Counseling Patients on Diabetes Self-Management

Jasmine D. Gonzalvo, PharmD, and Dhiren Patel, PharmD, share best practices for helping patients with diabetes self-management, including advice on lifestyle modification.

Jasmine D. Gonzalvo, PharmD: Regarding the most important questions to ask patients when trying to improve or support their self-management of diabetes, I would say to always start out with, “Tell me how you’re doing.” Starting out more broadly like that usually allows for patients to come up with what’s bothering them the most. They know that they’re seeing me for their diabetes, so oftentimes it will be related to their diabetes and they’ll bring up what’s most bothersome to them.

From there, we really just navigate: “OK, it’s either your barriers or your issues.” How do we problem-solve and troubleshoot to address those specific barriers that they have identified versus me as the provider asking, “Is this an issue, is this an issue, is this an issue?” or trying to ask specific questions that may not really get at what the issue is at hand for the patient or what’s most important for the patient? For me, the most important questions to ask really start out very broadly just by asking “How are you feeling today? What issues have you come across? What have you been thinking about? What has been the most troublesome for you?” Those usually garner the most important information relative to their care.

I’m not typically saying, “Do this, do that, here’s a tip, here’s a handout that would be a catchall that would be helpful” to somebody with diabetes. Oftentimes, it’s getting to know your patients with diabetes and building rapport, understanding where they’re coming from or trying to understand where they’re coming from. What are their biggest issues? What do they struggle with? What are their obstacles? Being that diabetes is a lifelong condition, there are ups and downs; it’s a roller-coaster that patients need to deal with, that they have to deal with. I try to be supportive as much as possible and listen to what their areas of concern are.

Finding options where the patient might find something more tolerable or find something easier to use, and really just supporting the patient in those ways, is how I feel I can do the best job and be most supportive. Those are really the things that affect adherence, so to speak: supporting the patient and the things that they’re doing on their own when they go home without me there, without me reminding them or giving them tips, so to speak. It’s what they’re going to choose to do when they’re at home. If they’re most comfortable doing that, if they understand why they’re doing something—I feel like those things are most important to being supportive of the patient and having the patient be most successful and healthy in the long term.

Dhiren Patel, PharmD: Best practices for lifestyle modifications are anything that is going to work for that patient. The question that I get asked a lot is, “What is the best diet that’s out there?” My answer to that is, “Whatever works for the patient is the best diet.” The big thing here to emphasize with patients is that small steps are basically what’s will last and what’s going to translate into long-term outcomes. Anything that’s done in a drastic fashion will essentially not stick with that patient and it’s going to be a short-term weight loss, a short-term behavior change. And so, I would say let it be very small and deliberate for it to become a long-term habit change.

When we look at lifestyle modification, it includes everything from smoking cessation to the appropriate amount of alcohol consumption, nutrition, and physical activity. Each of those should be customized to the patient when specifically looking at physical activity as well as nutrition. Every patient’s not going to be able to take X number of steps or be able to run half a marathon. You need to be able to cater that to the patient and make it specific to something they can do in terms of increasing their activity from baseline, where it’s not just a blank recommendation of eat less, exercise more. We know that is not something that works for all patients.

As pharmacists, we have a very unique way of talking to our patients about their day-to-day activities, specifically when it comes to lifestyle modifications and nutrition. Regarding questions that I usually ask my patients instead of telling them, “These are all the healthy things to eat,” I actually flip it and ask them, “What is it that you eat in a given day? Please describe an average breakfast, an average lunch, an average dinner, what you snack on, and what you basically consume through liquids.”

It’s more relevant if you can customize to what the patient is telling you. If the patient is telling you, “I consume a regular amount of soda and tons of juice,” you can go in and tailor it and give a specific recommendation for that, versus just giving blanket recommendations and saying, “Hey, you should eat low-fat or low-carb foods.” Modify it, make it to their schedule. If a patient’s eating unhealthily, I’ll work with them and pull up a menu. For example, they might be eating at MacDonald’s. That’s OK, because behavior change takes time and the smaller it is, the better it’s going to be in terms of long-term success. What can we eat that’s better on this menu?

Again, take very baby steps when it comes to reduction, whether it be calories, unhealthy patterns such as soda consumption, or anything that they might be doing that you know is a culprit. Work slowly in time to minimize it. And to all of my patients I always say, “There’s nothing that you can never eat.” Many patients with diabetes think, “Because I have it, I can never eat this.” I think everything in moderation is OK.