Real Strategies for Real Life

By Eileen Hayes, NP, Jessica Tropp, NP, and Holly Kinnell-Rust, NP

Diabetes is a progressive disease that plagues the United States with rising financial burdens and reduced quality of life. An estimated 17 million U.S. residents now have diabetes, but about one-third of these are undiagnosed. Diabetes is often undetected for 5 to 10 years after onset, when micro- and macrovascular complications become apparent.¹

Managing diabetes is challenging even with the best medical guidance and patient compliance. Recent major studies prove that intensive therapy for tight glycemic control that does not induce unacceptable hypoglycemia or other adverse effects reduces and delays both micro- and macrovascular damage and associated complications.^2-4 It behooves us, therefore, to encourage and collaborate with patients to help them attain optimal levels for blood sugar, blood pressure and lipids.

The current health care environment imposes time and cost constraints that can hinder adequate patient assessment and teaching.⁵ By implementing a few effective strategies during the routine office visit, adverse events may be reduced, and patient outcomes may be improved. This article outlines three practical strategies for helping patients meet their glycemic goals: taking a good history, providing thorough patient education, and overcoming common barriers to care.

History, History, History

Diabetes management is particularly challenging when a patient's blood glucose level is not well controlled. A careful history may reveal the solution. Table 1 summarizes specific issues to consider when patients are not meeting their glycemic goals.

Forgetting to take medications. One of the most common problems in achieving control is forgetting or omitting doses of medications. Carefully phrase your inquiry about this. Instead of asking, "Do you ever forget?" ask, "How often do you forget?" Patients might respond more honestly to this empathetic approach and provide valuable information about actual usage.

Running out of medications. Due to financial, transportation or other issues, patients may forgo filling or refilling prescriptions for weeks or months. An uninsured person who uses two types of insulin and test strips alone incurs out-of-pocket expenses of about $300 a month. Add two oral diabetes medications, a statin for cholesterol and two blood pressure agents, and the expenses could easily double. Even insured patients might have copayments of $200 to $300 per month if they take 10 or 12 medications. Ask patients whether they ever have to choose between medications and food. Financial support programs are available for many medications. Check http://www.needymeds.com or https://www.pparx.org/Intro.php.

Incorrect dosing. A patient may report taking the prescribed level of insulin, but the number of vials used does not correlate with the dose prescribed. A dose of 30 units per day corresponds with use of about one vial per month, while a dose of 50 units per day corresponds with one insulin pen per month. A strategy for understanding this discrepancy is to ask the patient to draw up and administer a dose of saline in your presence. This may reveal that the syringe is partially full of air, or that injections have been intradermal or intramuscular instead of subcutaneous. Also, patients do not always remember to adequately mix suspensions in vials or insulin pens. They may forget to invert the insulin vial or pen 15 or 20 times to evenly suspend the solution. Such errors may lead to serious underdosing. Patients who cannot master the syringe technique may achieve more accurate dosing with an insulin pen.

Scheduling medications incorrectly. Patients may take medications on the wrong schedule, such as twice-daily medications only once or daily medications twice a day. They may reverse the dosing of long-acting and short-acting insulin or take rapid-acting insulin after meals instead of before. These errors will inadequately cover insulin needs and may result in hypoglycemic episodes that are difficult to control. Identify these problems by reviewing the specific times patients take their insulin.

Insulin storage. Shelf life in open insulin vials and pens may be much shorter than expected, even when refrigerated. Unopened bottles and pens retain potency until the expiration date — provided they are refrigerated. Once in use, insulin pens should be at room temperature. Once the rubber stopper on a vial has been pierced, it must be used within 1 month. Pens and cartridges must be used within 10 to 28 days, depending on the type. Newer insulin analogs may be more likely to lose their potency after 1 month, so a good strategy is to open a fresh one at the beginning of each month.

Needle size. Short needles (3 mm to 5 mm) are much more comfortable for injections, but about 20% of overweight patients using short needles do not absorb injected insulin appropriately. When changing to a short needle, watch patients carefully to determine whether any difficulties arise from a potentially lower dose. Conversely, very lean patients using longer needles may inadvertently inject themselves intramuscularly, with more immediate absorption leading to undesirable hypoglycemic effect.

