Education of Patients

Arguably, over the last 10 years, nothing has changed more fundamentally in diabetes care than the emphasis on lifestyle intervention. For decades, physicians and patients paid lip service to the notion that lifestyle intervention is important. Now we have significant clinical trial evidence that each component of lifestyle intervention, when appropriately administered, can contribute to improved outcomes.^20,21 Furthermore, since the Balanced Budget Act of 1997 and the passage of complementary legislation by most state governments, lifestyle intervention has become a covered benefit for most patients with diabetes in the United States.

Diabetes is a lifelong disease, and health care providers have almost no control over the extent to which patients adhere to the day-to-day treatment regimen. The appropriate role of the health care provider is to serve as a coach to the patient, who has primary responsibility for the delivery of daily care. Thus, it is essential that health care professionals understand the context in which patients are taking care of their disease. Using a prescriptive approach in which patients are told what to do can work on occasion but fails more often than not because of unrecognized barriers to the execution of a particular plan.

As defined by the ADA,²² diabetes self-management education is the process of providing the person with diabetes the knowledge and skills needed to perform self-care, manage crises, and make lifestyle changes. As a result of this process, the patient must become a knowledgeable and active participant in the management of his or her disease. To achieve this rather daunting goal, patients and providers work together in a long-term, ongoing process. Comprehensive diabetes education should be individualized, with emphasis on the issues highlighted in Table 22-2. There are many more specialized topics relevant to almost all patients, such as how to adjust therapy when eating out or during travel, as well as how to access available local health care resources and negotiate the complexity of health care financing in the United States. Although only limited studies are published to date, as a body of work, they do provide support for the concept that diabetes education can be cost effective and can improve outcomes.^21–23

A team of providers is generally required to optimally implement the process of diabetes self-management education, because the amount of information that needs to be exchanged is large and the range of expertise required is broad. It is generally impossible to cover the recommended content fully in the context of several or even many brief encounters with a physician in an office setting. Potential providers in a team care approach could include nurses, dietitians, exercise specialists, behavioral therapists, pharmacists, and other medical specialists including diabetologists or endocrinologists, podiatrists, medical subspecialists, obstetrician-gynecologists, psychiatrists, and surgeons. In the diabetes self-care process, the potential role of the community where the patient lives and works is enormous. At a minimum, this community includes family, friends, employers, health care systems, and health care insurers. Each member of the team has a role to play in the process, and it is useful to review these roles frequently (Table 22-3). The primary role of the providers in this process is to provide guidance in goal setting to manage the risk of complications, suggest strategies to achieve goals and techniques to overcome barriers, provide training in skills, and screen for complications. For this process to be a success, the patient must commit to the principles of self-care, participate fully in the development of a treatment plan, make ongoing decisions regarding self-care from day to day, and communicate honestly and with sufficient frequency with the team.

Fortunately, barriers to providing team care are becoming less daunting, in large measure because of the rapidly expanding number of diabetes education programs and improved insurance coverage for services. The American Association of Diabetes Educators (800-TEAM-UP4; www.diabeteseducator.org) and the ADA (800-DIABETES; www.diabetes.org) can provide information regarding diabetes educators and education programs nationwide.

For diabetes care to be effective, communication and mutual respect among the patient-centered team is critical. Unfortunately, in many communities, the full benefit of the consultation and ongoing care with diabetes educators, nurses, dietitians, pharmacists, medical consultants, and primary care providers is not achieved because of overly hierarchical approaches to care. Non–health care professionals, such as lay or peer supporters, can provide benefit to patients in developing effective diabetes self-care behaviors. Key functions of such efforts have been identified and include assistance in managing and living with diabetes in daily life, social and emotional support, and linkage to clinical care.²³

Perhaps some of the most overlooked contributors to ineffective care in the setting of type 2 diabetes are the relatively common barriers created by psychiatric, neurocognitive function, and adjustment disorders, which are largely responsive to psychosocial therapies.²⁴

