Occupational therapy and diabetes… are there some overlooked opportunities?
As an OT who spends much of her clinical career in an inpatient rehab setting, or treating lymphedema outpatient- I see a LOT of people with diabetes! Diabetes Mellitus is a pervasive issue, affecting 1 in 10 people in America, and leading to a host of unpleasant health complications. Have you ever wondered if your occupational therapy role could be less compensatory and more focused when it comes to setting goals and working with your patient with Diabetes? Here, I’m going to focus on some of the essential ways an OT can be instrumental in treating a person who has DM in a holistic and practical way.
Re-thinking Diabetes
Firstly- you may think you don’t need to know any more about diabetes- what it is and who it affects. Older people who have sugar issues, right? Well, perhaps surprisingly, DM can come in more than two forms.
A proposed reclassification system from a researchers in Finland and Sweden, in 2018, broke up Diabetes into 5 sub groups, instead of the usual Type 1 and Type 2. Why do this? It became clear that by dividing Diabetes into these subgroups, correlations between each group and increased risk of developing certain complications became clear. Of course- it clearly follows that by knowing why the Diabetes developed that future health impairments would be easier to predict.
Yes- by defining the type, we can now identify who is at what risk of developing differing complications- such as amputation, kidney damage, retinopathy, and cardiovascular diseases.
These ‘types’ of diabetes were:
| Group 1: Severe autoimmune diabetes (SAID) – Corresponds to Type 1 diabetes and latent autoimmune diabetes in adults (LADA) and is characterized by onset at a young age, poor metabolic control, impaired insulin production and the presence of GADA antibodies |
| Group 2: Severe insulin-deficient diabetes (SIDD) – Includes individuals with high HbA1C, impaired insulin secretion and moderate insulin resistance. This group had the highest incidence of retinopathy |
| Group 3: Severe insulin-resistant diabetes (SIRD) – Characterized by obesity and severe insulin resistance. This group had the highest incidence of kidney damage |
| Group 4: Mild obesity-related diabetes (MOD) – Includes obese patients who fall ill at a relatively young age |
| Group 5: Mild age-related diabetes (MARD) – This is the largest group and consists of the most elderly patients |
As healthcare practitioners, this brings us closer to providing a patient-specific plan of care, as opposed to the same treatment to every person with diabetes. In occupational therapy, this drives us even further to educate patients about their increased risk for certain outcomes, teach them how to monitor their health and what ‘red flags’ to be alerted to, given their specific sub-classification of Diabetes.
How can occupational therapy be most effective when working with people with diabetes?
Occupational therapists can be key practitioners with people with diabetes over several domains of function. When a client with diabetes presents into a setting like hospital and inpatient rehab, OTs are *sometimes* reduced to mostly teaching compensatory methods- such as strength and endurance building, and education about doing what the dietician tells them to. But what if there were more specific, and less common goals that we could be focusing on?
Let’s go through and examine some Occupational Therapy-specific goals that can be set when working with diabetes- and how to meet them!
- Health awareness and Education
OT uncommon goal? “independently use a tracking and planning device to manage a healthy diet and exercise program.”
Occupational therapists are uniquely positioned to help people examine their lifestyles and the intersection between the person, environment, and their occupation. Often, lifestyle adaptation and modification must occur to ensure that healthy choices are being made to ensure ongoing wellness- and who better to evaluate the ability to modify the environment than OTs!
Helping your patient examine their current roles, routines and habits is the first step in the self-monitoring and awareness your client will need to cultivate. If your client needs to change their diets and exercise habits, you can help them track their food intake- where, what and when they are eating, how their mood and environmental triggers may be hindering their efforts, and how to modify these external cues to create a more sustainably health-focused lifestyle.
As an OT, you can also help you patient with the technological skills they may need to use a smartphone app (if they use a device). A great list of some apps that are free and easy to use can be found- right here.
Self-tracking is all well and good, but for lasting success, planning ahead is also crucial! Empower your client to plan out meals and snacks, monitor their own insulin levels, and engage in an easy to achieve and sustainable exercise program- however that looks for your client.
