Jennifer Burkmar, MD, MBA Emory Family Medicine

Managing Type II Diabetes for the Family Medicine Resident

Part 1 – Roadmap, Behavior, Lifestyle, Nutrition, and Overcoming Barriers

Managing Type II Diabetes for the Family Medicine Resident

Part 1 – Roadmap, Behavior, Lifestyle, Nutrition, and Overcoming Barriers

Jennifer Burkmar, MD, MBA

Emory Family Medicine

Jennifer Burkmar, MD, MBA

Emory Family Medicine

Learning ObjectivesLearning Objectives

Specify current ADA/EASD and AACE/ACE goals & guidelines for managing type II diabetes

List evidence-based data for appropriate glycemic control

Explain the problem of clinical inertia & why we need to change the course

Understand issues with behavior and compliance in patients with type II diabetes

Be able to count grams of carbohydrates for appropriate insulin therapy & review the Quick-Carb Count system

Describe current ADA nutrition recommendations for type II diabetes

List potential HbA1c reduction levels associated with medical nutrition therapy for diabetes

Learn methods to overcome barriers in care

Specify current ADA/EASD and AACE/ACE goals & guidelines for managing type II diabetes

List evidence-based data for appropriate glycemic control

Explain the problem of clinical inertia & why we need to change the course

Understand issues with behavior and compliance in patients with type II diabetes

Be able to count grams of carbohydrates for appropriate insulin therapy & review the Quick-Carb Count system

Describe current ADA nutrition recommendations for type II diabetes

List potential HbA1c reduction levels associated with medical nutrition therapy for diabetes

Learn methods to overcome barriers in care

Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among U.S. Adults Aged 18 Years or Older

Obesity (BMI ≥30 kg/m2)

Diabetes

1994

1994

2000

2000

No Data <14.0% 14.0–17.9% 18.0–21.9% 22.0–25.9% 26.0%

No Data <4.5% 4.5–5.9% 6.0–7.4% 7.5–8.9% >9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

2010

2010

The UKPDS demonstrated that a 1% reduction in HbA1c results in …….% reduction in microvascular disease.

The UKPDS demonstrated that a 1% reduction in HbA1c results in …….% reduction in microvascular disease.

1. 12%

2. 19%

3. 31%

4. 37%

1. 12%

2. 19%

3. 31%

4. 37%

An epidemic that is only becoming worseAn epidemic that is only becoming worse

Prediabetes & Early Cardiovascular DiseasePrediabetes & Early Cardiovascular Disease

Compared with normoglycemic controls, asymptomatic patients with prediabetes have worse:

Diastolic blood pressure during exercise

Retinal score

EKG score

Elasticity of small & large arteries

Levels of BNP

Compared with normoglycemic controls, asymptomatic patients with prediabetes have worse:

Diastolic blood pressure during exercise

Retinal score

EKG score

Elasticity of small & large arteries

Levels of BNP

What factor is associated with the greatest risk for CAD in type 2 DM?What factor is associated with the greatest risk for CAD in type 2 DM?

1. Increased LDL cholesterol

2. Elevated HbA1c

3. Elevated systolic blood pressure

4. Smoking

1. Increased LDL cholesterol

2. Elevated HbA1c


4. Smoking

Rank the order of risk factors for CAD in type 2 diabetesRank the order of risk factors for CAD in type 2 diabetes

Increased LDL

Decreased HDL

Elevated HbA1c

Elevated systolic blood pressure

Smoking

Increased LDL

Decreased HDL

Elevated HbA1c

Elevated systolic blood pressure

Smoking

Rank the order of risk factors for CAD in type 2 diabetesRank the order of risk factors for CAD in type 2 diabetes

1. Increased LDL

2. Decreased HDL

3. Elevated HbA1c


5. Smoking

1. Increased LDL

2. Decreased HDL

3. Elevated HbA1c


5. Smoking

Comprehensive Management of DiabetesComprehensive Management of Diabetes

BLOOD GLUCOSE

But there is also:

Antiplatelet therapy

Blood pressure

Cholesterol

Dietary changes

Exercise changes

BLOOD GLUCOSE

But there is also:

