The Impact of

Psychosocial Factors

on Diabetes

Amy Walters, PhD Psychologist

Director of Behavioral Health Services

St. Luke’s Humphreys Diabetes Center

Objectives

Clarify differences between type 1

and type 2 diabetes

Identify impact of psycho-social

factors on diabetes

Understand the importance of

support for behavior change goals

Learn practical strategies to enhance

health behavior and cope more

effectively with diabetes

What is Diabetes?

Disease of insulin production and use - body stops making

insulin, can’t make enough or cells become resistant to

insulin

Two Types:

Type 1 (juvenile diabetes) - autoimmune

Type 2 - metabolic

Insulin is required for cells to use glucose as fuel. Blood

glucose levels become too high and cause damage to

various systems

Unmanaged diabetes leads to serious complications including vascular disease (micro and macro), nerve

disease (neuropathy & amputation) kidney disease, eye

disease and death

Type 1 Diabetes Basics

Auto-immune disease (genetic predisposition with environmental trigger)

Typically diagnosed in childhood (adolescent and adult onset possible)

Insulin dependent from diagnosis – life threatening if omitted (diabetic ketoacidosis)

Insulin delivery through syringe, pen or pump

Requires rigorous daily medical regimen for lifetime

Glucose monitoring 4-6x per day for adjustments

Each meal carbohydrates must be calculated and insulin dosed accordingly

Factors impacting glucose levels: stress, hormones, changes in sleep, changes in routine, exercise

Disordered Eating and Type 1

Type 1 patients higher incidence of disordered eating

Emotional eating, binge eating, diabulimia

Diabulimia: deliberate omission or underuse of insulin to control weight

Insulin omission results in the purging of calories through urination

It is included in the purging behaviors listed for a diagnosis of bulimia & EDNOS

Prevalence: 14-36% T1D report insulin misuse to control weight

Mild eating disturbances compromise metabolic control – tend to be persistent

(Nuemark et al 2002; Jones 2000, Wark 2007, Elkins 2012, Goebel-Fabbri 2008)

Type 2 Diabetes Basics

Metabolic condition – strong genetic component;

obesity is risk factor

Cells become insulin resistant, pancreas works to over-

produce insulin, glucose builds up in bloodstream

Often asymptomatic until advanced stage; “silent

killer” resulting in nerve are cardiovascular damage

Treatment is a combination of oral medications and

injectables

Progression: monotherapy, dual therapy, triple

therapy

Metformin, GLP1, SGLT2, DPP4, TZD, etc and

eventually insulin

Weight management is a challenge – insulin

resistance cycle

Insulin Resistance

Increased

Insulin

Needs

Higher Levels of

Insulin

Increased Fat

Storage

Weight

Gain

Insulin Resistance/Weight

Cycle

Treatment: Daily Balancing

Act

Diet

MedicationExercise

Treatment

Dietary change

Limit carbohydrates; heart healthy diet

45g per meal for maintenance

30g per meal for weight loss

Physical activity

150 minutes per week cumulative

30 minutes x 5 days (50 minutes for weight loss)

Medication

Type 1: insulin – multiple daily injections with all food

intake

Type 2: orals, injectables (GLP1), insulin

How do psycho-social

factors impact

diabetes and chronic

disease?

Diabetes and Mental Health

Higher rates of diabetes among people with chronic mental illness

60% increased risk of diabetes with depression

2-4x higher risk among people with schizophrenia (impaired glucose tolerance and insulin resistance)

Co-occurring diabetes and mental illness may increase risk factors

and costs of treatment

Lower quality of life

Poorer treatment adherence

Poorer glycemic control

Increased rates of ER visits and hospitalizations

Some psychiatric medications may increase issues with weight and insulin resistance (Amitriptyline, mirtazapine, Clozapine, olanzapine, Lithium, divalproex,)

Balhara (2011); Journal of Endocrinology and Metabolism; Lancet (2015)

Areas of Impact

Chronic Disease

Physical

FamilyImpact

Financial Impact

Career Impact

Mental Impact

Emotional Impact

Social Impact

Health in Context

Culture

Community

Family

Person

Family Impact of Chronic

Disease

Relationship is bi-directional

Illness impacts family life

Family life impacts illness

Why do psychosocial issues

occur?

