Transcript Effectively Changing Behavior for Improved Diabetes Outcomes

Welcome
Understanding
Behavioral Change
to Help Improve
Diabetes Outcomes
Understanding
Behavioral Change
to Help Improve
Diabetes Outcomes
Jocelyne Duerksen
RN, BSN, CDE
Endocrinology and Metabolism Program
Diabetes, Hypertension and Cholesterol
Educator
Roche Diagnostics Canada
Promoting Behavior Change
in Diabetes: Secrets of
the Seven Tipping Points
Authors: William H. Polonsky, PhD, CDE
President and Founder
Behavioral Diabetes Institute
Associate Clinical Professor, Psychiatry
University of California
San Diego, California
Ralph’s Story
• Age 54; type 2 diabetes for 8
years; has never paid much
attention to it
• Knows he’s overweight (BMI
32); suspects his diabetes is
not in the best control
• Knows at next medical visit
he’ll be told to exercise and
stop smoking (has been told
this often); doesn’t feel there
is anything he can/wants to
do about this
• Has been labeled “in denial”
Ralph’s Story
• Loves eating; not really
concerned about his weight
• Knows diabetes can harm
him; has other things to worry
about that seem more
pressing
• Never checks BGs; sees no
point to it (“it is always high”)
• Has many family members
with diabetes; some doing
• Feels luck plays a big role
well; some doing poorly
in what happens with
diabetes
Motivation in Diabetes
“Strong” endorsements by physicians
Poor self-discipline
53.2%
Poor willpower
50.0%
Not scared enough
36.9%
Not intelligent enough
16.3%
Polonsky WH, Boswell SL, Edelman SV. Diabetes. 1996;45(Supp 2):14a Abstract 41.
True Nature of
Motivation in Diabetes
• Almost no one is unmotivated to live a long
and healthy life
• Problem:
– Rewards for good diabetes care may seem not
so rewarding
– Obstacles to self-care often outweigh possible
benefits, tipping patients into poor self-care
– There are many potential tipping points
Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999.
Seven Tipping Points
1. Depression
Polonsky WH. Unpublished data.
Depression Rates in Diabetes
• Rates 1.5–2.0x higher
– Review of controlled studies (n=20): 20.5%
patients with diabetes were depressed vs.
11.4% controls1
– Recent Kaiser study compared 16,000 type 2
patients to 16,000 matched controls: 17.9%
patients with diabetes were depressed vs.
11.2% controls2
1. Anderson RJ, et al. Diabetes Care. 2001;24:1069-1078.
2. Nichols GA, Brown JB. Diabetes Care. 2003;26:744-749.
How Depression Influences Diabetes
• Depression makes it harder to initiate and
maintain healthy behavior changes
–
–
–
–
–
Poor self-management1
Poor BG control2
Strongest predictor of increased hospitalization3
3x higher incidence of CAD and retinopathy4,5
2x higher risk of mortality6
1. Polonsky WH, Parkin CG. Practical Diabetology. 2001;Dec:20-29. 2. Lustman PJ, et al. Diabetes Care.
2000;23:934-942. 3. Rosenthal MJ, et al. Diabetes Care. 1998;21:231-235. 4.de Groot M, et al. Psychosom Med
2001;63:619-630. 5. Kovacs M, et al. Diabetes Care. 1995;18:1592-1999. 6. Katon WJ, et al. Diabetes Care.
2005;28:2668-2672.
Seven Tipping Points
1. Depression
2. “No big deal”
• “I feel fine, so why worry?”
Polonsky WH. Unpublished data.
Seven Tipping Points
1. Depression
2. “No big deal”
3. Inevitability
• “Diabetes is a death sentence, so why
bother trying?”
Polonsky WH. Unpublished data.
Seven Tipping Points
1. Depression
2. “No big deal”
3. Inevitability
4. Treatment skepticism
• “No matter what I do, these numbers are
always high!”
Polonsky WH. Unpublished data.
Seven Tipping Points
1. Depression
2. “No big deal”
3. Inevitability
4. Treatment skepticism
5. Unrealistic plans for action
• “I know, I know. I need to eat perfectly and
never cheat.”
