Understanding Diabetes And The Role Of Psychology In Its Prevention And Treatment

2. UNDERSTANDING DIABETES AND THE ROLE OF
PSYCHOLOGY IN ITS PREVENTION AND TREATMENT
0 What is diabetes?
0 Types of diabetes
0 Prevalence of diabetes
0 Etiological factors of Type 1 and Type 2 Diabetes
0 Mental health Comorbidities ( depression, anxiety &
eating disorders)
0 Non pharmacological interventions for the prevention of
Type 2 diabetes mellitus
0 Behavioral, Emotional and Psychological interventions in
Diabetes
0 Interventions to alleviate diabetes related distress
0 The role of psychologist in Diabetes care

3. Diabetes is characterized by a disruption in metabolic processing system
that results in high levels of glucose circulating in the blood, caused by
impairment in the body’s ability to produce or efficiently use insulin, or
impairment in both systems
Glucose, largely supplied by our food intake, is the main source of energy
for the cells in the body. In normal metabolic processing, the pancreas
detects glucose in the blood- stream and releases the correct amount of
insulin, which is a hormone that is essential in facilitating the transport
of the glucose from the blood stream into cells.

4. Types of Diabetes
0 Type 1Diabetes
0 a serious chronic
disease
0 T1D is an autoimmune
disease characterized by
a failure to produce
insulin
0 previously referred to as
juvenile diabetes and
insulin-dependent
diabetes mellitus.
0 Type 2 Diabetes
0 Pre diabetes, Being
overweight or obese is a
significant and
potentially modifiable
risk factor for pre
diabetes and the
development of T2D

7. Prevalence of diabetes
0 Diabetes affects an estimated 29.1 million people, or 9.3%
of the United States population.
0 86 million Americans have pre diabetes, which puts them
at increased risk for developing diabetes
0 Individuals with diabetes have a 50% higher risk of early
death and double the medical costs compared to those
without diabetes
0 Studies suggest that by the year 2030, 439 million (7.7%)
of the global adult population will have diabetes (Shaw,
Sicree, & Zimmet, 2010).

8. Ratio of Diabetes
0 Diabetes prevalence has been rising more rapidly in
middle- and low-income countries.
0 Diabetes is a major cause of blindness, kidney failure,
heart attacks, stroke and lower limb amputation.
0 Almost half of all deaths attributable to high blood
glucose occur before the age of 70 years.
0 WHO estimates that diabetes was the seventh leading
cause of death in 2016.

9. Prevalence of diabetes
in Pakistan
0 The Diabetes Prevalence Survey of Pakistan has revealed
staggering 16.98 % prevalence of diabetes, as 35.3 million
people among the adult population are found diabetic in
Pakistan.
0 The latest data of 2017 disproves the old figures of 6.56
percent of diabetes prevalence affecting just 7.6 million
people in Pakistan
0 at least 17.85% female population is affected and 16.22%
male populations is suffering from the disease
0 based on census results of 2017 for adult population,
approximately 21.9 million were suffering from diabetes
mellitus

10. Etiological factors of Type 1 and
Type 2 Diabetes
Type 1 Diabetes Type 2 Diabetes
0 Genetic
0 Environmental
factors
0 dietary factors
0 vitamin D
deficiency
0 The main
etiological risk
factors ;
0 age, obesity, family
history, and
physical inactivity
0 Dietary risk factors

11. Mental health Comorbidities
( depression, anxiety & eating disorders)
0 Psychologists have an important role to play in
identifying and effectively treating the mental health
and psychosocial challenges that many people with
diabetes experience.
0 For example, individuals with diabetes are at
increased risk for depression and diabetes distress,
and both are linked to decrements in self-
management, quality of life, and diabetes-related
outcomes (Holt et al., 2014; Fisher, Gonzalez, &
Polonsky, 2014).

12. cont...
0 Combined treatment of depression and diabetes self-
management results in improvement in both
depression and diabetes outcomes whereas treatment
of the depression alone alleviates depression but does
not usually result in much improvement in diabetes
outcomes (Van Cornelis et al., 2010).
0 individuals with serious mental illness such as
schizophrenia and bipolar disorder are at increased
risk for obesity and diabetes, partially due to the
medications used to treat those conditions
(Fiedorowicz, Palagummi, Forman-Hoffman, Miller, &
Haynes, 2008).

13. Patterns of co-occurrence of diabetes and
psychiatric disorders
0 Comorbidity of diabetes and psychiatric disorders can
present in different patterns
0 Co-occurring psychiatric disorders in patients with
diabetes are associated with impaired quality of life
(Goldney et al., 2004) increased cost of care (Hutter&
Baumeister, 2010), Poor treatment adherence
(Gonzalez, Safren& Cagliero, 2007), poor glycemia
control (evidenced by elevated HbA1c levels),higher
frequency of hospitalization, and higher rate of
absenteeism (Stewart& Ismail, 2007).

