Diabetes Ther (2019) 10:791–804
https://doi.org/10.1007/s13300-019-0614-6
REVIEW
Euthymia in Diabetes: Clinical Evidence and Practice-
Based Opinion from an International Expert Group
Sanjay Kalra . A. K. Das . M. P. Baruah . A. G. Unnikrishnan . Arundhati Dasgupta . Parag Shah .
Rakesh Sahay . Rishi Shukla . Sambit Das . Mangesh Tiwaskar . G. Vijayakumar . Manoj Chawla .
Fatimah Eliana . Ketut Suastika . Abbas Orabi . Aly Ahmed Abdul Rahim . Andrew Uloko .
Roberta Lamptey . Nancy Ngugi . Silver Bahendeka . Abdurezak Ahmed Abdela . Fariduddin Mohammed .
Mohammed Faruque Pathan . Muhammed Hafizur Rahman . Faria Afsana . Shajada Selim .
Muaz Moosa . Moosa Murad . Pradeep Krishna Shreshtha . Dina Shreshtha . Mimi Giri .
Wiam Hussain . Ahmed Al-Ani . Kaushik Ramaiya . Surender Singh . Syed Abbas Raza .
Than Than Aye . Chaminda Garusinghe . Dimuthu Muthukuda . Muditha Weerakkody .
Shyaminda Kahandawa . Charlotte Bavuma . Sundeep Ruder . Koy Vanny . Manish Khanolkar .
Leszek Czupryniak
Received: February 23, 2019 / Published online: April 22, 2019
 The Author(s) 2019
ABSTRACT associated with diabetes mellitus (DM) and its
management.
Aim: To develop an evidence-based expert Background: Diabetes mellitus is a metabolic
group opinion on various types of euthymia syndrome characterized by diverse biomedical
and psychosocial features. Emotional health
disturbances may lead to psychological and
Enhanced Digital Features To view enhanced digital
features for this article go to https://doi.org/10.6084/ psychiatric dysfunction and may negatively
m9.figshare.7946273. influence glycemic control. Patients with DM
& P. ShahS. Kalra ( )
Department of Endocrinology and Diabetes, Gujarat
Department of Endocrinology, Bharti Hospital and
Endocrine Centre, Ahmedabad, India
BRIDE, Karnal, Haryana, India
e-mail: brideknl@gmail.com R. Sahay
Department of Endocrinology, Osmania Medical
A. K. Das
College, Hyderabad, India
Department of Endocrinology and Medicine,
Pondicherry Institute of Medical Sciences, R. Shukla
Puducherry, India Department of Endocrinology, Regency Hospital
Ltd., Kanpur, India
M. P. Baruah
Department of Endocrinology, Excel Hospital, S. Das
Guwahati, Assam, India Department of Endocrinology, Apollo Hospitals,
Bhubaneswar, India
A. G. Unnikrishnan
Department of Endocrinology and Diabetes, M. Tiwaskar
Chellaram Diabetes Institute, Pune, Maharashtra, Department of Diabetology, Shilpa Medical
India Research Centre, Mumbai, India
A. Dasgupta G. Vijayakumar
Department of Endocrinology, Rudraksh Department of Diabetology, Apollo Hospitals,
Superspecialty Care, Siliguri, India Chennai, India
792 Diabetes Ther (2019) 10:791–804
may experience diabetes distress (DD) associ- Results: After due discussions and extensive
ated with burden of self-care, interpersonal deliberations, the expert group provided several
issues, and emotional worries regarding the recommendations on implementing the con-
ability to cope with the illness. Euthymia or a cept of euthymia in DM care.
state of positive mental health and psychologi- Conclusions: Introduction of the concept of
cal well-being should be considered a key out- euthymia in routine clinical practice is impor-
come of diabetes care. Therefore, to achieve tant to improve the quality of life and coping
optimal outcomes, the consideration and mea- skills in patients with DM. A timely clinical
surement of psychological and psychiatric assessment of psychological and psychiatric
aspects along with glycemic levels are very aspects along with patient-reported outcomes of
important. A group of multidisciplinary clinical diabetes contributes to overall health and well-
experts came together in an international being of affected individuals.
meeting held in India to develop a workable Funding: Sanofi India.
