OT Intervention Strategies for Diabetes Management

Editor’s note: This text-based course is a transcript of the webinar, OT Intervention Strategies for Diabetes Management, presented by Rina Pandya, PT, DPT.

Learning Outcomes

• After this course, participants will be able to recognize the challenges and needs faced by patients with diabetes.
• After this course, participants will be able to identify the role of OT in helping patients and their families both physically and psychosocially.
• After this course, participants will be able to recognize evidence-based strategies for meeting patient and family needs.

Introduction

My name is Rina, and I have been a PT for quite a while now. The topic of diabetes is relevant to any profession across the board. Diabetes affects not just a patient but the whole family structure. I have tried to streamline this topic as much as possible towards the OT side of things. Hopefully, this will be a good resource for you.

Fast Facts from CDC (1,2) 

• Fast Facts on Diabetes
  • Total: 34.2 million people have diabetes (10.5% of the US population)
  • Diagnosed: 26.9 million people, including 26.8 million adults
  • Undiagnosed: 7.3 million people (21.4% are undiagnosed)

I have a few fast facts from the CDC with the most recent data about diabetes. About 34.2 million people have diabetes in the US, which is about 10.5 percentile of the entire population, of which 26.9 million are formally diagnosed, and more are suspected of having it. Some are pre-diagnosed, meaning they have not gotten a formal diagnosis yet or have genetic or familial ties to the disease.

• Fast Facts on Prediabetes
  • Total: 88 million people aged 18 years or older have prediabetes (34.5% of the adult US population)
  • 65 years or older: 24.2 million people aged 65 years or older have prediabetes

About 88 million people aged 18 years or older have been identified with prediabetes, and in those 65 years and older, it is 24.2 million. These numbers are staggering.

We rarely come across a patient who has only one primary diagnosis. We often see comorbidities like high cholesterol, diabetes, hypertension, kidney disease, et cetera.

The National Diabetes Prevention Program (CDC)

• Was created in 2010 to address the increasing burden of prediabetes and type 2 diabetes in the United States.
• Partnerships between public and private organizations to offer evidence-based, cost-effective interventions for the prevention of DM II. 

The CDC created the database in 2010 to address the increasing burden of prediabetes and type two diabetes in the US and build partnerships between the public and private organizations to spread the word.

One key feature of the National Diabetes Prevention Program is the lifestyle change program. Who better than therapists to create, pioneer, pilot, and be a part of this lifestyle program. We have many face-to-face sessions with our patients and learn about their lives. We have been the center of the world for an extended time compared to the rest of the medical professions.

• One key feature of the National DPP is the CDC-recognized lifestyle change program, a research-based program focusing on healthy eating and physical activity which showed that people with prediabetes who take part in a structured lifestyle change program could cut their risk of developing type 2 diabetes by 58% (71% for people over 60 years old).
  • https://www.CDC.Gov/diabetes/index.Html
  • https://www.CDC.Gov/diabetes/prevention/pdf/ndpp_infographic.Pdf

The lifestyle program focuses on healthy eating and physical activity. It showed that people with prediabetes who took part in this program cut their risk of developing type two diabetes by 58%, and in people over the age of 60 years old, by 71%. This highlights how important it is to ensure that people participate. I have included some good resources on this.

Diabetes In Youth (American Diabetes Association) (3,4)

• About 210,000 Americans under age 20 are estimated to have diagnosed diabetes, approximately 0.25% of that population.
• In 2014—2015, the annual incidence of diagnosed diabetes in youth was estimated at 18,200 with type 1 diabetes, 5,800 with type 2 diabetes.

Diabetes in the younger population is about 210,000 Americans under the age of 20. And in 2014-2015, there were estimated to be 18,200 youth with type one diabetes and 5,800 with type two diabetes.

• The rates of diagnosed diabetes in adults by race/ethnic background are:
• 7.5% of non-Hispanic whites
• 9.2% of Asian Americans
• 12.5% of Hispanics
• 11.7% of non-Hispanic blacks
• 14.7% of American Indians/Alaskan Natives 
  • https://www.cdc.gov/diabetes/data/statistics-report/index.html
  • https://www.diabetes.org/resources/statistics/statistics-about-diabetes

You can find out more about these demographics at the links provided.

Death

• Diabetes was the seventh leading cause of death in the United States in 2017 based on the 83,564 death certificates in which diabetes was listed as the underlying cause of death.
• Studies have found that only about 35% to 40% of people with diabetes who died had diabetes listed anywhere on the death certificate, and about 10% to 15% had it listed as the underlying cause of death.

Diabetes was the seventh leading cause of death in the United States based on the death certificates that listed diabetes as the cause of death. Studies have found that about 35 to 40% of people who had diabetes did not even have it listed on there. This shows how much-hidden data there is around diabetes.

Expenses

• $327 billion: Total cost of diagnosed diabetes in the United States in 2017
• $237 billion was for direct medical costs
• $90 billion was in reduced productivity
• After adjusting for population age and sex differences, average medical expenditures among people with diagnosed diabetes were 2.3 times higher than what expenditures would be in the absence of diabetes.

This data shows the expenses in billions. This is staggering in terms of cost to the family, employers, healthcare, and the country.

A1c Test

• Normal: Below 7
• 5.7 - 6.5%:
  • Prediabetes Range
• 6.5% Or Higher:
  • Diabetes Range

One of the ways that we can test for diabetes is the A1C test shown in Figure 1.

Figure 1. A1c test.