14. Diagnosing psychiatric disorders among
patients with diabetes
0 One of the biggest challenges in management of
psychiatric disorders among those suffering from
diabetes is the low rate of detection
0 Brief instruments; such as patient health questionnaire
(PHQ) and symptom checklist-90 (SCL-90)
0 Hospital Anxiety and Depression Scale (HADS)
0 Psychiatric disorders could be diagnosed
0 ICD-10
0 DSM- V

15. The Mental Health Comorbidities of
Diabetes
0 rates of depression among individuals with type 1 or type 2
diabetes across the life span are 2 times greater than in the
general population
0 Young adults with type 1 diabetes are especially at risk for poor
physical and mental health outcomes and premature mortality
(Gonzalez & Peters, 2013).
0 diabetes distress is now recognized as an entity separate from
major depressive disorder.
0 Increased anxiety in persons with type 1 or type 2 diabetes can
occur when diabetes is first diagnosed and when diabetes
complications first occur( Anderson & Mansfield, 2007).
0 Women with type 1 diabetes have a increased risk for
developing an eating disorder and a 1.9 increased risk for
developing sub threshold eating disorders than women without
diabetes (Goebel-Fabbri, 2013).

16. Non pharmacological interventions for
the prevention of Type 2 diabetes
mellitus
 Elements of T2DM prevention include;
 Identification of individuals at risk
 Obesity management
 Healthy Eating
 Increasing physical activity

17. Cont..
0 Identification of individuals at risk
Risk identification strategies need to be adapted for each nation
using tools that have been evaluated in the population and reflect
its risk profile, and diagnostic tests that take into account access
and availability of local resources.
biochemical testing remains important in those with high risk
scores
0 Obesity management
Obesity is one of the most important risk factors for t2DM
Weight reduction seems to be beneficial, at least in the short term,
regardless of the mechanism of weight loss (that is, diet or physical
activity or both).
Interestingly, beneficial changes in glucose metabolism are
detectable soon after the initiation of an energy-restricted diet, even
before any significant reduction in body fat has occurred

18. Cont..
0 Healthy Eating
• diabetes prevention studies have shown the benefits of lifestyle
changes by increasing physical activity even without notable
weight reduction an important contributor is physical activity
• studies have suggested that several dietary factors are
associated with an increased (for example, intake of refined
grains, red and processed meat, sugar-sweetened beverages,
heavy alcohol consumption) or decreased diabetes risk (for
example, intake of whole-grain cereal, vegetables, legumes,
nuts, dairy, coffee, moderate alcohol consumption),
independently of body weight change (Kaline & Bornstein,
2007).
0 Increasing physical activity
 WHO currently ranks physical inactivity as the fourth leading
cause of mortality worldwide, ahead of both obesity and dietary
factors .
 The importance of the attributable risk associated with physical
inactivity is, in part, driven by the high prevalence of inactive
behavior within the population

19. Psychosocial intervention for patients
with type 2 diabetes mellitus and
comorbid depression:
0 Researches determined that the psychosocial
intervention was effective in improving depressive
and anxiety symptoms of T2DM patients with
depression.
0 Moreover, the addition of psychosocial intervention
during diabetes management could improve glycemic
control in those patients.

20. MODELS OF BEHAVIOR AND
BEHAVIOR CHANGE
0 Based on a synthesis of existing theories/models that four categories of factors
should be the target of behavior change interventions in diabetes: motivators,
inhibitors/facilitators, intentions, and triggers
0 Motivators are factors that predispose one to action—perceived need,
perceived benefits of treatment, outcome expectancies, rewards/ incentives,
and cues to action.
0 inhibitors/ facilitators are barriers to or resources for action; barriers can be
the absence of prerequisites to action (i.e., resources such as funds, skills, or
support) as well as the presence of an obstacle.
0 Intentions are the proximal cause of behavior change; individuals must have an
intention to change, be ready to change in the present, and have a particular
goal toward which they can work.
0 Triggers are the events that shift a person from being predisposed to action into
an action state.

21. BEHAVIOR CHANGE INTERVENTIONS
0 behavior change interventions designed to improve
health outcomes.
0 The more common interventions include;
goal setting, motivational interviewing, problem-
solving and coping skills training, environmental
change (barrier reduction), behavioral contracting, self-
monitoring, use of incentives/rewards, and social
support

22. Implication of Behavioral
Interventions:
This sequence consists of five major steps (the 5C intervention):
1. Constructing a problem definition
 Start with the patient’s problem
 Specify the problem
2. Collaborative goal setting
3. Collaborative problem solving
 Identify barriers to goal attainment
( cognitions, emotions, social networks, physical environment)
 Formulate strategies to achieve the goal
4. Contracting for change
Track outcomes
Rewarding success
5. Continuing support
Important plan for relapse prevention

23. EMOTIONAL SUPPORT
INTERVENTIONS
0 use of coping strategies in behavioral/ psychosocial
interventions revealed that problem-focused interventions
are more common than emotion-focused interventions
(Hardeman & Johnsoton, 2000).
0 Research suggests that most clinicians know that emotional
distress is common among their patients with diabetes and
that this distress has a harmful effect on diabetes outcomes,
but fewer clinicians feel able to treat this distress (Peyot ,
Rubin, Lauritizen, & Snoel, 2005).

