Another example is a smoker who willingly discusses quitting not because she wants to live to be 90, but because personal discipline is a core spiritual value. These are examples of people who have identified a connection between healthy behavior and a value they prize or a personal goal to which they aspire. It is this discrepancy between current behavior and personal goals, values, and desires that pushes healthiness further up the list of daily priorities.
If clinicians can help patients identify this discrepancy, they will become more open to conversations about change. Discrepancies are discovered through skillful use of evocative questions and careful listening. Those discrepancies are strengthened by the reinforcement of patients' change talk and commitment language. One challenge regarding effective medical education is the need to keep information relevant and succinct.
Motivational Interviewing and Diabetes: What Is It, How Is It Used, and Does It Work?
After eliciting a short list of patient ideas and concerns, practitioners are then challenged with the task of providing information in a manner that maintains rapport and patient involvement, in other words, instructing in the spirit of MI. Three keys to success are: A range of other MI techniques can structure MI conversations and clarify ambivalence and barriers to change. Agenda-setting, a concept from Rollnick et al.
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Using a simple chart Figure 2 , practitioners elicit from patients preferences regarding the focus of the consultation. The goal of the agenda-setting technique is to provide patients with the opportunity to discuss that which they are most ready to change and practitioners with the opportunity to deliver a dose of more tailored education to interested individuals.
Where there is a pressing clinical concern that must be addressed or another issue of importance to the practitioner, the patient's concerns are tackled first, followed by the concerns of the practitioner, in a negotiated fashion. Agenda-setting is easily adapted to briefer interventions by limiting the choice to a fixed list of two or three topics. A visual aid is not necessary, however, and patients can simply be presented verbally with a menu of options or prompted for their own topics of interest.
The importance-confidence ruler technique incorporates many of the basic elements of MI: Furthermore, the ruler exercise yields for practitioners a clear sense of how ready patients are for change and how to be most helpful. On a scale of 0 to 10, what number would you give yourself?
Once the importance of change has been explored in this manner, the conversation can shift to questions regarding self-efficacy or confidence around change, using the confidence ruler.
And clinicians follow with the same questions as before: After these tool-assisted conversations, clinicians should take a reflection break, summarizing patients' barriers to change and emphasizing the disadvantages of staying the same as well as the benefits of change. Using the importance-confidence ruler, clinicians can quickly obtain a good idea of patients' readiness to change a target behavior and whether to focus initially on exploring the importance of changing or building confidence in their ability to change. A patient with high initial importance can be moved quickly to a discussion on building confidence and overcoming practical barriers.
A patient with low importance around change can be helped to think through the pros and cons of the status quo with the decisional balance tool Figure 1 to increase importance before tackling confidence. In , Zweben and Zuckoff, 16 in their review of the impact of MI on treatment adherence, identified 21 studies from to , including interventions targeting alcohol and drug abuse, dual psychiatric diagnoses, diabetes, weight control, exercise, HIV prevention, and eating disorders. Despite problems with internal validity seen in many of these studies i. It is important to note that there are multiple models for using MI in a clinical trial.
MI can be used as a stand-alone treatment, usually with one to four sessions that can be conducted in person or via telephone. More commonly, MI is seen as an adjunct to an already-established treatment. A more recent review by Hettema et al. The authors observed that the effect of MI is enhanced and maintained over time when MI is added to or precedes a standardized treatment. They noted that one of the primary benefits of MI seems to be promoting treatment engagement and adherence. Generally, findings of Hettema et al. Those interested are encouraged to explore this comprehensive review for more detail.
It should be noted that there have recently been dramatic improvements in the standards of interventionist training and treatment fidelity, including now routine coding of audiotapes of interventionist-patient interactions, using standardized coding tools of key MI counseling attitudes and behaviors. See the review by Belg et al. Smith West et al. Women in the MI condition lost significantly more weight than those in the control condition at 6 months —4. This superior weight loss was mirrored by enhanced adherence to the treatment program on all process variables examined over the initial 6 months: The pattern remained consistent in the 12 months of follow-up.
Women receiving MI had greater weight losses at 12 months — 4. At 18 months, weight losses still favored the MI condition — 3. Thus, MI appears to facilitate adherence to weight loss maintenance efforts as well as weight loss induction and as such merits consideration for inclusion in standard behavioral weight control programs.