Antiplatelet therapy

Blood pressure

Cholesterol

Dietary changes

Exercise changes

Comprehensive Management of DiabetesComprehensive Management of Diabetes

And let’s not forget…

Smoking

Weight

Regular examination of:

Eyes

Mouth/teeth

Feet/skin

Kidneys

And let’s not forget…

Smoking

Weight

Regular examination of:

Eyes

Mouth/teeth

Feet/skin

Kidneys

Recommended Targets for T2DMRecommended Targets for T2DM

ADA AACE

HbA1c < 7.0% < 6.5%

Preprandial glucose 70 – 130 < 100

Peak postprandial glucose < 180 < 140

Blood pressure < 130/80

LDL <100< 70 (overt CVD)

Triglycerides < 150

HDL > 40 (male)> 50 (female)

Rationale for TLC as Initial TherapyRationale for TLC as Initial Therapy

Weight loss

Effective in lowering blood glucose

Possible elimination of diabetes

Weight loss & exercise

Improved CVD risk factors

Safe, cost-effective with few difficulties

Support needed to promote long-term adherence

Benefits generally seen rapidly, often before substantial weight loss

Weight loss

Effective in lowering blood glucose

Possible elimination of diabetes

Weight loss & exercise

Improved CVD risk factors

Safe, cost-effective with few difficulties

Support needed to promote long-term adherence

Benefits generally seen rapidly, often before substantial weight loss

What effect do statins have on glucose control?What effect do statins have on glucose control?

1.↑ glucose

2.No effect

3.↓ glucose

1.↑ glucose

2.No effect

3.↓ glucose

Statins and Diabetes RiskStatins and Diabetes Risk

The use of high-dose statin therapy is associated with an ↑ risk of T2DM compared with moderate-dose statin therapy

FDA mandates statin label change in 2012

Label change for statin class (except pravastatin), issuing a warning that they can raise blood sugar & A1c levels

JUPITER study showed 27% ↑ in risk of T2DM in patients taking rosuvastatin

Women’s Health Initiative showed 48% ↑ risk of diabetes among women

Multiple other studies showed ↑ risk of T2DM with high-dose statin

The use of high-dose statin therapy is associated with an ↑ risk of T2DM compared with moderate-dose statin therapy

FDA mandates statin label change in 2012

Label change for statin class (except pravastatin), issuing a warning that they can raise blood sugar & A1c levels

JUPITER study showed 27% ↑ in risk of T2DM in patients taking rosuvastatin

Women’s Health Initiative showed 48% ↑ risk of diabetes among women

Multiple other studies showed ↑ risk of T2DM with high-dose statin

JUPITER Trial on CVD Risk Reduction with Statin TherapyJUPITER Trial on CVD Risk Reduction with Statin Therapy

Justification for Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin

N = 17,603

Studied patients without cardiovascular disease or diabetes

Treatment – Rosuvastatin 20mg daily or placebo

Followed for up to 5 years

Conclusion – CV benefits of statin therapy exceed the diabetes hazard

Justification for Use of Statins in Primary Prevention: An Intervention Trial Evaluating Rosuvastatin

N = 17,603

Studied patients without cardiovascular disease or diabetes

Treatment – Rosuvastatin 20mg daily or placebo

Followed for up to 5 years

Conclusion – CV benefits of statin therapy exceed the diabetes hazard

Disadvantages of Current Paradigm for T2DM ManagementDisadvantages of Current Paradigm for T2DM Management

Few patients achieve glycemic targets

The stepwise approach is usually applied at a slow pace, with long delays between steps

When insulin is initiated, the average patient has spent 5yrs with an A1c >8% & 10yrs with an A1c > 7%

Prolonged hyperglycemia & resultant glucotoxicity may accelerate β-cell failure

Few patients achieve glycemic targets

The stepwise approach is usually applied at a slow pace, with long delays between steps

When insulin is initiated, the average patient has spent 5yrs with an A1c >8% & 10yrs with an A1c > 7%

Prolonged hyperglycemia & resultant glucotoxicity may accelerate β-cell failure

Treatment of T2DMTreatment of T2DM

Treat-to Failure Principle

“We continue the SAME treatment plan until the situation is disastrous & failing before we make changes in managing the patient.”