concept for euthymia in diabetes care. A mul-
tidisciplinary approach was suggested to Keywords: Diabetes distress; Diabetes mellitus;
enhance the clinical outcomes and facilitate Euthymia; Psychological; Stress
patient-centered care. During the meeting
emphasis was given to the concept of a euthy-
mia model in diabetes care. This model focuses INTRODUCTION
on enhancement of self-care skills in diabetic
patients and preventative health awareness Diabetes mellitus (DM) has a profound impact on
among diabetes care providers. Euthymia also both the physical and mental well-being of the
encompasses patient–provider communication affected individual. Management of DM is mul-
to aid enhancement of coping skills. tifaceted. In addition to accepting prescribed
M. Chawla S. Bahendeka
Department of Diabetology, Lina Diabetes Care and Department of Internal Medicine, Diabetes and
Mumbai Diabetes Research Centre, Mumbai, India Endocrinology, St. Francis Hospital, Nsambya,
Kampala, Uganda
F. Eliana
Department of Internal Medicine, Faculty of A. A. Abdela
Medicine, YARSI University, Jakarta, Indonesia Department of Internal Medicine, Addis Ababa
University, Addis Ababa, Ethiopia
K. Suastika
Indonesian Association of Endocrinology, Jakarta, F. Mohammed
Indonesia Department of Endocrinology of Bangabandhu
Sheikh, Mujib Medical University, Dhaka,
A. Orabi Bangladesh
Department of Internal Medicine, Faculty of
Medicine, Zagazig University, Zagazig, Egypt Mohammed FaruquePathan  F. Afsana
Department of Endocrinology, Bangladesh Institute
A. A. A. Rahim of Research and Rehabilitation for Diabetes,
Department of Diabetes and Metabolism, Endocrine and Metabolic Disorders (BIRDEM),
Alexandria University, Alexandria, Egypt Dhaka, Bangladesh
A. Uloko M. H. Rahman
Department of Medicine, Aminu Kano Teaching Department of Endocrinology, Dhaka Medical
Hospital, Kano, Nigeria College and Hospital, Dhaka, Bangladesh
R. Lamptey S. Selim
Department of Family Medicine, Korle Bu Teaching Department of Endocrinology, Bangabandhu
Hospital, University of Ghana, School of Public Sheikh Mujib Medical University, Dhaka,
Health Ghana, Accra, Ghana Bangladesh
N. Ngugi M. Moosa  M. Murad
Department of Internal Medicine and Diabetes, Department of internal Medicine, Indira Gandhi
Kenyatta National Hospital, Nairobi, Kenya Memorial Hospital, Malé, Maldives
Diabetes Ther (2019) 10:791–804 793
pharmacotherapy, patients with DM have to fol- response characterized by extreme apprehension,
low physician’s advice with regards to non-phar- discomfort, or dejection due to perceived inability
macologic interventions focusing mainly on to cope with the challenges and demands of liv-
lifestyle changes. Facing additional responsibili- ing with diabetes [3]. As DD is a common occur-
ties of self-monitoring and adherence to the rence in DM patients, healthcare professionals
marked readjustment in lifestyle factors entail a should identify the cause for DD andminimize its
fair amount of stress [1]. Diabetes mellitus is impact on the affected person.
linked to a high burden of psychiatric morbidity, The concept of euthymia is not confined
whereas depression and anxiety are worsened by only to patients with diabetes; euthymia is
hyperglycemia. Therefore, in DM patients, in applicable to diabetes care providers as well, as
addition to the evaluation of glycemic levels, they are constantly under stress due to work
measurement of distress, depression, and anxiety pressure. It is important for healthcare providers
is crucial to achieve optimal outcomes. Learning to adopt preventive health strategies to achieve
and maintaining self-management, coping skills, overall health and well-being.
disease progression, and onset of complications Patient–provider communication constitutes
may also precipitate psychological issues in most an integral part of the euthymiamodel in diabetes
of patients with DM [2]. care. Effective communication between the
Some mental health disorders, such as anxiety patient and provider is crucial to aid the motiva-
and depression, are more prevalent in DM tional interview with the patient and also to pro-
patients, whereas certain conditions, such as dia- mote enhancement of coping skills in the patient.