Below the level of seven is considered normal, between 5.7 to 6.5ish. 

Type 1 Diabetes (5)

• Type 1 diabetes is a disease in which autoimmune destruction of pancreatic β-cells leads to insulin deficiency.
• T1d commonly presents in childhood or adolescence; however, the disease can appear at any age.
• Antibody markers of autoimmunity against β-cell include islet-cell autoantibodies, autoantibodies against insulin, glutamic acid decarboxylase (gad), or tyrosine phosphates ia-2 and ia-2β, and znt8.3. At least one, and usually more than one, of these autoantibodies are present at the time fasting hyperglycemia is initially detected in 85-90% of individuals who will eventually develop type 1 diabetes.

Type one diabetes is caused by the autoimmune destruction of pancreatic β-cells, leading to insulin deficiency in the body. It is an autoimmune disorder where your own body fights against you. Type one diabetes presents in childhood or adolescence, but overall this disease can appear at any age.

Antibody markers of our autoimmunity against β-cells include all those names that you guys are seeing out there, and usually, more than one antibody is present. Your pancreatic β-cells revolt against your body and do not produce enough insulin, and as a result, the sugars are not metabolized.

• Some patients, most typically children and adolescents, have ketoacidosis as the first symptom of the disease. Less commonly and typically in older patients, T1D can present with mild fasting hyperglycemia or diminished glucose tolerance that can rapidly transition to severe hyperglycemia and/or ketoacidosis in the presence of infection or stress.

Some patients, usually children and adolescents, have ketoacidosis as the first symptom of the disease. We are going to talk more about ketoacidosis as we go along. Type one diabetes can present with mild fasting hyperglycemia or diminished glucose tolerance that turns into hyperglycemia and ketoacidosis in the presence of stress or infection. If a child has anxiety due to school, sports, family, or emotional stress, it is easy to trigger this response.

• Signs and symptoms of severe insulin deficiency and hyperglycemia include:
  • Polydipsia (increased thirst),
  • Polyphagia (increased appetite),
  • Polyuria (increased urination),
  • Weight loss and fatigue.
  • Blurred vision
• These are due to defective transport of glucose from the bloodstream into tissues, resulting in increased glucose levels in the blood, elevated glucose in the urine, and concomitant calorie and fluid losses in the urine. 

When I look at the signs and symptoms, I like to think of it as a case in front of me. I can remember my patients and their symptoms much better than what I read in a book. For example, you may have a 15-year-old patient who comes who tells you, "I'm thirsty all the time, and I cannot stop eating. I also go to the bathroom a lot." I may reply, "Have you been losing weight?" To which they may reply, "Yes, and I am tired all the time." You may then ask, "Do you have any issues with vision? Are you feeling any fuzziness or blurred vision?" Think about all of this symptomology that was presented. It only takes a few minutes to ask these types of questions.

We just looked at the number of adolescents affected by prediabetes. As such, I like to ask these questions during my screening because the symptoms are being caused by glucose not getting transported from the bloodstream into the tissues. The carrier molecules transport the glucose to the tissues, but the glucose remains in the bloodstream with prediabetes. We see high glucose content in the blood, urine, and so on.

Ketoacidosis Symptoms 

• A person might also develop ketoacidosis, a complication of diabetes. Symptoms of this condition include:
• Rapid Breathing
• Dry skin and mouth
• Flushed Face
• Fruity Breath Odor
• Nausea
• Vomiting or stomach pain

As promised, here is information on ketoacidosis. One symptom of ketoacidosis is rapid breathing. Think about a patient who is sitting in front of you. You may see that their breath rate is up or fighting for breath, similar to running up stairs although they were in the waiting room. Another symptom is dry skin and mouth where they are licking their lips or drinking more often. Remember, these clients are going to drink a lot of water. They may have a flushed face or fruity breath odor. They may also complain about nausea, vomiting, or stomach pain. Not all seven symptoms have to be positive, but if the majority are or they have a family history, do some digging.

Type 2 Diabetes (ADA)

• Urinating often
• Feeling very thirsty
• Feeling very hungry—even though you are eating
• Extreme fatigue
• Blurry vision
• Cuts/bruises that are slow to heal
• Weight loss - even though you are eating more (type 1)
• Tingling, pain, or numbness in the hands/feet (type 2)

With type 2 diabetes, there is increased urination, thirst, hunger, fatigue, and blurry vision- the same as type 1. They also report cuts and bruises that are slow to heal. You may see this in a 30 or 40-year-old client and think that that does not sound right. There is weight loss and neuropathies with tingling, pain, and numbness. Again, most of his symptomology is very similar, but the difference is with the age groups. It is essential to ask the right questions as it might save someone's life.

Complications

• Urinating often
• Feeling very thirsty
• Feeling very hungry—even though you are eating
• Extreme fatigue
• Blurry vision
• Cuts/bruises that are slow to heal
• Weight loss - even though you are eating more (type 1)
• Tingling, pain, or numbness in the hands/feet (type 2)

What are the complications? We talked about dry skin, mucus membranes, lips, mouth, tongue, et cetera. If the skin is dry, it is easy to cut, bruise, tear, or infect. Neuropathies can lead to foot complications. Kidneys may also be affected due to high blood pressure, which may lead to a stroke. If I have someone presenting with dry skin, a wound that does heal, or a "glove and stocking" kind of tingling or numbness, I will look deeper into that. "Is there any history in the family?" Or, "Has your doctor tested you recently?" You do not have to do this during the initial evaluation, but keep these questions in mind. When you are in later sessions, you can observe them, and if you see signs, you can dig deeper and see how these complications are related to symptom presentation.

