Type I Diabetes: Motivational Interviewing for Chronic Illness

[SafetyNurse1968, ADN, BSN, MSN, PhD]

BACKGROUND ON TYPE I DIABETES

In 1910, english physiologist Sir Edward Albert Sharpey-Schafer discovered that Insulin is secreted from the pancreas, but until commercial production of insulin began in 1923, Type I Diabetes (DMI) was a "death sentence". Gary's experience with type I diabetes begins in 1957, when urine glucose was the standard, and synthetic insulin and insulin pumps were still years away from first production.¹

TYPE I OR TYPE II?

People with diabetes either have a total lack of insulin or too little insulin. Type I used to be called juvenile-onset, and is also called insulin-dependent diabetes affects only 5-15% of all diabetics. The body's immune system destroys all insulin producing cells in the pancreas - without insulin the cells in the body can't absorb glucose (sugar), which is needed for energy. Type II (formerly called adult-onset or non-insulin dependent diabetes) can develop at any age. It commonly appears during adulthood, but can affect children and teens. Type 2 is found I 90-95% of people with diabetes. In type 2, the body can't use insulin correctly - having insulin resistance. As type 2 worsens, the pancreas may make less insulin, causing insulin deficiency.

SYMPTOMS

Type 1 diabetics commonly experience low blood sugar (hypoglycemia) whereas those with type II won't have hypoglycemia unless they are on insulin or other diabetic medications. Type I cannot be prevented, whereas type 2 can be prevented or delayed with a healthy lifestyle, including weight loss, eating well and exercising regularly. Complications of both include blindness, kidney failure, and increased risk of heart disease, stroke, foot and leg amputations.

TREATMENT

Treatment for type I includes infusion of insulin with a syringe, pen or pump, and blood sugars need to be checked 4-10 times daily. Type 2 can be treated with weight loss, bariatric surgery, controlling carbohydrate intake and physical activity, as well as oral diabetic medications. Type 2 changes over time and may mean more medication is needed to maintain control of blood glucose. Not everyone with Type 2 needs to check CBGs.

THE FIRST INSULIN INJECTION

Treatment of diabetes has come a LONG way! Consider the story of the first insulin injection. Leonard Thomson, age 14, arrived at Toronto General Hospital on December 2, 1921 weighing only 65 lbs. He had been diagnosed with diabetes 2 years earlier. He was put on a 450 calorie per day diet and his blood glucose was usually around 504 mg/dl, and he was always acidotic. Doctors only expected him to live a few days. On January 11, 1922, Leonard was injected with insulin isolated from dog pancreas. The next day, his blood glucose was tested and had fallen from 441 to 320.4 but there was still a lot of sugar in his urine. Twelve days later, after working on purification techniques, they repeated the injection and Leonard's blood glucose dropped from 520.2 to 120.6, with practically no sugar in his urine. In the following weeks he continued to get daily injections, with subsequent weight gain and strength. By February six other patients with diabetes had experienced positive results.

DISCOVERY OF INSULIN

The biggest breakthrough in treatment was the discovery of insulin in 1921, but hypoglycemia continued to be an issue since monitoring was by urine testing, and was crude at best. Allergic reactions to insulin were common (impurities often were 80,000 parts per million - 8%). Modern insulin by comparison is less than 10 parts per million. Major improvements in the tools to manage Type I were developed in late 70s and early 80s with purified insulin in 1982, and the invention of pumps. Improvements in monitoring also helped. Self-monitoring of blood glucose and the introduction of hemoglobin A1c around the same time, allowed measurement of long term control.²

THE INTERVIEW

Gary was diagnosed with DMI on April Fools day in 1957 when he suddenly slipped into a coma. "My grandfather was almost aware of what was going on - the symptoms - everything and he rushed me to a hospital. I vaguely remember being put in the backseat of his car. After that what I remember is waking up in an oxygen tent."