Polonsky WH. Unpublished data.
Seven Tipping Points
1. Depression
2. “No big deal”
3. Inevitability
4. Treatment skepticism
5. Unrealistic plans for action
6. Poor social support
Polonsky WH. Unpublished data.
Seven Tipping Points
1. Depression
2. “No big deal”
3. Inevitability
4. Treatment skepticism
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
Polonsky WH. Unpublished data.
Courtesy of WH Polonsky.
Seven Tipping Points
1. Depression
2. “No big deal”
3. Inevitability
4. Treatment skepticism
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
Polonsky WH. Unpublished data.
Seven Tipping Points
1. Depression
2. “No big deal”
3. Inevitability
4. Treatment skepticism
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
And there are many more!
Polonsky WH. Unpublished data.
Tipping Points Are Additive1
• Diabetes is perceived as more difficult/
pointless as these issues accumulate
• Patients come to believe that diabetes
cannot be managed, or it is not important
enough to manage2
• Slowly but surely, patients become
apathetic or drop out of treatment
1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999. 2. Polonsky WH. Current Diabetes Reports. 2002;2:153-159. 3. Peyrot M et al.
Diabetes Care. 2006;29(6):1256-1262.
Tipping Points Are Additive1
• Diabetes is perceived as more difficult/
pointless as these issues accumulate
• Patients come to believe that diabetes
cannot be managed, or it is not important
enough to manage2
• Slowly but surely, patients become
apathetic or drop out of treatment
And providers may feel this way, too!2,3
1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999. 2. Polonsky WH. Current Diabetes Reports. 2002;2:153-159. 3. Peyrot M et al.
Diabetes Care. 2006;29(6):1256-1262.
Tipping Points Overlap
• Tipping points influence each other1,2
• This is problematic, but also presents
opportunities
• For example:
– Unrealistic action plans may lead to treatment
skepticism
– Treatment skepticism may lead to inevitability
1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:
American Diabetes Association; 1999. 2. Polonsky WH. Current Diabetes Reports. 2002;2:153-159.
Addressing the Diabetes
Tipping Points Is an ART!
Polonsky WH. Unpublished data.
Addressing the Diabetes
Tipping Points Is an ART!
Assess
Polonsky WH. Unpublished data.
Addressing the Diabetes
Tipping Points Is an ART!
Assess
Review (discuss & prioritize)
Polonsky WH. Unpublished data.
Addressing the Diabetes
Tipping Points Is an ART!
Assess
Review (discuss & prioritize)
Treat
Polonsky WH. Unpublished data.
The Assessment Step
TP1: Depression
ASSESS
CORE FEATURE
• “During the past month,
have you often:
a. been bothered by
feeling down,
depressed, hopeless?
b. had little interest/
pleasure in doing
things?”
• See PHQ-91
• Symptoms of depression
(i.e., low mood, sleep
problems, fatigue, and
anhedonia) are interfering
with patient’s ability to
function well in his life2
1. Kroenke K et al. J. Gen Intern Med. 2001;16:606-613. 2. DSM-IV-TR 2000. Available at:
http://online.statref.com/document.aspk?fxid=37&docid=192. Accessed March 16, 2007.
The Assessment Step
TP2: “No Big Deal”1
ASSESS
CORE FEATURE
• “What worries you about
having diabetes?”
• “Do you ever think that
you might develop
complications?”
• “Your last A1C was 9.2%,
what does that mean to
you?”
• Patient indicates no need
to worry about diabetes
because he “feels fine”
and/or doesn’t expect
diabetes to harm him1,2
1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999. 2. Skinner TC. European J Endocrinol. 2004;151:T13-17.
The Assessment Step
TP3: Inevitability
ASSESS
CORE FEATURE
• “What worries you about
having diabetes?”
• “Do you ever think that
you might develop
complications?”
• “Your last A1C was 9.2%,
what does that mean to
you?”
• Patient indicates that
complications, or
worsening complications,
are inevitable
• “This disease is going to
get me and there is
nothing I can do about it.”
Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999.
