A common source of frustration faced by health practitioners trying earnestly to assist our clients adopt a healthier lifestyle through diet, exercise and adhering to their medications is when the diabetic patients themselves seem to not take their condition serious. They seem to downplay the seriousness of their conditions, they seem to avoid any conversation about diabetes and make their condition a low priority in their life. These patients are often said to be stuck in the denial phase of a grief response.
Often, out of my own frustrations I have even thought of using a “in your face” shock tactic of showing gruesome, potentially disturbing pictures for e.g an amputated leg, in order to trigger some of my clients into (from my perspective) positive action.
For me I think one of the reasons for my frustrations are due to the basic concept I have preset in my mind that I am the expert and that the patients comes to me to be taught by me, and I assume that they will learn and I assume that the patient will respect what I tell them as “gospel truth” and therefore follow my advice to the end. When my clients don’t make appropriate adjustments, (and many don’t) I get frustrated.
These patients whom I perceive as being resistant to change, have their own perspectives, beliefs, world views, life circumstance which may contribute one way or an other to their ambivalence (having two minds) towards adopting a healthier lifestyle. I am now more appreciative of that and my approach in my interactions with these clients must be such that I seek ways to understand their perspective and work with them to uncover some of these reasons that may be holding them back and facilitate the discovery of their own motivation and own solutions.
Overwhelming evidence had already existed that showed that interventions (non-pharmacological and or pharmacological) that help patients achieve near normal blood glucose (HbA1c <7%), the control of lipids and BP levels and the cessation of smoking lead to better overall morbidity and mortality outcomes for diabetics. DCCT Research Group (1993) and UKPDS Group (1996).
Why the DAWN study came about.
Despite this well establish knowledge and the availability of improved treatment options and technologies which if utilised properly will assist in achieving these aims, it was recognised that many diabetics are still not achieving the ideal levels of glucose, lipids and blood pressure that were associated with lower risks of cardiovascular events.
According to Saddinne J B et al (2006) as cited Funnell M M (2006), In the USA “only 42% of adults have hemoglobin A1c (A1C) values < 7%, and one in five still have A1C levels > 9%” Saddine J B et al (2006) also go on to highlight other aspects of diabetes care and therapeutic targets that were not being met by a substantial number of diabetics in the USA.
The Diabetes Attitude Wishes and Needs (DAWN) study, now seen as a landmark study, Funnell MM (2006), was done because it was recognised by opinion leaders and especially the International Diabetes Federation (Whom were one of the main collaborators in the this cross-sectional multicentre study, international study) that the situation as highlighted above was not unique to the USA but similar findings were seen around the world.
It had became apparent that knowledge about diabetes alone was not enough for diabetic patients to make the appropriate lifestyle adjustments and treatment adherence necessary to achieve better outcomes as measured by their glycaemic control, blood pressure and lipid control and ultimately better mortality (death rates) and morbidity (Sickness) outcomes.
It was thought that there was a need to incorporate into the diabetes care protocols and guidelines mechanisms and principles that allowed greater understanding by the health care team (and health policy maker) of the patients’ psycho-social issues, which may act as a barrier to them achieving better outcomes.
According to the official DAWN study website (DAWN 2016)
The DAWN (Diabetes Attitudes Wishes and Needs) study in 2001 was a massive collaborative undertaking involving Novo Nordisk, the International Diabetes Federation and an international expert advisory board the largest diabetes study of its kind ever conducted.
My initial concern and question from the perspective of a primary care doctor living in a developing country was – will the good intentioned recommendations from the DAWN study be applicable in my country?
(Developing countries are anticipated to have the highest rise in prevalence of T2DM IDF (2016))
As I read more I am somewhat reassured and I can see ways by which I can extract and utilise many of the recommendations from this landmark study to apply in my practice that would be appropriate to the avaerage urban dwelling Papua New Guinea. Aspects of the DAWN study reccommendations will need to be modified to some extend to retain local relevance.
The summary of the key findings/recommendations of the DAWN study as highlighted in the official website, DAWN (2016) are:
- Enhance communications between people with diabetes and healthcare providers
- Promote team-based diabetes care
- Promote active self-management
- Overcome emotional barriers to effective therapy
- Enable better psychological care for people with diabetes
Reassuringly for me these recommendations are applicable to varying extent in my country especially if the existing pool of specialist get together to develop locally appropriate strategies.
An important ingredient in the success of a drive towards bettering diabetes care services in strong commitment from the PNG Government.
From a national policy perspective the greatest challenge in Papua New Guinea is the small pool of healthcare professional that will be required to form the multidisciplinary team which the DAWN study strongly advocates for.
If any appropriate GoPNG official is reading this? I strongly urge the GoPNG to partner with certain people and groups that have the energy and passion and genuine desire to see diabetes care services improve in PNG.
The GoPNG must be seen to be doing something constructive about a huge public health issue that is already having a huge negative impact on individuals, families, communities and the nation as a whole.
This problem will be with us long after the big resource hungry events like the SP Games, Under 20 Women’s FIFA World and the APEC summit have come and gone.
- DAWN (2016), Study Result, Available at http://www.dawnstudy.com/dawn-programmes/study-results.html# Accessed: 9/11/2016
- DCCT Research Group (1993), ‘ The Effect of Intensive Treatment of Diabetes on the development and progression of long term complications in IDDM, The New England Journal of Medicine, Sept 30, Vol 329, No. 14
3. Funnell M M 2006, ‘Diabetes Attitudes, Wishes and Needs” (A review article), Clinical Diabetes, Volume 24, Number 4,
4. UKPDS Group. (1996) ‘UK Prospective Diabetes Study 17: A nine-year update of a randomized, controlled trial on the effect of improved metabolic control on complications in non-insulin-dependent diabetes mellitus’. Ann Intern Med; 124: 136–4