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Managing Type II Diabetes for the Family Medicine Resident Part 1

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Managing Type II Diabetes for the Family Medicine Resident Part 1 Roadmap, Behavior, Lifestyle, Nutrition, and Overcoming Barriers Jennifer Burkmar, MD, MBA – PowerPoint PPT presentation

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Title: Managing Type II Diabetes for the Family Medicine Resident Part 1


1
Managing Type II Diabetes for the Family Medicine
ResidentPart 1 Roadmap, Behavior, Lifestyle,
Nutrition, and Overcoming Barriers
  • Jennifer Burkmar, MD, MBA
  • Emory Family Medicine

2
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
    Quick-Carb 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

3
Age-adjusted Prevalence of Obesity and Diagnosed
Diabetes Among U.S. Adults Aged 18 Years or Older
Obesity (BMI 30 kg/m2)
Diabetes
CDCs Division of Diabetes Translation. National
Diabetes Surveillance System available at
http//www.cdc.gov/diabetes/statistics
4
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5
The UKPDS demonstrated that a 1 reduction in
HbA1c results in . reduction in microvascular
disease.
  1. 12
  2. 19
  3. 31
  4. 37

6
The UKPDS demonstrated that a 1 reduction in
HbA1c results in . reduction in microvascular
disease.
  1. 12
  2. 19
  3. 31
  4. 37

7
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8
An epidemic that is only becoming worse
9
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

10
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

11
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

12
Rank the order of risk factors for CAD in type 2
diabetes
  • Increased LDL
  • Decreased HDL
  • Elevated HbA1c
  • Elevated systolic blood pressure
  • Smoking

13
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

14
Comprehensive Management of Diabetes
  • BLOOD GLUCOSE
  • But there is also
  • Antiplatelet therapy
  • Blood pressure
  • Cholesterol
  • Dietary changes
  • Exercise changes

15
Comprehensive Management of Diabetes
  • And lets not forget
  • Smoking
  • Weight
  • Regular examination of
  • Eyes
  • Mouth/teeth
  • Feet/skin
  • Kidneys

16
Recommended Targets for T2DM
ADA AACE
HbA1c lt 7.0 lt 6.5
Preprandial glucose 70 130 lt 100
Peak postprandial glucose lt 180 lt 140
Blood pressure lt 130/80 lt 130/80
LDL lt100 lt 70 (overt CVD) lt100 lt 70 (overt CVD)
Triglycerides lt 150 lt 150
HDL gt 40 (male) gt 50 (female) gt 40 (male) gt 50 (female)
17
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

18
What effect do statins have on glucose control?
  1. ? glucose
  2. No effect
  3. ? glucose

19
What effect do statins have on glucose control?
  1. ? glucose
  2. No effect
  3. ? glucose

20
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
  • Womens Health Initiative showed 48 ? risk of
    diabetes among women
  • Multiple other studies showed ? risk of T2DM with
    high-dose statin

21
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

22
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 gt8 10yrs with an
    A1c gt 7
  • Prolonged hyperglycemia resultant glucotoxicity
    may accelerate ß-cell failure

23
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.

24
Treat-to-Failure ApproachSuboptimal Glycemic
Control
OAD Oral Antidiabetic Drug
A1c goal
25
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

26
Treat-to-Target Approach to T2DM
27
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28
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29
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

30
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

31
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

32
Implications of ACCORD, ADVANCE, VADT Trials
  • Lack of significant CVD benefit with intensive
    glycemic control
  • HOWEVER
  • HbA1c lt 7 still the general target
  • May be beneficial in patients with
  • Shorter duration T2DM
  • Without established atherosclerosis
  • Long life expectancy

33
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

34
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

35
ADA-EASD Position Statement on Management of
Hyperglycemia in T2DM
  • Glycemic targets
  • HbA1c lt 7.0 ? mean plasma glucose 150-160
  • Preprandial PG lt 130
  • Postprandial PG lt 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

36
Clinical Inertia
  • What is it??????

37
Clinical Inertia
  • Failure of healthcare providers to initiate or
    intensify therapy when indicated.
  • Are you doing anything?
  • Are you doing enough?

38
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)

39
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 patients medical
    record (perhaps as a graph)

40
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/attendi
    ngs
  • Feedback group intensified therapy and maintained
    this over 3 years better than other groups
  • Combination of feedback and reminders had best
    results

41
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
  • Patients Negative Perception of Insulin Therapy
    ? patient needs assurance that insulin is a
    positive approach to achieving glycemic control
    is most effective when dose properly

42
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

43
Impact of a Multidisciplinary Team on Glycemic
Control Hospital Admissions
44
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

45
Our plan for Ms. S.
  • STOP SMOKING!
  • LOSE WEIGHT!
  • FOLLOW YOUR DIET!
  • EXERCISE!
  • MONITORS BLOOD GLUCOSE 4X DAY!

46
What Ms. S. hears
  • If you dont 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

47
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

48
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 its 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

49
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

50
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 cant make me. I have
    to make myself

51
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

52
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

53
Diabetes-Related Distress
  • Fearful
  • Frustrated
  • Overwhelmed
  • Anxious
  • Guilty
  • Angry
  • Powerless
  • Discouraged

54
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

55
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

56
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

57
AASAP
  • Anticipate the feelings
  • Acknowledge the feelings
  • Standardize normalize the feelings
  • Accept understand basis for problems
  • Plan how to respond to the feelings

58
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

59
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

60
Communication Strategies
  • Self-management occurs in the context of daily
    life
  • Recommendations must accommodate the patients
    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?

61
Communication Strategies
  • What is hardest or your greatest concern?
  • Whats one thing that drives you crazy about your
    diabetes?
  • How has your conditions changes your/your
    familys 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 ???

62
Medication Assessment
  • How often?
  • Do you miss your
  • During a typical month, what of the time do you
    miss your
  • Its 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.

63
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?

64
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

65
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

66
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?

67
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

68
Nutrition Carbohydrate Counting
  • A patient diagnosed with type 2 DM should follow
    a diabetic diet?
  • A True
  • B - False

69
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

70
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.
201235(Suppl 1)S11-S63. Dattilo AM, et al. Am
J Clin Nutr. 199256320-328. Metz JA, et al.
Arch Intern Med. 20001602150-2158. Stevens VJ,
et al. Ann Intern Med. 20011341-11. Tchernof A,
et al. Circulation. 2002105564-569.
71
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.
72
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

73
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.
74
Talk About the Effect of the Various
Macronutrients on Blood Glucose
10 - 35 Total Calories
20 - 35 total calories
45 - 60 Total Calories
75
Quick-carb Counting
  • Dosage of insulin is based on total grams of
    carbohydrates. For example
  • InsulinCHO ratio of 115
  • If the total grams of CHO is 60, then 4.0 units
    of insulin would be administered
  • InsulinCHO ratio of 110
  • 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

76
Key Points
  • Glycemic targets treatment must be
    individualized treat to target
  • Diet, exercise, education- foundation of T2DM
    program
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