Diabetes%20mellitus Patient Education

• Patients with pre-diabetes should be informed of their increased diabetes mellitus and cardiovascular disease risk, and should be counseled about effective ways to lower their risk
  • Interventions and follow-up should be most vigilant in patients with HbA1c >6%, who are considered to be at very high risk for developing diabetes
  • Annual monitoring for the development of diabetes mellitus is advised
• Counsel women of reproductive age regarding contraception and measures to avoid fetal exposure to harmful medications

Diabetes Self-Management Education and Support (DSMES)

• Should be offered to all individuals with type 2 diabetes mellitus
• A skills-based approach focusing on how to help patients with diabetes to make informed self-management choices
• An unending process that incorporates the needs, goals and life experiences of patients with diabetes mellitus which facilitates knowledge, decision-making, skill and ability that they need for self-care
• Given to patients with diabetes at the time of diagnosis, anually for assessment of education, nutrition and emotional needs, if there are new complicating factors affecting self-management, changes in health or social status, and if there is transition in care or life situation
• Helps patients with diabetes to initiate useful self-management and cope with diabetes mellitus as soon as they are diagnosed
• Aids patient to optimize metabolic control, prevent and manage complications, and maximize quality of life in a cost-effective way
• Includes medical nutrition therapy, physical activities, weight management, sufficient sleep, preventing smoking, limiting alcohol consumption, counseling on substance abuse and reducing stress on psychosocial issues through psychological support
• Key results are effective self-management and quality of life
• Studies have shown that diabetes self-management education improved diabetes knowledge and self-care behavior, improved clinical (eg lower HbA1c) and psychological results, reduced weight, decreased hospitalization and all-cause mortality, and improved quality of life at lower cost
• It has been found that better HbA1c reduction is achieved when there is more contact time between the patient with diabetes mellitus and the educator

Motivational Counseling

• Counseling approach that incorporates motivational interviewing as part of a structured lifestyle intervention has been found to have beneficial effects in diabetes management
• Evidences show a higher weight loss and maintenance of weight loss when motivational interviewing was used in weight loss program for type 2 diabetes mellitus
• The Decision Balance Technique is often used in motivational counseling and seeks to clarify issues about change, lower resistance and enhance motivation to change using knowledge and experiences of the patient

Medical Nutrition Therapy (MNT)

• Focuses on how to improve metabolic outcomes of diabetes mellitus by modifying nutrient intake and lifestyle
• Important in preventing and managing hyperglycemia and preventing, delaying and treating diabetic complications
• In patients with pre-diabetes, medical nutrition therapy may help lower diabetes mellitus and cardiovascular  disease risk by promoting healthy food choices and physical activity which will lead to moderate weight loss that is sustained
• In patients with diabetes mellitus, medical nutrition therapy will help reach and maintain blood glucose, blood pressure and lipid profile levels as close to normal
  • Deals with individual nutritional needs based on personal and cultural preferences, severity of disease, and patient’s readiness for change
  • Maintains eating pleasure by only restricting food choices that are necessary for metabolic control
• In patients with diabetes mellitus treated with Insulin or insulin secretagogues, medical nutrition therapy provides self-management training for safe performance of exercise, preventing and treating hypoglycemia, and managing acute hyperglycemia
• Adjustment of insulin dose should match carbohydrate intake with specific reference to sucrose-containing or high glycemic index food
• Studies had shown that after 3 to 6 months of medical nutrition therapy, HbA1c is decreased by 1% in type 1 diabetes mellitus and 1-2% in type 2 diabetes mellitus and LDL-C reduced by 15-25 mg/dL (0.4-0.6 mmol/L)
• There is no recommendation on nutrition that can prevent type 1 diabetes mellitus

Diet

• The cornerstone of diabetes mellitus management
• Advise patients to avoid missing meals and it should be synchronized with time actions of the medication
• A balanced diet is recommended 
  • Individualized based on glucose and lipid targets
  • Lower fat intake, especially saturated fat, may decrease diabetes mellitus risk by producing an energy-dependent improvement in insulin resistance and promoting weight loss
• A Mediterranean or plant-based diet rich in unsaturated fat is recommended to reduce cardiovascular risk 

Calories

• Total calories (amount/day) must be calculated based on patient’s needs
• Studies suggest that for patients with diabetes, there is no ideal percentage of calories from carbohydrates, protein and fat
  • Macronutrient distribution should be individualized based on metabolic goals, current eating patterns and preferences

