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Diabetes

Setting and achieving glycemic goals

Faminu, Femi, MSN, RN, CDE

doi: 10.1097/01.NURSE.0000549727.37810.3d
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Abstract: Implementing lifestyle changes can be a substantial challenge for patients with diabetes. This article offers nursing strategies to help patients set and meet glycemic goals and manage their own therapy.

Initiate these nursing strategies to help patients set and meet glycemic goals and manage their own therapy.

Femi Faminu is a clinical nurse with the US Department of Veterans Affairs Greater Los Angeles Healthcare System.

The author has disclosed no financial relationships related to this article.

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AS PART OF A MULTIDISCIPLINARY APPROACH, nurses improve diabetes-related outcomes by collaborating with the healthcare team, patients, and family members in the prevention and management of diabetes.1,2 Successful outcomes depend on patient participation, and nurses are ideally positioned to offer education and support for self-management. This article reviews diabetes management and strategies nurses can use to improve patient engagement with lifestyle changes, medication adherence, and other prescribed therapies.

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Diabetes-related complications

The cumulative effects of hyperglycemia can be detrimental to vasculature, resulting in calcification and endothelial cell dysfunction.3 These lead to a decline in organ functionality and higher incidences of micro- and macrovascular complications in patients with diabetes, including retinopathy, nephropathy and neuropathy, ischemic heart disease, stroke, and peripheral arterial disease.4

Managing hyperglycemia may require medications such as sulfonylureas, glinides, or insulin.5 Each of these carries an increased risk of hypoglycemia due to higher levels of circulating insulin. Prolonged or repeated exposure to hypoglycemia can result in desensitization to low blood glucose levels and increased mortality, so educating patients about the importance of glycemic control is vital.5 Signs and symptoms of hypoglycemia include shakiness, irritability, tachycardia, and hunger.2 More severe reactions include impaired cognition, seizures, and death.5

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Measuring glucose

The goal of managing diabetes is to normalize blood glucose levels while simultaneously avoiding the consequences of hyper- or hypoglycemia. Hemoglobin A1C (A1C) represents the principle glycated hemoglobin in most adults. Testing can be useful in measuring the effectiveness of a diabetes management plan, as it provides an idea of an individual's blood glucose trends up to 3 months prior to testing (see Diagnostic criteria for diabetes mellitus).6,7

Table

Table

Goals for A1C levels should be individualized to the patient, with emphasis on managing hyperglycemia while avoiding hypoglycemia. A reasonable A1C goal for nonpregnant adults with diabetes is less than 7%, which approximates to fasting glucose values between 80 mg/dL and 130 mg/dL and peak postprandial values of less than 180 mg/dL up to 3 months prior to testing.2 Although A1C values below 7% have been associated with a further reduction in complications, they are also associated with an increased risk of hypoglycemia and polypharmacy without statistically significant benefits.2

Day-to-day blood glucose fluctuations may not be evident in A1C values, so self-monitoring by patients is an important part of assessing and meeting glycemic goals.6,8 Older adults may be at an increased risk for hypoglycemia due to progressive renal insufficiency, unidentified cognitive deficits, and insulin deficiency necessitating insulin therapy.9 As such, the individualized A1C target goal for some may be as high as 8.5%. Due to increased red blood cell turnover, pregnant women may target lower A1C levels between 6% and 7%. For children and adolescents, an A1C level of 7.5% or lower may be reasonable (see Diabetes through the years).2

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Nursing and diabetes management

Individuals identified as prediabetic have glucose levels that are higher than normal (A1C values between 5.7% and 6.4%), but not yet in the range of diabetes.10 This puts this patient population at an increased risk for developing diabetes.10 Between increased rates of morbidity and mortality and the associated costs of care, diabetes and prediabetes affect almost every area of healthcare.

For the most effective patient outcomes, collaboration is essential to enhance coordination and consistency of care and avoid duplication or fragmentation of care.2 With the largest number of healthcare workers functioning across multiple settings as part of the multidisciplinary team, nursing can strongly influence patient outcomes.11

Nurses and patients should review objective, evidence-based targets with the healthcare team, including goals for the following levels:

  • blood glucose
  • weight
  • BP
  • serum lipid levels.

