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The diabetes education team in the management of non-insulin-dependent diabetes mellitus
The Diabetes
Education
Team in the Management Diabetes Mellitus Sherman
of Non-Insulin-Dependent
M. Holvey
Non-insulin-dependent diabetes mellitus (NIDDM) is a complex disease that lasts a lifetime. It can be controlled but not cured. Treatment involves extensive changes in the patient’s lifestyle, particularly in the areas of diet and exercise, which can often result in noncompliance with treatment regimens. Efforts to bring about these lifestyle changes usually require an enormous amount of time and attention on the part of the physician, and thus, are best carried out with the help of a diabetes education team. An ideal team would consist not only of the physician, patient, and family, but also a diabetes educator, a nutritionist or dietitian, an exercise therapist, a psychologist or social worker, a podiatrist, and an ophthalmologist or retinologist. A smaller number of team participants can offer a viable alternative by doubling up discipline areas, and bv. using_ interested members of the community as a referral source. m 1987 by Grune & Stratton, inc.
N
ON-INSULIN-DEPENDENT diabetes mellitus (NIDDM) is a complex disease that can eventually affect virtually all of the organ systems within the body. It can be controlled but not cured, and thus, is a chronic disease that will continue to affect the patient throughout his or her lifetime. Unlike diseases such as hypothyroidism, in which once-daily medication is usually the only treatment regimen, the management of NIDDM also requires extensive modifications in a number of important areas of the patient’s lifestyle, particularly in the areas of diet and exercise. Many patients come to the physician with the hope that he or she can do something that is really impossible, that is, make the diabetes go away. What can be done is to provide the patient with information that will enable him or her to live a healthy life. Because of required modifications in the patient’s behavior, the treatment of the disease not only affects the patient but also those in close contact with that individual, ie, family, friends, and associates at work. Changes in a person’s behavior are notoriously difficult to make, particularly when they have been initiated in childhood and have become closely entwined with the lifestyles of family and friends. Thus, any attempt to bring about such changes must involve an education program that reviews the nature of the disease and the devastating consequences if left uncontrolled. In addition, such a program must cover practical techniques for achieving these required lifestyle changes. RATIONALE
FOR CREATING A DIABETES EDUCATION TEAM
It is usually impossible for a single physician to find the time necessary to accomplish these goals in a regular medical practice. Early in my own practice, I soon realized that the needs of both patients and their families for education and support was extensive. If I had attended to all of their requirements in this area, I would not have been able to spend time to develop the treatment program and deal with the medical management of these patients. It became apparent to me that it was necessary to augment what I was doing in my own practice with the addition of other persons who would help deliver the necessary information, and support its implementation on an ongoing basis. At that time, I found that my patients were often asking for advice from my laboratory technologist. Since she was Metabolism, Vol 36, No 2, Suppl 1 (February), 1987: pp 9-l 1
bright and communicated well with the patients, I invited her to become my diabetes educator. Twenty-nine years later, she remains an important member of our diabetes education team. In the beginning, the responsibilities of the diabetes educator were all inclusive, covering general education as well as both diet and exercise programs in the treatment of patients with NIDDM. With the growth of my practice, a dietitian was added to the team to focus on making dietary assessments, to develop specific diet plans for each patient, and to teach patients how to modify their eating behavior. This process has required continued motivation of the patient and continued modification of the dietary regimen in order to achieve ongoing success. As self blood glucose monitoring and insulin pump therapy became available, the diabetes educator spent increasing amounts of time educating patients in these areas to provide them with basic information. We then realized that our practice was not adequately addressing the emotional and behavioral problems that patients and families encounter when coping with NIDDM. Therefore, the next addition to our team was a psychologist. With the passage of time, we discovered two unforeseen advantages of the team approach. Team members became interdependent, seeking advice and support from each other. Also, patients began to take a more active role in their own treatment; they felt they were participating members of the treatment team, and this greatly increased their compliance. My own experience with creating a diabetes education team has paralleled the experience of other diabetologists around the country. Presently, diabetes education teams exist in many different areas-in hospital inpatient and outpatient programs, and in a number of private office practices. When the development of a full-time teaching team has not proved feasible, some physicians have instead developed a peripheral diabetes education team made up of interested members of the health care community, such as a
From the School of Medicine, University of California: and the Diabetes Unit, Century City Hospital, Los Angeles. Address reprint requests to Sherman M. Holvey. MD. 2080 Century Blvd. Los Angeles, CA 90067. o 1987 by Grune & Stratton, Inc. 0026-0495/87/3602-1001$03.00/0 9
