Recognizing Denial And Behaviors In Patients With Diabetes

Some folks have a real psychological need to be “in control.” All their lives, these individuals resist authority, public opinion and social pressures to conform. They may be devilishly effective salespeople and negotiators, but one cannot cheat diabetes at the bargaining table. Lacking the emotional skills to deal with a condition they cannot overcome and being unable to confront it in their traditional fashion, these folks are in a situation that is as bad as being lost at sea. 

If a patient with diabetes understood his or her risks for developing a foot ulcer, an infection or may be facing a lower extremity amputation, he or she might think twice about eating that piece of chocolate cake, skipping medication or ignoring any of the other steps toward maintaining good foot health. 

For example, I tell my patients who smoke “you can have your cigarettes, or you can have your legs but you probably won’t get to keep both.” For my overweight patients, I suggest: “Now that we have your feet in good shape, you just need small victories. Please consider starting a walking program, start with half a mile a day. Your goal is to lose a pound this month.” 

For patients with diabetes to have the best chance to live a normal life, they must recognize their own denial and decide to take action to live as healthy a life as possible in spite of their condition. Denial has a few catchphrases. If you hear patients saying these things or you suspect they are thinking like this, they may be avoiding some part of their diabetes care. 

• One bite of this candy won't hurt. 
• This sore will heal by itself. 
• I will go to the doctor later. 
• I do not have time to check my blood sugar levels. 
• My diabetes is not serious. I only have to take a pill, not shots. 

Denial can creep into any aspect of diabetes self-care and it can sabotage a patient's health care. Denial is human. It is bound to crop up from time to time. When it does, patients can recognize what is going on and fight back. Here are a few tips for recognizing denial in your patients 

Not testing blood glucose levels. Some patients say it is a bother for them to check their blood glucose regularly. They may decide they “know” what their blood glucose is by how they feel. Even though patients know how they feel, a meter is a much better measure of blood glucose than feelings are. 

Ignoring their meal plan. Changing eating habits and food choices may be difficult and challenging. When a doctor suggests consulting a dietitian, following a meal plan and/or changing their eating habits, patients may sometime think to themselves …

• It is too expensive to see a registered dietitian. 
• I cannot ask my family to change what they eat. I do not want to eat alone or fix two meals. 
• There is no place to buy healthy food where I work. 
• It is too hard to bring my lunch. 

Eating right may not be as difficult as one may think. A dietitian can help patients with diabetes put together an acceptable plan that meets their personal needs. 

Forgetting their feet and shoes. We always emphasize that patients with diabetes, and especially those with neuropathy, should check their feet and shoes every day. They should be on the alert for any red, swollen or locally warm areas on their feet, and be sure there are no cracks to the skin. Some patients may feel that doing this takes too much time or they forget, or they do not care. Alternatively, though, these patients may have poor eyesight or limited mobility that may prevent them from monitoring their feet as often as we would like them to. With these patients, it is essential to consider appropriate referrals to other providers and educate family members or other caregivers about the need to check the feet of these patients on a daily basis. 

We also need to continue to communicate to patients that washing and checking their feet for signs of trouble every day is essential to avoid serious injury. Checking their shoes is also critical to ensure there are no foreign objects that could become triggers for mechanical trauma that can lead to foot ulcers and infections. 

Smoking. Smoking for 10 minutes can decrease tissue oxygen concentration and cutaneous blood flow in the body for up to one hour. In one study, subcutaneous wound-tissue oxygen (PsqO₂) tension in eight volunteers fell rapidly and significantly in response to smoking and remained low for 30 to 50 minutes.¹ This is known as tissue hypoxia. If a patient with diabetes smokes regularly throughout the day, his or her body is consistently denied the oxygen needed to assist a wound that is trying to heal. Some patient may rationalize this by saying they only take a few puffs or maintain that smoking keeps them from eating too much. 

Podiatrists need to emphasize to these patients that smoking and diabetes are a deadly duo. In fact, patients with diabetes who smoke have a 50 percent increased risk of heart attack or stroke. So quitting is one of the best things they can do for their health. 

Final Notes

In summary, recognizing behaviors consistent with denial is the key to making changes that will remove patients from these self-destructive attitudes/habits. The payoff will be a better quality of life for our patients and reduced costs of health care. 

Dr. Hinkes is President and Chief Medical Officer of ePrevenir, Inc. He is board-certified by the American Board of Foot and Ankle Surgery, and is a Fellow of the American College of Foot and Ankle Surgeons and the American Professional Wound Care Association. He is the author of “Healthy Feet for People With Diabetes” and “Keep the Legs You Stand On,” which are available at www.amazon.com.

Reference

1. Jensen JA, Goodson WH, Hopf H, Hunt T. Cigarette smoking decreases tissue oxygen. Arch Surg. 1991;126(9):1131-1134.