CHALLENGES OF TYPE 2 DIABETES AND ROLE OF HEALTH CARE SOCIAL WORK: A Neglected Area of Practice
DeCoster, Vaughn A., Health and Social Work
Across the world, diabetes mellitus is one of the most prevalent and serious chronic diseases. In the United States alone, almost 16 million people suffer from diabetes, which costs many of them their eyesight, kidney function, lower limbs, or life itself, and costs the U.S. health care system billions of dollars. Currently, social work involvement with this chronic disease appears limited; however, social workers have the potential to make remarkable differences in the lives of people coping with diabetes. To facilitate involvement, this article outlines the basic aspects of Type 2 diabetes mellitus, its biopsychosocial challenges, and the roles health care social workers that may be assumed in assisting adult patients and their families.
Diabetes mellitus is one of the most prevalent and serious chronic diseases facing the U.S. health care system. According to the Centers for Disease Control and Prevention (CDC) (1998), diabetes affects 15.7 million people in the United States, 10.3 million of who have been diagnosed and 5.4 million of who are unaware that they have this disease. The American Diabetes Association (ADA) (1998) estimates that in 1997 alone medical care for diabetes cost $44.1 billion dollars. Diabetes exacts an equally devastating physical toll; it is the leading cause of blindness, end-stage renal disease, noninjury-related lower limb amputations, and cardiac disease, and it is the seventh leading cause of death in this country (CDC, 1998). Currently, social work involvement with this chronic disease is limited. For instance, as of 1998, social work clinicians made up less than 1 percent (n = 57) of the professionals listed with the American Association of Diabetes Educators, the principal organization of diabetes professional s. As a topic of research, a review of the social work literature identified 13 articles on diabetes-related topics (see Table 1). Although there are probably many social workers treating and researching diabetes, their involvement seems inconspicuous. Considering the ability of diabetes and its treatment to challenge an individual's biopsychosocial functioning, social workers have the potential to make remarkable differences in the lives of people coping with this disease. Nevertheless, according to Sidell (1997), mental health professionals "typically receive little training specifically designed to help them assist people with chronic illnesses" (p. 10).
To assist people with diabetes, social workers first need to understand the disease, how it challenges patients, and then ways to become involved. This article outlines the basic aspects of Type 2 diabetes, its incessant challenges, and several interventions health care social workers may use to assist adults with this chronic disease.
Diabetes mellitus is a cluster of endocrine diseases characterized by the body's complete or partial inability to absorb glucose, the principal source of energy, from digested foods into cells (Harris, 1995b). Unabsorbed glucose accumulates in the bloodstream, eventually exceeding physiologically tolerable levels, damaging blood vessels and capillaries. According to the National Institutes of Health (NIH) (1995), diabetic complications include blindness, renal failure, peripheral neuropathy, and peripheral vascular disease. People with diabetes are also at greater risk of cardiac disease, strokes, amputations, retinopathy, cataracts, glaucoma, and gestational complications compared with people of similar age without diabetes (CDC, 1998; NIH, 1995).
Distinguishing Type 2 from Type 1 Diabetes
There are primarily two forms of diabetes. In Type 1 diabetes, formerly called "insulin-dependent diabetes mellitus," the pancreas produces very little or no insulin, necessitating an injected supply of insulin. Type 1 accounts for between 5 percent and 10 percent (from 515,000 to 1.3 million) of diagnosed cases (CDC, 1998). Although Type 1 diabetes is the most frequent chronic childhood disease, formerly referred to as "juvenile diabetes," 60 percent (from 309,000 to 780,000) of cases are among people over 19 years of age (LaPorte, Matsushima, & Chang, 1995). The focus of this article is Type 2 diabetes, a disease in which either the insulin secreted or the body's use of insulin is less effective compared with nondiabetics; it is treated through initially diet, exercise, and oral medications, although insulin injections may be required as the disease progresses (Hillson, 1996).
Although previously termed "noninsulin-dependent diabetes mellitus," 40 percent of adults with Type 2 diabetes need supplemental insulin (CDC, 1998). Labeled "adult onset diabetes" because of its common onset after age 40, Type 2 diabetes makes up approximately 90 percent to 95 percent (from 9.2 to 9.7 million) of diagnosed cases (CDC, 1998). During the 1990s, however, the incidence of Type 2 diabetes among adolescents, referred to as maturity onset diabetes of the young, rose to epidemic proportions among some groups, particularly African American and Native American children (Dabelea, Pettitt, Jones, & Arslanian, 1999). The signs and symptoms for both types of diabetes include sudden weight loss, blurred eyesight, fatigue, frequent infections, increased thirst, hunger, and urination (Davidson, Davidson, & Richard, 1998).