The Assessment Step
TP4: Treatment Skepticism
ASSESS
CORE FEATURE
• “How well are your
prescribed treatments
helping you to control your
diabetes and improve your
health?”
• Patient indicates little faith
in at least one
recommended self-care
behavior1
• “No matter what I do, these
numbers are still too high!”
• “I’ve done everything, but I
don’t feel any different.”
1. Skinner TC. European J Endocrinol. 2004;151:T13-17.
The Assessment Step
TP5: Unrealistic Plans of Action
ASSESS
CORE FEATURE
• “What does taking good
care of your diabetes
mean to you?”
• “What exactly should you
be doing?”
• Patient describes plan for
self-care that is
unachievable
• May be due to
– vagueness (“I should lose
weight.”)
– extreme demands (“I must eat
perfectly.”)
– pointlessness (“I’m not sure
why I’m supposed to do this.”)
Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999.
Hagar © King Features Syndicate. April 6, 1999.
The Assessment Step
TP6: Poor Social Support
ASSESS
CORE FEATURE
• “Ever feel that:
a. family/friends don’t
support your self-care
efforts?”
b. family/friends don't
appreciate the difficulty of
living with diabetes?”
c. you’re all alone with
diabetes?”
• Patient feels isolated and
unsupported regarding his
diabetes care
Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999.
The Assessment Step
TP7: Environmental Pressures
ASSESS
CORE FEATURE
• “What is it about your daily
life that makes diabetes
self-care difficult?”
a. Financial pressures?
b. Competing demands?
c. Life stresses?
d. Hard-to-change habits?
• When it comes to
successful diabetes selfcare over time, patient
feels that life is getting in
the way
Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999.
The Review Step
• Tackle one tipping point at a time
–
Even a single tipping point removed may be enough to
tip the mindset, producing huge change
• All tipping points are not created equal; Start at the
top of the tipping points list and work down
• Earlier tipping points are not more important than
later tipping points, but later tipping points may not
be resolvable until earlier tipping points are
addressed
• Discuss and review with patient
Polonsky WH. Unpublished data.
The Review Step
TIPPING POINT
LEVEL OF CONCERN
?
Low
Medium
High
1. Depression
2. “No big deal”
3. Inevitability
4. Treatment skepticism
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care
professional’s diagnosis.
Polonsky WH. Unpublished data.
Ralph’s Assessment Review
TIPPING POINT
1. Depression
LEVEL OF CONCERN
?
Low
Medium
High
X
2. “No big deal”
X
3. Inevitability
X
4. Treatment skepticism
X
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
X
X
X
Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care
professional’s diagnosis.
Polonsky WH. Unpublished case study.
Ralph’s Assessment Review
TIPPING POINT
1. Depression
LEVEL OF CONCERN
?
Low
Medium
High
X
2. “No big deal”
X
3. Inevitability
X
4. Treatment skepticism
X
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
X
X
X
Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care
professional’s diagnosis.
Polonsky WH. Unpublished case study.
Ralph’s Assessment Review
TIPPING POINT
1. Depression
LEVEL OF CONCERN
?
Low
X
Medium
High
I feel OK, so I figure–no
problem!
2. “No big deal”
X
3. Inevitability
X
4. Treatment skepticism
X
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
X
X
X
Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care
professional’s diagnosis.
Polonsky WH. Unpublished case study.
Ralph’s Assessment Review
TIPPING POINT
1. Depression
LEVEL OF CONCERN
?
Low
Medium
High
X
I understand that diabetes
will get me in the longXrun.
2. “No big deal”
3. Inevitability
X
4. Treatment skepticism
X
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
X
X
X
Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care
professional’s diagnosis.
Polonsky WH. Unpublished case study.
Ralph’s Assessment Review
TIPPING POINT
1. Depression
LEVEL OF CONCERN
?
Low
Medium
High
X
2. “No big deal”
3. Inevitability
X
Never checks BGs; sees no
X
point to it.
4. Treatment skepticism
X
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
X
X
X
Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care
professional’s diagnosis.
Polonsky WH. Unpublished case study.
