Prior to the 20th century, most people died from acute infection and life expectancies were too short for people to develop chronic diseases. Though we now enjoy longer lives and much higher standards of living, which permit us to indulge in eating, spending, and other forms of leisure, this also increases the likelihood of developing chronic disease.
In general, chronic diseases are defined as those that persist indefinitely, cannot be prevented by vaccines, and cannot be cured by medication, leading to ongoing pain, suffering, disability, and diminished quality of life. Globally, it has been estimated by the World Health Organisation that 60% of deaths in 2005 were due to chronic disease, with 80% of these deaths occurring in low- and middle-income countries.
Besides the longer life expectancy, there are many contributing factors to the rise in chronic diseases, including smoking, pervasive obesity, sedentary lifestyle, poor diet, larger food portion sizes, fast-paced lifestyle, and increased pollution.
Diabetes, caused when an individual develops a dysfunction in insulin production or action, which induces an inability to metabolise blood glucose, is the leading chronic disease in Oman, with a prevalence of 7.2% amongst men and 8.3% amongst women. It is responsible for 10% of all deaths in the Sultanate (WHO, 2016).
Two types of diabetes are distinguishable: Type I diabetes, also called Juvenile Diabetes, can appear very early in life, and seems to be caused by an autoimmune reaction in which the body destroys the insulin-producing cells of the pancreas. Type I diabetes is incurable, and leads to the patient becoming insulin-dependant. Type II diabetes, also called Adult Onset Diabetes, begins with the development of insulin resistance, and depending on lifestyle, may develop into a full-blown insulin-dependent condition. Type II diabetes is thus a chronic disease which, under certain conditions, is preventable.
Although it is likely the result of a complex interaction of genetic, behavioural, and environmental influences, the rate at which Type II diabetes has risen clearly suggest that behavioural and environmental factors have played a larger role than just biological changes. Unhealthy behaviours , such as eating too much of what we know is bad for us, lying on the couch instead of being active, and smoking, can unfortunately be quite enjoyable.
It can be difficult to help someone who has yet to experience any negative health consequences, to give up such pleasurable indulgences. While a healthier lifestyle may sound like a good thing, it requires consistent hard work, dedication, and comfort with delay of gratification. Delayed gratification is a particularly challenging issue for many in our “get it now” society. Moreover, adopting a healthy lifestyle and engaging in preventive health care requires consideration of and value for one’s future health. Individual’s beliefs about themselves, their health problems, and their behaviours can effect both the development of mental and physical health problems as well as their outcomes.
The initial psychological adjustments following the diagnosis of diabetes generally involve issues related to loss. Loss of function, loss of control, or loss of perspective. Individuals at the stage of diagnosis confront the reality that their health has, most probably irreversibly, changed. In coming to terms with the diagnosis, the diabetic will have to go through several stages of grief. In the first stage, denial, the diabetic still refuses to acknowledge that there is a problem.
In the next stage, anger, one is looking for something to blame, which eventually will lead to the realisation that the only culprit is the very own body’s reaction to food or sugar. Bargaining may then ensue, which involves efforts to revert the situation. One sees patients desperately trying all kinds of therapies, without much effect, however, with the exception of shattered hopes. This leads to a stage of depression.
It is not surprising that the likelihood of depression more than doubles among those suffering from common chronic medical conditions such as diabetes, obesity, cancer, hypertension, chronic heart or cardiovascular disease. Diabetic patients who are depressed have worse treatment adherence and glucose control, more symptoms, and an elevated rate of complications, compared to non-depressed diabetics.
Anxiety disorders are also more common among these patients, and are associated with high levels of bodily symptoms, functional impairment, health care utilisation, and adverse effects such as smoking, substance abuse, and sedentary lifestyles. In addition, diabetes-specific anxiety problems may develop, such as a fear of needles, or avoidance of blood glucose control. With physicians focused on physical health, but not having enough time to also attend to the mental health as well as the broader aspects that may cause an impact on the patient, many diabetics would benefit from more education as well as comprehensive and multidisciplinary approaches.
Coping with a chronic disease may therefore have a tremendous impact on a person’s consideration of the future, and the fatigue, hopelessness, loss of motivation, and dysphoria that typically constitute psychological problems undermine a person’s ability to engage in healthy behaviours or undermine their capacity for self-management of health problems. The purpose of educational intervention is to increase a patient’s knowledge of his condition and the behaviours needed to manage the disease, while behavioural interventions aim towards helping patients put the knowledge to action, establishing goals and using behavioural strategies to make healthy behaviour changes and to improve diabetes control.
Consulting a clinical psychologist could help address a number of relevant challenges in diabetes, including adjustment to diagnosis, stress management, problem solving and coping skills, assessment and treatment of comorbid psychological problems, and facilitating treatment engagement and adherence (e.g. diet, physical activity, medication, self-management of blood glucose). Cognitive Behavioural Therapy (CBT), and in particular Acceptance Commitment Therapy (ACT), which involve relaxation training, changing maladaptive thought processes and behavioural goal setting, have across studies proven their efficacy in improving glycaemic control in patients with diabetes, as well as emotional distress.
Similarly, family and group therapies focusing on diabetes-relevant topics, such as complex lifestyle changes, as well as emotional expression, stress management, conflict resolution and interpersonal skills have also shown their effectiveness in promoting diabetes management, treatment engagement, and adherence, as well as promoting recognition, acceptance, awareness, and social support. A holistic bio-psychosocial treatment, in which physicians, psychologists, nurses, and dieticians work together, has demonstrated to influence immediate (learning), intermediate (behaviour change), post-intermediate (clinical improvement) and long-term (health status improvement and quality of life) outcomes.
Living with diabetes on a day-to-day basis, constantly checking blood glucose levels, getting used to new dietary rules and learning to live with certain restrictions and limitations, will eventually lead to greater self-awareness and knowledge. The patient learns what to expect from his body under certain conditions and in situations, and will thus come to adjust his/her lifestyle accordingly. Eventually, the patient will reach the last stage of the grieving process, acceptance, which refers to recognising the irreversible condition and trying to move forward, in this sense it comes close to acquiescence, which in Latin means ‘finding rest in’.
Realising that the chronic disease should not define nor determine one’s whole existence, that one is not diabetic but one has diabetes, will lead to establishing new relationships: With one’s body, food, and of course, the environment. Becoming reacquainted with their bodies, the person will learn to become more mindful and aware of the effect certain foods as well as surroundings and situations may have on him or her, recognise the emotions along with the physical symptoms, and try to find new ways and strategies of dealing with things.
Redirecting one’s focus in life, discovering personal meaning in diagnosis, changing one’s perspective and goals, and finding a new purpose, such as a more conscious enjoyment of family moments, or spiritual fulfilment, will eventually increase one’s confidence, self-esteem and resilience, thus improving his or her quality of life.
Dr Fabian Saarlos is a clinical health psychologist at Al Harub Medical Centre