Although the precise etiology of Type 2 diabetes is unclear, researchers have identified four major risk factors: (1) age, (2) obesity, (3) family history; and (4) ethnicity. The incidence of diabetes increases rapidly with age, so that people over the age of 64 are 3.5 times more likely to be diagnosed (Kenny, Aubert, & Geiss, 1995). Overweight adults are also at greater risk; men and women 20 percent above their desirable weight, a common indicator of obesity, are twice as likely to be diagnosed with Type 2 diabetes (Harris, 1995a). A family history of diabetes (parent, grandparent) also increases the risk.
Rewers and Hamman (1995) found that adults with a diabetic parent were four times as likely to contract diabetes. Several ethnic minority groups are also at greater risk of diabetes. The CDC (1999) reported that non-Hispanic black people, Latino Americans, and Asian Americans and Pacific Islanders are twice as likely, and American Indians and Alaskan Natives almost three times as likely, as non-Hispanic white people of similar ages to acquire diabetes. Although family history and ethnicity indicate a genetic cause, behavioral and lifestyle variables (diet, alcohol consumption, physical inactivity, socioeconomic status, and urbanization) also heighten a person's risk of diabetes (Rewers & Hamman, 1995).
To date, research with Type 2 diabetes (Kumamoto Study, University Group Diabetes Program, and Veterans Affairs Cooperative Study on Glycemic Control and Complications in Type 2 Diabetes) and similar studies with Type 1 diabetes (Diabetes Control and Complications Trial) decisively support the aggressive control of blood glucose levels as the paramount treatment approach to reduce many diabetic complications (ADA, 1999b; Cerveny, Leder, & Weart, 1998; Herman & Eastman, 1998).
A typical treatment plan striving to achieve tight glycemic control in Type 2 diabetes may include oral medication or insulin supplements, home monitoring of glucose levels, diet, exercise, and strategies to minimize psychological stress (ADA, 1999b). To meet the requirements of such a regime demands that patients learn a remarkable amount of information (for example, basic diabetes pathology and physiology, symptoms of hypo/hyperglycemic reactions, and dietary guidelines), master several skills (for example, glucose monitoring and insulin injections), and make multiple life adjustments (such as eating habits, regular exercise, and healthy stress management) (Davidson et al., 1998). Common tasks may include finger sticks to test blood glucose levels before meals, oral medication compliance, calculated meal planning, and 20 minutes of daily cardiovascular activity--all on a time schedule (Hillson, 1996).
Plans also may involve weight loss (Nuttall & Chasuk, 1998) and abstaining from alcohol or cigarettes (Rimm et al., 1993). Treatment, therefore, demands significant involvement, responsibility, and change from patients and their families across an array of challenges. It is important to note that even with perfect compliance, blood sugars still may fluctuate, and complications occur (Feinglos & Bethel, 1998).
Diabetes Self-Care Knowledge and Skills
For patients, diabetes treatment involves much information and skill, requiring them to become "self-regulating" (Toobert & Glasgow, 1991). To manage effectively Type 2 diabetes, a person must understand the basic pathological and physiological nature of diabetes, for example, what causes blood sugars to rise and fail as well as the effects of these high and low blood sugars (Hillson, 1996). Although patients need not become "diabetes experts," adequate self-care requires a "working knowledge" of the interaction between personal behavior and immediate glucose control and complications (Assal, Jacquemet, & Morel, 1997). According to Clement (1995), patients also must master self-monitoring of glucose (for example, meter use, recording and interpreting results, and disposing of "biohazardous" materials), become adept at recognizing and treating hypo- or hyperglycemic episodes, planning and executing an exercise program, skin and foot care, ketone testing, care during a cold or flu (sick care), as well as a mult itude of diet-related issues (that is, healthy meal planning, grocery shopping, food preparation, and restaurant choices).
Knowledge and skills also may be needed to manage oral medications or insulin, the latter involving proper storage, dosage calculation and timing, and administration of injections or continuous infusions with computerized pumps. Patients also must master navigation of health care systems (that is, clinics, hospitals, and insurance companies), self-advocacy; and successful interaction with a host of professionals (dieticians, physicians, nurses, and social workers) (Rubin, Biermann, & Toohey, 1997).