Ralph’s Assessment Review
TIPPING POINT
1. Depression
LEVEL OF CONCERN
?
Low
Medium
High
X
2. “No big deal”
X
3. Inevitability
X
Good diabetes care means
X
eating birdseed.
4. Treatment skepticism
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
X
X
X
Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care
professional’s diagnosis.
Polonsky WH. Unpublished case study.
Ralph’s Assessment Review
TIPPING POINT
1. Depression
LEVEL OF CONCERN
?
Low
Medium
High
X
2. “No big deal”
X
3. Inevitability
X
4. Treatment skepticism
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
X
X
Has other things to worry about
that X
seem more pressing.
X
Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care
professional’s diagnosis.
Polonsky WH. Unpublished case study.
Ralph’s Assessment Review
TIPPING POINT
1. Depression
LEVEL OF CONCERN
?
Low
Medium
High
X
2. “No big deal”
X
3. Inevitability
X
4. Treatment skepticism
X
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
X
X
X
Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care
professional’s diagnosis.
Polonsky WH. Unpublished case study.
Helping Patients Succeed
with Diabetes Is an ART!
Assess
Review/prioritize treatment targets
Treat
Polonsky WH. Unpublished data.
Helping Patients Succeed
with Diabetes Is an ART!
Assess
Review/prioritize treatment targets
Treat
Polonsky WH. Unpublished data.
The Treatment Step:
What Doesn’t Work
• Urging more willpower
– “If you would just try harder”
• Threatening bad outcomes
– “You’ll go blind if you don’t do what I tell you
to do…”
• The gift of advice
– “Maybe if you joined a nice fitness center…”
Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999.
Cullum, L. The New Yorker. May 9, 2005.
The Treatment Step
TP1: Depression
TREAT
REMEMBER
• Refer for formal evaluation
and treatment
• Diabetes patients may
benefit less from current
treatments than other
patients2
• Chronic hyperglycemia,
complications, and
diabetes-related distress
may be linked to poorer
outcomes1,2
– Antidepressant
medications1
– Cognitive behavioral
therapy1
– Regular exercise1
– See http://impact-uw.org
– Promote sense of selfefficacy in diabetes care2
Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999. 2. Polonsky WH, Parkin CG. Practical Diabetology. 2001;Dec:20-29.
The Treatment Step
TP2: “No Big Deal”
TREAT
REMEMBER
• Use A1C results and other
metabolic feedback to make
diabetes more real, not just
frightening1
• “I already told him it was
too high” is not a sufficient
intervention1,2
– Lead with your leverage (“I
know you’re interested in
living a long, healthy life…”)
– Must be a discussion, not a
lecture1
1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999. 2. Hoover JW. Diabetes Educ. 1983;9:41-43.
Overcoming “No Big Deal”
HCP: What worries you about diabetes?
R:
Not much. I feel OK, so I figure—no
problem! I understand that diabetes
will get me in the long run, but that’s
the way life goes.
HCP: You’ve taken the time to be here, so
I know you are interested in living a
long, healthy life. At the same time,
you’re not sure that putting more
effort into diabetes care will be
worth the effort. True?
R:
Well, yeah.
Polonsky WH. Unpublished case study.
Overcoming “No Big Deal”
HCP: May I share some info with you?
R:
Sure.
HCP: First, the bad news. You may not be
doing as well as you think you are,
even if you feel OK. This could
mean bad things for your health—
and soon. Second, the good news.
With some effort, odds are pretty
good you could live a long, healthy
life with diabetes. What do you think
of that?
Polonsky WH. Unpublished case study.
Overcoming “No Big Deal”
R:
Yeah, but how do I do that? I don’t
want to eat just birdseed.
HCP: The first step is to find out about the
A1C test—that 3-month average
blood sugar test. Does that sound
familiar?
R:
I think my doc told me that my A1C
was 8.8%—whatever that means.
HCP: The A1C test is a useful tool for us.
And it is one good way to know how
well you are managing your
diabetes.
Polonsky WH. Unpublished case study.