HOLVEY
teaching nurse, an exercise specialist, a dietitian, and a psychologist or social worker who work on a referral basis. HOW THE PHYSICIAN
BENEFITS
The creation of a diabetes education team frees the physician from many day-to-day responsibilities involved in patient education and support, and allows the physician the freedom to carry on a more comprehensive medical care program, thus improving the quality of care delivered. The design of the therapeutic program is thereby expanded in complexity and made more flexible for the individual patient’s needs. Implementation of the treatment plan is improved by the close surveillance of the patient by the various team members. Communication between patient and care giver is also improved, since information can flow back and forth between physician and patient through multiple channels. Also, because of the availability of the various team members, these communication channels remain open during the intervals between office visits, while not interfering with the physician’s practice time. Naturally, the physician and team members need to communicate with each other on a regular basis, sharing progress reports on each patient and continuously modifying treatment plans according to the patient’s progress. Thus, a need for a change in medication as determined by self blood glucose monitoring may become apparent between office visits; this information can be acted on immediately without waiting for the next appointment. HOW THE PATIENT AND FAMILY BENEFIT
Many physicians who have a busy practice are difficult to reach by phone when a worried patient or family member wants an immediate answer to a question or needs reassurance about a problem. In this case, the other team members can respond immediately, acting as a buffer for the physician, and thereby greatly reducing the patient’s sense of isolation and detachment from the treatment process. The various team members can also provide the patient with in-depth education about the nature and treatment of NIDDM. There are now a number of excellent books, pamphlets, and videotapes about diabetes that can be offered to the patient. However, there is also an accompanying need for the active participation of team members to “lay the groundwork” and answer any questions that might arise from the patient’s use of these educational aids. In addition, the members of the diabetes education team are able to offer positive reinforcement for the day-to-day lifestyle changes that are necessary for the NIDDM patient. Probably the most important benefit the team can offer is the feeling of security and emotional support that is available to the patient on an ongoing basis. ROLES OF DIABETES EDUCATION
TEAM MEMBERS
The ideal diabetes team consists of the physician, the patient and family, the diabetes educator, the nutritionist or dietitian, the exercise specialist, the psychologist or social worker, the podiatrist, and the ophthalmologist or retinolo-
gist. Often, however, one single team member may have to handle more than one specialty, such as the diabetes educator also acting as the exercise specialist. Also, some specialties, such as podiatry and ophthalmology, are usually handled in the community by consultants who are interested in accepting referrals. The Physician
As team leader, the physician develops the strategies and coordinates the treatment program for each patient. He or she is the person who is originally approached by the patient and family often in search of a cure. If the patient and family are somewhat knowledgeable about diabetes and realize there is no real cure, they expect the physician to help the patient achieve proper diabetic control, to prevent complications, and to extend his or her life span. By meeting regularly with the other members of the diabetes education team, the physician can help structure and refine the treatment program and address any medical problems that arise. The physician is also responsible for monitoring any possible complications and providing physical examinations of the patient on a regular basis. The Patient and Family
It is often overlooked that the patient and family are very important participants in the diabetes education team. They are a primary source of information about the patient’s progress, and should be carefully questioned by members of the team. The patient, sometimes with the aid of a family member, will be performing self blood glucose monitoring during the intervals between office visits. This information can be used by the patient, once he or she has been properly trained, to adjust the dosage of medication, modify the diet, or change exercise activities. The inclusion of the patient and family in the diabetes education team changes the role of the patient from passive recipient of treatment to active participant in treatment strategies and implementation, often resulting in enhanced patient compliance. The Diabetes Educator
The individual trained as the diabetes educator may have come from a number of different disciplines, ie, diabetes teaching nurse, physician’s assistant, or nurse practitioner. The primary role of the diabetes educator is to teach the patient and family about the nature of NIDDM and to tell them how they can best cope with the disease. The educator also teaches the patient how to perform self blood glucose monitoring, and keeps in close contact with the patient so as to continuously track glucose levels and check the patient’s monitoring equipment. The diabetes educator is available to answer questions from the patient and family, and to offer constant emotional support. Where necessary, he or she alerts the physician to any changes in the patient’s condition that require an adjustment of the patient’s treatment program. The educator may recommend to the physician that the patient be referred to a specialist, such as a psychologist or social worker, when
