Non-Pharmacologic Therapy for Type 2 Diabetes
Diabetes Self-management Education and Support (DSME/S)
The American Diabetes Association Standards of Medical Care recommend that ALL patients receive education and on-going support according to the national DSME/S standards when diabetes is diagnosed and as needed thereafter. In spite of provider frustration about patients who do not achieve lifestyle or metabolic goals, only 5-7% of insured adults receive DSME. This means that the vast majority of people with diabetes in the US are not receiving quality diabetes care and do not have the knowledge and skills to effectively manage their disease.
DSME/S has been shown in multiple studies and meta-analyses to improve glycemic control and other clinical outcomes, improve quality of life and lower costs. DSME/S is also associated with the increased use of primary and preventive services and lower use of acute, inpatient and hospital services. Patients who receive DSME/S are also more likely to follow best practice treatment recommendations (eg, retinopathy screening) and have lower claim costs. Formal DSME is often provided through an accredited, reimbursed education program with follow-up support provided in the patient’s primary care setting. People with diabetes who receive a combination of formal group and individual engagement and follow-up tend to have the most improved outcomes.
In a recent Position Statement, the ADA, AADE and the National Academy of Nutrition Sciences provided more specific guidance for when, what and how to educate adults with type 2 diabetes during routine care. The algorithm identifies four crucial times to assess, provide, and reinforce DSME/S, as well as address nutrition and psychosocial needs. These are at diagnosis, annually, when there are new complicating factors or comorbidities and when transitions that affect self-management occur. The algorithm also delineates areas on which to focus, content and action steps to address during a visit at each of these critical times. (http://care.diabetesjournals.org/content/early/2015/06/02/dc15-0730).
Medical Nutrition Therapy
Although an “ADA diet” or a “diabetic diet” is frequently ordered, there actually is no such thing. Current Standards of Care from the American Diabetes Association state that persons with diabetes “should receive personalized Medical Nutrition Therapy, preferably from a Registered Dietitian.” The meal plan developed by the patient and dietitian will consider preferences, schedule, family situation and finances, ethnicity and culture and the patient’s goals for blood glucose, weight, lipids, and blood pressure as well as other medical conditions. The guidelines also state that “the best mix of carbohydrate, protein and fat may be adjusted to meet the metabolic goals and individual preferences” of the person with diabetes
Carbohydrates, Protein and Fat
There is no specific amount or type of carbohydrates recommended for people with diabetes, however monitoring carbohydrates is a key strategy for achieving blood glucose targets. The type or glycemic index of carbohydrate is less important than the total amount in terms of blood glucose level; carbohydrates are no longer categorized as simple or complex. In addition, both fiber and fat slow down the impact of carbohydrates on blood glucose levels. Although individual carbohydrate goals need to be established with the patient during the meal planning process, generally 50-70% of total calories are from carbohydrate foods. As a general guideline, 60 grams of carbohydrate per meal for men and 45 grams of carbohydrate per meal for women, with an additional 15-30 grams as snacks, are consistent with this approach.
The recommendations for protein, fat, sodium and fiber are the same as for the general public. Restricting protein is no longer recommended for improving GFR or slowing the progression of kidney disease. It is recommended that saturated fat intake be less than 7% of total calories and intake of trans fats should be minimized. Vitamin and mineral supplements are not routinely recommended and alcohol can be included in moderation.
Meal Planning Approaches
At the time of diagnosis, advising patients to eat three meals a day (including breakfast even if it is very small) and to spread meals out over the day can help to balance blood glucose levels throughout the day and may help lower the fasting blood glucose level by preventing overeating in the evening.
In the most recent nutrition guidelines, meal planning recommendations were modified in order to match the diet with the treatment plan, as follows:
Healthful eating and portion control are recommended for patients using no medications, oral medications, incretin mimetics and fixed or mixed doses of insulin.
Carbohydrates should be included at all meals if taking medications with the potential to cause hypoglycemia.
Consistency in meal and medication schedules will help to ensure more even glucose levels.
Carbohydrate counting is recommended only for patients using intensive insulin regimens or an insulin pump. In order to maximize the results, the patient should be referred to a dietitian to learn carbohydrate counting, be provided with an insulin:carbohydrate ratio to manage pre-meal insulin as well as a correction dose and receive frequent follow-up.