Overcoming “No Big Deal”1
HCP: Even if you feel OK, if your A1C is
high, then bad things could be
happening. But if you get your A1C
into a safe range— typically that
means <7.0%2,3, you make it more
likely that you can live a long,
healthy life. Your last number,
8.8%, tells us you are right to
worry.
R:
OK, I see what you mean, but
what can I do?
1. Polonsky WH. Unpublished case study. 2.American Diabetes Association. Checking your blood glucose. Available at:
http://www.diabetes.org/type-1-diabetes/blood-glucose-checks.jsp. Accessed: March 19, 2007. 3. Canadian Diabetes
Association. About diabetes. Available at: http://www.diabetes.ca/section_about/index.asp. Accessed: March 27, 2007.
The Treatment Step
TP3: Inevitability
TREAT
REMEMBER
• Challenge inaccurate
beliefs
• Patients need a sense of
hope that complications
and an early death are not
inevitable
– Ask patients to estimate
their risk of complications
– Share the good news
Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999.
FACTS AND FICTIONS
Q. Diabetes is the leading cause of adult
blindness, amputation, and kidney failure.
True or false?
American Diabetes Association, Complications of Diabetes in the United States. Available at:
http://www.diabetes.org/diabetes-statistics/complications.jsp. Accessed March 21, 2007.
FACTS AND FICTIONS
Q. Diabetes is the leading cause of adult
blindness, amputation, and kidney failure.
True or false?
A. False. To a large extent, it is poorly controlled
diabetes that is the leading cause of adult
blindness, amputation and kidney failure.
American Diabetes Association, Complications of Diabetes in the United States. Available at:
http://www.diabetes.org/diabetes-statistics/complications.jsp. Accessed March 21, 2007.
FACTS AND FICTIONS
Q. Diabetes is the leading cause of adult
blindness, amputation, and kidney failure.
True or false?
A. False. To a large extent, it is poorly controlled
diabetes that is the leading cause of adult
blindness, amputation and kidney failure.
Well-controlled diabetes is the leading
cause of… nothing.
American Diabetes Association, Complications of Diabetes in the United States. Available at:
http://www.diabetes.org/diabetes-statistics/complications.jsp. Accessed March 21, 2007.
Joslin 50-Year Medalists
Courtesy of Joslin Diabetes Center.
Joslin 50-Year Medalists
1984–2005
180
160
140
120
100
80
60
40
20
19
84
19
87
19
90
19
93
19
96
19
99
20
02
20
05
0
Data on file. Joslin Diabetes Center.
Number of
Medal Winners
The Treatment Step
TP4: Treatment Skepticism
TREAT
REMEMBER
• Select appropriate goals,
de-select inappropriate ones
• Set-up home experiments;
Show patients their actions
make a difference
– Exercise affects BGs
– Insulin affects fatigue
– Overall efforts affect A1C
• It is exhilarating to actually
see that your actions can
positively influence your
health
• Experiments should be
suggested with some
caution. Take a holistic
approach.
Polonsky WH. Unpublished data.
Example: Sam’s Exercise Experiment
Day
Daily walk
(30 minutes)
For 1 week,
measure BG right
before and after
my walk
Pre-Exercise Post-Exercise BG Change
1
7.8 mmol/L
6.2 mmol/L
-1.6 mmol/L
2
10.3 mmol/L
5.7 mmol/L
-4.6 mmol/L
3
6.8 mmol/L
5.0 mmol/L
-1.8 mmol/L
4
9.8 mmol/L
8.5 mmol/L
-1.3 mmol/L
5
8.3 mmol/L
8.1 mmol/L
-0.2 mmol/L
6
11.4 mmol/L
7.4 mmol/L
-4 mmol/L
7
7.3 mmol/L
5.2 mmol/L
-2.1 mmol/L
Average BG change: -2.2 mmol/L
Polonsky WH. Unpublished case study.
Example: How Insulin Affects
Feelings of Fatigue for Maddy
3 Mos Prior
to Insulin
Extreme
Begin
Insulin
9
8
Fatigue Level
7
6
5
4
3
2
1
None
0
Polonsky WH. Unpublished case study.
