by Jeffrey M. Levine MD, AGSF, CWS-P
by Mary Ellen Posthauer RDN, CD, LD, FAND
In last month's blog I discussed the steps that could be taken for a client who is a qualifying beneficiary under Medicare Part B, to receive the services of a dietitian for Medical Nutrition Therapy (MNT) and/or to a Diabetes Self Management Training (DSMT) program for assistance in achieving glycemic control. This month we will follow a non-compliant client through the assessment and treatment process.
We will assume Ms. Y is a 60-year-old woman on disability with Type 2 diabetes and a chronic diabetic foot ulcer. Additional diagnoses include Class III obesity, hypertension, sleep apnea, hypercholesterolemia, hiatal hernia and osteoarthritis. Her HbA1C runs between 9-11%, which is above the desired 7%, and her cholesterol/lipid levels are also elevated. Her treatment plan includes daily oral hypoglycemic plus sliding scale insulin, hypertensive medication, a statin, an anti-arthritic,a proton pump inhibitor, a diuretic and an antibiotic for her infected foot ulcer. Ms. Y is 63“ tall, weighs 270 lb. with a BMI of 47. Her chronic diabetic foot ulcer limits her daily activity so she spends the majority of her day at the computer on the Internet eating high calorie snack food.
Ms. Y’s physician recommends that she consult a registered dietitian who can help her establish a diet plan to control elevated blood sugar. After repeated phone calls to Ms. Y, the dietitian finally schedules an appointment to discuss the client’s routine meal and snack pattern. Prior to the initial visit, the dietitian requested Ms. Y write down everything she ate and drank the past week and where the activity took place. The client’s written food record is incomplete but it becomes obvious that most of her eating occurs in front of the computer or in the car as she travel home from the fast food restaurant. Because Ms. Y is on the Internet until 2 or 3 a.m. and sleeps until 10 a.m., she never eats breakfast. She drinks at least 8 or 10 cans of 12oz regular sodas daily along with salty chips. She doesn’t eat fruit or many vegetables because she can’t afford them and has limited refrigeration. The dietitian and the client discuss the type of food she enjoys and what she could purchase on the limited budget, noting her frequent trips for fast food are expensive. While Ms. Y is surprised to learn how many calories and sodium are in the items she frequently purchases, she states her “food trips” keep her from getting depressed about her health.
Together they attempt to outline a reasonable food budget that includes non-perishable food items that are lower in calories, fat and sodium. The dietitian encourages her to purchase apples, oranges and canned fruit packed in natural juice, plus small packages of frozen vegetables that she likes. Together they plan simple meals and snacks that Ms. Y enjoys and could prepare. Any attempt to suggest that she substitute her regular sodas for low calorie drinks or water is met with resistance. Based on her erratic schedule, it is difficult to establish routine meal times where she can consume a consistent amount of carbohydrates. Ms.Y does agree to try and establish a routine eating pattern and perhaps substitute a sandwich and fruit in place of her bag of chips that she consumes during the night. They both agree to this initial plan and decide the next visit will focus on websites that provide reliable nutrition information for her. This recommendation is in concert with her insatiable Internet habit.
Ms. Y fails to come to her next appointment and after several phone call and emails to her, she emails the dietitian and states she isn’t interested in coming any more and that, “I only came because the doctor told me to visit you.” The dietitian suggests she attend a group class where Ms. Y could swap concerns and ideas with others who have similar health problems. While Ms. Y is worried because her chronic diabetic foot ulcer is limiting her activity and causing her pain and suffering, she fails to make the connection between her unhealthy lifestyle and her physical problems. She never attends the classes or makes any further contact with the dietitian.
The next time the dietitian sees Ms.Y, she is in the hospital following her below-knee amputation (BKA). Once again, the process will begin of trying to encourage her to embrace techniques that will improve her diet and her over-all health.
This example, which resulted in an amputation, is not extreme and is one that we have all encountered in our practice. While Ms. Y was resistive to change and assumed she lacked the resources to effectively alter her lifestyle, the dietitian did attempt to offer practical solutions for her concerns. However, when the individual is not willing to take even small steps to make a lifestyle change, the health care professional shouldn't assume they are responsible for the negative outcome.
About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Panel and the American Dietetic Association’s Unintentional Weight Loss work group.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.