betes distress (DD) and insulin distress, are very
specific to the disease per se. Diabetes distress can
be explained as an emotional worry that forms a METHODS
part of the spectrum of patients’ feelings and
experiences during the management of DM. At the international meeting, the experts
Diabetes distress is defined as an emotional reviewed the available literature evidence and
P. K. Shreshtha
Department of Internal Medicine, Tribhuwan S. A. Raza
Department of Endocrinology, Shaukat Khanum
University Teaching Hospital, Kathmandu, Nepal
Hospital and Research Center, Lahore, Pakistan
D. Shreshtha
Department of Endocrinologist, Norvic T. T. Aye
Myanmar Society of Endocrinology and
International Hospital Kathmandu, Kathmandu,
Metabolism, Yangon, Myanmar
Nepal
C. Garusinghe
M. Giri
Department of Endocrinology, Nepal Mediciti Department of Endocrinology, Colombo South
Teaching Hospital, Colombo, Sri Lanka
Hospital, Kathmandu, Nepal
D. Muthukuda
W. Hussain
Department of Endocrinology, Sri Jayawardenapura
Department of Endocrinology & Diabetes, Dr Wiam
Clinic, Royal Hospital, Awali Hospital, Awali, General Hospital, Sri Jayawardenapure Kotte, Sri
Lanka
Bahrain
M. Weerakkody
A. Al-Ani
Department of Endocrinology, Teaching Hospital
Department of Internal Medicine, Hamad Hospital,
Doha, Qatar Karapitiya, Galle, Sri Lanka
S. Kahandawa
K. Ramaiya
Department of Endocrinology, District General
Department of Diabetology, Shree Hindu Mandal
Hospital, Dar es Salaam, Tanzania Hospital, Matara, Sri Lanka
C. Bavuma
S. Singh
College of Medicine and Health Science, University
Department of Internal Medicine, Aster Al Raffah
of Rwanda, Kigali, Rwanda
Hospital, Muscat, Oman
794 Diabetes Ther (2019) 10:791–804
provided their individual insights based on clini- the burden of mental health dysfunction is high
cal experience in the management of DM. The in DM patients. Mental health dysfunction and
primary focus areas of this international meeting hyperglycemia have a bidirectional relation-
were DD, psychological burden in diabetes, and ship. Euthymia delivers a sense of healthy life
physician’s workload in diabetes care. The panel’s and healthy coping with diabetes. The concept
key discussion points were based on scientific of euthymia emphasizes the ability to identify
evidence and collective clinical judgment from and acclimatize to various situational demands
practice. These key discussion points considered in diabetes management. Euthymia highlights
as ‘‘clinical expert opinions’’ were developed for the importance of maintaining adequate bal-
the topics mentioned above and have been ance among important life domains and to
summarized in this statement. This article is display compatibility in one’s behavior
based on previously conducted studies and does throughout the course of the DM management
not contain any studies with human participants (Fig. 1) [4].
or animals performed by any of the authors.
Redefining Diabetes Distress
As discussed earlier, emotional worries that
RESULTS
form a part of the spectrum of patients’ feelings
and experiences during the management of
Euthymia in Patients with DM (DD)
chronic diseases, such as DM, over time, are
defined as diabetes distress. The clinical expert
Understanding the Concept of Euthymia group, however, relooked into the definition of
in Diabetes DD. Diabetes distress was redefined as persistent
Euthymia refers to optimal mental state or mood emotional burden or worries that form a part of
and is an essential part of good health and well- the spectrum of patients’ feelings and experi-
being. The word euthymia (‘‘eu’’ = well ? ‘‘thy- ences during the management of chronic dis-
mos’’ = soul/emotion) was first defined by the ease such as diabetes mellitus, over time [1].
Greek scholar Democritus as ‘‘one is satisfied with
what is present and available, taking little heed of
Prevalence of DD
people who are envied and admired and observ-
A large proportion of research in the literature
ing the lives of those who suffer and yet endure.’’
takes into consideration both type 1 DM
Euthymia could be broadly described as a state of
(T1DM) and type 2 DM (T2DM) when exploring
positive mental health, eustress, and psychologi-
the prevalence of DD. However, this approach
cal well-being [4].
may not be appropriate to define DD, as the
Euthymia should be considered as an
emotional concerns may differ in patients with
important tool and target in diabetes care, as
T1DM compared to those with T2DM. A meta-
analysis by Perrin et al. evaluated the overall
S. Ruder prevalence of DD in patients with T2DM. The
Department of Endocrinology and metabolism, meta-analysis included 55 studies with 36,998
Charlotte Maxeke Johannesburg Academic Hospital, T2DM patients. The overall prevalence of DD
Johannesburg, South Africa was calculated to be 36% in T2DM patients. The
K. Vanny meta-analysis also reported a significantly
Department of Diabetes and endocrinology, Dr higher prevalence of DD in samples with a
KoyVanny Diabetes & Endocrine Clinic, Phnom higher prevalence of comorbid depressive
Penh, Cambodia
symptoms and female sample majority [5].
M. Khanolkar
Department of Endocrinology and Diabetes, Time Points in DM Patients Associated
Waikato Hospital, Hamilton, New Zealand
with Increased Levels of DD
L. Czupryniak At some point during the diabetes trajectory all
Department of Diabetology & Internal Medicine, patients experience distress. It is important to
Medical university of Warsaw, Warsaw, Poland
Diabetes Ther (2019) 10:791–804 795
Fig. 1 Proposed model for achieving euthymia in diabetes care
identify the periods during which the level of responses that differ from one patient to another
distress is at its peak. Some of the identifiable and include any of the following responses: feel-
periods during which the probability of having ing unmotivated, burned out, overwhelmed,
high levels of distress include: frustrated, angry, guilty, fear (of hypoglycemia or
• complications), or lonely [8].Around the time of diagnosis of DM
• Several different measures are used for theAt the time of learning how to self-manage
assessment of clinical depression and DD in DM
DM
• patients in clinical practice and research. TheAt the emergence of complication
• most commonly used measures for screeningAt the time of switching medications and
clinical depression in DM patients are the
healthcare plans
• Diagnostic and Statistical Manual of MentalAt the time of switching healthcare provi-
Disorders Criteria for Major Depressive Disor-
ders [6]
ders, Patient Health Questionnaire 9, and Cen-
ter for Epidemiological Studies Depression
Differentiating DD and Clinical Depression Scale. Unlike CD, measurement of DD in
Unlike clinical depression, DD is persistent over patients with DM is context-specific and more
time, associated with glycemic control and dis- straightforward. Some of the most commonly
ease management, and expressed in terms of used screening measures include Problem Areas
magnitude and content. Content refers to the in Diabetes (PAID), Diabetes Distress Scale
factors that are associated with feelings of distress, (DDS), and GlucoCoper [7].