A guiding principle of diabetes management is to help patients set realistic goals to improve their health and quality of life.12 The appropriate goals will vary according to the practitioners and patients involved.12

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Patient buy-in is key

Successful diabetes management depends on the patient's participation, and evidence-based guidelines emphasize the importance of a patient-centered approach.1,2,13 A patient's daily routine beyond the oversight of the healthcare team may have a significant impact on his or her outcomes. If the patient is not committed to the goals set by the healthcare team, the chances of accomplishing them are greatly diminished. Using patient values to guide clinical decisions increases the chances of patient adherence to therapy, leading to better outcomes.2 Nursing practices that emphasize patient self-engagement and support can improve adherence to lifestyle and behavioral changes such as taking medications as prescribed, increasing physical activity, and improving diet.

Providing effective guidance to patients with diabetes requires patience and understanding to find a balance between adhering to the treatment plan and maintaining their preferred lifestyle.14

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Collaborating with the patient

The shift from a provider-centered model to a patient-centered model can be challenging. Certain clinical behaviors can detract from developing a truly collaborative plan of care. Many patients with diabetes report wanting to play a more active role in managing the disease, but they may not be encouraged to do so.13 Verbal and nonverbal cues from staff can discourage patient participation and engagement. For example, nurses who focus on gathering and documenting data may shift the priority of an encounter from the patient's needs to those of the nurse.14-16 One study found that nurses sometimes avoid uncomfortable topics with patients by focusing on tasks such as BP measurements, which can cause patients to assume a more passive role.14

To effectively teach patients to better manage their health, nurses must apply specific intent, skills, and patience. By assessing patient comprehension, willingness, and ability to participate in diabetes management, nurses can modify treatment goals to fit individual circumstances.

Diabetes self-management education improves outcomes by increasing patients' understanding of their disease.2 Structured, evidence-based guidance is available, but how the information is delivered to patients influences the effectiveness of instruction.13

Empathy, reflective statements, and active listening are useful to enhance patient-nurse communication.2 Encourage patients to set individual behavioral goals by identifying their self-management problems and developing strategies to solve them.13 For example, rather than focusing on getting patients to improve their diets by cutting out fast food entirely, consider the different options available at their preferred venue. Nutritional information from many restaurants is readily available online, and a discussion about which choices best suit their glycemic goals may be beneficial. The balance of carbohydrates, proteins, and fats should be tailored to individual patient preferences and desired outcomes, such as weight loss or preventing hypoglycemia.2

It is also important for nurses to help develop a plan that will help the patient make the desired behavior changes.16 Rather than simply setting a goal to eat healthier, for example, discuss the possibility of substituting lower-calorie drinks for higher-calorie drinks three times a week.

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Avoiding hypoglycemia

A 2015 study documented the benefits of tighter glucose control, as well as adverse reactions such as an increased risk of dementia, decreased quality of life, weight gain, and death.17 Hypoglycemic events occur more frequently than healthcare professionals may realize, and the effort to avoid the unpleasant experience can prevent patients from reaching their target glycemic range. Actions that may interfere with glucose control and weight management and negatively impact quality of life include the following:17

  • altering insulin doses
  • increasing caloric intake
  • avoiding physical activity
  • minimizing blood glucose management.

In older adults, aggressive blood glucose management may increase risks without significant benefits.2 Glycemic goals in this population may not be as stringent, factoring in life expectancy, comorbidities, and cognition. Additionally, both older adults and children under age 6 years may have difficulty articulating and managing hypoglycemia.2 Nurses must be familiar with potential challenges specific to these patients.

Patients attempting to live a healthier lifestyle by reducing their caloric intake and increasing physical activity without an accompanying adjustment of their medications may be at increased risk for hypoglycemia. Meal planning, including what to eat and when to eat it, is one of the most challenging aspects of diabetes management for patients.2 Other factors that may predispose patients to hypoglycemia include intensive glucose management regimens, alcohol use, and comorbidities.18

Early reports on the effectiveness of a medication regimen and treatment plan are significant, as the excessive use of medication may precipitate hypoglycemia. Careful initiation and titration of medications can reduce the risk. To improve patient understanding and adherence to plans of care, ask about any occurrences of hypoglycemia.2 Review signs and symptoms of hypoglycemia during each visit, educate patients about treating hypoglycemia if it occurs, and ensure medications and treatment goals are adjusted accordingly.18

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The complexities of self-management

To improve outcomes, patients must feel confident in their ability to manage diabetes.2 They may need to obtain blood samples at potentially inconvenient times and locations. They also need thorough education about their medications, including how to modify dosages depending on the situation. For example, patients are expected to anticipate the effects of physical activity and diet on blood glucose levels and to respond appropriately to prevent complications.

