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admin | Category: Ed Treatment Exercise | 01.04.2016
This multidisciplinary event investigated best practice, collaborative working and the establishment of referral pathways between professionals involved in the care of patients with Type 2 diabetes. This online recording of the seminar will appeal to all members of the Multidisciplinary Heath Care Team including GPs, physicians, dentists, nurses, optometrists, podiatrists, pharmacists, physiotherapists, Aboriginal Health Workers and other allied health professionals. The recorded seminar can be purchased to view at your convenience via the online registration.
The online seminar presentation provides six hours of CPD learning and credits with optional online assessment. Behavioral self-management in diabetes and CKD is particularly challenging because of the intensive nature of the diabetes regimen. The success of strategies to promote glycemic control and minimize progression of CKD depends upon patient self-management, or the ability and willingness of the patient to change and subsequently maintain appropriate behaviors regarding diet, physical activity, medicines, self-monitoring, and medical follow-up visits. Due to complexity of the behavioral self-management regimen for diabetes and CKD and high frequency of nonadherence, alternative approaches to traditional education should be considered. A recent meta-analysis examining factors that influence adherence to disease management regimens found that patients have the least difficulty with circumscribed regimens (eg, medicines) and the most difficulty with regimens requiring extensive behavior change (eg, dietary change). A recently completed systematic review of 20 studies conducted between 1966 and 2003 measured adherence to diabetes medicines (Table 55).570 The study found that, among patients using oral agents, adherence rates ranged from 36% to 93% and were even lower for insulin. The management plan should include careful coordination of care, addressing both diabetes and CKD.
Although intensive glycemic control reduces diabetes complications,116, 134, 562, 564 once patients develop CKD, there may be a tendency to place less emphasis on glucose management.
Behavioral adherence should be assessed in all patients, particularly in those who do not respond to therapy.
Intensive glycemic control may increase the number of hypoglycemic episodes, with the need to increase food intake to cover peak times of insulin action. Self-management approaches based in behavioral medicine may be effective in enhancing adherence to the management regimen for diabetes and CKD. No studies were found of interventions to enhance adherence of individuals to management regimens for diabetes and CKD.
Assessments and educational efforts should take into consideration modifiable barriers to self-management, should be culturally appropriate, and should consider the unique learning needs of the patient. Behavior change requires repeated contacts and sustained support from the health care team. A meta-analysis summarized the numerous clinical trials that have been done to enhance the adherence of people with diabetes to self-management regimens (Table 55).593 These studies generally define adherence as an educational or behavioral issue. Research that pertains to self-management in those with diabetes and CKD is virtually nonexistent. Simplification of the management regimen (including medicines, diet, physical activity, and self-monitoring requirements) may be helpful for encouraging adherence. Education of the patient regarding medicines should include, at a minimum, the reason the medicine is being prescribed, instruction regarding side effects, importance of adherence, consequences of nonadherence, and signs or symptoms that should trigger a return call or visit to a health care provider. Aging of the population will require regular reassessment of the patient's ability to independently handle the management regimen. Development of culturally sensitive educational materials and services is necessary to ensure adherence to medical recommendations and requires time and resources that may be beyond the control of the individual clinician. The approach to the patient should be individualized, taking into consideration his or her culture, economic situation, knowledge and beliefs regarding the disease and treatment, response to medication (in particular, side effects), ability (emotional, functional, cognitive, visual) to adhere to the prescribed regimen, and changes in status over time. Being active – Moving your body is important to keeping your blood sugar and cholesterol down.
Taking medication – A diabetes educator explains how medications work and simplifies instructions for taking them.

