Diabetes Forecast

Changing Health Behaviors Benefits Those With Diabetes

Techniques to help you change your health behaviors

Haleigh Eason (illustration); GhostlyPixels/CreativeMarket (textures)

People with diabetes know managing the disease takes extraordinary motivation, organization, and focus. And the work involved can be tough on the mind: Psychologists are beginning to recognize that the daily tasks of self-care—the constant struggle to maintain blood glucose levels in a healthy range, whether through exercise, medication, diet, or a combination—can be a psychological drain.

“All these things deplete you of internal resources,” says Lisa Sharp, PhD, a psychologist at the University of Illinois. Over time, the psychological toll means people with diabetes might have a harder time sticking to self-care behaviors or getting motivated to make changes.

Behaviors encompass everything from eating (what, when, and how much) to the way people administer insulin and other medications important for treating their diabetes. Unhealthy behaviors are often heavily influenced by the environment: Healthy food might be hard to find in your neighborhood, or you might feel too stressed to check your blood glucose regularly. Others might come from within: It’s not just people with diabetes who struggle to find the motivation to exercise every day, for example.

The challenge is finding ways to overcome bad habits and make healthy behaviors part of your routine. To help, researchers around the country are turning to insights and approaches from psychology—specifically, cutting-edge knowledge about human motivation and behavior. It’s called behavior science, and it’s being used across the spectrum of people living with diabetes. Here are a few ways behavioral science experts say you can modify habits for good—and ease the burden of diabetes.

Reward Yourself

Studies have shown that incentive programs—paying people or rewarding them for good behavior—can be powerful tools for change. The approach is intuitive and common: 12-step programs such as Alcoholics Anonymous use incentives such as chips to encourage members to stay sober; employers use pay raises to reward productivity.

Nancy Petry, PhD, a researcher at the University of Connecticut Health Center, has spent decades applying the psychology of rewards and incentives to substance abuse problems. In therapy programs for smokers, drug users, and heavy drinkers, she made the incentives for healthy behaviors random and less frequent, rewarding participants for staying clean with weekly draws from a fishbowl filled with slips of paper. Half of the slips offered encouragement such as “Good Job!” The rest were vouchers for small prizes worth about a dollar. Sprinkled in were a handful of large prizes worth $20 and a single big-ticket item worth $100.

The incentives worked so well for people trying to quit drugs and cigarettes that Petry wondered if similar rewards could help people lose weight or exercise more. In the experiments she’s conducted so far, incentives seem to work: “Similar things might be at play in terms of behaviors associated with type 2 [diabetes],” Petry says. To replicate the success at home, Petry suggests celebrating milestones with specific rewards—such as movie tickets or new shoes.

One question researchers still don’t agree upon is the extent to which incentives have a lasting effect—do the positive behaviors disappear when the rewards stop? Petry admits that the behavior change can start to slip once the rewards are taken away, but she argues that even short-term change can open the door to more lasting behavior modification. “Once you’ve lost weight, that should help with your motivation to keep it off,” she says. “But you can’t get long-term change without first getting initial change.”

Discuss as a Family

In a 2006 article for Diabetes Spectrum, Michael Harris, PhD, compared small children to dogs: They’re straightforward to discipline, love to be around you, and crave attention and affection. Teenagers, on the other hand, have more in common with cats. While they still crave and enjoy affection, they’re “independent, enjoy their solitude, need a great deal of cajoling to do things, and are difficult to discipline,” Harris wrote.

Yet parents often fail to adjust as their kids morph from dog to cat. “As kids move into becoming more independent, there’s an increase in conflict because parents have a hard time giving up control,” says Harris, who is now a psychologist at Oregon Health and Science University.

When it comes to helping kids manage their diabetes, typical family conflicts can have serious health consequences: Teens may see well-meant reminders to check blood glucose or managediet as nagging, for example. As for important diabetes self-care behaviors, Harris says, “the more they’re nagged, the less likely they are to check.”