2. Community integration/Socialization
OT uncommon goal? “Engage in a social activity based around food or exercise once per week in a healthful manner”
Socialization and being part of a community is an important aspect of holistic treatment. If you teach your client to manage their insulin, prepare safe meals and complete a HEP at home, they will be safe for a while- but it isn’t sustainable! Social isolation is a major problem that can have its own health risks.
Therefore, incorporating a community integration goal from the get go, that addresses making healthful choices in a restaurant (such as looking the menu up ahead of time, or having a few key items to order), as well as linking exercise to a social activity (such as a walking program) may be a powerful means of creating an atmosphere of motivation and independence for your client. After all, doing things together is way more fun that going it alone!
3. Leisure
OT uncommon goal? “Make a diabetic friendly dessert once a week” or “join a diabetic-friendly exercise group”
Leisure goals can often be more satisfying to work on than, say, a BADL goal! Drilling down on your patients interests can be a way of accessing a more playful way of looking at, and meeting, their overarching health goals. Does your client love to cook/bake? Help them look up diabetic friendly recipes that can help scratch that itch (think- low sugar ice cream, almond butter cookies, or anything from this list). If your person has shown that they can track their carbs and understand balance, then they can still have fun with food!
Diabetic-friendly exercise groups can be a great resource for fun, making connections and learning more about the condition (and how to handle it in an ongoing way). Help your client look into local groups, or even online support groups that they can lean into to make their exercise program more enjoyable and east to integrate into their lives.
If an exercise group specific to diabetes is not available, then help the person find an exercise/movement output that is meaningful to them! This may be empowering them to find a walking partner, a swimming class, or another activity such as gardening that will help them to move their body in an enjoyable way.
4. Basic ADL goals
OT Uncommon goal: “Independently manage self-care of lower legs”
This goal, as the preceding ones, can have many subcomponents. As clients with Diabetes are at high risk for Peripheral Artery Disease and Neuropathy, the Occupational therapist can teach the client to monitor for, or treat, the symptoms that they may be at risk for. This goal may seem self explanatory, but all too often the foot care component of diabetic management can be vague, non sepcifc, or left up to the nurse/podaotrust to complete. OTs have a great oportyunitie at this pont to teach a client how to complete their own self management, what red flags to be midful of, and how to modify their current routine to include this step.
To download a self check sheet, and other helpful resources- get our FREE ‘Ultimate Guide to the management of the Diabetic Foot’
Neuropathy is mot commonly associated with the feet, but can also affect the distal upper extremities.
5. Foster a sense of empowerment and control
OT uncommon goal: “Use active and passive reinforcements to facilitate an environment of success and control in order to boost self-efficacy and esteem.”
The person who has contracted Diabetes may be feeling overwhelmed, disappointed, out of control, or even grieving for a former “way of life” wherein they felt well, had more self-regard and less restrictions. A disease of diabetes, I think we could all agree- is very much a condition of “cannot’s”- “you can’t eat that” “you must do this” “you can’t skip this medication, or this exercise, or essential step”. I am in no way advocating a romantic, rose-tinted view of this condition- it is serious, and can lead to even more serious complications if treated incorrectly. However, I strongly believe that as OTs, we take a holistic and person-centered approach to everything we do. Part of this may be heading off issues such as a flagging self-image, a sense of powerlessness or even depression, before they occur (or preventing them from getting worse!).
Use of techniques such as temptation bundling (doing one favorite activity with a less preferred one), such as listening to music when planning out your weekly meals; or positive, specific affirmations left as reminders in places people can see (examples from this list include “I create good health by talking about and thinking about my wellness.” and “I most love the parts of me that need love the most right now.”
As with many different aspects in occupational therapy, thinking outside the box can make a huge difference in the lives of our patients with diabetes. By focusing on ‘uncommon’ goals such as these, we may transition away from more compensatory strategies and into a more empowering and holistic space.
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