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Despite improvements in knowledge, therapies, and management strategies, prospects remain dismal for people at risk of diabetes, obesity, and cardiovascular disease, according to Davida F. Kruger, MSN, APRNBC, of Henry Ford Health System in Detroit, Mich.
"In the last 15 years, there's been an amazing selection of drugs developed to treat diabetes," Kruger says. "Despite numerous therapeutic options, glycemic control has not improved. We're doing worse instead of better."
Kruger made these remarks as a participant in a panel discussion on how to help patients overcome barriers to diabetes management regimens. The symposium, held at the American Association of Diabetes Educators annual meeting last summer, was sponsored by the Council for the Advancement of Diabetes Research and Education (CADRE), a nonprofit educational organization for health care professionals based in Brooklyn, N.Y.
One of the most important roles for health care providers is to paint an accurate and complete picture of diabetes, since the symptoms may be mild for many people and the consequences a distant possibility.
Patients and providers must "acknowledge that diabetes is a progressive disease," Kruger says. Letting patients know early that the disease will get worse and that insulin is likely in their future helps them prepare emotionally.
INDIVIDUAL TASTES
Panelist Melinda D. Maryniuk, RD, CDE, of Joslin Diabetes Center in Boston, began with an overview of medical nutrition therapy (MNT) and the 2006 nutrition recommendations from the American Diabetes Association (ADA).1 Adopting a more healthful diet is among the first strategies suggested by health providers for combating diabetes and its complications and is among the most difficult to achieve.
Maryniuk praised the ADA recommendations for doing a better job taking personal tastes and cultural differences into account. The goals for MNT, according to the recommendations, include nutritional adequacy that addresses "personal and cultural preferences and willingness to change." The document suggests providers "limit food choices only based on evidence and to maintain the pleasure of eating."
"It's nice to see that ADA recognizes that the enjoyment of food is important to people," Maryniuk says.
Overcoming obstacles to diabetes treatment begins with recognizing patients as individuals, with distinct cultural and ethnic backgrounds, whether considering dietary choices or their values and beliefs about behavioral change and medication.
Maryniuk suggested that symposium attendees use the "ESFT" model for cross-cultural communication and compliance:2
Explanation: Doctors, nurses, and diabetes educators need to explain diabetes to patients in terms and a context they understand. Rather than deliver a monologue about the illness, they can break down information into small units and listen carefully for what is being understood.
Social and environmental factors: The health care team should seek out and address cultural and ethnic values that affect adherence to therapy. Some groups of people believe that diabetes is divinely influenced. Other groups don't have a tradition of recreational exercise. No matter how important adherence is, patients can't be expected to accept treatment unless it fits within their personal values and beliefs.
Fears and concerns about medication: The provider should be aware of the patient's concerns about medications. Perhaps no aspect of diabetes care is more fraught with anxiety than the need to begin insulin. A fear of needles is common. Many people believe insulin causes blindness or will make them gain excessive weight. Insulin often represents a worsening condition and a loss of control.
For some patients, the need for insulin means they have failed therapy. "The patient hasn't failed, the therapy failed," Kruger says.
Therapeutic contracting and playback: Health care providers should discuss approaches to adherence to therapy. "Get [patients] to specify, as clearly as possible, exactly how they intend to implement the plans," Maryniuk says. "Really try to think out the steps."
Listening to patients is a critical skill frequently missing from clinical practice, she adds. Within the few minutes of an office visit, patients often are interrupted by practitioners before finishing a thought and are unable to completely express their concerns about health and medical treatment.
But patient participation in the decision fosters a greater concordance
between the goals of the patient and the provider, an increased sense of
confidence that the patient is in control and can make the changes, and
improved health outcomes, Maryniuk says. "It's our job to help bridge
the gap between knowledge and the patient's behavior." 
Footnotes
The U.S. Department of Health and Human Services Office of Minority Health sponsors online cultural competency continuing education programs for physicians (and soon for nurses) at www.thinkculturalhealth.org.
References
2. Betancourt JR, Carrillo JE, Green AR: Hypertension in multicultural and minority populations: Linking communication to compliance. Curr Hypertens Rep 1:482–488, 1999.[Medline]
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