COMMENTARY

Three Quick Tips for Diabetes Management in Primary Care

Jay H. Shubrook, DO

Disclosures

July 01, 2016

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I am Jay Shubrook, family physician and diabetologist. I am a professor in the Primary Care Department at Touro University, College of Osteopathic Medicine, and I serve the clinics at Solano County Family Health Services. I am speaking to you today from the American Diabetes Association Scientific Sessions. I am going to share with you three things that I have done in my practice to make the care of my patients with diabetes more efficient and effective.

First, it is important to remember that diabetes prevention is a big part of diabetes treatment. We know that for every person with diabetes, there are probably three other people who have prediabetes. When you screen for diabetes, remember that if the A1c or glucose level is in the prediabetes range, we have very effective evidence-based treatments that can help reduce the patient's risk of developing diabetes. Think about the National Diabetes Prevention Program (NDPP). The Centers for Disease Control and Prevention has a national website that shows all of the different programs that are available in each community. Remember to include the NDPP as part of your treatment algorithm for diabetes.

My second tip concerns the use of metformin. We all agree that metformin is the first and probably the most important treatment for type 2 diabetes along with lifestyle modification. Therapeutic lifestyle change alone is rarely enough. Studies show that the use of metformin at the diagnosis of type 2 diabetes is much more effective than waiting until the patient attempts a period of lifestyle intervention. Waiting just 3 months after the diagnosis of type 2 diabetes to start metformin can reduce its efficacy and durability by 50%.[1] Time is not your friend in treating type 2 diabetes. Think about early and effective interventions. Get your patients on metformin with a timely but stepwise approach to titration to get them to a therapeutic dose of at least 1000 mg metformin twice daily.

My third tip is to treat diabetes as a chronic disease. Help your patients celebrate small successes. This is a disease that takes a lot of time—many hours every day of self-management. In the visits that we have, we focus on the numbers, and that is one measure of success. Remember that every change in that number requires many hours of work. As much as you can, celebrate the process—and not only the product—of your patients' work. Remember to give them kudos when they are doing the work, not just when they reach a number that you want them to achieve. I draw small smiley faces. I give patients high-fives. I am always surprised at how important those things are to them, and how they find that it helps to engage them to continue the work for another 3 months.

Finally, remember that if you are working with your patients and they achieve their best A1c ever, congratulate them, but also know that this is a chronic disease and they are not always going to continue to improve towards zero. There will be bumps in the road. Their ability to care for themselves will wax and wane. Work with them through the challenges, and help them celebrate the small successes.

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