Healthful eating refers to a balanced diet including each of the 5 main food groups in recommended amounts spread throughout the day. Portion control refers to managing both the amount and type of food by using serving sizes and nutrition information to choose nutrient dense foods and limit portions of higher calorie foods.
The plate method is often used as a way to implement healthful eating and portion control. The plate method recommends filling one half of the plate with non-starchy vegetables, one fourth with carbohydrate and one fourth with protein along with a small piece of fruit and/or a glass of milk at lunch and supper. The breakfast plate eliminates the vegetables. This fairly simple method helps to manage both carbohydrate intake and total calories.
A modest amount of weight loss can have a significant effect on blood glucose levels, especially early in the course of the disease when the primary cause of hyperglycemia is insulin resistance. Weight loss occurs with a 500-700 Kcal/day energy deficit. Although benefits are seen with as little as 5% weight loss, sustained weight loss of >7% is optimal.
The best weight loss meal plan is one that the patient can use on an on-going basis. Low-fat, low- carbohydrate or Mediterranean diets may be effective in the short-term (up to 2 years). Monitoring lipid levels, renal function and protein intake (for those with nephropathy) and adjusting medications as needed are recommended for patients who choose low carbohydrate diets.
Using snacks to prevent hypoglycemia was common in the early days of multiple insulin injections. However, with the increased use of long-acting insulins and insulin analogs, snacks are needed much less often. Some patients want to have a snack because it is part of their usual routine and may help them to better stick with their meal plan. The general guideline is that about 15-30 grams of carbohydrate per day can be added as snacks. If patients are experiencing nocturnal hypoglycemia, decreasing medication doses is preferred instead of adding a snack at bedtime. Snacks may be needed prior to unusual, unplanned or strenuous exercise or before or during long periods of driving to maintain safe blood glucose levels.
Helping Patients Stick with the Meal Plan
Meal planning is generally the most difficult aspect of diabetes self-management for most patients. Creating a personal plan with the help of a registered dietitian is a good starting point for many patients and has been shown to improve outcomes. Point out that there are no good, bad or forbidden foods and that there is no such thing as cheating on a diet. As adults, patients have the right to make food choices and to evaluate the results in terms of both quality of life and clinical outcomes. Using a meal plan is a learning process about what does and does not work in the long term, not an absolute. Rather than deciding that the patient is or is not “following the diet,” suggest patients think in terms of making choices and evaluating the consequences in terms of their results and the impact on their own glucose, weight and other goals and priorities.
Monitoring 2 hours after a meal helps the patient understand the impact of foods on glucose levels and decide whether the choice was beneficial or if they would do something differently next time. Let patients know that perfection is not expected nor possible, and that it is what they do most of the time and what they learn from their experiences that count.
In general, adults with diabetes should be advised to do at least 150 minutes per week of moderate-intensity aerobic physical activity. Because of the established benefits of resistance training on reducing insulin resistance, adults should be advised to perform resistance training at least two times per week, including older adults. A total of 150 minutes of physical activity per week (30 minutes done 5 days per week) generally provides cardiac benefit and done regularly helps to lower blood glucose levels. To maintain weight, 45 minutes of exercise per day is generally needed. To lose weight, 60 minutes of exercise per day is needed if exercise is the only weight loss strategy being used by the patient. It is also recommended that all adults reduce the amount of time spent in sedentary activities and break up extended time spent sitting (>90 minutes) by briefly standing, walking or moving.
Exercise causes increased glucose uptake into active muscles balanced by hepatic glucose production with greater reliance on carbohydrate to fuel muscle activity as exercise intensifies. Lower blood glucose levels have been reported with both aerobic and resistance exercise up to 72 hours post exercise. Although exercise improves blood glucose levels and insulin action in the short term, the risk for hypoglycemia among patients who do not take insulin or insulin secretagogues is minimal.
For individuals using insulin and/or secretagogues, added carbohydrate is needed as a snack prior to exercise if pre-exercise glucose levels are less than 100 mg/dL Patients who are hypoglycemic (blood glucose <70 mg/dL) should be advised to treat the hypoglycemia and wait until the blood glucose is 70-100 mg/dL depending on the intensity and duration of the planned exercise. Exercise should be avoided when patients are hyperglycemic and ketotic, but there is no reason to postpone exercise if the patient is hyperglycemic, feels well, is adequately hydrated and is negative for ketones.