such as diet control, strain, or social relationships.
Severity or magnitude refers to the extent to
Screening and Diagnosis of DD
which the patient experiences these feelings [7].
Several self-reported measures, such as ATT39,
For a patient to be diagnosed with clinical
Questionnaire on Stress in Patients with Dia-
depression, five or more of the symptoms men-
betes-Revised (QSD-R), and PAID Scale, are used
tioned below need to be present for a period of at
to assess the nature and extent of DD. These are
least 2 weeks, representing a significant change
used as screening measures for clinical and
from baseline functioning. The symptoms
research purposes. However, these measures
include depressed mood, diminished inter-
have some limitations [9]:
est/pleasure in daily activities, change in appetite,
insomnia or hypersomnia, psychomotor agitation • Some of the measures do not cover a few
or retardation, fatigue, feeling of worthlessness or critical areas of interest adequately. For
guilt, and diminished concentration. In contrast, instance, in PAID there is only one item that
DD encompasses a wide range of emotional
796 Diabetes Ther (2019) 10:791–804
addresses the patients’ feelings about their patient–provider conversation and com-
healthcare provider. munication. Therefore, this management
• In some measures, the items may be confus- approach is termed diabetes therapy by ear
ing for the patient. For example, in QSD-R, [12].
one item reads, ‘‘I suffer from irritability,’’ 2. Focused treatment approach
but this may be difficult for the patients to A focused treatment approach specifically
comprehend. targets the following four areas in DD [12]:
• Measures such as ATT39, QSD-R, and PAID
have established subscales, which are not (a) Emotional burden
brief. (b) Physician-related distress
• Certain critical areas of interest are not (c) Regimen-related distress
covered by these measures [9]. (d) Interpersonal distress
Therefore, the DD scale was developed to 3. Helping patients cope with distress
address all these limitations. The DD scale aids Physicians should listen to patients and
in identification of the major sources of distress, identify the underlying feelings that can
which include powerlessness, negative social drive distress and influence management.
perceptions, physician’s distress, friend or fam- Some practical approaches include:
ily distress, hypoglycemia distress, management
distress, and eating distress [6]. (a) Helping patients talk about their expe-
1. The 2-item DD screening scale rience of diabetes
The 2-item DD scale is a screening measure (b) Identifying the specific sources of their
that aids in the assessment of two potential distress
problem areas that patients with DM may (c) Normalizing these feelings
experience. The scale aids in assessment of (d) Helping patients cope with distress as
the level of distress with regard to these two part of a regular diabetes care [6]
items in a patient during the past month.
The patient is required to circle the items
based on the severity of the symptoms
suggested in the scale [10, 11]. Key recommendations of the international multidisci-
plinary expert group
2. The 17-item DD screening scale
The 17-item DD scale lists the 17 potential DD was redefined as an emotional response
problem areas that a patient with T2DM
characterized by extreme apprehension, discomfort,
may experience. Patients are required to
consider the degree or level to which each or dejection due to a persistent perceived inability to
of the items included in the scale may have cope with the challenges and demands of living with
distressed him/her during the past 1 month diabetes
and then to circle the appropriate number Diabetes care professionals must work to identify the
[10, 11]. cause or etiopathogenesis of DD and minimize its
impact
Management of DD
1. Diabetes therapy by ear The 17-item DD screening scale must be preferred over
The four important aspects of the manage- the 2-item DD scale. An appropriate time interval for
ment of DD include strengthening of self- DD evaluation should be determined. The physician
care skills, optimization of coping skills, should take responsibility to identify the risks of DD
minimizing the discomfort associated with and should provide adequate counseling to a patient,
change, and utilization of support from instead of referring the patients to other specialists
other stakeholders. It is important to note
that all these interventions are non-phar-
macological and are purely based on
Diabetes Ther (2019) 10:791–804 797
Table a continued burnout may also result in percutaneous needle-
stick injuries, motor vehicle crashes, or near-
Preventative counseling is essential for patients who are miss incidents while driving. Excessive work
at high risk of developing psychological and stress and burnout may also have serious out-
psychiatric issues following a diagnosis of diabetes. comes in the wellness of the physicians. They
Diabetes counselors need to educate the patients on may indulge in substance abuse or may face
the need for continued usage of medications in their relationship troubles, depression, or death. In
addition, burnout may lead to job and career
counseling sessions
turnover (increased probability of changing jobs
Newer ideas, such as the GlucoCoper and shifting focus within medicine or abandoning the practice of
from suffering from diabetes to living with diabetes, medicine entirely, increased absenteeism, and
may help patients in attaining and maintaining interest in early retirement) [15].