Review of Types of Diabetes

• Type 1 diabetes (5%–10% of cases) results from cellular-mediated autoimmune destruction of the pancreatic b-cells, producing insulin deficiency, occurring more rapidly in youth than in adults.
• Gestational diabetes mellitus occurs during pregnancy, with screening typically occurring at 24–28 weeks of gestation in pregnant women not previously known to have diabetes. 

Type one diabetes results from autoimmune issues or when your body rebels against you. Gestational diabetes mellitus occurs during pregnancy, and screening typically occurs between 24 to 28 weeks of gestation. It is essential to keep this in mind with your pregnant clients and ask if they have been screened for gestational diabetes. If they say they are positive, your approach is going to change. I will go more into this toward the end of the talk.

• Prediabetes is diagnosed when blood glucose levels are above the normal range but not high enough to be classified as diabetes. Affected individuals have a heightened risk of developing type 2 diabetes but may prevent/delay its onset with physical activity and other lifestyle changes.

Prediabetes is diagnosed when blood sugar levels are above average, but they are not high enough to be classified as diabetes. They are at a heightened risk of developing the disease, and this is where we come in. There is a window to turn the tables at this point via lifestyle changes, activity modifications, and exercise. We can create change by knowing the symptoms of diabetes. We may find out a client has a genetic disposition. Perhaps his mother is positive and has neuropathy. We may ask, "What are you eating? How much are you exercising?" Taking a diabetic-related history is highly critical (can happen in sessions 2, 3, or 4).

COVID-19 Perspective (6) 

• SARS, MERS: diabetes persons at high risk [7]. As are patients with coronavirus disease (COVID-19) [9]
• Diabetes patients are at higher risk (up to 50 %) from the virus(9).

Diabetic patients can quickly catch infections and are at high risk for COVID-19 and SARS and MERS as well. Diabetic patients have a 50% higher risk of catching and suffering consequences from COVID-19. Keeping this client safe from COVID-19 is an additional consideration besides other rehab goals. However, due to remote therapies, consultations, and reduced ER availability, these patients may not get enough face-to-face time with clinicians. We may need to fill the gap to help these clients.

• Challenge To Self Management:
  • Lack of Confidence in Self-care: Solution--counseling.
  • Technology Awareness: Information and communication technologies (ICT) for the use of e-health, health, and telemedicine technologies - Internet-of-Medical-Things (IoMT) leading to healthcare Cyber-Physical System (H-CPS) [8]. 

Information and communication technologies for use in e-health, mental health, and telemedicine can help us communicate with our patients. I am not sure how many of you work remotely with your patients. Although they may be coming to you for a completely different reason, ask them one extra question about diabetes as it may make a difference.

• Proper Diet Plan:
• Avoid high carbohydrate and saturated fats.
• Economic and Social Obstruction: cost-effective therapeutic materials, essential medical care should be the main focus of the country's government. 

Often, we can give them diet advice like avoiding high carbs and saturated fats. One thing that we have to keep in mind is economics and social obstruction. You can get a McDonald's burger for a dollar, whereas you will spend a lot more if you go to a health food store. We can provide them with some economic ideas for a healthier diet, but it may not be available in their area. We may have to do some investigation to give them economically viable options.

• “There are several recommendations formulated for diabetic patients during COVID-19 by various as follows (9,10)
• One has to drink a substantial volume of fluid in order to avoid any sort of dehydration.
• The glycemic profile has to be maintained by everyone to the target value suggested by the concerned doctor. Especially, the female patient with Gestational Diabetes needs a continuous measurement of glucose level that could be beneficial to control the glucose profiles (11). 

Clients also have to drink a substantial volume of fluid not to dehydrate. The glycemic profile has to be maintained by everybody to target the value suggested by the doctor while they are in our care. How can we merge this with our interventions? 

• Continuous monitoring of blood glucose levels throughout the day inhibits ketoacidosis and hypoglycemic condition.
• In the case of type-1 diabetes patients if the value goes beyond 180 mg/dl, then it is recommended to pump insulin into the blood for maintaining the glucose level.
• Personal and surrounding hygienic are inevitable in any circumstances. Specifically, repeated hand washing and proper cleaning of all medical equipment such as glucometer and insulin pump with alcohol-based sanitizers and soap water are important.” 

Here is an example of a female patient with gestational diabetes that needs continuous measurement of her glucose level to prevent ketoacidosis and hypoglycemia. If the value goes beyond 180, it is recommended to pump insulin.

We also do not want them to get blisters, ulcers, or any kind of infection. Repeated hand washing proper cleaning are also obviously important.

What Does DSM Involve?

• Kaplan et al. and Correia et al. summarized the components of DSM as follows :
• Diabetes self-management (DSM): Patients take on responsibility for:
  • Nutrition,
  • Physical activities,
  • Insulin therapy, and
  • Glucose monitoring, to
  • Maintain good metabolic control and
  • Reduce diabetes complications 

Diabetes self-management involves these criteria, and they can be used to break down your patient care.

• Steiner, 2012: "DSM is not a single behavior but rather a complex, dynamic constellation of behaviors influenced by changes in social, environmental, and individual circumstances across the lifespan

What does DSM involve? Steiner states that it takes a village, including the family and community, to help a person manage diabetes.