Treat-to Failure Principle

“We continue the SAME treatment plan until the situation is disastrous & failing before we make changes in managing the patient.”

Treat-to-Failure Approach:Suboptimal Glycemic ControlTreat-to-Failure Approach:Suboptimal Glycemic Control

OAD = Oral Antidiabetic DrugA1c goal

Jennifer Burkmar

Treatment of T2DMTreatment of T2DM

INSTEAD we need to follow the Treat-to-Target Principle

“We need to design our management plan based on reaching TREATMENT TARGETS.”

If the fasting glucose is consistently 148, we need to alter our treatment plan

INSTEAD we need to follow the Treat-to-Target Principle

“We need to design our management plan based on reaching TREATMENT TARGETS.”

If the fasting glucose is consistently 148, we need to alter our treatment plan

Treat-to-Target Approach to T2DMTreat-to-Target Approach to T2DM

ADA-EASD Position Statement: Management of Hyperglycemia in T2DM

ADA-EASD Position Statement: Management of Hyperglycemia in T2DM

Other considerations:

Weight

Majority of T2DM patients are overweight/obese

Intensive lifestyle program

Metformin

GLP-1 receptor agonists

? Bariatric surgery

Consider latent autoimmune diabetes in adults (LADA) in lean patients

Other considerations:

Weight

Majority of T2DM patients are overweight/obese

Intensive lifestyle program

Metformin

GLP-1 receptor agonists

? Bariatric surgery

Consider latent autoimmune diabetes in adults (LADA) in lean patients

Intensive glycemic control may be beneficial in all of the following except:

Intensive glycemic control may be beneficial in all of the following except:

1.Shorter duration T2DM

2.No established atherosclerosis

3.Long life expectancy

4.Extensive comorbid conditions

1.Shorter duration T2DM

2.No established atherosclerosis

3.Long life expectancy

4.Extensive comorbid conditions

Implications of ACCORD, ADVANCE, & VADT TrialsImplications of ACCORD, ADVANCE, & VADT Trials

Lack of significant CVD benefit with intensive glycemic control

HOWEVER

HbA1c < 7% still the general target

May be beneficial in patients with:

Shorter duration T2DM

Without established atherosclerosis

Long life expectancy

Lack of significant CVD benefit with intensive glycemic control

HOWEVER

HbA1c < 7% still the general target

May be beneficial in patients with:

Shorter duration T2DM

Without established atherosclerosis

Long life expectancy


Intensive glycemic control may NOT be beneficial in patients with:

Longstanding T2DM

Known history of severe hypoglycemia

Advanced microvascular/macrovascular complications

Extensive comorbid conditions

Advanced age/frailty

Limited life expectancy

Intensive glycemic control may NOT be beneficial in patients with:

Longstanding T2DM

Known history of severe hypoglycemia

Advanced microvascular/macrovascular complications

Extensive comorbid conditions

Advanced age/frailty

Limited life expectancy


Affirmed need for treatment of all vascular risk factors – not just hyperglycemia

↓ risk of new/worsening albuminuria when HbA1c lowered to 6.3% vs. 7.0%

Overall – intensive therapy decreases microvascular adverse outcomes

Does not significantly affect CVD or mortality

Affirmed need for treatment of all vascular risk factors – not just hyperglycemia

↓ risk of new/worsening albuminuria when HbA1c lowered to 6.3% vs. 7.0%

Overall – intensive therapy decreases microvascular adverse outcomes

Does not significantly affect CVD or mortality

ADA-EASD Position Statement on Management of Hyperglycemia in T2DM

ADA-EASD Position Statement on Management of Hyperglycemia in T2DM

Glycemic targets

HbA1c < 7.0% mean plasma glucose 150-160

Preprandial PG < 130

Postprandial PG < 180

Individualization is key

Lower target (6.0 – 6.5%) – younger, healthier

Higher target (7.5 – 8.0%) – older, comorbidities, hypoglycemia prone, etc

Avoid hypoglycemia

Glycemic targets

HbA1c < 7.0% mean plasma glucose 150-160

Preprandial PG < 130

Postprandial PG < 180

Individualization is key

Lower target (6.0 – 6.5%) – younger, healthier

Higher target (7.5 – 8.0%) – older, comorbidities, hypoglycemia prone, etc

Avoid hypoglycemia

Clinical InertiaClinical Inertia

What is it??????What is it??????


