According to the Alexandria, Va.-based American Diabetes Association’s Web site, the condition occurs when the body either does not produce or use insulin, a hormone that converts foods, including sugar or starches, into energy. When the body senses sugar is present, the pancreas produces insulin, which then allows cells to use the sugar, explains Sheila Matlak, RN, CDE, a registered nurse and diabetes educator at the Diabetes Center at Mercy Hospital in Baltimore.

In the U.S., 23.6 million adults and children – or 7.8 percent of the population – have diabetes, but nearly a quarter of them have not been diagnosed.

Diabetes comes in a variety of forms. Type 1 results from the body’s failure to produce insulin and is estimated to affect 5 percent to 10 percent of Americans diagnosed with diabetes. Most diagnoses, however, are for Type 2, which results from insulin resistance, where the body fails to use insulin properly. Gestational diabetes comes about during pregnancy and is similar to Type 2. Additionally, 57 million Americans have pre-diabetes, in which blood glucose levels are above normal, but not as high as in Type 2.

 

Fatigue is among the standard symptoms of either Type 1 or Type 2 diabetes, Matlak says. High blood sugar levels indicate that cells are not receiving the nutrition they need. The individual will feel hungry and will eat; however, with Type 1 diabetes, because there is no insulin, they often lose weight because of poor nutrition. The heightened blood sugar levels will also cause the body to try to flush out the excess through urine, meaning the individual becomes dehydrated.

Long-term effects of poorly controlled or uncontrolled diabetes, regardless of the type, can include loss of vision. Matlak says the disease is the leading cause of new cases of blindness in the U.S. Diabetes can also affect the kidneys and is the leading reason for dialysis. It can also lead to neuropathy, which is nerve damage to the feet and legs in particular, but also some times to the arms and hands.

“[Diabetes] goes hand-in-hand quite well with heart disease, high blood pressure, and strokes,” Matlak says. But for a chronic disease, she adds, diabetes is manageable.

There is both good and bad news about diabetes, says Wendy Satin Rappaport, PsyD, MSW, an adjunct professor at the Diabetes Research Institute (DRI) in Miami, and a professor in the graduate school of social work at the University of Maine’s outreach center in Belfast, Maine.
 

Rapaport adds, “There’s a lot you can do to take care of yourself, as opposed to other illnesses that you get and you’re lucky or you’re not because the doctors take care of you. So, the good news is you can do something; the bad news is you have to do something, and that it’s hard. The things you have to do are all the things everybody has trouble with – namely, eating correctly and exercising. The other dimension that’s diabetes-specific is testing blood sugar, reacting to the outcome without becoming crazy with failure, perfectionism, and then picking how much insulin you take to match what that blood sugar is.”

Matlak says Type 1 diabetes ultimately requires insulin replacement and management, but Type 2 can sometimes be managed with dietary and meal planning and with activity or exercise.

She adds, “Type 2 is a progressive disease, in that it will usually continue to worsen throughout time. Now, it may vary with different individuals as far as how quickly it will progress. But some people are fine for years on meal planning and the activity control. Then they may need a little help in the way of oral medications that encourage the pancreas to produce a little more insulin or tells the liver to hold on to stored-up glucose, so that it can be managed somewhat that way. It may ultimately get to the point where the person with Type 2 diabetes may have to have replacement insulin, or supplemental and then replacement.”

Matlak says, “It can be very frustrating, especially for somebody with Type 2 diabetes, because they’re doing what worked, and now all of a sudden it’s not working.”

 

The clients Matlak works with are primarily not hospital in-patients. She explains that part of the reason is that in-patients are often too sick to learn very well, and floor nurses have been trained to teach them survival skills. As patients are discharged from the hospital, they can make appointments to come to the Diabetes Center. Outside doctors also send patients to the center.

“They refer them to us for education and/or management, because we have an endocrinologist here, as well, so we can do team management with the dietitian, the nurse-educator, and then the physician, as well,” Matlak says.

There are five diabetes management tools Matlak goes over with her patients. She educates them about what diabetes is and how to take care of it. Patients also learn about helpful forms of activity. Meal-planning teaches them about what to eat, portion size, and timing. Patients also learn about medications, if needed, how they work and when to take them.

“And then the last thing is the glucose monitoring or finger sticks, so that you know what your blood sugars are doing on a regular basis,” Matlak says. In working with clients, she uses a variety of tools, including discussion, visual aids, and printed materials.

Therapy Times blogger Lanah J. Brennan, RD, CDE, with a private practice in Lafayette, La., called Reactive Nutrition LLC, says her role with diabetic patients will vary with the individual. “Really, I’m a source of support for them, especially, when they’ve first been been diagnosed. A lot of times, the physician’s office doesn’t have time to really sit down and do a lot of education with the patient,” she adds.

Brennan says she talks to patients about what diabetes is, but mostly emphasizes how patient food choices affect their body. “We create a meal plan that’s going to be individualized for that person, and I try to base it on what they’re already doing,” she adds.
 