Overall, the empirical evidence regarding the impact of MI, particularly as an additive to other effective treatments, is promising, although the next wave of MI intervention studies will tell us more and correct some of the methodological weaknesses of many articles to date. Future studies will be informed by recent methodological position statements e.
These enhancements, as part of an overall strengthening of the evaluation research in MI studies, will likely lead to clearer evidence regarding the clinical utility of MI. They may also help elucidate what type and doses of MI are required for what patients and in which clinical contexts to produce maximal health benefits. We are in the 2nd year of a 4-year randomized controlled trial examining the usefulness of MI in the management of patients with poorly controlled type 2 diabetes.
In this study, the MI spirit and MI strategies have both been woven into the usual educational activities. A standardized protocol for the delivery of education in an MI-consistent manner was developed. Patients receive seven MI-based sessions over a 1-year period and a 1-year follow-up. Outcomes include blood glucose control, quality of life, self-management behaviors, and health care utilization.
The study involves four certified diabetes educators, two of whom are randomized to receive a comprehensive MI training program over the course of the study. These two educators were exposed to an initial series of 2-day workshops to explain the basic theory and practice of MI and were then were coached to achieve a minimum standard of MI skills over a period of several months, using the Motivational Interviewing Treatment Integrity MITI 19 coding system during audiotaped patient sessions.
Behavior counts were also tracked for MI-adherent behaviors i. Also, we tracked with MITI coding the frequency of open and closed questions and the use of simple and complex reflections that foster patients' change talk and that strengthen motivation. Entering the 2nd year of the study, educators receive a 2-hour training session every 2 weeks and a full-day workshop every 3 months.
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We use digital voice recording units to capture educator-patient sessions and download these recordings directly onto a computer for review, using a desktop interface. Our experience with the MI training program to date is that MI-trained educators were successfully brought up to our skills criteria after the initial 6 months of training were completed.
They scored a mean of 5. Also, the MI educators scored 4. The MI educators asked more open-ended questions 6. Also, they were giving less unsolicited advice and providing about one-third as much general information. These are indicators that the model of integration is working as expected. We will continue to track both the general MI skills and specific behavior counts based on our initial criteria, but we are becoming more aware of subtle differences, reflected in the closed question scores, between MI used in a counseling conversation and MI used in an education-oriented conversation.
On completion of the study, a more comprehensive coding analysis, using the MISC Motivational Interviewing Skills Code, 20 will be conducted on study educator sessions for all educators to examine trends in patient and educator interaction and examine study outcomes. MI instructs us to appreciate the limits of a direct-persuasion, advice-giving model of clinician influence, guides toward a strong appreciation of the role of ambivalence in behavior change and the value of eliciting patient change talk, and models the use of effective listening skills to build rapport, engage, understand, and facilitate behavior change.
The spirit of MI shares much with the established Empowerment Model already used in diabetes education training. Whether one has the luxury of extended patient contact or must work within the parameters of a brief scheduled or opportunistic exchange, there are opportunities to integrate elements of the MI guiding style into everyday practice. Training in this approach takes time on the part of clinicians, and an important feature of training is the use of global ratings and counts of counseling behaviors based on MI principles.
Clinicians interested in learning MI will need a supportive system of feedback and guidance from a member of the MINT network of trainers. It is critical that the MI trainer is fully immersed in the realities of the day-to-day life of the clinical team and works within the clinical team to build a practical MI intervention protocol that meets the needs of patients and staff.
Much more research needs to be done, but there is encouraging empirical support from a recent metaanalysis by Miller and Rollnick 21 that MI can be taught in busy clinical settings and is effective. We look forward to reporting the findings of our current study evaluating an intensive MI intervention comprising individual MI sessions run by certified diabetes educators with the goal of improving patient medical and quality-of-life outcomes.
We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address. Skip to main content. Diabetes Spectrum Jan; 19 1: Understanding Ambivalence Ambivalence is a normal attribute of the behavior change process because most patients have conflicting feelings about changing familiar routines or habits. Exchanging Information One challenge regarding effective medical education is the need to keep information relevant and succinct.
Menu of diabetes options tool. What the Research Shows In , Zweben and Zuckoff, 16 in their review of the impact of MI on treatment adherence, identified 21 studies from to , including interventions targeting alcohol and drug abuse, dual psychiatric diagnoses, diabetes, weight control, exercise, HIV prevention, and eating disorders. MI Training With Diabetes Educators We are in the 2nd year of a 4-year randomized controlled trial examining the usefulness of MI in the management of patients with poorly controlled type 2 diabetes.
