The Use Of Language In Diabetes Care And Education

The Use of Language in Diabetes Care and EducationMelinda D. Maryniuk, RD, MEd, CDESaturday, February 10, 201810:30 a.m. – 11:15 a.m.The language that we use as healthcare professionals in our conversations with patients can have aprofound impact in both positive and negative ways. Many words that are commonly part of thediabetes vocabulary are associated with feelings of judgment, fear, blame, guilt and shame. Somewords inappropriately label people with diabetes and perpetuate misunderstandings.Research drawn from other fields indicates that language does have an impact on the patient-providerrelationship and may likely affect diabetes self-care behaviors and ultimately blood glucose levels andother clinical outcomes. For example, lessons learned from expectancy theory research indicates thatwhen students are labeled in a certain way, they are more likely to perform to match that label.The American Diabetes Association and the American Association of Diabetes Educators convened aTask Force to look more deeply at the literature and identify recommendations regarding the use oflanguage in diabetes care and education. A paper was prepared and jointly published in December 2017that presents five recommendations:1.2.3.4.5.Use language that is neutral, non-judgmental and based on facts, action or physiology/biology.Use language that is free from stigmaUse language that is strengths-based, respectful, inclusive and imparts hope.Use language that fosters collaboration between patients and providers.Use language that is person-centered.The paper also presents a table of words with potentially negative connotations and suggestsreplacement language along with the rationale for doing so. While the paper was published with thehealthcare professional audience in mind, the goal is to get the message out to a much wider audienceincluding pharmaceutical industry professionals, the media and people affected by diabetes.The audience is encouraged to identify specific steps to both identify problematic words/phrases in theirown language (spoken and written) and discuss steps towards making revisions that are more in linewith the recommendations.ReferencesDickinson J, Guzman SJ, Maryniuk MD, O’Brian CA, Kadohiro JK, Jackson RA, D’Hondt N, Montgomery B,Close KL, Funnell MM. The use of language in diabetes care and education. Diabetes Care. 2017 Dec;40(12): 1790-1799 and Diabetes Educ 2017 Dec; 43 (6) 551-564.Dickinson J, Maryniuk M. Building Therapeutic Relationships: Choosing Words That Put People First.Clinical Diabetes. 2017 Jan; 35(1)51-54.Speight J, Conn J, Dunning T, Skinner TC, Diabetes Australia. Diabetes Australia position statement. Anew language for diabetes: improving communications with and about people with diabetes. DiabetesRes Clin Pract 2012 Sep; 97(3): 425-31.

Resources from AADE: Quick Guide for Healthcare Professionals: Speaking the Language of Diabetes Media Guide for Journalists: The Power of Language in Reporting on gemedia-guide.pdf?sfvrsn 0

Objectives Identify real life examples of words that made adifference to people with diabetesWORDS MATTER Discuss the research on how language affectsA Discussion About Making a Difference Discuss the value of becoming aware of andpeoplechanging the language around diabetes.Melinda D. Maryniuk MEd, RDN, CDESenior Consultant; Maryniuk & AssociatesDiabetes Education & Nutrition ConsultantsBoston, MAAcknowledgement: Jane K. Dickinson, PhD Susan Guzman, PhDReal Life Examples

SufferRESEARCH: Does LanguageAffect people?Expectancy TheoryExpectancy Effects: 4 Main Factors The emotional climate was affected by expectations.(Teachers were warmer toward students they expected todo well) The behaviors of teachers were different. (Teachers gave“spurters” more difficult study materials.) The opportunities to speak out in class were different.(Teachers gave “spurters” more opportunities to respondand more time to answer questions. The level of detailed feedback about performance wasdifferent. (Teachers gave “spurters” more informativefeedback.)Rosenthal & Fode, 1963; Expectancy Effects(Rosenthal, 1994)UncontrolledWhat words negatively affect you? 6 Themes Judgment (non-compliant, uncontrolled, don’t care, should, failure) Fear/Anxiety (complications, blindness, death, DKA) Labels/Assumptions (diabetic, all people with diabetes are fat, suffer) Oversimplifications/Directives (lose weight, you should, you’ll get used to it, atleast it’s not ) Misunderstanding/Misinformation/Disconnected (cure, reverse, bad kind, you’refine) Body Language and Tone (no eye contact, accusatory tone) (Dickinson, inPress)