Brennan reviews what a typical day is like for the patient, and what their eating habits and food preferences are. “From there, we go on to make some adjustments to their current foods. Maybe it’s just switching up their cereal to something with a little bit more fiber in it,” Brennan says. She also instructs patients on how to use a glucometer for checking blood sugar, or how to use insulin, if they are on it. “Just preventing complications, I think, is the main goal of what I do,” Brennan says.

Other than taking medication or using insulin, diet and activity are the only tools patients have for controlling their diabetes, according to Brennan. The nutritional guidelines she recommends for patients include having smaller meals, including snacks, throughout the day, to ensure they do not go for too long without eating, and balancing carbohydrates with proteins or healthy fats.

Using the meal plan prepared by a dietitian, an occupational therapist with a basic level of understanding about diabetes and nutrition management can use information about carbohydrate counting or portion control when working with clients on kitchen activities and cooking, says Debra A. Sokol-McKay, MS, CVRT, CLVT, CDE, OTR/L, SCLV, a Bethlehem, Pa. consultant whose previous experience includes providing low-vision and adaptive diabetes self-management through visits for a local home-care agency.

As a patient with diabetes has more complications, such as neuropathy or cardiac loss, an OT might be working with them in more areas and for longer periods of time. Sokol-McKay explains that part of the work she does as an OT is to help patients with adaptive techniques for monitoring blood glucose if they have coordination or vision problems.

She says, “So I work to help people on the direct skills of managing diabetes – measuring insulin, blood glucose monitoring, maybe returning to exercise and keeping in mind things like low blood sugar, precautions related to physical and visual disabilities.”

Sokol-McKay says she is currently pursuing training to teach patients how to use insulin pumps. “My goal would be that I would be able to develop techniques, or be seen as a person who could be referred to, as far as adaptations for people with disabilities, be it visual or physical,” she adds.

 

Present 24 hours a day, seven days a week, diabetes has a significant psychological impact, says Sokol-McKay. “It impacts how you look at food and the kind of food you eat. It impacts your physical activities and your activity levels. So everything that you do in life is impacted by diabetes, and I think that makes it more challenging for OTs because their clients can’t get away from it.”

Rapaport says that what attracted her to the DRI 34 years ago is its recognition of the psychological, social, and behavioral aspects of diabetes. The condition has both psychosomatic (i.e., the mind affects the body) and somatopsychic (i.e., the body affects the mind) dimensions. “When your blood sugars go up and down and they’re not tending toward normal, there’s a biochemical moodiness that comes with it. You don’t feel well,” she explains.

Rapaport adds that diabetes patients are told that if they do not take care of themselves, their entire body may be affected, such as through loss of vision or limbs, or heart or kidney disease. There can also be sexual complications. “For men, there can be impotency. So there’s all those fears and concerns that people live with,” she says.

Self-esteem can be tied to the goal of getting blood sugar down to normal levels. “It’s very hard to do it well, because you can’t always predict what your body’s going to do, or where you eat. Sometimes, you binge, or you’ll make a mistake in what you think you need in insulin, and you’ll take too much, and your blood sugar will go low, or you don’t take enough, and it will go high,” Rapaport says.

 

Rapaport say compliance can be an issue for patients with diabetes. For instance, they might not do things they should, like monitor their blood sugar, because it depresses them. Rapaport says she helps patients not only deal with the grief of having been diagnosed, but also not to feel that they have failed.

“I run a support group monthly for individuals and their families with Type 1 diabetes, and I am part of the MYD (Mastering Your Diabetes) program, which is an intensive educational effort to improve individual management of diabetes in a group setting. I see patients in a one-on-one or family setting for the emotional adjustment by the whole family to diabetes, interpersonal interactions, and behavioral follow through,” she adds.

Rapaport explains that she trains family members and medical staff in communications skills. For instance, if a patient is feeling out of sorts, their spouse might offer to help them test their glucose. “It’s very different than judging or being angry with your family member for not having normal blood sugars,” Rapaport says.

At DRI, she and several colleagues started the PEP (“Parents Empowering Parents”) Squad. Parents of children diagnosed with diabetes are trained to become mentors for parents of new patients. “What it does is it helps the people that have already been diagnosed realize how far they’ve come, how successful they’ve been in handling a very difficult thing. If you can help another person, you know how that always helps you, no matter what, when you’re depressed.” Rapoport says.

The PEP Squad meets monthly, except during the summer. The group’s core consists of a dozen mothers. “They go and they meet other individual families. They come back to get their strength and tell their stories, to get advice, because they’re mentors,” Rapoport says. “They do play dates and groups with their husbands and children. Some of the families get together outside, because there’s nothing better than a kid who meets another kid, and it’s time to eat, so everybody takes their insulin. Diabetes camps are very popular for that reason.”

 

— Mark D. Marotta is staff writer for Therapy Times. Questions and comments can be directed to mmarotta@therapytimes.com.