I always ask patients what they are willing to do and how soon they plan to commit to these changes. I inform them that I will add and/or change medication(s) as needed based on what they are not willing to do with regard to lifestyle modification. I tell them that immediate changes in diet aimed to nearly eliminate simple sugars and reduce refined or “white foods” (white bread/pasta/potatoes/flour), in addition to establishing regular exercise, will have immediate impact on lowering blood sugars. Weight loss is not required for immediate improvements in blood sugars, but instead will have lasting benefits with as little as a 5% to 10% loss.
Q: If the Diabetes Prevention Program demonstrated such amazing results in the prediabetes population, shouldn’t we surmise that these same results could be applied to the T2DM population?
The Diabetes Prevention Program showed a 58% reduction in risk for T2DM in patients with prediabetes when they were treated with intensive lifestyle intervention resulting in at least 7% weight loss and 150+ minutes of exercise weekly. The metformin arm of the study showed a significant 31% reduction in risk for T2DM (still 27% less effective than lifestyle intervention).
Although my personal success with patients willing to fully embark on TLCs is low, I still spend a good portion of my consultations and follow-up time teaching the importance of diet and exercise. I reiterate these principles at each and every visit. If you don’t place a high emphasis on these changes, neither will your patients.
If you want your patient to succeed, set obtainable goals, no matter how simple or achievable. Explain that even a 5% to 10% weight loss yields significant benefits, which may prevent the need to add medications and could possibly lead to a reduction in their current medications.
Show a true concern and interest for the patient; demonstrate your belief in them for change. Don’t use threats of additional medications or increased risk for morbidity and mortality. Yes, fear is a powerful motivator, but so is benefit. If you scare the patient, he or she may not return to you for follow-up. I aim to create a sense of heightened concern about the realities of poor diabetes control while strongly emphasizing the benefits of diet, exercise, and weight loss. This helps the patients gain a full appreciation of the need for TLCs.
Our lack of belief that a patient will actually undertake the necessary means to improve their diet and embark on a regular exercise program is not a justifiable excuse for not spending time teaching and encouraging them. Avoid becoming frustrated with your belief and the reality that the majority of people don’t adopt and continue the necessary TLCs to lose weight and keep it off. We owe it to our patients to become knowledgeable about TLCs, believe in the value of them, and be positive, encouraging, and a good coach. The small percentage of patients who actually succeed and become happy about their success will spark your belief and motivation to keep promoting
TLCs.
SUGGESTED READING
Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32(1):193-203.
Rodbard HW, Jellinger PS, Davidson JA, et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology Consensus Panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocr Pract. 2009;15:540-559.
National Heart, Lung and Blood Institute, NIH. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf.
National Diabetes Information Clearinghouse. Diabetes Prevention Program. http://diabetes.niddk.nih .gov/dm/pubs/preventionprogram.