Take your medicine

Did you take insulin?

Test your blood sugar

What did you eat?

You need to eat more/less

You can’t have that!

Did you do your exercises?

Count your carbs

Your meds cost how much?

Psycho-social Impact

Patients report:

significant feelings of grief and loss which recur at various times in life

lifelong issues with social isolation, hopeless, helplessness, guilt, frustration, fear & ineffectiveness

feeling as if their chronic illness rules their lives and defines them as individuals

struggling to balance the demands of their illness with the demands of their lives

Depression and anxiety are common among people with chronic illness (30 to 50%)

Anderson, B and Brackett, J. (2005 ).

Adherence

Most chronic diseases have adherence rates below 50%

the majority of patients are non-adherent!

Poor adherence is the norm, not the exception

Self-report of adherence has poor accuracy across conditions

We over-report success and under-report issues

It’s not lying, it’s human nature

The proof is in the data

Pediatric adherence rates decline from childhood to adolescence

Bodenheimer et al (2002); Dunbar and Stevens (2007)

Understanding Adherence

Good adherence- carry out 80% of recommendations

Factors impact adherence

self-efficacy

initial adherence (interruption vs motivation)

multi-behaviors regimens

schedule changes or disruptions

Reasons they miss:

#1 forgetting

#2 varied dosing based upon symptoms (+/-)

#3 Schedule disruptions (travel, dining out, interruptions)

Dunbar et al 1996; Conn et al 1994

It’s All About Change

Successful adjustment to diagnosis and

management of chronic disease is all

about change

changes in behavior

changes in emotion

changes in thinking

Addressing Behavior

Change

It is the elephant in the room

Behavior change is required to meet all other

treatment goals (diet, exercise, medical

regimen, healthy lifestyle)

Healthy coping is critical to adjustment and

adherence

. . . BUT it is often an unsupported treatment

recommendation for patients with chronic illness

Result

“I know what to do, I just

can’t do it!”

I feel frustrated

I feel like a failure

I give up and . . . go for the chocolate,

eat what I like, lay on the couch and

watch TV, skip my meds . . .

Supporting Behavior

Change

Health information is necessary but seldom sufficient to affect behavior change

Approximately 90% of patients who successfully lose weight experience relapse

Non- adherence with medical regimen is the norm not the exception.

Mental health professionals have expertise in supporting behavior change and are valuable members of the treatment team

(Jordan-Marsh et al, 1984)

Helping Patients Live Well

with Diabetes

3 main factors

Maintaining motivation and building

resilience

Coping and stress management

Behavior change – its all about change

(behaviors, emotions & thinking patterns)

Motivation: Focus on Health

and Wellbeing

What does the person want?

What does the person need?

How can we provide appropriate support ?

How can we accommodate?

What are their goals and values

What behavioral changes

can they make to live according

to their values?

5 Keys to Success & Wellness

(BRASS)

Motivation and Resilience – perception is key

Balance – in life and care

Realistic – goals & expectations

Attitude – Loco – let go of perfection,

objective, caring, optimistic

Support – personal & professional

Stress – coping & management

Stress and Health

STRESS: demands of a situation exceed our perceived ability/resources to cope

Up to 75% of primary care visits are for physical problems related to stress

Physical systems impacted: cardiac, respiratory, immune, endocrine, muscular-skeletal, gastro-intestinal and reproductive

For patients with diabetes, stress can increase glucose levels and interfere with weight loss

High levels of persistent stress negatively impact our physical and emotional health

Strategies for Stress

Management

Human nature to avoid pain and do what’s easy and feels

good – unfortunately, often not healthy

Help patient identify healthy, “go to strategies” that fit lifestyle

“Name 3 things could do that support health goals”

Not fancy, just functional -- brainstorm ideas

- walk/movement - time with friends/family

- deep breathing/meditation - time in nature

- take a break - time with pets

- music & art - time management

- planned recreation - scheduled time for

relaxation

How do we support behavior change?