DIABETES EDUCATION TEAM
necessary. However, when resources are limited, he or she may take on an additional role, such as dietitian or exercise specialist. In my own practice, the diabetes educator is the first to meet a new patient. The educator reviews the program structure, schedules laboratory tests, and records a patient’s history. Only after this initial screening process has occurred is there a meeting of the patient, family, physician, and other members of the diabetes education team. At this time, the treatment strategy for the patient is reviewed in detail. The Nutritionist
The nutritionist or dietitian begins by obtaining a detailed diet history from the patient. Since the majority of NIDDM patients are overweight, the nutritionist designs a weight reduction program tailored to the needs of the individual patient. He or she also explains the need for an increase in complex carbohydrates and fiber, as well as a decrease in cholesterol, fat, and protein. From then on, the patient is seen by the nutritionist at regular intervals to determine compliance and to offer support, guidance, and positive reinforcement. The dietary plan is also modified, where necessary, according to the patient’s level of progress. The Exercise Specialist
The exercise specialist designs a regimen for the patient that is realistically tailored to his or her needs and abilities. In the absence of an exercise specialist, referrals can also be made to an adult fitness program at the YMCA or YWCA, to a cardiac rehabilitation program in a local hospital, or to a private exercise therapist or health club. The Psychologist or Social Worker
Because of the continual stress of adapting to a rigorous diabetes treatment program, as well as the anxiety about potential organ system damage, the presence of a psychologist or social worker can prove very helpful to the patient. The patient can be taught to develop better coping skills, thus reducing the anxiety, fear, guilt, and anger that adversely affect blood glucose levels. This can be accomplished in one-to-one sessions between patient and therapist, as well as in group therapy sessions that are often led jointly by the therapist and diabetes educator. In addition, the psychologist can provide information to the other team members about relevant emotional issues the patient may be experiencing, and can tell the team members how they can best deal with these issues. The Podiatrist and Ophthalmologist
Patients are referred to a podiatrist who is knowledgeable about diabetes for routine foot care and when vascular complications begin to affect the lower extremities. Proper
11
foot care is particularly important for patients with NIDDM, as end-stage disease may result in gangrene and subsequent amputation. In addition, patients are referred to an ophthalmologist or retinologist for regular evaluation and treatment of ocular complications, if they develop. PATIENT COMPLIANCE
Even with the best of diabetes education teams, the primary issue facing every team member is that of patient compliance with the treatment program. The patient’s emotional response to the diagnosis and treatment of NIDDM, as well as his or her willingness to follow treatment strategies, depends in large part on his or her health care beliefs. Therefore, it is important for the team members to explore these beliefs with the patient. A patient may deny the existence of the disease, may appear indifferent to its diagnosis, or may express futility about attempting to deal with the disease. These attitudes can only be corrected by the intensive efforts of the team members to educate the patient about the nature of the disease and the values of the treatment program. A patient may feel overwhelmed by the complexity of the treatment program and attempt to ignore the more difficult areas. Team members can help by breaking the program down into discrete units or steps, making these as simple as possible and providing achievable goals. Too much information given too soon can burden the patient. Careful attention should be paid to the building of the patient’s technical skills, such as the ability to accurately perform self blood glucose monitoring. Repetition and support are useful here, and will also help alleviate the patient’s fear that too much will be expected of him or her by the respective team members. A patient may also feel resistant to changing behavior, such as modifying diet or consistently following an exercise regimen. The setting of achievable goals by team members is particularly important, since even a small success is reinforcing. It also helps if the patient participates in the setting of his or her personal goals as an active member of the team. Any effort toward progress should be encouraged, and each success should be immediately reinforced with praise. Noncompliance by the patient may be related to a poorly functioning or nonexistent support system, either among family or friends. It is very hard for a patient to diet if family members, through a lack of education about the disease, tempt the patient to eat forbidden foods. Members of the team can encourage better support by family, while offering their own supportive environment. Diabetes exists for the lifetime of the patient, and temporary setbacks in compliance should be expected. The members of the diabetes education team must be sensitive to this, and should avoid trying to instill guilt in the patient. Instead, continuing support by the various team members will help guide the patient back towards adherence to the program goals.