“Failure of healthcare providers to initiate or intensify therapy when indicated.”

Are you doing anything?

Are you doing enough?

“Failure of healthcare providers to initiate or intensify therapy when indicated.”

Are you doing anything?

Are you doing enough?


Negative attitudes on the part of the patient and/or clinician about the:

Complexity of treatment

Anticipated complications

Disease severity

May apply to oral as well as injectable therapies

May have significant impact on:

Treatment adherence (patient)

Management plan (clinician)

Negative attitudes on the part of the patient and/or clinician about the:

Complexity of treatment

Anticipated complications

Disease severity

May apply to oral as well as injectable therapies

May have significant impact on:

Treatment adherence (patient)

Management plan (clinician)

Strategies to Overcome Clinical Inertia: PatientStrategies to Overcome Clinical Inertia: Patient

Establish an “actionable” HbA1c goal for the patient

Establish time frame for achievement of HbA1c goal

Display progress toward achieving HbA1c goal

Keep results displayed in patient’s medical record (perhaps as a graph)

Establish an “actionable” HbA1c goal for the patient

Establish time frame for achievement of HbA1c goal

Display progress toward achieving HbA1c goal

Keep results displayed in patient’s medical record (perhaps as a graph)

Strategies to Overcome Clinical Inertia: Primary Care ResidentsStrategies to Overcome Clinical Inertia: Primary Care Residents

3yr trial with 345 IM residents managing 4,038 patients with T2DM

Computerized reminders at every visit

Performance feedback from endocrinologists/attendings

Feedback group intensified therapy and maintained this over 3 years better than other groups

Combination of feedback and reminders had best results

3yr trial with 345 IM residents managing 4,038 patients with T2DM

Computerized reminders at every visit

Performance feedback from endocrinologists/attendings

Feedback group intensified therapy and maintained this over 3 years better than other groups

Combination of feedback and reminders had best results

Overcoming Physician Concerns About Insulin Therapy in T2DMOvercoming Physician Concerns About Insulin Therapy in T2DM

Hypoglycemia severe hypoglycemia very uncommon

Worsening Atherosclerosis no evidence of worsening CVD

Weight Gain modest & controlled by diet & exercise, also controlled if metformin or GLP-1 receptor agonist is used

Patient’s Negative Perception of Insulin Therapy patient needs assurance that insulin is a “positive” approach to achieving glycemic control & is most effective when dose properly

Hypoglycemia severe hypoglycemia very uncommon

Worsening Atherosclerosis no evidence of worsening CVD

Weight Gain modest & controlled by diet & exercise, also controlled if metformin or GLP-1 receptor agonist is used

Patient’s Negative Perception of Insulin Therapy patient needs assurance that insulin is a “positive” approach to achieving glycemic control & is most effective when dose properly

Overcoming Patient Concerns about T2DMOvercoming Patient Concerns about T2DM

Ask the patient about their concerns!

Use your team to help the patient deal with their concerns

Multidisciplinary team requires:

Common goals

Supportive, nurturing approach

Commitment to principles of self-care

Good interpersonal skills of team members

Clear definition of specific & shared responsibilities of team

Effective leadership

Tailoring of team members according to setting & resources

Ask the patient about their concerns!

Use your team to help the patient deal with their concerns

Multidisciplinary team requires:

Common goals

Supportive, nurturing approach

Commitment to principles of self-care

Good interpersonal skills of team members

Clear definition of specific & shared responsibilities of team

Effective leadership

Tailoring of team members according to setting & resources

Impact of a Multidisciplinary Team on Glycemic Control & Hospital Admissions

Impact of a Multidisciplinary Team on Glycemic Control & Hospital Admissions

Behavior & Diabetes: Moving from Compliance to CollaborationBehavior & Diabetes: Moving from Compliance to Collaboration

Case Study – Ms. S.T2DMA1c is 9.4%BMI is 29SmokesOn metformin & glyburideRarely monitors glucose levelsFrequently does not keep appointmentsAlways promises to do better

Case Study – Ms. S.T2DMA1c is 9.4%BMI is 29SmokesOn metformin & glyburideRarely monitors glucose levelsFrequently does not keep appointmentsAlways promises to do better

Our plan for Ms. S.Our plan for Ms. S.

