Last week, I saw a patient who I had not seen in a long time. When I reviewed his chart it looked like he had not been seen for more than a year. Back in 2015, we worked hard to help him get control of his diabetes with a regimen of walking, healthy eating, and a combination of medications. All of this work resulted in a hemoglobin A1c we were both happy with. He was feeling confident that he had a routine that he could manage and maintain, so we set a 3-month follow-up visit. However, 18 months later, he returned with his hemoglobin A1c double what it was before.
When he arrived in my office we said our hellos and I mentioned that it had been a while. He confided that he had lost control, so much so that he had been hospitalized following a hyperglycemic crisis just a week earlier. He went on to explain that, due to family setbacks, he had stopped taking all of his medications. He felt that he had been able to get his life together but was embarrassed to come back in, only doing so now because the hospitalization had scared him.
While this is a dramatic example, this is clearly a diabetes holiday. Managing diabetes is tough. It is a lifelong disease that does not take time off. Day in and day out, a patient’s actions affect their diabetes. Diabetes is a largely self-managed disease that patients need to account for in their shopping for and preparation of healthy meals, their physical activity, adoption of coping strategies, medication adherence, glucose monitoring, problem solving for hyperglycemia and hypoglycemia, and complication risk reduction. Key components of self-care have been estimated to take up to 3 hours per day, every day. It is a full-time job to do the work of managing diabetes. However, living a healthy life as a person with diabetes is similar to living a healthy life in general, but this is not so common in our communities. So diabetes self-care is like constantly swimming upstream. The good news is that effective self-care makes a big difference in long-term control for many patients. Nonetheless, the return on investment comes years later; give up something today to feel better later. This is a hard paradigm for many people to engage with.
Taking a diabetes holiday is normal. As a lifelong chronic disease, we should expect people to have times when they are more engaged and less engaged. It is inevitable, as perfection is not attainable. So what are some of the ways that you can help your patients?
- Know that diabetes holidays are normal and should be expected.
- Do not judge your patient. If they are back in the office, they are likely to want your help.
- Give it a name. We all do different things on holidays and by doing this it removes judgment from the patient.
- Ask the patient what they need to get back on course.
- Let them know that you believe in them and their ability to get control of the disease.
- Celebrate the small victories.
Too often when we try to "get back on the horse" we want everything to return to normal quickly, but this takes time. So, help your patients set small incremental goals that have a high likelihood of achievement and then celebrate your patient when they achieve those small goals. I routinely use stars, smiley faces, and “WOW-well done!!” in my notes to patients, as this lets them know we are proud of them and allows them to show their family. While this may seem simplistic it really is well received by patients.
Remember to reward the process of self-care and not just the end product. Too many patients feel like they get a diabetes report card when they go for a diabetes check. While the communication regarding treatment targets is important, consider that each goal is achieved after many hours of work and that acknowledging the work will reinforce these self-care behaviors. One of the best ways to survive a diabetes holiday is to help prevent the need for one.
So remember that diabetes is a lifelong disease, and, despite their best efforts, our patients are stuck with this. Help them to adjust by giving them the leeway to be human and the support to get them back on track when they take a diabetes holiday.
- Currie CJ, Peyrot M, Morgan CL et al. The impact of treatment noncompliance on mortality in people with type 2 diabetes. Diabetes Care 2012; 35: 1279–1284. PMC full text
- Polonsky WH, Fisher L, Hessler D, Edelman SV. What is so tough about self-monitoring of blood glucose? Perceived obstacles among patients with type 2 diabetes. Diabet Med 2014; 31: 40–46. Full text (subscription may be required)
- Polonsky WH, Henry RR. Poor medication adherence in type 2 diabetes: recognizing the scope of the problem and its key contributors. Patient Prefer Adherence. 2016; 10: 1299–1307. PMC full text
- Polonsky WH. Poor medication adherence in diabetes: What's the problem? J Diabetes 2015; 7: 777–778. PMC full text