Health Psychology: Understanding Diabetes and the Role of Psychological Treatment

The Local Scene

According to a recent 2016 article in The Straits Times, Singapore has the 2nd-highest proportion of diabetics among developed nations, a report in 2015, revealed by the International Diabetes Federation (IDF).  A focus on diabetes prevention was reported as being a crucial task for the nation.  What's identified as patients being in the pre-diabetes stage, one-third of them would become diabetic, and another one-third will remain pre-diabetic.  It was pointed out that with exercise and weight-loss, the remaining one-third can revert to normal glucose levels.  To quote some figures from the Singapore Ministry of Health, ...

"Diabetes is a growing problem in Singapore today. Figures from the National Health Survey 2010 reveal that 11.3%, or 1 in 9 Singapore residents (Singapore citizens and Permanent Residents) aged 18 – 69 years were affected by diabetes. Of these, 1 in 3 diabetics were unaware that they had diabetes. Among the diabetics who were aware of their disease, 1 in 3 had poor control of their condition.

Prevalence of Diabetes in Singapore *

• Year 1998 ---> Rate 9.0%
• Year 2004 ---> Rate 8.2%
• Year 2010 ---> Rate 11.3%

* For Singapore residents aged 18 – 69 years.  (Source: National Health Survey 2010).

In 2014, around 440,000 Singapore residents aged 18 years and above had diabetes. If we do not do anything, the number of diabetics in Singapore could rise to 670,000 by 2030 and nearly 1 million by 2050, based on an estimate by the Saw Swee Hock School of Public Health." 

Despite consistent reports by notable sources like the Diabetic Society of Singapore, published public information on the War on Diabetes by the Ministry of Health, and other newsworthy highlights in recent times on How Seriously Do You Take Diabetes?, there is still a lack of sufficient information made available to the public on the role of psychology in its prevention and treatment.  The importance of psychologists for improving disease management and quality of life, cannot be further underlined.  As this includes the contributions of the behavioural and social sciences toward improved diabetes prevention and treatment, there are many opportunities for psychologists to close the gap in the research, develop practice competencies, and increase training opportunities to meet the challenges of diabetes for Singaporeans and the public at large.

The Case for Psychology

In routine clinical care, there are two primary methods to measure glycemic control, a haemoglobin blood test (3-monthly), and daily self-monitoring.  Both ways requiring a mix of medication and lifestyle behaviours that is one of the central goals of diabetes management.  We're talking quite possibly a certain amount of mental discipline and awareness of the importance of these and many associated lifestyle factors involved in the disease management process - consider the difficulties in trying to manage diabetes in the paediatric, child, or geriatric population, let alone the adult population.  Advances in care are needed, including a focus on behavioural and psychosocial approaches to improve disease management.  

"Maintaining good glycemic control requires individuals to consistently engage in multiple disease management behaviours, which can be burdensome for the individual with diabetes and their loved ones.  Self-management often requires regular self-monitoring of blood glucose values, adherence to a medication regime, sustained changes in diet and physical activity, preventive self-management (e.g., foot and eye exams), and other behavioural strategies for maintaining healthy mood and quality of life." (American Diabetes Association, 2015)

According to Psychologist Christine Hunter (2016), all of these self-management behaviours are influenced by the type of diabetes, duration of illness, and presence of physical and psychological comorbidities, as well as differing requirements for treatment and support across the life span.  Hence, psychologists play an important role, not only in delivering psychological care, but also in developing new approaches to improve prevention and treatment that are tailored to an individual's developmental stage, social support networks, and capacity for self-management.  If you think about it, it's not unlike patients with other chronic and debilitating psychological issues like Schizophrenia or Major Depressive Disorder, for instance.

Psychological Intervention

Kids. Psychologists with competencies in paediatric care and family therapy can help families develop improved problem solving, communication and behavioural management skills as a means to improve quality of life for the child and family and to optimise disease management. 

Adolescents. This is a time when individuals in this age range would experience deteriorating glycemic control and withdrawal from regular health care, and can be accounted for by normal pubertal, social, emotional, and cognitive changes that occur.  This relates to need for increased autonomy, which requires a shift in responsibility for disease management activities, and can be problematic when the relationship between parents/adolescent is strained.  Add on increasing influence by peers, adolescents would have concerns fitting in and possible stigma associated with diabetes, and be experimenting with substance use, all of which can influence adherence to the diabetes management regimen.

Young Adulthood. Same issues as adolescents, but add on the expected social, financial and health care changes that occur when there are pressures to live independently and support oneself.

Adults. Adults with diabetes must balance the disease management demands in the context of their employment and/or building and caring for family.  These can be made complicated by the diabetes medical regime and maintenance of quality of life, incorporating the management and treatment of new diabetes or age-related comorbidities such as cardiovascular disease cognitive impairment, musculoskeletal disorders, vision and hearing loss, end stage renal disease, and painful neuropathies.  

It is clear that the role of psychology is crucial and necessary in the treatment of diabetes overall.  For e.g., aspects such as motivational interviewing and psychoeducation can be easily inserted into treatment, as part of modifying current patient views of their disease through lifestyle changes, and treatment adherence, both cornerstones of diabetes management.  Also, not to mention the high rate of incidence of individuals falling into depression and anticipatory anxiety in relation to fears of further health risk all contribute to a burgeoning area that may be underlooked in our nations diabetic health management.  

With the growing demands of diabetes prevention and care, the integration of psychological services into primary care and into community prevention efforts will undoubtedly be important for timely and efficient prevention and health care delivery.  As pointed our by Hunter (2016), the role of the psychologist in interdisciplinary teams is integral given our knowledge of issues related to different phases of the patient's life, as more basic behavioural science is needed to identify individual differences in treatment response and the behavioural, psychological, or social mechanisms that contribute to successful initiation and maintenance of behaviour change. 

For more detailed information about measuring glycemic control, see the Gonder-Frederick, Shepard, Grabman, & Ritterband (2016). Also, the ADA annually publishes updated guidelines for assessment and treatment. These guidelines also include many recommendations for the psychosocial and behavioural disease management support. Psychologists who plan to work with individuals with diabetes should be familiar with the latest guidelines at http://professional.diabetes.org/ResourcesForProfessionals.aspx?cid=84160&loc=rpslabnav

Source: Hunter, C. M. (2016). Understanding Diabetes and the Role of Psychology in Its Prevention and Treatment. American Psychologist, Vol. 71, 7, 515-525.