Feature Story
Comorbid Diabetes: How Can We Help Our Patients Manage Their Diabetes?
Tracey Connolly, MSN RN AGCNS-BC CRRN
My father died from complications of diabetes ten years ago at the age of 65. He was diagnosed with type 2 diabetes at the age of 35 despite being fairly thin and active. I was not very understanding of his battle until I was diagnosed with diabetes myself two years ago. It is easy to blame diabetes on the patient’s weight, poor diet, lack of exercise, non-compliance, etc. However, it is very different to LIVE with diabetes.
Unfortunately, there is a lot of misinformation around diabetes, even among healthcare professionals. This is partially due to the overabundance of research on diabetes. The American Diabetes Association (ADA) publishes Standards of Medical Care in Diabetes, and they update the guidelines frequently throughout the year (four updates as of July 31st, 2019). While this is wonderful for patients, it makes it challenging for nurses to keep up with the latest evidence. Below, I will share what was updated this year and how this information should impact the way you educate your patients to help them manage diabetes.
Much of the updates are related to cardiovascular health and new medications for diabetes that also reduce the risk of cardiac complications. According to the ADA, atherosclerotic cardiovascular disease is the leading cause of morbidity and mortality in people with diabetes. Cardiology Magazine (American College of Cardiology, 2017) states that nearly one in 10 Americans has diabetes and about 65 percent of them will die from cardiovascular disease. While it may not be possible to keep up-to-date with every medication, it is important to understand the two new classes of medications that have been shown to be cardioprotective. These are the sodium-glucose cotransporter 2 (SGLT2) inhibitors and the glucagon-like peptide-1 (GLP-1) receptor agonists. Both have been shown to reduce cardiovascular events in diabetic patients in addition to their glucose-lowering benefits. The SGLT2 medications come in an oral form. They block a protein in the kidney that stops reabsorption of glucose from urine. The SGLT2 medications include: canaglifozin, dapaglifozin, and empaglifozin. The GLP-1 medications stimulate insulin secretion and inhibit glucagon secretion. They also delay gastric emptying and decrease appetite, which can help with weight loss. They are injectable medications that do require some refrigeration. The GLP-1 medications include: dulaglutide, exenatide, liraglutide, semaglutide and also come in combination with insulin. For a more in-depth look at these classes of medications and the clinical trials that were conducted, I recommend the article “Cardioprotective anti-hyperglycemic medications: a review of clinical trials” published in the European Heart Journal in 2018 (Ahmed, Khraishah & Cho).
Another area that has seen a lot of change over the last few years is dietary recommendations for diabetics. If you have been telling your diabetic patients that they need to count their carbs or never eat sweets, you may not realize that there are no longer strict guidelines of what people with diabetes can eat or not eat. You are not alone, however, in your misconceptions. I recently attended a four-day-long wound care conference that included a group of about 30 nurses. In response to a discussion about how diabetic patients are largely non-compliant with their diet and medications, I had to speak up. I told the group that I was diabetic and that it was not fair to generalize that all diabetics are non-compliant. I also did not like the implication that diabetes is solely the result of poor health maintenance. For the rest of the conference I was conscious of other people watching what I ate. One nurse was even embarrassed after telling me how good the cookies were at the meeting, finishing with “sorry that you can’t have one.”
The ADA update states, "Evidence suggests that there is not an ideal percentage of calories from carbohydrate, protein and fat for all people with diabetes (Living Standards of Medical Care in Diabetes, April 18, 2019)." The update goes on to recommend that instead, more attention be placed on individualized assessment of current eating patterns, individual preference and metabolic goals. The update further stresses overall healthy diets like the Mediterranean-style, low carbohydrate, and plant-based diets work well for diabetic patients. Nurses should focus emphasis on the importance of non-starchy vegetables, minimizing added sugar and refined grains, and choosing whole foods over highly processed foods. Studies have shown that highly restrictive diets are often doomed to failure. Personally, I know that I am more likely to have a salad rather than a sandwich if I know that I can have a small piece of chocolate with my meal. It is about balance, not about restricting my diet to the point that I am miserable. If your patient has been diabetic for a while, they probably have a pretty good idea about what they should or should not eat to control their blood glucose. Discussing how they ate before their disease or disability caused them to need rehabilitation is a good way to begin. Reminding them that good glucose control will help with their recovery, and discussing how to best control their blood glucose while participating in rehabilitation, is a good way to get them involved in their own care. A consult with a dietitian is also recommended to ensure that they are on the right track and have considered the additional caloric demands of physical therapy.
The final ADA updates so far this year are in relation to kidney disease in diabetics and continuous glucose monitoring. In addition to being cardioprotective, canaglifozin was found to decrease worsening of diabetes-related kidney disease. Therefore, any patients that you care for who also have renal failure and are not taking a SGLT2, might benefit from an endocrinology consult or follow-up appointment. I wish that these medications had been available 10 years ago. My father died from ESRD secondary to his diabetes. Adding canaglifozin to his medication may have extended and improved his quality of life. Continuous Glucose Monitoring (CGM) is another advance that can help patients better control their diabetes. It is useful for both type 1 and type 2 diabetics. It can help patients to know how diet and exercise impact their blood glucose in real time. CGM can be short-term to get a snap-shot of how a person’s blood glucose changes throughout the day or long-term to titrate insulin doses. People wearing a short-term CGM need to keep a journal of activity and caloric intake that they submit when the monitor is removed. This allows the endocrinologist to look for trends and helps in the choice of appropriate medication.
I hope that you learned something new and that you will be better prepared to help your diabetic patients to control their blood glucose while they are in rehabilitation. If you would like to learn more, the ADA has resources for professionals available on their website, www.diabetes.org.
References:
Ahmed, H.M., Khraishah, H., & Cho, L. (2018). Cardioprotective anti-hyperglycaemic medications: a review of clinical trials. European Heart Journal, 39, 2368-2375. DOI: 10.1093/eurheartj/ehx668
American College of Cardiology (2017). Cardioprotection in diabetes. New drugs, new opportunities. Cardiology, 46(8), 20-23. Retrieved from: https://www.bluetoad.com/publication/?i=431571#{"issue_id":431571,"page":24}
American Diabetes Association (2019). Living standards of medical care in diabetes. Retrieved from: https://care.diabetesjournals.org/living-standards
Nwankwo, R. & Funell, M. (2016). What’s new in nutrition for adults with diabetes? Nursing, 46(3), 28-33. DOI: 10.1097/01.NURSE.0000480595.99521.56