Conclusions MI instructs us to appreciate the limits of a direct-persuasion, advice-giving model of clinician influence, guides toward a strong appreciation of the role of ambivalence in behavior change and the value of eliciting patient change talk, and models the use of effective listening skills to build rapport, engage, understand, and facilitate behavior change.
Diabetes Care Concepts
Preparing People for Change. New York, Guilford Press, Motivational interviewing in medical and public health settings. New York, Guilford Press, , p. On Becoming a Person. In Advances in Experimental Social Psychology. New York, Academic Press, , p. In type 2 diabetes, severe hypoglycemia is associated with reduced cognitive function, and those with poor cognitive function have more severe hypoglycemia.
In a long-term study of older patients with type 2 diabetes, individuals with one or more recorded episode of severe hypoglycemia had a stepwise increase in risk of dementia Tailoring glycemic therapy may help to prevent hypoglycemia in individuals with cognitive dysfunction. In one study, adherence to the Mediterranean diet correlated with improved cognitive function However, a recent Cochrane review found insufficient evidence to recommend any dietary change for the prevention or treatment of cognitive dysfunction Given the controversy over a potential link between statins and dementia, it is worth noting that a Cochrane systematic review has reported that data do not support an adverse effect of statins on cognition.
Food and Drug Administration FDA postmarketing surveillance databases have also revealed a low reporting rate for cognitive-related adverse events, including cognitive dysfunction or dementia, with statin therapy, similar to rates seen with other commonly prescribed cardiovascular medications Therefore individuals with diabetes and a high risk for cardiovascular disease should be placed on statin therapy regardless of cognitive status. Severe mental disorder that includes schizophrenia, bipolar disorder, and depression is increased 1.
The prevalence of type 2 diabetes is two—three times higher in people with schizophrenia, bipolar disorder, and schizoaffective disorder than in the general population Diabetes medications are effective, regardless of mental health status. Treatments for depression are effective in patients with diabetes, and treating depression may improve short-term glycemic control If a second-generation antipsychotic medication is prescribed, changes in weight, glycemic control, and cholesterol levels should be carefully monitored and the treatment regimen should be reassessed if significant changes are noted Patients with HIV should be screened for diabetes and prediabetes with a fasting glucose level before starting antiretroviral therapy and 3 months after starting or changing it.
If initial screening results are normal, checking fasting glucose each year is advised. If prediabetes is detected, continue to measure levels every 3—6 months to monitor for progression to diabetes. Diabetes risk is increased with certain protease inhibitors PIs and nucleoside reverse transcriptase inhibitors NRTIs. NRTIs also affect fat distribution both lipohypertrophy and lipoatrophy , which is associated with insulin resistance. Individuals with HIV are at higher risk for developing prediabetes and diabetes on antiretroviral ARV therapies, so a proper screening protocol is recommended In those with prediabetes, weight loss through healthy nutrition and physical activity may reduce the progression toward diabetes.
Among HIV patients with diabetes, preventive health care using an approach similar to that used in patients without HIV is critical to reduce the risks of microvascular and macrovascular complications. For patients with HIV and ARV-associated hyperglycemia, it may be appropriate to consider discontinuing the problematic ARV agents if safe and effective alternatives are available In some cases, antidiabetes agents may still be necessary.
Strategies for improving care. In Standards of Medical Care in Diabetes— Diabetes Care ;39 Suppl. We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address. Skip to main content. Diabetes Care Jan; 39 Supplement 1: Recommendations A patient-centered communication style that incorporates patient preferences, assesses literacy and numeracy, and addresses cultural barriers to care should be used.
B Treatment decisions should be timely and based on evidence-based guidelines that are tailored to individual patient preferences, prognoses, and comorbidities. B Care should be aligned with components of the Chronic Care Model to ensure productive interactions between a prepared proactive practice team and an informed activated patient. A When feasible, care systems should support team-based care, community involvement, patient registries, and decision support tools to meet patient needs. Diabetes Care Concepts In the following sections, different components of the clinical management of patients with or at risk for diabetes are reviewed.
The American Diabetes Association highlights the following three themes that clinicians, policymakers, and advocates should keep in mind: Care Delivery Systems There has been steady improvement in the proportion of patients with diabetes treated with statins and achieving recommended levels of A1C, blood pressure, and LDL cholesterol in the last 10 years 2. Chronic Care Model Numerous interventions to improve adherence to the recommended standards have been implemented.