Depth of understanding and mastery of skills vary according to the patient's intellectual capacity and education and often are impeded by the sheer volume of material (Glasgow, 1995). The onset of diabetes may be the first time many adults have had extended involvement with health care professionals and systems, and thus they lack familiarity with the medical culture (that is, language, role expectations, and norms) (Graziani, Rosenthal, & Diamond, 1999). The learning process also may be hindered by a sense of urgency to get the disease "under control," the presence of other health problems or disabilities, pre-existing learning challenges (for example, attention deficit disorder or dyslexia), mental retardation, psychosocial problems (such as thought or mood disorders or family problems), language incompatibility with the professionals, illiteracy, level of emotional acceptance, access to diabetic education (for example, programs, professionals, and materials), absence from diabetic classes or appointments, or insufficient time to study (Overland, Hoskins, McGill, & Yue, 1993).
Diabetes-informed social workers are an asset to diabetes educators and programs, serving as the resident behavioral science experts (Daley, 1992). Social workers can interject, affirm, and interpret relevant psychosocial factors during initial assessments and progress evaluations--highlighting strengths, needs, family involvement and functioning, and the effects of patient, family, and group cultures on outcomes (Auslander, Bubb, Rogge, & Santiago, 1993). They are invaluable as consultants or instructors to diabetic clients also dealing with cognitive deficits, learning disabilities, or chronic mental illnesses. Likewise, social workers are indispensable in designing and implementing education programs and materials tailored to meet the information and skill needs of people with learning challenges or educational deficits and especially young or elderly patients. In particular, social work practitioners are ideally suited to develop and teach the psychosocial component of a diabetes program that may include presentations on behavior modification, emotions, depression, stress and time management, and community resources. Social workers also can serve as resources to those lacking access to traditional diabetes programs, such as rural, homebound, uninsured, or underinsured populations or in medical settings with limited diabetes education resources.
When client or family psychosocial issues inhibit the educational process, social work intervention can help resolve or contain the problem, allowing continued instruction. Facilitating a family-centered approach-- family as the focus of intervention--, among the multidisciplinary diabetes team may be a more preventive approach for addressing resistance (EII & Northen, 1990). Family-centered interventions may include soliciting and addressing family concerns, encouraging family attendance and participation at appointments, fostering shared responsibility and credit for treatment outcomes, incorporating family members' talents and health needs in the care plan, enlisting participation in classes, and selling everyone on the benefits of healthy habits for wellness and delaying or preventing the onset of diabetes.
To improve participation in outpatient programs, social workers can identify and address client barriers to keeping appointments, such as inadequate transportation, noncooperative employers or family members, limited financial or child care resources, or even poor client motivation. Pairing newly diagnosed patients with "diabetic sponsors"--individuals who are experienced and successful at managing their diabetes--also may enhance attendance. Rather than relying on clients to come to clinics, social workers may need to bring the clinics to clients by organizing diabetic health fairs, outreach, or training programs in work settings, church facilities, or community centers.
Diet and Exercise
For people with Type 2 diabetes, medical nutritional therapy (MNT) is often the "first-line therapy of choice" (Lipkin, 1999). The goal of MNT is to maintain near-normal glucose levels by matching dietary consumption with actual caloric (energy) needs, necessitating that the right foods in correct proportions be eaten at prescribed times (Nuttall & Chasuk, 1998). For many MNT may include a secondary goal--weight loss. In meeting either goal, the person must become aware of his or her individual food consumption patterns and basic caloric needs for height, weight, age, and level of activity; be able to prepare and plan well-balanced meals using fresh foods as often as possible; be able to read and interpret nutritional information on food labels; and be able to incorporate regular meal times into work and home schedules (ADA, 1999c; Franz et al., 1994).
Nutritional self-management or compliance with a prescribed diet can be handicapped by many of the same factors that impede self-care knowledge and skill mastery. The hectic schedules of patients and caregivers may not allow adequate time or energy to prepare "healthy meals," learn different cooking methods, or shop more frequently for fresh foods. Time and energy limitations plague women with diabetes responsible for food preparation in a family of nondiabetics who protest eating "diabetic food," although educators emphasize that what is good for a person with diabetes is good for someone without diabetes (Rubin et al., 1997).
For some, the availability or ability to acquire nutritionally adequate and safe foods may be limited or uncertain, a circumstance referred to as "food insecurity" (Campbell, 1991). Although predominately attributed to low income, several other factors have been found to contribute to food insecurity: the absence of supermarkets in either remote rural or urban inner-city settings, poor health, limited physical mobility, inadequate transportation, sudden unemployment, homelessness, and budget cuts or poor access to government or private food assistance programs (American Dietetic Association, 1998; Andrews, Nord, Bickel, & Carlson, 1999; Campbell, 1991). In MNT, food assumes an almost medicinal quality, and many may resist altering long-held consumption patterns, inasmuch as food plays a part in their cultural heritage or serves as a source of pleasure; therefore, dietary changes are interpreted as loss of either function. For others, as Quatromoni et al. (1994) discovered with Caribbean Latinos, a belief in destiny or a sense of "fatalism" may inhibit changes in dietary or health behaviors; clients surrender their diabetes care and lives to fate, luck, or God. Alcohol or substance abuse also hinders dietary compliance (Cox, Blount, Crowe, & Singh, 1996).
