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CASE STUDY
"Sister Ann" •  Understanding and Treating Diabetes

Ellen Griffiths, RD, MPH is the staff nutritionist at Saint Luke Institute.

Sr. Ann is a 52-year-old social worker who works with deprived, inner-city youth in the criminal justice system in a large urban area. She finds her work rewarding, knowing that her interactions are often the only positive ones experienced by some of her clients. The victories are few and far between however. She gives 150% of herself, working through a difficult bureaucratic system, managing a sparse staff, and whenever possible on weekends, making an occasional personal visit to a client. Sr. Ann is respected and appreciated by many.

The demands of her ministry are numerous. Because her days are long, she finds little time for relaxation. Her daily commute is 60 miles roundtrip. Her meals are usually on the run, some breakfasts are eaten in the car. Although eating like this stirs up her irritable bowel syndrome, she sometimes jokes that this is just another example of her "multi-tasking." When she schedules down time, something invariably happens to fill the void.

Although she is very well respected and liked at work, her personal life is quite different. She lives with two other sisters, both of whom she barely knows. There are scheduled community dinners on most nights, but Sr. Ann often misses them. When she is at home, she often recounts some of what she deals with daily and the other sisters are often overwhelmed or frightened. Usually when she returns home, what she really feels she needs is a nap.

When her work required her to have a tuberculin skin test, her doctor also required a complete physical. The doctor diagnosed obesity and an elevated fasting blood glucose of 157mg/dl, meeting the criterion for a diagnosis of diabetes. This was a devastating blow to Sr. Ann, who remembered her mother's suffering with diabetes. She decided for the moment not to address her care; she was overwhelmed by the diagnosis. Despite the prescription and the referrals her doctor gave her, she kept up the same routine. She rejected the treatment recommendations saying that "my mother's blood sugars were much higher than mine." She was in denial that when her mother ate whatever she wanted and did not take her medication, she deteriorated rapidly. With some insistence by her physician and her community, Sr. Ann took a week off to address diabetes and the other neglected aspects of her life. She got the prescription filled, rested, and got her car serviced. Within a few weeks, however, she went back to the usual intensity, taking her medication haphazardly. Eventually, when she noticed her vision blurring, Sr. Ann became frightened and made an appointment to see her doctor. During this appointment, she began to sob as she admitted to the pain of the diagnosis and also to her experiences of almost nightly insomnia. She also admitted for the first time that she thought she might be depressed.

Understanding and Treating Diabetes
Diabetes is a chronic disease in which the body does not produce or properly use the hormone insulin. Insulin is needed by the body to convert carbohydrates (sugar, starches and other foods) into energy needed for daily life. The cause of diabetes remains unknown, although genetics and environmental factors such as obesity and lack of exercise appear to play roles. Appropriate eating, regular exercise, and medication when needed help to control diabetes and reduce the risk of complications, which present the greatest threat to health.

In September 2005, the Centers for Disease Control and Prevention acknowledged that depression is a risk factor for chronic illnesses such as diabetes. Depression makes the management of any disease more problematic. Depression as a "comorbid condition" with a chronic disease makes the chronic disease worse. Sleep disturbance is not an unusual occurrence with obesity and depression and may increase the likelihood of diabetes.

At Saint Luke Institute we treat the client holistically, aware that physical conditions affect emotions and spirit. Clients are not admitted to our programs because of the presence of diabetes alone. We are aware, however, that their diabetes must be addressed. In our effort to assist clients with achieving physical health, we provide a complete physical exam at evaluation or admission. For those with diabetes, we recommend diabetes education classes if the clients have not had the education within the past three years or if they seem limited in their knowledge. As is the case with all clients, those with diabetes receive a nutritional assessment and a fitness assessment. They work with both the nutritionist and the exercise physiologist to achieve the best possible health. In addition, all clients are followed throughout treatment by a medical doctor. Blood tests are done regularly to assure that all health conditions, including diabetes, are adequately addressed. When needed, referrals are made to medical specialists to prevent or lessen the progression of complications. Clients for whom depression is a concern are also seen by the psychiatrist and evaluated for anti-depressant medication. Clients are in individual and group psychotherapy throughout treatment and it is often the case, that the psychotherapy seems more beneficial once the diabetes and depression are medically addressed.

" Dieting" is a national obsession with confusing implications and often without any regard for health. Consuming a healthy diet, or nutrient intake, is not the same. Nutritional assessment at SLI seeks to elicit significant information from the client for identifying achievable healthy nutritional outcomes. The client does not necessarily have to conform to rigid dietary strictures. The goal is to help the client enjoy a healthy relationship with food where the body's needs are met appropriately.

While in treatment, Sr. Ann worked with a nutritionist to identify her problematic behaviors which included inadequate time for meals, eating while performing stressful activities, lack of attention to the quality and quantity of what she eats, eating for alertness after lack of sleep, and avoidance of social interaction at meal times. She is learning to prioritize and care for herself and to relax and savor her meals. Having a daily routine can be very helpful to clients with diabetes seeking good blood sugar control. In addition, Sr. Ann is getting regular exercise which helps both her diabetes control and her depression. Sr. Ann is learning what physician and author George Sheehan affirms: "The mind's first step into self awareness must be through the body."

LUKENOTES is a bimonthly publication of Saint Luke Institute.
Permission to use these materials must be requested in writing by contacting
lukenotes@sli.org

SLI EDUCATION DEPARTMENT
Saint Luke Institute
8901 New Hampshire Ave.
Silver Spring, MD 20903
(301) 422-5499 • (301) 422-5519 (fax)

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