STOP SMOKING!

LOSE WEIGHT!

FOLLOW YOUR DIET!

EXERCISE!

MONITORS BLOOD GLUCOSE 4X DAY!

STOP SMOKING!

LOSE WEIGHT!

FOLLOW YOUR DIET!

EXERCISE!

MONITORS BLOOD GLUCOSE 4X DAY!

What Ms. S. hears…What Ms. S. hears…

If you don’t change your behavior, you will have to go on the needle

You are a noncompliant, bad patient

You are a failure

You are a “diabetic”, not a person

If you don’t change your behavior, you will have to go on the needle

You are a noncompliant, bad patient

You are a failure

You are a “diabetic”, not a person

The real Ms. S…The real Ms. S…

Works at a convenience store at varying times of the day

Recently separated from husband

Son has severe asthma requiring multiple medications

Handles stress by smoking & eating chocolate

Insurance does not cover diabetes supplies or medication

Works at a convenience store at varying times of the day

Recently separated from husband

Son has severe asthma requiring multiple medications

Handles stress by smoking & eating chocolate

Insurance does not cover diabetes supplies or medication

Behavior & DiabetesBehavior & Diabetes

Approach to behavior has historically been disease focused and didactic

Very little understanding or focus on the impact of diabetes on the patients’ lives

Message was “it’s easy to take care of and control your diabetes”

Doctors telling patients “You should…”

RNs telling patients “Do it for me…”

Failure is neither the fault of healthcare professionals nor patients

Approach to behavior has historically been disease focused and didactic

Very little understanding or focus on the impact of diabetes on the patients’ lives

Message was “it’s easy to take care of and control your diabetes”

Doctors telling patients “You should…”

RNs telling patients “Do it for me…”

Failure is neither the fault of healthcare professionals nor patients

Behavior & DiabetesBehavior & Diabetes

Diabetes self-management is less than optimal

Self-management problems are due in large part to psychosocial problems

Psychological problems are common but rarely treated

85% reported severe diabetes distress at diagnosis

15yrs later, 43% continued to have these feelings

Access to team care & communication between patients and healthcare professionals is associated with better outcomes

Initiatives to address psychosocial needs must have a high priority to improve outcomes

Diabetes self-management is less than optimal

Self-management problems are due in large part to psychosocial problems

Psychological problems are common but rarely treated

85% reported severe diabetes distress at diagnosis

15yrs later, 43% continued to have these feelings

Access to team care & communication between patients and healthcare professionals is associated with better outcomes

Initiatives to address psychosocial needs must have a high priority to improve outcomes

EmpowermentEmpowerment

Helping people discover and use their own innate ability to gain mastery over their diabetes

Diabetes is self-managed and I am the “self”

You can teach me, but you can’t make me. I have to make myself

Helping people discover and use their own innate ability to gain mastery over their diabetes

Diabetes is self-managed and I am the “self”

You can teach me, but you can’t make me. I have to make myself

What can we do?What can we do?

Educate for informed decision-making

Learn effective patient-centered communication and other strategies to better our patients

Actively engage patients in decision-making

Teach for informed decision-making, clinical content, psychosocial, and behavioral issues

Educate for informed decision-making

Learn effective patient-centered communication and other strategies to better our patients

Actively engage patients in decision-making

Teach for informed decision-making, clinical content, psychosocial, and behavioral issues

8 Key Lessons8 Key Lessons

1. Diabetes is self-managed no rules

2. DSM requires education & ongoing support

3. Treatment will change over time

4. Negative emotions are common

5. Behavior change strategies are essential

6. Complications are not inevitable

7. DSM involves trial & error

8. DSM is not easy

1. Diabetes is self-managed no rules

2. DSM requires education & ongoing support

3. Treatment will change over time

4. Negative emotions are common

5. Behavior change strategies are essential

6. Complications are not inevitable

7. DSM involves trial & error

8. DSM is not easy

Diabetes-Related DistressDiabetes-Related Distress

Fearful

Frustrated

Overwhelmed

Anxious

Guilty

Angry

Powerless

Discouraged

Fearful

Frustrated

Overwhelmed

Anxious

Guilty

Angry

Powerless

Discouraged

DAWN-2 StudyDAWN-2 Study

Diabetes-related distress reported by 44.6%, but only 23.7% reported that their healthcare team has asked them how diabetes impacted their life