Exercise is one of the most important and effective methods for managing diabetes. Exercise improves glycemic control, cholesterol levels, cardiovascular fitness, physical strength, and flexibility; decreases blood pressure; and aids weight loss. Also, exercise may prevent or delay the onset of Type 2 diabetes (ADA, 1999b). The ADA recommends an accumulation of 30 minutes of daily moderate physical activity. Most people are encouraged to meet this goal as long as existing diabetic complications are monitored and they are in good glucose control (ADA, 1999a). For some, exercise necessitates well-established self-management skills, pre- and postexercise glucose monitoring, and medication or insulin adjustments according to the proposed activity.
Poor exercise may result from a lack of time or energy competing domestic tasks, family needs, or work demands (Glasgow, 1995). Diabetic complications or medical problems (heart disease, pulmonary disease, arthritis) also may hinder activity. In contrast, many may lack motivation because of the absence of complications, depression, or embarrassment over personal appearance (Swift, Armstrong, Beerman, Campbell, & PondSmith, 1995). Living in high crime areas also may limit establishing adequate exercise routines (Maillet, D'Eramo-Melkus, & Spollett, 1996).
Again, social workers' behavioral science background; ability to work with individuals, groups, or families; cultural competence; and ecological approach can be useful to patients and diabetes programs. In group, classroom, and individual sessions, the practitioner can provide instruction and assistance with behavior modifications, targeting diet and exercise habits in a manner respectful of cultural differences. Families can be engaged as change agents, enlisted to assist and support the patient in altering diet and activity habits, and used as a target for intervention itself through the alteration of family dietary and activity patterns (Rolland, 1994). Specialized behavior plans and monitoring can be developed for challenging patients (that is, noncompliant or behaviorally or cognitively challenged) or those in institutional settings (for example, nursing homes, group homes, assisted living centers, or state hospitals). Given the difficulty of these lifestyle changes, social workers also can provide supp ortive counseling to patients and their significant others. Developing a buddy system, as used with adolescents (Daley, 1992), to partner newly diagnosed people with experienced diabetic mentors (sponsors) is another possible social work intervention.
For some patients, making these lifestyle changes may require assistance with concrete resources. As resource brokers, social workers can assess needs and link clients with community agencies for nutritional assistance, fitness training, additional diabetic education (professionals or material), medical care, health insurance, insulin and glucose monitoring supplies, prescription assistance, transportation, and counseling or support groups.
Resource brokering also is realized when the social worker serves as a community resource expert for other professionals. As recognized by Vest, Ronnau, Lopez, and Gonzales (1997), many social workers may not appreciate and accommodate viable alternative treatment resources (such as herbal medicine, osteopathy, and therapeutic touch), foster understanding of these practices among professionals, and assist clients with incorporating these with conventional treatment. Community-level interventions may focus on neighborhood safety, walk-and-talk exercise groups based in area churches or community centers, food insecurity, or dietary compliance when meals are prepared outside the home (for example, in senior citizen centers, meals-on-wheels programs, or nursing homes). Again, traditional mental health interventions may be necessary to address challenges frustrating compliance with the diabetes diet and exercise plans.
As the treatment regime suggests, diabetes care requires significant investments of time and energy and a degree of punctuality. Wdowik, Kendall, and Harris (1997) found that poor time management was the leading barrier to diabetes management among college students. For example, skipping lunch, eating a late dinner, taking medication or injecting insulin too early or to late, or exercising before breakfast all had immediate and long-term effects. Accommodating the temporal demands of diabetes self-care assumes that life is predictable and orderly and that work or home environments conform to a rigid time schedule, which may in effect curtail spontaneity and add an additional layer of stress for some patients and families.
Social workers can instruct diabetes patients in the area of time management principles and skills, aiding them in prioritizing life activities and accommodating diabetic self-care demands within their personal, family, and work schedules. Social workers may encourage self-advocacy or advocate on behalf of clients for adequate time in the workplace for glucose monitoring, for equitable divisions of household labor, or for greater awareness of the challenges and needs of people with diabetes among family, friends, and the community. Although advances with insulin pumps have increased flexibility and spontaneity for many, the technology is not without problems (for example, pump failure or catheter occlusions) and requires a highly motivated patient with good glycemic control and mastery of additional technical information and skills (American Association of Diabetic Educators, 1997; Dunn, Nathan, Scavini, Selam, & Wingrove, 1997; Lorenz, 1999). In short, diabetes self-care requires a lifestyle change, and soc ial workers can be indispensable in guiding clients through this process.
