Vol. 21 Issue 9
Caring for this common condition is an occupation in itself
Approximately 18.2 million people have diabetes, costing the medical field approximately $132 billion in 2002, according to the American Diabetes Association (Hogan, Dall & Nikolov, 2003).
Statistics can convey the impact of a disease on a population. On a personal level, however, numbers and dollars cannot paint the picture of how type 2 diabetes truly affects one's daily life. Those with this incurable condition often must modify their lifestyle, develop new habits and adapt or abandon familiar routines.
Within the complicated world of the medical model, many allied health providers consider diabetes a secondary disease. Yet diabetes is often the cause of the primary issues that occupational therapists treat, including low vision, cardiovascular complications, stroke, neuropathy, skin breakdown and kidney disease. But even without these complications, managing diabetes is a key occupation for individuals with this condition.
When working with clients with diabetes, occupational therapists must understand how the condition forces clients to alter their daily lives. If the therapist does not address diabetes management as part of the activities of daily living of an individual with diabetes, then crucial daily management of the disease could lead to further devastating complications.
Occupational therapists can make significant contributions to their clients with diabetes by helping them incorporate diabetes management into the daily routine. Therapists can easily integrate simple suggestions and methods to monitor diabetic complications into treatment sessions.
In the case of diabetes, if it is not appropriately managed, complications develop more quickly. Through everyday treatment sessions with clients with diabetes, occupational therapists can act as advocates for the prevention of complications caused by diabetes that impede function.
Diet and Exercise
After a diagnosis of diabetes, an individual must make many lifestyle modifications to manage the diabetes. For ideal diabetes control, they must incorporate exercise and appropriate diabetic nutrition into their lives. Diet and exercise are the main regimen for newly diagnosed individuals, along with close monitoring to see if medication management is necessary (University of Tennessee, 2000). Even small amounts of weight loss due to nutrition management and increased activity can improve glycemic control, slowing down the evolution of diabetic complications (Klein, et. al., 2004).
Despite the proven value of diet and exercise in diabetic management, many clients do not incorporate these elements into their lives. As occupational therapists, it is essential to emphasize exercise and appropriate diet. Beyond standard activity and nutrition changes, however, OTs can help clients integrate these changes through the exploration of meaningful tasks that meet the goals set forth for diabetes management.
Although there are many fitness programs available, encourage meaningful activity engagement. Some individuals respond to aerobic exercise programs while others find them meaningless. Getting to know the client can help establish a routine of activity that is both meaningful and meets the diabetes regimen. If disability alters participation in exercise and meal preparation, for example, help the client explore other avenues for meaningful activity.
Blood Glucose Monitoring
Besides medication management, exercise and a diet plan, blood glucose monitoring will become a necessary routine for individuals with diabetes. Blood glucose monitoring is intrusive to one's lifestyle if an individual has not established it as a habit. Diabetics need to follow a schedule to ensure appropriate blood glucose readings around meals and bedtime.
The key to managing diabetes is to maintain a blood glucose level within the normal range of 90-130 mg/dl prior to a meal and less than 180 mg/dl two hours after a meal (American Diabetes Association, 2005). Initially, diabetics will need to check their blood glucose more frequently as they get their blood sugar to an optimal level. Individuals who maintain control of their blood glucose can check themselves less often and monitor more closely if a problem arises.
Occupational therapists need to explore the individual meaning associated with occupational engagement in blood glucose monitoring. Don't just assume non-compliance; instead, investigate the individual's daily routine to explore what barriers exist to appropriate blood glucose monitoring. Barriers could simply be a busy schedule or the inability to pay for expensive test strips.
Understanding these barriers helps adjust a treatment plan to meet these needs. OTs should include daily blood glucose monitoring in the treatment plan of any individual with diabetes as a part of activities of daily living across practice settings.
Diabetics, especially those with poor circulation and neuropathy, need to be autonomous in checking skin integrity to ensure that skin breakdown does not occur. Skin breakdown in clients with diabetes can lead to amputation or systemic infection.