Understanding

Guidance

Strategy

Stages of Change

Contemplation

Planning

Action

Maintenance/

Relapse

Pre-contemplation

Prochaska and DiClemente (1982)

Typical Progression of Health

Behavior Change

Expected Change

Actual Change

Guiding Patient Behavior

Change

Motivational Interviewing (Miller and Rollnick)

Patient-centered (agenda and goals)

Guiding style -encourage self-based problem solve

dancing not wrestling, guiding not directing,

consulting not instructing

Active listening – empathetic, non-judgmental

Open ended questions to evoke patient’s interests,

desires and reactions

Explore concerns

Affirm and acknowledge positive effort and steps

Paradox of change

“ when people feel accepted for who they are and what they do (regardless of how unhealthy) it allows them the freedom to consider change, rather than needing to defend against it” (Miller

and Rollnick, 2010)

Studies suggest empathy is the best predictor of patient behavior change

Case Conceptualization

The 4 Qs of case conceptualization;

What is the concern

Why does it create a problem

What to do next (behavior plan)

How to do it (skill building)

Work to understand the nature of the behavior:

3 Ts – time, trajectory, triggers?

What need does it serve?

Is it helping them achieve their goals?

Sperry et al 2005 ; Robinson and Strosahl 2017

Work Love

Play Health

Problem

Work Love

Play Health

Problem

Functional Assessment to

Understand Behavior

Based in behavioral psychology

Identify basic elements which drive and maintain

the current behavioral pattern

Do current thoughts, feelings, behaviors and

environment support or sabotage desired goal?

What are triggers and sustaining elements?

What would happen if these elements

changed?

Brainstorm options for change at each level

using MI

4 Levels of Impact

ABCEs of Behavior

Behavior

Affect Cognition

Environment

FACTS of Behavior Change

Thoughts

FeelingsActions

Consequence

Behavior Intervention Strategy

Remember change is hard – our natural instinct is to repeat old behavior patterns

Explore and problem solve barriers in a non-judgmental way

Understand the nature of the behavior

Use functional analysis: Identify ABCE elements of the situation

Affect

Behavior

Cognition

Environment

Important Concepts for

Intervention

Motivation

Expectations & Beliefs

Skill buildingBehavior

Modification

Social Support

Example Intervention

Problem: Mr. V has AIC of 11 and needs help with lifestyle

change

Context:

60 yr male, lives with wife who is a great cook

High stress job, worried about retirement and $

Multiple health issues including hypertension, neuropathy,

insomnia; obesity

Use to enjoy outdoor rec but neuropathy gets in way, go out to

dinner for fun

3 Ts

Diabetes 15 years, neuropathy

Use to be active, but time, pain, stress get in way

A1C gradually increasing over time

Takes oral and GLP1, wants to avoid insulin

Functional Impact of Behavior

Uses food to cope with stress

Food is pleasure and connection to wife

Avoids activity due to pain

Pain, fatigue, stress, discouraged

Food is love – my wife will be insulted.