Carbohydrate

• Amount and type of carbohydrate ingested determine the postprandial response
• Should be obtained from fruits, vegetables, whole grains, legumes and low-fat milk
• Glycemic index (GI) may be used in guiding choices of food and provides benefit in altering postprandial response
  • Ranked on a scale of 0-100, it is a measure to classify carbohydrate based on its effect on the blood glucose level
  • Food with high GI value (≥70) raises blood glucose more rapidly than food with medium (56-69) or low (≤55) GI
• Total intake of carbohydrate should be consistent and equally distributed throughout the day
  • Monitor total daily intake of carbohydrate to achieve glycemic control
• Should match carbohydrate content of meal to doses of Insulin and insulin secretagogues
• Resistant-starch/high-amylose foods
  • Eg legumes, raw potato, formulated cornstarch
  • May alter postprandial glycemic response, prevent hypoglycemia and decrease hyperglycemia; however, no long-term studies have shown benefit from using resistant-starch in patients with diabetes mellitus

• Sweeteners
  • Sucrose may substitute for other carbohydrate sources in the meal plan (up to 10% of total daily energy intake)
    
    • Sucrose intake is counted as part of the total carbohydrate intake; ensure blood glucose, lipids and body weight are adequately controlled
  • Naturally occurring fructose in fruits, vegetables and other foods may be used which only accounts for 3-4% of energy intake
  • Artificial sweeteners (eg acesulfame K, aspartame, neotame, saccharin, sucralose) and sugar alcohols (eg erythritol, isomalt, lactitol, maltitol, mannitol, sorbitol, isomalt, xylitol, tagatose, hydrogenated starch hydrolysates) may be used within daily intake levels
    • Sugar alcohols have lower available energy (2 cal/g) and produce a lower postprandial glucose response than sucrose or glucose
    • Sugar alcohols lower the risk of having dental caries but have no evidence in decreasing blood sugar, energy intake, or weight

Fiber 

• Because of the general health benefits of fiber, individuals with diabetes mellitus are encouraged to increase intake to 14 g fiber/1000 kcal/day or approximately 38 g/day for men and 25 g/day for women
• Five to seven servings or 20-30 g of fiber/day is recommended
  • Eg vegetables, fruits, legumes, whole grain products and fiber-rich cereals (≥5 g fiber/serving)
  • Dietary fiber and whole grain-containing foods are associated with better insulin sensitivity and ability to secrete insulin sufficiently to overcome insulin resistance

Dietary Fat and Cholesterol

• There is a lack of evidence to recommend an ideal amount of total fat intake for patients with diabetes
• As recommended for the general public, an increase in foods rich in n-3 linolenic acid and long-chain n-3 fatty acids (EPA, DHA) is also recommended to patients with diabetes
• In individuals with type 2 diabetes mellitus, a Mediterranean-style, monounsaturated and polyunsaturated fatty acid-rich diet may be recommended as an effective alternative to a higher carbohydrate, lower-fat eating pattern since these may benefit cardiovascular disease risk factor and glycemic control
• In type 2 diabetes mellitus, the recommended amount of dietary saturated fat, trans fat and cholesterol is the same as that for the general public

Protein

• Good-quality protein (eg meat, poultry, fish, eggs, milk, cheese, soy) has high protein digestibility-corrected amino acid scoring pattern (PD-CAAS) scores and supplies all 9 indispensable amino acids
  • PD-CAAS is the preferred method by Food and Agricultural Organization of the United Nations/WorldHealth Organization (FAO/WHO) in the measurement of protein value in human nutrition as it has a more accurate characterization of the protein quality of foods
  • A food can be considered as good quality source of protein if the corrected protein level is ≥10% of the daily value per reference amount customarily consumed
• Should not be used for the treatment of acute or for the prevention of nocturnal hypoglycemia since protein increases insulin response without increasing plasma glucose concentrations

Alcohol

• Limit to ≤1 drink/day for women and ≤2 drinks/day for men to reduce diabetes mellitus, coronary heart disease and stroke risk
  • 1 alcohol-containing beverage is defined as 12 oz beer, 5 oz glass of wine or 1.5 oz distilled spirits which contains 15 g of alcohol
  • All types of alcohol-containing beverage have similar effects
• In patients using insulin or insulin secretagogues, alcohol should be consumed with food to lower risk of nocturnal hypoglycemia
• May increase blood glucose level when taken with carbohydrate

Micronutrient

• There is insufficient evidence of benefit from mineral or vitamin supplementation in patients with diabetes who do not have underlying deficiencies

Sodium

• Na intake should be limited to <2300 mg/day as per recommendation to the general public
  • Should avoid foods high in sodium (eg soy sauce or other sauces, pre-mixed cooking paste, preserved and processed foods) and salt in cooking should be limited to ¼-½ teaspoonful/day
• For patients with both hypertension and diabetes, further reduction in sodium intake should be individualized

Physical Activity

• Must be individualized based on presence of type 2 diabetes mellitus-associated comorbidities (eg coronary artery disease, heart failure, atrial fibrillation, peripheral neuropathy, retinopathy), age and frailty
• Regular aerobic exercise improves blood glucose control, lowers cardiovascular disease risk factors, contributes to weight loss, decreases the risk of falls and fractures, improves quality of life by improving functional capacity and sense of well-being and prevents the development of type 2 diabetes mellitus in individuals who are at high risk
  • At least 8 weeks of exercise intervention has been shown to reduce HbA1c by 0.66% in patients with type 2 diabetes mellitus

