144 TYPE 2 DIABETES History: diabetes therapy and control, miscarriages, fetal anomalies, macrosomia, LGA and birth control Medications: if hypertensive, switch to methyldopa or hydralazine, ACE inhibitors and beta blockers contraindicated in pregnancy Complications: hypoglycemia unawareness; retinopathy; nephropathy; neuropathy Discuss pregnancy-related risks including association of hyperglycemia with maternal and fetal complications Physical exam: include funduscopic eye exam (with dilation) by ophthalmologist Laboratory: CBC; UA/UC; thyroid studies; 24 hour urine for creatinine clearance and albumin; HbA 1c ; EKG Correlate SMBG and HbA 1c ; assess nutritional status, self-management skills, and psychological status • • • • • • History, physical exam, and laboratory evaluation by clinician Patient planning pregnancy Patient on sulfonylurea, metformin, a-glucosidase inhibitor, meglitinide, thiazolidinedione. NO NO SMBG and/or HbA 1c within target range? Work with patient to establish BG control Re-assess current therapy Start or adjust intensified regimen as needed; see Insulin Stage 3 or 4 Continue with birth control Continue co-management with a diabetes specialist • • • • Follow-up Medical: Education: phone every 1–2 weeks, then office visit every 1–2 months every 2–3 months or as needed Stop birth control and continue insulin or glyburide therapy maintain SMBG and HbA 1c within target range until pregnancy confirmed Stop oral agent (except glyburide) and start insulin or glyburide regimen Note: All oral agents except glyburide pass the placental barrier SMBG Targets • • • • More than 50% of SMBG values within range Pre-meal: 70–100 mg/dL (3.9–5.6 mmol/L) Post-meal: Ͻ140 mg/dL (7.8 mmol/l) 1 hour after start of meal; Ͻ120 mg/dL (6.7 mmol/L) 2 hours after start of meal No severe (assisted) or nocturnal hypoglycemia Goals may be changed for hypoglycemia unawareness HbA 1c Target • At least 2 values 1 month apart within normal range • • SMBG: up to 7 times/day; before and 2 hours after start of meals and at bedtime HbA 1c : at least 2 values 1 month apart Monitoring YES YES Figure 4.18 Guidelines for Pregestational and Gestational Diabetes PATIENT EDUCATION 145 Patient education All patients require education to understand their diabetes, to learn how to manage it, and to rec- ognize when complications are occurring. This section reviews the principles of education spe- cific to type 2 diabetes. It is preferable to refer patients needing diabetes and nutrition education to nurses and dietitians trained in providing edu- cation to individuals with diabetes. This, however, may not be possible. This section provides an overview of the areas covered by patient education in order to acquaint the clinician with what is to be expected if an educator is available, or what is to be addressed if an educator is not available. Where appropriate, the specific education needed for each therapy is also detailed. A complete set of Deci- sionPaths describing diabetes education, medical nutrition therapy, and exercise assessment can be found in the Appendix. Diabetes education Quality diabetes education starts with the estab- lishment of an education plan (see Figure 4.19 and the Appendix, Figures A.8 and A.9). Briefly, the education plan is developed after an extensive physical, psychological, and social assessment of the patient. Based on this assessment, therapeutic (SMBG and HbA 1c ) and self-management goals are established. The topics to be discussed at the initial diabetes education visit include patho- physiology, medication action and administration, SMBG technique, prevention and treatment of hy- poglycemia, and procedures for handling diabetes related medical emergencies. For patients treated with insulin, additional education topics include insulin action, insulin injection technique, site ro- tation, proper use of glucagon, insulin storage, syringe disposal, and urine ketone monitoring. In order to ensure quality diabetes education, the American Diabetes Association has established a set of 15 diabetes education content areas (see Figure 4.20). Ideally, patients should have access to spe- cially trained diabetes educators. In the United Establish Education Plan Assessment • Height/weight (BMI)/BP/foot exam with monofilament • Risk factors (family history, obesity, ethnicity, GDM) • Diabetes knowledge/skills • Psychosocial issues (denial, anxiety, depression) • Economic/cultural factors • Readiness to learn/barriers to learning • Lifestyle (work, school, food, and exercise habits) • • Support systems • Health goals Goals • SMBG/HbA 1c in target • Achieve self-management knowledge/skills/ behavior (SMBG, medications, nutrition, exercise) Plan • • Establish 3 behavior change goals with patient (exercise, nutrition, medications, monitoring) Teach