Education
Team in the Management Diabetes Mellitus Sherman
of Non-Insulin-Dependent
M. Holvey
Non-insulin-dependent diabetes mellitus (NIDDM) is a complex disease that lasts a lifetime. It can be controlled but not cured. Treatment involves extensive changes in the patient’s lifestyle, particularly in the areas of diet and exercise, which can often result in noncompliance with treatment regimens. Efforts to bring about these lifestyle changes usually require an enormous amount of time and attention on the part of the physician, and thus, are best carried out with the help of a diabetes education team. An ideal team would consist not only of the physician, patient, and family, but also a diabetes educator, a nutritionist or dietitian, an exercise therapist, a psychologist or social worker, a podiatrist, and an ophthalmologist or retinologist. A smaller number of team participants can offer a viable alternative by doubling up discipline areas, and bv. using_ interested members of the community as a referral source. m 1987 by Grune & Stratton, inc.
N
ON-INSULIN-DEPENDENT diabetes mellitus (NIDDM) is a complex disease that can eventually affect virtually all of the organ systems within the body. It can be controlled but not cured, and thus, is a chronic disease that will continue to affect the patient throughout his or her lifetime. Unlike diseases such as hypothyroidism, in which once-daily medication is usually the only treatment regimen, the management of NIDDM also requires extensive modifications in a number of important areas of the patient’s lifestyle, particularly in the areas of diet and exercise. Many patients come to the physician with the hope that he or she can do something that is really impossible, that is, make the diabetes go away. What can be done is to provide the patient with information that will enable him or her to live a healthy life. Because of required modifications in the patient’s behavior, the treatment of the disease not only affects the patient but also those in close contact with that individual, ie, family, friends, and associates at work. Changes in a person’s behavior are notoriously difficult to make, particularly when they have been initiated in childhood and have become closely entwined with the lifestyles of family and friends. Thus, any attempt to bring about such changes must involve an education program that reviews the nature of the disease and the devastating consequences if left uncontrolled. In addition, such a program must cover practical techniques for achieving these required lifestyle changes. RATIONALE
FOR CREATING A DIABETES EDUCATION TEAM
It is usually impossible for a single physician to find the time necessary to accomplish these goals in a regular medical practice. Early in my own practice, I soon realized that the needs of both patients and their families for education and support was extensive. If I had attended to all of their requirements in this area, I would not have been able to spend time to develop the treatment program and deal with the medical management of these patients. It became apparent to me that it was necessary to augment what I was doing in my own practice with the addition of other persons who would help deliver the necessary information, and support its implementation on an ongoing basis. At that time, I found that my patients were often asking for advice from my laboratory technologist. Since she was Metabolism, Vol 36, No 2, Suppl 1 (February), 1987: pp 9-l 1
bright and communicated well with the patients, I invited her to become my diabetes educator. Twenty-nine years later, she remains an important member of our diabetes education team. In the beginning, the responsibilities of the diabetes educator were all inclusive, covering general education as well as both diet and exercise programs in the treatment of patients with NIDDM. With the growth of my practice, a dietitian was added to the team to focus on making dietary assessments, to develop specific diet plans for each patient, and to teach patients how to modify their eating behavior. This process has required continued motivation of the patient and continued modification of the dietary regimen in order to achieve ongoing success. As self blood glucose monitoring and insulin pump therapy became available, the diabetes educator spent increasing amounts of time educating patients in these areas to provide them with basic information. We then realized that our practice was not adequately addressing the emotional and behavioral problems that patients and families encounter when coping with NIDDM. Therefore, the next addition to our team was a psychologist. With the passage of time, we discovered two unforeseen advantages of the team approach. Team members became interdependent, seeking advice and support from each other. Also, patients began to take a more active role in their own treatment; they felt they were participating members of the treatment team, and this greatly increased their compliance. My own experience with creating a diabetes education team has paralleled the experience of other diabetologists around the country. Presently, diabetes education teams exist in many different areas-in hospital inpatient and outpatient programs, and in a number of private office practices. When the development of a full-time teaching team has not proved feasible, some physicians have instead developed a peripheral diabetes education team made up of interested members of the health care community, such as a
From the School of Medicine, University of California: and the Diabetes Unit, Century City Hospital, Los Angeles. Address reprint requests to Sherman M. Holvey. MD. 2080 Century Blvd. Los Angeles, CA 90067. o 1987 by Grune & Stratton, Inc. 0026-0495/87/3602-1001$03.00/0 9