Diabetes impacts the lives of adult family members, resulting in substantial burden & distress

Supporting a family member was perceived as a significant burden by 35.3%, and 61% reported high levels of distress

Confirms that psychosocial problems of family members are barriers to their effective involvement in self-management

Diabetes-related distress reported by 44.6%, but only 23.7% reported that their healthcare team has asked them how diabetes impacted their life

Diabetes impacts the lives of adult family members, resulting in substantial burden & distress

Supporting a family member was perceived as a significant burden by 35.3%, and 61% reported high levels of distress

Confirms that psychosocial problems of family members are barriers to their effective involvement in self-management

Depression vs. DistressDepression vs. Distress

Diabetes-related distress has a significantly higher prevalence & incidence than clinical depression, and is significantly more persistent over time

Different “conditions” – over 70% of type 2 adults with high distress are NOT clinically depressed

Does it matter?

Diabetes-related distress significantly linked to

HbA1c

Diabetes self-efficacy

Diet

Physical activity

Diabetes-related distress has a significantly higher prevalence & incidence than clinical depression, and is significantly more persistent over time

Different “conditions” – over 70% of type 2 adults with high distress are NOT clinically depressed

Does it matter?

Diabetes-related distress significantly linked to

HbA1c

Diabetes self-efficacy

Diet

Physical activity

Diabetes Distress Scale – short formDiabetes Distress Scale – short form

On a scale of 1-6, to what degree do the following items cause distress:

Feeling overwhelmed by the demands of living with diabetes

Feeling that I am often failing with my diabetes regimen

This can be done by MA or RN during intake

On a scale of 1-6, to what degree do the following items cause distress:

Feeling overwhelmed by the demands of living with diabetes

Feeling that I am often failing with my diabetes regimen

This can be done by MA or RN during intake

AASAPAASAP

Anticipate the feelings

Acknowledge the feelings

Standardize & normalize the feelings

Accept & understand basis for problems

Plan how to respond to the feelings

Anticipate the feelings

Acknowledge the feelings

Standardize & normalize the feelings

Accept & understand basis for problems

Plan how to respond to the feelings

Behavior ChangeBehavior Change

Collaboratively set goals

Collaborate with patient in thinking creatively about how to achieve these goals

Collaborate with patient to create a specific plan to change behaviors & achieve goals

Collaboratively set goals

Collaborate with patient in thinking creatively about how to achieve these goals

Collaborate with patient to create a specific plan to change behaviors & achieve goals

DAWN2DAWN2

61.4 – 92.9% of healthcare professionals felt that people with DM needed to improve various self-management activities

Healthcare professionals also noted

Need to improve healthcare organization

Address emotional problems

Improve self-management among people with diabetes

61.4 – 92.9% of healthcare professionals felt that people with DM needed to improve various self-management activities

Healthcare professionals also noted

Need to improve healthcare organization

Address emotional problems

Improve self-management among people with diabetes

Communication StrategiesCommunication Strategies

Self-management occurs in the context of daily life

Recommendations must accommodate the patient’s goals, priorities, values, & barriers

Patients are in control of decisions & responsible for consequences

Focus is on informed decisions & choices & consequences, not on adherence/ compliance

What was your decision? Why? What happened as a result?

Self-management occurs in the context of daily life

Recommendations must accommodate the patient’s goals, priorities, values, & barriers

Patients are in control of decisions & responsible for consequences

Focus is on informed decisions & choices & consequences, not on adherence/ compliance

What was your decision? Why? What happened as a result?


What is hardest or your greatest concern?

What’s one thing that drives you crazy about your diabetes?

How has your conditions changes your/your family’s life?

What is the hardest thing for you in managing diabetes?

What can I or my staff do that would make it easier for you?

What is your biggest fear about ???

What is hardest or your greatest concern?

What’s one thing that drives you crazy about your diabetes?

