic barriers to therapeutic
adherence exist; varying combinations of
which are present in any individual patient.
Individualising patient care is particularly
important when considering therapeutic
adherence in a chronic condition such as
diabetes.
Mr Brown was eloquent in expressing his
opinion that therapeutic adherence is a part
of the greater whole of self-management
in the patient with diabetes. Distinguishing
between the use of the dated word ‘com-
pliance’ and the preferred ‘adherence’, Mr
Brown defined compliance as ‘the extent
to which patient behaviour coincides with
medical advice…, the patient is placed in a
passive role, bearing blame and with impli-
cation of disobedience.’ Adherence, on the
other hand, implies ‘an active, voluntary
and collaborative involvement in mutually
acceptable behaviour to improve therapeu-
tic outcome’. Adherence implies choice,
mutuality in goal setting and treatment
plan implementation.
Adherence is a multi-dimensional disci-
pline. The dynamic nature of therapeutic
regimens, dietary requirements and exercise
considerations, as well as the capacity for
self-reflection and self-care are factors con-
tributing to self-management in the person
with diabetes. Most importantly however,
‘
perspective changes everything’. Mr Brown
furnished the example of a physician with
the concerns of excessive cardiovascular risk
resulting in increased mortality and morbidity,
whereas the asymptomatic patient is aggres-
sively managed with a bag full of medicines.
A number of factors including attitudes,
wishes, needs, values, beliefs, culture, reli-
gion, worldview and motivation affect
how that patient reacts. Also of note is the
patient’s general state of health, the pres-
ence of co-morbidities, past experiences with
complications of diabetes and financial con-
straints. When taking into account this array
of confounding factors, coaching is possibly
the best approach to improving self-manage-
ment. ‘Most learning is not a result of instruc-
tion, but due to unhampered participation in
a meaningful setting.’ Coaching allows the
individual to realise his/her potential, is inspi-
rational and provides support to live ‘the best
life, doing what he/she enjoys’.
Coaching requires specific tools for each
job and Mr Brown recommended the fol-
lowing approaches for improving self-man-
agement:
It’s all about the patient. As collabo-
•
ration is the key to adherence, this
requires a relationship of trust between
the healthcare provider and the patient.
Patient-centred care that is respectful
and responsive should contextualise
the needs, preferences and tolerance
of each patient.
Focus on the right agenda. It is essen-
•
tial to make a sincere attempt to dis-
cover and understand the needs of
each patient.
Take some time. Don’t interrupt the
•
patient; wait longer before responding
to a question or statement.
Self-awareness is vital. Reflection on the
•
part of both the practitioner and the
patient is vital to the therapeutic proc-
ess. Facilitate the patient’s understand-
ing of his/her own attitudes, thoughts
and beliefs; ‘What do you think caused
your diabetes?’
Don’t focus on behavioural change.
•
Ultimately, behavioural changes are
critical in the person with diabetes, but
these should be positively reinforced by
focusing on the drivers of the required
changes. This requires a process of col-
laboration, clarifying the context of a
problem, exploring and resolving any
ambivalence or dissonance, identify-
ing skills and resources, and facilitating
self-discovery and improved self-confi-
dence. A deeper level of understanding
can be attained through the ‘Five-Why’
technique of root-cause analysis.
Don’t make assumptions. Don’t act out
•
of the context of the patient.
Listen intently. Don’t get distracted
•
with formulating your responses. Listen
to what is not being said.
Remember the emotional HbA
•
1
c
.
Mental
health, expressed broadly by the ability
to love and work affects HbA
1
c
levels.
If things don’t add up... investigate fur-
•
ther.
Focus on risk factors and not things to
•
do. The patient needs to understand
why we treat what we treat.
Aim for a target but negotiate the
•
route.
Set realistic but firm time frames, which
•
should be reviewed regularly.
Keep recycling. Revisit previous agree-
•
ments.
Treat the right problem.
•
Act early. The legacy effects of early,
•
good self-management are long-last-
ing decreases in morbidity and mortal-
ity risk.
Use the healthcare team.
•
Have realistic expectations, essential
•
for achievable goal setting.
Mr Brown concluded, ‘The person with dia-
betes is your most important resource. He/
she holds the answers on how to improve
his/her self-management skills, if you have
the skills to facilitate the process.’
Exercise in type 1 diabetes: a
double-edged sword
Mr Andrew Heilbrunn, senior biokineticist,
Centre for Diabetes and Endocrinology,
Houghton, Johannesburg
The benefit of exer-
cise in type 2 diabetes
is well established,
with the latest ADA
and SEMDSA guide-
lines
recommend-
ing a minimum of
150
minutes’ exercise
per week, combining
moderate-intensity
aerobic exercise with
strength/resistance
training. Mr Andrew
Heilbrunn said that while one could postulate
that exercise guidelines for type 2 diabetes
are suitable for use in type 1 diabetes, there
have been no large-cohort prospective stud-
ies to suggest that the above combination of
exercises would improve or worsen glycaemic
control in people with type 1 diabetes.
In the absence of comprehensive guide-
lines as to what type of exercise, and
Mr Andrew Heilbrunn
1...,34,35,36,37,38,39,40,41,42,43 45,46,47,48,49,50,51,52