Tearing my hair out over noncompliant DM2 patients!

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I am a new NP and don't know how to "wake up" noncompliant DM2 patients. Unfortunately, a significant number of these patients are in denial and refuse to make any lifestyle changes and some even refuse to take their medications and/or insulin as prescribed. I experienced this during clinical rotations and now am seeing this as a practicing NP. Has anyone had success with this situation and can share some tips?

Examples:

1. Patient who is DM2 for 20 years comes in and says he/she eats whatever they want, whenever they want. A1C1 > 12 !!! Shrugs at everything I say. Their biggest concern is hypoglycemia, although they are only on a low dose of basal insulin and can't specify their last episode of hypoglycemia. Called clinic today to say they no longer want to use insulin and only want to be on one oral medication (I refused and said patient must make appointment to see me). This patient also has refused to get any annual lab work for past 3 years or other exams such as eye, foot, etc.

2. Another long-term DM2 patient with A1C1 > 10 and random BG > 180. This patient's biggest concern is hypoglycemia and is convinced that a BG of 150 is perfect and that an A1C1 of 10+ is just fine; became agitated when I explained this is not the case. Patient admitted close relative had just had a foot amputation due to DM2, but was indifferent. Patient had lost weight due to other health issue, is still slightly overweight, and was concerned about being too thin and frail. Patient stated they don't know what they eat and don't care. I had a hard time convincing this patient to obtain routine lab work, but they did it. I had a panic attack when I received CMP: eGFR 65, Creatinine > 3.0. I was amazed this patient was still alive! Patient was sent to ER, of course.

Any suggestions would be welcome!

I'm fairly certain that is rather simplistic for a complex thing. We are finding more and more it isn't just calories in and out.

No we actually arent. Considering I just finished nutrition, microbiology and physiology courses and they are all teaching the same thing.

Calories and cellular respiration.

Yes there are some glandular conditions.

Yes former obese pts will retain adipose tissue at higher levels than those who were never obese.

Yes, there are some physiological reasons for obesity and type 2 diabetes. But 33%+ of the population didnt all suddenly develop physiological conditions as contributors.

What did change? Eating habits.

You can see the process being replicated in Africa presently. Western fast food restaurants have been introduced to the African continent and already we are seeing a corresponding spike in obesity there.

They are called lifestyle diseases for a reason. Trying to deny that or pitter patter around it wont change the basic scientific principles of what's at play.

Pointing out that "calories in and out works" when she clearly articulated it isn't working for her is absolutely disappointing and shows some of us aren't listening to the deeper issues at play our willing to go much deeper than their own personal preconceptions.

It does work. Stop reading fad internet diets and read peer reviewed nutritional longitudinal studies.

Food addicts are like any other addict, heroin or otherwise, they will lie, they will sneak food, and they will blame anyone and everything for why they have fallen off the wagon but themselves.

So yeah when someone claims it magically and suddenly all stopped working, that the very biochemical process of their body rewrote itself, in direct confrontation to all the available research out there, I call bullox.

I have patients who tell me they "try" to eat healthy and in the same breath tell me their go to snack is a chocolate covered peanut something

Bingo. They are either ignorant of nutrition or simply lying to themselves and you.

You just said it yourself.

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Specializes in Nursing Professional Development.

So my very sincere question is this:

When a patient such as yourself comes in to my office, what can I do to help that hasn't already been done for you?

Thank you for your sincere efforts to understand and to help. I have no magic answers: believe me, if I did, I would be using them myself and publishing them. But here are a few of my thoughts at this point.

1. The judgmental, "It's all your fault" approach to patients in not helpful to a patient such as me. Maybe it helps some people, but it's not going to help me. I beat myself up a couple of times each day ... when I step on the scale, when my thin clothes don't fit, when look in the mirror, when I take all my meds, etc. I don't need anybody else beating me up.

2. Recommending a basic "eat fewer carbs, exercise more" won't help either and implying that I don't know that won't help me either. I'm not an idiot. Nor am I "in denial." I've already done that, been successful for about 5 years, promised myself I would never "go back", etc. There is plenty of research that shows that when people feel judged negatively by health care professionals, they start avoiding them. Make sure your patients feel comfortable coming to you and being honest with the difficulties they are experiencing.

3. A supportive partnership would be nice. Work WITH the patient to help identify the root causes of their problems with compliance (whatever they may be) and help them find ways to manage those problems. Emotional eating? Disliking vegetables? Physical issues that make exercise a challenge? (e.g I have osteoporosis and have had to deal with a couple of broken bones in the middle of all of this.) etc. Support them emotionally as they win some battles and lose others.