initial education topics Tobacco/alcohol use Figure 4.19 Guidelines for establishing a diabetes education plan 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. American Diabetes Association Education Content Areas Pathophysiology of diabetes and treatment options Medical nutrition therapy Physical activity Medications Blood glucose monitoring and use of results Prevention, detection, and treatment of acute complications Prevention, detection, and treatment of chronic complications Goal Setting Psychosocial adjustment Preconception care, pregnancy, and gestational diabetes management Figure 4.20 Required e ducation content areas for American Diabetes Association recognition 146 TYPE 2 DIABETES States, such educators are certified by the National Certification Board of Diabetes Educators. Known as certified diabetes educators (CDEs), they are qualified to provide both basic and advanced di- abetes education. Patients have responsibility in terms of self-management and, therefore, must leave the office confident in their skills and un- derstanding. Arrange a follow-up educational visit within 2–4 weeks (or sooner if starting insulin) to review understanding and skills. Nutrition education Nutrition education is an integral part of as- sisting the patient in following a food plan. A registered dietitian with experience in diabetes should counsel the patient as soon as feasible. At the initial nutrition visit, general education Establish Nutrition Therapy Plan Assessment · · · · · · · · · · · · Food history or 3 day food record (meals, times, portions) Nutrition adequacy Height/weight/BMI Weight goals/eating disorders Psychosocial issues (denial, anxiety, depression) Economic/cultural factors Nutrition/diabetes knowledge Readiness to learn/barriers to learning Work/school/sports schedules Exercise (times, duration, types) Tobacco/alcohol use Vitamin/mineral supplements Goals · · · · SMBG/HbA 1c in target Achieve desirable body weight (adults) Normal growth and development (children) Consistent carbohydrate intake Plan · · · · · · Establish adequate calories for growth and development/reasonable body weight Set meal/snack times Integrate insulin regimen with medical nutrition therapy (insulin users) Set consistent carbohydrate intake Encourage regular exercise Establish adequate calories for pregnancy/ lactation/recovery from illness Figure 4.21 Guidelines for establishing a nutrition therapy plan Medical Nutrition Therapy Guidelines Total fat ϭ 30% total calories; less if obese and high LDL Saturated fat Ͻ10% total calories; Ͻ7% with high LDL Cholesterol Ͻ300 mg/day Sodium Ͻ2400 mg/day Protein reduced to 0.8 g/kg/day (~10% total calories) if macroalbuminuria Calories decreased by 10–20% if BMI Ͼ25 kg/m 2 • • • • • • Figure 4.22 Medical nutrition therapy guidelines about the inter-relationship between food and di- abetes should be discussed along with a nutri- tional assessment and the creation of an initial food plan (see Figure 4.21). The food plan should incorporate consistent carbohydrate intake at es- tablished meals and, for patients using insulin, integration of the insulin regimen with the food plan. In addition, the food plan should take into account basic medical nutrition therapy guide- lines for fat, cholesterol, and sodium intake (see Figure 4.22). For more specific information, see the Appendix (Figures A.8 and A.9) as well as information on carbohydrate counting and food choices (Figures A.14 and A.15). The next visit will be a reassessment combined with an individ- ualized food plan that reflects the ethnic, socio- economic, and special preferences of the patient while addressing the needs of one with diabetes. Here integration of blood glucose results, food plan records, and exercise are discussed. The pa- tient should understand the importance of appro- priate food intake, know how to measure caloric intake, and be aware of the effects different nutri- ents have on blood glucose level. Exercise/activity education Patients are often unaware of the importance of exercise (or increased activity) and its relationship to metabolic control. Exercise education begins with detailing how exercise affects blood glucose levels. Once the patient understands the r ole of exercise or activity in managing diabetes, the next step is to develop an exercise (activity) plan (see Figure 4.23). Careful evaluation of overall PATIENT EDUCATION 147 Establish Exercise Plan Goals Consistent exercise schedule Include aerobic (jog, swim, bike) and anaerobic (weight lifting, push-ups) exercises • • • Frequency: 3 times/week • • Duration: 30 minutes/session Intensity: 50–75% maximum heart capacity (220 Ϫ age ϭ100%) • If obese, expend 700–2000 calories/week Plan • Individualize based on fitness level, age, weight, personal goals, and