The Hive 2017

Supporting people who live with diabetes and obesity

Leigh Spokes FACN

As you begin reading this piece let me first make a disclaimer. It will not contain clinical references or fancy graphs with beautifully gathered statistics. What it will contain is my real life experiences of supporting people with diabetes and obesity. It can be a struggle to control weight for many people whether they have diabetes or not. Many have eating patterns that have been entrenched from childhood and/or lifestyle habits that are affected by their everyday struggles.

Just another day at the office

The sun is shining; it’s a perfect spring day. Jack waits to see me; he is on the doorstep as I arrive at work. I am greeted with his friendly smile and he asks if I have time to see him before he goes to Centrelink this morning. He is a 45-year-old Aboriginal man who has not been to our clinic for two years.

I overhear his discussions with the receptionist. He outlines that he has not seen anyone about his health in two years, as he has been out of town on family matters. Jack has type 2 diabetes and was diagnosed in 2012. He also tells reception he can’t remember when he last had his tablets.

The conversation

How did we start our meeting?

I told him it was good to see him again, and asked how he was going and what could we do for him today.

I can hear his despair at losing family members. I can hear his love for his family and country. He has had to move his family back to town and they are all here for better access to medical care. I could hear from his descriptions that his diabetes is a cause for concern; he knows it as well. I can hear that his wife is telling him he has to get well. Most importantly, it’s totally clear his family need him now, more than ever.

He told me about his journey over the past few years. His family has been very unwell and sadly, a number of them have passed. Jack now describes himself as the “all-rounder” support person. He used to have a job in town but stopped to become a full time carer for his nephew, wife, mother and older brother, who is now experiencing renal failure. They have all moved back to town to be closer to medical services. He has not been feeling so well lately. He is tired, moody at times, waking up to pass urine and craving cola.

“I just love my Coca-Cola.

Jack tells me, his health is his main focus now, and his wife will help him. However, she has told him he has to help himself first.

The alarm bells are already ringing loudly in my head. I ask if it’s ok to do a check of basic things, including blood pressure and blood glucose. He continues to talk to me throughout this examination. Among these observations, I find that his weight is 130kgs, BMI is 46, random blood glucose level is 20.0 mmol/L (no blood ketones), and HbA1c is 101 mmol/mol (11.4 %).

Some nurses may read this and will be shocked by such a high BGL. Take a deep breath, and calm down. This can be a regular occurrence at our service. It might also shock you to know that this can be successfully managed, without ambulance and hospital admission, and all the associated social impacts.

How I feel about what he is telling me, can impact on his care. Often the initial reaction to such a presentation is: I have to fix this! The first reaction can be to prescribe medications, give him a regime, encourage him to start dieting and exercise, refer him to a dietitian and exercise psychologist, tell him to come back for a review, etc.

Do you ever think this way? Do you ever think: we have to FIX THIS NOW! This is the place your brain can run to, when people like Jack first present. And while, yes, we need to set a pathway and priorities, there is one way to do it, and another way that will instantly turn Jack away from you and the clinic.

The outcome

Social and emotional wellbeing are paramount. Yes, he needs to make changes to help him lose weight and have improved diabetes control. But these changes have already started: focus on the positive.

Think about your response to a difficult situation: how do you feel about what you know?

I express to Jack how good it is that he is here to see us today. I ask him what his plans are with the family today and for the rest of the week. How does he feel about going back onto some medications today?

Look at the big picture: is there food security, is there appropriate housing, does he have transport? Link this in with a culturally-appropriate team.

Our service has a fantastic team of Indigenous health workers who know his family. If we help Jack with his home life and family, Jack will then be able to help himself. Jack is happy for our support worker to accompany him to Centrelink and help with housing questions. They also go to the “friendly” chemist in town and make sure he starts back on his medications.

Our drop-in clinic is open every morning and Jack has expressed that he would like to come back each day for a checkup. We will provide transport.

There were a few missed appointments but his BGL came down nicely once he went back on his medications. After his family were linked in with support services, he was also keen to see the rest of our team. He has lost some weight, stopped drinking cola and his overall diet improved as the family settled.

The more you know the less you need to say (Jim Rohn)

Before you can listen and support anyone about weight loss you need think about how you feel about what you know. There are questions you need to ask yourself about how you feel about change.

Over my 42 years of nursing, I have meet colleagues who are brilliant and knowledgeable doctors and nurses. They quote endless evidence-based data about diabetes and how weight loss can improve long term outcomes, but many just don’t see the “big picture” and look at the person holistically.

Yes, they know it all, but if we asked them to make changes in their own lives could they? How easy would it be? One of the most important tools a nurse can have is the ability to be able to have reflective practice. A true “internal” reflective practice is where one not only looks at the task/communication/patient that takes place. They must also examine how they felt about what had occurred, and how many external factors influence someone to make positive change.

Lastly, if you are a diabetes educator, have you ever considered dropping “educator” out of your title? Sometimes, people that need to make changes in their lives, don’t need an “educator”- they need a nurse. Especially in the Indigenous community.

I found that patients repeatedly failed to attend appointments while I was an “educator” but they do come to see me as a nurse. Why do patients come to see nurses? Because we listen to them.

 

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