euthymia
Adverse Health Conditions Experienced
by HCPs
(a) Chronic diseases among HCPs Physicians
Physicians’ Euthymia
may develop chronic diseases due to work-
related stress and depression. The actual
Background: Importance of Health and Well- prevalence of chronic illness in HCPs is
Being of the Healthcare Practitioners often under-reported because most of the
Healthcare practitioners (HCPs) are exposed to physicians just adapt and carry on, even
significant health-related risks owing to their before accepting their illnesses. Also, with
profession, many of which remain largely the awareness of their inabilities and limi-
unrecognized by the public and may be under- tations, most physicians with chronic ill-
estimated by the professionals themselves. A ness are at risk of depression [16].
few of these risks include fatigue, emotional/ (b) Anxiety and depression among HCPs Physi-
psychological trauma, physical injury caused by cians experience higher rates of anxiety
the use of machinery, back injuries, and possi- and depression than the general public.
ble physical assault from a patient or a hospital The prevalence rates of depression or
visitor. Also, there are other risks that are depressive symptoms vary from 3% to
acquired in the course of time, such as physical 60%, depending on the region of study
damage caused by the prolonged use of toxic and other study factors (such as specialty,
substances and infectious diseases acquired as a postgraduate year, and sex) [17].
result of air-borne pathogens and needle-stick (c) Burnout among HCPs Chronic exposure to
injuries [13]. stress may lead to burnout, a term com-
The three major health hazards that con- monly used to describe the emotional
tribute to the ill health of a HCP include: exhaustion experienced by workers in pub-
1. Work-related stress and burnout lic services. Burnout among doctors is a
2. Mental health disorders such as depression global phenomenon. Apart from adversely
3. Substance abuse [14] affecting the health outcomes of the HCPs,
burnout can also lead to poor quality of
Excessive job stress and workload are associated care delivered to patients, increased medi-
with negative personal and professional conse- cal errors, and poor retention [18].
quences for the physicians. Physicians who are
physically and emotionally stressed out may Important Lifestyle Changes Required
suffer from several fears, failures, and even to Enhance Overall Health of HCPs
death (due to suicidal tendency). They have an Physicians should pay attention to preventive
increased risk of burnout that often culminates healthcare and their lifestyle behaviors to
in difficult interactions with their families and enhance their overall health. An increased focus
other medical personnel. In some instances,
798 Diabetes Ther (2019) 10:791–804
on healthy daily living among physicians could in case of personal health issues, a practice
help prevent the progression to serious health that is considered unethical by all medical
issues, including mental health problems and associations. It is therefore essential that
addiction. Healthcare professionals should pri- all the physicians have their own general
oritize health aspects, such as nutrition, exer- physician (GP) who can provide regular,
cise, sleep, and self-care, along with professional continual, and effective healthcare. This
demands, as these can affect the physician’s practice would avoid the issue of self-
health on a daily basis [14]. prescribing and ensure that physicians are
taking the recommended preventive
(a) Nutrition Physicians should maintain a
screening measures [14].
proper nutritional diet high in fruits, veg-
etables, and unprocessed whole foods.
Physicians who eat a healthy diet are more Barriers to Healthy Preventative Habits
likely to counsel their patients about the among HCPs
importance of proper nutrition. Further- Doctors often experience barriers while access-
more, a healthy diet may minimize emo- ing healthcare, which they ought to overcome
tional symptoms, such as irritability and in order to improve their physical and mental
frustration, and physical symptoms, such health. The barriers may be divided into three
as light-headedness, tremor, and nausea. It categories [19]:
may also impact the cognitive effects (dif- (a) The ‘‘Patient’’ category that reflects the
ficulty in concentrating and poor/slow barriers specifically related to the doctor-
decision-making) [14]. patient seeking healthcare
(b) Exercise Regular exercise allows the doctors (b) The ‘‘Provider’’ category that reflects the
to stay fit and serve as healthy role models barriers that are under the control of the
in their community. Simple initiatives medical care provider
toward regular exercises, such as modifica- (c) The ‘‘Platform (or System)’’ category that
tions to the workplace that promote work- reflects barriers within the medical system
outs, installing secure bike racks, having itself [19]
shower facilities on-site for those who
exercise before work or during their lunch Stress Management Strategies to Improve
break, and encouraging team entries to Health Status of HCPs
events such as local walk/runs, may instill Several creative approaches have been evolved
healthy habits in HCPs [14]. in recent years to address the rising problem of
(c) Sleep Sleep deprivation may both acutely burnout. Initially, in 2007, Politsky et al. [20]
and chronically affect the doctor’s health. developed a program involving verbalization of
It was estimated that nearly half of the patients (making the patients verbalize their
general practitioners report sleep difficul- inner feelings) accompanied by various relax-
ties, and almost two-thirds complain of ation techniques, such as music, yoga, medita-
exhaustion or sleepiness at least 3 days per tion, affirmations, and therapeutic messages.
