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.
Specializes in Cardiology, Research, Family Practice.
After practicing as an FNP for 4+ yrs in one of the top 5 fattest cities in the country, I am losing my motivation to help these people. It makes me sad because there was a time I enthusiastically and naively thought that if I just impart them with knowledge and tools, they would be equipped to take control of their health. As it turns out, this has not been the case for most of my patients. Most people will not do what it takes, whether they have the knowledge, time, or money. It comes down to motivation, and apparently food is a powerful motivator.
Of course, I've had a handful of successes. And the ones who have lost weight/come off meds will sometimes come back and tell me, "it was when you said this, or that..." that helped them change. For example, the erection thing occasionally works with men, but not a majority of the time. Often wives will ask me "what more can I do?" besides making healthy food options available, and I say "there's nothing else you can do, you're not the one putting the food in his mouth." A few men have come back and told me that comment opened their eyes. I take pictures of my meals, which are generally of the lean meat + green vegetable combination, and when people ask me "how do you stay thin?" I bust out my phone and show them pictures. I push metformin and victoza like nobody's business. Phentermine, belviq, contrave, etc... I have grocery lists of cheap, healthy, easy to prepare foods, breakfast ideas, lunch ideas, and so forth. Suggested menu items at local restaurants. Ideas for truck drivers. My medical assistant has lost almost 100 lbs, and she has served as an inspiration to a few pts. And every now and then somebody makes a complete 180 and I want to do cartwheel.
But alas, I have grown weary. Just today, as I was walking out of the room of a chronically non-compliant 393 lb diabetic pt's room he says "I'm going to do a lot better this time" and I said "I'll believe it when I see it." Yikes.
After practicing as an FNP for 4+ yrs in one of the top 5 fattest cities in the country, I am losing my motivation to help these people.
But alas, I have grown weary. Just today, as I was walking out of the room of a chronically non-compliant 393 lb diabetic pt's room he says "I'm going to do a lot better this time" and I said "I'll believe it when I see it." Yikes.
Chronic overeating, is an addiction no different than heroin or opioids. Its motivators are closely linked. You have no more hope of motivating an obese diabetic to lose weight than you do a heroin junkie to go clean.
The change must be self-motivated.
The US' suicide rate has increased 25%. Obesity and opioid epidemics are through the roof. Our nation as a whole is sick.
I'm never very good at articulating my perspective, at least it's never well received, but the majority of our society is non compliant including within our own tribe. Those of us who haven't hit DM2 yet but don't modify our diet and move more like we should, we're non complaint as well. We draw a line for those who fit the profile of the non compliant type 2s but as a group look the other way while we are still pre type 2.
I took a new desk job that has over faced me for the last year. I live on take out (of the $$ sort) and haven't moved regularly in over a year. No one would call me overweight or unhealthy because of my outward appearance, no one would put me in the same category of the non complaint type 2. I'm a desirable low maintence well insured patient.
But the truth is, I'm skinny fat and my immune system has taken a hit. In fact, I consider myself more culpable than the 300+ non complaint over utilizing patients because 1) I know better 2) I can afford to live healthy 3) I chose a challenging position and to throw myself into it 4) I was born into good circumstance 5) I'm blessed with a high metabolism.
Eating too much of and/or the wrong type of foods without yet symptomology isn't much of a bragging right but that's 2/3rds of us. We're just procrastinating until we really have to be compliant, god forbid we do something about it before than, but we're as weak in our constitution as the most difficult patients.
I understand the frustration with the futile efforts to help someone who comes in for help but then doesn't heed it but get ready, the wave is coming faster and bigger as our lifestyles catch up with us.
I'm never very good at articulating my perspective, at least it's never well received, but the majority of our society is non compliant including within our own tribe. Those of us who haven't hit DM2 yet but don't modify our diet and move more like we should, we're non complaint as well. We draw a line for those who fit the profile of the non compliant type 2s but as a group look the other way while we are still pre type 2.
I took a new desk job that has over faced me for the last year. I live on take out (of the $$ sort) and haven't moved regularly in over a year. No one would call me overweight or unhealthy because of my outward appearance, no one would put me in the same category of the non complaint type 2. I'm a desirable low maintence well insured patient.
But the truth is, I'm skinny fat and my immune system has taken a hit. In fact, I consider myself more culpable than the 300+ non complaint over utilizing patients because 1) I know better 2) I can afford to live healthy 3) I chose a challenging position and to throw myself into it 4) I was born into good circumstance 5) I'm blessed with a high metabolism.
Eating too much of and/or the wrong type of foods without yet symptomology isn't much of a bragging right but that's 2/3rds of us. We're just procrastinating until we really have to be compliant, god forbid we do something about it before than, but we're as weak in our constitution as the most difficult patients.
I understand the frustration with the futile efforts to help someone who comes in for help but then doesn't heed it but get ready, the wave is coming faster and bigger as our lifestyles catch up with us.