Measurement of blood glucose. Another part of history taking involves reviewing the patient's meter-generated data and assessing for accuracy. Meter electronics can become unreliable after about 5 years, so patients should replace their meters before then. Incorrect calibration of the meter may also give false glucose readings. Some people may press the incorrect setting and receive results in mmol/L rather than mg/dL, yielding results that are often far below the true value. If there is a discrepancy between the data and clinical picture, the meter and strips should be checked for accuracy. This can be done using control solution (a small vial of glucose) instead of a drop of blood. The control solution must be fresh (within 90 days of opening the vial). Alternatively, the patient can check a meter glucose reading against a simultaneously drawn venous glucose determined by a laboratory. The results should not vary more than 15%.

Encourage patients to bring their meters to each visit. Most meters have memory that allows readings to be reviewed or printed using the manufacturer's software. Most patients have difficulty doing so unless they are fully committed to managing their diabetes. A useful strategy is to ask patients to test only twice a day, but at specific times. One day, test before and 2 hours after breakfast. Test before and 2 hours after lunch on the next day, and before and 2 hours after supper on the following day. For someone with type 2 diabetes, a week or two of this limited testing will yield a reliable indication of glucose management.

Diet review: portion size. The next part of history taking includes a careful diet review. Everything the patient eats or drinks all day, not just at meals, must be included. People may report in detail what they ate for meals, but not acknowledge beverages or snacks. Find out if "sandwich" means two slices of sandwich bread with 2 ounces of meat or an overstuffed 12-inch sub. If the patient had a steak for dinner, was it 4 ounces or 12 ounces? A small frozen bagel is very different from bakery or coffee shop versions that can account for four or five carbohydrate servings. Have patients visualize the size of portions. For example, an average-sized fist is about 1 cup.

Some meals affect glucose control more than others. For example, eggs and bacon with two slices of buttered toast has only 30 g of carbohydrate and will not affect blood glucose level as much as a cup of whole grain cereal with skim milk, a piece of whole wheat toast with all-fruit jam, and a glass of orange juice. In terms of nutrients, the whole grain breakfast is probably a much healthier meal, but has a much larger impact on blood glucose levels.

Small changes in meal size and content can make a difference. A regular tuna sandwich and a small apple provide 45 g of carbohydrate, but a 6-inch tuna grinder and a small bag of potato chips have about 70 g of carbohydrate.

Promoting Patient Understanding

Patient understanding of the five basic concepts listed in Table 2 can promote improved diabetes management. The first concept is that glucose or blood sugar is an essential substance for life. All carbohydrates raise blood glucose levels, making carbohydrate management an important part of maintaining diabetes control. A second concept is that the purpose of insulin is to metabolize the body's major fuel, making it available for immediate energy needs or for storage to use between meals or during exercise. This helps explain why premeal insulin is necessary even if the blood glucose level is normal. A third and significant concept is that type 2 diabetes is a progressive disease. Insulin resistance and decline in insulin secretion may begin years before a person is diagnosed with diabetes. The decline in insulin secretion is often progressive. Given this course of events, it is not surprising that 10 to 15 years after developing type 2 diabetes, many patients require insulin therapy.

A fourth concept in patient teaching is learning healthy eating habits. Teaching your patients how to add fiber and monounsaturated fat while reducing refined carbohydrates and saturated fats is often more effective than a prescribed diet plan. Patients benefit greatly from meeting with a registered dietitian who can teach healthy eating habits and carbohydrate management. The fifth concept is the importance of regular exercise and resistance training. Aerobic exercise is important for reducing blood glucose, burning calories and promoting cardiovascular fitness in patients. In people with type 2 diabetes, resistance training is also important because it increases muscle mass, and greater muscle mass improves insulin sensitivity.

Barriers to Using Insulin

The third strategy for promoting better outcomes for patients with type 2 diabetes is overcoming barriers to insulin use when oral agents are no longer effective or safe. A single evening injection is often all that is required. If patients perceive that providers are reluctant to prescribe insulin, it reinforces their negative perception of insulin therapy. Emphasize positively and strongly that taking insulin is not negotiable and that insulin is needed to preserve the patient's health. Patients will respond to a firm, positive directive.

A strategy for convincing patients to begin insulin is to have them self-inject 15 units of sterile saline using an insulin syringe. Most will acknowledge that it is painless. After this major barrier has been overcome, the patient usually is ready to learn. Self-injection with saline is also an effective strategy for providers who have a negative view of insulin themselves. This strategy can completely change provider attitude about starting patients on insulin.

For many people, an insulin pen may be much less intimidating than a syringe and its use is easy to teach in an office visit.

