Diabetes is a group of diseases involving high levels of blood glucose resulting from insufficient amounts of insulin or a decreased ability of the body to use insulin. Insulin, a hormone secreted from the pancreas, allows glucose (sugar) to enter cells and be converted into energy. Insulin is needed to synthesize protein and store fats. [5] Therefore, diabetes treatment is aimed at keeping blood glucose levels near normal levels at all times. [4] If diabetes is not managed, glucose and lipids (fats) remain in the bloodstream and eventually can damage vital organs and contribute to heart disease. [5]

Most people with diabetes have one of two main types. Ninety to 95 percent of people diagnosed with diabetes have Type 2, which mainly affects people over age 40 and is more common in overweight people. Type 2 sometimes can be treated with dietary measures alone, but oral drugs and sometimes insulin injections may be needed. Type 1 diabetes occurs when the pancreas produces far too little or no insulin. Dietary measures are important, although insulin injections are needed to manage this type of diabetes. Type 1 affects 5 to 10 percent of people diagnosed with diabetes and most often appears suddenly in childhood or the teenage years. A third type, gestational diabetes, occurs in 2 to 5 percent of pregnancies but disappears when pregnancy is over; women who have gestational diabetes are at greater risk of developing Type 2 diabetes later in life. Other types of diabetes result from specific genetic syndromes, surgery, drugs, malnutrition, infections, and other illnesses. [4,5,9,15]

Interview #1: 'Improving Self-Management through Collaborative Care'

Russell Glasgow, PhD, is a clinical psychologist with a special interest in behavior theory and the application of behavioral principles to health issues, including the management of diabetes mellitus. Since 1998, he has been senior scientist at AMC Cancer Research Center, where he is charged with expanding and diversifying the center’s work in the cancer arena to diabetes and other chronic health conditions. Previously, for 14 years, he was a research scientist at the Oregon Research Institute. He also serves on advisory committees for the American Diabetes Association and the Centers for Disease Control and Prevention.

Q: Diabetes is a lifelong condition that can be managed but cannot be cured. How should health care for chronic problems like diabetes differ from health care for acute health problems?

A: One of the key issues is that patients must be responsible for management of chronic conditions. In our present health care system, the one in which most medical professionals have been trained, the general view is that it is the professional’s responsibility to diagnose and then to prescribe a course of treatment that involves the patient doing something like taking a medication or having a procedure done to them. This works reasonably well for acute conditions, but for chronic conditions like diabetes, the basic relationship is quite different. You need to involve the patient and take a more long-term view. By implication, follow-up and having a planned approach are particularly critical in managing chronic conditions.

Q: Why is the patient’s own behavior so crucial to successful diabetes care, health maintenance, and prevention of complications?

A: Because diabetes is chronic and the patient lives with it all the time, the focus has to be on the patient. Patients need to be involved in managing the disease. They are the ones who ultimately control their diabetes.

Q: What is "collaborative management?"

A: Collaborative management brings the perspective that patients are experts on their own lives and situations, and that medical or health care professionals must work with them as equal partners rather than in a hierarchical model in which one partner tells the other partner what to do. Chronic care is most successful when there is an open conversation and an understanding by both sides of the medical and broader health issues, the implications of different courses of care, and the personal and lifestyle implications. The patient and health care professional should agree on a set of treatment goals, such as consuming less saturated fat by eating red meat less often, or getting more exercise by taking a morning walk for 20 minutes, five days a week.

Q: What do patients need to pay attention to in self-managing their diabetes?

A: Eating a healthy, low saturated fat, high fiber diet and monitoring one’s blood glucose levels have always been emphasized and continue to be important aspects of diabetes management. More recently, the substantially increased risk of cardiovascular disease among diabetics has become apparent, and patients and professionals have to discuss how behaviors such as stopping smoking and becoming more physically active can dramatically decrease the risk. The importance of these behavioral factors has recently been emphasized by both the American Diabetes Association Technical Review on Smoking and the Healthy People 2010 Report that highlights the need for making increased physical activity levels a national priority.

Q: How does the care of people with diabetes treatment differ from care of people with other chronic conditions, such as heart disease or depression?

A: In general, there are far more similarities than differences. The basic principles—encouraging self-management, working with patients rather than doing things to them, developing coping strategies or plans, and proactively following up with patients—apply to most chronic illnesses.

The encouraging news is that there are commonalties and that some intervention approaches work across these different chronic conditions. For example, physical activity and eating a low fat, high fruit and vegetable diet are recommended for all of those conditions. The differences come in the specific medical course: with diabetes you are monitoring blood glucose levels, with respiratory conditions you are monitoring peak flow volume, and with depression you are monitoring other symptoms.