24. cont..
0 The health consequences of emotional problems are clear-cut; they
are associated with poorer self-care behavior, poorer metabolic
outcomes, morbidity, mortality, functional limitations, and poorer
quality of life (Ciechanowski & Wanger, 2004; Rosenthal et al.,
2001).
0 All clinicians should be able to (Rubin & Peyrot 2001):
1. Identify patients who are suffering from diabetes-related distress.
● Are you having trouble accepting your diabetes?
● Do you get the support you need from your family for diabetes
management?
2.Apply effective treatments to reduce diabetes-related distress.
3. Identify patients who are suffering from psychiatric disorders.
4. Refer patients for specialized mental health care when appropriate.

25. Primary Interventions to alleviate
diabetes related distress
0 Helping patients recognize the power of “self-talk” (what
they say to themselves) can enhance emotion-focused
coping and is the foundation of the preferred approach for
dealing with emotional distress, termed cognitive
behavioral therapy (CBT).
0 CBT-based interventions can be integrated into the
behavior change support process
0 Enhancing diabetes-specific self-efficacy (a sense that
is associated with lower depression )
0 Encouraging realistic expectations (emotion-focused
coping skill)
0 Enhancing motivation
0 Identifying psychiatric disorders

26. Cont..
0 Treating depression
Depression in patients with diabetes can be treated
effectively with medication or counseling (Ciechanowski &
Wanger, 2004; Rosenthal et al.,2001; Lustman ey al., 1998;
Lustam & Freeland, 2000).
In depressed patients who are not in good control of their
diabetes, counseling (especially CBT) is the preferred
treatment (either alone or in conjunction with medication).
Medication may relieve the symptoms of depression, but
this may not improve diabetes outcomes such as glycemic
control (William & Katon 2004).

27. Multiplier Effects
0 The behavior change and emotional coping support
processes are collaborative processes in which the clinician
stimulate and guides the patient’s input.
0 However, similar processes have been adapted to a coping
skills training model in which patients are taught how to
implement a behavior change or emotion- focused coping
process on their own, without requiring health care
resources (Rubin, 1993). Patients can then implement that
process whenever they need it.
0 benefits of these programs include improved emotional well-
being, self-care behavior, and glycemic control

28. Role of psychologist in Diabetes
care
0 The scope of diabetes and the multiple factors that go into successful
management of the disease make it clear that a bio psychosocial
approach to diabetes management is vital for achieving improved
individual and population health outcomes.
0 Psychologists are uniquely composed to address these areas
including;
0 self-management behaviors (Lifestyle Changes )
0 Adherence
Adherence to clinical practice guidelines and self- management
behaviors is another cornerstone of diabetes management.
Some of the common reasons for poor adherence are related to
complexity of the schedule, patient misunderstandings of the
treatment, attitudes or beliefs about medications, forgetfulness, and
difficulty understanding the long-term risk (Stirratt et al., 2015).

29. Cont..
0 For example, many people at risk are not screened for diabetes, and if they are
found to have prediabetes they often receive little evidenced-based follow-up
or referral care (Karve & Hayward, 2010).
0 Technology
the application of technology to diabetes prevention and treatment.
1. the advances in technologies that are directly related to monitoring blood
glucose or delivering insulin such as blood glucose monitors, insulin pumps
Psychologists can support in identifying the human and psychosocial factors that
impair or improve an individual’s ability to maximize the use of these tools
2. potential for research and practice includes information and communication
technologies such as the Internet
A recent systematic review found that Internet-delivered diabetes education and
support resulted in improved glycemic control as compared to usual care
(Pereira, Phillips, Johnson, & Vorderstrasse, 2015)
These technologies can potentially provide flexibility in the pace and timing of
the intervention delivery and remove barriers to face-to-face treatment such as
travel and scheduling.

31. Conclusion
0 The strategies described here are consistent with a
number of behavioral theories and models. They are
practical and can be implemented within the context
of standard diabetes care visits.
0 They can work effectively with diabetes patients, as
well as patient’s without diabetes that are struggling
with living a healthy lifestyle

32. 0 Diabetes is a common, chronic, and costly condition
that currently affects millions of individuals in the
United States and worldwide with even greater
numbers at high risk for developing the disease.
0 Although genetic, biological, and environmental factors
play a role in the risk for and progression of diabetes.
0 behavioral, cognitive, and psychosocial management
are crucial to prevention and improved health
outcomes.
0 In many ways, diabetes is a model disease for the
importance of a bio psychosocial approach to health
care