To help families adjust, Harris and colleague Tim Wysocki of the Nemours Children’s Clinic in Jacksonville, Florida, have adapted a family therapy technique called behavioral family systems therapy to a diabetes care context. The goal is to get parents and teens talking about problems by teaching them to work things out in a productive way. “We explain what’s normal and start hammering away at communication deficits and skills,” Harris says.

Take, for instance, checking blood glucose. First, the therapist or psychologist will lay out the problem, beginning a discussion to show that business as usual isn’t helping solve the issue. Then the therapist will help the family brainstorm approaches to reduce the back-and-forth between teens and parents, such as offering incentives for checking regularly, programming alarms, silently setting the meter out on the breakfast table, or ignoring missed blood glucose checks and praising those things teens remember to do on their own.

Together, the family looks for a solution that fits them best; in follow-up sessions, parents and teens discuss the approach and tweak it if it’s not working. “These are basic things most families don’t do,” Harris says. “We’re getting them to think in ways that can be very effective.”
When dealing with their child’s behavior, parents should keep in mind:

  • Structure and routine at home help adolescents with diabetes better take care of themselves.
  • Teens with diabetes benefit from parental affection and involvement coupled with a democratic, as opposed to authoritarian, approach to problem-solving.
  • Teens need role models. When parents and caregivers maintain a healthy lifestyle, their kids are more likely to take care of themselves and their diabetes.

In several studies comparing the behavioral family systems therapy approach to treatment as usual, Harris has shown that talking things through with the help of a counselor can reduce family conflict and improve glycemic control in teens. Last year, his work won him the American Diabetes Association’s Richard Rubin Award for innovative contributions to the understanding of behavioral aspects of diabetes.

Harris is taking things a step further, examining how technology can help families benefit from the behavioral family systems therapy approach. Among other things, he’s looking at whether the approach works remotely—via Skype counseling sessions, for example. No matter how the message is delivered, his basic advice remains the same: As their children mature into teenagers, “parents need to change their old approach to accommodate a different animal.”

Ask for Help

Diabetes is a huge problem in America’s inner cities. But it’s just one of many. Poverty, stress, access to healthy foods, and a lack of safe places to exercise crowd the list of people’s worries, making managing type 2 diabetes even more of a struggle. “They’re struggling and don’t have control over so many aspects of their life,” says Lisa Sharp, PhD, a clinical health psychologist at the University of Illinois at Chicago’s Institute for Health Research and Policy.

To help low-income people cope, Sharp is researching ways to give them back some control. One approach is to work with a community health worker, typically someone who’s from the community the person with diabetes lives in and is trained to act as a link between patients and their health care team. Community health workers visit people with diabetes at home regularly, getting to know them, discussing the issues they’re struggling with, and helping them come up with a plan to manage their diabetes. The personalized support can work wonders, improving glucose control and weight loss.

Sharp is hoping to harness this approach to help low-income people manage the barrage of medications they’re prescribed by different doctors. Because diabetes is associated with many other conditions, from high blood pressure and heart disease to kidney problems and depression, people with diabetes see multiple health care providers.

In a pilot study, Sharp equipped the community health workers with iPads. During patient visits, they connected people with diabetes with pharmacists who went through their health records to figure out what medications were appropriate to be taken at the same time. In a related study, she used text messages to send people reminders a day or two in advance of doctors’ appointments and medication refills, along with occasional simple encouragement, such as “You have come a long way—keep up the good work!” The messages were crafted in cooperation with the community health worker to be specific to the patient. “We were able to get their A1C down 1 percent and keep it down for a year,” she says.

Learn to Problem-Solve

As anyone with diabetes knows, self-care is a defining feature of the disease. Health care providers and loved ones can only do so much to help out. Ultimately, the day-to-day burden of managing diabetes—whether it’s type 1 or type 2—is a personal one. Figuring out how to do it can be tough.
In other words, says Felicia Hill-Briggs, PhD, ABPP, self-care takes some serious problem-solving skills.