Nutrition

The ADA has published technical reviews that exhaustively document the literature regarding the effect of medical nutrition therapy and specific advice on diabetes-related outcomes such as A1C and weight, as well as a position statement.25–27 These are summarized in Table 22-4. An individually negotiated nutrition program in which each patient’s circumstances, preferences, cultural background, and the overall treatment program are considered is most likely to result in optimal outcomes. Ideally, a registered dietitian with specific skill and experience in implementing nutrition therapy in diabetes management should work collaboratively with the patient and other health care team members in providing medical nutrition therapy. For optimum outcomes, this counseling should be performed over a series of visits initially, with intermittent follow-up thereafter. Analogously, physicians and other members of the health care team need to support the nutritional plan developed collaboratively.

Individualized dietary advice can be developed by a physician from a brief diet history obtained by asking: “What do you eat for breakfast? … lunch? … supper? Do you have snacks between breakfast and lunch? … lunch and supper? … supper and bedtime? What do you drink during the day?” Ideally, this information should be obtained at each visit, with specific suggestions for change that both patient and provider agree are important in the context of the overall treatment plan as well as both achievable and sustainable. Easy issues to address include caloric beverages, which tend to elevate glucose levels dramatically and can generally be replaced relatively easily with artificially sweetened alternatives. Juices are generally perceived as healthy but can significantly affect glycemic control and total caloric intake. Portion control and recipe modification are excellent dietary techniques, particularly for meats and fried foods. Substituting low-fat products for higher-fat foods is often useful but needs to be done with the recognition that they are generally higher in carbohydrates. It is important that patients recognize that “fat-free” and “sugar-free” foods are not “free” and that attention to both total carbohydrate and calorie content are critical.

Eating approximately every 4 hours while awake is the most practical dietary plan for most overweight people. Frequent small meals have been shown to be of benefit when used in a controlled inpatient setting, but in general when overweight patients are encouraged to eat more frequently they often overeat more frequently. At a minimum, avoiding high-calorie snacks is reasonable advice for most people with diabetes. If all health care providers repeatedly obtain a diet history every few weeks to months, effective assessment of whether previously agreed-to changes were enacted, reinforcement of the importance of dietary efforts, and the patient’s gradual evolution to a more healthful diet through further dietary modification can be accomplished.

In general, the critical nutrient for glycemic control is carbohydrate. Essentially all carbohydrates consumed are converted to glucose in the gut and require the action of insulin to be cleared from the circulation. A dietary technique called carbohydrate counting can be used in patients with type 2 diabetes to facilitate consistent carbohydrate intake or to allow insulin dose adjustment in response to changes in carbohydrates consumed.²⁸ Although this technique requires less insulin than fixed meal dosing and may help curb weight gain, it has not been shown to improve glycemic control or reduce the rate of hypoglycemia in patients with type 2 diabetes.²⁹ Whereas the β cell in type 2 diabetes has generally lost its responsiveness to glucose, the second phase of insulin secretion is largely spared in type 2 diabetes and is in part driven by amino acids and fatty acids. Therefore, including some protein and fat in each meal and snack may be useful.

Dietary fat is the nutrient most closely associated in epidemiologic studies with the risk of developing type 2 diabetes. Although dietary fat clearly has a major impact on total caloric intake, as well as on circulating lipids, it has a minimal acute impact on glycemia. It is recommended that people with diabetes, if they are overweight, consume a diet modestly restricted in calories, with less than 10% of total calories as saturated fat, less than 10% as polyunsaturated fat, and total avoidance of trans fats. Some advocate substituting foods high in monounsaturated fatty acids—seeds, nuts, avocado, olives, olive oil, and canola oil—for carbohydrate, but most patients do not find adequate variety in the monounsaturated fatty acid category and often overeat these high-caloric-density foods.

Dietary protein similarly has a minimal impact on glucose levels, although as mentioned, amino acids do promote insulin secretion. Metabolism of protein results in the formation of acids and nitrogenous waste that may result in bone demineralization and glomerular hyperfiltration. At least 0.8 g of high-quality protein per kilogram is generally recommended. Protein restriction in the setting of kidney disease has been recommended and is more fully discussed in Chapter 28. There is no evidence that protein intake materially effects the risk of developing kidney disease in patients with diabetes.