week. Steps that would minimize sleep Italia et al. [21] studied art therapy as a treat-
deprivation include allocating duty hour ment for burnout in an oncology unit. They
limits and allowing every physician to get found a statistically significant decrease in the
at least 4 h of constant ‘‘anchor sleep’’ (a burnout level after participation in the art
consistent 24-h cycle of sleep and wakeful- therapy interventions. Studies by Dileo et al.
ness to reduce fatigue) [14]. [22] and Repar et al. [23] confirmed that the use
(d) Self-care Physicians usually deny or avoid of massage, yoga, art, music, and writing helped
personal medical problems. Most physi- in reducing stress and depression in medical
cians refuse to seek help, even though they professionals. Massage with aromatherapy and
may realize the need for it. Furthermore, music for stress reduction in nurses was studied
HCPs rely on self-prescribing medications by Cooke et al. [24].
Diabetes Ther (2019) 10:791–804 799
Brooks et al. investigated the effects of music Background: Need for Striking Smart
imagery (creation of mandalas) on self-reported Conversations with DM Patients: When
burnout, sense of coherence, and job satisfac- and How?
tion in medical professionals. Qualitative results Striking smart conversations with the patients is
suggested that the music imagery helped the necessary throughout the course of the disease,
subjects relax, rejuvenate, and refocus, enabling but is especially important when:
them to complete their shifts with renewed • Diabetes is first diagnosed
energy [25]. • Inappropriate self-care behaviors occur
• Conflicts arise between belief systems and
Key recommendations from the international expert therapies
group • Insulin therapy becomes necessary
• Cardiovascular risk is increased
HCPs are exposed to significant health risks by virtue of • Sexual dysfunction (SD) occurs [26]
their profession. Many of these health hazards remain
largely unrecognized by the public and may be
underestimated by the professionals themselves The tools for striking smart conversations in
the above scenarios include:
Physicians should develop a structured lifestyle to
(a) Patient-centered clinical methods These
overcome health hazards. A structured program for
methods are performed by exploring the
bringing in lifestyle changes that are visible, practical, disease as well as illness experiences—fears,
and possible can help physicians cope with the feelings, functionality, expectations (FIFE);
possibility of burnout understanding the whole person; finding
A small gym or recreation corner in the clinic may help common ground; incorporating preventive
health-maintenance services; enhancing
physicians overcome stress
the patient–doctor relationship; and being
Medical students and postgraduates should be made realistic [26].
aware of the pitfalls of hospital and clinical practice (b) Biopsychosocial model A biopsychosocial
model is a combinationof thepsychological,
Work–life balance and synchronization can help improve
social, and biological aspects of health. The
happiness quotient among the physician community.
biopsychosocial model takes into account
This can be achieved if physicians can get involved in the patient, the social context in which he
diverse aspects of patient care, such as technological lives, and also the role of the physician and
innovations and patient advocacy programs the healthcare system in dealing with the
effects of the illness. The sociological and
psychological factors can have an influence
Partnership Euthymia on patients’ adherence to treatment. As
societal, psychological, and biological fac-
tors can individually or collectively impact
Concept of Partnership Euthymia
disease morbidity, the biopsychosocial
Patient–healthcare provider communication
model should be considered an appropriate
plays an integral role in diabetes care. In clinical
tool for striking smart conversations [26].
practice, euthymic diabetes conveys a positive
(c) Wagner’s chronic care model
aura and could be used to nullify DD. Therefore,
(d) Motivational interviewing
patient–provider communication should be
more focused on achieving diabetes euthymia,
rather than discussions targeted to avoid DD. Striking Conversations with DM Patients
This concept of partnership euthymia empha- about SD
sizes the importance of the biopsychosocial Sexual dysfunction is widespread in diabetic
model of health, rather than a purely gluco- patients, and, most often, patients with SD tend
centric or biomedical approach. to suffer in silence. The common SDs include
800 Diabetes Ther (2019) 10:791–804
erectile dysfunction, diminished sexual desire, efficiency. A few attributes are essential to the
lack of ejaculation with sexual climax (an ejac- success of a high-quality counseling service [29].
