Address Psychosocial Status to Assure Best Outcomes in Diabetes Care, Says ADA

In promoting a patient-centered approach to diabetes care, endocrinologists are urged to assess mental state of patients as a means to better outcomes.

Evidence-based standards for patient-centered, psychosocial care for both pediatric and adult patients with diabetes has been released by the American Diabetes Association (ADA) in a position statement appearing in Diabetes Care,1 aiming to produce better medical outcomes with improved psychological well-being. The standards focus on the commonly occurring psychological comorbidities arising in patients with diabetes, including: depression, anxiety, disordered eating and diabetes distress.

“Successful management of diabetes extends beyond blood sugar and hemoglobin A1c numbers. The behavioral demands of a self-management regimen are burdensome but necessary for success in treatment outcomes,” co-authors Deborah Young-Hyman, PhD, in the Office of Behavioral and Social Science Research at the National Institutes of Health in Bethesda, MD, and Mary de Groot, PhD, an associate professor of medicine at Indiana School of Medicine in Indianapolis, told EndocrineWeb.

"Recognition and simultaneous treatment of the behavioral and emotional needs of patients with diabetes will improve patient engagement in self-care, health outcomes and well-being,” said Dr. Young-Hyman and Dr. De Groot.

The recommendations highlight the value of incorporating systematic evaluation of psychosocial issues of patients with diabetes that may negatively impact self-care and identifies a variety of tools for screening patients at all ages. Also, alliances between primary care providers and behavioral/mental health providers who are familiar with diabetes management are encouraged to aid referrals and collaborative care.

Focus on Physical Activity for Mental Health  

Among the recommendations for addressing psychological comorbidities, the statement notes that routine physical activity can improve the mental health of patients with diabetes, and physical activity was the subject of another ADA position statement2 released in November.

“Being active plays a significant role in [improving] mental and physical well-being,” the lead author of the guidelines, Sheri R. Colberg-Ochs, PhD, a professor emerita of exercise science at Old Dominion University in Norfolk, Virginia, told EndocrineWeb.

“Exercise is an excellent way to lower mild to moderate levels of depression and anxiety and improve mood. It's such a critical part of the management of psychosocial issues, but behavior must be modified and barriers to participation overcome to make it a lasting habit,” added Dr. Colberg-Ochs.

Drs. Young-Hyman and de Groot agree that exercise is important, telling EndocrineWeb, “In addition to diabetes education, medical nutrition therapy, and mental health services, routine physical activity has been shown to improve patient's well-being. With all self-managed components of care, lifestyle behaviors must be agreed upon by the patient and significant others with whom they share their life and disease management. Thus, the person with diabetes is at the center of the care team.”

On the subject of eating behaviors, Dr. Young-Hyman and Dr. de Groot told EndocrineWeb that it is important for clinicians to focus on the diabetes-related causes of disordered eating, such as disruption of appetite and satiety cues, and hypoglycemia associated with exogenous insulin use, rather than eating disorders such as binge eating that is a behavioral concern distinct from diabetes. However, they continued that there is a “need for screening and evaluation of eating patterns, including commonly reported binging and insulin/medication omission for weight loss purposes.”

Best Opportunities for Enhancing Practice

Angela Fitch, MD, an associate professor of medicine at the University of Cincinnati in Cincinnati, Ohio, and a member of the EndocrineWeb editorial board who was not involved in developing the guidelines highlighted the top 5 changes that endocrinologists and primary care physicians can make in response to these psychosocial guidelines in order to improve their patients care:

  1. Screen patients and recognize diabetes distress symptoms. We have intuitively have known for years that diabetes itself has a psychological toll, yet we have not formalized screening and diagnosis around the goal of treatment to improve diabetes outcomes.
  2. Screen and diagnose eating disorders. Binge eating disorder is the most common eating disorder in the population, and without effective treatment, it is very hard to control diabetes when patients also have binge eating disorder.
  3. Recognize that patients who are not in control of their diabetes can utilize mental health professionals to help motivate them and create change. Motivational interviewing was the start to this, but it would be great to be able to leverage even more help from psychologists.
  4. Talk more openly about how mood can impact the outcome of chronic diseases such as diabetes.
  5. Understand the association of diabetes with dementia and monitor patients more closely for these changes.

Acknowledged Barriers to Implementation

In addition to urging changes in diabetes care, the ADA position statement also highlights the significant challenges to achieving the new standard of care, particularly a lack of mental health professionals who are familiar with diabetes management as well as structural barriers to collaborative care.

To address the first challenge, the ADA is joining with the American Psychological Association to prepare more mental health professionals to work with patients with diabetes. Fortunately, recent changes in the healthcare laws are making team care models more viable.

Highlighting the importance of care alliances, Dr. Young-Hyman and Dr. de Groot told EndocrineWeb, “It is not expected that any single provider can address medical, behavioral and psychological components of care. Thus it is imperative to form a care team however that is best accomplished in the context of the practitioner’s care setting.”

“Integrated care has been shown to have the greatest likelihood of improving health and psychological outcomes,” they said.

Continue Reading:
A Review of Treating Depression in Diabetes: Emerging Findings
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