medical history • Select type of exercise with patient • Set exercise schedule with patient • Measure, record, and review SMBG before and 20 minutes after exercise • Patient to record type, duration, and intensity • Patient to note any symptoms, i.e., pain, dizziness, shortness of breath, hypoglycemia Follow-up Each week for 2 weeks Figure 4.23 Guidelines for establishing an exercise plan fitness level is important. Any concerns about cardiovascular disease should be evaluated prior to starting an exercise program. Generally, the patient should be evaluated for fitness on three parameters: 1. endurance (repetitive movements), shown in Photos 4.2 and 4.3 2. strength (lifting weight resistance bands), shown in Photo 4.4 3. flexibility (stretching), shown i n Photo 4.5 Endurance can be measured by asking the patient to step up and down from a one-step stool continuously for 1 minute. If a station- ary exercise bicycle is available, repeated ped- dling with midrange resistance for 1 minute is another means of assessing endurance. While there are some general standards that are age and gender specific, the patient should be able to perform these activities without any appar- ent stress. Strength is measured by stretching a standard resistance band or lifting a five pound weight with an outstretched arm. Again, age- and gender-specific tables will provide the aver- age expected strength that would permit eventual Photo 4.2 Endurance: stationary bike Photo 4.3 Endurance: treadmill repeated exercise. Flexibility can be measured in several ways: simple stretching while standing; touching toes while standing or lying; or reach- ing with both feet flat on the ground. Collec- tively, these measures are meant to provide an overall rapid assessment of the patient’s fitness for exercise. 148 TYPE 2 DIABETES Photo 4.4 Strength: resistance bands The level of exercise is determined individually and must answer such questions as when, how of- ten, how long, and at what pace. The Appendix contains Specific DecisionPaths for exercise as- sessment, developing an exercise plan, and exer- cise education topics. SMBG testing should oc- cur before and immediately following exercise. For routine exercise, this should be repeated Photo 4.5 Flexibility: stretching three to five times until a clear pattern emerges. Many patients report significant improvement in blood glucose levels when exercise is included in the overall treatment strategy. While an exercise specialist is desirable, many CDEs are qualified to evaluate fitness and to develop an exercise prescription. Behavioral issues and assessment Behavioral issues may be divided into two general categories: adherence to regimen and underlying psychological or social pathology. While non- adherence to a specific regimen may have under- lying pathology, it is suggested in a primary care setting to first determine whether the problem is due to other causes. Staged Diabetes Management provides a simple set of pathways to review pos- sible avenues to explore before considering psy- chological and social causes. Assessment begins with an evaluation of the current level of glycemic control as reported by the patient (SMBG) and the laboratory (fasting plasma or HbA 1c ). This is be- cause medical intervention is justified when the current therapy is not working. If the correlation between SMBG and HbA 1c (see Figure 4.24) is poor, make certain that technique, device, and reporting by the patient are understood. Have patients demonstrate SMBG technique using their meter and draw a simultaneous blood sample for the laboratory. If the correlation between patient and laboratory data is still poor, consider re- education. Adherence assessment Four diabetes-related areas of adherence that can be readily assessed in the primary care setting in- clude medical nutrition, medication, SMBG, and exercise. Each area is approached in a similar manner. First, determine whether the patient un- derstands the relationship between the behaviour and diabetes. Second, determine whether the pa- tient is prepared to set explicit short-term behav- ioral goals. Third, determine why the goals are not met; and fourth, be prepared to return to a BEHAVIORAL ISSUES AND ASSESSMENT 149 % Hemoglobin HbA 1c (assuming normal range of HbA 1c is 4–6%) Average Blood Glucose in mg/dL(mmol/L) 678910111213 400 (22.2) 350 (19.4) 300 (16.7) 250 (13.9) 200 (11.1) 150 (8.3) 100 (5.5) If Hba 1c is: Average SMBG is:HbA 1c * 7% ~150 mg/dL (8.3 mmol/L) ~180 mg/dL (10.0 mmol/L) ~210 mg/dL (11.7 mmol/L) ~245 mg/dL (13.6 mmol/L) ~280 mg/dL (15.6 mmol/L) ~310 mg/dL (17.2 mmol/L) ~345 mg/dL (19.2 mmol/L) ~380 mg/dL (21.1 mmol/L) 8% 9% 10% 11% 12% 13% 14% 1 Percentage point above normal 2 Percentage points above normal 3 Percentage points above normal 4 Percentage