Quoting for posterity on probably one of the most reflective and accurate posts I've ever read. I'm thankfully down 35 pounds and going but still could stand to get to the gym. But it's taken a whole lifestyle change that I'm hoping at 38 well actually last. I know my own drive, motivations, and ability to make good choices. But I don't expect the same of my patients because as you noted my background as a whole is much less complicated than many I care for. I just keep giving them the tools to help and the few I can reach and impact I consider a victory.
I'm always frustrated when nurses immediately jump to the conclusion that patients are non-compliant because they don't know the facts and/or are stupid. A lot of us know the facts and live lifestyles that are unhealthy for us anyway. "Educating us" is not going to change our behavior. If a lack of information were the root of the problem, a lot of health problems would have been solved years ago. But it is more complicated than that.
Thank you, Libby1987 and some of the other posters above who recognize that. It's more of a psychological/emotional issue than an education one. Those of us suffering from food addiction, carbohydrate addiction, emotional eating, stress eating, etc. need help -- not disdain -- not being labeled as "stupid" or willfully non-compliant. We need help to find and establish everyday life practices that promote our physical health rather than meeting our emotional needs with foods and rest (lack of exercise) that hurt us physically. Food addiction is different from drug addiction in that we all need to eat several times per day to live. Imagine expecting a drug addict or alcoholic to just have 1 or 2 doses per day, but "don't overdo it." Everyone knows that wouldn't be successful for a drug addict or alcoholic -- but that is what is expected of someone addicted to food/carbohydrates.
My story: I developed Type 2 about 12 years ago. For the first 7 years or so, I was the ideal patient -- went low carb, lost 55 pounds over about 3 years, was able to succeed with no medications. Then, the weight started creeping back on. I increased my exercise to the point where my muscles were sore everyday. I didn't feel healthy: I hurt ... and yet I kept regaining the weight. I had been keeping food diaries and counting calories and carbs and tried harder and harder, and I kept gaining weight. Finally, my doctor increased my does of Levothyroxine a little. That helped slow down the weight gain, but didn't stop it. My blood glucose remained OK through all of this, so I remained off meds.
After regaining about 40 pounds, my glucoses started going up. I had to go on medication to control my glucoses. That was about 2 years ago. I have continued to gain weight and have now regained all that I lost + an extra 5 pounds. I don't exercise nearly as much now as I used to because I am older, fatter, and it is not at all pleasant. I eat way too many carbs again because the med allows me to.
Throughout these last 5 years or so of back-sliding, I have been seeing my doctor every few months + a "wellness coach" -- both of whom don't really know what to say. "Eat less and exercise more" eventually got replaced by "maybe you need to take a little break," "maybe your body has gone into starvation mode and not allowing you to lose weight unless you starve yourself" "perhaps it would help to do less strenuous exercises as you are getting older" .... etc. etc. etc. In short, no one knows what went wrong or how to help me. I just know that everything that worked in the first few years after my diagnosis stopped working -- and I couldn't be happy long-term with a "low-carb, high exercise" regime that felt more like punishment than a life worth living.
So when you see some of "non-compliant" Type 2 patients, don't assume we are ignorant of the basic facts, or in denial, or weak-willed, or don't care. Some of us used to be successful at fighting this disease -- we were praised and respected as ideal patients. And some of us have become old warriors" who are weary of fighting this losing battle with very little help or sympathy from our health care providers or from society in general.
I'm always frustrated when nurses immediately jump to the conclusion that patients are non-compliant because they don't know the facts and/or are stupid. A lot of us know the facts and live lifestyles that are unhealthy for us anyway.
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.
Imagine expecting a drug addict or alcoholic to just have 1 or 2 doses per day, but "don't overdo it." Everyone knows that wouldn't be successful for a drug addict or alcoholic --
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.
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...
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. There are combinations of therapies that work better and worse for some as we are all very different collections of microorganisms. To base it down to someone failing to meet such a simplistic measure fails to take into account the real psychosocial and ancillary things that negatively affect weight gain/loss. Even hormone changes once supplemented still leave a person with huge struggles with weight. It's important that we acknowledge every deficit as part of the equation and not mitigate it to willful noncompliance.
Specializes in Cardiology, Research, Family Practice.
Bottom line: personal choices.
I too have seen addiction ruin lives and relationships in my own family, enough to know that the addict has to be the one to make a change. Nobody can do it for him.
Yes, there are a multitude of societal and likely genetic complexities that confound the issue. There isn't a pill for any of them.
Show me a place where people are simultaneously hungry and obese. Adopt a major lifestyle change, or remain overweight. It isn't really that simple, and yet it really is that simple.
A lot of us know the facts and live lifestyles that are unhealthy for us anyway. "Educating us" is not going to change our behavior.
We need help to find and establish everyday life practices
I don't exercise nearly as much now as I used to because I am older, fatter, and it is not at all pleasant. I eat way too many carbs again because the med allows me to.
and I couldn't be happy long-term with a "low-carb, high exercise" regime that felt more like punishment than a life worth living.
don't assume we are ignorant of the basic facts, or in denial, or weak-willed, or don't care.
some of us have become old warriors" who are weary of fighting this losing battle with very little help or sympathy from our health care providers or from society in general.
