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doi: 10.1097/JCN.0000000000000604
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New Preventive Cardiovascular Nurses Association Diabetes Tool Available

Approximately 30.3 million people of all ages, or 9.4% of the US population, had diabetes in 2015, the majority being type 2 diabetes. The percentage of adults with diabetes increased with age, reaching a high of 25.2% among those aged 65 years or older.1 Atherosclerotic cardiovascular disease (CVD) is the leading cause of morbidity and mortality for individuals with diabetes.2 Healthcare providers are well aware of this risk and understand that the biggest fear of people with diabetes is developing complications resulting in blindness, amputation, and dialysis.

Acknowledging this, the Preventive Cardiovascular Nurses Association (PCNA) and the American Diabetes Association collaborated to create a patient education resource that provides information about the connection between diabetes and CVD. A major emphasis of this important resource is empowering patients to play a major role in their care, manage their diabetes, and lower their risk factors for CVD.

Diabetes and Your Heart: Close Connections is a multimedia tool used to address different learning styles. For those who learn best from reading, there is a printed booklet written at an eighth-grade level, with an easily readable font, pictures, and ample white space. For those with visual impairment or who are auditory learners, an online version is narrated, and keywords can be clicked on for further definition. To maximize patient engagement, there are “knowledge check-ins” and additional tools to support action, including SMART Goal sheets, Blood Glucose Monitoring Logs, and Exercise Trackers.

The simple message of the booklet is as follows: Your everyday choices can reduce your risks. Included are tips for reaching goals, establishing a SMART Goal, and importantly, problem-solving barriers to achieving the goal. Lifestyle is a powerful “insulin sensitizer,” and guidelines are incorporated into the tool that focus on how to start staying active, eating healthy (what, when, and how much to eat), monitoring to reduce short-term and long-term complications, taking medicines, problem-solving, reducing risks to improve health, and taking care of yourself with healthy coping.

In the context of shared decision-making for best outcomes, patients ultimately choose their optimal plan. The plan incorporates reviewing clinical targets, identifying an area on which the patient desires to focus, and having simple, clear education to support everyday decisions. Diabetes and Your Heart: Close Connections provides a great starting point in a patient's path to reaching their goals. The adjunct tools and logs can be used independently and with a healthcare provider in helping people with diabetes stay healthy.

To order this booklet, go to https://pcna.net/ and look under “Clinical Resources” and then “Diabetes Tools and Handouts.” The virtual tool can be accessed at pcna.net/diabetes-cvd. Share this link with your patients so they can view the tool on their own as often as needed.

In addition, the project editors of the tool book, Cindy Lamendola, MSN, ANP, and Donna Louie, RN, BSN, CDE, participated in a webinar for healthcare professionals on February 27, 2019, entitled “Connecting Diabetes and Heart Disease: Achieving Improved Cardiovascular Outcomes in Patients With Diabetes.” There were several objectives for this program. The webinar described the scientific link between diabetes and CVD and identified gaps between healthcare providers' messages and patients' knowledge and understanding of CVD complications from diabetes. The webinar reviewed best practices and effective strategies in managing patients with diabetes in the CVD setting and summarized the antihyperglycemic therapies and management, with a focus on (a) new medications that also decrease CVD and (b) where they fit into the treatment plan. There was a focus on respectful, inclusive, and person-centered approaches to improve communication and enhance motivation, health, and well-being of people with diabetes.3 This resource is a great combination of increasing the understanding of the science, guidelines, and treatments as well as understanding the perspective and concerns of the patient with diabetes. This continuing education webinar is available in the online CE portal at PCNA.net. Upon completion of the webinar, learners will receive 1.0 contact hour including 0.3 pharmacology.

  1. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2017.
  2. American Diabetes Association. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes–2019. Diabetes Care 2019; 42(suppl 1):S103–S123. https://doi.org/10.2337/dc19-S010
  3. Dickinson JK, Guzman SJ, Maryniuk MD, et al. The use of language in diabetes care and education. Diabetes Educ. 2017;43(6):551–564.
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2018 Physical Activity Guidelines

Preventive cardiovascular nurses facilitate physical activity (PA) and educate about its benefits, with the goals of reducing cardiovascular risk and improving quality of life. Overall, the public health benefit from PA versus being sedentary is very large in terms of reduced medical costs. In addition, individual benefits for health and well-being are well documented and include positive health effects accompanied by increased feelings of energy and vitality with heightened aerobic capacity and strength.