DIABETES IN THE 1950s

Gary said his parents were with him night and day, but that he wasn't really aware of what DMI was at the time. He was too busy enjoying the huge box of toys that he received! When he was discharged, his routine involved a daily shot, which his dad gave him. "Back then there were needles that dad would sharpen on an emery board we had to sterilize and keep [them] in alcohol. We didn't sterilize them every day, we would boil them in distilled water maybe twice a week. Before too long I was practicing on an orange, I learned how to give myself a shot."

When I asked Gary about checking his blood sugars he started laughing. "Back then it was urinalysis and the problem with that is what you're seeing is 5 hours before, so when they came out with actually testing blood sugar, and I could find out what my blood sugar was at the time. I would say I probably didn't start testing blood sugar until 1980-ish"

GROWING UP WITH DIABETES

I asked Gary what it was like growing up with DMI. "When I was younger it was embarrassing when I had to go into the restroom to give myself a shot. I remember one of my first years at camp I had to keep my insulin in the refrigerator in the kitchen of the dining room, so I had to go there in the morning after I got dressed and get my insulin out, and one morning at camp the camp directors daughter was real curious and wanted to see how I gave myself a shot, well I was wearing pants that day, which means I had to take my pants down to do it and I'm going nope, this ain't working (laughter) so I found a restroom."

THE STATE OF THINGS

Currently Gary sees an endocrinologist once or twice a year, as well as twice-yearly visits to his regular doctor. He also sees an ophthalmologist and a podiatrist. I asked him about his current health and he said, "My current doctor has called me the poster child for type I diabetes. He gave examples of people who were 20 years younger than I was doing terrible, losing eyesight, kidney failure, terrible stuff." He says his goal is to check his blood sugar 5-6 times daily, counts carbohydrates by reading food labels, stay away from sugar and exercise, however he and I both agreed he isn't perfect (I've seen him put away some birthday cake!).

I asked Gary if he has always taken such good care of himself. Again he laughed.

"When I was younger, see I grew up with four brothers and they were normal, and my dad liked sweets too, and I would sneak, steal, whatever - sweets all the time. I also went trick or treating because the folks wanted to keep me as normal as possible. So I would get bags of regular sugar candy, and as I was trick or treating (mimes eating candy) so my blood sugar was probably just way off the rack. When I was in college, I went to my doctor, he took a blood sugar on me and it was over 700 and he looked at me going 'I don't understand why you're still standing here'.

He also talked about how his driver's license was revoked several years ago, and how that was the prime motivator for him to take better care of himself. "I was on the highway and I was not going side to side, but I was going off on the shoulder, and then I got on the side street and I was hitting curbs. Not only that, I passed out right before a red light, and luckily I was not going that fast at that point and almost coasted into the back of an SUV, which stopped. I scratched the bumper of the SUV and kinda smashed my front end."

Finally, I asked Gary about how it feels to be a "patient" and if he had any advice for nurses or those who care for patients with DMI. "I wish they wouldn't be so demanding. I feel like they [family members] are always saying, you need to take something. If my blood sugar is low, I'm in a confused state. But I have been there by myself before and was able to react to it. It takes me a little more time to analyze things, so suggesting things calmly, saying you know, you look like you have low blood sugar, can I get you something instead of telling me what to do."

He mentioned how difficult it was to get Medicare to pay for him to check his blood sugar 6 times daily, the standard is three times a day. I asked him if he had ever considered an insulin pump to simplify his routine. "I think because I am so active, I honestly feel it would be cumbersome, and because of the fact that I am doing pretty well, I don't want anything to do with it, but that's me. I know Doctors that have them that are Type I."

We've been working on him to get a pump, but so far, we haven't had any luck! His advice for those with DMI: check blood sugars frequently, read food labels and exercise! "It's a lifestyle change, and once you get at it and realize how much better you feel and look, you have more energy and you can deal with emotional and psychological things better, it's all good."

