Education and Lifestyle

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2 Education and Lifestyle Provide strategies to incorporate patient education into diabetes selfmanagement Develop plans to involve other healthcare professionals to support the care of patients with type 2 diabetes Understand the activity and nutritional recommendations for patients with type 2 diabetes

3 Treatment Challenges in Diabetes Care Primary care providers deliver 80% to 95% of diabetes care in the U.S. Many have challenges when providing ongoing diabetes management; for example: Telephone-based management of glycemia Ongoing education Behavioral interventions Risk factor reduction Health promotion Periodic examination for early signs of complications Often, PCPs end up treating acute illness rather than providing ongoing disease management

4 Diabetes Self-Management Education/Training (DSME/T) At diagnosis or if high risk, refer to CDE for DSME/T May or may not be well covered by insurance Covered by Medicare in limited amount Pre-diabetes education not covered except by some HMOs Curriculum needs to be simplified and focussed What is the patient capable/willing to do? What does patient want to learn? Progress report to HCP DSME/T = diabetes self-management education/training; CDE = Certified Diabetes Educator; MCR = Medicare; HMO = Health Maintenance Organization; HCP = Health Care Professional; PPO = Preferred Provider Organization

5 National Standards for Diabetes Self- Management Education Programs In order to obtain reimbursement, must be recognized by the American Diabetes Association or American Association of Diabetes Educators Must include this four-step process 1. Assessment of individual needs 2. Identification of specific short- and long-term goals 3. Educational intervention based on set goal(s) 4. Evaluation of goals and/or outcomes Funnell, MM et al. Diabetes Care; Jan. 2010;33(S1):pS89-S96.

6 Accessed on April 10, 2011 AADE 7 Self-Care Behaviors Healthy eating Being active Monitoring Problem solving Reducing risks Healthy coping Taking medication

7 Education at Diabetes Diagnosis Nature and natural history of diabetes and its progression Lifestyle issues including nutrition, physical activity, and smoking cessation Targets for glucose, A1C, blood pressure, LDL cholesterol, and triglycerides Sequential therapies, including insulin, likely to be necessary Self-monitoring of blood glucose (SMBG) Resources available in the community American Diabetes Association. Diabetes Care. 2011;34(S1):S1-96. Riddle MC. Endocrinol Metab Clin North Am. 1997;26:

8 National Standards for Diabetes Self-Management Education (DSME) DSME Guiding Principles Diabetes education is effective for improving clinical outcomes and quality of life DSME has evolved from didactic presentations to more theoretically based empowerment models Behavioral and psychosocial strategies demonstrate improved outcomes Group education is effective Ongoing support is critical to sustain participants progress made during the DSME program Behavioral goal-setting is an effective strategy to support selfmanagement behaviors Funnell, MM et al. Diabetes Care; Jan. 2010;33(S1):pS89-S96.

9 The Chronic Care Model Strives For: An informed, activated patient A prepared, proactive practice team Productive encounters and improved outcomes

10 Barriers To Treatment Financial Fear Schedule disruption Lack of instructions Complex regimens Denial Concerns about sideeffects Health beliefs Weight gain Hypoglycemia Anxiety Low health literacy Depression Lack of social support Cultural differences Funnell, MM et al. Diabetes Care; Jan. 2010;33(S1):pS89-S96.

11 Patient Physician Team Approach Partnership with other HCPs Nurse Practitioner Physician Assistant Endocrinologist Ophthalmologist Podiatrist Nephrologist Dentist Community Health Worker Certified Diabetes Educator (CDE) Registered Nurse Registered Dietitian Pharmacist Medical Assistant Exercise Trainer Psychologist Social worker Funnell, MM et al. Diabetes Care. Jan 2008;31(S1):S97-S104. Funnell, MM et al. Diabetes Care; Jan. 2010;33(S1):pS89-S96.

12 Getting Patients Involved with Diabetes Care How do I get patients involved when I Have little time to spend on education Have to address numerous patient concerns Sound like a broken record

13 Do Patients Really Hear When we say You need to follow a diet What We Say? Patient hears or feels I have to give up my favorite foods I have to start counting calories Food is my enemy Eating is bad for me Deprivation, restriction, negativity My food is going to taste bland

14 We Tell Patients to Avoid or Cut Down on Certain Foods When we say Avoid sugar, sweets Avoid fruits Avoid white foods Patient hears or feels I can never have dessert, cookies, or sweets ever again! Fruits are bad Sugar is bad for me I have to buy sugar-free products

15 We Ask Patients to Avoid Carbohydrates Or Go Low Carb When we say Cut down on carbohydrates Patient hears or feels I can t eat any pasta, potato, or bread I can only eat boiled vegetables What is left to eat? I m going to starve

16 Use Communication Skills That Foster Early Development of Good Self-Care Use open-ended questions that elicit conversation, not yes or no answers Good open-ended interview questions should facilitate the discovery of areas where the patient needs change, or is most likely to change Affirm the person Provide genuine recognition of the patient s positive behaviors Reflective listening Confirm that you understood the patient, emphasize positive changes Summarize the patient s perspective on change Sum up what you heard, focus on a desire to change, confirm the accuracy of your summary, and elicit the patient s response using open-ended questions Miller R, Rollnick S, eds. Motivational Interviewing. New York, NY: The Guilford Press; 2002.