HOLVEY
teaching nurse, an exercise specialist, a dietitian, and a psychologist or social worker who work on a referral basis. HOW THE PHYSICIAN
BENEFITS
The creation of a diabetes education team frees the physician from many day-to-day responsibilities involved in patient education and support, and allows the physician the freedom to carry on a more comprehensive medical care program, thus improving the quality of care delivered. The design of the therapeutic program is thereby expanded in complexity and made more flexible for the individual patient’s needs. Implementation of the treatment plan is improved by the close surveillance of the patient by the various team members. Communication between patient and care giver is also improved, since information can flow back and forth between physician and patient through multiple channels. Also, because of the availability of the various team members, these communication channels remain open during the intervals between office visits, while not interfering with the physician’s practice time. Naturally, the physician and team members need to communicate with each other on a regular basis, sharing progress reports on each patient and continuously modifying treatment plans according to the patient’s progress. Thus, a need for a change in medication as determined by self blood glucose monitoring may become apparent between office visits; this information can be acted on immediately without waiting for the next appointment. HOW THE PATIENT AND FAMILY BENEFIT
Many physicians who have a busy practice are difficult to reach by phone when a worried patient or family member wants an immediate answer to a question or needs reassurance about a problem. In this case, the other team members can respond immediately, acting as a buffer for the physician, and thereby greatly reducing the patient’s sense of isolation and detachment from the treatment process. The various team members can also provide the patient with in-depth education about the nature and treatment of NIDDM. There are now a number of excellent books, pamphlets, and videotapes about diabetes that can be offered to the patient. However, there is also an accompanying need for the active participation of team members to “lay the groundwork” and answer any questions that might arise from the patient’s use of these educational aids. In addition, the members of the diabetes education team are able to offer positive reinforcement for the day-to-day lifestyle changes that are necessary for the NIDDM patient. Probably the most important benefit the team can offer is the feeling of security and emotional support that is available to the patient on an ongoing basis. ROLES OF DIABETES EDUCATION
TEAM MEMBERS
The ideal diabetes team consists of the physician, the patient and family, the diabetes educator, the nutritionist or dietitian, the exercise specialist, the psychologist or social worker, the podiatrist, and the ophthalmologist or retinolo-
gist. Often, however, one single team member may have to handle more than one specialty, such as the diabetes educator also acting as the exercise specialist. Also, some specialties, such as podiatry and ophthalmology, are usually handled in the community by consultants who are interested in accepting referrals. The Physician
As team leader, the physician develops the strategies and coordinates the treatment program for each patient. He or she is the person who is originally approached by the patient and family often in search of a cure. If the patient and family are somewhat knowledgeable about diabetes and realize there is no real cure, they expect the physician to help the patient achieve proper diabetic control, to prevent complications, and to extend his or her life span. By meeting regularly with the other members of the diabetes education team, the physician can help structure and refine the treatment program and address any medical problems that arise. The physician is also responsible for monitoring any possible complications and providing physical examinations of the patient on a regular basis. The Patient and Family
It is often overlooked that the patient and family are very important participants in the diabetes education team. They are a primary source of information about the patient’s progress, and should be carefully questioned by members of the team. The patient, sometimes with the aid of a family member, will be performing self blood glucose monitoring during the intervals between office visits. This information can be used by the patient, once he or she has been properly trained, to adjust the dosage of medication, modify the diet, or change exercise activities. The inclusion of the patient and family in the diabetes education team changes the role of the patient from passive recipient of treatment to active participant in treatment strategies and implementation, often resulting in enhanced patient compliance. The Diabetes Educator
The individual trained as the diabetes educator may have come from a number of different disciplines, ie, diabetes teaching nurse, physician’s assistant, or nurse practitioner. The primary role of the diabetes educator is to teach the patient and family about the nature of NIDDM and to tell them how they can best cope with the disease. The educator also teaches the patient how to perform self blood glucose monitoring, and keeps in close contact with the patient so as to continuously track glucose levels and check the patient’s monitoring equipment. The diabetes educator is available to answer questions from the patient and family, and to offer constant emotional support. Where necessary, he or she alerts the physician to any changes in the patient’s condition that require an adjustment of the patient’s treatment program. The educator may recommend to the physician that the patient be referred to a specialist, such as a psychologist or social worker, when