MOTIVATIONAL INTERVIEWING

While I was doing this interview, I thought about all the patients I have talked to who are like Gary in that they know what they are supposed to be doing, they know the right thing to do, but they continue to make choices that don't necessarily support optimal health. With Gary, he is aware that he eats too much sugar, and that he could be more consistent with checking his blood sugars, and with exercise. One thing we do know as nurses, is that simply telling a patient to do something doesn't usually work. There are many techniques for getting a patient, loved one, family member to realize that they need to make changes, and to support them in making those changes. One of my favorite techniques is motivational interviewing, or MI. MI has been used successfully to help people change addictive behaviors - it's a style of counseling that can help resolve the mixed feelings that prevents clients from realizing personal goals.

"Motivational interviewing is a way of being with a client, not just a set of techniques for doing counseling."³

I am not an experience practitioner of MI, but I try to remember to use some of the principles when I see a person struggling with something they actually want to do, but can't seem to find a way to do it. It's normal to have mixed feelings about illness, and presenting acceptance of those feelings is the first step of MI - don't judge (easy to say, hard to do!). MI operates under the assumption that an empathetic, supportive, yet directive style provides conditions under which change can occur. When you argue or get aggressive, the confrontation can increase defensiveness and reduce the likelihood of behavioral change.

The 5 basics of MI⁴

1. Express empathy through reflective listening.
2. Develop discrepancy between clients' goals or values and their current behavior.
3. Avoid argument and direct confrontation.
4. Adjust to client resistance rather than opposing it directly.
5. Support self-efficacy and optimism.

The biggest tool is the readiness ruler⁵-where you try to move the client from talking about reasons "why not", to reasons "why" they should make a change. You can use the readiness ruler by asking, "How ready are you to make a change?" On a scale of 1-10, with 10 being the most ready and 1 being not at all ready. You can then follow up with, "How could you move from this number to a higher number?" and, "Why didn't you rate yourself lower?". The client is coming up with the answers and solutions, not you - making it much easier for the client to be open to change. A final question before finishing the session is, "On scale of 1-10, how confident are you that you can make a change?" When you meet the client again, you can follow up on these questions to see how effective the client's ideas have been, and make modifications as needed.

Gary admitted to me that despite knowing sugar is bad for him, he still craves it, and occasionally eats candy, cake or a small bowl of ice-cream. I decided to try a little MI on him.

ME: So on a scale of 1-10, 10 being the best self-care - someone who follows every single rule for Type I diabetes, and 1 being the worst - the person who doesn't do anything they are supposed to do, where do you think you would fall?

G: Seven and a half.

ME: What would it take to get you to an 8 or 8.5?

G: (Laughs) Consciously decide that sugar is really bad, although it's good because Stevia has been around for a while, even coconut sugar metabolizes so much better for a diabetic than regular processed stuff. If I want sweet stuff, I should bake it myself and put the right stuff in it.

ME: Yeah, you can make a lot of stuff with erithrytol, xylitol -the sugar alcohols that don't affect your blood sugar and Stevia

As you can see, motivational interviewing is a tool that focuses on building motivation for and reducing resistance to behavior change. And as you can see, my father-in-law, just like anyone else who has dealt with health issues, wants to do the right thing. Sometimes using the right tools can support people in accomplishing what they know they need to do, and sometimes not. Gary still hasn't got that insulin pump! I've included some videos on how to do MI in the references, please check them out and consider using this tool to support positive change in your patients with chronic illness.^6.7.8

REFERENCES

1. History of Diabetes: American Diabetes Association®

2. https://www.karger.com/ProdukteDB/Katalogteile/isbn3_8055/_83/_53/Insulin_02.pdf

3. Miller W. R., Rollnick S. (2013). Motivational Interviewing: Preparing People for Change, 3rd Edn. New York, NY: Guildford Press.

4. Welcome to the Motivational Interviewing Website! | Motivational Interviewing Network of Trainers (MINT)

5. Tools for MI: Page not found - ADEPT Two - Motivational Interviewing - Tools and Techniques.pdf

6. Finding Your Way to Change: How the Power of Motivational Interviewing Can Reveal What You Want and Help You Get There

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[traumaRUs, MSN, APRN]

Great article.

A lot of times you have to be a detective, especially with meds and OTC/herbals