Understandably, patients experience a great deal of psychological stress at the onset of diabetic symptoms, when diagnosed, while adjusting to treatment, and during complications, in addition to stress from ongoing life events and challenges (Rubin et al., 1997). Stress during acute events (for example, the death of a partner or an automobile accident) can double or triple glucose levels (Greenberg, 1993). Accumulations of chronic stress from work or home may elevate glucose as much as 25 percent above normal (Aikens, Wallander, Bell, & McNorton, 1994). There is also evidence that stress indirectly affects glycemic control through forgetfulness; accidents; or poor coping habits such as denial, isolation, avoidance, increased eating and through alcohol consumption and cigarette smoking (Delamater, Kurtz, Bubb, White, & Santiago, 1987; Peyrot & McMurry, 1992). Essentially, patients need to recognize the signs and symptoms of the sources of stress (positive and negative stressors) and then implement remedies (fo r example, alter perceptions, eliminate or reduce stressors, expose themselves to humor or fun, or engage in relaxation techniques).
Stress management often is constrained by time and resource limitations, pessimism, unassertiveness, inadequate emotional support, limited access to educational or treatment programs, insufficient control over living or work environments, Type A personality traits, or, unbeknownst to many Americans, an addiction to stress itself (Greenberg, 1993). For some, poor diabetes self-care, erratic glucose levels, complications, and stress can become entwined, necessitating professional intervention (Rubin et al., 1997).
As stated earlier, the principal social work intervention may be to provide didactic and experiential lessons on stress management and relaxation techniques to enhance the patients' ability to detect signs and symptoms of stress, foster effective and healthy ways of coping, and encourage relaxation techniques such as progressive muscle relaxation, diaphragmatic deep breathing, or guided imagery. It is important for clients to understand the effects of stress on blood glucose control and the tendency, when stressed, to revert back to earlier, less healthy, coping mechanisms like smoking, overeating, or drinking alcohol (Peyrot & McMurry, 1992). In individual sessions, social workers can identify and assist patients and families with stressors (for example, inadequate resources or problematic life events),offer supportive counseling, or provide guided relaxation instruction. Mediation also may be necessary to ameliorate conflictive relationships between patients and family or patients and frustrated health pro fessionals. Ideally, a staff or on-call social worker can provide immediate assistance to clients during periods of crisis.
In addition to the educational, behavioral, and temporal challenges, chronic diseases like diabetes also bring about significant emotional challenges (Ivinson, 1995; Sidell, 1997). Patients and families face a "literal torrent of affect" throughout their lifetimes with such a disease (Rolland, 1984). Jacobson (1996) asserted that the state of "emotional adjustment" might have a significant influence on the success of glycemic control. Focusing on anticipatory loss in physical illness, Rolland (1994) suggested that patients and families experience an "emotional roller coaster" shaped by their ethnic, gender, and cultural frameworks and the "illness life cycle" (Rolland, 1984)--that is, the temporal phases in a disease: crisis (initial onset and diagnosis), chronic (ongoing adaptation), and terminal (impending death). Although it is beyond the scope of this article to detail a diabetes--specific-stage theory of emotional adjustment, the literature and my clinical experience suggest that people typically encount er six emotion-oriented challenges in various degrees and orders: denial, anger, fear or anxiety, guilt, grief or sadness, and depression.
Denial. Denial can be a feeling of utter disbelief at the diagnosis, a belittling of the seriousness or chronic nature of the disease, or an avoidance of the consequences (Ivinson, 1995). Denial also occurs as a refusal to acknowledge the disease strategically when overindulging at mealtimes or as a defense mechanism against being overwhelmed by multiple losses (that is, loss of control, independence, and health), the treatment regimen, or complications (Cox, 1994). As Ivinson suggested, denial serves a viable function; it allows the person or family to gradually process the event, information, and life changes. Despite its psychological value, denial can be physically devastating to a body battling diabetes. Chronic denial is common and easy for adults who are asymptomatic or erroneously diagnosed as having "borderline diabetes" (NIH, 1995).