points above normal 5 Percentage points above normal 6 Percentage points above normal 7 Percentage points above normal 8 Percentage points above normal * assumes normal range of 4-6% Nathan, DM, et al: N engl J Med 310: 341-346, 1984 Figure 4.24 Relationship between glycosylated hemoglobin A 1c and blood glucose levels previous step along this pathway if the current step is not completed. The Specific DecisionPath for assessing adher- ence to nutrition therapy is shown in Figure 4.25. DecisionPaths for assessing adherence to medica- tion, SMBG, and exercise regimens are located in the Appendix. Based on the transtheoretical model of behaviour change, 37 all of the adherence DecisionPaths begin with whether the patient un- derstands the connection between the behaviour and diabetes. It has been found that changing be- haviour without understanding why it is important to do so will most likely fail. Thus, providing the patient with specifics as to how food, exercise, medications, or SMBG is related to diabetes man- agement and prevention of complications is criti- cal. Next, determine specifically what the patient is willing to do. In most cases, any misunder- standing as to the importance of adhering to the prescribed regimen can be resolved through this systematic approach. The next step involves set- ting goals with the patient. Set simple, reasonable, and explicit short-term goals like “replace whole milk with skim milk” or “increase walking by 10 minutes per day.” Next, determine whether the pa- tient has met or is attempting to meet the goals. Be prepared to reset the goals and move back a step. As the behaviour changes, negotiate new explicit goals. Always ask the patient to help set the new goal. There are, however, those patients for whom this approach will not work. Some patients are not ready to change their behaviours. Continued reinforcement for change, combined with educa- tion, will sometimes overcome this reluctance to modify behaviour. If this is not effective consider referral to a behavioral expert. Psychological and social assessment The diagnosis of type 2 diabetes carries with it the risk of psychological and social dysfunction. Al- most half of newly diagnosed cases are uncovered after a complication (such as retinopathy or heart disease) has been discovered. The knowledge that they may have had undetected diabetes for several years combined with the added burden of diabetes related complications presents a unique dilemma. On the one hand the individual is expected to re- turn to normal life; on the other hand he or she is expected to be responsible for self-management. With the need to restore near euglycemia, this be- comes even more problematic. The initiation of a new approach to treatment (such as introducing in- sulin therapy), may also cause both psychological and social dysfunction. This is often reflected in how the individual adjusts to changes in lifestyle brought about by type 2 diabetes and its treat- ment. Patients’ ability to acquire the new knowledge and skills is related to their psychological and social adjustment. Such psychological factors as depression and anxiety and social factors such as conduct disorders significantly interfere with ac- quiring self-care skills and with accepting the seri- ousness of diabetes. Additionally, eating disorders may directly affect the efficacy of treatment and may present serious, long-lasting complications. If the psychological and social adjustment of the in- dividual with diabetes proves to be dysfunctional, 150 TYPE 2 DIABETES Patient with food plan adherence issues YES NO Does patient understand the food plan and its relationship to managing BG levels, medication effectiveness, and exercise optimization? YES NO Is patient willing to set food plan behavior goals? YES NO Is patient taking an active role in changing food plan behaviors? Set Goals with Patient Write clear, simple, achievable goals; must be measurable; include timeline; limit to one goal Example: I will drink 1% milk instead of 2% or whole milk at meals and snacks for the next 2 weeks. Re-set goals as necessary YES NO Is patient consistently following food plan? Follow-up Evaluate food plan goals at each visit Re-educate patient about purpose and importance of following a food plan; consider referral to registered dietitian Re-educate patient; consider referral to diabetes educator or licensed psychologist for counseling Assess patient's ability to: Assist patient with problem solving Consider referral to diabetes educator or licensed psychologist for counseling identify problem areas self-adjust goals and behaviors take deliberate action to change behaviors self-monitor behavior change actions • • • • Figure 4.25 Nutrition Therapy Adherence Assessment DecisionPath it will most likely be