I can’t do what I enjoy –what’s the point

High stress, food rich (source of pleasure), limitation in activity

Intervention Ideas

Increase activity

Biggest bang for buck – glucose, stress, sleep, obesity, fatigue

Other forms physical activity – start small to ensure success

Recreation – adapted form, non-food based

Family meeting to discuss healthy food choices, other types of

entertainment, other ways show love

Changes to environment (remove high temptation foods,

make activity part of routine, prioritize health with time)

Work on sleep hygiene

Stress management training

3 things to do when stressed before turn to food

Meditation, deep breathing

CBT/ACT: beliefs around food, behavioral engagement,

value-based living, pain management

Key Concepts for

Intervention

Normalization – chronic disease isn’t for “sissys”

Person first – challenge they face, not their identity; D impact on what else matters in life

Communication-with patient, family, medical team

Adaptability – energy, cognition, behavior

Hope & Optimism - “Can Do” approach, never too late to make a positive impact

Skills training – targeted areas as needed

Values- tie intervention to core values

Strategies for Making Change

Lifestyle and behavior take years to develop and

also take time to change

Set realistic goals

Take small steps (shape behavior, SAG)

Choose one area of focus. Make a specific, concrete plan.

Record progress and check in.

Set up the environment for success

Acknowledge and reward successes, problem-solve

difficulties

Engage social supports

Identify and connect to values to enhance motivation

Plan for set-backs, practice acceptance, problem-solve

Result: Hope, inspiration,

behavior change, gratitude

Case Example

Patient

“Betty” - female in mid 60s, presented with poorly

controlled diabetes and depression. Not testing

glucose levels, inconsistent with insulin use.

Diabetes 15+ years and always struggled with

adherence (denial, ignoring, avoidance, resentment). A1C: 10.7;

Treatment regimen: Glyburide, Invokana,

metformin; Insulin (Lantus and NovoLog

Married, retired, chronic pain from neuropathy;

Inconsistent eating habits & several serving daily of Coke. Hypersomnia (up to 12 hours)

Case Ex continued Intervention: Initial Assessment and 4 follow-up sessions (over 4

month period) with BHP

Treatment goals: reduce depression, improve diabetes management

Intervention: Motivational Interviewing and CBT/FACT for depression (no changes to meds)

Results

Significant decrease in depressed symptoms

Daily testing of blood sugars daily and insulin as directed,

Reduced Coke to 1 serving daily, ate regular meals twice daily

Began engaging in activities she enjoyed. spending time with friends; followed regular sleep schedule

Objective Measures:

Pre: PHQ9: 22 GAD7: 17 PAID: 46 A1C: 10.7

Post: PHQ9: 3 GAD7: 2 PAID: NA A1C; 9.4

Take Home Points

Psycho-social factors have a significant impact

on diabetes (bio-psychosocial model)

Think about health in system context -

bidirectional impact

Change is a process (not linear) – meet patients

where they are - use MI to guide change

Change is hard and chronic illness is exhausting –

issues with adherence are the rule, not the

exception

Normalize – strive for typical developmental tasks

SAG principle – Small Achievable Goals

Small changes can have big effects – celebrate

the small victories

Contact Information

Amy Walters, PhD, Licensed Psychologist

Director of Behavioral Health, St. Luke’s HDC

331-1155 awalters@slhs.org

References

Anderson, B and Brackett, J. (2005 ). Diabetes in Children. In Snoek, F. and Skinner,

T.Psychology in Diabetes Care – 2nd Edition (pp 1-25). England: John Wiley & Sons.

Conn V, Taylor S, Miller R. (1994) Cognitive impairment and medication adherence. Journal of Gerontology Nursing ;20(7):41–47.

J.Dunbar and Stephens (2001 )Treatment adherence in chronic disease Journal of Clinical 54 (2001) S57–S60

Dunbar-Jacob J, Kwoh C, Rohay J, Burke L, Sereika S, Starz R.(1996) Adherence in chronic disease. Paper presented at the Fourth International Congress of Behavioral Medicine, Washington, DC.

Fennell (2003) Managing Chronic illness using the 4 phase treatment approach. Hoboken, NJ: Wiley

Havermans T, Colpaert K, Dupont LJ (2008). Quality of life in patients with cystic fibrosis: association with anxiety and depression; Journal of Cystic Fibrosis; 7(6) 581-584.

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