Category: for Patients

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Why is it so Hard to Motivate Patients?

Weather is to lose weight, to adhere to a healthy diet or even to take their medications every day. It often seems like most of my patients make little progress in controlling their diabetes or high blood pressure. Thinking I was doing a good job by reviewing the complications of diabetes and high blood pressure, IT MIGHT HAVE BEEN DOING THE OPPOSITE. We are told to educate patients regarding complications which often results in scaring patients. We are told that by scaring patients, will lead patients to make the right decisions. But the sad reality is that it doesn’t work. Why was I not able to motivate patients into making better decisions based on what could happened in the future? Why is it so hard to motivate patients?
If you try to stop yourself from snacking, we will tell our self you will be fat. If some one is smoking you will tell them, you will die of cancer. We have a deep-rooted belief that by scaring ourselves or others we will do the right thing. Except that science shows that warnings have limited impact on behavior. Graphic images on cigarette packets, do not deter people from smoking. (Ruite & Kok, 2005; Taubman Ben-Ari, Florian & mikulincer, 1999’ Trenholm et al, 2007; Ennett et al, 10994)

Warning and treats work but have a very limited impact in motivating people into action.

When animals get scared, they have two reactions, freezing or fleeing. Human beings are animals and have the same responses to fear or being scared. When something is scary, we try to eliminate what is scaring us using rationalization. We could tell ourselves, I had my blood sugars high for a while now and nothing has happened. The process makes you feel stronger than before and makes it harder to do the right thing.
Many of us will act like the Ostridge and place our head on the ground. We ignore what is front of us, people avoid negative information because it makes us feel bad. People will start facing reality when is too late, when we have bad outcomes or complications that can not be ignored. People will avoid worrying about something that might or might not happen in the future now, they choose to worry about it when it does happen.
Studies show that people prefer to go along with the better or positive outcome. People listen to the positive information. Ability to learn from positive information remains the same throughout life, where learning from bad news is less in the young and elder but better with those right before midlife.

How can we use this information to motivate ourselves and others?

Using positive information uses three principles that drive peoples’ decision and behavior. The first is:

*Social incentives (response to opinion of others that lead to change, Edelson, Sharot, Dolan & Dudai, 2011=science). We are social people, we want to know what others are doing and we want to do it better.
*Immediate reward Values rewards you can get now more than rewards you can get in the future. Choose something tangible now rather than something is insure in the future. Can you reward people now for actions that are good for them in the future? Actions become associated with the rewards, leading to the desire outcomes.
*Progress monitoring highlight progress not the decline.

Do we need to stop communicating risks? No but we might want to re-think how to approach motivating ourselves and others. Because fear of loosing your health will lead to inaction or freezing. While positive information will lead to action.

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Why is it so Hard to Control Blood Sugars?

Often patients get very frustrated because even if they are eating healthier and smaller amounts, blood sugars may still not be controlled. Why is it so hard to control blood sugars? Our bodies are wonderful machines that can modify and adjust to different situations when is working the way it was design to do. For patients with diabetes, is up to them to control several factors and adjust medication, exercise and food.

Factors that can affect blood sugars

According to one of my favorite blogs, diatribe.org there are about 22+ factors that affect blood sugars. Many of which come to us easily such as carbohydrates, amount of food, protein and alcohol.  Some that are not as obvious such as inaccurate blood sugar readings and expired insulin. Patient with diabetes need to realize that they will not have perfect blood sugar numbers and that fluctuations are part of living diabetes. Living with diabetes is hard, the only thing healthcare professionals and patients can expect is for them to try their best.

Change your mind setting

Change the way you think about living with diabetes, instead of thinking about all the foods you should avoid think about eating healthy to become healthier. Instead of thinking about exercise as a chore to control blood sugars, think about exercise as a way of becoming heathier and feeling better. Think about medication as another way to feel better and preventing diseases like brushing your teeth to prevent cavities or washing your hands to prevent spread of colds or flu.

Medications and Blood sugars

We know the medications and insulin used to treat diabetes affect blood sugars. Tthere are other medications that can affect the way you respond to sugars.
Statins: medications for cholesterol can increase blood sugars and can increase risk for developing Type 2 diabetes. Most experts think that the benefits of reducing cardiovascular complications outweigh the risks for most patients.