How has your conditions changes your/your family’s life?

What is the hardest thing for you in managing diabetes?

What can I or my staff do that would make it easier for you?

What is your biggest fear about ???

Medication AssessmentMedication Assessment

How often?

Do you miss your …

During a typical month, what % of the time do you miss your…

It’s easy to forget to take your medicines. About how often does that happen to you?

Why?

Is paying for your medication a problem for you?

Are there times when you decide not to take your medicines? If so, why?

What gets in the way of taking your….

What would help you to be more faithful in taking your….

How often?

Do you miss your …

During a typical month, what % of the time do you miss your…

It’s easy to forget to take your medicines. About how often does that happen to you?

Why?

Is paying for your medication a problem for you?

Are there times when you decide not to take your medicines? If so, why?

What gets in the way of taking your….

What would help you to be more faithful in taking your….

Concerns AssessmentConcerns Assessment

1. What is hardest or causing you the most concern about caring for your diabetes at this time?

2. What do you find difficult or frustrating about it?

3. Describe your thoughts or feelings about this issue.

4. What would you like us to do during your visit to help address your concern?

1. What is hardest or causing you the most concern about caring for your diabetes at this time?

2. What do you find difficult or frustrating about it?

3. Describe your thoughts or feelings about this issue.

4. What would you like us to do during your visit to help address your concern?


ALE – ask, listen, empathize/encourage

Actively listening with reflections & support is therapeutic

Reflection leads to insight which leads to insight which leads to change

Motivational interviewing

Helps patient explore & resolve ambivalence and strengthen desire/motivation for change

Tone is nonjudgmental, empathetic, encouraging

No attempt to convince, persuade, or advise

ALE – ask, listen, empathize/encourage

Actively listening with reflections & support is therapeutic

Reflection leads to insight which leads to insight which leads to change

Motivational interviewing

Helps patient explore & resolve ambivalence and strengthen desire/motivation for change

Tone is nonjudgmental, empathetic, encouraging

No attempt to convince, persuade, or advise

DAWN2DAWN2

“Most people with diabetes are not actively engaged by their healthcare professionals to take control of their condition; education & psychosocial care are often unavailable.”

48.8% had received formal education; 81.1% found it helpful

“Most people with diabetes are not actively engaged by their healthcare professionals to take control of their condition; education & psychosocial care are often unavailable.”

48.8% had received formal education; 81.1% found it helpful

Closing the LoopClosing the Loop

What questions or concerns do you want addressed today?

Ask patient to summarize in their own words (or dictate your note)

What is one thing you will do to care for your diabetes?

What questions or concerns do you want addressed today?

Ask patient to summarize in their own words (or dictate your note)

What is one thing you will do to care for your diabetes?

Shared Decision-MakingShared Decision-Making

Cost-effective approach that ensures participation in treatment decisions

Improved knowledge of options

More accurate expectations of possible benefits & harms

Greater participation in decision-making

Choices more closely related to stated values

Improves communication with provider

Cost-effective approach that ensures participation in treatment decisions

Improved knowledge of options

More accurate expectations of possible benefits & harms

Greater participation in decision-making

Choices more closely related to stated values

Improves communication with provider

Nutrition & Carbohydrate CountingNutrition & Carbohydrate Counting

A patient diagnosed with type 2 DM should follow a diabetic diet?

A – True

B - False

A patient diagnosed with type 2 DM should follow a diabetic diet?

A – True

B - False

Medical Nutrition TherapyMedical Nutrition Therapy

There is no such thing as a “diabetic” diet

“No single meal planning approach works for every patient” – ADA

“Preplanned diet sheets are ineffective and should not be used” – AADE

“All who have diabetes or prediabetes should receive individual medical nutrition therapy” - ADA

There is no such thing as a “diabetic” diet

“No single meal planning approach works for every patient” – ADA

“Preplanned diet sheets are ineffective and should not be used” – AADE

“All who have diabetes or prediabetes should receive individual medical nutrition therapy” - ADA

