Refocusing Education for Type 2 Diabetes

Highlights from the International Diabetes Federation’s 20th World Diabetes Congress, Montreal, QC

Educational Objectives

The goal of this program is to improve diabetes education and management. After hearing and assimilating this pro­gram, the clinician will be better able to:

1.   Initiate effective self-monitoring of blood glucose.

2.   Provide preconception counseling to diabetic women.

3.   Explain the importance of carbohydrate distribution in preventing weight gain in patients on insulin therapy.

4.   Advise patients about lifestyle modification.

5.   Assist newly diagnosed patients in developing a diabetes self-management plan.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Owens is on the Speakers’ Bureau for LifeScan, Merck Sharp & Dohme, Novo Nordisk, Pfizer, Roche Diagnostics, and sanofi-aventis. Drs. Mbanya and Jovanovic, Ms. Moreira-Cali, Mr. Weiss, and the planning commit­tee reported nothing to disclose.

Acknowledgements

Drs. Mbanya, Owens, and Jovanovic, Ms. Moreira-Cali, and Mr. Weiss were recorded in Montreal, QC, at the International Diabetes Federation’s 20th World Diabetes Congress, presented October 19-22, 2009. The Audio-Digest Foundation thanks the speakers and the International Diabetes Federation for their cooperation in the production of this program.

Global Perspective

Jean Claude Mbanya, MD, Professor of Endocrinology, University of Yaounde, Cameroon, and President, In­ternational Diabetes Federation

Need for diabetes prevention: insulin discovered in 1921, but 19 yr later, many people in lower and middle income countries died due to lack of insulin; risk of developing diabetes increasing; investment in diabetes prevention needed

International Diabetes Federation Guidelines for Self-monitoring of Blood Glucose

David Owens, MD, Director, Diabetes Research Unit, University Hospital Llandough, Cardiff, Wales

Introduction: self-monitoring of blood glucose (SMBG) essential for patients with insulin-treated type 1 and type 2 diabetes; controversial whether SMBG should be extended to noninsulin-dependent diabetic patients

Critical considerations: 1) evidence of effects of SMBG controversial; must review findings of selected (based on quality) publications, and clinical and metabolic impact and costs of BG monitoring; 2) must consider limitations of previous studies when making recommendations for future studies; 3) must propose recommendations for SMBG in noninsulin-treated patients

Potential uses of SMBG: hemoglobin (Hb) A_1C identifies whether patient in reasonable control of diabetes (if not, can help correct); diabetes education; lifestyle modification (eg, diet, exercise); glycemic assessment; optimization of therapy; benefits therefore possible for noninsulin-treated diabetics, but only when patients and health care pro­fessionals have knowledge, skills, and ability to interpret data

When to initiate SMBG: at time of diagnosis; education about BG response to various environments critical; SMBG tells patients how certain foods, exercise, and therapy affect BG; SMBG ongoing process (adjust management and therapeutic intervention as disease progresses); treat cases individually

Recommendations and protocols: need structured approach to how and when BG measured; chart results and look for patterns; important to exchange knowledge between physician and patient; protocols should be individually de­signed and agreed upon by physician and patient; methods of collecting data must be relatively easy; patients must be able to monitor performance of BG meters; protocols should focus on SMBG as part of educational process, and be linked to clear set of instructions; evaluate how best to train patients and health care professionals to execute management; address behavioral issues (determine best way to change behaviors)

Summary: SMBG can be used to enhance understanding of diabetes as part of education, facilitate healthy behavior of patients for best outcomes, facilitate timely treatment, and adjust therapy as disease progresses

International Diabetes Federation Guidelines for
Diabetes in Pregnancy

Lois Jovanovic, MD, Clinical Professor of Medicine, Keck School of Medicine at the University of Southern California, Los Angeles, and Chief Scientific Officer, Sansum Diabetes Research Institute, Santa Barbara, CA

Introduction: diabetes or hyperglycemia complicating pregnancy occurs in >10% of all pregnancies worldwide; lack of identification of diabetes or hyperglycemia during pregnancy results in complications in mother and infant (eg, fetal malformation or death, intrauterine growth retardation, or macrosomia; associated with subsequent metabolic syndrome or frank diabetes in adult)

Goals of International Diabetes Federation (IDF) pregnancy global guidelines: identify women previously un­aware of having diabetes or hyperglycemia during pregnancy; immediately improve BG control; teach women al­ready diagnosed with diabetes how to improve BG control for better pregnancy outcomes

Preconception counseling: identify all women at risk for diabetes and convey to them importance of requesting test­ing; counsel diabetic women about importance of good BG control before becoming pregnant; guidelines recom­mend instructing women to normalize BG and achieve Hb A_1C <6.5% before conception; women with preconception Hb A_1C >8% should be advised to delay pregnancy until level improved; targets for control  —  premeal BG level, <5.5 mmol/L (based on self-monitoring); no BG level >8.0 mmol/L (even 1 hr after eating)