reflected in poor glycemic control. This, in turn, raises the risk of acute and chronic complications, which contribute still fur- ther to the psychological and social dysfunction. To break this cycle it is necessary to identify the earliest signs of dysfunction and to intervene as soon as possible. The primary care physician generally initiates psychological and social interventions in diabetes only after symptoms occur. Many of the more BEHAVIORAL ISSUES AND ASSESSMENT 151 Assess psychological well-being Assess social well-being Assess behavior patterns Assess eating disorders YES NO Have any significant psychological problems been identified? YES NO Have any significant social problems been identified? YES NO Have any significant behavior problems been identified? YES NO Have any significant eating disorders been identified? Refer to licensed psychologist or MSW for further evaluation and counseling as necessary; continue with assessment Refer to licensed psychologist or MSW for further evaluation and counseling as necessary; continue with assessment Refer to licensed psychologist or MSW for further evaluation and counseling as necessary; continue with assessment Refer to licensed psychologist or MSW for further evaluation and counseling as necessary; continue with assessment Document and communicate recommendations in writing to referral source Follow-up Evaluate at each visit • Problems with peer relationships • Work/school phobia • Difficulty sleeping • Depression or anxiety problems • Organic functioning problems • Major change in affect or mood • Age inappropriate behavior • Family system dynamics • Family conflict • School/work absenteeism • Drop in grade/work performance • Addictive behavior to drugs/alcohol • Aggressive behavior • Withdrawal from school, work, or family • Family response to diabetes • Anorexic or bulimic behavior • Binge or compulsive eating • Hyperglycemia as a basis for weight management • Food refusal • Overactive behavior • Impulsive behavior • Overwork and/or work to exhaustion • Lack of attention Figure 4.26 Psychological and Social Assessment DecisionPath common symptoms can be found in the Psycho- logical and Social Assessment DecisionPath (see Figure 4.26). In anticipation of such symptoms, it might be appropriate for primary care physi- cians to refer newly diagnosed patients, and pa- tients for whom significant changes in therapy are being contemplated, to a psychologist or so- cial worker trained to detect the earliest symp- toms of psychological or social dysfunction and to intervene before they result in destructive be- haviours. Often one or two counseling sessions are required to detect underlying psychological or social problems and to intervene effectively. Recognizing these early warning signs requires a complete psychological and social profile of the individual. One approach to obtaining this infor- mation is to begin the patient encounter with the 152 TYPE 2 DIABETES idea that diabetes will be co-managed by the pa- tient and the physician (and team) and that the patient will be empowered to make decisions. Most patients begin interactions with physicians assuming the power to make all clinical decisions rests with the physician. For successful diabetes management (where 90 per cent is the responsibility of the patient) co- empowerment of the patient with the health care team effectively brings the patient onto the team and ensures that the patient understands and takes on clinical care responsibilities. Co-empowerment recognizes that the patient and physician may have a different view of the seriousness of the disease, the responsibilities of each health care profes- sional, and the expectations of the patient’s perfor- mance. The individual with diabetes may feel the physician will make all decisions related to care and the patient should be passive. Alternatively, the physician may feel the patient should make daily decisions about diet, insulin, and exercise. Co-empowerment is an agreement between the patient and health care team that delineates the re- sponsibilities and expectations of each participant in care and also provides the DecisionPath all team members have agreed to follow. From a psy- chosocial perspective, it may be seen as a contract in which the patient spells out in detail his or her expectations and in which health care profession- als have an opportunity to determine how well those responsibilities and expectations fit with the diabetes management plan. It presents an oppor- tunity to review behaviours that may be dysfunc- tional to the overall treatment goal. The person who refuses to test, who is hyperactive at work, or who binge eats must be encouraged to share this information with the health team. 