Role of OT

• OT’s core belief is that humans are occupational beings whose ability to involve in desired and meaningful activities is essential to their well-being and health. (12)
• OT treatments are informed by activity analysis where demands of desired activities are broken down at the level of the individual (e.g., spiritual, affective, cognitive, and physical components), environment (e.g., cultural, institutional, physical, and social environments), and tasks (e.g., steps required to perform the desired activity). (12)

OT's core belief is that humans are occupational beings and that meaningful activities are essential to their well-being and health. We need to keep clients moving, able, active, and functional. We want to give out clients wings to fly.

OT treatments are informed by activity analysis and are broken down at the level of the individual and environment. Then, tasks also need to be analyzed. What is wrong with the environment? What is affecting performance? Remember routines and roles also need to be assessed in diabetic management.

• Barriers at each of these levels are then identified and addressed to develop person-centered interventions to promote activity performance(2)
• Promote routine → habits → health-promoting behaviors → promote diabetic self-management (DSM) (12)
• Occupational therapists can bring value to the diabetes care team by evaluating multiple levels of influence on Diabetes self-management (DSM) and treatment adherence, addressing personal and environmental barriers to well-being and DSM, and supporting patients to develop highly complex competencies and skills to satisfactorily self-manage diabetes. (13)

OTs can bring value to diabetes care by evaluating multiple diabetic self-management treatment adherence levels while addressing both personal and environmental barriers. 

Resilient, Empowered, Active Living with Diabetes (REAL Diabetes)

• It aims at promoting patient autonomy and the establishment of health-promoting habits and routines to manage diabetes.
• 1:1 time with patients, with an individual approach, REAL Diabetes is grounded in an adapted, diabetes-focus lifestyle, applies activity analysis to the DSM tasks (2).
• OT worked at homes and community settings over 6 months in a minimum of 10 hours of treatment session depending on the complexion of individuals’ care needs and the progress toward their goals. 

The Resilient Empowerment, Active Living with Diabetes (REAL Diabetes) aims at promoting autonomy, habits, and then routines. One-on-one time is spent with the patient using an individualized approach grounded in an adaptive, diabetic-focused lifestyle. There was a group of OTs who worked at home and community settings over six months with a minimum of 10 hours of one-on-one sessions with the patients,

• For patients who had identified social support as a challenge, their family members were encouraged to participate in diabetes-related education workshops (2).
• A multidisciplinary care team composed of an endocrinologist and a social worker for consultations regarding medical and social issues outside the scope of OT practice (2).

Family members of those who identified social support as a challenge were given diabetic-related education. When we see a person with diabetes or an obese patient, we may also see similar lifestyles or body structures. Using our earlier example, if a patient is struggling and eating McDonald's burgers, most likely other family members are as well. Let's educate the family in these cases.

A multidisciplinary care team can also include an endocrinologist and a social worker to consult medical and social issues.

7 Modules

• The intervention consists of seven content modules (2):
  • Assessment and goal setting;
  • Basic self-management knowledge and skills;
  • Self-advocacy in health care and community settings;
  • Establishment and maintenance of health-promoting habits and routines;
  • Seeking and receiving social support;
  • Enhancing emotional well-being;
  • Self-reflection and strategies to maintain long-term health.
• Personalized customized achievable goals are set

This intervention includes seven modules: assessment and goal setting; self-management knowledge and skills; self-advocacy in healthcare and community settings; establishment and maintenance of health-promoting habits and routines; seeking and receiving social support; enhancing emotional well-being; self-reflection and strategies to maintain long-term health. These seven modules take a look at life three-dimensionally. Keep these seven modules on hand somewhere to start addressing these with people as they are components needed to navigate life. 

Randomized Control Trial (RCT 2)

• Size: Eighty-one ethnically diverse young adults (22.6 ± 3.5 years; English and/or Spanish speakers).
• Demographic: Residents of Los Angeles county, low socioeconomic status (household income ≤ 250% of the federal poverty level) and have type 1 or type 2 diabetes ([HbA1c] = 10.8%/95mmol/mol ± 1.9%/20.8mmol/mol).

A randomized control trial looked at 81 ethnically diverse young English and/or Spanish speakers of low socioeconomic status from Los Angeles. They were specifically looking at poor lifestyles and dietary habits. They also had to have type one or type two diabetes for inclusion in the study.

• Technique: Participants were then randomly allocated to the intervention group (IG) to receive biweekly OT sessions guided by the REAL Diabetes manual and to the control group (CG) to receive standardized educational materials published by the National Diabetes Education Program and biweekly follow-up phone calls for 6 months [11]. 

They split up the participants into a control group and a REAL group. The control group was given standardized educational material; whereas, the REAL group was assigned the format that we just talked about. They also had a one-on-one intervention with the family present. Additionally, a multidisciplinary team was involved. 

• Findings: significant improvement in IG group, as compared to CG, in glycemic control ([] = -0.57%/6.2mmol/mol vs. +0.36%/3.9mmol/mol, p = 0.01), diabetes-related quality of life (+0.7 vs. +1.7, p = 0.04), and habits strength for monitoring blood glucose level (+3.9 vs. +1.7, p = 0.05) [11].
• Conclusion: These results suggest that structured OT DSM interventions, such as REAL Diabetes, could contribute to improving glycemic control as well as psychosocial outcomes among patients with diabetes.

There was a significant improvement in the REAL intervention group compared to the control group. This shows that a highly effective multidisciplinary team approach using the seven modules. This also helped with psychosocial outcomes.

