February 20, 2018

Diabetes is a disease that disproportionately affects low income individuals. At the same time, diabetes self-management presents significant challenges for people who struggle with financial resources. Since food is part of the medicine for diabetes, access to healthy options can be a barrier.  As diabetes educators, we seek to understand these challenges and incorporate this understanding into the plans and goals that we construct with our patients. The following are some suggested strategies when working with low income individuals.

Screen for food insecurity:

The American Diabetes Association (ADA) recommends screening for food insecurity.  A simple two-question screening tool can be easily incorporated into early discussions with a patient.  For example, “Within the past year, did you ever worry whether your food would run out?  Was there a time when the food that you bought just didn’t last?”  We can normalize this inquiry by stating that this is something that we ask all our patients.  In addition to providing information regarding local food programs and referral to social work, our education and self-management support needs to incorporate this issue.

Focus on the healthier choice rather than the healthiest choice. What is the best choice that is realistic?

Focus education on identifying which foods have carbohydrate, and what is an appropriate portion size.   Discuss ways to avoid filling up on carbohydrates by including foods like frozen or canned vegetables, eggs, tuna, peanut butter, low fat cheese and Greek yogurt. Also talk through the importance of spreading out the intake of carbs throughout the day whenever possible, rather than consuming large quantities at one meal.

Provide suggestions for alternative physical activity:

Low income patients may not have access to safe and affordable exercise options.  Be sure to provide suggestions for low-cost options, such as chair exercises at home, or using canned food in place of hand weights.  The PBS Program Sit and Be Fit is broadcast in cities across the nation, providing a free chair exercise class every day where the program is aired (https://www.sitandbefit.org/).

Support smoking cessation

Aside from the health benefits, quitting smoking has a huge impact on the overall monthly budget.  Provide information on the free smoking cessation program available through the American Cancer Society (1-866-QUIT-4-LIFE or https://www.quitnow.net).  The program includes a personalized quit coach as well as free nicotine replacement therapy products.

Confirm that the patient understands how to treat hypoglycemia

Cover topics important to patient safety first, including how to treat a low sugar.  If an individual has identified food insecurity as an issue, create a low or no food day plan, just as you would develop a sick day plan.  If a food insecure individual is experiencing low blood sugars, be sure that their health provider is aware of the patient’s inconsistent food intake.  Fixed dose insulin regimens and sulfonylureas may need to be replaced with medications with a lower risk of hypoglycemia.

Focus on the ‘Need to Know’

Low income individuals may also struggle with low health literacy and numeracy.  As with all patient education, we try to focus on skill building rather than on knowledge.  Emphasize the ‘need to know’ versus the ‘nice to know’.  For example, clarify instructions for how to treat a low sugar, rather than discuss the mechanism of action for sulfonylureas.  Most of us can retain about three key pieces of information at one time, so we want to choose wisely which information to impart.  It’s always a good practice to ask the patient to teach back what they understand, allowing us the opportunity to close the loop on any miscommunication.

Finally, as with all our patients, we seek to learn from their expertise at problem solving.  If you’re like me, you will end up gaining jewels of insight from talking with people who have been managing diabetes with limited resources for years and years, and it will be an honor and a privilege to pass on their wisdom to your other patients facing similar barriers.

Andrea Zurawski, RN, MSN, CDE

Certified Diabetes Educator at Cecelia Health

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