Q: Why aren’t we promoting therapeutic lifestyle changes (TLCs) as a “true” therapeutic option for our patients with type 2 diabetes?
From a clinician’s perspective, here are three actual cases:
1. A 47-year-old man presents to our endocrine practice with type 2 diabetes (T2DM) diagnosed three years ago by his primary care provider (PCP). He is being treated with metformin ER (500 mg bid), and glimepiride (4 mg/d), and his A1C is 8.2%. He has a BMI of 37 kg/m2, and since starting treatment for his diabetes he has not made any changes in his diet and does not exercise. His PCP informed him that he needs to start insulin right away since none of the remaining noninsulin options has the efficacy to lower his A1C to 6.5% (–1.7%).
2. A 53-year-old woman is referred to our endocrine practice with a new diagnosis of T2DM, made two weeks ago during a routine health maintenance exam. Since her A1C is 9.6%, her PCP told her she needed to start metformin plus insulin or a GLP-1 receptor agonist right away. Dietary note: The patient has drunk four to five (12-oz) cans of regular cola daily for the past two years and states, “I’ve never been an exerciser.”
3. A 44-year-old patient has a new diagnosis of T2DM and A1C of 7.4%. Patient was started on metformin (500 mg bid) before any TLCs were implemented.
In each case, the plan suggested by the PCP is an acceptable option based on current diabetes consensus algorithms. However, one problem I encounter time and time again is that TLCs have not been adequately discussed with the patients as a viable option. It is important to remember that patients with a recent diagnosis of T2DM who are drug naive will have the best glucose-lowering response to oral diabetes medications. Therefore, you will likely observe the highest A1C reductions compared with the average expected reductions in patients who are already taking other diabetes medications.
My experience has been that most PCPs—and even endocrinologists—will start metformin or other diabetes drugs as an initial medication and spend little time on promoting TLCs. I’m uncertain if it’s appointment time constraints, experience, or lack of belief that TLCs will actually be undertaken and continued by the patients. Patients often ask me why other health care providers didn’t enthusiastically promote changes in diet and exercise as a viable treatment option to improve glycemic control. It is not unusual to see patients decrease their A1C value by > 1.0%—and even experience hypoglycemia—on their current diabetes medications when carbohydrates and refined sugars are decreased and light-to-moderate exercise five to seven days per week is instituted.
Remember that the first-line therapy for hypertension, dyslipidemia, prediabetes, and T2DM is lifestyle modification. This first-line approach is all too often the last thing emphasized—or at least it receives little attention.
Q: Are we communicating to patients that TLCs actually have little value and we don’t think they have the ability to make necessary changes?
It seems to be the norm for many providers to evade this sometimes time-consuming yet underrated therapeutic discussion. It is as if we are convinced that the patients won’t make TLCs, so why spend the time discussing them? We essentially discount the patient’s willingness to change, and we default to the quick-and-easy “write a prescription,” since we have scientific studies that support the efficacy of current medications.
Instead, I say, we should be creating a sense of support, empowerment, credibility for change, and an opportunity for a victorious attitude in the patient, not one of failure. If you don’t spend valuable time discussing TLCs and the benefits they have on hypertension, dyslipidemia, and diabetes, then who will? I advise creating a referral list of those professionals who specialize in areas of TLCs, including certified diabetes educators, registered dieticians, behavioral health specialists, and certified personal trainers and fitness consultants.
T2DM is a progressive disease requiring additional medications over time, with the ultimate need for insulin. We should be cautious in how we use this information, as it may frustrate patients and make them feel, “Why should I try since it will not make any difference in the end?” The fact is that the progression of the disease can be altered with diet, exercise, and weight loss in such a fashion that some patients will be able to decrease their current diabetes medications and possibly even discontinue some, including insulin. Keep in mind that this will depend on the number of years they have had T2DM (ie, reflecting their insulin reserves).
I always ask patients what they are willing to do and how soon they plan to commit to these changes. I inform them that I will add and/or change medication(s) as needed based on what they are not willing to do with regard to lifestyle modification. I tell them that immediate changes in diet aimed to nearly eliminate simple sugars and reduce refined or “white foods” (white bread/pasta/potatoes/flour), in addition to establishing regular exercise, will have immediate impact on lowering blood sugars. Weight loss is not required for immediate improvements in blood sugars, but instead will have lasting benefits with as little as a 5% to 10% loss.
Q: If the Diabetes Prevention Program demonstrated such amazing results in the prediabetes population, shouldn’t we surmise that these same results could be applied to the T2DM population?
The Diabetes Prevention Program showed a 58% reduction in risk for T2DM in patients with prediabetes when they were treated with intensive lifestyle intervention resulting in at least 7% weight loss and 150+ minutes of exercise weekly. The metformin arm of the study showed a significant 31% reduction in risk for T2DM (still 27% less effective than lifestyle intervention).
Although my personal success with patients willing to fully embark on TLCs is low, I still spend a good portion of my consultations and follow-up time teaching the importance of diet and exercise. I reiterate these principles at each and every visit. If you don’t place a high emphasis on these changes, neither will your patients.
If you want your patient to succeed, set obtainable goals, no matter how simple or achievable. Explain that even a 5% to 10% weight loss yields significant benefits, which may prevent the need to add medications and could possibly lead to a reduction in their current medications.
Show a true concern and interest for the patient; demonstrate your belief in them for change. Don’t use threats of additional medications or increased risk for morbidity and mortality. Yes, fear is a powerful motivator, but so is benefit. If you scare the patient, he or she may not return to you for follow-up. I aim to create a sense of heightened concern about the realities of poor diabetes control while strongly emphasizing the benefits of diet, exercise, and weight loss. This helps the patients gain a full appreciation of the need for TLCs.
Our lack of belief that a patient will actually undertake the necessary means to improve their diet and embark on a regular exercise program is not a justifiable excuse for not spending time teaching and encouraging them. Avoid becoming frustrated with your belief and the reality that the majority of people don’t adopt and continue the necessary TLCs to lose weight and keep it off. We owe it to our patients to become knowledgeable about TLCs, believe in the value of them, and be positive, encouraging, and a good coach. The small percentage of patients who actually succeed and become happy about their success will spark your belief and motivation to keep promoting
Nathan DM, Buse JB, Davidson MB, et al. Medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy. A consensus statement of the American Diabetes Association and the European Association for the Study of Diabetes. Diabetes Care. 2009;32(1):193-203.
Rodbard HW, Jellinger PS, Davidson JA, et al. Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology Consensus Panel on type 2 diabetes mellitus: an algorithm for glycemic control. Endocr Pract. 2009;15:540-559.
National Heart, Lung and Blood Institute, NIH. The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf.
National Diabetes Information Clearinghouse. Diabetes Prevention Program. http://diabetes.niddk.nih .gov/dm/pubs/preventionprogram.