Insulin distress, an emotional response of the patient to the suggested use of insulin, acts as a major barrier to insulin therapy in the management of DM. Addressing patient-, physician- and drug-related factors is important to overcome insulin distress. |
A group of endocrinologists came together at an international meeting held in India to develop a tool kit that would aid a practitioner in implementing insulin motivation strategies at different stages of the patient journey through insulin therapy. |
Bringing in positive behavioral change by motivating the patient to improve treatment adherence helps overcome insulin distress and achieve treatment goals. |
Introduction
Insulin Distress: A Barrier to Optimal Insulin Use
Definition
Prevalence of Psychologic Insulin Resistance
Patient-Specific Barriers to Insulin Initiation
Healthcare Provider-Specific Barriers to Insulin Initiation
Tools for Evaluation of Distress
Patient Management Strategies for Improved Insulin Acceptance
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Identifying personal obstacles.
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Overcoming fear of injections.
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Explaining management of hypoglycemia.
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Trying to explain to the patient that they have not failed with their diabetes management and try to restore a sense of personal control.
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Demonstrating the ease of insulin injection and initiation.
Panel Recommendations on Insulin Distress
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Insulin distress is a part of and contributes to diabetes distress.
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It is brought about mainly because of misconceptions about insulin therapy and a lack of accurate information.
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Insulin initiation is perceived as the ‘end of the road,’ and this perception often leads to distress, which can be acute or chronic.
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Physicians need to apply the biopsychosocial model of health rather than a purely glucocentric or biomedical approach.
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Physicians need to initiate sequential counseling and use easy-to-understand analogies to help patients with diabetes overcome insulin distress.
Behavior Change in Persons with Diabetes: Does It Really Matter?
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Maintaining clarity in communication: Clearly communicating information on the desired behavior change may eliminate misunderstandings between physicians and patients with diabetes. Strategies to facilitate accurate understanding of recommendations include the following:
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Simplifying the message: Focusing on a single recommendation at a time and providing a small quantity of information in multiple formats depending on the literacy level of the patient [16].
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Focusing on a single recommendation at a time with small chunks of information.
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Providing information in multiple formats (e.g., spoken, written, etc.) and at the literacy level of the individual.
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Applying the teach-back method: For better comprehension of patients with low health literacy, they may be asked to teach the provider the key information that they have understood [16]. In a direct observation study, which included 38 physicians and 74 patients with diabetes, it was reported that good glycemic control was achieved among patients with diabetes in whom the teach-back method was employed compared with those for whom this method was not used [17].
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Avoiding ‘one-size-fits–all’ recommendations: Tailoring recommendations according to the patient's characteristics, such as gender, ethnicity, age and resources, help in successful behavior change [16]. Motivational interviewing is one of the clinical approaches that provides health behavior advice in the context of individual beliefs and preferences, with potential applications and benefit in diabetes. In a randomized controlled trial, which included 66 teenagers (14–17 years) with type 1 DM attending a diabetes clinic in South Wales, UK, motivational interviewing facilitated improved behavioral changes in terms of positive well-being and improved quality of life and subsequent improvement in glycemic control [18].
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Planning proper timing for health behavior message delivery: Diabetes care visits are often scheduled quarterly, making it difficult to provide timely behavioral recommendations. Advising patients to pair the recommended behavior with an existing daily routine (e.g., pairing blood glucose monitoring with brushing teeth in the morning and evening) can help in sustaining the recommended behavior [16, 19].
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Being empathetic and supportive: Healthcare providers should be compassionate and supportive while communicating about self-management of diabetes. For example, the tone of the healthcare provider while providing recommendations for behavior change should be encouraging instead of discouraging. Shaming, guilt trips and scaring the patients do not help in implementing and sustaining behavior change [16].
Understand that behavior of patients with diabetes may vary widely between individuals and hence a universal approach may not be appropriate for empowering behavior change |
Frame goals for achieving recommended targets in a collaborative manner after taking into consideration individual factors including ethnicity and family values |
Respect the choices made by patients with DM even if they do not align with recommendations |
Provide adequate training and support to empower self-management |
Recommend that the patient takes an interest in community programs |
Periodically review laboratory and biometric data and revisit set goals |
Review and tweak the treatment plan as appropriate during each visit |
Panel Recommendations on Behavioral Science
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Bringing about a behavioral change largely depends on the motivating factors as perceived by the patients.
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It is important to understand the concept of a ‘reinforcer’ in bringing about a behavioral change in patients with diabetes.
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Periodic reinforcement of benefits of using insulin needs to be adopted, but an individualized approach is recommended; a one-size-fits-all approach should be avoided.
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Patients need to understand and accept that day-to–day care of their diabetes is their responsibility with physicians being the facilitators.
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Patients will change their behavior depending on their hierarchy of needs, and family members may play a crucial role in insulin initiation and maintenance.
