The patient with type 2 diabetes must adjust to a demanding treatment regimen and the eventual onset of diabetes-related complications (24 - 28). In this section we discuss some of these psychosocial issues and provide an update on treatment approaches in these areas. Most of the research on psychosocial issues in diabetes in the United States has been carried out on Caucasians, principally in academic clinics and hospital diabetes centers, rather than in primary care settings, where most type 2 diabetes care is delivered. Despite these limitations, there is a sizeable body of research available that can help us understand the psychosocial impact of type 2 diabetes, and identify clinically useful interventions to manage patient problem areas.
Reflecting clinician time constraints, their training focus, institutional support, and reimbursement practices, most clinical interviews in diabetes practice focus largely on medical or educational aspects of type 2 diabetes, and concentrate little on psychosocial features that, for a subgroup of patients, should be at the forefront of priorities (33). Psychosocial issues in type 2 diabetes have a significant influence on both patient outcomes and quality-of-life.
High blood sugar levels, associated with poor blood sugar control, cause a range of medical complications (e.g., cardiovascular disease, retinopathy, neuropathy, nephropathy) that can impact many areas of the patients life, including ability to work, family functioning, quality-of-life, and sexual functioning (24,25,34).
As with other chronic medical conditions, the patient needs to carry out many daily treatment-related tasks if adequate blood glucose control is to be achieved. While a sound medical plan is important (e.g., a patient on oral agents who is undermedicated will find food and exercise regimens relatively ineffective), a good medical plan is a necessary but not sufficient condition to ensure good blood glucose control.
Diet and exercise, blood glucose monitoring, timing and dosage of prescribed diabetes medications (insulin and/or oral agents), hypoglycemia management and prevention, foot care, sick day management, clinic visits, and various necessary medical screenings and education activities must all be successfully incorporated into life roles and any unexpected crises (33,35). Changes to food habits can be particularly difficult to achieve and sustain.
Also, diabetes regimen changes must be maintained by the individual patient within the context of helpful or unhelpful peer and social pressures, domestic and economic responsibilities, and distracting life events (36). Self-care behavior change must be sustained over time to translate into improved blood glucose control and a reduction or slowing down of diabetes complications progression (37).
Type 2 diabetes typically emerges in middle adulthood, a period of life where lifestyle patterns and behaviors have become firmly established and may require greater effort to change. Also, during the precomplications phase of type 2 diabetes, and even in the early phase of complications, the patient is often asymptomatic. Driving forces that might motivate a patient to seek medical care - unpleasant symptoms and awareness and fear of a serious illness - are therefore not present to provide a sufficient level of threat and motivation to make changes.
Garry W. Welch, Alan M. Jacobson, and Katie Weinger
Behavioral and Mental Health Research, Joslin Diabetes Center, Boston, Massachusetts, U.S.A.