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%
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%
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
3. Elevated systolic blood pressure
4. Smoking
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
3. Elevated systolic blood pressure
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
4. Elevated systolic blood pressure
5. Smoking
1. Increased LDL
2. Decreased HDL
3. Elevated HbA1c
4. Elevated systolic blood pressure
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
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
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
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
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
Implications of ACCORD, ADVANCE, & VADT TrialsImplications of ACCORD, ADVANCE, & VADT Trials
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
Implications of ACCORD, ADVANCE, & VADT TrialsImplications of ACCORD, ADVANCE, & VADT Trials
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
“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?
Clinical InertiaClinical Inertia
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?
Communication StrategiesCommunication Strategies
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?
Communication StrategiesCommunication Strategies
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
Insulin:CHO ratio of 1:10
If the total grams of CHO is 60, then 6.0 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:
Insulin:CHO ratio of 1:15
If the total grams of CHO is 60, then 4.0 units of insulin would be administered
Insulin:CHO ratio of 1:10
If the total grams of CHO is 60, then 6.0 units of insulin would be administered
How do you know?Test the 2 hour post-prandial blood glucose
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