The new 2018 PA Guidelines1 have 5 major messages:

Can PA help individuals feel better? In addition to a strong research base on the beneficial effect of PA on prevention, the guidelines state that PA can help people better perform daily tasks better, like carrying groceries, sleep better including falling asleep, and feel better with less anxiety.

Do PA benefits happen immediately? According to the guidelines, benefits to health begin after 1 session. For example, reduced blood pressure is seen the day PA is performed. Days and weeks of PA have additive benefits, so adopting a PA routine is best.

Does the latest research show continued evidence for reduced risk of many diseases and conditions? Physical activity has been shown to provide health benefits from age 3 years. Anytime PA is successful in helping prevent weight gain and reduce weight, a whole cascade of related cardiometabolic disorders can be prevented. Also, PA benefits like reducing the risk of dementia or falls were noted.

How can the benefits of PA be achieved? The guideline supports the performance of any PA and states that the evidence to have a minimum of 10 minutes is not strong, so it is no longer supported. Accumulating as much PA time per day is what is important.

What interventions were found to be effective? For the greatest effect, physical activities at many levels are suggested. There is strong evidence for the continuation of individual-level programs that increase the amount of PA in youth and adults. Also, larger programs such as those that are community or school based can improve PA volume.

At the PCNA Annual Symposium in April 2019, a keynote presentation shared by incoming PCNA President Kim Newlin, MSN, ANP, and Geoffrey Moore, MD, emphasized the well-known cardiovascular benefits of PA within overall lifestyle interventions and pointed specifically to its role in improving glucose metabolism and, in some cases, remission of type 2 diabetes mellitus. They reinforced that the 2018 PA Guidelines recommend 150 to 300 minutes per week (500–1000 MET-minutes) of moderate to vigorous PA. Muscle strength training was recommended at least 2 to 3 days a week with a day of rest between each strength training day. The speakers gave excellent points of how nurses could effectively promote the PA Guidelines using an Exercise Is Medicine/Screening, Brief Intervention and Referral to Treatment model:

Screening, Brief Intervention, and Referral to Treatment includes:

  • PA assessment and American College of Sports Medicine screening algorithm
  • Brief advice/counseling
  • Prescription for PA (depending on health, fitness, and patient and provider preferences)
  • Refer patient to PA resources: programs, facilities, certified exercise professionals, self-directed

More detail and resources, including the algorithm, a patient-friendly exercise prescription, patient handouts, and provider coding and billing tips, are available on the Exercise is Medicine website: https://www.exerciseismedicine.org/support_page.php/provider-action-guide/. The PCNA's Heart Healthy Toolbox found at PCNA.net includes a wealth of patient-friendly resources on exercise and PA. While evidence continues to grow related to specific mechanisms of action for PA, the guidelines are clear and provide strong support for action from preventive cardiac nurses to enact PA assessments, counseling, and follow-up at each patient encounter.

  1. Physical Activity Guidelines Advisory Committee Scientific Report. US Department of Health and Human Services. Health.gov/paguidelines/second-edition/report/pdf/PAG_Advisory_Committee_Report.pdf.
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2019 American College of Cardiology/American Heart Association Guideline on Primary Prevention

Cardiovascular disease does not discriminate, and as the global impact of CVD is more prevalent, action plans are necessary for prevention. Cardiovascular disease remains the top killer of Americans, second only to cancer.1 The Centers for Disease Control and Prevention reports that the leading driver of healthcare expenses are chronic diseases such as heart disease, cancer, stroke, and diabetes. These chronic diseases are preventable when considering modifiable risk factors. Lifestyle modification such as tobacco avoidance, healthy diet, and increasing physical activity will drastically reduce death from chronic disease. In March 2019, the American College of Cardiology and the American Heart Association released current guidelines for the primary prevention of CVD. The recommendations were based on the most recent clinical trial evidence2 and covered 9 categories: nutrition, obesity, physical activity, diabetes, lipids, statin therapy, hypertension, tobacco, and aspirin. The guidelines also emphasized the importance of shared decision-making in conjunction with a team-based approach for the implementation of lifestyle modification. In addition, these prevention guidelines outline the significance of determining the social determinants and addressing barriers to healthcare.