3 Mos
With Insulin Treatment
6 Mos
9 Mos
12 Mos
Example:
Mary’s Diabetes Management Over 1 Year
Hemoglobin A1C Level (%)
9
8
7
6
Baseline
3 Months
6 Months
9 Months
12 months
With Diabetes Management
Polonsky WH. Unpublished case study.
The Treatment Step
TP5: Unrealistic Plans for Action
TREAT
REMEMBER
• Emphasize that patients don’t
have to do “everything”1
• Start with 1-2 actions only
• Patients may feel
overwhelmed by the
needed self-care tasks1
• Therefore, make use of the
“bang for your buck”
concept1
– Not attitudes, numbers, or
actions to stop2
– Concrete, achievable, and
personally meaningful1
• Set implementation steps
– “What exactly will you do
tomorrow morning?”1
1. Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999. 2. Rollnick s et al. BMJ. 2005;331:961-963.
Ralph: Action Planning
HCP: To reach our goal for your A1C
number, we can start anywhere you
want—small changes to how you eat,
new medications, exercise, or
perhaps something else. What do
you think?
R:
Walking doesn’t seem that tough. I
guess I could give it a try.
HCP: How do you think it might help you?
R:
I know it can give me more energy,
but if it can also really help me to live
a longer, healthy life and keep
diabetes from getting me, that
sounds pretty good.
Polonsky WH. Unpublished case study.
Ralph: Action Planning
HCP: If you’re ready to get started, what is
your first step?
R:
I think I’ll ask my wife if she’d like to
walk to the coffee shop with me
tomorrow morning. It’s about ½ mile
each way.
HCP: Sounds good. How often do you
want to do that this week?
R:
Well, if we don’t make coffee, we’ll
have to start going every day. That
shouldn’t be so tough…
Polonsky WH. Unpublished case study.
The Treatment Step
TP6: Poor Social Support
TREAT
REMEMBER
• Clarify the support needed,
urge patients to ask for it
• Suggest inviting family
members to attend/
participate at visits and
determine who is
responsible for tasks
• Encourage support group
attendance
• Diabetes self-care becomes
much easier when the
burden can be shared with
others
Polonsky WH. Diabetes Burnout: What to Do When You Can’t Take It Anymore. Alexandria, Virginia:American
Diabetes Association; 1999.
The Treatment Step
TP7: Environmental Pressures
TREAT
REMEMBER
• Acknowledge what cannot
be addressed1
• Encourage environmental
changes to support self-care
efforts
• Make good use of patient’s
expertise regarding their
own lives and ability to
problem solve1
• “Given the situation, what
might you do?”
– www.foodpsychology.org
– Encourage patient’s own
problem solving2
– Do not debate time issues
1. Polonsky WH. Unpublished data. 2. Skinner TC. European J Endocrinol. 2004;151:T13-17.
Seven Tipping Points
1. Depression
2. “No big deal”
3. Inevitability
4. Treatment skepticism
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
Polonsky WH. Unpublished data.
Tipping Points Profile Form
TIPPING POINT
LEVEL OF CONCERN
?
Low
Medium
High
1. Depression
2. “No big deal”
3. Inevitability
4. Treatment skepticism
5. Unrealistic plans for action
6. Poor social support
7. Environmental pressures
Convenience tool for recording the health care professional’s interpretations. Not intended to replace the health care
professional’s diagnosis.
Polonsky WH. Unpublished data.
Addressing the Diabetes
Tipping Points Is an ART!
Assess
Review (discuss & prioritize)
Treat
Polonsky WH. Unpublished data.
Addressing the Diabetes
Tipping Points Is an ART!
Assess
Review (discuss & prioritize)
Treat
GOAL: Promote a new mind-set, by tipping
those tipping points in a positive direction
Polonsky WH. Unpublished data.
Addressing the
Diabetes Tipping Points1
• Take hope!
• As patients become
more successful,
providers report
greater job
satisfaction2
• Overcoming patient
burnout can lead to
overcoming provider
burnout as well
1. Polonsky WH. Unpublished data. 2. Clark CM, et al. Diabetes Care. 2001;24:1079-1086.
Time for Practice
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