Anger. Anger is common for people with diabetes (Cox, 1994; Rubin et al., 1997). When well-being is threatened, anger serves as an initial defense, a "primal reaction" associated with the fight-or-flight response (Greenberg, 1993). Anger is also a classic response to the unanswerable paradox of why "bad things happen to good people" (Kushner & Fetterman, 1997). It may be a product of the bombardment of "have to, must, and should," sometimes referred to as "infantilization" (Rabin, Amir, Nardi, & Ovadia, 1986). Anger can be directed at the diabetes nurse educator, dietitian, or occasionally the physician. Often, though, it is patients themselves or loved ones that bare the brunt of this emotion. Although appropriate, excessive or chronic anger can be destructive to glycemic control, mental health, and personal relationships (Rubin et al.).
Fear and Anxiety. After leaving the protective state of denial and the feeling of control sometimes associated with anger, the fearful reality of diabetes becomes clear (Cox, 1994). Pollin (1995) noted that individuals with chronic diseases like diabetes often fear the loss of control, self-image, and independence, as well as being stigmatized, abandoned, isolated, disabled, or overwhelmed by anger. Diabetes can be a constant reminder of the fragility of life and inevitable mortality, with the unrelenting treatment protocols robbing a person of traditional defense mechanisms like repression and suppression. As with denial and anger, diabetes warrants a reasonable dose of fear and respect (Hendricks & Hendricks, 1998). Nevertheless, fear as well as anxiety has a limited capacity to motivate treatment compliance or behavioral changes and may be debilitating, leading to avoidance, inaction, and depression (Rubin et al., 1997).
Guilt. Guilt and self-blame are also common emotions among people with diabetes (Cox, 1994; Rubin et al., 1997). Because "bad things" are supposed to happen to "bad people' adults with diabetes may blame themselves (because of obesity, improper diets, and stress) for being diagnosed and for poor glycemic control or when diabetic complications surface. Parents may feel a sense of guilt for genetically "passing on" diabetes to their children. Dependency can be a source of guilt among those who feel they are a burden to family, friends, or health care providers (Rubin et al.). Guilt also can stem from self-care mistakes, inactivity; procrastination, or overindulgence or as a chronic means of penance (Amir, Rabin, & Galatzer, 1990). As with other emotions, guilt is appropriate and purposive, serving as an indicator for deviations from treatment protocols. Chronic guilt, however, is destructive; perfect glycemic control is a laudable goal, but unreachable given the unpredictable nature of diabetes.
Grief and Sadness. Grief and sadness are expected reactions to the losses encountered from diabetes (Cox, 1994; Rubin et al., 1997). As Zemars (1984) suggested, someone with a chronic illness "can never fully return to his or her preillness [sic] state of health. Thus the experience of loss ensues" (p.44). Rolland (1994) suggested that patients and families facing threatened loss of control, disruption of individual role functions, and the ambiguity of disease and its treatment might lead to "frenetic behavior or immobilization." Sadness also may accompany the loss of bodily control, behavioral freedom, culinary culture, family traditions, uncertainty for the future, or loss of vision, renal function, or an amputated limb (Rubin et al.). A period of "bereavement" for losses is appropriate, although if unchecked and without resolution may lead to depression (Peyrot & Rubin, 1999).
Depression. Under the circumstances it is understandable why adults with diabetes might feel overwhelmed, vulnerable, and out of control, which can lead to clinical depression (Peyrot & Rubin, 1999; Rubin et al., 1997). Adults with diabetes are five times as likely as the general public to suffer from major depression at least once during their lifetime (Carney, 1998). Among adults with poorly controlled diabetes, the presence of depression can go undetected by health care providers who mistake its symptoms for those of hyperglycemia (characterized by fatigue and sleepiness) and hypoglycemia (characterized by shaky or anxious feelings, despondence, lethargy, and agitation) (Jacobson, 1996). In contrast, patients may attribute physiological symptoms of poor glycemic control to their psychological disposition. Depression is a debilitating illness but when it is combined with diabetes, its effects (for example, depressed mood, decreases in activity, fatigue, anhedonia, weight loss or gain, sleep disturbance, an d poor concentration) can have disastrous consequences for a person's glucose control and for some may lead to an untimely death. As Black and Markidel (1999) found among older Mexican Americans, when depression was comorbid with diabetes, mortality rates were substantially higher than those in comparable groups. Psychopharmacological interventions may have negative side effects as well, with antidepressants increasing or decreasing glucose levels either physiologically or through changes in eating and exercise habits (Jacobson, 1996).
Emotional challenges may be complicated by several factors. First, unresolved personal issues, marital or family difficulties, and pre- existing psychological or alcohol and substance abuse problems can prolong and complicate emotional balance (Rolland, 1994). Normal adult development (for example, identity, career, and retirement) or common life events (for example, marriage, divorce, birth, and death) of patients, family, or friends also can affect emotional reactions. Finally, the severity of the diabetes, presence of complications, or level or ease of glycemic control can complicate these challenging emotions (Lustman, Freedland, Griffith, & Clouse, 1998).