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Practice guidelines for medical nutrition therapy provided by dietitians for [...]... type 2 diabetes American Indian, Alaska Native, African- American, Hispanic, Asian, and Native Hawaiian and other Pacific Islander children have between three and ten times greater risk of developing type 2 diabetes than age matched Caucasian children and adolescents Mexican-American) are at higher risk of type 2 diabetes Lean children are more likely to have type 1 and obese children are at greater risk... with GDM in any pregnancy Acanthosis nigricans American Indian; Alaska Native; African-American; Asian-American; Native HawaiianPacific Islander; Mexican-American Premature pubarche, oligomenorrhea, hirsutism PCOS Diagnosis Plasma Glucose Symptoms Urine Ketones Treatment Options Casual у200 mg/dL (11.1 mmol/L) plus symptoms, fasting у126 mg/dL (7.0 mmol/L), or 100 gram oral glucose tolerance test (OGTT)... However, as the complications are often associated with persistent hyperglycemia, a child whose diabetes actually began at age 8 and was discovered at age 15 may have the same risk of complications as an adult with 7 years duration of diabetes In many cases the complication can be managed and its progression slowed if found early Staged Diabetes Management provides explicit protocols for the detection and... clinician to initiate the most efficacious therapy Staged Diabetes Management has a built-in mechanism in the Specific DecisionPath that evaluates a therapy against set goals If the therapy does not meet the goals, it is adjusted until maximum clinical effectiveness is obtained If targets are not achieved, a new therapy is initiated The sequential movement to new therapies has timelines to assure that no patient... diabetes is thought to be equal to or higher than the incidence of type 1 diabetes in children and adolescents, it is critical to ascertain whether the patient belongs to a high-risk group In general, Caucasian children (especially of Scandinavian descent) are at a higher risk of developing type 1 diabetes, while children of certain ethnic groups (American Indian, Alaska Native, African-American, Asian-American,... is to choose the appropriate treatment 173 modality Staged Diabetes Management provides a Master DecisionPath for type 2 diabetes to facilitate rapid selection of the starting therapy and to lay out the options if the therapy fails to improve glycemic control Staged Diabetes Management stresses the need to reach an agreed-upon therapeutic goal, which may entail moving the child or adolescent from simple... beneficial Completing this evaluation (with appropriate referral) is necessary to meet national standards for diabetes management Type 2 Diabetes complications surveillance Additionally, surveillance for disorders associated with insulin resistance (such as hypertension and dyslipidemia) as well as microvascular and macrovascular complications of diabetes should occur (see end of this section) For example,... When HbA1c is normal, although indicative of normoglycemia, TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS when there is a rapid onset of type 1 diabetes, the HbA1c may initially appear normal In rare instances the abnormally high or low HbA1c may be due to a hemoglobinopathy (such as Sickle-cell trait) Treatment options Treatment of type 2 diabetes often requires both behavioural and pharmacological interventions... and adherence to MNT can be assessed Annually, a fasting lipid profile, albuminuria screen, complete foot examination (pulses, nerves, and inspection), dental examination, and dilated TYPE 2 DIABETES IN CHILDREN AND ADOLESCENTS eye examination are recommended Additionally, nutrition and diabetes skills review and evaluation of other risk factors (smoking, alcohol intake, and weight management) are beneficial... Weight Management NO Start Therapy Food Plan/Start • Decrease highcarbohydrate, simple sugar food choices • Spread food intake to 3 spaced meals Medical Nutrition Therapy Guidelines • Maintain adequate nutrition for age appropriate growth and development • If available, refer to diabetes nutrition specialist Activity/Start • Encourage Ͻ2 hours sedentary activity per day Follow-up Medical: Weekly if treated . risks. Hispanics, African-Americans, Native Americans, and Asian-Americans have an incidence rate that varies from two- to tenfold that of Caucasians. MAJOR STUDIES 157 Prevention of type 2 diabetes Can. care, pregnancy, and gestational diabetes management Figure 4. 20 Required e ducation content areas for American Diabetes Association recognition 146 TYPE 2 DIABETES States, such educators are. quality diabetes education, the American Diabetes Association has established a set of 15 diabetes education content areas (see Figure 4. 20). Ideally, patients should have access to spe- cially