How Can OT’s Help With DSM (Critically Appraised Link) 

• Bridges Diabetes Support Group Manual (BDSGM):
  • https://www.aota.org/-/media/Corporate/Files/Practice/EvidenceExchange/Approved-CAPs/HW/Haltiwanger_diabetes_2012.pdf
  • https://www.readcube.com/articles/10.1002/oti.320
  • Extra recommended reading

These are additional resources about the REAL treatment and peer support for you to review.

Culturally Sensitive Diabetes Peer Support

• A Culturally Sensitive Diabetes Peer Support for Older Mexican-Americans Emily Piven Haltiwanger1*† & Henry Brutus2 1University of Texas at El Paso, Rehabilitation Sciences, El Paso, TX, USA 2El Paso Diabetes Association, El Paso, TX, USA
• Objective: The purpose of this study was to determine if a peer-led diabetes support group intervention could improve adherence to recommendations for self-management in 42 Mexican-American elders with type 2 diabetes—a 10-week program.

I love this study because this is a "teach the teacher" approach. They took 42 Mexican American elders with type two diabetes and put them on a 10-week program. They taught people in the community to teach these clients.

• Sample size: 16 Mexican-American older adults aged 60-85. All participants had type 2 diabetes and lacked the motivation to establish health-promoting habits. Split into mentors and mentees. Peer mentors were Mexican Americans with Type 2 diabetes mellitus; were older than 60 years; read and write English; followed guidelines for diet, glucose monitoring, and physical activities; and expressed an altruistic desire to help others.
• Peer mentees were Mexican Americans with Type 2 diabetes mellitus; were older than 60 years; read and wrote English, and could state that their glucose control was not as good as others expected it to be

This study focused on 16 Mexican Americans between the ages of 60 to 85 who were traditional and set in their ways. They all had type two diabetes and lacked the motivation for health-promoting habits. They split this group into mentors and mentees. The peer mentors were Mexican Americans with type two diabetes mellitus, read and wrote English, and followed the guidelines for diet, glucose, physical activities, and so on. The peer mentees had similar inclusion criteria and could state that their glucose control was not as good as others. 

• Method: 2 Phases. Phase 1: train the trainers. Phase 2: mentor the patients. Each BDSGM chapter used stories to teach concepts and asked thoughtful questions at the end of each chapter to encourage readers to reflect on their motivations for changes and self-preservation behaviors and refine their problem-solving and social skills, which are considered essential competencies are adhering to the prescribed diabetes management regimen. The intention of this manual is to counteract negative thinking and correct faulty information by exposing participants to different viewpoints and to provide topics for shared discussion in group sessions led by a peer mentor.

They trained the trainers. Then, they split the group into those who followed instructions and taught the people who did not follow the instructions. What an ingenious way of doing that. For example, a mentee might say, "I can't live without this." Or, "I understand there may be high carbs." However, another client (mentor) may say, "I found this alternative food that tastes as great as other foods." This is wonderful. In this way, the mentee could reflect on their behavior, lifestyle, and cultural biases.

• Results: Participants displayed statistically significant improvements in blood sugar, self-efficacy, transformational change, and personal resources.
• The results suggested a consultation role for occupational therapists in training peer leaders to learn to lead and manage community-based diabetes self-management programs.
• Limitations were the sample size of the convenience sample and the lack of qualitative analysis of the control group discussion.

The participants displayed statistically significant improvement in blood sugar, self-efficacy, transformational change, personal resources, and so on. This approach may help those that are having trouble following protocols. Although this was a small sample, I think this approach can help someone see a different perspective and find common ground. 

Pediatric Population

• DSM + parents mandatory
• The goal was to adjust parental involvement in DSM to promote patients’ independence in DSM and to improve patients' adherence to their diabetes management regimen (14)
• Occupational therapists also initiated parent-child negotiation regarding proper parental involvement in DSM and encouraged renegotiation of DSM responsibilities between parents and their children during adolescence.

The goal here is diabetic self-management, but it involves the parents. The occupational therapist initiated a parent-child negotiation about proper parental involvement in diabetic self-management. Negotiation is an important part here, especially with dealing with teenagers. Instead of hounding the client, we want to give them tools as they will grow up and need to know how to manage for themselves.

• To promote adolescent patients’ independence and autonomy in DSM, occupational therapists use a variety of creative ways, such as using formal behavioral contracts for parents to reduce nagging [57] and fortnightly reminders to parents to provide positive affirmations to their children.
• Technology: apps, monitored by an occupational therapist, parents are given a link to access and monitor children’s blood glucose data and were encouraged to cease their cues for self-management, which could also promote children’s independence in DSM.

OTs played a significant role in creating the negotiating grounds, providing the child the training on the importance of diabetics management, and giving them the independence towards it. This can include formal behavioral contracts for parents to reduce the nagging and nightly reminders to provide positive affirmations. Children can use apps as they are way more adept with technology to increase compliance and self-management. This routine will be necessary for the rest of their life so you should train them early to get results sooner.

• Online discussion forums
• Discuss and troubleshoot diabetes-related challenges
• Encourage joining support groups online
• ? reimbursement for prevention

It is also essential to enroll children in online discussion forums for troubleshooting and talking to their peers. One teenager talking to another is highly beneficial because they do not feel the adults are hounding them. Let them be in forums where they can relate to each other and join support groups online. This is both for the parents and for the kids. 