Q: You’ve studied the recent research on behavioral approaches to diabetes care. What areas of this research are most important or most striking?

A: The role of patient-centered interventions really is key. The second issue is the importance of consistent follow-up. Finally, the research shows the importance of designing programs that take into account the patient’s social environment. This environment includes barriers and supports, such as how often and where a person eats out and how the person’s work responsibilities and schedule affect diabetes management.

Q: What is self-management and how does it relate to collaborative care?

A: Self-management consists of the activities a person with a chronic condition needs to do in everyday life to manage the condition and to produce optimal outcomes. For people with diabetes, self-management includes taking medication and monitoring blood glucose levels, making lifestyle changes related to diet and regular physical activity, as well as addressing emotions, coping, and adjustment. The person with diabetes and his or her family need to put all of this into effect in a way that fits them and their values for the rest of the person’s life.

Q: How does this self-management approach impact the role of the health care professional?

A: Health care professionals need to be realistic by working with patients to understand what they are willing to do and what is consistent with their values. In addition, self-management needs to be ongoing and integrated into the patient’s primary care. Very often, self-management education, or "diabetes education," is provided only when the patient initially is diagnosed with diabetes.

Q: What types of behavioral interventions are most effective for diabetes?

A: The most successful interventions incorporate joint goal setting and proactive follow-up into ongoing, routine care. That may involve changing the nature of the office visit, but it doesn’t require much additional time. Examples include nurse care-management approaches that incorporate telephone follow-up and the use of interactive computer programs that encourage lifestyle changes.

Q: Does that mean that traditional diabetes patient education is not enough?

A: Because of how we were trained, we fall back on teaching patients that "This is your pancreas," "This is how insulin works," and that sort of thing. We’ve learned that that is not the only type of information, skills, or support that people with diabetes need. Instead of providing a standard course of didactic knowledge—teaching patients about the medical condition of diabetes—we need to provide information that patients want when they are ready to hear it. For example, we should provide information about the importance of decreasing saturated fat consumption when the person is ready to make dietary changes. We also need to focus on setting realistic treatment goals in the context of the patient’s social environment and barriers instead of thinking that one method of treatment is suitable for everyone.

Q: Are managed care organizations increasingly recognizing the importance of collaborative management of diabetes and other chronic conditions?

A: I think they are. As a group, both managed care organizations and some of the community health centers responsible for providing care for low-income and uninsured populations are the leaders in recognizing this and making changes in their delivery systems.

Q: Is the physician’s role changing in light of new knowledge and approaches?

A: The role is changing but in a subtle way. Improving diabetes care involves making changes in health care practice systems. In most settings, it is not feasible for the primary care physician himself or herself to make all of the needed changes. What they can do is work with their staffs to figure out how they can change their practice systems and the responsibilities of staff members—receptionists, LPNs, nurses, educators, and physicians—to encourage more collaborative approaches to care. The other key role the physician can play is to emphasize to the staff and patients the importance of both the lifestyle and quality-of-life aspects of managing diabetes.

Interview #2: 'The Role of Diet in Diabetes Management'

Clinical psychologist Richard Surwit, PhD, is a professor and vice chair of the Department of Psychology and Behavioral Sciences at Duke University Medical Center. His research interests range from mouse genetics to cognitive behavior therapy in the management of diabetes and obesity. Dr. Surwit and his colleagues currently are conducting studies on the role of fat in the diet, the interaction of drugs in diet-induced diabetes, and compliance of diabetics with medication regimens.

Q: Why is a person’s diet so important in managing diabetes?

A: Diabetes is a metabolic disease that impairs the way energy is produced in the body. In a nutshell, diabetes is a disease that develops from an interaction between the environment and genetic background, the environment particularly being diet. Twenty years ago, an endocrinologist postulated the "thrifty gene theory," which says that the metabolic perturbations that make up diabetes evolved because they allow people to subsist on fewer calories, in particular lower amounts of fat than normally would be available. The gene was never maladaptive until the 20th century, when large amounts of fat became readily available to some populations.

Q: So diabetes can become more prevalent because a population’s diet changes?

A: Right. You can see this in groups where diabetes is now epidemic. For instance, the Pima Indians lived on a subsistence diet for centuries. Around the turn of the century, the river they relied on for farming was dammed off and they began to starve, so the federal government sent in lard as a way to keep them fed. This changed their dietary habits. One of their staples today is fried bread, which is eaten by most Southwest Native Americans. Shortly after these changes took place, the Pimas began to develop diabetes. Today, 50 percent of the Pima Indians have diabetes. This story is interesting because there is another group of Native Americans who live in Mexico and are genetically identical to the Pimas. They live a more subsistence life, and their rate of diabetes is very, very low. That provides evidence, at least in this group, that dietary changes, as well as other lifestyle changes, were critical in the development of the disease.