Problem-solving – It’s important to plan ahead to avoid problems with glucose levels, and a diabetes educator can explain how to do that, including by bringing snacks and taking medication correctly. Healthy coping – It’s important for everyone to know how to cope when life throws you a curve ball, whether big (divorce, financial crises) or small (traffic makes you late for work). Doctors say diabetes education really helps their patients with diabetes.  Ask your doctor about working with a diabetes educator. Instantly download 5 Healthy Diabetes Recipe e-books and the “Costco Heart-Healthy Shopping Guide” eBook! Education alone is not sufficient to promote and sustain healthy behavior change, particularly with such a complex regimen. Glucose self-monitoring is particularly important for balancing physical activity and diet against medicines to control glycemia and prevent or impede the progression of complications.116,134,562-564 This regimen requires tremendous effort on the part of the patient. Individual perceptions of dietary restrictions, particularly feelings of deprivation, are difficult for patients and health care professionals to address.
Adherence also was found to be related inversely to the number of diabetes medicines prescribed.
While no studies document inattention to glycemic control in early-stage CKD, a recent review of dialysis patient records found diabetes management to be suboptimal.574 Individuals with diabetes and CKD require the attention of a health care team that can address social, educational, emotional, and medical consequences of both conditions. Although DCCT and UKPDS demonstrated that patients receiving intensive treatment had better glycemic control, they also were more likely to experience weight gain than those receiving usual care. However, 2 meta-analyses have been published that provide valuable information about the most effective approaches for encouraging adherence to the diabetes regimen (Table 55). They perceived physical discomfort, feared hypoglycemia, and had perceptions that they were too overweight. Those that conceptualized adherence as an educational issue tested interventions that involved the development of materials or unique teaching approaches to help people with diabetes learn about the disease and its management. Accordingly, evidence regarding adherence to blood pressure management regimens and to self-management of diabetes were extrapolated to people with diabetes and CKD. Self-management, as described, requires frequent and repeated contacts with health care professionals for education, goal setting, evaluation of progress, and teaching self-monitoring and problem-solving skills. If appropriate, the patient should be instructed that other medicines are available if side effects become unmanageable. Yet managing everything you’re supposed to do, from eating right, to exercising to taking your medications, can seem overwhelming.
Research shows diabetes education works, helping people with diabetes lower their blood sugar, blood pressure and cholesterol levels, which help reduce the risk of complications.
A diabetes educator will help you read food labels, count carbohydrates, manage portion sizes, and make choices that are healthy and work for you.
A diabetes educator can help with that, as well as guide you in what to do when to do when your numbers are out of range. If you experience any side effects or are taking any over-the counter medications, be sure to let your doctor or diabetes educator know.
A diabetes educator can also help you plan how to solve a problem when an unexpected issue arises, such as illness or a delay in travel that interferes with a meal. A diabetes educator can explain why it’s important not to smoke, as well as why you should see an eye doctor once a year.
Thus, the addition of medicines for other common comorbid conditions (eg, hypertension and dyslipidemia) is likely to further reduce adherence. The ADA has developed Standards for Diabetes Self-Management Education.575 These standards summarize evidence that self-management education is most effective when delivered by a multidisciplinary team. Intensive treatment also may mask poor adherence to the treatment regimen, especially adherence to diet and physical activity.

Those that conceptualized adherence as a behavioral issue employed techniques based in behavioral medicine or psychology to foster behavior change (eg, motivational interviewing, verbal persuasion, goal setting, positive reinforcement, social support, and coping, among others).
Establishing and maintaining self-management behaviors likely will require multiple ongoing contacts with members of the health care team.
But you don’t have to go it alone.  A diabetes educator has the knowledge and skills to help you figure out the best way to take charge of your diabetes.
A diabetes educator will help you explore ways to get more activity in your day without it being a burden. A diabetes educator will work closely with you to figure out healthy ways that work best for you to cope with problems, such as faith-based activities, activity, hobbies or medication. You should work closely with your doctor and diabetes educator to avoid complications, such as by taking medication to lower your cholesterol. Maintenance of adherence requires ongoing support from a variety of health care professionals. To our knowledge, no studies have specifically examined adherence of people with diabetes and CKD to self-management regimens. Rates of adherence to an exercise program ranged from 19% to 30% in people with diabetes,571, 572 indicating that compliance issues impact on multiple aspects of disease management. This team should include a combination of expertise in medical treatment, nutrition, teaching skills, and behavioral psychology. Over time, inattention to behavioral aspects of the regimen may mitigate the potential benefits of intensive treatment. Regardless of how adherence was conceptualized, these studies found that interventions to enhance adherence tend to improve glycemic control. However, the challenges of modifying behavior to achieve adherence and successful self-management for those with diabetes are well established (Table 55).
Ideal self-management requires vigilance regarding the content of meals and balancing nutritional intake with medicines and physical activity to achieve good glycemic control. Each patient should have an individualized assessment, educational plan, and periodic reassessment pertaining to educational needs.
Knowledge was not consistently related to glycemic control, and factors other than knowledge are needed to achieve long-term behavioral change.576 The second conducted a meta-regression analysis on 28 studies between 1990 and 2000 to characterize the components of behavioral interventions most likely to result in improved glycemic control.
The greatest improvements were made in interventions involving frequent contact with the patients. Patients should be aware of day-to-day patterns in their blood glucose levels to make informed choices. Table 56 lists the components and principles of a diabetes and CKD self-management program, combining educational elements from the ADA Standards,575 Guideline 5 of the NKF-KDOQI™ CPGs for Hypertension and Antihypertensive Agents in CKD,5 and predictors of nonadherence. Face-to-face delivery (compared with telecommunication and written materials), cognitive reframing (involving goal setting and problem solving as opposed to didactic education), and interventions that included an exercise component were key to improving glycemic control.577 The principles noted in Table 57 enhance adherence to medical management in other patient populations and, in the opinion of the Work Group, should be applicable to patients with diabetes and CKD. Unfortunately, improvements generally were lost within 1 to 3 months after stopping the intervention.583 No literature was found regarding the frequency and duration of contacts required to make and sustain behavior change in patients with diabetes and CKD.
However, given that CKD only complicates the self-management regimen, the Work Group concluded that interventions to support and sustain behavior change should be comparable to or exceed those required for good self-management of diabetes.

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