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?
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.
Specializes in Cardiology, Research, Family Practice.
Honestly, I fear it is too late to help a whole generation of people. I am shifting my focus to the kids. Let's teach them from a young to love fresh, whole foods so that when they're older eating healthy and exercising will not feel like "a life not worth living".
Let's stop using food as a reward, especially processed fake food known to be full of preservatives and flavor-enhancers which are probably contributing to food addiction in the first place.
It goes against my belief in personal liberty, but I'm rethinking my opposition to legislation such as the bans against trans fats and the Big Gulp (though I 100% agree with the ruling that it was capricious and arbitrary). To protect the health of the next generation, maybe we need the govt to step on our freedom to choose. I feel dirty for even typing that.
Honestly, I fear it is too late to help a whole generation of people. I am shifting my focus to the kids. Let's teach them from a young to love fresh, whole foods so that when they're older eating healthy and exercising will not feel like "a life not worth living".
Let's stop using food as a reward, especially processed fake food known to be full of preservatives and flavor-enhancers which are probably contributing to food addiction in the first place.
It goes against my belief in personal liberty, but I'm rethinking my opposition to legislation such as the bans against trans fats and the Big Gulp (though I 100% agree with the ruling that it was capricious and arbitrary). To protect the health of the next generation, maybe we need the govt to step on our freedom to choose. I feel dirty for even typing that.
A whole generation is teaching their kids their bad habits. At this point the focus should be less than 5 and even that's debatable. There is a lot that needs to change about food from how it's advertised, how it's accessed, to even what really is the "right" choices. But even modern medicine doesn't have a handle on it. Every few years a new diet is deemed helpful or better. 20 years ago we were cutting out all fats and now we're encouraging it to some degree and significantly reducing carbs. There's some people saying to cut out meat while others disagree with dietary extremes that minimize or eliminate food groups. I've had fantastic results with ketogenic diet which is still technically a form of calorie restriction, but it isn't good for everyone and to date I'm not entirely sold on who it should be used in outside of epileptic patients.
The shameful part is the judgement. The clear cut and dry manner people handle others even when that person vocalizes and pours their hear about their specific path of trying to do things "right" and how nobody to date being able to effectively help. What llg posted was one of the most sincere descriptions of a person at her wits end with her problem and the first response was to tell her that she knows the facts and is ignoring them. 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.
I still maintain there are educational barriers. 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 that they get from a store that sells it as a healthy option. There surely are people with knowledge deficits but more specifically many of these aren't just for food related but general life related. They appear to lack the mental capacity to make the right choices because they are picking up bits and pieces of information that's fed to them daily and trying to make sense of it. That is the bulk of my morbidly obese patients in flint, Michigan. Granted I get those who know and choose wrong things regardless and I readily offer my assistance whenever they are interested.
Smokers have similar tendencies. But we still educate them on the importance of quitting and put them on copd meds despite their failing lungs. Because in the long run, we are here for two jobs... To prevent long term problems from developing and manage those that we can't prevent. And it is not our place to judge or make them feel like they are less than because they don't meet societal ideas of appropriate behavior or our own personal expectations. That's taking this job and career way too personally.
GoodNP
208 Posts
After practicing as an FNP for 4+ yrs in one of the top 5 fattest cities in the country, I am losing my motivation to help these people. It makes me sad because there was a time I enthusiastically and naively thought that if I just impart them with knowledge and tools, they would be equipped to take control of their health. As it turns out, this has not been the case for most of my patients. Most people will not do what it takes, whether they have the knowledge, time, or money. It comes down to motivation, and apparently food is a powerful motivator.
Of course, I've had a handful of successes. And the ones who have lost weight/come off meds will sometimes come back and tell me, "it was when you said this, or that..." that helped them change. For example, the erection thing occasionally works with men, but not a majority of the time. Often wives will ask me "what more can I do?" besides making healthy food options available, and I say "there's nothing else you can do, you're not the one putting the food in his mouth." A few men have come back and told me that comment opened their eyes. I take pictures of my meals, which are generally of the lean meat + green vegetable combination, and when people ask me "how do you stay thin?" I bust out my phone and show them pictures. I push metformin and victoza like nobody's business. Phentermine, belviq, contrave, etc... I have grocery lists of cheap, healthy, easy to prepare foods, breakfast ideas, lunch ideas, and so forth. Suggested menu items at local restaurants. Ideas for truck drivers. My medical assistant has lost almost 100 lbs, and she has served as an inspiration to a few pts. And every now and then somebody makes a complete 180 and I want to do cartwheel.
But alas, I have grown weary. Just today, as I was walking out of the room of a chronically non-compliant 393 lb diabetic pt's room he says "I'm going to do a lot better this time" and I said "I'll believe it when I see it." Yikes.