4. Remember that the internal drive for carbohydrates is extremely strong in some of us -- similar to a physical addiction. Keep up with the research on that topic as it is changing every day.

5. We need a lot more research on the topic of coaching patients struggling with these issues. While some people may think they already have all the answers -- obviously they don't, because the problems are still so prevalent.

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If you know the facts and choose to ignore them, then you are in fact willfully noncompliant. No one is forcing you to binge on carbs or use eating as an emotional outlet versus exercise or some other more constructive hobby for stress relief.

Not true at all. I myself grew up in a family of addicts from alcohol to pill popping. Generations of it. Saw it daily in my home. I simply made the decision that I would use healthier alternatives for stress relief, such as working out, skydiving, surfing, etc.

Life sucks enough, dealing with life with a hangover simply sucks more.

But I can and do drink on occasion and have no problem only having one or two.

Again its a learned behavior and coping mechanism.

As for why you gained weight or anyone else does, it's not magic, unless you have an undiagnosed glandular condition its simply a matter of calories in greater than calories burned. There is no magic to it. You need enough to support your resting metabolic rate, the chemical processes of life, anything beyond that gets converted to fat.

Is it hard? Sure. Do I sympathize? Of course. I mean holy heck I love food. But I chose to love being around and healthy for my daughter and being able to do the active sports that I do more, so I monitor what I eat.

My goodness, I'm sure glad you aren't my provider! You've completely disregarded this women's experience. With an attitude like that, good luck motivating any meaningful change in people.

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Hmm I find it interesting that no one brought up food desserts that disproportionately affect the poor, who are more likely to be obese and experience the worst adverse health outcomes. Yes, you will find yourself ripping your hair out to reinforce any education regarding healthy eating and choosing whole food options if the poor people you serve DON'T HAVE ACCESS to those food options.

Want to really make some change, galvanize your fellow NPs and take it up to Washington. Make healthy food access a requirement for all in the richest nation in the world. No...too much work? Okay, keep patting yourselves on the back for your "efforts" and ripping your hair put while you blame the "non-complants" ;)

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Hmm I find it interesting that no one brought up food desserts that disproportionately affect the poor, who are more likely to be obese and experience the worst adverse health outcomes. Yes, you will find yourself ripping your hair out to reinforce any education regarding healthy eating and choosing whole food options if the poor people you serve DON'T HAVE ACCESS to those food options.

Want to really make some change, galvanize your fellow NPs and take it up to Washington. Make healthy food access a requirement for all in the richest nation in the world. No...too much work? Okay, keep patting yourselves on the back for your "efforts" and ripping your hair put while you blame the "non-complants" ;)

I do think access to quality whole foods is important. But the problem isn't legislation. It's that grocery stores won't go into those poor neighborhoods to set up shop. In downtown Detroit, the only grocery store for miles is a whole foods in the middle of mid town where their "revival"is happening where the only people who can afford their good work at the numerous hospitals that are nearby. The poor communities nearby have to travel a good distance just for groceries, or they go to the corner store that has a host of processed meals ready to eat or nearby McDonalds dollar menu items. Guess where they are likely to go?

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Specializes in Nursing Professional Development.
Hmm I find it interesting that no one brought up food desserts that disproportionately affect the poor, who are more likely to be obese and experience the worst adverse health outcomes. Yes, you will find yourself ripping your hair out to reinforce any education regarding healthy eating and choosing whole food options if the poor people you serve DON'T HAVE ACCESS to those food options.

Want to really make some change, galvanize your fellow NPs and take it up to Washington. Make healthy food access a requirement for all in the richest nation in the world. No...too much work? Okay, keep patting yourselves on the back for your "efforts" and ripping your hair put while you blame the "non-complants" ;)

Good point about the food desserts. And it's not just "bad neighborhoods." A similar problem often exists in places of employment -- healthy food can be hard to find. For example, I work in an office building without a cafeteria. But we have a sandwich shop, with great big fatty sandwiches on thick brick. I try to bring my lunch from home most days -- but sometimes, packing is pretty inconvenient. The only things available for me to buy are pretty unhealthy.

It would help us lead healthier lives if employers would make it easier to eat healthy at work.

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My goodness, I'm sure glad you aren't my provider! You've completely disregarded this women's experience. With an attitude like that, good luck motivating any meaningful change in people.

Yes I have. Nursing and health care are based on evidence based practices, not anectdotal evidence or pseudo science.

Obesity and weight loss are hard, but the science behind how to loose weight is firmly understood.

