1. Engaging the Disengaged:
Promoting Successful Self-Management in Patients with Chronic Medical Illnesses
William H. Polonsky, PhD, CDE
January 9, 2017

2. Three Operating Principles
Living well with a chronic medical illness can be tough 1.

4. Three Operating Principles
Living well with a chronic medical illness can be tough 1.
The typical reasons why we think it’s tough are wrong 2.

5. HCP Attributions Regarding Problem Patients
HCP top 5 complaints about patients with diabetes:
Patients say they want to change, but are not willing to make the necessary changes
Not honest/Only tells me what they think I want to hear
Don’t listen to my advice
Diabetes not a priority/Uninterested in their condition/
”In denial”/Don’t care/Unmotivated
They do not take responsibility for self-management
Edelman et al, 2012

7. Three Operating Principles
Living well with a chronic medical illness can be tough 1.
The typical reasons why we think it’s tough are wrong 2.
No one is unmotivated to live a long and healthy life 3.

8. Percentage of Patients Achieving ADA Treatment Targets
% reaching ADA target
24.9%
Wong et al., 2013

9. Re-Thinking Motivation
If no one is unmotivated, then what’s the problem?
Obstacles to self-care outweigh possible benefits
The benefit conundrum
And there are typically a TON of obstacles!
The underlying theme to most obstacles is a lack of “worthwhileness”

10. Lack of Worthwhileness

11. 1. Emotional Distress in CHD
Carney and Freedland, 2016

12. 1. Emotional Distress in Diabetes
Emotional distress makes it harder to
make healthy behavior changes
Poor self-management1
Poor BG control2
More hospitalizations3
3x higher incidence of
CAD and retinopathy4,5
2x higher risk of mortality6
1. Ciechanowski et al, 2003; 2. Lustman et al., 2000; 3. Rosenthal et al., 1998; 4. Carney et al., 2002; 5. Kovacs et al., 1995; 6. Katon et al., 2005

14. Diabetes Distress
…diabetes is taking up too much of my mental and physical energy every day
…I am often failing with my diabetes regimen
…diabetes controls my life
…friends or family are not supportive enough of my self-care efforts
…I will end up with serious long-term complications, no matter what I do
Polonsky et al, 1995; Polonsky et al, 2005

15. Diabetes Distress Prevalence
Type 1 diabetes (n = 390): 39%
Type 2 diabetes (n = 503): 35%
Fisher et al, 2010; Fisher et al, 2015

16. 2. No Perceived Benefits
What’s the difference? This disease is going to get me no matter what I do.
I’ve been taking these blood pressure meds like I’m supposed to, but I don’t feel any better.
Why bother bringing my BG logbook to my doc? I’m just going to get chewed out.

17. SMBG Beliefs and SMBG Use
Polonsky et al, 2013

18. 3. Perceived Costs Are Too High
24 hours a day, 7 days a week. I can’t go 10 minutes without thinking about this damned disease. There’s never a break. I am sick of it!
Taking all of these pills can’t be good for me

20. Patient Medication Beliefs
Perceived Costs
Adverse effects
Concerns about long-term adverse effects
Represents “sickness”
Perceived Benefits
Rarely apparent
HCP may state that long-term risks are reduced

23. Meet Bobbie 62 years old, recently diagnosed with T2D.
Has refused to start metformin as directed by her physician.
“I heard on TV that any of these medications can cause heart failure and other problems. And I saw a program about controlling diabetes, or even reversing it, with supplements instead of these dangerous medications.”

25. Patients and HCPs Have Very Different Medication Beliefs
HCPs see regimen intensification as expected in response to inevitable beta-cell decline.
Patients highlighted the negative response they felt toward intensification, emphasizing the goal of reducing therapy if possible.
THEREFORE: HCPs and patients tend to have opposing goals (regimen intensification vs. regimen reduction).
Grant et al, 2010

26. 4. Vague/Unrealistic Expectations
I did everything I was supposed to, and my blood sugars are still all over the place.
I must take care of my diabetes perfectly, or I am a failure.

29. 5. Environmental Pressures
I have more important things to worry about, like making sure that I don’t lose my job. So I don’t have time for exercise and stuff like that.

30. Lack of Worthwhileness

31. So What To Do?

32. Lack of Worthwhileness
Emotional distress
Perceived benefits are nil
Perceived costs are too high
Unrealistic (or too vague) expectations
Environmental pressures

33. When Perceived Benefits are Nil: Addressing the Problem
Provide hope
Promote urgency
Provide personalized evidence that positive
actions can make a positive difference

34. Facts and Fictions
Q. Diabetes is the leading cause of adult blindness, amputation, and kidney failure. True or false?
A. False. To a large extent, it is poorly controlled diabetes that is the leading cause of adult blindness, amputation and kidney failure. 34
Well-controlled diabetes is the leading cause of… NOTHING!