Motivational Interviewing in Diabetes Care: Because the Word Still Matters
Four Pillars of Motivational Interviewing (MI)
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Expressing empathy is a simple and effective tool for communicating respect and empowerment. It involves the clinician asking permission before proceeding with advice or providing information if the patient has not asked for it [21].
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Rolling with resistance is a type of empathy, where the clinician avoids arguing and tries to understand patients’ reluctance to change [21].
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Developing discrepancy is another key MI element that is considered critical to the patient’s behavioral change through effective listening. The element ‘developing discrepancy’ depends on the patient’s current behavior, personal goals and values [21].
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Supporting self-efficacy acknowledges that showing the willingness to change is only half of the behavior change battle. Clinicians should boost the patients' confidence in this regard. They must explain to the patients that one can succeed at health behavior change with persistence [21].
Key Points of Spirit of MI
Skills and Strategies of Motivational Interviewing: OARS
Micro-skills of MI | Example |
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Open-ended question | What do you think is the hardest thing about wearing your CGM? |
Affirmation | It is great that you are actively using your CGM and adjusting your insulin rates using that information. Not everyone is able to understand how to monitor their glucose levels soon after starting on a CGM |
Reflection | I understand that you have been getting frustrated with the spikes in your blood sugar but not having insulin that can react fast enough |
Summarize | So overall, it has not been very inconvenient to wear the sensor and it seems like you are doing well with understanding your CGM; the only issue that has been bothering you is not having insulin that peaks fast enough. Did I miss anything? |
Impact of Motivational Interviewing on Clinical Outcomes in Patients with DM
Panel Recommendations on Motivational Interviewing
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Change is hard for patients with chronic illnesses such as diabetes.
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Providing information in multiple formats and at the literacy level of the individual may help in motivating patients.
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Winning the confidence of patients with simple measures can help motivate them to use insulin.
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The ‘teach-back’ method could be a useful approach for motivating patients to initiate and maintain insulin therapy.
The Insulin Conversation
General Challenges in Insulin Therapy in Clinical Practice
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Delay in Initiation of Insulin Therapy: Delay in initiating insulin therapy has been a major challenge in real-world clinical practice. Many Asian and international studies have shown that even when there was no significant improvement in glycemic control, initialization of insulin therapy was always delayed [29].
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Insufficient Dose Titration: Timely initiation of insulin therapy is not the only factor that provides optimal glycemic control. Insufficient dose titration, even after timely insulin initiation, may also contribute to inadequate glycemic control. The International Diabetes Federation guidelines recommend a self-titration regimen of initiation of a low-dose insulin (usually 10 U/day) and increasing the start dose by two units every 3 days until the target of < 6.0 mmol/l (< 108 mg/dl) premeal blood glucose has been achieved [29].
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Uncertainties Regarding Insulin Titration: In routine clinical practice, titration of the insulin dose is determined based on patient characteristics. Based on the physician’s clinical judgment about an individuals’ condition, a decision is made about the titration regimen. In developing countries like Asia, lack of support and inappropriate use of titration algorithms may contribute to dosing errors or insufficient dose titration [29].
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Adherence and Persistence to Therapy: Adhering to insulin therapy is a key determinant of glycemic control. Poor adherence to insulin therapy is associated with lower glycemic control and complications. Studies indicate that the rate of hospitalizations and mortality is higher in nonadherent patients with T2DM than in adherent patients. Also, significantly higher HbA1c levels were observed in patients with T2DM who missed insulin injections compared with those who never missed a dose [29].
Patient and Physician Barriers
Myths Associated with Insulin Therapy
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Insulin means I am a failure.
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Insulin does not work.
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Insulin causes complications or death.
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Insulin causes weight gain.
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Insulin injections are painful.
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Insulin causes hypoglycemia.
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Insulin is addictive.
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Insulin is too expensive.
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Insulin will change my life.
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Can never stop insulin.
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Patient care not good enough.
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Not confident about therapy.
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Lack of fairness.
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Problematic hypoglycemia.
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Life will be restricted.
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My diabetes will be more serious.
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Insulin causes problems like blindness.
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Anticipated pain (injections).
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Fear of injections.
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Diabetes worsens.
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Seen as sick.
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Weight gain.
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Less flexibility.
When Should This Conversation Be Initiated?
The Concept of Euthymia
Importance of Patient-provider Communication in Diabetes
Panel Recommendations on Patient-provider Communication
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Patient-provider communication aimed at gaining mutual trust may help achieve diabetes euthymia.
Effective Insulin Initiation: ‘A Good Start for Good Adherence to Insulin’
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Effective Insulin Conversation
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Timely Self-management Education
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Effective Titration
Key Behaviors of Healthcare Providers that Motivate Insulin-reluctant Patients with Diabetes to Start Insulin Treatment
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Making the patient understand that insulin helps in controlling diabetes and associated complications in the future.
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Establishing trust with the patient.
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Providing support and being available to discuss any concerns.