Assuming a counseling role, a social worker is invaluable in aiding patients through these typical emotional challenges. Initially, this maybe accomplished by assessing the patient and family's illness belief systems and previous coping patterns related to emotions (Ivinson, 1995; Rolland, 1994). A social worker also may educate patients and families about these emotional challenges within a psychosocial module during a diabetes self-care class or through individual or family counseling sessions-- normalizing responses, identifying resources, and enabling coping mechanisms (Piening, 1984). In addition, patients can be helped or educated to differentiate between physical sensations associated with high and low blood glucose levels (such as anxiousness, irritability, and lethargy) versus psychosocially based emotion, with the former easily confused with the latter (Rubin et ad., 1997).
Psychoeducational groups for newly diagnosed patients or those with ongoing challenges with self-care skills, self-esteem, assertiveness or those making the transition from professional to self-based care also are advisable (Rabin et al., 1986). More intensive social work interventions may be necessary when these emotional challenges are complicated by pre-existing mental health concerns.
As a therapist, the social worker may practice independently or in conjunction with other professionals (such as psychiatrists and psychologists) to treat more serious mental health issues inhibiting the management of diabetes. In this role a social work practitioner may screen and treat illnesses with high rates of comorbidity among diabetes patients, such as major depression or eating and anxiety disorders (Jacobson, 1996). The social worker also may ensure the management of preexisting chronic mental illnesses like schizophrenia, bipolar disorder, and alcohol or substance abuse. Often the stress of diabetes or complications may exacerbate existing social or work dysfunctions or revive unresolved personal issues (for example, adjustment disorders and identity and self-esteem problems) or family issues (for example, domestic violence and role conflict or strain), also necessitating social work interventions. For some, the potential or actual occurrence of diabetic complications such as amputations, blindnes s, and kidney failure can prove overwhelming, leading to suicide ideation or attempts. Serious treatment noncompliance may require skilled therapeutic interventions to identify and deal with psychological obstacles within the individual or family systems. Strained supportive resources and relationships also may require assistance to restore personal and family functioning.
Diabetes itself presents several short-term and long-term challenges. Hypoglycemia, an abrupt drop in blood sugars, typically less than 50 mg/dL, although the precise level when symptoms occur varies from person to person, is the most prevalent and feared short-term diabetic complication (Hillson, 1996). As defined by Davidson et ad. (1998), symptoms may include feeling shaky; being tired, hungry, and sweaty; having blurred vision, headaches, and numbness or tingling in mouth or lips; and experiencing irritability, confusion, or combativeness. In some instances an individual may be unable to swallow or become unconscious, requiring an injection of glucagon. By taking too much medication or insulin, skipping or eating meals at the wrong time, or engaging in excessive physical activity, patients frequently "over treat" hypoglycemia, raising glucose levels too high. Even with correct treatment, clients typically feel ill for hours or a full day after a low blood sugar episode.
In contrast, hyperglycemia is persistently elevated glucose levels, markedly above normal, more than 180 mg/dL, often the result of treatment noncompliance such as eating too much or engaging in insufficient exercise, taking inadequate medication or insulin, being physically ill, or being psychologically stressed (Davidson et ad., 1998). Patients often experience thirst, hunger, increased urination, dry itchy skin, feeling tired or sleepy, vision problems, infections, or slow healing cuts and sores. A serious consequence of prolonged hyperglycemia is a condition called "ketoacidosis," the dangerous accumulation of an acidic byproduct called ketones from the body's use of fat as a source of energy (Hillson, 1996). Indicated by blood sugars above 240 mg/dL and ketones in the urine, patients experience symptoms similar to hyperglycemia as well as weight loss, upset stomach, vomiting, fruity smelling breath, or rapid or shallow respirations. Untreated, ketoacidosis inflicts serious damage to the body and may lea d to a coma or death (CDC, 1999). In the long run, poorly controlled glucose levels cause irreversible damage, often unknowingly until long-term complications arise.
Regardless of how infrequently these complications occur, they demonstrate the ability of diabetes to seize control of the body and interrupt life, for both newly diagnosed and experienced patients regardless of glycemic control. Frequent reoccurrences may signal deteriorating glucose control and necessitate re-evaluation of diet and activities, closer monitoring, or intensive care management. Although diabetes can be managed effectively and these short-term complications delayed for years, it is a progressive chronic disease and, unfortunately, long-term complications (for example, cardiovascular diseases, neuropathy, and retinopathy) inevitably occur, disturbing experiences that can be aided by either individual or group-based supportive counseling.