Vitamin B12: metformin, first line medication for type 2 diabetes can interfere with absorbing vitamin B12. Your Doctor or health care provider can test your level and let you know if you need to take vitamin B 12. The American diabetes Associations guideline recommend testing for vitamin B12 once a year. Low Vitamin B12 can lead to Vitamin B12 anemia which is a lack of healthy red blood cells caused when you have lower than normal amounts of certain vitamins. Vitamins linked to vitamin deficiency anemia include folate, vitamin B-12 and vitamin C

Beta blockers: (metoprolol, atenolol, nadolol, carvedilol) Can mask symptoms of low blood sugars like fast heartbeat, sweating or anxiety. Niacin might increase blood sugar. People with diabetes who take niacin should check their blood sugar carefully.

Steroids: like prednisone, can increase blood sugars and lead to weight gain. Weight gain can lead to higher blood sugars.

Niacin: a form of B3, can increase blood sugars.
Diuretics: like furosemide and hydrochlorothiazide, don’t lead to higher blood sugars but increase the risk of dehydration in patients who have high blood sugars leading to more problems.

Vitamin D: Low vitamin D levels have been correlated to uncontrolled diabetes, your doctor or health care provider can check your vitamin D level and recommend replacement if levels are low. There is enough evidence to show that low levels of vitamin D make it hard to control blood sugars.

Herbals:

Many herbals do not have enough information regarding drug interactions and actual effects.
• Aloe Vera drinks can sometimes enhance low blood sugars.
• Stinging Nettle can drop blood sugars, sometimes fast. This is also a natural diuretic, see above.
• Goldenseal, asparagus extract, dandelion, green tea and Matcha tea are natural diuretics, see above.
• Spirulina and chlorophyll usually added to green drinks are said to reduce blood sugars after weeks of use.
• The following have all been reported to decrease blood sugars, again not enough data to verify claims. Fernugreek, Gymmena sylvestre, bitter melon extract, stinging nettle, myrrh, marshmallow, alfalfa, holy basil, alpha-lipoic acid.
Taking supplements is not recommended unless prescribed by your doctor or health provider. Getting all your nutrients from your diet is the prefer way.

Weight and Exercise:

Insulin resistance can make it hard to control blood sugars. The higher your weight the more insulin resistance you have. Insulin resistance can be o your indigenous (own) insulin or the insulin you inject, requiring more insulin to work. Higher body weight can lead to increased insulin resistance. This is a complex topic and how weight makes you more resistance is not well understood. What we know is that losing weight, as little as 7% can lead to better blood sugar control. Patients on insulin who have uncontrolled blood sugars may need more insulin or adjustment of when and how much insulin to inject.

Always consult your doctor, your health care provider, pharmacist or certified diabetes educator for help controlling blood sugars.

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Groceries or Insulin

The high Cost of Insulin

Many patients are finding themselves unable to afford insulin, they must make a choice between buying groceries or insulin. As a follow up to my blog the High Cost of Insulin , the human cost of insulin. NBC News (8/15) reported on patients rationing insulin and leading to death. One of my favorite bogs also addressed this topic, E&M Blogosphere . In the article Hyma Gogineni, Pharm. D, MSc, BCACP, TTS, talks about why the high cost and list available programs that both insured, and uninsured can use to help afford insulin.

Recently USA today published an article calling for free medications for those who need it and can not afford it. This is a growing problem that is only getting worst. In January the New York Times wrote an article about drug makers accused of fixing insulin prices, that lead to a law suit. It seems like everyone from manufacturers, PBM and all middle players are getting rich while the neediest patients go without much needed insulin as reported by PBS news hour.

President Trump promised to lower prices of high cost medications as reported by AARP and Bloomberg.  We are still waiting for something to be done about high price medicines. Many practitioners have taken to petition state and federal law makers to curtail the cost of much needed medicines but not much has been accomplished. Meanwhile, many patients find themselves going without or rationing insulin to last them longer leading to many complications and in some cases as reported above to death.

Biosimilar

Two biosimilars recently approved with lower prices but still too high for patients to afford. Basaglar a biosimilar to Lantus and Admelog biosimilar to Humalog.  Whole sale prices of $348.78 for 15 milliliters (5 pens) of Basaglar and $251.83 for 10 milliliters of Humalog. Compared to Lantus price $430.14 and Humalog $294.85, the difference is not much. These biosimilars (almost an identical copy of an original product) are still too expensive for needy patients to afford.
Rightcare Alliance a petition directed to manufacturers to help patients afford insulin.

The Story behind  Rightcare Alliance was reported on WBUR, A Mother’s Day Message To Pharma: Lower Your Insulin Prices. Many more petitions can be found and many more tragic stories. Contact your senators and congress representatives and tell them make insulin affordable.

Sign the ADA’s petition

The American Diabetes Association has set an online petition to make insulin affordable: Sign the petition now.