Doses of insulin and insulin secretagogues may need to be adjusted for patients who are participating in a regular, moderately intense exercise program. However, patients who exercise occasionally or do not routinely exercise may prefer to have a small snack prior to unusual exercise to avoid hypoglycemia. While there are no precise guidelines for the carbohydrate needed in the exercise snack, 20-60 grams is generally recommended for moderate-intensity exercise and 30-90 grams is needed for high-intensity exercise depending on exercise duration, body weight and pre-exercise glucose levels.
Before beginning an exercise program that is more intense than brisk walking, sedentary persons with type 2 diabetes may benefit from a physician evaluation. Routine screening using ECG exercise stress testing for individuals at low risk of CAD is not needed, and the need for screening should be done on an individual basis using clinical judgment.
There are specific safety guidelines about exercise for patients with the following long-term complications of diabetes:
Proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy — Avoid vigorous aerobic or resistance exercise.
Peripheral neuropathy without acute ulceration — Moderate weight-bearing exercise is safe; however, foot care education and appropriate footwear are critical.
Cardiac autonomic neuropathy — Specific instructions based on the results of exercise stress testing.
CVD — Patients with moderate to severe angina should exercise as part of a supervised cardiac rehabilitation program.
(For more information, see chapter on Diabetes and Cardiovascular Disease.)
Helping patients initiate and maintain physical activity
Because patients frequently hear about the benefits of weight loss and exercise both from the media and health care providers, it can be easy for them to tune out this advice. Rather than repeating the commonly cited benefits, point out benefits that may be particularly relevant for an individual (e.g., stress relief, look better, more energy). Asking patients about their current activities and how they believe exercise could be specifically beneficial for them may help patients to reframe their thoughts about exercise.
Asking patients about their barriers to exercise and what they could do to overcome those barriers can also help to decrease resistance. Rather than offer specific advice, ask if there is something that they enjoy (or can at least tolerate). Starting small and gradually increasing exercise duration and intensity can help to build self-efficacy, which has been shown to positively influence exercise behavior. While walking is often chosen as a first step, helping patients identify alternatives for bad weather or in unsafe neighborhoods (e.g., walk inside at home, put on some music and dance) can help them succeed. Use of pedometers, wearable digital devices, apps to track movement, lifestyle intervention and supervised exercise programs has been shown to have some benefits for initiating and maintaining exercise behaviors.
Blood Glucose Monitoring
When to Test
Because the evidence for the benefit of self-blood-glucose monitoring among patients who do not take insulin is mixed, there are no clear-cut guidelines for the frequency or timing of testing for those patients. Recommendations made to individual patients are often based on insurance coverage of strips and the patient’s willingness to do the testing. Clinician preferences also vary; some recommend only fasting and pre-meal testing, while others recommend post-meal monitoring. Because of the impact of postprandial glucose levels on A1C levels that are closer to 7%, a reasonable recommendation is post-meal testing among patients who have elevated A1C levels with fasting and pre-meal blood glucose values that are consistently within the target range. Post-meal testing is generally 2 hours after the start of a meal with a target blood glucose level of less than 180 mg/dL.
One approach that was found to be effective for lowering A1C levels among type 2 patients with high A1C levels (>9%) using oral medications was testing 8 times per day (fasting, bedtime and before and after all meals) for only the 3 days prior to their appointment. Patients also recorded intake as usual/more/less than usual and rated their stress level. This provided clinically useful information for the health care professionals and gave patients insights into the impact of their behavior on blood glucose levels.
Recommendations for insulin-taking patients are based on the type of insulin, number of injections per day and glucose levels most affected by the insulin regimen. Asking patients to use a log-book to write down blood glucose readings or to download the information has the advantage of helping you and the patient view patterns, rather than just focusing on individual readings stored in the meter’s memory.
Helping patients monitor more faithfully
One of the common elements among studies showing benefits of monitoring is the need for patients to actively use the information at the time it was collected and for health professionals to demonstrate that they valued the patients’ efforts. Asking the patient to tell you about what they have learned from monitoring is often more helpful than quickly trying to scan 3 months of blood glucose values. Downloading meters so that trends, averages and values above and below target can be more quickly determined is also an efficient way to make appropriate dose adjustments. Key educational messages to patients are
Blood glucose readings are numbers, not judgments.