Exploring the relationships between illness perceptions, self-efficacy, coping strategies, psychological distress, and quality of life in a cohort of adults with diabetes mellitus

• Common Sense Model (CSM) the mediating role of coping patterns, self-efficacy, anxiety, and depression symptoms on the relationship between illness perceptions and QoL in patients diagnosed with diabetes were evaluated.
• Sample: A total of 115 participants with diabetes (56, Type 1; 59, Type 2), 51% female and an average age of 52.69 (SD = 15.89) in Australia. 

This is another pediatric study in Australia that used the Common Sense Model. The study looked at the mediating role of coping patterns, self-efficacy, anxiety, and depression symptoms on the relationship between illness perception as a diabetic and quality of life. They asked, "How was the psychologically affecting the quality of life?" The research was conducted on 115 participants with diabetes, with 56 being type one and 59 being type two. Fifty-one percent were females. 

• Method: self-report measures of illness perceptions and psychological well-being. Baseline measures included illness perceptions, coping styles, psychological distress (anxiety and depression symptoms), self-efficacy, and quality of life.
• Result: The relationship between illness perceptions and QoL was partially mediated by anxiety; illness perceptions and depression were fully mediated by maladaptive coping and self-efficacy, and self-efficacy and QoL were partially mediated by depressive symptoms. 

The methods were self-report, and participants had to complete a questionnaire on categories of psychological distress, coping challenges, etc. As a result, the relationship between illness perceptions and QoL was partially mediated by anxiety; illness perceptions and depression were fully mediated by maladaptive coping and self-efficacy, and self-efficacy and QoL were partially mediated by depressive symptoms. Thus, patients with diabetes might also have anxiety, depression, and quality of life issues.

Can they swim? Can they compete in sports? How do they feel? Are they fatigued? Do they feel different from their peers even as an adult? 

AADE 7TM Self-Care Behaviors, by American Association of Diabetes Educators

• Healthy eating
• Remaining active
• Monitoring the disease
• Taking Medications
• Solving problems
• Healthy coping skills
• Reducing risks

The American Association of Diabetes Educators came up with seven different checklists for healthy eating, exercising, monitoring the disease, taking medications in time, problem-solving, healthy coping, and risk reduction. 

• Role of OT: Provide recommendations for safe, appropriate physical activity.
• Educate on appropriate meal choices and cooking techniques.
• Assist with medication tracking and organization. 
• Share tips for effective blood glucose monitoring.
• Utilize strategies and compensations for those with sensory loss.
• Help alleviate anxiety and depression through daily lifestyle changes.
• Recommend assistive devices as needed.

They further stated that the role of occupational therapy is recommendations for safe physical activity, education on meal choices and cooking techniques, assistance with medication, tips for blood glucose monitoring, compensating strategies for those with sensory loss, lifestyle changes to alleviate anxiety and depression, and assistive devices as needed. Many modifications can be made within the home for safety, and assistance can be provided for meal prep, taking medication, using alarms as reminders, etc.

Again, one question may lead you to determine someone may be pre-diabetic or diabetic. It then becomes your business as a therapist to help the client manage their hand or neck pain, mobility, and ADLs, but also help manage diabetes as well.

Bottom Line

• Activity-focused treatments and psychosocial interventions by targeting multiple levels of influence,
• including individual capacity, family, organization,
• community factors to facilitate DSM and psychosocial adjustments to chronic disease 

The bottom line is there should be activity-focused treatments and psychological interventions for the client to have a healthy mind and body as they work with each other. Beyond an individual, it takes a village to educate and help the client manage their condition.

OT Can Help With Secondary Complications

• Some of the secondary complications of diabetes that may impede DSM include:
  • Loss or poor vision
  • Hand deformities
  • Carpal tunnel syndrome
  • Loss of motor and sensory function of the hand
  • Raynaud's disease
  • Peripheral neuropathy
  • Limited joint mobility                                     

Now, we are stepping into the rehab aspect of it. What can OT do to help with rehab? What is the disease had how does it progress? What are the complications, and what do we see as clinicians? They might come to us with loss or poor vision, deformities of the hand, or carpal tunnel syndrome. We may see sensory issues, motor wasting of the muscles, Raynaud's disease, neuropathy, and/or overall limited joint mobility. 

Proposed Interventions By AOTA

• Promote healthy food choices and safe cooking methods;
• Instruct in safe and appropriate ways to incorporate exercise and physical activity into daily routines;
• Provide techniques to organize and track medications;
• Instruct in the use of low-vision and nonvisual devices to draw up and measure insulin;
• Instruct and provide strategies to successfully use a talking blood glucose monitor or use a blood glucose monitor one-handed 

We talked about many of these. There are low vision devices to assist the client in drawing up and measuring insulin. It would be best if you did your research. Can they use a blood glucose monitor with one hand? Look to see what is out in the market as there are new things every day.

• Incorporate protective techniques and compensate for a peripheral sensory loss in activities that involve exposure to heat, cold, and sharp objects;
• Educate in techniques to structure time and simplify activities to cope with depression, such as breaking down dietary changes and an exercise program into manageable steps and incorporating them into present daily routines.

Incorporate protective techniques to compensate for peripheral sensory loss for texture, temperature, vibrations, and sharp objects. Educate in techniques to structure time and simplify activities to cope with depression. We need to be there for them cognitively and emotionally.

How many people say they feel good once they start eating healthy? I have heard this so many times. Develop an exercise program into manageable steps to not overload them. We want adherence to the program and the treatment to become routine and integrated into daily routines. For example, "When you're making a coffee, make sure you are using your little dumbbells there while your coffee is being heated to get some cardio going." Or, "When you're brushing your teeth, stand on one foot or turn your head side to side to retrain your balance and vestibular system. There are many things we can do alongside ADLs to get them moving. Remember, we are changing their habits and behavior to make it routine.