17 Empower Patients Frame message in positive and specific terms Focus on identifiable behavior and measurable change Emphasize making healthy choices Provide written information Plate method Sample menus Portion size chart Healthier fast food choices

18 Patient Responsibilities Food: Understand the basics first Physical Activity: Progressively increased physical activity; should not be overwhelming Medication: Collaborate with provider to establish plan and then follow it Monitor blood glucose and share records Hypoglycemia: Prevent, recognize, treat Establish follow-up and emergency care plans

19 Patient Goals Noncompliance means 2 people working toward different goals When we support the patient s goals, motivation leads to positive outcomes When stop acting like it is all about our goals, noncompliance will disappear

20 Diabetes Etiquette: Avoid These Terms Non-compliance: Does this really mean that patient does not meet healthcare providers goals? Instead, seek to increase patient participation in regimen. Diabetic: Do not use as noun; instead, person with diabetes Brittle: Is the patient unstable or does he/she have labile BGs? Sliding scale: This term confuses patients and providers alike, rarely works well, insulin does not work backwards. Failure: As in, oral agent failure; implies fault on part of patient Also, do not use insulin as the next step as a threat

21 Effect of Lifestyle Modifications on Type 2 Diabetes Prevention Diabetes Prevention Program (USA) Da Qinq (China) Finnish Healthy Lifestyles Stockholm Diabetes Prevention Program Indian Diabetes Prevention Program Knowler, WC, et al. N Engl J Med, Feb 2002;346(6): ; Pan,XR et al. Diabetes Care. 1997;20(4):537-44; Tuomilehto et al. N Eng J Med 2001, 344(18):1390-2; Andersson et al. Health Promotion International. 2002;17(4): ; Ramachandran et al. Diabetes Care. 2007; 30:

22 Incidence of Diabetes Diabetes Prevention Program (DPP) (n=1082) (n=1073, p<0.001 vs. Placebo) (n=1079, p<0.001 vs. Metformin p<0.001 vs. Placebo) Risk reduction 31% by metformin 58% by lifestyle Knowler, WC, et al. N Engl J Med, Feb 2002;346(6):

23 Healthy Eating All patients should follow a healthy eating regimen Goal in overweight patients with type 2 diabetes: lose at least 5-7% Different diets can be used to achieve this goal Low-fat Low-carbohydrate Mediterranean Glycemic index/load

24 Which Diet is Best? Low-fat, Mediterranean, or Low-carb Low-fat / restricted-calorie diet: Based on AHA guidelines with 30% of calories from fat, 10% of calories from saturated fat, and 300 mg of cholesterol per day Mediterranean diet: Moderate-fat, restricted-calorie, rich in vegetables and low in red meat, with poultry and fish replacing beef and lamb. Restricted energy intake with goal of 35% of calories from fat; the main sources of added fat are 30 to 45 g of olive oil and a handful of nuts (5 to 7 nuts, <20 g) per day Low-carbohydrate diet: Initially allows 20 g of carbohydrates per day with an increase to a maximum of 120 g per day to maintain weight loss. Total intake of calories, protein, and fat not limited AHA = American Heart Association; mg = milligram; g = gram Shai, et al. NEJM: 359: , 2008

25 Weight Changes during 2 Years According to Diet Group This graph compares weight changes in 3 different diet groups (low-fat, Mediterranean, and low-carbohydrate diets) over a 2-year period Shai, et al. NEJM: 359: , 2008

26 Medications It is good to know how meds work, but If meds are too confusing/expensive, patients won t take them Stress importance of how much and when to take meds Before you increase med dose, make sure the patient is taking them Low-cost meds may be available through pharmaceutical assistance plans

27 Recommendations for Taking Medications Encourage patient to keep medication list with them: Rx wallet cards for patients at initial visits Request patient bring it to each visit Phone record of meds Provide written information on diabetes medications, using straightforward terms Include: action, side effects, dosage, timing and frequency, instructions for storage, travel and safety, hypoglycemia

28 Tips for Helping Patients Improve Self-Monitoring of Blood Glucose Barriers to Consistent Testing No one wants to fail a test Falling outside the target range can feel like failure Checking can be inconvenient Patients may have scheduling conflicts between testing and daily activities High blood glucose results can be discouraging Patient may develop an attitude of why bother? Checking hurts It s not bad, but it can be improved Suggest a New Mindset Set reasonable expectations The patient and team agree on a target range that allows some flexibility Develop a routine that works for patient- check BG not test. Planning ahead can avert most timing conflicts with checking Learn how to use the results Have a plan in place for glucose levels that are too high or too low Develop a friendly relationship with your glucose meter American Diabetes Association Web site. Accessed March 24, 2009.

29 Summary Diabetes is a disease that requires a multidisciplinary team to treat Not all patients have coverage for this approach, due to insurance/costs Healthy eating and physical activity are important parts of diabetes management These should receive the same amount of attention as other modalities, but usually do not Use of other healthcare team members can help

30 Other Resources American Association of Clinical Endocrinologists American Association of Diabetes Educators American Diabetes Association American Heart Association Centers for Disease Control National Diabetes Info. Clearinghouse USDA Food Pyramid National Diabetes Education Program