Outcomes of Medical Nutrition TherapyOutcomes of Medical Nutrition Therapy

Reported drop in HbA1c

1% for Type 1

1-2% for Type 2

Reduces LDL by 15-25 mg/dL

Reduces triglycerides by 10-14 mg/dL

Raises HDL by 2-19 mg/dL

Reduces BP by 4-9/3-5 mm Hg

Reported drop in HbA1c

1% for Type 1

1-2% for Type 2

Reduces LDL by 15-25 mg/dL

Reduces triglycerides by 10-14 mg/dL

Raises HDL by 2-19 mg/dL

Reduces BP by 4-9/3-5 mm HgAmerican Diabetes Association. Diabetes Care. 2012;35(Suppl 1):S11-S63. Dattilo AM, et al. Am J Clin Nutr. 1992;56:320-328.Metz JA, et al. Arch Intern Med. 2000;160:2150-2158.Stevens VJ, et al. Ann Intern Med. 2001;134:1-11.Tchernof A, et al. Circulation. 2002;105:564-569.

ADA RecommendationsADA Recommendations

Monitoring carbohydrates remains a key strategy in achieving glycemic control

Emphasize a variety of minimally processed nutrient-dense foods in appropriate portions

Ideal percentage of calories from carbohydrate, protein, and fat does not exist

Meal plans can and must accommodate personal preferences, metabolic and other health issues and goals, culture, and lifestyle

Monitoring carbohydrates remains a key strategy in achieving glycemic control

Emphasize a variety of minimally processed nutrient-dense foods in appropriate portions

Ideal percentage of calories from carbohydrate, protein, and fat does not exist

Meal plans can and must accommodate personal preferences, metabolic and other health issues and goals, culture, and lifestyle

American Diabetes Association. Diabetes Care 2013;(Suppl 1):S11-S66.

Strategies for Weight LossStrategies for Weight Loss

Intake by 500 calories per day 1 pound weight loss per week (3,500 calories in a pound)

Increasing physical activity will increase insulin sensitivity and aid in weight management (45-60 minutes 5 days/week)

Monitor weight at least once a week

Recommend keeping a food diary

Intake by 500 calories per day 1 pound weight loss per week (3,500 calories in a pound)

Increasing physical activity will increase insulin sensitivity and aid in weight management (45-60 minutes 5 days/week)

Monitor weight at least once a week

Recommend keeping a food diary

Healthy Food ChoicesHealthy Food Choices

3 balanced meals and snacks spread out over the day

Monitor portion sizes Concentrated sugars in small amounts Eat foods high in fiber Foods low in saturated fats and cholesterol Eat 6 servings of fruits and vegetables daily If alcohol is consumed, do so only in moderation

(women 1 drink/day; men 2 drinks/day)

3 balanced meals and snacks spread out over the day

Monitor portion sizes Concentrated sugars in small amounts Eat foods high in fiber Foods low in saturated fats and cholesterol Eat 6 servings of fruits and vegetables daily If alcohol is consumed, do so only in moderation

(women 1 drink/day; men 2 drinks/day)

American Diabetes Association. Diabetes Care 2013;(Suppl 1):S11-S66.

Talk About the Effect of the Various Macronutrients on Blood Glucose

Talk About the Effect of the Various Macronutrients on Blood Glucose

glucose fructose

m onosaccharides

glucose

sucrose lactose

disaccharides

glucose

starch

polysaccharides

Carbohydrate15 m in - 1 hr

100% glucose

am ino acids

Protein2 - 3 hr

58% glucose

fatty acids

Fat3 - 4 hr

10% glucose

FOO DS

45% - 60% Total Calories

10% - 35% Total Calories

20% - 35% total calories

Quick-carb CountingQuick-carb Counting

Dosage of insulin is based on total grams of carbohydrates. For example:

Insulin:CHO ratio of 1:15

If the total grams of CHO is 60, then 4.0 units of insulin would be administered



How do you know?Test the 2 hour post-prandial blood glucose

Dosage of insulin is based on total grams of carbohydrates. For example:





How do you know?Test the 2 hour post-prandial blood glucose

Key PointsKey Points

Glycemic targets & treatment must be individualized; treat to target

Diet, exercise, education- foundation of T2DM program

Glycemic targets & treatment must be individualized; treat to target

Diet, exercise, education- foundation of T2DM program

Jennifer Burkmar, MD, MBA Emory Family Medicine

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