The long-term effects of diabetes on cognition, vision, and sensation can make self-management more difficult. Another potential barrier to self-management is the psychological distress of dealing with the associated complexities, emotional burdens, and anxieties of living with diabetes. Diabetes distress is characterized by stress, guilt, and denial regarding the challenges of managing the disorder.19 It can negatively impact blood glucose trends, self-efficacy, medication routines, and dietary and exercise behaviors.2 Patients struggling with self-management may be labeled as “noncompliant” or “nonadherent” by healthcare professionals, a perspective that indicates that these caregivers may not be sensitive to the everyday challenges of living with diabetes.2,20

Managing their weight, BP, and blood glucose levels often requires patients to change long-standing habits or develop new ones immediately. Certain medications, such as those taken multiple times a day or at specific times around meals, may require drastic lifestyle changes with little regard for how these changes will be made.21 With cost, inconvenient schedules, and adverse drug reactions contributing to low rates of adherence, many patients with diabetes do not take their medications as prescribed.2,14 If these factors are not considered, hypoglycemia, hyperglycemia, and poor BP control are potential outcomes.

To better understand patient perspectives, dietetic, nursing, and pharmacy students participating in one of two similar studies were asked to follow diabetes management plans for a brief period.20,22 Despite receiving more instruction on diabetes management than most patients, the students were still somewhat overwhelmed by the challenges of diet modification and blood glucose testing. They acknowledged that successful diabetes management often requires skills beyond the abilities of many patients.20 After the experience, the students from both studies reported more empathy when counseling patients on diabetes self-management.20,22

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Emphasize the positive

Negative emotions diminish patient focus, decrease open-mindedness, and impair creativity, problem solving, and strategic thinking.23 Nurses can address these feelings with mindful listening and reflection to generate positivity, reducing self-criticism, and promoting hope for behavior changes.23 For example, having patients describe their best day, activity, or experience since their last encounter can help improve the effectiveness of each visit.23

Patients may have difficulty adhering to the necessary lifestyle changes, and a nurse's acceptance and understanding of the inevitable lapse in self-management may encourage patients to report problems and seek collaborative resolutions, especially in the early stages.2 It can take anywhere from 2 to 8 months for a patient to process a change, learn new methods to accomplish it, and implement the new behaviors.13 Outcomes may take longer than expected. Nurses must be mindful of the need to inspire all patients to initiate a change rather than focusing on those who appear ready to do so.

Developing small changes in the short term may simplify long-term goals and improve patient adherence to a treatment plan.21 It may also be beneficial to work within the limits of patient parameters, exploring options that allow for balance between current lifestyles and the desired changes.14 Consider dosing schedules and medications that are compatible with a patient's current lifestyle to reduce the risk of hypoglycemia and improve glycemic control.

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Competing priorities

A primary focus on clinical outcomes may detract from the patient's personal priorities. Although the healthcare team may focus on meeting standardized targets for A1C or BP in a group of patients, this may compete with an individual patient's priority for minimal disruption to his or her daily routine. Without negotiating a resolution, the competing priorities of the healthcare team and the patient can lead to poorer outcomes. Additionally, differing values may cause some patients to be viewed as nonadherent, with a preference shown for patients who are considered more adherent by the healthcare team.15 The healthcare staff may expect patients to assume a passive role by doing as instructed, but this dynamic can diminish successful outcomes in diabetes management.2

A nurse's sense of responsibility and expertise may increase the difficulty of collaborating with patients on a plan of care. During observational studies of nurses interacting with patients with diabetes, the nurses demonstrated a tendency to ignore or minimize patient resistance to instruction without exploring the underlying reasons, ultimately correlating with poorer outcomes.14,16 Adults may resist being told what to do, and changes in patient behavior are more likely to occur and be sustained with internal, rather than external, motivations.23

In fulfilling their role as healthcare experts, the nurses provided a lot of information. This was general information, however, rather than information tailored to the knowledge, beliefs, and emotions of their individual patients.16 Additionally, the nurses demonstrated less confidence in their coaching skills, which required effective communication to achieve the desired changes.14

It is important to provide patients with information, but there must be a balance between expertise and counseling when educating patients with diabetes. Coaching patients requires an understanding of their goals and motivations.16 Rather than telling a patient what to do, nurses can ask questions that encourage the patient to consider different solutions. These typically require more than a yes or no response.2,23