Proper footwear is extremely important. Shoes should be neither too tight nor too loose. Shoes that are too tight can inhibit blood flow and put pressure on the skin, causing skin breakdown. Loose shoes can cause shearing on the skin which can result in wounds; loose shoes may also lack the support and stability for safe ambulation.
Occupational therapists need to be aware of the consequences of improper footwear for clients with diabetes. Therapists who notice a problem with a client's footwear can encourage the client to see a podiatrist or purchase more appropriate diabetic footwear. Replacing cotton or leather shoelaces with elastic shoelaces may allow enough room in the shoes if the foot enlarges due to swelling.
As a part of daily living skills, therapists should encourage clients to check their feet when they don and doff shoes. Recommend a long handled mirror if feet are too difficult to monitor. Therapists also need to educate clients that proper cleaning of the feet is an important part of a diabetic's daily routine. Observing the process of bathing of a client with diabetes can help guide a therapist in providing appropriate instructions regarding foot care. Occupational therapists can play a major role in wound prevention education. Don't forget, however, to discuss with the client a plan of action if a wound does develop. Encourage immediate follow up with a physician.
Mental Health and Culture
The mental health of an individual with diabetes is vital to successful diabetes management; depression can inhibit participation in necessary behaviors to manage the condition. In a recent study, researchers found that the difficulties of managing medication, exercise and diet could easily lead to depression in clients with diabetes (Lin, et. al., 2004).
Occupational therapists can explore meaningful activities that address the issues of medication management, exercise and diet. At times, the answer is as simple as a pillbox or nutritional guidelines that are culturally relevant. If depression is persistent and disruptive to daily life, refer the client to a psychologist. However, occupational therapists can continue to assist the client by exploring avenues for engagement in diabetes management that provide more meaning and purpose to the individual. Creating a meaningful diabetes regimen that the client feels is feasible can help dissolve situational depression related to diabetes management.
Occupational therapists also must explore and understand the influence that culture can play in diabetes management. For example, some Middle Eastern cultures believe that that diabetic complications come directly from God (Khoury, 2001). In this case, individuals may feel it is meaningless to participate in strict diabetic regimen when God is in control.
Additionally, minority groups have higher levels of diabetes and experience disparity in treatment of the disease. Occupational therapists need to recognize that cultural influences impact diabetes management and explore culturally relevant ways to manage diabetes.
Occupational therapists have insight into the daily lives of individuals and the value of meaningful tasks in one's life. Individuals with diabetes will need to make modifications in their daily life which can be difficult to start and maintain. Occupational therapists, in any practice setting, need to explore the daily routines of individuals with diabetes to ensure that diabetes management becomes a core element of treatment in activities of daily living.
References available at www.advanceweb.com/OT or upon request.
Joy D. Voltz, OTR/L, OTD, works for Creighton University in the Office of Interprofessional Scholarship, Service and Education and does private practice in health ministry in the community. You are encouraged to reach her at firstname.lastname@example.org.
Private Health Insurance Poses Many Barriers for People with Diabetes
Individuals with diabetes encounter barriers to proper management in all components of the private health insurance system, according to a recent study by the American Diabetes Association in conjunction with the Georgetown University Health Policy Institute.
Common problems highlighted by the report document serious flaws in the private and publicly financed health insurance system in America. These flaws include health insurance policies that did not cover basic diabetes needs; high risk pools with pre-existing condition exclusions that deterred people from enrolling; health insurance premium surcharges for diabetes that drove premiums above what individuals and small businesses could afford; medical underwriting practices that designated diabetes as "uninsurable;" Medicaid eligibility limits that left many low income people unable to access this safety net; cumbersome insurance processes that fail to help people navigate complex rules and deadlines; and application procedures that drove many to give up on seeking coverage altogether.
The study, "Falling Through the Cracks, Stories of How Health Insurance can Fail People with Diabetes," was funded by the Commonwealth Fund, Robert Wood Johnson Foundation and W.K. Kellogg Foundation. To obtain a copy of the study, visit www.diabetes.org/insurancereport or www.healthinsuranceinfo.net.