As we have no cure for diabetes yet, we are left with the following treatment modalities: diet, exercise, medication, self monitoring of blood glucose, and support from a multidisciplinary diabetes team. Diet and exercise are behavioral interventions that are perhaps the most difficult to achieve. Another behavioral requirement is self-monitoring of blood glucose. My patient age group includes infants through young adults. As I have mentioned in the past, different techniques are necessary for diabetes management in each of these age groups.
Since I see patients on a daily basis, new situations and ideas happen spontaneously often prompting changes to my current operating procedure. One afternoon, after a day packed with teenage patients, all of whom tested blood sugars less than recommended by most diabetes teams (at least 4 times/daily), I actually came up with a spontaneous humorous quip: TEST to TEXT.
Case scenario: My patient (13-year-old female) and her mother entered my exam room and we discussed insulin regime, blood sugars, etc. My teen was busily texting on her cell phone, while her mother and I discussed her diabetes care. I almost allowed this behavior to continue until I decided that this appointment MUST be more important than whatever was occurring on the young lady's cell phone! I now ask for all communication devices to be turned off and put away, including parents' Blackberries so that everyone is paying attention to the office visit. Usually, the teen is either startled or annoyed at my request-but at least I get her/his attention!
In this case, my young patient had not been testing blood sugars sufficiently to provide us with the necessary data to make treatment modifications (insulin adjustments, including insulin/carbohydrate ratios, correction factor, etc.). I patiently explained that I could not do my job without the necessary information and that despite the hb A1c result, I still needed blood sugars to change insulin doses. The exasperated parent said, "She refuses to test blood sugars, no matter what we say. We can't make her do it. We are at a loss of what to do. You make her do it!" First of all, I can't make anyone do anything. I can, however, offer suggestions and behavioral negotiations (with contracts) in an effort to improve adherence to specific behaviors. I wearily exclaimed that my patient needed to TEST to TEXT! What does this mean?
It is my belief that diabetes self-care skills are essential to survival and that long-term control of blood sugars has been demonstrated repeatedly to decrease diabetes complications in the future. Therefore, I feel that blood glucose monitoring is absolutely essential for a diabetes team to adjust insulin doses to avoid both hyper and hypoglycemia. For those patients on insulin, blood glucose testing should be a rule, not an option. Hence, TEST to TEXT. My teenage patient informed me that she cannot live without her cell phone. That is fine by me. However, as an incentive to increase adherence to blood glucose monitoring, I tell her mom that she should base privileges upon her daughter's compliance to required family behaviors, such as testing blood glucose.
If the teen wishes to continue her texting (which is an extra cost, as I discovered with my own young adult who likes to text), she must increase and improve her testing behavior. Since the adult caregiver controls the financial source for the phone, if the teen will not test, then there shall be no money for texting. This concept that the adult caregiver controls the money often empowers parents to set the necessary limits.
My teen patient and her mother then negotiated a contract stating that testing four times per day translated into a specific number of allowed text messages and that an increased amount of testing would increase the allotted text message amount.
Other incentives can be employed as well. For some of my patients, computer time is at a premium. Set the amount of time available for computer use (video games, Nintendo, Wii, etc.) based on the required behavior. Use the same limit setting approaches as you would for your toddler, but update the consequences appropriate for the specific developmental stage. You may be surprised that your child/teen is extremely impressed with your strategy. I know that my patient was most impressed with TEST to TEXT. She even suggested that I write about in my next blog. So I did!
Published On: September 22, 2009