Monitoring provides the data you need to make informed decisions as you make the many daily self-management choices required by diabetes.
Although the readings reflect your behavior, they also reflect your overall treatment plan, your level of stress and other factors that can affect you.
Testing gives you feedback on the consequences of the choices you make so you can figure out if the decision helped or hindered you in reaching your goals and what to do next time.
Diabetes is largely a self-managed disease; patients have the final “say” in what happens once they leave their provider’s office. One of the frustrations of clinicians is the failure of patients to take medications as prescribed. It is estimated that 30-40% of patients do not take their medications at all, take them incorrectly or take them for only a short period of time. Because this is such a pervasive issue, it is incumbent on physicians to assess whether patients are taking some, all or none of their medications correctly in order to make appropriate clinical decisions. The following questions can be asked during the intake process or by the clinician during the visit.
In the past month, about how many days did you miss taking your medicines?
What is the most common reason you miss taking your medicines?
What are the things that get in the way of taking your medicines?
The responses to these questions not only help you to determine if patients are taking their medicines but can also give you insights into what strategies and solutions are needed. For example, the solution to forgetting to take your medicine when eating out is very different from not being able to afford a medicine. Although time is always a concern during a visit, knowing the answer to these questions can actually save time by identifying a specific area on which to focus.
Diabetes-related Distress and Depression
The American Diabetes Association recommends assessing patients’ psychological and social situation as an on-going part of medical management, including screening for depression, diabetes-related distress and other psychological problems. Depression is about twice as common among people with diabetes and can significantly influence patients’ ability to self-manage their diabetes and thus their outcomes. Treating clinical depression can result in significant improvements in A1C and other outcomes.
Diabetes-related distress is increasingly recognized as an essential component patient care because of its significant, independent influence on A1C levels, other outcomes and self-management behavior. Diabetes-related distress is the shame, guilt, anger, fear, and frustration that many patients experience throughout a lifetime of diabetes, and reflects the everyday struggle most people experience at diagnosis and on a recurring basis as they try to manage this complex disease in the context of their lives and other priorities and stressors.
The psychological assessment needs to be done as part of the annual diabetes visit. There are validated, standard measures for both depression and diabetes-related distress, but asking patients two questions along with screening for depression can help you better understand their level of distress.
On a scale of 1 to 5 with 5 being almost all of the time, how would you rate your experience with the following for the past month:
Feeling overwhelmed by the demands of living with diabetes
Feeling that I am often failing with my diabetes routine
Feeling that I will get the complications of diabetes no matter what I do
If patients indicate a problem, ask how you can help, keeping in mind that you are not expected to solve this problem for the patient. Although this may seem like a burden given the time-constraints of a busy appointment, it may give you the insight you need to be helpful to those patients with whom you feel frustrated when nothing seems to work in helping them reach the targeted outcomes. It is also more efficient and effective than repeating the same messages, scolding or blaming the patients for failing to do what they are told.
Patient-centered Diabetes Care
A great deal of emphasis has been placed on providing patient-centered care, yet many practices struggle to implement this approach during routine care. Fortunately, there are patient-centered strategies that can help reframe the interaction and shorten the visit or make it more efficient and effective.
Start the visit by letting the patient know that you have some things you need time to do, at the end of the visit but that you want to start with what is important to them. Ask the patient to identify what is hardest or the biggest struggle about managing diabetes, any issues that they need addressed and cover those first. This question can also be asked by clinic staff or in written form in the waiting area. End the visit by asking the patient to “teach back” what you have agreed to during that visit and also to tell you one thing they will do between now and the next visit to manage their diabetes. This approach helps to prevent the “hand on the doorknob syndrome” by identifying the issues at the start of the visit rather than after you have completed the exam.
There are a variety of effective non-phamacological therapies for diabetes. All of these begin with basic diabetes self-management education (DSME) and Medical Nutrition Therapy (MNT) and include on-going education and support. Referral for these services is recommended by standards of Care and is essential for improving outcomes and providing quality of care.
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