Six Core Elements The CCM includes six core elements for the provision of optimal care of patients with chronic disease: Delivery system design moving from a reactive to a proactive care delivery system where planned visits are coordinated through a team-based approach Self-management support Decision support basing care on evidence-based, effective care guidelines Clinical information systems using registries that can provide patient-specific and population-based support to the care team Community resources and policies identifying or developing resources to support healthy lifestyles Health systems to create a quality-oriented culture Redefining the roles of the health care delivery team and promoting self-management on the part of the patient are fundamental to the successful implementation of the CCM 8.
Three specific objectives, with references to literature outlining practical strategies to achieve each, are as follows: Change the Care System An institutional priority in most successful care systems is providing high quality of care When Treatment Goals are not Met In general, providers should seek evidence-based approaches that improve the clinical outcomes and quality of life of patients with diabetes.
Processes of Care Processes of care included periodic testing of A1C, lipids, and urinary albumin; examining the retina and feet; advising on aspirin use; and smoking cessation. Intermediate Outcomes and Treatment Intensification For intermediate outcomes, such as A1C, blood pressure, and lipid goals, tools that improved processes of care did not perform as well in addressing barriers to treatment intensification and adherence 6. Improving Adherence Simplifying a complex treatment regimen may improve adherence.
A systematic approach to achieving intermediate outcomes involves three steps: Tailoring Treatment to Vulnerable Populations Health Disparities The causes of health disparities are complex and include societal issues such as institutional racism, discrimination, socioeconomic status, poor access to health care, and lack of health insurance. Access to Health Care Ethnic, cultural, religious, sex, and socioeconomic differences affect health care access and complication risk in people with diabetes.
Addressing Disparities Therefore, diabetes management requires individualized, patient-centered, and culturally appropriate strategies. Lack of Health Insurance Not having health insurance affects the processes and outcomes of diabetes care. Recommendations Providers should evaluate hyperglycemia and hypoglycemia in the context of food insecurity and propose solutions accordingly. A Providers should recognize that homelessness, poor literacy, and poor numeracy often occur with food insecurity, and appropriate resources should be made available for patients with diabetes.
A Food insecurity FI is the unreliable availability of nutritious food and the inability to consistently obtain food without resorting to socially unacceptable practices. Food Insecurity and Hypoglycemia Type 1 Diabetes Individuals with type 1 diabetes and FI may develop hypoglycemia as a result of inadequate or erratic carbohydrate consumption following insulin administration. Type 2 Diabetes Those with type 2 diabetes and FI can develop hypoglycemia for similar reasons after taking certain oral hypoglycemic agents.
Homelessness Homelessness often accompanies the most severe form of FI. Literacy and Numeracy Deficiencies FI and diabetes are more common among non-English speaking individuals and those with poor literacy and numeracy skills. Cognitive Dysfunction Recommendations Intensive glucose control is not advised for the improvement of poor cognitive function in hyperglycemic individuals with type 2 diabetes.
B In individuals with poor cognitive function or severe hypoglycemia, glycemic therapy should be tailored to avoid significant hypoglycemia. C In individuals with diabetes at high cardiovascular risk, the cardiovascular benefits of statin therapy outweigh the risk of cognitive dysfunction. A If a second-generation antipsychotic medication is prescribed, changes in weight, glycemic control, and cholesterol levels should be carefully monitored and the treatment regimen should be reassessed.
Dementia The most severe form of cognitive dysfunction is dementia. Hyperglycemia In those with type 2 diabetes, the degree and duration of hyperglycemia are related to dementia. Hypoglycemia In type 2 diabetes, severe hypoglycemia is associated with reduced cognitive function, and those with poor cognitive function have more severe hypoglycemia.
Nutrition In one study, adherence to the Mediterranean diet correlated with improved cognitive function Statins Given the controversy over a potential link between statins and dementia, it is worth noting that a Cochrane systematic review has reported that data do not support an adverse effect of statins on cognition.
National Standards for Diabetes Self-Management Education
Mental Illness Severe mental disorder that includes schizophrenia, bipolar disorder, and depression is increased 1. Medications Diabetes medications are effective, regardless of mental health status. Diabetes Care in Patients With HIV Recommendation Patients with HIV should be screened for diabetes and prediabetes with a fasting glucose level before starting antiretroviral therapy and 3 months after starting or changing it.
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1. Strategies for Improving Care
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