In Conclusion

• Skill Building
• Education
• Self tailoring
• Adaptability: Physical/psychosocial
• Lifestyle redesign (R)
• MSK intervention

In conclusion, we need to look at skill-building, education, physical/psychological adaptability, lifestyle redesign, and musculoskeletal interventions.

Timing for Exercises (17)

• Aerobic exercise decreases blood glucose levels if performed during postprandial (after food) periods with the usual insulin dose administered at the meal before exercise (Tansey, 2006), and prolonged activity done then may cause exaggerated decreases (Mallad, 2015; Manohar, 2012; Dube,2006).
• Exercise while fasting may produce a lesser decrease or a small increase in blood glucose (Turner, 2016). Very intense activities may provide better glucose stability (Yardley, 2013) or a rise in blood glucose if the relative intensity is high and done for a brief duration (<10 min) (78). 

Exercise timing is critical. Aerobic exercises decrease blood sugar levels if performed after food; however, insulin can be administered at mealtime before they exercise. Remember, prolonged activity may cause exaggerated decreases of insulin levels in the body. Exercise while fasting will produce a lesser or slight increase in blood glucose. At the same time, very intense activities may provide better glucose, stability, or rise in blood glucose if the relative intensity is high and done for a brief duration. We want to maintain the sugar levels in the body.

• Mixed activities, such as interval training or team/individual field sports, are associated with better glucose stability than those that are predominantly aerobic (Dube 2013; Bally 2016; Garcia 2015; Maran 2010; Guelfi 2007), although variable results have been reported for intermittent, high-intensity exercise (Garcia, 2015)
• To prevent hypoglycemia during prolonged (>30 min), predominantly aerobic exercise, additional carbohydrate intake and/or reductions in insulin are typically required. 

We need to give them high-intensity exercises, varied activities, such as interval training. These types of exercises are associated with better glucose stability. These are all evidence-based reports. Variable results have been reported for intermittent to high-intensity activities. To prevent hypoglycemia during prolonged aerobic exercises, which would be over 30 minutes, additional carb intake and/or reduction in insulin are required.

• To prevent hypoglycemia during prolonged (>30 min), predominantly aerobic exercise, additional carbohydrate intake and/or reductions in insulin are typically required.
• For low- to moderate-intensity aerobic activities lasting 30-60 min when circulating insulin levels are low (i.e., fasting or basal conditions), 10-15 g of carbohydrate may prevent hypoglycemia.

Next, we look at low to moderate-intensity aerobic activities lasting 30 to 60 minutes. For fasting or basal condition, a slice of toast or bread (10 to 15 grams of carbs) may prevent hypoglycemia. We need to keep them at average to moderate intensity and monitor their symptoms (sweating profusely or drinking more water). This is subjective from patient to patient. Aerobic, light resistance exercises are going to be helpful.

• For activities performed with relative hyperinsulinemia (after bolus insulin), 30-60 g of carbohydrate per hour of exercise may be needed, which is similar to carbohydrate requirements to optimize performance in athletes with or without type 1 diabetes.
• The target range for blood glucose prior to exercise should ideally be between 90 and 250 mg/dL (5.0 and 13.9 mmol/L).
• Carbohydrate intake required will vary with insulin regimens, the timing of exercise, type of activity, and more, but it will also depend on starting blood glucose levels.

People performing activities with hyperinsulinemia (after insulin) need a higher carb level in their body to maintain the glucose level. This is similar to carb requirements that we might see in runners and athletes. The target blood range for glucose prior to exercise should be between 90 to 250. The carb intake required will vary with insulin regimens. Additionally, their movement and activities will depend on their glucose level.

What does this mean for us? How much insulin they are taking and the amount of exercise they can tolerate is relative. This is similar to using weights. If you want more reps, you may need to reduce the weight. You want to tailor the activity to each patient. You may choose light resistance, moderate intensity, 10 to 15 minutes of duration, and see how they do with this. 

• Impact of exercising on various conditions
  • Microalbuminuria: Exercising does not progress the kidney disease. Encourage the patient to participate in moderate to vigorous physical activity, with exception of avoiding high-intensity exercise the day before the urine protein test to prevent false-positive readings. 
  • Overt nephropathy: aerobic and resistance exercises have positive effects. Begin ex’s at low intensity and increase as tolerated
  • End-stage renal disease: Supervised, moderate aerobic exercises are recommended. Begin at ow intensity; monitor electrolytes when ex’s during dialysis sessions

Here is the impact of exercising on various conditions. If your patient has microalbuminuria, this means the kidney excretion of albumin is not great. Exercising is not going to harm that, but you may want to avoid high intensity before the day they are supposed to be doing a urine test as it might give the wrong reading. The same thing with nephropathy stands. Aerobic and resistance exercise have good results with people with nephropathy, but you need to begin at low intensity and then go to where it is tolerated. For patients suffering from end-stage renal diseases, supervised moderate aerobic exercises are recommended, again starting at low intensity, and monitor electrolytes, especially if they are within a dialysis session at that time.