ulation or retrograde ejaculation), and prema- CARES is a pneumonic, which describes the
ture ejaculation. Very few patients approach basic qualities necessary to successfully manage
their diabetologists to discuss these issues. Male MSD:
SD (MSD) can be manifestations of biological
C Confident competence
(biogenic) problems or intra-psychic or inter-
A Accessible authenticity
personal (psychogenic) conflicts or even a
R Reciprocal respect
combination of these factors. Stress plays an
E Expressive empathy
important role in the pathogenesis of MSD. In
S Straightforward simplicity
fact, a good doctor–patient rapport is crucial to
make patients more comfortable and open to
talk about their sexual function [27]. Counseling Methods in Patients with MSD
Physicians must use their experience to make A healthy diet forms an important part of coun-
patients comfortable and free to discuss their seling for MSD. Physicians/counselors must
problems without any inhibition. Irrespective of encourage patients with MSD to eat a balanced
the magnitude of the problem, physicians must diet rich in vitamins and minerals, supplemented
address the need of the patients with courtesy and by nutraceuticals if necessary. Avoidance of
empathy. Physicians must work toward providing smoking and moderation of alcohol intake are
solutions within the ethnic and cultural frame- essential points for discussion [28].
work of the patients. Physicians must provide a Sexual fitness will be achieved only if one is
calm and relaxed atmosphere for patients to dis- physically fit, and attention should be paid to
cuss their problems. Each relevant aspect of his- the aspects of physical health that may impair
tory should be explored in detail. At all times, the sexual function, such as obesity, musculoskele-
five E’s of sexual history taking, i.e., empathy, tal weakness, lack of flexibility, and other
etiquette, experience, ethnic/cultural under- medical conditions. Patients should be encour-
standing, and environment conducive for relax- aged to indulge in moderate physical activity at
ation, must be followed [28]. least three times a week [28].
Physicians should interview patients with Training in coping skills should form a part
general questions, and then consider questions and parcel of each counseling session on MSD.
related to the distant past before inquiring This training includes inculcating positive
about present complaints—physicians should mechanisms and avoiding negative mecha-
begin with questions related to adolescent fan- nisms of coping [28].
tasies, and enquire about any premarital sexual Patients who do not respond to non-phar-
contact, experiences, and difficulties, before macological and conventional pharmacological
probing into the current marital sexuality. therapy may need to be treated with various
During taking the sexual history, probing devices, invasive procedures, or surgery.
questions on non-genital aspects should be Patients who may need these treatments must
considered before enquiring about genital be explained about the need for such therapy
issues. Questions directed toward the present well in advance, which would encourage them
medical history should focus on non-sexual to stick to their decision regarding the choice of
symptoms (i.e., symptoms suggestive of skin treatment and proven post-device or post-sur-
infection or urinary tract infection) before gical regret [28].
probing sexual function-related concerns [28].
Striking Conversations with DM Patients
Important Aspects of Counseling in MSD About CV Risk
Counseling is an integral part of diabetes man- Effective individualized cardiovascular disease
agement, but is not fully utilized in clinical (CVD) risk communication can be constructed
practice. Physicians must utilize all the available around several general principles. Patients want
resources and sharpen their counseling practical, concise information focused on the
Diabetes Ther (2019) 10:791–804 801
identification of the problem, what specifically • Ask people with diabetes to identify their
they need to do, why it is in their best interest, high-priority concerns or goals. Prompt
and what outcomes they can expect. The fol- them to plan for challenging situations
lowing methods may be employed to create and set short-term achievable goals.
awareness among patients [27]: • People with diabetes need to avoid
• smoking and using smokeless tobaccoGraphic illustration of the atherosclerotic
products [31].
process using simple language, diagrams,
and analogies 2. Support self-care behaviors
• Graphic description of the consequences of a Support self-care behaviors such as:
CVD event, e.g., pain, disability, and death,
as possible consequences of a myocardial • Daily foot care
infarction • Eye care
• Use of risk calculators to predict the current • Daily oral care: brush and floss
risk of CVD • Monthly oral self-exam
• Provide optimal therapeutic regimen • Selection and use of a blood glucose
• Shared decision-making to develop a treat- monitor as needed
ment plan [30] • Knowledge of your ABC goals and how
to reach them
Personal CVD risk is a fundamental compo-
• Use of medications as prescribed [31]
nent of the overall CVD risk message; however,
many patients do not reliably understand and 3. The longer the counseling, better the treatment
interpret numerical probability of risk. The risk adherence
must be potentially conveyed to patients in Physicians can tackle the adherence prob-
terms of high, moderate, or low risk [30]. lem through quality patient counseling.