Q: Is poor diet one of the strongest risk factors for diabetes?

A: Poor diet and interaction with genetic background. There are major differences in metabolism based on the individual's genetic background. There are people who can eat large quantities of food and not gain weight. There are also people who can gain weight on what would be considered an average caloric intake for their size and build. The chances are we can say the same thing for diabetes. Diet alone does not cause diabetes, obesity, hypertension, or heart disease. An interaction of diet and genetic predisposition does.

Q: If a person’s genes make such a difference, then how important is changing one’s diet in managing diabetes?

A: It is very well known that diabetes can be treated, at least in its early stages, by manipulating diet. In fact, my research has demonstrated that animals carrying the genes for diabetes can be kept normal as long as the fat content of their diet is reduced. There is anecdotal evidence that this is true in humans. The trouble in humans is that once people are diagnosed with diabetes, the disease has really gone too far, and it may not be reversible at that point. People usually are not diagnosed until after they’ve had the disease for many years.

Q: Are people with diabetes aware of the importance of diet in managing the disease?

A: They are generally aware but need a lot more education about what specifically is important. That’s why I am interested in pursuing the notion that fat may play a very critical role in the development of the disease. We are trying to determine which nutrients are the most important in the etiology and treatment of the disease so we can give people more specific advice.

Q: How could this type of information be communicated to consumers?

A: Much of behavioral science never gets disseminated because there is no convenient way to market behavioral medicine knowledge. One of the ideas I have for marketing behavioral medicine knowledge is to work with industries, such as the food industry. For instance, behavioral scientists could work with companies that have produced fat substitutes to study whether or not those products actually are satisfactory supplements for consumers. They also could work with industry to develop novel products that take advantage of research.

Q: How could collaboration with industry improve diabetes management in the long run?

A: We know from research with animals and humans that if you lower the fat content of the diet to 10 percent or less, for certain forms of diabetes you get a dramatic improvement in the symptomatology and course of the disease. If we can come up with products that are palatable yet provide people with very low fat content, then these products may have a big impact on diabetes.

Case Study: HMO Overhauls Systems to Improve Diabetes Care, Increase Patient Satisfaction, and Cut Costs

People with diabetes can benefit from proactive, well-planned, collaborative support from their health care providers. In today’s health care environment, however, primary care providers (from whom most people with diabetes get their health care) often are not in a position to provide the level of education, resources, and support they know their diabetic patients need. [12,14]

Group Health Cooperative (GHC) of Puget Sound, a not-for-profit staff-model HMO that serves 18,000 diabetic patients, has shown that patient care and outcomes can be enhanced if patients and providers are given the tools they need. During the past five years, GHC diabetologist David McCulloch, MD, and colleagues have instituted the Diabetes Roadmap program, a "population-based," collaborative effort that has improved diabetes care, increased patient and physician satisfaction, and decreased costs. [12]

Through the program, GHC has overhauled the way it provides care to diabetic patients at its 25 clinics throughout western Washington state. New program components include an electronic Diabetes Registry that informs primary care physicians about services provided system-wide to their diabetic patients and alerts them to patient care needs; a diabetes expert team that sees patients jointly with primary care physicians; evidence-based diabetes practice guidelines and clinical outcome indicators; and patient self-management support services, including a "Right Track" notebook, nurse case-management, group visits, and telephone-based counseling. [12,13]

"One of the most unusual aspects of our program is having the diabetes expert team travel to all of the primary care sites on a regular, ongoing basis to provide on-site coaching of primary care teams," says McCulloch. "By the end of 1997, more than 80 percent of practices had used the team at least once. Although the diabetes expert team had direct contact with only 7 percent of patients in those practices, the improvement in outcomes in all patients in those practices was substantial." [12]

Since Diabetes Roadmap was initiated, retinal eye screening, foot exams, and microalbuminuria and hemoglobin A_1c testing rates have increased; the number of primary care and specialty visits by diabetic patients has decreased; and total costs for diabetic patients have dropped substantially, even when costs for all GHC patients increased. [13] The Diabetes Roadmap team attributes the program’s success to better coordinated and better integrated diabetic services.

"We are seeing more productive interactions between patients who are more empowered and clinicians who are better prepared to provide the type of support that people with diabetes need," McCulloch says.

