Diabetes is a life-long, 24-hour-a-day disease that requires self-management, time, and lots of patience. Most people with diabetes know where their numbers should be, but many struggle to follow recommended behaviors. Despite the availability of new medications and treatment devices, as well as the emphasis placed on diabetes treatment adherence over the last decade, National Health and Nutrition Examination Survey (NHANES) data show that 45 percent of patients with diabetes have not achieved A1Cs lower than 7% (an average of approximately 150-170 mg/dL).
In a recent study, “The Effect of a Structured Behavioral Intervention on Poorly Controlled Diabetes,” Dr. Katie Weinger, Assistant Professor of Psychology at Joslin, and her associates looked at adults with type 1 and type 2 diabetes with A1Cs over 8% to determine the most effective form of behavioral diabetes intervention for improving glycemic control.
Using three “arms”–education, cognitive behavior, and individualized therapies–the researchers found that a structured cognitive behavioral therapy (CBT) program was more effective in improving glycemic control in adults with long-duration diabetes. Control improved in all three groups, but the group with the highly structured therapy, in which the nurses and dietitian educators were trained to use scaffolding techniques and brief CBT strategies, showed the most improvement.
“We taught the participants that all information is valuable,” Weinger says. “Even a BG reading of 350 is good because it’s information. People need to think about it differently. The number is the problem, not them.” This technique, which is called “cognitive restructuring,” can help patients understand what’s happening inside their bodies. Weinger says that many patients have no understanding of body mechanics and that this can be a barrier to good care. “Our goal was to help them understand their bodies,” she adds.
In the highly structured group, participants kept food, exercise, and blood glucose logs and shared them in class. “We thought they might not be open to sharing their logs in class, but people loved talking about their results because it wasn’t a blaming thing, it was more like a puzzle. How did this happen and how can I fix it?…Students would come in to the groups and say, ‘I’ve been bad,’ and the CDE would say, ‘No, that’s not allowed.’ The important questions were: what happened and what can you do differently next time?” The social support may have also led to more engagement in participant’s self-care.
During the study, each participant worked on goal planning and identified a broad goal, such as to lose weight and/or lower A1C. “Then we chunked goals to make them more specific,” Weinger says. “Students used worksheets to figure out what they needed to do to reach their goals and then recorded the percentage of goals met. This created concrete steps in their minds so they would actually do it.”
The study showed that participants with type 2 diabetes were particularly responsive to the education, and many maintained that response over time. These findings may result from the fact that people with type 1 diabetes receive more basic educational and behavioral support at diagnosis and throughout the course of their diabetes than those with type 2 diabetes.
Living with chronic illness means that we are in this for the long haul. We don’t get to take a vacation from diabetes, and when things get tough, we shouldn’t have to do it alone. Many people feel too embarrassed and ashamed to ask their doctors for help, but this study shows that additional education and support for people with A1Cs higher than 8% will decrease glycemic levels. Weinger recommends using the ADA website to find a diabetes educator. She says, “The take-home message of this study is that if you are struggling, you don’t have to do it alone.”
Weinger, K. Beverly, E.A., Lee, Y., Sitnokov, L., Om P. Ganda, O.P, A. Enrique Caballero, A. E., The Effect of a Structured Behavioral Intervention on Poorly Controlled Diabetes, Arch Intern Med. Published online October 10, 2011. doi:10.1001/archinternmed.2011.502