CLINICAL HANDBOOK OF SCHIZOPHRENIA

428 VI. SPECIAL POPULATIONS AND PROBLEMSDiabetes requires a range of self-management activities that may be especially challengingfor persons with a serious mental illness. For example, a person with diabetesneeds to have good knowledge of dietary and exercise requirements, and the relationshipbetween exercise, diet, medication, and blood sugar level. Diabetes educators can helppersons with diabetes manage their illness. Individuals with schizophrenia often requiremore prompting, assistance in monitoring and self-administering their medications, andmore self-management support compared to persons without mental illness. Consequently,establishing collaboration between the mental health case manager and medicalprovider or diabetes educator is important. Staff at group homes or family and friendscan also be a valuable resource.All persons with type 1 diabetes (and many persons with type 2 diabetes) monitortheir blood sugar levels with a glucometer (pricking a finger to measure the current bloodglucose level). The blood sugar level provides important guidance for how to adjust andfine-tune the dosage of the diabetic medication. In addition, medical providers check aspecific type of blood hemoglobin called hemoglobin A1c (HbA1c) every 3–6 months toget a picture of “average” level of blood sugar over the past months. To minimize the riskof diabetic complications, it is important to keep the HbA1c measure low. When the HbA1cis above target range, medications may need to be adjusted. In addition, self-managementskills should be revisited when the diabetic control is not optimal. It is important to identifyapproaches that enable individuals to take diabetic medications regularly, eat appropriately,and exercise more frequently. Examples of helpful enablers include written orphone-call reminders; prompting by family members or by care providers; and ongoingeducation, support, and reinforcement of positive health behaviors.Some persons with schizophrenia may not have the skills or financial resources toshop for healthy foods or to prepare healthy meals. Case managers, rehabilitation counselors,nurses, and others can provide information, education, and even direct assistancein helping patients learn how to locate healthy (and low-price) foods in the grocery storeand to prepare simple, nutritious meals. Those who live in group homes generally do nothave the ability to choose their daily diet. In some cases, it may be necessary to engage dieticiansand diabetes educators to help staff ensure that meals meet specific dietary requirements.A person with schizophrenia may also benefit from assistance in designing apersonalized exercise routine that includes a schedule and instructions on where and forhow long a walk should occur, or, the location of the local Young Men’s Christian Association(YMCA), and how to obtain and use a membership. Exercising with a friend maybe a useful and important strategy to maintain motivation.In addition to regular visits with the medical provider, a person with diabetes shouldreceive regular screening for potential complications of diabetes. These screening tests aredesigned to detect potential complications early and to allow for prompt treatment. Table41.2 provides examples of important follow-up. Over time, diabetes can damage theblood supply to the retina (the back of the eye and the location of visual receptor cells),which can result in a condition called retinopathy. If not promptly treated, this conditioncan result in diminished vision and blindness. Regular dilated eye exams help detect retinalchanges early. Diabetes can also damage the kidneys. Urine and blood tests are usedto monitor and detect early changes in kidney function. In addition, persons with diabetesshould have regular checkups to evaluate cardiovascular health, due to their increasedrisk of heart disease, stroke, and blood vessel disease. Finally, diabetes can cause damageto the nerves responsible for sensation or the perception of heat, cold, and pain in the feetand hands. For example, this nerve damage (called diabetic neuropathy) can make personswith diabetes unaware of injuries or minor infections of their feet, which, if undetected,can progress to life-threatening infections that result in amputations, permanent