What Does Self-Care Mean for Diabetic Patients?
When patients can’t — or won’t — see a health care provider, they’re left to their own devices, which often leads to self-care, a practice that many people take for granted.
Self-care usually refers to indulgent relaxation: taking a hot bath, pouring a glass of wine or cutting an extra-large slice of cake. Diabetics have to be careful when partaking in those practices because they can cause more stress than they relieve. For diabetics, medical self-care means a long-term commitment to avoiding health complications in the absence of a medical provider.
This type of self-care can be overwhelming for diabetics, and it’s unsurprising that a study published in the Journal of General Internal Medicine found that most patients struggle with motivation and support for self-care. The link below leads to a worksheet that helps diabetics and their caregivers to keep track of self-care strategies and to stay accountable to their health goals.
Understanding Diabetes and Blood Sugar
Diabetes mellitus is a chronic condition characterized by hyperglycemia — also known as high blood sugar levels. Diabetes is caused by the body’s inability to create or absorb the proper amount of insulin, a hormone that regulates the amount of sugar in the blood, which is called glucose.
There are three common forms of diabetes:
Type 1: Most often occurring children, whose bodies create little to no insulin, Type 1 diabetes forces people to rely on insulin injections that move the body’s sugar, or glucose, from the bloodstream to the cells. Only 5 percent of diabetes patients have Type 1.
Type 2: The most common form of diabetes has historically occurred in adults though in recent years an increase in pediatric diagnoses has alarmed health care providers. People with Type 2 diabetes have developed an insulin resistance, meaning the body does not absorb insulin easily. Their high blood sugar levels can go undetected for years if symptoms such as increased thirst, frequent urination, headaches and fatigue aren’t reported early on.
Prediabetes: This condition indicates an increased risk of developing Type 2 diabetes during adulthood. Prediabetic patients have high blood sugar, and polyuria, or urinary frequency, may be seen in people with high levels of blood glucose. However, the symptoms of prediabetes can be easily confused with other health complications, so it’s critical for adults to get tested.
According to the American Diabetes Association, people with prediabetic symptoms may:
- Qualify as overweight or obese, which can be characterized as having a BMI over 25 or 30, respectively
- Have a high amount of body fat around the abdomen
- Lack regular physical activity
- Be women who have had gestational diabetes
- Be related to someone who has had Type 1 or Type 2 diabetes
The Importance of Self-Care
Diabetes can contribute to long-term damage or failure of different organs — especially in the eyes, kidneys, heart, nerves and blood vessels, according to the American Diabetes Association. Therefore, self-care is necessary to limit potential organ damage, and it can reduce the likelihood of hospitalizations and ER visits for patients.
A study published in the Journal of Diabetes & Metabolic Disorders concluded that the following seven self-care practices help diabetes patients avoid hospital visits and serious health complications:
- Healthy eating
- Being physically active
- Monitoring blood sugar levels
- Complying with medications
- Using problem-solving skills
- Developing healthy coping skills
- Practicing risk-reduction behaviors
The above strategies have been positively correlated with blood sugar control, fewer complications and overall improved of quality of life. However, there are several other recommendations that are often overlooked.
Dr. Tracie Kirkland, professor at the USC Suzanne Dworak-Peck School of Social Work Department of Nursing, regularly treats patients with diabetes in Houston, Texas, and suggests several clinically proven strategies that patients can practice at home after discussing with a provider.
Attending annual eye exams: Seeing an ophthalmologist regularly is part of maintaining good eye care and can help catch early signs of retinopathy — a condition characterized by blurred vision or partial blindness caused by damage to blood vessels in the eye.
Caring for feet: Check the skin and webs of the toes for any open lesions or sores, and make sure that nails are trimmed straight across. Wearing closed-toed shoes can help prevent foot injuries.
Reporting symptoms, especially numbness or tingling: Numbness can be a sign of nerve damage, called peripheral neuropathy, which is dangerous for older patients who lose feeling in their limbs and aren’t able to test if bathwater is too hot or feel an open wound. Maintaining a healthy blood pressure and sugar level will deter symptoms associated with peripheral neuropathy, as will curbing fat intake. “Early recognition can also help prevent some complications associated with resistant strains of bacterial infections that may lead to kidney complications,” says Kirkland. “The earlier symptoms are reported, the better.”
Practicing good oral hygiene: Maintaining dental health, like brushing and flossing right after eating, can minimize the effects of gingivitis and periodontitis. If these diseases develop, they have the potential to contribute to blood glucose irregularity. Visiting a dentist twice a year can help catch early symptoms.
