● Early combination therapy can be considered in some patients at treatment initiation to extend the time to treatment failure. ● The early introduction of insulin should be considered if there is evidence of ongoing catabolism (weight loss), if symptoms of hyperglycemia are present, or when A1C levels (>10% [86 mmol/mol]) or blood glucose levels (≥300 mg/dL [16.7 mmol/L]) are very high. ● A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include effect on cardiovascular and renal comorbidities, efficacy, hypoglycemia risk, impact on weight, cost, risk for side effects, and patient preferences. ● Among patients with type 2 diabetes who have established atherosclerotic cardiovascular disease or indicators of high risk, established kidney disease, or heart failure, a sodium– glucose cotransporter 2 inhibitor or glucagon-like peptide 1 receptor agonist with demonstrated cardiovascular disease benefit is recommended as part of the glucose-lowering Nutrition therapy is recommended for all patients with type 1 and type 2 diabetes. For those patients who are overweight or obese, modest weight loss may provide significant clinical benefits such as improved glucose control and lipid levels and reduction in blood pressure, especially early in the course of the disease (ADA, 2021h). Evidence-based practice! Research suggests that there is a benefit to eating protein or protein and vegetables before eating the carbohydrate portion of a meal (ADA, 2021h). healthcare professionals should collaborate to ensure patients and families have access to planning the best meal options for persons with diabetes. Non-pharmacologic diabetes management Nutrition The goal of a good nutrition plan is to get the nutrients needed while keeping blood glucose levels within target range. The patient’s goals, tastes, preferences, lifestyle, and medications should be considered when meal planning (CDC, 2021f). According to the CDC (2021f) a good meal plan will: ● Include more non-starchy vegetables, such as broccoli, spinach, and green beans. ● Include fewer added sugars and refined grains such as white bread, rice, and pasta with less than two grams of fiber per serving. Physical activity Being overweight or obese is linked to a vast number of medical problems, including heart disease and cancer. Proper nutritional intake and physical activity not only help patients to achieve weight goals but also have a positive impact on diabetes. Exercise may also have a positive effect for depression associated with the consequences of the need for diabetes management. As previously noted, the American Heart Association (2021) recommends: ● At least 150 minutes per week of moderate-intensity aerobic physical activity; ● Or 75 minutes per week of vigorous-intensity aerobic physical activity (or a combination of the two); ● And muscle-strengthening exercises at least two days per week. People who have diabetes must monitor their physical activity in relation to their glycemic levels. For example, exercise can lead to Smoking cessation All patients should be advised not to use any tobacco products or e-cigarettes. Nonsmokers should be advised not to use Psychosocial care Mental health and well-being are important to general health and wellness and can impact the patient’s or family’s ability to implement diabetes treatment. The physical and emotional stress that can accompany a chronic health problem can put the patient
regimen independent of A1C and in consideration of patient- specific factors. ● In patients with type 2 diabetes, a glucagon-like peptide 1 receptor agonist is preferred to insulin when possible. ● Recommendation for treatment intensification for patients not meeting treatment goals should not be delayed. ● The medication regimen and medication-taking behavior should be reevaluated at regular intervals (every 3–6 months) and adjusted as needed to incorporate specific factors that impact choice of treatment. ● Clinicians should be aware of the potential for over- basalization with insulin therapy. Over-basalization is titration of basal insulin beyond an appropriate dose to achieve glycemic targets. Clinical signals that may prompt evaluation of over-basalization include basal dose more than ∼0.5 IU/ kg, high bedtime-morning or post-preprandial glucose differential, hypoglycemia (aware or unaware), and high variability. Indication of over-basalization should prompt reevaluation to further individualize therapy. ● Focus on whole foods instead of highly processed foods as much as possible. The CDC (2021f) recommends using a plate method as part of the meal planning process. Patients should consider a nine-inch dinner plate and: ● Fill half of the plate with non-starchy vegetables, such as salad, green beans, broccoli, cauliflower, cabbage, and carrots. ● Fill one-quarter of the plate with a lean protein, such as chicken, turkey, beans, tofu, or eggs. ● Fill one-quarter of the plate with carb foods such as grains, starchy vegetables (peas, potatoes), rice, pasta, fruit, and yogurt. A cup of milk counts as a carb food. ● Choose water or a low-calorie drink such as unsweetened tea to go with a meal. Many people appreciate having a guide as to what constitutes a “portion” of a particular nutrient. The CDC (2021f) offers the following suggestions for estimating portion size. ● Three ounces of meat, fish, or poultry: Palm of hand (no fingers) ● One ounce of meat or cheese: Thumb tip to base ● One cup or one medium fruit: Fist ● One to two ounces of nuts or pretzels: Cupped hand ● One Tablespoon: Thumb tip (tip to first joint) ● One teaspoon: Fingertip (tip to first joint) hyperglycemia or hypoglycemia depending on its intensity, timing, duration, and type of physical activity (ADA 2021h). People who take insulin or oral pharmacological agents are at risk for hypoglycemia if insulin dose or carbohydrate intake is not adjusted with exercise. Exercise regimens should be planned with the healthcare team. The ADA (n.d.) recommends following the 15-15 rule: ● Check blood sugar ● If the reading is 100mg/dL or lower have 15-20 grams of carbohydrate. Examples include four glucose tablets, one glucose gel tube, four ounces of juice ore regular soda, or one tablespoon of sugar or honey. ● Check blood sugar again after 15 minutes. If it is still below 100 mg/dL another servicing of 15 grams of carbohydrate is needed. ● Repeat these steps every 15 minutes until blood sugar is at least 100 mg/dL.
e-cigarettes. Smoking cessation should be a routine part of diabetes management (American Heart Association, 2021).
and her family at risk for mental health problems (ADA, 2021o; Grygotis, 2016). Psychosocial screening and follow-up treatment include attitudes about illness; expectations for management and outcomes; affect/
Book Code: ANCCUS2423
Page 67
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