Patient Empowerment and Diabetes Care

Day-to-day management of chronic illnesses like diabetes rests most heavily on those who are affected by the condition. [2,3,19] However, many people with diabetes feel significantly challenged by the daily demands of the disease [18] and look to health care providers, including diabetes educators, for help.

Traditionally, the goal of diabetes education has been to help patients to adhere to health care professionals’ treatment recommendations. [2] Ten years ago, though, Martha Funnell, MS, RN, and other experts at the University of Michigan Diabetes Research and Training Center (MDRTC) concluded that this "compliance-based" approach was less than ideal, and they began advocating a more collaborative, patient-oriented empowerment approach. Empowerment, they wrote, is "the discovery and development of one’s inherent capacity to be responsible for one’s own life." [7] Patient education in this approach is designed to arm patients with the knowledge and skills needed to make decisions and manage their disease.

"Empowerment addresses the reality of diabetes, which is that most of the care is given by the person who has diabetes," explains Funnell, who is a certified diabetes educator and MDRTC’s administrative director. "It has patient-centeredness at its heart because it says to each individual, ‘What is important to you?’ ‘What are your goals?’ and ‘How can we help get you there?’

Since introducing the empowerment philosophy to diabetes care a decade ago, Funnell and her colleagues have studied the value of patient empowerment education in addressing the psychosocial aspects of living with diabetes. For example, in a randomized controlled trial, they demonstrated that self-efficacy improved more for patients who participated in a six-week empowerment education program than for patients who did not participate in the program. Moreover, program participants significantly improved their blood glucose control following the empowerment program. [2]

"More and more health professionals are recognizing that what they’re doing isn’t as effective as it could be," Funnell notes. As a result, she says, they are embracing the idea of more patient-centered approaches such as empowerment.

New Technology Enhances Patient-Provider Collaboration

Technology holds promise for improving health and quality of life for people with diabetes. Computer-assisted learning tools can enhance patient education, [8] automated voice-messaging systems can remind patients about foot care or medication-taking and provide pre-recorded educational messages, [17] and pre-programmed clinical algorithms can advise clinicians about needed insulin adjustments. [11]

A new form of technology—the blood glucose monitor with memory capacity—has been shown to influence patient-provider communication positively and to reinforce collaborative problem-solving. [8] Although blood glucose monitors are not new, the recent addition of memory capacity allows patients to gather data about their blood glucose levels—as often as four or more times a day—and then periodically transmit the data to their physicians’ offices for analysis and recommendations.

Richard Surwit, PhD, of Duke University Medical Center explains that this type of technology—including a patented device he and associates recently sold to a major medical device firm—directly applies behavioral management techniques to self-care for diabetes and enhances patient-physician collaboration.

Palm-size blood glucose monitors require that the user draw a drop of blood; put it on a test strip; and place the strip in the device, which digitally displays a glucose reading. Surwit’s advanced generation will ask the user questions and give an insulin dosage. Once a week, it also will prompt the user to send the data to a physician’s office via a phone line.

"The physician can monitor how well the patient is doing and then change the insulin dosing algorithm remotely by communicating with the server," Surwit explains. "If the physician sees that a patient is not doing well and realizes that the patient schedule is not appropriate, he or she can change the schedule and download it to the server. The next time the patient contacts the server he or she will get the new program. The user doesn’t have to be technology-savvy. All he or she has to do is push a button."

Future generations of glucose monitoring devices may take the technology even further, say some who have studied the application of computers in diabetes care. For example, implantable, non-invasive devices may eliminate the need for finger pricking and facilitate more frequent monitoring. [11] Such increased monitoring is likely to improve glucose control, which in turn could reduce complications of diabetes and improve quality of life. [16]

Steps to Collaborative Management of Chronic Conditions:

Once a chronic condition has been identified, patients do best if there is on-going commitment by patients, their families, and their health care providers to work together over time. There is strong evidence that the following simple steps taken by providers and patients can significantly improve health and well-being.

1. Define the problem jointly: Providers often define problems in terms of medical diagnoses and treatments, while patients define them in terms of the impact that symptoms have on their lives. Patients are more likely to benefit when these two perspectives are harmonized in a shared definition of the problem.

2. Develop common action plan: Managing chronic conditions is more successful when providers and patients focus on a few specific concerns, identify realistic goals, and commit to a joint plan of action in which the responsibilities of both parties are clear.

3. Explore possible programs and services: Many chronic conditions are better managed when patients are referred by providers to special support services or behavior change programs tailored to their priorities, needs, and preferences.

