July, 2006

Definition of the Problem
Diabetes mellitus (DM) refers to two related illnesses. Both affect how a person metabolizes glucose (sometimes called “blood sugar”). In Type I diabetes, the pancreas stops producing insulin, possibly because of an autoimmune process of some kind. Type I diabetics need carefully monitored insulin replacement therapy to survive. Type I diabetics make up around 10% of the diabetic population (Votey and Peters, 2005a).

In Type II diabetes, the pancreas may or may not be producing enough insulin, but the insulin receptor cells have closed down (“insulin resistance”). The liver may also be affected, producing more glucose than the body needs (Votey and Peters, 2005a).

Type II diabetes is associated with high-fat, high-calorie diets, sedentary lifestyles, overweight, and economic hardship (Black, 2002; Bo, Menato et al, 2002; Votey and Peters, 2005b).

Stress is a major contributing factor in diabetes. It raises blood glucose by stimulating the release of glucose by the liver, and can also interfere with people following their doctors’ orders and recommendations (Surwit, van Tilburg et al, 2002; Arsham and Lowe, 1997).

Scope and Cost of the Problem
Diabetes is one of the most prevalent, most expensive, and fastest growing chronic conditions in the U.S.A. and the world. About 18.2 million Americans had diagnosed diabetes in 2002 (Votey and Peters, 2005a). In 1998, their care involved 513,000 hospital admissions, averaging 5.2 days per stay (Hall and Popovic, 2000).

Direct medical expenditures for diabetes in 1997 totaled $44.1 billion – about $7.7 billion for glycemic care, and $36.4 billion for treatment of complications and excess prevalence of general medical conditions (Votey and Peters, 2005b). People visited doctor’s offices 24.7 million times in 1999-2000 for Type 2 diabetes alone (Burt and Schappert, 2004).

According to the American Diabetes Association, indirect costs of diabetes (from premature mortality and disability) in 1997 totaled $54.1 billion. Total medical expenditures incurred by people with diabetes totaled $77.7 billion or $13,243 per person, compared with $2,560 for people without diabetes (Votey and Peters, 2005). ADA research also found that in the United States, diabetes accounted for a loss of nearly 88 million disability days in 2002).

Diabetes is a chronic illness in which outcomes, quality of life, and use of medical resources depend almost entirely on patient compliance. That is, the ability to follow prescribed diet, exercise, glucose monitoring, infection prevention, and medication regimens.

But many find this program burdensome and frustrating (Polonsky, 1999). Noncompliance is the biggest cause of diabetic complications, including kidney failure, blindness, amputation, and heart disease (Arsham and Lowe, 1997). Any program that enables patients to better comply with treatment plans will be extremely valuable and cost-effective.

Medical Treatment
Medical treatment of Type I diabetes centers on insulin replacement, which is usually done by self-administered injections. Continuous insulin pumps are now available for some patients and allow for greater glycemic control and ease of treatment. Type II diabetics are usually treated with oral medications (sulfonylureas, biguanides, alpha-glucosidase inhibitors, and thiazolidinediones) (Arsham and Lowe, 1997).

Compliance with Diabetes Treatment
The Diabetes Clinical Control Trial (NIDDKD, 2003) demonstrated that diabetics who maintain excellent glycemic control face relatively little risk of kidney failure, retinopathy, or amputation. Improvements in glucose testing technology and medications have made glucose control possible for a greater number of diabetics. Still, the physical and psychological demands of tight control are difficult for many patients.

The Role of Relaxation, Hypnosis, and Imagery
Stress reduction is a vital part of diabetes management. This is especially true in Type II diabetes, where it appears to lower blood glucose directly (Feinglos, Hastedt and Surwit, 1987; Surwit, van Tillberg et al, 2002).In Type I, the advantages of relaxation, hypnosis, biofeedback, and guided imagery appear to stem largely from improved behaviors, although there is some evidence of a direct effect (McGrady and Gerstenmaier, 1990; Ratner, Gross et al, 1990).

Researchers found that both depression and anxiety worsen glycemic control both directly, and indirectly through behavior (McGrady and Horner, 1999). Depression and anxiety can be partially relieved through relaxation and self-hypnosis (guided imagery) (Davidson, Fambach and Richardson, 1978; Stetter, Walter et al, 1994). Other researchers found that several areas of diabetes self-care behavior improved in a group of patients who listened to guided imagery tapes (Wichowski, Jubsch, 1999).

Biofeedback and relaxation significantly lowered blood glucose, A1C, muscle tension, depression, and anxiety in subjects (McGinnis, McGrady et al, 2005). Thermal biofeedback, when used alone or in combination with other mind-body techniques, can improve quality of life and the level of activity by improving blood flow, pain, neuropathy, healing ulcers (Galper, Taylor, et al, 2003).

A low-cost guided imagery-based program can improve compliance in diabetics of both types and improve glycemic control in Type II diabetics.

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