I can empathize without giving in to a patient's delusions or excuses.

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Yes I have. Nursing and health care are based on evidence based practices, not anectdotal evidence or pseudo science.

Obesity and weight loss are hard, but the science behind how to loose weight is firmly understood.

I can empathize without giving in to a patient's delusions or excuses.

There are few things in science that are "firmly understood". I've seen people calorie count and show me detailed logs who don't lose an ounce. And personally handled their labs to verify there's nothing hormonal or otherwise wrong with them outside an out of control a1c and years of obesity to the point that the only explanation is a low metabolism.

Science tells me the guy I now have on triple therapy maxed out anti hypertensives should be seeing a huge drop, but reality isn't always the case.

I don't doubt the simplistic idea that calories in and out is the basis of most of our ideas of how to lose, gain, or maintain weight. But there is plenty of research out there that encourage different ways of approaching weight that isn't about strictly calories. Someone calorie counting eating nothing but garbage or sugary products can still gain weight... Showing there is much more to it than simply calories in and out.

The problem with it and your approach is you fail to take into account cultural and psychosocial issues that negatively impact weight. Chalking it up to simply inability or unwillingness to eat the right calories fails at accounting for those factors and risks alienating patients and can hurt your rapport with that patient.

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No actually I'm not discounting psychosocial issues. As I earlier acknowledged over eating is a devastating addiction similar to that of opioid or alcoholism.

And in some ways perhaps even harder.

But just like treatment of these addictions, it very much comes down to the individual addict's willingness to effect change in their lives.

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Specializes in Psychiatric and Mental Health NP (PMHNP).

Thank you to everyone who responded. I greatly appreciate the many great suggestions and also those who provided insight into the psychological side of obesity and DM2. My goal is to stay positive and focus on small changes and improvements. I was able to "reach," at least for the time being, 3 patients. One patient just seemed hopeless and defiant - she literally said she didn't care if she died, went blind, etc. Well, I persuaded her to get her annual labs and her eGFR was in the single digits! We called her and told her to go to the ER ASAP, which she did. She almost died. She spent 10 days in the hospital and a couple of weeks later, came back for a follow up visit. She was a changed woman! She thanked me and said she was now determined to live and beat diabetes. Her family has also been very supportive and her BG and A1C1 are slowly coming down. If I hadn't persuaded her to get her annual labs, she could very well be dead. I'm just praying for the strength to take it one patient at a time and stay positive.

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Specializes in Cardiology, Research, Family Practice.
Hmm I find it interesting that no one brought up food desserts that disproportionately affect the poor, who are more likely to be obese and experience the worst adverse health outcomes. Yes, you will find yourself ripping your hair out to reinforce any education regarding healthy eating and choosing whole food options if the poor people you serve DON'T HAVE ACCESS to those food options.

Want to really make some change, galvanize your fellow NPs and take it up to Washington. Make healthy food access a requirement for all in the richest nation in the world. No...too much work? Okay, keep patting yourselves on the back for your "efforts" and ripping your hair put while you blame the "non-complants" ;)

I wish people would stop perpetuating the myth that people don't eat healthy because they either can't afford it or don't have access to it. There are numerous studies that demonstrate otherwise. A few of them are referenced in this article. There are many more.

Giving the Poor Easy Access to Healthy Food Doesn’t Mean They’ll Buy It - The New York Times

Similar results are seen when parks and walking paths are created - people don't use them.

To continue to pretend that people would choose to eat healthier if only there was a better grocery store on the corner is disempowers individuals, creates victimhood mentality, and removes impetus over self-determination.

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I wish people would stop perpetuating the myth that people don't eat healthy because they either can't afford it or don't have access to it. There are numerous studies that demonstrate otherwise. A few of them are referenced in this article. There are many more.

Giving the Poor Easy Access to Healthy Food Doesn't Mean They'll Buy It - The New York Times

Similar results are seen when parks and walking paths are created - people don't use them.

To continue to pretend that people would choose to eat healthier if only there was a better grocery store on the corner is disempowers individuals, creates victimhood mentality, and removes impetus over self-determination.

Nobody suggests that just adding access is the be all end all, but it is part off the equation. As your article points out "The cost of food - and people's habits of shopping and eating - appear to be much more powerful than just convenience.". In downtown Detroit, the only access you have to healthy options is shopping at whole foods. So the cost party is out. Hobbits are a huge one, but habits are reinforced by convenience. Access to fast food and crappy corner stores with blocks eliminate the need to travel miles to get to the store. Location isn't the only reason, but it's far from a myth.

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