The prevention guidelines provided 10 takeaway messages that depict a condensed summary of the recommendations.3 These takeaways help guide lifestyle change in clinical practice and initiating patient conversation. The major theme of the prevention guidelines enlists the importance of incorporating a healthy lifestyle across the lifespan and achieving change requires a team-based approach.3 A 10-year atherosclerotic CVD (ASCVD) risk estimation and a coronary artery calcium scan should be completed in adults ages 40 to 75 years in conjunction with a discussion of those risks before implementation of any pharmacological therapy. A diet rich in fruits, vegetables, legumes, nuts, whole grains, lean vegetable or animal protein, and fish but limited in trans-fats, processed meats, refined carbohydrates, and sweetened beverages is encouraged for all adults.3 Physical activity for adults should be an engagement of 150 minutes weekly that is of moderate intensity or 75 minutes weekly of vigorous intensity. Lifestyle modification is also encouraged for adults with type 2 diabetes, with metformin being the first-line therapy. It may be followed with a sodium-glucose cotransporter 2 inhibitor or a glucagon-like peptide-1 receptor agonist. Tobacco use and cessation discussion should be assessed at every healthcare visit for all adults. Because there is a lack of net benefit, aspirin should be used sparingly in routine primary prevention of ASCVD.3 The recommended first-line therapy for primary prevention of ASCVD with elevated low-density lipoprotein cholesterol in adults is statin therapy. This recommendation also encompasses adults ages 40 to 75 years with diabetes and have been determined to be at risk for ASCVD. Finally, nonpharmacological interventions are the standard therapy for adults with increased blood pressure. For those populations requiring pharmacological therapy, the target blood pressure should be less than 130/80 mm Hg.3

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Implementing the Guidelines

One of the most effective tools for guideline implementation is education and raising awareness.4 The American Heart Association/American College of Cardiology guidelines (2019) on primary prevention for CVD have indicated the importance of the advanced practice nurse placing an intensified focus on having crucial conversations regarding a healthy lifestyle with their patient population by empowering, educating, and engaging the patient.5 The key to guideline implementation is education; involve frontline nurses whenever possible and adapt the teaching to the individual circumstances. Explaining the benefits of lifestyle modification can help to motivate the patient to make healthy changes. In addition, reassuring the patient that making small goals will lead to big changes is an effective strategy for long-term success. Finally, the advanced practice nurse should evaluate any social determinants that affect the individual from making healthy changes to define therapy decisions.2

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REFERENCES

1. Centers for Disease Control and Prevention. Heart Disease Facts. 2017. https://www.cdc.gov/heartdisease/facts.htm. Accessed May 31, 2019.
2. American College of Cardiology. AHA/ACC guidelines on the primary prevention of cardiovascular disease. 2019. http://www.onlinejacc.org/sites/default/files/additional_assets/guidelines/Prevention-Guidelines-Made-Simple.pdf. Accessed July 10, 2019.
3. American Heart Association. Top ten things to know: 2019 CVD primary prevention guidelines. 2019. https://professional.heart.org/professional/ScienceNews/UCM_503728_Top-Ten-2019-CVD-Primary-Prevention-Guideline.jsp. Accessed July 10, 2019.
4. M. Murphy, B. Staffileno, & M. Foreman. Research for Advanced Practice Nurses. 3rd ed. 2018. Accessed May 30, 2019.
5. Roberts ME, Davis LL. Cardiovascular disease in women: a nurse practitioner's guide to prevention. (2013). https://doi.org/10.1016/j.nurpra.2013.08.018. Accessed May 30, 2019.
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