If HCPs stopped using these words Diabetes Stigma Would feel respected or listened to, that the HCPs reallycare. “I would have more faith in my health care providers ifthey didn’t use words that I think convey a lack ofinformation, sensitivity or understanding of myexperience.”(Dickinson, In Press)People with diabetes perceived as Having a character flaw or a failure of personal responsibility. Being a burden on the healthcare system Being weak, fat, lazy/slothful, overeaters/gluttons, poor, bad,and not intelligentGuilt, shame, blame, fear, embarrassment Avoidance/Hiding Additional Barriers Disengagement Isolation Depression Health Outcomes (Liu et al, 2017; Tak-Ying et al, 2003; Browne et al, 2013; Browne et al, 2014;Vishwanath, 2014)HCP communicationsConversation elementsHow emotionally distressed arethey with their diabetes?Emotional DDSMessages at diagnosisPositive(β -0.367)Factor 1Encouraging(β -0.412)(β 1.690)PositiveFactor 2CollaborativeHow well do they feel?WHO-5(β 0.391)Positive(β 0.436)Negative(β -1.242)Factor 3DiscouragingHow distressed by the regimenare they with their diabetes?Regimen-related DDSPositivePositiveNoImpactQuality ofpatient–physiciancommunication atdiagnosisPositive(β 1.093)Do they follow a healthy diet?SDSCA General Diet ScorePositive(β 0.880)Do they eat healthier foods?SDSCA Specific Diet ScorePositive(β 0.702)(β 0.093)PositiveDo they exercise frequently?SDSCA Exercise Score(β 0.910)Factor 4Recommending OtherResourcesPolonsky et al, 2017To what extent do they taketheir medication?SDSCA Medication Score

Take Away Messages Language conveys meaning that can determineexpectations. Expectations can lead to bias that affectsoutcomes (even if we aren’t aware of it). Messages that convey stigma, judgment, fear, andmisunderstanding can lead to disengagement,avoidance and distress HCPs have an important role in defining this experienceby communicating collaborative and encouragingmessagesLook around ploads/2015/03/IDF-LANGPHI2.pdfA much bigger step!One small step .Dickinson & Maryniuk. Building therapeutic relationships: Usingwords that put people first. (2017) Clinical Diabetes, 35(1), 51-54.Committee Jane K. Dickinson, RN, PhD, CDE(chair) Susan J. Guzman, PhD Melinda D. Maryniuk, RD, MEd, CDE Catherine A. O’Brian, PhD Jane K. Kadohiro, DrPH, APRN, CDE, FAADE Richard A. Jackson, MD Nancy D’Hondt, RPh, CDE, FAADE Brenda Montgomery, RN, MSHS, CDE Kelly L. Close, BA, MBA Martha M. Funnell, MS, RN, CDE

Becoming aware of andchanging our wordsGuiding principles Diabetes is a complex and challenging diseaseProblematicPreferredinvolving many factors and variables Stigma that has historically been attached to adiagnosis of diabetes can contribute to stress andfeelings of shame and judgment Every member of the healthcare team can servepeople with diabetes more effectively through arespectful, inclusive, and person-centered approach Person-first, strengths-based, empowering languagecan improve communication and enhancemotivation, health and well-being of people withdiabetes.DiabeticPerson living with diabetesTest (blood glucose)Check / monitorControl (verb)Manage; describe what theperson is doingControl (noun)Define what you mean by controland use that instead (bloodglucose level, A1C)Good/Bad/PoorSafe/unsafe levels; target levels;use numbers and focus on factsinstead of judgmental termsCompliant / AdherentTakes medicine about half thetime; Eats vegetables a few timesa week; engagement;participation Recommendation #1 Recommendation #2 Use language that is neutral, non-judgmental and Use language that is free from stigma.based on facts, action or physiology/biology.Instead of this .Your diabetes is not in goodcontrol. It seems that yourefforts with meal planning,exercise and metformin havefailed, so it’s time to addanother medication.Say this .Your recent A1C level is8.5. That is above thetarget goal of 7.0 wediscussed. I’m thinking thatadding another medicinethat works in a different waycould help. How does thatsound?Instead of this .While I’m willing to refer thispatient to you (an RDN), Idoubt it will do any good, asshe has been obese for along time, and is unmotivatedand in denial. She has notdone anything I’vesuggested.Say this .I’m referring a new patientto you. She has a BMI of 35and while I’ve suggestedshe cut back on high caloriefoods, it has not resulted inweight loss. Let me knowwhat you learn and whatyou’d recommend. Recommendation #3 Recommendation #4 Use language that is strengths-based, respectful, Use language that fosters collaboration betweeninclusive and imparts hope.Instead of this .Mrs Lee, I see that you’vebeen non-compliant with BGtesting as you’re not doing itafter meals as we discussed.You really should be doingthis.patients and providers.Say this .Mrs Lee, I see you’ve beensuccessfully checkingfasting BG 2-3 times thispast week. Great work.What might make it easierfor you to also check aftermeals a few times?Instead of this .Mr. Smith, I see that youdidn’t fill yourprescriptions. Let mesee your blood glucoselog, please.Say this .Mr. Smith, I see that yourlast A1C result is 9.2% Doyou have concerns you’dlike to discuss perhapsabout any challenges youface taking medicines?

Recommendation #5Discussion Use language that is person-centered.Instead of this .Diabetics who sufferfrom hypertensionshould follow a DASHdiet.Say this .People with diabeteswho also havehypertension maybenefit from learningabout the DASHapproach to mealplanning.melinda@melindamaryniuk.com

Clinical Diabetes. 2017 Jan; 35(1)51-54. Speight J, Conn J, Dunning T, Skinner TC, Diabetes Australia. Diabetes Australia position statement. A new language for diabetes: improving communications with and about people with diabetes. Diabetes Res Clin Pract 2012 Sep; 97(3): 425- 31.