Medications: avoid glucose-lowering medications; use insulin when medications fail to achieve optimal control; for blood pressure (BP) and lipid control, stop drugs that may have adverse effects on fetus (eg, angiotensin-converting enzyme [ACE] inhibitors, angiotensin-receptor blockers [ARBs], and statins); methyldopa and hydralazine well-studied and may be used; use diuretics cautiously as third-line agents; use labetalol cautiously in midpregnancy if benefit outweighs risk; minimizing hydration to avoid volume overload, bed rest (with change of positioning so uterus does not place pressure on inferior vena cava), and monitoring of salt intake usually effective for stabilizing BP

Pregnancy-associated hypertension: not preeclampsia; treat as chronic hypertension; use magnesium sulfate in pa­tients with superimposed preeclampsia; prescribe immediate bed rest with salt and water restriction; adding meth­yldopa and hydralazine (every 4-6 hr) safe; ACE inhibitors and ARBs contraindicated

Problems in preconception counseling: physicians must learn to ask patients of childbearing age who have type 2 diabetes or other metabolic disorder whether they are interested in becoming pregnant (eg, “are you still planning another pregnancy”); check Hb A_1C immediately and discuss risks of pregnancy with women who have not had pre­conception counseling; repeat Hb A_1C screening to check glucose control; women with any suggestion of undiag­nosed type 2 diabetes should receive oral glucose tolerance test (75-g glucose drink) immediately; all pregnant women who pass should undergo repeat testing between 26 and 28 wk gestation; offer test to rule out unidentified hyperglycemia

Follow-up visit: should be scheduled based on need and glucose control; utilize experts who understand pregnancy and diabetes to educate patients; nutritional counseling focuses on carbohydrate restriction and use of carbohy­drates with low glycemic index

Management of gestational diabetes: SMBG 4 times/day (in fasting period and 1 hr after eating); peak postprandial response dictates outcome; highest BG measurement of day predicts risk for abnormal fetal growth; glucose control must be monitored in frequent visits to ensure insulin and diet adjusted appropriately; check Hb A_1C to confirm SMBG; treatment based on SMBG rather than Hb A_1C 

After delivery: discuss protocol for immediate postpartum decrease in insulin requirement and doses, insulin doses and nutrition for breastfeeding, and follow-up management; in women with gestational diabetes that appears to have resolved, repeat glucose tolerance testing within 6 wk postpartum

Standard of care: should be same for all pregnant women with diabetes; intensify BG control; normalize BG; teach health care professionals how to provide specialized diabetes and pregnancy care; universal testing to rule out or rule in gestational diabetes; provide patients with tools and techniques (lack of SMBG does not justify not provid­ing care)

Lifestyle Modification: Advice From a Dietician and Diabetes Educator

Patricia Moreira-Cali, Clinical Dietician and Diabetes Educator, Diabetes and Nutrition Education Center, Gainesville, FL

Introduction: Ms. Moreira-Cali sees patients individually or in small groups; patients achieve good glycemic control and long-term weight loss (mean weight loss, 10-11 kg; mean Hb A_1C, 6.4%)

Studies: change in use of hypoglycemic medications  —  >1200 patients studied over 1- to 2- yr period; in 1 yr, <2% of patients increased medications; at 6 mo, 13% of patients off medication or taking less medication; at 1 yr, 19.8% off medication or taking less medication; at 12 mo, mean Hb A_1C 6.34% (P value, 0.001); weight gain in patients on insulin  —  common occurrence; >1000 patients; inclusion criteria diabetes education within previous 4 yr and ³2 follow-up visits; exclusion criteria included cancer and other hypermetabolic diseases; compared 18-mo outcomes in patients on insulin to those not on insulin; both groups achieved good BG control; starting Hb A_1C for patients on insulin nearly 9.0% (»7.5% for patients not on insulin); by 3 mo, Hb A_1C 6.5% or 7.2%; by 1 yr, Hb A_1C <6.5% in patients not on insulin (6.7% for patients on insulin); both groups started with body mass index (BMI) >30; at 18 mo, both groups achieved weight loss of 11 kg (»25 lb; >10%); patients on insulin who receive proper education about caloric restriction and carbohydrate distribution can achieve weight loss

Initial evaluation: only 14% of patients present with any diabetes education; address misconceptions about diet (eg, “you cannot eat any sweets”); inform patients that all foods can be part of healthy diet; discuss carbohydrate distri­bution (ie, amount of carbohydrates eaten per meal); consider that many patients receive information about diabetes from media

Lifestyle modification: important to make patients understand that BG increases due to insulin dysfunction; prob­lems arise from overweight and lack of physical activity; losing 5% to 10% of initial body weight helpful; consider patient’s agenda and reasonable goals (eg, losing 1 lb/wk or walking 10-15 min per day several days per week); carbohydrate distribution  —assess amount of carbohydrate patient consumes at each meal;  speaker does not dis­cuss grams of carbohydrate with patient, just quantities of “real food”; plate method  —  educational tool; fill half of plate with vegetables; divide other half of plate evenly between protein (eg, chicken, fish) and carbohydrates (eg, rice, pasta, beans, bread); advise patients to avoid beverages high in calories or carbohydrates (eg, 24 fl oz of milk contains entire carbohydrate allowance for one meal); advise patients to avoid skipping breakfast; consuming large lunches or dinners may be due to skipping meals or emotional eating (due to stress or boredom)

