Supporting Self Care Network
Newsletter
June 4, 2002, #4

Self Care and Diabetes...

Contents

Welcome
Editorial
Highlights
Member Profiles
In Practice
Sharing Resources

Welcome

By Clarence Clottey, MD, MPH (Harvard)
Director, Diabetes Division, Health Canada

I am delighted to welcome you to the fourth issue of the Supporting Self- Care Network newsletter. The articles in this issue provide a stimulating discussion on Self-Care related to diabetes.

This issue presents articles written by individuals who have personal experience with diabetes and those in the diabetes health care field. The importance of active living is highlighted, some barriers to adequate self-care are identified and solutions for improving diabetes self-care are presented.

This theme is significant as the prevalence of diabetes in Canada is rising significantly. First Nations communities are particularly affected and the need to improve management and self-care in those with diabetes is paramount to maximizing quality of life.

Ultimately, Self-Care in diabetes encourages patient education and empowerment, access to health care services and better relationship between patients and providers.

Editorial

Supporting Self-Care Through A Collaborative Alliance Practice Model
by Cheri Ann Hernandez, RN, PhD, CDE, Associate Professor, Faculty of Nursing, University of Windsor

The health care field, including diabetes care, has changed significantly over the past few years due to increased knowledge regarding health, economic, cultural and other factors. The focus on acute illness has changed as the number of clients with chronic conditions escalates and primary health outcomes become those of care rather than cure. Illness prevention and health promotion have become mandatory health activities. A new consumer attitude is being reflected by clients who have become more knowledgeable and self-determining of their health destinies instead of blindly complying with a regimen set by a beneficent health care professional.

Qualitative research results, derived from the client perspective rather than that of the health care professional, have demonstrated the notion of the expert client. This is a client with a chronic illness who "tunes in" to body cues and signals. Through trial and error, regimen adjustments are made based on this information as well as on personal and lifestyle preferences. Quantitative research results and anecdotal evidence both point to the limited efficacy of a fixed diabetes regimen to achieve ideal glycemic control. A multiplicity of factors, known and unknown, such as food and nutrient absorption patterns, insulin absorption factors, exercise, emotional stress, anger and pain defy standardization. How can the concerns of the health care professional and the needs of the client both be accommodated to achieve positive physiological and psycho social outcomes? I recommend that health care professionals practice within a new model of care: the collaborative alliance practice model (CAPM).

The collaborative alliance practice model promotes the development of collaborative alliance relationships. A collaborative alliance is a relationship between the client and the health professional in which the interaction is characterized by mutual trust and respect, and reciprocity in the areas of participation, power and acknowledgment of expertise. This model recognizes the existence of two equally valid types of chronic illness knowledge: scientific (research results) and personal (knowledge of one's body and how it responds in particular situations). Ignoring either will result in negative health outcomes. By practising within the CAPM, the diabetic client and the health care professional become co-experts in collaborative diabetes practice. What would the CAPM look like in diabetes care and treatment? The difference in philosophy has been described above. Here, the client is acknowledged as an expert with equal power in the relationship and is active and self-determining. This is the type of relationship in which the client and health care professional, as partners, are ideally poised to support self-care. Diabetes education programs will become more flexible, informal, and discussion-focussed with client involvement in all aspects of education (content, sequencing, timing, instructional strategies, and materials). Clients are engaged as knowledgeable peers in the health relationship. The diabetes regimen is viewed as guidelines or suggestions from which to start, rather than rigid regulations demanding adherence: The client revises and adjusts the regimen with experience and self-experimentation in order to accommodate personal and lifestyle preferences. I believe the use of the CAPM would revolutionize diabetes self-care, lead to better health outcomes and promote more satisfying interactions between clients and health care professionals.

Highlights

Self-monitoring of blood glucose in diabetes.
by Dr Jeffrey A. Johnson, Institute of Health Economics, Edmonton, AB

Self-care activities are considered the cornerstone of diabetes management for people with diabetes. These activities include diet, exercise, medication taking and self-monitoring of blood glucose (SMBG). Clinical practice guidelines suggest that SMBG is an integral component of self-management for people with diabetes. There have been questions raised, however, as to the overall benefit of SMBG in all patients with diabetes. It is generally agreed that there is a clear benefit of SMBG in patients with type 1 diabetes, due to the risks associated with hypoglycemia. There is little research evidence, however, of the effect of SMBG in patients with type 2 diabetes. Both the American and Canadian practice guidelines indicate that the optimal frequency for SMBG in people with type 2 diabetes is not known.

The cost of testing supplies for SMBG is of relevance to current policy discussions in Canada, but has received relatively little attention as a component of the overall cost of care for people with diabetes. The economic impact of diabetes is drawing increasing attention in Canada. A current estimate of the total cost of diabetes in Canada is a gross estimate of $9 billion based largely on estimates from the United States, which included both direct medical costs (e.g., hospitalizations) as well as indirect costs (e.g., lost work time due to early mortality).