• Structured exercise intervention is recommended in patients with type 2 diabetes mellitus with or without cardiovascular disease and includes:
  • At least 150 minutes/week of moderate-intensity exercise spread over at least 3 days/week with no >2 consecutive days without exercise or 75 minutes of vigorous endurance activity
  • Twice-thrice weekly resistance, flexibility and/or balance training, if without contraindications, is recommended

• Vigorous activity is not recommended in patients with ketosis
  • Can worsen hyperglycemia of patients with diabetes mellitus type 1 who have not received insulin for 12-48 hours or are ketotic 

• In patients on insulin or insulin secretagogues, it is advisable to take extra carbohydrate before exercise if pre-exercise glucose levels are <5.0 mmol/L (<90 mg/dL)
  • Physical activity can cause hypoglycemia if medication dose or carbohydrate consumption is not adjusted in patients taking insulin or insulin secretagogues

• Should assess patient for certain exercises that might be contraindicated to their condition (ie uncontrolled hypertension, severe autonomic neuropathy, history of foot lesions, unstable proliferative retinopathy)
  • High-risk patients should be advised to start with low-intensity exercise at short periods and then slowly increase the intensity and duration
  • Vigorous aerobic or resistance exercise should be avoided by patients with proliferative or severe nonproliferative diabetic retinopathy due to possible risk of vitreous hemorrhage or retinal detachment
  • Proper footwear should be advised in all patients with peripheral neuropathy, and those patients with foot injury should be restricted to nonweight-bearing activities
  • Cardiac investigation should be done in patients with diabetic autonomic neuropathy before starting any intense physical activity since autonomic neuropathy is strongly associated with cardiovascular disease in diabetic patients
  • There are no exercise restrictions in patients with diabetic kidney disease but they should be reminded that physical activity can acutely increase urinary protein excretion

• Moderate-intensity and vigorous exercise may improve insulin sensitivity and reduce risk for type 2 diabetes mellitus
• Evidence has shown that breaking bouts of sedentary activity every 30 minutes by briefly standing or walking may help prevent type 2 diabetes mellitus for those who are at risk and may aid in the glycemic control in those with diabetes mellitus

Weight Management

• A ≥5% weight loss from initial body weight over a 6-month period is advised in all individuals who are overweight or obese who have or are at risk of diabetes mellitus which can be achieved by a lower calorie intake (20-25 kcal/kg body weight), lower dietary fat intake, at least 150 minutes/week physical activity and behavioral modification
  • In Asians, waist circumference ≥31 inches (≥80 cm) in women and ≥35 inches (≥90 cm) in men, and BMI >23 kg/m² are at high risk for type 2 diabetes mellitus and cardiovascular disease
  • Moderate weight loss leads to decreased insulin resistance, improved blood sugar and lipid levels, and lower blood pressure
  • A low-carbohydrate or a low-calorie meal plan with meal replacements and the Mediterranean diet can be used safely and effectively in the short term (1 to 2 years) to achieve weight loss 
  • Lipid profiles, renal function, and protein intake should be monitored in patients on low-carbohydrate diet, and antidiabetic therapy must be adjusted
  • Weight loss medications may be advised in overweight or obese patients with type 2 diabetes mellitus
    • Please see Obesity disease management chart for further information
      
  • Metabolic/bariatric surgery is effective in improving glucose control and often results in disease remission; it is recommended in individuals with type 2 diabetes mellitus who have a BMI:
    • ≥40 kg/m² (≥37.5 kg/m² in patients with Asian ancestry) or 
    • 35-39.9 kg/m² (32.5-37.4 kg/m² in patients with Asian ancestry) who failed to have durable weight loss and improvement in comorbidities with reasonable non-surgical methods

Sleep

• All patients should be advised to sleep approximately 7 hours per night to maintain energy levels and well-being
• Evidence supports that 6 to 9 hours of sleep per night is associated with a decrease in cardiometabolic risk factors
  • Sleep deprivation causes aggravation of insulin resistance, hypertension, hyperglycemia and dyslipidemia and increases inflammatory cytokines

Behavioral Support 

• Patients with diabetes mellitus are encouraged to join community groups that promote healthy lifestyle for emotional support and motivation
• There are high rates of anxiety and depression in patients with diabetes mellitus and obesity that can adversely affect outcomes
• Cognitive behavioral therapy was found to be beneficial

Smoking Cessation 

• It has been found that smoking may have a role in the development of type 2 diabetes mellitus 
• Reduces mortality rate by 36% in patients with type 2 diabetes mellitus with cardiovascular disease 
• For patients having difficulty with smoking cessation, nicotine replacement therapy should be considered
• For more recalcitrant patients that cannot stop smoking on their own, structured programs are recommended