Practicality Needed

Diabetes management should be practical. Communication, trust and negotiation are essential. Given the difficulty of living with diabetes, patients may view providers as adversaries if they try to force solutions that are incompatible with personal lifestyle. Meet patients at their level of readiness to change. By working with patients to enact the healthy changes they are ready to make and by not scolding them for noncompliance with a specific plan, you can foster an atmosphere of trust that promotes change.

People in some populations have little control of their lives, much less their diabetes, and contemplating change is difficult. Good diabetes control may not be fully possible for them. When a patient's quality of daily life is poor, preventing long-term complications may not be a realistic goal. Adjust treatment goals to prevent crises or very high or low blood sugar levels. Small gains are important. By reducing hemoglobin A1c by just 1%, the risk of complications is reduced by 25% to 35%.³ For a patient with a hemoglobin A1c of 12, a reduction to 10 is a major accomplishment.

Cultural and socioeconomic factors may influence responses to and beliefs about illness. Patients who are fatalistic may not believe they can take charge of their health and change outcomes, so they accept disease complications as part of life. The focus of care can be on feeling better and developing a trusting, nonintimidating relationship in which gradual gains may be possible. It is gratifying to see a reluctant patient start insulin and feel much better within a few weeks.

Updating education about diabetes and nutrition is essential for anyone with diabetes, especially longtime patients. Concepts and techniques change, so it is important to update patient knowledge at least every 5 years.

Putting It Into Practice

Reviewing diabetes care at every office visit can produce great dividends, but a patient's diabetes status can be lost amid other priorities in a 15-minute appointment scheduled for another issue. However, because diabetes care is fundamental to managing other problems, glycemic control and screening for foot problems or occult infections should be addressed at every patient visit. If glycemic control is not being achieved, quickly review items in Table 1.

NPs who negotiate and promote change within a trusting patient-provider relationship and address diabetes at every visit can greatly improve their patients' quality of life and reduce diabetes complications.

Eileen Hayes is a family nurse practitioner with a PhD who is coordinator and adviser for the family nurse practitioner concentration at the University of Massachusetts School of Nursing in Amherst. She is a member of the ADVANCE for Nurse Practitioners editorial advisory board. Jessica Tropp is an adult nurse practitioner who works with Jeffrey Korff, MD, in an endocrinology practice in Northampton, Mass. Holly Kinnell-Rust is a family nurse practitioner who provides health care to students at the University of Massachusetts in Amherst.

References

1. Funnell MM, Kruger DF. Type 2 diabetes: treat to target. The Nurse Practitioner. 2004;29(1):11-15, 19-23.

2. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin dependent diabetes. N Engl J Med. 1993;329(14):977-986.

3. UK Prospective Diabetes Study (UKPDS) Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet. 1998;352(9131):837-853.

4. Shichiri M, Kishikawa H, Ohkubo Y, Wake N. Long-term results of the Kumamoto study on optimal diabetes control in type 2 diabetic patients. Diabetes Care. 2000;23(suppl 2):B21-B29.

5. Hayes E. Nurse practitioner self-confidence and attitudes regarding managed care. J Am Acad Nurs Pract. 2003;15(11):501-508.

Table 1: History for Patients With Diabetes That Is Difficult to Control

Medication

Omitted Doses

• How often do you forget your medication?

• Do you ever run out of your medication?

• Do you have trouble affording your medications?

• Have you ever had to choose between food and medications?

Storage

• How do you store your insulin?

• When did you last open a fresh bottle of insulin?

• How long do you keep an open bottle of insulin?

Technique

• How much insulin is actually in the syringe?

• Is the insulin well mixed in the syringe?

• What size needle do you use?

Scheduling

• When do you take your insulin?

• Which insulin do you take?

Accuracy of Meters & Test Strips

• How old is your glucose meter?

• How is your meter calibrated?

• When has your meter been checked?

• How old is your control solution?

• How old are your test strips?

• What is the expiration date on your test strips?

• How often are you checking blood sugars with test strips?

Nutrition

• What are you eating throughout the day, not just at meals?

• Do you understand what an appropriate portion size is?

• Do you measure portion sizes before or after you cook?

Note: Acute hyperglycemic changes require a different approach, such as recognizing and treating infections or silent myocardial infarction.

Table 2: Basic Teaching Concepts in Diabetes Management

1. Purpose of glucose in the body

2. Progressive nature of diabetes

3. The purpose of insulin

4. Healthy eating habits

5. Benefits of aerobic exercise and resistance training