• Orthopedic considerations
  • Joint changes are common in patients suffering from diabetes, such as adhesive capsulitis, metatarsal fractures, carpal tunnel syndrome, neuropathies, and so on. Our goal is to maintain flexibility to maintain ROM, hence including warm-up and cool-down stretches. Strengthening with resistance training. If the patient has Charcot joints, avoid overpressure on the feet. 
  • Ex’s to be mod to low intensity, use non-weight bearing techniques
  • Avoid contact sports or rapid directional changes

They might have complications of diabetes which could be adhesive capsulitis, metatarsal fractures, neuropathies, joint deformities, and so on. Our goal as MSK therapists is to maintain the range of motion. This is through stretching, warm-up, cool-downs, mild resistance, moderate resistance, et cetera. Ensure they are not hopping, jumping, bouncing, or marching on Charcot or nephrotic joints. Swimming and noncontact sports are suitable for these patients. You can also use moderate to low intensity, non-weight bearing techniques as much as possible, like pilates or yoga. Take them through the motions, keeping their heart rate elevated with steady exertion.

• Soft tissue disorders secondary to diabetes
  • It is important to inquire about other MSk systems involving various body areas as they may be a complication of diabetes. 
  • Some examples of soft tissue disorder include:
  • Shoulder: Frozen shoulder/adhesive capsulitis
  • Hand: Dupuytren’s contracture, carpal tunnel syndrome, stiff hand syndrome, flexor tendonitis (AKA trigger finger )

Ask if any other part of the body has an issue. If somebody is referred to you for risk, please ask. "Do I need to know about any other problem in your body?" For instance, if this person is typing on the computer, why is his one hand more injured than the other? Why do they feel neuropathy is one side more than the other? 

Diabetes may also affect the small joints of the body. No matter how much therapy, unless the RA is taken care of, you will not be of much help. You may also encounter a frozen shoulder, adhesive capsulitis, Dupuytren's, carpal tunnel, stiff hand, or trigger finger. All these are common complications of the upper extremities. 

• Joint disorders secondary to diabetes
  • Charcot joint
  • Gouty arthritis
  • Osteoarthritis
  • Rheumatoid arthritis (RA)
  • Osteoporosis and related fractures

Do not forget to ask about what is happening in the spine and the lower extremity. Things to look for are Charcot joints, gouty arthritis, OA, RA osteoporosis, and related fractures.

• Muscle related disorders
  • Diabetic Amyotrophy
  • Diabetic muscle infarction
  • Co-occurrence of these pathologies in the body provides us with the confirmation of the impact of diabetes in our patients 
  • Patients may complain of pain, loss of function, limited exercise tolerance.
  • In addition, the use of NSAIDs and corticosteroids adversely affects glycemic control and kidney function

We talked about the atrophy of muscles. This can cause clawing in the hands called diabetic amyotrophy. There can also be diabetic muscle infarction, which is reduced blood supply to the muscle. Many of these symptoms may confirm diabetes in our patients. We assess them, and we may see atrophied muscles, fragile bones, or blue fingertips. They may have decreased sensation. What is their family history? What is their diet? How about their physical appearance? Are they drinking excessive water, have dry skin, or have wounds not healing? Patients may complain of pain, loss of function, and limited exercise tolerance. NSAIDs or corticosteroids affect glycemic control and kidney function, so always ask patients. They may go to Sam's club and buy that big jar of ibuprofen or Tylenol. Ask them if they are taking pain medication. Also, are you hurting anywhere else in the body? They may be having chronic back pain and self-medicating, which can affect kidney function.

• Recommended reading: https://medcraveonline.com/JDMDC/JDMDC-07-00202.pdf

Here is some recommended reading.

Last Thoughts

We need to look at the complications of chronic hyperglycemia, dehydration, medications, et cetera. Older adults with diabetes or autonomic neuropathy and pulmonary disease should avoid exercising outdoors on hot and humid days. Your prescription will be different for each patient; however, you need to know that exercises used with older individuals with diabetes may lead to exercise-related overuse injuries. It is important to assess that and perhaps switch up the routines.

It takes a village to work with those that have diabetes. I love the REAL approach. In the amount of time that we are gifted to work with these patients, we can hopefully give them the discipline, the motivation, and the dedication towards working with this disease. We want to get to them in the pre-diabetic window as this can change the entire life course by making positive habits and behavioral changes. These lifestyle changes can make them feel better emotionally and help them deal with anxiety, depression, and stress. We can educate them on maintaining their body's sugars to improve their quality of life.

Questions and Answers

What have you done when dealing with clients such as these? Have you done some group sessions? And I liked how you talked about taking a village to make it work. Have you done that in your practice?

We often come across situations where a patient is not progressing. I think this is when we start thinking outside the box. Why is this patient not building endurance? Why is he getting tired so quickly? Over time, you start mentally grouping these patients because you have data. When working in acute care or a skilled nursing facility, you may have two or three patients together with diabetes and see how it boosts their morale when they share stories. I enjoy that. If there is even an overlap of five minutes, this can help. Using a multidisciplinary team approach or even a peer-to-peer approach has worked well for me.

I can see a lot of great applications for this in the future as well as we are trying to be proactive. I liked how you said it does not take long to do a quick screen. And, how maybe you do not address it the first time you are doing your assessment, but keeping that at the forefront of your mind and looking for things is helpful.

Absolutely. It only takes one screening question. We do not have to be in a hurry on the first day. Let's finish with the prescribed diagnosis and then attend to this. 

I also can see an application for this in the community, like at senior centers and different exercise programs. This is very beneficial, especially with the screening as people are coming in.

Some OTs are also working in gyms, dance groups, etc., and these are great opportunities to identify this clientele.