As diabetes case (care) managers, social workers may provide an impressive array of services. They can coordinate a comprehensive assessment, treatment plan, and intervention, striving for an optimal level of collaboration among professionals, patients, and families. Financially, social work case management can effectively and efficiently use community resources, creating an optimal environment that promotes glycemic control to delay complications and reduce hospitalizations (Kanter, 1996). They also can establish continuity of care, through a comprehensive approach by coordinating interagency efforts, providing ongoing evaluations, and monitoring planned follow-ups. In short, this amalgamation of roles maximizes patient and family functioning through an informed appreciation and skilled assistance with diabetic challenges.
Adults with diabetes confront a remarkable array of challenges, both from the disease and its treatment. Given the nature of diabetes, its escalating presence, and patient-dependent treatment regimen, social workers have immense potential to improve the lives of people facing this chronic illness through well-established roles of educator, advocate, counselor, therapist, community developer, and resource broker. Although social workers in traditional health care settings such as acute and rehabilitation hospitals, clinics, dialysis units, home health, or hospice agencies must increase their awareness and involvement with diabetes, the same holds true for social work practitioners in other areas of practice (for example, adult protection, mental health, substance abuse, and public health). Social work researchers also should become more involved by developing and testing interventions, exploring compliance and outcome predictors, and improving empirical understanding of the psychosocial experiences of adults d ealing with the challenges of diabetes mellitus.
ABOUT THE AUTHOR
Vaughn A. DeCoster, PhD, ACSW, LCSW, is assistant professor, College of Social Work, University of Tennessee, 822 Beale Street, 2nd Floor, Memphis, TN 38163; e-mail: email@example.com. An earlier version of this article was presented at the Tennessee Conference on Social Welfare, March 1999, Nashville. The author thanks the anonymous reviewers of Health & Social Work, social work scholar Dr. John Orme, endocrinologist Dr. Douglas Gordon, diabetes educator Claire Groff dietician Charlotte Kilburn, and director Peggy Bourgeois and staff of the Diabetes Center, Memphis, for their numerous contributions in the conceptual development and writing of this article.
Accepted October 26, 2000
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Social Work Articles Investigating Diabetes Mellitus Authors Year Amir, Rabin, & Galatzer 1990 Auslander, Anderson, Bubb, 1990 Jung, & Santiago Auslander, Bubb, Rogge, & 1993 Santiago Auslander, Thompson, 1997 Dreitzer, & Santiago Blackburn, Piper, 1978 Wooldridge, Hoag, & Hanan Daley 1992 Fair 1993 Hill & Hynes 1980 Kanter 1996 Piening 1984 Rabin, Amir, Nardi, & 1986 Ovadia Safyer et al. 1993 Vest, Ronnau, Lopez, & 1997 Gonzales Authors Subject Population Amir, Rabin, & Galatzer Diabetic adults (N = 70) Auslander, Anderson, Bubb, Diabetic children and their families N = 42) Jung, & Santiago Auslander, Bubb, Rogge, & Newly diagnosed diabetic children and their families (N=53) Santiago Auslander, Thompson, Mothers/female caregivers of children with diabetes (N=158) Dreitzer, & Santiago Blackburn, Piper, Dialysis patients with and without diabetes (N=22) Wooldridge, Hoag, & Hanan Daley Adolescents with diabetes (N=54) Fair Diabetic children with ocular disease--conceptual paper (N=0) Hill & Hynes School-age diabetic children and families--program review (N=0) Kanter Depressed adult male with diabetes (N=1) Piening Families of diabetes patients--conceptual paper (N=0) Rabin, Amir, Nardi, & Adult women with diabetes (N=9) Ovadia Safyer et al. Prepubescent diabetic children and their parents (N=49) Vest, Ronnau, Lopez, & Mexican American adults with diabetes (N=36) Gonzales NOTE: The literature review was conducted using Social Work Abstracts PLUS (SWAB+ CD- ROM) from 1977 to 1999, all years currently available in this database, to identify articles by social workers or from journals that were clearly targeting social workers on any topic related to diabetes mellitus.…
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Publication information: Article title: CHALLENGES OF TYPE 2 DIABETES AND ROLE OF HEALTH CARE SOCIAL WORK: A Neglected Area of Practice. Contributors: DeCoster, Vaughn A. - Author. Journal title: Health and Social Work. Volume: 26. Issue: 1 Publication date: February 2001. Page number: 26. © 1999 National Association of Social Workers. COPYRIGHT 2001 Gale Group.
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