Mental and emotional engagements can be Enhancing communication between the
encouraged through interactive multimedia physician and the patient is a key and
presentations in the forms of video, graphics, effective strategy in boosting the patient’s
animation, sound, and text. Interactive tech- ability to follow a medication regimen. The
nology may be effective in addressing the issues ask–educate–ask approach, teach-back
of limited health literacy [30]. method, and motivational interviewing
can help ensure patient understanding of
Important Messages to Reinforce While the counseling provided. A study described
Striking Smart Conversations that a significant proportion of patients
1. Promote healthy lifestyle who were non-adherent to treatment prior
A healthy lifestyle is key to diabetes control, to counseling became adherent after proper
and hence physicians need to talk to counseling [32].
patients about lifestyle choices [31].
• Advise people with diabetes to aim for a Key recommendations from the international expert
healthy weight. group
• Encourage meal planning that includes a
variety of foods, controlled portion sizes, According to the expert group, a good doctor–patient
and snacks. Increasing fiber and limiting rapport is crucial to make patients more
refined carbohydrates, salt, and fat will comfortable and open to talk about their sexual
help control blood glucose, blood pres- problems
sure, and cholesterol.
• Advise people with diabetes to include In all newly diagnosed diabetic patients, physicians need
moderate–intense physical activity (such to enquire about any SD in last 3 months
as brisk walking) in their daily life.
802 Diabetes Ther (2019) 10:791–804
Table c continued and are not intended to substitute for profes-
sional medical advice, diagnosis or treatment.
Approach to patient during assessment for SD should
be systematic, from non-threatening to threatening Funding. This expert opinion initiative has
questions been funded by Sanofi India. The article pro-
cessing charges received by the journal were
Diabetes mellitus patients with a favorable response to
paid for by Sanofi India. All authors had full
assessment should be referred for further evaluation access to the articles reviewed in this manu-
and care to a specialist script and take complete responsibility for the
In this context, the clinical expert group came up with integrity and accuracy of this manuscript.
recommendations for appropriate timing for
Medical Writing and Editorial Assis-
assessment of SD in male and female DM patients
tance. Medical writing and editorial support
The team also suggested that a protocol for MSD and was provided by Dr Rajshri Mallabadi and Dr
female SD assessment should be implemented in Kavitha Ganesha from BioQuest Solutions Pvt.
clinical practice Ltd. which was paid for by Sanofi, India.
Authorship. All named authors meet the
International Committee of Medical Journal
Editors (ICMJE) criteria for authorship for this
article, take responsibility for the integrity of
CONCLUSION the work as a whole, and have given their
approval for this version to be published.
Psychiatric disorders, such as anxiety and
depression, occur with greater frequency in Disclosures. Sanjay Kalra is a member of the
patients with DM. Additionally, DM patients journal’s Editorial Board. A. K. Das, M.
are at an increased risk of developing DD and P. Baruah, A. G. Unnikrishnan, Arundhati Das-
insulin distress, which can influence clinical gupta, Parag Shah, Rakesh Sahay, Rishi Shukla,
outcomes. Introduction of the concept of Sambit Das, Mangesh Tiwaskar, G. Vijayakumar,
euthymia in routine clinical practice is impor- Manoj Chawla, Fatimah Eliana, Ketut Suastika,
tant to improve quality of life and enhance Abbas Orabi, Aly Ahmed Abdul Rahim, Andrew
coping in patients with DM. Implementation of Uloko, Roberta Lamptey, Nancy Ngugi, Silver
a euthymic model of care promotes well-being Bahendeka, Abdurezak Ahmed Abdela,
of both patient and diabetes care provider. Fariduddin Mohammed, Faruque Pathan,
Muhammed Hafizur Rahman, Faria Afsana,
Shajada Selim, Muaz Moosa, Moosa Murad,
ACKNOWLEDGEMENTS Pradeep Krishna Shreshtha, Dina Shreshtha,
Mimi Giri, Wiam Hussain, Ahmed Al-Ani,
Kaushik Ramaiya, Surender Singh, Syed Abbas
We acknowledge Shalini Menon, Senthilnathan
Raza, Than Than Aye, Chaminda Garusinghe,
Mohana Sundaram, Romik Ghosh and S.
Dimuthu Muthukuda, Muditha Weerakkody,
Amarnath from Sanofi India for their logistics
Shyaminda Kahandawa, Charlotte Bavuma,
assistance, guidance and expertise in convening
Sundeep Ruder, Koy Vanny, Manish Khanolkar
an expert forum meeting. The content pub-
and Leszek Czupryniak have nothing to
lished herein represents the views and opinions
disclose.
of the various contributing authors and does
not necessarily represent the views or opinion Compliance with Ethics Guidelines. This
of Sanofi and/or its affiliates. The details pub- article is based on previously conducted studies
lished herein are intended for informational, and does not contain any studies with human
educational, academic and/or research purposes
Diabetes Ther (2019) 10:791–804 803
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