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Demonstrating the insulin injection process.
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Assuring the patient that the insulin injecting process is easy.
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Referring the patient to a specialist if warranted.
Best Practices for Insulin Motivation at the Pre-initiation, Initiation, Titration and Intensification Stages
Pre-Initiation and Initiation: Best Practices
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Social stigma as a result of starting insulin therapy is one of the biggest barriers identified in the region.
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Sharing testimonials of people having successfully managed their diabetes with insulin therapy may help in this regard (e.g., well-known personalities on insulin who may act as brand ambassadors).
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People requiring insulin should be counseled individually, and a structured education program involving two or three visits before commencing insulin therapy may help.
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The LISTEN approach could be a useful tool in increasing patients’ acceptance of insulin.
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Use of simple, easy-to–use basal insulin accompanied by adequate insulin education can improve adherence to insulin therapy and increase patients’ acceptance. (The LISTEN approach is: L: list the patient’s concerns and fears; I: information equipoise; S: share sources of support; T: therapeutic patient education/teamwork; E: empathic understanding/expression; N: neutral nonjudgmental communication.)
Proposed Toolkits for Practitioners for Insulin Use in DM Patients
Tool Kit for Pre-initiation of Insulin Therapy
Patient Queries and Recommended Responses
Toolkit for Initiation of Insulin Therapy
Titration and Intensification: Best Practices
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Titration inertia can be a result of reluctance/inaction or the HCP or patient, or both.
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Simpler titration algorithms and educational self-management programs for diabetic individuals are essential for optimizing clinical outcomes.
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Most physicians believe that insulin is the most effective agent for achieving glycemic goals, yet they are reluctant to intensify insulin therapy.
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Insulin intensification inertia can be addressed by using better insulins with good efficacy and safety profiles and newer medications for type 2 diabetes as well as through patient education and effective communication between HCPs and patients with diabetes.
Toolkit for Titration
Toolkit for Intensification
Panel Recommendations for the Pre-Initiation Conversation
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Patient concerns at this stage are mainly centered on the impact on the quality of life.
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The pre-initiation conversation must be initiated at the second or third visit if the HbA1c level is high at diagnosis.
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Candidates for this counseling include those with long duration of diabetes with poor glycemic control despite being on multiple OADs.
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Challenges faced at this stage are unique and require priming and reinforcement approaches.
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A biopsychosocial model encouraging both primordial and primary awareness is needed at this stage.
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The key message that needs to be delivered is that insulin therapy is viable and safe, as it is used even by pregnant women and children.
Panel Recommendations for Initiation
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Patient concerns at this stage still focus on the impact on the quality of life; therefore, the safety and tolerability of insulin must be reinforced at this stage.
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A few concerns that need to be addressed include the proper injection technique, site rotation and self-monitoring as well as insulin usage during religious fasts.
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Lack of diabetes educators is a major challenge at this stage.
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Innovative solutions for delivery of open-channel communication as well as user-friendly insulin delivery devices can help at this stage.
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Tools that can be used by physicians include starter kits and device usage demonstrations.
Panel Recommendations for Titration
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This stage is a reality-check and expectation-setting stage.
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Practical troubleshooting, including identification of alarm symptoms as well as patient empowerment, is crucial at this stage.
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A few of the challenges faced by physicians include lack of adherence, irregular monitoring and unstructured lifestyles.
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Education, use of pragmatic regimens and lifestyle counseling could help at this stage.
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Tools recommended at this stage include hypoglycemia kits, mobile applications to help in titrating doses and training paramedics in communication with the patients.
Panel Recommendations for Intensification
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This is a stage of fears in which the patient starts to worry about complications and the ability to self-manage diabetes.
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Perception correction, patient-centered care and logistical support can help at this stage.
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Physicians need to improve their skills via peer-to-peer interactions to manage patients in this stage.
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Recommended tools include regimen-specific diaries and ready reckoners.
Improving Compliance and Adherence
Impact of Empowerment on Medication Adherence and Self-care Behaviors
r Coefficient | p Value* | |
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Medication adherence | 0.170 | 0.003 |
Diabetes knowledge test | 0.155 | 0.007 |
General diet | 0.235 | < 0.001 |
Exercise | 0.247 | < 0.001 |
Blood sugar testing | 0.115 | 0.043 |
Foot care | 0.178 | 0.002 |
Panel Recommendations on Improving Adherence
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Adherence to medications is a major challenge in patients with diabetes since improvements in glycemic control are not visible on a day-to-day basis.
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Physician inertia in initiating insulin is also a factor that needs to be acknowledged in this context, as should the fact that insulin appears to be a complex treatment regimen.
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A ‘start low, go slow’ approach may be useful in this regard.
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Using motivational interviewing techniques when discussing medication-taking behaviors is the best way to obtain and impart key information.
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Use of basal insulin, advanced technology and effective communication strategies can reduce non-adherence and non-compliance.