35. Fact Check
This doesn’t mean good care will guarantee that you will not develop complications.
This does mean: with good care, odds are good you can live a long, healthy life with diabetes.

36. Joslin 50 Year Medalists

37. T1D Complications After 30+ Years

38. T1D Complications After 30+ Years

39. Conclusions: “This study shows a normal life expectancy in a cohort of subjects with type 2 diabetes patients in primary care when compared to the general population.”

40. A “New” Perspective on Chronic Medical Illness
“To live a long and healthy life, develop a chronic disease and take care of it.” - Sir William Osler

41. Promoting Urgency
An uncontrolled chronic medical illness can hurt you, even if you feel okay
Treatment should not be delayed

42. Back on Track Feedback Name: Molly B. FID #: x Tests Usual Goals
Your Results
FID #:
Your score should be
SAFE: At or better than goal
NOT SAFE: Not yet at goal
A1C
7.0% or less
8.7% x
Blood Pressure
130/80
125/75
LDL
100 or less
116

44. Personalized A1C Feedback
Reference
Type
Number of subjects
A1C Difference
Chapin et al, 2003
Chart in medical record, conversation presumed
127 T2D adults
0.7%*
Levetan et al, 2002
Laminated poster, then call from educator
150 T1D/ T2D adults
0.5%*
O’Connor et al, 2009
Periodic mailed brochures, no discussion
3703 T1D/T2D adults
0.0%
Sherifali et al, 2011
465 T2D adults
0.1%

45. Communication and Refill Adherence
Ratanawongsa, et al, 2013

46. When Perceived Benefits are Nil: Addressing the Problem
Provide hope
Promote urgency
Provide personalized evidence that positive
actions can make a positive difference

47. Perceived Treatment Efficacy
Help people to see that their actions can make a positive difference
The wise use of personalized feedback
Polonsky and Skinner, 2010

49. Effectiveness of the feedback message Frequency of Feedback
Personal meaningfulness
Clarity
Guidance and support
Patient characteristics
Patient engagement and behavior change
Polonsky and Fisher, 2015

50. Paired Testing: Sam’s Story
Age 42, married, school teacher
T2D 6 yrs, BMI 33, last A1C 7.9%
Steady weight gain since dx
Used to be very active, but quit sports 5 years due to injury
No longer checks BGs due to “consistently high readings”
Takes glargine, 80 units QD
Was encouraged to begin walking, but refuses (“won’t help”).

51. Sam’s Exercise Experiment
Day
Pre-
Exercise
Post- BG
Change 1 2 3 4 5 6 7
129 mg/dL
101 mg/dL
-28 mg/dL
194 mg/dL
153 mg/dL
-41 mg/dL
157 mg/dL
94 mg/dL
-63 mg/dL
141 mg/dL
108 mg/dL
-33 mg/dL
152 mg/dL
127 mg/dL
-25 mg/dL
130 mg/dL
98 mg/dL
-32 mg/dL
124 mg/dL
102 mg/dL
-22 mg/dL
Daily walk
(45 minutes)
7 consecutive days: Measure BG right before and after walk
Average BG change: -35 mg/dL

52. “I wonder how breakfast affects me
“I wonder how breakfast affects me.” “I wonder why I’m often so tired in the evening.” “I wonder which type of beer would raise my BG’s the least.” .

54. Lack of Worthwhileness
Emotional distress
Perceived benefits are nil
Perceived costs are too high
Unrealistic (or too vague) expectations
Environmental pressures

56. Five Medication “Secrets”
Big bang. Taking your meds is one of the most powerful things you can do to improve your health
Working silently. Your meds are working even if you can’t feel it
Balancing the claims. There are always pro’s and con’s; the con’s are probably not as big as you think.
No blame. Needing more meds isn’t your fault
Not a health metric. More meds don’t mean you’re sicker, fewer meds don’t mean you’re healthier

57. A Diabetes Quiz
ROY takes 2 different diabetes pills and insulin, and his last A1C is 6.8%. SAM hasn’t been prescribed any diabetes pills, and his last A1C was 9.1%. Both patients have had diabetes for the same length of time.
Who is doing better with his diabetes?
________________________________________
ROY. How healthy you are, and your risk of complications, is not determined by the type of treatment or how many pills you take. It is your metabolic results that matter.
Even if you are not taking pills or insulin, high blood sugars will likely lead to future problems. 57

60. Thanks for Listening