The recent Diabetes Report Card 2001, published by the Canadian Diabetes Association, indicates cost and access to diabetes-related drugs and supplies under the provincial health systems remains a serious area of concern. There is wide variation in the extent of public insurance coverage for diabetes testing supplies across the provinces. Using data from Saskatchewan Health from 1996, we found that diabetes testing strips accounted for approximately 12.5% of the total costs of the Saskatchewan Prescription Drug Plan (SPDP) claims for individuals identified as having diabetes. Less than one-half of diabetic individuals had SPDP claims for diabetes testing strips. The mean total cost for diabetes testing strips per individual was approximately $240. On average, people with diabetes paid just over one-half (54%) of this amount, either out-of-pocket or through private insurance and the government plan covered the remainder. It is not possible from this data, however, to conclude whether out-of-pocket costs for testing strips is related to whether or not people actually test. Good control of BG helps to avoid long-term complications of diabetes, as well as day-to-day highs and lows of BG. People with diabetes should monitor their BG in such a way that they are aware of their level of control in order to achieve these goals.

Member Profiles

Lucy Barney BSN
In conversation with L. Young RN PhD
(9/5/2002)

Diabetes is endemic in First Nations people; many of those who are affected do not manage it. Is this passive suicide? Is it lack of knowledge or fear of obtaining the knowledge? This made me heartsick, so on completing my BSN, I took a Diabetes Nurse Educator position for First Nations Communities, funded by the Canadian Diabetes Association, and began my journey to supporting diabetes self-care with my people.

Diabetes for many First Nations people is a disease of 'shame'. I came to understand that there are more pressing priorities that take precedence over diabetes: sexual abuse, poverty, lack of education, or just finding food that day. Such difficulties create an emotional overload which is a barrier to dealing with diabetes. I had been focussing on the emotional and physical without due attention to the spiritual but in the course of graduate work, I developed the "Braid Theory". Here, the emotional, physical, and spiritual are interwoven dimensions of life that together are essential for good health. This led me down a new path.

I formed a committee to advise me on preparing educational materials and ways to integrate the spiritual aspect of the person into my work. In First Nations' culture, the spiritual is fostered through dance, song, preparing feasts, traditional welcoming, story-telling, and talking circles. After consultation, we decided that I should integrate the emotional, physical and spiritual at such gatherings. Since I am a traditional dancer, this was easy to do. At these community gatherings, there are display tables for crafts and information and I began to "slip in" displays of diabetes education material.

Over time, our diabetes initiative became more visible in First Nations Communities. Then, we began to negotiate gatherings with a diabetes theme at which diabetics were honoured and invited to tell their stories. In planning these events, experts such as psychologists and eye specialists were also invited to speak. The success of our work was related to the community's level of wanting to learn, and this often related to the community's progress with self-government, health care, etc. Through this experience, I learned to build on the strengths of the person and the community, and also that the strength of the family matters. I learned to assess whether or not a community is ready for diabetes education. Is there a nurse? A Community Health representative? Access to healthful foods? For those wanting to learn more about Supporting Self-care with First Nations people, I recommend the video, Lifetime Solutions, available from David Martin Regional, Director, First nations and Inuit Health Branch, 604-666-6155.

In Practice

A Diabetic's life experience : traveling with diabetes
by Joyce Mitchell, Executive - Treasurer, National Pensioners and Senior Citizens Federation Inc.

Shortly after September 11th, I was travelling from Ottawa to Edmonton with a change of planes at Toronto. I was worried because of all the tales about what we could and could not do. At security, I informed them that I had insulin and needles with me. I was prepared to submit my insulin case to the cabin crew but would need it during the flight. They were very courteous at both Ottawa and Toronto airports and assured me that this could go on board as needed medical supplies. I was asked to inform the flight attendant prior to removing needles from my case. Worry over!

A small nylon lunch bag with zippers and compartments is what I use to carry my supplies. The monitor goes into the outside pouch; Insulin, needles, testing strips etc. go inside. A small bottle of water frozen and wrapped in a tea towel (or some other article) makes a great cooling pack as well as a nice cool drink when needed. This is portable and easily taken into any public place; an inexpensive way to carry diabetic supplies.

I have retired but I do a lot of volunteer work, especially with seniors. My travels take me to meetings and workshops where I learn new information on topics that can be passed on to seniors' groups. I enjoy it, but I know that when the agenda reads, "breakfast served prior to the meeting", it will be a muffin, croissant, or sweet roll. Such a No No for diabetics! I plan ahead, get up earlier and head for the restaurant and my normal breakfast. I wish that more meeting organizers would offer choices to the many people with special dietary needs. The working lunch is another pitfall. Notice that the nicest, sweetest, most attractive desserts are served, with no options for diabetics or people on a restrictive diet. This is when you need an apple or a banana in your purse or briefcase.