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Building trust

Self-management requires ongoing practical and emotional support, with which patients are more likely to raise concerns, ask questions, and assume more responsibility for their health.14 The threat of negative outcomes or complications is unlikely to affect patient engagement or self-management.21,24 The necessary behavioral changes are unlikely to occur if patient concerns are not addressed. Trust is fostered by treating each patient as unique.14

Patients with diabetes should feel comfortable sharing their frustrations and difficulties with the nursing staff. The goal of the relationship is to support lasting behavioral changes by encouraging the patient to develop self-awareness and gain new insights.23 As patients begin to sustain self-determined goals, they will be more receptive to learning new information.25,26 Provider empathy when counseling patients with diabetes has been found to increase patient satisfaction and lower the rate of metabolic complications.22

When patients are newly diagnosed, experiencing complications, or in transitional phases of diabetes, more contact may be required with the healthcare team.13 There is a tendency to increase appointment frequency in response to problems.16 Even when things are going well, however, regular contact is important to maintain stability and trust between the patient and the healthcare team. These sessions provide opportunities for ongoing assessment, answers to patient questions, and encouragement and celebration of accomplishments.13,14,16,21

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Nurses as coaches and counselors

In managing diabetes, many options and goals are available to improve patient outcomes. With patience, the healthcare team can collaborate with patients to determine which goals will be the priority and provide ongoing support as patients progress in self-management. Nursing professionals must demonstrate flexibility and insight when working with this patient population, acting as clinical experts, coaches, counselors, and sources of referral as appropriate.

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Diabetes through the years1,2,4,27

Between 1980 and 2014, the number of adults with diabetes around the world nearly doubled from 4.7% to 8.5%. On the other hand, the number of people diagnosed with diabetes in the US has tripled in the last 20 years. Approximately 30 million people have diabetes in the US, with 84 million estimated to have prediabetes. The prevalence of diabetes continues to rise, affecting patient outcomes and costs of care. Additionally, the rate is growing in low- and middle-income countries faster than in those with higher incomes. This is primarily attributed to increased risk factors, such as being overweight or obese and sedentary lifestyles. An increasing incidence of gestational diabetes in these populations results in children predisposed to developing diabetes later in life.

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REFERENCES

1. Department of Veterans Affairs; Department of Defense. Clinical practice guideline for the management of type 2 diabetes mellitus in primary care. 2017. http://www.healthquality.va.gov/guidelines/CD/diabetes/VADoDDMCPGFinal508.pdf.
2. American Diabetes Association. Standards of Medical Care in Diabetes-2018. Diabetes Care. 2018;41(suppl 1):S1–S159.
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5. Cryer PE. Glycemic goals in diabetes: trade-off between glycemic control and iatrogenic hypoglycemia. Diabetes. 2014;63(7):2188–2195.
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7. Rao LV, Pechet L, Jenkins A, et al Laboratory tests. In: Wallach's Interpretation of Diagnostic Tests. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011.
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19. Kreider KE. Diabetes distress or major depressive disorder? A practical approach to diagnosing and treating psychological comorbidities of diabetes. Diabetes Ther. 2017;8(1):1–7.
20. Smith-Miller CA, Thompson C. Transformative learning and graduate nurses' understanding of the complexities of diabetes self-management. J Nurses Prof Dev. 2013;29(6):325–332.
21. Greene J, Hibbard JH, Alvarez C, Overton V. Supporting patient behavior change: approaches used by primary care clinicians whose patients have an increase in activation levels. Ann Fam Med. 2016;14(2):148–154.
22. Gaba A, Wong SS, Ghatak R. Two days with diabetes: experiential education for dietetics students promotes understanding of diabetes management challenges. Top Clin Nutr. 2016;31(2):125–133.
23. Sforzo GA, Moore M, Scholtz M. Delivering change that lasts: health and wellness coaching competencies for exercise professionals. Am Coll Sports Med Health Fitness J. 2015;19(2):20–26.
24. Steinberg G, Scott A, Honcz J, Spettell C, Pradhan S. Reducing metabolic syndrome risk using a personalized wellness program. J Occup Environ Med. 2015;57(12):1269–1274.
25. Wolever RQ, Dreusicke MH. Integrative health coaching: a behavior skills approach that improves HbA1c and pharmacy claims-derived medication adherence. BMJ Open Diabetes Res Care. 2016;4(1):e000201.
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27. Centers for Disease Control and Prevention. Division of diabetes translation at a glance. 2018. http://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm.
Keywords:

diabetes; glucose; glycemic control; hemoglobin A1C; hyperglycemia; hypoglycemia

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