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Unraveling Diabetes: Treating the Total Patient


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Posted: 10/5/2010

Diabetes is on the rise. The seventh leading cause of death in the U.S. today, it affects 24 million people, nearly 3 times the number in 1980. Another 57 million have a condition that puts them at heightened risk of the illness. Diabetes costs the nation as much as $218 billion a year.  It is most common among older adults, low-income, urban dwellers, and ethnic and minority populations. Many questions about these illnesses remain unanswered: Does diabetes cause depression? How does depression contribute to diabetes? Can reducing the impact of one illness forestall the others? What issues affect the trajectory of diabetes management for different patients, including those being treated for other health problems?

Issues like these have spurred JHUSON professor and associate dean for research Jerilyn Allen, ScD, RN, FAAN, associate professor Cheryl Dennison, PhD, RN, ANP; professor Miyong Kim, PhD, RN, FAAN and assistant professor Deborah E. Jones, PhD, RN, to broaden their research on cardiovascular health and health disparities to include diabetes and its management. Their separate studies give rise to several common findings: the importance of capable self-care by diabetic patients and how depression can affect and be affected by diabetes compliance. Their research also highlights the important roles nurses and community health workers play in diabetes management. According to Allen, who partnered with Dennison in many of these studies, the research is about “doing what is natural for nurses because we take a whole person approach to both clinical care and research. The same risk factors for diabetes, like obesity and sedentary lifestyle, are implicated in cardiovascular disease.” 
When it comes to diabetes management, like managing high cholesterol or hypertension, knowledge is necessary but must be paired with action to be most effective. It’s a concept called “self-care,” a practice found to be particularly difficult for many with diabetes or its precursor conditions. Allen notes, “Patients need to understand there is no magic pill to avoid diabetes; genetics alone cannot be blamed. When it comes right down to it, you can’t escape the need to modify a lifestyle. In doing so, you can help limit the impact or even the onset of diabetes or heart disease.”

Despite best efforts many find it hard to make these important lifestyle changes. Deborah Jones, whose research, like that of Allen and Dennison, has focused on older, urban African-American populations, notes, “When patients can’t do it alone, nurses can help patients understand and attend to their self-care practices, like increasing activity and establishing a healthy diet and giving up cigarettes and alcohol.” Similarly, Cheryl Dennison suggests that health care providers, particularly nurses, can “prime” patients for self-care by encouraging small steps toward change that are consistent with an individuals culture, beliefs, and behaviors. “By working one-on-one and building individualized plans for patients, we can help patients overcome barriers to living better with illnesses like diabetes,” says Dennison. ? 

Miyong Kim agrees and has found self-care confidence to be crucial to successful diabetes and cardiovascular disease management for Korean Americans, particularly older recent immigrants. She has observed that education and a monthly counseling call by a bilingual nurse or community health worker can boost that confidence despite limited English. Allen, too, values the work of community health workers to break through barriers to self-care, noting “Because they are from the community, they are trusted and often more effective than others in helping patients achieve and sustain self-care. The power of a nurse/community health worker team to help diabetic patients achieve behavior change cannot be underestimated.”

Diabetes begets Depression begets Diabetes
Uniformly, the researchers have found that undiagnosed depression is not uncommon among people with or at risk for diabetes and heart disease. Allen and Dennison have found it can breed fatalism about complying with diabetes control regimens and the risk for diabetes-related cardiac problems. Allen notes “The strong association between depression and both diabetes and heart disease suggests that depression can’t be ignored if we want to improve a diabetic patient’s overall health. When we treat the depression, we reduce hopelessness and empower a patient to take charge of his or her health and future.”   

Similarly, Jones has found that, even at low levels, depression is associated with poor self-care of diabetes and its companion problem hypertension. Yet, it can become the 2-ton elephant in the room that no one sees. Not wanting to overdiagnose, the physician may not raise the potential of depression; at the same time, the patient doesn’t want to broach the issue, fearing the stigma of a mental problem. As a result, as self-care diminishes, diabetes and its complications become exacerbated. Again, the pivotal role of the nurse in treating the full range of issues that confront the diabetic patient becomes evident. Jones puts it simply, “Physicians often focus on the condition; nurses focus on the whole person.”

Knowledge To Practice Improves Diabetes-Aware Hospital Care at JHH
When a person with diabetes is hospitalized for another purpose, diabetes management can get short shrift, resulting in potential medical complications, such as infections and slow-healing wounds. A few years ago, as a member and facilitator of a Johns Hopkins Hospital task force charged by hospital leaders to improve diabetes care, nurse practitioner Joanne Dintzis, MSN, CRNP, CDE, had her hands full. Nurse education seminars instituted to educate nurses about the dangers facing diabetic inpatients whose blood sugar is insufficiently monitored proved an inefficient way to reach the 4,000 nurses at JHH. The solution? Establishment and deployment of nurse experts in diabetes management and patient care — a group Dintzis calls Diabetes Super-users — to work on each of the hospitals 40 care units. Today, over 90 Super-users are helping to educate their colleagues about proper diabetes management in their primarily medical/surgical patients. Dintzis notes, “It’s a perfect role for nurses. We spend the most time with patients and the program helps us really focus on keeping our patient safe and avoiding harm because it is a dangerous disease.”