Another thought I would like to share is about meal timing. Do not be shy to ask your hostess or function organizer what time the meal will be served. Use your smarts and have available a few crackers or a couple of arrowroot biscuits, in case it is delayed. I have found that if you tell the planner that you are insulin dependent and need to know when the meal will be served, your needs will be taken into account.

My message to everyone? Don't be SHY in making others aware of your needs. We have many professionals keeping us up to date on what we should and should not do, so all we need to do is STOP, THINK, and ACT for ourselves.

Sharing Resources

Book review
by Barbara Patterson
President, Canadian Association for Nursing Research, CANR/ACRI, Vancouver BC
Transforming Health Promotion Practice: Concepts, Issues and Applications, L. E. Young & V. Hayes (Eds.) 2002 Philadelphia: FA Davis Company

The editors of this book promise that it will provide nurses and nursing students clarity about the meaning and applications of health promotion in a variety of practice settings, such as hospice nursing, the human genome project, and nursing education. The authors are to be commended for their contribution to this goal.

The text includes several features that are likely to be useful for students in the field, such as reflective questions and an extensive bibliography. There are several chapters in the book that challenge and expand current understandings of health promotion in nursing practice. For example, MacDonald presents a fascinating historical and theoretical overview of health promotion, laying the foundation for understanding and reflecting upon the content of the chapters that follow. Berland and Young challenge the reader to reconsider the meaning of quality care within a hospital health promotion perspective. An interesting feature is the final chapter, a critique of preceding chapters by Larry Green and Mark Daniel. These critics offer some salient insights about the book, including challenges to some authors' claims and a call for extending the discussions of health promotion to strategies in application. As in all books with multiple authors, there is some variation in both the level of conceptualization and the writing of various chapters. In addition, there was inconsistency in the authors' conceptualization of health promotion. However, in general, the book offers a timely and provocative overview of health promotion in nursing practice.

Article review
by Linda J. Patrick RN, PhD, Assistant Professor, Faculty of Nursing, University of Windsor Jones, H., Ruggiero, L., Edwards, L., Vallis, T.M., Rossi, S., Rossi, J. S. et al. (2001). Diabetes stages of change (DiSC): Evaluation methodology of a new approach to diabetes management. Canadian Journal of Diabetes Care, 25 (2), 97-107.

People living with diabetes must do so 24 hours a day, seven days a week for a lifetime. The percentage of care that is self-directed has been reported to be as high as 95 % leaving only 5 % of time for health care professionals to influence outcomes. Our role has evolved from being the directors of care demanding adherence and compliance with treatment regimens to a more collaborative role as educator and coach. The latter role is more supportive of the client's autonomy and right to make informed decisions about their own care.

Increasing evidence supports optimal metabolic control for the prevention and/or delay of the complications associated with diabetes and optimal glycemic control is best achieved through self-management (Jones et al., 2001). There are few people with diabetes who really want poor control. Diabetes self-management activities include self-monitoring, making lifestyle changes and taking prescribed medications. One could spend the 5% of time imparting our professional knowledge to our clients with diabetes. How much better it would be to recognize the person's self-knowledge and together with our professional knowledge achieve client-determined goals.

Website review
by Daniel Laguitton

Whether looking for specific information related to diabetes or just curious about what a good website can do, a visit to www.diabetes123.com is a worthwhile stop on the information highway. The site is hosted by Diabetes123, an Ohio-based organization whose mission is "to be the world leader in online diabetes care, improving the quality and reducing the cost of care by increasing the understanding of, and providing traditional and innovative products and services for, the treatment of all types of diabetes".

At the bottom of a "fully loaded" homepage that features many items for children with diabetes, a link takes you to The Diabetes Monitor at www.diabetesmonitor.com where diabetes happenings in cyberspace have been monitored since May 1995. This site brings together descriptions of and links to all those places where people with diabetes can find useable resources on wide-ranging issues like diagnosis, glossaries, history, standards of care, complications, research, etc. Under "research", for instance, ( www.diabetesmonitor.com) one finds a list of "What might soon be available to help people with diabetes and what's been tried before, but doesn't seem too likely to work", (e.g. insulin patches, bloodless blood sugar meters, inhaled insulin, etc.) Tips for travelling with diabetes include a vast array of items, from vibrating watches and similar gadgets to specific instructions about how to cope with air-line security when travelling with syringes (http://store.yahoo.com/diabetes/syringe.html). I repeat, this is a model of what a good website can do.