4. Track progress and anticipate course corrections: Scheduled, on-going communication between providers and patients is critical to tracking progress in achieving goals, identifying potential barriers and complications, and making needed adjustments in the joint plan of action.

For more information on the Behavior Change in Managed Care Settings project, visit our Web site http://www.cfah.org

The References:

1. Centers for Disease Control and Prevention. (1998). National Diabetes Fact Sheet. Atlanta, GA. http://www.cdc.gov/diabetes/pubs/facts98.htm.

2. National Institute on Diabetes and Digestive and Kidney Disorders. (1999). Diabetes Statistics. Rockville, MD: National Institutes of Health Publication No. 99-3892.

3. Centers for Disease Control and Prevention. (1999). Diabetes: A Serious Public Health Problem. Atlanta, GA. http://www.cdc.gov/diabetes/pubs/glance.htm.

4. American Diabetes Association. (1999). Diabetes Facts and Figures. Alexandria, VA. http://www.diabetes.org/ada/facts.asp.

5. DCCT Research Group. (1993). The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. New England Journal of Medicine, 329:977-986.

6. National Institute on Diabetes and Digestive and Kidney Disorders. (1999). Diabetes Control and Complications Trial (DCCT). National Institutes of Health Publication No. 97-3874. http://www.niddk.nih.gov/health/diabetes/pubs/dcct1/dcct.htm.

7. Glasgow RE, et al. (1999). Behavioral science in diabetes: Contributions and opportunities. Diabetes Care, 22(5):832-843.

8. Hoffman, et al. (1996). Persons with chronic conditions: Their prevalence and costs. JAMA, 276:1473-1479.

9. Herman, WH, & Eastman, RC. (1998). The effects of treatment on the direct costs of diabetes. Diabetes Care, 21(Supplement 3):C19-C24.

10. Selby JV, et al. (1997). Excess costs of medical care for patients with diabetes in a managed care population. Diabetes Care, 20(9):1396-1402.

11. Goldmann DR (Ed.) (1999). Metabolic disorders. In: American College of Physicians Complete Home Medical Guide. New York: DK Publishing, Inc.

12. McCulloch DK, et al. (1998). A population-based approach to diabetes management in a primary care setting: Early results and lessons learned. Effective Clinical Practice, 1(1):12-22.

13. McCulloch DK. (1994). A systematic approach to diabetes management in the post-DCCT era. Diabetes Care, 17(7) 765-769.

14. McCulloch DK, et al. (In press). Improvement in diabetes care using an integrated population-based approach in a primary care setting.

15. Von Korff M, et al. (1997). Collaborative management of chronic illness. Annals of Internal Medicine, 127(12):1097-1102.

16. Anderson RM, et al. (1996). Using the empowerment approach to help patients change behavior. In: Practical Psychology for Diabetes Clinicians, Rubin R & Anderson R (Eds.). Alexandria, VA: American Diabetes Association.

17. Anderson RM, et al. (1995). Patient empowerment: Results of a randomized controlled trial. Diabetes Care, 18(7):943-949.

18. Rubin RR, & Peyrot M. (1999). Quality of life and diabetes. Diabetes/Metabolism Research and Reviews, 15:205-218.

19. Funnell MM, et al. (1991). Empowerment: An idea whose time has come in diabetes education. The Diabetes Educator, 17(1):37-41.

20. Piette JD & Mah, CA. (1997). The feasibility of automated voice messaging as an adjunct to diabetes outpatient care. Diabetes Care, 20(1), 15-20.

21. Lehmann ED & Deutsch T. (1995). Application of computers in diabetes care—A review. II. Computers for decision support and education. Medical Informatics, 20(4):303-329.

Facts of Life is prepared with assistance from:

Academy of Behavioral Medicine Research
Academy of Psychosomatic Medicine
American College of Neuropsychopharmacology
American Psychiatric Association
American Psychological Association
American Psychological Association-Division 38
American Psychosomatic Society
American Society of Psychiatric Oncology
College on Problems of Drug Dependence
International Psycho-Oncology Society
International Society for Traumatic Stress Studies
Society of Behavioral Medicine
Society for Developmental and Behavioral Pediatrics
Society for Public Health Education
Society for Research on Nicotine and Tobacco

The Center for the Advancement of Health, , a nonprofit institute, promotes the science that explores health as a complex and dynamic system of relationships among biology, behavior, psychology, and social context and works to integrate this knowledge into public awareness, health care policy, and health care practice. The Center was founded by the John D. and Catherine T. MacArthur Foundation and the Nathan Cummings Foundation, which continue to provide core funding.

Funding for this series was provided by the Robert Wood Johnson Foundation.

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