Hill-Briggs, a clinical psychologist at Johns Hopkins University and president of health care and education for the American Diabetes Association, has developed a structured curriculum called Decision-Making Education for Choices in Diabetes Everyday to teach people with diabetes problem-solving skills. It’s an approach psychologists have been using for decades to help people deal with depression and other mental health issues, adapted to the context of diabetes self-care.

Her program teaches people to identify and solve problems for themselves, walking them through crucial steps:

8 Steps to Successful Problem-Solving

  1. Identify which behaviors are the hardest to change.
  2. Be aware of the barriers.
  3. Note how a barrier gets in the way.
  4. Brainstorm possible solutions.
  5. Pick one solution and create a plan.
  6. Carry out the plan.
  7. Evaluate your results.
  8. Adjust as needed.

For example, you might want to lose weight, but you’re not sure how. You’d start by thinking about what’s standing in your way (no time to make healthy meals, for instance), then you’d come up with a plan to overcome the challenges (rearranging your schedule or finding simpler recipes), and finally carry it out. Recognize that your first plan might not work, and reflect and adjust as needed.

At the heart of the approach is a well-researched piece of behavior science: “Lifestyle behavior change doesn’t work if we set goals like what we call New Year’s resolutions,” Hill-Briggs says. “Changes you don’t plan and prepare for do not last.”

The approach has been tested in low-income neighborhoods in Baltimore and in rural Colorado, West Virginia, and North Carolina. Hill-Briggs has shown that people can teach themselves using workbooks or online modules with results similar to or better than what they get from structured classes. “What we find is not only behavior changes but phenomenal results in A1C and blood pressure and cholesterol,” Hill-Briggs says.

Share the Decision-Making

A few decades ago, the doctor-patient relationship was very clear: Doctors gave orders, and patients followed them. But in recent years, researchers have concluded that the approach not only leaves patients in the dark but may also lead to worse health outcomes.

One solution is an approach called shared decision-making, where patients and health care providers share information and work together to come up with treatment plans that take into account the patient’s preferences and values. The shared decision-making approach encourages people to be active participants in their own medical care, asking questions, raising concerns, and, if necessary, pushing back on a doctor’s orders.

When people feel like they own part of the decision, says University of Chicago associate professor Monica Peek, MD, MPH, MSc, they’re more likely to come up with more realistic plans from the get-go. And that makes them more likely to follow through when it comes to behavior changes.

As part of the South Side Diabetes Project, a study that works with six clinics in low-income Chicago neighborhoods, Peek is investigating how shared decision-making affects health behaviors. For her, the work isn’t as simple as pushing people to be pushier in the doctor’s office. The community where she works is primarily lower income and African American. She’s found that patient education is a critical first step. “People can’t share in decision-making unless they understand what the decision is about,” she says.

Prescriptions for food and exercise can also help people stick with healthy habits. “We know a physician’s recommendation can be a powerful motivator for behavior change,” Peek says. “Things written on that pad tend to be taken more seriously.”

The team designed a prescription pad that resembled an official one, including the phrase “I recommend the following nutrition for my patient,” followed by checkboxes for low-carbohydrate, low-fat, high-fiber, and low-sodium eating plans. On the back of a participating doctor’s “prescription” for healthier food is a coupon or voucher for a farmer’s market, which breaks down one more barrier (affordability) to behavior change.

Over the eight years since the study was launched, Peek’s team has seen improvements in the self-management behavior of patients in the shared decision-making program—along with improvements in their cholesterol and blood glucose measurements. “Anyone can benefit from shared decision-making,” she says.

Changes Ahead

Behavior change is all about turning healthy behaviors into habits that stick. People with diabetes know it’s not easy, and that’s why many of the approaches researchers are testing involve building a support network: getting peer coaches, family members, and health care providers involved and on your side.



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