Patient education: physicians often feel patients unwilling to accept education; in United States, education (in group or individually) guaranteed benefit for patients on Medicare; currently, only Medicaid patients or patients without insurance do not have coverage for diabetes education; once patient meets with educator, feelings about being helped, diet, and physical activity change; physicians must believe in effect of education and encourage patients; process  —  physicians identify patients in need; start education immediately after patient diagnosed; encourage pa­tients who decline education; educator informs physician about issues addressed (eg, cholesterol, BP, renal failure) and other insights (eg, need for adjustment of insulin therapy); laboratory testing every 3 mo to tailor education to patient’s needs; give patients positive feedback to encourage continuation with program

Summary: well-educated patients have high chance for success; do not assume that patients on insulin gain weight; help patients understand relationship between insulin, body, and diet

The LIFE Approach to Self-Management:
A Patient’s View

Michael A. Weiss, Attorney, and Co-Author, “The Little Diabetes Book You Need to Read,” Pittsburgh, PA

Introduction: Mr. Weiss diagnosed with diabetes in 1984; diabetes greatly affected daily life (“self-management is a 24/7 job”); improvements in diabetes education lagging behind those in biomedical community; education critical to self-management

Response to diagnosis: fear, anger, and frustration; initial diabetes education from highly medical and clinical pam­phlets (about, eg, function of pancreas; “not what we need to hear when we’re first diagnosed”); primary question  —“how is my diabetes going to affect me?”

Initial lessons patients need to learn: 1) patient must take responsibility for disease self-management; 2) disease re­quires much education and support; 3) treatments and therapies for diabetes change over time (eg, insulin may be needed as disease progresses); important for patient to be prepared for changes; need for insulin inevitable for many patients; new standards encourage use of insulin earlier in disease; 4) diabetes replete with negative emotion (eg, guilt about not eating correctly or not exercising enough); parents of children with type 1 diabetes feel guilt for passing on disorder genetically; patients know they cannot blame others; 5) complications not inevitable; in most cases, good management and control can retard onset or reduce severity of complications; 6) diabetes self-manage­ment is trial and error; 7) diabetes self-management difficult; 5 yr ago, Mr. Weiss diagnosed with colon cancer; cur­rently, Mr. Weiss free of cancer, but still affected by diabetes on daily basis; anger, fear, and frustration felt toward cancer diagnosis and treatment pales in comparison to that felt toward diabetes; cancer managed and treated by physicians (patient has limited responsibility); with diabetes, “there’s always something more that I can do”

LIFE approach to self-management: 1) learn as much as possible about diabetes; learn functions of health care pro­fessionals (eg, resources, consultants); learn about oneself (eg, understand needs and capabilities); 2) identify guid­ing principles in development of self-management plan; a) determine what role to take in development of plan, eg, be active and work collaboratively with health care professionals, or allow health care professionals to design plan; principles may change or be mixed; b) determine amount of flexibility needed in life; regimented plans often diffi­cult; greater flexibility requires greater responsibility (eg, more frequent BG testing); c) establish targets to be achieved within reasonable time; focus on behavior as much as outcome; 3) formulate plan; plan can and should be adjusted; 4) experiment and evaluate efficacy of plan; do not become frustrated; learn from experiences

Suggested Reading

Beto JA et al: So just what can I eat? Nutritional care in patients with diabetes mellitus and chronic kidney disease. Nephrol Nurs J 36:497, 2009; Boinpally T et al: Management of type 2 diabetes and gestational diabetes in pregnancy. Mt Sinai J Med 76:269, 2009; Boutati EI et al: Self-monitoring of blood glucose as part of the integral care of type 2 diabetes. Diabetes Care 32 Suppl 2:S205, 2009; Hansen MV et al: Frequency and motives of blood glucose self-monitoring in type 1 diabetes. Diabetes Res Clin Pract 85:183, 2009; Jovanovic L: Point: Oral hypoglycemic agents should not be used to treat diabetic pregnant women. Diabetes Care 30:2976, 2007; Jovanovic L: using meal-based self-monitoring blood glucose (smbg) data to guide dietary recommendations in pa­tients with diabetes. Diabetes Educ 35:1023, 2009; Jovanovic LG: Using meal-based self-monitoring of blood glucose as a tool to improve outcomes in pregnancy complicated by diabetes. Endocr Pract 14:239, 2008; Klonoff DC et al: Consensus report of the co­alition for clinical research-self-monitoring of blood glucose. J Diabetes Sci Technol 2:1030, 2008; Lawson VL et al: Mediation by illness perceptions of the effect of personality and health threat communication on coping with the diagnosis of diabetes. Br J Health Psychol 2009 Nov 17 [Epub ahead of print]; Rodrigues FF et al: Knowledge and attitude: important components in diabetes educa­tion. Rev Lat Am Enfermagem 17:468, 2009; Weiss M et al. The Little Diabetes Book You Need to Read. Philadelphia, PA: Running Press; 2007.