The role of vitamins, trace minerals, and nutritional supplements in the treatment of diabetes is poorly understood. There are some patients and providers who are absolutely convinced of the utility of soluble fiber, magnesium, chromium, zinc, folic acid, pyridoxine, cyanocobalamin, vitamin A, vitamin C, vitamin E, vanadium, selenium, garlic, and others. Clinical trial data to support their safety and efficacy are inconclusive. Many patients are convinced that nutritional supplementation is healthful, and it is often counterproductive to engage in scholarly discussion of the nature of the evidence base for their decision. At a minimum, discussion should include the documented efficacy of lifestyle and pharmacologic interventions and the idea that these efforts should not be left by the wayside when budgetary constraints affect potentially more effective interventions.^30,31 A multivitamin/mineral preparation may be reasonable for most patients with diabetes. A recent randomized control trial in patients with diabetes demonstrated fewer self-reported infections and related absenteeism.³² Studies demonstrating the benefits of B-vitamin supplementation on restenosis after angioplasty³³ have recently been called into question; the possibility has been raised that such therapy could increase rates of restenosis after stent placement.³⁴

Although there are proponents of a wide range of dietary composition, there are few data to support these recommendations from long-term outcome studies of prescribed diets. Mixed meals containing 10% to 20% of calories from protein, no more than 10% of calories from saturated fat, no more than 10% from polyunsaturated fats, and the remainder largely from monounsaturated fats (seeds, nuts, avocados, olives, olive oil, canola oil) and carbohydrates, particularly whole grains, fruit, vegetables, and low-fat milk, are probably most reasonable. High-carbohydrate, low-fat diets, although historically recommended by many health organizations, have been shown to increase postprandial blood glucose and triglyceride levels, elevate fasting triglyceride levels, and decrease high-density lipoprotein (HDL) cholesterol levels in insulin-resistant people, including those with type 2 diabetes. Several studies have demonstrated improved lipid levels and blood glucose control in both short- and intermediate-term studies in which total fat intake approaches 45% of calories and carbohydrate intake is as low as 40% of calories. Reducing fat or carbohydrate intake in obese individuals will not necessarily lead to reduced calories. Since weight loss will occur only in the setting of caloric restriction, arguably the most appropriate approach is to limit intake of both fat and highly processed, easily digestible carbohydrates. The treatment of obesity is discussed in Chapter 2; the principles discussed are appropriate when type 2 diabetes is complicated by obesity. To date, short-term studies of medical nutrition therapy, physical activity, and comprehensive lifestyle approaches have been shown to improve the control of classic CVD risk factors, as well as intermediate markers of CVD risk such as C-reactive protein; no long-term, large-scale study of intentional weight loss has been powered to examine CVD endpoints. Look AHEAD (Action for Health in Diabetes) will examine CVD events for up to 11.5 years in a study in which patients with type 2 diabetes 45 to 74 years of age with a body mass index = 25 kg/m² will be recruited. Patients will be randomized to a 4-year intensive weight loss program (calorie restriction and physical activity) or to diabetes support and education. With planned recruitment of 5000 patients at 16 centers over 2.5 years, the study is designed to provide a 0.90 probability of detecting an 18% difference in major CVD event rates between arms.³⁵

Exercise

There is a substantial body of literature supporting exercise as a modality of treatment in type 2 diabetes, including a recent technical review by the ADA.^36,37 The recommendations of this technical review are summarized in Table 22-5. Exercise is perhaps the single most important lifestyle intervention in diabetes, because it is associated with improved glycemic control, insulin sensitivity, cardiovascular fitness, and cardiac remodeling. Aerobic exercise and resistance (strength) training both have a positive impact on glucose control. Improvements in glycemic control are generally apparent immediately, become maximal after a few weeks of consistent exercise, but only persist for 3 to 6 days after the cessation of training. To maintain effects on glycemia, a minimum of three exercise sessions a week is suggested, with no more than 2 days rest between sessions.