Checking the skin: Inspect skin for discoloration or dryness, which can make skin susceptible to scrapes and sores, especially when the body is dehydrated. Take note of uneven hair distribution or hair loss, which can result from hormonal changes, increased stress or nerve damage, and is sometimes a side-effect of insulin injections. Drinking water and staying hydrated can keep skin strong and hair healthy.
Maintaining sexual health: In men and women, increased urination can be a sign of complications. For women, checking for yeast infections or abnormal discharge is critical as well. Men with diabetes are at risk for erectile dysfunction, which may correlate with poorly controlled diabetes or high glucose levels. Patients should take note of symptoms and ask any questions when they see a gynecologist or a primary care provider each year.
Relying on social circles: Though self-care implies solitude, Kirkland encourages patients to talk about their routines with family members, caregivers or friends. “It’s hard to be motivated when you are alone,” she said. Patients can look for a support group in their local communities or online through the American Diabetes Association.
Reducing stress: Feeling physical or emotional stress can make it more difficult to follow a treatment plan and can leave patients feeling hopeless or unmotivated. Because stress reduction is different in every person, Kirkland emphasizes the importance of discussing methods with a provider or caregiver and keeping track of what works effectively. The guide above can be used by patients or providers to write down their strategies each day.
The Social Determinants of Self-Care
The recommendations for diabetes management are complex and demanding; adherence to proper health management has been alarmingly low in many studies. However, this isn’t because patients aren’t willing or motivated to practice self-care, according to Kirkland. They simply lack the resources.
The National Center for Education Statistics sites several social determinants that put patients at risk for low adherence to their medical treatment plans. According to Kirkland, some patients might experience a variety of these social determinants at once, which causes high stress that puts them at increased risk and, therefore, in need of greater support from their medical providers.
Education: People with low academic achievement often have low health literacy, meaning they have a harder time reading and understanding medical information.
Housing status: Without stable access to shelter, patients are unable to store their medication safely. Other patients who live in apartment buildings or urban neighborhoods are less likely to have access to safe outdoor spaces for exercise or an accessible kitchen in which to cook their own meals.
Food security: Living in an area without regular access to a grocery store makes it difficult to find healthy food that has valuable nutrients, like vitamins and minerals. In 2016, there were 6 million households that didn’t know where their next meal would come from.
Income: Socioeconomic status affects a person’s health care coverage, ability to purchase nutritional food, access to transportation for appointments and more. According to Kirkland, many patients struggle to justify time off work for medical appointments, leaving them less able to pursue follow-up care.
Age: Older adults may have developed other chronic conditions with symptoms that make them unable to adhere to an exercise routine or care for themselves independently.
How Nurses Can Be Supportive
In Kirkland’s experience as a nurse practitioner, she’s worked in private practices, military hospitals and academic medical settings; now she sees patients who have survived Hurricane Harvey, many of whom have had to perform self-care simply because clinics were closed. Kirkland’s experience has yielded many lessons in supporting patients who struggle to support themselves.
Cater to the patient’s learning style. “Everyone learns differently,” Kirkland says, “so you have to make use of what works for them.” She suggests motivational interviewing to understand what social determinants affect a patient or to discover if they have pre-existing habits like smoking or drinking. “Auditory learners want to hear the information like a story, but visual learners want to see their charts from the past few years to understand how much their blood sugar is going up,” she explains. Providers can also use the teach-back method, in which a patient can repeat back what they understood about a conversation, to verify that they have processed the new information.
Develop long-term relationships. Seeing the patients consistently can help establish a dialogue over time and encourage them to open up about questions they might not have asked a new provider. “If I’ve been seeing a patient for the past few years, I really understand their struggles, and I can be a better resource for them,” Kirkland says. “It makes a difference to them if we can work as a team.”
Help set goals and form habits. “Lasting change is created by taking small steps,” Kirkland explains, emphasizing the importance of creating achievable goals. “But some patients need more help with those steps than others.” Many prediabetics don’t always recognize their symptoms and understandably find it difficult to inquire about a seemingly invisible problem. However, establishing camaraderie with other diabetics can promote accountability for good self-care habits.
Don’t blame the patient. Adhering to goals and habits is difficult, and it’s important to offer help rather than blame. Many adults just need incentives to participate, as well as a healthy balance between treatment recommendations from their provider and celebrating positive behaviors, Kirkland says.
Ultimately, patients need to feel informed in their choices, which is why it’s critical for NPs to offer support and guidance at every turn. “The most important thing is that they’re able to commit to taking care of themselves,” Kirkland says. “And our support is a major part of that.”
Citation for this content: Nursing@USC, the online FNP program at the University of Southern California