DIABETES EDUCATION TEAM
necessary. However, when resources are limited, he or she may take on an additional role, such as dietitian or exercise specialist. In my own practice, the diabetes educator is the first to meet a new patient. The educator reviews the program structure, schedules laboratory tests, and records a patient’s history. Only after this initial screening process has occurred is there a meeting of the patient, family, physician, and other members of the diabetes education team. At this time, the treatment strategy for the patient is reviewed in detail. The Nutritionist
The nutritionist or dietitian begins by obtaining a detailed diet history from the patient. Since the majority of NIDDM patients are overweight, the nutritionist designs a weight reduction program tailored to the needs of the individual patient. He or she also explains the need for an increase in complex carbohydrates and fiber, as well as a decrease in cholesterol, fat, and protein. From then on, the patient is seen by the nutritionist at regular intervals to determine compliance and to offer support, guidance, and positive reinforcement. The dietary plan is also modified, where necessary, according to the patient’s level of progress. The Exercise Specialist
The exercise specialist designs a regimen for the patient that is realistically tailored to his or her needs and abilities. In the absence of an exercise specialist, referrals can also be made to an adult fitness program at the YMCA or YWCA, to a cardiac rehabilitation program in a local hospital, or to a private exercise therapist or health club. The Psychologist or Social Worker
Because of the continual stress of adapting to a rigorous diabetes treatment program, as well as the anxiety about potential organ system damage, the presence of a psychologist or social worker can prove very helpful to the patient. The patient can be taught to develop better coping skills, thus reducing the anxiety, fear, guilt, and anger that adversely affect blood glucose levels. This can be accomplished in one-to-one sessions between patient and therapist, as well as in group therapy sessions that are often led jointly by the therapist and diabetes educator. In addition, the psychologist can provide information to the other team members about relevant emotional issues the patient may be experiencing, and can tell the team members how they can best deal with these issues. The Podiatrist and Ophthalmologist
Patients are referred to a podiatrist who is knowledgeable about diabetes for routine foot care and when vascular complications begin to affect the lower extremities. Proper
11
foot care is particularly important for patients with NIDDM, as end-stage disease may result in gangrene and subsequent amputation. In addition, patients are referred to an ophthalmologist or retinologist for regular evaluation and treatment of ocular complications, if they develop. PATIENT COMPLIANCE
Even with the best of diabetes education teams, the primary issue facing every team member is that of patient compliance with the treatment program. The patient’s emotional response to the diagnosis and treatment of NIDDM, as well as his or her willingness to follow treatment strategies, depends in large part on his or her health care beliefs. Therefore, it is important for the team members to explore these beliefs with the patient. A patient may deny the existence of the disease, may appear indifferent to its diagnosis, or may express futility about attempting to deal with the disease. These attitudes can only be corrected by the intensive efforts of the team members to educate the patient about the nature of the disease and the values of the treatment program. A patient may feel overwhelmed by the complexity of the treatment program and attempt to ignore the more difficult areas. Team members can help by breaking the program down into discrete units or steps, making these as simple as possible and providing achievable goals. Too much information given too soon can burden the patient. Careful attention should be paid to the building of the patient’s technical skills, such as the ability to accurately perform self blood glucose monitoring. Repetition and support are useful here, and will also help alleviate the patient’s fear that too much will be expected of him or her by the respective team members. A patient may also feel resistant to changing behavior, such as modifying diet or consistently following an exercise regimen. The setting of achievable goals by team members is particularly important, since even a small success is reinforcing. It also helps if the patient participates in the setting of his or her personal goals as an active member of the team. Any effort toward progress should be encouraged, and each success should be immediately reinforced with praise. Noncompliance by the patient may be related to a poorly functioning or nonexistent support system, either among family or friends. It is very hard for a patient to diet if family members, through a lack of education about the disease, tempt the patient to eat forbidden foods. Members of the team can encourage better support by family, while offering their own supportive environment. Diabetes exists for the lifetime of the patient, and temporary setbacks in compliance should be expected. The members of the diabetes education team must be sensitive to this, and should avoid trying to instill guilt in the patient. Instead, continuing support by the various team members will help guide the patient back towards adherence to the program goals.