Managing Type II Diabetes for the Family Medicine Resident Part 1
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 Learning 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 QuickCarb 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) 1994 No Data <14.0% 2010 2000 14.0–17.9% 18.0–21.9% 22.0–25.9% 26.0% Diabetes 1994 No Data 2010 2000 <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 The UKPDS demonstrated that a 1% reduction in HbA1c results in …….% reduction in microvascular disease. 1. 12% 2. 19% 3. 31% 4. 37% The UKPDS demonstrated that a 1% reduction in HbA1c results in …….% reduction in microvascular disease. 1. 12% 2. 19% 3. 31% 4. 37% An epidemic that is only becoming worse Prediabetes & 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 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 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 Rank the order of risk factors for CAD in type 2 diabetes Increased LDL Decreased HDL Elevated HbA1c Elevated systolic blood pressure Smoking Rank 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 Comprehensive Management of Diabetes BLOOD GLUCOSE But there is also: Antiplatelet therapy Blood pressure Cholesterol Dietary changes Exercise changes Comprehensive Management of Diabetes And let’s not forget… Smoking Weight Regular examination of: Eyes Mouth/teeth Feet/skin Kidneys Recommended Targets for T2DM HbA1c Preprandial glucose Peak postprandial glucose Blood pressure LDL Triglycerides HDL ADA AACE < 7.0% < 6.5% 70 – 130 < 100 < 180 < 140 < 130/80 <100 < 70 (overt CVD) < 150 > 40 (male) > 50 (female) Rationale 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 What effect do statins have on glucose control? 1.↑ glucose 2.No effect 3.↓ glucose What effect do statins have on glucose control? 1.↑ glucose 2.No effect 3.↓ glucose Statins 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 JUPITER 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 Disadvantages 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 Treatment 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 Approach: Suboptimal Glycemic Control A1c goal OAD = Oral Antidiabetic Drug Treatment 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 Treat-to-Target Approach to 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 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 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 Implications 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 Implications 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 Implications 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 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 Clinical Inertia What is it?????? Clinical Inertia “Failure of healthcare providers to initiate or intensify therapy when indicated.” Are you doing anything? Are you doing enough? Clinical 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) Strategies 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) Strategies 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 Overcoming 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 Overcoming 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 Impact of a Multidisciplinary Team on Glycemic Control & Hospital Admissions Behavior & Diabetes: Moving from Compliance to Collaboration Case Study – Ms. S. T2DM A1c is 9.4% BMI is 29 Smokes On metformin & glyburide Rarely monitors glucose levels Frequently does not keep appointments Always promises to do better Our plan for Ms. S. STOP SMOKING! LOSE WEIGHT! FOLLOW YOUR DIET! EXERCISE! MONITORS BLOOD GLUCOSE 4X DAY! 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 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 Behavior & 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 Behavior & 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 Empowerment 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? 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 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 Diabetes-Related Distress Fearful Frustrated Overwhelmed Anxious Guilty Angry Powerless Discouraged DAWN-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 Depression 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 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 AASAP Anticipate the feelings Acknowledge the feelings Standardize & normalize the feelings Accept & understand basis for problems Plan how to respond to the feelings Behavior 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 DAWN2 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 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? Communication 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 ??? Medication 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…. Concerns 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? Communication 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 DAWN2 “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 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? Shared 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 Nutrition & Carbohydrate Counting A patient diagnosed with type 2 DM should follow a diabetic diet? A – True B - False Medical 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 Outcomes 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 American 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 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 American Diabetes Association. Diabetes Care 2013;(Suppl 1):S11-S66. Strategies 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 Healthy 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) American Diabetes Association. Diabetes Care 2013;(Suppl 1):S11-S66. Talk About the Effect of the Various Macronutrients on Blood Glucose FOODS Carbohydrate 15 min - 1 hr 100% glucose Protein 2 - 3 hr 58% glucose Fat 3 - 4 hr 10% glucose monosaccharides disaccharides polysaccharides amino acids fatty acids glucose fructose sucrose lactose starch 10% - 35% Total Calories 20% - 35% total calories glucose glucose 45% - 60% Total Calories Quick-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 Key Points Glycemic targets & treatment must be individualized; treat to target Diet, exercise, education- foundation of T2DM program
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