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“We’ll stop by McDonald’s once I get out of the hospital,” Arturo told his brother. Arturo (not his real name) was 21 years old and had just been diagnosed with diabetes. He and his brother loved fast food, McDonald’s being one of their most frequent haunts. Unfortunately, this new diagnosis was likely to change that.
This was Arturo’s first health problem, ever. He had a few days of being extremely thirsty but needing to urinate every hour or two. Then, for about a day he couldn’t keep anything down. Vomiting, his belly aching, he came into the ER with his brother.
I admitted him to the intensive care unit for a dangerous condition called ketoacidosis. Without insulin, his cells couldn’t absorb glucose, leading to a paradoxical situation — his cells were starving for sugar despite high levels of glucose in his blood. To compensate, his cells were making acid, a life-threatening condition if left untreated.
Now that he was in the hospital, the medical aspects of Arturo’s case were clear. There are textbook guidelines on what type of IV fluids he needed, how often to check his blood, and how much insulin to give him to safely transition his blood from acidic back to normal.
But the most challenging aspect of diabetes is the care that comes later. It’s tough for anyone who was never concerned about their health to monitor what they eat, check their blood sugar multiple times a day, and give themselves injections of insulin. It can be tougher for a 21-year-old who bonds with his brother by going out to fast-food restaurants.
The importance of family and friends as part of your “healthcare team”
I was reminded of Arturo when I read a recent article in the New England Journal of Medicine called “Engineering Social Incentives for Health” by David Asch and Roy Rosin at the Center for Health Care Innovation at the University of Pennsylvania.
In their article, Asch and Rosin explain how we might engage patients like Arturo. In our healthcare system, our interactions with doctors or nurses are usually infrequent and brief. It is no surprise that most of our discussions about health take place with our friends and family as we struggle with our health problems on a day-to-day basis.
We are rarely conscious of it, but those closest to us heavily affect many of our health decisions. “People are strongly influenced by what others do and by what others think of them, which means that our behavior can change or affect others’ behavior when it’s made visible,” Asch and Rosin write. But these social interactions can be used to help patients make healthier choices, a process they call “social engagement.”
Of course, there are the individual things that nudge us into healthier choices, like walking to work instead of driving, or joining a gym that’s on the way home from work rather than a 15-minute drive away.
But we can also make our desire for certain healthy choices more visible to those around us. Being public about certain activities, the idea goes, makes us more aware when we’re making unhealthy choices and helps others be supportive of our healthy choices. For example, some studies show that telling family and friends the date that a smoker will quit smoking helps make them aware and support the decision.
This involves explicitly engaging family and friends in our healthy efforts. Simply asking loved ones to call and remind us to take our medications, or asking the household grocery buyer to avoid bringing home tempting sweets, can go a long way to pushing us toward healthy choices.
Group commitments and competitions can increase social accountability for our healthy choices too. Having a family competition to reach a certain number of steps per day, or committing to go to the gym with a friend three times per week, helps meld healthy behaviors into activities that strengthen relationships.
Social connections toward better health are important, but not always easy
Arturo’s situation reminded me how, even with social engagement, diabetes is a long road. During the two days he was in the ICU, our nurses and case managers had a number of discussions with Arturo and his family on how to treat diabetes: avoiding foods like bread that were high in the starch and carbohydrates that would raise his blood sugar. I also chatted with his brother about finding other ways the two could hang out rather than over fast food. I could sense his skepticism: “He has diabetes; I don’t,” he told me.
It seemed to slowly dawn on Arturo just how many changes he’d have to make to his life. His brother was supportive, offering to help check his blood sugar. But cutting out fast food was, for now, a step too far. On his last night in the hospital, I overheard Arturo and his brother talking about what McDonald’s burgers they would get on the way home.